Complications of the intrapartum and postpartum periods

• Def: when pregnancy exceeds 42 completed weeks from the 1st day of the LMP
• Effects: Placental aging, decrease AFV (amniotic fluid volume); Problems: asphyxia, meconium aspiration, RDS, put around 1/2lb per week after

• Risk factors: pervious posterm delivery, estrogen deficiency, decrease placental sulfatase (which produces estrogen), decrease adrenal coritcal function.
• S/S: diminished fetal growth, oligohydramnios (decrease fluid), meconium-stained fluid

subcutaneous fat loss, long fingernails, wrinkled peeling skin, alert facies, absence of lanugo and vernix

• Fetal kick counts
• side-lying position
• good hydration
• NST and CST
• BPP weekly
• Weekly cervical checks

• Fetal acidosis
• Oligohydramnios (decrease fluid)
• meconium aspiration
• fetal wasting
• neonatal mortality
• Neonatal hypoglycemia
• Neonatal polycythemia (hyperbilirubinemia)
• Neonatal impaired thermoregulation

• Def: deliberate initiation of labor, prior to the onset of spontaneous contractions
• Augmentation of labor: stimulation of uterine contractions after labor has started but is not progressing satisfactorily

• Mechanical: amniotomy (can scratch baby's head if decreased fluids)
• Physiologic: ambulation, maternal position change, nipple stimulation
• Chemical: Prostaglandins, misoprostel, oxytocin

• Maternal problems: Diabetes, PIH, PROM, chorioamnionitis, abruption, postdates
• Fetal problems: fetal hemolytic disease, IUGR, low BPP, intrauterine death...

• Capability of delivering vaginally: r/o structural abnormalities, previous GYN/abd surgeries
• Fetal maturity: assess L/S ratio (tests if lungs are mature)
• Cervical readiness/fetal station: Bishops score

• Max # is 13
• 0-4 is unfavorable
• 5-8 is questionable
• >8 is successful induction

• nipple stimulation (oxytocin is released)-sex or orgasm is a great thing for this!
• Herbal remedies
• Stripping the membranes (can break water)

• Prostaglandin gel (strongly increases contractions; contraindication is asthma and pitocin)
• Cervidil: like a flat tampon, releases over 12 hrs, you can take it out. *Both these forms have suppository's, in larger doses, are are used for aborting fetus bc of STRONG DOSE!!!!!!
• Misoprostel (Cytotec): 25ug tab in posterior vag fornix, some oral, NOT fda approved!
• Mechanical means: laminaria (seaweed in cervix), foley cath in cervix
• Oxytocin

• Def: synthetic posterior pituitary hormone, induction or augmentation of labor.
• Usage: controlled infusion pump, piggyback, fetal monitoring
• -very short half life, monitor pt 20 minutes BeFoRe giving!

• 1. Uterine Hyperstimulation
• ->75 mmHg, >90sec duration, closer than 2 minutes ("tetanic contractions")
• -placental abruption, aminiotic fluid embolism, cervical laceration, precipitous labor and birth, PP hemorrhage.
• 2. Fetal distress
• 3. Water intoxication (anti-diurectic effect): s/s-N+V, hypotension, tachy, headache, blurred vision, increase bp and Respirations, rales, coughing.

• 1. Continuous monitoring for signs of fetal distress (brady, tachy, absent variability, decels
• 2. Monitor uterine activity: to r/o hyperstimulation (contractions >2min apart, or lasting longer than 90 sec)
• 3. Vital Signs (espec. BP and HR) monitor frequently
• 4. Monitor I&O's: to r/o fluid retention (water intoxication)
• 5. Informed consent: IV, continuous fetal monitoring, limited mobility, increase risk of fetal distress & c/s

• [Late decels, severe variable decels, bradycardia]
• *Turn off oxytocin infusion
• Increase rate of maintenance IV fluids (dilutes pitocin)
• Administer Oxygen by face mask
• Change position, side-lying or hand/knees (puts pressure off cord)
• Notify health care provider

Done when cervix is soft and pt often goes into labor around 12 hrs after

• Complications:Increase risk fetal distress r/t decrease amniotic fluid, meconium stained amniotic fluid, **umbilical cord prolapse (EMERGENCY), infection
• -increase molding of fetal head lol! goes back!

