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).
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)
Hypotonic uterine contraction.
Hypertonic uterine contraction.
Incoordinate uterine action.
Pelvic factors (abnormalities of the passage):
Contracted pelvis (inlet - midpelvis - outlet) contracture.
Abnormal pelvic shape.
Soft tissues obstruction.
Fetal factors (abnormalities of the Passenger):
Unusually large fetus & fetal anomaly.
Abnormal fetal number.
Abnormal fetal disposition.
Placental factors (abnormalities of the Placenta):
Unusually large placenta.
Abnormal shape
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 anesthesia.
Chorioamnioitis.
Malpresentation, 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 Handle'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 abdominal Muscles.
3. Epidural anesthesia.
4. Debilitating diseases as Anemia, RHD & Diabetes.
PRECIPITATED LABOR
Definition:
Labor lasting less than 3 hours, it is more common in
multipara women. In some women, the uterus is over
efficient and the onset of labor to birth is an hour or less.
Much or all of the first stage is not recognized because
contractions are not painful and the realization of the birth of the head
may be the first indication that labor has actually started.
Predisposing factor:
There are common factors which may cause a woman to deliver
rapidly. These factors include:
A multipara with relaxed pelvic or perineal floor muscles
may have an extremely short period of expulsion.
A multipara with unusually strong, forceful contractions.
Two to three powerful contractions may cause the baby to
appear with considerable rapidity.
Inadequate warning of imminent birth due to absence of
painful sensations during labor.
Risks to the baby include:
Hypoxia as a result of the frequency and strength of the contractions.
Intracranial hemorrhage from the sudden compression and
decompression of the fetal skull as it passes through the birth canal
with speed
Possible injury as the head and body delivered rapidly and possibly
fall to the floor.
strong frequent uterine contractions reducing placental perfusion,
Rupture of the umbilical cord.
Risks to the mother:
Lacerations of the cervix, vagina and perineum.
Shock.
Inversion of the uterus.
Postpartum hemorrhage:
Sepsis due to, lacerations, inappropriate surrounding condition during
labor.
Management of precipitate labor:
Before delivery:
Patient who had previous precipitate labor should be
hospitalized before expected date of delivery.
During delivery:
Inhalation anesthesia as nitrous oxide and oxygen is given to
slow the course of labor
Tocolytic agents as ritodrine may be effective
Episiotomy: to avoid perineal lacerations and intracranial
hemorrhage.
After delivery:
Examine the mother and fetus for injuries
Check perineum for lacerations
Immediate fetal resuscitation
Immediate repair of lacerations
Slow labor (prolonged labor)
Labor lasting more than 24 hours that leads to increased levels
of stress, anxiety and fatigue and the increased the risk of infection,
post partum hemorrhage and emergency cesarean section. A
partogram is very useful to assess progress
Causes
Excessive analgesia.
cephalopelvic disproportion.
Malpresentations and malpositions.
Abnormal uterine action
Risks of prolonged labor
There are risks to the mother:
- Prolonged labor increases the chances that you will need a C-section.
- Infection
- Maternal exhaustion,
- Postpartum hemorrhage
-Risks to fetus:
Labor that takes too long can be dangerous to the baby. It may
cause:
Low oxygen levels for the baby
Abnormal heart rhythm in the baby
Abnormal substances in the amniotic fluid
Uterine infection
If the baby is in distress, you will need an emergency delivery.
This is the time where close monitoring is important to the health
of you and your baby.
Diagnosis:
if the 1st stage of labor lasting more than the normal duration
or if the cervical dilatation arrested for more than 2 hrs
when the mother in the latent phase complaining from irregular
uterine contractions, discomfort and pain
rate of cervical dilatation less than 1 cm in primipara and 1.5
cm in multipara /hr
Management
Reassessment of the condition.
Pain relief: Pethidine or epidural analgesia.
Amniotomy: if membranes still intact.
Oxytocin: if amniotomy does not bring good uterine
contractions and there is no contraindication for it.
Caesarean section is indicated in when the following occur:
Failure of the above measures.
cephalopelvic disproportion.
Malpresentations not amenable for vaginal delivery.
Contraindications to oxytocin.
Fetal distress.
OBSTRUCTED LABOR
It is the arrest of vaginal delivery of the fetus due to
mechanical obstruction
Etiology
Maternal causes:
Bony obstruction: e.g. contracted pelvis, tumors of pelvic bones.
Soft tissues obstruction:
Uterus: fibroid, constriction ring opposite the neck of the fetus
Cervix: cervical dystocia.
Vagina: septa, stenosis, tumors.
Fetal causes:
Malpresentations and malpositions: eg: occipito-posterior and deep
transverse arrest, mento-posterior and transverse arrest of the face
presentation, brow, shoulder, impacted frank breech.
Large sized fetus (macrosomia).
Congenital anomalies e.g.:
Hydrocephalus.
Fetal ascites
Fetal tumors
Locked tumors
Diagnosis
It is the clinical picture of obstructed labor with impending rupture
uterus (excessive uterine contraction and retraction)
History
Prolonged labor
Frequent and strong uterine contraction\
Rupture membrane
General examination:
It shows signs of maternal distress
Abdominal examination:
The uterus: is hard and tender frequent strong uterine contraction
with no relaxation in between rising retraction ring is seen and felt
as an oblique grooves across the abdomen
The fetus: fetal parts cannot be felt easily FHS are absent or show
fetal distress due to interference with the utero-placental blood
flow
Vaginal examination:
Vulva: is edematous
Vagina: is dry and hot
Cervix: is fully or partially dilated, edematous
The membranes: are ruptured.
