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Intrapartal Complications Learning objectives

1. Define the terms dystocia and dysfunctional labor
and how common deviations in the power (force of
labor), the passage, or the passenger can cause
dystocia or dysfunctional labor
2. Assess a woman in labor and during birth for
deviations from the normal labor process
3. Identify expected outcomes associated with
deviations from normal labor and birth and resultant
complications
4. Integrate the knowledge of deviations of normal in
labor and birth with nursing process to achieve
quality maternal and child health nursing care

Our Lady of Fatima University

College of Nursing

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Dystocia
A difficult labor arising from any of
Complications with the Power
the 5 components of the labor (The Force of Labor)
process:
• Power (uterine contractions) Dysfunctional Labor
• Passenger (fetus) • Sluggishness of contractions, or the force of
labor, has occurred
• Placenta • Can occur at any point in labor
• Passageway (birth canal) • Classification:
• Psyche (perception) • Primary – occurring at the onset of labor
• Secondary – occurring later in labor
• Increases risk of maternal postpartal infection,
hemorrhage, and infant mortality

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Ineffective Uterine Force
Uterine contractions
• Basic force moving the fetus through the
birth canal
• Occur because of interplay of the
contractile enzyme adenosine triphosphate
and the influence of major electrolytes
such as calcium, sodium, and potassium,
specific contractile proteins (actin and
myosin), epinephrine and norepinephrine,
oxytocin, estrogen, progesterone, and
prostaglandins
• 95% - completed labors with contractions
that follow a predictable, normal course.
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1. Hypotonic Contractions
• Risk factors:
• Administration of analgesia
• Bowel or bladder distention
• Overstretched uterus (multiple
gestation, larger-than-usual
single fetus, hydramnios)
• Relaxed uterus (grand
multiparity)
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1. Hypotonic Contractions
• The number of contractions is
unusually low or infrequent (not
more 2 or 3 occurring in a 10-
minute period)
• Resting tone of the uterus
remains less than 10mmHg and
the strength of contractions does
not rise above 25mmHg.
• Commonly occurs during the
active phase of labor
• Painless
1. Hypotonic Contractions
• Complication:
• Pospartum hemorrhage
Nursing intervention (Post partum):
• Palpate uterus and assess lochia
every 15 minutes (1st hour after
birth)
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2. Hypertonic Contractions 2. Hypertonic Contractions

Complications:
• Increase in resting tone to more
than 15mmHg • Fetal anoxia
• Uterine rupture
• Contractions occur frequently
and are most commonly seen in • Abruptio Placenta
the latent phase of labor
• Contraction occurs because the Nursing Management:
muscle fibers of the myometrium • Apply uterine and a fetal external monitor for at least 15 minutes
do not repolarize or relax after a • Administer IV fluids and short- acting barbiturates as prescribed
contraction.
• Provide comfort measures and emotional support
• Contractions are more painful • Prevent infection
than usual
• Prepare patient for Cesarean Section if needed

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3. Uncoordinated Contractions
• More than one pacemaker may be initiating
contractions, or receptor points in the
Dysfunctional Labor and
myometrium may be acting independently of the
pacemaker Associated Stages of Labor
• Uncoordinated contractions occur so closely
together that they do not allow good cotyledon A. Dysfunction at the 1st B. Dysfunction at the
filling Stage of Labor 2nd Stage of Labor
• Difficult for woman to rest between contractions
or to use breathing exercises with contractions 1. Prolonged Latent Phase 1. Prolonged Descent
Management: 2. Protracted Active Phase 2. Arrest of Descent
3. Prolonged Deceleration
• Applying a fetal and a uterine external monitor Phase
and assessing the rate, pattern, resting tone, and
fetal response to contractions for at least 15 4. Secondary Arrest of C. Contraction Rings
minutes Dilatation
• Oxytocin administration D. Precipitate Labor

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Dysfunction at the 1st Dysfunction at the 1st

Stage of Labor Stage of Labor
Prolonged Latent Phase Prolonged Latent Phase
• A latent phase that is longer than 20 hours • Management:
in nullipara or 14 hours in a multipara. • Reassess the cervix
• Tends to be in a hypertonic state • If no change,
• May occur if: • Provide adequate fluid for hydration
• Cervix not “ripe” at beginning of • Pain relievers (morphine sulfate)
labor • Provide comfort
• Excessive use of analgesic early in • Decrease noise and stimulation
labor • Oxytocin infusion/ amniotomy
• Cesarean Delivery

