INTRAPARTAL COMPLICATIONS

A. Problems with the force of labor

1. Ineffective uterine force
- Hypotonic uterine contraction
- Hypertonic uterine contraction
2. Precipitate labor
3. Uterine Inversion
4. Uterine Rupture
B. Problems with the passenger
1. Prolapsed umbilical cord
2. Multiple Gestations
3. Malpresentation
- Occipitoposterior Position
- Breech Presentation
- Face Presentation
- Brow Presentation
- Transverse Lie
C. Problems with the passageway
1. Inlet Contraction
2. Outlet Contraction
Common causes of dysfunctional labor
▪ Inappropriate use of analgesia
▪ Pelvic bone contraction
▪ Poor fetal position
▪ Extension rather than flexion of the fetal head
▪ Over distension
▪ Cervical rigidity
▪ Presence of a full rectum or urinary bladder
▪ Mother becoming exhausted from labor
▪ Primigravida
PROBLEMS WITH THE POWER

INEFFECTIVE UTERINE FORCE

Description
➢ Ineffective uterine force refers to uterine contractions, the basic force that moves the fetus through the
birth canal, that is abnormal.
➢ There are three types of abnormal uterine contractions: hypotonic, hypertonic, and uncoordinated
contractions.
➢ Hypotonic contraction is usually low or infrequent, not increasing beyond two or three in a 10-minute
period; the resting tone remains below 10 mm Hg and strength does not rise about 25 mm Hg.
➢ Hypotonic contractions are most apt to occur during the active phase of labor, when analgesia has been
administered too early (before cervical dilation of 3 to 4 cm) or when bowel or bladder distention is
present and prevents descent or firm engagement. They may occur in a uterus overstretched by a multiple
gestation, a larger than usual single fetus , or hydramnios or in a lax uterus from grand multiparity.
➢ Hypotonic contractions increase the length of labor because so many of them are necessary to achieve
cervical dilation; because of the exhaustion from a long labor, the uterus may not contract as effectively,
thus increasing the woman’s chance for postpartal hemorrhage; with the cervix dilated for a long period,
both the uterus and the fetus are prone to infection.
➢ Hypertonic contractions are marked by an increase in resting tone to more than 15 mm Hg, occurring
frequently and the most currently seen during the latent phase of labor.
➢ Hypertonic contractions occur because the muscle fibers of the myometrium do not repolarize following a
contraction. They tend to be painful and do not allow for optimal artery filling, which may cause the fetus
to begin to suffer anoxia early in the latent phase.
➢ Uncoordinated contractions involve contractions with more than one pacemaker initiating the contraction,
or receptor points in the uterus are acting independently of the pacemaker; they occur so closely together
that they do not allow good cotyledon filling, making it difficult for the woman to rest or use breathing
exercises between contractions.
➢ All of these types of uterine contractions are ineffective, resulting in an ineffective labor.
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Nursing Implications
➢ Obtain a thorough history and physical examination to establish a baseline and ongoing for changes.
➢ Assess the client’s complaints of and monitor uterine contractions, including frequency, duration, and
intensity.

If the client is experiencing hypotonic contractions

➢ Anticipate ultrasonography to rule out cephalopelvic disproportion.
➢ Prepare for infusion of oxytocin for labor induction and augmentation.
➢ Assist with artificial rupture of membranes to speed labor.
➢ After delivery, palpate the uterus after every 15 minutes and assess lochia carefullt to ensure that
postpartal contractions are adequate for uterine involution.

If the client is experiencing hypertonic contractions

➢ Assist the client with relaxation as much as possible; be aware that the client may become frustrated or
disappointed with her breathing exercises for childbirth because they are ineffective in keeping her pain
free.
➢ Evaluate the client’s complaints of pain in relation to the quality of her contractions; apply a uterine and
external electronic fetal monitor if her complaints seem out of proportion for at least a 15-minute interval
to ensure that the resting phase of the contractions is adequate and the fetal pattern is not showing late
decelerations.
➢ Encourage the client to rest, and anticipate administering analgesia and sedation.
➢ Provide comfort measures, such as dimming the lights and decreasing noise and stimulation.
➢ Anticipate cesarean birth if deceleration in fetal heart rate, an abnormally long first stage of labor, or
lack of progress with pushing occurs.
➢ Provide support to the client and partner and assist them with understanding that although the
contractions are strong, they are ineffective and not achieving cervical dilation.

