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Labor and Delivery Complications

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Vernix stains yellow within 12-14 hours of exposure ... Lab studies:CBC,PT,PTT, Liver enzymes, fibrinogen, platelet count. Hydramnios ... – PowerPoint PPT presentation

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Title: Labor and Delivery Complications


1
Labor and Delivery Complications
  • Binnece J. Green MSN APNC
  • www.avc.edu.

2
Complications due to Anxiety and Fear
  • Individuals ineffective coping
  • Ineffective family coping and expectations
  • Fear of pain
  • Fear of change in family dynamics
  • Fear due to educational deficit
  • Support systems

3
Anxiety and Fear
  • Support the laboring woman
  • Education
  • Modeling and relaxation techniques
  • Support partner in relaxation techniques, and
    maintaining control
  • Establish confident rapport

4
Abnormal Laboring
  • Abnormal labor attributed to three factors
  • inefficient uterine action
  • persistent posterior presentation
  • cephalopelvic disproportion

5
Dystocia
  • Uterine contractions
  • normal occur regularly
  • 2 to 4 contractions per 10 minutes.
  • mean applitude 35mmHG in early
  • labor
  • progresses to
  • 4 to 5 contractions per 10 minutes
  • mean amplitude 40-50mmHG

6
Dystocia
  • Dysfunctional contractions are irregular, low
    amplitude, slow
  • Progress, cervical dilations slow or arrested.
  • Interventions by physician
  • evaluate size of maternal pelvis
  • position and presentation fetus
  • fetal weight

7
Dystocia continued
  • Do not give Oxytocin (Pitocin) if woman has
    cephalopelvic dysproportion. (CPD)
  • If no CPD, amniotomy, Pitocin (1mU/min) goal is
    to obtain 8 contractions per 20 minutes.
  • Assess vs, contractions, dilation, decent, fetal
    ht. rate

8
Dystocia Continued
  • Encourage changing position
  • Ambulation
  • Warm Showers
  • Relaxation (visualization)
  • Mouth care
  • Encourage Voiding
  • Nipple stimulation

9
Umbilical Cord Prolapse
  • Etiology
  • 1-275 deliveries
  • Definition umbilical cord that lies below/beside
    presenting part
  • Usually immature gestation
  • Results in fetal hypoxia death
  • gt 5 min results in CNS damage/ death

10
Umbilical Cord Prolapse
  • Precipitating factors
  • Long umbilical cord
  • Abnormal location on placenta
  • Small or preterm infant
  • Polyhydramnios
  • Multiple gestation
  • Amniotomy before fetal head is engaged

11
Umbilical Cord Prolapse
  • Clinical Manifestations
  • Cord observed or palpated
  • Bradycardia following ROM
  • Repetitive, variable decelerations that do not
    respond to medical intervention
  • Prolonged decelerations (gt15 bpm lasting 2 mins
    or longer yet lt10 mins)

12
Umbilical Cord Prolapse
  • Nursing interventions
  • Apply gentle upward pressure on presenting part
  • Knee chest position
  • Medical management
  • Immediate delivery of viable infant
  • C-section

13
Shoulder Dystocia
  • Etiology
  • Occurs in approx. 0.15-2.0 of all NSVDs
  • When the anterior shoulder does not fit under the
    pubic arch.
  • Cephalic presentation head has been delivered by
    extension problem with external rotation
    (shoulders unable to be delivered)
  • Highly associated with macrosomic infants (gt
    4000gms)

14
Shoulder Dystocia
  • Clinical Manifestation Turtle sign
  • Head presents on perineum and then retracts
  • Other signs and symptoms during labor
  • Excessive molding
  • Prolonged fetal rate of descent (lt1cm/hr in
    nulliparas/lt2.1cm/hr multiparas)

15
Shoulder Dystocia
  • Nursing interventions
  • OB emergency
  • Assist with positioning to expand pelvic space
    for delivery of infant
  • Woods maneuver
  • McRoberts maneuver
  • Stop maternal pushing
  • Call for assistance
  • Lower bed
  • Empty bladder via catheterization

