Intrapartum: High Risk Complications

15th Lectures

Maternity and Childhood Nursing Department-2

Intrapartum: High Risk Complications
Learning Outcomes:
Define the terms dystocia and dysfunctional labor and how
common deviations in the power, the passage, or the passenger can
cause dystocia or dysfunctional labor.
Use critical thinking to analyse ways to maintain family-centered
nursing care when deviations from the normal in labor or birth
occur.
Assess a woman in labor and during birth for deviations from the
normal labor process.
Integrate the knowledge of deviations of normal in labor and birth
with nursing process to achieve quality maternal and child health
nursing care.
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Dystocia
 Dystocia is “Difficult Labor” that is prolonged or more
painful/FAILURE TO PROGRESS IN LABOUR

It primarily results from one of four problems

 Powers-abnormal uterine activity, ineffective contractions

 Passageway- abnormal pelvic shape

 Passenger-abnormal fetal size or presentation

 Psyche-inadequate support, maternal stress & anxiety

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Complications of 1st and 2nd stages of Labor

CEPHALOPELVIC DISPROPORTION (CPD)

 A contracture or narrow diameter in birth passage especially if fetus

is larger than the maternal pelvic diameters.

Implications:
 Maternal: prolonged labor, arrest of descent, uterine rupture,
forceps-assisted birth with trauma
 Fetal: cord prolapse, excessive molding of head, birth trauma to

skull and CNS

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Nursing diagnoses r/t dysfunctional labor

 Anxiety r/t slow progress of  Risk for Infection r/t

labor prolonged labor
 Fatigue r/t the length of labor  Sleep pattern disturbance r/t
 Ineffective individual coping maternal exhaustion and
r/t inability to relax inability to relax
 Fluid volume deficit r/t lack of  Knowledge deficit r/t potential
fluid intake fetal distress and fetal sepsis

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Medical & Surgical Management of Labor Dystocia
 Induction of labor :labor is started artificially
 Augmentation of labor: assisting labor that has started spontaneously but is
not effective.
 Amniotomy (Artificial rupture of the membranes is performed to stimulate

labor)
 Oxytocin Augmentation

 Assisted and Operative Delivery

 Vacuum - Assisted Delivery

 Forceps Delivery

 Cesarean Birth

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 Oxytocin (Pitocin)
• Hormone produced by posterior pituitary gland (a synthetic form of
naturally occurring pituitary hormone)
• Stimulates uterine contractions
• Pregnancy Risk Category: C
• Used to induce labor or to augment a labor progressing slowly
because of inadequate uterine contractions
• Dosage: always administered by IV infusion pump into the main
line(mixed 10 IU of Pitocin to 1L of ringer's lactate) Start slowly
• Increase rate q 15-60 min (not to increase more than 20 drip/min)
until a contraction pattern similar to normal labor is achieved
• Prior to starting induction verify term pregnancy and vertex position

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Oxytocin for Labor Induction
Possible Adverse Effects: Nausea, vomiting, cardiac arrhythmias, uterine hypertonicity,
tetanic contractions, uterine rupture (with excessive dosages), severe water intoxication,
and fetal bradycardia
Nursing Implications
Monitor frequency, duration, and strength of contractions.
 Assess maternal pulse and blood pressure and watch for possible hypertension. If
hypertension occurs, discontinue drug and notify physician.
 Continuously monitor fetal heart rate for signs of fetal distress.
 Monitor intake and output and watch for signs of possible water intoxication, such as
headache or vomiting.
Stop if: contractions lasting ˃90 seconds; contractions ˂ 2 minutes apart, and with
fetal pattern of late decelerations

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Contraindications for the induction of labor
 Previous classic uterine incision
 Cephalopelvic disproportion
 Placentia previa
 Active genital herpes
 Preterm fetus
 Fetal malposition-breech
 Multiple gestations
 Non reassuring fetal status

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Prolapse of the umbilical cord
 A loop of the umbilical cord slips down in front of the presenting
fetal part (umbilical cord precedes the fetal presenting part, this can
interfere with fetal circulation)

