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Complications or circumstances outside of the normal may have a serious impact on the pregnant client during labor or the intrapartum phase of pregnancy. Some of these complications will be discussed and the role of the nurse in caring for the client with intrapartum complications. Multiple gestations (twins, triplets, quadruplets …) is a complication of pregnancy due to the multiple risks associated with the pregnancy and the rarity of multiple gestations. Some of these risks include preterm pre-labor rupture of membranes, preterm labor, HELLP, abnormal fetal presentation, and postpartum hemorrhage. Each of these is discussed individually due to the impact it can also have on a single gestation client. The care is the same and the client will be monitored closely.

Pre-labor Rupture of the Membranes (PROM)

The rupture of membranes before the onset of labor can be an alarming experience for the pregnant client. This can occur anytime prior to the start of labor. The preterm pre-labor rupture of membranes (PPROM) can occur prior to the onset of labor in a client who is less than 37 weeks. The risks associated with the rupture of membranes include infection such as chorioamnionitis or endometritis. Strict sterile techniques must be observed for all vaginal exams to help minimize the risk. With PROM the risk of a premature delivery also exists and the fetus will be monitored closely for complications such as a prolapsed cord. The prolapsed cord will become an obstetrical emergency and calls for immediate delivery.

Management of the client depends on the number of weeks pregnant, a term client will be induced, and continued monitoring for infection. If the fetus is <34 weeks gestation the management is conservative assuming no infection is present. If the client is <34  weeks bed rest is expected, with fetal lung maturity studies, administration of glucocorticoids 12mg Q 12 hours X 2 between 24-36 6/7 weeks, benefits are seen within 24 hours after the first dose but not after seven days. Fetal movements will be recorded and a non-stress test conducted daily. Antibiotics will also be ordered to decrease the risk of infection.

Preterm Labor & Birth

Preterm labor and/or birth occurs before 37 weeks gestation but after 20 weeks. Late preterm is classified between 34 0/7 – 36 6/7, moderate is 32 0/7 – 33 6/7, very preterm is 28 0/7 – 31 6/7, and extremely preterm is before 28 weeks gestation. Preterm birth is the leading cause of neonatal mortality in the United States. Risk factors that can impact preterm labor/birth include multiple gestations, infections, anemia, uterine anomalies/fibroids, foreign body like an IUD, domestic violence, low socioeconomic status, and inadequate prenatal care. Signs and symptoms of preterm labor may present differently than labor after 37 weeks and include contractions or cramping, diarrhea, low back pain that comes and goes, pelvic pressure, leaking of fluid, mucousy vaginal discharge, and bloody show.

The primary goal for the pregnant client presenting with preterm labor is to delay the birth by at least 48 hours so that glucocorticoids may be administered. The nurse caring for the client may anticipate and a number of orders to be provided. Screening tests for confirmation of preterm labor and possible causes include fetal fibronectin (fFN) that is collected between 22-34 weeks. It is a glycoprotein found in plasma and produced by the fetus. It is normal for it to appear in the cervical and vaginal secretions early and late in pregnancy. Its presence (a positive test) between 24-34 weeks is not a sensitive predictor of preterm birth, however, it has a negative predictive value of 99.2%. An in and out catheter may be utilized to collect a urine culture. Amnisure is used to detect PROM. Vaginal cultures will be collected along with ultrasound for cervical length/funneling. A cervical exam may be performed only AFTER the fFN has been performed.

Treatment of preterm labor may include the utilization of tocolytics to decrease uterine contractions. Tocolytics that may be utilized include beta-adrenergic agonists (Terbutaline), magnesium sulfate, calcium channel blockers (Nifedipine), and Indomethacin (NSAID). Give magnesium sulfate and nifedipine together with caution. Both block calcium and have been implicated in serious maternal side effects including cardiovascular collapse. The utilization of magnesium sulfate has been shown to reduce neurological risks in the newborn such as cerebral palsy and intraventricular hemorrhage (Ha, 2019). Preterm labor is not stopped if the pregnant client presents with the following conditions; fetal demise, lethal fetal anomaly, severe preeclampsia/eclampsia, placental abruption, chorioamnionitis, severe fetal growth restriction, fetal maturity, and nonreassuring fetal status. The pregnant client presenting with preterm labor may also be at risk from side effects of the tocolytics, thromboembolism related to bed rest, disruption of normal activities, financial, social, and psychological stress. The fetus is at risk for respiratory distress syndrome, apnea, cold stress, hypoglycemia, hyperbilirubinemia, patent ductus arterious, intraventricular hemorrhage, anemia, retinopathy, neurologic, auditory, and speech defects.