16
Shoulder Dystocia
  • Nursing Interventions
  • Anticipate fetal complications
  • Erbs Palsy (brachial plexus palsy)
  • Facial paralysis
  • Respiratory depression
  • Fractured clavicle
  • Anticipate maternal complications
  • Early postpartum hemorrhage r/t uterine atony
  • Hematomas (cervical/uterine/vaginal)
  • Hematuria
  • Infection
  • Hypovolemia

17
Meconium Stained Amniotic Fluid
  • Appearance of meconium in AF
  • Staining r/t amount of meconium passed in utero
  • Vernix stains yellow within 12-14 hours of
    exposure
  • Fetal fingernails stain yellow within 4-6 hours
    of exposure
  • Placental surface stains within 3 hours
  • Umbilical cord stains within 1 hour

18
Meconium Stained Amniotic Fluid
  • Observe amount, color, odor of AF
  • Report to CNM, MD
  • Amnioinfusion
  • 1000cc NS at room temperature/ blood warmer esp.
    if preterm
  • Bolus of 200-250 ml over 20 minutes then
    100cc/hr
  • Monitor FHR, uterine activity and resting tone

19
Meconium Stained Amniotic Fluid
  • Prepare Labor and delivery room
  • Anticipate fetal respiratory depression at
    delivery
  • Notify neonatal team will gentle
    oropharyngeal/nasopharyngeal suctioning with
    mechanical suctioning of head on the perineum
  • Laryngoscopy tracheal intubation and suctioning
    for depressed infants

20
Amniotic Fluid Embolism
  • Etiology
  • 1-80,000 deliveries
  • Maternal mortality rate of approx. 86
  • Short interval between onset and death
  • 10 minutes-32 hours
  • One quarter of the clients die r/t
    cardiopulmonary arrest within 1 hour
  • 50 of survivors develop acute DIC within 30
    mins- 4 hours
  • No known risk factors

21
Amniotic Fluid Embolism
  • Clinical ManifestationsMedical Emergency
  • Respiratory
  • Dyspnea
  • Acute cyanosis
  • Pink,frothy sputum
  • No chest pain
  • CNS
  • Convulsions
  • Apprehension
  • Extreme anxiety

22
Amniotic Fluid Embolism
  • Clinical ManifestationsMedical Emergency
  • Cardiovascular
  • Hypotension
  • Sudden,profound shock
  • dysrhythmias

23
Amniotic Fluid Embolism
  • Medical Management
  • CPR prn
  • Oxygen at high concentrations
  • Rapid volume infusion dopamine infusion if
    indicated
  • Fresh whole blood or packed RBCs, and fresh
    plasma to treat bleeding r/t DIC
  • Lab studiesCBC,PT,PTT, Liver enzymes,
    fibrinogen, platelet count

24
Hydramnios
  • Occurs when gt2000ml of amniotic fluid.
  • 1 all pregnancies
  • Unknown cause but is seen in conjunction with
    major congenital anomalies
  • Types Chronic
  • Acute

25
Hydramnios
  • Chronic fluid gradually rises, becomes problem
    3rd trimester
  • Acute rapid increase over days
  • Often diagnosed between 20-24 wks.
  • gt3000ml Sx. Shortness breath
  • edema
  • pain

26
Hydramnios (cont)
  • Maternal disorders
  • Diabetics
  • RH sensitization
  • Infection ex. CMV, syphilis
  • Treatment
  • supportive
  • If severe hospitalization, removal
  • fluid through AROM or amnio.
  • Indomethacin shown to decrease
  • amniotic fluid by decreasing fetal urine
  • output.

