Childbirth At Risk

Linda L. Franco RN MSN NE-BC

- Tie everything together

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Woman with Psychological Disorders

• Depression, Bipolar disorder, anxiety, phobias, obsessive-compulsive disorder, Posttraumatic stress disorder,Schizophrenia

• Effect on Labor– Jeopardize health of mother and fetus– Exacerbate pain– Myometrial dysfunction

• Nursing Intervention– Communicate concerns and make choices– Pharmacologic measures

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• The prevalence of psychological disorders among adults in the United States is 22.1%. The psychological disorders which most commonly affect pregnant women are depression, bipolar disorder, anxiety, phobias, obsessive-compulsive disorder, posttraumatic stress disorder, and schizophrenia.

• Maternal implications –• Depression – reduces the woman’s ability to concentrate or process information

provided by the health care team.• Bipolar – Exhibit same symptoms of depression during the depressed phase, but if

labor occurs during a manic phase, the woman may be hyperexcitable.• Anxiety disorders – may cause the woman to experience physical symptoms such

as chest pain, shortness of breath, faintness, or even terror.• Behaviors may be exaggerated during labor. Your goal as a nurse is to provide

strategies that will help decrease the anxiety of the woman and her partner, keep her oriented to reality, and promote optimal functioning while in labor. All questions and concerns should be addressed promptly. Pharmacological measures such as sedatives, analgesics, or antianxiety medications may be ordered.

Dysfunctional Uterine Contractions

• Hypertonic Labor Pattern– Contractions are more frequent but less effective– Increased pain and fatigue– Stresses coping abilities– Fetal distress– Dehydration and increased risk for infection– Nonreassuring fetal status– Prolonged pressure on fetal head– Irregular in strength, timing or both, then cervix

won’t dilate = prolonged labor3:154

• Difficult labor is most commonly due to uncoordinated uterine contractions, which results in a prolonged labor. Dysfunctional contractions are typically irregular in strength, timing, or both. These irregular uterine contractions often arrest cervical dilatation.

• Normal contraction pattern = 2 to 4 contractions in 10 minutes in early labor and 4-5 per 10 minutes in later phases.

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Clinical Therapy

• Bed rest• Sedation• Pitocin Infusion• Amniotomy• Provide Comfort and Support

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Hypotonic Labor Pattern

• Less than 2 to 3 contractions in a 10 minute period

• Maternal exhaustion• Stresses coping abilities• Increased risk for Postpartal Hemorrhage • Fetal Distress• Maternal and Fetal sepsis

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• Hypotonic labor pattern usually develops in the active phase of labor, after labor has been well established. May occur when the uterus is overstretched from a twin gestation, or in the presence of a large fetus, hydramnios (an excess of amniotic fluid, leading to overdistension of the uterus. Frequently seen in diabetic women, even if there is no coexisting fetal anomaly), or grand multiparity. Bladder and bowel distention and CPD (cephalopelvic disporportion) may also be associated with this pattern.

• Postpartal hemorrhage – from insufficient uterine contractions following birth.

• Fetal sepsis from pathogens that ascend from the birth canal.

Clinical Therapy

• Pitocin Infusion• Nipple stimulation- release natural pitocin• Amniotomy• Cesarean Section if labor does not become effective

or if complications develop• Assessment of Contractions, FHR, VS, amniotic fluid• Monitor for Infection, Dehydration, and Fetal

Distress

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• Pitocin increases the strength and regularity of contractions. • Nipple stimulation causes the release of endrogenous oxytocin (natural

Pitocin). Can use an electric breast pump or manual stimulation. Again, pelvis proportion, fetal maturity, and position of presenting part should be determined before progressing with these options.

• Amniotomy – may be used to stimulate the labor process.• If amniotic membranes are ruptured, the nurse assesses fro the presence

of meconium (dark green or black stool expelled from the fetal large intestine). The presence of meconium in the amniotic fluid is indicative that the fetus is experiencing some form of stress.

• Encourage the patient to void every 2 hours and check her bladder for distention. Evaluate patient for signs of infection (elevated temperature, chills, foul-smelling amniotic fluid, and fetal tachycardia). Vaginal exams should be kept at a minimum.

