Obstetric Complications (FL INITIAL Autonomous Practice- Differential Diagnosis)

Although pregnancy, labor, and delivery are normal physiological processes, many complications can arise. These complications can occur in the antepartum, intrapartum, and postpartum periods. Many of these complications are high-risk and low volume, meaning that they can be devastating, but do not occur often. Some of the most common complications will be discussed below.

Obstetric infections may require intensive care unit (ICU) admission, especially when the infection amounts to severe sepsis or septic shock. These infections are a significant cause of maternal morbidity and mortality (Reardon & Chen, 2023). These infections can also cause complications in the neonate, such as neonatal pneumonia, sepsis, meningitis, or even death (American College of Obstetricians and Gynecologists [ACOG], 2017).

There are different types and causes of infection. Antenatal infections occur before delivery and can include (ACOG, 2017):

• Intra-amniotic infection (chorioamnionitis)
• Pyelonephritis
• Cases of pneumonia caused by streptococcus pneumonia and influenza

Chorioamnionitis is an infection that can occur during labor and can affect the amniotic fluid, placenta, fetal, fetal membranes, and decidua. This type of infection can cause dysfunctional labor and put the woman at risk for postpartum uterine atony and hemorrhage (ACOG, 2017).

Postpartum infection can also occur. The most common postpartum infection is endometritis or mastitis. Other postpartum infections can include (Berens, 2023):

• Surgical site infections
• Necrotizing fasciitis
• Septic pelvic thrombophlebitis
• Urinary tract infection (UTI)
• Clostridium difficile colitis 

Urinary tract infections (UTIs) can occur with foley catheter use during labor. Therefore, foley catheter use should be limited as much as possible.

The management of infection and sepsis should be similar to that of the non-pregnant patient and use the same targets and treatment, including antibiotics and fluid management.

Acute fatty liver of pregnancy (AFLP) is an obstetric emergency. AFLP occurs in the third trimester of pregnancy. In AFLP, free fatty acids increase in later pregnancy and if there is any defect in maternal-fetal acid metabolism, the products of metabolism can accumulate and affect maternal hepatocytes (Lee, 2023). Patients experiencing acute fatty liver may see their provider or go to the hospital with (Lee, 2023):

• Nausea
• Vomiting
• Right upper quadrant pain
• Jaundice
• Increased serum aminotransferase levels

Treatment of AFLP is delivery of the fetus and supportive measures such as mechanical ventilation for coma, dialysis for renal failure, and blood products for coagulopathy. This rare but serious complication requires hospitalization and prompt delivery (Lee, 2023).

With an umbilical cord prolapse, the cord presents ahead of the presenting part of the fetus into the cervical canal or vagina.

Image 2:
Umbilical Cord Prolapse

Umbilical cord prolapse is an obstetric emergency because the prolapsed cord can be compressed, leading to umbilical vein occlusion and umbilical artery vasospasm, which can compromise fetal oxygenation. Membranes are usually ruptured before this occurs.

Cord prolapse is rare, and the cause is not always known. However, some factors that increase the risk can include (Bush, 2023):

• Malpresentation (breech, transverse, oblique, or unstable lie)
• Multiparity
• Prematurity
• Polyhydramnios
• Prolonged labor
• Low birth weight
• Low-lying placenta
• Uterine malformations/tumors
• Pelvic deformities
• Fetal anomalies
• Long umbilical cord
• Unengaged presenting part of fetus
• Atypical placental cord insertions

With a cord prolapse, the nurse may observe an abrupt, severe, prolonged fetal bradycardia or moderate to severe variable fetal heart rate decelerations. This complication usually occurs after amniotic membranes rupture or an obstetric intervention that moves the presenting fetal part from the birth canal, allowing the umbilical cord to come out before the fetus (Bush, 2023). The provider or nurse also may palpate a pulsating cord while performing a vaginal examination, done to assess labor progress, or a patient with ruptured membranes may report seeing or feeling something within the vagina.

