COMPLIC A T IO N S O F

LA BOR A ND D E L I V E R Y
MAINE DAL E B . ROB L ES
PREPARED BY: CHAR
INERTIA

•DENOTE SLUGGISHNESS OF CONTRACTIONS

•FORCE OF LABOR IS LESS THAN USUAL
•CURRENT TERM: DYSFUNCTIONAL LABOR
INERTIA

CLASSIFIED AS:
•PRIMARY: OCCURING AT ONSET OF LABOR
•SECONDARY: OCCURING LATER IN LABOR
PROLONGED LABOR
 LENGTH OF NORMAL LABOR
PRIMIS MULTIS
1st stage 12 ½ hours 7 hours, 20 min
2nd stage 80 min 30 min
3rd stage 10 min 10 min
Total 14 hours 8 hours
PROLONGED LABOR

CONDITION WHERE LABOR OCCURS FOR:

•PRIMIGRAVIDS: MORE THAN 20 HOURS
•MULTIGRAVIDS: MORE THAN 14 HOURS
PROLONGED LABOR
ASSOCIATED FACTORS
• PRIMIGRAVIDAS (CAUSES INEFFECTIVE UTERINE CONTRACTION)
• MALPRESENTATION (FACE AND BROW PRESENTATION)
• CPD
• UTERINE ATONY
• MATERNAL EXHAUSTION
• TIGHT NUCHAL OR SHORT CORD
PROLONGED LABOR
NURSING MANAGEMENT:
•MONITOR FOR BOTH MATERNAL AND FETAL VITAL SIGNS AND
WATCH OUT FOR SIGNS OF FETAL DISTRESS.
•MONITOR FOR MATERNAL EXHAUSTION.
•PROVIDE CHANCES FOR MATERNAL REST AND RELAXATION.
DYSTOCIA
DYSTOCIA

•ABNORMAL OR DIFFICULT LABOR

•IS OFTEN AN INDICATION OF OPERATIVE DELIVERY WITH
ITS ASSOCIATED COMPLICATIONS.
COMPONENTS OF LABOR (5 P’S)
•POWER (UTERINE CONTRACTION AND BEARING DOWN EFFORTS)
•PASSENGER (THE FETUS)
•PASSAGEWAY (THE PELVIS)
•PLACENTAL POSITION AND FUNCTIONS
•PSYCHOLOGICAL RESPONSE
DYSTOCIA:
PROBLEM WITH THE EXPULSIVE
FORCES (POWER)
UTERINE FORCE

•BASIC FORCE THAT MOVES THE

FETUS THROUGH THE BIRTH CANAL
INEFFECTIVE UTERINE FORCE

1. HYPOTONIC CONTRACTIONS
2.HYPERTONIC CONTRACTIONS
HYPOTONIC UTERINE CONTRACTION
HYPOTONIC UTERINE CONTRACTION
# OF CONTRACTIONS: LOW OR INFREQUENT
(NOT INCREASING BEYOND 2 OR 3 IN A 10 MINUTE
PERIOD)

OCCURS DURING THE ACTIVE PHASE OF LABOR

NORMAL : 3-4/10 MIN PERIOD WITH DURATION OF
30 SECONDS
HYPOTONIC UTERINE CONTRACTION
RISK FACTORS:
• BOWEL/BLADDER DISTENTION PREVENTS DESCENT/ENGAGEMENT
• MULTIPLE GESTATION
• LARGE FETUS
• HYDRAMNIOS
• MULTIPARITY
HYPOTONIC UTERINE CONTRACTION

SIGNS AND SYMPTOMS:

•PAINLESS, LESS FREQUENT CONTRACTION
HYPOTONIC UTERINE CONTRACTION
MANAGEMENT:
• OXYTOCIN ADMINISTRATION
• AMNIOTOMY
• PALPATE THE UTERUS AND ASSESS LOCHIA EVERY 15 MINUTES
• MONITOR MATERNAL VS AND FHR
• POSITION CHANGES TO RELIEVE DISCOMFORT AND ENHANCE PROGRESS
HYPERTONIC UTERINE CONTRACTION
HYPERTONIC UTERINE CONTRACTION
• INTENSITY OF THE CONTRACTIONS MAY NOT
STRONGER OR VERY ACTIVE

• FREQUENT CONTRACTIONS BUT INEFFECTIVE

• OCCURS MORE FREQUENTLY AND COMMONLY SEEN IN
LATENT PHASE OF LABOR’

• THE MUSCLE FIBERS OF THE UTERUS (MYOMETRIUM)

