Dysfunctional Labor

Reported by: Agripo, Kenje Kate T.

Also known as Inertia that refers to a sluggishness in the force of labor

An abnormal uterine contractions that interfere with the normal progress of labor.

Risks
-Maternal postpartum infection -Hemorrhage -Infant mortality

 Causes:
Problems related to passenger include fetal or an unusually large fetus - Problems related to power include pelvic contractures - Problems related to power include uterine contractions that are hypotonic, hypertonic, or uncoordinated - Inappropriate use of analgesia(excessive or too early administration)

 Causes:
- Poor fetal position (posterior rather than anterior position) - Cervical Rigidity (unripe) - Presence of a full urinary bladder that impedes fetal descent - Woman becoming exhausted from labor - Primigravida status

 1st Stage of Labor:

Prolonged Latent Phase - Uterus is at hypertonic state - May occur if: The cervix is not ripe at the beginning of labor and time must be spent getting truly ready for labor Excessive use of an analgesic early in labor - Management of this phase caused by Hypertonic contractions: Helping the uterus to rest Providing adequate fluid for hydration Pain relief with a drug such as Morphine Sulfate

 1st Stage of Labor:

Prolonged Latent Phase - Management of this phase caused by Hypertonic contractions: Changing linens and the womans gown Darkening room lights Decreasing noise and stimulation - If these measures is not effective: Cesarean birth or amniotomy Oxytocin infusion to assist labor if necessary
NULLIPARA Latent Phase lasts: Longer than 20 hours MULTIPARA 14 hours

 1st Stage of Labor:

Protracted Active Phase

- Usually associated with Cephalopelvic disproportion (CPD) or fetal disposition - Dysfunctional labor during the dilatational division of labor tends to be hypotonic , in contrast to the hypertonic action at the beginning of labor.
NULLIPARA
CERVICAL DILATION: ACTIVE PHASE LASTS: 1.2 cm/hr

MULTIPARA
1.5 cm/hr 6 Hours

 1st Stage of Labor: Prolonged Deceleration Phase -Results from abnormal fetal head position (cesarean birth is frequently required)
Deceleration of:

NULLIPARA 3 hours

MULTIPARA 1 hour

Secondary Arrest of Dilatation -This occur when there is no progress in cervical dilatation for longer than 2 hours (cesarean birth)

 2nd Stage of Labor: Prolonged Descent

- Occurs if the rate descent is less than 1.0 cm/hr in Nullipara or 2.0 in Multipara - Both prolonged active phase of dilatation and prolonged descent: Contractions have been good quality and proper duration Effacement and beginning dilatation have occurred But then contractions become infrequent ,poor quality and dilatation stops.

 2nd Stage of Labor: Prolonged Descent - Management: Rest and Fluid intake, as advocated for hypertonic contractions NULLIPARA
Rate of Descent:

MULTIPARA 2.0 cm/hr

1.0 cm/hr

 2nd Stage of Labor: Arrest of Descent

- Failure of descent has occurred when expected descent of the fetus does not begin or engagement beyond 0 station has not occurred. - Results when no descent has occurred for 1 hour in Nullipara or 2 hours in Multipara - Causes: Cephalopelvic disproportion
No Descent occur:

NULLIPARA 2 hours

MULTIPARA 1 hour

 Contraction Ring
- A ridge that may form around the uterus at the junction of the upper and lower uterine segments during the prolonged second stage of an obstructed labor. - The lower segment is abnormally distended and thin, and the upper segment is abnormally thick. - Warning sign that severe dysfunctional labor is occurring

 Contraction Ring
-Diagnostic test: Ultrasound
-Most frequent type is : Pathologic Retraction Ring (Bandls Ring) Usually appears during 2nd stage of labor and palpated as a horizontal indentation across the abdomen.

Pathologic Retraction Ring

- Occurs in early labor caused by uncoordinated contractions - Fetus is gripped by the retraction ring and c annot advance beyong the point and undelivered placenta will be held - Nursing interventions: Administration of IV morphine sulfate Inhalation of amyl nitrite may relieve a retraction ring Administration of Tocolytic to halt contractions

Precipitate Labor
- Birth occur when uterine contractions are so strong that a woman gives birth with only few, rapidly occurring contractions. - Labor that has completed in fewer 3 hours. - Causes: Grand multiparity Induction of labor by oxytocin or amniotomy.

NULLIPARA
Active Phase of Dilation: RATE

MULTIPARA

5 cm/hr (1cm/12 10 cm/hr (1 cm/6 minutes) minutes)

 Cervical Ripening
-Change in the cervical consistency from firm to soft -Until this has occurred, dilation and coordination of uterine contractions will not occur. Evaluating Cervical Readiness BISHOPs Scale -A tool to assess whether the patient is ready for labor -5 Factors: Cervical dilation Cervical Effacement Station Consistency Position

 Bishops Scale

Hygroscopic Suppositories -Suppositories of a seaweed that swell on contact with cervical secretions -Inserted to gradually and gently urge dilation

 Prostaglandin Gel -most commonly used method of speeding cervical ripening -Such as: Misoprostol -Procedure done: Women should remain in bed in a side-lying position to prevent leakage FHR should be monitored continuously for at least 30 minutes after each application -Side effects: Vomiting, fever, diarrhea, and hypertension

 1.)Induction of Labor
- Initiate labor before the time when it would have occurred spontaneously because a fetus is in danger , labor does not occur spontaneously and fetus appears to be at term - Primary reasons: Presence of pre-eclampsia Eclampsia Severe hypertension Diabetes Rh sensitization Induction of Labor by Oxytocin -Initiates contraction in uterus at pregnancy term -Administered Intravenously

 2.) Augmentation of Labor

-Assisting labor that has started spontaneously but is not effective -Required if labor contractions begin spontaneously but then so weak, irregular, or ineffective(hypotonic) that assistance is needed to strengthen them -Risk: Uterine rupture Decrease in the fetal blood supply from poor cotyledon Premature separation of the placenta -Cautiously used with women: Multiple gestation, Hydramnios, Grand parity, Maternal age older than 40 yrs. Old , Previous uterine scar

ASSESSMENT

G1P0 in latent stage of labor Membranes artificially ruptured approximately 1 hour ago Cervix dilated 4 cm,80% effaced, Internal electronic fetal monitor in place. Contractions every 5 minutes, with peak strength at 20-25 mmHg and a duration of 10 seconds FHR at 130 to 140 bpm Client and partner visibly apprehensive, watching monitor intensely Pelvic ultrasound and reveals fetus in occipito posterior position

DIAGNOSIS

Risk for Fetal Injury Related to prolonged labor

PLANNING

After 8 hours of Holistic caring care the patient will be able to Display FHR within normal limits, with good variability, no late decelerations noted

IMPLEMENTATION 1.Assess FHR manually or

electronically -Note variability, periodic changes, and baseline rate 2.Note uterine pressures during resting and contractile phases via intrauterine pressure catheter, if available.

IMPLEMENTATION

3.Identify maternal factors such as dehydration, acidosis, anxiety, or vena caval syndrome. 4.Note frequency of uterine contractions. Notify physician if frequency is 2 min or less. 5.Monitor fetal descent in birth canal in relation to ischial spines.

EVALUATION

The fetus fetal heart tone is normal as evidenced by 120140 bpm