Chapter 16 Intrapartum Complications
Uterine Inversion
-An inversion occurs when the uterus completely or partly turns inside out, usually during the third stage of labor. Such an event is uncommon but potentially fatal. -Causes • Excessive traction on the umbilical cord before the placenta detaches from the uterine wall spontaneously • Fundal pressure during birth • Fundal pressure on an incompletely contracted uterus after birth • Increased intraabdominal pressure • An abnormally adherent placenta • Congenital weakness of the uterine wall • Fundal placenta implantation -Signs and Symptoms: 1. Uterus is absent from the abdomen or depression in the fundal area is present. 2. Uterus appearing as a red, beefy mass. Massive hemorrhage, shock, and pain -Management 1. physician tries to replace the uterus through the vagina into a normal position. 2. Anesthesia may be required to produce enough relaxation to allow the uterus to be replaced. 3. If replacement is not possible, a laparotomy may be necessary. 4. Several units of blood are usually ordered immediately -Nursing consideration 1. Assess the uterine fundus for firmness, height, and deviation from the midline 2. Assess vital signs every 15 minutes or more frequently until stable 3. Observe for tachycardia and falling blood pressure, 4. indwelling catheter is used to observe fluid balance and keep the bladder empty so the uterus can contract well Assess the catheter for patency, and record intake and output. 5. NPO until her condition is stable
Maternal Exhaustion
-Assess the mother for the following signs of exhaustion: • Verbal expression of tiredness, fatigue, or exhaustion • Verbal expression of frustration with a prolonged, unproductive labor ("I can't go on any longer. Why doesn't the doctor just take the baby?") • Ineffectiveness of or inability to use coping techniques (e.g., patterned breathing) that she previously used effectively • Changes in her pulse rate, respiration, and blood pressure (increased or decreased) -Interventions 1. Conserving Maternal Energy -Position the woman to encourage comfort, promote fetal descent, and enhance fetal oxygenation. -Support her with pillows or birth balls to reduce muscle strain and added fatigue. -Help her change positions regularly (about every 30 minutes) to reduce muscle tension from constant pressure. -soothing back rub reduces muscle tension and thus decreases fatigue -Maintain IV fluid 2. Promoting Coping Skills
Preterm Labor
-Between 20 weeks and 37 weeks -Earlier than 32 weeks, birth may result in an infant who is ill-equipped for extrauterine life -Adverse effects include cerebral palsy, developmental delay, and vision and hearing problems Possible Causes of Preterm Labor: · Maternal medical conditions such as infections of the urinary tract, reproductive organs, systemic organs, dental disorders, preexisting or gestational diabetes, connective tissue disorders, chronic hypertension and drug abuse · Conceptions enhanced by assisted technology · Short cervical length (25mm or less) multifetal pregnancy, PPROM, preeclampsia, bleeding disorders that involve the woman, fetus or placental implantation area · Fetal conditions such as growth restriction, inadequate amniotic fluid volume, chromosome abnormalities and other birth defects · Social and environmental factors such as absent prenatal care, maternal smoking, homelessness · Demographic factors such as race and ages of parents, financial stability and the number and birth intervals of the woman's other children Signs and Symptoms: -Can be subtle, woman may only be vaguely aware that something is different -Only when preterm labor reaches the active phase is it likely to have characteristics typical of term labor Common symptoms · Uterine contractions that may or may not be painful (may not be felt at all) · A sensation that the baby is frequently balling up · Cramps similar to menstrual cramps · Constant low backache pain or irregular or intermittent · Sensation of pelvic pressure in the vagina and thighs · Change or increase in vaginal discharge · Abdominal cramps w/ or w/o diarrhea · A sense of just feeling bad or coming down with something Preventing Preterm Birth: Community Education · Role of early and regular prenatal care including dental care · Duration of normal pregnancy · Consequences of preterm birth · Conditions that increase risk for preterm birth · Signs and symptoms · Cons es for mother, baby and family members Preventing Preterm Birth During Pregnancy: · Reducing barriers and improving access to prenatal care for all women -Expanding the number of caregivers by using advanced practice nurses can reduce waits and provide better care · Assessing for risk factors to permit changes -Women should be screened regularly to identify new risks that emerge throughout the pregnancy · Promoting adequate nutrition -An adequate diet contributes positively to length of gestation and the infants birth wait · Promoting cessation of smoking and recreational drugs -These risk factors can be reduced or eliminated if the woman changes her lifestyle · Teaching women and their partners about subtle signs and symptoms -All women partners should be educated about preterm labor because half of preterm births occur in women with no identified risks · Empowering women and their partners to take active approach in seeking care if they have signs and symptoms of preterm labor -Women must advocate for themselves and seek help when they suspect preterm labor Therapeutic Management of Preterm Labor: -Identify those at risk, identify preterm labor early and delaying birth if possible -Hydrating the patient can help reduce uterine irritability and the risk for UTI's oral water intake should be encouraged Fetal Fibronectin= fFN is a protein present in the layers of the amniotic membrane -Normally found in cervical and vaginal secretions until 16 to 20 weeks and again at near term -If it appears too early if suggests that labor may begin early -Test specimen is collected at least 24 hours after significant vaginal manipulation from examination Tocolytic Medications= These may successfully delay the birth of preterm infant which can allow time for appropriate for use 24 to 34 weeks' gestation with regular uterine contractions and cervical change · Administration of maternal corticosteroids to reduce respiratory distress syndrome in the newborn · Antibiotics to prevent neonatal infection with GBS · To transfer the mother to a facility with an NICU that is appropriate for gestation of her fetus at the time of birth · To give magnesium sulfate for neuroprotection of a fetus less than 32 weeks' gestation 4 Types of Drugs Used to Tocolysis 1. Magnesium sulfate Usually used for hypertension in pregnancy to prevent seizures but because of its added effect on smooth muscle relaxation including quieting uterine activity it may be used to inhibit preterm labor -It is used as a short term tocolytic to provide for steroid therapy and for neonatal neuroprotection 2. Calcium antagonists Nifedipine is a calcium channel blocker usually given for hypertension, can be used in preterm labor to reduce muscular contraction of the uterus 3. Prostaglandin synthesis inhibitors Indomethacin and ibuprofen most often use for tocolysis 4. Beta-adrenergics Terbutaline a bronchodilator is used for preterm labor -Used to delay birth to administer corticosteroids and antibiotics
Dysfunctional Labor
-Dysfunctional labor : may result from problems with the powers of labor, the passenger, the passage, the psyche, or a combination of these. -Problems with the powers powers of labor may not be adequate to expel the fetus because of ineffective contractions or maternal pushing efforts. -ineffective contractions Effective uterine activity is characterized by coordinated contractions that are strong and numerous enough to propel the fetus past the resistance of the woman's bony pelvis and soft tissues Causes: • Maternal fatigue • Maternal inactivity • Fluid and electrolyte imbalance • Hypoglycemia • Excessive analgesia or anesthesia • Maternal catecholamines secreted in response to stress or pain • Disproportion between the maternal pelvis and fetal presenting part • Uterine overdistention such as with multiple gestation or hydramnios (excess volume of amniotic fluid) • Poor application of the presenting part to the cervix 1. Labor dystocia(difficult labor) -Contractions are coordinated but too weak to be effective -Are infrequent brief, and when palpated they can be indented easily with fingertips pressure at the peak -Occurs during the active phase of labor when progress normally quickens -Simple measures such as IV fluid replacement, maternal position changes ( particularly upright positions) can promote effective contractions -Measures such as amniotomy and oxytocin