Labor and Birth Complications

Learning Objectives

• Dystocia includes its primary causes along with associated nursing and medical interventions.
• Potential complications of dystocia in labor and related interventions are identified
• Grasping induction principles, augmentation techniques, and vaginal birth possibilities post-cesarean.
• Identifying and handling high-risk pregnancies, labor, and delivery to support healthy outcomes for both the mother and the infant.
• Outlining the principal obstetric emergencies along with associated nursing and medical actions.

Labor & Birth at Risk

• Perinatal morbidity and mortality risks increase when complications arise
• Some complications are anticipated when the mother is identified as high risk.
• Others are unexpected or unforeseen.
• Crucial for nurses to understand the normal birth process.
• Nurses should be able to prevent and detect deviations from normal labor and birth.
• Nursing measures should be implemented if complications arise.
• Nurse and obstetric team must use knowledge and skills to provide care in the event of complications.

Preterm Labor and Birth

• Regular uterine contractions with cervical effacement and dilation occurs between 20 and 37 weeks of gestation.
• A common obstetric complication is the risk of preterm birth if labor is not stopped.

Risk Factors for Preterm Labor

• Infections
• Previous preterm labor
• Black race
• Placenta previa or Abruptio placentae
• Multiple gestation
• Pre-pregnancy underweight or obesity (BMI >30)
• Smoking and substance abuse
• Low socioeconomic status
• High levels of personal stress

Predicting Spontaneous Preterm Labor & Birth Assessment

• Key assessments include risk factors, changes in vaginal discharge, pelvic pressure, low back ache, and cervical length.
• Check fetal fibronectin (fFN).
• Monitor for contractions frequently, noting if there are more than six in an hour.
• Note if there are four contractions every 20 minutes or eight contractions in one hour.

Preterm Labor: Nursing Assessment

• Assess for risk factors, preterm labor contractions, and need for lab and diagnostic testing
• Perform laboratory and diagnostic tests, including CBC, urinalysis, amniotic fluid analysis, fetal fibronectin, cervical length measurement and cervical culture.
• Prevention includes early recognition and diagnosis and lifestyle modifications.
• Lifestyle modifications include activity and restriction of sexual activity.

Suppression of Uterine Activity

• Tocolytic therapy aims to stop uterine contractions, and usually only delays delivery.
• Magnesium Sulfate relaxes the smooth muscle of the uterus.
• Brethine (Terbutaline) is a Beta-adrenergic medication.
• Nifedipine (Procardia) is a calcium channel blocker.
• Indomethacin (Indocin) is a Prostaglandin synthesis inhibitor.

Fetal Lung Maturity Promotion

• Corticosteroid use of Betamethasone can help with fetal lung maturity

Nursing Interventions

• Assess of mother and fetus, and ensuring immediate care.
• Have Calcium Gluconate on hand when administering Magnesium Sulfate.
• Discharge teaching can review warning signs of preterm labor.
• Antibiotic prophylaxis for women with group B streptococcus.

Prelabor Rupture of Membranes (PROM)

• PROM is the rupture of the amniotic sac and leakage of amniotic fluid at least 1 hour before the onset of labor.
• Infection is a major risk factor.

Risk Factors for PROM

• History of preterm PROM
• Short cervical length
• Low socioeconomic status
• Smoking and illicit drug use

PROM Care Assessment and Interventions

• Determine the risk for each woman.
• Monitor the fetal heart rate.
• Consistently check maternal vital signs, especially temperature.
• Infection is the greatest risk.
• Assess labs (CBC) for signs infection.
• Labor may be induced and the patient is usually hospitalized.

Chorioamnionitis

• It's a bacterial infection of the amniotic cavity, including fetal amnion and chorion membranes, and bacteria ascending into uterus from the vagina.
• Risk factors include prolonged rupture of membranes, multiple vaginal exams, and use of internal fetal monitoring.
• Signs and Symptoms include maternal fever of over 100.4, maternal and fetal tachycardia, uterine tenderness, foul smelling amniotic fluid.
• Treat with IV broad spectrum antibiotics (PCN, ampicillin).
• The placenta could be sent to pathology.
• Follow up with neonate requires blood cultures and IV antibiotics until blood culture results.
• Nurses should communicate findings, assess maternal WBC for being greater than 15,000, and administer antibiotics and antipyretics as ordered.

