CHAPTER

17

Labor and Birth Complications

KEY POINTS
Preterm labor consists of uterine contractions with cervical
change (e.g., effacement and dilation) that occur between 20 and
37 completed weeks of pregnancy; preterm birth is any birth that
occurs before the completion of 37 weeks of pregnancy.
Complications related to preterm birth account for more
newborn and infant deaths than any other cause.
The incidence of preterm birth in the United States varies considerably by race.
Preterm birth describes length of gestation, whereas low birth
weight describes only weight at the time of birth.
Preterm birth is divided into two categories: spontaneous and
indicated. Spontaneous preterm birth occurs after an early initiation of the labor process and comprises nearly 75% of all preterm
births in the United States. Indicated preterm birth occurs as a
means to resolve maternal or fetal risk related to continuing the
pregnancy.
The cause of preterm labor is unknown and is assumed to be
multifactorial.
Preconception counseling and care for women, especially those
with a history of preterm birth, may identify correctable risk
factors and provide a means to encourage women to participate
in health-promoting activities.
Because the onset of preterm labor can often be mistaken for
normal discomforts of pregnancy, nurses should teach all pregnant women how to detect the early symptoms of preterm labor
and to call their primary health care provider when symptoms
occur.
Bed rest, still a commonly prescribed intervention for preterm
labor, has many deleterious side effects and has never been
shown to decrease preterm birth rates; modified bed rest is
recommended.
The best reason to use tocolytic therapy is to achieve sufficient
time to administer glucocorticoids in an effort to accelerate fetal
lung maturity and reduce the severity of respiratory complications in infants born preterm. In addition, time is allowed for
transport of the woman before birth to a center equipped to care
for preterm infants.
When preterm birth appears inevitable, magnesium sulfate may
be administered to reduce or prevent neonatal neurologic
morbidity
If fetal or early neonatal death is expected, the parents and
members of the health care team need to discuss the situation

before the birth and decide on a management plan that is acceptable to everyone.
Premature rupture of membranes (PROM) is the spontaneous
rupture of the amniotic sac and leakage of amniotic fluid beginning before the onset of labor at any gestational age. Preterm
premature rupture of membranes is associated with approximately 10% of all preterm births in the United States.
Vigilance for signs of infection is an essential part of the care for
women with preterm PROM.
A postterm pregnancy poses a risk to both the mother and the
fetus.
Dysfunctional labor results from differences in the normal relationships among any of the five factors affecting labor and is
characterized by differences in the pattern of progress in labor.
Malpresentation (the fetal presentation is something other than
cephalic or head first) is another commonly reported complication of labor and birth. Breech presentation is the most common
form.
Obese women are at risk for several complications during labor
and birth, including cesarean birth. Even routine procedures
require more time and effort to accomplish when the woman is
obese.
Labor should not be induced electively until the woman has
reached at least 39 weeks of gestation.
Cervical ripening using chemical or mechanical measures can
increase the success of labor induction.
Amniotic membrane stripping or sweeping is a method of inducing labor through the release of prostaglandins and oxytocin.
Oxytocin is a hormone normally produced by the posterior pituitary gland. It stimulates uterine contractions and aids in milk
let-down. Synthetic oxytocin (Pitocin) may be used either to
induce labor or to augment a labor that is progressing slowly
because of inadequate uterine contractions.
Expectant parents benefit from learning about operative obstetrics (e.g., forceps- or vacuum-assisted or cesarean birth) during
the prenatal period.
Maternal indications for forceps-assisted birth include a prolonged second stage of labor and the need to shorten the second
stage of labor for maternal reasons. Fetal indications include
an abnormal FHR tracing or certain abnormal presentations,
arrest of rotation, or extraction of the head in a breech
presentation.

All Elsevier items and derived items 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

e20

UNIT 4 Childbirth

Vacuum-assisted birth is a birth method involving the attachment of a vacuum cup to the fetal head, using negative pressure
to assist in the birth of the head. It is generally not used to assist
birth before 34 weeks of gestation. Indications for its use are the
same as those for outlet forceps. Prerequisites for use include a
completely dilated cervix, ruptured membranes, engaged head,
vertex presentation, and no suspicion of CPD.
The basic purpose of cesarean birth is to preserve the life and
health of the mother and her fetus.
Possible maternal complications related to cesarean birth include
aspiration, hemorrhage, atelectasis, endometritis, abdominal
wound dehiscence or infection, urinary tract infection, injuries to
the bladder or bowel, and complications related to anesthesia.
The attitude of the nurse and other health care team members
can influence the womans perception of herself after a cesarean
birth. The caregivers should stress that the woman is a new
mother first and a surgical patient second.
Unless contraindicated, a vaginal birth may be possible after a
previous cesarean birth. A trial of labor (TOL) is the observance
of a woman and her fetus for a reasonable period of spontaneous
active labor to assess the safety of vaginal birth for the mother
and infant. It may be initiated if the mothers pelvis is of questionable size or shape or if the fetus is in an abnormal presentation or position. By far the most common reason for a TOL is if
the woman wishes to have a vaginal birth after a previous cesarean birth.

Labor management that emphasizes one-on-one support of the

laboring woman by another woman (doula, nurse, or nursemidwife) can reduce the rate of cesarean birth and increase the
VBAC rate.
The major risk associated with meconium-stained amniotic fluid
is the development of meconium aspiration syndrome (MAS) in
the newborn. The presence of a team skilled in neonatal resuscitation is required at the birth of any infant with meconiumstained amniotic fluid.
Shoulder dystocia is an uncommon obstetric emergency that
increases the risk for fetal and maternal morbidity and mortality
during the attempt to accomplish birth vaginally.
Umbilical cord prolapse may be occult (hidden, rather than
visible) at any time during labor, whether or not the membranes
are ruptured. It is most common to see frank prolapse directly
after rupture of membranes. Contributing factors include a long
cord, malpresentation, or an unengaged presenting part. Prompt
recognition of a prolapsed umbilical cord is very important.
During labor and birth, the major risk factor for uterine rupture
is a scarred uterus as a result of previous cesarean birth or other
uterine surgery. Prevention is the best treatment.
Amniotic fluid embolus (AFE) is a rare but devastating complication of pregnancy characterized by the sudden, acute onset of
hypoxia, hypotension, cardiovascular collapse, and coagulopathy.
Care must be instituted immediately. Cardiopulmonary resuscitation is often necessary.

All Elsevier items and derived items 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.