 Factors that contribute to prolapsed cord are

 Rupture of membranes before head is engaged
 Small fetus
 Breech presentations and transverse lie
 Hydramnios
 Unusually long cord
 Multifetal pregnancy
 Intrauterine tumors, cephalopelvic disproportion
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Nursing implementation to relieve prolapsed cord
[Link]

 Place woman’s hips higher than her head- knee-chest position, trendelenburg's
position, or side lying with hips elevated on a pillow
 With a sterile glove push fetal presenting part away from cord

 Give oxygen at 8 to 10 L/Min by face mask

 Monitor FHR

 Prepare for rapid vaginal (if woman fully or nearly fully) or caesarian birth

 If cord protrudes do not attempt to push any exposed cord back into the vagina

instead, apply sterile warm saline soaked towels to prevent drying of the cord and
maintain blood flow until infant is delivered
 Document the event, action taken, and the client’s response.

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Nursing Implementation of a Woman with Umbilical
Cord Prolapse

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FETAL DISTRESS
 Common causes: cord compression, uteroplacental insufficiency, placental
abnormalities, meconium-stained amniotic fluid
 Correct maternal hypotension and enhance uteroplacental blood

flow
 Change position that improves FHR,

 Increase rate of IV

 O2 via face mask

 Decrease uterine activity: adm. tocolytic

 Perform vaginal exam (prolapsed cord?)

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Complications of 3rd and 4th stages of Labor
 Retained Placenta: beyond 30 minutes after birth
 Lacerations: first, second, third (extends through the perineal body and
involves the anal sphincter and fourth (extends through the rectal mucosa to
the lumen of the rectum. Cervical or vaginal suspected when bright red
bleeding in presence of well contracted uterus
 Placenta anomalies:
 Placenta Accreta (unusually deep attachment of the placenta to the uterine
wall)
 Placenta Increta (placenta attaches into the uterine muscle)
 Placenta Percreta (placenta goes completely to uterine wall and invading
nearby organs)
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Indications for operative vaginal delivery

 Fetal Distress An irregular fetal heartbeat

 Bradycardia, under 100 beats per minute, between uterine contractions

 A rapid fetal heart - more than 160 beats per minute

 The passage of Meconium in cephalic presentations

 Maternal Conditions
 Maternal distress or exhaustion: This is shown by dehydration, pulse
above 100 and temperature.
 Maternal disease: When the mother has cardiac disease, toxemia, forceps
& vacuum can be used to shorten the second stage.

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Assisted and Operative Delivery- Forceps Delivery
[Link]
 Def: Two double-crossed, spoon like blades are used to assist in the delivery of the
fetal head
 Mechanism: Rotation & Traction of fetal presenting part with curved metal tongs.
 Before forceps are applied: Membranes must be ruptured; the cervix must be
fully dilated, & the woman’s bladder must be empty.
 Indication: Prolonged 2nd stage (> 3 hrs); maternal exhaustion;
 Contraindications: Cephalopelvic Disproportion (CPD); Most malpresentations
and malposition.
Disadvantages: Maternal and fetal trauma (Cephalohematoma ;Transient facial
paralysis)
 Nursing Responsibility: FHR checks q 5 minutes; obtain forceps; assess neonate
and mother for trauma.
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Assisted and Operative Delivery- Vacuum
[Link]
 Def: A cap-like suction device is applied to the fetal head to facilitate extraction
 Mechanism: Suction & Traction used to assist delivery of presenting part.
 Vacuum extraction has advantages over forceps birth in that little anaesthesia is
necessary (leaving the fetus with less respiratory depression at birth) and fewer lacerations
of the birth canal occur
 Indication: Most commonly related to prolonged 2nd Stage of Labor.
 Contraindications: Cephalopelvic Disproportion (CPD); Most malpresentations and
malpositions; extreme prematurity.
 Nursing Responsibility: FHR checks q 5 minutes; Handheld suction pump. Pressure
release between UC’s; Assess neonatal head for caput succedaneum resolution after
delivery.

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Cesarean Birth Definition
A surgical incision made into the abdomen and uterus to deliver the
fetus after 28 WK gestational age (It is called hysterotomy, if removal
is done before 28 weeks of pregnancy).

