MS.

JECELI ALVIOLA NOBLEZA, BSN-RN

GENERAL OBJECTIVE

 Critically analyze the nursing implications

of the client with intrapartal complications
 SPECIFIC OBJECTIVES
 Explain abnormalities that may result in dysfunctional labor.
Describe maternal and fetal risks associated with premature rupture
of the membranes.
Analyze factors that increase a woman’s risk for preterm labor.
Explain maternal and fetal problems that may occur if pregnancy
persists beyond 42 weeks.
Describe common intrapartum emergencies
Explain therapeutic management of each intrapartum complication.
Apply the nursing process to care of women with intrapartum
complications and to their families.
INTRAPARTUM
 pertaining to the
period of labor and
birth.
DYSFUNCTIONAL LABOR
 Dysfunctional labor is one that does not
result in normal progress of cervical
effacement, dilation, and fetal descent.

 Dystocia is a general term that describes

any difficult labor or birth.
 A dysfunctional labor may
result from problems with:
4 P’s
powers of labor
the passenger
the passage
the psyche,
or a combination of these.
 An operative birth (vacuum extractor– or forceps-
assisted or cesarean) may be needed if
dysfunctional labor does not resolve or if fetal or
maternal compromise occurs.
 Signs that indicate the need for an operative birth
fetal heart rate (FHR) patterns
fetal acidosis, and
meconium passage.

 Maternal exhaustion or infection may occur,

especially during long labors.
Problems of the Powers
 The powers of labor may not be
adequate to expel the fetus
ineffective contractions
ineffective maternal pushing efforts.
Ineffective Contractions
Possible causes:  Maternal catecholamines
 Maternal fatigue secreted in response to stress
 Maternal inactivity or pain
 Fluid and electrolyte  Disproportion between the
imbalance maternal pelvis and the fetal
 Hypoglycemia presenting part
 Excessive analgesia or
 Uterine overdistention,
anesthesia (multiple gestation or
hydramnios)
 Two patterns of ineffective uterine
contractions are
Hypotonic dysfunction
hypertonic dysfunction
Hypotonic Dysfunction Hypertonic Dysfunction
CONTRACTIONS
Coordinated but weak. Uncoordinated, irregular.
Become less frequent and shorter in duration. Short and poor intensity, but painful and
Easily indented at peak. cramp-like.
Woman may have minimal discomfort
because the contractions are weak.
UTERINE RESTING TONE
Not elevated. Higher than normal.
PHASE OF LABOR
Active. Typically occurs after 4-cm dilation. Latent. Usually occurs before 4-cm dilation.
More common than hypertonic dysfunction. Less common than hypotonic dysfunction.
THERAPEUTIC MANAGEMENT
Amniotomy (may increase the risk of Correct cause if it can be identified.
infection). Light sedation to promote rest.
Oxytocin augmentation. Hydration.
Cesarean birth if no progress. Tocolytics to reduce high uterine tone and
promote placental perfusion.
NURSING CARE
•Interventions related to amniotomy
and oxytocin augmentation.
•Encourage position changes. An
abdominal binder may help direct the
fetus toward the mother’s pelvis if her
abdominal wall is very lax.
•Ambulation if no contraindication and
if acceptable to the woman.
•Emotional support: Allow her to
ventilate feelings of discouragement.
Explain measures taken to increase
effectiveness of contractions. Include
her partner/family in emotional support
measures because they may have
anxiety that will heighten the woman’s
anxiety.
•Promote uterine blood flow: side-lying
position.
•Promote rest, general comfort, and
relaxation.
•Pain relief.
•Emotional support: Accept the reality
of the woman’s pain and frustration.
•Reassure her that she is not being
childish.
•Explain reason for measures to break
abnormal labor patterns and their goal/
expected results. Allow her to ventilate
her feelings during and after labor.
Include partner/family
 Ineffective Maternal Pushing
 may result from:
Use of incorrect pushing techniques or inappropriate
pushing positions
Fear of injury because of pain and tearing sensations felt
by the mother when she pushes
Decreased or absent urge to push
Maternal exhaustion
Analgesia or anesthesia that suppresses the woman’s
urge to push
Psychological unreadiness to “let go” of her baby
 Nursing care:
1. Upright positions such as
- squatting - add the force of gravity to her efforts.
- Semisitting, side-lying, and pushing while sitting on
the toilet are other options.
2. Regional analgesia methods may restrict
possible maternal positions and may alter a
woman’s spontaneous urge to push.
3. Encouraging to push with intermittent
contractions also allows her to maintain
adequate pushing effort.
4. Oral or intravenous fluids provide energy
for the strenuous work of second-stage
labor.
 B Suprapubic pressure
A McRobert's maneuver

 adds gravity to her pushing efforts.

