AT THE END OF THE DISCUSSION.

100% OF THE LEARNERS SHOULD:

• Identify different INTRAPARTUM

COMPLICATIONS.

• Identify the important concepts on

INTRAPARTUM COMPLICATIONS.
AT THE END OF THE DISCUSSION.
100% OF THE LEARNERS SHOULD:

• Identify the ETIOLOGY,

PATHOPHYSIOLOGY AND
SYMPTOMATOLOGY OF THE
INTRAPARTUM COMPLICATIONS

• Identify the MANAGEMENT

OF THE
INTRAPARTUM COMPLICATIONS
AT THE END OF THE DISCUSSION.
100% OF THE LEARNERS SHOULD:

• Internalize the importance of knowing

INTRAPARTUM COMPLICATIONS
IN PREGNANCY as a student nurse

• Answer the LEARNING FEEDBACK

DIARY for the lesson.
COMPLICATIONS
OF INTRAPARTUM
 DYSTOCIA
• Definition:Dystocia, or difficult labor,
abnormal 5P in labor.
1. Power; uterine contraction
2. Pathway; pelvis, cervix, birth canal
3. Passenger; fetus, placenta
4. Psychology; maternal fear and
anxiety
5. Position; maternal birthing position
1. Power ; Contraction
abnormalities
1.Contractions that are not strong enough or frequent
enough to produce a normal labor pattern will not
result in dilatation and effacement within a normal
time frame.
2. Problems with the force of labor will result in
ineffective contractions or ineffective bearing down
(pushing) during the second stage of labor.
3. Etiology of abnormalities in the force of labor
include:
a. Early or excessive use of analgesia
b. Overdistention of the uterus
c. Excessive cervical rigidity
d. Grand multiparity
e. Mild pelvic contraction
f. Postmature and large infants
 2. Passageway abnormalities
1. Problems in the pelvis or soft tissues of the reproductive
tract.
2. Most often problems with the passageway are a result of
pelvic abnormalities that interfere with the engagement,
descent, and expulsion of the fetus.
a. The size and shape of the pelvis is important.
b. Obstruction may result from problems of the soft tissue
such as a uterine or ovarian fibromyoma.
3. Contractions of the inlet are noted when the
anteroposterior diameter is less than 10 cm
4. Midpelvic contractions occur when the distance between
the ischial spines is less than 9 cm.
5. A contracted pelvic outlet is diagnosed when the distance
between the ischial spines is less then 8 cm.

