Dysfunctional labor
Problems with the powers
Hypertonic uterine dysfunction
Occurs when the uterus never fully relaxes between contractions.
Placental perfusion becomes compromised , thereby reducing oxygen to the fetus .
These hypertonic contractions exhaust the mother, who is experiencing frequent , intense , and painful contractions.
The force of the contractions occurs in the midsection of the uterus ,
at the junction of the active upper and passive lower segment of the
uterus rather than in the fundus. Thus , the downward pressure to push
the presenting part against the cervix is lost .
Diagnosis :
The diagnosis of a hypertonic labor pattern is based on the
characteristic hypertonicity of the contractions and the lack of labor
process .
Treatment :
It involves therapeutic rest with the use of sedative to promote relaxation and astop the abnormal activity of the uterus .
After a 4 – 6 hour rest period , many woman will awaken and begin a normal labor pattern.
Hypotonic uterine dysfunction.
Occurs during active labor ( dilation 4 cm) when contractions become
poor in quality and lack sufficient intensity to dilate and efface the
cervix .
Common factors associated with this dysfunctional labor pattern include :
1 ) overdistended uterus with a multyfetal pregnancy or a large single fetus.
2 ) too much pain medicine given too early in labor .
3 ) fetal malposition.
4 ) regional anesthesia.
Diagnosis :
Evaluation of the woman's labor to confirm that the woman is having hypotonic active labor rather than along latent phase.
The maternal pelvis and fetal presentation and position are also evaluated.
Treatment :
Identifying the cause of inefficient uterine action, which might include
a malepositioned fetus , a maternal pelvis that is too small , or
overdistention of the uterus with fluid or macrosomic fetus .
In addition , labor augmentation with oxytocin may be used to stimulate effective uterine contraction.
Precipitous labor
Is one that is completed in less than 3 hours. Charachterised by abrupt
onset of higher intensity contractions occurring in a shorter period of
time .
Woman experiencing precipitous labor typically have soft perineal tissue
that stretch readily , permitting the fetus to pass through the pelvis
quickly and easily .
Diagnosis :
Based on the rapidity of the progress through the stages of labor .
potential fetal complications may include head trauma, such as
intracranial hemorrhage or nerve damage , and hypoxia due to the rapid
progression of labor .
Treatment :
The fetus is delivered vaginally if the maternal pelvis is adequate .
Problems with the passenger
Persistent occipot posterior position
The fetal head engages in the left or right occipito-transverence
position and the occiput rotated posteriorly rather than into the more
favorable occiput anterior position. In the effect , the fetus will be
born facing upward instead of the normal downward position.
Diagnosis :
The diagnosis is made clinically by vaginal examination in conjunction with the mothers complaints of severe back pain.
Treatment :
The best management is to allow the labor to proceed , preparing the woman for along labor .
Comfort measures and maternal position changes can help promote fetal head rotation.
Effective pain reliefe is crutial to help the woman to tolerate the back discomfort.
Lateral abdominal stroking in the direction that the fetal head should rotate .
Anxiety reduction, continous reinforcement of the womans progress.
Face and brow presentations
They are rare and are associated with fetal abnormalities :
1 ) pelvic contractures.
2 ) high parity.
3 ) placenta previa.
4 ) hydramnios.
5 ) low birth weight .
6 ) large fetus.
If there is a complete extension of the fetal head , the face will present for delivery.
In a brow presentation the fetal head stays btw full extension and full
flexion so that the largest fetal skull diameter present to the pelvic .
this condition can be diagnosed only once labor is well established.
Diagnosis :
Diagnosis is made clinically by vaginal examination.
Treatment :
With a face presentation , labor will be longer , but if the pelvis is
adequately and the head rotates , a vaginal birth is possible. If the
head rotates backward , a cesarean birth is necessary. With a brow
presentation , unless the head flexes , a vaginal birth is not possible.
Breach presentation:
Associated with :
1 ) multifetal pregnancies .
2 ) grand multiparaity .
3 ) placenta previa.
4 ) hydramnios.
5 ) preterm births.
6 ) fetal anomalies such as hydrocephaly
Diagnosis :
Vaginal examination determine a breech presentation. it can present in three different attitudes :
1 ) Frank breech : the buttocks is the presenting part , with hips flexed and legs and knees extended upward .
2 ) complete breech : the buttocks is the presenting part, with hips flexed and knees flexed in cannonball position.
3 ) footling or incomplete breech : one or two feet is the presenting part, with one or both hips extended.
Treatment :
Some health care providers , consider any type of breech presentation as
an indication for cesarean birth , unless the fetus is small and the
mother has a large pelvis . others believe that a vaginal birth that a
vaginal birth is appropriate with a breech presentation.
