Chapter 32: Labor and Birth Complications

Preterm Labor and Birth

Preterm Labor – labor that occurs before 37 weeks and produces cervical effacement and dilatation

Preterm birth – birth that occurs between 20 weeks and 37 weeks

Rate has been dropping for all races, mainly due to three factors

1.improved fertility practices that reduce higher order multiple gestations (triplets, quads, etc)

2. limiting scheduled births of less than 39 weeks to only those with valid reasons

3. increase strategies to reduce preterm birth

Rate remains high for non-Hispanic black women, American Indian/Alaska Natives, and Hispanics

Classifications

Very preterm - < 32weeks of gestation

Moderately preterm – 32-34 weeks of gestation

Late preterm – 34-36 weeks of gestation

Risk is directly related to degree of prematurity

75% of preterm births are late preterm, have risk for early death and long term health problems

Greatest morbidity occurs in the very preterm infant

In the past birth weight was used to describe preterm infants. Not an accurate term, low birth weight babies are not necessarily
premature. An example is IUGR resulting from preeclampsia

Preterm birth can be either spontaneous or indicated. See box 32-1 and 32-2 for risk factors associated with each.

Diagnostic criteria is gestation between 20-36 6/7 weeks, uterine activity and progressive cervical change
Causes of Preterm Labor

Multifactorial Intrauterine inflammation

Infection is definitively associated with preterm labor Uterine vascular compromise

Bacterial cervical and UTI are most likely cause (most Uterine overdistention
common in <32 wks)

Allergic reaction
Intraabdominal infections (appendicitis) and
periodontal disease are also a suspect
 progesterone

Placental implantation bleed

Strong indication that the immune system and pro-inflammatory cytokines play large role in preterm labor

Cytokines are a large group of proteins, peptides or glycoproteins that are secreted by specific cells of immune
system. Cytokines are a category of signaling molecules that mediate and regulate immunity, inflammation and hematopoiesis.

Risk Factors

Previous preterm labor or birth Placenta disorders

Non-white race Obesity

Genital tract infection or colonization Advance maternal age

Multifetal gestation Oligo or polyhydramnios

Second trimester bleeding Poverty

Low pre-pregnancy weight Lack of education

Pre-existing medical conditions Lack of access of prenatal care

Gestational onset conditions Genetic relation

Predicting Preterm Labor

Identifying those at risks and then closely monitoring them

No one risk scoring system has been 100% accurate

Short cervical length

Fetal Fibronectin Test-found in cervix early in pregnancy and again late in pregnancy. Has a better negative predictive value.
ROM, vag exam with K-Y and sex will alter results

Combined approach of cervical length and fFN is better at determining who is at risk for preterm labor in next 7 days

Assessment and Prevention

Educate women on signs of preterm labor, ideally prior to conception but for sure in early pregnancy

Preconception care would include identifying women at risk based on prior OB hx, race or other factors

Primary prevention strategies include adequate diet, smoking cessation

Preterm labor is insidious and can be mistaken for normal discomforts of pregnancy

Teaching for Self Management, page 685

Box 32-3 Signs and Symptoms of Preterm Labor

Contrx less than 10 min apart persisting for Urinary frequency

more than hour

Change in vaginal discharge

Lower back pain, cramping, supra-pubic
pressure or pain

Prophylactic progesterone can help prevent preterm labor in women with short cervix or hx of PTL. Started at 16 wks and
cont’s until 36 wks. Does not work in multifetal gestation
Interventions to Reduce Neonatal Morbidity

Transfer to hospital with Level III NICU Glucocorticoids to stimulate surfactant production, also
reduce intraventricular hemorrhage and necrotizing
enterocolitis
Antibiotics to prevent or treat group B strep infection

Mag Sulfate for neuroprotective benefit

Lifestyle Modifications

Modified bed rest Keeping items in reach

Restriction of sexual activity Bed or couch near window or bathroom

Home care-assist the women with modification of Diversional activities

environment to reduce activities.

