Problems in Labor and Delivery A. PROBLEMS WITH THE POWERS (Force of Labor) TYPE DESCRIPTION 1. Hypotonic Contractions - number of contractions is unusually low or infrequent - two or three occurring in a 10-minute period) - most apt to occur during the active phase of labor 2. Hypertonic Contractions - intensity of the contraction may be no stronger than that associated with hypotonic contractions - occur frequently - most commonly seen in the latent phase of labor 3. Uncoordinated Contractions - more than one pacemaker may be initiating contractions, or receptor points in the myometrium may be acting independently of the pacemaker CAUSE/OCCURS AT/DUE TO - administration of analgesia; especially if the cervix is not dilatated to 3 to 4 cm - bowel or bladder distention; prevents descent or firm engagement - overstretched uterus by a multiple gestation - larger-than-usual single fetus - hydramnios - uterus that is lax from grand multiparity - muscle fibers of the myometrium do not repolarize or relax after a contraction - occur because more than one pacemaker is stimulating contractions - more than one pacemaker may be initiating contractions RESULTS SIGNS/SYMPTOMS - increase the length of labor; more contrax are necessary to achieve cervical dilatation - uterus to not contract as effectively during the postpartum period; exhaustion, increasing a woman’s chance for postpartal hemorrhage - resting tone of the uterus remains less than 10 mm Hg - strength of contractions does not rise above 25 mm Hg - anoxia of uterine cells that results - lack of relaxation between contractions may not allow optimal uterine artery filling; lead to fetal anoxia early in the latent phase of labor - marked by an increase in resting tone to more than 15 mm Hg - more painful than usual; myometrium becomes tender from constant lack of relaxation - become frustrated or disappointed with her breathing exercises for childbirth; such techniques are ineffective - may be difficult for a woman to rest between contractions or to use breathing exercises with contractions - do not allow good cotyledon (one of the visible segments on the maternal surface of the placenta) filling INTERVENTIONS - cesarean birth may be necessary; If deceleration in the fetal heart rate (FHR) or an abnormally long first stage of labor or lack of progress with pushing (“second-stage arrest”) occurs - Applying a fetal and a uterine external monitor - assessing the rate, pattern, resting tone, and fetal response to 4. Precipitate Labor 5. Prolonged Labor a. Prolonged Latent Phase b. Protracted Active Phase - labor that is completed in fewer than 3 hours - Precipitate dilatation 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 - uterine contractions are so strong that a woman gives birth with only a few, rapidly occurring contractions - grand multiparity - induction of labor by oxytocin or amniotomy - longer than 20 hours in a nullipara or 14 hours in a multipara - uterus tends to be in a hypertonic state - Relaxation between contractions is inadequate - contractions are only mild (less than 15 mm Hg on a monitor printout) and therefore ineffective - contractions become ineffective during the first stage of labor, a prolonged latent phase can develop - 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 - may reflect ineffective myometrial activity - associated with cephalopelvic disproportion (CPD) contractions for at least 15 minutes - Oxytocin administration stimulate a more effective and consistent pattern of contractions with a better, lower resting tone - Take histories and accomplish birth in a controlled surrounding - premature separation of the placenta, placing the woman at risk for hemorrhage - subdural hemorrhage may result from the rapid release of pressure on the head - may sustain lacerations of the birth canal from the forceful birth - phase is prolonged if cervical dilatation does not occur at a rate of at - helping the uterus to rest - providing adequate fluid for hydration - pain relief with a drug such as morphine sulfate - Changing the linen and the woman’s gown - darkening room lights - decreasing noise and stimulation can also be helpful - cesarean birth may be necessary - fetal malposition c. Prolonged Deceleration Phase d. Secondary Arrest of Dilatation e. Prolonged Descent - abnormal fetal head position f. Arrest of Descent - r arrest of descent during