COMPLICATIONS OF LABOR AND DELIVERY
Approximately 85% of all deliveries are considered normal; 15% are considered complicated. One nursing duty in the labor and delivery area is to assess for possible complications.
Maternal Hemorrhage
Intrapartum and postpartum maternal hemorrhage are life-threatening events that may occur without warning and are often not recognized until the woman experiences profound symptoms. Carefully observe the mother immediately after delivery for signs of hemorrhage or shock. Maternal hemorrhage requires aggressive measures to locate the cause. Begin localized and systemic therapy to avoid maternal mortality. Monitor fundal firmness because uterine atony is the number one cause of postpartum hemorrhage.
Nursing Alert Postpartum hemorrhage may occur quickly Take action and report any of the following to the birth attendant:
• Copious vaginal bleeding
• Boggy uterus (massage first and then report)
• Uterus high in the abdomen
• Signs of maternal shock
Premature Rupture of Membranes
Normally, the amniotic sac ruptures with a large gush slightly after the onset of labor. However, in 2% to 18% of all pregnancies, the amniotic sac, also referred to as the bag of waters (BOW) by the lay person, may have a small leak. In this scenario, the client may not go into labor for several days because the rupture is generally a small leak that she may not detect. When the amniotic sac loses fluids before the onset of labor, the condition is called premature rupture of membranes (PROM). Several complications may arise with PROM:
• Premature labor
• Intrauterine infection (the fetus is particularly susceptible to infections)
• Malpresentation and prolapsed cord
Nitrazine tests may be used to detect amniotic fluid in the vagina.
The woman should be admitted to the healthcare facility when PROM occurs. The woman and fetus are then assessed. Ultrasound and amniocentesis will determine fetal maturity, and labor is induced if the fetus is sufficiently mature.
Preterm Labor
Labor that occurs before the end of the 37th week of gestation is preterm, but it often still produces a viable fetus. Because prematurity is a leading cause of infant mortality, the birth attendant often attempts to postpone delivery until the baby is more mature.
The woman is placed on bed rest. Tocolytic agents (uterine relaxants) may be given to stop the contractions if there is no fetal distress, the membranes are intact, and the cervix is dilated fewer than 4 cm (see In Practice: Important Medications 68-1). Medications are usually administered IV until contractions cease, after which they may be administered orally. The woman and fetus must be followed up closely for the remainder of the pregnancy.
IN PRACTICE: IMPORTANT MEDICATIONS 68-1
TO STOP LABOR (TOCOLYTIC AGENTS)
Ritodrine HCl (Yutopar)
Terbutaline sulfate (Brethine, Bricanyl)
Magnesium sulfate Indomethacin (Indocin)
Nifedipine (Procardia)
Nursing Considerations
• Side effects of these drugs include dizziness, headache, tremor; and gastrointestinal symptoms.
• Side effects of ritodrine include maternal hypotension, maternal pulmonary edema, and maternal or fetal tachycardia.
• Dexamethasone may be given to speed maturation of fetal lungs.
• Indomethacin also may be given to the premature infant after birth to close a patent ductus arteriosus.
Precipitate Labor and Delivery
A precipitate labor is one that is brief (<3 hours) and in which contractions are unusually severe. It most often occurs in induced labor or multiparity. A precipitate delivery may be so rapid that the woman cannot be taken to the delivery room or prepared for delivery; the obstetrician or midwife is not always present.
When providing nursing care for a woman experiencing precipitate labor, stay with her, put the signal light on for help, remain composed, and assist the woman as much as possible until help arrives. Apply the principles of asepsis as the situation allows. Never prevent delivery in any way. Simply assist with the birth and make sure that the newborn is breathing adequately.
Because of the force and speed of labor, possible trauma can occur to the woman and newborn. Dangers to the woman include perineal laceration, hemorrhage, infection, and uterine rupture. Anoxia, subdural hematoma, and fractures may occur in the newborn. Hospitals usually have protocols on determining under what circumstances an infant born out of asepsis (BOA) (i.e., in an unsterile environment) needs isolation to prevent spread of infection to other infants.
Uterine Rupture
A ruptured uterus is one of the most serious complications of labor; fortunately, it is rare. Predisposing factors include a previous cesarean delivery or any uterine scar. Severe tonic contractions with no period of relaxation, dystocia (difficult labor), cephalopelvic disproportion, or injudicious use of drugs, such as oxytocin to stimulate uterine contractions, also may predispose to rupture.