Shoulder distocia
It is the obstruction of fetal descent and birth by the axis of the
fetal sholders after the fetal head has been dilevered .the fetal head
deliveres but the neck doesn’t appeare and the chin retracts against the
perenium , much like aturtle's head going back into his shell.
Although the nose and mouth are outside , the chest annot expand with
respiration. When shoulder distocia occur, umbilical cord compression
between the fetal body and the maternal pelvis is arisk due to impending
fetal acidosis .
Fetal risks include :
1 ) asphyxia
2 ) nerve damage
3 ) clavicle fracture.
4 ) CNS injury or dysfunction and death.
Diagnosis :
It is made when the newborn's head delivers but the neck and remaining body structure don’t.
Primary risk factors :
1 ) Suspected infant macrosomia.
2 ) presence of DM in the mother .
3 ) excessive maternal weight gain.
4 ) abnormal maternal pelvic anatomy .
5 ) use of epidural anesthesia.
Treatment :
Once shoulder dystocia is identify, the health care provider initiate manual maneuvers to facilitate birth.
The mothers thighs are flexed and abduct as much as possible , which straightens the pelvic curve.
Another method used to relieve shoulder dystocia suprapubic pressure :
pressure is applied just above the pubic bone , pushing the fetal
anterior shoulder downward to displace it from above the mothers
symphysis pubic.
The neonatal resuscitation team should be readily available in case of potential newborn injury, asphyxia, or both.
After the birth , the newborn should be assessed for cripitus ,
deformity, or bruising , which might suggest that a fracture is present.
Multiple gestation
Refers to twins , triplets, or more infants within asingle pregnancy.
Fetal hypoxia during labor is a signifecent threat bcz the placenta must
provide oxyden and nuitrients to more that one fetus. The most common
maternal complications is postpartum hemorrhage resulting from uterine
atony.
Diagnosis :
Nearly all multiple gestations are now diagnosed early by ultrasound. In
addition, most women with a multiple gestation go into labor earlier
that 37 weeks.
Treatment :
Throughout labor and birth , each fetal heart rate is monitored
separately . once the first fetus is delivered ,the cord is clamped and
the lie of the second twin is assessed carefully .
The second and subsequent fetuses are at grater risk for birth related
complications , such as umbilical cord prolapse, and abruption placenta.
Excessive fetal size and abnormalities
Complication associated with distocia related to excessive fetal size
and anomalies include an increased risk for postpartum hemorrhage,
dysfunctional labor, fetopelvic disproportion.
Although vaginal births are possible , much of the time vacuum-assisted
or low forceps are needed to assist in the birthing process.
Diagnosis :
Macrosomia can be suspected based on the findings of the ultrasound examination before labor begins.
Leopold's maneuvers are used to estimate fetal weight and position.
Treatment :
If the diagnosis was made before the onset of labor , a cesarean birth
might be scheduled to reduce the risk of injury to both the newborn and
the mother.
Problems with the passageway
The are related to a contraction of one or more of the three plans of the maternal pelvis: inlet, midpelvis, outlet.
Contraction of the midpelvis is more common than inlet contraction and causes an arrest of fetal descent.
The outlet of the pelvis can be assessed in early pregnancy to determine whether it can accommodate a normal-sized fetus.
Problems with Psyche
Many woman experience array of emotions during labor , which may include
fear, anxiety, helplessness , being alone, and weariness. These
emotions can lead to psychological stress , which indirectly can cause
dystocia.
Assisting her to relax and providing for her comfort will help her body work more effectively with the forces of labor.
Nursing Management
Assessment
1 ) monitor maternal vital signs for signs of infection or hypovolemia.
2 ) assess for abnormal uterine contractions.
3 ) monitor the fetal heart rate to identify abnormal patterns indicating hypoxia.
4 ) review laboratory tests for signs contributing to dystocia.
5 ) assess for emotional factors that might impede labor progress or affect the womans level of coping.
6 ) assess for afull bladder every two hours and encourage bladder emptying.
7 ) assess fetal position via leopold's maneuvers to identify any deviations.
8 ) assess for signs of infection, such as fever of foul-smelling amniotic fluid.
9 ) observe for visible cord and variable decelerations if breech.
Nursing intervention
1 ) provide labor support : emotional, educational , physical, and advocacy.
2 ) offer awarm shower to promote relaxation.
3 ) support the woman in comfortable position with pillows.
4 ) change the woman's position every 30 minutes to reduce tention and to enhance uterine activity.
5 ) offer a backrub to reduce muscle tension.
6 ) perform vaginal examination to determine dilation and effacement and progression.
7 ) make sure the woman is avoids supine position, with cause vena cave compression.
8 ) encourage upright position to facilitate fetal rotation and descent.
9 ) remain with the client to demonstrate caring.
