•INTRAPARTAL COMPLICATIONS

Inertia (dysfunctional labor) - is a time-honored term to denote

sluggishness of contractions, or the force of labor, has occurred.
Hypotonic uterine contractions
Hypertonic uterine contractions

Dysfunctional Labor and Associated Stages of Labor

First Stage of Labor
Prolonged latent phase – a latent phase longer than 20 hours in a
nullipara and 14 hours in multipara.
Protracted Active phase – usually is associated with CPD, although it
may reflect ineffective myometrial activity.
Prolonged decceleration phase – when it extends beyonds three
hours in nullipara and one hour in multipara caused by abnormal fetal
head position.

Secondary Arrest Dilatation – occurred when there is no progress in

cervical dilatation for more than 2 hours
Prolonged descent- if the rate of descent is less than 1 cm/hr in a
nullipara or less than 2 cm/hr in a multipara

Second Stage of Labor

•Arrest of Descent – results when no descent has occurred for 1 hour
in a multipara and 2 hours in a nullipara.

Contraction Rings
•*Constriction ring – a simple type which can occur at any point in the
myometrium and at any time during labor.

•*Pathologic Retraction Ring (Bandl’s ring) – occurs at the juncture of

the upper and lower uterine segment. It is a warning sign that severe
dysfunctional labor is occurring.
•PRETERM LABOR
Definition: Labor that occurs after the 20th week and before 37th week.
Predisposing /Precipitating Factors:
Maternal Factors
–Maternal infections (leading), illness, or disease
(renal/cardiovascular), DM
–PROM
–Bleeding
–Uterine abnormalities/overdistention, incompetent cervix
–Previous preterm labor, spontaneous or induced abortion,
preeclampsia, short interval (less than 1 year) between pregnancies.
–Trauma, poor nutrition, low socioeconomic status, no prenatal care,
lack of childbirth experience
–Extremes of age, decreased weight (less than 100 lbs) and less height
(less than 5 feet)
–Lack of rest/excessive fatigue, smoking
–Extreme emotional stress
Fetal Factor
•Multiple pregnancies
•Infections
•Polyhydramnios
•Congenital adrenal hyperplasia
•Fetal malformations

Placental Factors
•Placental separations
•Placental disorders

Unknown causes
Complications
–Prematurity
–Fetal death
–SGA/IUGR
–Increased perinatal morbidity and mortality
Treatment
a. If in preterm labor Prevent premature delivery
1. Hospital admission
•Bedrest on left lateral position
•Maintain HYDRATION

•Monitoring
–Uterine contractions and irritability q 1-2 hours (determine increasing
or decreasing contractions)
–Vital signs, as major drugs employed can alter them
–I and O
–Signs of infection
–Cardiac and respiratory status and distress sign

–Cervical consistency, dilation and effacement

–Fetal well-being
–Early signs of edema:pulmonary edema is a possible complication of
ritodrine use
•Promotion of physical and emotional comfort
–Keep client informed of the progress
2. Administration of TOCOLYTICS to arrest labor by causing relaxation
of the uterus
•Ritodrine HCL –antidote:INDERAL
•Contraindications
–Advance pregnancy
–Ruptured bag of water
–Maternal diseases like bleeding, complications, PIH, cardiovascular
disease–Fetal distress
–Presence of fetal problems like Rh isoimmunization
•
3. Administration of BETAMETHASONE (Celestone) to enhance
maturation of fetal lungs by stimulating the development of surfactant

b. Once contractions have been stopped and maternal and fetal

conditions stabilized DISCHARGED
1. Measures to prevent recurrences of premature labor:
•Bedrest maintained, left lateral preferred
•Well-balanced diet high in iron, vitamins and important minerals

•Continuation of oral medications (YUTOPAR) in the home

•Frequent prenatal visits: every week for the duration of remaining
week
•Activity/lifestyle evaluated and restricted as necessary
•Prompt reporting to the physician for symptoms of preterm labor.

