⚫DYSTOCIA
a difficult labor which can arise from
the POWER, the PASSAGEWAY, the
PASSENGER, PSYCHE and medical
interventions -labor that lasts >24 hours)
COMMON CAUSES OF DYSFUNCTIONAL
LABOR
⚫ Inappropriate use of analgesia (excessive or too early
administration)
⚫ Pelvic bone contraction that has narrowed the pelvic
diameter so that a fetus cannot pass (rickets) ⚫ Poor
fetal position (posterior rather than anterior positions)
⚫ Extension rather than flexion of the fetal head ⚫
Overdistention of the uterus, as with multiple
pregnancy, hydramnios, or an excessively oversized fetus
⚫ Cervical rigidity ( unripe)
⚫ Presence of a full rectum or urinary bladder that
impedes fetal descent
⚫ Mother becomes exhausted from labor
⚫ Primigravida status
COMPLICATIONS WITH THE POWER
(FORCE OF LABOR)
INERTIA- sluggishness of contractions, now known
as DYSFUNCTIONAL LABOR
⚫ PRIMARY (occurring at the onset of labor)
or ⚫ SECONDARY (occurring later in labor)
UTERINE TONES
NORMAL VALUES:
RESTING TONE= 5-15 mm Hg
MILD CONTRACTION= 15-30 mm Hg
MODERATE CONTRACTION= 30-50 mm Hg
STRONG CONTRACTION= 50-75 mm Hg
INEFFECTIVE UTERINE FORCE
HYPOTONIC CONTRACTIONS(2ary
inertia)/HYPOTONIC UTERINE INERTIA ⚫
The number of contractions is low or infrequent ( not
increasing beyond 2 or 3 in a 10-minute period ⚫ Resting
tone of the uterus remains < 10 mm Hg, & strength
of contractions does not rise above 25 mm Hg
⚫ Common in the ACTIVE PHASE
⚫ Increases length of labor & uterus does not contract
effectively postpartally due to exhaustion, increasing
chance for postpartal hemorrhage
⚫ Cervix is dilated for prolonged periods increasing risk
for infection of mother & fetus
Causes of Hypotonic Uterus
⚫ administration of analgesia when cervix is
not dilated to 3 or 4 cm,
⚫ bowel or bladder distention- prevents descent or
firm engagement,
⚫ multiple gestation,
⚫ LGA fetus,
⚫ hydramnios,
⚫ lax uterus due to grand multiparity
Complications
⚫ Maternal/fetal infections- cervix is dilated for a
prolonged time
⚫ Postpartum hemorrhage
⚫ Fetal distress and death
⚫ Maternal exhaustion
Management of Hypotonic Uterus ⚫
UTZ to rule out CPD
⚫ Walking, if not contraindicated
⚫ OXYTOCIN to augment labor by strengthening
contractions & making them effective
⚫ Amniotomy to speed up labor
⚫ 1st hour postpartum, palpate the uterus and assess
lochia q 15 minutes to ensure that postpartl
contractions are not also hypotonic & inadequate to
halt bleeding
OXYTOCIN for Hypotonic UI ⚫ Do not leave
pt alone
⚫ Client must be in true labor- at least 3 cm ⚫ No
obstruction, uterine overdistention, multiple
gestation
⚫ Monitor VS esp BP( most impt bec oxytocin
may cause hypo/hypertension
⚫ Assist w/ delivery: after failed trial labor of 6 hours
⚫ After delivery: observe for signs of injury & signs of
poor bonding dt difficult delivery
HYPERTONIC UTERUS( primary
inertia)
⚫ Increase in resting tone to > 15 mm Hg,
mostly seen in the LATENT PHASE
⚫Muscle fibers do not repolarize or relax after a
contraction, thereby wiping it clean to receive a
new pacemaker stimulus
⚫More painful because the myometrium
becomes tender from constant lack of
relaxation & the anoxia of uterine cells that
results
HYPERTONIC UTERUS ⚫Lack of
relaxation between contractions may not
allow uterine artery filling leading to fetal
anoxia
⚫ **Any woman whose pain is out of
proportion to the quality of her
contractions should have both a uterine &
fetal external monitor applied for at least 15
mins to make sure that the resting phase of
contractions is adequate & that the fetal
pattern is not showing late deceleration
Management of Hypertonic Uterus
⚫ Rest & pain relief with a drug like morphine
sulfate & sedatives
⚫ Change linen and client’s gown, darken the
room lights, decrease noise & stimulation
⚫ If (+) for deceleration in FHR, abnormally long 1st
stage of labor, or lack of progress with pushing (“2nd
STAGE ARREST”), CS may be necessary
HYPOTONIC vs HYPERTONIC
CONTRACTIONS
CRITERIA HYPERTONIC HYPOTONIC Phase of
Labor Latent Active Symptoms Painful Painless
Medication
Oxytocin Unfavorable
reaction
Sedation Helpful Little value
Favorable reaction
CONTRACTION RING
⚫ It is a hard band that forms across the uterus at the
junction of the upper and lower uterine segments and
interferes with fetal descent.
