III.

PROBLEMS WITH THE POWERS (The force of labor)

A. DYSTOCIA OR DIFFICULT LABOR

• Can arise from any of the three main components of the process: power, the passenger and the passageway

1. INERTIA OR DYSFUNCTIONAL LABOR

• Sluggishness of contraction or the force of labor. Time to denote sluggishness of contractions or the force of
labor.

Causes of dysfunctional labor

1. Inappropriate use of analgesia ( excessive or too early administration)
2. Pelvic bone contraction that has narrowed the pelvic diameter so that a fetus cannot pass such as could
occur in a woman with rickets.
3. Poor fetal position ( posterior rather than anterior position)
4. Extension rather than flexion of the fetal head
5. Overdistention of the uterus as with multiple pregnancy, hydramnios or an excessively oversized fetus.
6. Cervical rigidity ( unripe)
7. Presence of a full rectum or urinary bladder that impedes fetal descent.
8. Woman becoming exhausted from labor.
9. Primigravida status

Classification
a. Primary
• Occurring at the onset of labor
b. Secondary
• Occurring late in labor

2. INEFFECTIVE UTERINE FORCE

• Contraction occur because of
• the interplay of the contractile enzyme adenosine triphosphate
• the influence of major electrolytes such as calcium, sodium, and potassium
• specific contractile proteins ( actin and myosin)
• posterior pituitary hormone ( epinephrine and norepinephrine, oxytocin
• estrogen
• progesterone
• prostaglandins

a. HYPOTONIC CONTRACTIONS
• CONTRACTIONS: low , infrequent ( not more than 2 or three occurring in a 10 minute period)
• RESTING TONE OF UTERUS: <10 mmHg
• STRENGTH: does not rise above 25 mmHg
• Occur during:
• ACTIVE LABOR
• Occur after the administration of analgesia esp. if the cervix is not dilated to 3-4 cm
• if the bowel or bladder distention prevents descent or firm engagement.
• Uterus that is overstretched by multiple gestation
• Larger than usual fetus.
• Hydramnios
• Lax uterus from grand multiparity
• Contractions are not painful

• Lack of intensity

• A subjective symptom
• Increase the length of labor
• uterus does not contract
• exhaustion

Nursing care management

1. 1 hour after birth- palpate the uterus
st

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

b. HYPERTONIC CONTRACTIONS
• RESTING TONE: more than 15 mm Hg
 • INTENSITY: stronger
• Occur frequently
• Seen IN LATENT PHASE
• 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.
• Occur because more than one pacemaker is stimulating contractions.
• More painful- because the myometrium becomes tender from constant lack of relaxation and the
anoxia of uterine cellsresults.
• Woman is frustrated or disappointed bec she has ineffective breathing exercises
• Danger: lack of relaxation between contractions ---- may not allow uterine artery filling ------ leading to
fetal anoxia early in latent phase of labor.
• A woman whose pain is out of proportion to the quality of contraction should have both a uterine and 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.
• If deceleration in the FHT or abnormally long first stage of labor or lack of progress with pushing (2 stage) occurs
nd

------ CS may be necessary.

• Woman and her support person needs to understand that even though her contraction is strong, they are
ineffective and are not achieving cervical dilatation
Comparison of hypotonic and hypertonic contractions

Criteria Hypotonic Hypertonic

Phase of labor Active Latent
Symptoms Limited pain Painful
Contraction No contraction, weak Strong
Intensity Weak Strong, frequently
Resting tone of the uterus <10 mm Hg >15 mmHg
Medications used Favorable reaction Unfavorable reaction
Oxytocin Little value helpful
Sedation
Causes Uterus does not contract Myometrium doesn’t relax
Early administration of analgesia More pacemaker stimulus
Distented bowel and bladder
Overstretched uterus
Hydramnios
Large fetus
Lax uterus

2. UNCOORDINATED CONTRACTIONS
• NORMALLY: all contractions are initiated at one pacemaker point high in the uterus.
• Contraction sweeps down over the organ encircling it repolarization / relaxation or low resting
tone another pacemaker activated another contraction occurs

• With uncoordinated contractions

a. More than one pacemaker may be initiating contractions
b. Receptor points in the myometrium may be acting independently of the pacemaker
c. Appear closely together that they don’t allow good cotyledon (one of the visible segments on the maternal
surface of the placenta) filling
d. The woman doesn’t have time to rest or to use breathing exercises with contractions.

