COMPLICATIONSWITH THE POWER(THE FORCE OF THE

LABOR)

UNIVERSITY OF NORTHERN PHILIPPINES GRADUATE SCHOOL

MASTER OF ARTS IN NURSING

A.INEFFECTIVE UTERINE FORCE

Uterine contractions are the basic force moving the fetus through the birth canal.

Contractions occur because of interplay of enzymes, electrolytes, proteins and hormones.

About 95% of labors are completed with contractions that follow a predictable, normal course. When they become abnormal or ineffective, ineffective labor occurs.

Hypotonic Contractions

Hypertonic Contractions

Uncoordinated Contractions

THE CAUSES OF INEFFECTIVE UTERINE FORCE DEPEND ON THE 3 TYPES OF DYSFUNCTION:

HYPOTONIC CONTRACTIONS

Number of contractions: not more 2 or 3 occurring in a 10-minute period.

Resting tone: less than 10 mm Hg

Strength of contractions: does not rise above 25 mm Hg.

Phase of Labor: Active

Symptom: Painless

ETIOLOGY:

Overstretching of the uterus – large baby, multiple babies, polyhydramnios, multiparity.

Bowel or bladder distention, preventing descent.

Excessive use of analgesia.

THERAPEUTIC INTERVENTIONS:

OxytocinAmbulationNipple stimulationEnemaAmniotomy

HYPERTONIC CONTRACTIONS

Resting tone: more than 15 mm Hg.

Contractions: Frequent prolonged contractions that are not productive.

Phase of Labor: Latent

Symptom: Painful

Cause: This type of contraction occurs because the muscle fibers of the myometrium do not repolarize or relax after a contraction, thereby “wiping it clean” to accept a new pacemaker stimulus.

COMPLICATION: FETAL ANOXIA

Management:

Provide comfort measures Bedrest or position changes Hydration Mild sedation Tocolytics

Caesarean delivery

Uncoordinated Contractions

With uncoordinated contractions, more than one pacemaker may be initiating contractions, or receptor points in the myometrium may be acting independently of the pacemaker.

Uncoordinated contractions may occur so closely together that they do not allow good cotyledon (one of the visible segments on the maternal surface of the placenta) filling.

Uncoordinated Contractions cont’d

Applying a fetal and a uterine external monitor and assessing the rate, pattern, resting tone, and fetal response to contractions for at least 15 minutes (or longer if necessary in early labor) reveals the abnormal pattern.

Oxytocin administration may be helpful in uncoordinated labor to stimulate a more effective and consistent pattern of contractions with a better, lower resting tone.

B. DYSFUNCTIONAL LABOR AND ASSOCIATED STAGES OF LABOR

Dysfunction at the First Stage of Labor

Prolonged Latent Phase When contractions become ineffective during the

first stage of labor, a prolonged latent phase can develop.

A prolonged latent phase is a latent phase that is longer than 20 hours in a nullipara or 14 hours in a multipara.

This may occur if the cervix is not “ripe” at the beginning of labor and time must be spent getting truly ready for labor. It may occur if there is excessive use of an analgesic early in labor.

Prolonged Latent Phase cont’d With a prolonged latent phase, the uterus tends to be in a

hypertonic state. Relaxation between contractions is inadequate, and the contractions are only mild (less than 15 mm Hg) and therefore ineffective.

One segment of the uterus may be contracting with more force than another segment.

Management of a prolonged latent phase in labor that has been caused by hypertonic contractions involves helping the uterus to rest, providing adequate fluid for hydration, and pain relief with a drug such as morphine sulfate.

Changing the linen and the woman’s gown, darkening room lights, and decreasing noise and stimulation can also be helpful.

These measures usually combine to allow labor to become effective and begin to progress. If it does not, a cesarean birth or amniotomy (artificial rupture of membranes) and oxytocin infusion to assist labor may be necessary.

Protracted Active Phase A protracted active phase is usually associated with

cephalopelvic disproportion (CPD) or fetal malposition, although it may reflect ineffective myometrial activity.

This phase is 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 of the delay in dilatation 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 that CPD is not present, oxytocin may be prescribed to augment labor.

Prolonged Deceleration Phase

A deceleration phase has become prolonged when it extends beyond 3 hours in a nullipara or 1 hour in a multipara.

Prolonged deceleration phase most often results from abnormal fetal head position. A cesarean birth is frequently required.

Secondary Arrest of Dilatation A secondary arrest of dilatation has occurred

if there is no progress in cervical dilatation for longer than 2 hours. Again, cesarean birth may be necessary.

DYSFUNCTION AT THE FIRST STAGE OF LABORProlonged Descent Prolonged descent of the fetus occurs if the

rate of descent is less than 1.0 cm/hr in a nullipara or 2.0 cm/hr in a multipara. It can be suspected if the second stage lasts over 3 hours in a multipara.

