Nursing Care of A Family Experiencing A Complication of Labor or Birth

Chapter 23
Nursing Care of a Family

Experiencing a Complication of
Labor or Birth
POWER, PASSAGE, PASSENGER

OBJECTIVES
1. Describe the common deviations in the

power (i.e., force of labor), the passage,
or the passenger that can cause
complications during labor or birth.
2. Assess a woman in labor and during birth
for deviations from the usual labor
process.
3. Formulate nursing diagnoses related to
deviations in labor and birth.
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OBJECTIVES
4. Identify expected outcomes associated with

deviations from usual labor and birth across
differing healthcare settings.
5. Using the nursing process, plan nursing
care
6. Implement nursing care related to
complications of labor or birth, such as
preparing the family for a cesarean birth.

OBJECTIVES
7. Evaluate expected outcomes for

achievement and effectiveness of care.
8. Integrate knowledge of deviations from
normal labor and birth with the interplay of
nursing process.

INTRODUCTION
❖Dystocia—can arise from any of the four

main components of the labor process:
a) the power, or the force that propels the
fetus (uterine contractions);
b) the passenger (the fetus);
c) the passageway (the birth canal); or
d) the psyche (the woman’s and family’s
perception of the event) (Neal, Ryan,
Lowe, et al., 2015).

FOR A WOMAN WITH A LABOR OR BIRTH
COMPLICATION
❖Nursing Process Overview

❖ASSESSMENT
o conscientious assessment of labor progress and
to detect deviations of the fetal and uterine
changes.

COMPLICATION

❖NURSING DIAGNOSIS
❖Some examples might include:
1. Pain related to induction and labor procedures
2. Fear related to uncertainty of pregnancy
outcome
3. Anxiety related to medical procedures and
apparatus necessary to ensure health of woman
and fetus

COMPLICATION

4. Fatigue related to loss of glucose stores through
work and duration of labor
5. Ineffective coping related to lack of knowledge
or lack of preparation for labor
6. Fatigue related to prolonged labor

COMPLICATION

7. Risk for ineffective tissue perfusion related to
excessive loss of blood with complication of
labor
8. Risk for injury (maternal or fetal) related to
effect on woman and fetus of a labor
complication and treatment required

COMPLICATION

9. Risk for injury (maternal or fetal) related to
labor involving a multiple gestation pregnancy
10.Anticipatory grieving related to nonviable
monitoring pattern of fetus

COMPLICATION
❖OUTCOME IDENTIFICATION AND PLANNING
❖Encouraging a couple to clarify their
priorities when a complication occurs is
helpful.
❖For example,
o If fetal bradycardia occurs
▪ cesarean birth may become necessary.
o primary goal is really to have a healthy baby.

COMPLICATION
❖IMPLEMENTATION
o If a woman develops a complication of labor or
birth, actions to increase the fetal heart rate
(FHR) or to strengthen uterine contractions are
a priority and possibly an emergency.
o Interventions must be planned and performed
efficiently and effectively, based on the
individual circumstances.

COMPLICATION
❖OUTCOME EVALUATION
❖An evaluation of proposed outcomes may
reveal unhappiness because not every
woman who experiences a deviation from
the normal in labor and birth will be able to
give birth to a healthy child.
❖Some deviations will be too great;
❖Some interventions will not be maximally
effective because of individual
circumstances.
COMPLICATION
❖Some infants will die;
❖a few women may be left unable to bear
future children.
❖An evaluation may lead to a new analysis
that the couple’s chief need at that point is
to grieve for the child or for a lifestyle that
can no longer be theirs.

COMPLICATION
❖If the outcome is more positive, evaluate the
couple for signs that they are able to begin
interacting with their child after their
harrowing experience.
❖Examples of outcome achievement might
include:
1. Patient voices confidence she can cope with the
fear she feels about her fetus’s welfare.