Nursing care management

1. Apply a fetal and uterine external monitor assessing the arte, pattern, resting tone and fetal response to
contraction for at least 15 minutes reveals abnormal pattern.
2. Oxytocin administration ---- to stimulate a more effective and consistent pattern of contractions with a better,
lower resting tone.

Nursing process
Assessment
• fetal and uterine monitoring

Nursing Diagnoses
• Fear related to uncertainty of pregnancy outcome
• Anxiety r/t medical procedures and apparatus necessary to ensure health of mother and fetus
• Fatigue r/t loss of glucose stores through work and duration of labor

II. DYSFUNCTIONAL LABOR AND ASSOCIATED STAGES OF LABOR

A. DYSFUNCTION AT THE FIRST STAGE OF LABOR

• Involves prolonged latent phase
• Protracted active phase
 • Prolonged deceleration phase
• Secondary arrest dilatation

1. Prolonged latent phase

• According to Friedman: latent phase that is longer than 20 hours in a nullipara and 14 hours in a
multipara.
• This occur if the cervix is not ripe at the beginning of labor
• May occur if there Is excessive use of an analgesic early in labor.
• The uterus tends to be hypertonic state.
• Relaxation between contractions is inadequate
• Contractions are mild ( less than 15 mm Hg), ineffective
• One segment of the uterus may be contracting with more than another segment

Nursing care management

• Involves the uterus to rest
• Providing adequate fluid for hydration
• Pain relief with a drug such as morphine sulfate
• Changing the linen and the woman’s gown
• Darkening room lights
• Decreasing noise and stimulation
• Measures are combined to allow labor to become effective
• IF IT DOES NOT: CS or amniotomy ( artificial rupture of the membrane)
• Oxytocin infusion to assist labor.

Lengths of Phases and Stages of normal labor in hours

Nullipara Multipara
Phase Average Upper Normal Average Upper normal
Latent phase 8.6 20 5.3 14
Active phase 5.8 12 2.5 6
Second stage 1 1.5 0.25 -

2. PROTRACTED ACTIVE PHASE

• Associated with CPD or fetal malposition
• May reflect myometrial activity
• Prolonged if
• Cervical dilatation does not occur at a rate of at least 1.2 cm/hr in a nullipara or 1.5 cm/hr in a multipara
• Active phase lasts longer than: 12 hours in a primigravida
6 hours in a multigravida

Management
• CS ---- if due to CPD that causes delay of dilatation
• Oxytocin is given if CPD is not present

• Dysfunctional labor during the dilatational division of labor tends to be hypotonic in contrast to the hypertonic action
at the beginning of labor.

3. PROLONGED DECELERATION PHASE

• Becomes prolonged when it extends beyond 3 hours in nullipara and 1 hr in a multipara
• Often results from abnormal fetal head position
• CS is frequently required

4. SECONDARY ARREST DILATATION

• Occurred if there is no progress in cervical dilatation for longer than 2 hours.
• CS is necessary.

B. DYSFUNCTION AT THE SECOND STAGE OF LABOR

1. PROLONGED DESCENT
• Occurs if the rate of descent is less than 1.0 cm/hr in a nullipara or 2.0 cm/hr in a multipara
• Can be suspected if the second stage lasts over 3 hours in a multipara
• Contractions become infrequent and of poor quality
 • Dilatation stops

Management
• If faulty contractions, CPD and poor fetal presentation has been r/o by UTZ
• Rest and fluid intake
• If membranes have not ruptured
• Ruptured them
• Oxytocin/IV- to induce the uterus to contract effectively
• Semi fowler’s position, squatting, kneeling or more effective pushing may speed descent.