With both a prolonged active phase of dilatation and prolonged descent, contractions have been of good quality and proper duration, and effacement and beginning dilatation have occurred, but then the contractions become infrequent and of poor quality and dilatation stops.

Prolonged Descent cont’d

If everything is normal except for the suddenly faulty contractions and CPD and poor fetal presentation have been ruled out by ultrasound, then rest and fluid intake, as advocated for hypertonic contractions, also apply.

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.

A semi-Fowler’s position, squatting, kneeling, or more effective pushing may speed descent.

Arrest of Descent Arrest of descent results when no descent

has occurred for 1 hour in a multipara or 2 hours in a nullipara.

Failure of descent has occurred when expected descent of the fetus does not begin or engagement or movement beyond 0 station has not occurred.

The most likely cause for arrest of descent during the second stage is CPD. Cesarean birth usually is necessary.

If there is no contraindication to vaginal birth, oxytocin may be used to assist labor.

C. PATHOLOGIC RETRACTION

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.

The most frequent type seen is termed a pathologic retraction ring (Bandl’s ring). The ring usually appears during the second stage of labor and 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 uterine myometrium is much thicker above than below the ring.

C. PATHOLOGIC RETRACTION cont’d

When a pathologic retraction ring occurs in early labor, it is usually caused by uncoordinated contractions.

In the pelvic division of labor, it is usually caused by obstetric manipulation or by the administration of oxytocin.

In either event, the fetus is gripped by the retraction ring and cannot advance beyond that point. The undelivered placenta will also be held at that point.

Contraction rings often can be identified by ultrasound. Such a finding is extremely serious and should be reported promptly.

C. PATHOLOGIC RETRACTION cont’d

Administration of IV morphine sulfate or the inhalation of amyl nitrite may relieve a retraction ring. A tocolytic can also be administered to halt contractions.

If the situation is not relieved, uterine rupture and neurologic damage to the fetus may occur.

In the placental stage, massive maternal hemorrhage may result, because the placenta is loosened but then cannot deliver, preventing the uterus from contracting.

Most likely, a cesarean birth will be necessary to ensure safe birth of the fetus.

Manual removal of the placenta under general anesthesia may be required if the retraction ring does not allow the placenta to be delivered.

FIGURE (A) NORMAL SHAPE OF PREGNANT ABDOMEN DURING LABOUR, IN A WOMAN LYING ON HER BACK; (B) BANDL’S RING IN THE ABDOMEN OF A WOMAN WITH OBSTRUCTED LABOUR.

D. PRECIPITATE LABOR

Precipitate labor and birth occur when uterine contractions are so strong that a woman gives birth with only a few, rapidly occurring contractions.

It is often defined as a 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.

Such rapid labor is likely to occur with grand multiparity, or it may occur after induction of labor by oxytocin or amniotomy.

D. PRECIPITATE LABOR cont’d

Contractions can be so forceful that they lead to premature separation of the placenta, placing the woman at risk for hemorrhage.

Rapid labor also poses a risk to the fetus, because subdural hemorrhage may result from the rapid release of pressure on the head.

A woman may sustain lacerations of the birth canal from the forceful birth. She also can feel overwhelmed by the speed of labor.

A precipitate labor can be predicted from a labor graph if, 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.

D. PRECIPITATE LABOR cont’d

In such instances, a tocolytic may be administered to reduce the force and frequency of contractions.

Caution a multiparous woman by week 28 of pregnancy that, because a past labor was so brief, her labor this time also may be brief. This allows her to plan for appropriately timed transportation to the hospital or alternative birthing center.

Both grand multiparas and women with histories of precipitate labor should have the birthing room converted to birth readiness before full dilatation is obtained. Then, even a sudden birth can be accomplished in a controlled surrounding.

E. UTERINE RUPTURE

Uterine rupture occurs when a uterus undergoes more strain than it is capable of sustaining.

Rupture occurs most commonly when a vertical scar from a previous cesarean birth or hysterotomy repair tears.

Contributing factors may include prolonged labor, abnormal presentation, multiple gestation, unwise use of oxytocin, obstructed labor, and traumatic maneuvers of forceps or traction.

When uterine rupture occurs, fetal death will follow unless immediate cesarean birth can be accomplished.

If a uterus should rupture, the woman experiences a sudden, severe pain during a strong labor contraction, which she may report as a “tearing” sensation.

E. UTERINE RUPTURE cont’d

Rupture can be complete, going through the endometrium, myometrium, and peritoneum layers, or incomplete, leaving the peritoneum intact. With a complete rupture, uterine contractions will immediately stop.

Two distinct swellings will be visible on the woman’s abdomen: the retracted uterus and the extrauterine fetus.

Hemorrhage from the torn uterine arteries floods into the abdominal cavity and possibly into the vagina.

Signs of shock begin, including 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.