COMPLICATION
❖Examples of outcome achievement might
include:
2. Patient demonstrates adequate energy during
course of labor to maintain effective breathing
patterns.
3. Patient’s blood pressure does not drop below
90/50 mmHg despite excessive blood loss with
delivery of the placenta.
4. Patient begins positive grieving behaviors in
response to loss of newborn.
COMPLICATIONS WITH
THE POWER
(THE FORCE OF LABOR)
Dysfunctional labor

Dysfunctional Labor
❖Dysfunction can occur at any point in labor,

but it is generally classified as:
1. primary (i.e., occurring at the onset of labor) or
2. secondary (i.e., occurring later in labor).

INEFFECTIVE UTERINE FORCE
❖Uterine contractions are the basic force that
moves the fetus through the birth canal.
❖They occur because of the interplay of the
contractile enzyme adenosine triphosphate
and the influence of major electrolytes such
as calcium, sodium, and potassium, specific
contractile proteins (actin and myosin),
epinephrine and norepinephrine, oxytocin (a
posterior pituitary hormone), estrogen,
progesterone, and prostaglandins.

21
Problems with the Powers

• HYPERTONIC CONTRACTIONS:
• Primary dysfunctional labor
• Hypertonic uterine contractions are marked by an
increase in resting tone to >15 mmHg (normal
resting tone is 5-10 mmHg)
• A resting pressure > 20 mmHg causes decreased
uterine perfusion
• Signs:
1. Painful & frequent contractions
2. Contractions are ineffective in causing cervical
dilation & effacement
3. Contractions occur in latent stage (cervical
dilation < 4 cm)
4. Uncoordinated contractions
22

• HYPERTONIC CONTRACTIONS:
• Primary dysfunctional labor
• Signs (cont’d)
5. Force of contraction may be in the midsection
of the uterus rather than in the fundus.
❖Uterus unable to apply downward pressure to push
the presenting part against the cervix.
6. Uterus may not relax completely between
contractions.
23
24

HYPERTONIC CONTRACTIONS
• Causes:
• More than one uterine pacemaker is stimulating
contractions or because the muscle fibers of the
myometrium do not repolarize or relax after a
contraction, thereby “wiping it clean” to accept a
new pacemaker stimulus.
oThey tend to be more painful than usual because
the myometrium becomes tender from constant
lack of relaxation and the anoxia of uterine cells
that results.
25

• Occurs in the latent phase of labour, with an
increase in the frequency of contractions and a
decrease in their intensity.
• Contractions are extremely painful because of

uterine muscle cell anoxia but are ineffective in
dilating and effacing the cervix, which leads to
maternal exhaustion.
• Contraction may interfere with uteroplacental

exchange and lead to fetal distress and even death.
• Contractions may be uncoordinated and involve

only portions of the uterus.
26

• Effects on woman:
1. Intense pain
2. Loss of control related to the intensity of pain
and lack of progress.
• although contractions are strong, they are
ineffective and are not achieving cervical
dilatation.
3. Exhaustion.
4. Dehydration.
27

• Potential fetal effect:
• Fetal asphyxia with meconium aspiration, and
death.
➢Uncoordinated contractions can occur so closely
together that they can interfere with the blood
supply to the placenta.
28

• Effects on woman:
1. Intense pain
2. Loss of control related to the intensity of pain and
lack of progress.
3. Exhaustion.
4. Dehydration.
• Management:
1. Warm bath or shower
2. Administration of analgesics:
1) Morphine
2) Meperidine (Demerol)
3) Nalbuphine (Nubain)
29

HYPOTONIC UTERINE DYSFUNCTION
• Secondary uterine inertia
• Signs:
1. Woman initially makes normal progress into the
active stage of labor, then
2. Contractions become weak & inefficient, or stop
altogether.
3. Uterus is easily indented, even at the peak of
contraction
4. IUP is insufficient (usually < 25 mmHg; normal
is 25-100 mmHg) for progress of cervical
effacement and dilation.
30

