maternal

• Dystocia and dysfunctional labor can be caused by common deviations in the power, passage, or passenger during labor
• National Health Goals related to labor complications include reducing cesarean births among low-risk women and maternal mortality rates
• Critical thinking is used to maintain family-centered nursing care during deviations from normal labor or birth
• Assessment of a woman in labor includes monitoring uterine and fetal activity for deviations from the normal labor process
• Nursing diagnoses related to deviations from normal labor and birth include fatigue, risk for tissue perfusion, fluid volume deficiency, and maternal/fetal injury
• Expected outcomes associated with deviations from normal labor and birth include monitoring fetal well-being and administering IV fluids for maternal and fetal well-being
• Nursing interventions for complications of labor include preparing the family for a cesarean birth and evaluating the effectiveness of care
• Areas related to labor complications that could benefit from additional nursing research or evidence-based practice should be identified
• Integration of knowledge of deviations from normal labor with the nursing process is essential for quality maternal and child health nursing care
• Complications with the power of labor can lead to inertia or dysfunctional labor
• Ineffective uterine force can result from hypotonic or hypertonic contractions, requiring interventions such as oxytocin or amniotomy
• Uncoordinated contractions may require external monitoring and oxytocin administration to stimulate effective contractions
• Dysfunction at the first stage of labor can lead to prolonged latent phase, protracted active phase, prolonged deceleration phase, or secondary arrest of dilatation
• Management of dysfunctional labor during the first stage includes rest, hydration, pain relief, and potential cesarean birth if necessary
• Dysfunction at the second stage of labor can result in prolonged descent of the fetus, requiring interventions if the descent rate is inadequate
• Dysfunctional Labor and Associated Stages of Labor
• Dysfunction at the Second Stage of Labor
• Prolonged Descent:

  • Rest and fluid intake recommended if faulty contractions occur and CPD and poor fetal presentation are ruled out
  • Rupturing membranes may be helpful if not already done
  • IV oxytocin may be used to induce effective uterine contractions
  • Different positions like semi-Fowler’s, squatting, kneeling, or more effective pushing may speed descent
• Arrest of Descent:

  • No descent for 1 hour in a multipara or 2 hours in a nullipara
  • Failure of descent when expected descent of the fetus does not begin or engagement or movement beyond 0 station has not occurred
  • Most likely cause for arrest of descent during the second stage is CPD
  • Cesarean birth usually necessary
  • Oxytocin may be used if no contraindication to vaginal birth
• Contraction Rings
• A contraction ring is a hard band that forms across the uterus at the junction of the upper and lower uterine segments and interferes with fetal descent

  • Most frequent type seen is termed a pathologic retraction ring (Bandl’s ring)
  • Usually appears during the second stage of labor and can be palpated as a horizontal indentation across the abdomen
  • Warning sign of severe dysfunctional labor as it is formed by excessive retraction of the upper uterine segment; the uterine myometrium is much thicker above than below the ring
• Management:

  • Administration of IV morphine sulfate or inhalation of amyl nitrite may relieve a retraction ring
  • Tocolytic to halt contractions
  • Cesarean birth may be necessary if complications arise
  • Manual removal of the placenta under general anesthesia may be required if the retraction ring does not allow the placenta to be delivered
• Precipitate Labor
• Occurs when uterine contractions are very strong, leading to rapid birth

  • Often defined as labor completed in fewer than 3 hours
  • Precipitate dilatation occurs at a rapid rate
  • Complications include risk of hemorrhage and subdural hemorrhage
  • Tocolytics may be used to reduce the force and frequency of contractions
• Induction and Augmentation of Labor
• When labor contractions are ineffective, interventions such as induction and augmentation of labor with oxytocin or amniotomy may be initiated to strengthen them

  • Induction of labor means labor is started artificially
  • Augmentation of labor refers to assisting labor that has started spontaneously but is not effective
• Conditions for induction of labor:

  • Fetus is in a longitudinal lie
  • Cervix is ripe or ready for birth
  • A presenting part is engaged
  • No CPD
  • Fetus is estimated to be mature by date
• Cervical Ripening:

  • Change in cervical consistency from firm to soft
  • Methods include "stripping the membranes" or separating the membranes from the lower uterine segment manually, using hygroscopic suppositories, or applying prostaglandin gel like misoprostol
• Induction of Labor by Oxytocin:

  • Administration of oxytocin initiates contractions in a uterus at pregnancy term
  • Always administered intravenously for quick discontinuation if hyperstimulation occurs
  • Artificial rupture of membranes may be performed after cervical dilatation reaches 4 cm
• Augmentation by Oxytocin:

  • Required if labor contractions become weak, irregular, or ineffective
  • Active management of labor includes aggressive administration of oxytocin to shorten labor to 12 hours
• Pharmacological Method to Stimulate Contraction:

  • Oxytocin induction is common
  • Diluted in IV fluids and regulated with an infusion pump
  • Complications may include overstimulation of contractions, fetal compromise, uterine rupture, water intoxication
• Non-Pharmacological Method to Stimulate Contraction:

  • Walking or sitting upright
  • Nipple stimulation
  • Brushing with a dry washcloth or gently pulling on the nipple
• Uterine Rupture
• Occurs when a uterus undergoes more strain than it can sustain

  • Most common with a vertical scar from a previous cesarean birth or hysterotomy repair
  • Signs include sudden severe pain, two distinct swellings visible on the abdomen, and signs of shock
  • Management includes IV oxytocin to contract the uterus and minimize bleeding, preparing for possible laparotomy
• Inversion of the Uterus
• Uterine inversion refers to the uterus turning inside out with either birth of the fetus or delivery of the placenta

  • Can occur if traction is applied to the umbilical cord or pressure is applied to the uterine fundus
  • Signs include sudden gush of blood, fundus not palpable in the abdomen, and signs of blood loss
  • Never attempt to replace an inversion or remove the placenta if still attached
• Amniotic Fluid Embolism
• Occurs when amniotic fluid enters a maternal uterine blood sinus through a defect in the membranes

  • Possible risk factors include oxytocin administration and abruptio placentae
  • Immediate management includes oxygen administration and CPR
  • Prognosis depends on the size of the embolism and speed of intervention
• Interventions for Complications of Labor or Birth According to Power
• Provide adequate hydration, pain relief, decrease extraneous stimulation

  • Augmentation of labor via oxytocin infusion, cesarean birth, or amniotomy may be necessary