NURSING CARE OF A FAMILY EXPERIENCING A COMPLICATION OF LABOR OR BIRTH

Dystocia: Difficulty of labor

4 main components of the labor process

1. Power – the force that propels the fetus

2. Passenger – fetus
3. Passageway – birth canal
4. Psyche – the woman’s and family’s perception of the event

Nursing Diagnosis

 Fear related to uncertainty of pregnancy outcomes

 Anxiety related to medical procedures
 Fatigue related to loss of glucose stores through work and duration of labor
 Risk for ineffective tissue perfusion related to excessive loss of blood with complication to labor
 Risk for injury related to Multiple Gestations

Implementation

 Increase FHT, strengthen UTERINE CCONTRACTIONS – priority in complication of labor or birth.

 COMPLICATIONS WITH THE POWER

Inertia – sluggishness of contractions (Dysfunctional Labor) –classified as Primary (Onset of Labor)
Secondary (Later on Labor)

Risk for HEMORRHAGE, INFANT MORTALITY -> prolonged labor

 INEFFECTIVE UTERINE FORCE

Interplay of Adenosine Triphosphate (contractile enzyme), Influence of (Ca, Na, K), Specific Contractile
proteins (Actin, Myosin), epinephrine, norepinephrine, oxytocin (posterior pituitary hormone), E, P,
Prostaglandin

 Hypotonic Contractions

Characteristics:
o Active Phase
o Limited pain
o oxytocin is favorable
o sedation has a little value
o not 2 or 3 contractions in a 10 mins period
o resting tone of uterus is less than 10 mmHg
o strength does not rise from 25 mmHg
o Increases length of labor

Occurrence:
o After administration of analgesia especially when the cervix is not dilated 3-4 cm,
o bowel distention
o over stretching due to multiple gestations
o grand multiparity
o Macrosomia
o Hydramnios
 1 hr after labor - palpate uterus, assess lochia every 15 mins
  Hypertonic uterine contractions
Characteristics:
o Latent Phase
o Painful -> myometrium becomes tender , anoxia (lack of oxygen) of the uterine cells
o Oxytocin is unfavorable
o Sedation is helpful
o Increased resting tone (more than 15 mmHg)
o Occurs frequently
o Muscle fibers of the myometrium do not relax after contraction
o More than 1 pacemaker (Pacemaker is the area where contractions came from)
o Leads to fetal anoxia -> relaxation does not allow optimal uterine filling

 Uncoordinated Contractions
Characteristics:
o More than 1 pacemaker
o Does not allow good cotyledon filling
o Resting and Breathing exercises are ineffective
 - Assess the fetal response every 15 minutes, Oxytocin administration

 Dysfunction at the first stage of labor (From initiation of true labor to full cervical dilatation)
Components: Prolonged Latent Phase, Protracted active phase, prolonged deceleration phase, secondary
arrest of dilatation

Normal phases and stages of Labor (Hrs)

NuliPara: Latent: 8.6 –20 hrs ; Active: 5.8 – 12hrs ; Second stage 1 – 1.5 hr
MultiPara: Latent: 5.3–14 hrs ; Active 2.5 – 6 Hrs ; Second Stage .25 hr

 Prolonged Latent Phase

- Contractions become ineffective during the first stage of labor
- Longer for 20 hrs NP, 14 hrs MP
Occurrence - Cervix is not ripe @ the beginning of labor, excessive use of analgesic early in labor,
caused by HYPERTONIC CONTRACTIONS
Management:
o Help the uterus to rest
o Adequate fluid for hydration
o Pain relief – morphine sulfate
o Darkening room lights and decreasing noise
o Caesarian birth, oxytocin

 Protracted Active phase

- CPD
- Fetal malposition
- Prolonged cervical dilatation (1.2 cm/hr NP, 1.5 cm/ hr MP)
- Active phase more than 12hrs primy, 20 hrs multigravida
  Prolonged deceleration phase
- Abnormal fetal head position
- More than 3hrs NP, 1hr MP

 Secondary arrest of dilatation

- No progress of cervical dilatation for 2hrs

 Dysfunction at the first stage of labor ( FULL DILATATION UNTIL INFANT IS BORN)

 Prolonged Descent – rate of descent less than 1.0 cm/hr NP, 2.0 cm/hr MP
- Contractions are infrequent and poor quality and dilatation stops
- Faulty contractions, CPD

Managemet

- Rest
- Fluid intake
- IV of oxytocin

 Arrest of descent
- No descent for 1hr in MP, 2hrs NP
- FETUS @ Station 0

 Contraction Rings
- Hard band that forms across the uterus at the junction of upper and lower uterine segments and interferes
with fetal descent
- Pathologic retraction ring (Bandls ring)
- Second stage of labor
- Palpated horizontally in the abdomen
- Usually caused by uncoordinated contractions,
- Neurologic damage to fetus, uterine rupture, hemorrhage

Management: Administration of morphine sulfate, amyl nitrite -> relieve retraction ring ; Tocolytic -> halt contractions

