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Can arise from any of the three main components of thepower, or process: propels the labor the force that The
fetus ( uterine contraction) The passenger( the fetus) The passageway (the birth canal)
THE FORCE OF LABOR
Inertia= is time-honored term to denote that sluggishness of contractions, or the force of laabor. Dysfunctional labor is a more current term. It can occur in any point in labor.
Causes of dysfunctional labor
Inappropriate use of analgesia ( excessive or too early administration) Pelvis bone contraction that has narrowed the pelvic diameter so that a fetus cannot pass ( ex. A client with rickets) Poor fetal position (posterior rather than anterior position)
Overdistention of the uterus as with multiple pregnancy, hydamnios, or extremely oversized fetus Cervical rigidity ( unripe) Presence of a full rectum or urinary bladder that impedes fetal descent Mother becoming exhausted from labor Primigravida status
Ineffective uterine factors
Uterine contractions = is the basic force moving the fetus through the birth canal. It occur because of the interplay of the contractile enzyme adenosine triphosphate and the influence of major electrolytes such as calcium, sodium and potassium, specific contractile proteins ( actin and myosin), epinephrine and norepinephrine, oxytocin, estrogen, progesterone and prostaglandins.
The number of contractions is usually low or infrequent ( not increasing beyond two or three 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. It occur during the active phase of labor. It occur after the administration of analgesia, especially if the cervix is not dilated to 3 tp 4 cm or iif bowel or bladder distention prevents descent or firm engagement. It also occur in a uterus that is overstretched by a multiple gestation, a largerthan-usual single fetus, or hyrmanios, or in a uterus that is lax from grand multiparity.
It is not exceedingly painful because of their lack of intensity. The strength of a contraction is a subjective symptom. It is very painful.
It increase the length of labor because more of them are necessary to achieve cervical dilatation. This can cause the uterus to not contract as effectively during postpartal period because of exhaustion. Increasing a chance of postpartal hemorrhage. With cervix dilated for a long period both the uterus and fetus are at risk for infection.
For these reason, after ultrasonic confirmation rules out cephalopelvic disproportion (CPD), an infusion of oxytocin, a synthetic form of the naturally occurring pituitary hormone, usually started to augment labor by strengthening contractions and increasing their effectiveness. Membranes maybe artificially ruptured (amniotomy) to further speed labor. In the first hour after birth, palpate the uterus and assess lochia every 15 minutes to ensure that postpartal ontractions are not also
Hypertonic uterine contractions are marked by an increase in resting tone to more than 15mm Hg. Hypertonic ones tend to occur frequently and are most commonly seen in the latent phase of labor. It 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. More than one pacemaker is stimulating the contractions. It is more painful than usual, because the myometrium becomes tender from constant lack of relaxation and the anoxia of uterine cells that results.
Danger – this could lead to fetal anoxia early in the latent phase of labor. Both a uterine and a fetal external monitor applied for at least 15 minutes to ensure that the resting phase of the contractions is adequate and that the fetal pattern is not showing late deceleration. Management – rest and pain relief with a drug such as morphine sulphate. Changing the linen and the clients gown, darkening room lights, and decreasing noise and stimulation are also helpful.
Pathologic retraction ring (Bandl’s ring) that occurs at the junction of the upper and lower uterine segments. The ring usually appears during the second stage of labor as a horizontal indentation across the abdomen. It is a warning sign that severe dysfunctional labor is occurring. It is formed by excessive retraction of the upper uterine segment; the uterine myometrium is much thicker above than below the ring.
Uncoordinated contractions – in the pelvic division labor, it is usually caused by obstetric manipulation or by the administration of oxytocin. The fetus is gripped by the retraction ring and cannot advance beyond that point. Contraction ring can be identified by sonography. It is extremely serious and should be reported promptly. IV morphine sulphate or the inhalation of amyl nitrite may relieve a retraction ring.
Halt contractions – if the situation is not relieved, uterine rupture and death of the fetus may occur. In the placental stage, massive maternal hemorrhage may result, because the placental is loosened but then cannot be delivered. A cesarean birth will be necessary to ensure safe birth of the fetus.
Precipitate labor and birth occur when uterine contractions are so strong that the woman gives birth with only a few, rapidly occurring contractions.
PROLAPSE OF THE UMBILICAL CORD
Umbilical cord prolapsed, 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 part is not fitted firmly into the cervix.
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 a sonogram. Caesarean birth is necessary before rupture of the membranes occurs. Membrane rupture of the membranes occurs. Membrane rupture would cause the cord to slide down into the vagina from the pressure exerted by the amniotic fluid. Cord prolapsed is first discovered only after membranes have ruptures. The cord maybe visible at the vulva.