infusions may be needed 2. Tachysystole: -Either spontaneous or induced is defined as excessive uterine contractions -More than 5 contractions in 10 mins averaged over 30 mins -Each contraction varies in its intensity, the uterine tone between contractions may be higher than normal reducing uterine blood flow causing constant cramping -Nurse should be alert to possibility of placental abruption because symptoms can be the same -Mother can become very tired and discouraged -Oxytocin should be decreased or discontinued -Relief of pain is important intervention to promote normal labor patterns Ex: During latent phase, warm showers, baths for relaxation, low dose epidural analgesia Ineffective Maternal Pushing: -Use of non-physiological pushing techniques and positions -Fear of injury because of pain and tearing sensations -Decreased or absent urge to push -Maternal exhaustion -Analgesia or anesthesia suppresses urge to push -Psychological unreadiness to "let go" of baby -IV fluids can provide energy needed for 2nd stage of labor -Problems with Passenger Fetal Size: -Macrosomia is when infant weighs more than 8lb. (13oz, 4000g) at birth -Head or shoulders might not be able to adapt to the pelvis if it is too large Shoulder Dystocia: Shoulders may become impacted above the maternal symphysis pubis -May occur when fetus is large or the mother had diabetes -Urgent situation because umbilical cord can be compressed between the fetal body and the maternal pelvis -Turtle sign= Initial sign of shoulder dystocia, the head is born and retracts against the perineum -If turtle sign is seen, delivery team should make preparations for surgical delivery -All measures should be taken to deliver vaginally -McRoberts maneuver= pulling mothers knees up as far towards the shoulders as possible -Suprapubic pressure may assist in moving impacted shoulder past the symphysis -Fundal pressure should be avoided -After delivery baby's clavicles should be checked for crepitus, deformity and bruising would indicate fracture -Documentation is extremely important Ex: Time for accurate records, maneuvers used Abnormal Fetal Presentation or Positions: -May interfere with cervical dilation or fetal descent Rotation Abnormalities= Persistence of the fetus in (occiput posterior)OP or (occiput transverse)OT can contribute to dysfunctional labor -These positions prevent mechanisms of labor from occurring normally -Fetuses in OP position can spontaneously rotate to OA position -Fetuses may rotate or partly rotate and remain in the OT position -Labor will be longer and more uncomfortable when the fetus remains in OP or OT position -Causes intense back pain (back labor) Ways to promote the OA position and descent: -Hand knees -Side-lying position on opposite side of the fetal occiput -Squatting(for second stage) -Sitting , kneeling, or standing while leaning forward -Upright maternal positions promote descent which is usually accompanied by fetal head rotation -If spontaneous rotation does not occur on its own, HCP may assist with rotation and descent of the head by manual rotation or using forceps Deflexion Abnormalities: -Poorly flexed fetal head presents a larger diameter to the pelvis than flexed with the chin on the chest Vertex Presentation= Smallest head diameter Military/Brow Presentations= Largest head diameter Face presentation= Head diameter similar to vertex but maternal pelvis can be traverse only if fetal chin (mentum) is anterior Breech Presentation: -Cervical dilation and effacement are slower because the buttocks or feet do not form a smooth, round dilating wedge like the head -Greatest risk is the head is born last causing umbilical cord compression -3% to 4% term fetuses stay in breech position reasons include · Low birth weight · Fetal anomalies such as hydrocephalus(accumulation of cerebrospinal fluid (CSF) occurs within the brain) · Complications secondary to placenta previa or previous C-section birth -ECV (external cephalic version) may be performed which manually moves the fetus into cephalic presentation -Multifetal pregnancy: may result in dysfunctional labor because of uterine overdistention, which contributes to labor dystocia, and abnormal presentation of one or both fetuses Each twin's FHR is monitored during labor. When in bed, the woman should remain in the lateral position to promote adequate placental blood flow. After vaginal birth of the first