See Teaching for Self-Management, page 685

Suppression of Uterine Activity

Tocolytics – medications used to stop contractions once cervical dilation has begun

No approved tocolytic medication is available in the US/ Currently using medications that are “off-label”

Medications don’t reduce rate of preterm birth, rather they buy us time and allow for transport of mom and for corticosteroids
to reach maximum benefit

Contraindications to Tocolysis

Maternal Fetal

Preeclampsia with severe features or Fetal demise

eclampsia

Lethal fetal anomaly

Bleeding with hemodynamic instability

Non-reassuring fetal status

Contraindications to specific tocolytics

Chorioamnionitis

PPROM
Nursing Care – Tocolytic Therapy

Explain purpose and side effects Monitor maternal fluid balance (daily weights and
I&O)

Left side to enhance placental perfusion

Limit fluid intake to 2500-3000ml/day especially if on
Mag Sulfate or Beta Mimetic
Monitor V/S, Lung sounds, resp effort, maternal HR,
fetal status and labor status
Provide psychosocial support

Monitor for adverse reactions

Provide diversional activities

Tocolytic Medications

Mag Sulfate most commonly used, less side effects and neuroprotective benefit, not approved as a tocolytic, contraindicated in
women with Myasthenia Gravis

Beta Adrenergic agonists (Beta Mimetics) such as Brethine are also used but have more side effects.

Maternal Tachycardia

Maternal Hyperglycemia

DO NOT USE – women with suspected heart disease, pre-eclampsia, pregestational or gestational diabetes, hypothyroidism,
and women with migraines

Prostaglandin Synthetase Inhibitors (NSAIDS) ie Indomethacin

Tolerated well by mom but has serious fetal side effects such as constriction of ductus arteriosus and neonatal
pulmonary hypertension, oligohydramnios,

Use for less than 48 hours and before 32 weeks gest

Calcium Channel Blocker (Procardia)

Less maternal and fetal side effects

DO NOT USE with Mag Sulfate or give concurrently with Beta Mimetic. Will affect heart and blood pressure
Antenatal Glucocorticoids

Accelerates fetal lung maturity Dexamethasone, 6mg IM for four doses, 12 hrs apart

Reduces the incidence of RDS, IVH, NEC Assess maternal blood glucose. Women with diabetes
may require  insulin doses for several days after this
injection
Betamethasone, 12 mg IM for two doses, 24 hrs apart

May repeat dose if another episode of PTL occurs in the

pregnancy

Management of Inevitable Preterm Birth

Mag Sulfate recommend for neuroprotectant for 24-32 Birth may be rapid and malpresentations may occur
weeks of gestation. Dose is the same as tocolytic
therapy
Depending of gestational age, death may occur.

Prepare for life support of the infant.

Premature Rupture of Membranes/Preterm Premature ROM

PROM – spontaneous rupture of membranes before the onset of labor at any gestational age

PPROM – Rupture of membranes before 37 weeks gestation, weakening of membranes caused by inflammation, stress from
uterine contractions or other factors that increase intrauterine pressure

Box 32-6 Risk factors for PPROM

Chorioamnionitis is the most common complication of PPROM

Abruption may occur as well as sepsis, and death

Fetal complications are related to infection as well as cord prolapse, cord compression ant fetal hypoplasia
Care Management

If gestation 32-33 and fetal lung maturity is Risk to fetus and newborn is greater than risk of
documented, delivery will be expected infection

If gestation 34-36 weeks, delivery will be actively 7 day course of antibiotics- shown to  chorio, PP
pursued endometritis, pneumonia, IVH

The greatest risk is infection Fetal assessment and teach woman to keep genital area
clean.

If gestational age is less than 32 weeks then expectant

management will occur Watch for signs of infection

If signs of infection begin, vaginal bleeding occurs, placental abruption is suspected, or preterm labor and/or fetal compromise
starts then the baby will be delivered.

Postterm Pregnancy, Labor, and Birth

Postterm pregnancy (postdates) pregnancy greater than or equal to 42 weeks of gestation

less than 0.5% of all births in the United States

First date of LPM is not a reliable indicator of true gestational age.

Risk factors for it to occur – 1st preg, prior posterm preg, male fetus, obesity and genetic predisposition.

Clinical manifestations- maternal wt loss (> 3lbs/wk), decreased amniotic fluid, meconium in amniotic fluid and hard fetal
skull.

