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Complicated Labor Patterns Complications of Labor & Delivery


Complicated Labor Patterns Complications of Labor & Delivery NUR 264 TABLE 21 3 (continued) Placental and Umbilical Cord Variations Manual Removal of Placenta ... – PowerPoint PPT presentation

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Title: Complicated Labor Patterns Complications of Labor & Delivery

Complicated Labor Patterns Complications of Labor
  • NUR 264

If was not supposed to be hard work, it would not
have been called LABOR. Anonymous
Characteristics of Tachysystole Labor
  • Increase contraction frequency
  • lt 2 min frequency, gt 90 seconds duration
  • Decrease contraction intensity
  • Increase uterine resting tone gt 20 mm Hg
  • Prolonged latent phase
  • Painful due to uterine
  • muscle anoxia
  • Ineffective in dilating and
  • effacing cervix

Implications of Tachysystole Labor (contd)
  • Maternal exhaustion, dehydration, infection
  • Reduced uteroplacental exchange resulting in
    nonreassuring fetal status
  • Prolonged pressure on fetal head resulting in
  • Excessive molding
  • Caput succedaneum
  • Cephalhematoma

Effects of labor on the fetal head. A, Caput
succedaneum formation. The presenting portion of
the scalp area is encircled by the cervix during
labor, causing swelling of the soft tissue. B,
Molding of the fetal head in cephalic
presentations (1) occiput anterior, (2) occiput
posterior, (3) brow, (4) face.
Nursing Plan for Tachysystole Labor
  • Stop oxytocin
  • Increase IV rate
  • Administer O2 by face mask
  • Position in side-lying position
  • Provide support and encouragement
  • Monitor contractions and fetal status
  • Notify health care provider
  • Assist with amniotomy
  • Administer pharmacologic agents as ordered
  • Monitor maternal fatigue

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Hypotonic Labor
  • lt 2 to 3 contractions in 10 minutes
  • Causes
  • Fetal macrosomia
  • Multiple gestation
  • Hydramnios
  • Grand multiparity
  • CPD

Implications of Hypotonic Labor
  • Help with coping abilities
  • Prolonged labor results in
  • Maternal exhaustion, dehydration
  • Increased incidence of infection
  • Postpartum hemorrhage due to uterine atony
  • Nonreassuring fetal status
  • Fetal sepsis from pathogens ascending from birth

Nursing Plan for Hypotonic Labor
  • Frequent monitoring of vital signs, FHR and
  • Assist with amniotomy assess amniotic fluid for
  • Administer oxytocin or nipple stimulation
  • Assess bladder for distention and empty every 2
  • Minimize vaginal exams to decrease risk of

Nursing Plan for Hypotonic Labor (contd)
  • Assess for signs of infection
  • Maternal fever
  • Chills
  • Foul-smelling amniotic fluid
  • Fetal tachycardia
  • Provide emotional support
  • Provide information and encourage questions
  • Prepare for surgical delivery

Abnormal Presentation/Dystocia
  • Abnormal flexion of head, breech, twins
  • Large fetus macrosomia
  • CPD, shoulder dystocia
  • Poor quality contractions
  • - prolonged labor
  • Extensive perineal laceration at birth (3rd or
    4th degree) or vaginal trauma
  • Increased fetal morbidity and mortality

Abnormal Presentations
Breech Presentations
  • Likely cesarean birth
  • Increased risk of prolapsed cord
  • Increased risk of cervical spinal cord injuries
    due to hyperextension of fetal head during
    vaginal birth
  • Increased risk birth trauma (especially head)
    during any type of birth

Breech Presentations
Multiple Gestation
  • Frequent assessment of fetal heart tones of each
  • Education of mother about signs and symptoms of
    preterm labor
  • Encouragement of mother to rest frequently prior
    to birth
  • Preparation of equipment needed to care for each
    individual newborn

