Abnormal Progress in Labor

Precipitous Labor and Birth

Retraction Rings

Busa, Ana Marie

Nodalo, Evelyn Tan, Louie

Ymas, Christine

Precipitous Labor

and Birth

Precipitate Labor – occur when uterine contractions are so strong that the woman gives birth with only so strong that the woman gives birth with only a few, rapidly occurring contractions. It is also defined as an extremely rapid labor that last less than 3 hours from start to finish

Precipitate Birth - is a sudden and often unattended birth.

Contributing Factors:

•Multiparity•Large pelvis•Previous precipitous labor•Small fetus in a favorable position•Strong contractions

Signs & Symptoms• Increased pain more than normal• Increased maternal heart rate, pulse

and body temp• Increased BP • Nasal Flaring• Anxiety• Restlessness• Hypertonic Contractions

Maternal risk:• Lacerations of the cervix, vagina, and or

perineum• Uterine rupture• Amniotic fluid embolism• Postpartal hemorrhage• Abruptio placentae

Fetal/neonatal risk:• Fetal hypoxia• Cerebral trauma• Meconium stained fluid• Low apgar score

A D P I E

Assessment:• Assess previous labor history if the woman is a

multipara• Assess contraction status. Be alert for

contractions that are more frequent than every 2 minutes and dilatation that progresses faster than normal (more than 1.5cm/hr)

• Assess fetal status• Assess mothers comfort level• Assess mother’s coping abilities

Nursing Diagnoses:• Acute pain related to accelerated labor pattern• Risk for ineffective coping related to

ineffectiveness of breathing techniques to relieve discomfort

Planning:During the entire process of labor and birth:

• The nurse should closely monitor the woman’s contractions and cervical dilatation, and an emergency birth pack is kept near the bedside.

• The nurse should stay in constant attendance, assist the woman to a comfortable position and provides a quiet environment.

Nursing Interventions:Non- Pharmacologic:• Continue electric monitoring• Remain in room to provide support and

comfort measures for the woman

• Instruct the woman not to bear down until she is instructed to do so.

• Instruct woman to pant with contractions if fetal head is crowning

• Apply gentle pressure anteriorly against the fetal head to maintain flexion and prevent it from delivering too quickly.

• Support the perineum by making U shape with the other hand and supporting the descending head between contractions to prevent excess tearing and perineal lacerations.

Pharmacologic:• In such cases, a tocolytic agent such as

terbutaline may be administered to reduce the force and frequency of contractions

• Notify physician for rapid cervical changes

Evaluation:

• The woman and her baby are closely monitored during labor and a safe birth occurs

• The woman states that she feels supported and enhanced comfort during labor and birth

Retraction Ring

Retraction Ring - also called Bandl’s Ring

- occurs at the junction of the upper and lower uterine segments. The Ring usually appears at the 2nd stage of labor as a horizontal indentation across the abdomen and is a warning sign that a dysfunctional labor is occurring; it is formed by excessive retraction of the upper uterine segment.

-A constriction of the junction between the thinned lower uterine segment and the thick retracted upper uterine segment caused by obstructed labor; a sign of impending rupture of the uterus.

Retraction Ring

Retraction Ring

Ruptured Uterus

Contributing Factors• An abnormality in a mother’s pelvis (a

contracted pelvis).• Fetal causes (hydrocephalus, fetal ascitis,

sacrococcygeal tumours, conjoined twins• Cephalopelvic disproportion• Previous caesarean section, still births and

previous prolonged labor.• Delay in referral to higher level of care for

caesarean sections• Abnormal presentations and position

Signs & Symptoms• Hypertonic contractions• Presenting part driven/jammed• Mother experiences severe pain and excited or restless

emotions• Maternal pulse, temperature rise• Palpable, taut round ligaments; may also be visible• Baby entirely or almost entirely in lower uterine segment.• Ring felt as transverse ridge, as high up as umbilicus or

potentially even higher• Mother maybe cold and clammy Anxious and restless• Uterus is painful and sore to touch• Fundus is thickened and tense• The mother complains of severe abdominal pains

Maternal Risk:• Puerperal sepsis• rupture of the lower segment, • maternal hemorrhage• maternal exhaustion, inertia, and arrest of

contractions• maternal fistula, lacerations

• Neonatal Risk:• Asphyxia• Intracranial hemorrhage• Delayed complications—delayed milestones,

convulsive disorders, mental retardation etc.• placental abruption • uteroplacental insufficiency with resultant fetal

hypoxia and distress. • still births and neonatal death

Pathologic retraction ring occurs, strong uterine contractions w/o

cervical dilatation

“tearing sensation”

Complete Uterine rupture

Incomplete Uterine rupture

Rupturing of endometrium, myometrium and perimetrium

Rupturing of endometrium and myometrium

Uterine contraction stopsLocalized tenderness and

persisting aching pain over the area of the uterine segment

Swelling of the abdomen:•Retracted uterus

•Extrauterine fetus

Hemorrhage from torn uterine arteries

Bleeding into the peritoneal cavity

Bleeding to the vagina

Decreased blood volume

Decreased venous return

Decreased cardiac output

Decreased BP

Heart attempts to circulate remaining blood volume

Vasoconstriction of peripheral vessels, increased heart rate

Cold, clammy skin

Increases gas exchange to oxygenate better the decreased

blood volume

Increased respiratory rate

Continued blood loss will continue to fall BP

Uterine perfusion is decreased

Fetal distress

Decreased brain perfusion

Decreased kidney perfusion

Decreased LOC (lethargy, coma)Decreased urine output

Renal failure

Death of Mother and fetus

A D P I E

Assessment• Assess maternal vital signs; especially note an

increase in rate and depth of respirations, an increase in pulse , or a drop in BP indicating status change.

• Observe for signs and symptoms of impending rupture (ie, lack of cervical dilatation, tetanic uterine contractions, restlessness, anxiety, severe abdominal pain, fetal bradycardia, or late or variable decelerations of the FHR).

• Assess fetal status by continuous monitoring.• Assess fetal position, presentation and

descent.• Assess laboring woman for hydration status.• Assess woman’s comfort and coping level.

Diagnosis•Acute Pain related to inability

to relax secondary to labor pattern

•Fatigue and Anxiety related to prolonged labor

•Risk for deficient fluid volume related to length and work of labor.

PlanningDuring the entire process of labor and birth:

• The nurse should closely monitor the woman’s contractions and cervical dilatation, and an emergency birth pack is kept near the bedside.

• The nurse should stay in constant attendance, assist the woman to a comfortable position and provides a quiet environment.

InterventionNon-Pharmacologic Intervention• Monitor labor status and fetal status

through continuous electronic monitoring and then compare to expected norms.

• Assist in relaxation and breathing techniques, Back-rubs, change sheets

• Maintain a quiet and calm atmosphere to enhance relaxation.

• Try alternative maternal positions or activity that might facilitate rotation of fetal head or assist with fetal descent.

• Ask patient to lie on the left side to prevent impeding the vena cava.

Pharmacologic Interventions• Start IV Fluid as prescribed to

provide glucose for energy.• Prepare for Cesarean Section as

indicated.• Administer IV morphine sulfate or the

inhalation of amyl nitrate as prescribed to relieve retraction ring.

• Administer tocolytic as prescribed to halt contractions.

Evaluation• Client states that she is able to

continue active participation in labor and maintains effective breathing.

• The woman and her baby are closely monitored during labor and a safe birth occurs

• The woman states that she feels supported and enhanced comfort during labor and birth

Thank you for

Listening!!!!