the second stage is CPD g. Contraction Rings least 1.2 cm/hour in a nullipara or 1.5 cm/hour in a multipara, - active phase lasts longer than 12 hours in a primigravida or 6 hours in a multigravida - extends beyond 3 hours in a nullipara or 1 hour in a multipara - no progress in cervical dilatation for longer than 2 hours - rate of descent is less than 1.0 cm/hr in a nullipara or 2.0 cm/hour in a multipara - suspected if the second stage lasts over 3 hours in a multipara suspected if the second stage lasts over 3 hours in a multipara - suddenly faulty contractions - CPD - poor fetal presentation - hard band that forms across the uterus at the junction of the upper and lower uterine segments and interferes with fetal descent - formed by excessive retraction of the upper uterine segment - uterine myometrium is much thicker above than - If the situation is not relieved, uterine rupture and neurologic damage to the fetus may occur - no descent has occurred for 1 hour in a multipara or 2 hours in a nullipara - descent of the fetus does not begin or engagement or movement beyond 0 station has not occurred - appears during the second stage of labor and can be palpated as a horizontal indentation across the abdomen - cesarean birth is frequently required - cesarean birth may be necessary - rest and fluid intake, as advocated for hypertonic contractions - If the membranes have not ruptured, rupturing them at this point may be helpful - Intravenous (IV) oxytocin may be used to induce the uterus to contract effectively - Cesarean birth usually is necessary - no contraindication to vaginal birth, oxytocin may be used - can be identified by ultrasound - a finding is extremely serious and should be reported promptly 6. Uterine Rupture 7. Uterine Inversion - most frequent type seen is termed a pathologic retraction ring (Bandl’s ring) - warning sign that severe dysfunctional labor is occurring below the ring - caused by uncoordinated contractions; early labor - caused by obstetric manipulation or by the administration of oxytocin; pelvic division of labor - accounts for as many as 5% of all maternal deaths - Rupture can be complete, going through the endometrium, myometrium, and peritoneum layers, or incomplete, leaving the peritoneum intact - uterus undergoes more strain than it is capable of sustaining - e occurs most commonly when a vertical scar from a previous cesarean birth or hysterotomy repair tears (occurs in less than 1% of women who have a low transverse cesarean scar from a previous pregnancy; about 4% to 8% of women who have a classic cesarean incision) - prolonged labor - abnormal presentation - multiple gestation - Unwise use of oxytocin - obstructed labor - traumatic maneuvers of forceps or traction - fetal death will follow unless immediate cesarean birth can be accomplished - traction is applied to the umbilical cord to remove the placenta or if pressure is applied to the uterine fundus when the uterus is not contracted - placenta is attached at the fundus so that, during birth, - exsanguination could occur within a period as short as 10 minutes - uterus turning inside out with either birth of the fetus or delivery of the placenta - rare phenomenon, occurring in about 1 in 20,000 births - Inversion occurs in various degrees IF COMPLETE:Hemorrhage from the torn uterine arteries floods into the abdominal cavity, and vagina - Signs of shock begin: rapid, weak pulse falling blood pressure cold and clammy skin and dilatation of the nostrils from air hunger - Fetal heart sounds fade and then are absent IF INCOMPLETE: - signs of rupture are less evident: a localized tenderness and a persistent aching pain over the area of the lower uterine segmen - a large amount of blood suddenly gushes from the vagina - fundus is not palpable in the abdomen - woman will show signs of blood loss: hypotension, dizziness, - Administration of IV morphine sulfate - inhalation of amyl nitrite may relieve a retraction ring - tocolytic can also be administered to halt contractions - Administer emergency fluid replacement therapy as ordered - Anticipate use of IV oxytocin to attempt to contract the uterus and minimize bleeding - Prepare the woman for a possible laparotomy as an emergency measure to control bleeding and achieve a repair - - Never attempt to replace an inversion because handling of the uterus may increase the bleeding - Never attempt