Obstetric interventions are reported in 50% of cases of cord prolapse (Bush, 2023). Possible obstetric interventions can include (Bush, 2023; Arnold & Gawrys, 2020):

• Cervical ripening with a balloon catheter
• Rupture of membranes (more common with unengaged presenting part)
• Induction of labor
• Insertion of intrauterine pressure catheter (IUPC) or fetal scalp electrode
• Manual rotation of head
• Amnioinfusion (replacing amniotic fluid lost during labor)
• Version (process to rotate fetus)
• Assisted birth with forceps or vacuum

Obstetric management of a cord prolapse requires prompt delivery to avoid fetal compromise or death from compression of the cord between the presenting fetal part and the birth canal (Bush, 2023).

When a cord prolapse is detected, the nurse or provider should call for assistance and prepare for an emergency delivery. The nurse or provider should initiate maneuvers for intrauterine resuscitation, primarily aimed at moving the fetus off the umbilical cord to prevent compression. Intrauterine resuscitation may include maneuvers such as manual elevation of the presenting part by keeping a hand in the vagina pushing up on the head to prevent cord compression or retro-filling the bladder. It may be beneficial to place the patient in Trendelenburg or knee-chest position and administer a tocolytic because these interventions may reduce pressure on the cord (Bush, 2023). The fetal heart rate should be continuously monitored to determine whether resuscitative interventions are effective, which can impact the urgency of the delivery (Bush, 2023). The nurse or provider should also minimize manipulating a prolapsed cord and avoid exposing it to a cold environment. The nurse or provider should gently replace a prolapsed cord in the vagina and keep it moist with wet gauze. The provider should then perform an emergency delivery by the most rapid and safe route, typically a cesarean section (Bush, 2023).

Uterine inversion occurs when the top of the uterus, called the fundus, falls into the endometrial cavity, turning the uterus partially or completely inside out.

Image 3:
Uterine Inversion

It is a rare complication of vaginal or cesarean delivery, but when it occurs, it can be a life-threatening obstetric emergency (Macones, 2023). If a uterine inversion is not promptly recognized and treated, it can lead to severe hemorrhage and shock, which can result in maternal death (Macones, 2023).

There are 3 types of uterine inversion (Macones, 2023):

1. Acute occurs within 24 hours of delivery
2. Subacute occurs more than 24 hours but less than four weeks postpartum
3. Chronic occurs ≥ 1 month postpartum

Over 80% of cases of uterine inversion are acute (Macones, 2023).

The reason for uterine inversion is unknown, but excessive cord traction and fundal pressure during the third stage of labor, especially in an atonic uterus with fundal implantation of the placenta, may increase the risk of uterine inversion. A vaginal exam revealing "something" in the vagina and severe hemorrhage are the most common findings that suggest an inversion (Macones, 2023).

Treating uterine inversion means replacing the uterus, treating hemorrhage, and preventing reoccurrence. Uterotonic medications should be discontinued because the uterus needs to relax to be put back in. An emergency call for assistance, including anesthesia, is important. A second intravenous access, blood products, and fluids are needed to treat the hemorrhage. The provider should try to replace the uterus manually. Nitroglycerin is a good uterine relaxant with a short half-life, which is useful in women with severe hemorrhage and hemodynamic instability. Terbutaline or magnesium sulfate are other options for uterine relaxation. Surgical intervention is the last option. Once the uterus is replaced, the provider can hold it in place until the uterus is firm and stays in place. Uterotonic medications must then be given to treat the uterine atony. These medications can include (Macones, 2023):

• Pitocin
• Methergine
• Hemabate
• Misoprostol

Antibiotics may also be given (Macones, 2023).

Uterine rupture is a life-threatening complication of pregnancy for both mother and fetus. Most uterine ruptures in developed countries are associated with a trial of labor after cesarean delivery (TOLAC), although the risk is very low (Frey & Landon, 2023). The women with the highest risk are those with previous uterine rupture or previous fundal or high vertical hysterotomy (ACOG, 2019).

Induction of labor increases the risk of uterine rupture over spontaneous labor, with misoprostol causing the highest risk of rupture (ACOG, 2019; Frey & Landon, 2023).