• Common Causes of Dysfunctional Labor
1. Primigravida status
2. Pelvic bone contraction that has narrowed the
pelvic diameter so a fetus cannot pass
(cephalopelvic disproportion [CPD]) such as
could occur in a woman with rickets
3. Posterior rather than anterior fetal position or
extension rather than flexion of the fetal head
4. Failure of the uterine muscle to contract properly
31

• Common Causes of Dysfunctional Labor
5. Overdistention of the uterus, as with a multiple
pregnancy, polyhydramnios, or an excessively
oversized fetus
6. A nonripe cervix
7. Presence of a full rectum or urinary bladder that
impedes fetal descent
8. A woman becoming exhausted from labor
9. Inappropriate use of analgesia (excessive or too
early administration)
32

• Management:
1. Ultrasound
2. Monitor FHR & pattern
3. Assess characteristics of amniotic fluid if
membranes have ruptured
33

• Management (cont’d):
4. Assess maternal well-being
5. If findings are normal:
▪ Encourage ambulation
▪ Hydrotherapy
▪ Enema
▪ Rupture of membrane
▪ Nipple stimulation
▪ Oxytocin infusion
Assessment of a Family Experiencing a
Complication of Labor or Birth #3

35
DYSFUNCTIONAL LABOR AND

ASSOCIATED STAGES OF LABOR
❖Dysfunction at the First Stage of Labor
involves
1. A prolonged latent phase,
2. Protracted active phase
3. Prolonged deceleration phase, and
4. Secondary arrest of dilatation.
36
Prolonged Latent Phase

• When contractions become ineffective
during the first stage of labor, a prolonged
latent phase can develop.
• latent phase that lasts longer than 20
hours in a nullipara or 14 hours in a
multipara.
• This may occur if the cervix is not “ripe” at the
beginning of labor.
• It may occur if there is excessive use of an
analgesic early in labor.
• With a prolonged latent phase, the uterus tends
to be in a hypertonic state.
37

• Relaxation between contractions is inadequate,
and the contractions are only mild (less than 15
mmHg on a monitor printout) and, therefore,
ineffective.
• One segment of the uterus may be contracting
with more force than another segment.
38
TONUS (Resting tone)

• TONUS : intra uterine pressure in between the contractions.
• During Quiescent (inactive) stage- 2-3mm Hg
• During first stage of labour 8-10mmHg.
❖Uterine Tone
• The lowest intrauterine pressure between contractions is
called resting tone
• Normal resting tone is 5-10 mmHg;
• during labor resting tone may rise to 10-15 mmHg
• Pressure during contractions rises to ~25-100 mmHg (varies
with stage)
• A resting pressure above 20 mmHg causes decreased
uterine perfusion
39

• Management of a prolonged latent
phase in labor that has been caused by
hypertonic contractions involves:
1. helping the uterus to rest
2. providing adequate fluid for hydration
3. pain relief with a drug such as morphine
sulfate.
4. Changing the linen and the woman’s
gown
40

• Management of a prolonged latent
phase in labor that has been caused by
hypertonic contractions involves:
5. Darkening room lights
6. decreasing noise and stimulation
• These measures usually combine to allow labor to become
effective and begin to progress. If it does not, …
7. a cesarean birth or amniotomy (i.e., artificial
rupture of membranes) and oxytocin infusion to
assist labor may be necessary.
41
Protracted Active Phase

• A protracted active phase is usually associated
with fetal malposition or cephalopelvic
disproportion (CPD) (the diameter of the fetal
head is larger than the woman’s pelvic diameters),
although it may reflect ineffective myometrial
activity.
• This phase is prolonged if cervical dilatation does
not occur at a rate of at least 1.2 cm/hr in a
nullipara or 1.5 cm/hr in a multipara, or if the
active phase lasts longer than 12 hours in a
primigravida or 6 hours in a multigravida
• If the cause of the delay in dilatation is fetal
malposition or CPD, cesarean birth may be
necessary.
42
Protracted Active Phase

• Dysfunctional labor during the dilatational
division of labor tends to be hypotonic in
contrast to the hypertonic action at the
beginning of labor.
• After an ultrasound to show CPD is not
present, oxytocin may be prescribed to
augment labor.
43
Prolonged Deceleration Phase

