MODULE 10: Complications of Labor and Delivery

Question 1

An abnormal, long or difficult labor and delivery

Answer 1

Dystocia

Question 2

4 P’s of labor

Answer 2

a. passageway
b. passenger
c. psyche
d. power

Question 3

Forces acting to expel fetus

Answer 3

Power

Question 4

Power’s 2 types of force

Answer 4

a. Primary force
– involuntary uterine muscular
contractions causing complete effacement and dilatation
of cervix (during first stage of labor)

b. Secondary force
– use of abdominal muscles to push
during the second stage of labor (voluntary bearing
down)

Question 5

Phases of Contractions

Answer 5

Frequency
- Time between the beginning of one contraction and the
beginning of the next contraction

Duration
- From the beginning of the contraction to the completion
of that same contraction

Intensity
- Strength of the contraction during acme (peak)
a. Mild – the uterine wall can be indented easily
b. Strong – uterine wall cannot be indented
c. Moderate – falls between the said 2 ranges

Question 6

Bearing Down

Answer 6

a. Maternal abdominal muscles contract as the woman pushes
b. This pushing action aids in the expulsion of the fetus and
placenta
c. Cervix is not completely dilated – cervical edema, tearing and
bruising of the cervix, and maternal exhaustion

Question 7

Ineffective Uterine Force: Hypotonic Contraction / Uterine Inertia

Answer 7

a. Infrequent uterine contractions
b. Not more than 2-3 occurring in a 10-minute period
c. Uterus resting tone: <10mmHg and the strength does not rise
above 25mmHg

Question 8

Hypotonic Contraction: Etiology and Pathophysiology

Answer 8

a. Overstretching of the uterus
- Large baby, multiple babies, polyhydramnios, multiple
parity

b. Bowel or bladder distention preventing descent
c. Excessive use of analgesia

Question 9

Hypotonic Contraction: Assessment

Answer 9

a. Weak contractions – become mild
b. Infrequent (every 10-15 minutes +) and brief
c. Can be easily indented with fingertip pressure at peak of
contraction
d. Prolonged ACTIVE phase
e. Exhaustion of the mother
f. Psychological trauma – frustrated

Question 10

Hypotonic Contraction: Friedman’s Graph

Answer 10

Prolonged Active phase occurring at 8th - 14th hour before proceeding to transitional phase

Question 11

Ineffective Uterine Force: Hypertonic Contraction

Answer 11

a. Increase in resting tone of more than 15 mmHg
b. May occur because more than one pacemaker is stimulating
contractions
c. Muscle fiber of the myometrium does not repolarize or relax
after contractions (no relaxation)
d. More painful than usual contractions
e. Lack of relaxation contraction may not allow optimal uterine
artery filling (can lead to fetal anoxia)
f. Most often occur in first-time mothers, Primigravidas
g. Contractions are ineffectual, erratic, uncoordinated, and of
poor quality that involve only a portion of the uterus
h. Increase in frequency of contractions, but intensity is
decreased, do not bring about dilation and effacement of the
cervix.

Question 12

Hypertonic Contraction: Signs and Symptoms

Answer 12

a. PAINFUL contractions r/t uterine muscle anoxia, causing
constant cramping pain
b. Dilation and effacement of the cervix does not occur

c. Prolonged LATENT phase
o Stay at 2-3 cm; don’t dilate as it should

d. Fetal distress occurs early – uterine resting tone is high,
decreasing placental perfusion

e. Anxious and discouraged

Question 13

Friedman’s graph

Answer 13

Good guideline for expected progression
in labor and therefore helpful to note abnormal labor patterns

Question 14

Friedman’s Graph; Multi G

Answer 14

1st stage: phase
Duration: 2-10 h
Dilation: 1.5 cm/h
Arrested: >2h
2nd stage: 5-30 min
3rd stage: 0-30 min

Question 15

Friedman’s Graph: Nulli G

Answer 15

1st stage: active
Duration: 6-18 h
Dilation: 1 cm/h
Arrested: >2 h
2nd stage: 0.5-3 h
3rd stage: 0-30 min

Question 16

Hypertonic Contraction: Friedman’s Graph

Answer 16

Prolonged Latent Phase occurring during 0 - 8th hour

Question 17

Ineffective Maternal Pushing

Answer 17

Results from
a. Incorrect pushing techniques
b. Fear of injury
c. Decreased urge to push
d. Maternal exhaustion
* Treatment: Teaching

Question 18

Ineffective Uterine force: Uncoordinated Contraction

Answer 18

a. More than one pacemaker is initiating the uterine contractions
b. Receptor points in the myometrium may be acting
independently of the pacemaker

