Child birth at risk labor related complication -9

Copyright ©2011 by Pearson Education, Inc.All rights reserved.

Maternal & Child Nursing Care, Third EditionLondon • Ladewig • Ball • Bindler • Cowen

Childbirth at Risk: Labor-Related Complications



Learning Outcome Compare and contrast hypertonic and

hypotonic labor patterns, including risk, clinical therapy, and nursing care

management.



Characteristics of Hypertonic Labor

• Increased contraction frequency• Decreased contraction intensity• Increased uterine resting tone• Prolonged latent phase



Implications of Hypertonic Labor

• Increased discomfort due to uterine muscle cell anoxia

• Stress on coping abilities• Prolonged labor resulting in:

– Maternal exhaustion– Dehydration– Increased incidence of infection



Implications of Hypertonic Labor

• 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



Effects of Labor on the Fetal Head



Clinical Therapy for Hypertonic Labor

• Bed rest and relaxation measures• Pharmacologic sedation• Oxytocin• Amniotomy



Nursing Diagnoses for Hypertonic Labor

• Fatigue related to inability to relax and rest secondary to hypertonic labor pattern

• Acute pain related to woman’s inability to relax secondary to hypertonic uterine contractions



Nursing Diagnoses for Hypertonic Labor

• Ineffective individual coping related to ineffectiveness of breathing techniques to relieve discomfort

• Anxiety related to slow labor progress



Nursing Plan for Hypertonic Labor

• Provide support and encouragement• Facilitate rest• Administer pharmacologic agents as

ordered• Monitor maternal fatigue• Monitor contractions and fetal status




• Institute supportive measures– Ambulation– Position changes with pillow support– Quiet, soothing environment– Touch and massage techniques– Personal hygiene




• Institute supportive measures– Hydrotherapy (bath or shower)– Relaxation exercises– Visualization– Music




• Provide information and encourage questions– Cause, implications, and treatment of

dysfunctional labor



Outcomes for the Client with Hypertonic Labor

• Increased comfort• Decreased anxiety• Adequate coping• More effective labor pattern



Causes of Hypotonic Labor

• Fetal macrosomia• Multiple gestation• Hydramnios• Grand multiparity



Implications of Hypotonic Labor

• Stress on coping abilities• Prolonged labor resulting in:

– Maternal exhaustion– Dehydration– Increased incidence of infection



Implications of Hypotonic Labor

• Postpartum hemorrhage due to uterine atony

• Nonreassuring fetal status due to prolonged labor pattern

• Fetal sepsis from pathogens ascending from birth canal



Clinical Therapy for Hypotonic Labor

• Oxytocin infusion• Nipple stimulation• Amniotomy• IV fluids• Surgical birth, if needed



Active Management of Labor

• Purported benefits– Decreased incidence of protracted labor– Decreased cesarean birth rate

• Risks– Increased risk of infection– Excessive intervention– Increased instrument-assisted birth



Nursing Diagnoses for Hypotonic Labor

• Acute pain related to uterine contractions secondary to dysfunctional labor

• Ineffective individual coping related to unanticipated discomfort and slow progress in labor



Nursing Plan for Hypotonic Labor

• Frequent monitoring of vital signs, FHR, and contractions

• Assess amniotic fluid for meconium• Monitor maternal Input & Output




• Assess bladder for distention and empty frequently– Encourage voiding at least q 2 hours– Catheterize as needed with regional block

• Minimize vaginal exams to decrease risk of infection




• Assess for signs of infection– Maternal fever– Chills– Foul-smelling amniotic fluid– Fetal tachycardia

• Provide emotional support• Assist to cope with frustration of long labor




• Institute supportive measures to decrease anxiety and discomfort– Ambulation– Position changes with pillow support– Quiet, soothing environment– Touch and massage techniques– Personal hygiene




• Institute supportive measures to decrease anxiety and discomfort– Hydrotherapy (bath or shower)– Relaxation exercises– Visualization– Music




• Provide information and encourage questions– Dysfunctional labor process– Implications for mom and baby– Treatments, their disadvantages and

alternatives



Outcomes for the Client with Hypotonic Labor

• Woman maintains comfort during labor• Woman understands the type of labor

pattern and the treatment plan



Learning Outcome Describe the risks and clinical therapy in determining the community-based and

hospital-based nursing care management of postterm pregnancy on the childbearing

family.



Prolonged (Postterm) Pregnancy

• Prolonged 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



Prolonged (Postterm) Pregnancy

• Prolonged pregnancy may result in an increased possibility of– Meconium aspiration– Macrosomia or a loss of fat and muscle mass

resulting in small-for-gestational age (SGA) newborn



Learning OutcomeRelate the various types of fetal malposition

and malpresentation, risks, and clinical therapy to the nursing management for

each.



