compli of labor

• Preterm labor

  Labor that occurs after the 20th week & before the 37th week of gestation
• Risk factors for preterm labor

  • Maternal factors: Maternal infection (leading cause), illness or disease (renal/cardiovascular), diabetes mellitus
  • Premature rupture of membranes (PROM)
  • Bleeding
  • Uterine abnormalities/overdistention, incompetent cervix
  • Previous preterm labor, spontaneous of induced abortion, preeclampsia, short interval (less than 1 year)b/w pregnancies
  • Trauma, poor nutrition probably due to low socioeconomic status, no prenatal care, lack of childbirth experience
  • Extremes of age, decreased weight (less than 100 lb.) & less height (less than 5 feet)
  • Lack of rest/excessive fatigue
  • Smoking
  • Extreme emotional stress
• Risk factors for preterm labor

  • Fetal factors: Multiple pregnancy
  • Infections
  • Polyhydramnios
  • Congenital adrenal hyperplasia
  • Fetal malformations
• Risk factors for preterm labor

  • Placental factors: Placental separation
  • Placental disorders
• Risk factors for preterm labor

  • Unknown causes
• Complications of preterm labor

  • Prematurity
  • Fetal death
  • Small-for-gestational age/IUFD
  • Increase perinatal morbidity & mortality
• Treatment for preterm labor

  1. Hospitalization to prevent premature delivery

  2. Bed rest on left lateral recumbent position

  3. Adequate hydration: oral & parenteral

  4. Monitoring: Uterine contractions & irritability q1-2 hrs, v/s, Intake & output, Signs of infection, Cardiac & respiratory status & distress signs

  5. Cervical consistency, dilatation & effacement

  6. Fetal well-being

  7. Early signs of edema: pulmonary edema is a possible complication of ritodrine use
• Promotion of physical & emotional comfort

  Keep client informed of progress
• Administration of tocolytics

  To arrest labor by causing relaxation of the uterus, examples: magnesium sulfate, terbutaline & ritodrine
• Contraindications to arresting premature labor

  • Advanced pregnancy
  • Ruptured bag of waters
  • Maternal diseases like bleeding complications, PIH, cardiovascular disease
  • Fetal distress
  • Presence of fetal problems like Rh isoimmunization
• Administration of corticosteroids

  To enhance maturation of fetal lungs by stimulating the production of surfactant when there are contraindications to attempts to arrest preterm labor
• Discharge

  Once contractions have stopped, & maternal & fetal conditions stabilized, the client is discharged
• Health teachings to prevent recurrence of premature labor

  • Maintain bed rest, left lateral preferred
  • Well-balanced diet: high in iron, vitamins, & important minerals
  • Continuation of oral medications (Yutopar) at home
  • Frequent prenatal visit every week for the duration of the remaining weeks
  • Activity/lifestyle evaluated & restricted as necessary
  • Illnesses: chronic – monitored; acute – treated STAT
• Provide client teaching: symptoms of preterm labor & prompt reporting to the physician when present
• Precipitate labor

  Shorter labor that lasts 2 -3 hours or less
• Risk factors for precipitate labor

  • Multiparity – the most common/important factor
  • Trauma
  • Large pelvis & lax soft tissues
  • Small fetus
  • Labor induction by oxytocin & rupture of membranes
  • Severe emotional stress
• Complications of precipitate labor

  • Maternal: laceration, hemorrhage, infection, uterine rupture if birth canal is not readily distensible & hypotonic contractions – hemorrhage
  • Fetal: hypoxia, anoxia, sepsis & intracranial hemorrhage
• Treatment for precipitate labor

  1. Episiotomy

  2. Delivery
• Assessment findings for precipitate labor

  • Tetanic-like contractions
  • Rapid labor & delivery
  • Desire to push
  • Strong contractions
  • Ruptured membranes
  • Heavy bloody show
  • Bulging rectum
  • Severe anxiety
• Nursing implementation for precipitate labor

  1. Never leave client

  2. Monitor FHT q15 min to detect distress from fetal hypoxia secondary to tetanic contractions

  3. Provide emotional support

  4. Reassure that you will stay

  5. Explain precipitate labor in simple terms

  6. Inform the client of what is happening

  7. Provide care until unit physician/help arrives

  8. Assist client in retaining a sense of control over what is happening

  9. Assist with delivery: Never hold the baby back, Put on sterile gloves if available, & if there is still time, Have client pant & not push, Rupture the membranes when head crowns, Gently slip the cord over the head, Use gentle pressure to fetal head upwards toward the vagina to prevent damage/injury to fetal head & vaginal lacerations, Deliver head in-between contractions, Shoulders are usually born spontaneously after external rotation; if not, use gentle pressure downward pressure to move anterior shoulder under symphysis pubis & then use upward pressure for the delivery of posterior shoulder, Support the fetal body during expulsion & then wipe the body, Care for the cord: If materials are available, clamp cord in two places & cut b/w with clean knife or scissors, If there is no available instrument for cord clamping & cutting, just double tie using the cleanest possible piece of cloth or string (i.e., a clean handkerchief) ensuring that there is no pulsation b/w the ties to prevent transfusing newborn blood to the outside which will lead to neonatal hemorrhage & shock, Allow placenta to separate naturally, Place the infant on mother's abdomen, or better still encourage mother to breastfeed to induce uterine contractions & for reassurance that all is well, Institute measures as prescribed in the third & fourth stage of labor, Handle delivery gently to prevent injury to mother & baby
• Premature rupture of membranes (PROM)

