Intrapartal Complications - Jeceli

8/8/2019 Intrapartal Complications - Jeceli

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MS. JECELI ALVIOLA NOBLEZA, BSN-RN



GENERAL OBJECTIVE

Critically analyze the nursing implications

of the client with intrapartal complications



SP ECIFIC OBJECTIVESExplain abnormalities that may result in dysfunctionallabor.y Describe maternal and fetal risks associated with premature

rupture of the membranes.y Analyze factors that increase a woman¶s risk for preterm labor.y Explain maternal and fetal problems that may occur if pregnancy

persists beyond 42 weeks.y Describe common intrapartum emergencies

y Explain therapeutic management of each intrapartumcomplication.

y Apply the nursing process to care of women with intrapartumcomplications and to their families.



INTRAPARTUMpertaining to theperiod of labor and

birth.





DY SFUNCTIONAL LABORDysfunctional labor is one that does notresult in normal progress of cervical

effacement, dilation, and fetal descent.

Dystocia is a general term that describesany difficult labor or birth.



A dysfunctional labor mayresult from problems with:

powers of labor

the passenger the passagethe psyche,

or a combination of these.

4 P¶s



An operative birth (vacuum extractor± or forceps-assisted or cesarean) may be needed if dysfunctional labor does not resolve or if fetal or maternal compromise occurs.

Signs that indicate the need for an operative birthy fetal heart rate (FHR) patternsy fetal acidosis, andy meconium passage.

Maternal exhaustion or infection may occur,especially during long labors.



Problems of th e PowersT he powers of labor may not beadequate to expel the fetus

ineffective contractionsineffective maternal pushing efforts .



Ineffective Contractions

Maternal fatigueMaternal inactivity

Fluid and electrolyteimbalanceHypoglycemiaExcessive analgesia or anesthesia

Maternal catecholaminessecreted in response to stressor painDisproportion between thematernal pelvis and the fetalpresenting partUterine overdistention,(multiple gestation or hydramnios)

Possible causes:



T wo patterns of ineffective uterinecontractions arey Hypotonic dysfunctiony hypertonic dysfunction



H ypotonic Dysfunction H ypertonic Dysfunction

CON T RAC T IONS

Coordinated but weak.Become less frequent and shorter in duration.Easily indented at peak.Woman may have minimal discomfortbecause the contractions are weak.

Uncoordinated, irregular.Short and poor intensity, but painful andcramp-like.

UT ERINE RES T ING T ONE

Not elevated. Higher than normal.PHASE OF LABOR

Active. T ypically occurs after 4-cm dilation.More common than hypertonic dysfunction.

Latent. Usually occurs before 4-cm dilation.Less common than hypotonic dysfunction.

T HERAPEU T IC MANAGEMEN T

Amniotomy (may increase the risk of infection).Oxytocin augmentation.Cesarean birth if no progress.

Correct cause if it can be identified.Light sedation to promote rest.Hydration.Tocolytics to reduce high uterine tone andpromote placental perfusion.



NURSING CA RE

Interventions related to amniotomyand oxytocin augmentation.Encourage position changes. An

abdominal binder may help direct thefetus toward the mother¶s pelvis if her abdominal wall is very lax.

Ambulation if no contraindication andif acceptable to the woman.Emotional support: Allow her to

ventilate feelings of discouragement.Explain measures taken to increaseeffectiveness of contractions. Includeher partner/family in emotional supportmeasures because they may haveanxiety that will heighten the woman¶sanxiety.

Promote uterine blood flow: side-lyingposition.Promote rest, general comfort, and

relaxation.Pain relief.Emotional support: Accept the reality

of the woman¶s pain and frustration.Reassure her that she is not being

childish.Explain reason for measures to break

abnormal labor patterns and their goal/expected results. Allow her to ventilateher feelings during and after labor.Include partner/family



Ineffective Maternal Pushing may result from:y Use of incorrect pushing techniques or inappropriate

pushing positionsy

Fear of injury because of pain and tearing sensations feltby the mother when she pushesy Decreased or absent urge to pushy Maternal exhaustion

y Analgesia or anesthesia that suppresses the woman¶surge to pushy Psychological unreadiness to ³let go´ of her baby



Nu rsing ca re:1 . Upright positions such as

- squatting - add the force of gravity to her efforts.- Semisitting, side-lying, and pushing while sitting onthe toilet are other options.

2. Regional analgesia methods may restrictpossible maternal positions and may alter awoman¶s spontaneous urge to push.

3. Encouraging to push with intermittentcontractions also allows her to maintain

adequate pushing effort.4. Oral or intravenous fluids provide energy

for the strenuous work of second-stagelabor.



adds gravity to her pushing efforts.