If the client is experiencing uncoordinated contractions

➢ Apply a uterine and external fetal electronic monitor to assess the rate, pattern, resting tone, and fetal
response to contractions for at least a 15-minute interval.
➢ Anticipate oxytocin administration to help stimulate a more effective and consistent pattern of
contractions with a better lower resting tone.
➢ Provide education and guidance to the client and partner throughout the labor process to promote a safe
delivery.

PRECIPITATE LABOR
Description
➢ A precipitate labor and birth occurs when uterine contractions are so strong that the woman delivers with
only a few rapidly occurring contractions.
➢ It is often defined as a labor that is completed in fewer than 3 hours.
➢ Such rapid labor is likely to occur with multiparity and may follow induction of labor by oxytocin or
amniotomy.
➢ Rapid labor poses a risk to the fetus because subdural hemorrhage may result from the sudden release of
pressure on the head; the woman may sustain lacerations of the birth canal.
➢ Forceful contractions may lead to premature separation of the placenta and both maternal and fetal risk.
➢ A precipitate labor can be predicted from a labor graph during the active phase of dilation using the rate
as a guideline.

Assessment Findings
➢ Dilation rate >5 cm/hour (nullipara)
➢ Dilation rate >10 cm/hour (multipara)

Nursing Implications
➢ Monitor uterine contractions and fetal heart rate using electronic fetal monitoring.
➢ Be prepared to administer a tocolytic to reduce the force of contractions.
➢ Use a labor graph to chart labor progress, especially during the active phase of dilation, to possibly
predict a precipitate delivery.
➢ Inform the multiparous client at 28 weeks of pregnancy that her labor might be shorter than a previous
one so that she can make plans for rapid transportation to the hospital or alternative birthing center.
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➢ Prepare the birthing room for a rapid delivery for the grand multiparous client or a client who has a
history of precipitous delivery.

UTERINE INVERSION – the uterus turns inside out

• It may occur after the birth of the infant if traction is applied to the umbilical cord to remove the
placenta or if pressure is applied to the uterine fundus when the uterus is not contracted.
• It may also occur when there is insertion of the placenta at the fundus, so that during birth, the
passage of the fetus pulls the fundus down.
• Inversion occurs in various degrees. The inverted fundus may lie within the uterine cavity or the
vagina or, in total inversion, protrude from the vagina.

NURSING IMPLICATIONS:
• Never attempt to replace the inversion because without good pelvic relaxation this may only increase
the bleeding.
• Never attempt to remove the placenta if it is still attached because this will only create a larger
bleeding area.
• Administering an oxytocic drug only compounds the inversion.
• An intravenous line needs to be started; fluid line should be opened to achieve optimal flow of fluid
to try to restore fluid volume.
• Administer oxygen by mask and assess vital signs.
• The woman will be given general anesthesia or tocolytic drug IV immediately to relax the uterus.
• The delivering physician or nurse midwife then replaces the fundus manually.
• Administration of oxytocin after manual replacement helps the uterus to contract into place.
• Because the uterine endomerium was exposed, the woman will need antibiotic theraphy post partum
to prevent infection.

UTERINE RUPTURE

Description
➢ Uterine rupture occurs when the uterus undergoes more strain than it is capable of sustaining.
➢ Although rupture of the uterus is rare, occurring in about 1 in 1500 births, it is always a possibility.
➢ Rupture occurs most commonly when a vertical scar from a previous cesarean birth, hysterotomy, or
plastic repair of the uterus tears.
➢ Rupture can be complete, going through endometrium, myometrium, peritoneum, or incomplete, leaving
the peritoneum intact.
➢ Contributing factors include prolonged labor, faulty fetal presentation, multiple gestation, unwise use of
oxytocin, obstructed labor, and traumatic maneuvers using forceps delivery or traction.

Assessment Findings
➢ Pathologic retraction ring apparent by an indentation across the abdomen over the uterus
(impending rupture)
➢ Sudden, severe pain during a strong uterine contraction
➢ Complaints of a “tearing” sensation
➢ Stoppage of uterine contractions
➢ Failing fetal heart rate
➢ Change in abdominal contour with two visibly distinct swellings
➢ Rapid, weak pulse; falling blood pressure; cold, clammy skin; and dilation of the nostrils from air
hunger (signs of shock)
➢ Localized tenderness and a persistent aching pain over the lower segment (incomplete rupture)
➢ Stoppage of contractions (incomplete rupture)
➢ Fetal and maternal distress

Nursing Implications
➢ Perform electronic fetal monitoring for evaluation of fetal well-being and uterine contractions.
➢ Be prepared to administer emergency fluid replacement as well as intravenous oxytocin to attempt to
contract the uterus to minimize bleeding.
➢ Be prepared for emergence laparotomy.
➢ Obtain emergency preoperative laboratory studies. 3
➢ Offer support to the client or her support person and inform them as soon as possible about fetal outcome,
the extent of the surgery, and the woman’s safety.
➢ Allow the woman and her support person time to grieve about possible loss of her child and her fertility.

