Abnormal labor By Sanaa Ghareeb Ahmed

Assist.professor at maternity and neonatal nursing –Faculty Of Nursing- Al dammam

university

Outline: Objectives. Introduction. Related definitions. Factors that might complicate progress of labor. Problems in the powers. Problems in the passage. Problems in the passenger. Problems in placenta. Nursing management for dystocia.

Objectives: General objective: By the end of this lecture each student should be able to obtain comprehensive knowledge about abnormal labor & obstetric emergencies. Specific objectives: At the end of this chapter the student should be able to: Define related definitions correctly. Mention factors that might complicate labor completely.

Clarify problems in powers.

Identify problems in passage.

Mention problems in placenta.

Explain problems in passenger.

Discuss nursing management for abnormal labor

Introduction :

Dystocia of labor is defined as difficult labor or abnormally

slow progress of labor. Other terms that are often used

interchangeably with dystocia are dysfunctional labor, failure

to progress (lack of progressive cervical dilatation or lack of

descent), and cephalopelvic disproportion (CPD).

DYSTOCIA

- literally means “difficult labor”

- Dystocia: Prolonged, painful, or difficult delivery results

from deviation from normal interrelationships between five

essential factors of labor (power, passage, passenger, placenta

& psychological status).

Related definitions Immature labor :Termination of pregnancy between 20 -28 weeks (fetal weight 500 – 1000 gm). Premature labor : Termination of pregnancy between 28 - 38 weeks (fetal weight 1000 – 2500 gm). Postmature labor : Prolongation of pregnancy 2 weeks or more beyond the calculated date of delivery. Prolonged labor: The labor last for more than 24 hour in PG & 16 hour in MG.

Factors that might complicate progress of labor: Uterine factors (abnormalities of the power); Hypotonic uterine contraction. Hypertonic uterine contraction. Incoordinate uterine action. Pelvic factors (abnormalities of the passage); Contracted pelvis ( inlet – midpelvis – outlet ) contracture. Abnormal pelvic shape. Soft tissues obstruction. Fetal factors (abnormalities of the Passenger); Unusually large fetus & Fetal anomaly. Abnormal fetal number. Abnormal fetal disposition.

Placental factors (abnormalities of the Placenta); Unusually large placenta. Abnormal shape. Abnormal site of insertion. Psychological status; refers to client’s psychological state, available support system, preparation for childbirth, experiences & coping strategies.

Late signs of obstructed labour · On examination the mother is dehydrated, ketotic and in constant pain. · Clinical signs also include pyrexia and rapid pulse rate. · Urinary output is poor and haematuria may be present. · Evidence of fetal distress ,a maternal tachycardia.

Abnormalities in the power: Power Indicates primary involuntary uterine muscle contraction and secondary voluntary abdominal muscles contractions by bear down. Differentiation of Uterine Activity During active labor, Upper segment

actively contracting , becomes thicker as labor advances Lower segment

relatively passive develops into a much thinly walled passage for the fetus

Physiologic retraction ring :

As labor progresses -> thinning of the lower uterine segment and the concomitant thickening of upper segment -> the boundary between the two is marked by a ridge on inner uterine surface

Pathologic retraction ring (the ring of Bandle) In obstructed labor -> lower uterine segment’s extreme thinning -> the ring is very prominent

Pathological retraction ring

Hypotonic uterine contraction;

It means weak contraction that caused by

Over stretching in the uterus by multiple pregnancy

Epidural anaesthesia.

Chorioamnioitis.

Mal presentation, mal position.

Maternal disease.

It result in prolonged labor

Signs & symptoms:

Weak contraction.

Exhaustion.

Dehydration.

Sever pain.

Cervical and vaginal edema.

Premature rupture of membranes (PROM).

Sings of fetal distress like abnormal fetal heart rate (FHR).

Hypertonic uterine contraction; In which uterine contraction characterized by increase duration by more than 90 second, decrease interval less than 60 second and incomplete relaxation between contraction. This condition caused by disturbance in the fundal pacemaker. fetal mal presentation or mal position. over stimulation by Oxytocin. It result in precipitated labor Signs & symptoms: Tetanic (long and painful) uterine activity. Exhaustion. Sever pain. Signs of fetal distress.

