Complications of the intrapartum and postpartum periods

  1. Post term Pregnancy: def, effects
    • 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
  2. Post term pregnancy: risk factors, s/s
    • 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
  3. Post mature newborn:
    subcutaneous fat loss, long fingernails, wrinkled peeling skin, alert facies, absence of lanugo and vernix
  4. Management of post term pregnancy:
    • Fetal kick counts
    • side-lying position
    • good hydration
    • NST and CST
    • BPP weekly
    • Weekly cervical checks
  5. Complications of post term pregnancy:
    • Fetal acidosis
    • Oligohydramnios (decrease fluid)
    • meconium aspiration
    • fetal wasting
    • neonatal mortality
    • Neonatal hypoglycemia
    • Neonatal polycythemia (hyperbilirubinemia)
    • Neonatal impaired thermoregulation
  6. Induction of labor: def, augmentation of labor
    • 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
  7. Induction of labor: mechanical vs. physiologic vs. chemical
    • Mechanical: amniotomy (can scratch baby's head if decreased fluids)
    • Physiologic: ambulation, maternal position change, nipple stimulation
    • Chemical: Prostaglandins, misoprostel, oxytocin
  8. Indications for Induction:
    • Maternal problems: Diabetes, PIH, PROM, chorioamnionitis, abruption, postdates
    • Fetal problems: fetal hemolytic disease, IUGR, low BPP, intrauterine death...
  9. Readiness for Induction:
    • 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
  10. Bishop Pelvic scoring system:
    • Max # is 13
    • 0-4 is unfavorable
    • 5-8 is questionable
    • >8 is successful induction
  11. Methods of cervical ripening and labor induction: non meds
    • nipple stimulation (oxytocin is released)-sex or orgasm is a great thing for this!
    • Herbal remedies
    • Stripping the membranes (can break water)
  12. Methods of cervical ripening and labor induction: pharmalogical
    • 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
  13. Oxytocin (pitocin): definition & usage
    • 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!
  14. 3 complications of oxytocin:
    • 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.
  15. Management of Oxytocin:
    • 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
  16. Emergency measures for uterine hyperstimulation for non reassuring FHR pattern:
    • [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
  17. AROM: artificial rupture of membranes [amniotomy]
    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!
  18. AROM nrs actions:
    • 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)
  19. Dystocia (Dysfunctional labor): def, causes
    • 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
  20. Types and management of dystocia
    • 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)
  21. Cephalopelvic Disproportion (CPD): def, risk factors, s/s
    • 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
  22. Cephalopelvic Disproportion (CPD): management and complications
    • 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
  23. Chorioamnionitis
    • 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!
  24. Fetal distress/ non reassuring FHR tracing: def, causes, s/s
    • 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)
  25. Fetal distress: management
    • 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
  26. Meconium stained fluid: def, causes
    • 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
  27. meconium stained fluid: risk factors, s/s, management
    • 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.
  28. Complications for newborns with meconium stained fluid
    • Meconium aspiration
    • pneumothorax
    • Pneumonitis
    • Aspiration pneumonia
    • asphyxia
    • seizures
    • renal failure
    • death
  29. Shoulder Dystocia: def, associated factors
    • 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
  30. Shoulder dystocia: management and complications
    • 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
  31. Prolapsed Umbilical cord: def, cause, contributing factors
    • 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
  32. Prolapsed Umbilical cord: s/s, management
    • 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!
  33. Precipitious Labor and Birth: def, assoc factors, complications, management
    • 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!
  34. Amniotic Fluid embolism: def, assoc factors, causes
    • 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
  35. Amniotic Fluid embolism: S/S, management
    • 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)
  36. Disseminated Intravascular Coagulation (DIC)
    • 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)
  37. DIC predisposing factors, s/s, labs
    • 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
  38. DIC management:
    • 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
  39. Uterine Inversion
    • 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
  40. Uterine rupture:
    • 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
  41. Uterine rupture: s/s and management
    • 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
  42. L&D of multiple pregnancy
    • 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.
  43. Fetal Demise (Stillbirth)
    • 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
  44. Postpartum Hemorrhage
    • 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
  45. Subinvolution
    • 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
  46. Causes of PPH
    • *MOST FREQUENT*: uterine atony
    • lacerations of genital tract
    • hematoma
    • retained placental fragments
    • uterine inversion
    • blood coagulation disorders
  47. Predisposing factors for PPH
    • 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)
  48. Signs/symptoms of PPH
    • 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
  49. Nursing actions/prevention of PPH
    • Inspect placenta for missing parts
    • Massage fundus
    • Monitor lochia amount
    • Oxytocics
    • IV/monitor urine output
    • Ice to perineum (helps with pain)
    • Keep bladder empty
  50. Management of PPH
    • 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
    • *Bright red bleeding after 4 days
    • *Saturating pad <2 hrs
    • *Signs of infection
    • *Need to notify HCP
  51. Medications for PPH
    • 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
  52. What do you do for a retained placenta?
    Fundal massage


    Manual removal
  53. Postpartum infections of the reproductive tract
    • Def: infection accompanied by T>100.4 after 1st 24 hrs post delivery and lasting 2 successive days
    • Major cause of maternal morbidity & mortality
  54. Associated factors of PP infections
    • Chorioamnionitis
    • C-section
    • Diabetes
    • Substance abuse
    • malnutrition
    • PROM
    • PP hemorrhage
    • episiotomy
    • manual placenta extraction
  55. Signs/symptoms of PP infections:
    • 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
  56. Management of PP infection
    • 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
  57. Complications of PP infections
    • Sepsis
    • Septic shock
    • Peritonitis
    • Paralytic Ileus
  58. Urinary Tract Infections: def, predisposing factors
    • Def: >1,000,000 bacterial colonies/ml of urine
    • Predisposing factors: Overdistention, incomplete bladder emptying
    • Cystitis or pyelonephritis
  59. UTI's: s/s, management, complications
    • 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
  60. Mastitis: definition, causes, onset
    • 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
  61. Risk factors for mastitis
    • 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
  62. Signs/symptoms of mastitis
    • pain, erythema, warmth, swelling in breast
    • Flu-like symptoms (fever, chills, malaise, body aches, headache)
    • Enlarged or tender axillary lymph nodes
    • Cracked nipples
  63. Mastitis: diagnosis and management, complications
    • 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
  64. Thromboembolic Disease: def, causes
    • 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.
  65. Types of Thromboembolic Diseases (2)
    • 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
  66. Thrombophlebitis risk factors:
    • 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
  67. Thrombophlebitis Signs/symptoms (in the 2 diff types)
    • 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
  68. Prevention and Diagnosis of thromboembolic disease:
    • Prevention: early ambulation, leg exercises, adequate hydration
    • Diagnosis: Homan's sign, u/s, venography, clotting times, pt/ptt times
  69. Thromboembolic disease management:
    • 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
  70. Complications of Thromboembolic Disease
    • Pulmonary embolism (PE)
    • -signs/symptoms-
    • *Sudden dyspnea, SOB
    • *Cyanosis, Diaphoresis, hemoptysis
    • *Confusion, hypotension
    • *Increase HR, intense chest pain
  71. Postpartum Depression
    • PP blues (50-80%)
    • PP depression
    • Psychotic reaction

    Risk factors: high levels of anxiety, previous hx, inadequate support,low income, history of PMS
  72. Postpartum depression medications
    • Selective serotonin reuptake inhibitors
    • -zoloft, paxil, prozac
Card Set
Complications of the intrapartum and postpartum periods
Complications of the intrapartum and postpartum periods