2. Client teaching: symptoms of preterm labor

•Low, dull backache
•Uterine contractions, regular, and more than 1 hour at rest
•Uterine cramps and intestinal cramping
•Rupture of membranes

c. Provision of psychological support and encouragement

•PRECIPITATE LABOR
Definition: Short labor lasting for 2-3 hours or less

Predisposing/Precipitating Factors
•Multiparity-the most common and important factor
•Trauma
•Large pelvis and lax soft tissues
•Small fetus
•Labor induction by oxytocin and rupture of membranes
•Severe emotional stress
Treatment
•Episiotomy
•delivery
Assessment Findings:
•titanic-like contractions
•rapid labor and delivery
signs and symptoms of impending labor
–desire to push
–presenting parts visible
–frequency of strong contractions
–membranes ruptured
–heavy bloody show
–bulging rectum
–severe anxiety

•Analysis / Nursing Diagnoses

•Risk for maternal injury R/T rapid expulsion of fetus resulting
in lacerations and hemorrhage
•Risk for fetal trauma R/T cranial battering during rapid birth

Nursing Implementation
1.NEVER LEAVE CLIENT
2.Monitor FHT q15 min to detect distress from fetal hypoxia
3Provide emotional support
–Reassure that you will stay
–Explain precipitate labor
–Inform of what is happening
–Provide care until physician arrives
–Assist client in retaining a sense of control over what is happening
4. Assist with delivery
•Evaluation / Outcomes
•Mother remains injury free
•Neonate remains injury free
•DYSTOCIA
Definition: Prolonged difficult labor and/or delivery because of
problems with the factors in labor (P’s)

Predisposing/Precipitating Factors
1. Fault of the Passengers
•abnormal position, persistent occiput posterior (failure of the vertex
to rotate)
•malpresentations (shoulder, face ,brow,breech)
•hydrocephaly
•large fetus (over 4000 grams)
•abnormal lie (transverse)
•multiple pregnancy
2. Fault of the Passages
•cervical inertia
•contracted pelvis
•CPD
•Non-gynecoid pelvis
•Cervical scar tissue from previous surgery

•3.Fault of the Powers

HYPOTONIC UTERINE INERTIA
•Late onset – active phase
•Weak painless contraction
•Tension not synchronous

•Causes: overdistention, advanced

•Age, increased parity, contractures, fetal malposition,
analgesia/anesthesia
•Treatment: Enema, walking if not contraindicated; amniotomy,
oxytocin

HYPERTONIC UTERINE INERTIA

•Early onset- latent phase
•Strong, painful contractions
•Uncoordinated, increased contractions but ineffective in bringing
about further dilatation
•Causes: Primigravidity,
•Young age, injudicious use of oxytocin
•Treatment: Sedation
4. Faults of the Person/Client
Client’s poor psychosocial responses which are influenced by the
following factors:
*education and preparation *maternal position
*previous experiences *race and culture
*readiness *environment
*support system *socioeconomic status
Complications
•maternal exhaustion and dehydration
•infection
•traumatic operative births
•fetal distress
•birth injuries
•perinatal mortality
Treatment
•bedrest
•sedation for hypertonicity
•stimulation with oxytocin for hypotonicity
•CS section
•Forceps as indicated
Diagnosis
•Vaginal examination
•Leopold’s maneuvers
•Pelvimetry
•Ultrasonography
•Diagnosis of type of dystocia
•Analysis / Nursing Diagnosis
•Anxiety R/T the uncertainty and length of labor process
•Fatigue R/T prolonged labor
•Pain R/T prolonged unproductive contractions &
administration of oxytocics
•Risk for trauma R/T failure of cervix to amply dilate & / or
mechanical problems

Nursing Implementation
1. Prepare client for assist in various diagnostic exams.
2. Promote rest and comfort: quiet, darken room
3. Proper position for comfort: lateral position is comforting
4. Monitor
a. labor: uterine contractions
b. Feta well-being:FHT, movement, passage of meconium
5. Give reassurance and support
6. Administer oxytocin as ordered
a.Physician MUST BE PRESENT/AVAILABLE THROUGHOUT THE
PROCEDURE
b.Client must be in true labor-cervix at least 3 cm
c.No mechanical obstruction or uterine overdistention or multiple
fetuses
d.With indications for oxytocin: no history of CS (rupture), fetus in good
condition, client under 35 years old and less than para5
7. Monitor V/S, drip rate of IV oxytocin carefully and frequently.
Maternal hypo-and hypertension can result from oxytocin drip. BP
therefore is the single, MOST IMPORTANT to be monitored.
8. Assist with delivery: after failed trial labor (usually 6 hours)
a. vaginal delivery
b. Cesarean section
9.After delivery, observe mother and infant signs of injuries; and signs
of difficult interaction related to/resulting from difficult labor. Promote
bonding.
•Evaluation / Outcomes
•Rests / sleeps between contractions and delivery
•Progresses through labor to safe delivery of newborn
•Remains free from complications
•PREMATURE REPTURE OF MEMBRANES
•Definition: Rupture of the membranes before term/labor; unconnected
with labor.
•Assessment Findings:
1.Maternal report of fluid per vagina
2. Determination of alkaline amniotic fluid and not acidic urine or
vaginal discharge
Diagnosis
1.Nitrazine test – change in color of Nitrazine paper from yellow to blue
color because of neutral to slightly alkaline amniotic fluid (ph=7-7.5)
2.Ferning Test: amniotic, high in sodium content, will assume a ferning
pattern whne dried on the slide.
3.Sterile speculum examination- direct visualization of fluid from
cervical os is the MOST RELIABLE DIAGNOSIS OF PROM.
Complications
1.Maternal infections/chorioamnionitis-MOST COMMON
2.Cord prolapse
3.Premature Labor