 Precipitate labor
- Uterine contractions are strong
- Labor that is completed more than 3hrs
- Precipitate dilatation : cervical dilatation rate is 5cm/ hr NP, 10 cm/hr MP
- Occurs after induction oxytocin
- PROM -> hemorrhage, subdural hemorrhage (fetus) -> rapid release of pressure on the head, lacerations of
vagina
- Caution multiparous woman @ 28 week

 Induction And Augementation of Labor

Induction of labor – labor started artificially
Augmentation of labor – assisting labor that has started spontaneously but not effective.
- Risk of uterine rupture, decrease in fetal blood supply if premature rupture of placenta ,
MG, Hydramnios, GMP, maternal age over 40 years old., previous uterine scars

Induction of labor reasons

1. Pre-eclampsia
2. Eclampsia
3. Severe hypertension
4. Diabetes
5. Rh sensitization
6. Prolonged ROM
7. Post maturity
Considerations before induction of labor

1. The fetus is in longitudinal line

2. The cervix is ripe, ready for birth
3. Presenting part is engaged
4. There is no CPD
5. The fetus is matured in date ( lecithin – sphingomyelin test, ultrasound)

SCORING OF THE CERVIX FOR READINESS

Dilatation (cm) 0 : 0 , 1: 1-2, 2: 3-4, 3: 3-4

Effacement: 0: 0-30 % 1: 40-50% 2: 60-70% 3: 80%

Station 0: -3 1: -2 2: -1 -0 3: positive 1,2

 Cervical Ripening
- Change in cervical consistency from firm to soft and followed by dilatation and coordination of uterine
membranes
- If the woman score is 8 and above = cervix is ripen
- Methods to ripen the cervix: stripping the membranes (Separating the membranes from the lower uterine
segment manually using a gloved finger) hygroscopic suppositories (Suppositories of seaweed that swell in
contact with cervical secretions through luminaria technique) spreading of prostaglandin gel (misopristol
spread interior surface of the cervix - > 2-3 doses)

 Induction of Labor by Oxytocin

- Oxy - Administered IV ‘half life is 3 min.
- 10 IU in 1000 mL ringer’s sol.
- 4cm cervical dilatation S.T.O.P
- Peripheral dilatation (Side effect of oxy) : Causes hypotension due to peripheral dilatation , fetal death,
rupture of the uterus
- Excessive oxytocin stimulation -> tonic uterine contractions that results to fetal death ; administer
magnesium sulfate

Management: Check BP every 15 mins. , Monitor uterine contractions, , If signs of fetal distress occurs STOP
the IV infusion,

 Contractions should NOT occur often over 2 minutes, NOT stronger than 50 mmHg, do NOT last long
more than 70 seconds

 Augmentation of oxytocin
- Labor contractions: Weak, irregular, hypotonic
 Active management of Labor
- Aggressive administration of oxytocin (6 mU/ min)

 UTERINE RUPTURE
- Uterus undergoes more strain
- Occurrence: Vertical scar from CS, Prolonged labor, MULTIGRAVIDA, unwise use of oxytocin, forceps
delivery
- “Tearing sensation”
- Complete rupture:
1. Retracted uterus
2. Extra uterine fetus
- Incomplete rupture
1. Localized tenderness
2. Persistent aching in the lower uterine segment

MANAGEMENT: CS, IV Oxytocin -> contract the uterus and minimize bleeding, Prepare for laparotomy
 INVERSION OF THE UTERUS
- Uterus turning inside out with either birth of the fetus or delivery of placenta.
- Fundus not palpable in the abdomen
- Manifestations:
Signs of blood loss: hypotension, dizziness, paleness, diaphoresis
Signs of shock – Increase HR, RR, Decreased BP, Cold clammy abdomen
- Never attempt to replace an inversion
- Never move placenta if still attached -> bleeding

Management: CPR, Oxygen Mask, IV fluid line, administration of tocolytic drug,

 AMNIOTIC FLUID EMBOLISM

- Amniotic fluid is forced into an open maternal uterine blood sinus or some defects of the membranes
- it is not predictable
- associated with : meconium stain of the fetus goes to the lungs (pulmonary embolism)
- Manifestations:
o inability to breath,
o pale turns to typical bluish
- Management:
o Oxygen administration
o CPR within minutes
- Death may occur within minutes
- Even the woman survives there is high risk for DIC (Disseminated Intravascular Coagulation)

 PROBLEMS WITH THE PASSENGER

1. Prolapse of the Umbilical Cord

- A loop of umbilical cord slips down in the presenting fetal part
- Occurrence:
o PROM
o Feta presentation other than cephalic
o Placenta Previa
o Intrauterine tumors
o Microsomia
o CPD
o Hydramnios
o Multiple Gestations
- Assessment
o Utrasound
o Cord presenting at the vulva
o Always check FHR
- Therapeutic Mgt
o Place a gloved hand elevating the head of the fetus manually
o Place the woman in knee-chest position / tredelenburg position
o Administer oxygen 10 L/ Min
o Apply sterile gauze and nss to the cord presenting the vulva
o Tocolytic agent to reduce uterine activity
o Never push the cord back to the vagina

