Chapter 23: Nursing Care of a Family Experiencing a Complication of Labor or Birth Dystocia y a difficult labor y cane arise from

any of the 4 maincomponents of the labor process  power  passenger  passageway  psyche Complications with the POWER Inertia sluggishness of contractions or dysfunctional labor 2 classifications: 1. Primary happens during onset of labor 2. Secondary happens during later part of labor Ineffective Uterine Labor 1. Hypotonic contractions y Low (10-25 mmHg) or infrequent contractions (not more than 2-3 in a minute) y Occurs during active phase generally after administration of analgesia y Cervical opening of 3-4 inches y Bowel or kidney distention prevents engagement y Occurs in overstretched (multiple gestation, large baby or hydramnios) or lax uterus (grand multiparity). y Characteristics:  Not exceedingly painful  Lacks intensity y Outcomes:  Increase in length of labor  Uterus does not effectively contract during post-partal period  Increases chance of post-partal hemorrhage y To assess:  Uterus and lochia to ensure postpartal contractions are not too hypotonic 2. Hypertonic contractions y More frequent contractions but not necessarily more intense (15 mmHg or more) y Occurs during latent phase y Muscle fibers of myometrium do not relax after contractions y More painful y Makes breathing exercises less effective y Does not allow optimum uterine artery filling causing fetal anoxia y Does not achieve cervical dilation 3. Uncoordinated contractions y More than one pacemaker may be initiating contractions or receptor points in the myometrium may be acting independently of the pacemaker Dysfunctional Labor according to stage: Dysfunction at the first stage 1. Prolonged latent phase

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More than 20hours in a nullipara, and more than 14hours in a multipara y Brought about by  Unripe cervix  Excessive use of analgesia y What happens?  Uterus in hypotonic state  Inadequate relaxation between contractions  Contractions are mild and inadequate y Nursing mngt.  Help uterus to rest (oxyticin as ordered)  Provide adequate fluid  Pain relief (morphine sulfate)  Clean, dim, quiet enviro y Medical mngt.  Amniotomy  Oxytocin  C/S Protracted Active Phase y Associated with CPD or fetal malposition y Cervix opens slower than the standard rate of 1.2 cm/hr. for nullipara or 1.5 cm/hr. for multipara y Hypotonic contractions y Medical mngt.  No CPD oxytocin  With CPD C/S Prolonged deceleration phase y Beyond 3 hour for nullipara and 1 hour for multipara y Usually due to abnormal fetal head position y Medical mngt.  C/S y

Dysfunction according to Second Stage 1. Prolonged descent y Fetus descends at a rate less than 1cm/hr. for a nullipara and 2cm/hr. for a multipara y Takes over 3 hours in multipara y Nursing mngt.  Rest  Increase fluid intake  Position for more effective pushing:  Semi-fowlers  Squatting  kneeling y Medical Mngt.  Amnoitomy if membranes have not ruptured  Oxytocin (IV) 2. Arrest of Descent > no descent y Medical mngt.  No CPD oxytocin  With CPD C/S Contraction Rings hard band that forms across uterus at the junction of upper and lower uterine segment which interferes with fetal descent Bandl s Ring occurs early in labor due to uncoordinated contractions. Detected early through ultrasound. y Medical mngt.  IV morphine sulfate or inhalation of amyl nitrate for pain

 C/S delivery  Manual delivery of placenta if ring occurred after normal delivery of baby Precipitate Labor strong, few, rapid contractions resulting in a speedy delivery of 3 hours or less y Occurs during grand multi parity, or after amniotomy or after admin of oxytocin y Danger:  Mother lacerations and premature separation of placenta which could lead to hemorrhage  Fetus subdural hemorrhage y Nursing Mngt.  Educate multiparous to plan th early, be ready by the 28 week  Prepare (labor/birthing room) Precipitate dilation 5 cm/hr. in primi 10 cm/hr. in multi Induction and Augmentation of labor y Induction of Labor labor is started artificially, usually done when fetus is in danger or normal labor can no longer continue (i.e. eclampsia, pre-eclampsia, severe HTN, DM, Rh sensitivity, Prolonged ROM, intrauterine growth restriction, post-maturity of fetus) y Augmentation of Labor labor started spontaneously but is not effective often due to hypotonic contractions y Risks:  Uterine rupture  Decrease in fetal blood supply y Caution in:  Multi gestation  Hydramnios  Grand parity  Woman age 40+  Uterine scars y Necessary conditions  Longitudinal lie  Ripe cervix  Engaged  No CPD  Term Cervical Ripening change in cervical consistency from firm to soft (Bishop Score of 8+) How to ripen? 1. Stripping the membranes y Dangers  Bleeding of undetected low lying placenta  Infection  Inadvert PROM/amniotomy 2. Laminaria Technique or Hygroscopic suppositories (swelling seaweed) held in place by gauze sponges soaked in povidone iodine or antifungal cream 3. Prostaglandin gel (ex. Misoprostol) y Give every 6 hours in 2-3 doses y Side effects  Vomiting  Fever  Diarrhea  HTN

