Chapter 27: The Woman With an Intrapartum Complication

Welcome to Last Minute Lecture.

This free chapter overview is designed to help students review and understand key concepts.

These summaries supplement not replaced the original textbook and may not be redistributed or resold.

For complete coverage, always consult the official text.

Hello and welcome back to the Deep Dive.

Hey there.

Today we are tackling a really crucial subject for anyone stepping into the world of maternal child nursing.

A big one.

Yeah, opening up chapter 27 of the maternal child nursing textbook, sixth edition.

That's right.

The chapter title is The Woman with an Intrapartum Complication.

And honestly, this feels like the real heavy lifting of obstetrics.

Because most of the time, birth is this physiological normal event.

Right.

It's beautiful.

It works.

We spend so much time studying the happy path.

But the mission of this deep dive is to look at what happens when it doesn't go according to plan.

Exactly.

And that is really where the nurse's value just skyrockets.

Yeah.

We are talking about the why behind safe practice here.

Because while birth is usually normal, the nurse acts as the early warning system.

Okay.

Your primary challenge is prompt identification.

You have to spot the deviation from normal to save a life, whether that's the mothers or the babies.

So we've got a big stack of notes here.

We're going to break down the famous four Ps of dysfunctional labor, look at preterm and postterm issues, and then the big emergencies.

Yeah.

Then walk through some truly high stakes emergencies like cord prolapse and uterine rupture.

It sounds intense and it is, but we're going to keep the student friendly.

We're going to walk through it step by step, focusing on what you need to notice and more importantly, what you need to do.

All right, let's do it.

Let's jump right in with dysfunctional labor.

The text calls this dystocia.

Right.

Dystocia is just a, you know, a general term for a difficult labor or birth.

Basically the normal progress just stops.

It stalls out.

It stalls out.

The cervix isn't dilating, the effacement isn't happening, or the baby just isn't coming down the birth canal.

And when we try to figure out why, we look at the four Ps.

I love a good framework.

So let's unpack these Ps.

We have powers, passenger, passage, and psyche.

Let's start with the powers.

This is the engine, right?

The contractions.

It is.

The goal is coordinated contractions that are strong enough to push the fetus past the resistance of the pelvis.

But sometimes, well, sometimes the engine fails.

Ineffective uterine activity.

That's the term for it.

And I see here in the notes, there's a really important distinction between two types of dysfunction,

hypotonic and hypertonic.

Yes.

And I know table 27 .1 in the text breaks this down, but let's make it real.

Okay.

So what is hypertonic dysfunction look like if I'm the nurse at the bedside?

Hypertonic is actually the more common one.

It usually happens in the active phase of labor.

So she's already dilated past four centimeters.

Exactly.

Everything was going fine.

She was progressing.

And then the contractions just, they lose their steam.

They become coordinated, but they're weak.

They get infrequent.

And the text mentions a tactile check for this.

How does the nurse know just by feeling?

Okay.

So if you put your hand on the fundus, the top of the uterus, at the peak of a contraction, it feels soft.

You can easily indent it with your fingertips.

So it's not firming up like it should.

Not at all.

It feels like a muscle that is just too tired to flex hard.

It's just not doing the work.

What causes that?

Is the uterus just exhausted?

Often?

Yes.

Simple fatigue,

but it can also be caused by over distension.

Over distension?

Yeah.

Think about a rubber band.

If you stretch it too far, like with twins or hydramnios, which is too much amniotic fluid, it loses its snap.

It can't contract back effectively.

Right.

It can also be from fetal malposition or even just genetic factors.

So the uterus is tired and soft.

What do we do?

Do we just wait?

Well, first you have to rule out that the baby isn't too big for the pelvis, what we call cephalopelvic disproportion or CPD.

Okay.

Because if the baby literally cannot fit, stronger contractions won't help.

In fact, they'll just cause damage.

But if the fit is okay, the management is usually to give the engine a jumpstart.

A jumpstart.

I like that.

Yes.

That usually means an amniotomy breaking the water, which can stimulate prostaglandin release and tighten things up.

Or we start an oxytocin augmentation.

We use medication to strengthen those contractions and get the labor curve back on track.

Okay.

So hypertonic is weak and soft and it happens in the active phase.