B. Suprapubic pressure by an assistant pushes
the fetal anterior shoulder downward to
displace it from above the mother’s symphysis
pubis.
Fundal pressure should not be used, because
it will push the anterior shoulder more firmly
against the mother’s symphysis.
Problems With the Passenger
 Fetal size
 Fetal presentation or position
 Multifetal pregnancy
 Fetal anomalies
Frank breech Full breech Single footling breech
Shoulder presentation
(transverse lie)
Fetal Size
 Macrosomia
infant weighs more than 4000 g (8.8 lb) at birth.
 Shoulder Dystocia
Delayed or difficult birth of the shoulders may occur as
they become impacted above the maternal symphysis
pubis.
Abnormal Fetal Presentation or Position
 An unfavorable fetal presentation or
position may interfere with cervical
dilation or fetal descent.
Multifetal Pregnancy
 Uterine overdistention
 potential for fetal hypoxia during labor
is greater.
Twins can present in any combination of presentations and positions.
Fetal Anomalies
 hydrocephalus or a large fetal tumor
may prevent normal descent of the fetus.
 Abnormal presentations, such as breech or
transverse lie, are also associated with fetal
anomalies.
 A cesarean birth is scheduled if vaginal birth
is not possible or if it is inadvisable.
Problems of the Passage
 Dysfunctional labor may occur because of
variations in the maternal bony pelvis or
because of soft tissue problems that inhibit
fetal descent.
Pelvis
Maternal Soft Tissue Obstructions
 Gynecoid Anthropoid Android Platypelloid

25% White 30% 3%

50%
50% Nonwhite
Long, narrow oval. Heart- or triangular- Flattened: wide, short
Round, cylindric shape shaped inlet. Narrow oval. Transverse
Anteroposterior
throughout. Wide pubic diameter is longer diameterst hroughout. diameter wide, but
arch (90 degrees or than transverse Narrow pubic arch. anteroposterior
greater). diameter. Narrow diameter short.
pubic arc Wide pubic arch.
Maternal Soft Tissue Obstructions
 a full bladder is a common soft tissue obstruction.
Bladder distention reduces available space in the
pelvis and intensifies maternal discomfort.
○ Assessed for bladder distention and
encouraged to void every 1 to 2 hours
○ Catheterization may be needed if she
○ cannot urinate or if she receives regional block
analgesia such
○ as an epidural
Problems of the Psyche
 A perceived threat caused by pain, fear,
nonsupport, or one’s personal situation can
result in great maternal stress and interfere
with normal labor progress.
 Responses to excessive or prolonged stress, however,
interfere with labor in several ways:
1. Increased glucose consumption reduces the energy
supply available to the contracting uterus.
2. Maternal catecholamines can impair labor by interfering
with adequate uterine contractility. Maternal blood supply to
the placenta may also be reduced.
3. Labor contractions and maternal pushing efforts are
less effective because these powers are working against
the resistance of tense abdominal and pelvic muscles.
4. Pain perception is increased and pain tolerance is
decreased, which further increase maternal anxiety and
stress.
General nursing measures involve:
1. Establishing a trusting relationship with the
woman and her family
2. Making the environment comfortable by
adjusting temperature and light
3. Promoting physical comfort, such as
cleanliness
4. Providing accurate information
5. Implementing non-pharmacologic and
pharmacologic pain management
Abnormal Labor Duration
 An unusually long or short labor may result
in maternal, fetal, or neonatal problems.
Prolonged Labor
 (normally) active phase of labor
cervical dilation
○ 1.2 cm per hour in the nullipara
○ 1.5 cm per hour in the parous woman
Descent of the fetal presenting part
○ 1.0 cm per hour in the nullipara
○ 2.0 cm per hour in the parous woman
Potential maternal and fetal problems in prolonged
labor include:
 Maternal infection, intrapartum or postpartum
 Neonatal infection, which may be severe or fatal
 Maternal exhaustion
 Higher levels of anxiety and fear during a
subsequent labor
Nursing measures
mother fetus
 promotion of comfort  observation for signs
 conservation of energy of intrauterine infection
 Emotional support and for compromised
 position changes that fetal oxygenation
favor normal progress
 assessments for
infection.
Precipitate Labor
 rapid birth that occurs within 3 hours of
labor onset.
 There is often an abrupt onset of intense
contractions rather than the more gradual
increase in frequency, duration, and
intensity that typifies most spontaneous
labors.
 The fetus may suffer direct trauma, such as
intracranial hemorrhage or nerve damage,
during a precipitate labor.