Precipitous Labor & Birth• Precipitous Labor

– Labor that lasts less than 3 hours– Loss of coping abilities– Lacerations of cervix, vagina, and perineum– Postpartal Hemorrhage– Fetal distress– Cerebral Trauma– Pneumothorax from rapid descent

• Precipitous Birth– Unexpected, sudden, unattended birth

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• Contributing factors in precipitous labor are maultiparity, large pelvis, previous precipitous labor, and a small fetus in a favorable position. Precipitous labor and precipitous birth are not the same. A precipitous birth is an unexpected, sudden and often unattended birth.

• Postpartal hemorrhage is due to undetected lacerations or inadequate uterine contractions after birth. Fetal implications-

• Nonreassuring fetal status or hypoxia from decreased uteroplacental circulation due to intense uterine contractions.

• Cerebral trauma from rapid descent through the birth canal.• Pneumothorax from rapid descent through the birth canal.

Clinical Therapy

• History of Precipitous Labor– Close monitoring in last few weeks– Scheduled Induction of Labor– Emergency birth pack in room– Nurse remains in room– Monitor for Pitocin overdose– Monitor fetus for signs of distress– Dilation of >2cm/hr = precipitous labor

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• If the cervix softens and begins to dilate, the woman may be scheduled for immediate induction of labor. During labor the presence of one or both of the following factors may indicate potential problems:

• Accelerated cervical dilatation (>2 cm/hr in multigravidas and >1.2 cm/hr in primigravidas) and fetal descent.

• Intense uterine contractions with little uterine relaxation between contractions

• Pitocin overdose – Increase in BP by 30% above baseline. Cardiac output and stroke volume increase with a decrease in urine output.

• Fetal distress – nonreasuring fetal distress, bradycardia, late or variable decelerations.

• If the woman who is receiving Pitocin develops an accelerated labor pattern, the Pitocin is discontinued immediately, and the woman is turned on her left side to improve uterine perfusion. Oxygen may be administered to increase the available oxygen in maternal circulating blood, which in turn increases the amount available for exchange at the placental site. Continually monitor fetus for hypoxia.

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Postterm Pregnancy• Pregnancy that lasts more than 42 weeks• Maternal Risks

– Induction– Large for Gestational Age– Forceps, vacuum, or cesarean assisted birth– Psychological stress

• Fetal Risks– Decreased perfusion to placenta– Oligohydramnios– Meconium aspiration

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• A postterm pregnancy is one that extends more than 294 days or 42 weeks past the first day of the last menstrual period. It is important to distinguish between the term postdate, which means that the pregnancy has gone beyond the estimated date of birth (EDB), and postterm, which indicates that the pregnancy has gone at least 1 day beyond 42 complete weeks fro the last menstrual period.

• Occurrence is low 4-14%.• True cause is unknown, but it seems to occur more frequently in primigravidas and

women over age 35.• Fetal Risks:• The intrauterine environment becomes unfavorable for growth, and at birth the

infant has lost muscle mass and subcutaneous fat. Placental blood flow peaks around 36 weeks. After 40 weeks there is an increase in edema, fibrosis, fibrin deposits, and avascular villi. Premature aging can occur in HTN, IDDM, and renal disease. Smoking causes smaller, more fibrin deposits, and fewer capillaries.

• Oligohydramnious – decreased amount of amniotic fluid which increases the risk of cord compression.

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Clinical Therapy

• Nonstress Test and Biophysical Profile• Maternal monitoring of fetal movement• Induction of labor• Monitor FHR and amniotic fluid• Emotional support

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• Nonstress test – An assessment method by which the reaction for reaction (or response) of the fetal heart rate to fetal movement is evaluated.

• Biophysical profile – Assessment of five variables in the fetus that help to evaluate fetal risk: breathing movement, body movement, tone, amniotic fluid volume, and fetal heart rate reactivity. Emphasis is placed on the amniotic fluid volume portion. These tests may be done 2-3 times a week to help evaluate fetal well-being.

• Monitor FHR and amniotic fluid – Check for reassuring patterns and nonreassuring such as nonperiodic variable decelerations (which are associated with cord compression), so corrective actions can be taken.

• Assess amniotic fluid for meconium.

