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

10. 5. Maternal Position
• Up right position; using gravity
• Lie down position; supine hypotensive
syndrome

11. 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.

13. Power(자궁압력)

14. Descent

15. 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.

16. Complications
1. Maternal exhaustion
2. Infection
3. Fetal distress
4. Postpartum hemorrhage

17. 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.

20. Dilatation of cervix

21. Effacement of Cervix

22. 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

23. 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.

24. 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.

25. Evaluation
A. Verbalizes increased comfort
B. Verbalizes understanding of procedures

26. 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.

27. 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.

28. 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

29. 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.

30. 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

31. Cord
Prolapse

32. Nursing Assessment
1. Evaluate maternal respiratory status.
2. Inspect abdomen and evaluate uterine
height and compare with previous findings.

33. 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

34. 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.

35. 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.

36. 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.

37. 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.

38. 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.

39. 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

40. Preterm Premature Rupture of
Membranes
(PPRM)
OR
Premature Rupture of
Membranes
(PRM)

41. 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.

42. 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.

43. 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.

44. 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

45. 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.

46. Complications
1. Preterm labor
2. Prematurity and associated complications
3. Cord prolapsed
3. Maternal infection—chorioamnionitis
4. Fetal/neonatal infection

47. 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.

48. Nursing Diagnoses
• A. Risk for Infection related to ascending
bacteria
• Also see Preterm Labor,

49. 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.

50. Evaluation
A. Free from signs of infection

51. 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.

53. 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

54. 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

55. • NURSING ALERT:
Prolapse should be suspected with fetal
heart rate deceleration after rupture of the
membranes.

56. Management
1. Delivery of the fetus as soon as possible
2. Relief of pressure from the umbilical cord

57. 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

59. 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.

60. 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

61. Preterm Labor
Greatest risk of
preterm labor is
delivery of a
premature baby.

64. Risk Factors for Preterm Birth
1. More than one fetus
2. History of preterm birth
3. Abnormal uterus or cervix

65. Preterm Labor
Other
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

66. 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.

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

68. Preterm Labor
• Treatment Approaches
1. Bedrest
2. Hydration
3. Medications

69. 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

70. Complications
1. Prematurity and associated neonatal
complications, such as lung immaturity

71. Nursing Diagnoses
A. Anxiety related to medication and fear of
outcome of pregnancy
B. Diversional Activity Deficit related to
prolonged bed rest

72. 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

73. 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.

74. 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