Dystocia

Dystocia or difficult labor can be related to the uterus, pelvis, fetal descent, and cephalo-pelvic disproportion.

Uterine Dystocia

With uterine dystocia, the pregnant client may present with hypotonic labor, tachysystole, or precipitous labor. Each is related to uterine contractions that are not normal and is also called dysfunctional labor. Hypotonic labor occurs when the contractions become weaker and less frequent and may appear more like irritability. This causes slowing or arrest of cervical dilation in turn slowing or arrest of the fetal descent with no cervical change for 2 hours. Hypotonic labor can lead to prolonged labor, intrauterine infection or infection in the neonate, maternal exhaustion, psychological stress, and postpartum hemorrhage. The causes of hypotonic labor include overstretched uterine fibers, overuse or prolonged use of oxytocin, bowel or bladder distention, chorioamnionitis, maternal anxiety, and/or fear. The treatment for hypotonic labor includes artificial rupture of the membranes (amniotomy), augmented labor with oxytocin, placement of an intrauterine pressure catheter to assess uterine contractions, and ruling out of cephalo-pelvic disproportion and abnormal presentation.

Tachysystole occurs when there are more than 5 contractions in a 10 minute period of time or any contraction that lasts longer than 2 minutes. The uterus has a greater than normal state of constant tension, the baseline increases, and contractions become more painful than normal due to the increased muscle anoxia. This constant state of uterine contractions may interfere with the uteroplacental exchange that will lead to fetal distress. Causes of tachysystole include improper use of oxytocin and placental abruption. This can lead to uterine rupture, placental abruption (if not the cause), fetal distress, fetal death, and an emergency cesarean birth. The nurse can expect to turn off any oxytocin if it is running, minimize fetal distress by placing the client on the left lateral side, increasing IV fluids, administering tocolytics (e.g. Terbutaline 0.25 mg SQ), oxygen via facemask if indicated by the pregnant client’s SpO2 and preparation for an emergency cesarean birth.

The final cause of uterine dystocia is precipitous labor which is an extremely rapid dilation and effacement within less than 3 hours. Causes of precipitous labor include low resistance in the maternal tissues, extremely strong uterine contractions, multiparity, large pelvis, previous precipitous delivery, small fetus in a favorable position, injudicious oxytocin induction or augmentation, cocaine use, and placental abruption. There are several risks associated with a precipitous delivery and include delivery prior to arrival at a healthcare facility, lacerations of the cervix, vagina, perineum, postpartum hemorrhage, increased incidence of uterine rupture, increased risk of amniotic fluid embolism, increase in fetal hypoxia and bradycardia, meconium-stained fluid, brachial plexus injury, increased cerebral trauma to the infant, and facial bruising.

Pelvic Dystocia

Pelvic dystocia is related to the pelvis. The fetus cannot enter or pass through the bony pelvis of the mother and difficulty or failure of the fetal head to descend and/or engage will occur. The absence of pressure from the fetal head against the cervix will lead to ineffective contractions. The causes of pelvic dystocia are commonly associated with the size and shape of the pelvis. Typically the pregnant client with android or platypelloid types is predisposed. Abnormalities of the reproductive tract like uterine fibroids, cysts, tumors, or a distended bladder may also inhibit fetal descent. With the pregnant client experiencing pelvic dystocia an increased risk of prolapsed cord and abnormal presentations exist. In addition, the newborn may present with increased molding and caput upon delivery. The nurse will assess the fetal heart rate to ensure there aren’t any complications. In addition, the nurse will want to assess for bladder distention. Supporting the client in what is generally prolonged labor and possible preparation for a cesarean birth due to failure to progress or descend.

Fetal Dystocia

Fetal dystocia can be associated with a number of factors that are inhibiting fetal descent. Some of these include cephalopelvic disproportion (CPD) due to the size of the head or body of the fetus. Malposition such as occiput posterior or acynclitic. Malpresentation such as a face, brow, breech, or transverse lie. Each of these positions will need to be evaluated further for possible delivery via cesarean section.

