19.3 Obstetrical Conditions Affecting Labor and Birth

Meconium-Stained Amniotic Fluid

The brown or green staining of amniotic fluid due to the fetal passage of meconium is called meconium-stained amniotic fluid (MSF). Meconium passage can be attributed to normal gastrointestinal function, fetal response to hypoxia, and vagal response to umbilical cord compression. Two risk factors for MSF are postterm pregnancy and fetal distress (Mitchell & Chandraharan, 2018). Meconium aspiration is the most common complication related to MSF and can lead to neonatal pneumonia. The diagnosis of meconium aspiration is by observation of symptoms and chest x-ray.

Treatment of MSF in labor consists of amnioinfusion and preparation for resuscitation. The nurse calls the neonatal intensive care unit (NICU) team to be present at the birth. The neonatal team is prepared for resuscitation if needed. If the newborn is vigorous at delivery, no suctioning is necessary. If the newborn is not vigorous, the neonatal team will initiate the steps of neonatal resuscitation. The newborn would most likely go to the NICU for continued observation.

Oligohydramnios

Oligohydramnios is the lack of sufficient amniotic fluid. This amount is usually measured during ultrasound examination. Causes of oligohydramnios can be fetal or maternal. Identifying the causative agent is important to determine treatment. Indomethacin (Indocin), a medication used to treat preterm labor, has been associated with oligohydramnios. Fetal kidney and bladder disturbances and anomalies also lead to oligohydramnios. Table 19.5 reviews the diagnosis, causes, and symptoms of oligohydramnios.

Complications of oligohydramnios during pregnancy can be fetal growth restriction and fetal malformations. In cases of severe oligohydramnios, induction of labor is warranted. Complications during labor consist of nonreassuring FHR tracings, such as variable and prolonged decelerations due to cord compression during uterine activity. Amnioinfusion can replace fluid in the uterus to relieve umbilical cord compression during labor (Narbhavi et al., 2020).

Polyhydramnios

An increase in amniotic fluid amount, or polyhydramnios, may be caused by fetal abnormalities or genetic syndromes and conditions of the pregnant person. Two common reasons for polyhydramnios are fetal anomalies and diabetes in the pregnant person. See Chapter 12 Pregnancy at Risk for a complete discussion of polyhydramnios. Table 19.6 reviews the diagnosis, causes, complications, and associated discomfort of polyhydramnios.

Complications include premature labor, prelabor rupture of membranes, and postpartum hemorrhage because the uterine muscle is stretched more than with normal amniotic fluid levels; umbilical cord prolapse because the fetus does not descend into the maternal pelvis, allowing the umbilical cord to lie below the fetal presenting part; and stillbirth due to the increased risk of congenital anomalies and antepartum placental abruption. Placental abruption can occur after rupture of membranes due to the decompression of the uterus. Treatment depends on the etiology and gestational age. Labor induction can be initiated because of polyhydramnios. The nurse is aware of the increased risks of prolapsed cord and postpartum hemorrhage and is prepared for these complications. Polyhydramnios has been associated with fetal anomalies. Amniocentesis is sometimes used to remove excess amniotic fluid to relieve discomfort and prevent preterm birth; additionally, this fluid can also be used to test fetal chromosomes for abnormalities (Content Engine, 2023).

Chorioamnionitis

Chorioamnionitis, also known as intraamniotic infection and inflammation, is the infection and inflammation of the amniotic fluid, placenta, fetus, fetal membranes, or decidua (ACOG, 2017b). Chorioamnionitis is caused by different types of bacteria present in the vagina that ascend into the amniotic area. Risk factors during labor include prolonged labor, multiple vaginal exams, use of internal fetal monitors, meconium-stained fluid, and genital tract bacteria (ACOG, 2017b). Complications associated with chorioamnionitis are neonatal morbidity from pneumonia, meningitis, sepsis, and death. Complications in the laboring person consist of dysfunctional labor, postpartum atony, postpartum hemorrhage, endometritis, sepsis, and, rarely, death (ACOG, 2017b). Table 19.7 lists other characteristics of chorioamnionitis.

