Complications of labor and delivery

Table of Contents

Introduction

Childbirth, a transformative journey in a woman’s life, encompasses the profound and exhilarating experience of labor. In this pivotal event, dedicated healthcare professionals, particularly nurses, assume a central role in delivering comprehensive care and support. This nursing note endeavors to delve into the multifaceted aspects of labor, spanning from the initiation of contractions to the momentous delivery of a newborn. The exploration encompasses a thorough examination of distinct stages, diverse labor management techniques, and evidence-based nursing interventions.

Definition

Labor, in the context of childbirth, refers to the process by which the uterus contracts rhythmically to facilitate the expulsion of the fetus from the mother’s womb. It is a crucial and natural physiological event that marks the culmination of pregnancy. Labor typically involves a series of progressive stages, each characterized by specific changes in the cervix and the position of the baby. The onset of labor is often signaled by regular and increasingly intense contractions of the uterine muscles. These contractions work to dilate and efface the cervix, allowing the baby to move through the birth canal for delivery. Labor is a complex and orchestrated process that involves both the mother’s body and the baby adapting to the challenges of childbirth.

Foster cooperation and trust from the patient

To foster cooperation and trust from the patient and their family, it is crucial for the nurse to establish a therapeutic relationship. This begins with a warm introduction to make them feel welcome, especially considering the heightened anxiety they may be experiencing. The nurse should communicate messages gently and confidently during this initial encounter. Exploring the family’s expectations regarding childbirth is essential at this stage, providing an opportunity to also understand and respect their cultural values.

Admission assessment of a woman

Upon arrival at the labor floor, the admission assessment involves gathering pertinent information about the pregnant woman’s health history. This includes personal data such as blood type and allergies, details about previous illnesses, any pregnancy complications, preferences for labor and delivery, and preparations made for childbirth. Standard obstetric, medical, and social history is also obtained.

Furthermore, the nurse conducts assessments encompassing vital signs, a physical examination, evaluation of the contraction pattern (considering frequency, interval, duration, and intensity), inspection for the intactness of membranes through a vaginal exam, and assessment of fetal well-being. The latter involves monitoring fetal heart rate, examining the characteristics of amniotic fluid, and assessing contractions. Additionally, the nurse employs Leopold’s maneuver to determine the fetal presenting part, point of maximum impulse, fetal descent, and engagement.

Stages of Labor

The process of labor unfolds in distinct stages, each characterized by specific physiological changes. Here are the three main stages of labor: Stages of Labor: Duration and Progression

First Stage:

The first stage of labor begins with the onset of true labor contractions and concludes with full cervical dilatation. For nulliparous individuals, this stage typically lasts 10-12 hours, with the normal limit ranging from 6 to 20 hours. In contrast, multiparous individuals usually experience a duration of 6-8 hours, with the normal limit being 2-12 hours.

Latent Phase:

This phase starts with the onset of regularly perceived uterine contractions (mild contractions lasting 20-40 seconds) and extends until reaching 3 cm cervical dilatation. The typical duration is 6 hours for nulliparous and 4.5 hours for multiparous individuals.

Active Phase:

Marked by stronger uterine contractions lasting 40-60 seconds and 7 cm cervical dilatation, the active phase has a duration of 3 hours for nulliparous and 2 hours for multiparous individuals.

Transitional Phase:

Uterine contractions peak, occurring every 2-3 minutes for 60-90 seconds, leading to 10 cm cervical dilatation. Nulliparous individuals usually experience a 3-hour duration, while multiparous individuals typically take 1.5-2 hours.

Second Stage:

The second stage begins with full cervical dilatation and concludes with the birth of the infant. For both nulliparous and multiparous individuals, this stage typically lasts less than 2 hours, with a normal limit of 0.5-1 hour. If epidurals are involved, the duration may extend to 3 hours for nulliparous and 2 hours for multiparous individuals.

Third Stage:

The third stage starts with the birth of the infant and concludes with placental delivery. The maximum duration for this stage is 30 minutes.

These general guidelines provide an overview of the progression and duration of labor stages. Individual experiences may vary, and healthcare providers consider these factors while providing care during childbirth.

Latent (Preparatory) Phase Nursing Responsibilities:

During the Latent (Preparatory) Phase, extending from the onset of true labor contractions to 3 cm cervical dilatation, nurses undertake essential responsibilities to ensure optimal care and support for the laboring woman:

Assess Psychological Readiness:

Evaluate the patient’s psychological readiness for labor and childbirth. Provide continuous maternal support, exceeding standard care, to address emotional needs.

Measure Duration of Latent Phase:

Monitor and record the duration of the latent phase. Adhere to the guideline of not exceeding 6 hours for nulliparas and 4.5 hours for multiparas. Identify if anesthesia administration has occurred, as it can influence the duration of this phase.

Evaluate for Cephalopelvic Disproportion (CPD):

Assess for potential causes of prolonged latent phase, such as CPD. Recognize that CPD may necessitate cesarean birth, and prompt action may be required.

Promote Maternal Activity:

Encourage the patient to remain continually active during the latent phase. Advocate for upright maternal positions, particularly recommending walking for women without complications.

Facilitate Administrative Tasks:

Conduct necessary interviews and documentation, including the completion of forms such as the birth certificate. Optimize this phase, characterized by minimal discomfort, for administrative tasks.

Health Teaching:

Provide health education on breastfeeding, newborn care, and effective bearing down. Utilize this phase, when anxiety is controlled, to focus on the patient’s understanding of nursing instructions.

Introduction of Relaxation Techniques:

Educate the patient on various relaxation techniques. Initiate discussions on alternative pain relief therapies, acknowledging the importance of early intervention.

Limit Internal Examinations:

Ensure that the total number of internal examinations throughout labor does not exceed 5.

Support Birthing Companion Presence:

Facilitate and ensure the presence of the birthing companion chosen by the patient throughout the entire course of labor. These nursing responsibilities aim to create a supportive and informed environment for the laboring woman during the latent phase of labor.