The presenting part: is high and not engaged or impacted in the
pelvis. If it is the head it shows excessive molding and large caput.
Complication
Maternal: Maternal distress and ketoacidosis.
Necrotic vesico -vaginal fistula
Infection as choriomnionitis and puerperal sepsis.
Postpartum hemorrhage due to injuries or uterine atone
Fetal:
Asphyxia.
Intracranial hemorrhage from excessive molding.
Birth injuries,
Infection
Management
Preventive measures: Careful observation, paper assessment, early
detection and management of the causes of obstruction.
Curative measures:
Caesarean section is the safest method even if the body is dead as
must be immediately terminated and any manipulations may lead to
rupture uterus.
ABNORMAL FETAL PRESENTATION
1-Breech presentation
Definition
is the birth of a baby from a breech presentation, in which
the baby exits the pelvis with the buttocks or feet first as
opposed to the normal head-first presentation. In breech
presentation, fetal heart sounds are heard just above the
umbilicus.
Etiology
Uterine anomalies such as bicornuate uterus
Fetal anomalies as hydrocephalus or abdominal tumors
Multiple gestation
Premature fetus and low birth weight
Multiparty is associated with breech presentation
Cord around neck
Classification
There are either three or four main categories of breech births,
depending upon the source:
Frank breech – the baby's bottom comes first, and his or her legs
are flexed at the hip and extended at the knees (with feet near the
ears); 65–70% of breech babies are in the frank breech position
Complete breech – the baby's hips and knees are flexed so that the
baby is sitting cross legged, with feet beside the bottom
Footling breech – one or both feet come first, with the bottom at a
higher position; this is rare at term but relatively common with
premature fetuses
Kneeling breech – the baby is in a kneeling position, with one or
both legs extended at the hips and flexed at the knees; this is
extremely rare, and is excluded from many classifications.
Footling breach
Diagnosis
Abdominal examination show vertex is present in fundus and fetal
heart sound is auscultating above umbilical level. By ultrasonography
confirmed diagnosis
Factors affecting mode of delivery in breech presentation
Criteria for vaginal delivery
Fetal weight estimated as less than 3500 gm
Adequate pelvic size
Gestational age of 36 42 week
Birth attendant experienced in vaginal breech delivery and
pediatric support available in event of neonatal problem
Criteria for cesarean delivery
Absence of labor when fetal status requires delivery
Previous history of perinatal death
Inadequate pelvis suggested by previous birth
Nursing management
1-antenatal management
If midwife suspect or detect breech presentation at 36 weeks or
later she should refer woman to doctor
External cephalic version is external manipulation on mother
abdomen used to convert breech to cephalic presentation
Contraindication of external cephalic version is preeclampsia,
oligohydraminos, multiple pregnancy and rupture of membrane
2- during the course of intrapartum
Patient support and clarification of condition is essential
Intravenous infusion is started for possible cesarean section
Electronic fetal monitoring particularly in meconium attained
amniotic fluid
Pediatric nurse and medical staff should attend the labor
Maternal and fetal complication
Premature rupture of membrane
Cord prolapse
Maternal infection
Prolonged labor
Traumatic vaginal delivery and perineal laceration
2-Shoulder presentation
Definition
Shoulder presentation occur when fetus long axis is perpendicular
to maternal axis in transverse lie
Aetiology
Multiparity, lax abdominal muscle
Preterm labor
Low lying placenta
Macrosomic baby
Management
1-Antenatal
Identify the cause is important in management ultrasound
examination can detect placenta previa or uterine abnormalities any of
these causes require caesarean section. once they have excluded external
cephalic version may be attempted if this fail or if lie is again transverse
at next antenatal visit the woman admitted to hospital while further
investigation into cause are made she frequently remain there until labor
because of risk of cord prolapse if membrane rupture
2-Intrapartum
If transverse lie detected in early labor while membrane are still
intact doctor may attempt external cephalic version followed if this is
successful by controlled rupture of membrane. If membrane already
ruptures vaginal examination must be performed immediately to detect
possible cord prolapse
3-Face presentation
Face presentation occur when fetus is in head down. Face
presentation is diagnosed on vaginal examination where facial feature of
fetus are palpable
Aetiology
Contracted pelvis
Polyhydraminos
Congenital abnormality
Nursing management
Patient support and clarification of condition is essential
Nurse should be prepared for emergency delivery and resuscitation
effort if infant is compromised
1. Occiptoposterior position
Aetiology
Android or anthropoid pelvis
Cephalopelvic disproportion
Multiple pregnancy
Polyhydraminos
Nursing management
The nurse should encourage woman to use position that may help
fetal rotation and relieve backache as in squatting, knee chest
position.
The nurse should monitor intake and output as dehydration is
possible from prolonged labor
Evacuate bladder and assessment of urine for ketone bodies is
important
Avoid unnecessary P.V
Assess fetal heart rate closely especially at second stage of labor