Module No.

02
Date: 02 – 18 – 2022
Topic: Complications of Labor & Delivery

CUES/QUESTIONS/KEYWORDS NOTES

What to check when woman COMPLICATIONS WITH THE POWER

is in labor: Abnormal/ineffective contractions usually leads to ineffective labors
 Vital signs
 Contraction Dysfunctional labor - prolongation in the duration of labor in the
 Interval first stage of labor
 Frequency
 Pattern  Primary – occurs at the onset of labor
 Fetal heart rate  Secondary – occurs later in labor

Complications
Health Teaching during labor:  Maternal post-partal infection
 Correct positioning &  Hemorrhage
breathing  Infant mortality
 Where to hold
 Newborn care
 Breastfeeding INEFFECTIVE UTERIN FORCE
 Cord care
Hypotonic Contractions
 The number of contractions is usually low or infrequent
 Not more than 2 or 3 in a 10-minute period
 Resting tone: <10mmHg
 Strength contraction: <25mmHg
 Most apt to occur during the active phase of labor
 Contractions are not exceeding painful, because of lack of
intensity
 May occur after the administration of analgesia
 If cervix is not dilated to 3 to 4cm
 If bowel or bladder distention prevents descent or
firm engagement

Risk Factor
 Multiple Gestation
Note: Insert catheter if  Larger-than-usual single fetus
bladder is distended  to  Hydramnios
lower fetal head  Grand multiparity

Management
When to monitor  WOF postpartal hemorrhage
 15mins in 1st 2hrs  Up to 1hr postpartum, palpate the uterus and assess the
 30mins in 3rd hour lochia q15min
  1hr in 4th hour
Hypertonic Contractions
 Increased in resting tone >15mmHg
Check fundus  Occur frequently and are most commonly seen in the latent
phase of labor.
Normal location of fundus  More painful than usual, because the myometrium becomes
after labor tender from constant lack of relaxation and the anoxia of
 1cm below umbilicus uterine cell that results
 Fetal anoxia
Uterus must be FIRM
Management
 Uterine and fetal heart monitor
For continuous contraction,  Deceleration in FHR, or abnormally long first stage of labor –
check fetal heart rate CS birth

Criteria Hypertonic Hypotonic

Normal dilation  1cm per Phase of labor Latent Active
hour Symptoms Painful Limited pain
Medications Used:
Oxytocin Unfavorable reaction Favorable reaction
Sedation Helpful Little value
Must know hours of labor to
determine dilation Uncoordinated Contractions
More than one pacemaker may be initiating contractions, or
receptor points in the myometrium may be acting independently of
“Ripe cervix”  doesn’t the pacemaker.
become thin and dilate
Management
 Uterine and fetal heart monitor
Station  the location of
 Assess the rate, pattern, resting tone and fetal response to
engagement contractions for at least 15 minutes to reveal abnormal
 Higher location means (–) pattern
 Lower location means (+)  Oxytocin administration
 For continuous contraction
3 Kinds of placental invasion Lengths of Phases and Stages of Normal Labor in Hours
 Based on degree of Nullipara Multipara
invasion Phase Average Upper Average Upper
1) Accrete Normal Normal
2) Increta Latent phase 8.6 20.0 5.3 14.0
3) Percreta Active phase 5.8 12.0 2.5 6.0
Second stage 1 1.5 0.25 -*

* There is no limit to the length of the second stage as long as progress is being made and
Hysterectomy is the surgical fetal distress is not present.
removal of the uterus. It may
also involve removal of the
cervix, ovaries, fallopian tubes, DYSFUNCTION AT FIRST STAGE OF LABOR
and other surrounding
structures. Usually performed Prolonged Latent Phase
by a gynecologist, a  Latent phase that is longer than 20 hours in nullipara or 14
hysterectomy may be total or hours in multipara
partial  The uterus tends to be in hypertonic state
 Relaxation between contraction is inadequate
 Contractions are only mild (less than 15mmHg) and therefor
ineffective
 May occur if the cervix is not “ripe” at the beginning of labor
and time must be spent getting truly ready for labor
 May occur if there is excessive use of an analgesic early in
labor.

Management
 Help uterus rest
 Provide adequate fluids
 Pain relief such as MG04
 Changing the linens and women’s gown, darken lights,
decrease noise and stimulation
 CS birth
 Anatomy
 Oxytocin infusion
 To induce labor

Protracted Active Phase

 Usually associated with CPD or fetal malposition
 Ineffective myometrial activity
 Cervical dilatation occurs at <1.2cm/hr in a nullipara and
<1.5cm/hr in a multipara
 Tens to be hypotonic

Management
 If with CPD – CS birth
 Baby cannot enter pelvis due to tight passage
 If no CPD – Oxytocin management

Prolonged Deceleration Phase

 A deceleration phase has become prolonged when it extends
beyond 3 hours in a nullipara or 1 hour in a multipara
 Most often result from abnormal fetal head position
 CS birth

Secondary Arrest in Dilatation

 No progress in cervical dilatation for longer than 2 hours
 CS Birth

DYSFUNCTION AT SECOND STAGE OF LABOR

Prolonged Descent
 Rate of Descent: <1cm/hr in nullipara, <2cm/hr in multipara
 2nd stage of labor last over 3hrs in a multipara
 Contractions have been good quality and proper duration,
and enforcement and beginning dilatation have occurred, but
then the contractions become infrequent and poor quality
and dilatation stops.