DO NOT REPOLARIZE
HYPERTONIC UTERINE CONTRACTION
SIGNS AND SYMPTOMS:
• PAINFUL NONPRODUCTIVE CONTRACTIONS
• UTERINE TENDERNESS
• FETAL ANOXIA/DISTRESS
• DEHYDRATION DUE TO EXCESSIVE PERSPIRATION
• FATIGUE AND EXHAUSTION
HYPERTONIC UTERINE CONTRACTION
MANAGEMENT:
• ASSESS QUALITY OF CONTRACTIONS BY UTERINE/FETAL EXTERNAL
MONITOR APPLIED AT LEAST 15 MINUTES INTERVAL
• ADEQUATE REST
• PAIN RELIEF WITH MORPHINE SULFATE
• DECREASING ENVIRONMENTAL STIMULI
• CS DELIVERY
COMPARISON OF HYPOTONIC & HYPERTONIC UTERINE
CONTRACTION
CRITERIA HYPERTONIC HYPOTONIC
1. MOST COMMON PHASE OF LATENT ACTIVE
OCCURENCE
2. SYMPTOMS PAINFUL LIMITED PAIN
3. MEDICATIONS USED:
A. OXYTOCIN UNFAVORABLE REACTION FAVORABLE REACTION
B. SEDATION HELPFUL LITTLE VALUE
 DYSFUNCTIONAL LABOR &
ASSOCIATED STAGES OF LABOR
DYSFUNCTIONAL LABOR &
ASSOCIATED STAGES OF LABOR
1. DYSFUNCTION AT THE 1 ST STAGE OF LABOR
A. PROLONGED LATENT PHASE
B. PROTRACTED ACTIVE PHASE
C. PROLONGED DECELERATION PHASE
D. SECONDARY ARREST OF DILATATION
A. PROLONGED LATENT PHASE

LATENT PHASE THAT LAST LONGER THAN:

• 20 HOURS: NULLIPAROUS
• 14 HOURS IN MULTIPARA
A. PROLONGED LATENT PHASE
MANAGEMENT: HELPING THE UTERUS TO RELAX
• ADEQUATE FLUID FOR HYDRATION
• PAIN RELIEF: MORPHINE SO4
• CHANGE LINEN AND GOWN
• DARKENING ROOM LIGHTS
• DECREASING NOISE & STIMULATION
• TO ASSIST LABOR: CS, AMNIOTOMY, OXYTOCIN INFUSION
B. PROTRACTED ACTIVE PHASE
ASSOCIATED WITH;
•FETAL MALPOSITION
•CEPHALOPELVIC DISPROPORTION

UTERINE CONTRACTION: HYPOTONIC

B. PROTRACTED ACTIVE PHASE

PROLONGED IF:
CERVICAL DILATATION OCCUR AT A RATE OF ATLEAST
•1.2 CM/HR: NULLIPARA
•1.5CM/HR: MULTIPARA
B. PROTRACTED ACTIVE PHASE

PROLONGED IF:
ACTIVE PHASE LAST LONGER THAN:
•12 HRS: PRIMIGRAVIDA
•6 HRS: MULTIGRAVIDA
B. PROTRACTED ACTIVE PHASE

MANAGEMENT:
•CS
•LABOR: AUGMENTATION BY OXYTOCIN
C. PROLONGED DECELERATION PHASE
WHEN IT EXTENDS BEYOND:
•3 HRS: NULLIPARA
1 HR: MULTIPARA

MANAGEMENT: CS
D. SECONDARY ARREST IN DILATATION

•OCCURRED IF THERE IS NO PROGRESS IN CERVICAL DILATATION

FOR LONGER THAN 2 HOURS

•MANAGEMENT: CS
DYSFUNCTIONAL LABOR &
ASSOCIATED STAGES OF LABOR

2. DYSFUNCTIONAL AT THE 2ND STAGE OF LABOR

A. PROLONGED DESCENT
B. ARREST OF DESCENT
A. PROLONGED DESCENT

OCCURS IF THE RATE OF DESCENT IS:

•LESS THAN 1.0CM/ HR: NULLIPARA
•2.0 CM/ HR: MULTIPARA
A. PROLONGED DESCENT
MANAGEMENT:
• REST & FLUID INTAKE
• AMNIOTOMY
• IV OXYTOCIN
• SEMI FOWLER’S, SQUATTING, KNELLING
B. ARREST OF DESCENT

RESULTS WHEN NO DESCENT HAS OCCURRED FOR:

•2 HRS: NULLIPARA
•1 HR: MULTIPARA
B. ARREST OF DESCENT

•MOST LIKELY CAUSE: CPD

•CS: USUALLY NECESSARY
•IF NO CONTRAINDICATION TO VAGINAL BIRTH: OXYTOCIN, TO
ASSIST LABOR
PRECIPITATE LABOR
 LENGTH OF NORMAL LABOR
PRIMIS MULTIS
1st stage 12 ½ hours 7 hours, 20 min
2nd stage 80 min 30 min
3rd stage 10 min 10 min
Total 14 hours 8 hours
PRECIPITATE LABOR
CERVICAL DILATATION
PRIMIPARA 5 CM OR MORE/ HR
MULTIPARA 10 CM OR MORE/ HR
PRECIPITATE LABOR
•DEFINE AS LABOR THAT IS COMPLETED IN FEWER THAN 3
HOURS
•NORMAL LENGTH OF LABOR
•PRIMIPARA 14-20 HOURS
•MULTI – 8-14 HOURS)
PRECIPITATE LABOR

RISK FACTORS:
•LIKELY TO OCCUR IN MULTIPARITY MOTHERS
•PREVIOUS HISTORY OF PRECIPITATE LABOR
PRECIPITATE LABOR: COMPLICATIONS
MATERNAL
• INFECTION
• LACERATION
• UTERINE ATONY
• HEMORRHAGE
• ABRUPTION PLACENTA
PRECIPITATE LABOR: COMPLICATIONS
NEONATAL
INTRACRANIAL HEMORRHAGE
ASPIRATION OF AMNIOTIC FLUID
INFECTION
PRECIPITATE LABOR: MANAGEMENT
•INFORM MOTHER AT 28 WEEKS OF PREGNANCY
THAT LABOR MAY BE SHORTER THAN NORMAL
•TOCOLYTIC AGENT ADMINISTRATION
•COLD APPLICATIONS
•IN TIME OF HEMORRHAGE: MODIFIED
TRENDELENBURG POSITION
PRECIPITATE LABOR: MANAGEMENT
• IVF REPLACEMENT – FAST DRIP
• ADVICE PATIENT WHO HAVE HISTORY OF PRECIPITATE DELIVERY THAT
IT MAY HAPPEN AGAIN.
• PATIENT WHO HAS HISTORY OF PRECIPITATE DELIVERY AND THOSE
GRAND MULTIPARAS MUST BE BROUGHT TO D.R BEFORE FULL
DILATATION.
UTERINE RUPTURE
UTERINE RUPTURE

•RUPTURE OF THE UTERUS DURING LABOR

•ACCOUNTS FOR 5% OF MATERNAL DEATH
•INCIDENCE RATE IS 1 IN 1500 BIRTHS
UTERINE RUPTURE
RISK FACTORS:
• COMMONLY OCCUR FROM A VERTICAL SCAR DURING THE PREVIOUS CS OR
HYSTERECTOMY REPAIR TEARS
• PROLONG LABOR
• FAULTY PRESENTATION
• MULTIPLE GESTATION
• USE OF OXYTOCIN
• TRAUMATIC MANEUVERS
UTERINE RUPTURE

•OCCURS WHEN THE UTERUS CAN NO LONGER WITHSTAND THE

STRAIN PLACED UPON IT.
•TEARING OF THE MUSCLES OF THE UTERUS
•A SERIOUS COMPLICATION LABOR THAT CAN LEAD TO MATERNAL
AND FETAL DEATH.
UTERINE RUPTURE
COMPLETE RUPTURE
• GOING THROUGH ENDOMETRIUM, MYOMETRIUM AND PERITONEUM

INCOMPLETE RUPTURE
• LEAVING PERITONEUM INTACT
UTERINE RUPTURE
• USUALLY PRECEDED BY PATHOLOGIC
REFRACTION RING (AN INDENTATION IS
APPARENT ACROSS THE ABDOMEN OVER
THE UTERUS)
• THE FETUS IS GRIPPED BY RETRACTION
RING AND CANNOT DESCENT)
• STRONG UTERINE CONTRACTIONS
WITHOUT ANY CERVICAL DILATATION
BANDL’S RING
DURING LABOR THE UTERUS DIFFERENTIATE INTO TWO PARTS:

• THE UPPER CONTRACTING PORTION THAT BECOMES THICKER AND SHORTER AS LABOR
PROGRESSES.

• THE LOWER PASSIVE PORTION THAT DISTEND GRADUALLY TO ACCOMMODATE THE

DESCENDING FETUS.

• THIS DIVISION IS CALLED PHYSIOLOGIC RETRACTION RING.