• A deceleration phase has become
prolonged when it extends beyond 3 hours
in a nullipara or 1 hour in a multipara.
• A prolonged deceleration phase most often
results from abnormal fetal head position.
• A cesarean birth is frequently required.
44
Secondary Arrest of Dilatation

• A secondary arrest of dilatation has
occurred if there is no progress in cervical
dilatation for longer than 2 hours.
• A cesarean birth may be necessary
45
Dysfunction at the Second Stage

of Labor
• Dysfunction that occurs with the second
stage of labor involves:
1. prolonged descent and
2. arrest of descent.
46
Prolonged Descent
• Prolonged descent of the fetus occurs if the rate
of descent is less than 1.0 cm/hr in a nullipara or
2.0 cm/hr in a multipara.
• It can be suspected if the second stage lasts over
2 hours in a multipara (Zheng, 2012).
• With both a prolonged active phase of dilatation
and prolonged descent, contractions have been
of good quality and duration, effacement and
beginning dilatation have occurred, but then the
contractions become infrequent and of poor
quality, and dilatation stops.
47
Prolonged Descent
• If everything else is within normal limits except for
the suddenly faulty contractions and CPD and
poor fetal presentation have been ruled out by
ultrasound,
• then rest and fluid intake, as advocated for hypertonic
contractions, also applies.
48
Prolonged Descent
• If the membranes have not ruptured,
1. rupturing them at this point may be helpful.
2. Intravenous (IV) oxytocin may be used to induce the
uterus to contract effectively (see later discussion on
induction of labor by oxytocin).
3. A semi-Fowler’s position, squatting, kneeling, or more
effective pushing may speed descent.
49
Arrest of Descent
• Arrest of descent results when no descent
has occurred for 2 hours in a nullipara or 1
hour in a multipara.
• occurs when expected descent of the fetus does
not begin or engagement or movement beyond 0
station does not occur.
• Cause: CPD.
• Management:
1. Cesarean birth usually is necessary.
2. If there is no contraindication to vaginal birth,
oxytocin may be used to assist labor
50

PRECIPITOUS LABOR
▪ Labor lasts < 3 hrs. from the onset of
contractions to the time of birth.
▪ during the active phase of dilatation, the rate
is greater than 5 cm/hr (1 cm every 12
minutes) in a nullipara or 10 cm/hr (1 cm every
6 minutes) in a multipara.
May result from:
▪ Hypertonic uterine contractions that are
tetanic in intensity.
51

PRECIPITOUS LABOR
• Maternal Complications:
1. Uterine rupture
2. Laceration of birth canal
3. Amniotic fluid embolism
4. Postpartum hemorrhage
52

PRECIPITOUS LABOR
• Fetal Complications:
1. Hypoxia
2. Intracranial hemorhage r/t rapid birth
53
Uterine Prolapse
• Uterine prolapse is falling or sliding of the
womb (uterus) from its normal position into
the vaginal area.
• Causes:
• Muscles, ligaments, and other structures hold the
uterus in the pelvis.
❖If these muscles and structures are weak, the uterus
drops into the vaginal canal (This is called prolapse).
• This condition is more common in women who
have had one or more vaginal births.
54
Uterine Prolapse
• Other things that can cause or lead to
uterine prolapse include:
1. Normal aging
2. Lack of estrogen after menopause
3. Anything that puts pressure on the
pelvic muscles, including chronic cough
and obesity
4. Pelvic tumor (rare)
❖Long-term constipation and the pushing
associated with it can make this condition worse.
55
Uterine Prolapse
Symptoms
1. Feeling like you are sitting on a small ball
2. Difficult or painful sexual intercourse
3. Frequent urination or a sudden urge to empty
the bladder
4. Low backache
5. Uterus and cervix that stick out through the
vaginal opening
6. Repeated bladder infections
7. Feeling of heaviness or pulling in the pelvis
8. Vaginal bleeding
9. Increased vaginal discharge
56
Uterine Prolapse
• Exams and Tests
• A pelvic examination is done while client is
bearing down, as if she was trying to push out
a baby.
❖This shows the doctor how far the uterus has
dropped.
• Mild uterine prolapse is when:
❖the cervix drops into the lower part of the vagina.
• Uterine prolapse is moderate when:
❖the cervix drops out of the vaginal opening.
57
Uterine Prolapse
• Mild uterine prolapse :
❖the cervix drops into the lower part of the vagina.
• Moderate uterine prolapse:
❖the cervix drops out of the vaginal opening.
• Complete uterine prolapse:
❖Cervix and the body of the uterus protrude
through the vagina, and the vagina is inverted.
58
UTERINE PROLAPSE
59
Uterine Prolapse
• Exams and Tests
❖The pelvic exam may also show that the bladder
and front wall of the vagina (cystocele), or rectum
and back wall of the vagina (rectocele) are
entering the vagina.
❖The urethra and bladder may also be lower in the

