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Title: Labor and Birth Complications/ Variations During Postpartum


1
Labor and Birth Complications/ Variations During
Postpartum
  • February 10th, 2005
  • Maria Rubolino

2
Complications
  • Some anticipated
  • Higher perinatal mortality and morbidity
  • Some women feel a sense of failure

3
Dystocia
  • Long, difficult, or abnormal labor
  • Can be caused by
  • Dysfunctional labor
  • Alterations in the pelvic structure
  • Maternal position
  • Fetal causes
  • Psychologic responses

4
Dysfunctional Labor
  • Abnormal UCs, that prevent the normal progression
    of cervical dilation, effacement, or descent
  • Higher with AMA
  • Overweight
  • Uterine abnormalities
  • CPD
  • Malpresentation
  • Hyperstimulation
  • Maternal fatigue
  • Anesthesia

5
Hypertonic Uterine Dysfunction
  • Typically first time mom
  • Having painful and frequent UCs that are not
    causing dilatation
  • Maternal exhaustion
  • Loss of control
  • Tx Therapeutic rest

6
Hypotonic Uterine Dysfunction
  • Woman makes normal progress
  • Once active phase begins, UCs become weak and
    inefficient or stop contracting
  • CPD
  • Malpresentation

7
Bearing-Down Efforts
  • Anesthesia is given and blocks the effectiveness
    of pushing
  • Fatigue, inadequate hydration, maternal position
    can affect this

8
Pelvic Dystocia
  • Diameter of the pelvic inlet/outlet is contracted
  • Due to
  • -
  • -
  • -
  • -

9
Dystocia Related to the Fetus
  • Due to anomalies, fetal size, malpresentation,
    multiples
  • Typically an assisted delivery

10
CPD
  • 4000 gms or more
  • Cannot fit through the pelvis
  • Associated with certain conditions

11
Malposition
  • Head positioned incorrectly in the pelvis
  • ROP/LOP
  • Typically will have a longer second stage
  • More painful

12
Malpresentation
  • Something other than a head descending in the
    pelvis first
  • Face/Brow presentation
  • Shoulder presentation
  • Breech 3-4 of all births
  • Types
  • Frank
  • Complete
  • Incomplete

13
Types of Breech
14
Multiple Gestation
  • Twin birth rate has increased
  • Fertility enhancing drugs, AMA
  • Higher incidence of complications
  • ½ of all twin pregnancies have both fetuses in
    vertex position
  • Increased risk for mother

15
Precipitous Labor
  • Lasts less than 3 hours
  • Higher rates among mulitparous women and 40-49
    years old
  • Complications
  • Uterine rupture
  • Lacerations
  • Fetal hypoxia

16
External Version
  • Turn the fetus to vertex position
  • Typically before 37 weeks
  • Done inpatient setting
  • NST done prior to exam
  • IV
  • Relaxants
  • Informed consent
  • Done with UTZ
  • NST after procedure

17
Internal Version
  • Converting the presentation of the fetus in utero
  • Most often used for 2nd twin
  • Must be completely dilated

18
TOL
  • Done if questionable size/shape of the pelvis
  • Previous C/S
  • Evaluated often

19
Induction of Labor
  • Use of mechanical or chemical initiation of UCs
    prior to spontaneously occurring
  • Should be used when the risk of birth to mother
    or fetus is less than risk of continuing
    pregnancy
  • Inductions increasing with increased litigation

20
Bishops Score
  • Can be used to evaluate how inducible one is and
    how they should respond to labor

21
Augmentation
  • Progress of labor has slowed or needs to be
    speeded up due to maternal/fetal problems
  • Medications
  • Mechanical

22
Cervical Ripening
  • Ripen - soften and thin the cervix
  • Prostaglandin gels
  • Hydroscopic Dilators - seaweed substance absorbs
    fluid from surrounding tissue and then enlarges
  • Synthetic prostaglandin tablets
  • Vaginal insert
  • Needs monitoring
  • IV/Saline lock

23
AROM
  • Cervix should be favorable
  • Labor typically begins within 12 hours from
    rupture
  • Used in combination with meds
  • Head should be well engaged
  • Amnihook needed for procedure
  • Color, amount, odor, consistency is assessed
  • FHTs assessed

24
PROM
  • Rupture of amniotic sac at least 1 hour before
    the onset of labor
  • Typically begin labor within 12 hours

