Complication with the POWER (The force of Labor)

Inertia is a time-honored term to denote that sluggishness of contractions, or the force of labor, has
occurred. Also called 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).
- Prolonged labor appears to result from several factors. It is most likely to occur if a fetus is large.
Hypotonic, hypertonic, and uncoordinated contractions all play additional roles (Box 23.2).

Ineffective Uterine Force

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

- Contractile enzyme adenosine triphosphate

- Influence of major electrolytes such as calcium, sodium, and potassium (CaNaK)
- specific contractile proteins (actin and myosin), epinephrine and norepinephrine, oxytocin (a
posterior pituitary hormone), estrogen, progesterone, and prostaglandins.

RISK PROBLEM DURING POWER

1. Hypotonic Contraction
- The number of contractions is unusually low or infrequent (not more two or three occurring in
a 10-minute period).
- The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions
does not rise above 25 mm Hg
- Occur more frequently during Active Phase of Labor
- Contractions are not exceedingly painful, because of their lack of intensity
- This can cause the uterus to not contract as effectively during the postpartal period because of
exhaustion, increasing a woman’s chance for postpartal hemorrhage
- Increase length of labor to achieve cervical dilatation

Occurs when:

- After the administration of analgesia, especially if the cervix is not dilatated to 3 to 4 cm or;
- if bowel or bladder distention prevents descent or firm engagement.
- Occur in a uterus that is overstretched by a multiple gestation, a larger-than-usual single fetus,
hydramnios, or in a uterus that is lax from grand multiparity

Intervention
In the first hour after birth following a labor of hypotonic contractions:

- Palpate the uterus

- Assess lochia every 15 minutes to ensure that postpartal contractions are not also hypotonic
and therefore inadequate to halt bleeding.

2. Hypertonic Contractions
- Marked by an increase in resting tone to more than 15 mmHg.
- Tend to occur more frequently and during the latent phase of labor.
- They are more painful than usual, and they make the woman frustrated with her breathing
techniques because they are ineffective.
- The lack of relaxation between contractions may not allow optimal uterine artery filling that
could lead to FETAL ANOXIA.

Interventions:

- A uterine and fetal external monitor should be applied for at least 15 minutes to check the
resting phase of the contractions and that the fetal pattern is not showing a late deceleration.
- Cesarean birth would be necessary if there is late deceleration, an abnormally long first stage of
labor or lack of progress with pushing.
- Explain to the woman and her partner that although the contractions are very strong, they are
ineffective and are not achieving cervical dilatation.

3. Uncoordinated Contractions
- More than one pacemaker may be initiating contractions with uncoordinated contractions, or
receptor points in the myometrium may be acting independently of the pacemaker.
- It would be difficult for the woman to rest between contractions because they occur erratically.

Interventions:

- A fetal and uterine external monitor must be attached to the woman to assess the rate,
pattern, resting tone, and fetal response to contractions for at least 15 minutes.
- Oxytocin administration can also be done to stimulate a more effective and consistent pattern
of contractions with a better, lower resting tone.

4. Dysfunctional Labor
- Dysfunctional labor during the first stage involves prolonged latent phase, protracted active
phase, prolonged deceleration phase, and secondary arrest of dilatation
- Dysfunction during the second stage of labor involves prolonged descent and arrest of descent.
- If the rate of descent is less than 1 cm/hr in a nullipara or 2.0 in a multipara, then there is
prolonged descent of the fetus.