⚫ BANDL’S RING or PATHOLOGIC RETRACTION
RING- a type of contraction ring that usually appears at
the 2nd stage of labor & can be palpated as a horizontal
indentation across the abdomen.
⚫ It is a warning sign that severe dysfunctional labor is
occurring as it is formed by excessive retraction of the
upper uterine segment; the myometrium is much
thicker above than below the ring.
⚫ It is caused by uncoordinated contractions due to
CPD, manipulation or the use of oxytocin.
⚫ The fetus and the undelivered placenta are gripped
by the retraction ring and cannot advance beyond
this point.
BANDL’s RING
Management
⚫ Administration of IV morphine sulfate
or inhalation of amyl nitrate
⚫ Tocolytics to halt the contractions
⚫ Cesarian birth to ensure safety of the fetus
and manual removal of the placenta under
general anesthesia
Complications:
⚫Uterine rupture
⚫Neurologic damage to the fetus
PRETERM/PREMATURE LABOR
Definition:
labor that occurs before the
end of 37 weeks of gestation
⚫ Associated with:
⚫ Dehydration
⚫ Urinary tract infection
⚫ Periodontal disease
⚫ Chorioamnionitis
⚫ Large fetal size
⚫ Strenuous jobs during pregnancy
⚫ Shift work
⚫ Intimate partner violence and trauma
Assessment
⚫ Persistent uterine contractions (4 contractions every 4
minutes or less)
⚫ Low abdominal cramping with or without
diarrhea ⚫ Intermittent sensation of pelvic pressure,
urinary frequency
⚫ Persistent, dull low backache
⚫ Increased vaginal discharge, may be
pink-tinged ⚫ Leaking amniotic fluid
⚫ Cervical effacement > 80% & dilatation > 1 cm
PTL Management
⚫Lab test to detect presence of fetal
fibronectin to predict impending delivery;
if absent, labor will not occur for at least 14
days
⚫UTZ of cervix to determine shortening
⚫Patient is admitted & placed in complete
bed rest (preferably left side-lying) to
relieve pressure of the fetus on the cervix
Management cont’d ⚫ IV fluid to maintain
hydration which may help stop contractions
(dehydration stimulates PG to secrete oxytocin)
⚫ Vaginal, cervical & urine cultures to rule
out infection
⚫ Increase fluid intake since a full bladder
inhibits contractions
⚫ TOCOLYTICS- to halt labor
⚫ Discharge- once contractions have stopped
and maternal and fetal conditions have
stabilized ⚫ No MEPERIDINE(DEMEROL)
TOCOLYTIC AGENTS to halt labor
Drug Type/purpose Major side
effects
RITRODRINE
(YUTOPAR)
ß-adrenergic
TERBUTALINE
receptor
agonist/tocolysis
Maternal or fetal
tachycardia,
Nursing concerns
shortness of
breath, pulmonary
edema, tremors,
N/V,hyperglycemi a,
(BRETHINE)
ß-adrenergic/
tocolysis; antidote:
PROPANOLOL
SAME AS ABOVE SAME
AS ABOVE
hypokalemia
Assess VS, breath
sounds, FHR,
contractions &
maternal response
Drug Type/purpose Major side effects Nursing concerns
MgSO4 CNS
Depressant/Tocol
ysis
BETAMETHASONE
(CELESTONE) or
Lethargy, heat sensation,
10-12 mg/dl)
respiratory depression,
Assess RR, DTR, hourly urinary
depressed reflexes, cardiac
output, serum Mg levels
arrest if high serum levels (>
DEXAMETHASONE
infection & poor wound 48 hours before
Corticosteroid/
healing,
delivery to be
stimulates fetal lung hypoglycemia,
effective; commonly
maturation by
increased risk of
used between 24 to 34
stimulating
pulmonary edema when weeks AOG unless
given with a
fetal lung maturity can
surfactant
ß-adrenergic agent
be documented
production
Increased risk of
Must be given 24 to
PRECIPITATE LABOR Definition:
⚫ it is a labor that is completed in < 3 hours ⚫
It occurs when uterine contractions are so strong
that the woman gives birth with only a few, rapidly
occurring contractions.
