INTRAPARTAL COMPLICATIONS COMPLICATIONS WITH THE FORCE OF LABOR Dysfunctional labor sluggishness of labor or force of contraction; also inertia a. Primary occurred at onset of labor b.
Secondary occurred later in labor
Causes: a)
inappropriate use of analgesia (excessive or too early administration)
b)
pelvic bone contraction that has narrowed the pelvic diameter (women with rickets)
c)
poor fetal position (posterior r ather than anterior)
d)
extension rather than flexion of the fetal head
e)
overdistention of the uterus (e.g. multiple pregnancy, hydramnios, excessively oversized fetus)
f)
cervical rigidy (unripe fetus)
g)
full rectum or urinary bladder
h)
exhausted mother from labor
i)
primigravida
A. INEFFECTIVE UTERINE FORCE Uterine contractions basic force moving the fetus through the birth canal Mechanism:
1.
-
Contractile enzyme ATP
-
influence of major electrolytes (calcium, sodium, potassium)
-
specific contractile proteins (action and myosin)
-
epinephrine, norepinephrine, oxytocin, estrogen, progesterone and pr ostaglandins
Hypotonic contractions -
The number of contractions is usually low or infrequent (not increasing beyond two or three in a 10-minute period)
ASSESSMENT mmHg
-
Resting tone less than 10
-
Strength of contractions does not rise above 25 mmHg
-
These contractions are not exceedingly painful, because of their lack of intensity
-
Hypotonic contractions increase the length of labor which causes uterus not to contract effectively during postpartal period because of exhaustion, increasing risk for postpartal
hemorrhage -
Cervix
dilated for long period, uterus & fetus risk for infection
Occurrence: -
Most
-
May
likely to occur during the active phase of labor
occur after administration of analgesia, cervix is not dilated to 3 to 4 cm, bowel or
bladder distention
-
Overstretched uterus by multiple gestation
-
Large fetus
-
Hydramnios
-
Uterus lax from
grand multiparity
MANAGEMENT -
Oxytocin for augmenting labor by strengthening contractions and increasing their effectiveness
-
Amniotomy (artificially (artificially rupturing of membranes) to further speed labor st In the 1 hour after birth, palpate uterus and assess lochia every 15 min to make sure that
-
contractions are not hypotonic and therefore inadequate to control bleeding 2.
Hypertonic contractions -
marked by an increase in resting tone to more than 15 mmHg
-
contractions are strong, however they are ineffective and not achieving a certain cervical dilation
-
occurs because the muscle fibers of the myometrium do not repolarize or relax after a contraction
-
more than one pacemaker is stimulating the contraction
-
myometrium becomes tender from constant lack of relaxation and anoxia of uterine cells that results
ASSESSMENT -
occur frequently, commonly seen in latent phase of labor
-
more painful than usual
-
breathing exercises for childbirth are ineffective
-
may lead to fetal anoxia early in the latent phase of labor because the lack of relaxation between contractions may not allow optimal uterine artery filling
MANAGEMENT -
pain seems out of proportion to the quantity of her contractions (apply uterine and fetal external monitor for
15
min to ensure that the resting phase of the contractions is
adequate and fetal pattern is not showing late deceleration) -
administer morphine sulphate
-
changing the linen and the clients gown, darkening room lights, and decreasing nose and stimulation
caesarean Considering caesarean
3.
birth if:
a.
deceleration in the fetal heart rate (FH R) occurs
b.
abnormally long first stage of labor
c.
lack of progress in pushing (second-stage arrest) arrest)
Uncoordinated contractions -
More
than one pacemaker may be initiating contractions, or receptor points in myometrium
may be acting independently of the pacemaker -
Does
not allow good cotyledon filling
ASSESSMENT -
Woman
may find it difficult to rest between contractions or use breathing exercises with
contractions
MANAGEMENT -
Fetal and uterine external monitor
-
Asses the rate, r ate, pattern, resting tone, and fetal response to contractions for at least 15 min
-
Oxytocin administration administration for more effective and consistent contractions with lower resting tone
DYSFUNCTIONAL LABOR &ASSOCIATED STAGES OF LABOR 1.
Dysfunction with the
FIRST STAGE OF LABOR
a.
