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Childbirth at Risk: Labor Complications
Twila Brown, PhD, RN
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Dystocia and Dysfunctional Labor
Causes– Power
HypotonicHypertonic
– Passenger – Passage
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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
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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
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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
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Dysfunctional Uterine Contractions: Hypotonic Labor Patterns
Management– Assess for CPD and engagement– Amniotomy– Oxytocin– Provide comfort and decrease anxiety– Monitor mother– Monitor fetus
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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
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Precipitous Labor and Birth
Management– Tocolytic agent– Immediate delivery– Support for relaxation– Monitor contractions and fetal heart rate– Apply pressure to fetal head
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Fetal Position
Most common at delivery– Cephalic – Vertex– Chin flexed to chest
– Occiput Anterior
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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
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Fetal Malpresentation:Military, Brow, and Face
Management– Cesarean birth if CPD– Monitor for fetal hypoxia – Episiotomy extension– Forceps or manual conversion contraindicated– Newborn trauma
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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
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Fetal Malpresentation: Shoulder (Transverse lie)
Assessment– Maternal abdomen– Fetal head– Presenting part
Management– External version attempted– Cesarean delivery – Monitor for prolapsed cord
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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
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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
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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
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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
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Cephalopelvic Disproportion
Management– Monitor progression of
labor – Monitor for fetal distress– Emotional support– Cesarean delivery– Maternal position
McRoberts maneuver
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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
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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
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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
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Abruptio Placentae
Assessment– Fundal height increases– May or may not have vaginal bleeding– Painful – Irritable uterus– Rigid, boardlike abdomen – Enlarged uterus– Signs of shock
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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
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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
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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
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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
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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.