Types of Cesarean Incisions

-Lower Uterine Segment (Low Transverse): most common,
referred to as Pfannenstiel incision or bikini incision, making
possible to have VBAC
-Classical (Vertical Midline): used in placenta previa, leaves a
wide scar, will not be able to have subsequent vaginal birth

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INDICATIONS FOR ELECTIVE CS

 Known CPD  Uterine surgery eg. Hysterotomy,

 Fetal macrosomia > 4500 gm myomectomy
 Placenta previa  Severe IUGR
 HIV  Breech
 Active herpes  Multiple pregnancy
 Repeat CS  Transverse lie
 Ca of the Cx/ obstructing the birth
canal

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INDICATIONS FOR EMERGRENCY CS
 Severe PET,
 Abruptio placenta, APH
 Fetal distress
 Failure to progress in the first stage of labour
 Cord prolapse
 Obstructed labour
 Failed induction
 Malpresentation  brow, face presentation, shoulder & compound
presentations, breech

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COMPLICATIONS- Mother
INTRAOPERATIVE
 Bleeding & the need for blood transfusion

 Hysterectomy

 Complications of anesthesia

 Damage to the bladder, ureter, colon

POSTOPERATIVE
 Gaseous distension, Paralytic ileus

 Wound dehiscence & infection

 Infections  UTI, pulmonary

 DVT & pulmonary embolism, Death

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COMPLICATIONS-Baby

 Premature birth. If the due date was not accurately calculated,

the baby could be delivered too early.
 Fetal injury
 Breathing problems. Babies born by cesarean are more likely to
develop breathing problems such as transient tachypnea
(abnormally fast breathing during the first few days after birth).
 Low Apgar scores.

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Nursing care in the preoperative period
 NP0
 IV fluids
 Insertion of urinary catheter
 Medication may be given IV to prevent stomach irritation or
aspiration
 Consent is obtained
 Pubic shave now not needed
 Patient teaching and explanations of events
 Assessment of FHR, maternal vital signs

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Nursing care intra-operative period
Step 14: Uterus is closed in 2 layers
Skin preparations
Draping
COUNTS
Sterile field maintenance

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Nursing Diagnoses
Pain related to surgical incision
Risk for fluid volume deficient related to blood loss during surgery
Constipation related to effects of abdominal surgery and anesthesia
Risk for ineffective peripheral tissue perfusion related to immobility during and
after surgery
knowledge deficient,
Risk for situational low self-esteem, Powerlessness,
Risk for infection,
Risk for impaired fetal gas exchange,
Risk for maternal injury,
Impaired skin integrity related to surgical incision
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Postoperative Nursing Implementation
[Link]

Monitor vital signs every 15 minutes for first hour, then every 30 mins in
second hour then hourly until transferred to postpartum unit
Administer oxygen as ordered
Assess fundus for firmness, height, location, massage fundus if boggy
Assess vaginal bleeding for color amount and consistency
Assess abdominal dressing for bleeding
Assess urine output
Change woman’s position
Administer pain medication as ordered
Allow the mother to breast feed as soon as she wishes
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Postoperative Nursing Implementation
Oral fluids and food after caesarean section: wait until bowel sounds
are heard. When the woman is passing gas, begin giving her solid food

Removal of the urinary bladder catheter should be carried out once a

woman is mobile after anesthetic and not sooner than 12 hours

Ambulation enhances circulation, encourages deep breathing and

stimulates return of normal gastrointestinal function. Encourage foot and
leg exercises and mobilize as soon as possible, usually within 24 hours

If the dressing comes loose, reinforce with more tape rather than
removing the dressing. This will help maintain the sterility of the dressing
and reduce the risk of wound infection .
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Discharge Planning
Be sure a woman is aware of any restrictions on exercise or activity that she needs to
follow (e.g.: not to lift any object heavier than 4-5 kg or walk upstairs more than
once a day for the first 2 weeks)
Teach her to recognize signs of possible complications such as:
Redness or drainage at the incision line
Lochia heavier than a normal menstrual period
Abdominal pain (other than suture line or afterpain discomfort)
Temperature greater than 38° C
Frequency or burning on urination
Be sure that she has contraceptive information, if desired
Ensure that she has an appointment for a return visit with her health care provider
(usually in 2 weeks), for both herself and her newborn.
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Thank You

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