A breech presentation occurs in 3-4% of all births and involves risks to both the newborn and the pregnant client. The baby is at an increased risk of up to three times of mortality compared to cephalic presentations. Risk for prolapsed cord, fetal & neonatal asphyxia, meconium aspiration, hip dysplasia, intracranial hemorrhage from traumatic delivery of the head, and spinal cord injuries due to manipulation of the body & hyperextension of the fetal head at delivery. The mother is at risk for a cesarean birth. The nurse may assist the provider with an external cephalic version if the client is not in labor. If allowed to deliver vaginally it may lead to prolonged labor, lacerations of the birth canal or episiotomy extensions, postpartum infections, and passage of meconium.

The external cephalic version is turning the fetus from one position to another (typically breech or transverse to cephalic). The client must be at least 37 0/7 weeks and not be in labor, there must be adequate amniotic fluid, and NST should show fetal well-being. It is performed in the hospital setting in the event that an emergency cesarean must be performed. An ultrasound will be done first to confirm the fetal position. Risks associated with the version are placental abruption, umbilical cord compression/entanglement and they have a success rate of ~58% (ACOG, 2016). The nurse will be responsible for assisting with the procedure by obtaining a reactive NST and informed consent, start IV if ordered, give tocolytic (terbutaline), assist the physician as needed, monitor the fetus and mother during and for at least an hour after the procedure,  and give Rhogam to Rh-negative clients.

Induction/Augmentation of Labor

Induction of labor is the stimulation of uterine contractions before the onset of spontaneous labor, with or without ruptured membranes. Augmentation is the stimulation of uterine contractions when spontaneous contractions have failed to result in progressive cervical dilation or descent of the fetus.

Indications for Induction:

• Post-term Pregnancy (42 weeks 1 day)
• Diabetes Mellitus
• Chronic Hypertension
• Preeclampsia
• Chorioamnionitis
• Fetal Demise
• Elective (no medical indication)

Risks of Induction:

• Hyperstimulation of the uterus
• Fetal Hypoxia
• Placental Abruption
• Rapid Labor leading to cervical lacerations
• Uterine Rupture
• Water Intoxication (only if oxytocin is given in non-isotonic solution)

In post-term pregnancies, extending beyond 42-weeks a number of risks are associated with the pregnant client including the incidence of induction of labor or cesarean section, postpartum hemorrhage due to larger fetal size, anxiety, and emotional fatigue. The fetus is at risk for decreased placental circulation, oligohydramnios, umbilical cord compression, large for gestational age infant (LGA), and increased risk for meconium staining and aspiration at birth.

Induction and/or augmentation of labor is managed with oxytocin. Oxytocin is a synthetic hormone given to induce or augment labor by stimulating uterine contractions. It is also used in postpartum hemorrhage to stop bleeding. IT IS A PREGNANCY CATEGORY X MEDICATION!!! Make sure to use great caution when administrating. Adverse effects of oxytocin administration include placental abruption, uterine rupture, and fetal distress. Oxytocin is dosed in mu/min, but it is delivered via infusion pump in ml/hour. The administration of oxytocin is typically 2 mu/min increasing by 1-2 mu/min every 15-30 minutes until contractions occur every 2-3 minutes.

The management of oxytocin by the nurse is to ensure it is titrated slowly and to remember the goal is to achieve a contraction pattern that is 2-3 minutes apart. The nurse will monitor and document contractions, fetal heart tones, maternal blood pressure, and heart rate every 30-minutes up till active labor and every 15 minutes once in active labor. The nurse wants to avoid tachysystole, if it does occur the oxytocin needs to be turned off immediately. If fetal distress occurs stop the medication, turn the client to a left lateral position, notify the provider and apply oxygen via facemask if needed.

The pregnant client will be assessed by the provider prior to induction of labor. Cervical ripening may need to take place prior to administration of oxytocin and is dependent on the Bishop Score. With a Bishop score of 8 or more induction of labor is likely successful. If the score is less than 6 ripening should be considered before induction of labor. Cervical ripening can occur via chemical methods or mechanical methods. The following are chemical methods or cervical ripening and require a provider order to begin:

Cytotec

• Prostaglandin E1, given in tablet form intravaginally
• More effective in inducing labor, but greater risk of tachysystole, fetal distress, meconium
• Not approved by the FDA for labor induction, but commonly used for this purpose

Cervidil

• Prostaglandin E2; provided in an impregnated gauze strip that is placed intravaginally
• The advantage is that it can be quickly removed if tachysystole or fetal distress occurs
• Disadvantage: not as effective, and more expensive than Cytotec

