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Problem with the Powers

Dystocia
Premature labor
Precipitate labor & birth
Uterine inversion
Uterine rupture
Amniotic fluid embolism

Problems with the power (the force of labor)

Dystocia general term that describes any difficult labor or birth


Inertia term donote that sluggishness of contractions, or the force of labor
Dysfunctional labor(current term)

the force of labor

Effective uterine activity is characterized by coordinated contractions that


are strong & numerous enough to propel the fetus past the resistance of the
womans pelvis.

Dystocia

difficult labor or birth.


refers to any labor which does not advance normally
a dysfunctional labor may result from problems with powers of labor, the
passenger, the passage, the psyche, or a combination of these.

Factors:

Forces are inadequate (Faulty Power)


E.g. inertia sluggishness of uterine contractions
Abnormal position of the passenger (infant)
Abnormal passageway (birth canal)

Common causes of Dysfunctional labor

Maternal fatigue
Maternal inactivity
Inappropiate use of analgesia (excessive or too early administration)
disproportion between the maternal pelvis and fetal presenting part
Poor fetal position (posterior rather than anterior position)
Overdistention of the uterine as with multiple gestation, hydramnios,or
oversized fetus
Presence of a full rectum or urinary bladder that impedes fetal descent

Problems with the power (the force of labor)


Ineffective or abnormal uterine contractions are classified according to
strength:
Hypotonic Uterine dysfunction
Hypertonic Uterine dysfunction
Uncoordinated contractions

Comparison of Hypotonic and Hypertonic


contractions

CRITERIA HYPOTONIC HYPERTONIC


Contractions Coordinated but weak Uncoordinated, irregular
Become less frequent and of poor intensity, but
and short in duration painful and cramplike
Easily indented at peak Strong contraction in the
Woman may have midsection of the uterus
minimal discomfort (than in fundus)
because the contraction Anoxic uterine muscles
are weak Lack of relaxation
Symptoms Painless Painful
Uterine Resting Tone Not elevated Higher than normal,
important to distinguish
from abruption placenta
Phase of labor Active. Typically occur Latent. Usually occurs
after 4 cm dilatation before 4 cm dilation
Secondary dysfunction Primary dysfunction
Therapeutic Amniotomy (may Correct cause if can be
Management increase the risk of identified
infection) Light sedation to promote
Oxytocin augmentation rest
Cesarean birth if no Hydration
progress Tocolytics to reduce high
uterine tone and promote
placental perfusion
Nursing Care Interventions related to Promote uterine blood
amniotomy and flow; side-lying position
oxytocin augmentation Promote rest, general
Encourage position confort, and relaxation
changes Pain relief
An abdominal binder Emotional support
may help direct the Accept the reality of the
fetus toward the womans pain and
mothers pelvis if her frustration
abdominal wall is very Reassure her that she is
lax not being childish
Ambulation if no Explain reason for
contraindication and if measures to break
acceptable to the abnormal labor patterns
woman and their goals or
Emotional support; expected results
allow her to express Allow her to express her
feelings of feelings during and after
discouragement labor
Explain measures taken Include partner or family
to increase
effectiveness of
contractions
Include her partner or
family in emotional
support measures
because they may have
anxiety that will
heighten the womans
anxiety

Uncoordinated uterine contractions.


More than one contraction occur at the same time due to
myometrium acts independently from each other

Management:
fetal and uterine external monitor applied every 15 mins
Oxytocin to stimulate labor
Complication:
Mother: exhaustion and dehydration
Fetus: injury and death
dynsfunction in labor can occur at any point in labor, and classified
according to time when it occurs:
Primary dysfunction occuring at the onset of labor or prolong
latent phase of labor
Secondary dysfunction occuring later in labor or prolonged
active phase of labor fetus does not descend; cervix not dilated

Abnornal progress in labor


Dysfunction at the first stage:
1. Prolong Latent phase
latent phase longer than 20 hours in nullipara, 14 hours in multipara
may occur if:
cervix is not ripe at the beginning of labor
excessive analgesia
the uterus tends to be in hypertonic state
relaxation between contractions is inadequate

2. Protracted Active Phase


usually associated with CPD or fetal malpositions
this phase is prolong if cervical dilatation does not occur at a rate of:
1.2cm/hr or more in nullipara
1.5cm/hr in multipara or
if the active phase last over
12 hours in primiapara and
6 hrs in multi para
3. Prolonged Decceleration Phase
A decceleration has become prolonged when it extends beyond
3 hours in nulli para and
1 hour in multi para
4. Secondary arrest of Dilatation
Occurs when theres no progress in cervical dilatation for more than 2 hours.
5. Prolonged descent
Occurs if the rate of descent is :
less than 1.0 cm/hr in a nullipara or
less than 2.0 cm/hrin a multi para
Dysfunction at the Second stage:
1. Arrest of Descent
occur when no descent has occured for
1 hour in multi para and
2 hour in nulli para
failure of descent has occured when expected descent of the fetus
does not begin; cause : CPD
2. Contraction Rings
a. Pathologic retraction ring (bandl ring) the ring usually appears as
horizontal indentation
accross the abdomen.