27
Oligohydramnios
  • Less than normal amount of amniotic fluid
  • norm is 500ml.
  • Unknown cause
  • Found in cases of postmaturity with intrauterine
    growth restriction secondary placental
    insufficiency
  • Fetal conditions renal malformations

28
Oligohydramnios (cont.)
  • Concern with fetal adhesions
  • One part of fetus adhere to another
  • Fetal skin and skeletal abnormalities
  • Due to decrease in fetal movement
  • Pulmonary pulmonary hypoplasia
  • Complications in birthing process due to decrease
    fluid for cushioning

29
Oligohydramnios (cont.)
  • Monitor uterine growth (suspect if uterus
    doesnt increase in size.
  • Fetus easily palpated
  • Fetus not ballottable (fetus floats away and
    returns when pushed)
  • Monitor cord compression due to decrease
    cushioning during birth
  • Fetal monitoring
  • Amniofusion infuse sterile fluid(NS)through
    intrauterine catheter

30
Placental Complications Abruptio Placentae
  • Premature separation of placenta (prior to 3rd
    stage labor)
  • Source- maternal from uterine surface
  • More common with HX HTN, multiparas-gt5
  • Lower socioeconomic

31
Abruptio Placentae symptoms
  • Severe pain
  • Fetal distress
  • Dark bleeding
  • Rigid abdomen
  • Sx shock

32
Management
  • L lateral recumbant
  • O2 100
  • IV
  • Assess for Coagulation abnormalities
  • Monitor mother and fetus

33
Placenta Previa
  • Placenta implanted in lower region of uterus
  • Placenta precedes fetus
  • More common multiparas
  • Source- maternal
  • Placenta usually larger

34
Placenta Previa Symptoms
  • Painless
  • Vaginal bleeding
  • Bleeding bright red
  • Bleeding may not begin until labor begins

35
Management
  • No vaginal exam
  • HOB 20-30 degrees
  • 100 O2
  • IV
  • Monitor mother and fetus

36
Breech Presentation
  • 4 births
  • Gestational age 25-26weeks incidence increases to
    25
  • Frank Breech most common
  • Often associated with placenta previa,
    hydramnios, multiple gestation, fetal anomalies
  • Cord prolapse more common

37
Cesarean Births
  • Indications
  • Dystocia
  • Cephlopelvic disproportion
  • Maternal disease as diabetes
  • Active genital herpes
  • Benefit of the Fetus
  • Malpresentations multiple gestation
  • Placental abnormalities
  • Cord Prolapse
  • Emergency conditions

38
Breech Presentation (cont.)
  • Cesarean birth preferred due to increase in
    mortality and morbidity rate due to cord
    prolapse, birth trauma, fetal cervical trauma.
  • Contraindications for vaginal birth
  • fetal weight less than 1500g
  • hyperextention of fetal neck of
  • more than 90 degrees
  • anomalies ie hydrocephalus
  • maternal pelvic measurements

39
Cesarean Risks
  • Maternal
  • Infection
  • Hemorrhage
  • Urinary tract trauma
  • Thrombophlebitis
  • Atelectasis
  • Aspiration
  • Fetal
  • Inadvertant preterm birth
  • Transient tacypnea
  • Persistent pulmonary hypertension
  • Injury as laceration

40
Care During Aversion
  • A procedure used to change the fetal presentation
    by abdominal or
  • Intrauterine manipulation
  • External version
  • May be very painful

41
Cesarean Birth (cont.)
  • Surgical techniques
  • Vertical vs. Horizontal incisions
  • Maternal Risks Aspiration, PE, Infections,
    thrombophlebitis, injuries, risks related to
    anesthesia, emotional trauma
  • Fetal Risks Prematurity, injury, respiratory
    distress

42
Nursing Management
  • Provide emotional support
  • Use therapeutic communication to promote positive
    childbirth experience
  • Stress management techniques
  • Support person should be encouraged to remain
    with her during the birth
  • Provide teaching r/t cesarean experience

43
Nursing Considerations
  • Preoperative care VS, FHR, Retention Catheter,
    Informed consent, shaving, IV fluids, removal of
    jewelry, or attachments
  • Assess emotional preparation of both woman in
    labor and support persons

44
Birth Related Interventions
  • Amniotomy
  • Prostagalandin Administration
  • Misoprostol Administration
  • Induction of Labor
  • Amniofusion
  • Episiotomy
  • Forceps-Assisted Birth
  • Cesarean Birth

45
Precipitous Delivery
  • Precipitous labor is on the other end of the
    spectrum of labor abnormalities
  • gt5cm/hr dilatation in nullips gt10cm/hr in
    multips
  • Complications of precipitous labor include trauma
    to birth canal fetal distress and postpartum
    hemorrhage
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