difficult labor

8/7/2019 Difficult Labor

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DIFFICULT LABOR


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Can arise from any of thethree main components ofthe labor process: The power, or the force that propels the

fetus ( uterine contraction)The passenger( the fetus)

The passageway (the birth canal)


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THE FORCE OF LABOR

Inertia= is time-honored term to denotethat sluggishness of contractions, or theforce of laabor.

Dysfunctional labor is a more currentterm. It can occur in any point in labor.


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Causes of dysfunctional labor

Inappropriate use of analgesia ( excessiveor too early administration)

Pelvis bone contraction that has narrowedthe pelvic diameter so that a fetus cannotpass ( ex. A client with rickets)

Poor fetal position (posterior rather than

anterior position)


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Overdistention of the uterus as withmultiple pregnancy, hydamnios, orextremely oversized fetus

Cervical rigidity ( unripe)Presence of a full rectum or urinarybladder that impedes fetal descent

Mother becoming exhausted from laborPrimigravida status


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Ineffective uterine factors

Uterine contractions = is the basicforce moving the fetus through thebirth canal. It occur because of the

interplay of the contractile enzymeadenosine triphosphate and theinfluence of major electrolytes suchas calcium, sodium and potassium,specific contractile proteins ( actinand myosin), epinephrine andnorepinephrine, oxytocin, estrogen,

progesterone and prostaglandins.


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Hypotonic Contractions

The number of contractions is usually low or infrequent ( notincreasing beyond two or three in a 10-minute period). Theresting tone of the uterus remains less than 10 mm Hg, andthe strength of contractions does not rise above 25 mm Hg.It occur during the active phase of labor. It occur after the

administration of analgesia, especially if the cervix is notdilated to 3 tp 4 cm or iif bowel or bladder distentionprevents descent or firm engagement. It also occur in auterus that is overstretched by a multiple gestation, a larger-than-usual single fetus, or hyrmanios, or in a uterus that islax from grand multiparity.


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It is not exceedingly painful because oftheir lack of intensity. The strength of acontraction is a subjective symptom. It isvery painful.


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It increase the length of labor becausemore of them are necessary to achievecervical dilatation. This can cause theuterus to not contract as effectively

during postpartal period because ofexhaustion. Increasing a chance ofpostpartal hemorrhage. With cervixdilated for a long period both the uterusand fetus are at risk for infection.


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For these reason, after ultrasonicconfirmation rules out cephalopelvicdisproportion (CPD), an infusion ofoxytocin, a synthetic form of the

naturally occurring pituitary hormone,usually started to augment labor bystrengthening contractions and increasingtheir effectiveness. Membranes maybeartificially ruptured (amniotomy) tofurther speed labor. In the first hour afterbirth, palpate the uterus and assess lochiaevery 15 minutes to ensure thatpostpartal ontractions are not also


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HYPERTONIC CONTRACTIONS

Hypertonic uterine contractions are marked by an increasein resting tone to more than 15mm Hg. Hypertonic onestend to occur frequently and are most commonly seen inthe latent phase of labor. It occurs because the musclefibers of the myometrium do not repolarize or relax after a

contraction, thereby wiping it clean to accept a newpacemaker stimulus. More than one pacemaker isstimulating the contractions. It is more painful than usual,because the myometrium becomes tender from constantlack of relaxation and the anoxia of uterine cells thatresults.


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Danger this could lead to fetal anoxiaearly in the latent phase of labor. Both auterine and a fetal external monitorapplied for at least 15 minutes to ensure

that the resting phase of the contractionsis adequate and that the fetal pattern isnot showing late deceleration.

Management rest and pain relief with adrug such as morphine sulphate.Changing the linen and the clients gown,darkening room lights, and decreasing

noise and stimulation are also helpful.


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CONTRACTION RINGS

Pathologic retraction ring (Bandls ring)that occurs at the junction of the upperand lower uterine segments. The ringusually appears during the second stage

of labor as a horizontal indentation acrossthe abdomen. It is a warning sign thatsevere dysfunctional labor is occurring. Itis formed by excessive retraction of theupper uterine segment; the uterinemyometrium is much thicker above thanbelow the ring.


