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Topics: COMMON CAUSES OF DYSFUNCTIONAL

LABOR:
 Complications with the Power (FORCE of
Labor) 1. Inappropriate use of analgesics
 Dysfunctional Labor 2. Pelvic bone contraction that has narrowed the
 Precipitate Labor pelvic diameter so that a fetus cannot pass
 Induction and Augmentation of Labor
 Problems with the Passenger 3. Poor fetal position
 Problems with fetal position , presentation,
4. Extension rather than flexion of the fetal head
or size
 Problems with the Passage 5. Overdistention of the uterus (due to multiple
pregnancy)
6. Cervical rigidity (unripe)
A. COMPLICATIONS WITH THE POWER
7. Presence of full rectum or urinary bladder that
Definition:
impedes fetal descent
DYSTOCIA
8. Exhausted mother
-is defined as difficult labor. It may be associated
9. Primigravida status
with various abnormalities thd
at prevent or deviate from the normal course of 3 TYPES OF DYSFUNCTIONAL LABOR OR
labor ; j INEFFECTIVE UTERINE FORCE
and delivery. 1. HYPOTONIC CONTRACTIONS
-it is the consequence of 4 distinct abnormalities -the number of contractions is usually low or
that may exist singly or combination: the power, infrequent (<2-3 contractions in 10 mins) during
passage, passenger, and the psyche. the active phase of labor
MAIN COMPONENTS OF LABOR PROCESS: Causes:
1. POWER  After administration of analgesia
-the force that propels the fetus (uterine  Overstretched uterus
contractions)  Hydramnios

2. PASSENGER
-the fetus
3. PASSAGE
-the pelvis

INERTIA
-denotes the force of labor which had occurred (be
it sluggish or strong contraction)
UTERINE CONTRACTION
-basic force which moves the fetus through the
birth canal
-it occurs due to enter play of the following;
2. HYPERTONIC CONTRACTIONS
a) Contractile enzymes (adenosine
triphosphate) -there is an increase in intensity of the uterine
b) The influence of major electrolytes (Ca+ contractions in a shorter interval periods which
+,Na,K) occurs during the latent phase of labor.
DYSFUNCTIONAL LABOR or INEFFECTIVE -the resting phase has not achieved fully, then
UTERINE FORCE another contraction comes.
-is the sluggishness or the weakness of labor
contractions.
Danger:
  The lack of relaxation between contractions Cause:
may not allow optimal uterine artery filling
 Cervix is “not ripe” at the start of labor due
that leads to fetal anoxia early in the latent
to excessive use of analgesics early in labor
phase of labor
 Uterus
Management:

 Promote non-stimulating environment

(quiet, dark room)
 Monitor maternal and fetal monitoring use
CTG machine and watch for fetal
decelerations; if prolonged 1st & 2nd stage of
labor is detected may proceed with C/S
administer pain and rest relief (Morphine
SO4)
3. UNCOORDINATED CONTRACTIONS
-more than one pacemaker may be initiating
contractions or receptor points in the myometrium
may be acting independently of the pacemaker.

ends to be on hypertonic contractions

Management:

 Allow time for uterus to rest

 Administer adequate fluids to prevent
dehydration
DYSFUNCTIONAL LABOR OR
INEFFECTIVE UTERINE FORCE IN EACH  Administer morphine to relax hypertonicity
STAGE OF LABOR  Do amniotomy
 Start oxytocin infusion To assist labor
FIRST STAGE  Cesarian birth
1. Prolonged Latent Phase
2. Protracted Active Phase
3. Prolonged Deceleration Phase 2. PROTRACTED ACTIVE PHASE
4. Secondary Arrest of Dilatation
-it is usually associated with CPD or fetal
malposition, although it may reflect ineffective
myometrial activity.
PROLONGED LATENT PHASE
-this phase is prolonged if cervical dilatation does
-labor lasts longer than 20 hours in a nullipara not occur at a rate of at least 1.2cms/hr in nullipara
(G1P0) or longer than 14 hours in a multipara or 1.5cms/hr in multipara
Normal Parameters: -if the active phase lasts longer than 12hrs in a
 8-20 hrs (for primi) primipara or 6hrs in a multigravida; uterus tends to
be hypotonic contraction.
 5-14 hrs (for multipara)
Management: 3. Uterine Rupture
4. Inversion of the Uterus
 Cesarian birth 5. Amniotic Fluid Embolism
3. PROLONGED DECELERATION PHASE
-Deceleration phase become prolonged when it CONSTRICTION (CONTRACTION) RING
extends beyond 3 hrs in a nullipara or 1hr in a
multipara -it is a persistent localized annular spasm of the
circular uterine muscles
-it often results from abnormal fetal head position
-it occurs at any part of the uterus but usually at
Management: junction of the upper and lower uterine segments
 Cesarian birth is a must -it can occur at the 1st, 2nd, or 3rd stage of labor.
4. SECONDARY ARREST OF DILATATION Types:
-this occurs if there is NO progress in cervical 1. CONSTRICTION RING
dilatation for more than 2hrs.
-can occur at any point in the myometrium and at
any time during labor.
-simple type of contraction ring
2. PATHOLOGIC CONTRACTION RING (Bandl’s
ring)
-most common form of contraction ring

SECOND STAGE
1. PROLONGED DESCENT
-occur if the rate of descent is less than 1cm/hr in
the nullipara or 2cms/hr in a multipara
-prolonged descent with good quality of contraction
and duration; effacement and dilatation is normal
2. ARREST OF DESCENT
(cont’d)
-fetal head failed to descend within 1hr in a
-usually appear during the 2nd stage of labor and is a
multipara or 2hrs in a nullipara
warning sign that severe dysfunctional labor occurs.
-occurs at the function of the upper and lower
uterine segments as a horizontal indentation across
the abdomen.

