The woman who develops a complication during labor

and birth

Hypotonic Uterine ContractionThe number of contractions is usually low or infrequentMay occur after the administration of analgesia especially if the cervix is not dilated to 3 or 4 cm or if bowel and bladder distension prevents descent or from engagement.

Management Start oxytocin infusion

Amniotomy, to further speed labor

In the first hour after birth palpate the uterus and assess lochia every 5 minutes.

Hypertonic Contractions Are marked by an increased in resting tone.

Management:

Rest and pain relief with a drug such as morphine sulfate. Darkening room lights. Decrease noise and stimulation Cesarean birth maybe necessary.

POSTMATURE PREGNANCY

General information Defined as those pregnancies lasting

beyond the end of the 42nd week. Fetus at risk due to placental

degeneration and loss of amniotic fluid Decreased amounts of vernix also allow

the drying of the fetal skin, resulting in a dry, parchment like skin condition

Medical management Directed toward ascertaining precise

fetal gestational age and condition, and determining fetal ability to tolerate labor

Induction of labor and possibility cesarean birth

Nursing Interventions Perform continual monitoring of

maternal/fetal vital signs Support mother through all testing and

labor

PROLAPSED UMBILICAL CORD

General information Displacement of cord in a downward direction,

near or ahead of the presenting part, or into the vagina

May occur when membranes rupture. Associated with breech presentation,

unengaged presentations and premature labor Obstetric emergency if compression of the

cord occurs, fetal hypoxia may result in CNS damage or death.

Assessment findings Vaginal examination identifies cord prolapsed

into vagina

PROLAPSED UMBILICAL CORD

Nursing Interventions Check FHT immediately when

membranes rupture, and again after next contraction, or within 5 minutes; report decelerations

If fetal bradycardia, perform vaginal examination and check for prolapsed cord

If cord prolapsed into vagina, exert upward pressure against presenting part to lift part off cord, reducing pressure on cord

Get help to move the mother into a position where gravity assist in getting presenting part off cord (knee chest position or severe trendelenburg’s)

Administer oxygen for immediate cesarean birth

If cord protrudes outside vagina, cover it with sterile gauze moistened with sterile saline while carrying out above tasks. Do not attempt to replace cord.

FETAL DISTRESS

General information Cord compression Placental abnormalities Preexisting maternal diseaseAssessment findings Decelerations in FHR Meconium-stained amniotic fluid

with a vertex presentation

Nursing interventions: Check FHR on appropriate basis Conduct vaginal exam for presentation

and position Place mother on left side, administer

oxygen, check for prolapsed cord, notify physician

Support mother and family Prepare for emergency birth if indicated

DYSTOCIAGeneral information Any labor/delivery that is prolonged or difficult Usually results from a change in the

interrelationships among the 4 P’s that is the factors in labor and delivery

Frequently seen causes include: disproportion between fetal presentation (usually the head) and the maternal pelvis (CPD) if disproportion is minimal, vaginal birth may be attempted if fetal injuries can be minimized or eliminated.

cesarean birth needed if disproportion is great.

– problems with presentation» any presentation unfavorable

for delivery (e.g. breech, shoulder, face, transverse lie)

» posterior presentation that does not rotate, or cannot be rotated with ease.

» cesarean birth is the usual intervention

– problems with maternal soft tissue

Nursing Interventions Individualized as to cause Provide comfort measures for

client Provide clear, supportive

descriptions of all actions taken Administer analgesia if ordered Prepare oxytocin infusion for

induction of labor as ordered. Monitor mother/fetus continuously Prepare for cesarean birth if

needed

Shoulder dystociaShoulder dystocia

happens when after delivery of the head the anterior shoulder is trapped and arrested behind symphisis pubis.

Fetal complications:1. Erbs palsy2. Fracture humerus and

clavicle3. Abnormal neurologic

examinations

shoulder dystocia.flv

Management of shoulder dystocia

Mc Robert’s maneuver- flexing legs of the parturient sharply over the abdomen

Woodcorkscrew maneuver- rotating anterior shoulder 180 degrees to dislodge it

Cleidotomy- cutting the clavicles

Rubins maneuver- rocking the shoulders from side by side by applying force over the abdomen

Suprapubic pressure Strong fundal pressure• Rotate posterior arm to

anterior position• Extraction of posterior arm• All procedures should not

take more than five minutes

PRECIPITOUS LABOR AND DELIVERY

General Information• Labor less than 3 hours• Emergency delivery without clients

physician or midwife Assessment findings• As a labor is progressing quickly,

assessment may need to be done rapidly.