10 ) encourage the woman to express her fellings of feer and anxiety
Problems with the powers
Hypertonic uterine dysfunction
Occurs when the uterus never fully relaxes between contractions.
Placental perfusion becomes compromised , thereby reducing oxygen to the fetus .
These hypertonic contractions exhaust the mother, who is experiencing frequent , intense , and painful contractions.
The force of the contractions occurs in the midsection of the uterus ,
at the junction of the active upper and passive lower segment of the
uterus rather than in the fundus. Thus , the downward pressure to push
the presenting part against the cervix is lost .
Diagnosis :
The diagnosis of a hypertonic labor pattern is based on the
characteristic hypertonicity of the contractions and the lack of labor
process .
Treatment :
It involves therapeutic rest with the use of sedative to promote relaxation and astop the abnormal activity of the uterus .
After a 4 – 6 hour rest period , many woman will awaken and begin a normal labor pattern.
Hypotonic uterine dysfunction.
Occurs during active labor ( dilation 4 cm) when contractions become
poor in quality and lack sufficient intensity to dilate and efface the
cervix .
Common factors associated with this dysfunctional labor pattern include :
1 ) overdistended uterus with a multyfetal pregnancy or a large single fetus.
2 ) too much pain medicine given too early in labor .
3 ) fetal malposition.
4 ) regional anesthesia.
Diagnosis :
Evaluation of the woman's labor to confirm that the woman is having hypotonic active labor rather than along latent phase.
The maternal pelvis and fetal presentation and position are also evaluated.
Treatment :
Identifying the cause of inefficient uterine action, which might include
a malepositioned fetus , a maternal pelvis that is too small , or
overdistention of the uterus with fluid or macrosomic fetus .
In addition , labor augmentation with oxytocin may be used to stimulate effective uterine contraction.
Precipitous labor
Is one that is completed in less than 3 hours. Charachterised by abrupt
onset of higher intensity contractions occurring in a shorter period of
time .
Woman experiencing precipitous labor typically have soft perineal tissue
that stretch readily , permitting the fetus to pass through the pelvis
quickly and easily .
Diagnosis :
Based on the rapidity of the progress through the stages of labor .
potential fetal complications may include head trauma, such as
intracranial hemorrhage or nerve damage , and hypoxia due to the rapid
progression of labor .
Treatment :
The fetus is delivered vaginally if the maternal pelvis is adequate .
Problems with the passenger
Persistent occipot posterior position
The fetal head engages in the left or right occipito-transverence
position and the occiput rotated posteriorly rather than into the more
favorable occiput anterior position. In the effect , the fetus will be
born facing upward instead of the normal downward position.
Diagnosis :
The diagnosis is made clinically by vaginal examination in conjunction with the mothers complaints of severe back pain.
Treatment :
The best management is to allow the labor to proceed , preparing the woman for along labor .
Comfort measures and maternal position changes can help promote fetal head rotation.
Effective pain reliefe is crutial to help the woman to tolerate the back discomfort.
Lateral abdominal stroking in the direction that the fetal head should rotate .
Anxiety reduction, continous reinforcement of the womans progress.
Face and brow presentations
They are rare and are associated with fetal abnormalities :
1 ) pelvic contractures.
2 ) high parity.
3 ) placenta previa.
4 ) hydramnios.
5 ) low birth weight .
6 ) large fetus.
If there is a complete extension of the fetal head , the face will present for delivery.
In a brow presentation the fetal head stays btw full extension and full
flexion so that the largest fetal skull diameter present to the pelvic .
this condition can be diagnosed only once labor is well established.
Diagnosis :
Diagnosis is made clinically by vaginal examination.
Treatment :
With a face presentation , labor will be longer , but if the pelvis is
adequately and the head rotates , a vaginal birth is possible. If the
head rotates backward , a cesarean birth is necessary. With a brow
presentation , unless the head flexes , a vaginal birth is not possible.
Breach presentation:
Associated with :
1 ) multifetal pregnancies .
2 ) grand multiparaity .
3 ) placenta previa.
4 ) hydramnios.
5 ) preterm births.
6 ) fetal anomalies such as hydrocephaly
Diagnosis :
Vaginal examination determine a breech presentation. it can present in three different attitudes :
1 ) Frank breech : the buttocks is the presenting part , with hips flexed and legs and knees extended upward .
2 ) complete breech : the buttocks is the presenting part, with hips flexed and knees flexed in cannonball position.
3 ) footling or incomplete breech : one or two feet is the presenting part, with one or both hips extended.
Treatment :
Some health care providers , consider any type of breech presentation as
an indication for cesarean birth , unless the fetus is small and the
mother has a large pelvis . others believe that a vaginal birth that a
vaginal birth is appropriate with a breech presentation.
