CH 16: Complications Related to the Labor Process

What *color is meconium-stained amniotic fluid*?

*Green*

Atypical uterine contraction patterns prevent the normal process of labor and its progression. Contractions can be hypotonic or hypertonic with failure to efface and dilate the cervix. *What characterizes a Hypotonic & Hypertonic contraction?*

*Hypotonic* (weak, inefficient, or completely absent) *Hypertonic* (excessively frequent, uncoordinated, and of strong intensity with inadequate uterine relaxation)

2. a nurse is caring for a client who is in active labor and reports severe back pain. during assessment, the fetus is noted to be in the occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress? a. hands and knees b. lithotomy C. trendelenburg d. supine with a rolled towel under one hip

*a. CORRECT: having the client assume a position on her hands and knees can help the fetus rotate from a posterior to an anterior position.* b. the lithotomy position is when the client lies on her back with her knees elevated and does not facilitate labor progression. C. the trendelenburg position requires the client to lie on her back and does not assist in the rotation of the fetus. d. the supine position with a rolled towel under one hip can assist in preventing vena cava syndrome but does not assist in the rotation of the fetus

Nuchal cord

An umbilical cord that is wrapped around the fetus's neck. Sign: Low HR; cyanosis; eye hemorrhage If it's tight-stop pushing-cut the cord before delivery

Why meconium-stained amniotic fluid can cause devastating maternal damage?

Because it readily clogs the pulmonary veins completely

What type of coagulation problems can results from an Amniotic fluid embolism?

Disseminated intravascular coagulopathy (DIC)

Which type of complication is characterized by a difficult or abnormal labor related to the five P's of labor (passenger, passageway, powers, position, and psychologic response)?

Dystocia or Dysfunctional labor

What would be an expected finding w/ Fetal distress?

Nonreassuring FHR pattern with decreased or no variability

What type of labor is defined as labor that lasts 3 hr or less from the onset of contractions to the time of delivery?

Precipitous labor

*What type of complication occurs when the umbilical cord is displaced, preceding the presenting part of the fetus, or protruding through the cervix?* *This results in cord compression and compromised fetal circulation*

Prolapsed Umbilical Cord

What would considered as an *ominous sign* w/ regard to the fluid & FHR?

Stained fluid accompanied by variable or late decelerations in FHR

What would be considered as the priority nursing intervention to perform w/ a prolapsed umbilical cord?

● Use a sterile-gloved hand, insert two fingers into the vagina, and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off of the cord.

Indications of coagulation failure?

◯ Bleeding from incisions and venipuncture sites ◯ Petechiae and ecchymosis ◯ Uterine atony

Suction the mouth before the nose.

Think M comes before N

3. a nurse is caring for a client who is admitted to the labor and delivery unit. With the use of leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe? a. precipitous labor b. premature rupture of membranes C. postmaturity syndrome d. prolapsed umbilical cord

a. breech presentation would most likely cause dystocia (prolonged, difficult labor) rather than a precipitous labor. b. breech presentation has no effect on rupture of the membranes. C. breech presentation is not associated with postmaturity syndrome. *d. CORRECT: a prolapsed umbilical cord is a potential complication for a fetus in a breech presentation.*

4. a nurse is caring for a client who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus is at risk for developing? a. intrauterine growth restriction b. hyperglycemia C. meconium aspiration d. polyhydramnios

a. intrauterine growth restriction occurs earlier in the pregnancy and not at this point. b. a postterm neonate is at risk for hypoglycemia, not hyperglycemia. *C. CORRECT: postterm neonates are at risk for aspiration of meconium* d. postterm pregnancies result in oligohydramnios, not polyhydramnios.

1. a nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. the nurse should identify that this contraction pattern increases the risk for which of the following complications? a. prolonged labor b. Reduced fetal oxygen supply C. delayed cervical dilation d. increased maternal stress

a. precipitous labor, not prolonged labor, is often the result of hypertonic contractions and inadequate uterine relaxation between contractions. *b. CORRECT: inadequate uterine relaxation results in reduced oxygen supply to the fetus*. C. hypertonic contractions and inadequate relaxation of the uterus between contractions does not delay cervical dilation. d. a contraction pattern of hypertonic contractions and inadequate relaxation between contractions will increase maternal distress, but this is not an adverse effect.

5. a nurse is caring for a client in active labor. When last examined 2 hr ago, the client's cervix was 3 cm dilated, 100% effaced, membranes intact, and the fetus was at a -2 station. the client suddenly states "my water broke." the monitor reveals a FhR of 80 to 85/min, and the nurse performs a vaginal examination, noticing clear fluid and a pulsing loop of umbilical cord in the client's vagina. Which of the following actions should the nurse perform first? a. place the client in the trendelenburg position. b. apply pressure to the presenting part with her fingers. C. administer oxygen at 10 l/min via a face mask. d. Call for assistance.

a. the nurse should place the client in the trendelenburg position. however, evidence-based practice indicates that another action/assessment is the priority. b. the nurse should apply pressure to the presenting part with her fingers. however, evidence-based practice indicates that another action/assessment is the priority. C. the nurse should administer oxygen at 10 l/min via a face mask. however, evidence-based practice indicates that another action/assessment is the priority. *d. CORRECT: according to evidenced-based practice, the nurse should first call for assistance.*

Complications of precipitous labor for the Fetus?