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Fetal Malposition• Occiput Posterior- (most common) occiput of

fetal head at back of maternal pelvis– Low back pain for mom– Labor prolonged– Increased risks of 3rd and 4th degree lacerations

• Close monitoring of maternal and fetal status• Forceps, vacuum or cesarean assisted delivery • Changing maternal positions• Can still be born vag w/o C-Section• Do knee to chest position to direct head down

to foot19

• The occiput-posterior position is the most common fetal malposition. When the fetus is OP, the occiput of the fetal head is directed toward the back of the maternal pelvis. During labor 90-95% of OP fetuses rotate to an occiput-anterior position.

• Majority of OP fetuses are born vaginally.• Signs and symptoms of persistent OP position include complaints of intense back

pain by the laboring woman, a dysfunctional labor pattern, hypotonic labor (the fetal head does not put adequate pressure on the cervix), arrest of dilatation, or arrest of fetal descent. The back pain is caused by the fetal occiput compressing the sacral nerves.

• FHR is typically heard far laterally on the abdomen above the symphysis.• Changing maternal posture has been used for many years to enhance rotation of

OP or occiput-transverse (OT) to OA. The patient may be asked to rotate from one side to the other. This allows a support person to apply counter pressure on the sacral area to decrease discomfort. A knee-chest position provides a downward slant to the vaginal canal, directing the fetal head downward on descent.

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Cephalic Presentations

• Vertex– Occiput

• Military– Top of head

• Brow– Forehead

• Face– Face

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• In a normal presentation, the occiput is the presenting part.• In a brow presentation, the forehead of the fetus becomes

the presenting part.• In the military presentation, the fetal head is between flexion

and extension, whereas in the occipitomental presentation the fetal head enters the birth canal with the widest diameter of the head (approx. 13.5 cm) foremost.

• Brow presentation occurs more often in multiparas and is thought to be due to lax abdominal and pelvic musculature. Brow presentations are the least common type of abnormal presentations.

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Fetal Malpresentations

• Brow• Face• Breech• Transverse Lie

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Brow Presentation• Forehead is the presenting part

– Fetal head is between flexion and extension– Maternal/Fetal Implications

• Longer labor• Increased Cesarean birth• Cerebral and neck compression with damage to the trachea and

larynx– Clinical Therapy

• Episiotomy• Cesarean Section• Monitor for fetal distress Fetal-neonatal risks include increased mortality because of cerebral

and neck compression and damage to the trachea and larynx. In addition, facial edema, bruising, and exaggerated molding of the newborn’s head may be observed.

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Face PresentationMulti, preterm, anachephaly

• Face is presenting part 1:600• Maternal/Fetal Risks

– CPD and prolongation of labor– Infection– Cesarean Birth– Cephalhematoma and edema of the face and throat– Pronounced molding of the fetal head– Clinical Therapy

• Episiotomy,Cesarean Section and monitor for fetal distress

– Nurse plans same as brow

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• Face presentation occurs most frequently in multiparas, in preterm birth, and in the presence of anencephaly (absence of brain ). The incidence of face presentation is about 1 in 600 births.

• Maternal Risks• Infection due to prolonged labor• Nursing Assessment• FHR are audible on the side where the fetal feet are palpated. It

may be difficult to determine by vaginal examination whether a breech or face is presenting, especially if facial edema is already present.

• Nursing Plan is the same as for brow presentation.26

Face Presentation

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Face Presentation

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Face Presentation

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Breech presentations

• Frank Breech• Footling Breech• Complete Breech

• The exact cause of breech presentation is unknown. This malpresentation occurs in about 3-4% of labors and is frequently associated with preterm birth, placenta previa, hydramnios, multiple gestation, uterine anomalies, and fetal anomalies (especially anencephaly and hydrocephaly).

• Frank Breech – Buttocks is the presenting part. Legs are against the torso.• Footling (incomplete) – One foot is the presenting part.• Complete – Buttock is the presenting part with the infant lying in the left sacral

anterior position.