Nursing Implementation
1.maintain bedrest.DO NOT ALLOW AMBULATION to prevent prolapse.
2.calculate gestational age
3.monitor maternal V/S and fetal well-being
4.observe and record the character, amount, color and odor of
amniotic fluid
5.be alert for early sign of infections:fever, chills, malaise; and signs of
labor onset.
6.monitor for signs of prolapsed cord.
7. Provide appropriate treatment as ordered:
a. if with signs of infections: antibiotics and immediate delivery
b. if with no signs of infection, induction of labor delayed
provided fetus is healthy.
8. Provide psychological support:
1.explain the procedures and findings.
2.support client and family.
3.inform progress.
4.prepare client and family for early interruption of pregnancy as
indicated.
•UTERINE RUPTURE
•Definition: Rupture of the uterus because of the stress of labor and
extrusion of uterine contents into the abdominal activity.
•Precipitating/Predisposing Factors:
1.Previous CS scar- most common cause/contributory factors.
2.Improper use of oxytocin
3. Overdistention of the uterus
4. Strong contractions with non-progressive labor
5. Abnormal presentations
6. Trauma
7. Injudicious obstetrics: application of forceps when the cervix is not
yet fully dilated: second stage of labor fundal pressure; forced delivery
of the fetus with abnormality (hydrocephalus)
8. Ill-advised podalic version
Assessment Findings
•Sudden acute abdominal pain and tenderness
•Cessation of uterine contractions and FHT
•Presenting part no longer felt through the cervix
•A feeling in the mother that something happened inside.
•Signs of external bleeding; signs of shock
•Presence of predisposing factors
Complications
1.hemorrhage or shock
2.maternal and fetal mortality
3.infections from traumatized tissues
Treatment
1.Laparotomy to deliver the fetus
2.Hysterectomy for complete rupture
3.Blood, plasma and IV replacement
4.Antibiotics
Nursing Implementation
1.Stay with client; call for assistance
2.Promptly implement supportive measures
a.Positioning-shock position
b.Provision of warmth
c.Prompt IV infusion-D5LRs
d.Psychological support
3.Notify physician
4.Prepare for immediate surgery
•FETAL DISTRESS
Definition: fetal condition resulting from fetal hypoxia
Predisposing/Precipitating Factors:
1.dystocia
2.cord coil, cod compression
3.improper use of oxytocin, analgesia/anesthesia
4.DM, cardiac disease and other co-existing conditions in the
mother
5.bleeding complications in the third trimester (placenta
previa/abruption placenta)
6.PIH
7.Supine hypotensive syndrome
Assessment Findings:
TRIAD symptoms
1.FHT above 160 or below 120/min
2.Meconium-stained amniotic fluid in a non breech
presentation
3.Fetal hypermobility/hyperactivity

Nursing Implemetation
1. Reposition mother:LLR-relieve presuure on vena cava
thereby increasing venous return-increased perfusion of
placenta and fetus
2. Stop the oxytocin drip if being infused
3. Administer O2 per mask at 6-7 liters per minute.
4. Correct hypotension
a.elevate legs
b.increased IV rate (no oxytocin incorporation)
c.Turn mother to her left if it is a case of vena cava syndrome
d.Monitor FHT continuously
e.Notify physician
f.Prepare for emergency CS if indicated.
•VENA CAVAL SYNDROME/SUPINE HYPOTENSIVE SYNDROME
Definition: Partial occlusion of the vena cava from the pressure of the
pregnant uterus causing shocklike symptoms.
Predisposing/Precipitating Factors
1. Conditions where the uterus is extra large
Multiple pregnancy
Polyhydramnios
DM
2. Obesity
3. Prolonged Supine Position
Pathology

