Dysfunctional Labor and Associated
Stages of Labor
I.
Dysfunction at the First Stage
of Labor
1. Prolonged Latent Phase
- contractions become ineffective
during the first stage of labor
- uterus tends to be in a hypertonic
state
Occur when:


cervix is not “ripe” at the beginning
of labor and time must be spent
getting truly ready for labor
excessive use of an analgesic early
in labor
Management: Helping the uterus to rest

providing
adequate
fluid
for
hydration
 pain relief with a drug such as
morphine sulfate
2. Protracted Active Phase
- associated
with
cephalopelvic
disproportion
(CPD)
or
fetal
malposition
- delay in dilatation = CS
- prolonged if cervical dilatation1.2
cm/hr in a nullipara or 1.5 cm/hr
in a multipara
3. Prolonged Deceleration Phase
- prolonged when it extends beyond 3
hours in a nullipara
- Prolonged deceleration phase most
often results from abnormal fetal
head position. = CS
4. Secondary Arrest of Dilatation
- no progress in cervical dilatation for
longer than 2 hours = CS
II.
Dysfunction at the Second Stage
of Labor
1. Prolonged Descent
- 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 3 hours in a
multipara (Cheng et al., 2007)
2. Arrest of Descent
- no descent has occurred for 1 hour
in a multipara or 2 hours in a
nullipara
Contraction Rings - hard band that
forms across the uterus at the junction of
the upper and lower uterine segments and
interferes with fetal descent.
 Pathologic retraction ring (Bandl’s
ring)- during the second stage of
labor and can be palpated as a
horizontal indentation across the
abdomen
- caused
by
uncoordinated
contractions
The wall below the ring is thin and the
abdomen shows an indentation. This
constriction is caused by obstructed
labor and is a warning sign that if the
obstruction is not relieved, the lower
segment may rupture.
Precipitate Labor - when uterine
contractions are so strong that a
woman gives birth with only a few,
rapidly occurring contractions
-
is cervical dilatation that occurs at
a rate of 5 cm or more per hour in a
primipara or 10 cm or more per
hour in a multipara
-
forceful that they lead to premature
separation of the placenta = the
woman at risk for hemorrhage.
Cervical Ripening - change in the
cervical consistency from firm to soft,
is the first step the uterus must
complete in early labor
-
(hypotonic) that assistance
needed to strengthen them
is
Active Management of Labor
-
Bishop (1964) established criteria
for scoring the cervix
aggressive
administration
of
oxytocin (increases of 6 mU/min
rather than 1 or 2 mU/min) to
shorten labor to 12 hours, which
presumably reduces the incidence
of cesarean birth and postpartal
infection
Uterine Rupture
Induction of Labor by Oxytocin
- initiates contractions in a uterus at
pregnancy term (Archie, 2007)
- always administered intravenously, so
that, if hyperstimulation should occur, it
can be quickly discontinued
occurs when a uterus undergoes
more strain than it is capable of
sustaining
- most commonly when a vertical
scar from a previous cesarean birth
or hysterotomy repair tears
a. complete
rupture
uterine
contractions will immediately stop
- Two distinct swellings will be visible
on the woman’s abdomen: the
retracted
uterus
and
the
extrauterine fetus
b. Incomplete rupture - localized
tenderness and a persistent aching
pain over the area of the lower
uterine segment
Inversion of the Uterus
-
uterus turning inside out with
either birth of the fetus or delivery
of the placenta
Amniotic Fluid Embolism
-
Augmentation by Oxytocin
-
required if labor contractions begin
spontaneously but then become so
weak, irregular, or ineffective
amniotic fluid is forced into an open
maternal uterine blood sinus
through some defect in the
membranes or after membrane
rupture or partial premature
separation of the placenta
PROBLEMS WITH THE
PASSENGER
1. Umbilical Cord Prolapse
 a loop of the umbilical cord slips
down in front of the presenting fetal
part
Occur most often with:
• Premature rupture of membranes
• Fetal presentation other than cephalic
• Placenta previa
• Intrauterine tumors preventing the
presenting part from engaging
• A small fetus
• Cephalopelvic disproportion preventing
firm engagement
• Hydramnios
• Multiple gestation
Assessment: may be felt as the presenting
part on an initial vaginal examination
during labor
-
UTZ
Therapeutic
Management:
cord
compression, because the fetal presenting
part presses against the cord at the pelvic
brim
-
a.


b.


placing a gloved hand in the vagina
and manually elevating the fetal
head off the cord, or by placing the
woman in a knee–chest or
Trendelenburg
Amnioinfusion
addition of a sterile fluid into the
uterus to supplement the amniotic
fluid
just prevents additional cord
compression
Fetal Blood Sampling
inserting a fetal oximeter into the
uterus
small
scalpel
is
introduced
vaginally into the cervix, and the
fetal scalp is nicked - capillary tube
 A scalp blood pH greater than 7.25
is considered normal for a fetus
during labor. A pH between 7.21
and 7.25 should be remeasured in
30 minutes. A scalp blood pH lower
than 7.20 is acidotic and signifies a
level of fetal distress.
2. Multiple Gestation
 increased
incidence
of
cord
entanglement
and
premature
separation of the placenta
Problems with Fetal Position,
Presentation, or Size
1. Occipitoposterior Position - A
posteriorly presenting head does
not fit the cervix as snugly as one in
an anterior position
2. Breech Presentation
a higher risk of:
• Anoxia from a prolapsed cord
• Traumatic injury to the aftercoming
head
(possibility
of
intracranial
hemorrhage or anoxia)
• Fracture of the spine or arm
• Dysfunctional labor
• Early rupture of the membranes
because of the poor fit of the presenting
part
3. Face Presentation - A fetal head
presenting at a different angle than
expected is termed asynclitism
- Babies
born
after
a
face
presentation have a great deal of
facial edema and may be purple
from ecchymotic bruising
4. Brow Presentation - rarest of the
presentations. It occurs in a
multipara or a woman with relaxed
abdominal muscles.
- Brow presentations also leave an
infant with extreme ecchymotic
bruising on the face
Anomalies of the Placenta
normal placenta weighs approximately
500 g and is 15 to 20 cm in diameter
and 1.5 to 3.0 cm thick
1. Placenta Succenturiata
- placenta that has one or more
accessory lobes connected to the
main placenta by blood vessels.
- small lobes may be retained in the
uterus after birth, leading to severe
maternal hemorrhage
5. Vasa Previa
- umbilical vessels of a velamentous
cord insertion cross the cervical os
and therefore deliver before the
fetus
6. Placenta Accreta
- unusually deep attachment of the
placenta
to
the
uterine
myometrium so deeply the placenta
will not loosen and deliver
Anomalies of the Cord
2. Placenta Circumvallata
- the fetal side of the placenta is
covered to some extent with chorion
3. Battledore Placenta
- the cord is inserted marginally
rather than centrally
4. Velamentous Insertion of the Cord
- instead of entering the placenta
directly, separates into small
vessels that reach the placenta by
spreading across a fold of amnion
- This form of cord insertion is most
frequently found with multiple
gestation
1.
2.
-
Two-Vessel Cord
single umbilical artery
Unusual Cord Length
tendency to twist or knot
Cord loop