CH. 23

• Dystocia


  Can arise from any of the four main components of the labor process: the power (uterine contractions), the passenger (the fetus), the passageway (the birth canal), or the psyche (the woman's and family's perception of the event)
• Nursing Process Overview


  1. Assessment

  2. Nursing Diagnosis

  3. Outcome Identification and Planning

  4. Implementation

  5. Outcome Evaluation
• Outcome Identification and Planning

  Encouraging a couple to clarify their priorities when a complication occurs is helpful
• Fetal bradycardia


  Cesarean birth may become necessary
• Primary goal


  To have a healthy baby
• Implementation


  Actions to increase the fetal heart rate (FHR) or to strengthen uterine contractions are a priority and possibly an emergency
• Outcome Evaluation


  An evaluation of proposed outcomes may reveal unhappiness because not every woman who experiences a deviation from the normal in labor and birth will be able to give birth to a healthy child
• Dysfunctional labor


  Dysfunction can occur at any point in labor, but it is generally classified as primary (occurring at the onset of labor) or secondary (occurring later in labor)
• Ineffective uterine force


  Uterine contractions are the basic force that moves the fetus through the birth canal. They occur because of the interplay of various biochemical factors.

  
• Uterine contractions


  Begin at a pacemaker point located in the myometrium near one of the uterotubal junctions, and then sweep down over the uterus as a wave. In early labor, the pacemaker is not synchronous.
• Hypertonic contractions


  Primary dysfunctional labor, marked by an increase in resting tone to >15 mmHg (normal resting tone is 5-10 mmHg). A resting pressure > 20 mmHg causes decreased uterine perfusion.

  
• Hypertonic contractions


  • Painful & frequent contractions, ineffective in causing cervical dilation & effacement, occur in latent stage (cervical dilation < 4 cm), uncoordinated, force of contraction may be in the midsection rather than the fundus, uterus may not relax completely between contractions

  
• Hypotonic uterine dysfunction


  Secondary uterine inertia, where the woman initially makes normal progress into the active stage of labor, then contractions become weak & inefficient, or stop altogether. The uterus is easily indented, even at the peak of contraction, and the IUP is insufficient (usually < 25 mmHg; normal is 25-100 mmHg) for progress of cervical effacement and dilation.

  
• Common causes of dysfunctional labor

  • Primigravida status
  • Pelvic bone contraction (cephalopelvic disproportion)
  • Posterior or extended fetal position
  • Failure of uterine muscle to contract properly
  • Overdistention of the uterus
  • A nonripe cervix
  • Presence of a full rectum or urinary bladder
  • Woman becoming exhausted from labor
  • Inappropriate use of analgesia
• Dysfunctional labor and associated stages of labor

  Dysfunction at the First Stage of Labor involves: prolonged latent phase, protracted active phase, prolonged deceleration phase, and secondary arrest of dilatation.
• Prolonged latent phase

  When contractions become ineffective during the first stage of labor, a prolonged latent phase can develop. Latent phase that lasts longer than 20 hours in a nullipara or 14 hours in a multipara. Relaxation between contractions is inadequate, and the contractions are only mild (less than 15 mmHg on a monitor printout) and, therefore, ineffective. One segment of the uterus may be contracting with more force than another segment.
• Tonus (resting tone)


  Intra uterine pressure in between the contractions. During quiescent stage it is 2-3 mmHg, during first stage of labor it is 8-10 mmHg. Normal resting tone is 5-10 mmHg, during labor it may rise to 10-15 mmHg. A resting pressure above 20 mmHg causes decreased uterine perfusion.

  
• Uterine contractions


  • Only mild (less than 15 mmHg on a monitor printout) and, therefore, ineffective
  • One segment of the uterus may be contracting with more force than another segment

  
• Tonus (resting tone)


  Intra uterine pressure in between the contractions

  
• During Quiescent (inactive) stage, tonus is 2-3 mmHg
• During first stage of labor, tonus is 8-10 mmHg
• Uterine tone


  • The lowest intrauterine pressure between contractions is called resting tone
  • Normal resting tone is 5-10 mmHg
  • During labor resting tone may rise to 10-15 mmHg
  • Pressure during contractions rises to ~25- 100 mmHg (varies with stage)
  • A resting pressure above 20 mmHg causes decreased uterine perfusion

  
• Management of a prolonged latent phase in labor caused by hypertonic contractions

  1. Helping the uterus to rest

  2. Providing adequate fluid for hydration

  3. Pain relief with a drug such as morphine sulfate

  4. Changing the linen and the woman's gown

  5. Darkening room lights

  6. Decreasing noise and stimulation

  7. If it does not progress, a cesarean birth or amniotomy (i.e., artificial rupture of membranes) and oxytocin infusion to assist labor may be necessary
• Protracted active phase


  • Usually associated with fetal malposition or cephalopelvic disproportion (CPD)
  • Prolonged if cervical dilatation does not occur at a rate of at least 1.2 cm/hr in a nullipara or 1.5 cm/hr in a multipara, or if the active phase lasts longer than 12 hours in a primigravida or 6 hours in a multigravida
  • If the cause is fetal malposition or CPD, cesarean birth may be necessary
  • Dysfunctional labor during the dilatational division of labor tends to be hypotonic in contrast to the hypertonic action at the beginning of labor
  • After an ultrasound to show CPD is not present, oxytocin may be prescribed to augment labor
• Prolonged deceleration phase