PROBLEMS WITH THE PASSENGER

PROLAPSED UMBILICAL CORD – a loop of the umbilical cord slips down in front of the presenting
part.

Description:
• Prolapse may occur at any time after the membranes rupture and if the presenting part is not fitted
firmly into the cervix.
• Prolapsed cord tends to occur with premature rupture of the membranes, fetal position other than
cephalic presentations, placenta previa, intrauterine tumors or cephalopelvic disproportion that
prevents firm engagement of the fetus, a small fetus, polyhydramnios, and multiple gestation.
• Cord prolapse automatically leads to cord compression because the fetal presenting part presses
against the cord at the pelvic brim.
• The incidence of prolapsed cord is 1 in 200 pregnancies.
• Management is aimed at relieving pressure on the cord and thereby relieving the compression and the
resulting fetal anoxia.
• If the cervix is fully dilated at the time of prolapse, the physician may choose to deliver the infant
rapidly, possibly with forceps delivery, to prevent a lengthy period of anoxia.
• If dilation is incomplete, the birth method of choice is upward pressure on the presenting part by a
practitioner’s hand in the woman’s vagina until cesarean birth is complete.

Assessment Findings:
• Cord felt as presenting part
• Presence of cord in vagina after rupture of membranes
• Variable deceleration pattern on fetal monitor

Nursing Implications:
• Monitor fetal heart rate and observe for variable deceleration pattern.
• Monitor and record fetal heart rate immediately following rupture of membranes.
• Place the client in Trendelenberg or knee-chest position, which causes the fetal head to fall back from
the cord if cord prolapse is discovered.
• Prepare the client for relief of cord compression; a hand is placed in the vagina (insert two fingers
into the vagina to the cervix) and the fetal head is manually elevated off the cord.
• Administer oxygen at 10 L/min by face mask to prevent fetal anoxia.
• Be prepared to administer a tocolytic to reduce uterine activity.
• Cover any exposed portion of the cord with a sterile saline compress to prevent drying.
• Do not attempt to push any exposed cord back into the vagina because it may cause additional
compression by kinking or knotting.

MULTIPLE GESTATION (PREGNANCY) – occurs when more than one fetus is growing in the uterus.

Description:
• Multiple gestation is a complication of pregnancy because a woman’s body must adjust to the effects
of more than one fetus.
• Single-ovum (monozygotic, identical) twins usually have one placenta, one chorion, two amnions,
and two umbilical cords and are of the same sex.
• Double-ova (dizygotic, nonidentical) twins have two placentas, two chorions, two amnions, and two
umbilical cords and may be of the same or different sex.
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 • Multiple gestations of three, four, five or six children maybe singe-ovum conceptions, multiple ova
conceptions, or a combination of both.
• Multiple gestations often occur as a result of ovulation stimulation by clomiphene citrate (Clomid);
with in vitro fertilization, several fertilized ova are introduced into the uterus, resulting in a high
possibility of multiple births.
• Women with multiple gestations are more susceptible to complications such as pregnancy-induced
hypertension, hydramnios, placenta previa, postpartal hemorrhage and anemia.
• There is also a higher incidence of velamentous cord insertion (the cord inserted into the fetal
membrane).
• Monozygotic twins can share the same vascular communication, which can lead to an overgrowth of
one fetus and an undergrowth of the second (twin-to-twin transfusion).

Assessment Findings:
• Uterine size greater than expected for dates
• Elevated alpha-fetoprotein levels
• Ultrasonography positive for multiple pregnancy
• More than one set of fetal heart sounds

Nursing Implications:
• Obtain a thorough antepartal history and physical examination to establish a baseline.
• Ensure adequate nutrition by instructing the client to eat six small meals a day rather than three large
ones since the growing uterus will compress her stomach and reduce her appetite.
• Review with the client her need for extra rest periods and “shoes off” times during the day to increase
tissue perfusion.
• Advise the client to refrain from coitus during the last 2 to 3 months of pregnancy.
• Advise the client to return to the health care facility every month for ultrasound examination or
weekly nonstress tests to document normal fetal growth beginning with the 28th week of pregnancy.
• Encourage the client to adhere to her prescribed bed rest routine during the last 2 or 3 months of her
pregnancy.
• Monitor fetal heart rate and fundic height as well as maternal vital signs per facility’s protocol.
• Prepare the client emotionally and physically for labor and delivery of multiple fetuses.
• Twins may be born by cesarean birth to decrease the risk that the second fetus will experience anoxia;
this is also often the situation in multiple gestations of three of more, because of the increased
incidence of cord entanglement and premature separation of the placenta.

