Giving Birth & Intrapartum (part 2)

What are some Intrapartum Complications?

? Dysfunctional Labor/Dystocia
? Intrauterine infection
? Premature ROM - PPROM/PROM
? Preterm labor
? Abnormal labor durations
? Intrapartum emergencies - Cord prolapse - Fetal/maternal distress
? Alternative delivery methods


? It is any long and difficult labor
? But term used to describe components as well (i.e. shoulder dystocia)
Causes: 1. 4 P's 2. Dysfunctional labor 3. Induction of labor 4. Maternal responses

Dysfunctional Labor

Normal labor = steady progress
Dysfunctional labor = no, slow or precipitous progress
Dysfunctional labor should be "treated"
Assess the 4 P's 1. Powers 2. Passenger position 3. Passage 4. Psyche

Dysfunctional Labor: Powers

Primary Powers
Uterine Contractions
Effective UC's = coordinated, strong, and frequent enough to push baby down
Ineffective UC's
? Hypotonic (more common) - Coordinated but weak TX: Oxytocin, position change, amniotomy, IVF (F&E balance) ? Hypertonic - Un

Dysfunctional Labor: Powers Causes

? Maternal fatigue ? Maternal inactivity ? F & E balance ? Hypoglycemia ? Excessive analgesia/anesthesia ? Maternal catecholamines secreted in response to stress or pain ? Disproportion to maternal pelvis and fetal presenting part ? Uterine overdistention

Dysfunctional Labor: Passenger

? Fetal size - Macrosomia - Shoulder dystocia
? Fetal position/ presentation - OP/OT position - Breech presentation
? Multifetal pregnancy
? Fetal anomalies

Shoulder Dystocia

Difficult or delayed birth of the shoulders @ the pubic symphysis.
Signs to look for...
- Turtle sign - head retracts against perineum
- Incomplete shoulder rotation
Unpredictable and can happen with any size baby. It is an urgent situation d/t cord and c

McRoberts Maneuver

sharp flexion of the maternal hips that decreases the inclination of the pelvis increasing the AP diameter of the free anterior shoulder

Gaskin maneuver

hands and knees position

Shoulder Dystocia newborn assessment

Newborn Assessment You want to check ... ? Clavicle for crepitus, deformity or bruising ? Nerve injury to the brachial plexus or Erb's Palsy - May cause flaccid muscle tone on the affected side - Erb's palsy usually resolves within a few weeks with PT

Breech Complications

1.Head entrapment
2.Cord compression
Possible treatment: External Cephalic Version (ECV)

cephalopelvic disproportion (CPD)

Pelvis ? Impedes labor ? Obstructs fetal passage ? Cephalopelvic disproportion Maternal soft tissue obstructions ? Full bladder ? Assess for distention Q1-2 hours

pelvic shapes - best and least desired

Favorable for vaginal birth
Inlet rounded
All inlet diameters adequate
Midpelvis diameters adequate with parallel side walls
Outlet adequate
Not favorable for vaginal birth
descent into pelvis is slow
Fetal head enters pelvis in t


A perceived threat ? Pain ? Fear ? Nonsupport ? Personal situation

Abnormal Labor Durations

Active phase (~6cm) expected dilatation:
? 1.2 cm/hr nulliparas
? 1.5 cm/hr multipara
Expected fetal decent: ? 1cm/hr nullipara ? 2cm/hr multipara
Prolonged labor causes: ? Maternal or neonatal infection ? Maternal exhaustion, anxiety or fear

Nursing Interventions for Abnormal Labor Durations

? Provide comfort ? Promote energy conservation ? Emotional support ? Position changes ? Infection assessment Nursing Dx: Activity Intolerance

What are the benefits of upright maternal positions?

These promote descent, which is normally accompanied by fetal head rotation
Ensure safety and use what you have.

Intrauterine Infection

Assessment ? FHR > 160 for more than 10 minutes ? Maternal temp > 38C ? Maternal: HR/RR ? Amniotic fluid - Yellow or cloudy with fowl or strong odor (may be detectable on infant skin).
Reduce risk of infection ? Limit exams, hand washing, clean pads, per

Premature Rupture of Membranes (PROM)

Rupture of the amniotic sac prior to the start of true labor. ? pPROM is preterm premature rupture of membranes that occurs before 37 weeks and labor.
Causes: ? Infection - vaginal or cervical ? Weak sac, uterine over distension ? Insufficient cervix

PROM Nursing role

? Determine actual rupture ? Nitrazine, rapid testing (ROM +, AmnioSure), ferning (slide) ? Don't contaminate with exam! ? Determine if vaginal intercourse in last 24 hours.
? Assess fetal well-being ? Cord prolapse possible if head not engaged ? Twins ha

Pre-term Labor & Birth

? Uterine contractions resulting in cervical change after 20 weeks, but prior to 37 weeks S/S (usually absent until active labor) ? Cramping, pelvic pressure ? Constant or intermittent back pain Note: 1 in 8 babies is born premature. Infants born between

Factors associated with preterm labor

Causes - Infection - No PNC - OB conditions - Oligohydramnios - Multiples - Prior hx of PTL Risks - Lung maturity - < 34 weeks - PROM