to remove the placenta if it is still attached, large the passage of the fetus pulls the fundus down paleness, or diaphoresis surface area for bleeding - administration of an oxytocic drug only compounds the inversion or makes the uterus more tense and difficult to replace -IV fluid line needs to be started; large gauge needle - achieve optimal flow of fluid to restore fluid volume - Administer oxygen by mask and assess vital signs - Be prepared to perform cardiopulmonary resuscitation (CPR) i PROBLEMS WITH THE PASSENGER - maternal pelvis is so undersized, such as occurs in early adolescence or in women with altered bone growth from a disease such as rickets TYPE DESCRIPTION CAUSE/OCCURS RESULTS SIGNS/SY INTERVENTIONS AT/DUE TO MPTOMS 1. Umbilical Cord - loop of the umbilical cord - may occur at any time - cord may be felt as the - cesarean birth is necessary before Prolapse slips down in front of the after the membranes presenting part on an deceleratio rupture of the membranes occurs presenting fetal part rupture if the initial vaginal examination n FHR - assess fetal heart sounds immediately - incidence is about 0.5% of presenting fetal part is during labor pattern after rupture of the membranes cephalic births; this rises as not fitted firmly into - membrane rupture suddenly - relieving pressure on the cord, thereby high as 15% to 20% with the cervix would cause the cord to becomes relieving the compression and the breech or transverse lies o Premature rupture of slide down into the vagina apparent resulting fetal anoxia - reduced blood flow to the membranes from the pressure exerted - cord may - placing a gloved hand in the vagina and fetus can quickly cause fetal o Fetal presentation by the amniotic fluid be visible manually elevating the fetal head off the harm. other than cephalic - leads to cord at the cord o Placenta previa compression, because the vulva - placing the woman in a knee–chest or o Intrauterine tumors fetal presenting part Trendelenburg position, which causes preventing the presses against the cord at the fetal head to fall back from the cord 2. Fetal Malposition a. Occipitoposterio r Position - In approximately one tenth of all labors, the fetal position is posterior rather than anterior - posteriorly presenting head does not fit the cervix as snugly as one in an anterior position - During internal rotation, the fetal head must rotate, presenting part from engaging o A small fetus o Cephalopelvic disproportion preventing firm engagement o Hydramnios o Multiple gestation the pelvic brim - Posterior positions tend to occur in women with android, anthropoid, or contracted pelvis - suggested by a dysfunctional labor pattern such as a prolonged active phase, arrested - increases the risk of umbilical cord prolapse -increased molding and caput formation - Uterine dysfunction may result from maternal exhaustion - fetal head may arrest in the transverse position (transverse arrest), or - Administering oxygen at 10 L/min by face mask to the woman is also helpful to improve oxygenation to the fetus - A tocolytic agent may be prescribed to reduce uterine activity and pressure on the fetus - Amnioinfusion is yet another way to relieve pressure on the cord - Do not attempt to push any exposed cord back into the vagina; add to the compression by causing knotting or kinking - cover any exposed portion with a sterile saline compress to prevent drying - physician may choose to birth the infant quickly, possibly with forceps, to prevent fetal anoxia - Help maintain strict aseptic technique during insertion and while caring for the catheter. - Continuously monitor FHR and uterine contractions internally during the infusion - Record maternal temperature hourly to detect infection - obtaining a fetal oxygen saturation level by inserting a fetal oximeter; fetal cheek or scalp blood sampling - If the cord has prolapsed to the extent that it is exposed to room air, drying will begin, leading to atrophy of the umbilical vessels - woman may experience pressure and pain in her lower back owing to sacral nerve compressio - Applying counterpressure on the sacrum by a back rub may be helpful in relieving a portion of the pain - Applying heat or cold, whichever feels best, also may help - Lying on the side opposite the fetal back or maintaining a hands-and-knees position may help the fetus rotate - woman voids approximately