Intrapartum Complications

T Stone Godena, CNM, MSN

Spring, 2016

Common complications
Group B Strep
Chorioamnionitis
Dysfunctional Labor
Precipitous Labor
Cord Prolapse
Shoulder dystocia
Meconium
Amniotic Fluid embolism

What is Group B strep?

A type of Gram + streptococcal
bacteria (not to be confused with
strep throat-group A strep) found as
normal flora on intestinal, rectal and
vaginal and bladder mucus
membranes of many people

What is the prevalence?

(25-35%).
What are the consequences for the
mother?
Usually benign for the carrier.
What are the consequences for the
newborn?
Newborn immune system is immature
so it can cause neonatal sepsis

How do we manage it?

All pregnant women screened
between 35-37 weeks gestation.

What happens if they are

Positive?
Treatment begins with ROM or labor:
5 million units Penicillin G IV
loading dose then 2.5 million units Q
4 hours until birth. Goal is >2
completed doses.
For PCN allergy, Clindamycin 900 mg
IV Q 8 hours if bacteria is sensitive

Why not treat in pregnancy?

If treated in pregnancy, about 65% of
the time the bacteria will recolonize
prior to labor (since it is a normal part
of the persons flora)

How do we screen?
A Q tip is inserted into the lower 1/3 of
the vagina, swiped down the
perineum then into the anus. The Qtip
contents are then planted into a
culture. Results are positive or
negative. If positive, antibiotic
sensitivities are recorded.

What if no screening was done?

Treat based on risk factors:
Labor <37 weeks gestation (with or
without ruptured membranes).
Term with membranes ruptured longer
than 18 hours.
Unexplained fever in labor.
Previous baby with GBS infection.
Bladder or kidney infection in
pregnancy caused by the GBS
bacteria.

What is chorioamnionitis?
An infection of the membranes of the
placenta and amniotic fluid caused by
bacteria ascending from the maternal
urogenital tract (anus, vagina). Generally
polymicrobial (not just one type of
bacteria).
What is the Incidence?
Occurs 2-4% of the time

Who is at risk?
Women with Premature &/or
prolonged rupture of membranes,
multiple vaginal exams,
internal monitoring,
immunocompromised state,
STIs

What are Signs/Symptoms?

Maternal fever (>100.4 o F)
Maternal/fetal tachycardia
Foul smelling amniotic fluid
Uterine tenderness

How do we diagnose it?

Diagnosis per signs and symptoms or
blood culture

How do we treat it?

IV antibiotics until birth
Acetominophen for relief of
tachycardia
Expedite birth
Common antibiotics
Ampicillin +Gentamycin +
Clindamycin

Complications chorioamnionitis
Maternal
(2-3 x risk
Cesarean Section )
PP endometritis
Wound infection
PP hemorrhage
Pelvic/leg blood
clots

Fetal/Neonatal
Meningitis
Intraventricular
hemorrhage
Sepsis
Cerebral Palsy (4 x
risk over random
population)
Death

Dysfunctional labor
Other names: Arrest of labor, arrest of
descent, failure to progress, labor dystocia,
protracted labor, obstructed labor.
May be HYPO or HYPERtonic contractions
or inadequate expulsive efforts.
HYPERtonic occurs early in latent phase
HYPOtonic may cause protraction or arrest
disorders and can occur during latent
phase, active phase or the second stage of
labor
Inadequate expulsive efforts is in 2nd stage

Associated factors
Extremes of reproductive age
Soft tissue abnormalities
Pelvic abnormality
Short maternal stature, esp. if BMI

Large baby
Exhausted, fearful or dehydrated
mother
Malpresentation/malposition
Ill-timed anesthesia/analgesia

Categories of dysfunctional labor

Category

Nullipara

Multipara

Prolonged latent phase

> 20 hrs

> 14 hrs

Protracted dilatation

< 1.2 cm/hr

< 1.5 cm/hr

Arrest of dilatation*

> 2 hrs without

change

> 2 hrs without

change

Protracted descent

< 1 cm/hr

< 2 cm/hr

Arrest of descent*

> 2 hrs without

descent

> 1 hour without

descent

Prolonged second stage

without (with) epidural

>2 hr(>3 hr)

>1 hr (>2 hr)

* With documentation of
adequate contractions =

>200 Montivideo
units (MVU) per 10
minutes x 2 hours

A Po labor > 30 hrs associated with risk C/S and NICU admissions

Proposal for change

Both American College of Obstetrics and
Gynecology (ACOG) and the Consortium on Safe
Labor (CSL)have proposed extending the minimum
period before diagnosing active phase arrest.
The CSL defines 6 hours as the 95th percentile of
time to go from 4 cm to 5 cm dilation, with the active
phase defined as beginning at 6 cm (instead of 4
cm). ACOG has stated that extending the time from
2 to 4 hours with oxytocin augmentation appears
effective for allowing adequate time for cervical
change without increasing risk to mother or fetus.

