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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 womans 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:
powers of labor
the passenger
the passage
the psyche,
or a combination of these.

4 Ps

An operative birth (vacuum extractor or forcepsassisted 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 fatigue
Maternal inactivity
Fluid and electrolyte
imbalance
Hypoglycemia
Excessive analgesia or
anesthesia

Maternal catecholamines
secreted in response to stress
or pain
Disproportion between the
maternal pelvis and the fetal
presenting part
Uterine overdistention,
(multiple gestation or
hydramnios)

Two patterns of ineffective uterine


contractions are
Hypotonic dysfunction
hypertonic dysfunction

Hypotonic Dysfunction

Hypertonic Dysfunction
CONTRACTIONS

Coordinated but weak.


Become less frequent and shorter in duration.
Easily indented at peak.
Woman may have minimal discomfort
because the contractions are weak.

Uncoordinated, irregular.
Short and poor intensity, but painful and
cramp-like.

UTERINE RESTING TONE


Not elevated.

Higher than normal.


PHASE OF LABOR

Active. Typically occurs after 4-cm dilation.


More common than hypertonic dysfunction.

Latent. Usually occurs before 4-cm dilation.


Less common than hypotonic dysfunction.

THERAPEUTIC MANAGEMENT
Amniotomy (may increase the risk of
infection).
Oxytocin augmentation.
Cesarean birth if no progress.

Correct cause if it can be identified.


Light sedation to promote rest.
Hydration.
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 mothers 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 womans
anxiety.

Promote uterine blood flow: side-lying


position.
Promote rest, general comfort, and
relaxation.
Pain relief.
Emotional support: Accept the reality
of the womans 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
may result from:
Pushing

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 womans
urge to push
Psychological unreadiness to let go of her baby

Nursing
1. Upright positions such as
care:
- squatting - add the force of gravity to her efforts.
- Semisitting, side-lying, and pushing while sitting on
the toilet are other options.
2.

3.

4.

Regional analgesia methods may restrict


possible maternal positions and may alter a
womans spontaneous urge to push.
Encouraging to push with intermittent
contractions also allows her to maintain
adequate pushing effort.
Oral or intravenous fluids provide energy
for the strenuous work of second-stage
labor.

McRobert's maneuver

adds gravity to her pushing efforts.

Suprapubic pressure

B.

Suprapubic pressure by an assistant pushes


the fetal anterior shoulder downward to
displace it from above the mothers symphysis
pubis.
Fundal pressure should not be used, because
it will push the anterior shoulder more firmly
against the mothers 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

25% White
50% Nonwhite
Long, narrow oval.
Round, cylindric shape
Anteroposterior
throughout. Wide pubic diameter is longer
arch (90 degrees or
than transverse
greater).
diameter. Narrow
pubic arc
50%

Android

30%
Heart- or triangularshaped inlet. Narrow
diameterst hroughout.
Narrow pubic arch.

Platypelloid

3%
Flattened: wide, short
oval. Transverse
diameter wide, but
anteroposterior
diameter short.
Wide pubic arch.

Maternal Soft Tissue


a full bladder is a common soft tissue obstruction.
Obstructions
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 ones 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
2.
3.
4.
5.

woman and her family


Making the environment comfortable by
adjusting temperature and light
Promoting physical comfort, such as
cleanliness
Providing accurate information
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

promotion of comfort
conservation of energy
Emotional support
position changes that
favor normal progress
assessments for
infection.

fetus

observation for signs


of intrauterine infection
and for compromised
fetal oxygenation

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

chorioamnionitis and fetal infection


group B streptococci and Escherichia coli

Signs Associated With


Intrapartum Infection

Fetal tachycardia (>160 beats per minute


[bpm])

Maternal fever (38 C, or 100.4 F)

Foul- or strong-smelling amniotic fluid

Cloudy or yellow amniotic fluid

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).

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 mothers 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


Medical History
Obstetric History
Preterm
Labor Previous preterm labor
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 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

Uterine distention (e.g., multifetal


pregnancy, hydramnios)
Abdominal surgery during
pregnancy
Uterine irritability
Uterine bleeding
Dehydration
Infection
Anemia
Incompetent cervix
Preeclampsia
Preterm premature rupture of
membranes (PPROM)
Fetal or placental abnormalities

Lifestyle and Demographics


Little or no prenatal care
Poor nutrition
Age 18 yr or 40 yr
Low educational level
Low socioeconomic status
Smoking 10 cigarettes daily
Nonwhite
Employment with long hours
and/or long standing
Chronic physical or psychological
stress
Intimate partner violence
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

contn 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:
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
1.

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 infants 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
Sulfate

used in the management of pregnancy-induced hypertension to


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
Synthesis
Inhibitors

Prostaglandins - stimulate uterine contractions, drugs may be used


to inhibit their synthesis. Indomethacin is the drug in this class that
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
(ACOG, 2001; Garite,
2004): of the vagina or cervix Hydramnios
Infections
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

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
fetus is 35 weeks gestation or more
Management
If labor does not begin spontaneously, the womans
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 infants 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