BANDL’S RING
MANAGEMENT:
1. MORPHINE SULFATE – RELAX THE UTERUS
2. CS – IMMEDIATE DELIVERY OF THE FETUS AND PREVENT UTERINE
RUPTURE
3. IF DEVELOP DURING THE PLACENTAL STAGE – WOMAN IS PLACED
ANESTHESIA AND PLACENTA IS REMOVED MANUALLY.
UTERINE RUPTURE: SIGNS AND SYMPTOMS
• SUDDEN SEVERE PAIN DURING A STRONG LABOR CONTRACTIONS
• REPORT “A TEARING SENSATION”
• HEMORRHAGE FROM A TORN UTERUS INTO THE ABDOMINAL CAVITY AND INTO THE VAGINA
• SIGNS OF SHOCK (RAPID, WEAK PULSE, FALLING BLOOD PRESSURE, COLD CLAMMY SKIN)
• ABSENT FETAL HEART SOUNDS
• LOCALIZED TENDERNESS AND ACHING PAIN FROM THE LOWER SEGMENT
• FETAL DISTRESS
UTERINE RUPTURE: CAUSES
• RUPTURE OF SCAR FROM PREVIOUS CS
• PROLONGED LABOR OBSTRUCTED
LABOR
• MALPOSITION AND MALPRESENTATION
• MULTIPLE GESTATION
• INJUDICIOUS USE OF OXYTOCIN
• FORCEPS AD VACUUM EXTRACTION
• INTERNAL INVERSION
• PRECIPITATE LABOR AND DELIVERY
• MANUAL-REMOVAL OF THE PLACENTA
• OVER-DISTENTION OF THE UTERUS
• EXTERNAL TRAUMA SHARP OR BLUNT.
• PLACENTA INCRETA OR ACCRETA
UTERINE RUPTURE: MANAGEMENT
1. BLOOD TRANSFUSION AND ADMINISTRATION OF IVF- CORRECT SHOCK
2. ADMINISTER MASK OXYGEN
3. EMERGENCY LAPAROTOMY
4. PROVIDE EMOTIONAL SUPPORT
5. POST-OP CARE (AFTER HYSTERECTOMY)
UTERINE INVERSION
UTERINE INVERSION
•UTERUS TURNS COMPLETELY OR
PARTIALLY INSIDE OUT
•IT OCCURS IMMEDIATELY FOLLOWING
DELIVERY OF THE PLACENTA OR IN THE
IMMEDIATE POSTPARTUM PERIOD
•INCIDENCE RATE IS 1 IN 15, 000 BIRTHS
UTERINE INVERSION
CAUSES:
• OCCURS AFTER BIRTH OF THE INFANT IF TRACTION IS APPLIED TO
UMBILICAL CORD TO REMOVE PLACENTA
• PRESSURE IS APPLIED TO THE UTERINE FUNDUS WHEN UTERUS IS NOT
CONTRACTED
• OCCURS WHEN PLACENTA ATTACHED AT THE FUNDUS
(THE PASSAGE OF THE FETUS PULLS THE FUNDUS DOWN)
UTERINE INVERSION
SIGNS AND SYMPTOMS:
• SUDDEN GUSHES OF BLOOD FROM VAGINA
• FUNDUS IS NOT PALPABLE
• SHOW SIGNS OF BLOOD LOSS (HYPOTENSION, DIZZINESS AND
PALENESS)
• BLEEDING
UTERINE INVERSION: MANAGEMENT
RECOGNIZE SIGNS OF IMPENDING INVERSION AND IMMEDIATELY NOTIFY THE PHYSICIAN
NEVER ATTEMPT TO REPLACE THE INVERSION BECAUSE HANDLING MAY INCREASE THE
BLEEDING

NEVER ATTEMPT TO REMOVE THE PLACENTA IF IT STILL ATTACHED

TAKE STEPS TO PREVENT OR LIMIT HYPOVOLEMIC SHOCK
USE LARGE GAUGE IV CATHETER FOR FLUID REPLACEMENT
MEASURE AND RECORD MATERNAL VS EVERY 5 TO 15 MINUTES TO ESTABLISH BASELINE CHANGES
UTERINE INVERSION: MANAGEMENT
• ADMINISTER OXYGEN BY MASK
• BE PREPARED TO PERFORM CPR IF THE HEART FAILS DUE TO SUDDEN BLOOD
LOSS
• THE MOTHER WILL BE GIVEN GENERAL ANESTHESIA OR NITROGLYCERIN OR A
TOCOLYTIC DRUG IV TO IMMEDIATELY RELAX THE UTERUS
• PHYSICIAN/NURSE MIDWIFE REPLACES THE FUNDUS MANUALLY
(PUSH THE UTERUS BACK INSIDE)
THERAPEUTIC MANAGEMENT OF
PROBLEMS OR POTENTIAL PROBLEMS
IN LABOR AND BIRTH
INDUCTION OF LABOR