• Monitor FHR before and after AROM
• Observe/record color, amount, odor of fluid
• Monitor her temp q2hrs after
• Limit vag exams
• good hygeine (prevent infections)

• Def: long, difficult, or abnormal labor
• Causes:
• -Fetal factors: large fetus, fetal anomaly, malpresentation, malposition
• -Uterine factors: hypo/hypertonic, precipitous, or prolonged labor
• -Pelvic factors: contracture of inlet, midpelvis, or outlet
• -Pysche factors: maternal anxiety, fear, lack of preperation

• Types: Hypertonic uterine dysfunction and Hypotonic uterine dysfuction.
• Management: monitor uterine activity by EFM, monitor fetal status, woman's status, need to rule out cephalopelvic disproportion (CPD)

• Def: fetal head is too large to fit through maternal pelvis
• Risk factors: DM, fetal malformation, maternal pelvic size/shape, position/shape of fetal head
• S/S: lack of fetal descent, lack or slow progress of cervical change, uncontrollable urge to push before complete dilation of cervix

• Management: trial of labor, u/s estimation of fetal size, Friedman's curves (standard labor progression curve), labor care and position changes
• Complications:
• -Maternal: c/s, exhaustion, PPH (pp hemorrhage), 2 degree uterine atony, infection
• -Fetal: cord prolapse, birth trauma, fractured clavicle, erbs palsy, anoxia

• Def: uterine infection (chorion and amnion)
• Associated factors: premature/prolonged ROM, also increase vaginal exams and interal monitoring
• S/S: maternal fever/tachy, *FETAL tachycardia*, uterine pain, hypotension, foul-smelling amniotic fluid, increase wbc
• Management: IV Antibiotics

*Baby should be born within 24 hrs of diagnosis!

• Def: insufficient O2 supply to meet fetal needs
• Causes: cord compression and uteroplacental insufficiency
• S/S: meconium stained amnio fluid, FHR baseline changes, decreased/absent fhr variability, repetitive late decels, severe variable decels (<90 bpm x >60 seconds)

• Stop pitocin
• Change position
• Oxygen by face mask
• Notify MD
• IV fluid bolus
• Amnioinfusion (floats cord)
• Fetal scalp sampling (blood ph sample)
• Intrauterine resuscitation (terbutaline)-stops contractions
• Labs: preop; consent for c/s

• Def: fluid with meconium from fetus
• Causes: in response to hypoxia, fetal intestinal activity increase and anal sphincter relaxes, resulting in passage of meconium. Sequelae to cord compression

• Risk factors: posterm, prolapsed cord, fetal distress, infection
• S/S: green or brownish amniotic fluid
• Management: EFM to evaluate fetal status, suctioning of head prior to first breath by infant, assess newborn O2 signs for R distress, prepare intubation equipment.

• Meconium aspiration
• pneumothorax
• Pneumonitis
• Aspiration pneumonia
• asphyxia
• seizures
• renal failure
• death

• Def: Failure of the shoulders to deliver the application of gentle, downward traction "turtle signs"-head keeps bouncing back inside
• Assoc. factors: diabetes, large baby, maternal obesity, posterm pregnancy, prolonged labor and 2nd stage, oxytocin induction

Brachial plexus may become stretched and damaged when force is applied

• Call for help, empty bladder, assist with positioning (McRobert's=legs hyperflexed, knees to chest position), suprapubic pressure
• complications:
• -Do NOT push directly on top bc this will lodge it more.
• -Maternal: lacerations, PPHemorrhage
• -Fetal: hypoxia, clavicle fractures, injury to neck/head, risk of brachial palsy

• Def: when the umbilical cord goes first out of cervix before baby
• Cause: fetus not engaged
• Contributing factors: ROM prior to engagement, small fetus, breech or shoulder presentation, multiples

• Signs: DECREASE FHR
• management: Call for help, vaginal exam-elevate fetal head
• -oxygen to mom, position hips higher than head ( downward dog posit, or sidelying), prepare for immediate delivery.
• -Almost always a c-section!

• Def: <3 hrs duration
• Associated factors: prior precipitous labors, multiparas, small fetus, large pelvis
• complications:
• -maternal: cervical/vag/rectal lacerations, amniotic fluid embolism, uterine rupture, increase risk for PPH
• -Fetal: hypoxia, intracranial hemorrhage, birth injury
• Management: monitor strength of uterine contractions, assess fetal status frequently, positioning on side, do not leave women , call for help!