M c R obert's maneuver A B S uprapubic pressure



B. Suprapubic pressure by an assistant pushesthe fetal anterior shoulder downward todisplace it from above the mother¶s symphysispubis.

Fundal pressure should not be used, becauseit will push the anterior shoulder more firmlyagainst the mother¶s symphysis.



Problems With th e Pa ssengerFetal sizeFetal presentation or position

Multifetal pregnancyFetal anomalies



Frank breech Full breech Single footling breech



Shoulder presentation(transverse lie)



F etal SizeMacrosomiay infant weighs more than 4000 g (8.8 lb) at birth.

Sh oulder Dystociay Delayed or difficult birth of the shoulders may occur as

they become impacted above the maternal symphysispubis.



Ab normal F etal Presentation or Position An unfavorable fetal presentation or position may interfere with cervical

dilation or fetal descent.



Multifetal Pregnancy U terine overdistentionpotential for fetal hypoxia during labor

is greater.



T wins can present in any combination of presentations and positions.



F etal Anomalieshydrocephalus or a large fetal tumor y may prevent normal descent of the fetus.

Abnormal presentations , such as breech or transverse lie, are also associated with fetalanomalies.

A cesarean birth is scheduled if vaginal birthis not possible or if it is inadvisable.



Problems of th e Pa ss a geDysfunctional labor may occur because of variations in the maternal bony pelvis or

because of soft tissue problems that inhibitfetal descent.P elvisMaternal S oft Tissue Obstructions



G ynecoid Anthropoid Android Platypelloid

5 0% 25 % White5 0% Nonwhite

30% 3%

Round, cylindric shapethroughout. Wide pubicarch (90 degrees or greater).

Long, narrow oval. Anteroposterior diameter is longer than transversediameter. Narrowpubic arc

Heart- or triangular-shaped inlet. Narrowdiameterst hroughout.Narrow pubic arch.

Flattened: wide, shortoval. T ransversediameter wide, butanteroposterior diameter short.Wide pubic arch.



Maternal Soft Tissue O b structionsa full bladder is a common soft tissueobstruction.y Bladder distention reduces available space in

the pelvis and intensifies maternal discomfort. Assessed for bladder distention andencouraged to void every 1 to 2 hoursCatheterization may be needed if she

cannot urinate or if she receives regionalblock analgesia suchas an epidural



Problems of th e Psy ch e A perceived threat caused by pain, fear,nonsupport, or one¶s personal situation can

result in great maternal stress and interferewith normal labor progress.



R esponses to excessive or prolonged stress, however,

interfere with labor in several ways :1 . Increased glucose consumption reduces the energysupply available to the contracting uterus.

2. M aternal catecholamines can impair labor by interfering

with adequate uterine contractility. Maternal blood supply tothe placenta may also be reduced.

3. Labor contractions and maternal pushing efforts areless effective because these powers are working againstthe resistance of tense abdominal and pelvic muscles.

4. Pain perception is increased and pain tolerance isdecreased , which further increase maternal anxiety andstress.



Gener a l nu rsing me a s u res involve:1 . Establishing a trusting relationship with the

woman and her family2. Making the environment comfortable by

adjusting temperature and light3. Promoting physical comfort, such as

cleanliness4. Providing accurate information5 . Implementing non-pharmacologic and

pharmacologic pain management



Abnorm a l La bor D u rat ion An unusually long or short labor may resultin maternal, fetal, or neonatal problems.



Prolonged La b or (normally) active phase of labor y cervical dilation

1.2 cm per hour in the nullipara1 .5 cm per hour in the parous woman

y Descent of the fetal presenting part1 .0 cm per hour in the nullipara

2.0 cm per hour in the parous woman



Po ten t ia l m at ern a l a nd fe ta l p roblems in p rolonged la bor inc lu de:

Maternal infection, intrapartum or postpartum

Neonatal infection, which may be severe or fatalMaternal exhaustion

Higher levels of anxiety and fear during a

subsequent labor



Nu rsing me a s u res

promotion of comfortconservation of energy

Emotional supportposition changes thatfavor normal progressassessments for infection.

observation for signsof intrauterine infection

and for compromisedfetal oxygenation

mother fetus



Precipitate La b or rapid birth that occurs within 3 hours of labor onset.

T here is often an abrupt onset of intensecontractions rather than the more gradualincrease in frequency, duration, andintensity that typifies most spontaneous

labors.



T he fetus may suffer direct trauma , such asintracranial hemorrhage or nerve damage,

during a precipitate labor.

