Dystocia

PROBLEMS WITH POWERS

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Normal Labor (review)
• Contractions that
result in a more
normal progression of
labor (moderate to
strong)
*2-4 contractions in 10
min in early labor & 4-
5/ 10 min in later
phases.
 Dystocia/Dysfunctional Labor
• long, difficult, or abnormal labor
• caused by various conditions associated with the
five factors affecting labor
• described as abnormal uterine contractions that
prevent the normal progress of cervical dilatation,
effacement and fetal descent
Dystocia (Uncoordinated Uterine
Contraction)
• Resulted in a prolonged
labor
• Typically irregular in
strength, timing, or both
• often arrest cervical
dilatation
Common Causes of Dysfunctional labor
1. Inappropriate use of analgesia
2. Pelvic bone contraction that has narrowed the pelvic
diameter so that the fetus cannot pass
3. Poor fetal position (posterior rather than anterior)
4. Failure of the uterine muscle to contract properly
Common Causes of Dysfunctional labor
5. Extension rather than flexion of the
fetal head
6. Overdistension of the uterus
7. Cervical rigidity
Common Causes of Dysfunctional
labor
8. Presence of a full rectum or urinary
bladder that impedes fetal descent
9. Mother becoming exhausted from labor
10. Primigravida status
Hypertonic Contractions/ Hypertonic uterine
Dysfunction
• Ineffective uterine
contractions of poor quality
• occur in the latent phase of
labor
• Contractions usually become
more frequent, but their
intensity may decrease
• Contractions are painful but
ineffective in dilating &
effacing cervix
• Prolonged latent phase
Hypertonic Uterine Dysfunction

Maternal risks:
1. Increased discomfort due to uterine
muscle cell anoxia
2. Fatigue as the pattern continues & no labor
progress results
3. Stress on coping abilities
4. DHN & increased incidence of infection if
labor is prolonged
Fetal-neonatal risks:
1.Fetal distress because
contractions & increased resting
tone interfere with the
uteroplacental exchange
2.Prolonged pressure on the fetal
head cephalhematoma, caput
succedaneum, or excessive
molding
Medical Management
1. Bedrest
2. Administration of analgesics such as
morphine, meperidine (Demerol),
nalbuphine (NUBAIN) or sedatives such
as zolpidem (ambien)
3. Tocolytic drugs – terbutaline (brethine)
NURSING MANAGEMENT

Nursing assessment
Evaluate the relationship between intensity of the
pain being experienced & the degree to which
the cervix is dilating & effacing
Note whether anxiety is negatively affecting labor
progress
 Nursing Diagnoses

• Fatigue related to inability to relax & rest secondary to a hypertonic

labor pattern
• Acute pain related to woman’s inability to relax secondary to
hypertonic uterine contractions
• Ineffective individual coping related to ineffectiveness of breathing
techniques to relieve discomfort
• Anxiety related to slow labor progress
 Planning & Implementation

• Provide comfort & support to the laboring woman & her partner.
• Supportive measure such as a change of position
• Provide information about the cause of the hypertonic labor pattern
& assure the woman that she is not overacting to the situation
• Client’s education
 Evaluation
Anticipated outcomes of nursing care include the following:
• The woman has increased comfort & decreased anxiety.
• The woman & her partner are able to cope with the labor.
• The woman experiences a more effective labor pain.
 Hypotonic Contractions/ Hypotonic Uterine Dysfunction

• Fewer than 2-3 contractions in a 10

min period
• Develops in the active phase
• Contractions are coordinated but
too weak, infrequent & brief
 Hypotonic Contractions/ Hypotonic Uterine Dysfunction
• Associated with :
• Overstretched uterus
• Presence of a large fetus
• Hydramnios
• Grand multiparity
• Bladder or bowel distension
• CPD
 Hypotonic Contractions/ Hypotonic Uterine
Dysfunction
Maternal implications include the risk of :

a) Maternal exhaustion
b) Stress on coping abilities
c) Postpartal hemorrhage from insufficient uterine
contractions following birth
d) Intrauterine infection if labor is prolonged
e) Increased risk of infection
Hypotonic Contractions/ Hypotonic Uterine
Dysfunction
Fetal-neonatal implications include the
risk of :

a) Fetal distress
b) Fetal sepsis
 Medical Management
*Improving the quality of the uterine contractions
•Ultrasound or x-ray examination to rule out CPD
•Assessing FHR & labor pattern, characteristics of AF if membranes are
ruptured and maternal well-being
 Medical Management
• Active Management of Labor (AMOL)
- amniotomy
- augmentation of labor
Nursing Management