Always assess fetal heart sounds immediately after rupture of the membranes occurring either spontaneously or by amniotomy.
Cord prolapse automatically leads to cord compression, because the fetal presenting part presses against the cord at the pelvic brim. Management is aimed toward relieving pressure on the cord, thereby relieving the compression and the resulting fetal anoxia. 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.
Administering oxygen at 10 L/min by face mask to the mother is also helpful to improve oxygenation to the fetus. A tocolytic agent may be prescribed to reduce uterine activity and pressure on the fetus.
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 at the vagina. This may add to compression by causing knotting or kinking. Instead, cover ny exposed portion with a sterile saline compress to prevent drying.
If the cervix is fully dilated, deliver the infant quickly, possibly with forceps, to prevent fetal anoxia. If dilation is incomplete, the birth method of choice is upward pressure on the presenting part to keep pressure off the cord until the baby can be born by caesarean birth.
Twins may be born by caesarean birth to decrease the risk that the second fetus will experience anoxia; this also is often the situation in a multiple gestations of three or more, because of the increased incidence of cord entanglement and premature separation of the placenta.
Anemia and Spregnancy-induced hypertension occur during multiple gestations. Be certain to assess the woman’s hematocrit level and blood pressure closely during labor or while waiting for caesarean surgery.
If a woman with a multiple gestatin will be giving birth vaginally, she is usually instructed to come to the hospital early in labor. During labor, support the woman’s breathing exercises to minimize the need for analgesia or anesthesia; this help to minimize any respiratory difficulties the infants may have at birth because of their immaturity.
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. Uterine dysfunction from a long labor, an over stretched uterus, and premature separation of the placenta after the birth of the first child may also be more common.
After the birth of the first child, the lie of the second fetus is determined by external abdominal palpation and sonography. If the presentation is not vertex, external version may be attempted to make it so. If this is not successful, a decision for a breech delivery or caesarean birth must be made. If the infant will be born vaginally, an oxytocin infusion may be begun at this point o assist uterine contractions, thereby shortening the time span between births. Nitroglycerin may be
The placenta of the first infant separates before the second fetus is born, and there is sudden, profuse bleeding at the vagina. The uterus cannot contract as it normally would, because it is still full with the second twin so it is difficult to halt the bleeding. If all of the foetuses are not vertex presentations, they will be born by cesarean birth.
Assess the mother carefully in the immediate postpartal period, because the uterus that has been overly distended due to the multiple gestation may have more difficulty contracting than usual, placing the mother at the risk for hemorrhage from uterine atony.
PROBLEMS WITH POSITION, PRESENTATION, OR SIZE
Occipitoposterior position Posterior positions tend to occur in women with android, anthropoid, or contracte pelves. A posterior position is suggested by a dysfunctional labor pattern such as a prolonged active phase, arrested descent, or fetal heart sounds heard best at the lateral sides of the abdomen.
A posteriorly presenting head does not fit the cervix as snugly as pone in an anterior position. Because this increases the risk of umbilical cord prolapsed, the position of the fetus is confirmed by vaginal examination or by sonogram. The majority of foetuses presenting in posterior positions, if they are of average size and in good flexion and aided by forceful uterine contractions, rotate through the large arc, arrive at a good birth position for the pelvic outlet, and are born satisfactorily with only increased molding and caput formation. Because the arc of rotation is greater, it is usual for the labor to be somewhat prolonged.
The fetal head rotates against the sacrum, a woman may experience pressure and pain in her lower back due to sacral nerve compression. These sensations may be so intense that she asks for medication for relief, not for her contractions but for the intense back pressure and pain. Counterpressure on the sacrum (e.g. back rub, change of position) maybe helpful in relieving a portion of the pain. Applying heat or cold, whichever feels best, also may help.
Lying on the side opposite the fetal back or maintaining a hands-and-knees position may help the fetus rotate. During a long labor, be certain the woman voids approximately after 2 hours to keep her bladder empty, because a full bladder could 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 to replace glucose stores used for energy.
If contractions are ineffective, or if the fetus is larger than average or not in good flexion, rotation through the 135-degree arc may not be possible. Uterine dysfunction may result from maternal exhaustion. The fetal head may arrest in the transverse position, or rotation may not occur at all (persistent occipitoposterior position0. The fetus must be born by caesaraean birth.