When the pelvis is contracted and the fetus cannot fit

through the pelvis, CPD(cephalo-pelvic disproportion) exists.
3. Passenger; Fetal abnormalities
1. Normal fetal passage
a. Normally the fetus enters the pelvic inlet
transversely and then rotates to an occiput
anterior position, allowing for the smallest
diameter of the fetal head to pass through the
pelvis.
b. When the fetal head enters the pelvis
posteriorly, it must rotate to the anterior
position.
3. If the fetus does not turn, then it remains in the
posterior position and may slow down the
progress of descent.
a. If the pelvis is large enough, the baby can be
born in the posterior position.
b. If the pelvis is borderline and the contractions
ineffective, a Cesarean section may be
3.Passenger; Fetal Abnormalities
4. Breech presentations occur in approximately
3% of all deliveries.
a. This presentation is more common in multiple
gestations, increased parity, hydramnios,
placenta previa, and preterm infants.
b. Usually the method of choice for delivery is a
cesarean section.
5. Shoulder presentation occurs when the infant
lies crosswise in the uterus. The infant is
delivered by cesarean section.
6. A large infant may not fit through the pelvis
and CPD may result.
 4. Maternal psychology
• Maternal fear, anxiety influenced cervical
dilatation and adequate tissue
perfusion.
• Fear anxiety catecholamine hormone
release vasocontraction ineffective
perfusion to fetus fetal distress
• Fear anxiety catecholamine hormone
release ineffective cervical dilatation
and maternal exhausted prolonged
labor
 5. Maternal Position
• Up right position; using gravity
• Lie down position; supine hypotensive
syndrome
 Diagnostic Evaluation
1. Inadequate progress of cervical effacement, dilatation, or
descent of the presenting part as determined by vaginal
examination
2. Evaluation of labor progress by recording and assessing
serial vaginal examinations using Freidman's curve
a. Using Freidman's curve, a prolonged latent phase in the
primigravida is greater than 20 hours and in the
multigravida it is greater than 14 hours.
b. During the active phase, the cervix of a primigravida will
normally dilate at least 1.2 cm/h, and the multigravida
1.5 cm. In addition,
c. The fetus should be descending through the birth canal.
In the primigravida the rate of descent is 1 cm/h and 2
cm/h for the multigravida.
Power(자궁압력)
Descent
 Management
1. Treatment for contraction abnormalities
involves stimulation of labor through the use of
oxytocin. An intrauterine pressure catheter may
be used.
2. Management for maternal passageway or fetal
passage problems(CPD) involves delivery in the
safest manner for the mother and fetus.
a. If the problem is related to the inlet or
midpelvis, a cesarean delivery is indicated.
• b. If the size of the outlet is the problem, a
forceps/vacuum/C-section delivery is usually
performed.
 Complications
1. Maternal exhaustion
2. Infection
3. Fetal distress
4. Postpartum hemorrhage
 Nursing Assessment
1. Evaluate fetal presentation, position,
and size.
2. Evaluate progress of labor, noting
dilations and effacement in relation to
time of labor along with descent of the
fetal head.
3. Monitor fetal heart rate and contraction
status at least every 30 minutes.
4. Monitor maternal vital signs at least
every hour.
5. Assess bladder fullness.
Dilatation of cervix
Effacement of Cervix
 Nursing Diagnoses
A. Pain related to physical and
psychological factors of difficult labor
B. Anxiety related to threat of change in
the health status of self and fetus
 Nursing Interventions
A. Promoting Comfort

1. Review relaxation techniques.

2. Encourage use of breathing techniques learned in
Childbirth education classes.
3. Encourage frequent change of position.
4. Encourage voiding every hour.
5. Provide back rubs and sacral pressure as needed.
6. Offer ice chips as needed to combat a dry mouth, if
permitted.
7. Provide a quiet, darkened room.
8. Provide frequent encouragement to the woman and her
support person.
9. Administer pain medication for analgesia, as ordered.
10. Assist with the administration of anesthesia, as indicated.
B. Decreasing Anxiety
1. Provide anticipatory guidance regarding the
use of medication, equipment, and
procedures.
2. Educate the woman about the administration
of oxytocin (Pitocin).
3. Discuss with the woman the nature of the
contractions associated with an induced labor
(ie, short acceleration, intense plateau, short
deceleration).
4. Prepare the family for cesarean delivery, if
necessary.
 Evaluation
A. Verbalizes increased comfort
B. Verbalizes understanding of procedures
 HYDRAMNIOS
(POLYHYDRAMNIOS)
Definition
• Hydramnios (polyhydramnios) is caused by
an excessive amount of amniotic fluid.
• Normal amnionic fluid; 500-1200cc
• Hydramnios (polyhydramnios) 2000cc over
• Oligohydroamnios less then 300cc