Post Term Pregnancy

• A pregnancy is considered completed at 42 weeks' gestation.
• Always review EDD, because the etiology is unknown.

Maternal Risks

• Risks include large fetus, increased risk for Cesarean birth, dystocia, birth trauma, postpartum hemorrhage and infection.
• There may be an increased risk for forcep or vacuum assisted birth and/or induction of labor

Fetal Risks

• Risks include Macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, decreased perfusion, and meconium staining/cephalopelvic disproportion.
• Perfusion will decrease as the placenta ages.

Postterm Pregnancy: Assessment & Management

• Nursing assessment and management should assess the estimated date of birth, daily fetal movement counts and perform non-stress tests twice weekly.
• Check biophysical profile to assess AFI and weekly cervical exams.
• The nurse should assess the client’s understanding.
• Fetal surveillance is key if the plan is to wait.

Dystocia

• Dystocia refers to difficult labor or "failure to progress."
• It describes an abnormally long labor and often is the reason for cesarean sections.
• Factors influencing labor (5 P’s) include abnormalities of powers, passage, passenger, position and psychological factors.
• Early identification and interventions for dystocia are important to minimize maternal and fetal risk.

Uterine Dystocia: Problems with the Powers

• Hypertonic uterine dysfunction occurs when the uterus does not fully relax between contractions.
• Risk factors include induction/augmentation, tachysystole and abruption.
• Assessment includes frequent contractions, inadequate resting tone, little cervical changes, and potential Category II or III FHR pattern

Hypotonic uterine dysfunction

• Occurs during active labor where uterine contraction is insufficient promote cervical dilation and effacement, less than 25 mm Hg
• Risk factors: uterus overstretched, bladder distention
• Assessment findings: deceased frequency, duration and intensity of contractions, little or no cervical changes
• Management & actions include evaluating labor progress, assess uterine/fetal activity to determine cause, and consider augmentation with oxvtocin.

Uterine Dystocia: Problems With The Powers (Precipitate Labor)

• Precipitate labor lasts less than 3 hours from onset of labor to birth.
• Risk factors include grand multiparity and history of previous precipitous labor.
• Assessment findings include hypertonic UC less than 2 minutes apart and lasting over 60 seconds, rapid cervical changes, and potential for Category II or III FHR patterns.
• Nursing actions include monitoring fetus and the mother.
• One should prepare for delivery and anticipate possible postpartum (hemorrhage) and neonatal (hypoxia) complications.

Dystocia: Problems With The Passage

• The passageway refers to the pelvis and birth canal, with risk factors including small pelvis and abnormal pelvic shape.
• Assess for delayed descent of the fetal head.
• Nursing and medical care includes evaluating the pelvis and descent of fetal head.
• Perform SVE for descent and engagement of the fetal head.

Dystocia: Problems with the Passenger

• Fetal dystocia refers to excessive fetal size, malpresentation, multifetal pregnancy, fetal anomalies, and cephalopelvic disproportion
• Risk factors include contraction or narrowing of pelvis, abnormal fetal presentation/position, fetal anomalies, and fetal macrosomia (greater than 4,500 g).

Nursing Actions and Medical Management

• Assess fetal status and progress via SVE or ultrasound. Use Leopold's maneuvers.
• Determine need for obstetric interventions with forceps, vacuum, and cesarean birth.

Dystocia: Pelvic and Maternal Psyche

• Intense anxiety stimulates the sympathetic nervous system and creates problems with psyche.
• Psychological distress is one such problem.

Obesity

• Obesity is becoming an increasingly serious problem for pregnant women.
• Rates increase for non-Hispanic Black women.
• Women are likely to begin their pregnancy with preexisting conditions, like hypertension and diabetes.
• Increased risk can lead to postdate pregnancy complications.
• Nursing care has many challenges.

Obstetric Procedures

These include the versioning and induction of labor.

• External cephalic version is used.
• Elective induction, evaluating the Bishop score, and being at least 39 weeks gestation are all steps to consider during labor.