2. Multiple Gestation
-causes flurry excitement in a birthing room.
- PIH and anemia higher than usual in MG (Assess woman’s hematocrit level)
 PROBLEMS WITH FETAL POSITION, PRESENTATION OR SIZE

 Occipitoposterior position
- Fetal position is posterior rather than anterior
- ROP, LOP
- During internal rotation fetal head rotates @ 90 degree arc instead of 135 degrees (this can be aided by:
having the woman assume a hands and knee position, squatting, lying on her left side)
- Posterior presenting head increases the risk of cord prolapse , dysfunctional labor and prolonged active
phase
- Manifestations:
o Pain and pressure in the lower back -> fetal head rotates against the sacrum
Mgt: apply counter pressure on the sacrum by a back rub, maintain hands-knee position
- Assesment
o Keep the bladder empty
o IV glucse sol. For energy

 Breech Presentation
- high risk for:
o Anoxia from a prolapsed cord
o Traumatic injury to the after coming head
o Fracture of spine or arm
o Dysfunctional labor
o Early ROM
- Assessment :check FHT, Leopold maneuver, ultrasound
- Causes :
o Gestational age less than 40 weeks
o Abnormality in the fetus such us anencephaly, hydrocephalus, menengocele
o Hydramnios
o Multiple gestation
o Pendulous abdomen
- Birth technique (read book page 643)

 Face presentation
- Head presenting at a different angle (asynclitism)
- Occurrence:
o a woman has contracted pelvis
o placenta previa
o Multipara
o Prematurity
o Hydramnios
o fetal malformation
- Ultrasound = confirms face presentation
- Babies born with face presentation have FACIAL EDEMA may be purple due to ecchymotic bruising
- Mgt: Gavage feeding, observe patent airway

 Brow presentation
- Occurrence:
o Multipara
o woman with relaxed abdomen
- Results: obstructed labor
- Babies born with brow presentation have ecchymotic bruising

 Transverse Lie
- Occurrence:
o woman with pendulous abdomen
o woman with uterine fibroids
o congenital abnormalities of the uterus
o Hydramnios
o infants with hydrocephalus, prematurity,
- CS is necessary
 MACROSOMIA
- More than 300 g (Asian)
- More than 4000- 4500 american
- Associated with
o woman having diabetes
o Multiparity

 Shoulder Dystocia
- Problem occurs at the 2nd stage of labor
- Fetal head is born but the shoulders are too broad to enter the pelvic outlet which results to
brachial plexus
- Result to cervical lacerations and tears for the woman
- Occurrence:
o Diabetic woman
o Multipara
o Post-date pregnancy
Mgt: ask the woman for McRobert’s position, appy suprapubic pressure
 Fetal anomiles – complicate birth
o Anencephaly
o Hydrocephaly

 PROBLEMS WITH THE PASSAGE

1. Inlet contraction
- Is the narrowing of the anteroposterior diameter to less than 11 cm
- Caused by small pelvis
2. Outlet contraction
- Narrowing the transverse diameter by less than 11 cm

 FORCEP BIRTHS
- forceps outlet procedure which the forcep are applied after the fetal head reaches the perineum.
- Leads to: rectal sphincter, dyspareunia, anal incontinence, urinary incontinence
- Conditions to initiate forceps delivery
o A woman is unable to push with contractions in the pelvic division if labor
o Cessation of descent in the 2nd stage of labor
o Fetus is in abnormal position or is immature
o Fetus is in distress due to complications such as cord prolapse
- Term low forceps birth used to indicate that the feta head is in the positive 2 station or more
- Term mid forceps birth if the fetal head is engaged but less than positive 2
- Considerations before forceps delivery
o Membranes must be ruptured
o CPD must not be present
o Cervix is fully dilated
o Bladder is empty
 Vacuum Extraction
- Fetal head at the perineum ; disk shaped cup is pressed against the fetal scalp

 ANOMALIES WITH THE PLACENTA AND CORD

ANOMALIES WITH THE PLACENTA
Normal wt of the placenta is 500 g. 15-20 in diameter. 1.5-3.0 thick (1/6 wt of the fetus)
 1. Placenta Succenturiata – placenta has 1 or more accessory lobes connected to the main placenta
2. Placenta Circumvallata – the fetal side of the placenta is covered with chorion
3. Placenta Marginata – the fold of chorion reaches the edge of the placenta
4. Battledore Placenta – cord is inserted marginally rather than centrally
5. Velamentous insertion of the cord – cod instead of entering the placenta directly, separates into small
vessels that reach the placenta by spreading across a fold of amnion
6. Placenta previa (vasa previa) – the umbilical vessels f a velamentus cord insertion across the cervical os
and therefore deliver before the fetus
7. Placenta Accreta – unusually deep attachment of the placenta t the myometrium whereby the placenta
will not loosen and deliver

ANOMALIES OF THE CORD

1. TWO VESSEL CORD

- Normal cord 1 vein 2 arteries
- Absence of an artery causes genital heart anomalies, kidney anomalies

2. Unusual cord length

- Normal cord length is 21 cm long
- Results in premature rupture of placenta, abnormal fetal lie.