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