Causes:
grand multiparity,
induction of labor by OXYTOCIN or AMNIOTOMY
PRECIPITATE LABOR
Causes:
⚫
grand multiparity,
⚫Large pelvis
⚫ Small fetus
⚫ induction of labor by OXYTOCIN or
⚫ AMNIOTOMY
PRECIPITATE LABOR
Symptoms:
⚫ rate of dilatation in the active phase:
⚫ > 5 cm/hr (1 cm/12 mins) in a nullipara
⚫ 10 cm/hr (1 cm/6 mins) in a multipara;
⚫ tocolytics may be administered
PRECIPITATE LABOR
Maternal Complications:
⚫ premature separation of the placenta leading
to hemorrhage,
⚫ infection
⚫ lacerations on the birth canal
⚫ Uterine rupture
⚫ Amniotic fluid embolism
Fetal Complications
⚫ Fetal hypoxia, anoxia
⚫ Erb-Duchenne palsy
⚫ Injuries like falling to
the
floor in unattended
childbirth
⚫ Subdural hemorrhage on the
fetus due to sudden release
of pressure on the head,
⚫ hemorrhage
PRECIPITATE LABOR Management:
⚫TOCOLYTICS
⚫ In multiparous women with history of a
brief past labor, advise to prepare for
appropriately timed transport starting
on her 28th week of gestation(BIRTH
PLAN)
⚫
Never leave client
⚫ Monitor FHT q15 min
⚫ Provide emotional support: inform client of what
is happening
⚫ Assist with the delivery, advising the client to pant
or blow and NOT to push
⚫ Never hold the baby back
⚫ Support the perineum with a towel to
prevent lacerations and also subdural
hemorrhage(MODIFIED RITGEN’S
MANEUVER)
⚫ Deliver baby in-between contractions
⚫ Inspect the perineum for possible lacerations
INVERSION OF THE UTERUS
Definition:
⚫turning inside
out of the uterus
with either birth
of the fetus or
the delivery of
the placenta
INVERSION OF THE
UTERUS
Predisposing Factors
⚫ Pulling or traction on the umbilical cord to
remove the placenta
⚫ Vigorous pressure is applied to the fundus while
the uterus is not contracted
⚫ The placenta is attached at the fundus and the
passage of the fetus during birth pulls it down
INVERSION OF THE UTERUS Types of
Inversion
⚫ 1. Complete or Total Inversion
⚫ The uterus is visible outside the vaginal
introitus ⚫ Life threatening because of severe
hemorrhage & shock
⚫ 2. Partial Inversion
⚫ The inverted fundus may lie within the
uterine cavity
⚫ It is not visible but may be palpated
⚫ It hampers or impedes contractions & control
of hemorrhage
INVERSION OF THE UTERUS
Assessment
⚫ Sudden gushing of blood from the vagina
⚫ Signs of blood loss: hypotension,
dizziness, paleness or diaphoresis
⚫Because bleeding is continuous,
exsanguination could occur within 10
minutes
INVERSION OF THE UTERUS
Management
⚫ Never attempt to replace an inversion since handling
of the uterus will worsen the hemorrhage
⚫ Never attempt to remove the placenta if it is
still attached
⚫ Oxytocic drugs makes the uterus more tense thus,
more difficult to replace
⚫ Start an IV line (use a large-gauge needle to be used
in BT) & open it to achieve optimal flow to restore
fluid volume
Management cont’d
⚫Administer O2 by mask
⚫Assess VS
⚫Prepare to administer CPR
⚫General anesthesia, nitroglycerin or a
tocolytic is administered to relax the
uterus
⚫Physician or midwife will then replace the
fundus manually
⚫After replacement, administer
Oxytocin ⚫Antibiotic therapy to prevent
infection ⚫CS is recommended for
succeeding pregnancies
PROBLEMS WITH
THE PASSENGER
PROLAPSE OF THE UMBILICAL CORD
Definition
⚫A loop of the umbilical cord slips down in
front of the presenting fetal part
⚫ It may occur any time after the
membranes have ruptured if the
presenting part is not fitted firmly into the
cervix
Cord Prolapse
Predisposing Factors
⚫ Premature rupture of membranes
⚫ Fetal presentation other than
cephalic ⚫ Placenta previa
⚫ Intrauterine tumors preventing the
presenting part from engaging
⚫ A small fetus
⚫ CPD preventing firm engagement
⚫ Hydramnios
⚫ Multiple gestation
CORD COMPRESSION
Cord Prolapse Assessment
⚫ The cord may be felt as the presenting part on an
initial vaginal examination during labor ⚫ UTZ
evidence ( a CS is necessary before rupture of
membranes)
⚫ variable deceleration pattern becomes
apparent ⚫ The cord may be visible at the vulva
⚫ To r/o prolapse, assess FHR immediately after
rupture of membranes
Management
⚫ cord prolapse will lead to cord compression
because the presenting part will press against the
cord at the pelvic brim
⚫ Place the mother’s hips higher than her
head: knee-chest position
⚫ Trendelenberg position
Management
⚫ Amnioinfusion-to
reduce compression on
the cord with infusion of
5ooml warmed NSS.