Pre-term Labor & Birth Management

? Prevention � Early and regular PNC � Pre-pregnancy assessment ? Improve access to care � Provide phone numbers � Progesterone needed from compounding pharmacy ? Identify risk factors � +FFN � Previous hx � Short cervix � UTIs ? Nutrition � WIC � Proper

Pre-term Labor & Birth Treatment

? Identify/tx ? Maternal infections or conditions ? Medications ? Tocolytics/ corticosteroids ? Magnesium sulfate ? Neuro protection (fetus) (update from practice) ? Education ? Hydrating ? Limiting activity

Prolonged Pregnancy

? > 42 weeks Post-term ? Post-dates = past EDD Complications ? Aging placenta ? placental insufficiency ? Oligohydramnios - Cord compression Diagnostic ? Biophysical Profile

Placental Complications

Accreta ? Abnormally adherent (penetrates muscle wall) placenta ? Immediate or delayed hemorrhage after birth ? Prevents full UC d/t fragments Increta ? Invades uterine muscle Percreta ? Penetrates myometrium

Cord Prolapse

OB Emergency!! Cord slips down after ROM ? compression between fetus & pelvis Causes: - High fetal station - Small fetus - Twin B, Breech Treatment - Position - Lift presenting part/O2 - Riding the gurney

Uterine Rupture

OB Emergency!
Tear in the uterine wall d/t pressure ? Typically seen in VBAC & previous classical C/S Complete ? Into peritoneal cavity Incomplete ? Into peritoneum that covers uterus Dehiscence ? Partial separation ? Common in diabetic clients

Uterine Rupture S/S, Cause, Treatment

S/S: ? Abdominal pain, tenderness ? Chest pain, pain between the scapula ? Absent fetal heart tones/ fetal compromise ? Cessation of UCs
Causes ? Prior uterine incision: Classical c/s, repeat c/s, fibroid removal
Treatment ? Stabilize mom ? Crash c/s with

Uterine Inversion

Uterus turns completely or partially inside out
Etiology ? Fundal pressure, tugging on cord or adherence
Signs and symptoms ? Massive hemorrhage, shock and pain
Treatment ? Tocolytics ? manual uterine replacement ? General anesthesia, transfusion, tocolyt

Anaphylactoid Syndrome AFE (Amniotic Fluid Embolism)

OB Emergency!
Amniotic fluid drawn into maternal circulation to women's lungs.
? Pressure forces amniotic fluid with fetal particulate matter into open uterine or cervical veins
? Originally believed to be an embolus (PE) causing obstruction. Ins

Anaphylactoid Syndrome

Signs and Symptoms ? "Sense of impending doom", restlessness ? Respiratory distress ? Dyspnea ? Cyanosis ? Patient high risk if it is a tumultuous labor ? Be prepared to intubate and Crash!

Trauma in Pregnancy

Direct trauma
? Pelvic fx? skull fx or ICH
Indirect trauma
? Abruption or uterine rupture
Maternal death #1 cause of fetal death
? Management
? Kleihauer-Betke (blood test that IDs placental disruption that allows fetal disruption to leak into maternal ci

Trauma in Pregnancy Facts

? Trauma complicates 8% of pregnancies ? During 1st trimester fetus protected by pelvis ? Higher blood volume ? Tx: ABCs, O2, Volume resuscitation (IV x2), lateral decubitus position, C/S ? 23% caused by MVA

Pregnant Trauma Protocols

? Shield for all x-rays (UTS & MRI no effect) - Consult radiologist for rad >5 ? High flow O2 ? Prevent Vena Cava Syndrome - 15 degree left tilt in C-Spine ? Postmortem C/S in all pregnancies >24 weeks - C/S within 20 min of maternal arrest - Ideally by 4

Alternative Deliveries

1. Forceps Assisted Vaginal Delivery (rarely if even used anymore)
2. Vacuum Assisted Vaginal Delivery
3. Cesarean Section Delivery
Indications ? Persistent non-reassuring FHR patterns ? Cord compression ? Maternal exhaustion ? Ensure bladder is empty

Forceps Assisted Vaginal Delivery

Vacuum Assisted

Maternal indications
? Severe cardiac or cerebral vascular disease
? Ineffective pushing
? Exhaustion
Fetal indications
? Prolonged stage II of labor
? Cat III fetal tracing

Cesarean Section (C/S) Delivery

? 31.9% (2018) down from 32.7% in 2015
? Overall increase since 1970 (5%)
? VBAC rate increased among non-Hispanic and Hispanic women (2018) Why is this important?
? Birth rates increased for ages 35-44 and decreased or were unchanged for other age groups

Cesarean Indications

? Maternal health problems ? Fetal position ? Placental location ? Cephalopelvic disproportion ? Fetal distress ? Fetal anatomical abnormality

Cesarean Complications

? Dehiscence ? Blood loss ? DVT ? Surgical ? VBAC ? Adhesions*

Patient Centered Care

? Incorporate family-centered care for laboring mother - Communicating with patient & support person(s) about current status, including plan of care.
Skills: ? Encourage open, effective communication between patient, support person(s) and multi