Complications of Labor and Birth – Part I

Definitions – Preterm
Preterm (or premature) infant
infant born before 37 completed weeks of gestation
Late preterm infant (a recently identified category)
infant born between 34 and 36 weeks gestation
Moderately preterm infant
infant born between 32 and 36 completed weeks of gestation
Very preterm infant
infant born between 28 - 32 completed weeks of gestation
Extremely preterm infant
infant born before 28 completed weeks of gestation

Definitions – Low Birth Weight

Low birthweight (LBW)
 infant who weighs less than 2,500 grams at delivery
Very low birthweight (VLBW)
 infant who weighs less than 1,500 grams at delivery
Extremely low birthweight (ELBW)
 infant who weighs less than 1,000 grams at delivery

Preterm Births by Gestational Age

Preterm Birth Clinical Significance

 12.7% of births are premature
 Preterm Labor is responsible for approximately 50% of preterm births.
 Preterm Labor Causes Not well understood
 INFLAMMATION PROCESS
 MOM OR BABY IS STRESSED
 NOT WELL UNDERSTOOD

Preterm Labor Prediction

Diagnosis
 > 6 contractions an hour with documented cervical change
 Gestation between 20 and 36 6/7 weeks
 Persistent uterine contractions
 Documented cervical change
 Cervical effacement of >80%
 Cervical dilatation of >1 cm
Current best prediction
 Transvaginal Ultrasound of cervical length < 2 cm
 Positive Fetal Fibronectin -
Biochemical Markers
Fetal fibronectin: Glycoproteins produced during fetal life and found in the cervical canal early and late in pregnancy; best used to
determine who will NOT go into preterm labor.
- SPILLS FF AT CERVIAL OPENING BETWEEN 20 – 36 WEEKS
- SWAB TO BE TESTED FOR POSTITVE FF
- POSITIVE – PREDICTS LABORING
- NEGATIVE – NO LABORING
Salivary estriol: Estrogen produced by the fetus and elevated before preterm birth; might be useful to determine who will NOT go
into preterm labor.

Urgent Symptoms to Report

 If any of the following symptoms occur, CALL HEALTH CARE PROVIDER IMMEDIATELY:
o Fluid leaking from the vagina
o Vaginal bleeding
o Odorous vaginal discharge
o Contractions every 5 minutes or less or more than 5/hour
 Action to take if symptoms occur
 IF SHES RESTING AND CONTRACTIONS CONTINUE – COME IN FOR EXAMINATION

High Risk for Preterm Delivery

 More frequent prenatal visits are indicated.
 A study of nursing telephone support to at-risk women significantly reduced preterm births among low-income African-American
women (Moore et al., 1998).
 Teach Patient to identify symptoms between 20 and 37 weeks of pregnancy

Recommendations
 No clear “first-line” tocolytic drugs
 Antibiotics do not appear to prolong gestation
 AVOID MAINTENANCE OR REPEATED DOSES OF TOCOLYTICS
 TOCOLYTIC DRUGS MAY PROLONG PREGNANCY 2-7 DAYS, WHICH MAY ALLOW THE ADMINISTRATION
OF STEROIDS TO IMPROVE FETAL LUNG MATURITY
o SLOW CONTRACTIONS TO GIVE CORTICOSTEROIDS TO ALLOW THE BABY TO “COOK”
o DO IT ONLY ONCE TO GIVE ENOUGH TIME (48 HOURS) TO GIVE THE CORTICOSTERIOIDS
 Antenatal corticosteroids significantly reduced the neonatal respiratory distress syndrome, intraventricular hemorrhage
and necrotizing enterocolitis.
 Cervical ultrasound examination and fetal fibronectin.
 Amniocentesis
 Bed rest, hydration, and pelvic rest

Progesterone
 Weekly injections of progesterone offers significant protection against a recurrent preterm birth
 Progesterone given vaginally reduces preterm birth (18.5 percent for placebo group vs. 2.7 percent for progesterone group)

