Complication o Labor

Psychologic Disorders

Alterations in thinking, mood or behavior

Keep her well oriented and promote optimal functioning in labor. Focus on maintaining safe environment and ensuring fetal and maternal well-being

Dystocia r/t dysfunctional contractions

Accounts for ~ 50% C/S for primips; <5% C/S for multips

Hypertonic: in 1st phase- poor quality U/Cs, become more frequent, but ineffective and changing dilatation or effacement prolonged latent phase

Tx: sedation, oxytocin, amniotomy

Hypotonic: irreg, low amplitude protracted labor and arrest of dilatation

Tx: oxytocin, amniotomy

Active Management of Labor

Standardized criteria for diagnosis of labor

Standardized method of labor management

One-to-one nursing care in labor

Prenatal education to teach re: this protocol

Method:Amniotomy right away

VE frequently

If change not as expected, oxytocin

Precipitous Labor and Birth

From beginning of regular contractions to delivery is 3 hours or lessRisks:

AbruptionCervical and perineal lacerationsFetal head trauma

Women with history may be scheduled for induction

Post-term Pregnancy> 42 completed weeks Cause of true post-term is unknown; often incorrect datesMaternal Risks:

Large baby and associationsPsychologic ills

Fetal-Neonatal Risks:Placental changes insufficienciesOligohydramniosmacrosomia birth trauma, glucose maintenance problemsMeconmium stained fluid (aspiration)

As pregnancy approached term, fetal well-being studies done

Fetal Malposition

OP position:Fetus must rotate 135° or occasionally born in OP position

If born OP, increased risk of 3rd or 4th degree laceration, broken symphysis

May use forceps or manual rotation

Positioning: knee chest, pelvic rocking

Fetal Malpresentation

Brow Usually C/S recommendedPerinatal morbidity and mortality:

Trauma: cerebral and neck compression; damage to trachea and larynx

Tx: pelvimetry, oxytocin?, C/S

FacePerinatal morbidity and mortality:

Risk of prolonged labor, fetal edema, swelling of neck and internal structures, petechiae, ecchymosis

Tx: C/S in no progress

Fetal Malpresentation

BreechMost common malpresentation

Frank breech most common

Risk of cord prolapse; fetal anomolies 3x higher

If vag del: head trauma, fetal entrapment

Tx: external version (50-60% success), if vag del: epidural, double set-up

Fetal Malpresentation

ShoulderVersion may be attempted

C/S

Compound presentation

Macrosomia

>4500 gObese 3-4x more likely to have macrosomic baby↑risk of perineal lacerations, infectionMost significant problem is shoulder dystocia

OB emergency permanent injury of brachial plexus, fx clavicle, asphyxia, neurologic damageTx:

Assessment of adequacy of pelvisSuprapubic pressureIntentional breaking of clavicle?C/S

Multiple Gestation

Mother at risk for:Hypertension or preeclampsia

Anemia

Hydramnios

PPROM, IUGR, incompetent cx

Malpresentation

More physical discomforts

Multiple Gestation

Tx:U/S to diagnose amnion/chorion, follow growth, observe for twin-twin transfusion

Frequent office visits to monitor for problems

Likely to deliver by C/S

Abruptio Placentae

Premature separation of normally implanted placenta from the uterine wallVery high mortalityCause unknown but r/t

Maternal hypertensionMaternal traumaCigarettes, cocaineShort umbilical cord, high parity

More common in Caucasian and African American than Asian or Latin American

Abruptio Placentae

Abruptio Placentae

Abruptio Placentae

http://video.about.com/pregnancy/Placenta-Abruptio.htm

Abruptio Placentae

ClassificationO=asymptomatic, diagnosed after birth

I=mild, most common

II=mod, both mom and baby show signs of distress

III=severe, maternal shock and fetal death likely

Abruptio Placentae

TypesMarginal-blood passes between fetal membranes and uterine wall and escapes vaginally; separation at periphery of placenta

Central-separates centrally, blood trapped between placenta and uterine wall. No overt bleeding

Complete-massive vaginal bleeding in presence of almost total separation

Abruptio Placentae

Abruptio Placentae

Blood invades myometrial tissue pain and uterine irritability.

May necessitate hysterectomy after delivery secondary to inability to uterus to contract.

May lead to coagulation defects

Abruptio Placentae

Maternal RisksBlood coagulation problemsShockRenal failure (r/t hemorrhage)Possible hysterectomy

Fetal-Neonatal RisksIf separation ~50% 100% demiseDepending upon separation, time before delivery, maturity of baby neurologic damage

Abruptio Placentae

TxContinuous EFM (if baby alive)

Develop plan for birth

Maintain CV status/tx hypovolemic shock

Follow blood coag studies/have blood factors available

Placenta Previa

Improperly implanted in lower uterine segment

TypesLow lying: close proximity to os, but doesn’t reach it

Marginal: edge of placenta at margin of the os

Partial: internal os is partially covered by placenta

Total: internal os completely covered

Placenta Previa

Placenta Previa

Placenta Previa

Placenta Previa

Placenta Previa

Cause unknown, but associated withMultiparityIncreased ageDefective development of blood vessels in deciduaDefective implantation of the placentaPrior C/SSmokingLarge placenta

Placenta Previa

TxContinuous EFM

Differential diagnosis

☺No vag exam until previa r/o (U/S, other assessments)

Care depends on amt bleeding, gestational age, assessment of fetus