Multiple Gestation
Multiple Gestation
Cephalopelvic Disproportion
  • Occurs when fetal head is larger than maternal
    pelvic diameter
  • Lack of fetal descent in presence of strong
  • Labor usually prolonged

Cephalopelvic Disproportion (contd)
  • Increase pelvic diameter during labor by
    squatting, sitting, rolling from side to side,
    maintaining knee-chest position, use of a labor
    ball - AVOID lithotomy!
  • Vaginal birth may be possible depending upon type
    of CPD
  • CPD may make cesarean only available method of

Fetal Macrosomia
  • Newborn weighing more than 4500 g or more
  • May be postterm, IDM
  • Identification of fetal macrosomia is conducted
  • Palpation of fetus in utero
  • Ultrasound of fetus
  • X-ray pelvimetry
  • Shoulder Dystocia

Management of Fetal Macrosomia
  • Continuous fetal monitoring if labor is allowed
    to progress
  • Requires notification of health care provider for
    early decelerations, labor dysfunction, or
    nonreassuring fetal status
  • McRoberts manuever legs to chest suprapubic
  • Cesarean birth performed if fetus is greater than
    4500 g

Shoulder Dystocia
McRoberts Maneuver
Care of Mother
  • Care of mother after birth of newborn with
    macrosomia requires
  • Fundal massage to prevent maternal hemorrhage
    from overstretched uterus
  • Close monitoring of vital signs and vaginal blood

Care of Newborn
  • Care of newborn with macrosomia requires
    assessment of newborn for
  • Cephalhematoma
  • Erb's palsy
  • Fractured clavicles
  • Anoxia
  • Cord prolapse

Implications of Hydramnios
  • Rh sensitization
  • Malformations of fetal swallowing
  • Neural tube defects with exposed meninges
  • Anencephaly
  • Cardiac anomalies
  • Esophageal or duodenal atresia
  • Provide information and emotional support

Nursing Plan for Oligohydramnios
  • Reduced AFI
  • Evaluate EFM tracing for variable decels or
    nonreassuring fetal status
  • Reposition mother to relieve cord compression
  • Notify clinician of signs of cord compression
  • Evaluate newborn
  • Anomalies of skin skeleton, adhesions
  • Pulmonary hypoplasia
  • Renal agenesis, lower UTI obstructive lesions
  • Postmaturity

Cord Prolapse
  • Umbilical cord precedes fetal presenting part
    placing pressure on cord and diminishing blood
    flow to fetus
  • Bed rest is recommended if engagement has not
    occurred and membranes have ruptured
  • Assess for nonreassuring
  • fetal status

Cord Prolapse
  • Examiners fingers must remain in vagina
  • Have patient assume knee-chest position,
    Trendelenburg position, or side-lying position
    with hips elevated on pillow (head/chest up if
  • Apply O2 at 8 10 L/min
  • Vaginal birth may be attempted if completely
    dilated and pelvic measurements adequate
  • Cesarean section is delivery of choice

Precipitous Delivery
  • Precipitous birth is one that occurs rapidly
    without physician or certified nurse-midwife in
  • Mother may fear what is going to happen and feel
    that everything is out of control
  • Mother needs to assume comfortable position

Precipitous Delivery (contd)
  • Nurse scrubs his or her hands if time permits
    applies gloves
  • When infant's head crowns, mother should pant
  • Gentle pressure is applied against fetal head to
    prevent it from popping out rapidly
  • Perineum is supported and head is born between

Postterm Pregnancy
  • Postterm pregnancy may result in an increased
    possibility of
  • Probable labor induction
  • Forceps or vacuum-assisted or cesarean birth
  • Decreased perfusion to the placenta
  • Decreased amount of amniotic fluid and possible
    cord compression
  • Meconium aspiration
  • Macrosomia or a loss of fat and muscle mass
    resulting in small-for-gestational age (SGA)