Symptoms of chorioamnionitis are tachycardia in the laboring person and/or fetus, uterine tenderness, foul-smelling amniotic fluid, and purulent cervical discharge. Culture of the fluid would be the best diagnostic tool; however, the laboring person does not have the time to wait on culture results. Therefore, diagnosis is determined by clinical presentation. The person is treated with broad-spectrum antibiotics (Conde-Agudelo et al., 2020). The antibiotic regimen is usually continued until after the birth. The role of the nurse is to treat the symptoms according to the health-care provider’s orders, monitor for distress in the laboring person and fetus, and explain the purpose of the medications being administered.

Multiple Gestation

Multiple gestations are prevalent because of the various assisted reproductive techniques available. In 2018, the rate of twin pregnancies was 32.6 twins per 1,000 total births (ACOG, 2021). Multiple gestation pregnancies rarely progress to 40 weeks. Recommendations for delivery in a normal twin pregnancy is delivery within the 38th week (ACOG, 2021). Delivery of a complicated twin pregnancy is determined according to the complication and degree of prematurity.

Complications of multiple gestation during labor and birth include uterine labor dystocia, abnormal fetal presentation, umbilical cord prolapse, placental abruption, emergent operative delivery, and postpartum hemorrhage (ACOG, 2021). Therefore, safety measures are instituted to prepare for complications. The nurse maintains continuous fetal monitoring for both FHRs, ensures blood is readily available, and has a sonography machine in the room to evaluate the presentation of the fetuses during labor. The labor and delivery surgical suite is available for delivery of twins or an emergency cesarean birth. Each newborn will have a separate pediatric team with two of all equipment.

Intrauterine Fetal Demise

Intrauterine fetal demise (IUFD) occurs in 1 in 160 births and is normally caused by fetal hypoxia. Sometimes, however, the cause is unknown (Metz et al., 2020). One cause of IUFD can be placental insufficiency due to disease, postterm pregnancy, or placental infarcts (Fadel & Mashally, 2022). Placental abruption is a risk factor for IUFD. Umbilical cord accidents such as knots, loops, or prolapse can cause IUFD. During labor, IUFD can occur due to malpresentation, prolonged labor, cord accidents, and hypoxia. Table 19.8 lists the causes and incidences of IUFD.

Many risk factors for IUFD have been identified, but most of these risk factors cannot be used to predict or prevent stillbirth. However, a history of prior stillbirth greatly increases the risk of repeat stillbirth. Nulliparity, advanced maternal age, obesity, preexisting diabetes, chronic hypertension, multiple gestation, smoking, and use of alcohol during pregnancy have been associated with IUFD (Metz et al., 2020). Autopsy and DNA testing can be performed with parental consent to determine the cause of death in hopes of preventing another demise. The role of the nurse is to discuss options with the laboring person and family regarding holding the baby, taking pictures, and spending time with the baby. The nurse plays a large role in emotionally supporting the person and family. This can be emotionally difficult for the nurse, and many labor and delivery units have access to support groups, social workers, or counselors that help the nurse as well as train nurses in assisting with perinatal bereavement.

Malpresentation of the Fetus

When the fetus is in a malpresentation, labor is more difficult for the fetus and the laboring person. The fetal head presents in the pelvis for 95 percent of labors and is breech in 3 to 4 percent of labors (Mohammed & El-Chaar, 2022). Risk factors for fetal malpresentation are unstable fetal lie, contracted pelvis, pendulous abdomen, uterine anomalies, and abnormal placenta location. The fetal risk factors include large infant, abnormal internal rotation, fetal extension, multiple gestation, and polyhydramnios.

Malpresentation can cause higher rates of operative deliveries. Prolonged labor or labor dystocia is common. Many times, the cervix will dilate or efface slowly because the fetal head is not compressing the cervix. Fetuses in an abnormal lie will have more molding and caput succedaneum, and they might also have lower Apgar scores due to long, difficult labors.

The most common malpresentation is the occiput posterior presentation. This occurs in 15 to 30 percent of cephalic presentations (Mohammed & El-Chaar, 2022). Figure 19.10 illustrates the occiput posterior position. The cause of this and many malpresentations is cephalopelvic disproportion. The nurse can help place the laboring person in hands-and-knees, forward-leaning, or side-lying positions to encourage rotation of the fetal occiput. If this presentation does not resolve, it is called a persistent occiput posterior position. Although vaginal delivery does occur in persistent posterior positions, the incidence of labor dystocia and fetal distress is significantly higher than in fetal occiput anterior positions.