Active Phase Nursing Responsibilities:

During the Active Phase, spanning from 4 cm to 7 cm cervical dilatation, nurses play a pivotal role in providing care and support as labor intensifies. Key responsibilities include:

Informing on Labor Progress:

Communicate regularly with the patient about the progress of her labor. Alleviate anxiety by keeping the patient informed, fostering trust, and promoting cooperation.

Monitoring with WHO Partograph:

Initiate the use of the WHO partograph, focusing on the 2-hour action line, to track labor progression.

Encouraging Continual Activity:

Motivate the patient to stay active to optimize the effectiveness of uterine contractions. Recommend upright maternal positions when tolerated to enhance labor progress.

Assisting with Comfortable Positions:

Assist the patient in finding a comfortable position. For those unable to remain upright, advocate left-side lying to prevent disruptions in fetal oxygenation.

Regular Monitoring of Vital Signs:

Monitor maternal vital signs and fetal heart rate at intervals of every 2 hours, or as per the doctor’s orders.

Anticipating Patient Needs:

Proactively address patient needs to enhance comfort (e.g., sponging face with a cool cloth, maintaining a clean and dry bed, providing ice chips or lip balm).

Assessing Bladder Status:

Determine when the patient last voided, as a full bladder can impede rapid labor progress.

Implementing Non-Pharmacological Pain Measures:

Institute non-pharmacological pain relief measures, such as breathing exercises, distraction methods, imagery, and music therapy, to assist the patient in managing discomfort. During this active phase, the nurse’s focus is on providing comprehensive care, promoting comfort, and facilitating effective labor progress, while being attentive to the individual needs and preferences of the laboring woman.

Transition Phase Nursing Responsibilities: Throughout the Transition Phase, spanning from 8 cm to full 10 cm cervical dilatation with full cervical effacement, nurses play a crucial role in supporting the laboring woman. Responsibilities during this intense stage include:
Informing on Labor Progress: Provide regular updates on the progress of the labor to keep the patient informed and ease anxiety.
Assisting with Breathing Techniques: Assist the patient in practicing pant-blow breathing techniques to manage the intense contractions and support optimal oxygenation.
Continuous Monitoring: Monitor maternal vital signs and fetal heart rate more frequently, ranging from every 30 minutes to 1 hour, based on the doctor’s orders. Maintain continuous contraction monitoring to assess labor progression.
Preparation for Delivery: When perineal bulging becomes noticeable, prepare for imminent delivery. Ensure the room temperature is within the range of 25-28°C and devoid of air drafts to create a comfortable environment. Notify the necessary staff and assemble essential supplies and equipment, including a resuscitation machine. Perform handwashing and double gloving in preparation for the delivery.
During the Transition Phase, the nurse’s focus is on close monitoring, effective communication, and proactive preparation for the imminent delivery. This stage often presents a mix of emotions in the laboring woman, ranging from exhaustion and withdrawal to aggression and restlessness, necessitating a supportive and attentive care approach.

The World Health Organization (WHO) does not endorse the following nursing interventions during labor due to their low-quality evidence:

Routine Perineal Shaving: Shaving the perineal area is not recommended as a routine practice during labor.
Routine Use of Enema: The routine administration of enemas is discouraged during labor.
Admission Cardiotocography (CTG) for Low-Risk Women: Routine use of admission CTG for women classified as low-risk during labor is not recommended.
Vaginal Douching: Vaginal douching is not recommended as a routine intervention during labor.
Routine Amniotomy for Patients in Spontaneous Labor: The routine artificial rupture of membranes (amniotomy) for patients in spontaneous labor is not endorsed.
Massage and Reflexology: The routine use of massage and reflexology is not supported as standard interventions during labor.

These recommendations are made by WHO based on the available evidence, emphasizing the importance of evidence-based practices to ensure the safety and well-being of both the laboring woman and the newborn.

Second Stage of Labor Nursing Care:

The Second Stage of Labor commences at 10 cm cervical dilatation and concludes with the delivery of the baby. During this phase, the nurse plays a crucial role in coaching quality pushing and providing support. Here are key nursing care tips for this stage:

Instructing on Quality Pushing: Guide the patient on effective pushing techniques, emphasizing the coordinated effort of abdominal muscles with uterine contractions for optimal delivery.
Creating a Quiet Environment: Provide a serene and focused environment to assist the patient in concentrating on the bearing-down efforts.
Offering Positive Feedback: Encourage the patient with positive feedback during the pushing phase to enhance motivation and confidence.
Reiterating Doctor’s Instructions: Repeat the doctor’s instructions, recognizing that the patient’s attention is primarily directed towards the birthing process, making communication challenging.
Recording Time of Delivery: Take note of the time of delivery and promptly initiate essential newborn care practices, with consideration for delayed cord clamping, as recommended.
Assisting with Episiotomy: Provide assistance with a restrictive episiotomy when necessary for patients undergoing vaginal births.

WHO-Not Recommended Interventions.

The World Health Organization (WHO) does not recommend the following interventions during delivery due to their low-quality evidence:

Perineal Massage: Routine perineal massage is not endorsed as a standard practice during delivery.
Use of Fundal Pressure: The routine use of fundal pressure is discouraged due to its low-quality evidence.
These recommendations align with evidence-based practices, emphasizing the importance of safe and effective care during the crucial second stage of labor.

Third Stage of Labor Nursing Care:

The Third Stage of Labor, encompassing the birth of the infant to the delivery of the placenta, involves two distinct phases: placental separation and placental expulsion. Nursing care during this stage is crucial and involves the following considerations:

Signs of Placental Separation:

Lengthening of Umbilical Cord: The umbilical cord visibly lengthens as the placenta begins to separate.
Sudden Gush of Vaginal Blood: A sudden gush of blood from the vagina signifies placental separation.
Change in the Shape of the Uterus: The uterus takes on a globular shape as it contracts during placental separation.
Firm Uterine Contractions: The presence of firm uterine contractions is an indicator of the ongoing process.
Appearance of Placenta in Vaginal Opening: The placenta becomes visible at the vaginal opening as it moves downward.

