Professional Documents
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About 95% of labors are completed with contractions that follow a predictable, normal course. When they
become abnormal or ineffective, ineffective labor occurs.
Dysfunctional labor (Dystocia of labor- slow progress)
o Primary-occurring at the onset of labor
o Secondary - occurring later in labor
o Complications
Maternal post-partal infection
Hemorrhage
Infant mortality
Hypotonic Contractions
The number of contractions is unusually low or infrequent
Not more than 2 or 3 in a 10-minute period
Resting tone: <10mmHg
Strength of contractions: 25mmHg
Most apt to occur during the active phase of labor
Contractions are not exceedingly painful, because of lack of intensity.
May occur after the administration of analgesia
o If the cervix is not dilated to 3 to 4 cm.
o If bowel or bladder distention prevents descent or firm engagement.
Risk Factors (overstretched uterus)
- Multiple gestation
- Larger-than-usual single fetus
- Hydramnios
- Grand multiparity
Management
- WOF postpartal hemorrhage
- Up to 1hr postpartum, palpate the uterus and assess the lochia ql5min
Hypertonic Contractions
Increased in resting tone 15mmHg
Occur frequently and are most commonly seen in the latent phase of labor.
More painful than usual, because the myometrium becomes tender from constant lack of relaxation and the
anoxia of uterine cells that results
Fetal anoxia (when your body or brain completely loses its oxygen supply)
Management
- Uterine and fetal heart monitor
- Deceleration in FHR, or abnormally long first stage of labor
- CS birth
Uncoordinated Contractions
More than one pacemaker may be initiating contractions, or receptor points in the myometrium may be
acting independently of the pacemaker.
Management
- Uterine and fetal heart monitor
- Assess the rate, pattern, resting tone and fetal response too Contractions for at least 15 minutes to
reveal abnormal pattern
- Oxytocin administration
Contraction Rings
Management
- Ultrasound
- IV MSO4, inhalation of amyl nitrite
- Tocolytics
- CS birth
Precipitate Labor
Labor that is completed in fewer than 3 hours
Precipitate dilatation-cervical dilatation that occurs at a rate of 5cm or more per hour in a primipara
(giving birth for the first time) or 10 cm or more per hour in a multipara
Risk Factor:
- Grand multiparity
- Induction of labor by oxytocin
- Amniotomy
Complications
- Abruptio placenta
- Hemorrhage
- Fetal subdural hemorrhage
- Perineal lacerations
Management: Tocolytics
Uterine Rupture
Vertical scar from a previous CS birth or hysterotomy tears
o 1% in low transverse
o 4-8% in classic CS
Prolonged labor
Abnormal presentation
Multiple gestation
Unwise use of oxytocin
Obstructed labor
Traumatic maneuvers of forceps or traction
Assessment
- Impending rupture pathological ring
- Strong uterine contractions without cervical dilatation.
- A Sudden, severe pain during a strong labor contraction.
- She may report a "tearing" sensation.
- Incomplete rupture
Intact peritoneum
Localized tenderness and persistent aching pain over area of the lower uterine segment.
Fetal and maternal distress (FHR, VS changes; Lack of contractions)
Confirmed by ultrasound
- Complete rupture
Endometrium, myometrium, peritoneum layers
Uterine contractions will immediately stop
Two distinct wolling:
1. Retracted uterus
2. Extrauterine fetus
Hemorrhage
Signs of shock
Management
- Highly vascular !!!! Uterine rupture is an immediate emergency situation
- Emergency fluid replacement therapy
- IV Oxytocin
- Prepare for possible laparotomy
- Viability of the fetus: extent of rupture and time elapsed between rupture and abdominal extraction
- Woman's prognosis: Depends on extent of the rupture and the blood loss.
- Most Women are advised not to conceive again after a rupture of the uterus, unless the rupture
occurred in the inactive lower segment.
- Consent for cesarean hysterectomy or tubal ligation
Uterine Inversion
The uterus turning inside out with either birth of the fetus or delivery of the placenta.
120,000 births
Inversion occurs in varying degrees
May lie within the uterine cavity or vagina
Total inversion D protrudes from vagina
Risk Factors
- Traction is applied to the umbilical cord to remove the placenta
- Pressure is applied to the uterine fundus when the uterus is not contracted
- The placenta is attached at the fundus so that, during birth the passage or the fetus pulls the fundus
down.
Assessment
- Large amount of blood suddenly gushes from the vagina
- Fundus is not palpable in the abdomen
- Prolonged bleeding; hypovolemic shock
Management
- NEVER attempt to replace an inversion
- NEVER attempt to remove the placenta if it is still attached
- Oxytocic drugs will make the uterus more tense and harder to replace
- O2 via face mask
- Assess VS, anticipate need for CPR
- General anesthesia, nitroglycerin, tocolytic drug before replacing manually.
- Prophylactic antibiotic therapy
- CS for any subsequent pregnancies
Amniotic Fluid Embolism
Amniotic fluid is forced into an open maternal uterine blood Sinus through
o Some defect in the membranes
o after membrane rupture
o partial premature separation of the placenta
Occurs in 1/20,000 births, accounts for 10% of maternal deaths in the Us
It is not preventable because it is not predictable.
Risk Factors: Oxytocin administration, Abruptio Placentae, Hydramnios
Assessment
- A woman, in strong labor, sits up suddenly and grasps her chest because of sharp pain and inability
to breathe as she experiences pulmonary artery constriction.
- She becomes pale and then turns the typical bluish gray associated with pulmonary embolism and
lack of blood flow to the lungs.
Management
- O2 administration; endotracheal intubation
- CPR death
- Even if woman survives initial insult, high risk for DIC
Assessment
- In rare instances, the cord may be felt as the presenting part on an initial vaginal examination during
labor
- Ultrasound
- 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.
- Always assess fetal heart sounds immediately after ROM
Management
- Management is aimed at relieving pressure on the cord, thereby relieving the compression and the
resulting fetal anoxia
- Manual elevation of fetal head off the cord
- Knee-chest or Trendelenburg
- O2 10 L/min by face mask
- Tocolytic agents
- Amnioin fusion
- If cord prolapse is exposed to air; drying; atrophy of 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 to0 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, LO prevent fetal anoxia.
- If dilatation is incomplete, apply upward pressure on the presenting part until CS birth.
Shoulder Dystocia
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.
Risk Factors: women with DM, multiparas, post-date pregnancies
Maternal complicationprolaps: vaginal or cervical tears
Fetal complication: cord compression, fractured clavicle or brachial plexus injury
McRobert's maneuver
Applying suprapubic pressure