Complications During the Intrapartal Period

4. Disorders affecting comfort, rest, mobility: dystocia
1. Definition - difficult labor.
2. General aspects (MOTHER, “3 P's”: Psych, Placenta, Position):
   1. Pathophysiology - see specific disorders.
   2. Etiology - due to effects of factors that affect the FETUS (also “3 P's”):
      1. POWER: forces of labor (uterine contractions, use of abdominal muscles).
         1. Premature analgesia/anesthesia.
         2. Uterine overdistention (multifetal pregnancy, fetal macrosomia).
         3. Uterine myomas.
      2. PASSAGEWAY: resistance of cervix, pelvic structures.
         1. Rigid cervix.
         2. Distended bladder.
         3. Distended rectum
         4. Dimensions of the bony pelvis: pelvic contractures.
      3. PASSENGER: accommodation of the presenting part to pelvic diameters.
         1. Fetal malposition/malpresentation.
            1. Transverse lie.
            2. Face, brow presentation.
            3. Breech presentation.
            4. CPD.
         2. Fetal anomalies.
            1. Hydrocephalus.
            2. Conjoined (“Siamese”) twins.
            3. Meningomyelocele
         3. Fetal size.
   3. Hazards:
      1. Maternal:
         1. Fatigue, exhaustion, dehydration - due to prolonged labor.
         2. Lowered pain threshold, loss of control - due to prolonged labor, continued uterine contractions, anxiety, fatigue, lack of sleep.
         3. Intrauterine infection - due to prolonged rupture of membranes and frequent vaginal examinations.
         4. Uterine rupture - due to obstructed labor.
         5. Cervical, vaginal, perineal lacerations - due to obstetric interventions.
         6. Postpartum hemorrhage - due to uterine atony or trauma.
      2. Fetal:
         1. Hypoxia, anoxia, demise - due to decreased O₂ concentration in cord blood.
         2. Intracranial hemorrhage - due to changing intracranial pressure.
3. Hypertonic dysfunction
   1. Pathophysiology - increased resting tone of uterine myometrium; diminished refractory period; prolonged latent phase:
      1. Nullipara - more than 20 hr.
      2. Multipara - more than 14 hr.
   2. Etiology - unknown. Theory - ectopic initiation of incoordinate uterine contractions.
   3. Assessment:
      1. Onset - early labor (latent phase).
      2. Contractions:
         1. Continuous fundal tension, incomplete relaxation.
         2. Painful.
         3. Ineffectual - no effacement or dilation.
      3. Signs of fetal distress
         1. Meconium-stained amniotic fluid.
         2. FHR irregularities.
      4. Maternal vital signs.
      5. Emotional status.
      6. Medical evaluation: vaginal examination, x-ray pelvimetry, ultrasonography - to rule out CPD.
   4. Analysis/nursing diagnosis:
      1. Pain related to hypertonic contractions, incomplete uterine relaxation.
      2. Anxiety/fear for self and infant related to strong, painful contractions without evidence of progress.
      3. Ineffective individual coping related to fatigue, exhaustion, anxiety, tension, fear.
      4. Impaired gas exchange (fetal) related to incomplete relaxation of uterus.
      5. Sleep pattern disturbance related to prolonged ineffectual labor.
   5. Nursing care plan/implementation:
      1. Medical management:
         1. Short-acting barbiturates (see Unit 10) - to encourage rest, relaxation.
         2. Intravenous fluids - to restore/maintain hydration and fluid-electrolyte balance.
         3. If CPD, cesarean birth.
      2. Nursing management:
         1. Goal: emotional support - assist coping with fear, pain, discouragement,
            1. Encourage verbalization of anxiety, fear, concerns.
            2. Explain all procedures.
            3. Reassure. Keep couple informed of progress.
         2. Goal: comfort measures.
            1. Position: side-lying - to promote relaxation and placental perfusion.
            2. Bath, back rub, linen change, clean environment.
            3. Environment: quiet, darkened room - to minimize stimuli and encourage relaxation, warmth.
            4. Encourage voiding - to relieve bladder distention; to test urine for ketones.
         3. Goal: prevent infection. Strict aseptic technique.
         4. Goal: prepare for cesarean birth if necessary.
   6. Evaluation/outcome criteria:
      1. Relaxes, sleeps, establishes normal labor pattern.
      2. Demonstrates no signs of fetal distress.
      3. Successfully completes uneventful labor.
4. Hypotonic dysfunction during labor
   1. Pathophysiology - after normal labor at onset, contractions diminish in frequency, duration and strength; lowered uterine resting tone; cervical effacement and dilation slow/ cease.
   2. Etiology:
      1. Premature or excessive analgesia/anesthesia (epidural block or spinal block).
      2. CPD.
      3. Overdistention (hydramnios, fetal macrosomia, multifetal pregnancy).
      4. Fetal malposition/malpresentation.
      5. Maternal fear/anxiety.
   3. Assessment:
      1. Onset - may occur in latent phase; most common during active phase.
      2. Contractions: normal previously, demonstrate:
         1. Decreased frequency.
         2. Shorter duration.
         3. Diminished intensity (mild to moderate).
         4. Less uncomfortable.
      3. Cervical changes - slow or cease.
      4. Signs of fetal distress - rare.
         1. Usually occur late in labor due to infection secondary to prolonged rupture of membranes.
         2. Tachycardia.
      5. Maternal vital signs may indicate infection (f temperature).
      6. Medical diagnosis - procedures: vaginal examination, x-ray pelvimetry, ultrasonography - to rule out CPD (most common cause).
   4. Analysis/nursing diagnosis:
      1. Knowledge deficit related to limited exposure to information.
      2. Anxiety/fear related to failure to progress as anticipated; fear for fetus.
      3. High risk for injury related to prolonged labor or ruptured membranes.
   5. Nursing care plan/implementation:
      1. Medical management:
         1. Amniotomy - artificial rupture of membranes.
         2. Oxytocin augmentation of labor - intravenous infusion of oxytocin to increase frequency, duration, strength, and efficiency of uterine contractions.
         3. If CPD, cesarean birth.
      2. Nursing management:
         1. Goals: emotional support, comfort measures, prevent infection - as for Hypertonic dysfunction.
         2. Other
   6. Evaluation/outcome criteria:
      1. Reestablishes normal labor pattern.
      2. Experiences successful birth of viable infant.