Question 19

Dysfunctional Labor: 1st stage

Answer 19

a. 1st stage: prolonged latent phase
b. 1st stage: prolonged / protracted active phase
c. 1st stage: prolonged deceleration phase
d. 1st stage: secondary arrest of dilatation

Question 20

First stage: Introduction

Answer 20

a. Begins with true labor contractions and ends until the cervix is
fully dilated
b. Divide into 3 segments: Latent, active, transitional phase

Question 21

1st stage: Prolonged Latent Phase

Answer 21

a. Contractions become ineffective
o > 20 hrs. in nullipara
o > 14 hrs. in multipara

b. Excessive analgesia on the early signs of labor

Question 22

1st stage: Prolonged / Protracted active phase

Answer 22

a. Ineffective myometrial activity
b. Usually associated with fetal malposition or CPD

c. If active phase lasts longer than:
o > 12 hrs. in primigravida
o > 6 hrs. in multigravida

d. Occurs if cervical dilatation does not occur at a rate of:
o 1.2cm/hr. in a nullipara
o 1.5cm/hr. in a multipara

Question 23

1st stage: Prolonged deceleration phase

Answer 23

a. > 3 hrs. in nullipara
b. > 1 hr. in multipara
c. Results from abnormal fetal head position
o Deceleration – dapat may fetal head engagement na

Question 24

1st stage: secondary arrest of dilatation

Answer 24

No progress of cervical dilatation for >2 hours

Question 25

Dysfunctional Labor: 2nd stage

Answer 25

a. 2nd stage: prolonged descent b. 2nd stage: arrest if descent

Question 26

2nd stage: Prolonged Descent

Answer 26

a. Rate of descent: o < 1cm/hr. in nullipara o < 2cm/hr. in multipara ▪ Lasts >2 hrs. in multipara b. Contractions become infrequent, poor quality, and dilatation stops

Question 27

Second stage: Introduction

Answer 27

Begins with the full cervical dilatation until the expulsion of the fetus

Question 28

2nd stage: Arrest if descent

Answer 28

a. Rate of descent: o < 1cm/hr. in nullipara o < 2cm/hr. in multipara ▪ Lasts >2 hrs. in multipara b. Contractions become infrequent, poor quality, and dilatation stops

Question 29

Complications with the Passenger

Answer 29

a. fetal size b. abnormal presentation and position c. problems of passenger d. prolapse of the umbilical cord

Question 30

Fetal Size

Answer 30

a. Macrosomia o Infant weighs more than 8 lb. (13 oz.) b. Shoulder dystocia o McRoberts maneuver - Involves hyperflexing the mother's thighs tightly against her abdomen to widen the pelvic outlet o Suprapubic pressure - Applies firm pressure above the pubic bone to help dislodge the baby's shoulder during shoulder dystocia

Question 31

Abnormal Presentation and Position

Answer 31

a. Malposition o Posterior position – usually mom complains of back pain b. Malpresentation o Brow o Face o Breech o Transverse

Question 32

Problems of Passenger

Answer 32

a. Cephalopelvic Disproportion (CPD) - fetal head is too large or the maternal pelvis is too small for a safe vaginal delivery o Large baby or small pelvis o Usually diagnosed when there is an arrest in descent o Station remains the same b. Multiple Fetus o Twins, triplets, etc.

Question 33

Prolapse of the Umbilical Cord

Answer 33

a. Occult (hidden) prolapse o The cord is compressed between the fetal presenting part and pelvis but cannot be seen or felt during vaginal examination b. Complete cord prolapses o The cord can be seen protruding from the vagina

Question 34

Prolapse of the Umbilical Cord

Answer 34

Definition - Prolapse of the umbilical cord through the cervical canal alongside of the presenting part Etiology/Risk Factor - Occurs anytime if the inlet is not occluded - Fetus is not well-engaged Goal - Relieve the pressure on the cord - Support mother and the family

Question 35

Complication with the Passage / Passageway

Answer 35

a. Size of the maternal pelvis (diameters of the pelvic inlet, midpelvis, and outlet) b. Type of maternal pelvis (gynecoid, android, anthropoid, platypelloid, or a combination) c. Ability of the cervix to dilate and efface and ability of the vaginal canal and the external opening of the vagina to distend

Question 36

4 Classic types of Pelvis

Answer 36

a. gynecoid - Favorable for vaginal birth b. anthropoid - Favorable for vaginal birth c. android - Not favorable; descent into pelvis is slow; fetal head enters pelvis in transverse or posterior position with arrest of labors frequent d. platypelloid - Not favorable; fetal head engages in transverse position; difficult descent through midpelvis; frequent delay of progress at outlet of pelvis