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Dysfunction at the 1st Dysfunction at the 1st

Stage of Labor
Protracted Active Phase
• Active phase lasts longer than 12 hours in
a primigravida or 6 hours in a
multigravida
• Cervical dilation does not occur at a rate
of at least 1.2 cm/ hour in a nullipara or
1.5 cm/ hour in a multipara
• Tends to be in hypotonic contractions
• Causes:
• Cephalopelvic Disproportion (CPD)
• Fetal malposition
• Management: Oxytocin (if not CPD)/ Cesarean
birth
Stage of Labor
Prolonged Deceleration Phase Secondary Arrest of Dilatation
• When deceleration phase • No progress in cervical dilatation
extends beyond 3 hours in a for longer than 2 hours
nullipara or 1 hour in a
multipara
• Management: Cesarean Birth
• Results from abnormal fetal
head position
• Management: Cesarean birth

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Dysfunction at the 2nd Dysfunction at the 2nd

Stage of Labor Stage of Labor
Prolonged Descent Arrest of Descent
• Occurs if the rate of descent is <1 cm/ hour in a • No descent occurred for 1 hour in a
nullipara or 2 cm/ hour in a multipara multipara or 2 hours in a nullipara
• When 2nd stage lasts over 3 hours in a multipara
• Occurred when expected descent of the
• Contractions become infrequent and of poor quality fetus does not begin or engagement or
and dilatation stops
movement beyond 0 station has not occurred
• Management:
• Rest and fluid intake • Cause: CPD
• Amniotomy • Management:
• Oxytocin infusion
• Positioning (semi-fowlers, squatting, kneeling) • Oxytocin (If no CPD)
• More effective pushing technique • Cesarean Birth

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Contraction Rings Contraction Rings

• A hard band that forms across the • Management:
uterus at the junction of the upper • IV morphine sulfate or Amyl
and lower uterine segments and Nitrite Inhalation
interferes with fetal descent • Tocolytics
• Pathologic retraction ring (Bandl’s • Cesarean birth
ring) • Manual removal of placenta
• Causes: • Complications:
• Uncoordinated contractions • Uterine rupture
• Obstetric manipulation • Neurologic damage to fetus
• Administration of oxytocin • Massive maternal hemorrhage
• Diagnostic: Ultrasound (Placental stage)

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Precipitate Labor
Precipitate Labor
• Labor that is completed in fewer than 3
hours
• Uterine contractions are so strong that birth • Diagnostic: Labor graph
occurs with only a few rapidly occurring (Partograph)
contractions
• Causes:
• Management:
• Grand multiparity • Tocolytics
• Induction of labor by oxytocin • Birth plan for multiparous
and amniotomy women and women with
• Complications: history of precipitate labor
• Premature separation of the
placenta
• Fetal subdural hemorrhage
• Lacerations (birth canal)

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Uterine Rupture Uterine Rupture

• Occurs when a uterus undergoes more strain • Anticipate need for an immediate
than it is capable of sustaining cesarean birth
• Contributing factors:
• Sudden, severe pain during a
• Vertical scar from previous surgery (CS/ strong labor contractions
Hysterotomy) repair tears
• Prolonged labor • Complete rupture
• Abnormal presentation • Uterine contractions immediately
stop
• Multiple gestation • Two distinct swelling visible on
• Unwise use of oxytocin the abdomen (retracted uterus
and the extrauterine fetus)
• Obstructed labor
• Hemorrhage
• Traumatic maneuvers of forceps or traction • Signs of shock begin
• Pathologic retraction rings • Absent Fetal heart sounds
• Strong uterine contractions without cervical
dilatation

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Uterine Rupture Uterine Inversion

• Incomplete rupture
• Localized tenderness and • Refers to the uterus turning inside out with
either birth of the fetus or delivery of the
persistent aching pain over the placenta
lower uterine segment
• Causes:
• Diagnostic: ultrasound
• Traction applied to umbilical cord to
• Management: remove the placenta
• Fluid replacement • Pressure applied to uterine fundus when
• IV oxytocin uterus is not contracted
• Prepare for possible laparotomy with tubal • Placenta attached at the fundus and the
ligation/ CS hysterectomy passage of fetus pulls the fundus down
• Secure Consent
• Psychological and emotional support

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Uterine Inversion Uterine Inversion