•DONE WHEN LABOR CONTRACTIONS ARE INEFFECTIVE

•MEANS THAT LABOR IS STARTED ARTIFICIALLY
INDUCTION OF LABOR
INDICATIONS:
• PRE-ECLAMPSIA
• ECLAMPSIA
• SEVERE HYPERTENSION/DM
• RH SENSITIZATION
• PROLONG RUPTURE OF MEMBRANES
• POST MATURITY
INDUCTION OF LABOR
REQUIREMENTS FOR LABOR INDUCTION;
•FETUS MUST BE IN LONGITUDINAL LIE
•CERVIX MUST BE RIPE
•PRESENTING PART MUST BE ENGAGED
•NO CPD
•FETUS IS MATURED BY DATE, LS RATIO OR SONOGRAM (BI-PARIETAL
DIAMETER)
METHODS OF INDUCTION OF LABOR
CERVICAL RIPENING BY PROSTAGLANDIN GEL
• COMMONLY USED METHOD OF SPEEDING CERVICAL RIPENING AND IS APPLIED TO
THE INFERIOR SURFACE OF THE CERVIX
• APPLIED BEFORE LABOR INDUCTION
• CAN ALSO BE APPLIED ON THE EXTERNAL SURFACE BY APPLYING THE GEL TO THE
DIAPHRAGM THEN PLACING THE DIAPHRAGM AGAINST THE CERVIX
• APPLY EVERY 6 HOURS FOR 2-3 DOSES
METHODS OF INDUCTION OF LABOR
CERVICAL RIPENING BY PROSTAGLANDIN GEL (MANAGEMENT)
• PLACE WOMEN IN FLAT POSITION TO PREVENT LEAKAGE OF MEDICATION
• THE WOMAN REMAINS ON BED REST FOR 1 TO 2 HOURS AND IS MONITORED
FOR UTERINE CONTRACTIONS
• MONITOR FHR CONTINUOUSLY FOR AT LEAST 30 MINUTES AFTER EACH
APPLICATION UP TO 2 HOURS
METHODS OF INDUCTION OF LABOR
CERVICAL RIPENING BY PROSTAGLANDIN GEL (MANAGEMENT)
• IV LINE WITH SALINE IS INITIATED IN CASE UTERINE HYPERSTIMULATION OCCURS
SUCH AS CONTRACTIONS LONGER THAN 90 SECONDS OR MORE THAN 5 CONTRACTION
IN 10 MINUTES
• EXPLAIN THE SIDE EFFECTS – VOMITING, FEVER, DIARRHEA AND HYPERTENSION
• OXYTOCIN INDUCTION CAN BE STARTED 6-12 HOURS AFTER THE LAST PROSTAGLANDIN
DOSE
METHODS OF INDUCTION OF LABOR

• INDUCTION OF LABOR BY OXYTOCIN –

A SYNTHETIC FORM OF PITUITARY
HORMONE INITIATES CONTRACTIONS
IN UTERUS
METHODS OF INDUCTION OF LABOR
NURSING CONSIDERATIONS; OXYTOCIN INDUCTION
GIVEN IV (TO HASTEN EFFECT), IV FORM OF OXYTOCIN NEEDS TO BE DILUTED
THE DRUG IS TRADITIONALLY MIXED IN THE PROPORTION OF 10 IU IN 1000ML OF
RINGER’S LACTATED (LR)
ADMINISTER THE MEDICATION BY PIGGYBACK ATTACH TO D5W AS THE MAIN IV
LINE (IF OXYTOCIN NEEDS TO BE DISCONTINUED, THE MAIN LINE WILL BE MAINTAIN)
METHODS OF INDUCTION OF LABOR
INDUCTION OF LABOR BY OXYTOCIN (NURSING CONSIDERATIONS)
WHEN CERVICAL DILATATIONS REACHES 4 CM, ARTIFICIAL RUPTURE
OF MEMBRANES IS PERFORMED TO FURTHER INDUCE LABOR AND
OXYTOCIN INFUSION IS DISCONTINUED
MONITOR FHR/UTERINE CONTRACTIONS AND CERVICAL DILATATION
DURING THE PROCEDURE
AUGMENTATION BY OXYTOCIN

•MAY BE USED IF LABOR CONTRACTION BEGINS SPONTANEOUSLY

BUT THEN BECOME WEAK, IRREGULAR OR INEFFECTIVE.
•PRECAUTIONS: SAME WITH INDUCTION