Causes of Persistent OP Fetal Positioning

• Poor quality contractions• Abnormal flexion of head• Inadequate maternal pushing efforts –

usually due to regional anesthesia• Large fetus



Occiput Presentation



Implications of Persistent OP Positioning

• Prolonged labor• Extensive perineal laceration at birth (3rd or

4th degree)• Vaginal trauma• Extension of midline episiotomy



Implications of Persistent OP Positioning

• Increased fetal morbidity and mortality related to– Prolonged labor– Instrumental or cesarean birth



Clinical Therapy for Persistent OP Positioning

• Close monitoring of maternal and fetal status

• Careful assessment of labor progress• Instrument-assisted birth as needed• Instrument-assisted rotation to OA• Cesarean if lack of labor progress or fetal

descent indicates CPD



Implications of Brow Presentation

• Prolonged labor due to ineffective contractions

• Arrested fetal descent• Cesarean birth for persistent brow

presentation• Increased risk episiotomy and extension if

vaginal birth attempted



Implications of Brow Presentation

• Increased fetal mortality from cerebral and nuchal compression

• Trauma to trachea or larynx• Facial bruising and edema• Exaggerated fetal head molding



Military and Brow Presentation



Clinical Therapy for Brow Presentation

• Monitor for conversion to face or occiput presentation

• Monitor for CPD with persistent brow presentation

• Cesarean indicated in most cases• Monitor for facial edema and

nonreassuring fetal status



Implications of Face Presentation

• Increased risk of CPD and prolonged labor• Cesarean birth if chin is posterior• Increased risk of infection (with prolonged

labor)• Pronounced molding of fetal head• Facial cephalhematoma• Edema of baby’s face and throat if chin is

anterior



Criteria for Vaginal Birth with Face Presentation

• No evidence of CPD• Mentum anterior• Effective labor pattern• Reassuring FHR



Face Presentation



Mechanism of Birth in Face Position



Mechanism of Birth in Face Position



Face Presentation



Clinical Therapy for Face Presentation

• Thorough assessment of fetal position/presentation

• Careful monitoring for labor progress• Cesarean birth if mentum posterior



Types of Breech Presentation

• Frank– Flexion at thighs, extension at knees– Feet up by head– Buttocks present

• Complete– Flexion at thighs and knees– Feet and buttocks present



Types of Breech Presentation

• Footling– Single or double– Extension at thighs and knees– Foot or feet present

• Kneeling– Extension at thighs, flexion at knees– Knees present



Breech Position



Breech Position



Breech Position



Breech Position



Conditions Associated with Breech Presentation

• Preterm birth• Placenta previa• Hydramnios• Multiple gestation• Uterine anomalies – e.g. bicornuate uterus• Fetal anomalies

– Anencephaly– Hydrocephaly



Implications of Breech Presentation

• Likely cesarean birth• Increased perinatal morbidity and mortality

rates• Increased risk of prolapsed cord• Increased risk of cervical spinal cord

injuries due to hyperextension of fetal head during vaginal birth



Implications of Breech Presentation

• Increased risk birth trauma (especially head) during any type of birth

• Increased risk of asphyxia and nonreassuring fetal status



Clinical Therapy for Breech Presentation

• External cephalic version (ECV) prior to labor between 36-38 weeks EGA

• Probable cesarean if version unsuccessful• Consider alternative methods of version



Conditions Associated with Transverse Lie

• Grand multiparity with lax musculature• Preterm fetus• Abnormal uterus• Excessive amniotic fluid• Placenta previa• Contracted pelvis



Transverse Lie



Transverse Lie



Implications of Transverse Lie

• High risk of prolapsed cord• Cesarean birth



Clinical Therapy for Transverse Lie

• Expectant management if <37 weeks EGA• ECV at 37 weeks EGA• Labor induction following successful

version• May attempt ECV in early labor• Cesarean birth if version unsuccessful



Learning Outcome Explain the identification, risks, and clinical

therapy in determining the nursing care management of the woman and fetus at risk

for macrosomia.



Fetal Macrosomia

• Newborn weighing more than 4500 g• Identification of fetal macrosomia is

conducted through– Palpation of fetus in utero– Ultrasound of fetus– X-ray pelvimetry



Management of Fetal Macrosomia

• Cesarean birth performed if fetus is greater than 4500 g

• Continuous fetal monitoring if labor is allowed to progress

• Requires notification of physician for early decelerations, labor dysfunction, or nonreassuring fetal status



Care of Newborn

• Care of newborn with macrosomia requires assessment of newborn for– Cephalhematoma– Erb’s palsy– Fractured clavicles



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



Learning Outcome Relate the maternal implications, clinical

therapy, prenatal history, and conditions that may be associated with nonreassuring fetal status to the nursing care of the mother and

fetus.



Nonreassuring Fetal Status Management



Intrauterine Resuscitation

• Corrective measures used to optimize oxygen exchange within maternal-fetal circulation




• To position:– Turn woman to left lateral position to treat

hypotension– Begin or increase IV flow rate– Perform vaginal exam to check for cord

prolapse– Have woman assume knee-chest position if

cord prolapse is suspected




• To position:– Discontinue Pitocin or administer a tocolytic

agent to decrease contraction frequency and intensity

– Administer oxygen– Notify physician– Obtain additional information about fetus by

fetal scalp blood sampling, fetal scalp stimulation or fetal acoustical stimulation



Learning OutcomeDescribe the nursing care for the mother and fetus with a prolapsed umbilical cord.