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Frank Breech

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Incomplete (Footling) Breech

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Complete Breech

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Maternal/Fetal Implications • Cesarean Birth• Perinatal morbidity and mortality • Prolapsed cord• Cervical cord injuries due to hyperextension of the fetal

neck• Birth trauma• FHR is usually auscultated above the umbilicus. Passage of meconium into the amniotic fluid due to

compression of the fetal intestinal tract is common. • Prolapsed cord – if the membranes are ruptured, the nurse is particularly alert for a prolapsed

umbilical cord, especially in footling breeches, because there is a space between the cervix and presenting part through which the cord can slip. If the infant is small and the membranes rupture, the danger is even greater. The risk of a prolapsed cord is one reason why any woman with ruptured membranes should not ambulate until a full assessment has been performed.

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Clinical Therapy

• External Version• Cesarean Section• Monitor for fetal distress• Observe for Meconium stained amniotic fluid

• External cephalic version (ECV) (procedure involving external manipulation of the maternal abdomen to change the presentation of the fetus from breech to cephalic). This may be attempted at 36 -38 weeks’ gestation as long as the woman is not in labor.

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Transverse Lie• External Version• Cesarean Section• Assess FHR• A transverse lie occurs in approx. 1 in 300 term births. Maternal conditions

associated with a transverse lie are grand multiparity with relaxed uterine muscles, preterm fetus, abnormal uterus, excessive amniotic fluid, placenta previa, and contracted pelvis.

• When a shoulder presentation is still evident at 37 weeks, an external cephalic version attempt is recommended, followed by induction of labor, because the associated risk of prolapsed cord is significant.

• On inspection the woman’s abdomen appears widest from side to side as a result of the long axis of the infant’s body lying parallel to the ground and across the mother’s uterus. FHR is usually auscultated just below the midline of the umbilicus.

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Transverse Lie

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Macrosomia “Large for gestational age (LGA)”

• Weight of > 4000gms = 8.8lbs• Offspring of large parents and women with

diabetes, male infant• Maternal/Fetal Implications

– CPD, Dysfunctional Labor, Tissue Laceration, and Postpartal Hemorrhage

– Meconium Aspiration, Asphyxia, Shoulder Dystocia, Brachial Plexus injury and fractured clavicles

– Result in fetal death38

• Weight of 4000 grams = 4 kilo = 8.8 pounds• CPD (cephalopelvic disproportion) Pelvis is too

small for the birth.• Shoulder dystocia, in which, after birth of the

head, the anterior shoulder fails to deliver either spontaneously or with gentle traction, may result in fetal death if unresolved.

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Clinical Therapy• Cesarean Section if weight > than 4500gms• McRoberts maneuver or suprapubic pressure• Monitor FHR and for signs of fetal distress• Monitor for PP hemorrhage• Monitor for:

– cephalhematoma “blood under the scalp of a newborn; caused by pressure during birth”

– Erb’s palsy “paralysis of the arm caused by injury to the upper group of the arm's main nerves”

– cerebral, neurological, or motor problems

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• If a large fetus is suspected, the maternal pelvis should be evaluated carefully. Fetal size can be estimated by palpating the crown-to-rump length of the fetus in utero and by ultrasound or x-ray pelvimetry. As an emergency measure the MD may ask the nurse to assist the woman into the McRoberts maneuver (sharp flexion of the thighs toward the hips and abdomen) or to apply suprapubic pressure in an attempt to aid in the delivery of the fetal shoulders. Fundal pressure should never be used since it can further wedge the anterior shoulder under the symphysis pubis.

• Monitor FHR – Early decelerations (caused by fetal head compression) could mean size disproportion at the bony inlet. Lack of fetal descent is another indicator that the infant is too large for a vaginal birth.

• Monitor for PP hemorrhage – the overstretching of the uterus may lead to contractile problems during labor and after birth. After birth, the overstretched uterus may not contract well (uterine atony) and will feel boggy (soft). In this case, uterine hemorrhage is likely. The fundus of the uterus is massaged to stimulate contraction, and IV or IM Pitocin may be needed. Maternal vital signs are closely monitored for deviation suggestive of shock.

• Monitor for cephalhematoma (subcutaneous swelling containing blood found on the head of an infant several days after birth; it usually disappears within a few weeks to 2 months), Erb’s palsy (Paralysis of the arm and chest wall as a result of a birth injury to the brachial plexus or a subsequent injury to the fifth and sixth cranial nerves), as well as cerebral, neurological, or motor problems.