Now let's flip it.

What is hypertonic dysfunction?

Hypertonic is the opposite and it usually happens earlier in the phase.

So before four centimeters, these contractions are erratic, uncoordinated, and super painful.

But here's the key.

They're ineffective.

So lots of pain, no progress.

Exactly.

And clinically, when you feel the uterus, it has a high resting tone.

It never fully relaxes between contractions.

It's in a state of constant cramping spasm.

Oh, that sounds just exhausting for the uterus.

And because the uterus never relaxes, blood flow to the fetus is reduced.

Right.

Because the baby gets its oxygen when the uterus is relaxed.

Correct.

So if it's always tight, the baby is essentially holding its breath for way too long.

So do we give oxytocin here?

I mean, if the contractions are uncoordinated, maybe we try to force them to coordinate.

No, that's a major red flag.

You do not give oxytocin to a uterus that is already too tight.

You'll rupture it or cause fetal distress.

The treatment here is therapeutic rest.

Rest.

You just stop everything.

Yes.

We need to stop the cycle.

We might give a mild sedative or pain relief like morphine to help her sleep.

Often, after a few hours of deep sleep, she wakes up and the uterus has reset itself into a normal, effective labor pattern.

That's a critical distinction.

So hypertonic needs a jump start.

Hypertonic needs rest.

You got it.

Now the powers also includes the mother pushing in the second stage.

What happens if she just can't push effectively?

That's the second part of the Or maybe the epidural is too dense and she literally can't feel where to push.

Or honestly, it could be fear.

Fear.

Yeah.

The sensation of the baby coming down, that tearing, burning sensation, can make a mother instinctively hold back.

It's a physiological reflex to pull away from pain.

So what's the nursing move there?

I'm picturing someone just yelling push in a movie.

Please don't just yell it.

No, we let her labor down.

Labor down.

It means if the baby and mom are stable, we let the contractions do the work for a while.

We wait until the urge to push becomes just undeniable.

We can also use gravity upright positioning, squatting, and talking her through it.

And education is huge.

Telling her that stretching feeling means you're doing it right can help her overcome the fear and work with her body, not against it.

That makes a lot of sense.

Yeah.

Okay, let's move to the second P.

The passenger,

the fetus.

Sometimes the passenger is the problem.

Right.

And usually it's about size, position, or presentation.

We talk about macrosomia.

That's infants weighing more than 4 ,000 grams.

Which is about 8 pounds, 13 ounces.

That's a big baby.

It is a big baby.

And the risk there is that the head fits, but the shoulders don't.

And this leads us to one of the scariest emergencies in obstetrics, shoulder dystocia.

Okay, let's spend a moment here because the text highlights this as a really urgent situation.

What does the nurse see?

What's the sign?

You see the turtle sign, the head is born, but then it sucks back continuously against the perineum.

Like a turtle going into its shell.

Exactly.

It's not advancing.

That means the anterior shoulder is stuck behind the mother's putic bone.

And the clock is ticking because the cord is compressed in the birth canal and the baby can't breathe.

What is the immediate nursing action?

The book has figure 27 .1 showing this clearly.

The first line of defense is the McRoberts maneuver.

The nurse helps the Like knees to ears basically.

As close as you can get.

This straightens out the pelvic curve and rotates the pelvis to open up space.

And at the same time you're applying suprapubic pressure.

Yes.

Okay, clarify that for me.

Where are we pushing and where are we not pushing?

Great question.

You are pushing with your fist or your palm directly above the pubic bone.

You are trying to push the fetal shoulder downward to pop it under the bone.

Okay.

You are not pushing on the top of the fundus.

Why not?

Fundal pressure.

Fundal pressure is so dangerous here.

If you push from the top you just wedge that shoulder tighter against the bone.

It's like trying to force a square peg in a round hole by hitting it harder.

That's a perfect analogy.

You can rupture the uterus.

So suprapubic pressure only.

Got it.

McRoberts legs back,

suprapubic pressure down and after the baby is out.

What's the follow up?

You have to assess the baby very carefully.

It was a traumatic exit.

Check the clavicles for crepitus.

A grating sound or feeling that indicates a fracture.

Okay.

And check for herb palsy which is a nerve injury to the arm from all that traction.

Now, aside from size, position matters.