Nursing Care Tips:

Coaching in Relaxation: Coach the patient in relaxation techniques to facilitate the delivery of the placenta.
Congratulating on Baby’s Delivery: Extend congratulations on the successful delivery of the baby.
Encouraging Skin-to-Skin Contact: Encourage skin-to-skin contact for bonding and facilitate early breastfeeding.
Inquiring about Placenta Importance: Ask the patient if the placenta holds significance for them before disposal. For those wishing to take it home, ensure compliance with infection precautions and hospital policies.
Administering Prophylactic Oxytocin: Administer prophylactic oxytocin as ordered to support uterine contraction and minimize bleeding.
Utilizing Controlled Cord Traction: Use the controlled cord traction technique to assist in the expulsion of the placenta.
Choosing Absorbable Synthetic Sutures: Opt for absorbable synthetic suture materials over chromic catgut for the primary repair of episiotomy or perineal lacerations.
Immediate Postpartum Nursing Care: Monitor vital signs and watch for excessive bleeding. Consider the first four hours post-birth as the fourth stage of labor, recognizing its critical nature for the mother. Perform nursing interventions to prevent infection and hemorrhage. Emphasize the importance of breastfeeding, ambulation, and newborn care to the mother.

The comprehensive nursing care during the third stage of labor aims to ensure the well-being of both the mother and the newborn while addressing critical aspects of delivery and immediate postpartum care.

WHO Recommendations for Immediate Postpartum:

Early Resumption of Feeding: Recommend early resumption of feeding within the first six hours for patients who have had a vaginal birth.
Prophylactic Antibiotics: Propose the use of prophylactic antibiotics for women who sustained third to fourth-degree perineal tears during delivery.
Early Postpartum Discharge: For healthy women delivering vaginally to term infants, WHO recommends early postpartum discharge.

Interventions Not Recommended During Immediate Postpartum:

Routine Use of Ice Packs: Discourage the routine use of ice packs during the immediate postpartum period.
Oral Methylergometrine for Vaginal Deliveries: WHO does not recommend the routine use of oral methylergometrine for patients who delivered vaginally.

These recommendations aim to promote evidence-based practices and ensure the well-being of both mothers and newborns during the critical immediate postpartum period.

Individualized Care Plan and Precise Assessment in Labor:

The cornerstone of a successful individualized care plan lies in the meticulous assessment and accurate collection of data. Continuous observation during labor is essential to monitor the progress of the woman and ensure a safe delivery for both the mother and the child. Key assessments during labor include:

Assessment for Signs of True Labor: Observe for signs of true labor, characterized by contractions that initiate irregularly but progress regularly and predictably. True labor pain typically begins in the lower back and radiates towards the abdomen, persisting irrespective of the woman’s activity level. Monitor for an increase in the duration, frequency, and intensity of contractions, coupled with evident cervical dilation.

Assessment for the Appearance of Show: Look for the presence of “show,” which involves the expulsion of the operculum or mucus plug, manifested by the discharge of blood mixed with mucus.

Assessment for Rupture of Membranes: Assess for the rupture of membranes, characterized by the scanty or sudden gush of clear fluid from the vagina.

Assessment for Engagement of the Fetal Head: Monitor for the engagement of the fetal head, denoting the settling of the presenting part into the pelvis at the level of the ischial spines.

Assessment for Station: Evaluate the station, indicating the relationship of the presenting part to the level of the ischial spines.

Assessment for Effacement and Dilatation of the Cervix: Assess for effacement, which involves the shortening and thinning of the cervical canal. Additionally, evaluate cervical dilatation, focusing on the enlargement or widening of the cervical canal.

The meticulous observation and assessment of these parameters contribute to a comprehensive understanding of the labor progress, enabling healthcare professionals to tailor care plans that meet the individual needs of the laboring woman.

Care Planning:

Based on the comprehensive data collected during the assessment and an accurate diagnosis, a tailored care plan will be devised to support the woman throughout the labor process.

Care of a Woman in the First Stage of Labor:

Natural Onset of Labor: Labor initiation should occur naturally, avoiding artificial induction.
Freedom of Movement: The woman should have the freedom to move unrestricted during labor, with a prohibition on unnecessary artificial interventions.
Non-Supine Delivery Position: Permit the woman to adopt a non-supine position for the delivery process.
Uninterrupted Breastfeeding and Bonding: Following the newborn’s delivery, both the mother and child should be afforded ample opportunities for uninterrupted breastfeeding and bonding.

Care of a Woman in the Second Stage of Labor:

Preparation for Delivery: Adequate preparations for the woman’s delivery location should be made during the second stage of labor.
Determining Comfortable Birth Position: Identify the most comfortable birth position for the woman during this stage.
Promoting Effective Pushing in the Second Stage: Emphasize the promotion of effective pushing during the second stage of labor.
Perineal Cleaning: Integral to the second stage is the essential practice of perineal cleaning.

Care of the Woman in the Third Stage of Labor:

Emphasis on Placental Delivery: Prioritize the delivery of the placenta during the third stage of labor.
Administration of Oxytocin: Following placental delivery, administer oxytocin intramuscularly to stimulate uterine contractions.
Integration of Perineal Repair: If an episiotomy is performed, incorporate perineal repair into the care plan.

Implementation for Comfort and Safety During and After Labor:

Encourage Regular Voiding: Advocate for the client to void every 2 hours to ensure comfort and prevent complications.
Monitor and Review Breathing Techniques: Observe and assess the client’s breathing techniques, providing guidance and support as needed.
Communication on Interventions: Keep the client informed if any interventions become necessary during the labor process.
Develop a Birth Plan: Collaborate with the client to create a birth plan, integrating her preferences into the overall care plan.
Relief for Dry Mouth: Offer ice chips, hard candies, or fluids to alleviate dry mouth and enhance the client’s comfort.
Create a Comfortable Environment: Establish a conducive and comfortable environment to facilitate effective coping for the client.
Encourage Movement during Labor: Support and allow the client to walk and move freely during labor to enhance physical comfort.
Non-Intervention during Contractions: Refrain from intervening with the client during contractions to maintain focus on her techniques and minimize disturbances.