twin, assessment of the second twin's FHR continues until birth -Fetal Anomalies such as hydrocephalus or a large fetal tumor may prevent normal descent of the fetus. Abnormal presentations such as breech or transverse lie also are associated with fetal anomalies detected by ultrasound before labor -Problem with the Passage Pelvis: -Small contracted or abnormally shaped pelvis may retard labor and obstruct fetal passage -Causes poor contractions, slows dilation, slow fetal descent and a long labor Four Pelvic shapes include · Gynecoid= Round cylindric shape, Favorable for vaginal birth with wide diameters and gentle curves throughout · Anthropoid= Long narrow oval, more favorable than android or platypelloid, fetus may be born in occiput posterior position · Android= Heart or triangular shape, narrow diameters and poor for vaginal birth · Platypelloid= Flattened wide short shape, poor for vaginal birth Maternal Soft Tissue Obstructions: Full bladder is a common soft tissue obstruction. Bladder distention reduces available space in the pelvis and intensifies maternal discomfort. Problems of the Psyche -Excessive prolonged stress interfere with labor in ways such as · Increased glucose consumption reduces the energy supply available to the contracting uterus. · Secretion of catecholamines (epinephrine and norepinephrine) by the adrenal glands stimulates uterine beta receptors, which inhibit uterine contractions (an action similar to that of tocolytic drugs such as terbutaline). · Adrenal secretion of catecholamines diverts blood supply from the uterus and placenta to the woman's skeletal muscles. · Labor contractions and maternal pushing efforts are less effective because these powers are working against the resistance of tense abdominal and pelvic muscles. · Pain perception is increased and pain tolerance is decreased, further increasing maternal anxiety and stress. · Assisting the woman to relax helps her body work more effectively with the forces of labor. Nursing measures may involve the following: · Establishing a trusting relationship with the woman and her significant other · Making the environment comfortable by adjusting temperature and light · Identifying coping measures the patient finds useful · Promoting physical comfort such as cleanliness · Providing accurate information · Implementing nonpharmacologic and pharmacologic pain management -Abnormal Labor Duration An unusually long or abnormally short, or precipitous, labor may result in maternal, fetal, or neonatal problems. Prolonged Labor Risks for Mother and Baby · Maternal infection · Maternal exhaustion · Higher levels of anxiety and fear Nursing Measures: -Promote comfort -Conservation of energy -Emotional support -Position changes -Assess for signs of infection Precipitous Labor: -Birth occurs within 3 hours of its onset -Intense contractions often begin abruptly rather than gradually increasing Risks: -Placental abruption -Fetal meconium -Infection -Maternal cocaine use -Postpartum hemorrhage -Low Apgar scores -Trauma from rapid birth may result in genital tract lacerations in mother and neonatal birth injuries -Fetal hypoxia is possible due to intense contractions without proper relaxation in between contractions -EFM may include bradycardia and late decelerations Interventions: -Promote fetal oxygenation Ex: side-lying position and administer oxygen, IV fluids, discontinue oxytocin and tocolytic drugs may be ordered to slow contractions
Boredom
-If activity is restricted, determine what skills the woman has for coping with boredom -Interventions 1. Identifying Appropriate Activities paperwork. phone call, game, reading 2. Changing the Physical Surroundings change of location
Trauma
-Most trauma during pregnancy occurs because of motor vehicle accidents, assault, or suicide. Battering, or interpersonal violence -Management A Kleihauer-Betke (K-B) test may be ordered at intervals to identify placental disruptions that allow fetal blood to leak into the circulation. -Consideration 1. focuses first on maternal and then on fetal stabilization 2. A wedge is placed under one side of the mother to tip her uterus away from her major blood vessels. 3. Placing her in a lateral tilt position 4. V/S, intake and output 5. Bloody urine suggests bladder or renal damage 6. palpate the woman's uterus for contractions periodically
Post term Pregnancy