Prepidil

• Prostaglandin E2; comes in a gel form that is inserted intravaginally

Nursing care for the client receiving chemical ripening of the cervix includes documentation of the insertion (nurses may administer Cytotec; physicians typically insert Cervidil or Prepidil, monitor fetal heart rate and maternal vital signs, maintain patient on bed rest for 30 – 40 minutes after Cytotec, 30 minutes after Prepidil and 2 hours after Cervidil. Oxytocin should not be started sooner than four hours after the last Cytotec dose, 6 – 12 hours after Prepidil instillation, and 30 – 60 minutes after removal of the cervidil.

Cervical ripening may also occur with mechanical measures by insertion of a cervical ripening balloon also called a Cook’s balloon. The balloon works by putting pressure on both inside and outside of the cervix, which stretches it and encourages the release of endogenous prostaglandins which will hopefully increase uterine contractility. The advantage of the Cook’s balloon is that it is low-cost relative to chemical prostaglandins and minimized risk of tachysystole or fetal distress.

Amniotomy

The artificial rupture of amniotic membranes (AROM) or amniotomy is also a method of augmenting labor. It is performed by the provider with an amnihook by making a small tear in the amniotic membrane allowing the escape of amniotic fluid. The cervix must be dilated at least 1 cm. AROM allows the presenting part to descend and place direct pressure on the cervix with accelerates dilation. It can provide access for internal monitors if needed and it allows the provider to assess the color of the amniotic fluid. However, there is also the risk of potential for a prolapsed cord and an increased risk of infection.

The nurse should ensure IV access prior to the procedure and assess fetal heart rate immediately before and after the procedure. The nurse and provider will document the color, amount, odor, and any presence of blood or meconium. The nurse will provide clean pads and linens. Once the AROM has occurred the number of vaginal exams should be as minimal as possible to decrease the risk of infection. The nurse will monitor the pregnant client’s vital signs every 30-minutes and temperature every 2 hours. If the presenting part is not engaged, the client should remain on bed rest to minimize the risk of a prolapsed cord. In the case of an emergency with a prolapsed cord with the AROM, the provider will stay in place to relieve pressure from the presenting part. The nurse will prepare the client for cesarean delivery.

Pharmacological management of pain during labor

Anesthetics

Nitrous Oxide

Instrument Assisted Vaginal Birth

In some rare cases, there may be a need for assistance with instrumentation during vaginal birth. Forceps and vacuum extraction are two common instrument-assisted devices. Forceps are only indicated with a prolonged second stage of labor, non-reassuring fetal status, maternal exhaustion, and when analgesia or fatigue interferes with the ability to push effectively. They may only be used by a trained provider due to the fetal and maternal risks associated with the use. Before they can be used the cervix must be completely dilated with the exact position and station of the fetal head known, the membranes must be ruptured, the maternal bladder is empty, adequate anesthesia, and the ability for a standby cesarean if indicated. The pregnant client is at risk of lacerations of the birth canal, the extension of a median episiotomy into the rectum which could lead to urinary & rectal incontinence, more perineal pain & sexual problems in the postpartum period, and the increased risk of postpartum infections and prolonged hospital stays. The risk is not only to the pregnant client, the newborn could appear with bruising & edema of the face, caput succedaneum, cephalhematoma, subdural hematoma, transient facial paralysis, low Apgar scores, retinal hemorrhage, ocular trauma, and/or fractured clavicle.

Vacuum extraction is another method of mechanical assistance. The indications are the same as forceps. With some additional risks including perineal trauma, edema, third and fourth-degree lacerations, postpartum pain & infection, more sexual difficulties postpartum. The newborn is at risk for scalp lacerations, shoulder dystocia, caput, cephalohematoma or subdural hematoma, intracranial hemorrhages, retinal hemorrhages/ocular trauma, fractured clavicle, and fetal death.