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Uncoordinated contractions in the pelvicdivision labor, it is usually caused byobstetric manipulation or by theadministration of oxytocin. The fetus is

gripped by the retraction ring and cannotadvance beyond that point.

Contraction ring can be identified by

sonography. It is extremely serious andshould be reported promptly. IV morphinesulphate or the inhalation of amyl nitritemay relieve a retraction ring.


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Halt contractions if the situation is notrelieved, uterine rupture and death of thefetus may occur. In the placental stage,massive maternal hemorrhage may result,

because the placental is loosened butthen cannot be delivered. A cesareanbirth will be necessary to ensure safebirth of the fetus.


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PRECIPITATE LABOR

Precipitate labor and birth occur whenuterine contractions are so strong that thewoman gives birth with only a few, rapidlyoccurring contractions.


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PROLAPSE OF THE UMBILICALCORDUmbilical cord prolapsed, a loop of theumbilical cord slips down in front of thepresenting fetal part. Prolapse may occurat any time after the membranes rupture

if the presenting part is not fitted firmlyinto the cervix.


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ASSESSMENT

The cord may be felt as the presenting part on an initialvaginal examination during labor. It may also beidentified in this position on a sonogram. Caesareanbirth is necessary before rupture of the membranesoccurs. Membrane rupture of the membranes occurs.

Membrane rupture would cause the cord to slide downinto the vagina from the pressure exerted by theamniotic fluid. Cord prolapsed is first discovered onlyafter membranes have ruptures. The cord maybe visibleat the vulva.


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Always assess fetal heart soundsimmediately after rupture of themembranes occurring eitherspontaneously or by amniotomy.


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THERAPEUTIC MANAGEMENT

Cord prolapse automatically leads to cordcompression, because the fetal presenting partpresses against the cord at the pelvic brim.Management is aimed toward relieving pressureon the cord, thereby relieving the compressionand the resulting fetal anoxia. This may be doneby placing a gloved hand in the vagina andmanually elevating the fetal head off the cord, orby placing the woman in a knee-chest or

Trendelenburg position, which causes the fetalhead to fall back from the cord.


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Administering oxygen at 10 L/min by facemask to the mother is also helpful toimprove oxygenation to the fetus. Atocolytic agent may be prescribed to

reduce uterine activity and pressure onthe fetus.


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If the cord has prolapsed to the extentthat it is exposed to room air, drying willbegin, leading to atrophy of the umbilicalvessels. Do not attempt to push any

exposed cord back at the vagina. Thismay add to compression by causingknotting or kinking. Instead, cover nyexposed portion with a sterile salinecompress to prevent drying.


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If the cervix is fully dilated, deliver theinfant quickly, possibly with forceps, toprevent fetal anoxia. If dilation isincomplete, the birth method of choice is

upward pressure on the presenting part tokeep pressure off the cord until the babycan be born by caesarean birth.


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MULTIPLE GESTATION

Twins may be born by caesarean birth todecrease the risk that the second fetuswill experience anoxia; this also is oftenthe situation in a multiple gestations of

three or more, because of the increasedincidence of cord entanglement andpremature separation of the placenta.


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If a woman with a multiple gestatin willbe giving birth vaginally, she is usuallyinstructed to come to the hospital early inlabor. During labor, support the womans

breathing exercises to minimize the needfor analgesia or anesthesia; this help tominimize any respiratory difficulties theinfants may have at birth because of theirimmaturity.


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Monitor each FHR by a separate fetalmonitor during labor. Because the babiesare usually small, firm head engagementmay not occur, increasing the risk for cord

prolapse after rupture of the membranes.Uterine dysfunction from a long labor, anover stretched uterus, and prematureseparation of the placenta after the birthof the first child may also be morecommon.


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After the birth of the first child, the lie ofthe second fetus is determined byexternal abdominal palpation andsonography. If the presentation is not

vertex, external version may beattempted to make it so. If this is notsuccessful, a decision for a breechdelivery or caesarean birth must bemade. If the infant will be born vaginally,an oxytocin infusion may be begun at thispoint o assist uterine contractions,thereby shortening the time spanbetween births. Nitroglycerin may be


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The placenta of the first infant separatesbefore the second fetus is born, and thereis sudden, profuse bleeding at the vagina.

