Chap 23

• Complications with the power:

  • Higher risk for postpartal infection, hemorrhage, infant mortality
  • Contraction strength is important for dilating the cervix and aiding the baby's descent
  • Inertia or dysfunctional labor can occur, especially if the fetus is large
  • Ineffective uterine force is caused by factors like hypotonic, hypertonic, and uncoordinated contractions
  • Desired frequency of uterine contractions in normal labor is one contraction every two to three minutes or less than five contractions in a 10-minute period
• Dysfunction at the First Stage of Labor:

  • Prolonged latent phase may require management like changing linen, decreasing noise, amniotomy, oxytocin administration, or cesarean section
  • Protracted active phase may be associated with cephalopelvic disproportion or fetal malposition, requiring oxytocin administration or cesarean section
  • Prolonged deceleration phase may result from abnormal fetal head position, managed with cesarean section
  • Secondary arrest of dilatation may require cesarean section or hysteroscopic dilation
• Dysfunction at the Second Stage of Labor:

  • Prolonged descent may need interventions like rupturing the amniotic sac, oxytocin administration, and specific positioning
  • Arrest of descent may require cesarean section or vaginal delivery with oxytocin administration
• Contraction Rings:

  • Pathologic retraction ring can interfere with fetal descent and may require interventions like morphine IV, tocolytic, cesarean section, or manual placenta evacuation
  • A contraction ring can delay delivery by contracting around the child's neck
• Precipitate Labor:

  • Labor completed in fewer than 3 hours with strong contractions
  • May result in premature separation of placenta or perineal lacerations
  • Tocolytic agents like magnesium sulfate, indomethacin, and nifedipine can be used for preterm labor
• Induction and Augmentation of Labor:

  • Induction started artificially, augmentation assists ineffective spontaneous labor
  • Reasons for induction include fetal danger, term baby with no contractions, PIH, diabetes, Rh sensitization, prolonged rupture of membranes, or post maturity
  • Considerations for induction include fetal position, cervical readiness, engagement, absence of CPD, and estimated fetal maturity
• Uterine Rupture:

  • Occurs from excessive strain on the uterus, leading to strong contractions without cervical dilatation
  • Causes include prolonged labor, abnormal presentation, multiple gestation, unwise oxytocin use, obstructed labor, or traumatic maneuvers
  • Symptoms include sudden severe pain during contractions, sign of shock
  • Management may involve cesarean section, fluid replacement, oxytocin administration, laparotomy, hysterectomy, and advising against future pregnancies
• Changes in the perineum indicating imminent birth:

  • Bulging perineum and rectum with an increase in bloody show
• Uterine rupture priority is limiting hypovolemic shock
• Uterine inversion refers to the uterus turning inside out during birth or delivery of the placenta
• Management of uterine inversion includes never attempting to replace inversion or remove the placenta, starting an IV line, administering oxygen by mask, performing CPR if cardiac arrest, antibiotic therapy, and Cesarean section for future pregnancy
• Amniotic fluid embolism occurs when amniotic fluid enters a maternal uterine blood sinus through a defect in the membranes or after membrane rupture
• Symptoms of amniotic fluid embolism include sharp chest pain, inability to breathe, and skin turning pale then bluish-gray
• Management of amniotic fluid embolism includes administering oxygen by cannula or mask and performing CPR
• In amniotic fluid embolism, the nursing priority is giving immediate and vigorous treatment
• Complications with the passenger during birth include prolapse of the umbilical cord
• Management of prolapse of the umbilical cord involves relieving pressure on the cord, placing the woman in knee-chest or Trendelenburg position, administering oxygen by mask, not pushing any exposed cord back into the vagina, and covering any exposed portion with a sterile saline compress
• Complications with the passenger also include multiple gestation
• Management of multiple gestation includes instructing the woman to come to the hospital early in labor, supporting the woman's breathing pattern during labor, and preparing for possible abnormal presentations
• Problems with fetal position, presentation, or size include face presentation
• Face presentation can result in asynclitism and may require a Cesarean section
• Complications with the passenger also include brow presentation
• Brow presentation is rare and can lead to obstructed labor, often requiring a Cesarean section
• Complications with the passenger further include transverse lie
• Transverse lie occurs in women with pendulous abdomen, uterine fibroid tumors, or polyhydramnios, and may require a Cesarean section
• Complications with the passenger also include macrosomia
• Macrosomia, weighing more than 4,000 to 4,500 g, can lead to uterine dysfunction and fetal pelvic disproportion, often requiring a Cesarean section
• Fetal risks of macrosomia include brachial plexus injury
• Brachial plexus injury during childbirth can result in Erb-Duchenne Palsy
• Shoulder dystocia occurs when the shoulders are too broad to be born through the pelvic outlet, requiring careful management to prevent hazards to the woman and infant
• Complications with the passenger also include breech presentation
• Breech presentation can lead to perinatal morbidity and mortality, and the sub-classifications include frank breech, complete breech, and footling breech
• Diagnosis of breech presentation involves abdominal and vaginal exams, x-ray, and ultrasound
• Complications with the Psyche:

  • A good emotional state during birth helps mom cope with pain effectively
  • Helps mom tune in to her body
  • Helps guide her to her baby's needs and allows the other 3 P's to sync up effectively
  • If mom is afraid, tense, stressed out, angry, feels unsafe or unsupported, she will not likely do well during birth
  • Fear can lead to scheduling a c-section or avoiding a vaginal birth
  • Fear may prevent cervical dilation, fetal descent, or prevent mom from pushing effectively
• • Primigravidas may experience engagement of the fetal head between weeks 36 and 38 of pregnancy
  • "Whatever goes in, comes out" - a head that engages into the pelvic brim will be able to pass through
  • Outlet Contraction:
  • Narrowing of the transverse diameter to less than 11cm
  • Rare, but should be readily diagnosed during routine assessment
  • Management options include NSD, Cesarean Section, and Trial Labor
• Complications with the Passage Anatomy of the Pelvis:

  • Dystocia can occur due to a contraction or narrowing of the passageway or birth canal
  • Contraction can happen at the inlet, midpelvis, or outlet
  • Narrowing causes CPD, a disproportion between the size of the fetal head and the pelvic diameters, resulting in failure to progress in labor
  • Inlet Contraction:
  • Narrowing of the anteroposterior diameter of the pelvis to less than 11 cm or of the transverse diameter to 12 cm or less
  • Usually caused by rickets or inherited small pelvis
• • Velamentous Insertion of the Cord:
  • Cord separates into small vessels that reach the placenta by spreading across a fold of amnion
  • Vasa Previa:
  • Blood vessels connecting the umbilical cord to the placenta lie over or near the entrance to the birth canal
• Anomalies of the Placenta and Cord:

  • Placenta Succenturiata:
  • A placenta with one or more accessory lobes connected to the main placenta by blood vessels
  • Small lobes may be retained in the uterus after birth and can cause hemorrhage
  • Placenta Circumvallata:
  • Chorion membrane transitions to a villous chorion from the placental edges
  • Placenta Accreta:
  • Unusual deep attachment of the placenta to the uterine myometrium
  • Management includes hysterectomy and administration of Methotrexate
  • Battledore Placenta:
  • Cord is inserted marginally rather than centrally
• Anomalies of the Cord:

  • Two-vessel cord:
  • Absence of one artery suggests congenital heart and kidney anomalies
  • Unusual Cord length:
  • Unusual short cord may indicate premature separation of the placenta or an abnormal fetal lie
  • Unusual long cord may lead to twisting or knotting/nuchal cord