Complication of Labor or Birth

• Dystocia


  Can arise from any of the four main components of the labor process: the power or the force that propels the fetus (uterine contractions), the passenger (the fetus), the passageway (the birth canal), or the psyche (the woman's and family's perception of the event)
• 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 each contraction begins at that point and then sweeps 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.
• Signs of hypertonic contractions

  • Painful & frequent contractions, ineffective in causing cervical dilation & effacement, occurring in latent stage, 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, with weak and inefficient contractions or contractions stopping altogether
• Dysfunctional labor in the first stage

  Involves a 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 latent phase that lasts longer than 20 hours in a nullipara or 14 hours in a multipara can develop, often due to an unripe cervix or excessive early analgesia use
• Hypertonic contractions


  Most common during the latent phase of labor
• Hypotonic contractions


  Most common during the active phase of labor
• Hypertonic contractions are painful, require oxytocin medication, and can lead to unfavorable reactions like sedation
• Hypotonic contractions have limited pain, a favorable reaction, and are of little value
• Dysfunctional labor


  • Involves a prolonged latent phase, protracted active phase, prolonged deceleration phase, and secondary arrest of dilatation
• Prolonged latent phase


  1. Contractions become ineffective

  2. Uterus is in a hypertonic state

  3. Relaxation between contractions is inadequate

  4. One segment of the uterus may be contracting with more force than another segment
• Uterine tone


  The lowest intrauterine pressure between contractions, normally 5-10 mmHg but may rise to 10-15 mmHg during labor
• Management of prolonged latent phase

  1. Help the uterus to rest

  2. Provide adequate fluid for hydration

  3. Provide pain relief with morphine

  4. Change linen and gown

  5. Darken room and decrease noise/stimulation

  6. If no progress, consider cesarean or amniotomy and oxytocin
• Protracted active phase


  • Usually associated with fetal malposition or cephalopelvic disproportion
  • Dilatation does not occur at expected rate
• Dysfunctional labor during dilatation tends to be hypotonic, in contrast to the hypertonic action at the beginning of labor
• Management of protracted active phase

  1. Perform ultrasound to check for cephalopelvic disproportion

  2. If no disproportion, use oxytocin to augment labor
• Prolonged deceleration phase


  • Extends beyond 3 hours in nullipara or 1 hour in multipara, often due to abnormal fetal head position
• Cesarean birth is frequently required for prolonged deceleration phase
• Secondary arrest of dilatation


  • No progress in cervical dilatation for longer than 2 hours
• Cesarean birth may be necessary for secondary arrest of dilatation
• Prolonged descent


  • Rate of descent less than 1.0 cm/hr in nullipara or 2.0 cm/hr in multipara, or second stage lasts over 2 hours in multipara
• Management of prolonged descent

  1. Rest and fluid intake

  2. Rupture membranes if not already done

  3. Use oxytocin to induce effective contractions

  4. Try different maternal positions to speed descent
• Arrest of descent


  • No descent for 2 hours in nullipara or 1 hour in multipara, usually due to cephalopelvic disproportion
• Cesarean birth is usually necessary for arrest of descent
• Precipitous labor


  Labor lasts less than 3 hours from onset of contractions to birth, with a rate greater than 5 cm/hr in nullipara or 10 cm/hr in multipara
• Maternal complications of precipitous labor

  • Uterine rupture
  • Laceration of birth canal
  • Amniotic fluid embolism
  • Postpartum hemorrhage
• Fetal complications of precipitous labor

  • Hypoxia
  • Intracranial hemorrhage
• Uterine prolapse


  Falling or sliding of the uterus from its normal position into the vaginal area
• Causes of uterine prolapse

  • Weak muscles, ligaments, and structures holding the uterus in place
  • Normal aging
  • Lack of estrogen after menopause
  • Anything that puts pressure on the pelvic muscles, including chronic cough and obesity
  • Pelvic tumor (rare)
• Symptoms of uterine prolapse


  • Feeling like sitting on a small ball
  • Difficult or painful sexual intercourse
  • Frequent urination or sudden urge to empty bladder
  • Low backache
  • Uterus and cervix protruding through vaginal opening
  • Repeated bladder infections
  • Feeling of heaviness or pulling in the pelvis
  • Vaginal bleeding
  • Increased vaginal discharge
• Degrees of uterine prolapse

  • Mild: cervix drops into lower part of vagina
  • Moderate: cervix drops out of vaginal opening
  • Complete: cervix and uterus protrude through vagina, vagina is inverted
• Lifestyle changes for uterine prolapse

  1. Weight loss for obese women

  2. Avoid heavy lifting and straining

  3. Treat chronic cough

  4. Quit smoking
• Vaginal pessary


  Device that holds the uterus in place, may be temporary or permanent
• Side effects of vaginal pessaries

  • Foul smelling discharge
  • Vaginal irritation
  • Vaginal ulcers
  • Problems with sexual intercourse
• Surgical treatments for uterine prolapse

  • Sacrospinous fixation
  • Vaginal hysterectomy
• Prevention of uterine prolapse

  • Kegel exercises
  • Estrogen therapy
  • Weight loss
  • Avoid heavy lifting