OTHER DYSFUNCTIONAL LABOR Causes:

1. Contraction Rings  Uncoordinated contractions
2. Precipitate Labor  Obstetrics manipulations
  Administration of oxytocin -is defined as a disruption of the uterine muscle
extending to and involving the uterine serosa or
Management: disruption of the uterine muscle with extension to
 IV morphine sulfate (pain reliever) the bladder or broad ligament
 Amyl nitrate inhalation -Uterine Dehiscence is defined as disruption of the
 Tocolytic agent uterine muscle with intact uterine serosa
 Cesarian birth
FACTORS WHICH CAUSES UTERINE
 Manual removal of placenta
RUPTURE
1. Tearing of the vertical scar from a previous C/S
PRECIPITATE LABOR
2. Prolonged labor
-expulsion of the fetus in less than 3 hours.
3. Abnormal presentation
-occurs when uterine contractions are so strong
4. Multiple gestation
that a woman gives birth with only a few, rapidly
occurring contractions 5. Unwise use of oxytocin
-it is often defined as labor that is completed in 6. Obstructed labor
fewer than 3 hours
7. Traumatic maneuvers of forceps or traction
-Precipitate dilatation is a cervical dilatation that
occurs at a rate of 5cm or more per hour in a Signs and Symptoms:
primipara or 10 cm or more per hour in a multipara  Sudden appearance of fetal distress during
-such rapid labor is likely to occur with grand labor (most common sign)
multiparity, or it may occur after induction of labor  Uterine contractions suddenly stop
by oxytocin or amniotomy.  Palpation of fetus in the abdomen (outside
the uterus)
Causes:
 Fetal death
 An abnormally low resistance of the soft  Hemorrhage then hypovolemic shock in
parts of the birth canal mother
 Abnormally strong uterine and abdominal
contractions
 The absence of painful sensations

Nursing Diagnosis:

 Anxiety related to concern for self and fetus

COMPLICATIONS OF PRECIPITATE LABOR  Acute pain related to uterine contractions
1. Premature separation of placenta  Impaired urinary elimination related to
epidural anesthesia of from pressure of the
2. Maternal and fetal Hemorrhage fetus
3. Fetal subdural hemorrhage due to sudden release  Ineffective coping related to discomfort
of pressure on the head  Risk for infection related to rupture of the
membranes
4. Woman may sustain lacerations of the birth  Impaired physical mobility related to
canal medical interventions and discomfort
 Ineffective breathing pattern related to pain
and fatigue

UTERINE RUPTURE
 -inversions are usually described as acute (<30 d
after delivery) or chronic (>30 d after delivery)
Causes:

 Uterine atony
 Genital tract trauma
 Retained placental tissue
 Low placental implantation
 Uterine inversion
 Coagulation disorders
Management:

AMNIOTIC FLUID EMBOLISM

-occurs when amniotic fluid is forced into an open
maternal uterine blood sinus (valve) through some
defect in the membranes or after rupture of
membranes or partial premature separation of
placenta
-this condition may either occur during labor or in
the postpartal period
Risk Factors:

 Oxytocin administration
 Abruptio placenta
 Hydramnios
Signs and Symptoms:

 Sudden sharp chest pain during strong labor

 Inability to breathe (due to pulmonary
artery construction)
 Becomes pale and bluish gray (cyanotic due
UTERINE INVERSION to pulmonary embolism)

-turning of uterus inside out due to failure of the Management:

placenta to detach properly from the uterine wall  Oxygen administration (face mask)
when it is expelled.  CPR
-severity graded by how much the uterus has Prognosis:
reversed itself
 DEATH of mother may occur depending on
-very painful and may rapidly cause shock
the size of embolus
-may occur immediately postpartum, or much less
frequently, during the puerperium
  Fetus is guarded because of reduced  Tumors like fibroids obstructing the birth
placental perfusion and should be BORN passage
immediately by C/S  Congenital rigidity of the cervix
 Scarring of the cervix due to previous
PROBLEMS WITH THE operations like conisation
PASSAGEWAY  Congenital vaginal septum
1. Abnormal size or shape of the pelvis
2. Cephalopelvic disproportion
3. Shoulder dystocia SHOULDER DYSTOCIA
-when the fetal head is born but the shoulders are
CEPHALOPELVIC DISPROPORTION (CPD) too broad to enter and be delivered