Intervention:

- Prolonged latent phase can be managed through helping the uterus to rest, providing adequate
fluid for hydration and pain relief.
- Oxytocin is prescribed during a protracted active phase to augment labor.
- Cesarean birth would also be necessary in a prolonged deceleration phase.
- In secondary arrest of dilatation, there is no progress with cervical dilatation for more than 2
hours, and then cesarean birth would be necessary.
- Encourage the woman to rest and increase her fluid intake.
- Intravenous oxytocin may also be administered to induce the uterus to contract effectively.
- A semi-Fowler’s position, squatting, kneeling, or more effective pushing may speed up the
descent.
- The most likely cause of arrest of descent in the second stage of labor is CPD, so cesarean birth
is necessary.
 5. Precipitate Labor
- Precipitate labor occurs when uterine contractions are so strong that a woman gives birth with
only a few and rapidly occurring contractions.
- Grand multiparity facilitates this kind of labor, or it can also happen after induction of labor by
oxytocin or amniotomy.
- Subdural hemorrhage for the fetus may occur from the rapid release of pressure on the head.
- The woman may also obtain lacerations of the birth canal due to forceful birth.
- If the rate is greater than 5 cm per hour in a nullipara or 10 cm/hr in a multipara, precipitate
labor is already occurring.

Intervention:

- Caution a multipara by her 28th week that her labor might still be brief if she has had a brief
labor in the past to allow the woman to plan her transportation.
- A birthing room must be converted to birth readiness before full dilatation is obtained.

Problems with Passenger

1. Umbilical cord prolapse

- In umbilical cord prolapse, a loop of the umbilical cord slips down in front of the presenting fetal
part
- Prolapse may occur at any time after the membranes rupture if the presenting fetal part is not
fitted firmly into the cervix.

It tends to occur most often with:

- Premature rupture of membranes

- Fetal presentation other than cephalic
- Placenta previa
- Intrauterine tumors preventing the presenting part from engaging
- A small fetus
- Cephalopelvic disproportion preventing firm engagement
- Hydramnios
- Multiple gestation

- The incidence is about 0.5% of cephalic births; this rises as high as 15% to 20% with breech or
transverse lies (Kish &Collea, 2007).

Intervention:

Assessment

- In rare instances, the cord may be felt as the presenting part on an initial vaginal examination
during labor. It may also be identified in this position on an ultrasound.
- When this happens, cesarean birth is necessary before rupture of the membranes occurs.

More often, however, cord prolapse is first discovered only after the membranes have ruptured, when
a variable deceleration FHR pattern suddenly becomes apparent. The cord may be visible at the vulva.
 - To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of the
membranes whether this occurs spontaneously or by amniotomy.

Therapeutic management

- This may be done by placing a gloved hand in the vagina and manually elevating the fetal head
off the cord, or by placing the woman in a knee–chest or Trendelenburg position, which causes
the fetal head to fall back from the cord (Relieving pressure on cord to avoid fetal anoxia)
- Administering oxygen at 10 L/min by face mask to the woman is also helpful to improve
oxygenation to the fetus.
- A tocolytic agent may be prescribed to reduce uterine activity and pressure on the fetus.
- Amnioinfusion is yet another way to relieve pressure on the cord (Hofmeyr, 2009).
- If the cord has prolapsed to the extent that it is exposed to room air, drying will begin, leading to
atrophy of the umbilical vessels.
- Do not attempt to push any exposed cord back into the vagina. This may add to the
compression by causing knotting or kinking. Instead, cover any exposed portion with a sterile
saline compress to prevent drying.
- If the cervix is fully dilated at the time of the prolapse, the physician may choose to birth the
infant quickly, possibly with forceps, to prevent fetal anoxia.
- If dilatation is incomplete, the birth method of choice is upward pressure on the presenting
part, applied by a practitioner’s hand in the woman’s vagina, to keep pressure off the cord until
the baby can be born by cesarean birth.

2. Multiple Gestation
- Twins may be born by cesarean birth to decrease the risk that the second fetus will experience
anoxia; this also is often the situation in multiple gestations of three or more, because of the
increased incidence of cord entanglement and premature separation of the placenta (Fortner,
Althaus, & Gurewitsch, 2007).
- Anemia and pregnancy-induced hypertension occur at higher-than-usual incidences during
multiple gestations. To detect these, be certain to assess the woman’s hematocrit level and
blood pressure closely during labor or while waiting for cesarean surgery.