T he fetus may become hypoxic becauseintense contractions with a short relaxationperiod reduce time available for gasexchange in the placenta.



Priori ty nu rsing ca repromotion of fetal oxygenationy Side-lying position

y Oxygen administrationy Stop oxytociny Tocolytic drud should be ordered

maternal comfort.y Coping skills - breathing techniquesy Remain with the client





IUI is most often caused by infectionascending from the vagina and the cervix

T he most common bacteria in spontaneouspreterm labor with intact membranesare U reaplasma urealyticum, Mycoplasmahominis, Gardnerella vaginalis ,peptostreptococci, and bacteroides species

y (Hillier et al. 1 988, Gibbs et al. 1 992, Krohn et al. 1 99 5 , Goldenberg et al. 2000).



chorioamnionitis and fetal infectiony group B streptococci and E scherichia coli



Signs Asso c iat ed With I n trapa r tu m Infe ct ionFetal tachycardia (> 16 0 beats per minute

[bpm])

Maternal fever (38º C, or 1 00.4º F)

Foul- or strong-smelling amniotic fluid

Cloudy or yellow amniotic fluid





In terven tionsNurses should wash their hands before and after each contact with the woman and her infant toreduce transmission of organisms.

Use gloves and other protective wear to preventcontact with potentially infectious secretions beforeand after birth (Standard Precautions).

Limit vaginal examinations to reduce transmission

of vaginal organisms into the uterine cavity, andmaintain aseptic technique during essential vaginalexaminations.



Keep underpads as dry as possible toreduce the moist, warm environment thatfavors bacterial growth.

Periodically clean excessive secretions fromthe vaginal area in a front-to-back motion tolimit fecal contamination and promote themother¶s comfort.

Prophylactic antibiotics to prevent neonatalsepsis are often given.





Preterm labor begins after the 20th weekbut before the end of the 37th week of

pregnancy.Preterm labor, however, may result in thebirth of an infant who is ill equipped for extrauterine life.



Mat ern a l Risk Fact ors for Pre term La borM

edicalH

istory ObstetricH

istoryLow weight for heightObesityUterine or cervical anomalies,uterine fibroidsHistory of cone biopsyDiethylstilbestrol (DES)exposure as a fetusChronic illness (e.g., cardiac,

renal, diabetes, clottingdisorders, anemia,hypertension)Periodontal disease

Previous preterm labor Previous preterm birthPrevious first-trimester abortions (>2Previous second-trimester abortionHistory of previous pregnancy losses(2 or more)Incompetent cervixCervical length 2 5 mm (2. 5 cm) or

less at midtrimester of pregnancyNumber of embryos implanted(assisted reproductivetechniques [AS T ])



Present Pregnancy Lifestyle and DemographicsUterine distention (e.g., multifetalpregnancy, hydramnios)

Abdominal surgery duringpregnancyUterine irritabilityUterine bleedingDehydrationInfection

AnemiaIncompetent cervix

PreeclampsiaPreterm premature rupture of membranes (PPROM)Fetal or placental abnormalities

Little or no prenatal carePoor nutrition

Age 1 8 yr or 40 yr Low educational levelLow socioeconomic statusSmoking 1 0 cigarettes dailyNonwhiteEmployment with long hoursand/or long standing

Chronic physical or psychologicalstressIntimate partner violenceSubstance abuse



Ma nifes tat ionsUterine contractions that may or may notbe painful; the woman may not feelcontractions at all.

A sensation that the baby is frequently³balling up .´Cramps similar to menstrual cramps.

Constant low backache; intermittent or irregular mild low back pain



con t· n m a nifes tat ionsSensation of pelvic pressure or a feelingthat the baby is pushing down .Pain, discomfort, or pressure in the vulva or

thighs.Change or increase in vaginal discharge(increased, watery, bloody).

Abdominal cramps with or without diarrhea. A sense of ³just feeling bad´ or ³comingdown with something.´



Ther ap e ut ic Ma na gemen tManagement focuses on

identifying preterm labor early

delaying birthaccelerating fetal lung maturity



Identifying Preterm Lab

or T he reason to identify preterm labor early is to delay birth, thus promoting

further fetal maturation.



c riteri a a re s u gges ted for p re term la bor:

1 . Gestation from 20 weeks to before 37weeks

2. Persistent uterine contractions (four in 20min or eight in 6 0 min), and:

² Documented cervical change, or ² Cervical effacement of 80% or greater, or

² Cervical dilation of greater than 1 cm



Stopping Preterm La b or Once the diagnosis of preterm labor is made,management focuses on stopping the uterineactivity before it reaches the point of no return,

usually after 3 cm dilation.If preterm delivery is inevitable, therapy is directedtoward reducing the infant¶s risk for respiratorydistress.



