Labor and Birth Complications/ Variations During Postpartum

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Labor and Birth Complications/ Variations During
Postpartum

• February 10th, 2005
• Maria Rubolino

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Complications

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

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Dystocia

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

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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

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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

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Hypotonic Uterine Dysfunction

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

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Bearing-Down Efforts

• Anesthesia is given and blocks the effectiveness
  of pushing
• Fatigue, inadequate hydration, maternal position
  can affect this

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Pelvic Dystocia

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

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Dystocia Related to the Fetus

• Due to anomalies, fetal size, malpresentation,
  multiples
• Typically an assisted delivery

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CPD

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

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Malposition

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

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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

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Types of Breech
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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

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Precipitous Labor

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

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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

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Internal Version

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

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TOL

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

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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

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Bishops Score

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

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Augmentation

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

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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

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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

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PROM

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

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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

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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

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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

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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

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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

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• 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

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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

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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

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• 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

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• 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

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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

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

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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

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• 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

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Types of C/S
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C/S

• Risks
• Blood loss
• Infection
• Uterine rupture
• Aspiration
• Pulmonary embolism
• Wound Infection
• Thrombophlebitis
• Bowel/Bladder injuries
• Complications with anesthesia

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Anesthesia

• Spinal
• Epidural
• General
• Local

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VBAC

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

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Preoperative Care

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

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Postoperative Care

• Vital Signs

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Postpartum Period
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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

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• 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

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Uterine Atony

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

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Lacerations

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

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Hematomas

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

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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

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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

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Treatment of PPH

• IV
• PRBCs
• Medications Pitocin, methergine, hemabate,
  cytotec, calcium gluconate
• Catheter
• O2

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Uterine Inversion

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

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Subinvolution

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

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Hypovolemic Shock

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

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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

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Von Willebrands Disease

• Type of hemophilia
• Factor VIII deficiency and abnormal platelet
  function
• Factor VIII increases during pregnancy

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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

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DVT

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

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• Doppler study to diagnose
• Tx anticoagulant therapy, bedrest

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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

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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

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Wound Infections

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

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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

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

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