Cesarean Delivery

Cesarean delivery may be indicated and planned when some antepartum complications are present. Some of these indications may include placenta previa, benign & malignant tumors that obstruct the birth canal, malpresentation, multiple gestations, previous cesarean birth, active genital herpes, and major congenital anomalies. Unplanned or emergent indications for cesarean delivery include failure to progress, failure of descent, malpresentation, placental abruption, uterine rupture, umbilical cord prolapse, and fetal distress. Prior to the delivery occurring the nurse will monitor the maternal vital signs and fetal heart rate. The nurse will also obtain patent IV access, maintain NPO, give preop medications as ordered (e.g. Bicitra, antibiotics), insert an indwelling urinary catheter, prepare the abdomen by washing and clipping, make sure all necessary personnel and equipment are present, assist the provider in obtaining consent, assist the anesthesiologist during the spinal placement, and position the client on the operating table. After the surgery, the nurse will monitor the vital signs of the client, check the surgical dressing and document findings, palpate the fundus & check the amount of lochia, monitor intake & output, administer oxytocin and pain medications as ordered, and possibly assist with newborn care including breastfeeding. The pregnant client is at risk for infection, reactions to anesthetic agents, blood clots, bleeding, urethral injury & bladder laceration, wound infection, and a four-fold increased risk of maternal death.

After a cesarean delivery, the client may decide to attempt a vaginal birth with subsequent pregnancies. This occurs with extreme caution and supervision. These clients may have either a trial of labor after cesarean (TOLAC) and if successful vaginal birth after cesarean (VBAC). The selection criteria are strict and the client may only have had one or two previous cesareans with a low transverse uterine incision, clinically adequate pelvis, no other uterine scars, and the physicians must be immediately available including anesthesia in the event of an emergent cesarean must be done. The nurse must continuously monitor the vital signs, FHT, and uterine contractions. If inducing with oxytocin titration occurs slowly. The nurse should prepare by having consents signed and the OR prepared. The NICU and anesthesia provider will be notified of the TOLAC and the nurse will provide emotional support and encouragement.

Risks for both a repeat cesarean and TOLAC are present in the pregnant client and include endometritis, operative injury, blood transfusion, hysterectomy, uterine rupture, and maternal death. In the newborn stillbirth could occur, hypoxic-ischemic encephalopathy (HIE), neonatal death, perinatal death, NICU admission, respiratory morbidity, transient tachypnea, and hyperbilirubinemia.

Emergencies in Labor & Delivery

Shoulder Dystocia

Shoulder dystocia during vaginal birth means that the shoulder of the newborn remains “stuck” after delivery. It may be referred to as a turtle sign by the provider. The pregnant client is at higher risk of shoulder dystocia with abnormal pelvic anatomy, gestational diabetes, post-date pregnancy, macrosomia, operative vaginal delivery, the protracted active phase of the first stage of labor or second stage. The fetus is at risk for brachial plexus injury, fractured clavicle, meconium aspiration, asphyxia, hypoglycemia, and neurological damage. Additionally, the pregnant client that suffers from shoulder dystocia is at risk for postpartum hemorrhage, third or fourth-degree episiotomy leading to rectovaginal fistula, symphyseal separation, and uterine rupture. Once it has been identified the fetus must be delivered as soon as possible to avoid fetal compromise and asphyxia. The nurse will assist the provider with a number of maneuvers to help successfully deliver the fetus including McRoberts, applying suprapubic pressure, the Woods Screw maneuver, Gaskin maneuver, an episiotomy, fracturing of the clavicle, and Zavanelli maneuver. If these maneuvers are unsuccessful and immediate cesarean delivery will need to be performed.

Uterine Rupture

Uterine rupture is a non-surgical disruption of the uterine cavity and occurs in 1 in 8000 to 1 in 15,000 births. When the uterus ruptures the membranes may be herniated into the peritoneal cavity and bleeding may occur. The extent of maternal and fetal distress is ni proportion to the degree of rupture. Uterine rupture is can be associated with a previous uterine incision and requires an emergent cesarean birth. The decision to incision must occur within 30 minutes.

Amniotic Fluid Embolus (Anaphylactoid Syndrome of Pregnancy)

The cause of anaphylactoid syndrome of pregnancy is unknown. The theory is that it occurs when a bolus of amniotic fluid, fetal cells, and other debris enter the maternal circulation. This activates an inflammation cycle that leads to complications such as DIC, ARDS, and neurologic injury. The onset of symptoms is rapid and includes restlessness, shortness of breath, hypoxia, hypotension, cyanosis, DIC, hemorrhage, cardiovascular and respiratory collapse. There is a 22% mortality rate and most who die, die within one hour of onset. The incidence is 1/8000. Management of care is immediate stabilization of the client via ventilation, CPR, aggressive fluid, and blood resuscitation, and if still pregnant C-section.