1. Complication of Intrapartum

2. Labor is a natural process,but one faced with many uncontrollable variables. 3. 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 4. 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 5. 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. 6. 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 necessary. 7. 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. 8. 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 9. 5. Maternal Position Up right position; using gravity Lie down position; supine hypotensive syndrome 10. 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. 11. Power() 12. Descent 13. 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. 14. Complications 1. Maternal exhaustion 2. Infection 3. Fetal distress 4. Postpartum hemorrhage 15. 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. 16. Dilatation of cervix 17. Effacement of Cervix 18. 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 19. Nursing Interventions A.Promoting Comfort1. 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. 20. 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. 21. Evaluation A. Verbalizes increased comfort B. Verbalizes understanding of procedures 22. 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. 23. 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. 24. 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 25. 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. 26. 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 27. Cord Prolapse 28. Nursing Assessment 1. Evaluate maternal respiratory status. 2. Inspect abdomen and evaluate uterine height and compare with previous findings. 29. 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 30. 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. 31. 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. 32. 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. 33. 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. 34. 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. 35. 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 36. Preterm Premature Rupture of Membranes (PPRM)OR Premature Rupture of Membranes (PRM) 37. 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. 38. 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. 39. 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. 40. Diagnostic Evaluation Nitrazine testpositive 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 41. Management 1. Once PROM is confirmed, the woman is admitted to thehospital 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. 42. Complications 1. Preterm labor 2. Prematurity and associated complications 3. Cord prolapsed 3. Maternal infectionchorioamnionitis 4. Fetal/neonatal infection 43. 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, foulsmelling 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. 44. Nursing Diagnoses A. Risk for Infection related to ascending bacteria Also see Preterm Labor, 45. Nursing Interventions A. Preventing Infection1. 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. 46. Evaluation A. Free from signs of infection 47. PROLAPSED UMBILICAL CORD A prolapsed umbilical cord slips in front of or alongside the fetal presenting part. Types of cord prolapse include: Completethe cord can be felt on vaginal examination and be seen in the vaginal canal. Occultthe 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. Forelyingthe cord can be felt on vaginal examination, but cannot be seen. The cord lies in front of the presenting part. 48. 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. Prematuritysmall fetus allows more space around presenting part 4. Hydramnioscauses greater amount of fluid to be released with greater force when membranes rupture 49. 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 Sims positon, elevate buttocks - Check FHS and O 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 50. NURSING ALERT: Prolapse should be suspected with fetal heart rate deceleration after rupture of the membranes. 51. Management 1. Delivery of the fetus as soon as possible 2. Relief of pressure from the umbilical cord 52. 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 53. 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. 54. 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 55. Preterm LaborGreatest risk of preterm labor is delivery of a premature baby. 56. Risk Factors for Preterm Birth 1. More than one fetus2. History of preterm birth 3. Abnormal uterus or cervix 57. Preterm LaborOther Possible Risk Factors for Preterm Birth: High blood pressure Diabetes Infections No prenatal care Smoking Vaginal bleeding Drug use Violence Very young or very old mother 58. 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. 59. Preterm Labor Treatment Approaches If preterm birth is suspected, giving mother steroids( at least 48 hours before birth can significantly help the baby breathe 60. Preterm Labor Treatment Approaches 1. Bedrest 2. Hydration3. Medications 61. 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 62. Complications 1. Prematurity and associated neonatal complications, such as lung immaturity 63. Nursing Diagnoses A. Anxiety related to medication and fear of outcome of pregnancy B. Diversional Activity Deficit related to prolonged bed rest 64. 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 65. 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. 66. 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