Cause: excessive retraction of the upper uterine segment


In a difficult labor (if fetus is larger than the birth canal), round ligaments of
the uterus become tense and may be palpable on the abdomen
Pathological Retraction Ring (Bandls Ring) common in obstructed labor;
retraction ring is indented deeply and palpable as a mass in the middle of the
abdomen
Danger sign signifies impending rupture of the lower uterine segment
if the obstruction is not relieved

Abnornal progress in labor


a. Pathologic Retraction Ring or Bandls ring
Junction of upper & lower uterine segment
Sign - severe dysfunctional labor occurs
Forewarning of a uterine rupture
Grip fetus and placenta
Assessment:
Horizontal indentation across abdomen
Uncoordinated contractions early in labor
Dilation phase caused by obstetrical manipulation and administration
of oxytocin

b. Constriction Ring
can occur at any point in the myometrium and anytime during labor, when
pathologic
occur during early labor, it is usually from uncoordinated
contractions.

Pathophysiology:
Fetus is grasped by the ring and cant advance or descent if fetus is
delivered, placenta can be held after delivery

Management:

Observe abdominal report immediately


administer IV morphine sulfate and amyl nitrate
C/S or manual extraction of placenta if not attended leads to Mother
(uterine rupture and
postpartum hemorrhage); fetus (death)

Curative Management Care:


Antibiotics
Sedative stop abnormal contractions
Short acting barbiturates to promote relax/ rest
Monitor FHB
NPO prepare for Surgery CS
Assist in delivery; vaginal or CS
Trial labor in borderline or adequate pelvis

PRECIPITATE LABOR/ DELIVERY


Occurs when uterine contractions are so strong that the woman delivers with
only a few rapidly occuring contractions
Labor that is completed in less than hour
> Likely to occur in:
- multipara
- following induction of labor
- amniotomy
Risks :
Fetus : sub-dural hemorrhage (sudden release of pressure on the head)
Mother : - lacerations of the birth canal
- premature separtion of the placenta (strong sudden force)
Goals :
To bring the delivery in a controlled surroundings to prevent risks to fetus &
mother

Theories behind precipitate labor:


1. Uterine strech theory
2. Oxytocin theory
3. Progesterone/ prostaglandin theory
4. Placental degeneration

PREMATURE LABOR/DELIVERY
Or Preterm labor
Occurs before the end of 37weeks AOG or before fetus weigh 2500gms.
Results in a premature infant, 2/3 neonatal death is due to LBW
Occurs in Approximately 10% of all pregnancies
Unknown cause
Conditions resulting to premature labor:
1. Cervical surgery as cone biopsy
2. Chorioamnionitis
3. Hydramnios
4. Multiple gestation
5. Maternal age
6. Previous preterm labor
7. Polynephritis, UTI
8. Short inter-pregnancy period
9. Smoking
10. Streneous or shift work
11. Uterine anomaly as tumor

Assessment:
1. More painless uterine contractions (30 sec. duration,or frequently as every 10
minutes for more
than 1 hour)
2. More backaches
3. More vaginal discharges
4. Associated with UTI or Chorioamnionitis

Management:
Halt Labor when [criteria]
* fetal membranes are intact [BOW]
* Fetal heart beat good
* No evidence of bleeding
* Cervical dilation not more than 3-4 cms.
* Effacement not more than 50%
[ Note: All these above criteria must be present ]
Measures to Halt labor:
4 Drugs used for Tocolysis
a. Beta-adrenergics
b. Calcium antagonists
c. Magnesium S04
d. Prostaglandin inhibitors
1. Ethanol (ethyl alcohol)
administered thru IV
blocks the release of oxytocin by the pituitary glands thereby blocking
or delaying labor pains
2. Beta-Adrenergic (sympathomimetic drugs)
- most frquently used beta receptors sites
- adipose tissue, heart, liver, pancreatic cells, GIT & other smooth
muscles as uterine muscles, bronchi, blood vessels
Beta-Adrenergic
stops production of prostaglandin stopping labor pain
3. Ritodrine Hydrochloride [Yutopar]
Terbutaline (Brethine) most used