Intervention:

- During labor, support the woman’s breathing exercises to minimize the need for analgesia or
anesthesia; this helps to minimize any respiratory difficulties the infants may have at birth
because of their immaturity.
- If possible, monitor each FHR by a separate fetal monitor during labor. Because the babies are
usually small, firm head engagement may not occur, increasing the risk for cord prolapse after
rupture of the membranes. Because of the multiple fetuses, abnormal fetal presentation may
occur. Uterine dysfunction from a long labor, an overstretched uterus, unusual presentation,
and premature separation of the placenta after the birth of the first child may also be more
common.
- After the first infant is born, both ends of the baby’s cord are tied or clamped permanently,
rather than with cord clamps, which could slip. This prevents hemorrhage the placenta.
 - The first infant is identified as A, and newborn care is started. Oxytocin will not be given, to
avoid compromising the circulation of the infants not yet born.
- After the birth of the first child, the lie of the second fetus is determined by external abdominal
palpation or ultrasound. If the presentation is not vertex, external version may be attempted to
make it so (Longo & Hankins, 2007). If this is not successful, a decision for a breech birth or
cesarean birth must be made (Cruikshank, 2007).
- If the infant will be born vaginally, an oxytocin infusion may be begun at this point to assist
uterine contractions, thereby shortening the time span between births. If uterine relaxation is
needed, nitroglycerin, an uterine relaxant, may be administered.
- For this reason, with most multiple gestations today, if all of the fetuses are not vertex
presentations, they will be born by cesarean birth.
- Assess the woman carefully in the immediate postpartal period, because the uterus that has
been overly distended owing to the multiple gestation may have more difficulty contracting than
usual, placing her at risk for hemorrhage from uterine atony (lacking normal tone).
- The infants need careful assessment to determine their true gestational age and whether a
phenomenon such as twin-to twin transfusion could have occurred

Problems with Fetal Position, Presentation and Size

1. Occipitoposterior Position
- The usual fetal position is posterior rather than anterior.
- Assuming that the presentation is vertex, the occiput is directed diagonally and posteriorly,
either to the left or to the right.
- During internal rotation in these positions, the fetal head must rotate through an arc of
approximately 135 degrees.
- Rotations from a posterior position can be aided by having the woman assume a hands and
knees position, squatting or lying on her side; however, this is tiring for women in labor.
- Posterior positions usually occur in women with android, anthropoid, and contracted pelvis.
- Posterior positions happen in dysfunctional labor pattern such as prolonged active phase,
arrested descent, or fetal heart sounds heard best at lateral sides of the abdomen.
- A head in posterior position does not fit the cervix like a head in anterior position does.
- This can be confirmed through vaginal examination or through ultrasound because it might
cause umbilical cord prolapse.
- Labor is prolonged because the arc of rotation is greater.
- Pressure and pain would be experienced by the woman in her lower back owing to sacral nerve
compression when the fetal head rotates against the sacrum.

Intervention:

- To relieve a portion of the pain, applying counterpressure on the sacrum by a back rub may be
done, and heat or cold application can also help.
- To help the fetus rotate, the woman may lie on the side opposite the fetal back or assume a
hands and knees position.
- The woman should void every 2 hours to keep her bladder empty and avoid impeding the
descent of the fetus.
- The woman may also need an oral sports drink or IV glucose solution to replace glucose stores
used for energy.
- Maternal exhaustion can cause uterine dysfunction, so a rotation of 135 degrees may not be
possible if the contractions are ineffective or if the fetus is larger than average.
- The fetal head might arrest in the transverse position or there might be no rotation at all,
so cesarean birth would be necessary.
- Provide reassurances to the woman that even though her labor is not “by the book” it is still
within safe and controlled limits.