Terbutaline
 Maternal side effects: Cardiac or cardiopulmonary arrhythmias, pulmonary edema, myocardial ischemia, hypotension,
tachycardia
 Fetal and neonatal side effects: Fetal tachycardia, hyperinsulinemia, hyperglycemia, myocardial and septal hypertrophy,
myocardial ischemia
 INHIBITS UTERINE ACTIVITY BY RELAING SMOOTH MUSCLE; CAUTION, CONTAINS A LOT OF SUGARS

Magnesium Sulfate
 Maternal side effects: Flushing, lethargy, headache, muscle weakness, diplopia, dry mouth, pulmonary edema, cardiac arrest
 Fetal and neonatal side effects: Lethargy, hypotonia, respiratory depression, demineralization with prolonged use
 RELAXES SMOOTH MUSCLE, MONITOR S/S OF TOXICITY, SLOWS CONTRACTIONS, MAY MAKE YOU FEEL LIKE
YOU HAVEA. FLU
 CALCIUM GUCABATE – REVERSES TOXIC SYMPTOMS
Calcium Channel Blockers
Nifedipine
 Maternal side effects: Flushing, headache, dizziness, nausea, transient hypotension.
 Fetal and neonatal side effects: None noted as yet
 Contraindications: cardiac disease; should not be used concomitantly with magnesium sulfate

Indomethacin
 Maternal side effects: Nausea, heartburn
 Fetal and neonatal side effects: Constriction of ductus arteriosus, pulmonary hypertension, reversible decrease in renal function
with oligohydramnios, intraventricular hemorrhage, hyperbilirubinemia, necrotizing enterocolitis
 Recommend less than 48 hrs. of treatment and less than 32 weeks gestation to decreased likely hood of closure of ductus
arteriosus

*CORTICOSTEROIDS*
 Corticosteroids given > 48 hours before delivery
 Betamethasone 2 doses12 mg IM 24 hours apart
 Dexamethasone 4 doses 6 mg IM given 12 hours apart

Preterm Labor Teaching

 Lifestyle modifications
 Bed rest
 Home care – MODIFY HOME ENVIRONMENT

Nursing Care Preterm Delivery

Management of inevitable preterm birth
 Cervical dilation of 4 cm likely to lead to inevitable preterm birth
 Tertiary care centers lead to better neonatal and maternal outcomes
 Transferred quickly to ensure best possible outcome
 Antenatal glucocorticoids should be given before transfer
 Anticipate NICU care
Preterm Premature Rupture of Membranes (PPROM)
 Refers to rupture of membranes prior to labor and prior to 37 weeks.
 PPROM risk factors
 PPROM symptoms & diagnosis
 PPROM Treatment

Post term Definitions

 POST TERM: > 42 completed weeks (>294d)
 POST DATE: > 40 completed weeks(280d)
 POST MATURITY: Specific syndrome of infant associated with postterm pregnancy
Post Term
 BY LMP : 7.5 %
 BY USG : 2.6 %
 BY LMP + USG : 1.1 %
 Previous 1 postterm : 27 %
 Previous 2 postterm : 39 %

Post Term Etiology

 Wrong dates
 Biological-previous prolonged pregnancy
 Irregular ovulation
 Possible causes:
o Decreased fetal estrogen production
o Placental sulfatase deficiency
o Anencephaly
o Extrauterine pregnancy (v.v. rare)

Post Term Problems

PLACENTAL CHANGES
 ageing (increased grading on US) calcification
AMNIOTIC FLUID CHANGES
 Oligohydramnios (diminished fetal urination)
 cloudy (flakes of vernix)
FETAL CHANGES
 45%-Macrosomia
 10%-IU malnutrition
MATERNAL
 Anxiety
 Traumatic vaginal delivery
 PPH risk
FETAL
 Fetal distress
 Meconium Aspiration Syndrome
 Fetal trauma
 Increased perinatal mortality
 Dysmaturity syndrome

Post Term Management

Confirmation of Gestational Age
 Reliable LMP
o Date known
o No OCP for 3 months
o Regular cycles
 First trimester CRL(+/-7d)
 Second trimester BPP (+/- 14d)
 First trimester Pelvic/Vaginal examination
 Doppler FHT 10 wks
 Quickening 16-18 wks
Ultrasound
 AFI <5 is oligohydramnios
 Macrosomia
 Placental grading
P/V examination
 Assess inducibility-BISHOP’S score

Post Term Prevention

 Sweeping/ Stripping of membranes at term if no vaginitis, malpresentation or placenta previa.