■ Fetal hypoxia due to hypertonic contractions or umbilical cord around fetal neck ■ Fetal intracranial hemorrhage due to head trauma from rapid birth

Nursing actions to take for Precipitous labor?

● *Do not leave the client unattended*. ◯ Provide reassurance and emotional support to help the client remain calm. ◯ Prepare for emergency delivery of the neonate. ● Encourage the client to pant with an open mouth between contractions to control the urge to push. ● *Encourage the client to maintain a side-lying position to optimize uteroplacental perfusion and fetal oxygenation*. ● Prepare for rupturing of membranes upon crowning (fetal head visible at perineum) if not already ruptured. ● *Do not attempt to stop delivery*. ● Control rapid delivery by applying light pressure to the perineal area and fetal head, gently pressing upward toward the vagina. This eases the rapid expulsion of the fetus and prevents cerebral damage to the newborn and perineal lacerations to the client. ◯ Deliver the fetus between contractions assuring the cord is not around the fetal neck. ◯ *If the cord is around the fetal neck, attempt to gently slip it over the head. If not possible, clamp the cord with two clamps and cut between the clamps*. ● Suction mucus from the fetal mouth and nose with a bulb syringe when the head appears. ● Next, deliver the anterior shoulder located under the maternal symphysis pubis: next, the posterior shoulder; and then allow the rest of the fetal body to slip out. ● Assess for complications of precipitous labor.

Nursing actions to perform to treat Amniotic fluid embolism?

● Administer oxygen via a mask at 8 to 10 L/min. ● Assist with intubation and mechanical ventilation as indicated. ● Perform cardiopulmonary resuscitation if necessary. ● Administer IV fluids. ● Position the client on her side with her pelvis tilted at a 30° angle to displace the uterus. ● Administer blood products as prescribed to correct coagulation failure. ● Insert an indwelling urinary catheter, and measure hourly urine output. ● Monitor maternal and fetal status. ● Prepare the client for an emergency cesarean birth if the fetus is not yet delivered.

Oxytocin stimulation

● Administered to augment or induce labor by increasing intensity and duration of contractions. ● Oxytocin stimulation can lead to hypertonic uterine contractions.

What are the expected/physical assessment findings for meconium-stained amniotic fluid?

● Amniotic fluid can vary in color: black to greenish, yellow, or brown, though meconium-stained amniotic fluid is often green. Consistency can be thin or thick. ● Criteria for evaluation of meconium-stained amniotic fluid ◯ Often present in breech presentation, and might not indicate fetal hypoxia ◯ Present with no changes in FHR ◯ Stained fluid accompanied by variable or late decelerations in FHR (ominous sign)

Nursing actions for Dysfunctional labor/Dystocia?

● Assist with application of *fetal scalp electrode and/or intrauterine pressure catheter*. ● Assist with *amniotomy (artificial rupture of membranes)*. ● Encourage client to engage in *regular voiding to empty her bladder*. ● Encourage *position changes* to aid in fetal descent or to open up the pelvic outlet. Assist the client to a position on her hands and knees to help the fetus to rotate from a posterior to anterior position. ● Encourage *ambulation* to enhance the progression of labor. ● Encourage hydrotherapy and other relaxation techniques to aid in the progression of labor. ● Apply counterpressure using fist or heel of hand to sacral area to alleviate discomfort. ● Assist the client into a beneficial position for pushing and coach her about how to bear down with contractions. ● Prepare for a possible forceps-assisted, vacuum-assisted, or cesarean birth. ● Continue monitoring FHR in response to labor.

S/S of respiratory distress

◯ Restlessness ◯ Cyanosis ◯ Dyspnea ◯ Pulmonary edema ◯ Respiratory arrest

Indications of circulatory collapse?

◯ Tachycardia ◯ Hypotension ◯ Shock ◯ Cardiac arrest

Nursing interventions to perform for a prolapsed umbilical cord?

● Call for assistance immediately. ● Notify the provider. ● *Use a sterile-gloved hand, insert two fingers into the vagina, and apply finger pressure on either side of the cord to the fetal presenting part to elevate it off of the cord* ● *Reposition the client in a knee-chest, Trendelenburg, or a side-lying position with a rolled towel under the client's right or left hip to relieve pressure on the cord.* ● *Apply a warm, sterile, saline-soaked towel to the visible cord to prevent drying and to maintain blood flow* ● *Provide continuous electronic monitoring of FHR for variable decelerations, which indicate fetal asphyxia and hypoxia* ● Administer oxygen at 8 to 10 L/min via a face mask to improve fetal oxygenation. ● Initiate IV access, and administer IV fluid bolus. ● *Prepare for an immediate vaginal birth if cervix is fully dilated or cesarean section if it is not* ● Inform and educate the client and her partner about the interventions.

What are the expected/physical assessment findings of a Uterine rupture?