-Pregnancy that lasts longer than 42 weeks Complications= Greatest risks are to the fetus and newborn -Insufficiency of the placental function secondary to aging and infarction reduces transfer of oxygen and nutrients to the fetus and removal of waste -Risk for oligohydramnios which increases the risk for stillbirth -Fetus is at risk for fetal compromise during birth -Meconium Aspiration Syndrome is a risk caused by the aspiration of meconium in the amniotic fluid before or during birth may result in respiratory distress in the newborn -Psychologically the woman feels as though her pregnancy will never end and increases her stress and fatigue during labor Therapeutic Management: -If women received no prenatal care or late prenatal care, must begin by determining her gestation as accurately as possible -Several markers are used such as ultrasound exam, fundal height, dates of quickening, and first identification of fetal heart tones -If a BPP shows that the fetus is thriving in the uterus a more conservative approach may be taken and allow labor to begin naturally -If pregnancy is truly post-term induction is usually indicated due to increased risk for perinatal morbidity and mortality Membrane Sweeping=May be used to begin process of labor -Involve HCP digitally separating the membranes from the lower uterine segment when the cervix is dilated
Premature Rupture of Membranes: PROM
-Rupture of amniotic membranes before onset of true labor PPROM= Rupture of membranes earlier than 37 weeks with or without contractions -Associated with preterm labor and birth Etiology: -Exact cause is unknown Conditions associated · Triple I infection · Infections possibly asymptomatic of the vagina or cervix such as gonorrhea or chlamydia · Previous preterm birth especially preceded by PPROM · Fetal abnormalities or malpresentation · Incomplete cervix or short cervical length (30mm or less) · Overdistention of uterus by polyhydramnios or multiple gestation · Maternal hormonal changes · Maternal stress or low socioeconomic stress • Maternal nutritional deficiencies and diabetes Complications of PROM: -Risk for infection Highest risk for postpartum infection and newborn is vulnerable to neonatal sepsis Therapeutic Management: -If less than 36 weeks care may involve short term tocolytic meds to delay delivery and allow steroid therapy to be administered to enhance fetal lung maturity -Antibiotics can be started to reduce chances of infection -For a woman near term, PROM may herald imminent onset of true labor Determining True ROM: -Fern test or Ph test may be done which involves collecting of fluid from the vagina during a sterile speculum exam -Once confirmed and labor does not occur spontaneously, labor may be induced for a near term pregnancy -If induction is unsuccessful or if infection or other complications arise a C-section birth is common For Preterm Gestation= HCP weighs the risk for maternal and fetal infection against newborns risk for complications or prematurity -The cervix is usually not favorable for induction far from term -Factors such as gestational age, amount of amniotic fluid left, fetal lung maturity and any signs of fetal compromise are considered -If no evidence of infection exists and fetal lungs are immature woman is observed for infection or onset of labor in the hospital -FHR, NST, BPP are all observed -Antibiotics are administered for 7 days Nursing considerations: -Woman may remain hospitalized until birth or sent home Home preparations include · No sexual intercourse · Avoid breast stimulation · Take temp 4x a day reporting a temp over 100.4F · Maintain activity restrictions · Note and report uterine contractions or a foul-smelling vaginal discharge
Intrauterine Infection
-Triple I (intrauterine inflammation or infection or both) -Also known as chorioamnionitis, intra-amniotic infection or intra-uterine infection Diagnosis of Triple I for the Mother: Fever + one indicator= suspected Triple I Fever + Confirmed testing= Confirmed Triple I Indicators Include · defined as an oral temperature of 39.0°C or greater (102.2°F) on one reading or 38.0°C (100.4° F) or greater but less than 39.0°C (102.2° F) on 2 readings, 30 minutes apart · Fetal tachycardia baseline greater than 160 BPM at least 10 mins · Maternal WBC greater than 15,000 · Purulent fluid from cervical os Ex: cloudy, yellowish thick discharge · Biochemical or microbiologic amniotic fluid results consistent with microbial invasion of the amniotic cavity · Confirmed testing includes a positive gram stain for bacteria and low amniotic fluid glucose Interventions: -Wash hands before and after patient contact -Limit vaginal exam and use aseptic technique -Keep under pads dry and clean excess vaginal secretions from front to back -Use PPE to avoid contact with body secretions -After birth collect specimens from uterine cavity of placenta to identify infectious organisms -Newborn may receive prophylactic antibiotics to prevent neonatal sepsis