• The amount of amniotic fluid present is

controlled in part by fetal urination,
swallowing, and breathing.
 Pathophysiology/Etiology
1. The etiology is often unclear.
2. Anomalies causing impaired fetal
swallowing or excessive micturition may
contribute to the condition.
3. It is associated with maternal diabetes,
multiple gestation and Rh isoimmunization.
4. Other associated factors are anomalies of
the central nervous system including spina
bifida and anencephaly or anomalies of the
gastrointestinal tract including
tracheoesophageal fistula.
 Clinical Manifestations
1. Excessive weight gain, dyspnea
2. Abdomen may be tense and shiny.
3. Edema of the vulva, legs, and lower
extremities.
4. Increased uterine size for gestational age
usually accompanied by difficulty in
palpating fetal parts and in auscultation of
fetal heart
 Management
1. Depends on the severity of the condition and the
cause; hospitalization is indicated for maternal
distress or for intervention regarding fetal prognosis.
2. If impairment of maternal respiratory status occurs,
amniocentesis for removal of fluid may be
performed.
a. The amniocentesis is performed under ultrasound
for location of the placenta and fetal parts.
b. The fluid is then slowly removed.
c. Rapid removal of the fluid can result in a
premature separation of the placenta.
d. Usually 500 to 1,000 mL of fluid is removed.
 Complications

1. Preterm labor
2. Cord prolapsed
3. Dysfunctional labor with increased risk
for cesarean section
4. Postpartum hemorrhage due to uterine
atony from gross distention of the uterus
Cord
Prolapse
 Nursing Assessment

1. Evaluate maternal respiratory status.

2. Inspect abdomen and evaluate uterine
height and compare with previous
findings.
 Nursing Diagnoses
A. Ineffective Breathing Pattern related to
pressure on the diaphragm
B. Altered Tissue Perfusion, Placental,
related to pressure from excess fluid
C. Impaired Physical Mobility related to
edema and discomfort from the
enlarged uterus
D. Anxiety related to fetal outcome
 Nursing Interventions
A. Promoting Effective Breathing
1. Position to promote chest expansion
with head elevated.
2. Provide oxygen by face mask, if
indicated.
3. Limit activities and plan for frequent
rest periods.
4. Maintain adequate intake and output.
 B. Promoting Placental Tissue
Perfusion
1. Position on left side if possible, with
head elevated. If unable to position on
side, use a wedge to displace the uterus
to the left.
2. Encourage passive or active assisted
range of motion to the lower extremities.
3. Monitor fetal heart rate as directed.
4. Provide a diet adequate in protein, iron,
and fluids.
 C. Promoting Mobility
1. Assist the woman with position
changes and ambulation as needed.
2. Advise on alternating activity with rest
periods for legs.
3. Instruct the woman to wear loose fitting
clothing and low-heeled shoes with
good support.
 D. Decreasing Anxiety
1. Explain the cause of hydramnios, if known.
2. Encourage the patient and family to ask
questions regarding any treatment or
procedures.
3. Encourage expression of feelings.
4. Prepare patient for the type of delivery that
is anticipated and for the expected finding
at the time of delivery.
5. Encourage presence of support person.
 Patient Education/Health
Maintenance
1. Instruct the woman to notify her health
care provider if she experiences
respiratory distress.
2. Teach the woman signs of preterm
labor and the need to report them to
health care provider.
 Evaluation
A. Respirations 20 and unlabored
B. Fetal heart rate within normal limits
C. Verbalizes improved comfort; moves
freely
D. Discusses realistically the pregnancy
outcome; questions regarding treatment
for self and fetus
Preterm Premature Rupture of
Membranes
(PPRM)
OR
Premature Rupture of
Membranes
(PRM)
 Definition
• Preterm(premature) rupture of
membranes (PROM) is defined as
rupture of the membranes before the
onset of spontaneous labor.
• Normally spontaneous membranes
rupture(break) end of 1st stage or
beginning of second stage.
Preterm Premature Rupture of Membranes:

When the water bag breaks before 37

weeks of pregnancy AND labor has not
started.

Premature Rupture of Membranes:

When the water bag breaks before the

start of labor.
 Pathophysiology/Etiology
1. The exact etiology of PROM is not clearly understood.