● Client reports sensation of "ripping," "tearing," or sharp pain. ● Client reports abdominal pain, uterine tenderness. PHYSICAL ASSESSMENT FINDINGS ● Nonreassuring FHR with indications of distress (bradycardia, variable and late decelerations, and absent or minimal variability) ● Change in uterine shape and fetal parts palpable ● Cessation of contractions and loss of fetal station ● Manifestations of hypovolemic shock: tachypnea, hypotension, pallor, and cool, clammy ski

What expected physical assessment finding will be seen w/ a prolapsed umbilical cord?

● Client reports that she feels something coming through her vagina. PHYSICAL ASSESSMENT FINDINGS ● Visualization or palpation of the umbilical cord protruding from the introitus ● *FHR monitoring shows variable or prolonged deceleration* ● Excessive fetal activity followed by *cessation of movement; suggestive of severe fetal hypoxia*

Uterine rupture

● Complete rupture involves the uterine wall, peritoneal cavity, and/or broad ligament. Internal bleeding is present. ● Incomplete rupture occurs with dehiscence at the site of a prior scar (cesarean birth, surgical intervention). Internal bleeding might not be present. ● This is a rare but life-threatening obstetric injury.

Risk factors for Uterine rupture?

● Congenital uterine abnormality ● Uterine trauma due to accident or surgery (previous multiple cesarean births) ● Overdistention of the uterus from a fetus who is large for gestational age, a multifetal gestation, or polyhydramnios ● Hyperstimulation of the uterus, either spontaneous or from oxytocin administration ● External or internal fetal version done to correct malposition of the fetus ● Forceps-assisted birth ● Multigravida clients

What nursing actions to perform for a meconium-stained amniotic fluid?

● Document color and consistency of stained amniotic fluid. ● Notify neonatal resuscitation team to be present at birth. ● Gather equipment needed for neonatal resuscitation. ● Follow designated suction protocol. ◯ *Assess neonate's respiratory efforts, muscle tone, and heart rate*. ◯ *Suction mouth and nose using bulb syringe if respiratory efforts strong, muscle tone good, and heart rate greater than 100/min*. ◯ *Suction below the vocal cords using an endotracheal tube before spontaneous breaths occur if respirations are depressed, muscle tone decreased, and heart rate less than 100/min*.

*Fetal distress* is present when?

● FHR: *BELOW 110/min* or *ABOVE 160/min* ● The FHR shows *decreased or no variability* ● There is *fetal hyperactivity or no fetal activity*.

*Expected findings of Precipitous labor?*

● Low backache ● Abdominal pressure and cramping ● Increased or bloody vaginal discharge ● Palpable uterine contractions ● Progress of cervical dilation and effacement ● Diarrhea ● Fetal presentation, station, and position ● Status of amniotic membranes (membranes can be intact or ruptured

Meconium-stained amniotic fluid

● Meconium passage in the amniotic fluid during the antepartum period prior to the start of labor is typically not associated with an unfavorable fetal outcome. ● The fetus has had an episode of loss of sphincter control, allowing meconium to pass into amniotic fluid.

What nursing interventions are performed for Fetal distress?

● Monitor vital signs and FHR. ● Position the client in a *left side-lying* reclining position with legs elevated. ● Administer 8 to 10 L/min of oxygen via a face mask. ●Discontinue oxytocin ● Increase IV fluid rate to treat hypotension if indicated. ● Prepare the client for an emergency cesarean birth.

Hypertonic uterine dysfunction

● Nonproductive, uncoordinated, painful, uterine contractions during labor that are too frequent and too long in duration and do not allow for relaxation of the uterine muscle between contractions (uterine tetany). ● Hypertonic contractions do not contribute to the progression of labor (cervical effacement, dilation, and fetal descent). ● Hypertonic contractions can result in uteroplacental insufficiency leading to fetal hypoxia.

How does an amniotic fluid embolism occur? Also called Anaphylactoid syndrome of pregnancy

● Occurs when there is a rupture in the amniotic sac or maternal uterine veins accompanied by high intrauterine pressure that causes infiltration of the amniotic fluid into the maternal circulation. ● The amniotic fluid then travels to and obstructs pulmonary vessels and causes respiratory distress and circulatory collapse. ● It can occur during labor, birth, or within 30 min following birth.

What *risk factors* are associated with a prolapsed umbilical cord?

● Rupture of amniotic membranes ● *Abnormal fetal presentation (any presentation other than vertex [occiput as presenting part])* ● *Transverse lie: Presenting part is not engaged, which leaves room for the cord to descend* ● Small-for-gestational-age fetus ● Unusually long umbilical cord ● Multifetal pregnancy ● Unengaged presenting part ● Hydramnios or polyhydramnios

What are some risk factors associated w/ meconium in the amniotic fluid?

● There is an increased incidence for meconium in the amniotic fluid after 38 weeks of gestation due to fetal maturity of normal physiological functions. ● Umbilical cord compression results in fetal hypoxia that stimulates the vagal nerve in mature fetuses. ● Hypoxia stimulates the vagal nerve, which induces peristalsis of the fetal gastrointestinal tract and relaxation of the anal sphincter.