pelvis than usual.
60
Uterine Prolapse
• Treatment
1. LIFESTYLE CHANGES
1) Weight loss is recommended in obese women
with uterine prolapse.
2) Heavy lifting or straining should be avoided,
because they can worsen symptoms.
3) Coughing can also make symptoms worse.
❖If you a chronic cough, ask your doctor how to prevent
or treat it.
❖If you smoke, try to quit. Smoking can cause a chronic
cough.
61
Uterine Prolapse
• Treatment
2. VAGINAL PESSARY
❖This device hold the uterus in place. It may be
temporary or permanent.
❖Vaginal pessaries are fitted for each individual
woman.
❖Some are similar to a diaphragm used for birth
control.
❖Pessaries must be cleaned from time to time,
sometimes by the doctor or nurse.
62
Uterine Prolapse
Treatment
2. VAGINAL PESSARY
• Side effects of pessaries include:
1) Foul smelling discharge from the vagina
2) Irritation of the lining of the vagina
3) Ulcers in the vagina
4) Problems with normal sexual intercourse and
penetration
63
Uterine Prolapse
Treatment
3. SURGERY
• The specific type of surgery depends on:
1) Degree of prolapse
2) Desire for future pregnancies
3) Other medical conditions
4) The women's desire to retain vaginal function
5) The woman's age and general health
64
Uterine Prolapse
Treatment
3. SURGERY
1) sacrospinous fixation
• This procedure involves using nearby ligaments to
support the uterus.
2) vaginal hysterectomy
• is used to correct uterine prolapse.
• Any sagging of the vaginal walls, urethra, bladder, or
rectum can be surgically corrected at the same time.
65
Uterine Prolapse
Prevention
1. Kegel exercises
2. Estrogen therapy, either vaginal or oral, in
postmenopausal women
3. Weight loss
4. Avoid heavy lifting.
PROBLEMS WITH THE
PASSENGER
66
PROLAPSE OF THE UMBILICAL
CORD
• Loop of the umbilical cord slips down

in front of the presenting fetal part.
• Tends to occur with the following
conditions:
1.Premature rupture of membranes
2.Fetal presentation other than cephalic
3.Placenta previa
67
PROLAPSE OF THE UMBILICAL
CORD
• Tends to occur with the following

conditions:
4. Intrauterine tumors preventing the
presenting part from engaging.
5. Small fetus
6. CPD preventing firm engagement
7. Hydramnios
8. Multiple gestation.
68
Prolapse of umbilical cord
69
Assessment:
1.Cord may be felt as presenting part on

initial vaginal exam.
2.Sonogram
3.Cord may be visible at the vulva.
4.Variable deceleration FHR pattern
70
Therapeutic Management:
1. Aimed toward relieving pressure on the cord.