Figure 19.10 Occiput Posterior Position The occiput posterior position occurs when the occiput is against the sacrum of the pregnant person. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Brow presentation occurs when the forehead of the fetus is presenting and is slightly extended. Because the diameter of the brow presentation is larger than the occiput presentation, this can cause cephalopelvic disproportion. Often the fetus rotates out of this position and either flexes to a vertex presentation or extends to a face presentation. Face presentation increases the risk of cesarean birth. See Figure 15.8 for illustrations of brow and face presentations.

Face presentation is similar to brow; however, in this presentation, the fetal head is totally extended. The presenting part is the face, and the position is determined by the chin, or mentum. The mentum anterior position allows for passage through the pelvic outlet. The mentum posterior position can cause the fetal head to become wedged. If the position is mentum posterior, cesarean birth is recommended. The nurse is aware that the newborn birthed in the face presentation will have edema and bruising of the face and prepares the parents for the newborn’s appearance.

Breech presentation occurs when the fetal sacrum is leading into the pelvis. Three to 4 percent of births are breech at term. The preterm fetus has the highest incidence of breech presentation. Most fetuses will position to cephalic by 34 weeks’ gestation. Maternal factors that increase the incidence of breech presentation include relaxed uterine muscles of a high-parity person, polyhydramnios, uterine anomalies, uterine masses, and contracted pelvis (Elfazari & El-Chaar, 2022). Placental factors include implantation at the fundal region of the uterus and placenta previa. Fetal factors include multiple gestation, hydrocephaly, anencephaly, chromosomal anomalies, and IUFD.

Breech presentation can be classified as frank, incomplete (footling), or complete, as shown in (Figure 19.11). Frank breech is the most common type of breech. Complications of vaginal breech birth are prolapsed cord, fetal asphyxia, and fetal injury. Double footling breech poses the highest risk for prolapsed cord, while frank poses the lowest risk. Footling breech maneuvers easily through the pelvis but allows less dilation for the fetal head to pass. Frank is the largest of the breech presentations, allowing the largest degree of dilation and making more room for the fetal head to birth (Elfazari & El-Chaar, 2022). In a breech position, the fetal head does not mold but remains round. This increases the risk of head entrapment and head trauma. Intracranial hemorrhage is a major concern for breech birth and fetal mortality (Elfazari & El-Chaar, 2022).

Figure 19.11 Breech Positions Breech presentation can occur in several positions. (a) Frank breech occurs when the buttocks and hips are presenting. (b) Complete breech occurs when the buttocks and hips present with the legs crossed. (c) Footling breech occurs when the presenting part is the foot or feet. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Birth of the breech fetus can be either vaginal or cesarean. Research has shown markedly reduced cases of fetal death during delivery with elective cesarean births (Elfazari & El-Chaar, 2022). Providers must be skilled at performing a breech cesarean birth because of the placement of the incision and ability to deliver the fetal head. The pregnant person with a large fetus, oligohydramnios, contracted pelvis, or prior cesarean should consider an elective cesarean birth.

Postterm Pregnancy

A pregnancy extending past 42 weeks and 0 days is considered postterm (ACOG, 2014). Risk factors for postterm birth are unclear; however, nulliparity, prior postterm pregnancy, male fetus, anencephaly, and maternal obesity have been suggested (ACOG, 2014). Some research suggests the placenta has limited capacity and leads to postmaturity syndrome when the pregnancy progresses past term (Patel & Rathod, 2022). Table 19.9 lists the adverse outcomes of postterm birth.

Characteristics of postterm syndrome are a newborn with wrinkled, patchy, peeling skin; a wasted-looking body, and an old appearance. Skin of the hands and feet are wrinkled and peeling due to lack of vernix caseosa. The nails are also long. Postmature newborns can have brown or green-tinged skin from meconium-stained fluid. During labor, the postterm fetus is at risk for uteroplacental insufficiency and oligohydramnios and the risk factors associated with both. The nurse will recognize FHR late decelerations because of uteroplacental insufficiency and variable decelerations because of cord compression. Amnioinfusion can help replace fluid to prevent cord compression. The postterm newborn is at risk for meconium aspiration.

Known and Undetected Fetal Anomalies

Some fetal anomalies are diagnosed during pregnancy, and preparations are made to address the anomaly during labor and birth. Other anomalies can be unexpected and require nursing interventions. One example is gastroschisis, an abdominal wall defect allowing the bowel to herniate into the amniotic sac.

