Complications During the Intrapartal Period

General aspects
1. Pathophysiology - interference with normal processes and patterns of labor/birth result in maternal or fetal jeopardy (e.g., preterm labor, dysfunctional labor patterns; prolonged [over 24] labor; hemorrhage: uterine rupture/inversion, amniotic-fluid embolus).
2. Etiology:
  1. Preterm labor - unknown.
  2. Dysfunctional labor:
    1. Physiological response to anxiety/fear/ pain - results in release of catecholamines, increasing physical/psychological stress - myometrial dysfunction; painful and ineffectual labor.
    2. Iatrogenic factors: premature or excessive analgesia, particularly during latent phase.
    3. Maternal factors:
      1. Pelvic contractures.
      2. Uterine tumors (e.g., myomas, carcinoma).
      3. Congenital uterine anomalies (e.g., bicornate uterus).
      4. Pathological contraction ring (Bandl's ring).
      5. Rigid cervix, cervical stenosis/stricture.
      6. Hypertonic/hypotonic contractions.
      7. Prolonged rupture of membranes. Note: Intrauterine infection may have caused rupture of membranes or may follow rupture.
      8. Prolonged first or second stage.
      9. Medical conditions: diabetes, hypertension.
    4. Fetal factors:
      1. Macrosomia (LGA).
      2. Malposition/malpresentation.
      3. Congenital anomaly (e.g., hydrocephalus, anencephaly).
      4. Multifetal gestation (e.g., interlocking twins).
      5. Prolapsed cord.
      6. Postterm.
    5. Placental factors:
      1. Placenta previa.
      2. Inadequate placental function with contractions.
      3. Abruptio placentae.
      4. Placenta accreta.
    6. Physical restrictions: when confined to bed, flat position, etc.
3. Assessment:
  1. Antepartal history.
  2. Emotional status.
  3. Vital signs, FHR.
  4. Contraction pattern (frequency, duration, intensity).
  5. Vaginal discharge.
4. Analysis/nursing diagnosis:
  1. Anxiety/fear for self and infant related to implications of prolonged or complicated labor/birth.
  2. Pain related to hypertonic contractions/ dysfunctional labor.
  3. Ineffective individual coping related to physical/psychological stress of complicated labor/ birth, lowered pain threshold secondary to fatigue.
  4. High risk for injury related to prolonged rupture of membranes, infection.
  5. Fluid volume deficit related to excessive blood loss secondary to placenta previa, abruptio placentae, Couvelaire uterus, Disseminated Intravascular Coagulation.
5. Nursing care plan/implementation:
  1. Goal: minimize physical/psychological stress during labor/birth. Assist woman in coping effectively:
    1. Reinforce relaxation techniques.
    2. Support couple’s effective coping techniques/mechanisms.
  2. Goal: emotional support.
    1. Encourage verbalization of anxiety/fear/ concerns.
    2. Explain all procedures - to minimize anxiety/fear, encourage cooperation/participation in care.
    3. Provide quiet environment conducive to rest.
  3. Goal: continuous monitoring of maternal/fetal status and progress through labor - to identify early signs of dysfunctional labor, fetal distress; facilitate prompt, effective treatment of emerging complications.
  4. Goal: minimize effects of complicated labor on mother, fetus.
    1. Position change: lateral Sims’ - to reduce compression of inferior vena cava.
    2. Oxygen per mask, as indicated.
    3. Institute interventions appropriate to emerging problems (see specific disorder).
6. Evaluation/outcome criteria:
  1. Woman has successful birth of viable infant.
  2. Maternal/infant status stable, satisfactory.

Disorders affecting protective functions. Preterm labor - occurs after 20 weeks of gestation and before beginning of week 38.
1. Pathophysiology - physiological events of labor (i.e., contractions, spontaneous rupture of membranes, cervical effacement/dilation) occur before completion of normal, term gestation.