• Client have history of previous precipitous labor and delivery

Nursing Intervention: If you have to deliver the

baby yourself: Asses the client’s affect and ability

to understand directions, as well as other resources available

Stay with the client at all times Do not prevent birth of the baby Maintain sterile environment if

possible

Rupture membranes if necessary

Support baby’s head as it emerges, preventing too-rapid delivery with gentle pressure

Use gentle aspiration with bulb syringe to remove blood and mucus from nose and mouth

Deliver shoulders after external rotation, asking mother to push gently

Provide support for baby’s body as it delivered

Hold baby in a head down position to facilitate drainage of secretions

Promote cry by gently rubbing over back and soles of feet

Dry to prevent heat loss Place baby on mother’s abdomen Check for signs of placental

separation Check mother for excess

bleeding, massage uterus prn

Hold placenta as it delivers Cut cord when pulsation

cease, if cord clamped available, if no clamps keep it intact.

Wrap baby in dry blanket, give to mother, put to breast if possible

Check mother for fundal firmness and bleeding

Record all pertinent data Comfort mother and family as

needed

SPONTANEOUS DELIVERY• The encirclement of the largest head

diameter by the vulvar ring is known as crowning.

• RITGEN MANEUVER * gloved hand is used to exert pressure on

the chin of the fetus through the perineum just in front of the coccyx

* allows controlled delivery of the fetal head

* favors extension of the fetal head

RITGEN MANEUVER

Vaginal delivery of breech presentation

PINARD MANEUVER

MAURICEU MANEUVER

PRAGUE MANEUVER

External Cephalic Version

AMNIOTIC FLUID EMBOLISM

General information Escape of amniotic fluid into the maternal

circulation, usually in conjunction with a pattern of hypertonic, intense uterine contractions, either naturally or oxytocin induced.

Obstetric emergency; may be fAtal to the mother or to the fetus.

Assessment findings Sudden onset of respiratory distress,

hypotension, chest pain, signs of shockBleedingCyanosisPulmonary edema

Nursing Intervention Initiate emergency life support

activities for mother.administer oxygenutilize CPR in case of cardiac

arrest establish IV line for blood

transfusion administer medication to control

bleeding as ordered prepare for emergency birth of

baby keep client/family informed as

possible

INDUCTION OF LABOR

General Information -Deliberate stimulation of uterine

contractions before the normal occurrence of labor.

Medical management Amniotomy (the deliberate rupture

of the membrane) Oxytocins, usually Pitocin Prostaglandin in gel/suppository

form to improve cervical readiness

Assessment findings Indication for use

Postmature pregnancyPreeclampsia/eclampsiaDiabetesPremature rupture of

membranes Condition of fetus; mature,

engaged vertex fetus , no distress

Condition of mother; cervix “ripe” for induction, no CPD

Nursing Interventions Explain the procedure to client Prepare appropriate equipment

and medications. Amniotomy; a small tear made

in amniotic membrane as part of sterile vaginal exam

Oxytocin (Pitocin); IV administration “piggybacked” to main IV

Know the continuous monitoring and accurate assessment are essential.

Discontinue oxytocin infusion when fetal distress, hypertonic contractions occur, signs of obstetric complications appear. (hemorrhage/shock, abruption placenta, amniotic fluid embolism)

Notify physician of any untoward reactions.

RUPTURED UTERUS

A ruptured uterus is characterized by a tearing or splitting of the uterine wall during labor; it is usually a result of a thinned or a weakened area that cannot withstand the strain and force of uterine contraction.

ASSESSMENT Risk factor:1. Multiparity2. Obstructive labor3. Improper use of pitocin4. Large fetus5. Weakened, old cesarean

section scar6. External forces such as traumaClinical manifestations: Pain above the symphysis

pubis Sudden, acute abdominal pain

during a contraction Vaginal bleeding, shock; fetal

distress

Uterine Rupture.flv

Treatment: Surgical: laparotomy to

remove fetus, followed by a hysterectomy.

Medical management:1. Blood transfusion2. Prophylactic

antibiotics

Nursing Intervention:Provide nursing management

associated with hemorrhage.Assess for early diagnosis:

Maternal mortality rate is highPrognosis for fetus is poor; fetus usually dies as a result of anoxia caused by placental separation.

INTRAUTERINE FETAL DEATH

Intrauterine fetal death is also called fetal demise.

ASSESSMENT: Absence of FHR and fetal

movement. Negative pregnancy test result Ultrasound examination

determines absence of FHR and occurrence of fetal skull collapse.

Nursing Intervention:Goal: To support the couple through

the grieving process.• Encourage expression of feelings;

do not minimize the situation or event.

• Provide opportunity for the couple to spend time with still born, if they so desire.

• Monitor for complication.