These implementation strategies aim to promote the well-being, comfort, and safety of the mother during and after the labor period, fostering a positive and supportive birthing experience.

Evaluation of Labor Process:

Bladder Function: Assess if the client shows no signs of bladder distention and maintains the ability to void every 2 hours.
Pain Management: Evaluate the client’s pain level, ensuring it falls within a good to tolerable range.
Expression of Preferences: Confirm that the client can effectively express her preferences during labor.
Understanding of Labor Process: Determine if the client possesses the ability to comprehend the typical course of labor.
Comfortable and Secure Environment: Verify that the client reports her environment as comfortable and secure.
Verbalization of Experiences: Assess if the client is capable of verbalizing her feelings and experiences during the labor period.

Successful evaluation of these factors indicates a smooth and positive labor experience, contributing to the likelihood of a safe and healthy delivery for the client.

Induction and Augmentation of Labor (Cervical Ripening)

Cervical ripening is a crucial aspect of early labor, ensuring the readiness of the cervix for dilation and effective uterine contractions. Bishop’s criteria are commonly used to assess cervical ripeness, with a score of 8 or greater indicating readiness for induction. Various methods are employed for cervical ripening, each carrying its own considerations:

Stripping the Membranes: This method involves manually separating the membranes from the lower uterine segment using a gloved finger in the cervix. Potential complications include bleeding, inadvertent rupture of membranes, and infection.
Hygroscopic Suppositories: Suppositories made of hygroscopic or seaweed materials that swell upon contact with cervical secretions gently facilitate dilation. Proper documentation of the number of sponges and dilators is crucial to prevent leaving any behind in the cervix.
Prostaglandin Gel Application: Prostaglandin gel is applied to the cervix’s interior or exterior surfaces, using a catheter, suppository, or a diaphragm. Monitoring fetal heart rate (FHR) is essential, with potential side effects including diarrhea, fever, hypertension, and vomiting.
Oxytocin Administration: Oxytocin administration may be initiated 6 to 12 hours after the last prostaglandin dose. Caution is advised in women with asthma, renal or cardiovascular disease, or glaucoma.
Contraindications for Prostaglandin Use: Women with a history of cesarean birth are contraindicated for prostaglandin use. Throughout these procedures, instruct the woman to maintain a side-lying position to prevent medication leakage. Continuous monitoring of FHR every 30 minutes post-complication is crucial for ensuring the safety and well-being of both the mother and the baby during the induction and augmentation processes.

Induction of Labor with Oxytocin

The administration of oxytocin can initiate contractions in a term pregnancy uterus. Administered intravenously, oxytocin allows for prompt discontinuation in cases of hyperstimulation, given its short half-life of approximately 3 minutes. To enhance safety and efficacy:

Oxytocin Preparation: Oxytocin is typically mixed with Ringer’s lactate (10 units in 1000 mL). It may be administered piggyback to a maintenance IV solution, ensuring the main IV line can be maintained if the infusion is discontinued.
Infusion Pump Usage: Employ an infusion pump to regulate the infusion rate, preventing changes even if the woman moves. Avoid increasing the rate without proper instructions, as it may lead to tetanic contractions.
Artificial Rupture of Membranes: Consider artificial rupture of membranes when cervical dilatation reaches 4 cm to further induce labor.
Peripheral Vessel Dilatation Awareness: Be vigilant for peripheral vessel dilatation, a side effect causing hypotension. Monitor the woman’s pulse and blood pressure every 15 minutes during induction.
Uterine Contractions and FHR Monitoring: Monitor uterine contractions and fetal heart rate (FHR) to ensure they occur within safe limits. Contractions should not be more frequent than every 2 minutes, longer than 70 seconds, or stronger than 50 mmHg.
IV Infusion Adjustment: Cease the IV infusion if contractions exceed safe limits or signs of fetal distress emerge.
Complications and Hyperstimulation: Hyperstimulation may lead to tonic uterine contractions with severe consequences. If hyperstimulation persists post-discontinuation, consider beta-adrenergic receptor drugs or magnesium sulfate to reduce myometrial activity.
Water Intoxication Risks: Oxytocin’s antidiuretic effect may cause water intoxication, leading to symptoms such as headache and vomiting. Monitor intake and output, assess urine specific gravity, and limit IV fluid to prevent fluid retention.
Duration of Induced Labor: Induced labor may have a shorter first stage compared to unassisted labor. Assure the woman that induced labor contractions are essentially normal, facilitating effective use of breathing techniques.
Infant Monitoring: Be vigilant for hyperbilirubinemia and jaundice in the newborn due to oxytocin-induced labor. Observe the infant closely during the initial days of life for these potential conditions.

Augmentation with Oxytocin

When labor contractions commence spontaneously but become weak, irregular, or ineffective, augmentation is necessary to enhance the labor process. Similar precautions for oxytocin administration apply as in primary induction of labor. Key considerations for augmentation include:

Effective Uterine Response: Oxytocin, when used for augmentation, may effectively stimulate uterine contractions.
Caution and Monitoring: Exercise caution during oxytocin administration, increasing the drug in small increments. Monitor fetal heart sounds throughout the procedure.
Labor as the Gateway to Delivery: The labor process serves as the gateway to a safe delivery. A smooth labor experience is crucial as it allows the woman to gather strength for delivering her precious bundle of joy. Ensuring proper augmentation with oxytocin involves vigilant monitoring and adjustments to promote effective contractions, ultimately contributing to a successful and safe delivery.

Labor Complications

Experiencing labor is an eagerly awaited event during a woman’s pregnancy. To circumvent complications, healthcare providers should conduct a thorough assessment early in the pregnancy.

