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Critically analyze the nursing implications

of the client with intrapartal complications


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.


pertaining to the
period of labor and


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
Excessive analgesia or

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

Two patterns of ineffective uterine

contractions are
Hypotonic dysfunction
hypertonic dysfunction

Hypotonic Dysfunction

Hypertonic Dysfunction

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


Not elevated.

Higher than normal.


Active. Typically occurs after 4-cm dilation.

More common than hypertonic dysfunction.

Latent. Usually occurs before 4-cm dilation.

Less common than hypotonic dysfunction.

Amniotomy (may increase the risk of
Oxytocin augmentation.
Cesarean birth if no progress.

Correct cause if it can be identified.

Light sedation to promote rest.
Tocolytics to reduce high uterine tone and
promote placental perfusion.

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

Promote uterine blood flow: side-lying

Promote rest, general comfort, and
Pain relief.
Emotional support: Accept the reality
of the womans pain and frustration.
Reassure her that she is not being
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:

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

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.



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

McRobert's maneuver

adds gravity to her pushing efforts.

Suprapubic pressure


Suprapubic pressure by an assistant pushes

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

Problems With the

Fetal size
Fetal presentation or position
Multifetal pregnancy
Fetal anomalies

Frank breech

Full breech

Single footling breech

Shoulder presentation
(transverse lie)

Fetal Size

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


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
A cesarean birth is scheduled if vaginal birth
is not possible or if it is inadvisable.

Problems of the
Dysfunctional labor may occur because of
variations in the maternal bony pelvis or
because of soft tissue problems that inhibit
fetal descent.
Maternal Soft Tissue Obstructions



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


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


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

Maternal Soft Tissue

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 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


General nursing measures

1. Establishing a trusting relationship with the

woman and her family

Making the environment comfortable by
adjusting temperature and light
Promoting physical comfort, such as
Providing accurate information
Implementing non-pharmacologic and
pharmacologic pain management

Abnormal Labor
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



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


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

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


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.


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

Keep underpads as dry as possible to reduce the

moist, warm environment that favors bacterial

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
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
Labor Previous preterm labor
Low weight for height

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,
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
Uterine irritability
Uterine bleeding
Incompetent cervix
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
Employment with long hours
and/or long standing
Chronic physical or psychological
Intimate partner violence
Substance abuse


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
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.


Management focuses on
identifying preterm labor early
delaying birth
accelerating fetal lung maturity

Identifying Preterm

The reason to identify preterm labor

early is to delay birth, thus promoting
further fetal maturation.

criteria are suggested for preterm

Gestation from 20 weeks to before 37
2. Persistent uterine contractions (four in 20
min or eight in 60 min), and:
Documented cervical change, or
Cervical effacement of 80% or greater,
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 infants risk for respiratory

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

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.

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.



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

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).


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

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).

(ACOG, 2001; Garite,
2004): of the vagina or cervix Hydramnios
chlamydia, gonorrhea, group B

streptococcal infection, and

Gardnerella vaginalis infection

Amniotic sac with a weak

Chorioamnionitis (intraamniotic

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
Incompetent cervix
Overdistention of the uterus
Maternal hormonal
Recent sexual intercourse
Maternal stress
Maternal nutritional

The mother is at higher risk for postpartum
The newborn is at greater risk for sepsis
after birth, with the most immature preterm
infants having the greatest risk for the
systemic infection.

fetus is 35 weeks gestation or more
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

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

Maternal Antibiotics

cephalosporin antibiotic,

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

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
Note and report uterine contractions.