A PREGNANT WOMAN

EXPERIENCING A COMPLICATION
OF LABOR OR BIRTH
A Nursing Process Overview
MARY JOY B. SANDE, RN., RM., PHDNED
 High-risk pregnancy
v Pregnancy is stressful but a good experience

v It is important to determine the risks involve for both of the mother

and child, that might put them at risk for complications

v Difficult Labor (DYSTOCIA) can arise from problems occurring from

the main components of the LABOR PROCESS (Power, Passenger,
Passageway, Psyche)
LABOR OR BIRTH COMPLICATIONS

qProblems of passenger
qProblems with the passageway
qProblems with powers
qPlacental problems
qProblems with psyche factors
 Things to Ponder
q Continuous assessment of laboring woman and her fetus
q Provide emotional support for the mother and her family
q The National 2020 Health Goals relate to attempts to decrease maternal
complications and prevent infant injury related to birth in which nurses can
help through
§ Identifying women in labor who are developing a complication
§ Assisting with CS births and careful assessment during labor
§ Being alert to preliminary symptoms of uterine rupture (accounts for
substantial number of maternal deaths during labor)
§ Fetal and uterine monitors are tools to detect deviations.

§ Requires frequent adjustment of the equipment to

achieve clear tracing

§ It is important to explain the importance of the apparatus

to the laboring woman and her partner to gain their
cooperation
 Examples Common to Woman experiencing
complications in Labor and Birth

• Pain related to induction and labor procedures

• Fear related to uncertainty of pregnancy outcome
• Anxiety related to medical procedures and apparatus necessary to ensure
health of woman and fetus
• Fatigue related to loss of glucose stores through work and duration of labor
• Ineffective coping related to lack of knowledge or lack of preparation for labor
• Fatigue related to prolonged labor
• Risk for ineffective tissue perfusion related to excessive loss of blood with
complications of labor
• Risk for injury (maternal/fetal) related to labor involving multiple gestation of
pregnancy
• Anticipatory grieving related to nonviable monitoring pattern of fetus
 Outcome Identification and Planning

§ Outcomes to be included in planning can be difficult to identify

because it may not be what the woman desires
§ Encourage the couple to clarify their priorities when complication
arise is helpful
§ Example:
§ Early labor: Woman desires to avoid equipment and analgesia but if
fetal bradycardia occurs, monitoring and CS becomes necessary, it is
important to remind her that the primary goal is to have a healthy
baby not avoid specific interventions, and this will help her accept
these changes
 Implementation

§ Priorities will be to:

- Increase FHR
- Strengthen uterine contractions
§ Interventions must be planned and performed efficiently and
effectively based on the individual circumstances.
§ Provide psychological reassurance to accompany actions to fully
safeguard both the woman and the fetus
 Outcome Evaluation

May reveal unhappiness but focus is more on

positive outcome and look the couple for signs that
they are able to begin interacting with their child after
their distressful experience
 Outcome Evaluation

§ Examples
§ Voices confidence she can cope with the fear she feels about her
fetus’s welfare
§ Patient demonstrates adequate energy during course of labor to
maintain effective breathing patterns
§ Patient’s blood pressure does not drop below 90/50 mmHg despite
excessive blood loss with delivery of the placenta
§ Patient begins positive grieving behaviors in response to loss of
newborn
REVIEW OF LABOR CONCEPTS
12
COMPLICATIONS OF LABOR
AND DELIVERY

PASSAGEWAY
14
15
16
CEPHALOPELVIC DISPROPORTION (CPD)

§ A disproportion between the size of the fetal

head and the pelvic diameters, which results
in failure to progress in labor

§ Every Primigravida should have pelvic

measurements before week 24 of pregnancy
CAUSES
ü Large baby due to:
§ Hereditary factors
§ Diabetes
§ Post-maturity (still pregnant after due date has passed)
§ Multiparity (not the first pregnancy)
ü Abnormal fetal positions
ü Small Pelvis
ü Abnormally shaped pelvis
INLET CONTRACTION
§ Narrowing of AP diameter of pelvis to less than 11 cm or
transverse diameter to 12 cm or less
§ Causes:
o Rickets in early life (lack in Calcium)
o Inherited small pelvis
§ Symptom
o No engagement of presenting part
o But in multigravida, engagement does not occur until
labor begins
OUTLET CONTRACTION
§ Narrowing of transverse diameter (distance
between the ischial tuberosities at the outlet) to
less than 11 cm
§ Measurement can be made through:
o sonogram during pregnancy
o Manually at prenatal visit or beginning of labor
ASSESSMENT
§ Large baby or small pelvis
§ Usually diagnosed when there is an
arrest in descent
§ Station remains the same
TRIAL LABOR
§ When woman has borderline (adequate) inlet
measurement and fetal lie and position are good