Post Dates Monitoring

Usually begin at 41 weeks
Twice weekly
 NST with AFI
 Or Biophysical Profile
 Or Contraction Stress Test
Bishop Score Cervical Readiness for Labor

Post Dates Induction

 Either routine Induction at 41+ weeks or 2X/week monitoring starting in the 41st week with Induction for abnormal test results is
reasonable
 With a Bishop score < 6, cervical ripening is recommended before Induction.
 PGE1 and PGE2 are all effective

Post Term Intrapartum

Nursing Management
 Be aware of risks of post dates
 EFM
 Amnioinfusion (750-1000 ml NS/RL)
o If meconium stained or variable decelerations.
 Pediatrician for delivery

Fetal Macrosomia
Macrosomia
 Vaginal Trial
 Monitor progress
 If second stage is slow, and crowning slow anticipate shoulder dystocia
 Implement hospital guidelines
 Because so many more babies would have unnecessary cesarean birth – vaginal trial is viable choice
Cesarean
 with an estimated fetal weight more than 4500 grams
 a prolonged second stage of labor
 arrest of descent in the second stage.
Diagnosis of fetal macrosomia is imprecise.
 For suspected fetal macrosomia, the accuracy of using ultrasound no better than clinical palpation (Leopold’s maneuvers).
Prophylactic Labor Induction
 Suspected fetal macrosomia is not an indication for induction of labor.
 Elective CS
 Labor and vaginal delivery are not contraindicated with estimated fetal weights up to 5,000 g
Preventing Shoulder Dystocia
 Planned cesarean delivery may be a reasonable strategy for diabetic pregnant women with estimated fetal weights exceeding 4250
to 4500 grams.
 Complications of Labor and Birth - Part II
Indications for Induction of Labor
 Post Dates
 Rupture of Membranes without subsequent Labor
 Gestational Hypertension
 Intrauterine Growth Retardation
 Placental Abruption
 Amnionitis
 Medical conditions: DM, Heart disease, renal disease
 Failed fetal tests of fetal well being. Low AFI, Non reactive NST, Non reassuring FHR pattern
 Maternal Convenience
Induction - Negative sides, Risks
 Inductions double the cesarean rate
 Labor dystocia versus failed induction
 Makes the latent labor longer in primiparous women, sometimes days
 Introduces risk of hypertonic contractions and subsequent fetal distress.
 Rupture uterus – esp grand multips and VBACs
 Iatrogenic infection
 Iatrogenic prematurity
 Increased epidural rate, and forceps and vacuum
 Increased birth trauma
 Increase rate of PPH
 Increases costs associated with childbirth
Bishop Score < 6 = unfavorable

Methods of Cervical Ripening

 Foley or balloon catheter
 Stripping the membranes
 Prostaglandins
o A relaxation of cervical smooth muscle facilitates dilation.
o Allow for an increase in intracellular calcium levels, causing contraction of myometrial muscle.
o I.E. Soften the Cervix and cause Contractions

Pharmacologic Methods of Induction

 Prostaglandins
o Increase likelihood of vaginal delivery within 24 hrs (Cochrane)
o 1. PGE2 dinoprostone
 - gel (Prepidil)
 -insert (Cervidil) - CAN CAUSE TACHYSYSTOLE
 o 2. PGE1 misoprostol
 decreased c-section rate
 reduced need for pit vs placebo (evidence level A)
 Contraindicated with previous c-section
 Misoprostol
o 50 mcg vaginal posterior fornix
o 100 mcg Orally
o Can repeat q 4hrs up to 6 doses
o Pitocin may start 4 hrs after dose.
 All pharmacologic methods of inducing labor can cause too many contractions = TACHYSYSTOLE
o > 5 contractions in 10 minutes
o Dinoprostone incidence 33%
o Misoprostol 31-49%
o BABY MAY DECELERATE BECAUSE THEY CANNOT HANDLE TOO MUCH CONTRACTION