During labor, a woman needs a great deal of support to prevent her from becoming panicked about the length of the labor. If forceps are used, this places a woman at risk fro reproductive tract lacerations, hemorrhage, and infection in the postpartum period.
Most foetuses are in a breech presentation early in pregnancy. The fetal head is the widest single diameter, the fetus’s buttocks (breech), plus the legs, actually take up more space. Fundus is the largest part of the uterus is probably the reason why, in approximately 97% of all pregnancies. There are several types of breech presentation; complete, frank, and footling. Breech presentation is more hazardous to a fetus than a cephalic
The inevitable contraction of the fetal buttocks from cervical pressure often causes meconium to be extruded into the amniotic fluid before birth. This, unlike meconium staining that occurs due to fetal anoxia, is not a sign of fetal distress but it is expected from the buttock pressure. Meconium excretion can, however, lead to meconium aspiration if the infant inhales amniotic fluid.
Breech presentation, fetal heart sounds usually are heard high in the abdomen. Leopold’s manuevers, a vaginal examination, or ultrasound examination reveals the presentation. If the breech is incomplete and firmly engaged, the tightly stretched gluteal muscles of the fetus may be mistaken on vaginal examination for a head; the cleft between the buttocks may be mistaken for the sagittal suture line. Sonography clearly confirms a breech presentation. Such a study also gives information on pelvic diameters, fetal skull diameters, and evidence of possible placenta previa causing the breech presentation.
Always monitor FHR and uterine contractions continuously. This allows early detection of fetal distress from a complication (e.g. prolapsed cord) and prompt intervention.
Born vaginally – the woman is allowed to push after full dilatation is achieved and the breech, trunk, and shoulders are born. The shoulders present to the outlet with their widest diameter anteroposterior.
Birth of the head is the most hazardous part of a breech birth. Because the umbilicus precedes the head, a loop of cord passes down alongside the head. The pressure of the head against the pelvic brim automatically compresses this loop of cord.
A second danger of breech birth is intracranial hemorrahge. With a cephalic presentation, molding to the confines of the birth canal occurs over hours. With a breech birth, pressure changes occur instantaneously. Tentorial tears, which can cause gross motor and mental incapacity or lethal damage to the fetus, may result. The infant who is delivered suddenly to reduce the duration of cord compression may suffer an intracranial hemorrhage. In contrast, the infant who is delivered gradually to reduced possibility of intracranial injury may suffer hypoxia.
To aid in delivery of the head, the trunk of the infant is usually straddled over the physicians right forearm.two fingers of the physician’s right hand are placed in the infant’s mouth. The left hand is slid into the mother’s vagina,palm down,along the infant’s back. Pressure is applied to the occiput to flex the head fully. Gentle traction applied to the shoulders (upward and outward) delivers to the head. An aftercoming head may also be delivered by the aid of piper forceps to control flexion and the rate of descent. The difficulty with delivering the head is the reason why planned caesarean birth is the usual method of birth for breech presentation infants today.
An infant who was born from a frank breech position may tend to keep his or her legs extended at the level of the face for the first two or three days of life. A footling breech may tend to keep the legs extended in a footling position for the first few days.
A fetal head presenting at a different angle than expected is termed asynclitism. Face and brow presentations are examples. Face (chin or momentum) presentation is rare, but when it does occur, the head diameter the fetus presents to the pelvis is often too large for birth to precede. A head that feels more prominent than normal, with no engagement apparent on Leopold’s maneuvers, suggest a face presentation
. The head abd back are both felt on the same side of the uterus with Leopold’s manuevers. If the back is extremely concave, fetal heart tones maybe transmitted to the forward-thrust chest and heard on the side of the fetus where feet and arms can be palpated. A face presentation is confirmed by vaginal examination when the nose, mouth, or chin can be felt as the presenting part.
A fetus in a prosterior position, instead of flexing the head as labor procedes, may extend the head, resulting in a face presentation;this usually occurs in a woman with a contracted pelvis or placenta previa. It also may occur in the relaxed uterus multipara or with prematurity, hydramnios, or fetal malformation.
It is a warning signal. Something abnormal is usually causing the face presentation. If a face presentation is suspected, a sonogram is done to confirm it; if indicted the pelvic diameters are measured. If the chin is anterior and the pelvic diameters are within normal limits, the infant may be born without difficulty (perhaps after a long first stage of labor, because the face does not mold well to make a snugly engaging part). If the chin is posterior, caesarean birth aybe the method of choice; otherwise, it could be necessary, to wait for a long posterior-to-anterior rotation to occur.