Uterine Rupture

Uterine Rupture: Uterine rupture is a rare yet severe complication, characterized by the inability of the uterus to withstand the strain it undergoes. Contributing factors include abnormal presentation, prolonged labor, multiple gestation, improper use of oxytocin, and traumatic effects of forceps use or traction. Immediate cesarean birth can prevent fetal death in the event of uterine rupture.
Symptoms: Sudden, severe pain during a labor contraction or a tearing sensation may precede rupture. Complete rupture penetrates the endometrium, myometrium, and peritoneum, leading to immediate cessation of contractions. Symptoms include hemorrhage, shock, fading fetal heart sounds, distinct swellings of the retracted uterus, and extrauterine fetus. In incomplete rupture, symptoms include localized tenderness, persistent aching pain in the lower uterine segment, lack of contractions, and fetal heart sounds.
Diagnosis and Management: Confirmatory diagnosis can be achieved through ultrasound. Anticipate emergency fluid replacement and IV oxytocin administration as ordered. Laparotomy is performed to control bleeding and repair the rupture. Cesarean hysterectomy or tubal ligation may be considered, with patient consent, to remove the damaged uterus and cease childbearing activity.
Communication and Patient Counseling: Inform the patient about fetal outcomes, the woman’s safety, and the extent of the surgery. Allow time for the patient to express emotions and provide consent for further procedures. Advise against conceiving again after uterine rupture unless the rupture is in the inactive lower segment.
Prognosis: Fetal viability and the woman’s prognosis depend on the extent of the rupture. Mitigating uterine rupture complications requires prompt diagnosis, effective intervention, and open communication with the patient regarding outcomes and future considerations.

Inversion of the Uterus

Uterine inversion occurs when the uterus turns inside out during the delivery of the fetus or the placenta. Contributing factors include the application of traction to the umbilical cord for placenta removal, pressure on the uterine fundus when it’s not contracting, or if the placenta is attached to the fundus, causing it to be pulled down during birth.

Signs of Inversion: Sudden gush of a large amount of blood from the vagina. Non-palpable fundus. Signs of blood loss such as hypotension, dizziness, and paleness. Continued bleeding may lead to exsanguination.
Management: Do not attempt to replace the inversion, and refrain from removing the placenta if still attached. Administration of oxytocic drugs can worsen the inversion, making replacement difficult. Establish an IV line with a large-gauge needle to restore fluid volume. Initiate oxygen administration and assess vital signs. Perform cardiopulmonary resuscitation if the woman experiences arrest. Intravenous nitroglycerin or a tocolytic drug may be given to relax the uterus. The physician will manually replace the fundus. Oxytocin is administered post-replacement to promote uterine contraction and stability. Prescribe antibiotics to prevent infection due to exposure of the endometrium.
Post-Management Information: Inform the woman that future pregnancies may require cesarean section delivery due to the risk of uterine inversion recurrence.

Amniotic Fluid Embolism:

Amniotic fluid embolism occurs when amniotic fluid is forced into an open maternal uterine blood sinus, often following membrane rupture or partial premature separation of the placenta. The primary cause is likely an anaphylactoid or humoral response. This condition cannot be predicted or prevented.

Risk Factors: Abruption placenta, Hydramnios, Oxytocin administration.
Clinical Presentation: Sharp chest pain, Breathlessness, Pallor, Impaired blood flow.
Emergency Measures: Oxygen administration, Cardiopulmonary resuscitation (CPR).
Prognosis: The woman’s prognosis depends on the prompt detection of the condition, the effectiveness and speed of emergency interventions, and the size of the embolism. Endotracheal intubation and fibrinogen therapy may be necessary due to the high risk of disseminated intravascular coagulation (DIC).
Fetal Prognosis: The prognosis for the fetus is uncertain, as reduced placental perfusion may result from a severe drop in maternal blood pressure. Amniotic fluid embolism is a critical emergency requiring swift and comprehensive intervention to improve outcomes for both the mother and the fetus.

Prolapse of the Umbilical Cord

Prolapse of the umbilical cord occurs when a loop of the umbilical cord slips down in front of the presenting fetal part. Factors contributing to prolapse include a small fetus, placenta previa, cephalopelvic disproportion (CPD), premature rupture of membranes, hydramnios, and multiple gestation.

Assessment and Diagnosis:

During vaginal examination assessing the presenting fetal part, the cord might be palpated. Diagnosis can be confirmed through ultrasound.

Management of Prolapse of the Umbilical Cord

Cesarean section is recommended before rupture of the membranes to prevent the cord from descending into the vagina. If cord prolapse is discovered after membrane rupture and variable deceleration in fetal heart rate, therapeutic management is crucial.

Goal: Relieve cord compression to prevent fetal anoxia.

Manually lifting the fetal head off the cord or placing the woman in a Trendelenburg position can achieve cord decompression. Oxygen administration improves fetal oxygenation. Tocolytic agents reduce uterine activity and fetal pressure. If complete dilatation has occurred, delivery may proceed to prevent fetal anoxia. In cases of incomplete dilatation, emergency cesarean birth is performed due to the risk of reduced blood flow harming the fetus. Amnioinfusion, supplementing amniotic fluid by adding sterile fluid into the uterus, helps prevent additional cord compression. Monitor fetal heart rate, uterine contractions, and record maternal temperature hourly during amnioinfusion to detect infection.

Post-Management:

Once the cord has prolapsed and is exposed to air, cover any exposed portion with a sterile saline compress to prevent drying and atrophy of umbilical vessels. Swift and comprehensive therapeutic interventions are essential to minimize the risks associated with umbilical cord prolapse and ensure the well-being of both the mother and the fetus.

Multiple Gestation

When a woman is expecting multiple gestations, the birthing room requires additional personnel, creating an atmosphere of excitement. It’s crucial to recognize that the woman may be more fearful than excited about the delivery.

Considerations and Management:

Multiple gestations often result in fetal anoxia for the second fetus, making cesarean birth a preferable option over normal delivery. Anemia and pregnancy-induced hypertension are common in multiple gestations; hence, regular assessment of blood pressure and hematocrit is necessary. Early hospital arrival is advised for women planning to give birth vaginally. Instruction on breathing techniques helps minimize the use of analgesia or anesthesia, reducing the risk of respiratory difficulties in infants due to lung immaturity.

