Abnormal labor
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.
· Problems in psychological status.
· Common complication.
· Nursing management for dystocia.
· Obstetric emergencies & its management.
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:
1. Define related definitions correctly.
2. Mention factors that might complicate labor completely.
3. Clarify problems in powers.
4. Identify problems in passage.
5. Mention problems in placenta.
6. Explain problems in passenger.
7. Discuss nursing management for abnormal labor
8. Identify obstetric emergencies accurately.
9. Explain nursing management for emergencies according to priority of care.
Abnormal labor
Introduction:
While many risk factors may appear in the prenatal period, others will only become evident in admission in the birthing unit or develop during birth and labor. The nurse plays a central role in promptly recognizing suspected and obvious abnormalities. When life-threatening condition arises rapid appraisal is necessary.
According to the national maternal mortality survey, obstructed and prolonged labor accounted for 8% of deaths from direct obstetrical causes (64.5%). And about 60% of maternal deaths occur in medical facilities.
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.
Precipitated labor: The labor last for about 1 – 3 hours.
Dystocia: Prolonged, painful, or difficult delivery results from deviation from normal interrelationships between five essential factors of labor (power, passage, passenger, placenta & psychological status).
OR Dystocia is defined as abnormal or difficult labor, whereas eutocia describes normal labor or childbirth and oxytocia describes rapid labor.
Factors that might complicate progress of labor:
Uterine factors (abnormalities of the power);
1. Hypotonic uterine contraction.
2. Hypertonic uterine contraction.
3. Incoordinate uterine action.
o Pelvic factors (abnormalities of the passage);
1. Contracted pelvis ( inlet – midpelvis – outlet ) contracture.
2. Abnormal pelvic shape.
3. Soft tissues obstruction.
Fetal factors (abnormalities of the Passenger);
1. Unusually large fetus & Fetal anomaly.
2. Abnormal fetal number.
3. Abnormal fetal disposition.
Placental factors (abnormalities of the Placenta);
1. Unusually large placenta.
2. Abnormal shape.
3. Abnormal site of insertion.
Psychological status; refers to client’s psychological state, available support system, preparation for childbirth, experiences & coping strategies.
Abnormalities in the power:
Power Indicates primary involuntary uterine muscle contraction and secondary voluntary abdominal muscles contractions by bear down.
Abnormal uterine contraction:
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.
Incoordinate uterine action;
- Contraction ring; It is a localized spasm of the circular muscle fibers of the uterus. It usually occurs around a groove in the fetal body e.g. neck. It not seen or felt abdominal.
- Retraction ring (Pathological or Bandle’s ring); occurs at the junction of the upper and lower uterine segment, it occurs at the level of umbilicus, it seen & felt as a sign of obstructed labor.
Factors leading to weak voluntary power are;
1. Weak abdominal muscles.
2. Obesity associated with weak abd. Muscles.
3. Epidural anesthesia.
4. Debilitating diseases as anemia, HD & diabetes.
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 o the fetus due to falling.
Role of the nurse
Major objectives of care are as follows: - Preventing maternal trauma.
- Preventing transmission of infection. - Establishing the neonate’s airway and maintaining respiration. - Minimizing blood loss.
- Reassuring the woman and securing medical help.
- The nurse must be prepared to evaluate the woman’s labor status, alert the birth attendant and other staff as needed.
- The nurse must immediately assess or the woman’s labor patterns, stage of cervical dilatation and effacement, and fetal station and presentation.
FHR should be auscultation at once and monitored for signs of apparent fetal distress.
- Once the second stage is initiated, place the palm of the hand firmly against the perineum and emerging fetal head.
- If time permits, turn the woman to aside lying or Sim,s position.
- When the head is born, suction the neonate’s mouth & nares.
- Clamp the cord, and complete the care as normal labor.
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.
Nursing implications:
- Continuous monitoring of progress of labor and fetal condition.
Fetal heart assessment for signs of distress and uterine assessment for titanic contractions and pathological ring is essential.
- Close monitor of intake and output and vital signs for possibility of uterine rupture.
- Comfort measures to relieve pain and encourage progress of labor.
- Give glaucose intravenous to avoid dehydration.
- Antibiotics to control infection.
- Intravenous oxytocin is started and fetal monitoring is closely observed
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.
Degrees of contracted pelvis:
Minor degree: The true conjugate is 9-10 cm. It corresponds to minor disproportion.
Moderate degree: the true conjugate is 8-9 cm. It corresponds to moderate disproportion.
Marked degree: the true conjugate is 6-8 cm. It corresponds to marked disproportion.
Extreme degree: The true conjugate is less than 6 cm. Vaginal delivery is not possible.