When uterine rupture threatens, the woman complains of continuous and intense pain. A Bandl’s ring may be noticeable as a thickened upper segment and a thin distended lower segment of the uterus. The woman appears apprehensive and restless. Contractions are tonic, pulse is rapid, and urination is frequent. If the threat of rupture occurs before delivery, the fetus is usually in great distress, as shown by irregular or absent FHTs.
Constant fetal monitoring is vital. The woman at high risk of, or with, a uterine rupture may need an emergency cesarean delivery to save her life and the life of her fetus. A hysterectomy may be needed to save the mother’s life.
Symptoms of rupture are a sharp, tearing pain followed by its sudden cessation. The woman is anxious and shows signs of shock and hypotension; her pulse is rapid and weak. (She is hemorrhaging internally.) Use emergency measures to treat her for shock and hemorrhage. Prepare her at once for an emergency cesarean delivery and possible hysterectomy.
Maternal Dystocia
Dystocia is prolonged, painful labor that does not result in effective cervical dilation or effacement. Labor is long but does not progress. Dystocia may be related to fetal factors, uterine or passageway abnormalities, or faulty contractions. Dystocia not only exhausts the woman, but also predisposes her and the fetus to possible danger and even death.
Uterine Inertia
Uterine inertia refers to insufficient, uncoordinated contractions that do not produce effective dilation. It is also called hypotonic dystocia. Causes include emotional stress, a thick and rigid cervix, and excessive or premature use of analgesic medications. Uterine inertia occurs most often in primigravi-das. However, it also is identified in some grand multiparas who have weak uterine muscle tone. Other women may suffer from uterine inertia if they have an overdistended uterus because of an extremely large fetus, a multiple pregnancy, or hydramnios.
Nursing care includes early recognition, prompt notification of the obstetrician, assessment of cervical dilation (if any), accurate evaluation of pain, assessment of the fetal heart rate related to the pattern of contractions by monitor, and positive emotional support and reassurance. Anticipate and be prepared to assist with treatments, such as IV fluids or efforts to stop the ineffective labor with medications such as morphine. Sleep and rest often enable the woman’s uterus to achieve a normal pattern when labor resumes. Other treatment may include IV oxytocin infusion or cesarean delivery.
Dystocia Caused by the Fetus
Sometimes the size of the fetus as compared with the size of the woman’s pelvis or the position or presentation of the fetus causes dystocia.
Cephalopelvic Disproportion
Cephalopelvic disproportion (CPD) means that the presenting part, usually the fetal head, is too large to pass through the woman’s pelvis. It may be related to maternal diabetes (which often results in large babies), heredity, or maternal nutrition. Cesarean delivery should be anticipated; however, some birth attendants use cesarean birth as a last resort. An ultrasound or x-ray pelvimetry is performed to determine CPD. Often the woman has dilated and effaced, but the presenting part fails to descend.
Fetal Positions and Presentations
The normal fetal presentation is the vertex (head-first) position. If the fetus assumes an abnormal position within the uterus, labor is difficult, and vaginal delivery may be impossible. Depending on the head’s position, difficulties may occur. For example, if the face is the presenting part, vaginal delivery is often impossible because this angle causes a CPD. An abnormal position also may cause a hand or foot or the buttocks to present. Ultrasonography can identify fetal position, as can the location of FHTs. A cesarean delivery may be done for an abnormal position or presentation.
Abnormal Fetal Presentations
Posterior Positions. Normal fetal presentations and positions are discussed.The most common abnormal fetal presentation is occiput posterior where the occiput, or back of the fetal head, is toward the woman’s back. Posterior positions are designated right occiput posterior (ROP), left occiput posterior (LOP), or direct occiput posterior (OP). Delivery can be difficult or impossible because the fetal neck is overflexed, the face is uppermost, and the head diameter may be too large to pass through the birth canal. This presentation can occur if the maternal pelvic floor is relaxed. The woman typically complains of a continuous low backache, and FHTs are heard on the woman’s flank (side).
Medical management may include manual rotation of the fetus (version) before engagement, forceps-assisted delivery, or cesarean delivery, which are discussed later in this topic. Help the woman do pelvic rocking exercises. Pelvic rocking is done while the woman lies flat in bed. She rocks the abdomen from top to bottom, alternating back and forth. First, she presses her backbone against the bed and rocks the hips away from the bed, while tightening the vaginal muscles. She then presses her buttocks into the mattress, while lifting the small of the back. Give emotional support, and massage the woman’s lower back.