Question 37

Size of Maternal Pelvis

Answer 37

a. Major pelvic bones include the two innominate bones (formed by the fusion of the ilium, ischium, and pubis around the acetabulum), the sacrum, and the coccyx. b. Division o Pelvis is arbitrarily divided into halves ▪ False pelvis ▪ True pelvis o False pelvis - serves to support the weight of the enlarged pregnant uterus and direct the presenting fetal part into the true pelvis o True pelvis - the size and the shape of the true pelvis must be adequate for normal fetal passage during labor and at birth. It consists of the inlet, pelvic cavity, and the outlet. c. Pelvic Inlet o Size and shape are determined by assessing 3 anteroposterior diameters ▪ Diagonal conjugate: From subpubic angle to the middle of the sacral promontory (12.5 cm) ▪ Obstetric conjugate: From middle of the sacral promontory to an area approx. 1 cm below the pubic crest * DC – 1.5 cm = Obstetric Conjugate ▪ True conjugate: From middle of the sacral promontory to the middle of the pubic crest (superior surface of the symphysis, approx. 10.5-11 cm) d. Pelvic Cavity - A curved canal with a longer posterior than anterior wall. A change in the lumbar curve can increase or decrease the tilt of the pelvis and can influence the progress of labor e. Pelvic Outlet - At the lower border of true pelvis. - Its size can be determined by assessing the transverse diameter or bi-ishial/intertuberous diameter. - Transverse diameter ▪ It helps determine the shape of the inlet; largest diameter and is measured by using the Linea terminalis as the point of reference

Question 38

Soft passage through maternal soft tissue structures

Answer 38

a. Soft tissues of the cervix, vagina, and perineum must stretch to allow passage of the fetus through the axis of the birth canal b. Progesterone and Relaxin help facilitate the softening and increase the elasticity of muscles and ligaments

Question 39

Engagement

Answer 39

a. Fetal presenting part reaches or passes through the pelvic inlet b. Confirms the adequacy of the pelvic inlet c. Determined by vaginal examination o In primigravida: 2 weeks before term o In multipara: several weeks before onset of labor or during the process of labor

Question 40

Station

Answer 40

a. Measurement of how far the presenting part has descended into the pelvis b. Referrant is ischial spine. - At ischial spines, station is "0" - Above ischial spines, station is negative number - Below ischial spines, station is positive number c. "High" or "floating" terms used to denote unengaged presenting part

Question 41

Can a Full bladder lead to a dysfunctional labor?

Answer 41

Yes, it can push the uterus or it can obstruct the passageway

Question 42

Abnormal Labor Duration: Prolonged

Answer 42

a. A labor lasting more than 18-24 hours or fails to make changes in dilation or effacements b. Cervical dilation o Primigravida: 1.2 cm/hr. o Multigravida: 1.5 cm/hr. c. Descent o Primigravida: 1 cm/hr. o Multigravida: 2 cm/hr.

Question 43

Abnormal Labor Duration: Prolonged: Etiology

Answer 43

a. CPD (Cephalopelvic Disproportion) b. Malpresentation, malposition c. Labor dysfunction

Question 44

Abnormal Labor Duration: Precipitous

Answer 44

a. Labor that last less than 3 hours b. Unexpected fast delivery

Question 45

Abnormal Labor Duration: Precipitous: Complications / Risks

Answer 45

a. If the baby delivers too fast, it does not allow the cervix to dilate and efface which leads to cervical lacerations b. Uterine rupture c. Fetal hypoxia and fetal intracranial hemorrhage

Question 46

Abnormal Labor Duration: Precipitous: Etiology

Answer 46

a. Lack of resistance of maternal tissue to passage of fetus b. Intense uterine contractions c. Small baby in a favorable position

Question 47

Rapid Delivery: Delivery outside normal setting

Answer 47

a. Everything is out of control b. Mom is frightened, angry, feels cheated

Question 48

Premature Rupture of Membranes

Answer 48

a. Etiology o Infections o Incompetent cervix o Fetal abnormalities o Sexual intercourse b. Major risk o Ascending intrauterine infection c. Other risk o Precipitous of labor

Question 49

Preterm Labor

Answer 49

a. Labor that occurs after 20 weeks but before 37 weeks b. Etiology o Urinary tract infections o Premature rupture of membranes c. Goal o Stop the labor and suppress uterine activity

Question 50

Ruptures Uterus

Answer 50

a. Spontaneous or traumatic rupture of the uterus b. Etiology o Rupture of a previous C-birth scar o Prolonged labor o Injudicious use of Pitocin (overstimulation) o Excessive manual pressure applied to the fundus during delivery c. Signs and Symptoms o Sudden sharp abdominal pain o Abdominal tenderness o Cessation of contractions o Absence of fetal heart tones o Shock