Yeah.

We hear about back labor.

That's usually an OP baby, right?

Yes.

Occiput posterior, we call it sunny side up.

The back of the baby's head is pressing against the mother's sacrum.

It causes this intense grinding back pain that persists even between contractions.

Can the nurse fix this or are we just managing pain at that point?

Oh, we can certainly help.

We want to encourage rotation.

The text suggests specific positions.

You can see them in figure 27 .2 and 27 .3.

Like what?

Hands and knees is great because gravity helps the heavy fetal backswing forward away from the spine.

Hammock effect.

Exactly.

The lunge is another one.

Placing one foot on a chair and lunging sideways or simply side lying on the opposite side of where the baby's back is.

We are just trying to use gravity and pelvic shape changes to turn the baby to occiput anterior or OA.

What about presentation?

Head first is best, obviously.

Yes.

Cephalic is the goal, but we have breech buttocks or feet first.

This is high risk because the dilation is often slow and the head, which is the biggest part, comes last and can get trapped.

And the core.

And a very high risk of cord prolapse because the butt isn't a perfect round cork like the head is.

It doesn't seal the cervix as well.

Okay.

Moving through our catechs, we have the passage,

the pelvis.

This is simple anatomy.

The text outlines four pelvic shapes in figure 27 .5.

The gynochoid is the round classic female pelvis optimal for birth.

About 50 % of women have this.

And the others?

Then you have the android, which is heart -shaped, more of a male type pelvis, and platypilloid, which is flat.

Those have a poor prognosis for vaginal birth.

But nurses can't change the bone structure.

That's just genetics.

Is there a passage problem we can fix?

Yes.

And it's the most common soft tissue obstruction.

And it's one you can absolutely fix.

A full bladder.

Really?

Just a full bladder?

Absolutely.

Think about the anatomy.

The bladder sits right there.

A full bladder acts like a balloon taking up valuable space in the pelvis.

It can actually stop fetal descent dead in its tracks.

And it makes it more painful.

Way more painful.

And if she has an epidural, she might not even feel the urge to void.

Right.

So a key nursing intervention is scheduled voiding every one to two hours.

If she can't go or can't feel it, you might need to straight catheterize.

It's a simple fix that can restart a stalled labor almost immediately.

That's a great clinical tip.

Okay, finally, the fourth P.

The psyche.

We cannot underestimate this.

This isn't just feelings.

It's pure physiology.

When a woman is stressed, fearful, or in a lot of pain, her body releases catecholamines.

Fight or flight hormones.

Exactly.

And what do they do to labor?

They work against it.

Strictly against it.

They consume the glucose the uterus needs for energy.

They divert blood away from the uterus to the skeletal muscles so she can run away.

And they actually inhibit uterine contractions.

So fear literally stops labor.

It does.

So the nursing role of therapeutic communication, creating a calm environment, dimming the lights, explaining what is happening to demystify the process, that's not just nice to have, it's physiological management of labor.

You're trying to lower the adrenaline so the oxytocin can work.

That's it in a nutshell.

It's amazing how interconnected the mind and body are here.

Now, before we leave dysfunctional labor, we have to touch on duration.

We have prolonged labor, which makes sense.

Infection risk, exhaustion.

But what about when it goes too fast?

Precipitate labor.

This is defined as birth occurring within three hours of the onset of labor.

Three hours.

That sounds, well, efficient.

It sounds nice in theory, but it is abruptly intense.

The contractions are frequent and severe with almost no relaxation time in between.

For the fetus, this is really dangerous because they get hypoxic.

There's no time for the placenta to recharge with oxygen between squeezes.

And the rapid pressure change as they rocket through the birth canal can actually cause intracranial hemorrhage.

And for the mom, what are the risks?

Uterine rupture and severe lacerations.

She's bruising and tearing because the tissues don't have time to stretch gradually.

So if a nurse sees this happening, a precipitate birth is imminent.

What do they do?

What's the protocol?

First rule.

Do not leave her.

Put on gloves.

Support the perineum to control the speed of delivery slightly.

But, and this is vital, do not try to hold the head back to delay birth.

Right now.

That can cause major fetal injury.

You are just guiding the baby out safely.

You're not stopping it.

So that's dystocia in the four Ps.