2. Place a gloved hand on the vagina and
manually elevating the fetal head off the cord.
3. Place woman in a knee-chest or Trendelenburg
position
4. Administer O2 at 10 L/min. by face mask.
5. Tocolytic agent is administered
- To reduce uterine activity & pressure on the
fetus.
71
6. Do not attempt to push any exposed cord back
into the vagina.
7. Cover any exposed portion with a sterile saline
compress to prevent drying.
8. If cervix is fully dilated, the physician may
choose to deliver the infant quickly (by forceps) to
prevent fetal anoxia.
9.If dilatation is incomplete, the birth method is
upward pressure on the presenting part in the
woman’s vagina, to keep pressure off the cord, and
baby can be born by C/S. 72
PROBLEMS WITH POSITION,
PRESENTATION, or SIZE
73
Occipitoposterior Position
(ROP or LOP)
- In these positions, during internal

rotation, the fetal head must rotate
through an arc of 135°
74
Assessment:
1.Android, anthropoid, or contracted pelves

2.Prolonged active phase, arrested descent
3.Fetal heart sounds heard best at the lateral
sides of the abdomen.
4.Position confirmed by sonogram
5.Prolonged labor because the arc of rotation is
greater.
6.Woman experience pressure & pain in her
lower back due to sacral nerve compression.
75
1.Counterpressure on the sacrum

(e.g. back rub)
▪ Relieve a portion of pain
2.Applying heat or cold
3.Let woman void every 2 hrs. to keep bladder
empty
▪ Full bladder could further empede descent of the
fetus
4.During long labor, IV glucose solution to
replace glucose stores used for energy.
76
5. Fetus may be born by C/S if:

▪ Contractions are ineffective
▪ Fetus larger than average
▪ Fetus not in good flexion
▪ Fetal head may arrest in the transverse
position.
▪ Persistent occipitoposterior position
77
Breech Presentation
- Types:
1.Complete
2.Frank
3.Footling
- Complications:
1.Anoxia from prolapsed cord
2.Traumatic injury to the after-coming head
(possibility of intracranial haemorrhage or
anoxia)
78
Breech Presentation
- Complications:
3. Fracture of the spine or arm
4. Dysfunctional labor
5. Early rupture of the membranes
because of the poor fit of the presenting
part.
6. Meconium aspiration
79
Breech Presentation
- Assessment:
1.FHT heard high in the abdomen
2.Leopold’s, vaginal exam, or ultrasound
exam reveals the presentation.
3.Monitor FHR and uterine contractions
80
Breech Presentation
- Birth technique:
1.Vaginal delivery
▪ Birth of head is the most hazardous because
umbilicus precedes the head.
▪ Head compresses the cord
▪ 2nd danger is intracranial hemorrhage
2.Planned C/S – usual method
▪ secure consent
▪ NPO
81
82
Face Presentation
• Asynclitism
o Fetal head presenting at different angle.
• Face presentation
o Fetus is in poor flexion
o Back is arched
o Neck extended
o Complete extension
o Presenting the occipitomental diameter (13.5
cm)
83
Face Presentation
• Assessment:
1.Woman with contracted pelvis
2.Placenta previa
3.Relaxed uterus of a multipara
4.Prematurity, hydramnios, or fetal
malformation
5.A sonogram is done to confirm
84
Face Presentation
• Therapeutic management:
1.Observe infant for patent airway
▪ May have a great deal of facial edema
and may be purple from ecchymotic
bruising.
2.Gavage feeding
▪ Lip edema is so severe that the infant
is unable to suck for a day or 2.
3.Delivered by C/S 85
Transverse Lie
- Occurs in women with:

1.Women with pendulous abdomen
2.Uterine masses that obstructs the lower uterine
segment
3.Contracted pelvic brim
4.Congenital abnormalities of the uterus
5.Hydramnios
6.Infants with hydrocephalus
7.Prematurity
8.Multiple gestation
86
Transverse Lie
- Assessment:
1.Uterus is more horizontal than vertical
2.Confirmed by Leopold’s maneuver
3.Ultrasound
- Therapeutic management:
1.C/S
87
Oversized Fetus
(Macrosomia)
 Fetus who weighs more than 4,000 –