Obstetric Procedures: External Cephalic Version

• This procedure attempts to turn the fetus from breech or shoulder presentation to vertex.
• It's usually done in multiparous women with normal amount amniotic fluid and non-engaged fetus after 37 weeks.
• Fetal position is altered by abdominal or intrauterine manipulation.
• Terbutaline may be administered to relax the uterus.

Contraindications for Versioning

• Include Cephalopelvic disproportion (CPD), placenta previa, ruptured membranes, and history of preterm labor and multiple fetuses.
• Prior to the version, one should r/o anomalies, placenta previa, and assess the amount of amniotic fluid and location of the cord and fetus using US.
• Perform NST test to assure fetal well-being.

Nursing Actions Post Versioning

• Continuously monitor FHR for bradycardia, variable decelerations and ultrasound
• Assess maternal VS
• After procedure monitors VS, uterine activity and vaginal bleeding
• Monitor FHR for at least 1 hour following procedure.
• Administer RhoGam for Rh negative women.

Labor Interventions: Labor Induction and Augmentation

• Augmentation enhances ineffective uterine contractions after onset of labor.
• Induction deliberately stimulates the use of UCs before the onset of spontaneous labor.
• Indications include premature rupture of membranes, gestational hypertension, diabetes, chorioamnionitis and intrauterine fetal demise.
• Contraindications include placenta previa, abruptio placentae, transverse fetal lie, prolapsed umbilical cord, active genital herpes classic uterine incision.
• Verify gestational age to be 39 weeks or greater and Bishop score.
• Check If there are any contractions present or prior.

Bishop Score

• Used to identify who would most likely achieve a successful labor induction with a 0-10 score
• A score of 8 or higher indicates a favorable cervix.
• Scores less than 6 should consider cervical ripening agents.

Obstetric Procedures: Cervical Ripening

• Factors to consider include: parity, gestational age, Bishop score, status of membranes and history of previous cesarean birth.
• Cervical ripening is the physical softening and opening of the cervix in preparation for labor and birth.
• Alternative methods include herbal agents. These include blue cohosh and castor oil.
• Mechanical and physical methods include Hygroscopic dilators-Laminaria and Lamicil.
• Use insertion of balloon catheter above cervical os and amniotomy to artificially rupture of membranes.

Pharmacological Methods of Cervical Ripening

• Prostoglandin E2 (PGE2) Dinoprostone (Cervidil insert) is the only medication that is FDA-approved for cervical ripening.
• Ripen the cervix before oxytocin for Bishop score is 4 or less.
• It's contraindicated if there is history of cesarean birth and cautioned if there's a history of asthma.
• The medicine is inserted intravaginal for 12 hours and the client should maintain side-lying position for 2 hours after insertion.
• Afterwards, monitor fetal heart rate and uterine tachysystole, assess cervical dilation and signs/symptoms of labor and delay oxytocin for 1 hour after removal of policy.
• Prostaglandin E1 (PGE1) Misoprostol (Cytotec) can be ingested through oral or intravaginal routes.

Prostaglandin E1 (PGE1) Misoprostol (Cytotec)

• USe of prostaglandins is intended for cervical ripening by softening the cervix.
• Repeat every 4 hours until effective contractions or Bishop score equals 8.
• Nurses should monitor maternal V/S, FHR, and contractions, and watch for uterine tachysystole.
• Clients should maintain side-lying position for 30-40 minutes after insertion.
• Delay oxytocin administration at least 4 hours after administering.
• Access any prior uterine contractions before use.

Induction/Augmentation of Labor Using Oxytocin

• The pharmacologic method for induction/augmentation of labor is administration of oxytocin
• The goal is to produce contractions of normal intensity, duration and frequency with the lowest dosage
• Risks include high alert medication, tachysystole (most common side effect), uterine rupture, fetal stress, infection, and postpartum hemorrhage.
• Side effects include anti-diuretic effect (water intoxication risk if prolonged induction), lethargy, blurred vision, headache, and convulsion.
• Contraindications for labor induction include placenta previa, genital herpes, fetal malpresentation, unconfirmed EDD, and being less than 39 weeks gestation.