every 2 hours to keep her bladder empty, not through a 90-degree arc, but through an arc of approximately 135 degrees 3. Fetal Malpresentation a. Breech Presentation - Most fetuses are in a breech presentation early in pregnancy - by week 38, a fetus normally turns to a cephalic presentation descent, or fetal heart sounds heard best at the lateral sides of the abdomen rotation may not occur at all (persistent occipitoposterior position) o Anoxia from a prolapsed cord o Traumatic injury to the aftercoming head (possibility of intracranial hemorrhage or anoxia) o Fracture of the spine or arm o Dysfunctional labor o Early rupture of the membranes because of the poor fit of the presenting part - cervical pressure often causes meconium to be extruded into the amniotic fluid before birth - lead to meconium aspiration if the infant inhales amniotic fluid - second danger of a breech birth is intracranial hemorrhage - Tentorial tears, which can cause gross motor and mental incapacity or lethal damage to the fetus, may result - may suffer an n because a full bladder could further impede descent of the fetus - need an oral sports drink or IV glucose solution to replace glucose stores used for energy - fetus must be born by cesarean birth - rotate by forceps - pelvic diameters, fetal skull diameters, and evidence of possible placenta previa causing the breech presentation - Always monitor FHR and uterine contractions continuously, if possible, during this time; detection of fetal distress intracranial hemorrhage b. Transverse Lie - obvious on inspection because the ovoid of the uterus is found to be more horizontal than vertical - abnormal presentation can be confirmed by Leopold’s maneuvers c. Face Presentation - fetal head presenting at a different angle than expected is termed asynclitism - Face (chin, or mentum) presentation is rare, but when it does occur, the head diameter the fetus presents to the pelvis is often too large for birth to proceed - face presentation is confirmed by vaginal examination - occurs in women with pendulous abdomens - with uterine fibroid tumors that obstruct the lower uterine segment - with contraction of the pelvic brim - with congenital abnormalities of the uterus - with hydramnios - occur in infants with hydrocephalus or another abnormality that prevents the head from engaging - occur in prematurity if the infant has room for free movement - in multiple gestation (particularly in a second twin) - if there is a short umbilical cord - usually occurs in a woman with a contracted pelvis or placenta previa - occur in the re laxed uterus of a multipara or with prematurity - hydramnios, - fetal malformation - ultrasound may be taken to further confirm the abnormal lie and to provide information on pelvic size - mature fetus cannot be delivered vaginally from this presentation; Cesarean birth is necessary. - great deal of facial edema and may be purple from ecchymotic bruising - lip edema is so severe that they are unable to suck for a day or two - head that feels more prominent than normal - with no engageme nt apparent on Leopold’s maneuvers , suggests a face - Ultrasound - Measure pelvic diamters - If the chin is anterior and the pelvic diameters are within normal limits,, vaginal - If the chin is posterior, cesarean birth is usually the method of choice - Observe the infant closely for a patent airway - Gavage feedings may be necessary to allow them to obtain enough fluid until they can suck effectively - may be transferred to a NICU for 24 hours d. Brow Presentation 4. Fetal Size a. Macrosomia b. Shoulder Dystocia - rarest of the presentations - occurs in a multipara - woman with relaxed abdominal muscles - results in obstructed labor because the head becomes jammed in the brim of the pelvis as the occipitomental diameter presents. - extreme ecchymotic bruising on the face - e complicate up to 10% of all births - most frequently born to women who enter pregnancy with diabetes or develop gestational diabetes. - associated with multiparity, because each infant born to a woman tends to be slightly heavier and larger than the one born just before. - birth problem that is increasing in incidence along with the increasing average weight of newborns most apt to occur in women with diabetes, - occurs at the second stage of labor, when the fetal head is born but the shoulders are too broad to enter and be born