Nursing Assessment
1. contractions
2. maternal vital signs
3. fetal heart rate (FHR)
Nursing Diagnoses
a)Pain related to uterine contractions secondary to dysfunctional labor

a)Health-seeking behavior related to lack of information about

dysfunctional labor.
 Planning & Implementation
1.Nursing measures to promote maternal-
fetal physical well being include frequent
monitoring of contractions, maternal vital
signs, & FHR
2.If amniotic membranes are ruptured,
assess the amniotic fluid for meconium.
• If there is meconium in the AF, close
observation of fetal status is more critical
because it often indicates that the fetus is
experiencing some form of stress. An intake
& output record provides a way of
determining maternal hydration or
dehydration.
 Planning & Implementation
• Encourage the woman to void every 2 hours & check her bladder for
distention.
• Continue monitoring the woman for signs of infection (elevated
temperature, chills, foul-smelling AF)
• Vaginal examinations should be kept to a minimum to decrease the risk of
introducing an infection
• Help the woman & her partner cope with the frustration of a lengthy labor
process
• Teaching plan – info. on dysfunctional labor process & its implications
Evaluation

• The woman maintains comfort during labor.

• The woman understands the type of labor pattern that is occurring &
the treatment plan.
Dysfunctional Labor & Associated
Stages of Labor

Abnormal Progress of Labor

 First Stage of Labor
A. Prolonged Latent Phase
• Major dysfunction that occurs in the 1st stage of
labor
• According to Friedman, it is a latent phase that is
longer than 20hrs in a nullipara & 14hrs in
multipara.
• Uterus tends to be hypertonic
• may occur if the cervix is not ripe at the beginning
of labor & time must be spent getting truly ready for
labor
• may occur if there is excessive use of an analgesic
early labor
 First Stage of Labor
A. Prolonged Latent Phase
- Uterus tends to be hypertonic
- Relaxation between contractions is
inadequate
- Contractions are mild and ineffective
Medical Management
• Help the uterus to rest & administer adequate
fluid to the woman to prevent dehydration
• Administration of morphine may relax
hypertonicity, this usually allows labor to
become effective & begin to progress. If it does
not, a cesarean birth or amniotomy & oxytocin
infusion to assist labor may be necessary.
 B. Protracted Active Phase
• Usually associated with CPD or fetal
malposition
• If cervical dilatation does not occur at
a rate of at least 1.2cm/hr in
nulliparas or 1.5cm/hr in a multipara,
or if the active phase last longer than
12hrs in a primigravida or 6hrs in
multigravida
• Uterus tends to be hypotonic
• Oxytocin may be prescribed to
augment labor
C. Prolonged Deceleration Phase
• A deceleration phase has become prolonged when
it extends beyond 3hrs in a nullipara or 1 hr in a
multipara

• Prolonged deceleration phase most often results

from abnormal fetal head position

• A CS birth is frequently required

 D. Secondary Arrest of Dilatation
No progress in cervical dilatation for more than 2 hrs.
 Second Stage of Labor
A. Prolonged Descent
• occurs if the rate of descent is less than
1.0cm/hr in a nullipara or 2.0cm/hr in a
multipara
• Management:
• If membranes have not ruptured, rupturing
them at this point may be helpful
• IV oxytocin may be used to induce the
uterus to contract effectively
• Semi Fowler’s position, squatting, kneeling
or more effective pushing may speed
descent
B. Arrest of Descent
• no descent for 1 hr in a multipara
or 2 hrs in a nullipara
• The most likely cause for arrest
of descent during the 2nd stage is
CPD
• CS birth usually is necessary
• If there is no contraindication to
vaginal birth, oxytocin may be
used to assist labor.
B. Arrest of Descent
CONTRACTION/CONSTRICTION/
RETRACTION RING

2 types
1. Physiologic retraction ring
2. Pathologic retraction ring
 Physiologic Retraction Ring
• can occur at any point in the
myometrium and at any time during
labor (1st, 2nd, and 3rd stage)
• a line of demarcation between the
upper and lower uterine segment
present during normal labor and
cannot usually be felt abdominally
CONTRACTION RING
CONTRACTION RING
 Pathologic Retraction/Bandl’s Ring
• most common form of constriction ring
responsible for dysfunctional labor
• occurs at the junction of the upper &
lower uterine segments
• occurs during the second stage of labor as
a horizontal indentation across the
abdomen
• ** It is usually caused by obstetric
manipulation or by the
administration of oxytocin.
 
 Pathologic Retraction/Bandl’s Ring
• When this occurs in early labor it is
usually caused by uncoordinated
contractions

• A warning sign of impending uterine

rupture.
Management

• identified by sonography
• Administration of IV morphine sulfate or the inhalation of amyl
nitrate may relieve the retraction ring
• Tocolytic
• CS
Management

In the placental stage, massive maternal hemorrhage may result,

because the placenta is loosened but then cannot be delivered,
preventing the uterus from contracting
• Management:
• Manual removal of the placenta under general
anesthesia
 The
end………….

A cademics.
T ouches heart.
E ducates mind.
A rticulates vision.
M odels excellence.