Management
 Rest and fluids for hypertonic contractions
 Intact BOW – amniotomy
 IV oxytocin
 Semi-Fowler’s position, squatting, kneeling, or more effective
pushing

Arrest Descent
 No descent has occurred for I hour in multipara or 2 hours in
nullipara
 Expected descent of the fetus does not begin or engagement
or movement beyond 0 station has not occurred.
 Most likely cause is CPD
 CS birth
 Oxytocin administration

Contraction Rings
 A hard band that forms accros the uterus at the junction of
the upper and lower uterine segents and interferes with the
fetal descent
 The most frequent type seen is termed a pathologic
retraction ring (Bandi’s Ring)
 Warning signs that severe dysfunction labor is occurring as it
is formed by the excessive retraction of the upper uterine
segment
 Early labor
 uncontrolled contraction
 Pelvic division of labor
 Obstetric manipulation or oxytocin administration

Management
 Ultrasound
 IV MS04, inhalation of amyl nitrate
 Tocolytics
 CS Birth

Precipitate Labor
 Labor that completed in fewer than 3 hours
  Precipitate dilatation: cervical dilation that occurs at a rate of
% cm or more per hour in primipara or 10 cm or more per
hour in multipara

Risk factor
 Grand multiparity
 Induction of Labor by oxytocin
 Amniotomy

Complications
 Abruptio placentae
 Hemorrhage
 Fetal subdural hemorrhage
 Perineal Laceration

Management
 Tocolytics

Uterine Rupture
 Vertical scar from a previous CS birth or hysterotomy tears
 <1% in low transverse CS
 4-8% in classic CS
 Prolonged labor
 Abnormal presentation
 Multiple gestation
 Unwise use of oxytocin
 Obstructed labor
 Traumatic maneuvers of forceps or traction

Assessment
 Impending rupture > pathological ring
 Strong uterine contractions without cervical dilatation.
 A sudden, severe pain during a strong labor contraction.
 She may report a "tearing" sensation.
 Incomplete rupture
 Intact peritoneur
 Localized tenderness and persistent aching pain over area
of the lower uterine segment,
 Fetal and maternal distress;
 ‘fHR Vs changes
 ‘Lack of contractions
 Confirmed by ultrasound

Complete rupture
 Endometrium, myometrium, peritoneum layers
 Uterine contractions will immediately stop
 Two distinct welling:
  Retracted uterus
 Extrauterine fetus
 Hemorrhage
 Signs of shock

Management
 Highly vascular > Ill uterine rupture is an immediate
emergency situation
 Emergency fluid replacement therapy
 IV oxytocin
 Prepare for possible laparotomy
 Viability of the fetus: extent of rupture and time elapsed
between rupture and abdominal extraction
 Woman's prognosis: Depends on extent of the rupture and
the blood loss.
 Most women are advised not to conceive again after a
rupture of the uterus, unless the rupture occurred in the
inactive lower segment.
 Consent for cesarean hysterectomy or tubal ligation

Uterine inversion
 The uterus turning inside out with either birth of the uterus or
delivery of the placenta
 1/20,000 births
 Inversion occurs in varying degrees
 May lie within the uterine cavity or vagina
 Total inversion protrudes from vagina

Risk factors
 traction is applied to the umbilical cord to remove the
placenta
 pressure is applied to the uterine fundus when the uterus is
not contracted
 the placenta is attached at the fundus so that, during birth,
the passage of the uterus pulls the fundus down

Assessment
 Large amount of blood suddenly gushes from the vagina
 Fundus isa not palpable in the abdomen
 Prolonged bleeding
 Hypovolemic shock

Management
 NEVER attempt to replace inversion
 NEVER attempt to remove the placenta if it is still attached
 Oxytocic drugs will make the uterus more tense and harder to
replace
  IV fluid replacement
 O2 via face mask
 Assess VS, anticipate need for CPR
 General anesthesia, nitroglycerin, tocolytic drug before
replacing manually
 Prophylactic antibiotic therapy
 CS for any subsequent pregnancies

Amniotic fluid embolism

 Amniotic fluid is forced into an open maternal uterine blood
sinus through:
 Some defect in the membranes
 After the membrane rupture
 Partial premature separation of the placenta
 Occurs in 1/20,000 births; accounts for 10% of maternal
deaths in the US
 It is not preventable because it is not predictable

Risk factors
 Oxytocin administration
 abruptio placentae
 hydramnios

Assessment
 A woman, in strong labor, sits up suddenly and grasps her
chest because of sharp pain and inability to breathe as she
experiences pulmonary artery constriction
 She becomes pale and then turns the typical bluish gray
associated with pulmonary embolism and lack of blood flow
to the lungs