 Avoid if woman has:  Cardiovascular dse  Glaucoma  Asthma  Nursing mngt.  Woman in bed, side lying  Monitor FHR or 30min after application  If oxytocin is to be give, be sure it at least 6-12 hours later to avoid uterine hyperstimulation Induction of Labor by Oxytocin Augmentation of Labor by Oxytocin Uterine Rupture y Accounts for 5% of all maternal deaths y Occurs when uterus undergoes more stress than it can sustain y Occurs in:  Women with previous vertical C/S scar  Long labor  Abnormal presentation  Multiple gestation  Obstructed labor  Unwise use of oxytocin  Traumatic use of forceps or traction y 2 Types: 1. Incomplete peritoneum left intact  Less evident signs compared to complete rupture  Lack of contractions  Changes in v/s  Localized tenderness in lower uterine segment 2. Complete goes thru all layers of the uterus  Contractions stop immediately  Two swellings visible on abdomen (fetus and uterus)  Blood floods into abdominal cavity and vagina  Shock begins  Air hunger (nasal flaring)  FHR fades then becomes absent y Medical management  Oxytocin to contract uterus  Laparoscopy  C/S hysterectomy Uterine Inversion uterus turns inside out y Nursing management  Never handle uterus  Never remove attached placenta  Increase IVF  Administer oxygen  Assess v/s  Prepare for CPR y Medical management  General anesthesia  Manual replacement of fundus  Antibiotics  C/S for future birth

Problems with the PASSENGER Prolapse of the umbilical cord loop of umbilical cord slips over presenting part y Occurs most often in:  PROM  Noncephalic presentation  Placental previa  Intrauterine tumors  Small fetus  CPD  Hydramnios  Multiple gestation y To assess  U/S  FHR (deceleration) y Nursing management  Manually elevate fetal head off cord  Position mother knee in chest or trendelenburg  Admin oxygen  Cover exposed cord with compress soaked in saline solution Amnioninfusion addition of sterile fluid into uterus to supplement amniotic fluid y Mother in lateral recumbent position y Strict aseptic method y Monitor FHR y Monitor temp for infection y Change wet bed frequently y Watch out for hydramnios Multiple Gestation y Assess hematocrit in case of PIH or anemia y Monitor each FHR Problems with fetal position, presentation and size: Face Brow Transverse Lie Breech y Causes y Less than 40 weeks y Abnormality in fetus y Hydramnios y Space occupying mass y Pendulous abdomen y Multiple gestation y Unknown factors Macrosomia Problems with PASSAGE A. Inlet contraction narrowing of anteropostertior diameter to less than 11cm and transverse diameter to less than 12cm y Caused by:  Inherited small inlet  Rickets early in life y Primigravidas should have pelvic measurement th taken before 24 week B. Outlet contraction narrowing of transverse diameter to less than 11cm. C. Trial labor determines whether labor can progress normally; 6-12 hours y Monitor FHR and contractions y Have woman void every 2 hours

y Educate and explain D. External cephalic version turning of fetus from breech to cephalic position before birth (34-35 weeks or 37-38 weeks) y Assess:  u/s  FHR y Give tocolytics to relax uterus y Contraindicated to:  Multiple gestation  Severe oligohydramios  Those contraindicated to vaginal birth  Cord wrapped around fetal neck rd  Unexplained 3 trimester bleeding  Possible placenta previa y Give women who are Rh-, RhIg E. Forceps Birth y Dangers to the woman:  Dyspareunia  Anal incontinence  Urinary stress incontinence y Necessary if:  Woman unable to push with contractions  Cessation of contractions at 2nd stage of labor  Fetal distress (cord compression) y Above +2 station low forceps birth y Below +2 station mid forceps birth y Before forceps birth, ensure:  Membranes are rupture  No CPD  Fully dilated cervix  Empty bladder  Take FHR (and again after application of forceps)  Record time and amount of last voiding y After procedure:  Assess newborn for facial palsy or subdural hematoma (transient erythematous mark gone in 2 days) F. Vacuum Extraction disc shaped cup placed against fetal scalp over posterior fontanel to suction and extract baby from birth canal. y Advantages over FB:  Less anesthesia  Fewer lacerations y Disadvantages:  Causes marked caput on newborn s head w/c lasts for 7 days  Tentorial tears y Not for:  Fetus that had a fetal scalp sampling  Preterms soft scalp Anomalies of PLACENTA and CORD Placenta normally 500g (1/6th the wt., of fetus), 15-20 cm. in diameter, 1.5 to 3 cm. thick y Syphilis or erythroblastosis = heavier placenta y Uterine scars or septum = wider placenta 1. Placenta succenturiata has one or more accessory lobes connected to the main placenta by blood vessels.

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After delivery, ensure no lobes are retained Placenta circumvallata fetal side of placenta covered to some extent by chorion Placenta Marginata chorion fold reaches to edge of placenta Battledore placenta cord is inserted marginally rather than centrally Velamentous insertion of cord instead of entering placenta directly, the cord separates into small vessels that reach placenta by spread across a fold of amnion. y Often in multiple gestation y Examine newborn carefully for anomalies Vasa previa umbilical vessels cross cervical os and is delivered before fetus y Danger:  Vessels may tear with cervical dilation  Insertion of instruments y Medical Management  C/S y 2 vessel cord associated with heart and heart anomalies Unusual cord length y Short - Causes premature separation of placenta or abnormal fetal lie y Long although cord tends to twist ant knot, pulsations keep blood flow adequate

Cord 1. 2.