PROBLEMS WITH PRESENTATION, POSITION AND SIZE

Occipitoposterior Position
Description:
• The occiput is directed diagonally and posteriorly, either to the right (ROP) or to the left (LOP).
• In these positions, during internal rotation, the fetal head must rotate, not through a 90-degree arc but
through an arc of approximately 135 degrees.

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 • Posterior positions tend to occur in women with android, anthropoid or contracted pelvis. A posterior
position is suggested by a dysfunctional labor pattern such as a prolonged active phase, arrested descent or
fetal heart sounds heard best at the lateral sides of the abdomen.
• A posteriorly presenting head does not fir the cervix snugly thus increases the risk of umbilical cord
prolapse.
• If the fetus is of average size and in good flexion and aided by forceful uterine contractions, rotate through
the large arc, arrive at a good birth position for the pelvic outlet, and are born satisfactorily with only
increased molding and caput formation.

Nursing Implications:
• As the fetal head rotates against the sacrum, a woman may experience pressure and pain in her lower back
due to sacral nerve compression.
• Counterpressure on the sacrum such as backrub or change of position may be helpful in relieving a portion
of the pain. Applying heat or cold, whichever feels best, also may help.
• Lying on the side opposite the fetal back or maintaining a hands-and-knees position may help the fetus
rotate.
• During a long labor, she may need an IV glucose solution to replace glucose stores used for energy.
• The fetal head may arrest in the transverse position (transverse arrest), or rotation may not occur at all
(persistent occipitoposterior position). In these instances, the fetus must be born by cesarean birth.

Breech Presentation
Description:
• Fetal presentation in which either the buttocks or feet are the first body parts to contact the cervix.
• The inevitable contraction of the fetal buttocks from cervical pressure often causes meconium to be
extruded into the amniotic fluid before birth. Such meconium excretion can lead to meconium aspiration if
the infant inhales amniotic fluid.
• With breech presentation, fetal heart sounds usually are heard high in the abdomen. Leopold’s maneuvers,
a vaginal examination or ultrasound examination reveals the presentation.
Risk of Breech Presentation
• Anoxia from a prolapsed cord • Dysfunctional labor
• Traumatic injury to the aftercoming head • Early rupture of the membranes because
• Fracture of the spine or arm of the poor fit of the presenting part
Causes of Breech Presentation
• Gestational age less than 40 weeks • Pendulous abdomen
• Abnormality in a fetus • Multiple gestation
• Hydramnios • Unknown factors
• Any space-occupying mass in the pelvis

Face Presentation
Description:
• Fetal presentation in which either the chin or mentum is the first body parts to contact the cervix.
• This presentation is rare, but when it does occur, the diameter that the fetus presents to the pelvis is often
too large for birth to proceed.
• If the chin is anterior and the pelvic diameters are within normal limits, the infant may be delivered
without difficulty.
• If the chin is posterior, cesarean birth will be the choice of birth.
This occurs in a woman with the following conditions:
▪ Contracted pelvis ▪ With Prematurity
▪ In the presence of Placenta Previa ▪ With Hydramnios
▪ Relaxed Uterus of a Multipara ▪ With Fetal Malformation

Brow Presentation
• Fetal presentation in which the brow is the first body parts to contact the cervix.
• Is the rarest of the presentations. It occurs with a multipara or with relaxed abdominal muscles. It results in
obstructed labor, unless the presentation spontaneously corrects, cesarean birth will be necessary to deliver
the infant safely. Brow presentations also leave the infant with extreme ecchymotic bruising on the face.
• Causes are the same as those of face presentation.

Transverse Lie
• Fetal presentation in which the shoulder is the first body parts to contact the cervix.
• The abnormal presentation can be confirmed by Leopold’s maneuvers.
• Often, the membranes rupture at the beginning of labor. Because there is no firm presenting part, the cord
or an arm may prolapse, or the shoulder may obstruct the cervix. Cesarean birth is necessary.
Causes:
1. women with pendulous abdomens
2. uterine masses such as fibroid tumors that obstruct the lower uterine segment 6
 3. contraction of the pelvic brim
4. congenital abnormalities of the uterus
5. women with hydramnios
6. infants with hydrocephalus or other gross abnormalities that prevent head from engaging
7. may occur in prematurity when the infant has room for free movement
8. multiple gestation
9. when there is short umbilical cord

Macrosomia (Oversized Fetus)

• Size may become a problem in a fetus who weighs more than 4,500 grams (10 lbs.). The large infant born
vaginally has a higher-than-normal risk of cervical nerve palsy, diaphragmatic nerve injury, or fractured
clavicle because of shoulder dystocia.
• If the infant is so oversized that he or she cannot be delivered vaginally, cesarean birth becomes the birth
method of choice.