2. ARREST OF DESCENT
• Results when no descent has occurred for 1 hr in multipara or 2 hours in a nullipara.
• Expected when
• the descent of fetus does not begin
• engagement or movement beyond 0 station has not occurred.
• CPD ==== most likely cause for arrest of descent
• CS is necessary
• If there is no contraindication to vaginal birth, oxytocin may be used to assist labor.
• Because labor is work it can cause a woman to deplete her glucose stores

Nursing Diagnoses
1. Fatigue and anxiety related to prolonged labor
During admission assess/ask
a. Last meal
• If she ate breakfast at 8AM and began labor by 2PM == she is only 6 hrs away from a full meal
• If she ate at 5PM and did not eat breakfast because she woke with labor she is 11 hours away from full
meal

Management
• Alert her midwife/doctor to this situation
o If the woman is still in labor
• She may ne encourage to drink a high carbohydrate fluid such as a sports drink or to eat a light
meal.
• IVF therapy to provide glucose for energy
• Sucking a lollipop or hard candy during labor can supply additional glucose

b. Emotion on labor
• Normal labor is shortened if the woman is frightened or tense

Management
• Transfer her to a health care facility without trauma
• Ask woman if she has other concerns
• Offer explanation of the procedure
• Help the support person feel just as welcome and comfortable as the woman herself.
• Allow the woman and support persons to make choices and give them sense of control

c. Pain
• Exhausting phenomenon

Management
• Encourage the use of nonpharmacologic comfort measures:
• Breathing
• back rubs
• changing sheets,
• using cool wash cloths
• Complimentary therapies
• aromatherapy
• music

d. Position
• Side lying position
• to increase the blood supply to the uterus and prevent hypotension
• to lift the uterus off the vena cava
• If SUPINE ----- Place a hip roll under one or other of her buttocks to cause the pelvis to tip and
move the uterus to the side.
 e. Comfort
• A full bladder prevents descent
• Urge the woman to void every 2 hours to keep her bladder empty and to aid in progress.

2 Risk for deficient fluid volume related to length and work of labor
.

• Low levels of serum electrolytes or body fluid can occur in labor for the same reason as a decreased glucose
level.
• Vomiting and diarrhea occasionally accompany labor – an increase fluid and electrolyte losses.
• Profuse diaphoresis and hyperventilation that occur with labor can further increase fluid and electrolyte losses
through insensible water loss.

Management
• Test voiding frequently during labor for glucose, CHON, ketones and specific gravity. (NV 1.003-1.030)
• Ketones in the urine suggest starvation ketosis
• A concentrated specific gravity suggests a lack of fluid
• Extreme dehydration :
• May slow labor
• Increase blood viscosity
• Increase the risk of thrombophlebitis during the postpartal period

3. CONTRACTION RINGS/ RETRACTION RINGS

• During Labor the uterus differentiate into two parts: Upper contracting portion that becomes thicker and shorter
as labor progresses and the lower passive portion that distends gradually to accommodate the descending fetus
• The division or boundary of these two uterine segments is called physiologic retraction ring.
• When labor is obstructed the fetus cannot descend into the birth canal. Because of this, uterine contractions
become stronger and more frequent in an effort to overcome the obstruction until it reaches a state of tonic
contraction when the uterus no longer relaxes. It is in this stage that Bandl’s ring or pathologic retraction ring
develops
• A hard band that forms across the uterus at the junction of the upper and lower uterine segments and interferes
with fetal descent.

Pathologic retraction ring/ Bandl’s ring = common type of contraction ring

• Appears usually at the 2 stage of labor
nd

• Can be palpated as a horizontal indentation across the abdomen

• A warning sign that severe dysfunctional labor is occurring.
• Formed by excessive retraction of the upper uterine segment, the uterine myometrium is much thicker above than
below the ring.
• IF OCCURS IN EARLY LABOR = usually caused by uncoordinated contractions
• In the pelvic division of labor = caused by obstetric manipulation or by administration of oxytocin
• Fetus and placenta are gripped and cannot advance
• Identified by ultrasound

Complications
1. If situation is not relieved === causes uterine rupture and neurologic damage to the fetus.
2. In the placental stage == massive hemorrhage- because the placenta is loosened but then cannot deliver
preventing the uterus from contracting.

Therapeutic Management
1. Administration of IV morphine sulfate or inhalation of amyl nitrite = to relieve retraction ring.
2. Tocolytic agent – to stop/halt contraction
3. CS
4. Manual removal of the placenta under general anesthesia= if the retraction ring does not allow the placenta to be
delivered.