Nurse’s Response to Hyperstimulation

o Hyperstimulation
o > or = 5 ctx in 10 minutes averaged over 30 minute window
o Abnormal Fetal Heart Rate Pattern.
o Sometimes defined as IUPC uterine tone >20 mm Hg
o Turn off the pitocin rate, keep mainline IV going
o Start O2
o GIVE BOLUS
o Possible terbutaline .25 mg SQ
o Continuous EFM
o Notify provider
o Document Care and responses to action
Induction when Cervix is “Ripe”
o Amniotomy
o AROM – QUICKENS PROCESS OF LABOR
o advised with the very ripe cervix and in a multiparous woman
Induction
o Prostaglandins to ripen cervix
o Then pitocin if labor has not started.
o Several providers don’t use the term induction unless Oxytocin is used.
Induction – Nurse’s Action
Patient Assessment
o Fetal Monitoring for 30 minutes prior medications
o Continuous EFM while on Pitocin
o Continuous EFM for a period of time after prostaglandins
o Encourage patient to assume upright positions, change position often, go to bathroom.
o Use telemetry if available
Pitocin Induction
o After admission and Initial EFM
o Continuous EFM while pitocin is administered
o Start IV then administer IV pitocin per protocol using infusion pump
o Low dose: start 1 mU/minute, increase by 1 or 2 every 15-30 minutes. Maximum 30-40 mU/min
o High dose: start at 6 mU/min increase by 1-6 every 20 minutes. Maximum 40 mU
o Stop increasing the dosage or decrease pitocin once have contraction every 2-4 minutes.
o As nurse must know your hospital policy on Pit administration
Labor Augmentation
o Augmentation is the use of pitocin after labor has begun for a labor that is not progressing well.
o After dystotic labor, or arrest of progress
o Nipple stimulation or Amniotomy may be used first
o Pitocin is used for augmentation, not prostaglandins
o Follow orders for starting rate (1-2 mU or 6 mU/min) and increasing the rate.
o Follow protocol and orders for dosage of pitocin
Assisted Delivery
o Forceps or Vacuum are used to speed up the delivery in 2nd stage.
o The fetal head needs to be at least +2 station
o The woman needs to understand why the procedure is being done (either fetal distress or slow second stage)
o The woman needs to understand she will need push hard during the procedure. She continues to be the primary force for delivery.
Vacuum or Forceps
The choice of Forceps or Vacuum is made by the physician
His or her experience with either device will influence the decision.
Vacuum Extraction