25
PPROM
  • Membranes rupture before 37 weeks gestation
  • 25 of all cases of preterm labor
  • Usually infection will cause this
  • Complication chorioamnionitis
  • Fetal complications pneumonia, sepsis and
    meningitis

26
Pitocin
  • Hormone produced by the posterior pituitary gland
  • Induce or augment labor
  • Fetal monitoring important
  • Can cause hyperstimulation of UCs
  • Every hospital has a protocol
  • Contraindications
  • Nonreassuring FHTs
  • Unable to trace FHTs
  • Previa
  • Prior classical incision/Prior cesarean section
  • Active herpes
  • Prolapsed cord
  • Malpresentation

27
Shoulder Dystocia
  • Emergency
  • Fetus can experience birth injuries
  • Mother can experience blood loss
  • Head is born but anterior shoulder cannot pass
    under the pubic arch
  • Head emerges, it retracts against the perineum
    and external rotation does not occur
  • Nursing care McRoberts maneuver

28
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29
Prolapsed Umbilical Cord
  • Cord lies below the presenting part of the fetus
  • May be hidden
  • May see after ROM
  • 1 in 400 births
  • Medical emergency for C/S unless fully dilated
    may attempt vaginal delivery with mechanical
    assistance
  • Relieve pressure on the cord by
  • Trendelenburg
  • Knee-Chest

30
Rupture of the Uterus
  • Rare but medical emergency
  • Typically separation of previous uterine scar,
    uterine trauma, uterine anomaly
  • During labor may be due to intervention with
    medication inducing drugs, malpresentation,
    multiples, versions
  • More often in multiparous

31
  • Bleeding is usually internal
  • Complete vs. incomplete
  • Signs/Symptoms
  • Maternal
  • Vomiting
  • Faintness
  • Increased abdominal pressure/tenderness
  • Hypotonic UCs
  • Fetus
  • May show decelerations
  • Decreased variability
  • Increased or decreased FHR

32
Amniotic Fluid Embolism
  • When amniotic fluid contains particles of debris
    enters the maternal circulation and obstructs
    pulmonary vessels, causing respiratory distress
    and circulatory collapse
  • More damaging if meconium present
  • Typically ventilated

33
Forceps Assisted Birth
  • Mechanical help in delivery of the fetus
  • Two curved blades help in assisting with the
    birth
  • Use has been decreasing
  • Indications
  • Fetal distress
  • Arrest of rotation
  • Deliver head in breech presentation

34
  • Outlet forceps - fetal scalp is visible on the
    perineum without separating labia
  • Low forceps head is at 2 station
  • Mid forceps fetal head is engaged no higher
    than station 0, but above 2 station

35
  • Simpson forceps typically used
  • Kjellands forceps rotation of the head
  • Piper forceps designed to facilitate delivery
    of the head after a breech delivery
  • Complications transient bruising
  • Laceration on the head or cervix

36
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37
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38
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39
Vacuum Assisted Birth
  • Attachment of vacuum to fetal head using
    negative pressure
  • Use declining
  • Vacuum applied by MD
  • Cup is placed over posterior fontanelle
  • Pop-offs occur if excessive force used
  • Some types of vacuums RN will control amount of
    suction
  • Kiwi vacuum operated independently by MD

40
  • Vacuum pressure is lowered in between UCs
  • Maternal risks
  • Perineal lacs
  • Vaginal lacs
  • Cervical lacs
  • Risks to fetus
  • Cephalhematoma
  • Scalp lacerations
  • Subderal Hematoma

41
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42
Cesarean Section
  • Surgical birth of a fetus through a
    transabdominal incision of the uterus
  • Planned or emergency
  • Preserve the life of the fetus
  • C/S have increased to more than 20
  • Women 35 years of age and older have a C/S rate
    that is almost 30

43
  • Some women want a trial of labor
  • Nurse can affect the rates
  • Indications
  • CPD
  • Non reassuring FHTs
  • Placental location
  • Malpresentation
  • Cord prolapse
  • HSV
  • Preeclamsia/Eclampsia
  • Multiples
  • Hypertensive disorders

44
Types of C/S
45
C/S
  • Risks
  • Blood loss
  • Infection
  • Uterine rupture
  • Aspiration
  • Pulmonary embolism
  • Wound Infection
  • Thrombophlebitis
  • Bowel/Bladder injuries
  • Complications with anesthesia

46
Anesthesia
  • Spinal
  • Epidural
  • General
  • Local

47
VBAC
  • Allowing TOL
  • Low transverse incision
  • Emergency resources should be available
  • Physician should be readily available (within 30
    minutes)