Firm head engagement may not occur for multiple gestations as the babies are typically smaller. Common conditions include abnormal fetal presentation, an overstretched uterus, premature separation of the placenta, and uterine dysfunction due to prolonged labor. Twin pregnancies usually present with vertex presentations, while gestations with three or more fetuses may have varied presentations. Oxytocin is administered after the birth of the last fetus to avoid compromising the remaining fetuses.

External version may be attempted if the next fetus does not have a vertex presentation, or a cesarean birth can be performed. To shorten the time span between births, an oxytocin infusion can be initiated. Nitroglycerin may be administered to relax the uterus. The first infant’s placenta separating before the birth of the second fetus can cause sudden, profuse bleeding, posing a significant risk to the woman.

If separation of the first placenta affects the other placentas or if there is a common placenta, fetal distress may be signaled by the fetal heart rate of the other fetuses. Cesarean section is often chosen for multiple gestations, especially those not in vertex presentation, ensuring they are born together for optimal survival. Parents should be provided with an opportunity to view and inspect their infants to alleviate any fears they may have about their well-being.

Thorough and immediate assessment of the woman after birth is essential, as an overly distended uterus may struggle to contract, increasing the risk of hemorrhage due to uterine atony. Infants require careful assessment to determine their gestational age and identify any unusual conditions.

Ineffective Uterine Force

Ineffective labor ensues when uterine contractions deviate from the normal pattern, impeding the fetus’s progression through the birth canal.

Hypotonic Contractions: In hypotonic contractions, the frequency of uterine contractions is unusually slow or infrequent, typically ranging from two to three contractions within a 10-minute period. The strength of contractions remains below 10 mmHg, predominantly occurring during the active phase of labor. Factors contributing to hypotonic contractions include analgesia administration, bowel or bladder distention, uterine overstretching due to multiple gestation, a large fetus, hydramnios, or a lax uterus from grand multiparity. Hypotonic contractions elevate the woman’s risk for postpartal hemorrhage. During the initial postpartum hour following hypotonic contractions, palpate the uterus and assess lochia every 15 minutes to promptly detect postpartal hypotonic contractions and prevent inadequate cessation of bleeding.

Hypertonic Contractions:

Hypertonic contractions are characterized by an elevation in resting uterine tone, surpassing 15 mmHg. These contractions tend to manifest more frequently, particularly during the latent phase of labor. They are notably more painful than typical contractions, causing frustration as the woman finds her breathing techniques ineffective.

The absence of relaxation between contractions may hinder optimal uterine artery filling, potentially leading to fetal anoxia. To assess the resting phase of contractions and ensure a healthy fetal pattern without late deceleration, the application of uterine and fetal external monitors for at least 15 minutes is essential.

Cesarean birth becomes a necessary consideration if late deceleration is observed, there is an abnormally prolonged first stage of labor, or if there is insufficient progress during the pushing phase. It is crucial to explain to the woman and her partner that, despite the intensity of the contractions, they are ineffective in achieving cervical dilatation.

Dysfunctional Labor:

Dysfunctional labor during the first stage encompasses prolonged latent phase, protracted active phase, prolonged deceleration phase, and secondary arrest of dilatation.

Prolonged latent phase: Management involves aiding the uterus to rest and providing sufficient fluids for hydration and pain relief.

Protracted active phase: Oxytocin may be prescribed to augment labor, and in cases of a prolonged deceleration phase, cesarean birth may be necessary.

Secondary arrest of dilatation: If there is no progress with cervical dilatation for more than 2 hours, cesarean birth becomes necessary.

Dysfunction during the second stage involves prolonged descent and arrest of descent. Prolonged descent: If the descent rate is less than 1 cm/hr in a nullipara or 2.0 in a multipara, encouraging the woman to rest and increase fluid intake is recommended. Intravenous oxytocin may also be administered, and alternative positions such as semi-Fowler’s, squatting, kneeling, or more effective pushing may expedite descent.

Arrest of descent: If no descent occurs for 1 hour in a multipara and 2 hours in a nullipara, and the cause is likely cephalopelvic disproportion (CPD), cesarean birth is necessary. Oxytocin may assist labor if there are no contraindications to vaginal birth.

Uncoordinated Contractions:

In instances of uncoordinated contractions, more than one pacemaker may initiate contractions, or receptor points in the myometrium may act independently of the pacemaker. This condition makes it challenging for the woman to experience adequate rest between contractions due to their erratic occurrence.

To comprehensively assess the rate, pattern, resting tone, and fetal response to contractions, it is imperative to attach a fetal and uterine external monitor to the woman for at least 15 minutes. Additionally, the administration of oxytocin can be considered to stimulate a more effective and consistent pattern of contractions with a lower resting tone.

Precipitate Labor:

Precipitate labor occurs when uterine contractions are exceptionally strong, leading to rapid and swift childbirth. Factors contributing to this type of labor include grand multiparity, or it can be induced through methods like oxytocin or amniotomy.

The rapid release of pressure on the fetal head during precipitate labor can result in subdural hemorrhage. Additionally, forceful birth may cause lacerations in the birth canal. If the rate of cervical dilation exceeds 5 cm per hour in a nullipara or 10 cm per hour in a multipara, precipitate labor is underway. Women with a history of brief labors should be cautioned by their 28th week to anticipate the possibility of another brief labor, allowing them to plan transportation accordingly.

To manage precipitate labor, birthing rooms must be prepared for birth readiness before full dilatation is achieved. This preparation ensures a safe and organized environment for the rapid progression of labor.

Comfort and Pain Management (Etiology and Physiology of Pain)

Pain serves as a fundamental protective mechanism, signaling a person that something potentially harmful is occurring in the body. Uterine contractions are unique in that they, unlike other involuntary muscles, cause pain when contracting.

