Complication o Labor

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Complication o Labor
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Psychologic Disorders

• Alterations in thinking, mood or behavior
• Keep her well oriented and promote optimal
  functioning in labor. Focus on maintaining safe
  environment and ensuring fetal and maternal
  well-being

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Dystocia r/t dysfunctional contractions

• Accounts for 50 C/S for primips lt5 C/S for
  multips
• Hypertonic in 1st phase- poor quality U/Cs,
  become more frequent, but ineffective and
  changing dilatation or effacement? prolonged
  latent phase
• Tx sedation, oxytocin, amniotomy
• Hypotonic irreg, low amplitude? protracted labor
  and arrest of dilatation
• Tx oxytocin, amniotomy

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Active Management of Labor

• Standardized criteria for diagnosis of labor
• Standardized method of labor management
• One-to-one nursing care in labor
• Prenatal education to teach re this protocol
• Method
• Amniotomy right away
• VE frequently
• If change not as expected, oxytocin

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Precipitous Labor and Birth

• From beginning of regular contractions to
  delivery is 3 hours or less
• Risks
• Abruption
• Cervical and perineal lacerations
• Fetal head trauma
• Women with history may be scheduled for induction

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Post-term Pregnancy

• gt 42 completed weeks
• Cause of true post-term is unknown often
  incorrect dates
• Maternal Risks
• Large baby and associations
• Psychologic ills
• Fetal-Neonatal Risks
• Placental changes ? insufficiencies
• Oligohydramnios
• macrosomia? birth trauma, glucose maintenance
  problems
• Meconmium stained fluid (aspiration)
• As pregnancy approached term, fetal well-being
  studies done

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Fetal Malposition

• OP position
• Fetus must rotate 135 or occasionally born in OP
  position
• If born OP, increased risk of 3rd or 4th degree
  laceration, broken symphysis
• May use forceps or manual rotation
• Positioning knee chest, pelvic rocking

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Fetal Malpresentation

• Brow
• Usually C/S recommended
• Perinatal morbidity and mortality
• Trauma cerebral and neck compression damage to
  trachea and larynx
• Tx pelvimetry, oxytocin?, C/S
• Face
• Perinatal morbidity and mortality
• Risk of prolonged labor, fetal edema, swelling of
  neck and internal structures, petechiae,
  ecchymosis
• Tx C/S in no progress

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Fetal Malpresentation

• Breech
• Most common malpresentation
• Frank breech most common
• Risk of cord prolapse fetal anomolies 3x higher
• If vag del head trauma, fetal entrapment
• Tx external version (50-60 success), if vag
  del epidural, double set-up

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Fetal Malpresentation

• Shoulder
• Version may be attempted
• C/S
• Compound presentation

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Macrosomia

• gt4500 g
• Obese 3-4x more likely to have macrosomic baby
• ?risk of perineal lacerations, infection
• Most significant problem is shoulder dystocia
• OB emergency? permanent injury of brachial
  plexus, fx clavicle, asphyxia, neurologic damage
• Tx
• Assessment of adequacy of pelvis
• Suprapubic pressure
• Intentional breaking of clavicle
• ?C/S

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Multiple Gestation

• Mother at risk for
• Hypertension or preeclampsia
• Anemia
• Hydramnios
• PPROM, IUGR, incompetent cx
• Malpresentation
• More physical discomforts

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Multiple Gestation

• Tx
• U/S to diagnose amnion/chorion, follow growth,
  observe for twin-twin transfusion
• Frequent office visits to monitor for problems
• Likely to deliver by C/S

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Abruptio Placentae

• Premature separation of normally implanted
  placenta from the uterine wall
• Very high mortality
• Cause unknown but r/t
• Maternal hypertension
• Maternal trauma
• Cigarettes, cocaine
• Short umbilical cord, high parity
• More common in Caucasian and African American
  than Asian or Latin American

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Abruptio Placentae
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Abruptio Placentae
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Abruptio Placentae

• http//video.about.com/pregnancy/Placenta-Abruptio
  .htm

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Abruptio Placentae

• Classification
• Oasymptomatic, diagnosed after birth
• Imild, most common
• IImod, both mom and baby show signs of distress
• IIIsevere, maternal shock and fetal death likely

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Abruptio Placentae

• Types
• Marginal-blood passes between fetal membranes and
  uterine wall and escapes vaginally separation at
  periphery of placenta
• Central-separates centrally, blood trapped
  between placenta and uterine wall. No overt
  bleeding
• Complete-massive vaginal bleeding in presence of
  almost total separation

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Abruptio Placentae
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Abruptio Placentae

• Blood invades myometrial tissue ? pain and
  uterine irritability.
• May necessitate hysterectomy after delivery
  secondary to inability to uterus to contract.
• May lead to coagulation defects

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Abruptio Placentae

• Maternal Risks
• Blood coagulation problems
• Shock
• Renal failure (r/t hemorrhage)
• Possible hysterectomy
• Fetal-Neonatal Risks
• If separation 50 ? 100 demise
• Depending upon separation, time before delivery,
  maturity of baby ? neurologic damage

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Abruptio Placentae

• Tx
• Continuous EFM (if baby alive)
• Develop plan for birth
• Maintain CV status/tx hypovolemic shock
• Follow blood coag studies/have blood factors
  available

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Placenta Previa

• Improperly implanted in lower uterine segment
• Types
• Low lying close proximity to os, but doesnt
  reach it
• Marginal edge of placenta at margin of the os
• Partial internal os is partially covered by
  placenta
• Total internal os completely covered

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Placenta Previa
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Placenta Previa
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Placenta Previa
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Placenta Previa
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Placenta Previa

• Cause unknown, but associated with
• Multiparity
• Increased age
• Defective development of blood vessels in decidua
• Defective implantation of the placenta
• Prior C/S
• Smoking
• Large placenta

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Placenta Previa

• Tx
• Continuous EFM
• Differential diagnosis
• ?No vag exam until previa r/o (U/S, other
  assessments)
• Care depends on amt bleeding, gestational age,
  assessment of fetus

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