Some of the risk factors for uterine rupture can include (ACOG, 2019; Frey & Landon, 2023):

• Increasing maternal age
• Gestational age >40 weeks
• Birth weight >4000 grams
• First pregnancy less than 18 to 24 months prior
• More than one previous cesarean delivery
• Previous second-trimester cesarean delivery

There is no reliable method to determine the risk of uterine rupture.

It is important to know the signs of uterine rupture. Signs may include a sudden abnormal fetal heart rate, which may include variable and prolonged decelerations, or bradycardia (Frey & Landon, 2023). Abdominal pain may be present but could be missed due to an epidural. Vaginal bleeding may occur. Loss of station of the fetal presenting part could occur if the fetus is partially extruding through the rupture (Frey & Landon, 2023). Hematuria may occur if the rupture extends into the bladder. Changes in contraction pattern could also be associated with uterine rupture. Unstable patients should be stabilized with fluids and blood transfusion, as appropriate, and prepared for cesarean delivery immediately. Anesthesia and neonatology should be notified urgently. The rupture may require a hysterectomy, although repair might be possible (Frey & Landon, 2023).

A 37-year-old patient, Darcy, was admitted for early labor. Darcy had had a previous cesarean section for the arrest of labor, about 15 months ago.

Darcy went into spontaneous labor. She progressed to full dilation.

An hour later, once she had been pushing for 40 minutes, the fetal monitoring tracing changes suddenly and records prolonged atypical variable decelerations (see Image 4).

Image 4:
Prolonged Atypical Variable Decelerations of Fetal Heart Rate

Let’s consider a few questions:

1. What was the first sign that there could be uterine rupture?
   • The fetal heart tracing after the patient begins pushing becomes abruptly abnormal, indicating a possible uterine rupture.
2. Should Darcy have been managed differently?
   • No, appropriate care was given. She was a candidate for a trial of labor after cesarean and a cesarean was decided upon as soon as the fetal heart tracing indicated a problem.
3. If Darcy was pushing, what other sign may have been seen?
   • A patient who is fully dilated and pushing may have a loss of presenting part when uterine rupture occurs. If the head was at 0 station and all of a sudden is floating, this should signal a possible rupture.

Although obstetric complications occur infrequently, they can be life-threatening to the mother and the fetus. It is very important that labor and delivery (L&D) nurses are aware of all of the complications that can occur. Treatment depends on the condition but is often urgent.

Nurses should also be aware of all of the risk factors that increase a patient’s chance of having a complication. It is important to remember that the conditions can be scary and cause trauma to the patient and families that are involved. It is important that culturally sensitive and compassionate care is offered at all times. Nurses can check-in often with the patient to see how they are coping. Communication, in a calm manner, is important and should include the support person whenever possible (Vogel & Coffin, 2021).

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• American College of Obstetricians and Gynecologists. (ACOG). (2019). Vaginal birth after cesarean delivery. American College of Obstetricians and Gynecologists (ACOG). Visit Source.
• Arnold, J., & Gawrys, B. (2020). Intrapartum fetal monitoring. American Family Physician, 102(3), 158-167. Visit Source.
• Berens, P. (2023). Overview of the postpartum period: Disorders and complications. UpToDate. Retrieved September 25, 2023. Visit Source.
• Bush, M. (2023). Umbilical cord prolapse. UpToDate. Retrieved September 25, 2023. Visit Source.
• Frey, H. & Landon, M. (2023). Uterine rupture: After previous cesarean delivery. UpToDate. Retrieved September 25, 2023. Visit Source.
• Lee, R. (2023). Acute fatty liver of pregnancy. UpToDate. Retrieved September 25, 2023. Visit Source.
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• Reardon, C. & Chen, F. (2023). Critical illness during pregnancy and the peripartum period. UpToDate. Retrieved September 25, 2023. Visit Source.
• Sharma, A., & John, S. (2023). Liver disease in pregnancy. StatPearls. Visit Source.
• Tita, A.T.N. (2023). Intra-amniotic infection. UpToDate. Retrieved September 25, 2023. Visit Source.
• Vogel, T. M., & Coffin, E. (2021). Trauma-informed care on labor and delivery. Anesthesiology Clinics, 39(4), 779-791. Visit Source.