Treating Infectionsy Infections associated with a more rapid preterm

birth are likely if the membranes have ruptured.y Broad-spectrum antibiotics, such as ampicillin,

penicillin, aminoglycoside, clindamycin or metronidazole

R estricting Activity y side-lying position - increases placental blood flow

and reduces fetal pressure on the cervix



H ydrating t h e Womany Hydration to stop preterm contractions has not

been shown to be beneficial for all women.

yHowever, dehydration may contribute to uterineirritability for some women.



Tocolyticsy usually delay preterm birth rather than prevent it.y T his delay may provide time to allow the use of

corticosteroids to accelerate fetal lung maturity or totransfer the woman to a facility with a neonatal

intensive care unit that is appropriate for the gestationof her fetusy Four types of drugs are used for tocolytic therapy:

(1 ) magnesium sulfate,(2) beta-adrenergics,(3) prostaglandin synthesis inhibitors(4) calcium antagonists.



T OCOLY T IC D RUGS

M agnesiumS ulfate

used in the management of pregnancy-induced hypertension toprevent seizures

Beta -Adrenergics Ritodrine (Yutopar ) is a beta-adrenergic currently approved by theU.S. Food and Drug Administration (FDA) to stop pretermcontractions.Terbutaline (Brethine), considered investigational to treat preterm

labor, is the more widely used drug in this class because it has alower cost, longer duration of action between doses, and the abilityto promptly administer a dose by the subcutaneous rather than oralroute if needed (AAP & ACOG, 2002).

ProstaglandinS ynthesisInhibitors

Prostaglandins - stimulate uterine contractions, drugs may be usedto inhibit their synthesis. Indomethacin is the drug in this class that

is most often used for tocolysis.

Calcium Blockers Nifedipine (Procardia ) is a calcium channel blocker often given for problems such as chronic hypertension. Calcium is essential for muscle contraction in smooth muscles such as the uterus, soblocking calcium reduces the muscular contraction.



Accelerating

F etal Lung Maturity

Administration of corticosteroid therapy tothe mother before preterm birth reduces the

severity of complications associated withimmature gestation.





Rupture of the amniotic sac before theonset of true labor, regardless of length

of gestation, is called premature ruptureof the membranes (P RO M).



Et iology (ACOG, 2001; Ga rite , 2004) :

Infections of the vagina or cervixy chlamydia, gonorrhea, group B

streptococcal infection, andGardnerella vaginalis infection

Amniotic sac with a weak

structureChorioamnionitis (intraamnioticinfection)y may be associated with group B

streptococci, N eisseriagonorrhoeae, Listeriamonocytogenes, or species such asMycoplasma, Bacteroides, andU reaplasma in the amniotic fluid

HydramniosFetal abnormalities or malpresentationIncompetent cervix

Overdistention of theuterusMaternal hormonalchanges

Recent sexual intercourseMaternal stressMaternal nutritionaldeficiencies



Com p licat ionsT he mother is at higher risk for postpartuminfection.

T he newborn is at greater risk for sepsisafter birth, with the most immature preterminfants having the greatest risk for thesystemic infection.



Ther ap e ut ic Ma na gemen t

fetus is 35 weeks gestation or morey If labor does not begin spontaneously, the woman¶s

pregnancy is at or near term, and her cervix is favorable,labor induction may be done.

y If the cervix is not favorable and no infection is present,induction may be delayed 24 hours or longer to allowcervical softening and administration of drugs to combatinfection associated with early membrane rupture.

y If induction is unsuccessful or if infection or other complications develop, a cesarean birth is most common.



woman is 34 weeks¶ gestation or earlier:y the physician weighs the risks of

infection against the infant¶s risk for complications of prematurity.

y Ceasarean birth is more common if delivery at the earlier gestation isneeded.



Mat ern a l An tibio tics AmpicillinGentamicin

Erythromycinclindamycin,cephalosporin antibiotic,

piperacillin



Nu rsing Consider at ionsObserve for signs of infection

Home management: Avoid sexual intercourse, orgasm, or insertion of anything into the vaginay increases the risk for infection, caused by ascending

organisms, and can stimulate contractions.

Avoid breast stimulation if the gestation is

pretermy it may cause release of oxytocin from the posterior pituitary and thus stimulate contractions.



Take her temperature at least four times aday, reporting any temperature of more than37.8° C ( 1 00° F).Maintain any activity restrictionsrecommended.Note and report uterine contractions.



END«

Intrapartal Complications - Jeceli

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