• Management:
• Assessment findings: • IV fluids (use Large-gauge needle)
• Large amount of blood gushes from • Blood transfusion
vagina • O2 therapy via face mask
• Fundus not palpable • Assess and monitor VS
• Hypotension • Be prepared for CPR
• Dizziness • Administer general anesthesia or
• Pallor tocolytics IV
• Diaphoresis • Manual replacement of uterus by OB
• Fleshy mass at or outside the introitus • Administer oxytocin after replacement
• Antibiotics
• CS in future pregnancies

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PROBLEMS WITH THE PASSENGER

Complications Umbilical Cord Prolapse

with the Passenger Umbilical Cord
• A loop of umbilical cord slips Prolapse
down in front of the presenting • Clinical types:
fetal part • Occult cord prolapse
• Causes: • Funic (cord) presentation
• PROM • Overt cord prolapse
• Fetal presentation other than • Assessment findings:
cephalic • Cord felt as presenting part
• Placenta previa during initial vaginal exam
• Intrauterine tumors preventing (rare)
the presenting part from • Visible cord at vulva
engaging • Variable deceleration FHR
• A small fetus pattern
• CPD
Diagnostic: Ultrasound
• Hydramnios
• Multiple gestation

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Umbilical Cord Multiple Gestation • Occurs when more than one fetus
is present in a single pregnancy
Prolapse (twins, triplets, etc)
• Therapeutic management: • Results from the splitting of a
• Manual elevation of fetal head off single zygote or the presence of
the cord two or more zygotes.
• Knee-chest or Trendelenburg • Monozygotic (Identical)
position • Dizygotic (Fraternal)
• Oxygen via facemask (10L/min) • Contributing factors:
• Tocolytic agent
• Ovulation induction
• Amnioinfusion
• Fetal blood sampling • In-vitro fertilization
• Cover exposed cord with sterile • Parity and age
saline compress/ gauze • Familial
• Forcep delivery (If fully dilated) • Increases risk of preterm labor
and PPROM.

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Multiple Gestation Multiple Gestation

• Assessment:
• Increase in size at a rate faster than usual
• Elevated Alpha-fetoprotein levels
• Quickening at different spots of
abdomen
• Multiple sets of FHR
• Ultrasound reveals multiple gestation
sacs
• Presentations: both vertex, vertex and breech,
breech and vertex, or breech and breech
• May be born either by Vaginal birth or Cesarean
birth
• Complications: PIH, hydramnios, placenta previa,
preterm labor, and Anemia, post partum bleeding,
LBW babies, congenital anomalies, velamentous
cord insertion,
Management:
• Vaginal birth (Vertex and vertex):
• Instruct to come to the hospital early in labor
• Support Breathing exercises
• Monitor FHR for each twin
• Monitor for possible complications:
• Risk for cord prolapse after rupture of
membranes
• Uterine dysfunction
• Premature separation of placenta
• After delivery of 1st infant, clamp or tie both
ends of baby’s cord to prevent hemorrhage

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Multiple Gestation Problems with Fetal

Management: Position, Presentation, or
• Do NOT administer oxytocin after an infant is
born to avoid compromising infants that are
size
not yet born Occipito-posterior Position:
• Determine the lie of 2nd fetus to determine a • The occiput is directed diagonally
decision for breech or cesarean birth. and posteriorly, either to the right or
to the left.
• Reassess for any bleeding
• Tends to occur in women with
• Cesarean Birth android, anthropoid, or contracted
• Inspect multiple gestation infants thoroughly after pelves.
birth • Does not fit the cervix as snugly as
one in an anterior position
• Proper identification of each infants
• Increases risk of umbilical cord
• Assess the woman carefully in the immediate prolapse
postpartal period, and the infants to determine their • Diagnostic: Vaginal examination/
true gestational age. ultrasound

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Problems with Fetal Position, Breach presentation

Presentation, or size • Fetus in a longitudinal lie with the buttocks or
feet closest to the cervix.
Occipito-posterior Position: • Types:
• Management: • Complete
• Pain – medication, back rub, • Frank
heat or cold application • Footling
• Fetal rotation - Side lying • Causes:
opposite the fetal back/ hands
& knees position • Gestational age <40 weeks
• Keep bladder empty • Fetal abnormalities
• Fluid intake or IV Glucose • Hydramnios
solution • Congenital anomalies of uterus
• Cesarean birth • Mass in the pelvis
• Frequent reassurance • Pendulous abdomen
• Multiple gestation