Diagnosis of disproportion
1-History
*Bone disease or fractures. *Previous difficult labor.
2-General examination
- Short stature less than 150 cm.
- Bone deformity or limping gait.
- Rachitic flat pelvis.
- A symmetrical due to poliomyelitis, pelvic turmors, or fracture.
3-Abdominal examination
- Pendulous abdomen.
- Malpresentation.
- Non-engagement of the fetal head after 37 weeks in primigravida.
4-Pelvic examination.
- Non engaged head.
- Palpable sacral promontory and prominent ischial spines.
- Convergent side walls.
- Narrow subpubic angle and arch.
- Unsatisfactory tests of disproportion.
5-During labor:
- Failure of the head to descend.
- Failure of the cervix to dilate progressively, even after the use of oxytocin stimulation.
- Excessive moulding and caput formation.
6-Radiological diagnosis
By x-ray or CAT scan. Lateral view is satisfactory to get data about the anteroposterior diameters of the pelvis, curve of the sacrum, sacrosciatic notch and engagement of the head.
Management of disproportion
It depends on the degree of disproportion.
Indication for elective cesarean section (C.S):
- Marked disproportion.
- Moderate disproportion with other obstetric complications as malpresentations, bad obstetric history, and previous c.s. or failed trial labor.
- Associated medical problems as diabetes, hypertension.
- Preterm labour. - Contracted out let.
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;
1. Ovarian tumor.
2. Uterine fibroid,
3. Bicornuate, double uterus, septate uterus or didelphys.
4. Cervical polyps.
5. Vaginal stenosis.
6. 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. A variety of fetal problems may have particular significance in the intrapartum period, increasing maternal and fetal risk. Other problems include fetal anomalies that influence the course of labor and birth; multifetal gestation, which poses additional risks to fetal well being in the intrapartum period; which not only affect the physiologic, but also the psychological process or labor and birth.
1-Multifetal gestation:
Multifetal gestation includes twins pregnancy, triplets, or quadrates. Prenatal care for woman with multifetal gestation as well as intrapartum care is essential in preventing hazards that can affect both maternal and fetal life and health.
Causes:
The aetiology of spontaneous monozygotic twins is unclear, Dizygotic twins has the following predisposing factors:
- 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. The incidence is approximately 20%.
- Race predisposition: It’s common among nigerian black women, while it is less seen among Japanese women.
- Multiparity: it is more common among parous women than nulliparous women.
Diagnosis:
- Multifetal pregnancy often suspected when the uterine size or fundal height is greater than dates.
- Ultrasonographic estimation of two or more feta noutlines and auscultation of more than one fetal heart is a positive sign.
Maternal and fetal implications:
Although the rates of morbidity to those women with multiple gestation the mortality rates is just slightly higher.
Intrapartum complications associated with multifetal gestation:
- Pregnancy induced hypertension.
- Abruption-placenta.
- Placenta-previa.
Role of nurse
- The nurse should evaluate fundal height on her first assessment and perform abdominal examination to identify fetal extremities.
- Report immediately suspicion of multiple gestations.
- Intrapartum care includes close observation of vital signs. Assessment of signs of pregnancy induced hypertension, including edema, proteinuria and hypertension. Close monitoring of fetal heart rates guided by ultrasonography is useful.
- Assessment of progress of labor and early detection of dystocia.
- Immediate newborn care and identification of the two twins, weighing them and keep them warm all the time. Avoidance of invasive procedure and gentle suctioning is essential.
Fig. 1 Different position for twins
2-Abnormal fetal position and presentation
Abnormal fetal presentation and position can lead to dystocia and ineffective uterine contractions. It includes the follows:
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.
Incidence: It occurs in 15-30% of labor, most of fetuses rotate during labor.
Aetiology:- Android pelvis. - Anthropoid pelvis.
- Cephalopelvic disproportion. - Pendulous abdomen.
- Multiple pregnancy.
Diagnosis: During abdominal assessment the fetal back is not identified well, while fetal small parts are easily identified, fetal heart rate may best heard at maternal flank, far from the midline. The anterior fontanel is readily felt in the anterior segment of the maternal pelvis, FHS are heard very well through fetal chest by ultrasonography shows the position of the fetus.
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.
Nursing implications:
- The nurse should encourage the woman to use positions that may help fetal rotation.
- The nurse should monitor intake and output as dehydration is possible from prolonged labor and assess of urine for ketone bodies is important.
- Evacuate the bladder and assessment of urine for ketone bodies is important.
- Encourage the woman to prevent frustration and assess fetal heart closely especially at the second stage of labor.