Nursing Care in Prolapsed Umbilical Cord

• Assess for nonreassuring fetal status• If a loop of cord is discovered, the

examiner’s gloved fingers must remain in vagina to provide firm pressure on fetal head until physician or CNM arrives

• Oxygen via face mask• Monitor FHR to determine whether cord

compression is adequately relieved




• Woman assumes knee-chest position or bed is adjusted to Trendelenburg position

• Transport to the delivery or operating room in this position






Learning Outcome Summarize the identification, maternal and fetal-neonatal implications, clinical therapy, and nursing care management of women

with amniotic fluid embolus.



Implications of Amniotic Fluid Embolism

• Sudden onset respiratory distress• Acute hemorrhage• Circulatory collapse• Cor pulmonale• Hemorrhagic shock• Coma and maternal death• Fetal death if birth not immediate



Signs and Symptoms of Amniotic Fluid Embolism

• Dyspnea• Cyanosis• Frothy sputum• Chest pain• Tachycardia• Hypotension• Mental confusion• Massive hemorrhage



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• Prepare for CVP line insertion• Administer blood



Learning Outcome Explain the types, maternal and fetal-

neonatal implications, and clinical therapy in determining the nursing care management

of the woman with cephalopelvic disproportion.



Cephalopelvic Disproportion

• Occurs when fetus is larger than pelvic diameter – clinical and x-ray pelvimetry used to determine smallest diameter through which fetal head must pass– Shortest AP diameter <10 cm– Diagonal conjugate <11.5 cm– Greatest transverse diameter <12 cm




• Labor usually prolonged in presence of CPD

• Vaginal birth may be possible depending upon type of CPD




• Woman may increase pelvic diameter during labor by squatting, sitting, rolling from side to side, maintaining knee-chest position, use of a labor ball –

• CPD may make cesarean only available method of birth



Learning Outcome Identify common complications of the third

and fourth stages of labor.



Retained Placenta

• Retention of placenta beyond 30 minutes after birth

• Occurs in 1 in 100-1 in 200 vaginal births• If not expelled, placenta must be manually

removed from uterus – if woman does not have an epidural anesthesia in place, conscious sedation may be required



Lacerations

• Lacerations suspected when bright-red bleeding in presence of contracted uterus

• Usually repaired immediately after birth of child

• Vaginal and perineal lacerations are categorized in terms of degrees



Placenta Accreta

• Chorionic villi attach directly to myometrium of uterus

• May result in maternal hemorrhage and failure of placenta to separate from uterus

• May result in need for hysterectomy at time of birth

• Incidence of placenta accreta is 1 in 533 births



Learning Outcome Explain the etiology, diagnosis, and phases

of grief in determining the nursing care management of the family experiencing

perinatal loss.



Perinatal Loss

• Results from three factors– Fetal factors: Fetus has or develops disorder

incompatible with life– Maternal factors: Mother has disorder such as

diabetes, preeclampsia, advanced maternal age, Rh disease, uterine rupture or ascending maternal infection that creates hostile environment for fetus



Perinatal Loss

• Results from three factors– Placental or other factors: Certain conditions

such as abruptio placentae, placenta previa or cord accident cut off blood supply to fetus, leading to death



Diagnoses 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 found



Tests to Determine Cause of Fetal Loss



Nursing Care

• 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

infant



Nursing Care

• Nursing care involves supporting family through grief work– Prepare items for family to keep to remember

infant– Provide opportunities for religious or spiritual

counseling and cultural practices– Visit or phone family after discharge to assist

in closure



Nursing Care

• Nursing care involves supporting family through grief work– Make referral to appropriate perinatal loss

counseling services if indicated



Learning Outcome Explain the psychologic factors that may

contribute to complications during labor and birth in determining the nursing care

management.



Psychologic Disorders

• Depression– Decreased ability to concentrate– Decreased ability to process information– Feeling overwhelmed– Hopelessness about outcome of labor

• Bipolar disorder– Symptoms of depression– Hyperexcitability if in manic phase




• Anxiety disorders– Chest pain– Shortness of breath– Faintness– Fear or terror




• Labor is time of mixed emotions – laboring woman with psychologic disorder may have impaired coping mechanisms and face additional emotional challenges during labor



Nursing Implications

• Orient to new environment• Thoroughly assess background• Encourage appropriate coping strategies• Maintain a safe environment• Decrease stimulation, as needed




• Ongoing observation for objectives signs of disorder

• Use therapeutic communication and information sharing to establish rapport




• Acknowledge woman’s fears, concerns, and symptoms – identify source of distress

• Use comfort measures, touch, and therapeutic communication as appropriate

• Assist in maintaining and regaining orientation to person/place/time




• Provide ongoing reassurance and information as needed

• Give pharmacologic agents as ordered for severe distress