HYPERtonic dysfunction
Usually < 4 cm.
Etiology unkown
Pain out of proportion to stage of labor
Contractions may be frequent but not
coordinated
Risks to mother: exhaustion, C/S
Risks to fetus, meconium passage,
possible hypoxia

Treatment HYPER
Augmentation if co-morbidity requires
hastening delivery
Therapeutic rest preferable:
Morphine sulfate given. Patient
sleeps and either awakens in active
labor or contractions stop.

HYPOtonic
Causes: Remember the 5 Ps
Risks to mother: Infection (if ROM),
exhaustion, C/Section, death
(amniotic fluid embolism)
Risks to fetus: infection, hypoxia,
asyphxia (permanent neurological
damage or death)

Treatment
Complete assessment of the 5 Ps.
Determine if there is cephalopelvic
disproportion(CPD) r/o Pelvic
contractures, young teens, h/o MVAs
If CPD ruled out: augmentation
Movement, hydration, hydrotherapy,
oxytocin. Fully address pain relief
needs

Persistent Occiput Posterior

Common cause of protracted dilatation or
protracted descent disorders.

Nursing interventions:
knee chest position
-squats
-lunges
-pelvic rocking
-rolling side to side (Rebozo)

Inadequate expulsive efforts

Causes: exhaustion, dense
anesthesia
Risk to mother: C/Section
Risk to fetus: hypoxia, asphyxia

Treatment
Labor down
Change position
Decrease level of anesthesia
Assisted vaginal birth if fetal head low
enough
C/Section

How do we Manage
dysfunctional labor?
Prolonged Latent Phase (PLP)
85% can be resolved with therapeutic
rest (same protocol as for HYPERtonic
uterine dysfunction.

Active phase dysfunction

Slow progress can be enhanced with
position change, hydration, reduction of
anxiety, encouragement
Augmentation: Pitocin or amniotomy
Documenting adequacy of Ucs (IUPC) is
important
Experimental: Low dose blockers
when abnormal contraction
patterns have not responded to
Pitocin

Precipitous Labor
Labor lasting <3 hours.
What are risks of precipitous labor:
Unplanned site of birth
Sometimes more painful & harder to cope
risk for Postpartum hemorrhage
Babies are usually fine, though there is a small
risk of delivering in an unclean area or facial
bruising
risk for perineal/cervical/vaginal lacerations
Small risk for shoulder dystocia

Nursing management
If woman arrives in advanced labor,
especially a multipara:
Observe perineum, Prepare for rapid
delivery, Notify provider stat, stay
calm and calm mother.

Name that complication

Definition Cord Prolapse

Passage of the umbilical cord through
cervix prior to birth of the baby
resulting in the presenting part compressing
the cord preventing oxygen transfer to the
fetus. Risk of hypoxia, CNS damage, death
Types of prolapse:
May be occult (alongside the presenting
part) neither visible nor palpable.
Or may be overt (visible or palpable). cord

Incidence1/300 births.

Predisposing factors
Prematurity
Malpresentation/Malposition
Multiple gestation
Polyhydramnios
Unusually long umbilical cord
Low lying placenta
AROM with high presenting part
Attempted rotation of posterior head
Grand multiparity

Diagnosis
Usually occurs when membranes
rupture
Nursing management at membrane
rupture= Auscultate fetal heart or
visually appreciate it on EFM
If bradycardia, prolonged or variable
decelerations, observe for cord outside
the vagina or place fingers in the
vagina

Management of Cord prolapse

Call for help.
Have assistant notify obstetrician, assess
FHTs, O2 8-10 L/min., insert IV or IVF
Move fetal presenting part off cord
Knee-chest, trendelenberg or side-lying
with hand manually elevating presenting
part
If cord protruding from vagina, cover with
sterile, moist towel
Prepare for immediate birth (C/S)
Administer tocolytic if ordered.

Name this complication

What is shoulder dystocia?