Uterine Rupture
-a tear in the wall of the uterus occurs because the uterus cannot withstand the pressure against it • Complete rupture is a direct communication between the uterine and peritoneal cavities. • Incomplete rupture is a rupture into the peritoneum lining of the uterus or into the broad ligament but not the peritoneal cavity. • Dehiscence is a partial separation of an old uterine scar. Little or no bleeding may occur. No signs or symptoms may exist, and the rupture ("window") may be found incidentally during a subsequent cesarean birth or other abdominal surgery. Cause -cesarean birth -surgery to remove fibroids ***vaginal birth after cesarean (VBAC) is not recommended -Signs and Symptoms 1. Abdominal pain and tenderness 2. Chest or shoulder pain, pain between the scapulae, or pain on inspiration 3. Hypovolemic shock caused by hemorrhage 4. Signs associated with impaired fetal oxygenation 5. Absent fetal heart sounds with a large disruption of the placenta; absent fetal heart activity by ultrasound examination. 6. Cessation of uterine contractions. 7. Palpation of the fetus outside the uterus (usually occurs only with a large, complete rupture) -Therapeutic Management 1. stabilize the woman and the fetus for a cesarean birth. 2. a large uterine rupture may require hysterectomy 3. Replace blood and blood product -Considerations 1. Administer uterine stimulant drugs cautiously to reduce the likelihood of excessive contractions. 2. Notify the birth attendant if tachysystole occurs. 3. A tocolytic drug may be needed to reduce excessive contractions.
Intrapartum Emergencies
Placental Abnormalities: Placenta Accreta= Occurs when the placenta is implanted to the uterine wall -All or part may be implanted to the wall Placenta Increta= Occurs when the chorionic villi invade the myometrium Placenta Percreta= Complete perforation through the uterine musculature and onto the adjacent organs such as the bladder Prolapsed Umbilical Cord: -Slips downward after the membranes rupture, subjecting it to compression between the fetus and the pelvis Causes · A fetus that remains at high station · A fetus that poorly fits the pelvic inlet because of small size or abnormal presentation· Breech presentations · Transverse lie · Hydramnios Signs of Prolapse: -Cord may be visible at the vaginal opening -Or not visible -Maybe palpated on vaginal exam as it pulsates synchronously with the fetal heart Occult Prolapse= The cord slips alongside the fetal head and shoulders -Cannot be palpated or seen but is suspected because of changes in the FHR such as sustained bradycardia, variable decelerations or prolonged decelerations Therapeutic Management: -Birth is almost always a C-section in this situation -Priority is to relieve pressure on the cord Prompt actions include · Position the woman's hips higher than her head to shift the fetal presenting part toward the diaphragm Ex: knee-chest, Trendelenburg, hips elevated with pillows with side-lying position maintained · Maintain vaginal elevation of the presenting part using a gloved hand while the woman is transferred to the OR until HCP orders cessation of vaginal elevation which is usually just before C-section · Avoid or minimize manual palpation or handling of the cord as much as possible to minimize cord vasospasm · Ultrasound exam may be used to confirm Presence of FH activity before C-section -While preparing for delivery give woman oxygen -Tocolytic may be given Prognosis for infant depends on how long and how severely blood flow through the cord has been impaired
Anaphylactoid Syndrome(amniotic fluid embolism)
occurs when amniotic fluid is drawn into the maternal circulation and carried to the woman's lungs and obstructs pulmonary vessels. -Intervention 1. CPR 2. Oxygen with mechanical ventilation 3. Correction of hypotension 4. Blood component therapy to correct coagulation defects