Maternal and Fetal risks if it occurs:

Increased Maternal morbidity Prolonged labor

Dysfunctional labor and birth canal trauma Shoulder dystocia or operative birth risks
increase

Labor and birth interventions more likely

Postmaturity syndrome in the infant -  SubQ
fat, lanugo and vernix; dry, peeling skin, long
Abnormal fetal growth (macrosomia) nails, and meconium staining of the skin, nails
and umbilical cord

Teaching for Self Management, Postterm pregnancy, p. 692.

Interprofessional Care management

 Controversial meaning differing views on how to management it. Will include all disciplines (Nursing, Radiology,
EFM)

Perinatal morbidity and mortality increase greatly beginning at 41 0/7 weeks of gestation

More frequent fetal assessment, testing

NST, contraction stress test (CST), BPP, woman is encouraged to assess fetal
or modified BPP activity daily, assess for signs of labor,
and keep appointments with her
obstetric health care provider

Practice in application…

Your client is a G2 P1001 at 42 weeks gestation. Her biophysical profile (BPP) exam was 4/10.

What does this mean about the health of her fetus?

Given her gestational age, what are some of the potential causes of this condition?

Her cervical exam reveals cervix is closed/ long/ -3/ firm/ posterior

What is her Bishop’s score? Given this score, what type of induction orders might the nurse anticipate?

Dysfunctional Labor (Dystocia):

Dystocia: lack of progress in labor for any reason

Dysfunctional labor: Long, difficult, or abnormal labor

Most common indication for c-birth; responsible for approximately 30% of all cesarean births

Five factors affect labor

The powers Maternal position

The passage Psychologic responses

The passenger

Abnormal Uterine Activity

 Latent Phase Disorders

Hypertonic uterine dysfunction – usually a first-time mother (not always) who is having painful and frequent
contractions which are not dilating or effacing the cervix.

Contrx’s may be occurring in the middle of the uterus rather than starting in the fundus which does not push the
presenting part downward . Uterus may not fully relax between contrx’s.

Managed expectedly because most women will enter the active stage of labor at some point.

Therapeutic rest – can also be used. Consists of warm bath or shower an analgesic (morphine, or Ambien),
Woman wakes up in active labor with normal contraction pattern.

Active Phase Disorders

Protraction disorders, where progress in labor is slower than normal; common cause is hypotonic uterine
dysfunction (OP presentation, brow or face presentation.

Arrest disorders, where there is no progress in labor. Initially makes normal progress into the active phase of
first-stage labor but then the contractions become weak and inefficient or stop altogether. (CPD)

Treatment – assess presenting part for optimal position, strength of contx’s, then Pitocin is started,

Dysfunctional Labor (Dystocia)

See Table 32.1 Dysfunctional Labor

Secondary powers

Problems with bearing-down efforts ( exhaustion, maternal position, i.e. positioned on her back in bed)

Abnormal labor patterns

Friedman’s classification of “normal” labor patterns

Updated, evidence-based awareness of “normal” labor is that modern labor is slower for both the primip and multip

Women in general are older and heavier which is both are associated with longer labors.

Precipitous labor

Labor that lasts less than 3 hours from the onset of contractions to the time of birth
 Occurs in approximately 3% of all births in the United States

May result from hypertonic uterine contrx’s that are tetanic (long and doesn’t let up in intensity) in nature.

Seen in placental abruption, uterine tachysystole and recent cocaine use

Maternal complications – uterine rupture, lacerations of the birth canal, AFI and PP hemorrhage.

Fetal – hypoxia, intracanal trauma

Dysfunctional Labor (Dystocia): Passageway

Alterations in pelvic structure

Pelvic dystocia

Contractures of pelvic diameters that reduce the capacity of the bony pelvis, inlet, midpelvis, or outlet (fractured
pelvis)

Soft-tissue dystocia

Results from obstruction of the birth passage by an anatomic abnormality other than that of bony pelvis
(placenta previa, HPV, cervical swelling, fibroids)

Dysfunctional Labor (Dystocia): Passenger

Fetal causes

Anomalies (hydrocephalus) Malpresentation (breech)

Cephalopelvic disproportion (CPD), also called Multifetal pregnancy (first twin vertex but
fetopelvic disproportion (FPD) second twin breech or transverse lie)

Malposition (OP)

Dysfunctional Labor (Dystocia): Position (Maternal)

Maternal position alters relationship between uterine contractions, fetus, and mother’s pelvis
 Upright or squatting position facilitates opening of pelvis and encourages proper presentation of the fetus in and through the
pelvic outlet.

