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Zuñega, Thomas Henry P.

October 4, 2010
BSN IV

COMPLICATIONS OF LABOR AND


DELIVERY

– Prolapsed Umbilical Cord


– Precipitous Labor and Delivery
– Preterm Labor
– Premature Rupture of Membrane
– Rupture of Uterus
Prolapsed Umbilical Cord

Definition:
• “Cord prolapse” is when the umbilical cord exits the birth canal prior to baby. If cord prolapse
occurs, the blood and oxygen flow to the baby can be interrupted or severed, which can cause
tissue, oxygen or brain damage.

Etiology:

2 major etiologic categories are:


1. Fetomaternal factors
2. Obstetric factors

The main fetomaternal factors are:

• Fetal malpresentation
• Prematurity
• Multiple gestation
• Multiparity
• Rupture of membranes
• Polyhydramnios

Obstetric factors:
• Artificial rupture of membranes
• Internal scalp electrode application
• Intra uterine pressure
• Catheter replacement
• Forceps or vacuum application
• Manual rotation of fetal head

Assessment findings:
• vaginal exams identifies cord prolapse into vagina

Nursing intervention:
• Check fetal heart tones immediately when membranes rupture and again after next contraction
or within 5 minutes; report deceleraton.
• If fetal Bradycardia; perform vaginal examination and check for prolapsed cord.
• If cord prolapsed into vagina, exert upward pressure against presenting part to lift part off cord,
reducing pressure on cord.
• Get help to move mother into a position where gravity assists in getting.
presenting part off cord (knee-chest position or severe trendelenburg’s).
• Administer oxygen and prepare for immediate cesarean birth.
• If cord protrudes outside vagina, cover with sterile saline while carrying out
above tasks. Do not attempt to replace cord.
• Notify physician

Precipitous Labor and Delivery


General Information:
• Labor of less than 3 hours
• Emergency delivery without clients physician/midwife

Assessment findings:

• As labor is progressing quickly, assessment may need to be done rapidly


• Client may have history of previous precipitous labor and delivery
• Desire to push
• Observe status of membranes, perineal area for bulging and for signs of
bleeding

Nursing intervention:
Emergency Delivery of an Infant

• If you have to deliver the baby yourself


• Assessed the client’s affect and the ability to understand directions, as well as other
resources available (other physicians, nurses, auxiliary personnel).
• Stay with client at all times; mother must not be left alone if delivery is imminent
• Do not prevent birth of baby
• Maintain sterile environment if possible
• Rupture membranes if necessary
• Support baby’s head as it emerges, preventing too rapid delivery with gentle pressure
• Check for nuchal cord, slip over head if possible
• Use gentle aspiration with bulb syringe to remove blood and mucus from nose and mouth
• Deliver shoulders after external rotation, asking mother to push gently if needed
• Provide support for baby’s body as it is delivered
• Hold baby in a head down position to facilitate drainage of secretions
• Promote cry by gently rubbing over back and soles of feet
• Dry to prevent heat loss
• Place baby on mother’s abdomen
• Check for signs of placental separation
• Check mother for excess bleeding
• Hold placenta as it is delivered
• Cut cord and apply a cord clamp
• Wrap baby in dry blanket, give to mother, put to breast if possible
• Check mother for fundal firmness and excess bleeding
• Record all pertinent data
• Comfort mother and family as needed

Preterm Labor

General information:

• Labor that occurs before the end of the 37th week of pregnancy

• Cause is frequently unknown, but the ff conditions are associated with premature labor:

–Cervical incompetence
–Preeclampsia/eclampsia
–Maternal injury
–Infection
–Multiple births
–Placental disorders
Prevention:
• Minimize or stop smoking; a major factor in preterm labor and birth.
• Minimize or stop substance abuse/chemical dependency.
• Early and consistent prenatal care.
• Appropriate diet/ weight gain.
• Minimize/prevent exposure to infections.
• Learn to recognize signs and symptoms of preterm labor.

Medical management:

• Unless labor is irreversible, or a condition exists in which the mother or fetus would be
jeopardized by the continuation of the pregnancy, or the membranes have ruptured, the usual
medical intervention is to attempt to arrest the premature labor (tocolysis).
• Medications used in the treatment of premature labor:
a. Magnesium sulfate – stops uterine contractions with fewer side effects than beta-
adrenergic drugs.
- Must monitor patient for magnesium toxicity
- Few serious side effects; initially patient feels hot, flushed, may
c/o headache, nausea, diarrhea, dizziness, nystagmus, and lethargy.
- Most common fetal side effect is hypotonia.
b. Beta-adrenergic drugs-Terbutaline and Ritodrine
–Decreases effect of calcium on muscle activation to slow or stop uterine
contractions
- Side effects: increased heart rate, nervousness, tremors, nausea
andvomiting, decrease in serum K+ level, cardiac arrythmias,
pulmonaryedema.
c. Nifedifine – Calcium channel blocker
–Side effects facial flushing, mild hypotension, reflex tachycardia,
headache, nausea

d. Indomethacin – Prostaglandin synthetase inhibitor


–Side effects: nausea, vomiting, dyspepsia

Nursing Intervention:

• Keep client at rest, side-lying position


• Hydrate the patient and maintain with IV fluids or PO fluids
• Maintain continuous maternal/fetal monitoring
• Administer drugs as ordered/ indicated
• Keep client informed of all progress/changes
• Identify side effects/ complications as early as possible
• Carry out activities designedto keep client comfortable

Premature Rupture of Membrane:

General information:

• Loss of amniotic fluid, prior to term, unconnected with labor


• Dangers associated with this event are prolapsed cord, infection and the potential need for
premature delivery

Assessment findings:

• Report from mother/family of discharge of fluid


• pH of vaginal fluid will differentiate between amniotic fluid (alkaline) and urine or purulent
discharge (acidic)
Nursing intervention:

• Monitor maternal/fetal vital signs on continuous basis, especially maternal temperature


• Calculate gestational age
• Observe for signs of infection and for signs of onset of labor
• If signs of infection, administer antibiotics as ordered and prepare for immediate delivery
• If no maternal infection, induction of labor may be delayed
• Observe and record color, odor, amount of amniotic fluid
• Examine mother for signs of prolapsed cord
• Provide explanations of procedures and findings and support mother/family
• Prepare mother/family for early birth if indicated

Rupture of Uterus

Description:

• A spontaneous or traumatic rupture of the uterus ie., the actual separation of


the uterine myometrium/ previous uterine scar, with rupture of membranes
and extrusion of the fetus or fetal parts into the peritoneal cavity. Dehiscence
is the partial separationof the old uterine scar; the fetus usually stays inside the uterus and the
bleeding is minimal when dehiscence occurs.

Risk factors:
• Woman who have previous surgery on the uterus
• Prior classical cesareans, where the incision is near the top of the uterus
• Prior removal of fibroid tumors if the incision extended through the full thickness of the
uterine wall
• Any other surgery that went through the full depth of the muscular portion of the uterus
• Grand multiparity
• Fetal malpresentation
• Labor- inducing medications
• Multiple gestation

Signs of uterine rupture:


• Localized pain and abnormalities of the fetal heart rate
• There may be vaginal bleeding and the vaginal examination ,may show that the babyis not as
low in the birth canal as he had beenearlier
Uterine rupture results in:

• bleeding

• rupture of the amniotic sac (bag of waters)

• partial or full delivery of the fetus into the abdominal cavity

• loss of oxygen delivery to the fetus

Classic symptoms of rupture include:

• pain above and beyond normal labor pain


• discontinuation of uterine contractions
• signs of fetal heart rate abnormalities
• hemorrhage
• shock

Prevention:
• Sudden severe abdominal pain in later pregnancy should be reported to your physician,
especially if you are at increased risk for rupture of the uterus.
• Women with risk factors such as prior classical cesarean, deep fibroid excisions,
and other major uterine surgeries should not attempt labor, and should be scheduled for
cesarean as soon as the fetus is expected to do well out in the wolrd, usually 36 and 39 weeks of
gestation.

Assessment:
• Descriptive characteristic of pain, including location, quality, intensity on a scale of 1-10,
temporal factors and sources of relief
• Fluid and electrolyte status, including weight, intake and output, urine specific gravity, skin
turgor, and mucous membranes

• Physiologic factors such as age and pain tolerance

• Physiological variables, such as body image, personality, previous experience with pain,
anxiety, and secondary gain

• Pulse, blood pressure, respiration, and temperature


• Evaluate maternal vital signs; espencially note an increase in rate and depth of respiration, an
increase in pulse, or a drop in BP indicating status change.

• Observe for signs and symptoms of impending rupture (ie, lack of


cervical dilatation, tetanic uterine contractions, restlessness,
anxiety, severe abdominal pain, fetal bradycardia, or late or
variable decelerations of the FHR).

• Assess fetal status by continuous monitoring.

• Speak with family, and evaluate their understanding of the situation

Intervention:
• Assess patient’s signs and symptoms of pain and administer pain medication as prescribed
• Start or maintain an IV fluid as prescribed. Use a large gauge catheter when starting the IV for
blood and large quantities of fluid replacement
• Perform comfort measures to promote relaxation such as relaxation techniques
• Administer fluids, blood or blood products
• Give brief explanation to the woman and her support person before beginning a procedure
• Answer questions that the family or woman may have
• Maintain a quiet and calm atmosphere to enhance relaxation
• Remain with the woman until anesthesia has been administered; offer support as needed

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