PRECIPITATE LABOR: The fetus is rapidly expelled from the birth canal. The duration of labor is less than 3 hours sometimes. Aetiology: - Strong frequent uterine contractions. - Laxity of the tissues of the birth canal, so more frequent in multiparae. - High pain threshold, so the patient does not feel except the last few strong contractions.

Complication: A-Maternal: - Lacerations of the cervix, vagina or perineum. - Postpartum hemorrhage (due to lacerations and there is no time for retractions). - Inversion of uterus. - Rupture of symphysis pubis. - Acute anemia. - Puerperal sepsis due to lacerations and unsuitable circumstances. - Amniotic fluid embolism. B-Fetal: - Asphyxia: the strong frequent uterine contraction interfere with placental circulation. - Intracranial hemorrhage due to rapid compression of the head. - Rupture of the cord. - Injury or death of the fetus due to falling.

PROLONGED LABOUR:- It is one in which regular uterine contraction with a dilation cervix have been present or 18 hours more or for 12 hours since admission. Causes:- Faults in the powers. - Faults in the passage. - Faults in the passenger. - Faults in the patient’s psychology. Complications: * Maternal - Maternal morbidity, dehydration, ketoacidosis. - Puerperal infection, postpartum hemorrhage. - Infection of urinary tract. * Fetal:- Perinatal death due to Pneumonia, Intrauterine infection, hypoxia and Stress from reduced placental circulation.

Abnormalities in the passage: Abnormal pelvic size; Contracted pelvis; means that the essential diameters of pelvis is decreased by 1 cm or more. Small size lead to inlet, mid pelvis or outlet contracture. Cephalopelvic Disproportion: Disproportion between the size of the fetal head and that of the maternal pelvis with resultant difficult labor, and danger to the fetus.

Abnormal pelvic shape; Android pelvis (male pelvis): the brim heart shaped with straight sacrum which prevent fetal rotation. Platypelloid pelvis: the brim kidney shape with short anterior posterior diameter which lead to difficult fetal engagement. Anthropoid pelvis: the brim oval shaped with short transverse diameter which lead to fetal mal position.

Soft tissues Obstruction;

Ovarian tumor.

Uterine fibroid,

Bicornuate, double uterus, septate uterus or didelphys.

Cervical polyps.

Vaginal stenosis.

Perineal tumors or cysts.

Abnormalities in passenger: Congenital anomalies and fetal malpresentation can result in fetal distress and deviation from the normal course of labor and birth. 1-Multifetal gestation: Multifetal gestation includes twins pregnancy, triplets, or quadrates.

Causes: - Age: it’s more common among women aged 20-39 years and dramatic decrease after this age occurs. - Fertility drugs: that stimulate the ovaries to produce many ovum. - Multiparity: it is more common among parous women than nulliparous women. Maternal and fetal implications: Intrapartum complications associated with multifetal gestation: - Pregnancy induced hypertension. - Abruption-placenta. - Placenta-previa.

-Abnormal fetal position and presentation A-Occipitoposterior position: In this position the fetal occiput and small posterior fontanel are located in the posterior segment of maternal pelvis, and the brow and face are in the anterior segment. Maternal, fetal and neonatal implications: - Cervical dilatation and fetal descent is often slow. - Labor is significantly prolonged. - Excessive backache and coupling of uterine contraction. - Premature rupture of membrane. - Midpelvis arrest. - Higher rate of instrumental delivery.