Shoulder distocia
It is the obstruction of fetal descent and birth by the axis of the
fetal sholders after the fetal head has been dilevered .the fetal head
deliveres but the neck doesn’t appeare and the chin retracts against the
perenium , much like aturtle's head going back into his shell.
Although the nose and mouth are outside , the chest annot expand with
respiration. When shoulder distocia occur, umbilical cord compression
between the fetal body and the maternal pelvis is arisk due to impending
fetal acidosis .
Fetal risks include :
1 ) asphyxia
2 ) nerve damage
3 ) clavicle fracture.
4 ) CNS injury or dysfunction and death.
Diagnosis :
It is made when the newborn's head delivers but the neck and remaining body structure don’t.
Primary risk factors :
1 ) Suspected infant macrosomia.
2 ) presence of DM in the mother .
3 ) excessive maternal weight gain.
4 ) abnormal maternal pelvic anatomy .
5 ) use of epidural anesthesia.
Treatment :
Once shoulder dystocia is identify, the health care provider initiate manual maneuvers to facilitate birth.
The mothers thighs are flexed and abduct as much as possible , which straightens the pelvic curve.
Another method used to relieve shoulder dystocia suprapubic pressure :
pressure is applied just above the pubic bone , pushing the fetal
anterior shoulder downward to displace it from above the mothers
symphysis pubic.
The neonatal resuscitation team should be readily available in case of potential newborn injury, asphyxia, or both.
After the birth , the newborn should be assessed for cripitus ,
deformity, or bruising , which might suggest that a fracture is present.
Multiple gestation
Refers to twins , triplets, or more infants within asingle pregnancy.
Fetal hypoxia during labor is a signifecent threat bcz the placenta must
provide oxyden and nuitrients to more that one fetus. The most common
maternal complications is postpartum hemorrhage resulting from uterine
atony.
Diagnosis :
Nearly all multiple gestations are now diagnosed early by ultrasound. In
addition, most women with a multiple gestation go into labor earlier
that 37 weeks.
Treatment :
Throughout labor and birth , each fetal heart rate is monitored
separately . once the first fetus is delivered ,the cord is clamped and
the lie of the second twin is assessed carefully .
The second and subsequent fetuses are at grater risk for birth related
complications , such as umbilical cord prolapse, and abruption placenta.
Excessive fetal size and abnormalities
Complication associated with distocia related to excessive fetal size
and anomalies include an increased risk for postpartum hemorrhage,
dysfunctional labor, fetopelvic disproportion.
Although vaginal births are possible , much of the time vacuum-assisted
or low forceps are needed to assist in the birthing process.
Diagnosis :
Macrosomia can be suspected based on the findings of the ultrasound examination before labor begins.
Leopold's maneuvers are used to estimate fetal weight and position.
Treatment :
If the diagnosis was made before the onset of labor , a cesarean birth
might be scheduled to reduce the risk of injury to both the newborn and
the mother.
Problems with the passageway
The are related to a contraction of one or more of the three plans of the maternal pelvis: inlet, midpelvis, outlet.
Contraction of the midpelvis is more common than inlet contraction and causes an arrest of fetal descent.
The outlet of the pelvis can be assessed in early pregnancy to determine whether it can accommodate a normal-sized fetus.
Problems with Psyche
Many woman experience array of emotions during labor , which may include
fear, anxiety, helplessness , being alone, and weariness. These
emotions can lead to psychological stress , which indirectly can cause
dystocia.
Assisting her to relax and providing for her comfort will help her body work more effectively with the forces of labor.
Nursing Management
Assessment
1 ) monitor maternal vital signs for signs of infection or hypovolemia.
2 ) assess for abnormal uterine contractions.
3 ) monitor the fetal heart rate to identify abnormal patterns indicating hypoxia.
4 ) review laboratory tests for signs contributing to dystocia.
5 ) assess for emotional factors that might impede labor progress or affect the womans level of coping.
6 ) assess for afull bladder every two hours and encourage bladder emptying.
7 ) assess fetal position via leopold's maneuvers to identify any deviations.
8 ) assess for signs of infection, such as fever of foul-smelling amniotic fluid.
9 ) observe for visible cord and variable decelerations if breech.
Nursing intervention
1 ) provide labor support : emotional, educational , physical, and advocacy.
2 ) offer awarm shower to promote relaxation.
3 ) support the woman in comfortable position with pillows.
4 ) change the woman's position every 30 minutes to reduce tention and to enhance uterine activity.
5 ) offer a backrub to reduce muscle tension.
6 ) perform vaginal examination to determine dilation and effacement and progression.
7 ) make sure the woman is avoids supine position, with cause vena cave compression.
8 ) encourage upright position to facilitate fetal rotation and descent.
9 ) remain with the client to demonstrate caring.
10 ) encourage the woman to express her fellings of feer and anxiety