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Multiple Gestation• Twins 30:1000

– Dizygotic– Monozygotic

• Incidence increasing with use of infertility drugs• Maternal Implications

– Physical discomforts, UTI, PIH, preterm labor, and placenta previa, uterine dysfunction, prolapsed cord, hemorrhage

• Fetal Implications– Decreased intrauterine growth rate, increased incidence of

fetal anomalies and cerebral palsy, prematurity, and abnormal presentations

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• In part due to advances in fertility treatments, the incidence of twins in the US has increased by 59% since 1980, to 30.1 per 1000 live births. The incidence of spontaneous twins varies, but is highest in African American women of greater age and parity, and women who are tall and overweight. The incidence is low in the Asian population.

• Dizygotic – Derived from two separate zygotes (fraternal twins)• Monozygotic – Derived from one fertilized ovum (identical twins)• Clues to multiple gestation pregnancy –• visualization of two gestational sacs at 5 to 6 weeks • fundal heights greater than expected for the length of gestation• Auscultation of heart rates that differ by at least 10 beats per minute

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• Maternal implications – Physical discomforts range from physical discomfort, shortness of breath, backaches, and pedal edema. PIH( Pregnancy induced hypertension). Placenta previa ( a placenta which develops in the lower uterine segment, in the zone of dilatation, so that it covers or adjoins the internal os; painless hemorrhage in the last trimester, particularly during the eighth month, is the most common symptom. In a woman who has delivered twins, the uterus has been stretched more than the average pregnancy. The over stretching may lead to contractile problems during and after birth which may lead to postpartum hemorrhage.

• Fetal Implications – the perinatal mortality rate is approximately 10 times greater for twins than for a single fetus, and the morbidity rate is 5 times higher. The perinatal mortality rate for monoamniotic siblings has been estimated to be as high as 50 – 60%.

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Presentations of Twins

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Clinical Therapy

• Frequent prenatal visits• Serial ultrasounds to monitor for IUGR• NST, BPP, and Doppler ultrasound• Nutrition counseling• Close monitoring Intrapartally• Cesarean Section• Electronic Fetal Monitoring of FHR

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• Testing usually begins at 30 to 34 weeks’ gestation. • NST ( nonstress test) and BPP (biophysical profile –

assessment of five variables in the fetal risk; breathing movement, body movement, tone, amniotic fluid volume, and fetal heart rate reactivity). BPP results of 8 or better for each fetus is considered reassuring.

• A weight gain of 40 to 50 lbs, with a 15 to 20 lb weight gain by 20weeks, has been recommended fro women with multiple gestation pregnancy.

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Fetal Distress – Nonreassuring Fetal status

• O2 supply insufficient for the physiologic demands of the fetus

• Contributing Factors– Cord Compression– Uteroplacental Insufficiency

• Warning Signs– Meconium stained amniotic fluid– Ominous FHR patterns – late decelerations or prolonged

decelerations, persistent severe variable decelerations – When oxygen supply is insufficient to meet the physiologic needs of the fetus, a

nonreassuring fetal status may result. If the resulting hypoxia persists and metabolic acidosis occurs, the situation could cause permanent damage to or be life threatening for the fetus.

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Clinical Therapy – Intrauterine resuscitation

• Turn to left lateral position• Intravenous fluids or incr• Discontinue Pitocin• Administer oxygen via face mask• Provide emotional support • Knee to chest to help Fetal HR (FHR)

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• When these patterns are detected, intrauterine resuscitation (corrective measures used to optimize the oxygen exchange within the maternal-fetal circulation) should be started without delay. Treatment of maternal hypotension involves having the woman turn to a left lateral position, start IV infusion or increase the flow rate if an infusion is already in place, or, if cord prolapse is suspected, having the woman assume a knee-chest position. Position changes that result in an increase in the fetal heart rate should be maintained. A vaginal exam should be performed to attempt to detect a prolapsed cord. Uterine activity can be decreased by discontinuing IV Pitocin administration or administering terbutaline to decrease contractions. Oxygen is also administered to the woman via face mask.

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Placental Problems

• Abruptio Placentae– Placenta abruptio is the separation of the

placenta from the inner wall of the uterus before the baby is delivered.