Management
 O2 administration
 endotracheal intubation
 CPR-death
 Even if the woman survives initial insult, high risk for DIC

PROBLEMS WITH THE PASSENGER

Umbilical Cord Prolapse

 A loop of the umbilical cord slips down in front of the
presenting part

Risk factors
 Premature rupture of membranes
 Fetal presentation other that cephalic
  Placenta previa
 Intrauterine tumors preventing the presenting part from
engaging
 A small fetus
 Cephalopelvic disproportion preventing firm engagement
 Hydramnios
 Multiple gestation

Prolapse of umbilical
Umbilical cord.
 (A) The cord is prolapsed but still within the uterus.
 (B) The cord is visible at the vulva. In both instances the
fetal nutrient supply is being compromised, although only a
cord such as that shown in B would be visible.
 Both prolapses could be detected by fetal monitoring.

Umbilical cord Assessment

 In rare instances, the cord may be felt as the presenting part
on an initial vaginal examination during labor.
 Ultrasound
 More often, however, cord prolapse is first discovered only
after the
 membranes have ruptured, when a variable deceleration FHR
pattern suddenly becomes apparent.
 The cord may be visible at the vulva.
 Always assess fetal heart sounds immediately after ROM

Management
 Management is aimed at relieving pressure on the cord,
thereby relieving the compression and the resulting fetal
anoxia
 Manual elevation of fetal head off the cord
 Knee-chest or Trendelenburg
 0210 L/min by face mask
 Tocolytic agents
 Amnioinfusion
 If cord prolapse is exposed to air drying dystrophy of umbilical
vessels
 DO NOT attempt to push any exposed cord back into
the vagina. This may add to the compression by
causing knotting or kinking.
 Instead, cover any exposed portion with a sterile saline
compress to prevent drying.
 If the cervix is fully dilated at the time of the prolapse, the
physician may choose to birth the infant quickly, possibly with
forceps, to prevent fetal anoxia.
 If dilatation is incomplete, apply upward pressure on the
 presenting part until CS birth.

Shoulder Dystocia
 The problem occurs at the second stage of labor, when the
fetal head is born but the shoulders are too broad to enter
and be born through the pelvic outlet.

Risk Factors
 Women with DM
 Multiparas
 post-date pregnancies
 Maternal Complications
 vaginal or cervical tears
 Fetal complication
 cord compression
 fractured clavicle or brachial plexus injury
 McRobert's maneuver
 Applying suprapubic pressure

SUMMARY
COMPLICATIONS WITH THE POWER
 Dysfunctional labor
 prolongation in the duration of labor

INEFFECTIVE UTERIN FORCE

 occurs when uterine contractions become abnormal or ineffective, as uterine contractions are
the basic force behind moving the fetus through the birth canal
 Hypotonic Contractions
 poor and inadequate uterine contractions that are ineffective to cause cervical dilation,
effacement, and fetal descent, leading to a prolonged or protracted delivery
 Hypertonic Contractions
 a contraction of increased duration or increased amplitude
 Uncoordinated Contractions

DYSFUNCTION AT FIRST STAGE OF LABOR

 Prolonged Latent Phase
 Protracted Active Phase
 Excessively prolonged active or pushing phase of labor
 Prolonged Deceleration Phase
 progress in dilation slows after 8 cm and uterine contractions become dysfunctional,
even after oxytocin administration
 the cervix starts to swell and take on fluid. In this situation, a C-section may be needed
 Secondary Arrest in Dilatation
 diagnosed when there has been no change in cervical dilation for at least 2 hours
DYSFUNCTION AT SECOND STAGE OF LABOR
 Prolonged Descent
 abnormally slow cervical dilation or fetal descent during active labor
 Arrest Descent
 the head of the fetus is in the same place in the birth canal during the first and second
examinations, which your doctor performs one hour apart
 signifies that the baby hasn't moved farther down the birth canal within the last hour
 Contraction Rings
 a spasmodic contraction of the lower portion of the uterus which usually occurs during
the first phase of labor, but persists into the second stage
 the ring contracts round the child's neck and prevents the child descending, thus
delaying and preventing delivery
 Precipitate Labor
 extremely rapid labor and delivery
 expulsion of the fetus within less than 3 h of commencement of regular contractions
 Uterine Rupture
 spontaneous tearing of the uterus that may result in the fetus being expelled into the
peritoneal cavity
 Complete rupture
 often seen as a very traumatic injury and almost always requires surgery in order to
regain proper function, regardless of where it is and of what type of tissue
 Uterine inversion
 occurs when the uterine fundus collapses into the endometrial cavity, turning the
uterus partially or completely inside out
 Amniotic fluid embolism
 occurs when amniotic fluid — the fluid that surrounds a baby in the uterus during
pregnancy — or fetal material, such as fetal cells, enters the mother's bloodstream

PROBLEMS WITH THE PASSENGER

 Umbilical Cord Prolapse
 occurs when the cord drops through the open cervix into the vagina before your baby
moves into the birth canal.
 Shoulder Dystocia
 occurs when one or both of your baby's shoulders get stuck during vaginal delivery