2. Etiology - causes may be from maternal, fetal, or placental factors.
3. Coexisting disorders:
  1. Infections that may cause PROM.
  2. PROM of unknown etiology.
  3. PIH (preeclampsia/eclampsia).
  4. Uterine overdistention.
    1. Polyhydramnios.
    2. Multifetal gestation.
  5. Maternal diabetes, renal or cardiovascular disorder, UTI.
  6. Severe maternal illness (e.g., pneumonia, acute pyelonephritis).
  7. Abnormal placentation.
    1. Placenta previa.
    2. Abruptio placentae.
  8. Iatrogenic: miscalculated EDB for repeat cesarean birth (rare).
  9. Fetal death.
  10. Incompetent cervical os (small percentage).
  11. Uterine anomalies (rare).
    1. Intrauterine septum.
    2. Bicornate uterus.
  12. Uterine fibroids.
  13. Positive fetal fibronectin assay (protein found in fetal tissue, membranes, amniotic fluid, and the decidua) found in cervical/vaginal fluid first half of pregnancy and normally absent through mid to late pregnancy (Î risk of PTL by 20%).
4. Prevention:
  1. Primary - close obstetric supervision; education in signs/symptoms of labor.
  2. Secondary - prompt, effective treatment of associated disorders .
  3. Tertiary - suppression of preterm labor.
    1. Bedrest.
    2. Position: side-lying - to promote placental perfusion.
    3. Hydration.
    4. Pharmacological (may require “informed consent”; follow hospital protocol). Betaadrenergic agents, MgSO ₄ (take ECG first) to reduce sensitivity of uterine myometrium to oxytocic and prostaglandin stimulation; increase blood flow to uterus.
    5. May be maintained at home with adequate follow-up and health teaching.
5. Contraindications for suppression: Labor is not suppressed in presence of:
  1. Placenta previa or abruptio placentae with hemorrhage.
  2. Chorioamnionitis.
  3. Erythroblastosis fetalis.
  4. Severe preeclampsia.
  5. Severe diabetes (e.g., “brittle”).
  6. Increasing placental insufficiency.
  7. Progressive cervical dilatation of 4 cm or more.
  8. Ruptured membranes (with maternal fever).
6. Assessment:
  1. Maternal vital signs. Response to medication:
    1. Hypotension.
    2. Tachycardia, arrhythmia.
    3. Dyspnea, chest pain.
    4. Nausea and vomiting.
  2. Signs of infection:
    1. Increased temperature.
    2. Tachycardia.
    3. Diaphoresis.
    4. Malaise.
    5. Increased baseline fetal heart rate; variability
  3. Contractions: frequency, duration, strength.
  4. Emotional status - signs of denial, guilt, anxiety, exhaustion.
  5. Signs of continuing and progressing labor. Note: Vaginal examination only if indicated by other signs of continuing labor progress.
    1. Effacement.
    2. Dilation.
    3. Station.
  6. Status of membranes.
  7. Fetal heart rate, activity (continuous monitoring).
7. Analysis/nursing diagnosis:
  1. Anxiety/fear related to possible outcome.
  2. Self-esteem disturbance related to feelings of guilt, failure.
  3. Impaired physical mobility related to imposed bed rest.
  4. Knowledge deficit related to medication side effects.
  5. Ineffective individual coping related to possible outcome.
  6. Impaired gas exchange related to side effects of medication (circulatory overload; pulmonary edema).
  7. Diversional activity deficit related to imposed bed rest, decreased environmental stimuli.
  8. Altered urinary elimination related to bed rest.
  9. Constipation related to bed rest.
8. Nursing care plan/implementation:
  1. Goal: inhibit uterine activity. Administer medications as ordered - terbutaline, magnesium sulfate, Procardia, Indocin.