2. Oversized Fetus
- Macrosomia or an oversized fetus weighs more than 4000 to 4500g, and this size may become a
problem.
- Macrosomic babies are usually born to women with diabetes or develop gestational diabetes,
and multiparas.
- Uterine dysfunction might result from an oversized fetus because of the overstretching of the
fibers of the myometrium.
- The wide shoulders pose a problem at birth because it can cause fetal-pelvic disproportion or
uterine rupture from obstruction.
- If a macrosomic baby is born vaginally, there are high risks for cervical nerve palsy,
diaphragmatic injury, or fractured clavicle due to shoulder dystocia.
- The woman is at risk for over because of the overdistended uterus and uterine atony.

Intervention:

- Cesarean birth is necessary if the fetus is so oversized to be born vaginally.

- To compare the size of the fetus with the woman’s pelvic capacity, pelvimetry or ultrasound can
be performed.

3. Shoulder Dystocia
- Shoulder dystocia occurs during the second stage of labor when the fetal head is born but the
shoulders are too broad to enter and be born through the pelvic outlet.
- The woman is at risk for vaginal and cervical tears, while the fetus is at risk for cord compression
between the fetal body and the bony pelvis.
- If birth is forced through the vaginal opening, the fetus would sustain a fractured clavicle or a
brachial plexus injury.
- Shoulder dystocia usually occurs in women who have diabetes, in multiparas, and in post-date
pregnancies.
- Shoulder dystocia is discovered often during the birth of the head and the shoulders lock
beneath the symphysis pubis.
- Other conditions that may suggest shoulder dystocia are prolonged second stage of labor, arrest
of descent, or when the head starts to crown, it retracts instead of protruding with each
contraction.

Intervention:
- Instruct the woman to flex her thighs sharply on her abdomen (McRobert’s maneuver) to widen
the pelvic outlet and allow the anterior shoulder to be born.
- Applying suprapubic pressure can also help the shoulder out from beneath the symphysis pubis.

4. Breech Presentation
- Most fetuses are in a breech presentation early in pregnancies; however, by week 38, it turns
into a cephalic presentation.
- The fetal head may be the widest single diameter but the fetus’ buttocks and legs take up more
space.
- The fetus turns into cephalic position mostly because the fundus is the largest part of the uterus,
so the buttocks and the lower extremities are in the fundus.
- Types of breech presentation include complete, frank, and footling.
- Breech presentation increases the fetal risk for anoxia, traumatic injury to the head, fracture of
the spine or arm, dysfunctional labor, and early rupture of membranes.
- Meconium present in the amniotic fluid is a sign buttock pressure, and this can lead to
meconium aspiration once the infant inhales amniotic fluid.
- Fetal heart sounds are heard high in the abdomen in breech presentation.
- In a breech birth, the birth of the head is the most dangerous part because a loop of umbilical
cord that has passed down alongside the head may be compressed.
- Intracranial hemorrhage is another danger of breech birth because of the pressure changes that
has occurred spontaneously.
- An infant born from a frank breech position usually extends his or her legs continuously during
the first 2 or 3 days of life, so be sure to point out to the parents that this is normal.

Intervention:

- Leopold’s maneuver and vaginal examination can determine breech presentation.

- Be certain to monitor the FHR and uterine contractions continuously to detect fetal distress
early and provide prompt intervention.
5. Face Presentation
- Face and brow presentations are called asynclitism or a fetal head presenting at a different
angle than expected.
- In face presentation, the head diameter the fetus presents to the pelvis is often too large for
birth to proceed.
- The back would be difficult to outline because it is concave.
- Face presentation usually occurs in women with contracted pelvis, or placenta previa, in a
relaxed uterus of a multipara, with prematurity, hydramnios, or fetal malformation.