4,500 g (9 – 10 lbs.)
 Risk factors:
1. Diabetic or develop gestational
diabetes
2. Multiparity
88
Oversized Fetus
(Macrosomia)
 Complications:
1. Uterine dysfunction during labor/birth
• Overstretching of the fibers of the myometrium
2. Wide shoulders cause fetal pelvic disproportion
3. Uterine rupture from obstruction
4. Fractured clavicle of the baby because of
shoulder dystocia
5. Woman has an increased risk of hemorrhage
• Overdistended uterus may not contract
89
Problems With the Passage
A. INLET CONTRACTION
❖In primigravidas, the fetal head normally
engages between weeks 36 and 38 of
pregnancy.
❖If this occurs any time before labor begins, it
is proof the pelvic inlet is adequate.
o If engagement does not occur in a primigravida,
then either a fetal abnormality (larger than usual
head) or a pelvic abnormality (smaller than
usual pelvis) should be suspected.

Interventions for Complications of Labor
or Birth According to the Passage #1
❖Problems With the Passage

A. INLET CONTRACTION
o If CPD exists, because the fetus may not engage
but instead remains “floating,” the possibility of
cord prolapse can lead to a secondary concern.

❖Problems With the Passage

B. OUTLET CONTRACTION
❖A narrowing of the transverse diameter, the
distance between the ischial tuberosities at
the outlet, to less than 11 cm.
o This measurement is made by sonogram during
pregnancy but can also easily be made manually
at a prenatal visit or at the beginning of labor.

TRIAL LABOR
❖If a woman has a borderline (just adequate)

inlet measurement and the fetal lie and
position are good, her primary care provider
may allow her a “trial” labor to determine
whether labor will progress normally.
❖The trial labor continues as long as descent
of the presenting part and dilatation of the
cervix continue to occur.

TRIAL LABOR
❖Therapeutic Management::
1. Monitor fetal heart sounds and uterine
contractions frequently.
2. Urge the woman to void every 2 hours so her
urinary bladder is as empty as possible, allowing
the fetal head to use all the space available.
❖ If, after a definite period (6 to 12 hours),

adequate progress in labor cannot be
documented, or if at any time fetal distress
occurs, the trial labor will be discontinued
and the woman will be scheduled for a
cesarean birth.
TRIAL LABOR
❖If the trial labor fails, cesarean birth is

scheduled.
o it is the method of choice to allow them to
achieve their goal of a healthy mother and
healthy child.

EXTERNAL CEPHALIC VERSION
❖is the turning of a fetus from a breech to a
cephalic position before birth.
❖It may be done as early as 34 to 35 weeks,
although the usual time is by 37 to 38 weeks
of pregnancy (Velzel, de Hundt, Mulder, et
al., 2015).
❖Procedure:
1. FHR and possibly ultrasound are recorded
continuously.
2. A tocolytic agent may be administered to help
relax the uterus.
❖Procedure:
3. The breech and vertex of the fetus are located
and grasped transabdominally by the examiner’s
hands on the woman’s abdomen.
4. Gentle pressure is then exerted to rotate the
fetus in a forward direction to a cephalic lie.

❖ Contraindications:
1. multiple gestation
2. severe oligohydramnios
3. small pelvic diameters
4. a cord that wraps around the fetal neck
5. unexplained third-trimester bleeding, which
might be a placenta previa.
❖ Women who are Rh negative should

receive Rh immunoglobulin after the
procedure in case minimal bleeding occurs.
FORCEPS BIRTH
❖Obstetrical forceps are steel instruments
constructed of two blades that slide
together at their shaft to form a handle.

FORCEPS BIRTH
❖Obstetrical forceps are steel instruments
constructed of two blades that slide
together at their shaft to form a handle.
❖Procedure:
1. One blade is slipped into the woman’s vagina
next to the fetal head, and the other is slipped
into place on the other side of the head.
2. The shafts of the instrument are brought
together in the midline to form the handle.
3. The primary care provider then applies
pressure on the handle to manually extract the
fetus from the birth canal.
FORCEPS BIRTH
❖ Today, the technique is rarely used (in only
about 4% to 8% of births) because it can
lead to rectal sphincter tears in the woman,
which can lead to dyspareunia, anal
incontinence, or increased urinary stress
incontinence (Halscott, Reddy, Landy, et al.,
2015).