Labor Interventions: Oxytocin

• Obtain confirmation that the fetus is engaged, Bishop score and gestational age.
• Always infuse with IV infusion pump, and verify when the last dose of cervical ripening agent was if they were used.
• Perform continuous fetal heart rate monitoring, assess fluid intake and output, and check uterine resting tone and contraction pattern.
• Discontinue oxytocin for uterine tachysytole and notify provider.
• Have oxygen available and administer 8-10 liters per minute by face mask for nonreassuring fetal heart rate patterns and address client’s pain.

Obstetric Procedures: Operative Vaginal Delivery

• Forceps or Vacuum Assisted Birth involves the application of traction to fetal head to assist with delivery.
• Indications for this procedure include prolonged second stage of labor, non-reassuring FHR pattern, and the the mother's inability to push effectively, and overall maternal fatigue.
• Use poses a risk of tissue trauma to mother and newborn.
• Maternal risks involve perineal, vaginal or cervical lacerations and soft tissue hematoma.
• Neonate risks involve cephalohematoma, caput succedaneum, scalp lacerations, and intracranial hemorrhage.

Obstetric Emergencies: Meconium-Stained Amniotic Fluid

• This includes when the fetus has passed the first stool before birth.
• There are three possible reasons: normal physiologic function, hypoxia induced peristalsis, and sequel to umbilical cord compression-induced vaginal stimulation.
• Infant is at risk for meconium aspiration syndrome, and care should be provided by a team skilled in neonatal resuscitation.

Dystocia: Problems with the Passenger

• Amnioinfusion is a therapeutic option when recurrent variable decelerations usually occurs with decreased amniotic fluid.
• Use solutions at room temperature. Normal saline or lactated ringers infused into uterus transcervically via intrauterine pressure catheter.
• Contraindications include vaginal bleeding, uterine anomalies, and active infection
• Nurses should monitor fetal and maternal response, document fluid infused and returned, and focus on avoiding polyhydramnios.

Dystocia: Problems with the Passenger

• Shoulder dystocia refers to difficulty during delivery of the shoulders after the birth of the fetal head
• Head is born but anterior shoulder can't pass underneath pubic arch.
• The “Turtle sign” can be seen, when pushing as fetal head begins to be seen.
• Fetal injuries occur due to asphyxia or trauma.
• Risks include Brachial plexus injury and fractured clavicle.
• The mother poses increased risk for postpartum hemorrhage and rectal injuries
• Prompt recognition and appropriate management can reduce severity of maternal/fetal injuries .

Obstetric Emergencies: Umbilical Cord Prolapse

• Prolapse of the umbilical cord is when the cord lies below the presenting part of the fetus.
• Compression interrupts blood supply to and from the placenta.
• Risk factors include a long cord, presenting part not engaged, and malpresentation (breech or transverse lie).
• Nursing actions include prompt recognition because fetal hypoxia can result in CNS damage or death within 5 minutes.
• Woman is placed immediately into knee chest, trendelenburg or manually elevating fetal head.
• Oxygen should be administered, and the fetal heart rate should be monitored.

Obstetric Emergencies: Uterine Rupture

• Uterine rupture is rare yet has a high incidence of fetal and maternal mortality.
• Assessment is related to internal hemorrhage.
• Manifestations include a sudden fetal bradycardia or loss of fetal heart rate, as well as tearing of the uterus at the site of a previous scar and shock.
• Requires astute assessment and rapid interventions by all team members.
• Risk factors include uterine hypertonia/tachysystole, multiple prior C/S's or other uterine surgery, multidetal gestation, and cocaine use.
• Deliveries warrant an urgent Cesarean Birth.

Obstetric Emergencies: Anaphylactic Syndrome/Amniotic Fluid Embolism

• Obstetric emergencies present as an acute onset of hypotension, hypoxia, cardiovascular collapse and coagulopathy.
• Amniotic fluid contains particles of debris and can occur during pregnancy, labor and after birth.
• Risk factors include age over 35, use of oxytocin, and placenta abnormalities
• Medical Management includes supportive measures to maintain oxygenation and hemodynamic function from nursing actions, and to correct coagulopathy.
• Critical care monitoring, the maintenance of fetal heart rate and preparation for any emergency delivery may also be required.