Intrapartum

Complications

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Intrapartum Complications

• During the intrapartum period the client must

be monitored carefully for complications, some
of which can be life-threatening for the mother
of fetus.
• Dystocia
• Lacerations,
• Instrumental Delivery
• Cesarean Section (C/S)

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DYSTOCIA

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Intrapartum Complications
DYSTOCIA
Dystocia is a difficult or abnormal labor. In many
cases, surgical intervention is required to safely
deliver the fetus.

Possible causes
 Contracted pelvis
 Obstructive tumors
 Malpresentation of the fetus
 Malformation of the fetus
 Hypertonic uterine patterns
 Hypotonic uterine patterns

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DYSTOCIA
Assessment findings
 Arrested descent
 Hypertonic
contractions
 Hypotonic
contractions
 Prolonged active
phase
 Prolonged
deceleration phase
 Protracted latent
phase
 Uncoordinated
contractions
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DYSTOCIA
Diagnostic evaluation
 Contraction monitoring reveals hypotonic or
hypertonic contractions and progression of labor.
 Abdominal and vaginal examinations are used to
determine fetal presentation.
 Ultrasonography confirms fetal presentation.
Treatment
 Amniotomy (artificial rupture of membranes)
 Fluid hydration
 Cesarean delivery
 Analgesic (or to relax hypertonic contractions):
morphine sulfate
 Labor augmentation: oxytocin
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DYSTOCIA
Nursing diagnoses
 Risk injury
 Anxiety
 Deficient knowledge (client and family members)

Planning and goals

 The client will have decreased fear during labor
because of health care and personal support.
 The client and her fetus will remain hemodynamically
stable during labor and delivery.
 The client will have increased knowledge of all
circumstances of labor and delivery.

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DYSTOCIA
Implementation
 Administer I.V. fluids to maintain adequate hydration
of the client and her fetus.
 Monitor fetal heart tones and vital signs to evaluate
hemodynamic status.
 Tell the client to remain in a side-lying position to
provide increased perfusion to the fetus.
 Answer all questions and findings to decrease anxiety
and assist her and her family members in
understanding the status of labor and planned
treatment.
 Be supportive of the client and her family to decrease
fear of complications.
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DYSTOCIA
Evaluation
 The client experience less fear.
 The client and fetus remain hemodynamically stable.
 The client has increased knowledge regarding her
labor.

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Lacerations
Laceration refers to tears in the perineum, vagina, or
cervix from the stretching of tissue during deliver. A
laceration is classified as first, second, third, or fourth
degree:
 A first-degree laceration involves the vaginal mucosa
and the skin of the perineum and fourchette.
 A second-degree laceration involves the vagina,
perineal skin, fasciae, levator ani muscle, and perineal
body.
 A third-degree laceration involves the entire
perineum and the external anal sphincter.
 A fourth-degree laceration involves the entire
perineum, rectal sphincter, and portions of the
mucosa. 10
Lacerations
Assessment findings
 Increased vaginal bleeding after delivery of
placenta
 Visualization of the tear

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Lacerations
Diagnostic evaluation
 Inspection of the affected area will reveal the
extent of laceration.

Treatment
 Surgical repair of episiotomy
 Administration of appropriate pain medication

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Lacerations
Nursing diagnoses
 Risk for deficient fluid volume
 Acute pain

Planning and goals

 The client will remain hemodynamically stable.
 The client will have relief from pain.

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Lacerations
Implementation
 Monitor vital sign after delivery to evaluate signs of
shock.
 Evaluate the amount of vaginal bleeding to determine
of surgical repair is warranted (if not done) or if the
client needs blood replacement.
 Administer appropriate pain medication to make the
client more comfortable.

Evaluation
 The client remains hemodynamically stable.
 The client has an expected amount of post-delivery
vaginal bleeding.
 The client verbalizes relief from pain.
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Instrumental
Delivery

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Instrumental Delivery
• FORCEPS DELIVERY are designed for rotating or
extracting the fetus.
• Most forceps are placed on each side of the fetal
vertex and others are utilized for special
considerations (Pipers: breech extraction).
• Forceps consist of two pieces: a right blade,
which is slipped into the right side of the
mother’s pelvis, and a left blade, which is slipped
into the left side.
• Unfortunately, forceps increase the diameter of
the presenting part, which may hinder delivery.
Special training and skill are required.