through the pelvic outlet - uterine dysfunction during labor or at birth because of overstretching of the fibers of the myometrium; wide shoulders may pose a problem at birth because they can cause fetal pelvic disproportion or even uterine rupture from obstruction - higher than-normal risk of cervical nerve palsy - diaphragmatic nerve injury - r fractured clavicle because of shoulder dystocia - increased risk of hemorrhage - can result in vaginal or cervical tears - can result in a fractured clavicle or a brachial plexus injury for the fetus presentatio n - Reassure the parents that the edema is transient and will disappear in a few days - cesarean birth will be necessary - weighs more than 4000 to 4500 g (approxima tely 9 to 10 lb) - cesarean birth becomes the birth method of choice - Pelvimetry or ultrasound can be used to compare the size of the fetus - asking a woman to flex her thighs sharply on her abdomen (McRobert’s maneuver) may widen the pelvic outlet a - Applying suprapubic pressure may also help the shoulder escape from beneath the symphysis pubis and be born - hazardous to the fetus if the cord is compressed between the fetal body and the bony pelvis - most apt to occur in women with diabetes - in multiparas - in post-date pregnancies may be suspected earlier if the: 1. second stage of labor is prolonged, 2. if there is arrest of descent, or if, 3. when the head appears on the perineum (crowning), it retracts instead of protruding with each contraction (a turtle sign) PROBLEMS WITH THE PASSAGEWAY - dystocia can occur is a contraction or narrowing of the passageway or birth canal - can happen at the inlet, at the midpelvis, or at the outlet - narrowing causes CPD - disproportion between the size of the fetal head and the pelvic diameters TYPE DESCRIPTION CAUSE/OCCURS AT/DUE TO 1. Abnormal size or shape of the pelvis a. Inlet - If engagement does not - caused by rickets in early Contraction occur in a primigravida, then life either a fetal abnormality - an inherited small pelvis (larger-than-usual head) or a pelvic abnormality (smallerthan-usual pelvis) should be suspected. b. Outlet Contraction RESULTS SIGNS/SYMPTOMS INTERVENTIONS - narrowing of the anteroposterior diameter to less than 11 cm - transverse diameter to 12 cm or less - pelvic measurements taken and recorded before week 24 of pregnancy - narrowing of the transverse diameter at the outlet to less than 11 cm - measure the distance between the ischial tuberosities, a measurement that is easy to make during a prenatal visit 2. Cephalopelvic Disproportion - lack of engagement at the beginning of labor - a prolonged first stage of labor - poor fetal descent PROBLEMS WITH PLACENTA TYPE DESCRIPTION 1. Placenta Previa - placenta is implanted abnormally in the uterus - occurs in four degrees: 1. implantation in the lower rather than in the upper portion of the uterus (low-lying placenta); 2. marginal implantation (the placenta edge approaches that of the cervical os); 3. implantation that occludes a portion of the cervical os (partial placenta previa); and 4. implantation that totally obstructs the cervical os (total placenta previa) - generally estimated in percentages: 100%, 75%, 30%, and so forth - approximately 5 per 1000 pregnancies - placenta is forced to spread to find an adequate exchange surface CAUSE/OCCURS AT/DUE TO - Increased parity - advanced maternal age - past cesarean births - past uterine curettage - multiple gestation - male fetus are all associated with placenta previa Bleeding occurs at: - placenta’s inability to stretch to accommodate the differing shape of the lower uterine segment or the cervix RESULTS SIGNS/SYMPTOMS INTERVENTIONS - increase in congenital fetal anomalies may occur if the low implantation does not allow optimal fetal nutrition or oxygenation - site of bleeding, the open vessels of the uterine decidua (maternal blood), places the mother at risk for hemorrhage - Because the placenta is loosened, the fetal oxygen supply may be compromised, placing the fetus at risk also - preterm labor (labor that occurs before the end of week 37 of gestation) may begin - painless bleeding in the third trimester of pregnancy - Bleeding with placenta previa begins when the lower uterine segment starts to differentiate from the upper segment late in pregnancy (approximately week 30) and the cervix begins to dilate - abrupt, painless, bright