The uterus cannot contract as it normally

would, because it is still full with thesecond twin so it is difficult to halt thebleeding. If all of the foetuses are notvertex presentations, they will be born bycesarean birth.


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Assess the mother carefully in theimmediate postpartal period, because theuterus that has been overly distended dueto the multiple gestation may have more

difficulty contracting than usual, placingthe mother at the risk for hemorrhagefrom uterine atony.


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PROBLEMS WITH POSITION,PRESENTATION, OR SIZEOccipitoposterior position

Posterior positions tend to occur inwomen with android, anthropoid, or

contracte pelves. A posterior position issuggested by a dysfunctional laborpattern such as a prolonged active phase,arrested descent, or fetal heart sounds

heard best at the lateral sides of theabdomen.


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A posteriorly presenting head does not fit the cervix as snugly aspone in an anterior position. Because this increases the risk ofumbilical cord prolapsed, the position of the fetus is confirmed byvaginal examination or by sonogram. The majority of foetusespresenting in posterior positions, if they are of average size andin good flexion and aided by forceful uterine contractions, rotate

through the large arc, arrive at a good birth position for thepelvic outlet, and are born satisfactorily with only increasedmolding and caput formation. Because the arc of rotation isgreater, it is usual for the labor to be somewhat prolonged.


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The fetal head rotates against thesacrum, a woman may experiencepressure and pain in her lower back dueto sacral nerve compression. These

sensations may be so intense that sheasks for medication for relief, not for hercontractions but for the intense backpressure and pain. Counterpressure on

the sacrum (e.g. back rub, change ofposition) maybe helpful in relieving aportion of the pain. Applying heat or cold,whichever feels best, also may help.


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Lying on the side opposite the fetal backor maintaining a hands-and-kneesposition may help the fetus rotate. Duringa long labor, be certain the woman voids

approximately after 2 hours to keep herbladder empty, because a full bladdercould futher impede descent of the fetus.Be aware of how long it has been since

the woman last ate. During a long labor,she may need an IV glucose solution toreplace glucose stores used for energy.


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If contractions are ineffective, or if thefetus is larger than average or not in goodflexion, rotation through the 135-degreearc may not be possible. Uterine

dysfunction may result from maternalexhaustion. The fetal head may arrest inthe transverse position, or rotation maynot occur at all (persistent

occipitoposterior position0. The fetusmust be born by caesaraean birth.


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During labor, a woman needs a great dealof support to prevent her from becomingpanicked about the length of the labor. Ifforceps are used, this places a woman at

risk fro reproductive tract lacerations,hemorrhage, and infection in thepostpartum period.


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BREECH PRESENTATION

Most foetuses are in a breechpresentation early in pregnancy. The fetalhead is the widest single diameter, thefetuss buttocks (breech), plus the legs,

actually take up more space. Fundus isthe largest part of the uterus is probablythe reason why, in approximately 97% ofall pregnancies.

There are several types of breechpresentation; complete, frank, andfootling. Breech presentation is more

hazardous to a fetus than a cephalic


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The inevitable contraction of the fetalbuttocks from cervical pressure oftencauses meconium to be extruded into theamniotic fluid before birth. This, unlike

meconium staining that occurs due tofetal anoxia, is not a sign of fetal distressbut it is expected from the buttockpressure. Meconium excretion can,

however, lead to meconium aspiration ifthe infant inhales amniotic fluid.


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Always monitor FHR and uterinecontractions continuously. This allowsearly detection of fetal distress from acomplication (e.g. prolapsed cord) and

prompt intervention.


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BIRTH TECHNIQUE

Born vaginally the woman is allowed topush after full dilatation is achieved andthe breech, trunk, and shoulders are born.

The shoulders present to the outlet with

their widest diameter anteroposterior.


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Birth of the head is the most hazardouspart of a breech birth. Because theumbilicus precedes the head, a loop ofcord passes down alongside the head. The

pressure of the head against the pelvicbrim automatically compresses this loopof cord.