Intervention:

- If the chin is anterior and the pelvic diameters are within normal limits, the infant can be born
vaginally.
- If the chin is posterior, cesarean birth is the birth method of choice.
- Face presentation can be determined through vaginal examination when the nose, mouth, or
chin is felt as the presenting part or through ultrasound.
- Facial edema and ecchymosis are present in a baby born after a face presentation.
- Assess the patency of the infant’s airway closely.
- Reassure the parents that the edema is transient and will disappear after a few days.
6. Brow Presentation
- The rarest among the presentations is the brow presentation.
- This presentation usually occurs in multipara women or in a woman with relaxed abdominal
muscles.
- Obstructed labor occurs because the head becomes jammed in the brim of the pelvis as the
occipitomental diameter presents.

Intervention:

- Cesarean birth would be necessary unless the presentation spontaneously corrects itself.
- Extreme ecchymosis on the face is also present in infants born after a brow presentation.
- Reassure the parents that the bruising over the same area as the anterior fontanelle is normal.

7. Inlet Contraction
- Inlet contraction is the narrowing of the anteroposterior diameter to less than 11 cm or the
transverse diameter to 12 cm or less.
- The usual cause is rickets in early life or by an inherited small pelvis.
- If the fetal head engages during the 36th to 38th week of pregnancy, then the pelvic inlet is
adequate.
- If there is no engagement in primigravidas, then either a fetal abnormality or a pelvic
abnormality should be suspected.

Intervention:

- Every primigravida should have pelvic measurements taken and recorded before week 24 of
pregnancy so that a birth decision can be made.
- In CPD, the fetus remains in a floating position that could further complicate the already difficult
situation.
- If the membranes rupture, then the risk for cord prolapse increases greatly.
8. Outlet Contraction
- Outlet contraction is the narrowing of the transverse diameter at the outlet to less than 11 cm.
- This is the distance between the ischial tuberosities, a measurement that is easy to make during
a prenatal visit, so the narrow diameter can be anticipated before labor starts.
- This can also be assessed easily during labor.
9. Trial Labor
- Trial labor refers to determination of the progress of labor in a woman who has borderline inlet
- measurement with a good fetal lie and position.
- Trial labor may continue as long as descent of the presenting part and dilatation of the cervix
continue to occur.

Intervention:

- Monitor fetal heart sounds and uterine contractions continuously.

- Instruct the woman to void every 2 hours to aid in fetal descent.
 - After the rupture of membranes, assess the FHR closely; if the fetal head is still high, there is an
increased danger of prolapsed cord and anoxia in the fetus.
-  Cesarean birth would be necessary if there is no progress in labor after 6 to 12 hours.
- If trial labor fails and cesarean birth is scheduled, provide an explanation about why cesarean
birth is the best birth method.
- Women undergoing trial labor need to be reassured, as well as her support person, that
cesarean birth is only an alternative, not an inferior, method of birth because the labor is not
progressing.

10. External Cephalic Version

- External cephalic version is the turning of a fetus from a breech to a cephalic position before
birth.
- As early as 34 to 35 weeks external cephalic version can be done but the usual time is 37 to 38
weeks of pregnancy.

Intervention:

- Record FHR and ultrasound continuously during the procedure.

- The uterus should relax, so administration of a tocolytic agent is done.
- The breech and vertex of the fetus are located and grasped transabdominally by the examiner’s
hands on the woman’s abdomen.
- External cephalic version can decrease the number of cesarean births necessary from breech
presentations.
- Contraindications to the procedure include multiple gestation, severe oligohydramnios, vaginal
birth, cord coil, and unexplained third trimester bleeding which could be placenta previa.
- The feeling of pressure may be uncomfortable for the woman.
- Women who are Rh negative should receive Rh immunoglobulin after the procedure in case
bleeding occurs.

Reference:

Pillitteri, Adele. (2007) Maternal & child health nursing :care of the childbearing & childrearing
family Philadelphia, PA : Lippincott Williams & Wilkins,

Belleza, M. (2017). Problems with fetal position, presentation size and passage: Nurses lab. Retrieved
from https://nurseslabs.com/problems-fetal-position-presentation-size-passage/