⚫ Used for only a short
time until the cervix is
fully dilated or a
cesarean birth can be
arranged.
⚫ Can also be
performed for women
with
oligohydramnios
⚫ Nursing
Consideration ⚫
Monitor FHR and
uterine contractions
continuously.
⚫ Monitor maternal
temp every hour
⚫ Placed the bag of
fluid in a radian
warmer to prevent
chilling
Management 1. Prevention:
⚫Always assess FHT after membranes rupture
⚫Place woman on bed rest after membranes
rupture 2. Reduce pressure on the cord by:
⚫Place in Knee-chest or Trendelenburg position,
or place folded towel under the hips
⚫Put on sterile gloves and insert 2 fingers into the
vagina, then push presenting part upward 3. If cord
is exposed to air, cover with saline moistened
sterile compress to prevent drying. ⚫Drying of
cord leads to atrophy & constriction of BV
Management
4. Never replace the cord back into the vagina
as it may result in kinking and knotting
obstructing blood flow
5. Administer O2 at 10 LPM to improve O2
supply to fetus
6. Deliver baby ASAP:
⚫Vaginal delivery if cervix is fully dilated & no
fetal distress
⚫CS if cervix is not fully dilated & if fetal distress
is present
Cesarean Section
Management ⚫ Place a gloved hand in the
vagina and manually lift the fetal head off the
cord
⚫ Administer O2 at 10 LPM by face mask to
the mother to increase oxygenation to the fetus ⚫
Tocolytic agent may be administered to reduce
uterine activity & pressure on the fetus ⚫ Maintain
continuous electronic fetal monitoring ⚫ Prepare
for rapid delivery vaginally or by CS
FETAL MALPOSITION
⚫The ideal position is flexed with
the occiput in the R or L Anterior
quadrant (ROA/LOA)
Types of Malposition
1. OCCIPITOPOSTERIOR
POSITION
⚫ It occurs in 1/10 of all labors and
during internal rotation the head must
rotate through 135 degrees instead of 90
degrees
⚫Failure to rotate is termed PERSISTENT
OCCIPUT POSTERIOR
⚫Common in women with android,
anthropoid or contracted pelves
OCCIPITOPOSTERIOR
Occipitoposterior Position
Symptoms:
⚫ prolonged active phase,
⚫ arrested descent,
⚫ FHT heard best at the lateral sides of the
abdomen, ⚫ intense back pain during labor
ROP/LOP
⚫Maternal risks: prolonged labor,
potential for CS birth, 3rd or 4th degree
lacerations
⚫Fetal risks: umbilical cord prolapse,
increased molding, caput formation
2. OCCIPUT TRANSVERSE
POSITION
⚫Due to ineffective contractions or a
flattened bony pelvis
⚫Vaginal delivery is possible with oxytocin
administration and application of forceps
for delivery
Management: ⚫Encourage mother to lie
on her opposite side from the fetal back
which may help with rotation
⚫Other positions: Hands and knees
position, squatting, pelvic rocking
Management
⚫Apply sacral counter-pressure with the
heel of the hand or do back rubs to relieve
back pain
⚫Apply heat or cold, as desired by the
patient
Occipitotransverse ⚫ Encourage voiding
every 2 hours
⚫ In prolonged labor, provide sports drink or
IV glucose to replenish glucose stores ⚫
Provide constant encouragement and inform
the client & family of progress
⚫ Prepare for a forceps delivery
FETAL MALPRESENTATION
1. BREECH PRESENTATION
2. VERTEX MALPRESENTATIONS
a. FACE PRESENTATION
b. BROW PRESENTATION
c. SINCIPITAL PRESENTATION
(MILITARY ATTITUDE)
FETAL MALPRESENTATIONS
3. SHOULDER PRESENTATION
(TRANSVERSE LIE)
4. COMPOUND PRESENTATION