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A second danger of breech birth is intracranial hemorrahge.With a cephalic presentation, molding to the confines of thebirth canal occurs over hours. With a breech birth, pressurechanges occur instantaneously. Tentorial tears, which cancause gross motor and mental incapacity or lethal damageto the fetus, may result. The infant who is delivered

suddenly to reduce the duration of cord compression maysuffer an intracranial hemorrhage. In contrast, the infantwho is delivered gradually to reduced possibility ofintracranial injury may suffer hypoxia.


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To aid in delivery of the head, the trunk of the infant is usuallystraddled over the physicians right forearm.two fingers of thephysicians right hand are placed in the infants mouth. The

left hand is slid into the mothers vagina,palm down,along theinfants back. Pressure is applied to the occiput to flex thehead fully. Gentle traction applied to the shoulders (upwardand outward) delivers to the head. An aftercoming head mayalso be delivered by the aid of piper forceps to control flexionand the rate of descent. The difficulty with delivering thehead is the reason why planned caesarean birth is the usualmethod of birth for breech presentation infants today.


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An infant who was born from a frankbreech position may tend to keep his orher legs extended at the level of the facefor the first two or three days of life. A

footling breech may tend to keep the legsextended in a footling position for the firstfew days.


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FACE PRESENTATION

A fetal head presenting at a differentangle than expected is termedasynclitism. Face and brow presentationsare examples. Face (chin or momentum)

presentation is rare, but when it doesoccur, the head diameter the fetuspresents to the pelvis is often too large forbirth to precede. A head that feels more

prominent than normal, with noengagement apparent on Leopoldsmaneuvers, suggest a face presentation


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. The head abd back are both felt on thesame side of the uterus with Leopoldsmanuevers. If the back is extremely concave,fetal heart tones maybe transmitted to the

forward-thrust chest and heard on the side ofthe fetus where feet and arms can bepalpated. A face presentation is confirmed byvaginal examination when the nose, mouth,

or chin can be felt as the presenting part.


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A fetus in a prosterior position, instead offlexing the head as labor procedes, mayextend the head, resulting in a facepresentation;this usually occurs in a

woman with a contracted pelvis orplacenta previa. It also may occur in therelaxed uterus multipara or with pre-maturity, hydramnios, or fetal

malformation.


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It is a warning signal. Something abnormal is usuallycausing the face presentation. If a face presentation issuspected, a sonogram is done to confirm it; if indicted thepelvic diameters are measured. If the chin is anterior andthe pelvic diameters are within normal limits, the infantmay be born without difficulty (perhaps after a long firststage of labor, because the face does not mold well tomake a snugly engaging part). If the chin is posterior,caesarean birth aybe the method of choice; otherwise, itcould be necessary, to wait for a long posterior-to-anteriorrotation to occur.


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Such rotation could result dysfunction or atransverse arrest. Babies born after a facepresentation have a great deal of facialedema and may be purple from eccymotic

bruising. Observe the infant closely for apatent airway. In some infants, lip edemais so severe that the infant is unnecessaryto allow the infant to obtain enough fluid

until he or she can suck effectively. Theinfant may be transferred to an ICUnursery for 24 hours. Reassure theparents that the edema is transient willdisapper in a few days, with no aftermath.

O S O


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BROW PRESENTATION

A brow presentation is the rarest of the presentations. It occursin a multipara or a woman with relaxed abdominal muscles. Italmost invariably results in obstructed labor, because the headbecomes jammed in the brim of the pelvis as the oxypitomentaldiameter presents. Unless the presentation spontaneouslycorrects, cesarea birth will be necessary to deliver the infant

safely. Brow presentations may also lived the infant with extremeecchymotic bruising on the face. On seeing this bruising over thesame area as the anterior fotanelle or soft spot, parents mayneed additional reassurance that the child is well after birth.

TRANSVERSE LIE


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TRANSVERSE LIE

Transverse lie occurs in women withpendulous abdomens with uterine masses(e.g. fibroid tumors) that obstruct thelower uterine segment, with contraction of

the pelvic brim, with congenitalabnormalities of the uterus, or withhydramnios. It may occur in infants withhydrocephalus or another abnormality

that prevents the head from engaging. Itmay also occur in prematurity if the infanthas room for free movement, in multiplegestation (particularly in a second twin),or if there is a short umbilical cord.