Prolonged latent phase
-
Longer than 20 hrs for nullipara and 14 hrs in multipara
-
May occur if there is
-
Hypertonic state, 15 mmHg contraction strength, ineffective
-
hypotonic
excessive use of analgesics
Management:
-
Help uterus to rest
-
Administer adequate fluids to prevent dehydration
-
Morphine to relax hypertonicity
-
Caesarean birth, amniotomy, oxytocin infusion (if
b.
Protracted
-
Associated with CPD or fetal malposition
-
Cervical dilatation is < 1.2
-
primigravida and > 6 hrs in multipara Active phase is > 12 hrs in primigravida
no progress)
active phase
cm/hr in nullipara and <1.5 cm/hr in a multipara
Management:
2.
-
If cause is CPD or fetal malposition: caesarean
-
If CPD not
c.
Prolonged deceleration phase
-
> 3 hrs in nullipara and >1 hr in multipara
-
Caesarean birth necessary
d.
Secondary arrest of Dilatation
-
No progress in cervical dilatation for 2 hrs
Dysfunction with the
birth
present: oxytocin to augment labor
SECOND STAGE OF LABOR
a.
Prolonged descent
-
<1.0
cm/hr in nullipara and <2.0 cm/hr in multipara
-
Contractions become infrequent and of poor quality and
dilatation stops
Management:
-
Amniotomy
-
IV
-
Semi-Fowlers position, squatting, kneeling, or more effective pushing may speed descent
b.
Arrest of descent
-
No descent has occurred in 2 hrs in nullipara and 1 hr in multipara
-
Most common cause: CPD
-
Caesarean is necessary; if no
oxytocin
contraindications contraindications in vaginal birth administer oxytocin
PROBLEMS WITH THE PASSAGENGER a.
Prolapse of the Umbilical Cord -
Loop of umbilical cord slips down in front of the presenting fetal part
-
May
occur at any time after the rupture of membranes if the presenting part is not fitted
firmly into the cervix Causes:
-
Premature rupture of membranes
-
Fetal presentation other than cephalic
-
Placenta previa
-
Intrauterine tumors
-
Small fetus
-
CPD
-
Hydramnios
-
Multiple gestation
ASSESSMENT -
Identified through sonogram
-
May be felt as
-
Caesarean birth is necessary before rupture of membrane occurs
-
Cord
the presenting part on initial vaginal examination during labor
prolapsed is first discovered only after the membranes have ruptured, when a variable
deceleration FHR pattern suddenly becomes apparent MANAGEMENT
-
Relieving pressure on the cord thereby relieving the compression and the resulting fetal anoxia
-
Manually elevating the head of the fetus off the cord
-
Place
-
O2 therapy at 10 L/min by facemask
-
Tocolytic agent to reduce uterine activity
the woman in a knee-chest or Trendelenberg position
b.
Multiple Gestation ASSESSMENT -
There is increased incidence of cord entanglement and premature separation of the placenta
-
Anemia and PIH occurs at a higher rate during multiple gestations
-
Because the babies are usually small, there is an increased risk for cord prolapse
MANAGEMENT
-
Assess for the womans hematocrit level and blood pressure closely during labor or while waiting for cesarean surgery
-
Twins may be born through caesarean surgery to decrease the possibility that the second fetus will experience anoxia
-
If
the woman decides to have a NS D, instruct her to come to the hospital early
-
The early hours of labor can be used for practicing breathing exercises to minimize the need for anesthesia and analgesia
-
Monitor each FHR
by a separate fetal monitor during labor
PROBLEMS WITH PASSAGE a.
Inlet contraction -
Narrowing of the anteroposterior diameter diameter to less than 11 cm, or of the transverse diameter to 12 cm or less
-
Caused
by rickets in early life or by an inherited small pelvis
ASSESSMENT -
If
in primigravida, engagement occurs between week 38 to 38 of pregnancy; if engagement
does not occur in a primigravida, then either a fetal abnormality (large than usual head) or a pelvic abnormality (smaller than usual pelvis) should be suspected -
Engagement does not occur in mul tigravida until labor begins
MANAGEMENT
-
Every primigravida should have a pelvic measurement taken and record before week 24 of
pregnancy b.
Outlet contraction -
c.