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FORCEPS DELIVERY
Types of Forceps Deliveries
ACOG definitions for obstetric forceps:

Outlet Forceps
1. Scalp is visible at the introitus without separating
labia.
2. Fetal skull has reached pelvic floor.
3. Sagittal suture in anteroposterior diameter or
right or left occiput anterior or posterior position.
4. Fetal head is at or on perineum.
5. Rotation does not exceed 45 degrees.

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FORCEPS DELIVERY
Types of Forceps Deliveries
ACOG definitions for obstetric forceps:
Low Forceps
1. Leading point of fetal skull is at station 2 cm or
above and not on the pelvic floor.
a. Rotation is less than 45 degrees (left or right
occiput anterior to occiput anterior or left or right
occiput posterior to occiput posterior).
b. Rotation is greater than 45 degrees.

Mid Forceps
1. Station is above 2 cm but head is engaged.

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FORCEPS DELIVERY
Indications for Forceps Delivery
1. No indication is absolute. The fetal head must be
engaged and the cervix fully dilated.
2. Prolonged second stage labor
a. Nulliparous women: lack of continuing progress
for 3 hours with regional anesthesia or 2 hours
without regional anesthesia
b. Multiparous women: lack of continuing progress
for 2 hours with regional anesthesia or 1 hour
without regional anesthesia
3. Suspicion of immediate or potential fetal
compromise
4. Shortening of the second stage for maternal benefit
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FORCEPS DELIVERY

Contraindications
1. Confirmed CPD
2. Face or brow presentation
3. Incomplete dilation of the cervix
4. Unengaged fetal head
5. Preterm infant

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FORCEPS DELIVERY
Management
1. The woman is placed in the lithotomy position.
2. The bladder is usually emptied by catheterization.
3. Regional anesthesia is most frequently used;
pudendal block can also be used.
4. The neonatal staff is in attendance at delivery.
5. An episiotomy may be performed prior to
manipulation.
6. Each blade is placed bilaterally over the fetal ear;
avoiding the face.
7. Gentle traction is administered in a downward
motion.

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FORCEPS DELIVERY

Complications
Maternal
1. Lacerations of the vulva, cervix, vagina, and rectum
2. Fracture of coccyx
3. Extensions of an episiotomy that may extend to the
rectum
4. Bladder trauma, uterine rupture
5. Postpartum infection, postpartum hemorrhage
secondary to uterine atony
6. Anemia secondary to uterine atony/hemorrhage

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FORCEPS DELIVERY
Complications

Fetal
1. Bruising
2. Cephalohematoma
3. Facial paralysis
4. Brachial palsy
5. Skull fracture
6. Ocular trauma
7. Intracranial hemorrhage
8. Brain damage
9. Cord compression

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FORCEPS DELIVERY

Nursing Assessment
1. After application of the forceps, the FHR should be
evaluated continuously or at least every 5 minutes
until delivery.
2. Evaluate maternal sensation.
3. Evaluate bladder fullness—bladder should be empty
before the application of the forceps.
4. Ensure that sterile technique is maintained.

Nursing Diagnoses
• Anxiety related to fetal outcome
• Acute Pain related to procedures

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FORCEPS DELIVERY
Nursing Interventions
Promoting Comfort
1. Encourage use of breathing and relaxation
techniques.
2. Make sure bladder is completely empty.
3. Encourage relaxation between contractions and use
of abdominal muscles and pushing with the
contractions.
4. Use blankets and pillow supports when positioning
the woman for delivery.

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FORCEPS DELIVERY

Nursing Interventions
Decreasing Anxiety
1. Explain how the forceps are applied.
2. Explain that a sensation of pressure will be felt.
3. Answer any questions.
4. Stay with the woman, and provide guidance
during the delivery process.

Evaluation: Expected Outcomes

• Verbalizes concerns regarding forceps; responds
to instructions
• Demonstrates increased level of comfort
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Instrumental Delivery

VACUUM EXTRACTION
• Vacuum extraction applies suction to the fetal
vertex to assist in delivery without increasing the
diameter of the presenting part.
• Advantages include ease of application and
ability; therefore, the procedure is gaining favor in
the United States.
• It is also associated with less maternal trauma and
less need for general or regional anesthesia.

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VACUUM EXTRACTION

Indications
1. Same as forceps.