4. PREMATURE LABOR / PRETERM LABOR/ PTL

• Cervical change or effacement and uterine contractions occurring after 20 weeks gestation and prior to 37 weeks
of gestation

Causes
1. PROM
2. Hydramnios
3. Placenta previa
4. Preeclampsia
5. Multiple gestation
6. Abruption placenta
7. Incompetent cervix
8. Fetal death
 9. Trauma
10. Intrauterine infection
11. Maternal factors: stress, Urinary Tract Infection, Dehydration

Assessment
1. Suprapubic pressure
2. Vaginal pressure
3. Low back pain
4. Regular uterine contractions
5. Cervical dilatation and effacement
6. Bloody show
7. Rupture of membranes

Nursing care management

1. Assess the maternal status and check for signs of labor
2. Obtain complete history
3. Obtain blood and urine specimens for lab test
4. Assess the frequency, intensity and duration of contractions
5. Evaluate cervical dilatation and effacement
6. Determine the status of membranes and check for bloody show
7. Monitor the fetus and evaluate for distress, size, maturity and activity
8. Perform measures to manage or stop labor from proceeding
9. Place client on lateral bed rest
10. Prepare client for possible UTZ, amniocentesis, tocolysis and steroid therapy
11. Give tocolytic medication as ordered (terbutaline, ritodrine)
12. Watch out for side effects of tocolytic therapy (hypotension, difficulty of breathing, chest pain, fetal tachycardia)
13. Discontinue tocolytic therapy if maternal pulse is >120beats/min
14. Give emotional and psychosocial support
15. Educate the patient and her family.

5. PRECIPITATE LABOR AND BIRTH

• Occur when uterine contractions are so strong that a woman gives birth with only a few rapidly occurring
contractions.
• Labor that is completed in fewer than 3 hours.
• Precipitate dilatation – cervical dilatation that occurs at a rate of 5 cm or more /hr in a primipara or 10 cm or more
/hr in a multipara
• Occur with:
• grand multiparity
• after induction of labor by oxytocin or amniotomy
• Contractions are forceful that may lead to:
• premature separation of the placenta
• hemorrhage
• lacerations
• Rapid labor also posses a risk to the fetus because subdural hemorrhage may result from the rapid release of
pressure on the head.
• Caution a multiparous woman by week 28 of pregnancy that because a past labor was so brief, her labor this
time also may be brief.

Classification
1. Precipitate Dilatation- When cervical dilatation is progressing at a rate of 5 cm or more per hour in nulliparas
and 10 cm per hour in multiparas
2. Precipitate Descent- when fetal descent is progressing at a rate of 5 cm per hour or more in nulliparas and 10
cm per hour or more in multiparas.

Predisposing Factors
1. Multiparity
2. Large Pelvis
3. Lax unresisting maternal tissue
4. Small baby in good position
5. Induction of labor-amniotomy and oxytocin administration
6. Absence of painful sensation and thus lack of awareness of vigorous labor

Assessment
1. Similar to woman with normal labor pattern but they appear suddenly without warning.
2. Patient complains of a sudden , intense urge to push
3. Sudden increase in bloody show
4. Sudden bulging of the perineum
5. Sudden crowning of the presenting part

Complications
1. Maternal
• Laceration of birth canal and uterine rupture
 • Postpartum hemorrhage
• Amniotic fluid embolism
2. Fetal- hypoxia
• Intracranial hemorrhage
• Erb Duchenne palsy
• Premature separation of placenta
• Injuries as a falling to the floor in unattended birth

Nursing care management

1. Anticipatory guidance for prevention
• adequate prenatal care
• warn women with history of precipitate labor that rapid labor and delivery may happen again
2. If accelerated labor pattern occurs during oxytocin administration. Stop infusion right away and turn woman on her
side

6. PROLONGED LABOR
• Pregnancy which extends beyond 42 weeks AOG

Causes of prolonged labor

• Large fetus
• Hypotonic
• Hypertonic
• Uncoordinated contractions
• Those who have prolonged labor are at risk of
• Postpartal infection
• Hemorrhage
• Infant mortality

Assessment
1. Weight loss and decreased uterine size
2. Excessively large fetus
3. Meconium stained amniotic fluid
4. Non-reassuring FHR pattern

Nursing care management

1. Evaluate the fetus
2. Prevent birth complications
3. Give emotional and physical support
4. Educate the patient and her family.