Another condition that needs attention after birth is spina bifida, which can occur anywhere on the spine. Spina bifida is a neural tube defect that can occur in different types:

• spina bifida occulta: the mildest form; defect is a small dimple in the spine without outpouching of a sac
• meningocele: a protrusion of a sac filled with spinal fluid; no spinal cord involvement
• myelomeningocele: the most severe form; a protrusion of a sac containing spinal fluid and part of the spinal cord and nerves (Centers for Disease Control and Prevention [CDC], 2020).

After birth, the infant is placed prone to avoid putting pressure on the herniation. The herniated sac is at risk for infection. The nurse protects the sac by covering it with a moist sterile dressing.

Fetal Distress

Fetal distress occurs when the fetus is not receiving sufficient oxygenation. Uteroplacental insufficiency is the most common reason for fetal distress. Causes of uteroplacental insufficiency can be the use of uterotonics causing tachysystole, maternal hypotension, prolonged umbilical cord compression, and aged placenta. Refer to Chapter 16 Electronic Fetal and Uterine Contraction Monitoring for fetal monitor tracings associated with fetal distress. The following are causes of fetal distress necessitating immediate birth:

• ruptured uterus
• severe placental abruption
• umbilical cord prolapse
• amniotic fluid embolus
• vasa previa causing fetal exsanguination (ACOG, 2014)

Preterm Labor

Any labor occurring from 20 to 36 6/7 weeks’ gestation is considered preterm labor. Preterm birth can occur spontaneously through preterm labor or preterm prelabor rupture of membranes. Spontaneous preterm labor is caused by many factors, among them, premature cervical dilation or cervical insufficiency, uterine fundal abnormalities, infection, and fetal anomalies (CDC, 2023). Uterine distention, the result of multiple gestation and polyhydramnios, also causes preterm labor.

Preterm prelabor rupture of membranes (PPROM) refers to rupture of membranes prior to the 37th completed week of gestation and before spontaneous labor. The most common causes of PPROM are low socioeconomic status, smoking, multiple gestations, polyhydramnios, gestational hypertension, and diabetes (Danei et al., 2022). Risk factors for preterm labor are prior preterm birth, early pregnancy threatened abortion, birth defects, young and advanced maternal age, and maternal use of cigarettes and illicit drugs. Periodontal disease has also been associated with preterm labor.

Precipitous Labor

Labor and delivery that is extremely rapid, usually less than 3 hours from start of the contractions to birth, is considered precipitous labor. The labor and birth may happen at home, in a birth center, or in the hospital. Pregnant persons may describe their labor as contractions that are very close together without a break between contractions, strong contractions without a slow build, or having a sudden urge to push. The true cause of precipitous labor is unknown; however, several risk factors have been associated with it, such as a small fetus, previous precipitous birth, cocaine use, or high blood pressure. Precipitous birth can lower 1-minute Apgar scores and increase the risk for postpartum hemorrhage, newborn respiratory distress, third- or fourth-degree lacerations, and placental abruption (Aiken et al., 2017; Suzuki, 2015).

In precipitous labor occurring in the hospital, the nurse focuses on promoting the well-being of the laboring person and the fetus. Patients may have increased anxiety or panic due to the rapid progression. The nurse should speak in a calm manner, explaining what to expect and reassuring the person they are safe. In preparing for the upcoming delivery, the nurse is expected to call the health-care provider and ensure medications to treat postpartum hemorrhage are readily available. If the fetus is born prior to the health-care provider’s arrival, the nurse will gently assist the delivery of the infant, dry the infant, cut the umbilical cord, and place the infant on the birthing person’s chest skin-to-skin. The greatest priority is keeping the infant warm. The pediatric team should be in the room in case the infant does not begin breathing spontaneously after the rapid descent and birth. The nurse should refrain from assisting the delivery of the placenta and allow the placenta to deliver spontaneously. If the placenta delivers spontaneously before the health-care provider is present in the labor and birthing suite, the nurse should be prepared to administer oxytocin per institution protocols to decrease the risk of postpartum hemorrhage.

