PROBLEMS WITH THE POWERS

1. Dystocia
The force of labor
1. Dystocia- general term that describes any difficult labor or birth
2. Inertia- term that denote that sluggishness of contractions, or the force of labor
3. Dysfunctional labor- current term

The Force of Labor

 Effective uterine activity is characterized by coordinated contractions that are
strong & numerous enough to propel the fetus past the resistance of the
woman’s pelvis.

Dystocia
 Difficult labor or birth
 Refers to any labor which does not advance normally
 A dysfunctional labor may result from problems with powers of labor, the
passager, the passage, the pysche, or a combination of these
Factors:
 Forces are inadequate(Faulty Power)
e.g.
Inertia- sluggishness of uterine contractions
 Abnormal position of the passenger (infant)
 Abnormal passageway(birth canal)

Common causes of dysfunctional labor

 Maternal fatigue
 Maternal inactivity
 Inappropriate use of analgesia (excessive or too early administration)
 Disproportion between the maternal pelvis and fetal presenting part
 Poor fetal position (posterior rather than anterior position)
 Overdistention of the uterine- as with multiple gestation, hydramnios or
oversized fetus
 Presence of a full rectum or urinary bladder that impedes fetal descent

Ineffective or abnormal uterine contractions are classified according to strength:

 Hypotonic Uterine Dysfunction
 Hypertonic Uterine Dysfunction
 Uncoordinated Contractions

Criteria 1. Hypotonic 2. Hypertonic

Therapeutic Management  Amniotomy (may  Correct cause if can be

increase the risk of identified
infection)  Light sedation to
 Oxytocin augmentation promote rest
 Cesarean birth if no  Hydration
progress  Tocolytics to reduce
high uterine tone and
promote placental
perfusion
Nursing Care  Interventions related to  Promote uterine blood
amniotomy and flow; side-lying position
oxytocin augmentation  Promote rest, general
 Encourage position comfort and relaxation
changes  Pain relief
 An abdominal binder
may help direct the
fetus toward the
 mother’s pelvis if her Emotional support:
abdominal wall is very  Accept the reality of the
lax woman’s pain and
 Ambulation if no frustration
contraindication and if  Reassure her that she
acceptable to the is not being childish
woman.  Explain reason for
measures to break
Emotional Support: abnormal labor patterns
 Allow her to express and their goals or
feelings of expected results
discouragement  Allow her to express
 Explain measures taken her feelings during and
to increase after labor
effectiveness of  Include partner or
contractions family
 Include her partner or
family in emotional
support measures
because they may have
anxiety that will
heighten the woman’s
anxiety.

3. Uncoordinated Uterine Contractions

 More than one contractions occur at thesame time due to myometrium acts
independently from each other

Management:
 Fetal and uterine external monitor applied every 15 mins
 Oxytocin to stimulate labor

Complication:
 Mother: exhaustion and dehydration
 Fetus: injury and death

Dysfunction in labor can occur at any point in labor, and classified according to time
when it occurs:
1. Primary dysfunction
 occuring at the onset of labor or prolonged latent phase of labor
2. Secondary dysfunction
 Occuring later in labor or prolonged active phase of labor; fetus does
not descend; cervix not dilated

Abnormal Progress in Labor

1. Prolong Latent Phase
 Latent phase longer than 20 hours in nullipara, 14 hours in multipara
 May occur if:
- cervix is not ripe at the beginning of labor
- excessive analgesia
 The uterus tends to be in hypertonic state
 Relaxation between contractions is inadequate
2. Protracted Active Phase
 Usually associated with CPD or fetal malpositions
 This phase is prolong if cervical dilatation does not occur at a rate of:
- 1.2 cm/hr or more in nullipara
- 1.5 cm/hr in multipara or
 If the active phase last over
 - 12 hrs in primipara
- 6 hrs in multipara
3. Prolonged Decceleration Phase
 A decceleration has become prolonged when it extends beyond
- 3 hrs in nullipara
- 1 hr in multipara
4. Secondary Arrest of Dilatation
 Occurs when there’s no progress in cervical dilatation for more than 2 hrs
5. Prolonged Descent
 Occurs if the rate of descent is:
- less than 1.0 cm/hr in a nullipara
- less than 2.0 cm/hr in a multipara

Dysfunction at the Second Stage

1. Arrest of Descent
 Occur when no descent has occured for:
- 1 hr in multipara
- 2 hrs in nullipara
 Failure of descent has occured when expected descent of the fetus does
not begin; cause: CPD
2. Contraction Rings
a. Pathologic Retraction Ring(Band’l ring)
 The ring usually indentation across the abdomen
 Cause: excessive retraction of the upper uterine segment

Pathological Retraction Ring (Band’l Ring)