2. In preterm PROM, risk factors include:

a. Infection
b. Previous history of PROM
c. Hydramnios
d. Incompetent cervix
e. Multiple gestation
f. Abruptio placentae

3. PROM is manifested by a large gush of amniotic fluid or

leaking of fluid per vagina, which usually persists.
 Diagnostic Evaluation
Nitrazine test—positive test will change
pH paper strip from yellow-green to
blue in the presence of amniotic fluid
taken from the vaginal canal.
Amniotic fluid; alkali
Urine; acid
 Management
1. Once PROM is confirmed, the woman is admitted to
the hospital and usually remains there until delivery.
2. The woman is evaluated to rule out labor, fetal
distress, and infection and to establish gestational
age. If all factors are ruled out, the woman is
managed expectantly.
3. For PROM, tocolytics, corticosteroids (to decrease the
severity of respiratory distress syndrome in the
premature neonate) and prophylactic antibiotics are
used, but remain controversial.
4. Management of PROM at 36 weeks' gestation or
greater focuses on delivery.
5. Vaginal examinations are kept to a minimum to
prevent infection.
 Complications
1. Preterm labor
2. Prematurity and associated
complications
3. Cord prolapsed
3. Maternal infection—chorioamnionitis
4. Fetal/neonatal infection
 Nursing Assessment
1. TPRBP check every 4 hours.
If temperature or pulse are elevated take
them every 1 to 2 hours as indicated.
2. Monitor the amount and type of amniotic
fluid that is leaking and observe for purulent,
foul-smelling discharge.
3. Evaluate daily CBC
4. Evaluate fetal status every 4 hours or as
indicated, noting fetal activity and heart rate.
5. Determine if uterine tenderness occurs on
abdominal palpation.
 Nursing Diagnoses
• A. Risk for Infection related to
ascending bacteria
• Also see Preterm Labor,
 Nursing Interventions
A. Preventing Infection

1. Evaluate amount and odor of amniotic fluid leakage.

2. Do not perform vaginal examinations without consulting the
primary health care provider.
3. Place patient on disposable pads to collect leaking fluid and
change pads every 2 hours or more frequently as needed.
4. Review the need for good hand washing technique and
hygiene after urination and defecation.
5. Monitor fetal heart rate and fetal activity every 4 hours or as
indicated.
6. Monitor maternal temperature, pulse respiration, blood
pressure, and uterine tenderness every 4 hours or as
indicated.
 Evaluation
A. Free from signs of infection
 PROLAPSED UMBILICAL CORD
A prolapsed umbilical cord slips in front of or
alongside the fetal presenting part.
Types of cord prolapse include:
▪ Complete—the cord can be felt on vaginal
examination and be seen in the vaginal canal.
▪ Occult—the cord cannot be felt on vaginal
examination or be seen. The cord lies between
the presenting part and the maternal pelvis.
Changes in the fetal heart rate are evident.
▪ Forelying—the cord can be felt on vaginal
examination, but cannot be seen. The cord lies
in front of the presenting part.
 Pathophysiology/Etiology
A fetal cord prolapse may occur when there is
adequate room between the fetal parts and the
maternal pelvis. Predisposing factors include:
1. Rupture of membranes, when the presenting
part is not engaged in the pelvis
2. More common in shoulder and foot
presentations
3. Prematurity—small fetus allows more space
around presenting part
4. Hydramnios—causes greater amount of fluid
to be released with greater force when
membranes rupture
 Prolapsed of cord
• Pathophysiology/Etiology:
PROM, Preterm, Hydroamnious, CPD
Breach presentation, Placenta previa,
• Clinical Manifestations : alteration FHS,
Palpitation cord with vaginal examination
• Management
- Knee-chest position or Sim’s positon, elevate buttocks
- Check FHS and O₂ supply 8 to 10 L/min.
- No vaginal examination
- Coved wet gauze on the prolapsed cord
-Prepared C-section delivery/vaginal delivery depending
to fetal condition
• NURSING ALERT:
Prolapse should be suspected with fetal
heart rate deceleration after rupture of
the membranes.
 Management
1. Delivery of the fetus as soon as
possible
2. Relief of pressure from the umbilical
cord
 Complications
A. Maternal
1. Infection
2. Risk for increased blood loss from
emergency delivery
3. Fear and anxiety