• Def: amniotic fluid entering maternal circulation
• Assoc factors: after difficult labor, with placental abruption, intrauterine death, multips, increase maternal age, oxytocin
• Causes: ?high tear in amniotic sac-fluid leak into chorionic plate and maternal circulation

• S/S: Acute onset of respiratory distress (dyspnea, chest pain, cyanosis, tachy, cough, frothy sputum), Shock-cardiac/renal/hepatic failure, hemorrhage-DIC
• management: oxygen, monitor cardio/pulm status, frequent VS, CvP line, transfuse and treat DIC
• -treat coagulapathies (platelets)

• Also called "consumptive coagulopathy"
• Causes: Large amounts of phospholipids (from OB complications)-hyperactivated coagulation mechanisms; Massive # of clots formed-depleted clotted factors-hemorrhage and organ failure (d/t clots)

• Predisposing factors: PIH, HELLP, aminiotic fluid embolism, sepsis, placental abruption, excess blood loss
• S/S: petechiae, increase lochia/bleeding, bleeding from gums, injection sites, incision
• Labs: Decrease platelets, fibrinogen
• *If bleeding doesn't stop=hysterectomy

• VS, FHR, I&O, bleeding
• Correct underlying cause
• Terminate pregnancy
• Replace essential clotting factors
• -whole or packed cells, freshfrozen plasma, platelets
• -Goal: platelets: 100,000ud, fibrinogen >150 mg/dl

• Def: uterus turn completely or partially inside out
• Types: Complete or partial inversion
• Causes: Forced inversion (pulling on cord or massage uterus) or Spontaneus inversion (higher with twins)
• S/S: INCREASE pelvic pain, sensation of extreme fullness in vagina
• Management: immediate manual replacement (push it back in) or may need surgery

• Def: seperation of uterine wall
• types: complete or incomplete
• Causes: seperation of scar from previous c/s, uterine trauma, intense uterine contractions, oxytocin hyperstimulation, difficult forceps delivery, versions
• Associated factors: previous uterine surgery, multiples, overdistention of uterus, epidural, placental abruption

• S/S: FETAL DISTRESS, sudden/sharp/lower abd pain, tearing sensation, shock, contractions stop, FHR stop, fetal parts palpable thru abd wall
• Management: Avoid uterine hyperstimulation, Monitor VS FHR, prepare for surgery

• Def: 2 or more fetuses in uterus
• Complications: Increase risk for c/s, preterm birth, IUGR, PPH, uterine rupture
• Management: Continuous EFM, IV, delivery in OR, both twins delivered prior to placentas.

• Def: intrauterine fetal death
• Assoc risk factors: advanced diabetics, systemic vascular disease, previous unexplained fetal loss
• S/S: absence of FHT by Doppler and no cardiac activity by u/s
• Management: Induction of labor (prostaglandins, oxytocin-doesnt work before 28 weeks), Analgesia, grief, increase risk of DIC

• Def: EBL or >500cc
• ~leading cause of maternal death worldwide~
• Early PPH: 1st 24 hrs (usually d/t uterine atony, lacerations, or retained placental fragments
• Later PPH: after 1st 24 hrs, caused by retained placental or bleeding disorders

• Def: failure of uterus to return to normal after pregnancy; lochia rubra >2weeks
• Causes: retained placental fragments and membranes, endometritis, uterine fibriod
• Management: antibiotics, D&C

• *MOST FREQUENT*: uterine atony
• lacerations of genital tract
• hematoma
• retained placental fragments
• uterine inversion
• blood coagulation disorders

• Hypotonic contractions (LONG labor)
• Overdistended uterus (large infant, multips, precipitous labor)
• Forceps or c-section
• Overdistended bladder
• Oxytocin induction
• Use of magnesium sulfate
• Prolonged 3rd stage of labor (>30min)

• Boggy, large uterus-vag bleeding (slow, steady, massive bleeding=shock-hypotension, thready pulse, pallor, dyspnea, chlls)
• Intense vaginal or vulvar pain from hematoma
• Complications: shock, occult bleeding, life-threatening infection, subinvolution, hemorrhage

• Inspect placenta for missing parts
• Massage fundus
• Monitor lochia amount
• Oxytocics
• IV/monitor urine output
• Ice to perineum (helps with pain)
• Keep bladder empty

• R/O uterine atony---bimanual uterine compression
• Uterine fundal massage
• inspection of perineum
• Monitor bleeding
• IV fluids, I&O, VS, LOC, temp/warmth
• Pad count/weigh pads (1g=1cc)
• Manual removal of clots
• TEACH WARNING SIGNS:
• *Bright red bleeding after 4 days
• *Saturating pad <2 hrs
• *Signs of infection
• *Need to notify HCP

• Oxytocin (Pitocin) IV and/or IM (20 units in 1000cc LR or 10 units IM)
• Methylergonovine (Methergine) IM/PO (q 4-6hrs if not hypertensive)
• Prostaglandin F2a (carboprosttromethamine or Hemabate) IM [N+V, diarrhea!]
• Misoprostel (per rectum)-absorbs quickly and works well