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Breach presentation Breach presentation

• Complications: • Management:
• Anoxia • Continuous monitoring of uterine
• Traumatic birth injury contractions and FHR
• Fracture of the spine or arm • Birth technique
• Dysfunctional labor • Vaginal birth
• Early rupture of the membranes • CS

• Assessment findings:
• FHR heard high in the abdomen
• Leopold’s maneuver and vaginal
examination reveals the presentation
• Ultrasound confirms breech presentation,
information on diameters of pelvis and
fetal skull

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Face presentation Brow presentation

• Asynclitism (fetal head presenting at a different angle)
• Head diameter of fetus is often too large for birth to proceed
• Occurs in a multipara or a woman with
• More prominent head with no engagement
relaxed abdominal muscles
• Back is difficult to outline during LM
• Confirmed by vaginal examination and ultrasound • Results in obstructed labor, because the
• Causes: head becomes jammed in the brim of the
• Occipitoposterior position pelvis as the occipitomental diameter
• Placenta previa presents
• Multipara • Management: CS
• Prematurity
• Complications: Ecchymotic bruise on face
• Hydramnios
• Fetal malformation
Management: vaginal birth (chin is anterior and pelvic diameters
are normal)/ CS)
Complications: Facial edema

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Transverse lie presentation Fetal Size: Oversized Fetus

• Occurs in women with pendulous abdomens, with (Macrosomia)
uterine fibroid tumors that obstruct the lower uterine
segment, with contraction of the pelvic brim, with • Fetus who weighs more than 4000 to 4500 grams (9-10
lbs)
congenital abnormalities of the uterus, or with
hydramnios • Born to women who enter pregnancy with diabetes or
develop GDM.
• Occur in infants with hydrocephalus or another • Associated with multiparity
abnormality that prevents the head from engaging, • Complications:
prematurity, multiple gestation (2nd twin), short
umbilical cord • Uterine dysfunction during labor
• Fetal pelvic disproportion
• Assessment:
• Uterine rupture
• Horizontal ovoid of the uterus • Management: CS
• Confirmed by LM • Complications:
• Ultrasound • Post partum hemorrhage
• Cervical nerve palsy
Management: CS
• Diaphragmatic nerve injury
Complication: Cord or arm prolapse
• Fractured clavicle

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Shoulder Dystocia Problems with Passage

• Occurs at the second stage of labor, when the fetal head
is born but the shoulders are too broad to enter and be Inlet contraction Outlet contraction
born through the pelvic outlet
• Narrowing of the anteroposterior diameter to • Narrowing of the transverse diameter at
• Causes: less than 11 cm, or transverse diameter to 12
cm or less the outlet to less than 11 cm
• Maternal DM
• Caused by rickets or by inherited small pelvis • Distance between the ischial tuberosities
• Multiparity
• Post-date pregnancies • Engagement does not occur in a primigravida • Can be measured during prenatal visit
(36-38 weeks) or in a multigravida (until labor
• Assessment findings: begins)
• Prolonged 2nd stage of labor • Management:
• Arrest of descent • Obstetric history
• Turtle sign • Pelvic measurements before week 24 of
• Management: McRobert’s maneuver, Suprapubic pressure pregnancy
application • CS
• Complications: • Complications:
• Vaginal or cervical tears • Malposition
• Cord compression • Cord prolapse
• Fractured clavicle or a brachial plexus injury

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Problems with Passage Problems with Passage

Trial Labor
• Determine whether labor can progress
normally
• Continues as long as descent of presenting
part and dilatation of the cervix continue to
occur
• Monitor FH sounds and uterine contractions
continuously
• Urge to void every 2 hours
• Assess FHR carefully after rupture of
membranes
• Inadequate progress in labor (6-12 hours) or
fetal distress occurs, schedule for CS
External Cephalic Version
• Turning a fetus from a breech to a cephalic
position before birth
• May be done as early as 34 to 35 weeks AOG
(usual time: 37-38 weeks)
• Procedure:
• Continuous recording of FHR and ultrasound
• Tocolytic agent administration
• Locate breech and vertex of fetus and grasp
abdominally
• Gentle pressure applied to rotate fetus in a
forward direction to a cephalic lie
• Rh negative women should receive Rh
immunoglobulin after procedure