TABLE 213 Placental and Umbilical Cord
TABLE 213 (continued) Placental and
Umbilical Cord Variations
Manual Removal of Placenta
Amniotic Fluid Embolism
  • Amniotic fluid fetal cells enter bloodstream
  • Triggers immune response similar to anaphylactic
  • Results in pulmonary artery vasospasm, pulmonary
    hypertension, hypoxia
  • Then hemorrhage and DIC

S/S of Amniotic Fluid Embolism
  • Sudden onset resp. distress - dyspnea
  • Cyanosis
  • Frothy sputum
  • Chest pain, cor pulmonale
  • Tachycardia, severe hypotension
  • Mental confusion
  • Massive hemorrhage, DIC, shock
  • Coma and maternal death
  • Fetal death if birth not immediate

Nursing Plan for Amniotic Fluid Embolism
  • Summon emergency team
  • Positive pressure oxygen delivery
  • Large bore IV
  • CPR as needed
  • Prepare for cesarean, if birth has not occurred
    and neonatal resuscitation
  • Prepare for CVP line insertion
  • Administer blood, hypotensive drugs, steroids
  • 85 maternal survivors and 50 fetal survivors
    have neuro damage

Birth-related Procedures
Vacuum Extractor
  • Assists birth by applying suction to fetal head
  • Should be progressive descent with first two
    pulls, procedure should be limited to prevent
    cephalhematoma - Risk increases if birth not
    within six minutes
  • Increases risk for jaundice - Due to reabsorption
    of bruising at cup attachment site

Vacuum extractor traction. A, The cup is placed
on the fetal occiput and suction is created.
Traction is applied in a downward and outward
direction. B, Traction continues in a downward
direction as the fetal head begins to emerge from
the vagina. C, traction is maintained to lift the
fetal head out of the vagina.
Risks of Forceps
  • Monitor FHR during procedure
  • Assess newborn for
  • Bruising
  • Edema
  • Facial lacerations
  • Cephalhematoma
  • Transient facial paralysis
  • Cerebral hemorrhage

Risks of Forceps (contd)
  • Empty bladder prior to procedure
  • Assess patient for
  • Vaginal or perineal lacerations
  • Infection secondary to lacerations
  • Increased bleeding
  • Bruising
  • Perineal edema
  • Bladder injuries

Application of forceps in occiput anterior (OA)
position. A, The left blade is inserted along the
left side wall of the pelvis over the parietal
bone. B, The right blade is inserted along the
right side wall of the pelvis over the parietal
bone. C, With correct placement of the blades,
the handles lock easily. During uterine
contractions, traction is applied to the forceps
in a downward and outward direction to follow the
birth canal.
Indications for Cesarean Section
  • Most common indications for cesarean birth
  • Fetal distress
  • Active genital herpes
  • Multiple gestation (three or more fetuses)
  • Umbilical cord prolapse
  • Tumors that obstruct birth canal
  • Lack of labor progression
  • Maternal infection
  • Pelvic size (cephalopelvic) disproportion
  • Placenta previa or abruptio placenta
  • Previous cesarean section
  • Fetal malpresentation

Preparation for C/S
  • Preparation for cesarean birth requires
  • Obtaining consent
  • Obtaining V/S and FHR
  • Establishing IV lines
  • Inserting indwelling urinary catheter
  • Performing abdominal prep
  • Maintaining NPO status
  • Administering preop
  • medications

Teaching C/S
  • Teaching needs include
  • What to expect before, during, and after delivery
  • Why is it being done
  • What sensations will the patient experience
  • Role of significant others
  • Turn, cough, deep breathe instruction
  • Early ambulation
  • Interaction with newborn

Pfannenstiel Classical Incision
increased risk of uterine rupture in subsequent
pregnancies and labor.
Nursing Care C/S
  • Routine postpartal care including
  • V/S and Fundus checks
  • Care of incision
  • Monitoring intake and output
  • Maintain IV access
  • Administer and teach about post-op medications
  • Assessment of respiratory system
  • Assessment of bowel sounds