Contraindications
1. CPD
2. Face or brow presentation
3 Breech presentation
4. Unengaged fetal head
5. Premature infant
6. Incomplete dilation of the cervix

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VACUUM EXTRACTION

Management
1. Fetus is in vertex presentation.
2. The woman is in the lithotomy position.
3. The bladder is usually catheterized.
4. Evaluate progress with suction.
5. Anesthesia may be indicated.
6. Unsuccessful extraction is followed by a
cesarean delivery.
7. Neonatal staff is in attendance at delivery.

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VACUUM EXTRACTION
Complications
Complications are usually less frequent and less severe
with vacuum extraction than with forceps.

Maternal
Lacerations of the cervix or vagina
Fetal
1. Cephalohematoma
2. Caput succedaneum (swelling of the scalp) from the
vacuum
3. Intracranial hemorrhage
4. Retinal hemorrhage
5. Abrasions
6. Subgaleal hemorrhage
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VACUUM EXTRACTION
Nursing Assessment
1. After application of the vacuum extractor, the FHR
should be evaluated at least every 5 minutes or
continuously until delivery.
2. Evaluate maternal sensation.
3. Evaluate bladder fullness—bladder should be
empty before the application of the vacuum
extractor.
4. Make sure sterile technique is maintained.
5. Monitor the vacuum pressure of the equipment
according to your facility’s protocol.

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VACUUM EXTRACTION
Nursing Assessment
6. Monitor “pop-offs” (vacuum extractor cup pops off
the fetal head); if three pop-offs have occurred, other
options (forceps, cesarean) should be considered.

Nursing Interventions
• Same as for forceps delivery.

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 Cesarean
Section (CS)
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Cesarean Section (C/S)

• Cesarean delivery is the planned or emergency

removal of the neonate from the uterus through
an abdominal incision.
• The surgical incision may be midline and vertical
(classic), allowing easy access to the fetus, and is
usually the approach of choice in emergency
situations.
• A low-segment, transverse, or Pfannestiel’s
(bikini) incision is usually chosen in a planned
cesarean birth.

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Cesarean Section (C/S)

Indications for Cesarean Delivery

1. Maternal medical complications: asthma, chronic
hypertension, cardiac disease.
2. Labor complications: dystocia, malpresentation,
CPD, Category III FHR pattern, prolonged or arrest of
first or second stage of labor, early labor induction
prior to cervical ripening.
3. Obstetric complications: placenta previa, breech,
elective induction of nulliparous (50% higher risk
than spontaneous labor).

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Cesarean Section (C/S)
Indications for Cesarean Delivery
4. Possible indications for cesarean hysterectomy:
a. Ruptured uterus
b. Intrauterine infection
c. Postpartum hemorrhage: unresponsive to
conservative management options
d. Laceration of major uterine vessel
e. Severe dysplasia or carcinoma in situ of the cervix
f. Placenta accreta
g. Gross multiple fibromyomas
h. Uterine inversion unresponsive to manual
replacement

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Cesarean Section (C/S)
Management: Preoperative
1. Assess patient’s last intake of food, surgery
should be delayed for 6 to 8 hours following last
meal; consult anesthesia.
2. A blood sample should be typed and screened
and available to be crossmatched if needed; a CBC
is obtained.
3. Anesthesia, regional or general, depends on
indication for surgery.
4. Consents signed and witnessed.
5. A large-bore I.V. is established with D5LR or
normal saline infusion.

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Cesarean Section (C/S)
Management: Preoperative
6. Insert indwelling urinary catheter; may wait until
after anesthesia placement to minimize discomfort.
7. Administer an antacid; reduces gastric acidity
limiting complications should aspiration occur.
8. Antibiotics may be given prophylactically.

Management: Intraoperative
1. Patient is moved onto and secured to the operating
table.
2. Abdominal preparation is completed with Betadine
and air-dried.
3. Grounding pad for electrocautery unit is applied to
patient’s upper thigh.
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Cesarean Section (C/S)
Management: Intraoperative
4. Perform instrument, needle/knife, and lap pad
counts periodically: before, during, and after surgery.
5. Assist with anesthesia as needed.
6. Assist personnel with gowning and gloving.
7. Receive and perform neonatal assessment.
8. Maintain sterile integrity.
9. Remove drapes and assist with application of
dressing.
10. Assist patient to stretcher.