Narrowing of the transverse diameter at the outlet to less than 11 cm
Trial labor -
trial labor determines whether labor can progress normally; it continues as long as descent of the presenting part and dilatation of the cervix are occurring
MANAGEMENT
-
Monitor fetal heart sounds and uterine
contractions
-
Encourage the woman to void every 2 hrs to empty her bladder as possible
-
Assess FHR carefully after rupture of m embranes
-
It
-
Reassure
is best for the baby to be born vaginally; if trial labor fails, caesarean birth is considered the woman and her support person that a caesarean birth is an alternative, not an
inferior, method of birth
d.
External cephalic version -
Is
the turning of a fetus from a breech to a cephalic position before birth
-
May
be done as early as 34 to 35 weeks, although usual time is 37 to 38 wee ks
MANAGEMENT
-
FHR and ultrasound are recorded continuously
-
A tocolytic agent may be administered to help relax the uterus
-
The breech and vertex of the fetus are located and grasped transabdominally by the examiners hand on the womans abdomen
-
Gentle pressure is then exerted to rotate the fetus in a forward direction to a cephalic lie
-
Women
who are Rh negative should receive Rh immunoglobulin after the procedure in case
minimal bleeding occurs Contraindications:
-
Multiple gestation
-
Severe oligohydramnios
-
Contraindications to vaginal birth
-
A cord that wraps around the neck
-
Unexplained third-trimester bleeding
ANOMALIES OF THE PLACENTA -
Normal placenta: 500 g; 1/6 that of the fetus weight 15 to 20 cm in diameter 1.5 to 3.0 thick
-
Placenta
is unusually enlarged in diabetic mothers; weighs half as much as the fetus in cases
where syphilis or erythroblastosis is present a.
Placenta succenturiata succenturiata -
Has one or more accessory lobes connected to the main placenta by blood vessels
-
It
is important that it be recognized, because the small lobs may be retained in the uterus
after birth, leading to severe maternal hemorrhage, hemorrhage, and therefore should be removed ASSESSMENT -
Placenta
appears torn at the edge, or torn blood vessels extend beyond the edge of the
placenta b.
Placenta circumvallata -
The fetal side of the placenta is covered to some extend with chorion
-
The umbilical cord enters the placenta at the usual midpoint, and large vessels spread out from there. They end up abruptly at the point where the chorion folds back onto the surface.
c.
Battledore placenta -
d.
The cord is inserted marginally rather than centrally
Velamentous insertion of the cord -
The cord separates into small vessels that reach the placenta by spreading across a fold of amnion instead of entering the placental directly
-
Mostly found in:
multiple gestation
-
Management
is to examine the newborn carefully because it is associated with fetal
anomaly e.
Vasa previa -
The umbilical vessels of a velamentous cord insertion cross the cervical os and therefore deliver before the fetus
-
The vessels may tear with cervical dilatation, just as a placenta previa may tear
ASSESSMENT -
Painless bleeding occurs with the beginning of
-
It may be confirmed with
cervical dilatation
sonography
MANAGEMENT
-
Before inserting any instrument such as an internal fetal monitor, structures should be identified to prevent accidental tearing of vasa previa
f.
If vasa previa is i dentified, infant needs to be born
by caesarean birth
Placenta accrete -
Unusually
deep attachment of of the placenta to the uterine myometrium
-
The placental will not loosen and deliver
-
Removing it manually may lead to extreme hemorrhage because of i ts deep attachment
MANAGEMENT
-
Hysterectomy
-
Methotrexate to destroy the still-attached tissue
ANOMALIES OF THE CORD a.
Two-vessel cord -
A normal cord contains one vein and two arteries
-
Absence of one of the umbilical arteries is associated with congenital heart and kidney anomalies
MANAGEMENT
-
Inspection
of the cord after birth should be done immediately and before it begins to dry,
since drying distorts the appearance of the vessels
b.
-
Document the number of vessels conscientiously
-
Observe carefully the child with only two vessels for other anomalies
Unusual cord length -
Abnormally short umibical cord: Premature
separation of the placenta
Abnormal fetal lie -
Unusually
TILLA-IN, KRISTELIE MAE BSN 2Y2 - 7
long umbilical cord cord has the tendency to twist or knot
