COMPLICATIONS OF LABOR & DELIVERY

Complications with the Power

 About 95% of labors are completed with contractions that follow a predictable, normal course. When they
become abnormal or ineffective, ineffective labor occurs.
 Dysfunctional labor (Dystocia of labor- slow progress)
o Primary-occurring at the onset of labor
o Secondary - occurring later in labor
o Complications
 Maternal post-partal infection
 Hemorrhage
 Infant mortality

Tocodynamometer (measure the length, frequency, and strength of uterine contractions)

Ineffective Uterine Force

 Hypotonic Contractions
 The number of contractions is unusually low or infrequent
 Not more than 2 or 3 in a 10-minute period
 Resting tone: <10mmHg
 Strength of contractions: 25mmHg
 Most apt to occur during the active phase of labor
 Contractions are not exceedingly painful, because of lack of intensity.
 May occur after the administration of analgesia
o If the cervix is not dilated to 3 to 4 cm.
o If bowel or bladder distention prevents descent or firm engagement.
 Risk Factors (overstretched uterus)
- Multiple gestation
- Larger-than-usual single fetus
 - Hydramnios
- Grand multiparity
 Management
- WOF postpartal hemorrhage
- Up to 1hr postpartum, palpate the uterus and assess the lochia ql5min
 Hypertonic Contractions
 Increased in resting tone 15mmHg
 Occur frequently and are most commonly seen in the latent phase of labor.
 More painful than usual, because the myometrium becomes tender from constant lack of relaxation and the
anoxia of uterine cells that results
 Fetal anoxia (when your body or brain completely loses its oxygen supply)
 Management
- Uterine and fetal heart monitor
- Deceleration in FHR, or abnormally long first stage of labor
- CS birth

 Uncoordinated Contractions
 More than one pacemaker may be initiating contractions, or receptor points in the myometrium may be
acting independently of the pacemaker.
 Management
- Uterine and fetal heart monitor
- Assess the rate, pattern, resting tone and fetal response too Contractions for at least 15 minutes to
reveal abnormal pattern
- Oxytocin administration

Dysfunction at First Stage of Labor

 Prolonged Latent Phase

 Latent phase that is longer than 20 hours in a nullipara (has not given birth) or 14 hours in a multipara
  The uterus tends to be in a hypertonic state.
 Relaxation between contractions is inadequate
 Contractions are only mild (less than 15mmHg) and therefore ineffective
 May occur if the cervix is not "ripe at the beginning of labor and time must be spent getting truly ready
for labor.
 May occur if there is excessive use of an analgesic early in labor.
 Management
- Help the uterus rest
- Provide adequate fluids
- Pain relief such as MSO4
- Changing the linens and women's gown, darken lights, decrease noise and stimulation
- CS birth
- Amniotomy
- Oxytocin infusion
 Protracted Active Phase
 Usually associated with CPD (Cephalopelvic disproportion) or fetal malposition
 Ineffective myometrial activity
 Cervical dilatation occurs at <1.2cm/hr in a nullipara and <1.5cm/hr in a multipara
 Active phase longer than 12 hours in a primigravid or 6 hours in a multigravida
 Tends to be hypotonic
 Management
- If with CPD CS birth
- If no CPDU Oxytocin management
 Prolonged Deceleration Phase
 Deceleration phase has become prolonged when it extends beyond 3 hours in a nullipara or 1 hour in a
multipara
 Most often results from abnormal fetal head position.
 CS birth.
 Secondary Arrest in Dilatation
 NO Progress in cervical dilatation for longer than 2 hours
 CS birth

Dysfunction at Second Stage of Labor

 Rate of descent: <lcm/hr in nullipara, <2cm/hr in multipara.

 2nd stage of labor lasts over 3 hours in a multipara
 Contractions have been of good quality and proper duration, and effacement and beginning dilatation
have occurred, but then the contractions become infrequent and of poor quality and dilatation stops.
 Management
- Rest and fluids for hypertonic contractions
- Intact BOW; amniotomy
- IV Oxytocin
- Semi-Fowler's position, squatting, kneeling, or more effective pushing
 Arrest of Descent
 No descent has occurred for 1 hour in multipara or 2 hours in nullipara.
 Expected descent of the fetus does not begin or engagement or movement beyond 0 station has not
occurred.
 Most likely cause is CPD
 CS birth
 Oxytocin administration
 Contraction Rings
 A hard band that forms across the uterus at the junction of the upper and lower uterine segments and
interferes with fetal descent
 The most frequent type seen is termed a pathologic retraction ring (Bandl’s ring)
 Warning Sign that severe dysfunctional labor is occurring as it is formed by excessive retraction of the
upper uterine segment
 Early labor uncoordinated contraction
 Pelvic division of labor obstetric manipulation or oxytocin administration