Vaginal Birth After Cesarean Birth
  • Can occur after trial of labor in cases of
    nonrecurring indications for cesarean birth
  • Most common risks are
  • Hemorrhage
  • Surgical injuries
  • Uterine rupture
  • Infant death or neurological complications
  • Classic or T uterine incision is contraindication
    to VBAC

Nursing Care for VBAC
  • Continuous EFM or Internal Fetal and Uterine
  • IV fluids
  • Avoid oxytocin if at all possible
  • Important for nurse to support couple, explore
    their feelings, and provide information
    throughout labor

Fetal Demise/Stillbirth
  • Results from three factors
  • Fetal factors
  • Has or develops disorder incompatible with life
  • Maternal factors
  • Has disorder such as diabetes or preeclampsia
    that creates hostile environment for fetus
  • Placenta or other factors
  • Certain conditions such as abruptio placenta or
    cord accident cut off blood supply to fetus,
    leading to death

Diagnosis of Fetal Loss
  • Diagnosis may be made when mother notices lack of
    movement in fetus or at regularly scheduled
    physician's visit when fetal heart tone cannot be

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Nursing Care - Fetal Loss
  • Nursing care involves supporting family through
    grief work
  • Assist family through labor and birth
  • Provide for woman's physical needs after birth
  • Encourage family members to express and share
    their thoughts and feelings about loss
  • Give family an opportunity to view, hold, name

Nursing Care Fetal Loss (contd)
  • Nursing care involves supporting family through
    grief work
  • Prepare items for family to keep to remember
  • Provide opportunities for religious or spiritual
    counseling and cultural practices
  • Visit or phone family after discharge to assist
    in closure
  • Make referral to appropriate perinatal loss
    counseling services if indicated

NCLEX Question
  • Nursing assessment of a labor patient includes
    BP 116/72, P 88, contractions q 2 to 3 minutes,
    duration 75-80 seconds, resting tone not
    returning to baseline, FHR 150-156 bpm w/
    moderate variability. Which nursing action is
  • continue present rate of oxytocin
  • decrease rate of oxytocin
  • discontinue oxytocin administration
  • increase rate of oxytocin

NCLEX Question
  • During the delivery, the fetal shoulders become
    stuck behind the symphysis pubis. What
    intervention can the nurse perform to assist with
    the delivery?
  • uterine fundal pressure
  • McRoberts maneuver
  • McDonalds procedure
  • vacuum suction

NCLEX Question
  • The nurse assesses uterine contractions as q 1
    11/2 minutes frequency and 30 second resting
    period during an oxytocin induction. Which is the
    priority nursing action?
  • increase intravenous rate
  • reposition client to side lying
  • notify health care provider
  • discontinue oxytocin

NCLEX Question
  • A laboring client is admitted with vaginal
    bleeding. Which interventions does the nurse
    perform? Select all that apply.
  • Obtain fetal heart rate
  • Perform vaginal exam
  • Start intravenous infusion
  • Obtain vital signs
  • Begin oxytocin infusion
  • Administer oxygen

NCLEX Question
  • Upon rupture the client has an excessive amount
    of amniotic fluid. What problem would the nurse
    assess the newborn for?
  • Respiratory distress
  • Fractured clavicle
  • Cephalohematoma
  • Esophageal atresia

Intrapartum Nursing Diagnoses
  • Fatigue related to inability to relax and rest
    amb hypertonic labor pattern
  • Acute pain related to womans inability to relax
    amb hypertonic uterine contractions
  • Ineffective individual coping related to
    ineffectiveness of breathing techniques to
    relieve discomfort amb irritability
  • Anxiety related to slow labor progress amb
    hypotonic contractions

Intrapartum Nursing Diagnoses
  • Acute Pain related to uterine contractions amb
    complaints of 10/10 pain scale
  • Ineffective individual coping related to
    unanticipated discomfort and slow progress in
    labor amb verbalizations

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