LABOR COMPLICATIONS

Anna Mae Smith, MPAS, PA-CLock Haven University

Physician Assistant Program

Dystocia/CPDDystocia – Laboring patient is not making any progress at cervical dilatation &/or fetal descent during the active phase of laborCephaloPelvic Disproportion –head fails to come down into the pelvis with full dilation of cervix

Causes of DystociaNot in labor!Dysfunctional laborCPD causes:

Persistent occiput posterior (OP) presentaionFetal macrosomiaPelvisFetal malpresentationsCongenital anomalies (hydrocephalus)

Pelvic Types and Characteristics

Posterior

Sagital

TYPE SHAPE Diameter PROGNOSIS

Gynecoid Round Average Good

Anthropoid

Long,oval Long Good

Android Heart shape

Short Poor

Platypelloid

Flat, Oval Short Poor

ManagementAmniotomyPitocinPossible C-section

Shoulder DystociaThe anterior shoulder gets caught above the pubic symphysisCommon in macrosomiaDiabeticsMaternal obesityPost dates pregnancy

Shoulder Dystocia Complications

Maternal: lacerations & hemorrhageFetal: Brachial plexus injury (Erb’s Palsy) adduction & internal rotation of the shoulder& flaccid paralysis of the affected arm(Waiter’s tip hand)Fx clavicleC-spineAsphyxia of the infant

ChorioamnionitisPreterm labor with intact mambranesMaternal infection/sepsis/endometritisNeonatal SepsisDiagnosis:

FeverUterine tendernessFetal tachycardiaFoul-smelling amniotic fluid

PROMMust deliver within 24hrs or greatly increased of infection!!If premature may gain time with antibiotics

ACTIVE PHASE COMPLICATIONS

Hypertonic dysfunction: contractions that are generated in the lower pole of the uterus or in multiple sites

Hypotonic dysfunction: An insufficient generation of action potentials from the myometrial pacemakerInadequate propagation of the signal throughout the myometriumLack of mechanical response to the signal

In either circumstance, the contraction pattern fails to result in cervical effacement and dilatation.

Primary Dysfunctional Labor

Active-phase dilatation that occurs at a rate less than the 5th percentileThis value is 1.2 cm/hr in nulliparas and 1.5 cm/hr in multiparas

Tx of above & hypo/hypertonic dysfunction is oxytocin

Labor InductionMaternal indications

Fetal demiseSevere hypertensive diseaseOther medical problems (DM, renal, pulm)Risk of precipitous labor or distance from hospital

Labor InductionFetal Indications:

Post-term pregnancyMaternal HTNDMPROMChorioamnionitisOligohydramniosIUGRRh sensitization

Relative Contraindications to Labor Induction

Placenta previaAbnormal lie or presentationPrior classic incisionActive genital herpesPelvic abnormalitiesInvasive cervical cancerPresenting part above pelvic inlet

Induction MethodsMembrane StrippingAmniotomyPitocinVaginal prostaglandins

Complications with second stage of Labor

Full dilation to delivery of the infantProblems are caused by protraction or arrest of descentCheck for…hypotonic dysfunction, overdistended bladder, strong perineal resistance, conduction anesthesia, or ineffectual bearing down

May require forceps, vacuum extractor or C-section

Prerequisites for Forceps Delivery

1.The membranes must be ruptured. 2.The cervix must be fully dilated. 3.The operator must be fully acquainted

with the use of the instrument. 4.The position and station of the fetal head

must be known with certainty. 5.Adequate maternal anesthesia for proper

application of the forceps must be present.

Prerequisites for Forceps Delivery

6. The maternal pelvis must be adequate in size for atraumatic delivery.

7. The characteristics of the maternal pelvis must be appropriate for the type of delivery being considered.

8. The fetal head must be engaged.

Vacuum ExtractorMom requires less anesthesiaSimilar outcomes to forceps

Complications of the Third Stage

Interval between delivery of the infant & delivery of the placentaPlacenta will come out on own in 10-15 mins after baby!

Don’t interfere…risk uterine inversion & hemorrhage!

Placenta is ready..have mom push one more time!

(1) a gush of blood from the vagina(2) descent of the umbilical cord(3) a change in shape of the uterine fundus from discoid to globular(4) an increase in the height of the fundus as the lower uterine segment is distended by the placenta

INSPECT the PLACENTA!!