On back is the worst. Slows contractions and decreases fetal descent.

Dysfunctional Labor (Dystocia): Psychologic responses

Hormones and neurotransmitters released in Build trust with your patient.

response to stress can cause dystocia

Ensure a calm and soothing environment.

Sources of stress and anxiety vary

Obesity

Obese pregnant women are at increased risk for complications:

Spontaneous abortion and stillbirth Fetal congenital abnormalities

Pregnancy-associated hypertensive disorders Cesarean birth

Gestational diabetes Venous thromboembolism

Intrapartum Challenges:

Standard furniture often not large enough Routine procedures require more time and
effort

Fetal monitoring can be difficult

Mobility is often a problem

Postoperative Challenges:

increased risk for blood clot formation pannus (large roll of abdominal fat)
causes area to remain moist

Keeping the incision clean and dry to

prevent wound infection and promote
healing

Induction of Labor

The chemical or mechanical initiation of uterine contractions before their spontaneous onset for the purpose of bringing about
birth
Labor may be induced either electively or for indicated reasons

Elective induction of labor

Labor is initiated without a medical indication

Many are for the convenience of the woman or her primary health care provider

Risks:

Increased rates of cesarean birth

Increased neonatal morbidity

Increased cost

See Box 32-7 for indications and contraindications for Labor Induction, page 699

Elective induction of labor should not be initiated until the woman reaches 39 completed weeks of gestation

Bishop’s score

A rating system used to evaluate inducibility or cervical ripeness.

13 possible points. A score of 8 or more indicates inducibility,

Should be documented before the use of cervical ripening agents

Table 32.2 for the parameters included in the Bishop score

Methods to Induce Labor: Cervical Ripening

Chemical Agents

Prostaglandin E1 (Cytotec)

Prostaglandin E2 (Cervidil, Prepidil)

These soften and thin the cervix making it more favorable to the use of Oxytocin.

PE1 is cheaper but associated with more instances of uterine tachysystole, abnormal fetal heart rate changes and meconium
amniotic fluid at higher doses.

PGE1 is not approved for cervical ripening by the FDA,

Nursing implications when using PGE1 Or PGE2:

Assess maternal vital signs and fetal HR for reassuring pattern before administering.

Monitor FHR continuously for any signs of hypoxia (late decels,  variability)

Do not give PGE2 to women with asthma, glaucoma, hypertension or hypotension, causes vasoconstriction.

Mechanical Methods

Balloon catheters (foley) can be inserted into the cervix which stimulate the release of endogenous prostaglandins when
inflated,

Low cost, stable at room temperature and reduced incidence of uterine tachysystole.

Hydroscopic dilators absorb fluid from surrounding tissue and swell.

Laminara is a natural dilator made from desiccated seaweed. Lamicel is a synthetic dilator made from mag
sulfate

Both cause release of endogenous prostaglandins

Hydroscopic dilators are as effective as PE1 and PE2 however, there is more discomfort during insertion and expansion and a
higher incidence pp infection and newborn infection
Induction of Labor: Other methods

Amniotic membrane stripping – method of releasing prostaglandins and oxytocin by separating the membrane from the wall of
the cervix and lower uterine segment.

HCP inserts finger into internal cervical os and rotates it Effectiveness has not ben validated
360 degrees.

Other methods are sexual intercourse, nipple stim,

Not comfortable for the patient walking and castor oil.

Induction of Labor: Amniotomy

AROM – artificial rupture of membranes

Labor usually begins within two hours and can be shorter by 2 hours on average.

Prior to procedure

Presenting part must be engaged and well applied to cervix to prevent cord prolapse

Woman should be free of active infections of the genital track.

Color, odor consistency and time are recorded.

See Box 32.8 for procedure.

The fetal heart rate must be assessed before and immediately after to detect any changes. Transient tachycardia is normal but
bradycardia and variable decels can indicate prolapsed cord

Maternal temp must be checked at least every 2 hours post rupture.

If temp ≥ 100.4 notify HCP.