• Placenta Previa- antepartum problem

– Where the placenta is implanted in the lower part of the uterus obstructing vaginal birth

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Abruptio Placentae

• Premature separation of placenta from the uterine wall

• Cause unknown • More frequent with PIH and Cocaine abuse• Divided into three types

– Marginal – edges – Central - centrally– Complete – total separation

• S & S – sudden, dark blood, severe abdominal pain, rigid abdomen

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• The premature separation of a normally implanted placenta from the uterine wall. Premature separation is considered a catastrophic event because of the severity of the resulting hemorrhage. The incidence of abruptio placentae is approximately 1 in 100 births and occurs more frequently in pregnancies complicated by hypertension and cocaine abuse.

• Some proposed theories –• decreased blood flow to the placenta through the sinuses during the last

trimester.• excessive intrauterine pressure caused by multiple gestation pregnancy,

hypertension, cigarette smoking, alcohol ingestion, increased maternal age and parity, trauma, domestic violence, nonvortex presentation and sudden changes in intrauterine pressure (as in amniotomy).

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• Types:• Marginal placenta separates at it edges, the blood passes between the fetal

membranes and the uterine wall, and blood escapes vaginally.• Central placenta separates centrally, and the blood is trapped between the

placenta and the uterine wall. Entrapment of the blood results in concealed bleeding. In severe cases of central abruptio placentae, the blood invades the myometrial tissues between the muscle fibers. This occurrence accounts for the uterine irritability that is a significant sign of abruptio placentae. If hemorrhage continues, eventually the uterus turns entirely blue because the muscle fibers are filled with blood. After birth the uterus contracts poorly and frequently a hysterectomy is necessary.

• Complete massive vaginal bleeding is seen in the presence of total separation. • Signs and Symptoms – Extreme tenderness of abdomen, rigid and boardlike

abdomen, and increase in the size of the abdomen

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Marginal Abruption with External

Bleeding

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Central Abruption

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Complete Abruption

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Implications and Treatment

• Maternal– Hemorrhage– Renal failure b/c of shock– Vascular spasm– Intravascular clotting

• Fetal– Anemia– Hypoxia– Death

• Birth by Cesarean Section (safest)• Hysterectomy in some cases

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• Large amounts of thromboplastin are released into the maternal blood supply. This thromboplastin in turn triggers the development of DIC and resultant hypofibrinogenemia. Fibrinogen levels, which are ordinarily elevated in pregnancy, may drop in minutes to the point at which blood will no longer coagulate. Because of the risk of DIC, evaluating the results of coagulation tests is imperative. In DIC, fibrinogen levels and platelet counts usually decrease; prothrombin times and partial thromboplastin times are normal to prolonged. Type and crossmatch blood for transfusion.

• Renal failure is due to shock• Fetal implications:• Perinatal mortality associated with abruptio placentae ranges from 25 – 35%. In severe

cases in the infant mortality rate is near 100%. The rate of survival is highest in fetuses who are delivered within 20 minutes of initial separation.

• Cesarean birth is safest.• If the separation is mild and the pregnancy is near term, labor may be induced and the

fetus born vaginally with as little trauma as possible. If rupture of membranes and Pitocin do not initiate labor, a C-section is required. A long delay would raise the risk of increased hemorrhage.

Placenta Previa

• Placenta implanted in lower uterine segment• Uterine contractions cause placental villi to tear

away from uterine wall causing bleeding• Implications

– Hypoxia– Anemia

• S & S – slowly progressive, bright red blood, pain only during labor, soft and relaxed abdomen

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• This implantation may be on a portion of the lower segment or over the internal cervical os. As the lower uterine segment contracts and dilates in the later weeks of pregnancy, the placental villi are torn from the uterine wall, thus exposing the entire uterine sinuses at the placental site.

• Types:• Total the internal os is covered• Partial the internal os is partially covered• Marginal the edge of the placenta is covered• Low-lying the placenta is implanted in the lower uterine segment in close

proximity to but not covering the os.• Cause is unknown. Statistically it occurs in about 4 per 1000 births.