Acts on Beta 2 receptor sites - it relaxes the bronchial and blood vessels
along with the uterine muscles labor is halted but heart rate
increases to move blood effectively hypocalcemia may occur from a
shift of K into the cells blood glucose and plasma insulin Increase
pulmonary edema occurs headache, nausea and vomiting due to
dilation of the blood vessels also manifests
Check pulse should not be given if pulse exceeds 120 BPM
Also acts entirely on beta 2 receptor sites
Mild tachycardia and hypotensive effects
[Note: use with caution in patients with DM increase BS overly DM, thyroid
dysfunction]
4. Magnesium SO4
- Effective to halt labor
- Check for signs of toxicity
5. Other Measures
Bedrest to take the pressure of the gravid uterus off the cervix
Hydration oral, hydration affects the secretion of ADH and oxytocin
by the pituitary gland oxytocin causes uterine contraction
Avoid psychologic stress
Administration of corticosteroid (betamethasone) to hurry formation of
fetal lung surfactant

Post Mature Pregnancy, Delivery/ Infant


Post Term Labor/Delivery
Post-gestational, post-mature
Pregnancy beyond normal AOG (38 42 weeks)
Occurs approximately 10% of all pregnancy

Post-Mature Infant
Whose gestation age is 42 weeks or longer
May show signs of weight loss with placental insufficiency
Develop post-mature syndrome
Etiology:
Unknown in many instances
Maternal Factors
- Primi and high parity at given age
- Prolonged gestation in preceding pregnancies
Characteristics: (Seen in 44 weeks or more)
I. Physical Appearance
Reduced subcutaneous tissues
Loose skin turgor at buttocks & thighs
Long curved fingernails & toenails
Amounts of vernix caseosa
Hypoglycemia-no adequate stores of glycogen
Abundant scalp hair
Poor temperature regulation-Low levels of subcutaneous fat
Wrinkled macerated skin, pale, cracked parchment- like skin
Alert appearance 2-3 weeks old infant after delivery
Greenish-yellow stain on skin fetal distress (meconium aspiration)
Intrauterine malnutrition and hypoxia = placental perfusion = oxygen &
nutrients
Low levels of estrogen
One post-term to another post-term
Maternal weight loss and uterine size

Complications:

Meconium aspiration
hypo or hypercalcemia
polycythemia ( Oxygenation)
pulmonary hemorrhage
pneumonia
asphyxia neonatorum
pneumothorax
Note: severity of problems depends on length of gestation. Nursing Care
is the same with premature
UTERINE RUPTURE

UTERINE RUPTURE- Complete or incomplete separation of the uterine tissue as a


result of a tear in the
wall of the uterus from the stress of labor

Complete: direct communication between the uterine and peritoneal cavities


Incomplete: rupture into the peritoneum covering the uterus but not into the
peritoneal
cavity
Factors:

Strained uterus
Beyond its capacity
Previous C/S, repair or hysterotomy
Contributory:
Prolonged labor
Faulty presentation
Multiple gestation
Unwise use of oxytocin
Obstruction labor
Traumatic maneuvers using forceps

Assessment:
Impending rupture suggested by pathologic retraction ring, strong uterine
contractions with cervical dilatation
When uterus rupture
S/S: sudden severe pain during strong labor

Manifestations vary with the degree of rupture


Abdominal pain
Chest pain
Rigid abdomen
Absent fetal heart rate
Signs of maternal shock
Contractions may stop or fail to progress
Fetus palpated outside the uterus (complete rupture)

Management:
Monitor for and treat signs of shock (administer oxygen, IV fluids, and blood
products)
Prepare client for immediate
Cesarean Section or
hysterotomy with hysterectomy
Provide emotional support for the client and partner

INVERSION OF THE UTERUS

Uterus completely or partly turns inside out


Fundus is formed thru the cervix, turned inside out
This usually occurs during delivery or after delivery of the placenta

Causes:
Attachment of placenta at fundus sudden delivery of fetus without support
fundus is pulled down
strong fundal push in an non-contracted state
attempts to deliver placenta before separation

Assessment:
the interior of the uterus protrude from vagina,
sudden gush of blood,
fundus no longer palpable,
uterus is not contracted
severe pain
hemorrhage with signs of shock

Management:
Monitor for hemorrhage and signs of shock and treat shock
Prepare the client for a return of the uterus to the correct position via the
vagina;