Obstetrics Daily Bread

PROBLEMS WITH THE POWERS

A DYSTOCIA (difficult labor)
PROBLEMS WITH THE PS OF LABOR AND DELIVERY
1 PROBLEM WITH THE POWER
A Ineffective Uterine Force
- Uterine contraction is the basic force moving the fetus through the birth canal.
1 HYPERTONIC CONTRACTIONS
- characterized by weak and infrequent contractions which are insufficient to dilate the cervix.
- not painful and occurs during the active phase.
CAUSES:Over distention of the uterus, multiple pregnancy, hydramnios.
Malpresentation and malposition.
Pelvic bone contraction.
Unripe or rigid cervix
Congenital abnormalities of the uterus.
Unknown causes
MANAGEMENT:
o re-evaluate pelvic size to roll out the fetopelvic disproportion
o vaginal delivery
o amniotomy of labor by oxytocin administration
o if contracted pelvic is present, cesarean section method of deliver.
2 HYPOTONIC CONTRACTIONS
- occurs in latent phase of labor
- contraction that are too frequent but uncoordinated
- more painful but ineffective
MANAGEMENT:
- evaluation of the pelvic size
- maintenance of fluid and electrolyte balance by infusion of IV fluids
- rest and pain relief with a drug such as morphine sulfate
- keep bladder empty to provide more space for passage of the fetus
- encouraged side lying position to maximize blood flow to the placenta and fetus
- watch for danger sign signals, fetal distress, passage of meconium, stained amniotic fluid.
B Dysfunctional Labor Associated to the Stages of Labor
1 Dysfunctional at the 1st Stage of Labor
A Prolonged Latent Phase
- a latent phase longer than 20 hours in a nullipara ad 14 hours in multipara
- may occur if the cervix is not ripe at the beginning of labor
- it may occur if there is excessive use analgesics early in labor
CAUSES:
- common cause is entering labor with poor cervical condition characterized by unripe, rigid and firm cervix.
- excessive sedation during latent phase
MANAGEMENT:
- therapeutic rest
- using normal sedatives
- administer adequate fluid to the woman
- CS and oxytocin infusion may be necessary
B Protracted Active Phase
- usually associated with CPD (Cephalo Pelvic Disproportion) or malposition
C Prolonged Deceleration Phase
- Deceleration Phase has become prolonged when it extends beyond three hours in nullipara and one hour in
multipara.
CAUSES:
Abnormal head position
MANAGEMENT:
Caesarian Section

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D

Prolonged Descent
- Prolonged descent of the fetus occurs if the rate of descent is less than 1cm/hour in nullipara of less than
2cm/hour in multipara.
- The contraction becomes infrequent and of poor quality and dilatations stop.
2 Dysfunction on the 2nd Stage of Labor
A Arrest of Descent
- Arrest when no descent had occurred for 1 hour in multipara or 2 hours in nullipara.
- Failure of descent had occurred when expected descent of the fetus does not begin.
CAUSE:Cephalo-pelvic disproportion (CPD)
MANAGEMENT:
- Caesarian Section
- If there is no contra-indication to vaginal birth, oxytocin maybe used to assist in labor.
B
-

Precipitate Labor
occurs when the uterine contraction is so strong that a woman gives birth with only a few rapidly occurring
contraction.
MATERNAL COMPLICATION:
Maternal laceration
Amniotic fluid embolism
Hemorrhage
FETAL COMPLICATION:
Hypoxia
Premature placental separation
Intracranial hemorrhage
Injuries as a falling to the floor in an unattended birth
SIGNS AND SYMPTOMS
o Similar to woman with normal labor but they appear suddenly without warning.
Sudden complain urge to push
Sudden increase in bloody show
Sudden bulging of the perineum
Sudden crowning of the presenting part
Uterine Rupture
- Tearing of the muscles of the uterus when the uterus can no longer withstand the strain placed upon it.
CAUSES:
- Prolonged labor, obstructed labor, malposition and malpresentation
- Over distention of the uterus, multiple gestation
- Injudicious use of oxytocin, forceps and vacuum extraction, internal version
- Precipitate labor and delivery
- Manual removal of the placenta
- External trauma-sharp or blunt
- Placenta increta or accrete
2 types:
a Complete
Signs and symptoms:
S-udden severe pain
S-ensation of sudden tearing and hemorrhage
S-hock (hypo, tachy and respiratory depression)
S-welling (uterus, extra uterine fetus)
S-ound (fetal and heart rate)
b Incomplete
Less dramatic
1 Localized tenderness
2 Gradual and fetal maternal distress
Signs and symptoms:
1 Strong uterine contraction
2 Pathologic retraction ring