 The fetus may become hypoxic because

intense contractions with a short relaxation
period reduce time available for gas
exchange in the placenta.
Priority nursing care
 promotion of fetal oxygenation
Side-lying position
Oxygen administration
Stop oxytocin
Tocolytic drud should be ordered
 maternal comfort.
Coping skills - breathing techniques
Remain with the client
 IUI is most often caused by infection
ascending from the vagina and the cervix
 The most common bacteria in spontaneous
preterm labor with intact membranes
are Ureaplasma urealyticum, Mycoplasma
hominis, Gardnerella vaginalis,
peptostreptococci, and bacteroides species

(Hillier et al. 1988, Gibbset al. 1992, Krohn et

al. 1995, Goldenberg et al. 2000).
 chorioamnionitis and fetal infection
group B streptococci and Escherichia coli
Signs Associated With Intrapartum
Infection
 Fetal tachycardia (>160 beats per minute
[bpm])
 Maternal fever (38º C, or 100.4º F)
 Foul- or strong-smelling amniotic fluid
 Cloudy or yellow amniotic fluid
 Assess amniotic fluid:
Yellow or cloudy fluid or fluid with a
foul or strong odor suggests infection
and vernix may be stained by
discolored fluid.
 Interventions
 Nurses should wash their hands before and after
each contact with the woman and her infant to
reduce transmission of organisms.
 Use gloves and other protective wear to prevent
contact with potentially infectious secretions before
and after birth (Standard Precautions).
 Limit vaginal examinations to reduce transmission
of vaginal organisms into the uterine cavity, and
maintain aseptic technique during essential vaginal
examinations.
 Keep underpads as dry as possible to reduce the
moist, warm environment that favors bacterial
growth.
 Periodically clean excessive secretions from the
vaginal area in a front-to-back motion to limit fecal
contamination and promote the mother’s comfort.
 Prophylactic antibiotics to prevent neonatal sepsis
are often given.
 Preterm labor begins after the 20th week
but before the end of the 37th week of
pregnancy.
 Preterm labor, however, may result in the
birth of an infant who is ill equipped for
extrauterine life.
Maternal Risk Factors for Preterm
Labor
Medical History Obstetric History
 Low weight for height
 Obesity
 Uterine or cervical anomalies,
uterine fibroids
 History of cone biopsy
 Diethylstilbestrol (DES)
exposure as a fetus
 Chronic illness (e.g., cardiac,
renal, diabetes, clotting
disorders, anemia,
hypertension)
 Periodontal disease
 Previous preterm labor
 Previous preterm birth
 Previous first-trimester abortions (>2)
 Previous second-trimester abortion
 History of previous pregnancy losses
(2 or more)
 Incompetent cervix
 Cervical length 25 mm (2.5 cm) or
less at midtrimester of pregnancy
 Number of embryos implanted
(assisted reproductive
 techniques [AST])
 Present Pregnancy Lifestyle and Demographics
 Uterine distention (e.g., multifetal  Little or no prenatal care
pregnancy, hydramnios)  Poor nutrition
 Abdominal surgery during  Age 18 yr or 40 yr
pregnancy
 Uterine irritability
 Low educational level
 Uterine bleeding
 Low socioeconomic status
 Dehydration  Smoking 10 cigarettes daily
 Infection  Nonwhite
 Anemia  Employment with long hours
 Incompetent cervix  and/or long standing
 Preeclampsia  Chronic physical or psychological
 Preterm premature rupture of stress
 membranes (PPROM)  Intimate partner violence
 Fetal or placental abnormalities  Substance abuse
Manifestations
 Uterine contractions that may or may not
be painful; the woman may not feel
contractions at all.
 A sensation that the baby is frequently
“balling up.”
 Cramps similar to menstrual cramps.
 Constant low backache; intermittent or
irregular mild low back pain
cont’n manifestations
 Sensation of pelvic pressure or a feeling that
the baby is pushing down.
 Pain, discomfort, or pressure in the vulva or
thighs.
 Change or increase in vaginal discharge
(increased, watery, bloody).
 Abdominal cramps with or without diarrhea.
 A sense of “just feeling bad” or “coming down
with something.”
Therapeutic Management
 Management focuses on
identifying preterm labor early
delaying birth
accelerating fetal lung maturity
Identifying Preterm Labor
 The reason to identify preterm labor
early is to delay birth, thus promoting
further fetal maturation.
criteria are suggested for preterm labor:

1. Gestation from 20 weeks to before 37

weeks
2. Persistent uterine contractions (four in 20
min or eight in 60 min), and:
—Documented cervical change, or
—Cervical effacement of 80% or greater,
or
—Cervical dilation of greater than 1 cm
 Stopping Preterm Labor
 Once the diagnosis of preterm labor is made,
management focuses on stopping the uterine
activity before it reaches the point of no return,
usually after 3 cm dilation.
 If preterm delivery is inevitable, therapy is directed
toward reducing the infant’s risk for respiratory
distress.
 Treating Infections
Infections associated with a more rapid preterm birth
are likely if the membranes have ruptured.
Broad-spectrum antibiotics, such as ampicillin,
penicillin, aminoglycoside, clindamycin or
metronidazole
 Restricting Activity
side-lying position - increases placental blood flow
and reduces fetal pressure on the cervix
 Hydrating the Woman
Hydration to stop preterm contractions has not
been shown to be beneficial for all women.