Assess for other signs of infection, odor, uterine tenderness, chills

Induction of Labor: Oxytocin

Hormone normally produced by the posterior pituitary gland, which stimulates uterine contractions and aids in milk let
down

Synthetic oxytocin (Pitocin) may be used either to induce labor or to augment labor that is progressing slowly because
of inadequate uterine contractions

Considered a high alert medication.

Maternal risks PP hemorrhage and infection

Placental abruption Fetal Risks

Uterine rupture Hypoxia

Unplanned C-section Acidemia

Goal is to produce contractions every 2 minutes, lasting 50-60 seconds in duration with firm intensity at the lowest dose
possible.

See medication guide, page 703.

See signs of uterine tachysystole emergency box on p704.

Commonly referred to as intrauterine resuscitation of the fetus

Low dose protocols have less risk for tachysystole.

Takes approximately 40 minutes to achieve steady state (rate of administration equals rate of elimination.

Has antidiuretic effect on woman. Watch for signs of fluid overload.

Augmentation of Labor

Stimulation of uterine contractions after labor has Active management of labor

started spontaneously and progress is unsatisfactory

Aggressive use of oxytocin so that the woman

Common augmentation methods include oxytocin gives birth within 12 hours of admission to the
infusion and amniotomy labor unit

Operative Vaginal Birth: Forceps and Vacuum Extractor

Forceps – assist in the delivery of the fetal head.

Only recommended for an outlet delivery, which is when the fetal scalp is visible on the perineum without manually
separating the labia.

Low forceps associated with greater risk to the fetus and maternal vaginal injury

Maternal indications

Prolonged second stage and the need to shorten (exhaustion, cardiac disease, FHR decels etc.)

Rate of use is decreasing, vacuum extractor becoming more popular.

Cervix must be fully dilated to prevent lacerations and hemorrhage. Bladder must be empty. Membranes must be ruptures.

FHR must be assessed prior to application of forceps and afterwards.

After delivery, the mother should be assessed for vaginal or cervical lacerations, urinary retention, and hematoma formation
in the pelvic soft tissues from blood vessel damage.

After delivery the infant should be assessed for bruising or abrasions at the site of clade application, facial palsy due to nerve
compression and subdural hematoma.

Vacuum Exatractor

Vacuum cup to the fetal scalp using negative pressure to assist in the birth of the head.

Not used in gestations less than 34 weeks.

Indications are the same as forceps outlet use.

Requirements are the same as forceps…

Fully dilated cervix, ruptured membranes, engaged head, vertex presentation, informed consent and no suspicion of
CPD

Becoming preferred method because it is easier to learn how to do this rather than forceps.
 Risks to the fetus: Maternal risks:

Cephalohematoma Perineal, vaginal or cervical lacerations

Scalp lacerations Soft tissue hematomas

Subdural hematoma

See Box 32.9 – Assisting with vacuum extractor birth

Must document the number of pulls attempted, the maximum pressure used and any pop-offs that occur.

Obstetric Procedures: Cesarean Birth

Birth of a fetus through a transabdominal incision of the uterus to preserve the well-being of the mother and her fetus

Cesarean birth rate in the United States has declined for the fourth consecutive year, to a rate of 31.9%

VBAC = Vaginal birth after cesarean

TOLAC = Trial of labor after cesarean

Indications – see box 32.11, page 708

Elective cesarean birth

Referred to as cesarean on maternal request, refers to a primary cesarean birth without medical or obstetric indication

No evidence to recommend this type

Scheduled cesarean birth

Reasons – labor and vaginal birth are contraindicated (placenta previa, active genital herpes etc.)

Birth is indicated but labor is not possible ( severe pre-eclampsia)

Repeat C-section

Unplanned or Forced
Cesarean Birth

Surgical Techniques

The type of skin incision does not necessarily indicate the type of
uterine incision.