  • Extends beyond 3 hours in a nullipara or 1 hour in a multipara
  • Most often results from abnormal fetal head position
  • A cesarean birth is frequently required
• Secondary arrest of dilatation


  • Occurs if there is no progress in cervical dilatation for longer than 2 hours
  • A cesarean birth may be necessary
• Dysfunction at the second stage of labor

  • Involves prolonged descent and arrest of descent
• Prolonged descent


  • Occurs if the rate of descent is less than 1.0 cm/hr. in a nullipara or 2.0 cm/hr. in a multipara
  • Can be suspected if the second stage lasts over 2 hours in a multipara
  • With both a prolonged active phase of dilatation and prolonged descent, contractions have been of good quality and duration, effacement and beginning dilatation have occurred, but then the contractions become infrequent and of poor quality, and dilatation stops
  • If everything else is within normal limits except for the suddenly faulty contractions and CPD and poor fetal presentation have been ruled out by ultrasound, rest and fluid intake, as advocated for hypertonic contractions, also applies
  • 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, and a semi-Fowler's position, squatting, kneeling, or more effective pushing may speed descent
• Arrest of descent


  • Results when no descent has occurred for 2 hours in a nullipara or 1 hour in a multipara
  • Occurs when expected descent of the fetus does not begin or engagement or movement beyond 0 station does not occur
  • Caused by CPD
  • Cesarean birth usually is necessary, but if there is no contraindication to vaginal birth, oxytocin may be used to assist labor

  
• Precipitous labor


  • Labor lasts < 3 hrs. from the onset of contractions to the time of birth
  • During the active phase of dilatation, the rate is greater than 5 cm/hr. (1 cm every 12 minutes) in a nullipara or 10 cm/hr. (1 cm every 6 minutes) in a multipara
  • May result from hypertonic uterine contractions that are tetanic in intensity

  
• Maternal complications


  • Uterine rupture
  • Laceration of birth canal
  • Amniotic fluid embolism
  • Postpartum hemorrhage

  
• Fetal complications


  • Hypoxia
  • Intracranial hemorrhage r/t rapid birth
• Uterine prolapse


  • Mild: cervix drops into the lower part of the vagina
  • Moderate: cervix drops out of the vaginal opening
  • Complete: cervix and the body of the uterus protrude through the vagina, and the vagina is inverted
  • The pelvic exam may also show that the bladder and front wall of the vagina (cystocele), or rectum and back wall of the vagina (rectocele) are entering the vagina
  • The urethra and bladder may also be lower in the pelvis than usual
• Treatment of uterine prolapse

  1. Lifestyle changes: weight loss, avoid heavy lifting or straining, treat chronic cough

  2. Vaginal pessary: holds the uterus in place, may be temporary or permanent, must be cleaned

  3. Surgery: sacrospinous fixation, vaginal hysterectomy
• Prevention of uterine prolapse includes Kegel exercises, estrogen therapy, weight loss, and avoiding heavy lifting
• Prolapse of the umbilical cord

  • Loop of the umbilical cord slips down in front of the presenting fetal part
  • Tends to occur with premature rupture of membranes, fetal presentation other than cephalic, placenta previa, intrauterine tumors, small fetus, CPD, hydramnios, multiple gestation
• Assessment and therapeutic management of umbilical cord prolapse

  1. Cord may be felt as presenting part on initial vaginal exam, sonogram, or visible at the vulva

  2. Variable deceleration FHR pattern

  3. Place a gloved hand on the vagina and manually elevating the fetal head off the cord

  4. Place woman in a knee-chest or Trendelenburg position

  5. Administer O2 at 10 L/min. by face mask

  6. Tocolytic agent is administered to reduce uterine activity & pressure on the fetus

  7. Do not attempt to push any exposed cord back into the vagina

  8. Cover any exposed portion with a sterile saline compress

  9. If cervix is fully dilated, deliver the infant quickly (by forceps)

  10. If dilatation is incomplete, keep pressure off the cord and baby can be borne by C/S
• Occipitoposterior position


  • Fetal head must rotate through an arc of 135° during internal rotation
  • Prolonged active phase, arrested descent
  • Fetal heart sounds heard best at the lateral sides of the abdomen
  • Prolonged labor because the arc of rotation is greater
  • Woman experience pressure & pain in her lower back due to sacral nerve compression
• Management of occipitoposterior position

  1. Counterpressure on the sacrum (e.g. back rub) to relieve pain

  2. Applying heat or cold

  3. Let woman void every 2 hrs. to keep bladder empty

  4. During long labor, IV glucose solution to replace glucose stores used for energy

  5. Fetus may be borne by C/S if contractions are ineffective, fetus larger than average, fetus not in good flexion, fetal head may arrest in the transverse position, or persistent occipitoposterior position
• Breech presentation

  • Types: complete, frank, footling
  • Complications: anoxia from prolapsed cord, traumatic injury to the after-coming head, fracture of the spine or arm, dysfunctional labor, early rupture of the membranes, meconium aspiration