Transverse Position. The transverse lie usually results in a shoulder presentation. The fetus lies across the woman’s abdomen in the uterus, so a risk of prolapsed cord or descent of a fetal arm exists if the membranes rupture. Management may include version, but a cesarean delivery will most likely be performed.
Face-Brow Presentation. Face-brow presentation (occipitomental), occurs when the fetal head is unfavorably positioned for delivery. Predisposing factors include multiparity, polyhydramnios, and a low-lying placenta. The woman may deliver spontaneously if flexion of the fetal neck occurs. Reassure the woman, and anticipate treatment to include an attempted version or cesarean delivery if fetal position cannot be altered.
Breech Presentations. Breech presentation occurs in 3% of all deliveries. In a complete breech, the buttocks present, with the knees bent and the feet next to the buttocks. A footling breech is one in which one or both feet present (single footling or double footling). In a frank breech, the buttocks present, with the legs extended straight up (the legs and feet are entwined around the face). Predisposing factors include placenta previa, CPD, multiple pregnancy, small fetus, tumors, and polyhydramnios. If the mother has had a previous breech birth, a subsequent one is more likely (see Breech Presentations, Fig. 66-1C).
Fetal mortality is higher in breech deliveries than in any other kind of delivery. The risks to the woman include laceration and hemorrhage; to the fetus, the risks include birth injuries and fetal anoxia, which may be caused by early rupture of the bag of waters and by cord prolapse. Because the head is delivered last, asphyxia can occur; the fetal head cannot undergo normal molding and may become caught in the birth canal.
Treatment may include diagnostic ultrasound and fetal maturity studies, the use of forceps for the head, or cesarean delivery. Nursing care is the same as for any woman in labor. Anticipate that FHTs will be located at or above the umbilicus, and meconium-stained amniotic fluid may be present. Prepare for newborn resuscitation if a spontaneous delivery occurs.
UMBILICAL CORD COMPLICATIONS
The umbilical cord can be a potential problem during delivery. Possible complications include prolapsed and nuchal cord.
Prolapsed Cord
In a prolapsed cord, the umbilical cord precedes the baby. The cord may protrude from the cervix or may drop as low as the vulva. An occult (hidden) prolapse is difficult to determine because the cord is compressed between the fetus and the uterine wall. A prolapsed cord is a serious complication because as the fetus’s head descends, it may press the cord against the hard structures in the woman’s pelvis, cutting off fetal circulation. This condition usually requires an emergency cesarean delivery.
A prolapsed cord can result from any factor that interferes with the engagement or adaptation of the presenting part to the pelvis, such as multiple pregnancy, a transverse lie, an abnormal presentation (e.g., a footling), hydramnios, or a high presenting part when the membranes suddenly rupture.
Sometimes electronic fetal monitoring detects this condition early. The birth attendant or nurse must insert a sterile gloved hand into the vagina to hold the fetal presenting part away from the cord. This measure ensures that fetal circulation is not cut off while the woman is prepared for an emergency cesarean delivery. If the cord has prolapsed outside the vagina, it is covered with sterile towels and moistened with warm, sterile normal saline. This measure prevents drying and caking of the cord and fetal blood. Place the woman in the Trendelenburg or knee-chest position as ordered. Fetal monitoring is essential. Notify the physician at once and prepare for resuscitation of the newborn. A postoperative complication may be maternal puerperal infection.
Nuchal Cord
As the fetus moves within the uterus, the umbilical cord may become wrapped around the neck. This condition is known as nuchal cord. If this condition is discovered before labor, cesarean delivery may be done. If it is not discovered until the woman is in labor, the cord may have become so tightly wrapped around the neck that the fetus is unable to receive oxygen. In this case, the birth attendant may use forceps to speed delivery, and the cord is cut immediately. If the nuchal cord is loose, the birth attendant may be able to slip it over the fetus’s head.
CONSIDERATIONS RELATED TO DELIVERY
Induction of Labor
The start of labor by medical interventions is called induction. Induction of labor may be initiated by a birth attendant for various reasons before labor begins naturally.
Labor is induced only in certain instances because it is not without risk. Reasons for induction include the possibility of fetal death without labor, worsening signs of PIH, a large or postterm fetus, and maternal diabetes mellitus.