1. Abnormal Presentation Vertex Sinciput Brow Face a. Brow presentation , Face presentation , . Shoulder presentation (Transverse Lie) • Causes of transverse lie include: multiparity (lax abdominal wall), preterm fetus, placenta previa, uterine anomaly, excessive amnionic fluid, and contracted pelvis

d. Breech presentation • Predisposing factors include uterine relaxation, great parity, multiple foetuses, hydramnios, anencephaly, previous breech delivery, uterine anomalies, tumors in the pelvis • Complications: cord prolapse, increased perinatal morbidity and mortality due to difficult delivery, low birth

3. Abnormal Development • Hydrocephalus § Large transverse diameter of the cranium overdistends the lower uterine segment → causes uterine rupture § The size of the head must be reduced (e.g. cephalocentesis) to allow the fetus to pass through the birth canal • Enlarged abdomen usually results from greatly distended bladder, ascites, or enlargement of the kidneys or liver. • Macrosomia § Defined as fetal weighing 4500 gms or more

Abnormalities in placenta: Abnormal placental size ; large placenta (most common in diabetic mother) lead to dystocia in 3rd stage. Abnormal placental shape ; Placenta succenturiata: placenta with one or more accessory lobes. Placenta bipartita or tripartita: two or three separate areas of placental tissue, there is one umbilical cord which divided & sending branch to each lobe.

Placenta circumvallata: chorion is still continuous with the edge of the placenta but its attachment is folded back to the fetal surface. Placenta velamentosa: insertion of cord into the membranes, blood vessels between cord and placenta across the membranes. When membrane rupture result in hemorrhage( Vasa previa). Battledore placenta: the umbilical cord is inserted at or near the placental margin.

Abnormal site of placental insertion ; placenta previa; that means abnormal situated placenta in lower uterine segment (LUS). It may be partly in LUS, marginalis to cervix, partly over internal Os or central lie over Os. Placenta accerta: abnormally adherence placenta to the uterine wall. - Placenta increta, the villi invade the myometrium.. - Placenta percreta, the villi penetrate the myometrium.

Management of Dystocia

Problems with the Powers Hypertonic labor contractions Bed rest and sedation to promote relaxation and reduce pain Measures to rule out fetopelvic disproportion and fetal malpresentation Evaluate of fetal tolerance to labor pattern, such as monitoring of FHR patterns Assess for signs of maternal infection Adequate hydration through IV therapy

Pain management through epidural or IV analgesics

Administration of intravenous oxytocin (Pitocin) to promote

normal labor pattern

Amniotomy to augment labor

Explanations to woman and family of dysfunctional pattern

Planning for operative birth if normal labor pattern is not

achieved

Hypotonic labor contractions

Oxytocin augmentation probable after fetopelvic disproportion is ruled out Amniotomy if membranes are intact Continuous electronic fetal monitoring Ongoing monitoring of vital signs, contractions, and cervix Assessment for signs of maternal and fetal infection Explanations to woman and family of dysfunctional pattern Planning for surgical birth if normal labor pattern is not achieved or fetal distress occurs

Precipitous labor

Close monitoring of woman with previous history of this

Use of scheduled induction to control labor rate

Pharmacologic agents, such as tocolytics, to slow labor

Constant attendance to monitor progress

Problems with the Passenger Persistent occiput-posterior position

Assessment for complaints of intense back pain in first stage of labor Possible use of forceps to rotate to anterior position at birth Manual rotation to anterior position at end of second stage Assessment for prolonged second stage of labor with arrest of descent (common with this malposition) Maternal position changes to promote fetal head rotation: hands and knees and rocking pelvis back and forth; side-lying position; sitting, kneeing, or standing while leaning forward; squatting position to give birth and enlarge pelvic outlet Possible cesarean birth if rotation is not achieved

Breech presentation

Assessment for possible associated conditions such as placenta previa, hydramnios, fetal anomalies, and multiple gestation Ultrasound to confirm fetal presentation External cephalic version possible at 37 weeks Tocolytics to assist with external cephalic version Trial labor for 4 to 6 hours to evaluate progress if version is unsuccessful Planning for cesarean birth if no progress is seen or fetal distress occurs

Problems with the Passageway

Assessment for poor contractions, slow dilation, prolonged labor Evaluation of bowel and bladder status to reduce soft tissue obstruction and allow increased pelvic space Trial of labor; if no labor progression after an adequate trial, plan for cesarean birth

Nursing management for dystocia: Prevention: During pregnancy; - Early detection of high risk women. - Discover contracted pelvis and mal presentation. - Improve standards of maternity services ( prenatal care, family

planning programs. - Follow up and health education during pregnancy about diet,

exercises, hygiene, activity and danger signs during pregnancy. - The multipara must be delivered in hospital.