However, dehydration may contribute to uterine

irritability for some women.
 Tocolytics
usually delay preterm birth rather than prevent it.
This delay may provide time to allow the use of
corticosteroids to accelerate fetal lung maturity or to
transfer the woman to a facility with a neonatal
intensive care unit that is appropriate for the gestation
of her fetus
Four types of drugs are used for tocolytic therapy:
○ (1) magnesium sulfate,
○ (2) beta-adrenergics,
○ (3) prostaglandin synthesis inhibitors
○ (4) calcium antagonists.
TOCOLYTIC DRUGS

Magnesium used in the management of pregnancy-induced hypertension to

Sulfate prevent seizures

Beta-Adrenergics Ritodrine (Yutopar) is a beta-adrenergic currently approved by the

U.S. Food and Drug Administration (FDA) to stop preterm
contractions.
Terbutaline (Brethine), considered investigational to treat preterm
labor, is the more widely used drug in this class because it has a
lower cost, longer duration of action between doses, and the ability
to promptly administer a dose by the subcutaneous rather than oral
route if needed (AAP & ACOG, 2002).
Prostaglandin Prostaglandins - stimulate uterine contractions, drugs may be used
Synthesis to inhibit their synthesis. Indomethacin is the drug in this class that
Inhibitors is most often used for tocolysis.
Calcium Blockers Nifedipine (Procardia) is a calcium channel blocker often given for
problems such as chronic hypertension. Calcium is essential for
muscle contraction in smooth muscles such as the uterus, so
blocking calcium reduces the muscular contraction.
Accelerating Fetal Lung
Maturity
 Administration of corticosteroid therapy to
the mother before preterm birth reduces the
severity of complications associated with
immature gestation.
 Rupture of the amniotic sac before the
onset of true labor, regardless of length
of gestation, is called premature rupture
of the membranes (PROM).
 Etiology
 Infections of the vagina or cervix
 chlamydia, gonorrhea, group B
streptococcal infection, and
Gardnerella vaginalis infection
 Amniotic sac with a weak
structure
 Chorioamnionitis (intraamniotic
infection)
 may be associated with group B
streptococci, Neisseria
gonorrhoeae, Listeria
monocytogenes, or species such as
Mycoplasma, Bacteroides, and
Ureaplasma in the amniotic fluid
(ACOG, 2001; Garite, 2004):
 Hydramnios
 Fetal abnormalities or
malpresentation
 Incompetent cervix
 Overdistention of the uterus
 Maternal hormonal
changes
 Recent sexual intercourse
 Maternal stress
 Maternal nutritional
deficiencies
Complications
 The mother is at higher risk for postpartum
infection.
 The newborn is at greater risk for sepsis
after birth, with the most immature preterm
infants having the greatest risk for the
systemic infection.
Therapeutic Management
 fetus is 35 weeks gestation or more
If labor does not begin spontaneously, the woman’s
pregnancy is at or near term, and her cervix is favorable,
labor induction may be done.
 If the cervix is not favorable and no infection is present,
induction may be delayed 24 hours or longer to allow
cervical softening and administration of drugs to combat
infection associated with early membrane rupture.
If induction is unsuccessful or if infection or other
complications develop, a cesarean birth is most common.
 woman is 34 weeks’ gestation or
earlier:
the physician weighs the risks of
infection against the infant’s risk for
complications of prematurity.
Ceasarean birth is more common if
delivery at the earlier gestation is
needed.
Maternal Antibiotics
 Ampicillin
 Gentamicin
 Erythromycin
 clindamycin,
 cephalosporin antibiotic,
 piperacillin
Nursing Considerations
 Observe for signs of infection
Home management:
 Avoid sexual intercourse, orgasm, or insertion of
anything into the vagina
increases the risk for infection, caused by ascending
organisms, and can stimulate contractions.
 Avoid breast stimulation if the gestation is
preterm
it may cause release of oxytocin from the posterior
pituitary and thus stimulate contractions.
 Take her temperature at least four times a
day, reporting any temperature of more than
37.8° C (100° F).
 Maintain any activity restrictions
recommended.
 Note and report uterine contractions.
END…