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Cesarean Section (C/S)
Management: Postoperative
1. Assist patient to postoperative recovery room.
2. Complete care or give report to postoperative care
provider.
3. Assist with patient stabilization as warranted by
patient’s condition.

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Cesarean Section (C/S)
Nursing Assessment
Before Delivery
1. Assess knowledge of procedure.
2. Perform admission assessment.
3. Obtain 20- to 30-minute fetal tracing strip to
assess fetal and uterine status (if needed).
4. Identify drug allergies; identify other allergies
(eg, latex, Betadine, tape).

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Cesarean Section (C/S)
Nursing Assessment: After Delivery
1. Assess maternal vital signs every 15 minutes the first
hour or more frequently as the patient’s condition
warrants.
a. Assess respiratory status: airway patency, oxygen
needs, rate/quality/depth of respirations,
auscultation of breath sounds, oxygen saturation
readings.
b. Circulation: BP, pulse, electrocardiogram (ECG)
monitoring for assessing dysrhythmias, color;
assess dressing for drainage.
c. LOC: orientation and response to verbal/tactile/
painful stimulation.
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Cesarean Section (C/S)
Nursing Assessment: After Delivery
2. Assess postpartum status (same intervals for
assessment): fundal position and contractions,
condition of incision and abdominal dressing,
maternal-neonatal attachment, lochia (color,
amount), neonate condition (if applicable); feeding
preferences.
3. Assess hourly intake and output (I.V., urine output)
and reestablishment of bowel sounds.
4. Perform pain assessment: evaluate level of
anesthesia, medications given (amount/time/results).

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Cesarean Section (C/S)

Nursing Diagnoses
• Anxiety related to surgical procedure
• Acute Pain related to surgical procedure
•Risk for Infection related to open abdominal
cavity
•Risk for Ineffective Parent/Infant Attachment
related to interruption in bonding process

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Cesarean Section (C/S)

Nursing Interventions
Relieving Anxiety
1. Explain the reason for the cesarean delivery.
2. Answer any questions.
3. Allow the support person to attend the birth if
appropriate.
4. Explain sensations of pressure that may be felt
during the
procedure; pain should be reported.
5. Explain procedures prior to initiation.
6. Inform patient and significant other of procedural
progress.

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Cesarean Section (C/S)
Nursing Interventions
Promoting Comfort
1. Encourage use of relaxation techniques after medication
has been given for pain.
2. Monitor for respiratory depression up to 24 hours after
epidural opioid administration.
3. Monitor and instruct patient on use of patient-controlled
anesthesia pump as applicable.
4. Use a back rub and a quiet environment to promote the
effectiveness of the medication.
5. Support and splint the abdominal incision when moving
or coughing and deep breathing.
6. Encourage frequent rest periods.
7. To reduce pain caused by gas, encourage ambulation or
use of rocking chair.
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Cesarean Section (C/S)
Nursing Interventions
Preventing Infection
1. Perform shaving or clipping of pubic hair per facility
guidelines.
2. Maintain sterile technique during surgery and use
sterile
technique when changing dressings postoperatively.
3. Provide perineal care along with vital signs every 4
hours or as needed.
4. Provide routine postoperative care measures to
prevent urinary or pulmonary infection.

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Cesarean Section (C/S)
Nursing Interventions
Promoting Effective Bonding
1. Encourage mother-child bonding as soon as possible.
2. Emphasize that adjustments to parenting under any
circumstances are necessary and normal

Evaluation: Expected Outcomes

• Verbalizes an understanding of the cesarean
delivery procedure and postdelivery care
• Reports relief of pain
• Has no signs of infection
• Participates in care of self and infant

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References
• Silvestri, L.A. (2014), “Saunders Comprehensive Review
for the NCLEX-RN Examination” Elsevier Publishing
• Nettina, S. (2010) “Lippincott Manual of Nursing
Practice.” 9th Edition. Wolters Kluwer Health. Lippincott
Williams & Wilkins.
• Springhouse Review for NCLEX-RN 6th edition. 2006.
Lippincott Williams and Wilkins.
• For images taken from https://www.google.com.sa
• Perry S, Hockenberry M, Lowdermilk D, Wilson D:
Maternal-child nursing care, ed 4, St. Louis, 2010,
Mosby.

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