48
Preoperative Care
  • Hospital protocol
  • Shave low abdomen
  • Jewelry removed
  • NST
  • Monitoring maternal VS
  • IV - bolus
  • Labs
  • Consent
  • Antibiotics
  • Foley
  • Antiemetics

49
Postoperative Care
  • Vital Signs

50
Postpartum Period
51
PP Hemorrhage
  • Loss of more than 500 ccs of blood during the
    first 24 hours after a vaginal delivery or 1000
    ccs after C/S birth
  • Can occur with little warning
  • 10 change in Hct
  • Blood loss can be underestimated by as much as 50

52
  • Cause uterine atony, retained placental
    fragments, placenta accreta, uterine rupture,
    coagulation problems
  • Risk factors Prolonged labor with prolonged use
    of labor inducing meds, overdistention of the
    uterus, previous PPH, fibroids, DIC

53
Uterine Atony
  • Accounts for 90 of all PPH
  • Boggy
  • Non-contracted uterus
  • Treatment
  • Massaging fundus
  • Replace fluids
  • Medications

54
Lacerations
  • Cervix, vagina, perineum
  • If bleeding continues even with uterus remaining
    firm and contracted
  • Extreme vascularity of the perineum typically
    cause this

55
Hematomas
  • Collection of blood in the connective tissue
  • Very tender/painful
  • Associated more often with assisted deliveries

56
Retained Placental Fragments
  • Typically placenta separates after birth of
    infant within 30 minutes after birth
  • Partial separation of a normal placenta
  • Common in preterm births
  • Treatment manual separation or DC

57
Prevention of PPH
  • Massage relaxed UT until firm
  • Notify MD if heaving bleeding persists or
    restarts
  • Give medications
  • Monitor uterus tone, location, height
  • Monitor VS

58
Treatment of PPH
  • IV
  • PRBCs
  • Medications Pitocin, methergine, hemabate,
    cytotec, calcium gluconate
  • Catheter
  • O2

59
Uterine Inversion
  • Medical emergency
  • Replacement of UT into pelvic cavity
  • Manual replacement is successful 75 of women
  • Antibiotics

60
Subinvolution
  • Delay in return to normal size and function of
    uterus characterized by large, boggy uterus
  • Prolonged lochia-sometimes heavy

61
Hypovolemic Shock
  • Emergency
  • Perfusion to body organs may become compromised
    resulting in death

62
Idiopathic Thrombocytopenia Purpura
  • Antiplatelet antibodies decreased the lifespan of
    the platelets
  • Increased bleeding time
  • Control of platelets
  • Splenectomy done if ITP does not respond to other
    management

63
Von Willebrands Disease
  • Type of hemophilia
  • Factor VIII deficiency and abnormal platelet
    function
  • Factor VIII increases during pregnancy

64
DIC
  • Form of clotting
  • Large amount of clots and platelets
  • Total bleeding from all cites can occur
  • Causes
  • Abruptio placenta
  • Amniotic embolism
  • Fetal demise (in utero at least 6 weeks)
  • Severe preeclampsia
  • Septic infection

65
DVT
  • Can extend from the foot to femoral region
  • 1 in 1000 to 2000
  • Early ambulation
  • Risk factors
  • Bedrest
  • Smoking
  • HTN
  • Obesity
  • Varicose veins

66
  • Doppler study to diagnose
  • Tx anticoagulant therapy, bedrest

67
PP Infection/Puerperal Sepsis
  • Any genital infection occurring within 28 days of
    birth
  • Fever typically seen
  • 6 of births in US
  • Greater likelihood after prolonged ROM, frequent
    VEs, C/S, IC after ROM,poor nutrition

68
Endometritis
  • Localized infection of the lining of the UT
  • Typically beginning at the placental site
  • 48-72 hours after delivery
  • May extend to other areas including fallopian
    tubes
  • Fever, chills, nausea, fatigue, PP

69
Wound Infections
  • C/S, episiotomy, laceration sites
  • Erythema, edema, odor, warmth

70
Mastitis
  • Breast infection
  • Typically develops when breast feeding
  • Develops after milk supply has been established
  • Bacteria enters through nipple fissures
  • Chills, fever, erythema, tenderness, engorgement,
    usually unilateral

71
  • Prevention hygiene, hand washing, empty breasts
    completely
  • TX antibiotics, ID (if severe), heat and cold
    packs, massage, expression of milk
  • Organism Staph aureus

72
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