§ Continues as long as descent of the presenting

part and dilatation of the cervix continues to
occur
SHOULDER DYSTOCIA

Fetal head is born but the shoulders are broad

ü Suspected earlier if there is
§ prolonged second stage of labor
§ arrest of descent
§ retraction of fetal head with every uterine
contraction (turtle sign)
DIFFERENT TECHNIQUES USED TO
AID IN FETAL DELIVERY
EXTERNAL CEPHALIC VERSION
§ Turning of a fetus from a breech to a cephalic position
before birth

§ Maybe done as early as 34 to 35 weeks but the usual

time is 37 to 38 weeks

§ Not always successful but can decrease number of CS

births

§ Woman may feel uncomfortable because of the

pressure
PROCEDURE
§ FHR and ultrasound are recorded continuously

§ Tocolytics are used to relax uterus

§ The breech and vertex of the fetus are located and

grasped trans abdominally by the examiner’s hands
on the woman’s abdomen

§ Gentle pressure is then exerted to rotate the fetus in

forward direction to a cephalic lie
American Journal of Obstetrics & Gynecology (SEP 12,
2016)

§ Administration of neuraxial analgesia significantly

increases the success rate of external cephalic
version among women with malpresentation at
term or late preterm, which then significantly
increases the incidence of vaginal delivery.
§ RISKS
o Reversion
o Abruption
o Cord compression
o Rupture of membrane
o Onset of labor
o Non-reassuring fetal status
§ Contraindications:
o Multiple gestation
o Severe oligohydramnios
o Ruptured membranes
o Small pelvic diameters
o A cord that wraps around the fetal neck
o Unexplained third-trimester bleeding (placenta previa)
o Hyper extended fetal head
o Significant fetal or uterine anomaly
FORCEPS BIRTH
§ Use of obstetrical
forceps
o Steel instruments
constructed of two
blades that slide
together at their
shaft to form a
handle
1. One blade is slipped into the woman’s vagina next to the fetal head
2. The other is slipped into place on the other side of the head
3. The shafts of the instrument are brought together in the midline to form the handle
4. Apply pressure on the handle to manually extract the fetus from birth canal
FORCEPS BIRTH
§ In the past, routinely used but today rarely used
(about 4% to 8% of births because of it can lead to:
o Rectal sphincter tears that can lead to
ü dyspareunia (painful intercourse)
ü Anal incontinence
ü Increased urinary stress incontinence
FORCEPS BIRTH
§ Necessary for the following conditions
oA woman is unable to push with contractions inn the
pelvic division of labor (regional anesthesia or spinal
cord injury)
o Cessation of descent in the second stage of labor
o A fetus in abnormal position
o A fetus in distress from complication (prolapsed cord)
§ Before forceps are applied
o Membranes must be ruptured
o CPD must not be present
o Fully dilated cervix
o Woman’s bladder is empty
§ Nursing interventions
o Record FHR before forceps application
o After forceps application
ü Assess again FHR
ü Assess cervix for lacerations
ü Record time and amount of first voiding (rule out bladder
injury)
ü Assess newborn for facial palsy or transient erythematous
mark on the check (will fade 1-2 days with no long-term
effects
VACUUM EXTRACTION
§ With the fetal head at the perineum, a soft disk-
shaped cup is pressed against the fetal scalp and
over posterior fontanelle

§ When vacuum pressure is applied, air beneath the

cup is suctioned out and the cup then adheres so
tightly to the fetal scalp that traction on the
vacuum cord leading to the cup extracts the fetus
 VACUUM
EXTRACTION
VACUUM EXTRACTION
§ Advantages over forceps delivery:
o Little anesthesia is necessary
§ Disadvantages
o More perineal laceration
o Marked caput on the newborn head maybe
noticeable as long as 7 days after birth
o Tentorial tears from extreme pressure
VACUUM EXTRACTION
§ When to not used
o Iffetal scalp blood sampling was used
(suction can cause severe bleeding at the
sampling site)
o Preterm infants (softness of preterm skull)