  2. Goal: safeguard status.
    1. Continuous maternal/fetal monitoring.
    2. I&O - to identify early signs of possible circulatory overload.
    3. Position: side-lying - to increase placental perfusion, prevent supine hypotension.
    4. Report promptly to physician:
      1. Maternal pulse of 110 or more.
      2. Diastolic pressure of 60 mm Hg or less.
      3. Respirations of 24 or more; crackles (rales).
      4. Complaint of dyspnea.
      5. Contractions: increasing frequency, strength, duration, or cessation of contractions.
      6. Intermittent back and thigh pain.
      7. Rupture of membranes.
      8. Vaginal bleeding.
      9. Fetal distress.
  3. Goal: comfort measures.
    1. Basic hygienic care - bath, mouth care, cold washcloth to face, perineal care.
    2. Back rub, linen change - to promote relaxation.
  4. Goal: emotional support.
    1. Encourage verbalization of guilt feelings, anxiety, fear, concerns; provide factual information.
    2. Support positive self-concept.
    3. Keep informed of progress.
  5. Goal: provide quiet diversion. Television, reading materials, handcrafts.
  6. Goal: health teaching
    1. Explain, discuss proposed management to suppress preterm labor.
    2. Describe, discuss side effects of medication.
    3. Explain rationale for bed rest, position.
9. If labor continues to progress:
  1. Goal: facilitate infant survival.
    1. Administer betamethasone, as ordered, 24 - 48 hours before birth—to increase/stimulate production of pulmonary surfactant.
    2. Give antibiotic to mother to lower down chance of neonatal sepsis.
    3. Notify neonatal ICU (NICU) - to increase chances for fetal survival, ensure prompt, expert management of neonate, and provide information and support to parents.
    4. Monitor progress of labor to identify signs of impending birth. Note: May give birth before complete (10 cm) dilation.
    5. Consider transfer to high-risk facility.
    6. Prepare for birth, or cesarean birth if infant less than 34-36 weeks of gestation.
  2. Goal: emotional support.
  3. Goal: comfort measures. Note: Analgesics used conservatively - to prevent depression of fetus/neonate.
  4. Goal: support effective coping techniques. Encourage support Lamaze (or other) techniques - coach, as necessary; discourage hyperventilation.
  5. Goal: health teaching - for severe preterm birth.
    1. Discuss need for episiotomy, possibility of outlet forceps-assisted birth - to reduce stress on fetal head, or
    2. Prepare for cesarean birth - to reduce possibility of fetal intraventricular hemorrhage.
    3. Rationale for avoiding use of medications to reduce contraction pain.
10. Immediate care of neonate :
  1. Goal: safeguard status.
    1. Stabilize environmental temperature - to prevent chilling (isolette or other controlled-temperature bed).
    2. Suction, oxygen, as needed; may need intubation.
    3. Parenteral fluids, as ordered - to support normal acid-base balance, pH; administer antibiotics, as necessary.
    4. Arrange transport to high-risk facility, as necessary.
  2. Goal: continuous monitoring of status.
    1. Electronic monitors - to observe respiratory and cardiac functions.
    2. Blood samples- to monitor blood gases, pH, hypoglycemia.
11. Postpartum care: Goal: emotional support.
  1. Facilitate attachment - photos if baby transferred or mother unable to visit.
  2. If couple, foster sense of mutual experience and closeness.
  3. Help her/them maintain a positive self-image.
  4. Encourage touching of infant before transport to nursery or high-risk facility; father/ partner may accompany infant and report back to mother.
  5. Encourage early contact- to facilitate mother’s need to ventilate her feelings.
  6. Assist parent(s) with grieving process, if necessary.
  7. Refer to support group if necessary.
12. Other - as for any postpartum woman.
13. Evaluation/outcome criteria:
  1. Woman verbalizes understanding of medical/ nursing recommendations and treatments.
  2. Woman complies with medical/nursing regimen.
  3. Woman experiences no discomfort from side effects of therapy.
  4. Woman experiences successful outcome - labor inhibited.
  5. Woman carries pregnancy to successful termination.
  6. If preterm birth occurs, woman copes effectively with outcome (physiologically compromised neonate, neonatal death).