 Contraction Rings
 Management
- Ultrasound
- IV MSO4, inhalation of amyl nitrite
- Tocolytics
- CS birth
 Precipitate Labor
 Labor that is completed in fewer than 3 hours
 Precipitate dilatation-cervical dilatation that occurs at a rate of 5cm or more per hour in a primipara
(giving birth for the first time) or 10 cm or more per hour in a multipara
 Risk Factor:
- Grand multiparity
- Induction of labor by oxytocin
- Amniotomy
 Complications
- Abruptio placenta
- Hemorrhage
- Fetal subdural hemorrhage
- Perineal lacerations
 Management: Tocolytics
 Uterine Rupture
 Vertical scar from a previous CS birth or hysterotomy tears
o 1% in low transverse
o 4-8% in classic CS
 Prolonged labor
 Abnormal presentation
 Multiple gestation
 Unwise use of oxytocin
 Obstructed labor
 Traumatic maneuvers of forceps or traction
 Assessment
- Impending rupture pathological ring
- Strong uterine contractions without cervical dilatation.
- A Sudden, severe pain during a strong labor contraction.
- She may report a "tearing" sensation.
- Incomplete rupture
 Intact peritoneum
 Localized tenderness and persistent aching pain over area of the lower uterine segment.
 Fetal and maternal distress (FHR, VS changes; Lack of contractions)
 Confirmed by ultrasound
- Complete rupture
 Endometrium, myometrium, peritoneum layers
 Uterine contractions will immediately stop
 Two distinct wolling:
1. Retracted uterus
2. Extrauterine fetus
 Hemorrhage
 Signs of shock
 Management
- Highly vascular !!!! Uterine rupture is an immediate emergency situation
- Emergency fluid replacement therapy
- IV Oxytocin
- Prepare for possible laparotomy
- Viability of the fetus: extent of rupture and time elapsed between rupture and abdominal extraction
- Woman's prognosis: Depends on extent of the rupture and the blood loss.
- Most Women are advised not to conceive again after a rupture of the uterus, unless the rupture
occurred in the inactive lower segment.
- Consent for cesarean hysterectomy or tubal ligation
 Uterine Inversion
 The uterus turning inside out with either birth of the fetus or delivery of the placenta.
  120,000 births
 Inversion occurs in varying degrees
 May lie within the uterine cavity or vagina
 Total inversion D protrudes from vagina
 Risk Factors
- Traction is applied to the umbilical cord to remove the placenta
- Pressure is applied to the uterine fundus when the uterus is not contracted
- The placenta is attached at the fundus so that, during birth the passage or the fetus pulls the fundus
down.
 Assessment
- Large amount of blood suddenly gushes from the vagina
- Fundus is not palpable in the abdomen
- Prolonged bleeding; hypovolemic shock
 Management
- NEVER attempt to replace an inversion
- NEVER attempt to remove the placenta if it is still attached
- Oxytocic drugs will make the uterus more tense and harder to replace
- O2 via face mask
- Assess VS, anticipate need for CPR
- General anesthesia, nitroglycerin, tocolytic drug before replacing manually.
- Prophylactic antibiotic therapy
- CS for any subsequent pregnancies
 Amniotic Fluid Embolism
 Amniotic fluid is forced into an open maternal uterine blood Sinus through
o Some defect in the membranes
o after membrane rupture
o partial premature separation of the placenta
 Occurs in 1/20,000 births, accounts for 10% of maternal deaths in the Us
 It is not preventable because it is not predictable.
 Risk Factors: Oxytocin administration, Abruptio Placentae, Hydramnios
 Assessment
- A woman, in strong labor, sits up suddenly and grasps her chest because of sharp pain and inability
to breathe as she experiences pulmonary artery constriction.
- She becomes pale and then turns the typical bluish gray associated with pulmonary embolism and
lack of blood flow to the lungs.
 Management
- O2 administration; endotracheal intubation
- CPR death
- Even if woman survives initial insult, high risk for DIC

PROBLEMS WITH THE PASSENGER

 Umbilical cord Prolapse

 A loop of the umbilical cord slips down in front of the presenting part
 Risk Factors
- Premature rupture of membranes
- Fetal presentation other than cephalic
- Placenta previa Intrauterine tumors preventing the presenting part from engaging
- A small fetus
- Cephalopelvic disproportion preventing firm engagement
- Hydramnios
 - Multiple gestation

 Assessment
- In rare instances, the cord may be felt as the presenting part on an initial vaginal examination during
labor
- Ultrasound
- More often, however, cord prolapse is first discovered only after the membranes have ruptured,
when a variable deceleration FHR pattern suddenly becomes apparent
- The cord may be visible at the vulva.
- Always assess fetal heart sounds immediately after ROM
 Management
- Management is aimed at relieving pressure on the cord, thereby relieving the compression and the
resulting fetal anoxia
- Manual elevation of fetal head off the cord
- Knee-chest or Trendelenburg
- O2 10 L/min by face mask
- Tocolytic agents
- Amnioin fusion
- If cord prolapse is exposed to air; drying; atrophy of umbilical vessels
- DO NOT attempt to push any exposed cord back into the vagina. This may add to the compression
by causing knotting or kinking
- Instead, cover any exposed portion with a sterile saline compress to0 prevent drying
- If the cervix is fully dilated at the time of the prolapse the physician may choose to birth the infant
quickly possibly with forceps, LO prevent fetal anoxia.
- If dilatation is incomplete, apply upward pressure on the presenting part until CS birth.
 Shoulder Dystocia
 The problem occurs at the second stage of labor, when the fetal head is born but the shoulders are too
broad to enter and be born through the pelvic outlet.
 Risk Factors: women with DM, multiparas, post-date pregnancies
 Maternal complicationprolaps: vaginal or cervical tears
 Fetal complication: cord compression, fractured clavicle or brachial plexus injury
 McRobert's maneuver
 Applying suprapubic pressure