The birth attendant must determine if the woman’s birth canal is large enough before inducing labor. If a CPD exists, induction should not be attempted. Fetal maturity also must be evaluated to make sure that the fetus is viable. Amniocentesis can determine maturity by assessing the LS ratio.
Nursing Considerations
Nursing assessment is important during induction. Carefully monitor the fetus for signs of distress. Take the woman’s blood pressure and pulse every 10 to 15 minutes during an IV or suppository induction and at least every half hour following the rupture of the bag of waters. Any sign of maternal or fetal distress is an emergency that you must report immediately. Be sure to provide physical and emotional support to the woman and family during induction.
Induction With Drugs
Drugs may be administered parenterally, orally, or vaginally to induce labor (In Practice: Important Medications 68-2). Oxytocin is the drug most commonly used to induce labor. Prostaglandin vaginal suppositories or gel may also be administered before oxytocin to ripen the cervix.
Amniotomy
Labor also can be induced by amniotomy, which means rupturing the amniotic membranes with a special hook. A physician performs this procedure under sterile conditions, at times with nursing assistance. Labor usually follows quickly. Chart the time of the amniotomy, the color and approximate amount of fluid, and the effects on the woman. If labor does not begin spontaneously after amniotomy, induction with medications will usually follow. Watch the woman for signs of uterine infection if delivery does not occur within 24 hours.
IN PRACTICE IMPORTANT MEDICATIONS 68-2
FOR INDUCTION OF LABOR
oxytocin (Pitocin, Syntocinon)
Nursing Considerations
• Oxytocin is given intravenous (IV), using a piggyback setup with a solution of normal saline or D5W (5% dextrose in water) to keep the vein open.
• Adjust the drip rate for optimum flow rate, character of contractions, and optimum relaxation time between contractions.
• Use the infusion pump to ensure accurate measurement and delivery of the drug.
• Use a fetal monitor to make sure the fetus is not in danger
Emergency Delivery
Sometimes not enough time is available for the woman to get to the healthcare facility for delivery. In this case, police officers, rescue personnel, or nurses may be asked to assist with emergency childbirth. A BOA pack of necessary delivery supplies and equipment is generally kept available at all times in emergency departments and ambulances and on obstetrical units.
Nursing Considerations
Never delay delivery. Preventing delivery can cause great damage to the woman and fetus. Remain calm and deliver the baby as safely as possible, following the best possible aseptic technique (In Practice: Nursing Care Guidelines 68-1).
Usually, few complications arise in a precipitous delivery. Important interventions in the care of the newborn include ensuring respirations and proper body temperature. Cutting the cord is inadvisable, unless the services of the birth attendant are unavailable. However, tie the cord in two places when the newborn is breathing or the placenta is delivered. Keep the newborn and placenta together if you anticipate a birth attendant’s or hospital’s services. Putting the newborn to the mother’s breast immediately helps the uterus to contract and prevents maternal hemorrhage. The mother will be examined for retained placental tissue, lacerations, and other complications when she receives medical assistance.
IN PRACTICE :NURSING CARE GUIDELINES 68-1
ASSISTING IN AN EMERGENCY DELIVERY
• Provide as much privacy as possible for the woman.
• Wear gloves.
• Do not attempt to prevent delivery
• Follow aseptic technique as closely as possible.
• Make sure the membranes have ruptured.
• Make sure the newborn’s airway is clear before he or she takes the first breath.
• Initiate respiration in the newborn.
• Keep the newborn warm.
• Tie off the umbilical cord in two places.
• Do not cut the umbilical cord.
• Have the mother hold the newborn and put it to her breast.
• Get medical assistance as soon as possible.
• Make sure the mother’s uterus contracts after delivery of the newborn and placenta.
• Write down the time of birth of the newborn and delivery of the placenta. Write down the mother’s name and address.
• Keep the mother warm.
• Reassure the mother
Lacerations
During a precipitous or emergency delivery, a laceration or tear into the perineal tissue and anus may occur. All lacerations are repaired while the woman is still on the delivery table or in the emergency department. Cervical tears are also repaired to prevent hemorrhage.
Lacerations are classified in several categories.
First degree involves the perineal skin and vaginal mucous membranes.
Second degree involves muscles of the perineal body.
Third degree involves the anal sphincter.
Fourth degree extends to the anal canal.