red, and sudden enough to frighten a woman - routine ultrasounds - avoid coitus, to get adequate rest, and to call her health care provider at any sign of vaginal bleeding - place the woman immediately on bed rest in a side-lying position - Be sure to assess: • Duration of the pregnancy • Time the bleeding began • Woman’s estimation of the amount of blood— ask her to estimate in terms of cups or tablespoons (a cup is 240 mL; a tablespoon is 15 mL) • Whether there was accompanying pain • Color of the blood (red blood indicates bleeding is fresh or is continuing) • What she has done for the bleeding (if she inserted a tampon to halt the bleeding, there may be hidden bleeding) • Whether there were prior episodes of bleeding during the pregnancy • Whether she had prior cervical surgery for premature cervical dilatation - Inspect the perineum for bleeding - Estimate the present rate of blood loss - Weighing perineal pads before and after - An Apt or Kleihauer-Betke test (test strip procedures) can be used to detect whether the blood is of fetal or maternal origin - Never attempt a pelvic or rectal examination with painless bleeding late in pregnancy - Continue to assess blood pressure every 5 to 15 minutes or continuously with an electronic cuff - intravenous fluid therapy using a large-gauge catheter a - . Attach external monitoring equipment to record fetal heart sounds and uterine contractions -Anticipate the order for a transvaginal ultrasound to detect this - Vaginal examinations (actual investigation of dilatation) to determine whether placenta previa exists are done in an operating room or a fully equipped birthing room - Betamethasone, a steroid that hastens fetal lung maturity, may be prescribed for the mother to encourage the maturity of fetal lungs if the fetus is less than 34 weeks’ gestation 2. Anomalies of the placenta - normal placenta weighs approximately 500 g - 15 to 20 cm in diameter and 1.5 to 3.0 cm thick - weight is approximately one sixth that of the fetus - placenta may be unusually enlarged in women with diabetes - In certain diseases, such as syphilis or erythroblastosis, the placenta may be so large that it weighs half as much as the fetus - if the uterus has scars or a septum, the placenta may be wide in diameter because it was forced to spread out to find implantation space TYPE DESCRIPTION CAUSE/OCCURS RESULTS SIGNS/SYMPTOMS INTERVENTIONS AT/DUE TO a. Placenta - placenta that has one or more - small lobes may be - No fetal abnormality is - remaining lobes are Succenturiata accessory lobes connected to the main retained in the associated with this type removed from the uterus placenta by blood vessels uterus after birth, - placenta appears torn manually to prevent leading to severe at the edge maternal hemorrhage maternal - torn blood vessels from poor uterine hemorrhage extend beyond the edge contraction of the placenta b. Placenta - no chorion covers the fetal side of the Circumvallata placenta - fetal side of the placenta is covered to c. Battledore Placenta d. Velamentous Insertion of the Cord some extent with chorion - umbilical cord enters the placenta at the usual midpoint, and large vessels spread out from there - cord is inserted marginally rather than centrally - anomaly is rare and has no known clinical significance either - cord is a situation in which the cord, instead of entering the placenta directly, separates into small vessels that reach the placenta by spreading across a fold of amnion. e. Vasa Previa - umbilical vessels of a velamentous cord insertion cross the cervical os and therefore deliver before the fetus f. Placenta Accreta - n unusually deep attachment of the placenta to the uterine myometrium so deeply the placenta will not loosen and deliver - form of cord insertion is most frequently found with multiple gestation - may be associated with fetal anomalies - vessels may tear with cervical dilatation, just as a placenta previa may tear. - painless bleeding occurs with the beginning of cervical dilatation - be certain to identify structures to prevent accidental tearing of a vasa previa as tearing would result in sudden fetal blood loss - infant needs to be born by cesarean birth. - Attempts to remove it manually may lead to extreme hemorrhage because of the deep attachment - Hysterectomy or treatment with methotrexate to destroy the still-attached tissue may be necessary