❖Although no longer used routinely, forceps
may be necessary with any of the following
conditions:
1. A woman is unable to push with contractions in
the pelvic division of labor such as might
happen with a woman who received regional
anesthesia or who has a spinal cord injury.
2. Cessation of descent in the second stage of
labor occurs.
3. A fetus is in an abnormal position.
4. A fetus is in distress from a complication such
as a prolapsed cord.
❖Before forceps are applied:
1. Record the FHR before forceps application.
2. Membranes must be ruptured.
3. CPD must not be present.
4. The cervix must be fully dilated.
5. The woman’s bladder must be empty.

❖After forceps are applied:
1. Record the FHR after forceps application.
2. The woman’s cervix needs to be carefully
assessed to be certain no lacerations have
occurred.
3. Record the time and amount of the first voiding
to rule out bladder injury.
4. Assess the newborn to be certain no facial palsy
exists from pressure.
❖ A forceps birth may leave a transient

erythematous mark on the newborn’s cheek
❖ This mark will fade in 1 to 2 days with no
long-term effects.
VACUUM EXTRACTION
❖Procedure:
1. With the fetal head at the perineum, a soft,
disk-shaped cup is pressed against the fetal
scalp and over the posterior fontanelle.
2. When vacuum pressure is applied, air beneath
the cup is suctioned out and the cup then
adheres so tightly to the fetal scalp that traction
on the vacuum cord leading to the cup extracts
the fetus.

VACUUM EXTRACTION
❖Vacuum extraction advantages over

forceps birth:
o in that little anesthesia is necessary, thus
leaving the fetus with less respiratory depression
at birth.
❖One disadvantage over natural birth is

that more perineal lacerations may occur
(Steinhauer, 2015).
❖Its major disadvantage is that it causes a
marked caput on the newborn head that may
be noticeable as long as 7 days after birth.
VACUUM EXTRACTION
❖Tentorial tears from extreme pressure also
have occurred.
❖A woman may need reassurance that the
caput swelling is harmless for her infant and
will decrease rapidly.
❖Vacuum extraction should not be used as a
method of birth if fetal scalp blood sampling
was used because the suction pressure can
cause severe bleeding at the sampling site.
❖Vacuum extraction is not advantageous for
preterm infants because of the softness of
the preterm skull.


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Nursing Care of A Family Experiencing A Complication of Labor or Birth

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Chapter 23

Nursing Care of a Family

POWER, PASSAGE, PASSENGER

1. Describe the common deviations in the

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4. Identify expected outcomes associated with

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7. Evaluate expected outcomes for

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❖Dystocia—can arise from any of the four

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❖Nursing Process Overview

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❖Nursing Process Overview

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❖Nursing Process Overview

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❖Nursing Process Overview

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❖Nursing Process Overview

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o primary goal is really to have a healthy baby.

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❖Dysfunction can occur at any point in labor,

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Problems with the Powers

Problems with the Powers

Problems with the Powers

Problems with the Powers

• Contractions are extremely painful because of

• Contraction may interfere with uteroplacental

• Contractions may be uncoordinated and involve

Problems with the Powers

Problems with the Powers

Problems with the Powers

Problems with the Powers

Problems with the Powers

Problems with the Powers

Problems with the Powers

Problems with the Powers

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DYSFUNCTIONAL LABOR AND

Prolonged Latent Phase

Prolonged Latent Phase

TONUS (Resting tone)

Prolonged Latent Phase

Prolonged Latent Phase

Protracted Active Phase

Protracted Active Phase

Prolonged Deceleration Phase

Secondary Arrest of Dilatation

Dysfunction at the Second Stage

Problems with the Powers

Problems with the Powers