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PROBLEMS WITH THE PLACENTA

Problems with Passage
External Cephalic Version
• Contraindications:
• Multiple gestation
• Severe oligohydramnios PLACENTA
• Contraindications to vaginal birth
• Cord coil around fetal neck PREVIA
(nuchal cord)
• Unexplained 3rd trimester Abnormal implantation of placenta in the lower uterine
bleeding segment, partially or completely covering the internal cervical
opening (os)

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Types/ Degree
RISK
FACTORS of Placenta
• Multiparity Previa
• Decreased
vascularity • Low-lying
in the upper
uterine • Marginal
segment
(scarring and • Partial
tumor)
• Complete or
• Increased
age (>35 Total
years old)
• Multiple
pregnancy

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Pathophysiolo Precipitating
gy Factors:

Assessment findings
Predisposing Previous abortion
Factors: Previous placenta
Age (35-40) previa
Race (nonwhite Multiple births
ethnicity) Endometritis
VBAC (vaginal birth
• Painless vaginal bleeding
Hereditary or familial Damage to after cesarean (fresh, bright red,
endometrium delivery) external) – 7th month
Lifestyle (smoking,
etc.) • Uterus soft/ flaccid
FOLLOWS A VICIOUS CYCLE: • Bleeding may be slight
Bleeding – Contractions – or profuse
Placental separation -
Bleeding

Bright bleeding occurs when cervix dilates, resulting in painless

bleeding

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Diagnosis Complicatio
ns
• Ultrasonography • Hemorrhage
• 95% accurate
result • Prematurity
• Detects site of • Obstruction of
placenta birth canal

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MEDICAL MANAGEMENT
• IV access
• Laboratory
examinations
• Blood typing and
cross matching
• Administration of
Betamethasone (if
premature delivery)
Nursing management
SURGICAL
• Maintain bed rest (left lateral recumbent with a head
MANAGEMENT
pillow)
• DO NOT PERFORM an IE or vaginal examination
• Careful assessment: VS, bleeding, onset/ progress of
labor. FHT
• Prepare client for diagnostic ultrasonography
• Amniotomy
• CS delivery • Institute shock measures as necessary
• Provide psychological and physical comfort
• Prepare for conservative management, double set-up
or classical CS
• Observe for bleeding after delivery

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Anomalies of the Placenta Placenta Battledore Placenta

Circumvallata
Placenta Succenturiata • The fetal side of the placenta is covered to • The cord is inserted marginally rather than
some extent with chorion centrally.
• Placenta that has one or more accessory
lobes connected to the main placenta by • The umbilical cord enters the placenta at the • Rare and no known clinical significance.
blood vessels usual midpoint, and large vessels spread out
from there
• No fetal abnormality
• No abnormalities
• Small lobes may be retained in the uterus
after birth (maternal hemorrhage)
• Placenta appears torn at the edge or torn
blood vessels extend beyond the edge of
the placenta
• Management:
• Manual removal of retained fragments

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Velamentous Vasa Previa Placenta Accreta

Insertion of the Cord
• The cord separates into small vessels that • The umbilical vessels of a velamentous cord
• Unusually deep attachment of the
reach the placenta by spreading across a fold insertion cross the cervical os and therefore placenta to the uterine
of amnion deliver before the fetus myometrium so deeply the
• Found with multiple gestation and may be • May tear with cervical dilatation just as a placenta will not loosen and
associated with fetal anomalies placenta previa may tear deliver
• Identify structures to prevent accidental • May lead to extreme hemorrhage
tearing of a vasa previa
• Management:
• Confirmed by ultrasound
• Hysterectomy
• Management: CS
• Methotrexate

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Two-vessel Cord Unusual Cord Length PROBLEMS WITH

• Absence of one of the umbilical arteries
• Associated with congenital heart and
kidney anomalies
• Inspect cord immediately after birth
• Document the number of vessels
present
• Observe carefully the newborn for other
anomalies during the newborn period
• Short umbilical cord
• Result in premature separation of the
placenta or an abnormal fetal lie
• Long umbilical cord
• Tendency to twist or knot
PSYCHE
A WOMAN WITHOUT A SUPPORT PERSON
• Rejects or want to labor without the
infant’s father
• Apprehensive about new life role
• Increased assessment of parent-child
bonding (post partal period)
VAGINAL BIRTH AFTER CESAREAN BIRTH
• No experience of labor
• Anxious and may be dismayed at length
and discomfort of labor

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Thank you!

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