During contractions, blood vessels constrict, reducing blood supply to uterine and cervical cells and leading to anoxia of muscle fibers. This anoxia causes pain, akin to the experience during a heart attack. As labor progresses, ischemia and anoxia intensify, resulting in heightened pain.

The stretching of the cervix and perineum also contributes to the pain. Once cervix stretching is complete, the woman experiences a strong urge to push, and the pain diminishes during the pushing phase. Additionally, pressure from the fetal presenting parts on tissues adds to the overall discomfort. Cultural differences play a role in how a woman perceives pain, influencing her experience during labor.

Pain sensations originate in nociceptors, stimulated by mechanical, chemical, or thermal stimuli. Chemical mediators facilitate the transmission of pain impulses along myelinated and unmyelinated fibers to the spinal cord. Neurotransmitters aid the pain impulse across synapses between peripheral and spinal nerves, eventually reaching the brain cortex, where it is interpreted as pain.

The Melzack-Wall gate control theory of pain suggests that pain can be interrupted at three points: peripheral end terminals, synapse points, or the point where the impulse is interpreted as pain. Pain medications primarily work by blocking spinal cord neurotransmitters, preventing the pain impulse from crossing into the spinal nerve.

Comfort Measures (Relaxation)

sRelaxation techniques are often emphasized in childbirth preparation classes, providing valuable tools for managing the challenges of labor. By consciously relaxing, the woman helps prevent tension in the abdominal wall, allowing the uterus to ascend during contractions without undue pressure against the abdominal muscles. Focusing on relaxation also serves as a distraction from the pain she may be experiencing. Encouraging the woman to discover her preferred position during labor can significantly enhance her ability to relax. Additionally, engaging in activities such as listening to favorite music or practicing aromatherapy within the birthing room further contributes to creating a calming environment conducive to relaxation.

Focusing and Imagery (Focusing)

Focusing involves intense concentration on a chosen object to serve as a distraction, effectively diverting sensory input from reaching the brain’s cortex and mitigating the experience of pain. The woman may use a photograph as a focal point during contractions, directing her attention to it. It is essential to refrain from interrupting the woman with questions while she is focusing, as this can disrupt her concentration and the effectiveness of the technique.

Prayer

Some women find solace in prayer during stressful situations, and incorporating religious items such as Bibles, rosaries, and crosses can provide comfort during labor. It is important to handle these items with care, especially when changing sheets, as they hold sacred significance for the woman.

Heat and Cold Application

During labor, women experiencing back pain may find relief through the application of heat to their lower backs. After labor, a cool cloth applied to the forehead can help soothe a woman who may feel fatigued from exertion. Additionally, providing ice chips can alleviate dryness in the woman’s mouth during labor.

Breathing Techniques

Childbirth preparation classes often include instruction on various breathing techniques or patterns. These techniques are designed to relax the woman’s abdomen during contractions, serving as a distraction method by redirecting her focus to slow-paced breathing rather than the pain. While it is optimal to teach breathing techniques before labor, women can still be coached on these methods even if they are unfamiliar with them during labor.

Therapeutic Touch and Massage

Therapeutic touch involves the use of touch to provide comfort and alleviate pain. Its underlying philosophy suggests that the body has energy fields, and maintaining abundant energy fields contributes to good health, while having few energy fields results in ill health. Through the laying of hands, therapeutic touch aims to redirect energy fields associated with pain. The application of touch or massage increases the release of endorphins, leading to a reduction in pain. Lamaze classes often teach techniques such as effleurage, which is particularly beneficial during the first and second stages of labor.

Pharmacologic Measures:

Narcotic Analgesics: Narcotics possess potent analgesic effects but are used cautiously due to their potential to cause fetal CNS depression. Pregnant women in preterm labor should avoid narcotics, given the risk of fetal lung immaturity. Meperidine, with sedative and antispasmodic effects, is advantageous during labor, providing pain relief and aiding cervical relaxation. To mitigate fetal exposure, meperidine is administered 3 hours before birth, allowing the drug’s peak action to diminish by delivery.
Regional Anesthesia: Regional anesthesia involves injecting a local anesthetic to block specific nerve pathways. Research indicates potential effects on the fetus, such as heart rate decelerations and symptoms like flaccidity, bradycardia, and hypotension in the newborn. While regional anesthesia enables a woman to remain awake and aware during birth, it also helps prevent postpartum hemorrhage by maintaining uterine tone, allowing the uterus to contract effectively after birth.
Local Anesthesia: Local anesthesia reduces the conduction of pain signals in local nerve fibers. Local infiltration involves injecting a local anesthetic into superficial perineal nerves, providing pain relief for about an hour, facilitating a pain-free birth and suturing of episiotomy. Pudendal nerve block, administered near the pudendal nerves at the ischial spine level, offers pain relief within 2 to 10 minutes for an hour. Immediate checks on fetal heart rate and maternal blood pressure are crucial to detect maternal hypotension after injection.

Occipitoposterior Position:

The typical fetal position is posterior rather than anterior, with the assumption that the presentation is vertex, and the occiput is directed diagonally and posteriorly, either to the left or right. In these positions, internal rotation of the fetal head must navigate an arc of approximately 135 degrees. Rotations from a posterior position can be facilitated by having the woman assume a hands-and-knee position, squat, or lie on her side. However, these positions can be strenuous for women in labor.

Posterior positions often occur in women with android, anthropoid, or contracted pelvis. They are associated with dysfunctional labor patterns, such as prolonged active phases, arrested descent, or fetal heart sounds heard best at the lateral sides of the abdomen. A head in the posterior position may not fit the cervix as well as an anterior position, and this can be confirmed through vaginal examination or ultrasound, as it might contribute to umbilical cord prolapse. Labor duration tends to be prolonged due to the greater arc of rotation.