-disproportion between the fetus and the pelvis -can cause vaginal or cervical tears

-2 pelvic measurements to determine the adequacy -can cause fetal cord compression between the fetal
of the pelvic size; body and the bony pelvis resulting to a fractured
clavicle or a brachial plexus injury
a) Diagonal conjugate (antero-posterior
diameter of the inlet) Risk Factors:
b) Transverse diameter of the inlet  Women with DM
-fetal head presented to the birth canal at less than  Multiparas
its narrowest diameter  Post-date pregnancies

-infant can’t be born vaginally Assessment:

Intervention:  Arrest of descent

 Turtle Sign
 C/S
Management/Intervention:
Causes/Risk Factors:
 Episiotomy: The episiotomy should be
a. Increased Fetal Weight
immediately increased in size and depth to
 Very large baby due to hereditary reasons – create more space in the vaginal canal
a baby whose weight is estimated to be  Flexion of Legs: With the woman lying on
above 5 kgs or 10 pounds her back, the legs are flexed on her thighs,
 Postmature baby – whene the pregnancy bringing her knees as close to her chest as
goes above 42 weeks possible – this widens out the vaginal
 Babies of women with diabetes opening (McRoberts Maneuver)
 Babies of mothers who have had a number  Traction of fetal head: Firm downward
of children – each succeeding baby tends to traction is made on the fetal head to move
be larger and heavier the upper shoulder which is impacted under
the symphysis pubis
b. Fetal Position  Suprapubic Pressure: Pressure is applied
just above the symphysis pubis. This helps
 Occipito-posterior – in this position the
to move the upper shoulder and causes it to
fetus faces the mother’s abdomen instead of
slide under the bone.
her back
 Internal rotation: If the baby is not born bu
 Brow presentation
the above maneuvers, the doctor should
 Face presentation
insert her hand into the vagina and attempt
c. Problems with the Pelvis to maneuver the upper shoulder
 Delivering the posterior arm: The doctor
 Small pelvis needs to insert her hand into the vagina,
 Abnormal shape of the pelvis due to take hold of the posterior arm and sweep it
diseases like rickets, osteomalacia, or across the fetal chest, keeping the elbow
tuberculosis flexed to prevent injury to the humerus.
 Abnormal shape due to previous accidents  Changing the position of the patient: The
 Tumors of the bones patient is made to get up in all-fours
 Childhood poliomyelitis affecting the shape position, so that the baby fall forward and
of the hips the shoulder gets disimpacted.
 Congenital dislocation of the hips  Other options: If all maneuvers fail, then the
 Congenital deformity of the sacrum or only options left to the doctor are;
coccyx a) Break the collar bone or clavicle to
decrease the diameter of the
d. Problems with the Genital tract shoulders
 b) Use a hook under the baby’s armpit
to deliver it.

COMPLICATIONS WITH THE

PASSENGER
1. Prolapse of the umbilical cord
2. Multiple gestation
3. Problems with the position
4. Problems with the presentation
5. Problems with size

CORD PROLAPSE
-the umbilical cord drops (prolapse) through the
open cervix into the vagina ahead of the baby, Predisposing Factors:
where it may lie adjacent to the presenting part
(occult cord prolapse) or below the presenting part  Multiple pregnancy
(overt cord prolapse)  High presenting part
 Polyhydramnios
 Premature labor
 Malpresentations
 Fetal abnormalities
 Uterine abnormalities

TYPES OF CORD PROLAPSE

1. OCCULT CORD PROLAPSE
-cord is adjacent to the presenting part
-cannot be palpated during pelvic examination
-might lead to variable decelerations or
unexplained fetal distress
2. FUNIC (CORD) PRESENTATION
-prolapse of the umbilical cord below the level of Signs and Symptoms:
the presenting part before the rupture of fetal
membranes  Variable deceleration: no consistent
relationship with uterine contraction
-cord can often be easily palpated through the  It is sometimes caused by compression of
membranes the umbilical cord between the uterus and
-often the harbinger of cord prolapse the fetal body, or because it is looped round
some part of the fetus
3. OVERT CORD PROLAPSE  Provided that it does not persist for more
than a few minutes it may have a little
-umbilical cord lies below the presenting part
significance, but persistence for more than
-associated with rupture of membranes, and 15 minutes would call for treatment
displacement of the cord through the vagina
Management:

 Fetal survival depends on swift action

 Call for help – midwifery colleagues/8000
 Factors to consider;
a) Viability of the fetus
b) Severe fetal abnormalities
 Emergency delivery for a normally formed
and mature fetus

Therapeutic Management:

 Manual elevation of the fetal head away

from the cord to prevent pressure on the
cord which causes fetal anoxia
 Putting the woman in a knee chest position
or Trendelenburg position causing the fetal
head to fall away from the cord
 Administer oxygen 5-10Lpm to the mother
to improve fetal oxygenation
 Administer tocolytic agent to reduce uterine
activity and pressure on the fetus
 If the cord is exposed to room air; COVER
the exposed portion with sterile cloth wet
with saline solution to prevent from drying
 Prepare for delivery (Forceps or C/S)