 In a difficult labor (if fetus is larger than the birth canal), round
ligaments of the uterus become tense and may be palpable on the
abdomen
 Common in obstructed labor; retraction ring is indented deeply and
palpable as a mass in the middle of the abdomen
 Danger Sign- signifies impending rupture of the lower uterine
segment if the obstruction is not relieved
 Junction of upper & lower uterine segment
 Signs: severe dysfunctional labor occurs
 Forewarning of a uterine rupture
 Grip fetus and placenta
Assessment:
 Horizontal indentation across abdomen
 Uncoordinated contractions early in labor
Dilation Phase:
 Caused by obstetrical manipulation and administration of oxytocin

b. Constriction Ring
 Can occur at any point in the myometrium and anytime during labor,
when pathologic occur during early labor, it is usually from
uncoordinated contractions
Pathophsiology:
 Fetus is grasped by thee ring and can’t advance or descent
 If fetus is delivered, placenta can be held after delivery
Management:
 Observe abdominal report immediately
 Administer IV morphine sulfate ang amyl nitrate
 C/S- or manual extraction of placena if not attended leads to mother(uterine
rupture and postpartum hemorrhage); fetus(death)
Curative Management Care:
 Antibiotics
 Sedative- stop abnormal contractions
 Short acting barbiturates- to promote relax/rest
 Monitor FHB
 NPO- prepare for Surgery- CS
 Assist in delivery; vaginal or CS
 Trial labor- in borderline or adequate pelvis
 2. Precipitate Labor/Delivery

 Occurs when uterine contractions are so strong that the woman delivers with
only a few rapidly occuring contractions
 Labor that is completed in less than hour
 Likely to occur in:
- multipara
- following induction of labor
- amniotomy
Risks:
 Fetus: sub-dural hemorrhage (sudden release of pressure on the head)
 Mother:
- lacerations of the birth canal
- premature separation of the placenta (strong sudden force)
Goals:
 To bring the delivery in a controlled surroundings to prevent risks to fetus &
mother
Theories behind precipitate labor:
1. Uterine stretch theory
2. Oxytocin theory
3. Progesterone/prostaglandin theory
4. Placental degeneration

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What is Precipitate Labor?

 A precipitate labor is normally very short, lasting less than three hours. A
precipitate labor as its own special problems and challenges.
 The duration of the labor may appeal to you, but you may NOT notice the signs of
the labor in the latent phase thereby missing the early signs of labor.
 Suddenly, you will be thrown into active, hard labor without time to prepare
psychologically. The first noticeable contractions can be long and crushingly intense
and accompanied by feelings of panic and confusion.
 Symptoms of precipitous labor may begin with true contractions that don’t seem to
have intermission.
 One contraction tends to directly follow another without a time interval.
 If you are at home, and your contractions are occurring quickly without breaks in
between, you may be progressing in labor more quickly than most people.

Predispose Factors:
 A multipara with relaxed pelvic or perineal floor muscles may have an extremely
short period of expulsion.
 A multipara with unusually strong, forceful contractions. Two to three powerful
contractions may cause the baby to appear with considerably rapidly.
 Inadequate warning of imminent birth due to absence of painful sensations during
labor.

Danger of Precipitate Delivery:

 Maternal
 Premature separation of the placenta
 Lacerations of the cervic, vagina and /or perineum
 Hemorrhaging originating from lacerations and/or hematomas of the cervix,
vagina and perineum
 Infection as a result of unsterile delivery
 Neonatal
 Intracranial hemorrhage resulting from a sudden change in pressure on the
fetal head during rapid expulsion
 Aspiration of amniotic fluid, if unattended at or immediately following delivery
 Infection as a result of unsterile delivery
Nursing Care to prepare for anticipated Precipitate Birth:
A. Assess patient for an Impending Precipitous Delivery Situation:
 Patient has previous obstretic history of rapid labor/delivery
 Patient complains of sudden, intense urge to push
 Notable increase in bloody show
 Sudden bulging of the perineum
 Sudden crowning of the presenting part
B. Call for help. Do NOT leave the patient unattended
C. Obtain a STERILE Obstretic or Precipitate Delivery Pack, if available. The pack
contains a variety of suplies to include towels, drapes, sanitary pads and so forth
D. Provide the cleanest environment possible
E. Provide for Asepsis to the greatest extent possible
F. Support the patient
 3. Premature Labor/Delivery

 Occurs before the end of 37 weeks

 AOG or before fetus weigh 2500gms
 Results in a premature infant, 2/3 neonatal death is due to LBW
 Occurs in approximately 10% of all pregnancies
 Unknown cause

Conditions resulting to premature labor:

1. Cervical surgery as cone biopsy
2. Chorioamnionitis
3. Hydramnios
4. Multiple gestation
5. Maternal age
6. Previous preterm labor
7. Polynephritis, UTI
8. Short inter-pregnancy period
9. Smoking
10. Streneous or shift work
11. Uterine anomaly as tumor
Assessment:
 More painless uterine contractions (30 sec. duration or frequently as every 10
minutes for more than 1 hr)
 More backaches
 More vaginal discharges
 Associated with UTI or chorioamnionitis
Management:
 Halth labor when [criteria]
* fetal membranes are intact [BOW]
* fetal heart beat- good
* no evidence of bleeding
* cervical dilation not more than 2-4 cms
* effacement not more than 50%
 Note: All these above criteria must be present
Measure to Halt labor:
 4 types of drug used for Tocolysis:
a. Beta-adrenergics
b. Calcium antagonists
c. Magnesium SO4
d. Prostaglandin inhibitors
1. Ethanol (ethyl alcohol)
 Administered thru IV
 Blocks the release of oxytocin by the pituitary glands thereby blocking or
delaying labor pains
 Stops production of prostaglandin stopping labor pain
[*Note: new knowledge on the effects of alcohol on a growing fetus nor made
halting labor with the use of alcohol questionable thus use of this method is no
longer advised]
2. Beta-Adrenergic (sympathomimetic drugs)
 Most frequently used beta receptors sites
 Adipose tissue, heart, liver, pancreatic cells, GIT & other smooth muscles
as uterine muscles, bronchi, blood vessels
3. Ritodrine Hydrochloride [Yutopar]
 Terbutaline (Brethine)- most used
 Acts on Beta 2 receptor sites- it relaxes the bronchial and blood vessels
along with theuterine muscles--> labor is halted but--> heart rate increases to
 move blood effectively hypocalcemia--> may occur from a shift of K into the cells-->
blood glucose and plasma insulin--> increase pulmonary edema occurs-->
headache, nausea and vomiting due to dilation of the blood vessels also manifests
Nursing Care:
 Check pulse- should not be given if pulse exceeds 120 BPM
 Also acts entirely on beta 2 receptor sites
 Mild tachycardia and hypotensive effects
[*Note: use with caution in patients with DM- increase BS overly DM, thyroid
dysfunction]
4. Magnesium SO4
 Effective to halt labor
 Check for signs of toxocity
5. Other measure
 Bedrest- to take the pressure of the gravid uterus off the cervix
 Hydration- oral, hydration affects the secretion of ADH and oxytocin causes
uterine contraction
 Avoid psychologic stress
 Administratio of corticosteroid (betamethasone) to hurry formation of fetal
lung surfactant
 4. Post-mature Labor

What is post-mature labor?

 It is also known as postdated pregnancy, prolonged pregnancy or post mature
birth
 Do not have any harmful effects on the mother, but the fetus, however, can begin
to suffer from malnutrition
 After the 42nd week of gestation, the placenta, which supplies the baby with
nutrients and oxygen from the mother, starts aging will eventually fail
 If the fetus passes fecal matter, which is not typical until after birth, and the child
breathes it in, then the baby could become sick with pneumonia
 Post term pregnancy may be a reason to induce labor
 The cause of post-term births is unknown but post-mature births are more likely
when the moter has experienced a previous post-mature birth
 Post-irregular births can also be attributed to irregular menstrual cycles
 Most post-mature pregnacies are at risk because the mother is not certain of her
last period, so in reality the baby is not technically post-mature

Signs and Symptoms:

 Post-mature newborn has dry, loose skin and may appear emaciated
 Overgrowth nails
 Abundant scalp hair
 Minimal fat deposits
 Visible creases on palms and soles of feet
 Staining of skin and nail beds with meconium
 Low blood sugar

Methods to monitor post-mature babies:

 Fetal movement recording
 Electronic fetal monitoring
 Ultrasound scan
 Biophysical profile
 Doppler flow study
 Radiograph
 Severe fetal congenital abnormalities in a baby born alive to a poorly
controlled type 1 diabetic mother
 Shows a functioning heart with a single atrium and a single ventricle, as
well as a degree of sacral dysgenesis

Complications of Post Maturity:

 Asphyxia- condition of severely deficient supply of oxygen to the body that arises
from being unable to breathe normally. An example of asphyxia is choking
- causes generalized hypoxia, which primarily affects the tissues and
organs
 Meconium Aspiration Syndrome(MAS)- in some cases, the baby passes stools
while still inside the uterus. This usually happens when babies are under stress
because they are not getting enough blood and oxygen.
 bluish skin color (cyanosis)
 Breathing problems (difficulty breathing- the infant needs to work hard
breathe, no breathing, rapid breathing)
 Limpness in infant at birth
 Neonatal hypoglycemia- occurs when the newborn’s glucose level is below the
level considered acceptable for the baby’s age.
 Bluish-colored (cyanosis)
 Breathing problems
 Decreased muscle tone (hypotonia)
 Grunting
 Irritability
 Nausea, vomiting
  Pale skin
 Pauses in breathing (apnea)
 Poor feeding
 Rapid breathing
 Problems with maintaining body heat
 Shakiness
 Sweating tremors seizures

Treatment:
 Resuscitation
 Oxygen
 Intravenous glucose solutions or frequent breast milk or formula feedings are given
to prevent hypoglycemia