Labor Complications Nursing Care & Management

Uterine Rupture

Uterine rupture is a rare but serious complication.
Uterine rupture is a condition wherein the uterus cannot sustain the strain that it underwent.
Factors that contribute to uterine rupture are abnormal presentation, prolonged labor, multiple gestation, improper use of oxytocin, and traumatic effects of forceps use or traction.
Fetal death can be avoided in uterine rupture if immediate cesarean birth can be performed.
Symptoms that a woman may feel preceding rupture are a sudden, severe pain during a labor contraction or a tearing sensation.
Rupture can be complete or incomplete.
With complete uterine rupture, the rupture goes through the endometrium, myometrium, and peritoneum, and then the contractions would immediately stop.
With incomplete uterine rupture, the rupture only goes through the endometrium and the myometrium only, with the peritoneum still intact.
Symptoms of complete uterine rupture include hemorrhage, shock, fading fetal heart sounds, distinct swellings of the retracted uterus and extrauterine fetus.
For incomplete rupture, there is localized tenderness, persistent aching pain in the lower uterine segment, and lack of contractions and fetal heart sounds.
Confirmatory diagnosis of uterine rupture can be revealed through ultrasound.
Administration of emergency fluid replacement as ordered should be anticipated as well as IV oxytocin.
Laparotomy would be performed to control the bleeding and repair the rupture.
Cesarean hysterectomy or tubal ligation can also be performed with consent from the patient to remove the damaged uterus and remove the childbearing activity of the woman.
Fetal outcome, the woman’s safety, and the extent of the surgery must be revealed to the patient and allow time for them to express their emotions.
The woman would be advised not to conceive again after a rupture of the uterus unless the rupture is in the inactive lower segment.
The viability of the fetus and the woman’s prognosis depends on the extent of the rupture.

Inversion of the Uterus

Uterine inversion occurs when the uterus turns inside out due to the delivery of the fetus or the placenta.
Factors that contribute to inversion are application of traction to the umbilical cord to remove the placenta, if pressure is applied to the uterine fundus when the uterus is not contracting, or if the placenta is attached to the fundus so during birth the fundus pulls it down.
Signs of inversion include sudden gush of a large amount of blood from the vagina, a non-palpable fundus, signs of blood loss such as hypotension, dizziness, and paleness, and if bleeding continues, exsanguinations.
The inversion should never be replaced and the placenta, if still attached, should never be removed.
Administration of oxytoxic drugs could only worsen the inversion and make the uterus tense so that it is difficult to replace.
To manage uterine inversion, an IV line with a large-gauge needle should be established to restore fluid volume, oxygen administration should be started, assessment of vital signs, and cardiopulmonary resuscitation if the woman undergoes arrest.
Nitroglycerin or a tocolytic drug would be given intravenously to relax the uterus, and the physician would replace the fundus manually.
Oxytocin would be given after manual replacement to help the uterus contract and remain in its natural place.
Antibiotics would be prescribed because the endometrium was exposed to prevent infection.
Inform the woman that a future pregnancy would need to be delivered via cesarean section because there is a possibility that the inversion would re-occur.

Amniotic Fluid Embolism

Amniotic fluid embolism occurs when the amniotic fluid is forced into an open maternal uterine blood sinus or after membrane rupture or partial premature separation of the placenta.
The most likely cause of the embolism is anaphylactoid or humoral response.
Amniotic fluid embolism cannot be prevented because it cannot be predicted.
Risk factors include abruption placenta, hydramnios, and oxytocin administration.
The woman experiences sharp chest pain, inability to breathe, pallor, and lack of blood flow.
Emergency measures include oxygen administration and CPR.
The woman’s prognosis would depend on the speed of the detection of the condition, the skill and speed of the emergency interventions, and the size of the embolism.
Endotracheal intubation and fibrinogen therapy would be needed because the risk for DIC is high.
The prognosis for the fetus is uncertain because reduced placental perfusion happens from a severe drop in maternal blood pressure.

Prolapse of the Umbilical Cord

In prolapsed of the umbilical cord, a loop of umbilical cord slips down in front of the presenting fetal part.
Factors that occur with prolapse are a small fetus, placenta previa, CPD, premature rupture of membranes, hydramnios, and multiple gestation.
During assessment of the presenting fetal part through vaginal examination, the cord might be felt.
Diagnosis of prolapsed of the membrane can be made through ultrasound.
Cesarean section should be performed before rupture of the membrane or the cord would slide down the vagina.
However, cord prolapsed is mostly discovered after rupture of the membranes, when the fetal heart rate has a variable deceleration.
Assessment of fetal heart sounds is necessary after rupture of membranes to rule out cord prolapse.
The goal in therapeutic management is to relieve cord compression to avoid fetal anoxia that can be achieved through manually lifting the head of the fetal head off the cord through the vagina or placing the woman in a Trendelenburg position.
Oxygen administration is also necessary to improve the fetal oxygenation.
Uterine activity and pressure of the fetus should also be reduced through a tocolytic agent.
Once the cord has prolapsed and is exposed to air, drying of the umbilical cord and atrophy of the umbilical vessels would begin.
Cover any exposed portion of the cord with a sterile saline compress to avoid drying.
If there is already complete dilatation, the physician can deliver the baby to prevent fetal anoxia.
If the cervical dilatation is not yet complete, cesarean birth would be performed as an emergency procedure because of the reduced blood flow that can harm the fetus.
Amnioinfusion, which is the addition of a sterile fluid into the uterus to supplement the amniotic fluid, can be performed just to prevent additional cord compression.
During the infusion, monitor the fetal heart rate and uterine contractions internally and record maternal temperature hourly to detect infection.