7. PRECIPITATE LABOR AND BIRTH

• Occur when uterine contractions are so strong that the woman gives birth with only a few rapidly occurring
contractions.
• It often defined as labor that is completed in fewer than 3 hours.
• Contraction may be too strong that can lead to premature separation of placenta, placing the mother and fetus at
risk for hemorrhage
• Rapid labor also poses a risk to the fetus because subdural hemorrhage may result from sudden release of
pressure on the head.
• The woman may sustain lacerations of the birth canal from the forced birth. She can also feel overwhelmed by the
speed of labor.

Causes
1. Multiparity
2. Induction of labor by oxytocin or amniotomy

8. UTERINE PROLAPSED
• Uterine prolapse is falling or sliding of the womb (uterus) from its normal position into the vaginal area.
• Muscles, ligaments, and other structures hold the uterus in the pelvis. If these muscles and structures are weak,
the uterus drops into the vaginal canal. This is called prolapse.
• This condition is more common in women who have had one or more vaginal births.

Causes
1. Normal aging
2. Lack of estrogen after menopause
3. Anything that puts pressure on the pelvic muscles, including chronic cough and obesity
4. Pelvic tumor (rare)
• Long-term constipation and the pushing associated with it can make this condition worse.

Assessment
1. Feeling like you are sitting on a small ball
2. Difficult or painful sexual intercourse
 3. Frequent urination or a sudden urge to empty the bladder
4. Low backache
5. Uterus and cervix that stick out through the vaginal opening
6. Repeated bladder infections
7. Feeling of heaviness or pulling in the pelvis
8. Vaginal bleeding
9. Increased vaginal discharge

Diagnostic Test
A pelvic examination
• The pelvic exam may also show that the bladder and front wall of the vagina (cystocele), or rectum and back wall
of the vagina (rectocele) are entering the vagina. The urethra and bladder may also be lower in the pelvis than
usual.

Treatment
1. Lifestyle changes
• Weight loss is recommended in obese women with uterine prolapse.
• Heavy lifting or straining should be avoided, because they can worsen symptoms.
• Coughing can also make symptoms worse. If you a chronic cough, ask your doctor how to prevent or treat it. If
you smoke, try to quit. Smoking can cause a chronic cough.

2. Vaginal passery
• Doctors may recommend placing a rubber or plastic donut-shaped device, called a pessary, into the vagina.
• The device holds the uterus in place. It may be temporary or permanent. Vaginal pessaries are fitted for each
individual woman. Some are similar to a diaphragm used for birth control.
• Pessaries must be cleaned from time to time, sometimes by the doctor or nurse. Many women can be taught how
to insert, clean, and remove the pessary herself.

Side effects of pessaries include:

1. Foul smelling discharge from the vagina
2. Irritation of the lining of the vagina
3. Ulcers in the vagina
4. Problems with normal sexual intercourse and penetration

3. Surgery
Surgery should not be done until the prolapse symptoms are worse than the risks of having surgery. The specific type of
surgery depends on:
1. Degree of prolapsed
2. Desire for future pregnancies
3. Other medical conditions
4. The women's desire to retain vaginal function
5. The woman's age and general health
6. Vaginal hysterectomy is used to correct uterine prolapse. Any sagging of the vaginal
walls, urethra, bladder, or rectum can be surgically corrected at the same time.

Complications
1. Ulceration and infection of the cervix and vaginal walls may occur in severe cases of uterine prolapse.
2. Urinary tract infections and other urinary symptoms may occur because of a
cystocele. Constipation andhemorrhoids may occur because of a rectocele.

Prevention
1. Tightening the pelvic floor muscles using Kegel exercises helps to strengthen the muscles and reduces the risk of
uterine prolapse.
2. Estrogen therapy, either vaginal or oral, in postmenopausal women may help maintain muscle tone in the vaginal
area.
3. Weight loss and avoiding heavy lifting can decrease the risk for uterine prolapse.