Placenta Previa

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Partial Placenta Previa

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Total Placenta Previa

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Clinical Therapy• Bed rest with BRP• No vaginal exams• Monitor blood loss and uterine contractility• Monitor FHR and Maternal VS• IV fluids• T & C 2 units of blood• Maintain pregnancy until 37 weeks if stable• Induction of labor if bleeding stable; C/Section if unstable• The goal of medical care is to identify the cause of bleeding and to provide treatment that

will ensure birth of a mature newborn. • No vaginal exams – Vaginal exams should never be performed on a woman with bleeding

since the examiner’s fingers could perforate the placenta if cervical dilatation has occurred.

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Prolapsed Umbilical Cord• Umbilical cord precedes the fetal presenting part; becomes

compresses between presenting part and maternal pelvis• Implications

– Emotional distress– Fetal distress– Fetal death

• Treatment – remains horizontal until head is engaged, examiner’s gloved fingers must remain in vagina to provide firm pressure on fetal head, oxygen via face mask, assume knee-chest position, emergency Cesarean Section

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Prolapsed Cord

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Amniotic Fluid-Related Complications

• Amniotic Fluid Embolism– Hole & amnotic fluid goes into circulatory

system- Mortality results. 50% die in 1hr.

• Polyhydramnios– too much amniotic fluid. >2000ml

• Oligohydramnios– too little amniotic fluid. <500ml

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• Amniotic Fluid Embolism – A rare and often fatal event characterized by the sudden onset of hypotension, hypoxia, and coagulopathy. Amniotic fluid containing particles of debris (e.g. Hair, skin, vernix, or meconium) enters the maternal circulation and obstructs the pulmonary vessels, causing respiratory distress and circulatory collapse. The incidence is approximately 1 case per 8000 to 80,000 pregnancies and carries a maternal mortality rate as high as 80% (Schoening, 2007).

• Polyhydraminios – Also known as hydramnios is a condition in which there is too much amniotic fluid (more than 2000 ml) surrounding the fetus between 32 and 36 weeks. It occurs in approx. 3% of all pregnancies and is associated with fetal anomalies of development. It is associated with poor fetal outcomes because of the increased incidence of preterm births, fetal malpresentation and cord prolapse (Rajiah, Banerjee, 2007).

• Oligohydramnios – A decreased amount of amniotic fluid (less than 500ml) between 32 and 36 weeks’ gestation. It occurs in 5 – 8% of all pregnancies. May result from any condition that prevents the fetus from making urine or blocks it from going into the amniotic sac. This condition puts the fetus at an increased risk of perinatal morbidity and mortality. Reduction in amniotic fluid reduces the ability of the fetus to move freely without risk of cord compression.

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Amniotic Fluid Embolism

• Amniotic fluid enters maternal circulation through small tear in chorion or amnion

• S & S – sudden onset of dyspnea, cyanosis, cardiovascular collapse, shock and coma

• Treatment – Oxygen with positive pressure, IV line, CPR, Blood transfusion, CVP line

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• Normally, amniotic fluid does not enter the maternal circulation because it is contained within the uterus, sealed off by the amniotic sac. An embolus occurs when the barrier between the maternal circulation and the amniotic fluid is broken and amniotic fluid enters the maternal venous system via the endocervical veins, the placental site (if the placenta is separated), or a site of uterine trauma. As many as 50% of women die within the first hour after the onset of symptoms. And about 85% of survivors have permanent hypoxia-induced neurological damage (Moore, 2006).

• No test can diagnose and amniotic fluid embolism. Nursing assessment skills are critical. Clinical appearance varies, but most woman report difficulty breathing, hypotension, cyanosis, seizures, tachycardia, coagulation failure, disseminated intravascular coagulation, pulmonary edema, uterine atony with subsequent hemorrhage, adult respiratory distress syndrome, and cardiac arrest (Moore and Ware, 2007).

• Nursing Interventions- inotropic agents to maintain cardiac output and blood pressure. Control hemorrhage – Oxytocin to control uterine atony and bleeding, seizure precautions, and administration of steroids to control inflammatory response.