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This is obvious on inspection, when theovoid of the uterus is found to be morehorizontal than vertical. The abnormalpresentation can be confirmed by

Leopolds maneuvers. A sonogram maybe taken to further confirm the abnormallie and to provide information on pelvicsize.

A mature fetus cannot be deliveredvaginally from this presentation. Often,the membranes rupture at the beginning

of the labor.

OVERSIZED FETUS


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OVERSIZED FETUS(MACROSOMIA)Size may become a problem in a fetuswho weighs more than 4,000 to 4,500 g(approximately 9 to 10 lb). Large babiesare also associated with multiparity,

because each infant born to a womantends to be slightly heavier and largerthan the one born just before.


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An oversized infant may cause uterinedysfunction during labor or at a birthbecause of overstretching of the fibers of themyometrium. The wide shoulders may pose a

problem at birth, because they can causefetal pelvic disproportion or even uterinerupture from obstruction. If the infant is sooversized that he or she cannot be delivered

vaginally, caesarean birth becomes the birthmethod of choice. The large sized of a fetusmay be missed in an obsess woman, becausethe fetal contours are difficult to palpate.Obesity does not necessarily indicate alar er-than-usual elvis. Pelvimetr or

SHOULDER DYSTOCIA


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SHOULDER DYSTOCIA

Shoulder dystocia is a birth problem that is increasing inincidence along with the increasing average weight of newborns. The problem occurs at the second stage oflabor,when the fetal head is born but the shoulders are toobroad to enter and be born through the pelvic outlet.this ishazardous to the mother because it can result in vaginal or

cervical tears. It is hazardous to the fetus if the cord iscompressed between the fetal body and the bony pelvis. The force of birth can result in a fractured clavicle or abrachial plexus injury for the fetus.


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Shoulder dystocia is mosy apt to occur inwomen with diabetes,in multiparas,and inpost-date pregnancies. The problem oftenis not identified until the head is already

been born ad the wide anterior shoulderlocks beneath the symphysis pubis. Thecondition maybe suspected earlier if thesecond stage of labor is prolonged,if there

is arrest of descent,or if,when the headappears on the perineum(crowing),itretracts instead of protruding with eachcontraction(a turtle sign).


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Asking a woman to flex her thightssharply on her abdomen (macrobertsmanuever) may widen the pelvic outletand let the anterior shoulder be delivered.

Applying suprapubic pressure may helpthe shoulder escape from beneath thesimphysis pubis and delivered.

PROBLEMS WITH THE


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PROBLEMS WITH THEPASSAGEDystocia can occur is a contraction ornarrowing of the passageway or birthcanal. This can happen at the inlet, at themidpelvis, or at the outlet. The narrowing

causes CPD, or a disproportion betweenthe size of the normal fetal head and thepelvic diameters.

INLET CONTRACTION


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INLET CONTRACTION

Inlet contraction is narrowing of theanteroposterior diameter to less than 11centimeter, or of the transverse diameterto 12 centimeter or less. It usually is

caused by rickets in early life or by aninherited small pelvis. Rickets, where milksupplies were not plentiful. Inprimigravidas, the fetal head normally

engages between week 36 to 38 ofpregnancy. Pelvic inlet is adequate. Ahead that engages or proves it fits intothe pelvic brim will probably also be able

to pass through the midpelvis and


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If engagement does not occur in primigravida, then either a fetalabnormality (smaller-thus-usual pelvis) should be suspected.Engagement does not occur in multigravidas until labor begins.For these women, previous birth of a full-termed infant vaginallywithout problems is proof that their birth canals are adequate.

Every primigravida pelvic measurements taken and recorded

before week 24 of pregnancy.With CPD, fetus does not engage but remains floating,

malposition may occur. The possibility of cord prolapsed increasesgreatly.

OUTLET CONTRACTION


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OUTLET CONTRACTION

Outlet contraction is narrowing of thetransverse diameter at the outlet to lessthan 11 centimeter. This is the distancebetween the ischilial tuberocitis.

EXTERNAL CEPHALIC


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EXTERNAL CEPHALICVERSIONExternal cephalic version is turning of afetus from a breech to a cephalic positionbefore birth.

difficult labor

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