Multiple Gestation

When a woman has multiple gestation, additional personnel are needed for the birth and there is excitement inside the birthing room.
Be aware of the needs of the woman during a multiple birth because she may be more frightened than excited of the delivery.
Multiple gestations often result in fetal anoxia on the part of the second fetus, so cesarean birth is more preferable than normal delivery.
Anemia and pregnancy-induced hypertension mostly occur in women with multiple gestations, so assessment of the blood pressure and hematocrit is necessary.
If the woman plans to give birth vaginally, she should be advised to come to the hospital early in labor.
Instruct the woman breathing techniques to minimize the use of analgesia or anesthesia, thereby decreasing the possibility of respiratory difficulties that the infants might experience because of lung immaturity.
There may not be firm head engagement for multiple gestations because the babies are small.
Common conditions that occur with multiple gestations are abnormal fetal presentation, an overstretched uterus, premature separation of placenta, and uterine dysfunction due to a long labor.
Twin pregnancies usually have vertex presentations, but in gestations with three or more fetuses, the presentations are varied.
Oxytocin is administered after the birth of the last fetus unlike in singleton pregnancies to avoid compromising the remaining fetuses.
If the next fetus does not have a vertex presentation, external version might be attempted to make it vertex or cesarean birth can be performed.
To shorten the time span between births, an oxytocin infusion can be started.
To relax the uterus, nitroglycerin may be administered.
The first infant’s placenta separates before the birth of the second fetus which causes a sudden, profuse bleeding at the vagina, creating a great risk for the woman.
If the separation of the first placenta causes loosening of the other placentas or there is a common placenta, the fetal heart rate of the other fetuses would signal distress.
Most multiple gestations today which are not in vertex presentation are born through cesarean section because they need to be born all at once so they can survive.
Parents should be given an opportunity to view and inspect their fetuses to dispel the fears that they have that their infants are less than perfect.
Assess the woman thoroughly and immediately after birth because an overly distended uterus might have difficulty in contracting, placing her at risk for hemorrhage due to uterine atony.
Infants also need careful assessment to determine their gestational age and if any unusual conditions have occurred.

Practice Quiz: Labor Complication Nursing Care

Quiz time!

1. A woman experiences uterine inversion with the placenta still attached. What would be your best action?

A. Remove the placenta manually so that the uterus contracts.
B. Give an emergency bolus of oxytocin.
C. Increase the woman’s intravenous fluid to help restore blood loss.
D. Attempt to replace the uterus so that it becomes compressed.

2. Which of the following would lead the nurse to suspect that a pregnant woman has developed amniotic fluid embolism?

A. Rapid cervical dilatation of 5 cm/hour.
B. Report of sudden severe chest pain and dyspnea.
C. Evidence of hypotonic contractions and poor force of labor.
D. Report of back pain when ambulating or lying in bed.

3. Conditions that may place the patient at high risk for uterine rupture during birthing process include which of the following?

A. Premature labor
B. Abnormal presentation
C. Primiparas
D. Previous episiotomy scar

4. The nurse recognizes that the pregnant woman is experiencing uterine inversion when she notes the following symptoms:

A. Sudden gush of a large amount of blood.
B. Sharp chest pain.
C. Two distinct swellings in the uterus.
D. Unusually low or infrequent uterine contractions.

5. How can a nurse confirm the diagnosis of uterine rupture?

A. Through laparotomy
B. Through ultrasound
C. Through CT scan
D. Through MRI

6. One of the factors that occur with prolapse of the umbilical cord is:

A. Hydramnios
B. Oligohydramnios
C. Primiparity
D. Uterine rupture

7. This intervention refers to the addition of sterile fluid into the uterus to supplement the amniotic fluid.

A. Fetal blood sampling
B. Amnioinfusion
C. Amniocentesis
D. Augmentation

8. What is the most common complication of multiple gestation?

A. Fetal death
B. Fetal anoxia
C. Shock
D. Severe drop in the maternal blood pressure

9. What would the nurse tell a multipara who has a term fetus which has still not engaged?

A. The fetus will not engage because the woman’s urinary bladder is empty.
B. Engagement would occur if the woman ambulates.
C. No firm engagement will occur for multiple gestations because the babies are small.
D. Engagement is firm among multiple gestations because every fetal head is of normal size.

10. Administration of oxytocin in multiple gestation occurs when?

A. After the birth of the last fetus
B. After the birth of the first fetus
C. Before the birth of the second fetus
D. Before the birth of the first fetus

11. Labor may be induced in which of the following women?

A. Presenting part engaged.
B. A premature fetus.
C. A fetus in transverse lie.
D. Cephalopelvic disproportion.