Preeclampsia

According to ACOG, “Preeclampsia is a disorder of pregnancy associated with new-onset hypertension, which occurs most often after 20 weeks of gestation and frequently near term” (2020b, p. e237). Pregnant patients with a blood pressure (BP) of greater than 140/90 mm Hg are hypertensive. The increased BP requires the nurse to assess the laboring person for other signs of preeclampsia, such as proteinuria, presence of a headache, and visual disturbances. See Chapter 12 Pregnancy at Risk for a full discussion of preeclampsia in pregnancy. When caring for patients diagnosed with preeclampsia, the nurse monitors the laboring person’s vital signs and symptoms more frequently than those of a low-risk patient.

Complications of preeclampsia can occur during labor and postpartum. It is important for the nurse caring for the laboring person diagnosed with preeclampsia to have a thorough understanding of possible complications and nursing interventions. Complications during labor can be seizure, fetal distress due to uteroplacental insufficiency, and stroke. Headaches, visual disturbances, and hyperreflexia can occur before an eclamptic seizure. Therefore, the nurse explains to the laboring person the importance of reporting headache, epigastric pain, or visual disturbances. The nurse also assesses deep tendon reflexes to determine hyperreflexia. Uteroplacental insufficiency can occur because of the rapid aging of the placenta due to hypertension. Therefore, the nurse monitors for signs of fetal distress during labor. HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelet count) syndrome, discussed in Chapter 12 Pregnancy at Risk, can cause bleeding issues during labor and postpartum. The nurse reviews the lab work to monitor for signs of HELLP syndrome. Stroke can occur when the blood pressure is critically high (160/110 mm Hg or higher). The nurse explains the importance of monitoring the blood pressure and administering antihypertensives per protocol to avoid stroke. The nurse also encourages the laboring person to rest and keeps stimulus to a minimum, such as keeping the lights low, limiting visitors, and keeping the room quiet. Severe increases in BP are rechecked and reported to the health-care provider.

Preeclampsia affects the entire body. The kidneys can be affected and cause edema in the extremities and lungs. Strict monitoring of the preeclamptic laboring person’s intake and output (I&O) is essential. The nurse should assess for pedal and facial edema during labor. The nurse also assesses the lungs for signs of pulmonary edema, such as crackles, wheezes, and dyspnea. If the kidneys are affected by preeclampsia, the nurse will limit IV fluids per health-care provider orders. A urine dipstick test for protein might also be ordered. The nurse assesses for epigastric pain, knowing that the laboring person might experience this when the liver is affected.

Medical management of preeclampsia could include antihypertensives and magnesium sulfate. It is important for the nurse to be familiar with the administration, side effects, adverse reactions, and nursing interventions associated with these medications. Nursing assessments for adverse reactions to magnesium sulfate are performed often, and many times the nursing care ratio is one-to-one. See Chapter 12 Pregnancy at Risk for a thorough discussion of antihypertensives and magnesium sulfate.

Diabetes Mellitus

Gestational diabetes is a condition causing intolerance to carbohydrates and insulin resistance leading to hyperglycemia in pregnancy. Patients with gestational diabetes are at increased risk for preeclampsia, cesarean birth, and development of diabetes mellitus (DM) later in life (ACOG, 2018a). See Chapter 12 Pregnancy at Risk for a full discussion of pregnancy and diabetes mellitus.

Persons with type 1 DM must have close monitoring of their blood glucose during labor. The fetus is affected by the laboring person’s glucose level. High maternal blood glucose during labor and birth places the newborn at risk for hypoglycemia. High energy expenditure and limited calorie intake put the laboring person at risk for hypoglycemia as well. The health-care provider will order the frequency of blood glucose checks and insulin infusion. Hourly blood glucose checks are common. Intravenous insulin and glucose must be titrated to keep the person normoglycemic; the goal is to prevent hyperglycemia. Ideal glucose levels in labor are less than 110 mg/dL (ACOG, 2018c).

Gestational diabetes is associated with prelabor rupture of membranes, induction of labor, operative delivery, cesarean birth, and shoulder dystocia. Birth injury to the fetus occurs more often in cases of gestational diabetes, especially with macrosomic infants (over 4,000 g). Newborn injuries include nerve damage, fractures, and cephalohematoma. To reduce risks to the fetus and pregnant person, induction of labor is recommended between 38- and 39-weeks’ gestation (ACOG, 2018a). During labor, the nurse will monitor the laboring person for signs of hypoglycemia. After birth, the newborn will be assessed for hypoglycemia, and glucose will be monitored per facility protocol. The postpartum person is encouraged to breast-feed or bottle-feed often.