9. UTERINE RUPTURE
• Occurs when a uterus undergoes more strain than it is capable of sustaining.
• Occur most commonly when a vertical scar from a previous CS or hysterectomy repair tears.
• Confirmed by Ultrasound
• An immediate emergency situation

Predisposing factors
1. Prolonged labor
2. Abnormal presentation
3. Multiple gestation
4. Unwise use of oxytocin
5. Obstructed labor
6. Traumatic maneuvers of forceps or tractions
 • If uterine rupture occurs fetal death will follow UNLESS immediate CS is done.
• Impending rupture may be preceded by a pathologic retraction ring and by strong uterine contractions without
cervical dilatation.
• TO PREVENT RUPTURE: anticipate the need of an immediate CS

Assessment
1. Sudden, severe pain during a strong labor contractions
2. Tearing sensation

Types
1. Complete rupture
• endometrium, myometrium and peritoneum layers
• uterine contractions will immediately stops
• 2 distinct swellings will be visible on the woman’s abdomen
a. The retracted uterus
b. Extrauterine fetus
• Signs of shock: rapid weak pulse, falling BP, cold clammy skin, dilatation of the nostrils, FHR fades and then are
absent.
2. Incomplete rupture
• leaving the peritoneum intact
• the signs of rupture are less evident
• woman experience only a localized tenderness and a persistent aching pain over the area of the lower uterine
segment
• fetal and maternal distress
• lack of contractions

Nursing care management

1. Administer emergency fluid replacement therapy as ordered.
2. Anticipate the use of oxytocin to attempt to contract the uterus and minimize bleeding
3. Prepare the woman for possible laparotomy as an emergency measure to control bleeding and achieve a repair
4. Advised not to conceive again after a rupture of the uterus---unless the rupture occurred in the inactive lower
segment.
5. Perform a ceasarian hysterectomy (with consent) fear of the removal of the damaged uterus or tubal ligation at
the time of laparotomy ==== result in the loss of childbearing ability.

10. INVERSION OF THE UTERUS

• Refers to the uterus turning inside out with either birth of the fetus or delivery of the placenta
• Occur if traction is applied to the umbilical cord to remove the placenta
• Occur if pressure is applied to the uterine fundus when the uterus is not contracted.
• Occur if the placenta is attached at the fundus and during birth the fetus pulls the fundus down
• Occurs in degrees
a. The inverted fundus may lie within the uterine cavity or the vagina
b. Total inversion it may protrude from the vagina

Assessment
1. Large amount of blood suddenly gushes from the vagina
2. If it continues: woman will show signs of blood loss: hypotension, dizziness, paleness and diaphoresis
3. Fundus is not palpable in the abdomen
4. Uterus is not contracting
5. Bleeding continues

Nursing care management

1. Never attempt to replace an inversion == because handling of the uterus may increase the bleeding.
2. Never attempt to remove the placenta if it is still attached == because this only creates a larger surface area for
bleeding.
3. Start an IV fluid using a large gauge needle
4. Administer O2 via mask
5. Assess Vital signs
6. Be ready to give CPR == due to sudden blood loss, heart will fail
7. Give general anesthesia, or possibly nitroglycerin or a tocolytic drug to relax the uterus
8. Physician/midwife/nurse replaces the fundus manually
9. Administer oxytocin after manual replacement helps the uterus to contract and to remain in its natural place
10. Antibiotic therapy == because the woman’s endometrium is exposed, preventing infection
11. Informed her that CS will probably be necessary in any future pregnancy == to prevent the possibility of future
inversion

III. PROBLEMS WITH THE PSYCHE FACTORS

1. Inadequate Voluntary Expulsive Forces

2. Fear/ anxiety
 • Psyche is the woman’s psychological outlook or refers to the state or feeling that a woman brings into labor.
• A feeling of apprehension or Fright.
• Women without adequate support can have a labor experience so frightening and stressful which can develop a
post traumatic stress syndrome.

Nursing care management

1. Encourage women to ask questions at prenatal visitsand to attend preparation for childbirth classes help prepare
them to labor.
2. Encourage to share their experience after labor serves a briefing time and helps them integrate the experience
into their totallife.