  Rupture of the membranes before term/labor; unconnected with labor
• PROM is rupture of the chorion & amnion 1 hour or more before the onset of labor. The gestational age of the fetus & estimates of viability affect management
• The precise cause & specific predisposing factors of PROM are UNKNOWN
• Assessment findings for PROM

  • Maternal report of passage of fluid per vagina
  • Determination of alkaline amniotic fluid & not acidic urine or vaginal discharge
  • Pooling of amniotic fluid in the vagina will be visualized during a speculum examination
  • Maternal fever, fetal tachycardia, & malodorous discharge may indicate infection
• Laboratory & diagnostic study findings to confirm PROM

  • Nitrazine test – change in the color of Nitrazine paper from yellow (acidic vaginal pH = 4-6) to blue color because of neutral to slightly alkaline amniotic fluid (pH = 7-7.5)
  • Ferning Test – amniotic fluid, high in sodium content, & will assume a ferning pattern when dried on the slide
  • Sterile speculum examination – direct visualization of fluid from cervical os is the most reliable diagnosis of PROM
• Complications of PROM

  • Maternal infection/chorioamnionitis – most common
  • Cord prolapse
  • Premature labor
• Nursing implementation/management for PROM

  1. Maintain bed rest. Do not allow ambulation to prevent prolapse of the umbilical cord

  2. Calculate gestational age

  3. Monitor maternal v/s & fetal well-being

  4. Observe & record the character, amount, color, & odor of amniotic fluid

  5. Be alert for early signs of infection: fever, chills, malaise, & signs of labor onset

  6. Monitor for signs of prolapsed cord

  7. Provide appropriate treatment as ordered: If there are signs of infection: antibiotics & immediate delivery, If without signs of infection, induction of labor delayed, provided fetus is healthy

  8. Provide psychological support: Explain the procedures & findings, Support client & family, Inform of progress, Prepare client & family for early interruption of pregnancy as indicated
• Cord prolapse

  Descent of the umbilical cord into the vagina ahead of the fetal presenting part with resulting compression of the cord b/w the presenting part & the maternal pelvis
• Cord prolapse is an emergency situation; immediate delivery will be attempted to save the fetus
• Cord prolapse occurs in 1 to 200 pregnancies
• Etiology of cord prolapse

  • Prematurity
  • Rupture of membranes with the fetal presenting part unengaged
  • Shoulder or footling breech presentations
  • The fluid rush may carry the cord along toward the birth canal
• Assessment findings for cord prolapse

  • Cord prolapse may be occult & occur at any time in the labor process, even when the amniotic fluid membranes are intact
  • Client reports feeling the cord within the vagina
  • Fetal bradycardia with deceleration during contraction
  • The umbilical cord can be seen or felt during a vaginal examination
• Nursing management for cord prolapse

  1. Identify prolapse cord & provide immediate intervention

  2. Assess a laboring client often if the fetus is preterm or small for gestational age, if the fetal presenting part is not engaged, & if the membranes are ruptured

  3. Periodically evaluate FHR, especially right after rupture of membranes (spontaneous or surgical), & again in 5 to 10 minutes

  4. If prolapsed cord is identified, notify the physician & prepare for emergency cesarean birth

  5. If the client is fully dilated, the most emergent delivery route may be vaginal. In this case, encourage the client to push & assist with the delivery as follows: Lower the head of the bed & elevate the client's hips on a pillow, or place the client in the knee-chest position to minimize pressure on the cord, Apply oxygen at 10 to 12 l/min, Apply firm upward manual pressure to the presenting part of the fetus with a sterile gloved hand to elevate the fetus & relieved pressure from the cord, Assess cord pulsations constantly, Gently wrap gauzed soaked in sterile normal saline solution around the prolapse cord

  6. Provide physical & emotional support

  7. Provide client & family education
• Prolonged pregnancy

  A pregnancy that extends past 42 weeks' gestation
• The incidence of prolonged pregnancy is approximately 10%
• The cause of prolonged pregnancy is unknown, but suggested etiology is estrogen deficiency
• Assessment findings for prolonged pregnancy

  • Weight loss & decreased uterine size (when the infant is suffering from placental dysfunction)
  • Excessively large uterus
  • Meconium-stained fluid
  • Nonreassuring fetal heart patterns
• Nursing management for prolonged pregnancy

  1. Carefully assess the fetus to identify risk

  2. Perform a careful risk assessment upon admission

  3. Closely monitor fetal status

  4. Assist with induction of labor

  5. Prepare for a difficult delivery notify the pediatric staff of the potential for a birth-injured baby

  6. Provide physical & emotional support

  7. Provide client & family education
• Fetal distress

  Fetal condition resulting from fetal hypoxia
• Risk factors for fetal distress

  • Dystocia
  • Cord coil, cord compression
  • Improper use of oxytocin, analgesia/anesthesia
  • DM, cardiac disease & other co-existing conditions in the mother
  • Bleeding complications in the third trimester like placenta previa & abruption placenta
  • PIH
  • Supine hypotensive syndrome