Failure of the fetal shoulders to
deliver after the head is born.
How does it happen?
It occurs because of a relative size or
positional discrepancy between the
fetal and pelvic bony dimensions.
How often does it happen?
Incidence: 0.3% in infants weighing 2500
4000 grams. 5-7% in infants weighing 4000
4500 grams Still time, they arent predictable

Who is at risk for shoulder

dystocia?
Women with h/o shoulder dystocia
Macrosomic infants
Diabetes/Impaired carbohydrate metabolism
Obesity/Excessive weight gain in pregnancy
Post-term pregnancies
Prolonged 2nd stage
Precipitous 2nd stage
Instrumental delivery

Mechanics
During the fetal heads extension during delivery,
and prior to expulsion, the fetal shoulders need to
rotate within the bony pelvis to arrive in the most
accommodating dimension of the pelvis: the
oblique diameter.
If either the fetal shoulders are too large or the
maternal pelvis is too narrow to permit this
rotation to the oblique, a persistent anteroposterior
orientation of the fetal shoulders may result in the
anterior shoulder being obstructed behind the
symphysis pubis, impeding delivery and leading to
shoulder dystocia.

Nursing Management
Identify risk factors
Have extra staff and foot stool
Break the bed
Recognize signs/symptoms: turtle
sign, normal traction not delivering
shoulders
Prepare to respond rapidly
Call time out loud every 30 seconds
after birth of head until the body is
expelled.

Management cont.
Perform maneuvers as directed:
McRoberts
Suprapubic pressure
Hands and Knees
Be prepared to resuscitate

McRoberts maneuver

Hyperflexion of maternal thighs toward the abdomen. It raises the

Symphysis about 9 mm.. Resolves almost of shoulder dystocias
without further maneuvers. May require 2 people.

Suprapubic pressure

firm or rocking 45o downward pressure with palm or fist

above the pubic bone to dislodge the fetal shoulder. May be
combined with McRoberts.

Hands and Knees

Rescuscitation

Name this complication

What is Meconium?
Sterile, viscous, dark-green substance
composed of intestinal epithelial cells, lanugo,
mucus, and intestinal secretions eg, bile (fetal
stool).
Who is at risk for passage before or during
birth?
Placental insufficiency, PEC,
oligohydramnios, maternal drug abuse,
especially tobacco and cocaine. Mature fetal
GI tract (postdates) and fetuses who were
breech for extended time.

Characteristics of Meconium
May occur remote from labor,during
labor or with first breath.
May be thin, thick, particulate, pea
soup
May or may not be associated with
fetal intolerance of labor
May or may not be aspirated by
fetus/newborn

Risks of meconium in amniotic

fluid
Decreases antibiotic properties of
amniotic fluid--risk chorioamnionitis
Meconium staining causes a
chemical irritation of fetal skin
causing desquamation
Meconium Aspiration Syndrome
(MAS)

Meconium Aspiration Syndrome

Meconium aspiration can occur in utero or
with the babys first breath.
Meconium Aspiration Syndrome (MAS)
causes respiratory distress: by deactivating
surfactant, mechanical blockage of airway,
chemical pneumonitis, alveolar collapse and
necrosis eventually leading to a bacterial
infection. Some develop persistent
pulmonary hypertension
~1-10% of babies with MAS die.
Surviving babies have a risk of asthma,
pneumonia, brain damage from hypoxia,
persistent pulmonary hypertension.

Management per AAP

1) Pediatrician present for birth.
2) Newborn transferred immediately to warmer for intubation and
deep suctioning if meconium visualized
below the cords.
DO NOT dry or stimulate the newborn.

3) If baby cries or breathes vigorously immediately after birth,

routine caredry, stimulate, put skin-to-skin.
4) Assess for immediate or delayed respiratory distress,
cyanosis.

Amniotic Fluid embolism

Not completely understood; thought to
be more like anaphylaxis than
embolism. Postulated: Amniotic fluid or
fetal cells enter maternal circulation
Risk factors: multiparity, abruption,
pitocin use, polyhydramnios, fetal
demise, meconium-stained amniotic
fluid.
Usually occurs intrapartum. Mortality
rate up to 85% maternal, 50% fetal.

Nursing Management
Identify risk factors
Recognize S/S: sudden chest pain, Acute
dyspnea, hypotension, cyanaosis,
tachycardia, seizure like activity, followed
by cardiac arrest. DIC follows shortly
(bleeding from orifices or IV site).
Call for help. Notify attending

Management cont.
Oxygen via face mask at 8-10 L/min.
Position woman on her side with pelvis tilted
at 30 degree angle to displace uterus
Administer IV fluids & blood products as
prescribed.
Insert foley catheter and measure I&O.
Monitor maternal and fetal status.
Prepare for Cesarean if undelivered
CPR: Assist with intubation and mechanical
ventilation prn.

Any questions?