Shoulder Dystocia
The problem occurs at the second stage of labor when the head is born but the shoulders are too broad to
enter and be delivered through the pelvic outlet.
• Hazardous to the mother because it can result in vaginal and cervical tears.
• Hazardous to the fetus because the cord is compresses between the fetal body and the bony pelvis,
possibly resulting in fractured clavicle or a brachial plexus palsy.
• Most apt to occur in women with diabetes, multiparas, and in post-date pregnancies.
• The condition may be suspected earlier if the second stage of labor is prolonged, if there in arrest of
descent, or if when the head appears on the perineum (crowning) it retracts instead of protruding with
contraction ( A TURTLE SIGN )
• Asking a woman to flex her thighs sharply on her abdomen (McRobert’s Maneuver) widens the pelvic
outlet and may let the anterior shoulder deliver.
• Applying suprapubic pressure may help the shoulder escape from beneath the symphysis pubis (Wood’s
Maneuver)
PROBLEMS WITH THE PASSAGEWAY
INLET CONTRACTION
Description
⚫ Inlet contraction is defined as a narrowing of the anteroposterior diameter of the pelvis to less than 11 cm,
or a maximum transverse diameter of 12 cm or less.
⚫ Inlet contraction is a problem associated with the passage that can cause dystocia, resulting in a failure to
progress in labor.
⚫ Inlet contraction is ordinarily due to rickets early in life or an inherited small pelvis.
⚫ The fetal head normally engages at weeks 36 to 38 of pregnancy and proves that the pelvic inlet is
adequate.
⚫ When engagement does not occur in primigravida, either a fetal abnormality (larger-than-usual head) or a
pelvic fetal abnormality (smaller-than-usual pelvis) is suspected of causing the lack of engagement.
Nursing Implications
⚫ Obtain a thorough antepartal history and physical examination to establish a baseline.
⚫ Assist with obtaining pelvic measurements antepartally.
⚫ Be aware that every primigravida should have pelvic measurements taken and recorded before week 24 of
pregnancy so that a birth decision can be made.
⚫ Provide guidance and support to the client and partner to alleviate any fears or anxieties.

OUTLET CONTRACTION
Description
⚫ Outlet contraction is defined as the narrowing of the transverse diameter to less than 11 cm.
⚫ The outlet or transverse diameter is the distance between the ischial tuberosities in the maternal pelvis.
⚫ Outlet contraction results in cephalopelvic disproportion.
⚫ Outlet contraction, a problem with the passage, can cause failure to progress in labor and can be easily
detected during a prenatal visit.
Nursing Implications
⚫ Obtain a thorough antepartal history and physical examination to establish a baseline.
⚫ Assist with obtaining pelvic measurements antepartally.
⚫ Be aware that every primigravida should have pelvic measurements taken and recorded before week 24 of
pregnancy so that a birth decision can be made.
⚫ Provide guidance and support to the client and partner to alleviate any fears or anxieties.

ANOMALIES OF THE PLACENTA

1. Placenta Succenturiata – has one or more accessory lobes connected to the main placenta by blood vessels.
2. Placenta Circumvalata – ordinarily the chorion membrane begins at the edge of the placenta and spreads to
envelop the fetus; no chorion covers the fetal side of the placenta. In placenta circumvallata, the fetal side
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 of the placenta is covered to some extent with chorion. The umbilical cord enters the placenta at the usual
midpoint, and large vessels spread out from there.
3. Placenta Marginata- the fold of chorion reaches just to the edge of the placenta.
4. Battledore Placenta – the cord inserted marginally rather than centrally.
5. Velamentous Insertion of the Cord – is a situation in which the cord, instead of entering the placenta
directly, separates into small vessels that reach the placenta by spreading across a fold of amnion.
6. Vasa Previa – the situation in which the umbilical vessels of the velamentious cord insertion cross the
cervical os so they would deliver before the fetus. The vessels may tear with cervical dilatation the same
as vasa previa may tear.
7. Placenta Accreta – is an unusually deep attachment of the placenta to the uterine myometrium.