Complications and risks

Anesthesia events Endomyometritis

Hemorrhage UTI

Bowel or bladder injury Wound hematoma formation

Amniotic fluid embolism, air embolism Dehiscence

Postpartum complications include: Infection, DVT and bowel disfunction

Atelectasis

Care management

NPO for 8 hours if elective Complete ‘time out”

Preop blood work Ensure adequate staffing for OR

Vital signs, IV, Foley catheter Participate in instrument and sponge counts
if circulator

Spinal or epidural anesthesia

Resuscitate and stabilize infant if
functioning in baby role.
Consents

Once transferred back to room,

Preserve modesty and drape postoperative assessments include fundus,
lochia amount, B/P, pulse, temp LOC,
airway, dressing site, output, and pain level.
Follow safety protocols for positioning
patient
Baby remains in room if stable.
Trial of Labor (TOL) and Vaginal Birth after Cesarean (VBAC)

TOLAC – observation of the woman in labor to determine how the fetus responds to stress of contraction.

If positive, vaginal birth will be attempted as long as the fetus responds well (reassuring fetal heart)

VBAC – women attempting to give birth vaginally after having a prior c-section birth

Contraindicated in women at high risk for uterine rupture

Women ae less likely to be successful if the have increased maternal age, are black or Hispanic, have a post date pregnancy, are
obese or are being induced. Short interval between pregnancies (< 19 months)

overall success rate of VBAC is approximately 60% to 80%

Obstetric Emergencies: Meconium-stained amniotic fluid

Indicates fetus has passed stool prior to birth

Possible causes

Normal physiologic function of maturity Hypoxia-induced peristalsis

Breech presentation Umbilical cord compression

Major complication – MAS – Meconium Aspiration Syndrome

Sever form of aspiration pneumonia that results from long standing intrauterine process rather than at birth

Resuscitation depends on infant's respiratory effort at birth

Suction only mouth and nose with bulb syringe if strong cry, good muscle tone and heart rate >100.

Suction trachea using ET tube connected to meconium aspiration device and suction source before many spontaneous breaths
have occurred if weak respiratory effort, decreased muscle tone and heart rate <100. Must do this before using PPV.

L&D nurses must be NRP certified.

Obstetric Emergencies: Shoulder Dystocia

Head is born, but anterior shoulder cannot pass under pubic arch

0.2% to 3%of all vaginal births are complicated by shoulder dystocia. Rate is increasing

Newborn more likely to experience birth injuries related to asphyxia, brachial plexus damage, and fracture

Mother’s primary risk stems from excessive blood loss from uterine atony or rupture, lacerations, extension of episiotomy, or
endometritis

Signs that indicate possible shoulder dystocia – slowing progress of second stage of labor and formation of caput succedaneum
that is increasing in size.

Turtle sign after delivery of head External rotation does not occur.

Most common injuries to the fetus are related to trauma (fractured clavicle or humerus and unilateral brachial plexus injury

Right arm is typically affected.

Care management

McRoberts maneuver – woman’s legs are hyperflexed on her

abdomen. This causes the sacrum to straighten, and the pelvis
and pubis rotate towards the mother's head. The angle of pelvic
inclination is decreased which frees the shoulder.

Suprapubic pressure –then can be applied over the anterior

shoulder

Fundal pressure is no longer recommended

Gaskin maneuver - hands-knee position

Nurses must assist with the maneuvers and document which ones are used, including the total amount of time
required to resolve the shoulder dystocia.

Obstetric Emergencies: Prolapsed umbilical cord

Occurs when cord lies below the

presenting part of the fetus

Contributing factors include:

 Long cord (longer than 100 cm)

Malpresentation (breech)

Transverse lie

Unengaged presenting part

Prompt recognition and intervention is a must,

Cord compression for more than 5 minutes will result in CNS damage or death of the fetus

Sterile gloved hand in vagina pushing and holding presenting part off cord.

Changing maternal position to modified sims, or knee chest or Trendeleburg position will help

See Emergency box on page 716

Obstetric Emergencies: Amniotic Fluid Embolus (AFE)

Also called anaphylactoid syndrome of pregnancy (ASP)

Rare but devastating complication of pregnancy characterized

by the sudden, acute onset of hypotension, hypoxia, , and
hemorrhage caused by coagulopathy

AFE is estimated to occur in 1 in 40,000 to1 in 50,000 births

Amniotic fluid containing particles of debris (e.g., vernix, hair,

skin cells, or meconium) enters the maternal circulation and
obstructs pulmonary vessels, causing respiratory distress and
circulatory collapse

Emergency Box page 718