B. Fetal
1. Prematurity
2. Complications resulting from hypoxia
3. Fetal death
Nursing Assessment/Interventions
1. Observe fetal heart rate deceleration.
2. Identify complete or forelying cord prolapse with a vaginal
examination by a qualified nurse or health care provider.
3. Explain procedures as much as possible to the woman
during this emergent situation.
4. Administer oxygen by face mask at 8 to 10 L/min.
5. Relieve pressure from the presenting part of the fetus off
the umbilical cord by manually pushing the presenting
part upward with a gloved hand. Pressure must be
relieved until the fetus is delivered via cesarean or
vaginally.
6. Provide constant support to the woman and her support
persons.
7. Encourage the woman to talk about her feelings
regarding herself and the baby after delivery.
 Preterm Labor

Definition:

1. 20 to 36 weeks of pregnancy
AND
2. Uterine contractions
AND
3. 80% thinning of the cervix
OR
4. Cervical dilation > 1cm
 Preterm Labor

Greatest risk of preterm

labor is delivery of a
premature baby.
 Risk Factors for Preterm Birth

1. More than one fetus

2. History of preterm birth

3. Abnormal uterus or cervix

 Preterm Labor

High blood pressure

Other •
• Diabetes
Possible • Infections

Risk •
•
No prenatal care
Smoking
Factors • Vaginal bleeding
for • Drug use
• Violence
Preterm • Very young or very old
mother
Birth:
 Management
• The focus of treatment is prevention of
delivery of a preterm infant.
• The method depends on the cervical
dilatation and contraction pattern.
• If contractions are detected early and
treatment is begun early, there is a
higher rate of stopping labor.
 Preterm Labor

• Treatment Approaches
If preterm birth is suspected,
giving mother steroids( at
least 48 hours before birth
can significantly help the
baby breathe after birth.
 Preterm Labor

• Treatment Approaches
1. Bedrest

2. Hydration

3. Medications
 B. Tocolytic Therapy
• If conservative therapy is not successful,
tocolytic therapy is instituted. These drugs
should be used only when the potential
benefit to the fetus outweighs the potential
risk
- Yutopar
- Bricanyl
- MgSO4
- Indocin
- Procardia
 Complications

1. Prematurity and associated neonatal

complications, such as lung immaturity
 Nursing Diagnoses
A. Anxiety related to medication and fear
of outcome of pregnancy
B. Diversional Activity Deficit related to
prolonged bed rest
 Nursing Interventions
A. Decreasing Anxiety
1. Provide accurate information on the status
of the fetus and labor (contraction pattern).
2. Allow the woman and her support person
to verbalize their feelings regarding the
episode of preterm labor and the
treatment.
3. If a private room is not used, do not place
the woman in a room with a woman who is
in labor or who has lost an infant.
4. Encourage relationship with other patients
B. Promoting Diversional Activities
1. Determine quiet craft activities that can be
done in bed.
2. Provide radio, books, and television.
3. Encourage visits from family, especially
other children and friends. If possible
encourage them to bring in favorite foods
for the woman and to dine as a family.
4. Encourage other family activities, such as
helping with homework. This will assist on
maintaining the family unit.
 Patient Education/Health
Maintenance
1. Educate the woman about the importance of
continuing the pregnancy until term or until
there is evidence of fetal lung maturity.
2. Encourage the need for compliance with a
decreased activity level or bed rest, as
indicated.
3. Teach the woman the importance of proper
nutrition and the need for adequate hydration,
at least 8 glasses of fluids a day.
4. Instruct the woman not to engage in sexual
activity.
5. Teach the woman the signs and symptoms of
infection and to report them
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