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Indentation that appears across the abdomen just before ruptured.
2 Types:
A Bandls Ring horizontal
o 2nd stage
o Retraction ring that appears on the upper and lower uterine segment
B Constricting Ring myometrium
o Occurs at the time or during the delivery
Inversion of the Uterus
- a serious complication of the 3rd stage of labor where in the uterus is partly or completely turned inside out.
CAUSES:
- pulling of umbilical cord or applying pressure on unconstructed uterus.
- placenta accreta
- uterine relaxation due to the effect of anesthesia and analgesia
- sudden increase in intra abdominal pressure such as when coughing, sneezing or straining.
SIGNS AND SYMPTOMS:
- fundus is no longer palpable
- sudden gush of blood from the vagina
- uterus appears in the vulva
MANAGEMENT:
Prevention:
- never apply pressure on an un-contracted uterus
- never pull the cord t hasten placental delivery
- if the placenta already separated the uterus is replaced in the uterine cavity then oxytocin is administered
- if the placenta is still attached:
Woman is placed under anesthesia to cause muscular relaxation and facilitate reinsertion of the uterus
in the pelvic cavity
The lower uterine segment is inserted first and fundus last then oxytocin is administered
Do not attempt to remove placenta if it is still attached to the uterus as this will only enlarged bleeding
area. Remove after the uterus is replaced and contracting
The placenta is delivered when the uterus is already replaced and contracting.
- Monitoring vital signs
Amniotic Fluid Embolism
- Occurs when the amniotic fluid is forced into an open maternal uterine blood sinus through same defect in
the membrane rupture or partial separation of the placenta.
RISK FACTOR
- Oxytocin administration
- Abruptio placenta
MANAGEMENT:
- Oxygen administration
- Caesarian section
- Endotracheal intubations
II. PROBLEMS WITH THE PASSENGER
Prolapsed of the umbilical cord
Umbilical cord descends in advance to the presenting part.
CAUSES:
Long cord
Polyhydramnious
Premature rupture of the membranes
Malpresentation and malposition
Placenta previa
SIGNS AND SYMPTOMS
Cord protrudes form the vagina and palpation of the cord in the vagina canal/cervix fetal distress.
MANAGEMENT:

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PREVENTION:

Place woman in bed rest after membranes have ruptured

Reduced pressure on the cord by:
Place knee-chest or trendelenburg position, or place a folded towel under the hips
Put on sterile gloves and insert two fingers into the vagina, then push presenting
part upward.
If cord is exposed to air cover it with a saline as this will result in cord kinking.
Administer mask oxygen until delivery is completed.

III. PROBLEMS WITH THE PASSAGE

- Another problem that can cause dystocia is the contraction or narrowing of the passage or birth canal.
Inlet contraction
- Narrowing of the anteroposterior diameter to less than 11 cm. or maximum transverse diameter of 12cm
- Due to rickets in early life or an inherited small pelvis.
PRETERM LABOR AND DELIVERY (CBQ)
Labor begins earlier in gestation than normal.
Rhythmic uterine contraction produce cervical changes as normal labor
Occur after fetal viability but before fetal maturity
Usually, occurs bet. 20th 37th wee AOG
Cause:
PROM (30-50% of all cases)
Hydramnios
Fetal death
Diagnosis:
Rhythmic uterine contraction
Cervical dilatation and effacement
Possible rupture of membranes
Expulsion of the cervical mucus plug
Bloody discharge
Prenatal history indicating 20th 37th week AOG
Ultrasonography showing position of the fetus in relation to mothers pelvis
Vaginal exam confirming progressive cervical effacement and dilatation
Management:
- Treatment to premature labor aims to suppress labor when test show:
Immature fetal pulmonary development
Cervical dilatation of less than 1cm
Conservative measure to suppress labor;
a Bed rest, close observation for signs of fetal and maternal distress and comprehensive
supportive care
b Medication is ordered
c Use sedatives and analgesics sparingly as they are HARMFUL to the fetus (back care, frequent
repositioning and alternative to reduce pain)
d Ensure adequate nutrition and rest
e Insertion of purse-string suture (cerclage) can reinforce an incompetent cervix at 14-18 weeks
AOG to avoid preterm delivery on a patient with previous history of disorder
f Pharmacologic measure to suppress labor include:
1 TERBUTALINE (Brethine) stimulate beta2 adrenergic receptors with inhibit
contractility of uterine smooth muscle. When administering this drug, monitor BP, PR,
respirations, FHR, and uterine contraction patterns.
2 MAGNESIUM SULFATE relax myometrium and stop contractions
g Monitor v/s and I and O
h Referral is sign of maternal and fetal distress occurs

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i
j

Watch for maternal adverse reactions to magnesium sulfate like: drowsiness, slurred speech,
flushing, decrease reflexes, decrease GI motility, and decrease respiration.
Watch for fetal and neonatal adverse effects of magnesium sulfate use, CNS depression, decreased
respirations and sucking reflex.

PRETERM DELIVERY
MATERNAL FACTORS. MAKING PRETERM DELIVERY A BETTER OPTIN INCLUDES:
1 Intrauterine infection
2 Abruption placenta
3 Severe preeclampsia
KEEP IN MIND:
1 Morphine (Duramorph) and Meperidine (Demerol) may cause fetal respiratory depression.Naloxone
(Narcan) is the antidote of toxicity.
2 Amniotomy should be avoided if possible to avoid cord prolapsed or damage to the fetuss tender skull
3 Preterm neonate has a lower for the stress of labor and is much more likely to become hypoxic than the
term neonate.
4 Administer O2 to pt as necessary via nasal cannula.
5 Observe fetal response to labor through continuousmonitoring
6 Reassurance to relieved anxiety
7 Keep informed to the progress of labor.