A lot to monitor there.

But there's another major aspect of Chapter 27.

Complications with the amniotic fluid.

Specifically,

PROM and PPROM.

Acronym time.

Yeah.

So PROM is premature rupture of membranes.

This is rupture before labor begins at any gestation.

PPPROM is premature rupture of membranes rupture before 37 weeks.

And what's the big danger here?

The water breaks.

So what?

Infection.

Once that protective barrier, that seal is broken, the clock starts for bacteria ascending from the vagina.

And we worry about chorioamnionitis.

Which is an infection of the amniotic sac.

How does the nurse spot chorioamnionitis?

What are the signs?

Maternal fever and uterine tenderness are the classic signs.

But often, the very first sign is fetal tachycardia, a heart rate over 160 beats per minute.

So the baby gets hot before the mom does.

The baby's heart rate response first is a key early indicator.

So if a woman comes in, thinks her water broke, what is the first rule of engagement regarding exams?

Keep your hands out.

No digital vaginal exams unless absolutely necessary or she's clearly in active labor and delivery is imminent.

Digital exams significantly increase the infection risk by pushing bacteria up.

So how do we confirm it?

We diagnose rupture with a sterile speculum exam looking for a pool of fluid and a pH test, like nitrazine paper which turns blue, or a fern test under a microscope.

And if she is preterm, say, 32 weeks, and the water breaks, do we deliver?

If there's no infection, we try expectant management.

We want to keep that baby inside to grow.

So we put her on pelvic rest, monitor her temperature four times a day to catch fever early, and give antibiotics.

The antibiotics usually bias time, often prolonging the pregnancy by days or weeks.

That time is called the latency period.

Speaking of keeping the baby inside, let's talk about preterm labor itself.

So PTL, this is labor between 20 and 37 weeks.

Yeah, and it's a major cause of neonatal morbidity.

And the tricky thing for you as a nurse is that the signs are so subtle.

It's not always the dramatic movie style labor with screaming and grabbing the stomach.

What are the complaints then?

I just feel bad.

Or a dull low back ache, maybe some pelvic pressure or menstrual -like cramps.

A change in vaginal discharge.

Things that are easy to dismiss.

Very easy to dismiss, which is why we have to teach patients to pay attention to these subtle cues.

So how do we predict who is actually going to deliver?

The test mentions a glue test.

Fetal fibronectin, or FFN.

It's a protein found in fetal tissues.

It acts like glue attaching the fetal sac to the uterine lining.

And we shouldn't find it in the vagina.

Exactly.

Not between 22 and 34 weeks.

If it leaks out, it means that attachment is being disrupted.

But the test is most useful when it's negative.

How so?

A negative FFN is a very strong predictor that she will not deliver in the next two weeks.

It gives us confidence to send her home and say, okay, let's just watch things.

Okay, but let's say she is in preterm labor.

We need to stop it, or at least slow it down.

We use tocolytics.

Yep.

And table 27 .3 in the book lists the big players.

Let's run through them because you really need to know the side effects.

Okay, first up is magnesium sulfate.

We use this for preeclampsia, but also for preterm labor.

Right.

It relaxes smooth muscle, including the uterus.

It also provides neuroprotection for the fetus.

It helps prevent cerebral palsy.

And the nurse needs to watch for toxicity, right?

That's the big one.

Absolutely.

It's a CNS depressant.

So you need to watch for loss of deep tendon reflexes or DTRs, respiratory depression, that's less than 12 breaths per minute, and low urine output, less than 30 milliliters per hour.

And if you see toxicity.

The antidote is calcium gluconate.

You always have that at the bedside.

Always.

Got it.

Next on the list is nifedpine.

This is a calcium channel blocker.

It's an oral med, which is convenient, since it relaxes blood vessels to stop the calcium from entering the muscle.

Blood pressure drops.

Yes.

The main side effects are hypotension and flushing.

You have to watch the maternal pulse.

If it's over 120, we hold the dose.

And then there's endomethacin.

That's an NSAI, a prostaglandin inhibitor.

It's effective, but it has specific fetal risks.

It can cause premature constriction of the ductus arteriosus in the fetal heart.

So we can't use it for long.

Right.

We limit its use to less than 48 hours, and usually only in gestations less than 32 weeks.