Outlet Forceps

Nurse’s Role
o Get the equipment and place on the sterile field
o Operate the vacuum pressure rapid up to 500 to 600 mm HG
o Count and document number of pulls – limit 3 sets of pulls
o Count and document number of pop offs 2 or 3
o Total vacuum application time (15-30 minutes)
o If assisted delivery fails, be prepared to do Cesarean Birth
o VACUUM – 2-3 PULLS AND POPOFFS, IN SYNC WITH CONTRACTIONS/MOM PUSHING, 15-30 MINS
o NURSE’S ROLE IS TO DOCUMENT THE AMOUNT OF PULLS AND POP OFFS, AND GATHERING EQUIPMENT
o AFTER THAT, IF BABY IS STILL NOT OUT, TAKE MOM TO OPERATING ROOM FOR C-SECTION
Cesarean Birth o Active herpes lesion or HIV positive
o Surgical Abdominal Delivery Cesarean Risks
o National rate was 32% o Hemorrhage
o Reasons for Cesarean: o Infection – wound, uterine, UTI
o Slow Labor 1st or 2nd stage – dystocia o Injury to other internal organs (bladder, intestines)
o Previous Cesarean o Injury to the fetus
o Fetal Distress o Pulmonary edema
o Breech/malpresentation o More difficult cesarean next time because of scar tissue
o Placental Abruption or Previa o Decreased fertility.
Cesarean Birth Process
o Start an IV
o Do an initial EFM monitor strip
o Consents signed and Patient admitted
o Move to OR
o Anesthesia (Spinal, Epidural, or General Anesthesia)
o Abdominal Prep (clip/shave, paint)
o Test for numbness
o Skin Incision
o Dissect the bladder from uterine wall
o Incision of uterus
o Delivery of Infant (typically 10 minutes)– requires fundal
pressure
o Suture the Uterus (typically 30-40 minutes)
o Suture the rectus (sometimes)
o Staple the incision or subcuticular sutures
o Total Procedure usually less than an hour.
o Classical incision: fastest incision to delivery.
o Low transverse cesarean section: strongest incision on the
uterus to prevent uterine rupture in future and the most aesthetic to
the mother.
PreOp Nursing Care
In admission or labor room:
o Initial VS, check labs, FHR, take history
o Start IV
o Verify patient understanding of procedure
o Notify OB, CNM, Anesthesiologist for preop visits
o Verify consent is given and signed.
o Remove nail polish, dentures, jewelry
In OR:
o Include support person/partner o Set up area to count laps
o Usually regional anesthesia first o Drape Patient
o Then foley, place bag where anesthesiologist can see it o Make sure baby nurse is notified and present – infant warmer
o shave with electric razor top of pubic care on and resuscitation equipment ready
o Abdominal prep with antimicrobial solution o Notify OB and assistant when ready for them
o Position patient, wedge for uterine displacement o Put partner on chair near mother’s shoulder
o Place Cautery Leg Plate o Count starting sharps and lap sponges
o Set Up Suction o Time Out: verify patient and procedure
o Document time of anesthesia start, surgery start
Surgical Interventions:
Skin Prep
o Method of hair removal: wet prep or clippers
o Anatomic perimeters: Similar to laparotomy—table side to table side; to xiphoid process extending down to mid thigh: NO
Vaginal prep
o Solution options: Betadine or Duraprep or Hibiclens
o Insert foley before prep
Draping/Incision
o Types of drapes:
o Laparotomy drape, which may sticky clear plastic around fenestration
o Fluid-catching channels
Post Cesarean Recovery Care
o After delivery, monitored in recovery until stable and epidural space which will give her 24 or more hours of
released impressive pain relief.
o BP, HR, Temp, RR, Pain level, Fundus and Flow o If she had a general anesthetic – she will need intensive pain
o Observe for Uterine tone, incisional bleeding, urine output management and likely IV PCA.
o If a woman has had a regional block (spinal or epidural) it is o Continue IV antibiotics if ordered.
likely they put Morphine or another narcotic in the spinal or o Will have orders on how soon she can have fluids
o Removal of foley after ambulation and not sooner than 12 o Do not remove dressing, but if > 1/3 bloody drainage on
hours after birth dressing notify provider.
o Ambulation (6-8 hrs versus 10-12 hrs) o Do encourage mother and baby togetherness
o Ambulation enhances circulation, encourages deep breathing o Breastfeeding – help position woman
and stimulates return of normal gastrointestinal function.
Chorioamnionitis ( Intrauterine Infection)
o If in labor and signs of Chorio- deliver soon, if close to vaginal delivery, otherwise Cesarean
o Antibiotics usually started as soon as suspected:
o Ampicillin (2 g i.v. every 6 hours) plus Gentamicin (1.5 mg/kg i.v. every 8 hours
o Clindamycin (900 mg i.v. every 8 hours) or Metronidazole (500 mg i.v. every 8 hours) may be added to provide additional
anaerobic coverage
o If not in labor: If unsure amniocentesis to measure WBC, glucose and bacteria in amniotic fluid.
Risk Factors Diagnosis
o Preterm Labor o Maternal fever > or = 38o C or 100.4o F
o Prolonged rupture of membranes o Uterine tenderness
o Prolonged rupture of membranes with early, frequent vaginal o Maternal or Fetal Tachycardia
exams o Vaginal discharge (foul smell)
o Internal monitoring o Elevated WBC count (over 15,000 cells/mm3).