Such rotation could result dysfunction or a transverse arrest. Babies born after a face presentation have a great deal of facial edema and may be purple from eccymotic bruising. Observe the infant closely for a patent airway. In some infants, lip edema is so severe that the infant is unnecessary to allow the infant to obtain enough fluid until he or she can suck effectively. The infant may be transferred to an ICU nursery for 24 hours. Reassure the parents that the edema is transient will disapper in a few days, with no aftermath.
A brow presentation is the rarest of the presentations. It occurs in a multipara or a woman with relaxed abdominal muscles. It almost invariably results in obstructed labor, because the head becomes jammed in the brim of the pelvis as the oxypitomental diameter presents. Unless the presentation spontaneously corrects, cesarea birth will be necessary to deliver the infant safely. Brow presentations may also lived the infant with extreme ecchymotic bruising on the face. On seeing this bruising over the same area as the anterior fotanelle or soft spot, parents may need additional reassurance that the child is well after birth.
Transverse lie occurs in women with pendulous abdomens with uterine masses (e.g. fibroid tumors) that obstruct the lower uterine segment, with contraction of the pelvic brim, with congenital abnormalities of the uterus, or with hydramnios. It may occur in infants with hydrocephalus or another abnormality that prevents the head from engaging. It may also occur in prematurity if the infant has room for free movement, in multiple gestation (particularly in a second twin), or if there is a short umbilical cord.
This is obvious on inspection, when the ovoid of the uterus is found to be more horizontal than vertical. The abnormal presentation can be confirmed by Leopold’s maneuvers. A sonogram may be taken to further confirm the abnormal lie and to provide information on pelvic size. A mature fetus cannot be delivered vaginally from this presentation. Often, the membranes rupture at the beginning of the labor.
OVERSIZED FETUS (MACROSOMIA)
Size may become a problem in a fetus who weighs more than 4,000 to 4,500 g (approximately 9 to 10 lb). Large babies are also associated with multiparity, because each infant born to a woman tends to be slightly heavier and larger than the one born just before.
An oversized infant may cause uterine dysfunction during labor or at a birth because of overstretching of the fibers of the myometrium. The wide shoulders may pose a problem at birth, because they can cause fetal pelvic disproportion or even uterine rupture from obstruction. If the infant is so oversized that he or she cannot be delivered vaginally, caesarean birth becomes the birth method of choice. The large sized of a fetus may be missed in an obsess woman, because the fetal contours are difficult to palpate. Obesity does not necessarily indicate a larger-than-usual pelvis. Pelvimetry or
Shoulder dystocia is a birth problem that is increasing in incidence along with the increasing average weight of new borns. The problem occurs at 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.this is hazardous to the mother because it can result in vaginal or cervical tears. It is hazardous to the fetus if the cord is compressed between the fetal body and the bony pelvis. The force of birth can result in a fractured clavicle or a brachial plexus injury for the fetus.
Shoulder dystocia is mosy apt to occur in women with diabetes,in multiparas,and in post-date pregnancies. The problem often is not identified until the head is already been born ad the wide anterior shoulder locks beneath the symphysis pubis. The condition maybe suspected earlier if the second stage of labor is prolonged,if there is arrest of descent,or if,when the head appears on the perineum(crowing),it retracts instead of protruding with each contraction(a turtle sign).
Asking a woman to flex her thights sharply on her abdomen (macrobert’s manuever) may widen the pelvic outlet and let the anterior shoulder be delivered. Applying suprapubic pressure may help the shoulder escape from beneath the simphysis pubis and delivered.
PROBLEMS WITH THE PASSAGE
Dystocia can occur is a contraction or narrowing of the passageway or birth canal. This can happen at the inlet, at the midpelvis, or at the outlet. The narrowing causes CPD, or a disproportion between the size of the normal fetal head and the pelvic diameters.
Inlet contraction is narrowing of the anteroposterior diameter to less than 11 centimeter, or of the transverse diameter to 12 centimeter or less. It usually is caused by rickets in early life or by an inherited small pelvis. Rickets, where milk supplies were not plentiful. In primigravidas, the fetal head normally engages between week 36 to 38 of pregnancy. Pelvic inlet is adequate. A head that engages or proves it fits into the pelvic brim will probably also be able to pass through the midpelvis and
If engagement does not occur in primigravida, then either a fetal abnormality (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 vaginally without 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 increases greatly.
Outlet contraction is narrowing of the transverse diameter at the outlet to less than 11 centimeter. This is the distance between the ischilial tuberocitis.
EXTERNAL CEPHALIC VERSION
External cephalic version is turning of a fetus from a breech to a cephalic position before birth.
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