It can also cause low amniotic fluid.

Finally, terbutylene.

This one has a serious warning attached.

It does.

It's a beta -adrenergic.

It causes tachycardia, a fast heart rate in both mom and baby.

It can also cause wet lung sounds or pulmonary edema.

That's why the FDA put a black box warning on it.

Exactly.

Against prolonged use, so more than 48 to 72 hours, we generally use it for short -term rescue, like stopping contractions just long enough to transfer a mom to a hospital that has an ICU.

Really, the goal of all these drugs isn't necessarily to stop labor forever, is it?

That's a great point.

Correct.

We usually can't stop it indefinitely.

The main goal is just to delay birth by 24 to 48 hours.

Why that specific window?

Why 48 hours?

So we can administer corticosteroids, betamethasone, or dexamethasone.

The lung shots.

The lung shots, exactly.

These steroids speed up fetal lung maturity and surfactant production.

If we can get two doses in 24 hours apart, the outcomes for the preemie improve drastically.

Fewer respiratory issues.

Fewer respiratory issues, less bleeding in the brain.

It's probably the most important intervention we have for preterm babies.

Before we move on, I want to touch on the psychosocial side of preterm labor.

The text mentions activity restriction.

We used to call it strict bed rest.

Right.

And we're moving away from strict bed rest because of the risks.

Blood clots, muscle atrophy, bone loss.

But we still limit activity.

And for the mom, this is incredibly stressful.

I can imagine.

She's bored.

She's worried about her job, her other kids.

The nurse needs to address that boredom and anxiety.

The nursing diagnosis, altered home maintenance, is so real here.

She's watching dust bunnies gather and can't do a thing about it.

Okay, let's swing the pendulum to the other side.

Prolonged pregnancy, post -term.

This is a pregnancy going beyond 42 weeks.

Why is staying in too long a problem?

You'd think a bigger baby is a stronger baby.

Not necessarily.

The problem is the placenta.

It has an expiration date.

It starts to age.

It calcifies.

We get what's called placental insufficiency, meaning the baby stops getting enough oxygen and nutrients.

So we would see distress on the monitor.

Yes, often late decelerations, indicating hypoxia.

We also see oligohydramnios, low fluid volume.

And because the baby is stressed, they might pass meconium, their first stool, in the womb.

And they can breathe that in.

If they inhale that thick, terry stool into their lungs, meconium aspiration syndrome, it can be very, very serious.

So accurate dating is crucial here, so we don't let them go too long.

We often induce before 42 weeks for this reason.

Okay, now we are arriving at the intrapartum emergency section.

These are the moments where training takes over and adrenaline spikes.

We already talked about shoulder dystocia.

Let's talk about prolapsed umbilical cord.

This is a dire emergency.

The membranes rupture and the cord slips down in front of the head.

So the head comes down and just squishes the cord against the pelvis.

It cuts off the oxygen supply.

Immediately.

Immediately.

You'll see a sudden severe bradycardia or deep variable decelerations on the monitor.

What does the nurse do?

The text is very specific here and this is critical.

You do not take your hand out.

If you do a vaginal exam and you feel that pulsating cord.

You feel the cord.

You leave your gloved hand in there and you push the fetal head up and off the cord.

You are the only thing keeping that baby alive.

You ride on the gurney to the O .R.

with your hand in place under the sterile drapes until the baby is delivered by C -section.

That is a vivid and terrifying image.

And positioning helps too, right?

Gravity again.

Put the mom in a knee -chest position so hips in the air, face down, or Trendelenburg with her head down.

This lets the fetus slide back towards the diaphragm and off the cervix.

Okay.

Emergency number two.

Uterine rupture.

This is catastrophic.

The uterine wall tears.

It's most common in women with a previous C -section scar.

Specifically, a classical or vertical incision.

Though it can happen with a low transverse scar too.

What are the signs?

How do you know?

It can be subtle, but often the woman reports a sharp pain or a feeling that something ripped.

But clinically, you might see the contractions just stop.

The monitor goes from active labor to flat.

And the baby's heart rate.

Fetal distress,

bradycardia, and the mom might have chest or shoulder pain.

Shoulder pain?

Why shoulder pain?

That seems so random.