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Polyhydramnios• More than 2000 cc’s of amniotic fluid• Associated with major congenital anomalies• Fetal swallowing of amniotic fluid is impaired• Implications – shortness of breath, edema from compression

of vena cava, abruptio placenta, postpartum hemorrhage, preterm birth, prolapsed cord

• Treatment – if severe can remove by amniocentesis• During the second half of a normal pregnancy, the fetus begins to swallow and inspire amniotic

fluid and to urinate, which contributes to the amount of amniotic fluid present. However, polyhydramnios is associated with fetal malformations that affect the fetal swallowing mechanism and neurological disorders in the fetal meninges are exposed in the amniotic sac. This condition is also found in cases of anencephaly, in which the fetus is thought to urinate excessively due to overstimulation of the cerebrospinal centers.

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Oligohydramnios

• Amount of amniotic fluid is severely decreased and concentrated

• More frequent with postmaturity, IUGR, fetal renal malformations

• Implications– Dysfunctional labor, fetal skin and skeletal anomalies,

pulmonary hypoplasia, umbilical cord compression

• Treatment – amnioinfusion, continuous fetal monitoring

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• As long as fetal well-being is demonstrated with frequent testing, no intervention is necessary. If fetal well-being is compromised, birth is planned along with amnioinfusion (the transvaginal infusion of crystalloid fluid to compensate for the lost amniotic fluid). The fluid is introduced into the uterus through an intrauterine pressure catheter. The infusion is administered in a controlled fashion to prevent overdistention of the uterus. Amnioinfusion is thought to improve abnormal fetal heart rate patterns, decrease c-sections, and possibly minimize the risk of neonatal meconioum aspiration syndrome (Norwitz & Schorge, 2006).

• Pulmonary hypoplasia – underdevelopment of the lungs.

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Cephalopelvic Disproportion

• Baby is larger than the pelvic diameters or the baby is in an abnormal position or presentation

• Maternal/Fetal Implications– Prolonged labor, uterine rupture, necrosis of maternal

soft tissues resulting in fistulas to other nearby structures

– Prolapsed cord, excessive molding of head, traumatic forceps-assisted birth

• Treatment – Trial of Labor, Cesarean Section

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• The birth passage includes the maternal bony pelvis, beginning at the pelvic inlet and ending at the pelvic outlet, and the maternal soft tissues within these anatomic areas. A contracture (narrowed diameter) in any of the described area can result in CPD if the fetus is larger that the pelvic diameters. The pelvic inlet is contracted if the shortest anterior-posterior diameter is less than 10 cm or the greatest transverse diameter is less than 12 cm.

• Membrane rupture can result from the force of the unequally distributed contractions being exerted on the fetal membranes. In obstructed labor, in which the fetus cannot descend, uterine rupture can occur. With delayed descent, necrosis of maternal soft tissues can result from pressure exerted by the fetal head. Eventually, necrosis can cause fistulas from the vagina to other nearby structures.

• If the membrane rupture and the fetal head has not entered the inlet, there is a danger of cord prolapse. Excessive molding of the fetal head can result. Traumatic, forceps-assisted birth can damage the fetal skull and central nervous system.

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Retained Placenta

• Retention of placenta beyond 30 minutes after birth– Excessive bleeding– Manual removal (flush/hand)– Removal with curettage– Occurs in 2-3% of all vaginal births. Bleeding as a result of a retained

placenta can be excessive. If placental expulsion does not occur, a manual removal of the placenta is attempted. In woman who have not had an epidural, intravenous sedation may be required because of the discomfort caused by the procedure.

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Lacerations

• First Degree - fourchette, perineal skin, and vaginal mucous membrane

• Second Degree – perineal skin, vaginal mucous membrane, underlying fascia, and muscles of the perineal body

• Third Degree - perineal skin, vaginal mucous membrane, underlying fascia, and muscles of the perineal body, and involves the anal sphincter

• Fourth Degree – same as the 3rd degree but extends through the rectal mucosa to the lumen of the rectum

• Lacerations should always be suspected in the face of a contracted uterus with bright red blood continuing to trickle out of the vagina.

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Placenta Accreta

• Chorionic villi attach directly to the myometrium of the uterus

• Two other types– Placenta increta – myometrium is invaded– Placenta percreta – myometrium is penetrated

• Maternal hemorrhage• Abdominal Hysterectomy• These placental abnormalities, although rare, carry a very high morbidity and

mortality rate, possibly necessitating a hysterectomy at delivery. The incidence of placenta accreta is 1 in 2500 cases (Cunningham, 2001).

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