During labor;

- Proper assessment for mother in admission through complete history

taking, physical examination and investigation.

- Close observation for progress of labor.

- Avoid misuse of Oxytocin.

- Frequent empty the bladder.

- Comfort measures and hydration.

Mangement: 1st stage: Complete assessment for mother in admission to detect the cause of dystocia. *Complete history *A careful physical examination must be performed . - General examination; ht., wt., …. - Abdominal examination with Leopold maneuvers in order to ascertain the presentation of the fetus and to estimate the fetal weight. The pelvic examination focuses on determination of the pelvis capacity using clinical pelvimetry . Vaginal examination to assess CD, station, effacement, fetal position & presentation.

Mangement:

*Investigations; C.B.C, RH, blood group, urine analysis, sonar,….

Close observation using electronic monitoring for

Progress of labor (cervical dilatation, fetal decent, uterine contraction

and condition of membranes).

Fetal condition (FHR). Maternal condition especially for dehydration, pallor, exhaustion, cervical & vaginal edema and sever pain, signs of shock and recording for any abnormality. Management of dystocia depends on underlying factors related to the maternal condition and fetal status .

Provide comfort measures to relieve pain and help client to adapt comfortable position. IV fluids to maintain hydration and observe intake & output Encourage frequent evacuation of bladder evacuate the rectum by enema. Administer the prescribed drugs (antibiotics, analgesics).

2- 2nd stage: Prepare the mother for instrumental delivery e.g .Forceps or Vacuum extraction or CS if necessary. Instrumental delivery: Preparation for place, equipment & appratus. Preparation for mother; postioning, sterlization, evacuate the bladder and anesthesia. Close observation for FHR, vital signs & contraction. Assist the doctor during delivery; follow fetal decent, supporting the perineum, cutting the episiotomy… Suctioning & oxygenation for baby at birth.

2- 2nd stage: Cesarean section: - Preparation for place, equipment & appratus Preparation for mother; remove any jewelry, assess vital signs, catheterization, IV line, collect specimen for lab, singed consent and anesthesia. Assist the doctor during delivery. Suctioning & oxygenation for baby at birth.

– 3rd stage:

If the placenta has not been delivered within 45 to 60 min of

delivery, manual removal may be necessary.

- The entire hand is inserted into the uterine cavity,

separating the placenta from its attachment, then extracting

the placenta.

– 3rd stage:

The placenta should be examined for completeness because fragments

left in the uterus can cause delayed hemorrhage or infection.

If the placenta is incomplete, the uterine cavity should be explored

manually under general anesthesia to detect retained placental

fragments.

– 4th stage: Observation for mother include vital signs, uterus, lochia, perineum, wound condition, intake & output… Uterine massage in case of instrumental delivery Perineal & breast care. IV fluids with oxytocic drugs. Physical & neurological examination for baby. Eye, cord & diaper care. Reassure the mother if there is any injury result from delivery. Encourage breast feeding as early as possible after delivery.

consequence of Abnormal Labor Short Term On the Mother: • Postpartum hemorrhage. • Increased rate of traumatic complications: Lacerations, injuries to adjacent organs. • Increased risk of infection (prolonged labor) • Increased rate of difficult operative delivery. Long Term Consequences: • Psychological effects of a Traumatic Experience On the Fetus: {increased rate of perinatal morbidity and mortality } • Potential Complications of traumatic delivery • Low Apgar score • Neonatal complications (Birth Asphyxia, trauma ..etc.

References Ricci S.Susan. Essentials of Maternity, Newborn and Women’s Health Nursing.2nd ed., Philadelphia: Lippincott co. 2010. Michele, R., Marcia, L. & Patricia, A. Olds` Maternal-Newborn Nursing & Women’s Health across the Lifespan. 9th edition. Pearson 2010. Neville, F., Joseph, C. & Calvin, J. Essentials of Obstetrics and Gynecology, 5th edition. Philadelphia: Lippincott co. 2010.