Common Problems of Labor, Delivery, and Postpartum

Meredith Harris, RNC, WHNP Eutocia Normal labor Follows a fairly predictable course Dystocia Difficult labor Hypertonic labor patterns Hypotonic labor patterns Precipitous labor and birth Hypertonic Labor Patterns Uterine contractions of poor quality Resting tone of the myometrium increases. Contractions become more frequent Contractions are painful but ineffective in dilating and effacing the cervix. Maternal Risks Increased discomfort Physically exhausted Emotionally discouraged Dehydrated Fetal-Neonate Risks Fetal distress because contractions and increased resting tone interfere with uteroplacental exchange.

Prolonged pressure on the fetal head, which may result in cephalhematoma, caput succedaneum, or excessive molding. Clinical Management Bed rest Sedation IV hydration Uterine contractions may be stimulated after CPD is ruled out. oxytocin infusion amniotomy
Hypotonic Labor Patterns Hypotonic = Fewer than 2-3 contractions in a 10minute period in the active phase of labor. Caused by: Early use of analgesia Uterine distention (twin gestation, a large fetus, hydramnios), Grand multiparity Bladder distention Bowel distention CPD Maternal Risks Maternal exhaustion Stress on coping abilities Postpartal hemorrhage Intrauterine infection Fetal-Neonate Risks Fetal distress related to prolonged labor

Fetal sepsis secondary to PROM

Clinical Therapy Active management of labor Amniotomy, timed cervical exams Augmentation with oxytocin Placental problems Abruptio placentae Premature separation of a normally implanted placenta from the uterine wall. Painful, dark, venous bleeding Placenta previa Placenta is implanted in the lower uterine segment Painless, bright red bleeding Prolapsed umbilical cord Umbilical cord precedes the presenting part. Compression of the cord results in decreased blood flow and leads to fetal distress. Amniotic fluid embolism Respiratory distress, circulatory collapse, acute hemorrhage, cor pulmonale Chest pain, dyspnea, cyanosis, frothy sputum, tachycardia, hypotension, massive hemorrhage, extreme anxiety, anaphylactoid syndrome
Prolapse of the Umbilical Cord Definition:

 Prolapse of the umbilical cord thorough the cervical

canal along side of the presenting part Etiology: Occurs anytime the inlet is not occluded. Fetus is not well engaged GOAL: RELIEVE THE PRESSURE ON THE CORD SUPPORT MOTHER AND THE FAMILY NURSING CARE / Therapeutic Interventions: **Get the pressure off the Cord --place in trendelenberg or knee-chest position OR elevate part with sterile gloved hand Palpate FHTs, NEVER ATTEMPT TO REPLACE CORD! Give O2 per mask at 10 Liters Cover exposed cord with sterile wet gauze Stay with the patient and offer support Amniotic Fluid Embolism

Contractions are ineffectual, erratic, uncoordinated, and involve only a portion of the uterus

Exhaustion of the mother Psychological trauma - frustrated

Therapeutic Interventions: 1. Ambulation getting up and walking will increase contractions 2. Nipple Stimulation causes release of endogenous Pitocin which can stimulate contractions 3. Enema--warmth of enema may stimulate contractions 4. AMNIOTOMY artificial rupture of the membranes Advantages of doing this before Pitocin Contractions are more similar to those of spontaneous labor Usually no risk of rupture of the uterus Does not require as close surveillance Disadvantages of an Amniotomy Delivery must occur Increase danger of prolapse of umbilical cord Compression and molding of the fetal head (caput) Nursing Care: # 1-Check the fetal heart tones Assess color, odor, amount Provide with perineal care Monitor contractions Check temperature every 2 hours 5. Pitocin for augmentation of labor Use only if CPD is not present Give 20 units / 1000 cc. fluid and hang as a secondary infusion, never as primary GOAL: Achieve contractions every 2 - 3 minutes of good intensity with relaxation between Nursing Care: Assess contractions--are they increasing but not tetanic Assess dilation and effacement Monitor vital signs and FHTs

Increase in frequency of contractions, but intensity is decreased, do not bring about dilation and effacement of the cervix. Signs and Symptoms: 1. PAINFUL contractions RT uterine muscle anoxia, causing constant cramping pain 2. Dilation and effacement of the cervix does not occur. 3. Prolonged latent phase. Stay at 2 - 3 cm. dont dilate as should 4. Fetal distress occurs early uterine resting tone is high, decreasing placental perfusion. 5. Anxious and discouraged Treatment of Hypertonic Uterine Contractions

Escape of amniotic fluid into the maternal circulation

Provide with COMFORT MEASURES Warm shower; Mouth Care; Imagery; Music; Back rub Mild sedation Bedrest Hydration Tocolytics to reduce high uterine tone HYPOTONIC UTERINE CONTRACTIONS UTERINE INERTIA

usually enters maternal circulation through open

sinus at placental site

Usually fatal to the Mother

amniotic fluid contains debris, lanugo, vernix,

meconium, etc. Signs and Symptoms:

dyspnea chest pain cyanosis shock

Therapeutic Interventions:

Etiology and Pathophysiology:

Overstretching of the uterus

--large baby, multiple babies, polyhydramnios, multiple parity

Bowel or bladder distention preventing descent Excessive use of analgesia

Signs and Symptoms of HYPOTONIC UTERINE INERTIA:

Deliver the baby Provide cardiovascular and respiratory support

to Mom HYPERTONIC UTERINE CONTRACTIONS

Most often occur in first-time mothers, Primigravidas

Weak contractions become mild Infrequent (every 10 15 minutes +) and brief, Can be easily indented with fingertip pressure at
peak of contraction.

Prolonged ACTIVE Phase