It's referred pain.

Blood accumulates under her diaphragm from the internal hemorrhage and the phrenic nerve sends that pain signal up to the shoulder.

It's a classic sign of massive internal bleeding.

So if you hear that, you're thinking internal hemorrhage.

You are.

And this requires an immediate C -section and likely blood transfusions.

Next up on this list of terrifying things.

Uterine inversion.

This is exactly what it sounds like.

The uterus turns inside out, usually during the third stage of labor.

So after the baby is out, but before the placenta is delivered.

How does that even happen?

Often it's a management error pulling on the umbilical cord before the placenta has separated.

So you pull the cord and the whole uterus comes with it.

You pull the uterus inside out or by pushing on the fundus when the uterus isn't contracted.

So the lesson is don't pull on the cord.

Never force it.

If inversion happens, it's massive hemorrhage and shock.

The provider has to replace the uterus manually, literally punching it back into place.

And the nurse's job.

Your job is to manage the shock IV fluids, blood products.

We might give tocolytics briefly to relax the uterus so the doctor can replace it, then immediately give oxytocin to firm it up so it stays put.

And the last emergency in this section, anaphylactoid syndrome.

We used to call this amniotic fluid embolism or AFE.

Right.

It's rare, but it's incredibly deadly.

Amniotic fluid containing fetal debris, hair, skin cells, meconium enters the mother's bloodstream and travels to her lungs.

And it causes a huge reaction.

A massive reaction.

It's not just a clog.

It's an inflammatory cascade, like a severe anaphylactic shock.

What does it look like?

How does it present?

It's sudden, sudden respiratory distress.

She can't breathe.

She's gasping.

Then circulatory collapse, severe hypotension.

And then usually DIC disseminated intravascular coagulation.

Her blood stops clotting and she bleeds from everywhere.

It happens very, very fast.

And nursing action is basically full code management.

It is CPR, high flow oxygen, mechanical ventilation, fluid resuscitation, and a ton of blood products like fibrinogen and platelets.

It has a high mortality rate, so rapid identification is the only chance.

Heavy stuff.

Okay, finally, let's touch briefly on trauma in pregnancy.

Car accidents, falls, domestic assault.

The number one killer of the fetus in trauma is the death of the mother.

So the rule is always treat the mother first.

ABCs.

Airway breathing circulation.

Always.

But pregnancy changes how we assess shock.

This is a key physiological adaptation we have to remember.

It does.

Pregnant women have increased blood volume up to 50 % more.

This means they can lose a lot of blood before their blood pressure drops.

But, and this is the key, the body will shunt blood away from the uterus to save the mom's heart and brain before you see those vital sign changes.

So the baby could be in distress while mom's BP is still perfectly normal.

Exactly.

The fetus is the canary in the coal mine.

That's why we do continuous fetal monitoring for at least four to six hours after any significant trauma, even if mom looks fine.

We're watching for abruptio placente, which is placental detachment.

And we also do a Klyhauer -Becca test.

A KB test.

Right.

That is a blood test that looks for fetal blood cells in the mother's circulation.

And what does that tell you?

If we find them, it indicates that the placental barrier has been disrupted and there has been mixing of blood.

This helps determine if we need to give Rogim, if mom is RH negative, and it indicates the severity of the trauma.

Wow.

We have covered a massive amount of ground from the mechanical issues of the four P's of dystocia to the pharmacology of preterm labor and some truly intense emergencies.

It is a lot.

But if I can summarize the nursing priority in all of Chapter Commie 7, it's one word, vigilance.

Vigilance.

That's the perfect word.

It is.

Whether it's noticing the uterus feels soft in hypotonic labor or recognizing the subtle back pain of preterm labor, seeing the turtle sign and shoulder dystocia, or keeping your hand in place during a cord prolapse,

the nurse is the one who identifies the problem and initiates the rescue.

You are the calm in the storm.

You are the one who knows what normal looks like so well that abnormal stands out immediately.

Precisely.

That brings us to the end of this deep dive into the woman with an intrapartum complication.

Huge thank you to the last minute lecture team for compiling this crucial information.

And to the students listening, you can do this.

These complications are rare, but being prepared for them makes you an incredible nurse.

Thanks for listening.

We'll see you on the next deep dive.