The pressure of the enlarged uterus on the inferior vena cava and
aorta especially during contractions reduced blood flow to the
heart reduced cardiac output decreased blood flow to the
placenta fetal distress
Nursing Implementation
1. Prevention – LLR for women in labor
2. Management – reposition mother to left stat in case of venal
syndrome or use a WEDGE-SHAPE PILLOW under the woman’s hip
(right) to shift the weight of the uterus, fetus off the woman’s aorta
and inferior vena cava; monitor frequently fetal heart tones.
•AMNIOTIC FLUID EMBOLISM
Definition: The escape of amniotic fluid into maternal circulation
through the placental site and into the pulmonary arterioles.
Predisposing Factors
1. Premature rupture of membranes
*The risk of having amniotic fluid embolism starts from the
moment the BOW ruptures.
2. Abruptio Placenta
3. Difficult Labor
Incidence: Rare but usually fatal; 25% of these women----mortality in
the first hour
Prognosis: Usually fatal for both mother and baby
Assessment Findings
1. Respiratory distress
acute dyspnea
cyanosis
sudden chest pains
pulmonary shock and edema
2. Circulatory collapse; signs of shock
3. Secondary: uncontrolled bleeding from DIC
Treatment: Cardiorespiratory
1.Initiate oxygenation stat
2.Improve hydration
IV fluid and plasma
Whole blood, fibrinogen transfusion
Monitor fluids, I & O
3.Digitalis for failing cardiac function
4.Heparin as ordered
5.Antibiotics
6.Stat delivery: forceps or vaginal if cervix is open and dilating
well
7.Continued monitoring of mother and fetus
Nursing Implementations:
1.Institute measures to support life
shock position as necessary
oxygenate promptly
maintain and monitor fluids and blood transfusion
provide warmth
administer ordered drugs
1.Inform family of the mother’s condition; provide support
2.Transfer to ICU after for intensive care and monitoring
•UTERINE INVERSION
Definition: rare phenomenon in which the uterus turns inside
out.
Causes:
•If traction was applied to the umbilical cord to remove the
placenta
•Pressure is applied to the uterine fundus when the uterus is
not contracted
Placenta attaches to the fundus, the passage of the fetus pulls
the fundus down
Assessment:
•Large amount of blood suddenly gushes from the vagina
•Fundus is not palpable in the abdomen
•Signs of blood loss: hypotension, dizziness, paleness,
diaphoresis
Management:
Intravenous line needs to be started
O2 by mask
Monitor vital signs
Prepare for CPR if sudden blood loss will occur
Tocolytic, anesthesia may be given to relax the uterus
Delivering physician/nurse midwives replaces the fundus
manually
Oxytocin may be administer after manual replacement
Antibiotics
•BREECH PRESENTATION
Definition: Abnormal position or presentation of the fetus.
Risks:
•Anoxia from a prolapsed cord
•Traumatic injury to the aftercoming head (can result in
intracranial hemorrhage or anoxia)
•Fracture of the spine or arm
•Dysfunctional labor
Causes:
•Gestational age under 40
•Abnormality in the fetus (anencephaly, hydrocephaly,
meningocele)
•Hydramnios that allows for free fetal movement
•Congenital anomaly of the uterus
•Any space occupying mass in the pelvis (ex. Fibroid tumor)
•Pendulous abdomen
•Multiple gestation
•Unknown factors
Assessment:
•Fetal heart sounds usually are heard high in the abdomen

Diagnosis:
•Leopold’s maneuver
•Vaginal examination
•Ultrasound (confirms a breech presentation)

*vaginal delivery is possible utilizing the birth technique

•Nursing Diagnoses
•Pain R/T prolonged posterior pressure of fetal buttocks
•Risk of maternal or neonatal injury R/T difficult birth
•Risk for suffocation of fetus R/T interruption in umbilical
blood flow because of umbilical cord compression
•Planning / Implementation
•Use measures to promote comfort
•Monitor the FHR in upper quadrants
•Evaluation / outcomes
•Mother remains free from injury
•Neonate remains free from injury

END