E. UTERINE RUPTURE cont’d

If the rupture is incomplete, the signs of rupture are less evident. With an incomplete rupture, a woman may experience only a localized tenderness and a persistent aching pain over the area of the lower uterine segment.

However, fetal heart sounds, a lack of contractions, and the changes in the woman’s vital signs will gradually reveal fetal and maternal distress.

Uterine rupture can be confirmed by ultrasound. Administer emergency fluid replacement therapy

as ordered.

E. UTERINE RUPTURE cont’d

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.

The viability of the fetus depends on the extent of the rupture and the time elapsed between rupture and abdominal extraction.

A woman’s prognosis depends on the extent of the rupture and the blood loss.

Most women are advised not to conceive again after a rupture of the uterus, unless the rupture occurred in the inactive lower segment.

F. INVERSION OF THE UTERUS

Uterine inversion refers to the uterus turning inside out with either birth of the fetus or delivery of the placenta.

It may occur if 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.

It may also occur if the placenta is attached at the fundus so that, during birth, the passage of the fetus pulls the fundus down.

Inversion occurs in various degrees. The inverted fundus may lie within the uterine cavity or the vagina, or, in total inversion, it may protrude from the vagina.

F. INVERSION OF THE UTERUS cont’d

When an inversion occurs, a large amount of blood suddenly gushes from the vagina. The fundus is not palpable in the abdomen.

If the loss of blood continues unchecked for longer than a few minutes, the woman will show signs of blood loss: hypotension, dizziness, paleness, or diaphoresis.

Because the uterus is not contracted in this position, bleeding continues, and exsanguination could occur within a period as short as 10 minutes.

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, because this only create a larger surface area for bleeding.

F. INVERSION OF THE UTERUS cont’d

In addition, administration of an oxytocic drug only compounds the inversion or makes the uterus more tense and difficult to replace.

An IV fluid line needs to be started, if one is not already present (use a large-gauge needle, because blood will need to be replaced).

If a line is already in place, open it to achieve optimal flow of fluid to restore fluid volume.

Administer oxygen by mask, and assess vital signs.

Be prepared to perform cardiopulmonary resuscitation (CPR) if the woman’s heart should fail from the sudden blood loss.

F. INVERSION OF THE UTERUS cont’d

The woman will immediately be given general anesthesia or possibly nitroglycerin or a tocolytic drug intravenously, to relax the uterus.

The physician or nurse-midwife then replaces the fundus manually.

Administration of oxytocin after manual replacement helps the uterus to contract and remain in its natural place.

Because the uterine endometrium was exposed, a woman will need antibiotic therapy to prevent infection.

She needs to be informed that cesarean birth will probably be necessary in any future pregnancy, to prevent the possibility of repeat inversion.

G. AMNIOTIC FLUID EMBOLISM

Amniotic fluid embolism occurs when amniotic fluid is forced into an open maternal uterine blood sinus through some defect in the membranes or after membrane rupture or partial premature separation of the placenta.

Previously, it was thought that particles such as meconium or shed fetal skin cells in the amniotic fluid entered the maternal circulation and reached the lungs as small emboli.

Now, it is recognized that a humoral or anaphylactoid response is the more likely cause.

This condition may occur during labor or in the postpartal period.

G. AMNIOTIC FLUID EMBOLISM cont’d

It is not preventable because it cannot be predicted.

Possible risk factors include oxytocin administration, abruptio placentae, and hydramnios.

The clinical picture is dramatic. A woman, in strong labor, sits up suddenly and grasps her chest because of sharp pain and inability to breathe as she experiences pulmonary artery constriction. She becomes pale and then turns the typical bluish gray associated with pulmonary embolism and lack of blood flow to the lungs.

The immediate management is oxygen administration by face mask or cannula.

G. AMNIOTIC FLUID EMBOLISM cont’d

Within minutes, she will need CPR. CPR may be ineffective, however, because these procedures (inflating the lungs and massaging the heart) do not relieve the pulmonary constriction. Therefore, blood still cannot circulate to the lungs. Death may occur within minutes.

A woman’s prognosis depends on the size of the embolism, the speed with which the emergency condition was detected, and the skill and speed of emergency interventions.

Even if the woman survives the initial insult, the risk for disseminated intravascular coagulation (DIC) is high, further compounding her condition.

G. AMNIOTIC FLUID EMBOLISM cont’d

In this event, she will need continued management that includes endotracheal intubation to maintain pulmonary function and therapy with fibrinogen to counteract DIC.

Most likely, she will be transferred to an ICU. The prognosis for the fetus is guarded, because

reduced placental perfusion results from the severe drop in maternal blood pressure.

Labor often begins or the fetus is born immediately by cesarean birth.

Thank you!!!BARROGA, Marilyn Richelle

DIGUEL, Brenda LeeGRAGERA, Jennifer C.MASIGMAN, Mary Ann

PAESTE, GloriaSERRANO, Cecille

VALENTON, Kathleen Anne Marie