Fundal massage

or

Manual removal

• Def: infection accompanied by T>100.4 after 1st 24 hrs post delivery and lasting 2 successive days
• Major cause of maternal morbidity & mortality

• Chorioamnionitis
• C-section
• Diabetes
• Substance abuse
• malnutrition
• PROM
• PP hemorrhage
• episiotomy
• manual placenta extraction

• Flu-like s/s (fever, lethargy, chills, tachy)
• Abdominal pain
• Subinvolution of uterus
• Reproductive tract infection (backache, abd pain-tenderness, foul smelling lochia)
• Wound infection
• Increase WBC count

• Cultures and antibiotics
• Antipyretics, frequent fluids, early ambulation, comfort measures
• Monitor VS
• Assess incision and perineum
• For episiotomy infection: sitz baths, remove stitches and debride. If abscess: incision and drain
• If septic: IV antibiotics
• Teaching: WASH HANDS

• Sepsis
• Septic shock
• Peritonitis
• Paralytic Ileus

• Def: >1,000,000 bacterial colonies/ml of urine
• Predisposing factors: Overdistention, incomplete bladder emptying
• Cystitis or pyelonephritis

• S/S: small voiding volume or inability to void, pain with urination, suprapubic pain, low/high grade fever, hematuria, increasing vag bleeding, frequency/urgency/dysuria, pyelonephritis: +flank pain (CVAT), chills, N+V
• Management: obtain specimens, antibiotics, catheter prn, teach self care (regular bladder emptying, proper perineal cleansing, need for increase fluids)
• Complications: Ascending infection and loss of kidney function

• Def: infection of the breast in the postpartum period
• Causes: usually hemolytic staph. aureus, E coli, or candida albicans; lesion-infected nipple fissure
• Onset: 2-4 weeks after birth, unilateral

• Sore, cracked nipples
• Poor maternal hygiene
• Poor positioning/poor latch
• Excessive or vigorous infant suck
• Decrease in breastfeeding d/t supplemental bottles (milk stasis)
• Fatigue, stress, health problems
• Maternal dehydration
• Tight clothing

• pain, erythema, warmth, swelling in breast
• Flu-like symptoms (fever, chills, malaise, body aches, headache)
• Enlarged or tender axillary lymph nodes
• Cracked nipples

• Diagnosis: CBC, culture of drainage
• Management: Assess BF practices, Prevention (position changes, latch, breast care, well-fitting bra), teach s/s, warm compresses, FREQUENT BF on affected side, rest fluids analgesics, antibiotics
• Complications: Breast abscess, inhibition of let down reflex

• Def: inflammation of a vessel wall in association with a thrombus (blood clot inside of a blood vessel)
• Causes: Injury or inflammation of vessel wall, decrease velocity of blood flow (blood stasis=dehydration), hypercoagulability of the blood.

• 1. Superficial venous thrombosis
• -usually saphenous veins, lower leg
• -usually seen with varicose veins
• -may be d/t positioning during L&D

• 2. Deep Vein Thrombosis:
• -any veins from foot to femoral region
• -predisposes to pulmonary embolus (PE)
• -May be d/t fetal head pressure during L&D

• Postpartum immobility (c/s)
• PIH
• Varicose veins/hx of venous thrombosis
• Smoking
• Obesity
• Excess fluid loss/dehydration
• Hydramnios
• Age >40, multiparity
• Diabetes, anemia, heart disease

• 1. Superficial venous thrombosis
• -3-4 days pp, more common PP
• -reddened, warm, swollen, tender over clot area
• -PE extremely rare

• 2. Deep vein thrombosis
• -In larger veins, Increase risk for PE
• -Pain, low grade fever, chills, swelling, paleness of affected leg, +Homan's sign

• Prevention: early ambulation, leg exercises, adequate hydration
• Diagnosis: Homan's sign, u/s, venography, clotting times, pt/ptt times

• Bedrest with leg elevated, change positions
• No sharply flexed positions
• Do not rub on affected area
• Daily measurements of calf and thigh
• Support stockings
• Moist heat applications
• Heparin, pain control

• Pulmonary embolism (PE)
• -signs/symptoms-
• *Sudden dyspnea, SOB
• *Cyanosis, Diaphoresis, hemoptysis
• *Confusion, hypotension
• *Increase HR, intense chest pain

• PP blues (50-80%)
• PP depression
• Psychotic reaction

Risk factors: high levels of anxiety, previous hx, inadequate support,low income, history of PMS

• Selective serotonin reuptake inhibitors
• -zoloft, paxil, prozac