The woman may experience pressure and pain in her lower back due to sacral nerve compression when the fetal head rotates against the sacrum. To alleviate some of the pain, counter pressure on the sacrum through back rubs and heat or cold application may be beneficial. Encouraging the woman to lie on the side opposite the fetal back or assume a hands-and-knees position can assist in fetal rotation. Regular voiding every 2 hours is important to maintain an empty bladder and prevent hindrance to fetal descent.

Oral sports drinks or IV glucose solutions may be administered to replenish glucose stores for energy. Maternal exhaustion can lead to uterine dysfunction, hindering the 135-degree rotation if contractions are ineffective or if the fetus is larger than average. In cases where the fetal head arrests in the transverse position or experiences no rotation at all, cesarean birth may be necessary. Reassure the woman that despite deviations from the ideal labor progression, her labor is within safe and controlled limits.

Oversized Fetus:

Macrosomia, characterized by a fetal weight exceeding 4000 to 4500g, can pose challenges during childbirth. These larger babies are often born to women with diabetes, gestational diabetes, or multiparas. The overstretching of myometrial fibers due to the oversized fetus may lead to uterine dysfunction. The broad shoulders of macrosomic infants can contribute to issues such as fetal-pelvic disproportion or uterine rupture during birth.

When the fetus is deemed too large for a safe vaginal delivery, a cesarean birth becomes necessary. To assess the fetus’s size relative to the woman’s pelvic capacity, pelvimetry or ultrasound can be performed. In instances where a macrosomic baby is delivered vaginally, there is a heightened risk of complications such as cervical nerve palsy, diaphragmatic injury, or a fractured clavicle resulting from shoulder dystocia. Additionally, the woman is at risk of postpartum hemorrhage due to the overdistension of the uterus and potential uterine atony. It is crucial to closely monitor and manage these risks to ensure a safe and healthy delivery for both the mother and the macrosomic baby.

Shoulder Dystocia:

Shoulder dystocia is a complication occurring in the second stage of labor when the fetal head is delivered, but the shoulders are too broad to pass through the pelvic outlet. This situation poses risks for both the woman and the fetus.

The woman is susceptible to vaginal and cervical tears, while the fetus faces the danger of cord compression between its body and the bony pelvis. Forceful attempts to deliver the baby through the vaginal opening may result in a fractured clavicle or brachial plexus injury.

This complication is more common in women with diabetes, multiparas, and post-date pregnancies. Shoulder dystocia becomes evident during the birth of the head when the shoulders become stuck beneath the symphysis pubis. Indicators of shoulder dystocia include a prolonged second stage of labor, arrest of descent, or retraction of the head instead of its smooth protrusion with each contraction.

To manage shoulder dystocia, instruct the woman to perform the McRobert’s maneuver, involving sharply flexing her thighs onto her abdomen to widen the pelvic outlet and facilitate the anterior shoulder’s birth. Additionally, applying suprapubic pressure can assist in releasing the shoulder from beneath the symphysis pubis. Prompt and appropriate interventions are crucial to ensure a safe delivery for both the mother and the baby.

Brow Presentation

Among the presentations, brow presentation is the rarest occurrence, usually observed in multiparous women or those with relaxed abdominal muscles. Obstructed labor can arise as the head becomes lodged in the pelvic brim, presenting with the occipitomental diameter. Cesarean birth is typically necessary unless the presentation spontaneously corrects itself.

Infants born after a brow presentation may exhibit extreme ecchymosis on the face. Parents should be reassured that bruising over the same area as the anterior fontanelle is normal and tends to resolve.

Inlet Contraction

Inlet contraction involves the narrowing of the anteroposterior diameter to less than 11 cm or the transverse diameter to 12 cm or less. Common causes include rickets in early life or an inherited small pelvis. If fetal head engagement occurs between the 36th to 38th weeks of pregnancy, the pelvic inlet is deemed adequate. Lack of engagement in primigravidas may suggest fetal or pelvic abnormalities.

It is advisable for every primigravida to have pelvic measurements taken and recorded before the 24th week of pregnancy to aid in birth decision-making. In cases of cephalopelvic disproportion (CPD), the fetus remains in a floating position, complicating the situation. Membrane rupture increases the risk of cord prolapse significantly.

Outlet Contraction

Outlet contraction refers to the narrowing of the transverse diameter at the outlet to less than 11 cm. This measurement, which represents the distance between the ischial tuberosities, can be easily assessed during prenatal visits. Anticipating the narrow diameter before labor begins is crucial for proper birth planning. Additionally, this measurement can be conveniently evaluated during labor to ensure appropriate management.

Trial Labor

Trial labor involves assessing the progress of labor in a woman with borderline inlet measurements, considering a favorable fetal lie and position. Continued trial labor is permissible as long as the descent of the presenting part and cervical dilatation are occurring.

Continuous monitoring of fetal heart sounds and uterine contractions is essential during trial labor. Instructing the woman to void every two hours aids in fetal descent. After the rupture of membranes, close assessment of fetal heart rate (FHR) is crucial, particularly if the fetal head remains high, as it may increase the risk of prolapsed cord and fetal anoxia.

If there is no progress in labor after 6 to 12 hours, cesarean birth becomes necessary. In such cases, clear explanations about the need for cesarean birth should be provided, emphasizing that it is a valid alternative, not an inferior method, especially when labor is not progressing.

External Cephalic Version

External cephalic version involves turning a fetus from a breech to a cephalic position before birth. This procedure can be performed as early as 34 to 35 weeks, with the usual time being 37 to 38 weeks of pregnancy.

Continuous monitoring of fetal heart rate and ultrasound is maintained during the external cephalic version. To facilitate the procedure, a tocolytic agent is administered to relax the uterus. The examiner’s hands are used to grasp the breech and vertex of the fetus transabdominally on the woman’s abdomen.

External cephalic versions can reduce the need for cesarean births in breech presentations. Contraindications include multiple gestations, severe oligohydramnios, vaginal birth, cord coil, and unexplained third-trimester bleeding (possibly indicative of placenta previa). Women experiencing pressure during the procedure should be reassured, and those who are Rh-negative should receive Rh immunoglobulin afterward as a precaution against potential bleeding.