19.11: Monitoring the Person in Labor for Complications Developing During the Process of Labor and Birth
By the end of this section, you will be able to:
- Explain the clinical manifestations, treatment, and nursing actions in the event of an undetected vaginal, cervical, or perineal laceration
- Explain the clinical manifestations, treatment, and nursing actions in the event of altered perfusion and oxygenation of the person during labor and birth
- Explain the clinical manifestations, treatment, and nursing actions in the event of altered neurologic function of the person during labor and birth
- Explain the clinical manifestations, treatment, and nursing actions in the event of psychosocial dysfunction of the person during labor and birth
Certain complications develop during the process of labor and birth. These complications include undetected lacerations, alteration in oxygenation, altered neurologic status, and psychosocial dysfunction. The nurse monitors for and attempts to prevent these complications.
Undetected Lacerations
The nurse assesses lochia every 15 minutes during the first hour after birth. Normal lochia is dark red with small clots. Bright red, brisk bleeding is not normal. If the uterus remains firm, undetected lacerations can be the cause of the vaginal bleeding. Risk factors for perineal trauma include older age, higher BMI, primiparity, gestational diabetes , hospital birth, longer second stage labor, and higher fetal weight and larger head circumference (Bączek et al., 2022). Lacerations can lead to symptoms of hemorrhage (hypotension, tachycardia, and decreased oxygen saturation) prior to the laceration being detected. The nurse examines the vagina and perineum to discover any undetected lacerations. Once a laceration is detected, the health-care provider is notified, and the laceration is repaired. The nurse will monitor for continued signs of bleeding. The hemoglobin and hematocrit will also be monitored. The health-care team will use lab results, vital signs, and the postpartum person’s ability to ambulate and perform activities to determine the need for a blood transfusion.
Alterations in Perfusion
Alterations in perfusion can occur during the birthing process. Pregnant persons with preeclampsia can have kidney damage due to vasoconstriction secondary to hypertension . They can also have a seizure ( eclampsia ) causing alteration in perfusion to the placenta and central nervous system. Preeclampsia with HELLP syndrome can lead to DIC, causing hemorrhage. Uterine atony can also lead to postpartum hemorrhage . Hemorrhage causes hypovolemia, which produces vasoconstriction in the peripheral vessels and shunting of blood to the vital organs. This causes alteration in perfusion of the extremities. Diabetes can decrease perfusion to the placenta because of abnormal aging of the placenta caused by elevated blood glucose. Other alterations in perfusion occurring during the postpartum period (hematoma, deep vein thrombosis, and pulmonary embolus) are discussed in Chapter 21 Postpartum Complications.
Signs of alteration in perfusion can be diminished peripheral pulses, decreased capillary refill, delay in milk production, and clammy, pale skin. Changes in vital signs can be seen, such as hypotension and tachycardia. Alteration in mental status can also occur. Kidney damage can result from hypertension, hypotension, or hypovolemia.
Nursing interventions include monitoring and increasing perfusion in the laboring and birthing person and notifying the health-care provider. The nurse will evaluate vital signs, oxygen saturation, nail beds, gums, and mucosa for color and temperature. Lowering the head of the bed and elevating the legs perfuses the heart and brain. Oxygen is administered if needed (Obermeyer et al., 2022).
Laboratory results should be monitored when altered perfusion is present. Proteinuria is present when kidneys are not being perfused. The 24-hour urinary output should be assessed. Hemoglobin, hematocrit, and platelets are monitored after postpartum hemorrhage. In massive hemorrhage or disseminated intravascular coagulation (DIC) , clotting studies and plasma fibrinogen should be monitored.
Alterations in Oxygenation
Alterations in oxygenation can occur during labor and birth. The most common cause of oxygenation complications is hemorrhage. Complications can also be caused by eclampsia, pulmonary edema , and pulmonary embolus. Signs of alteration in oxygenation include restlessness, cyanosis , nasal flaring, orthopnea, and use of accessory muscles. The nurse will assess respiratory rate, use of accessory muscles, nasal flaring, and abnormal breathing patterns. Auscultation for decreased ventilation should be performed. The person with altered oxygenation may have altered mental status or confusion that should be monitored. Nail beds and skin should be assessed for cyanosis. A pulse oximeter should be used to monitor pulse and oxygen saturation. Arterial blood gas tests might be ordered, and results should be monitored. Nursing interventions are elevating the head of the bed; administering oxygen; encouraging slow, deep breathing; and splinting for those post–cesarean birth persons who are coughing. The most important intervention is treating the cause of the alteration in oxygenation.
Alterations in Neurologic Function
During pregnancy, birth, and the postpartum period, alterations in neurologic function can occur. The most common causes of these alterations are seizure, stroke , and ruptured brain aneurysm. These complications are most likely due to preeclampsia and eclampsia. Seizures, sudden abnormal electrical activity in the brain, can occur any time before, during, or after birth. The cause of progression from preeclampsia to eclampsia is unknown. Eclamptic seizures lead to hypoxia and neurologic dysfunction. Stroke can be attributed to severe hypertension. A stroke, or cerebrovascular accident (CVA), is a sudden loss of brain function due to lack of blood supply to the brain. Peripartum migraines, infection, and coagulation disorders have been associated with stroke (Zambrano & Miller, 2019). Treatment of stroke requires rapid response from a multidisciplinary team. If the seizure or stroke is associated with hypertension, treatment should focus on reducing hypertension. A brain aneurysm is a bulging or weakening in a blood vessel in the brain. Aneurysms can rupture due to severe hypertension or preeclampsia. It is not within the scope of this text to discuss these disorders in detail. Refer to a medical-surgical text for in-depth discussion.
Nursing assessment of these persons includes monitoring for level of consciousness, voluntary/involuntary movements of extremities, blood pressure, ability to speak, cognition, and oxygenation. The nurse will support the person by giving positive feedback, decreasing their anxiety, and involving the family in care. The nurse will monitor for aspiration, thought processes, skin integrity, and improved mobility. The nurse will communicate with the health-care provider if vital signs become abnormal or if the person is unusually confused or cannot communicate, loses consciousness, or has another seizure.
Alterations in Psychosocial Function
Pregnancy, birth, and the postpartum period can be an exciting time for many people; however, others have alterations in psychosocial functioning. Postpartum depression is a common change. Some persons have difficulty in bonding with the newborn immediately after birth. Birth can trigger negative emotions in persons with a history of rape or sexual assault. Birth trauma can occur from difficult births or from feelings of lack of autonomy or control. Alterations in psychosocial functioning can also occur due to substance use. Pregnant persons are usually screened for substance use during the prenatal period. These persons should be offered assistance for their substance use disorder. When in labor, some persons are under the influence of substances. The nurse should be aware of the symptoms of certain substances. Cocaine and methamphetamine use causes higher risk for migraines, seizures, prelabor rupture of membranes, and placental abruption (National Institute on Drug Abuse, 2022). Infants born to persons using stimulants have symptoms of irritability, hyperactivity, tremors, high-pitched cry, and excessive sucking. Heroin use in pregnancy causes neonatal abstinence syndrome ( NAS ) in newborns; infants with NAS have symptoms similar to those of stimulant-dependent newborns, with the addition of gastrointestinal problems (National Institute on Drug Abuse, 2022). Alcohol use can result in fetal alcohol spectrum disorder , which affects fetal brain development and can cause birth defects. These defects can cause emotional and cognitive problems for the life of the offspring. If the nurse suspects the pregnant person is using an illegal substance, a drug screen can be obtained during pregnancy and at delivery. The nurse should also notify the nursery or NICU if the results are positive.