Childbirth at Risk: Labor Complications

Twila Brown, PhD, RN

Dystocia and Dysfunctional Labor

Causes– Power

HypotonicHypertonic

– Passenger – Passage

Dysfunctional Uterine Contractions: Hypertonic Labor Patterns

Latent phase of labor Contractions

– Ineffective in dilating and effacing the cervix– Resting tone of myometrium increases– Occur more frequent – Painful

Maternal risks Fetal risks

Dysfunctional Uterine Contractions: Hypertonic Labor Patterns

Management– Assess for cephalopelvic disproportion (CPD)– Bed rest and sedation– Oxytocin or amniotomy– Decrease pain and anxiety– Monitor fetal heart rate patterns– Provide fluids and glucose

Dysfunctional Uterine Contractions: Hypotonic Labor Patterns

Active phase of labor Etiology

– Sedation, over-distension of the uterus, bladder or bowel distention

– Advancing maternal age Contractions

– Low amplitude – Fewer than 2-3 contractions in 10 minutes– Irregular pattern– Cervical dilation less than 1 cm per hour

Dysfunctional Uterine Contractions: Hypotonic Labor Patterns

Management– Assess for CPD and engagement– Amniotomy– Oxytocin– Provide comfort and decrease anxiety– Monitor mother– Monitor fetus

Precipitous Labor and Birth

Labor and birth less than 3 hours– Intense contractions– Little relaxation between contractions– Rapid cervical dilation and fetal descent

Maternal risks Fetal risks

Precipitous Labor and Birth

Management– Tocolytic agent– Immediate delivery– Support for relaxation– Monitor contractions and fetal heart rate– Apply pressure to fetal head

Fetal Position

Most common at delivery– Cephalic – Vertex– Chin flexed to chest

– Occiput Anterior

Fetal Malposition: Occiput-posterior

Assessment– Intense back pain– Poor dilatation and descent – Depression in lower maternal abdomen– Fetal heart rate heard laterally– Anterior fontanelle in anterior– Perineal laceration or episiotomy extension

Management– Manual rotation– Side-lying or knee-chest – Forceps

Fetal Malpresentation:Military, Brow, and Face

Management– Cesarean birth if CPD– Monitor for fetal hypoxia – Episiotomy extension– Forceps or manual conversion contraindicated– Newborn trauma

Fetal Malpresentation: Breech

Assessment– Fetal head, feet, bottom, and heart tones

Management– External cephalic version – Cesarean delivery

Small maternal pelvis Fetal weight <1500gm or >3800gmNeck hyperextension, arms over head, anomalies

– If vaginal deliveryPain management, prolapsed cord, head trauma

Fetal Malpresentation: Shoulder (Transverse lie)

Assessment– Maternal abdomen– Fetal head– Presenting part

Management– External version attempted– Cesarean delivery – Monitor for prolapsed cord

Multiple Gestation

Risks– Hypertension or preeclampsia, anemia, hydramnios– Preterm birth, abnormal fetal presentation– Overstretched uterus, postpartum hemorrhage– Monochorionic placenta or Monoamniotic

Management– Prevent preterm labor– Monitor each fetus– May have Cesarean delivery

Nonreassuring Fetal Status:Fetal Distress

Etiology– Uteroplacental insufficiency

Fetal hypoxia Assessment

– Late or severe variable decelerations– Decrease in variability– Changes in baseline – Meconium staining of amniotic fluid– Fetal scalp blood pH below 7.20

Nonreassuring Fetal Status

Management– Maternal position– Increase intravenous fluid– Oxygen– Discontinue oxytocin– If fetal distress continues, cesarean delivery and

resuscitate– If delivery is imminent, deliver and resuscitate

Cephalopelvic Disproportion (CPD)

Signs– Slow cervical dilation and effacement– Lack of fetal engagement and descent

Maternal risks– Prolonged labor– Premature rupture of membranes– Uterine rupture

Fetal risks– Prolapsed umbilical cord– Head trauma

Cephalopelvic Disproportion

Management– Monitor progression of

labor – Monitor for fetal distress– Emotional support– Cesarean delivery– Maternal position

McRoberts maneuver

Prolapsed Umbilical Cord

Etiology– Not engaged when membranes rupture– Contributing factors

Assessment– Cord through the cervix– Fetal heart rate is irregular

Cord compressed – Occludes blood flow to fetus– Compression worsens during contractions

Emergency

Prolapsed Umbilical Cord

Management– Bed rest until engagement if ruptured membranes– Relieve cord pressure– Push back the presenting part– Fill bladder– Change maternal position– Administer oxygen– Monitor fetal heart tones– Cesarean delivery

Abruptio Placentae

Etiology– Decreased blood flow to the placenta– Maternal hypertension, abdominal trauma, cocaine

Maternal risks– Hypoxic uterus– Uterus difficult to contract after delivery– Maternal hemorrhagic shock

Fetal/neonatal risks– Complications from preterm labor, anemia, and

hypoxia

Abruptio Placentae

Assessment– Fundal height increases– May or may not have vaginal bleeding– Painful – Irritable uterus– Rigid, boardlike abdomen – Enlarged uterus– Signs of shock

Abruptio Placentae

Management– Monitor vital signs and fetal heart tones– Assess vaginal bleeding, pain, and fundal height– Bed rest– Administer oxygen, IV fluids, and blood products– Monitor and treat hypovolemia– Induce vaginal delivery if mild separation:– Cesarean delivery for moderate to severe

separation or fetal distress

Placenta Previa

Etiology– Placenta implanted in lower uterine segment – Placental villi are torn from uterus

Signs– Painless, bright red vaginal bleeding– Soft, nontender uterus– High presenting part

Types– Low-lying, Partial, Total

Placenta Previa

Management– Monitor vital signs, fetal heart rate, fetal activity– Assess amount and quality of bleeding– Vaginal exam is contraindicated– Ultrasound– Administer oxygen as prescribed for fetal distress– Preterm: Bed rest and monitor – Term with low-lying or marginal: Induce for delivery– Cesarean if complete previa or fetal distress

Intrauterine Fetal Death

Loss of heart rate on ultrasound and drop in maternal estriol levels

Induce labor or spontaneous labor within 2 weeks

Parental reaction Supportive care

References

Ladewig, P.A., London, M.L., & Davidson, M.R. (2006). Contemorary maternal-Newborn Nursing Care (6th ed.). Upper Saddle River, NJ: Prentice Hall.

Littleton, L.Y., & Engebretson, J.C. (2005). Maternity nursing care. Clifton Park, NY: Thomson Delmar Learning.

Olds, S.B., London, M.L., Ladewig, P.W., & Davidson, M.R. ( 2004). Maternal-newborn nursing & women’s health care (7th ed.). Upper Saddle River, NJ: Prentice Hall.

Silvestri, L.A. (2002). Saunders comprehensive review for NCLEX-RN (2nd ed.). Philadelphia: W.B. Sanders.

Straight A’s in maternal-neonatal nursing. (2004). Philadelphia: Lippincott Williams & Wilkins.