Problems with Power; Problems During Labor and Delivery Flashcards
(61 cards)
1
Q
Problems with Power
A
- Dystocia
- Inertia
- Ineffective Uterine Force
2
Q
Contractions Occur Because of…
A
- interplay of the contractile enzyme adenosine triphosphate
- influence of major electrolytes such as calcium, sodium and potassium.
- Specific contractile proteins (actin and myosin)
- Posterior pituitary hormone (epinephrine and norepinephrine, oxytocin)
- Estrogen
- Progesterone
- Prostaglandin
3
Q
Dystocia
A
- arise from any of the three main components of the process: power, the passenger, and the passageway
- due to problems of 4Ps
- another problem “Inertia”
- leads to dysfunctional labor
4
Q
Inertia
A
- Time to denote sluggishness of contractions of the force of labor
- Dysfunctional labor
5
Q
Causes of Problems with power
A
- Inappropriate use of analgesia
- Pelvic bone contraction
- Poor fetal position
- Extension rather than flexion of the fetal head
- Overdistension of the uterus
- Affect uterine contraction (weak), can lead to hemorrhage
- Cervical rigidity (unripe, do not open)
6
Q
HYPOTONIC CONTRACTIONS
A
- Contractions: low, infrequent (not more than 2 or 3 in a 10 minute period) Should be 3 contractions in 10 min period
- Resting tone: <10 mmHg, normal is 15
- Strength: does not rise above 25 mmHg
7
Q
HYPOTONIC CONTRACTIONS Occurs in
A
- Active labor/phase
- Occur after the administration of analgesia esp. if the cervix is not dilated to 3–4 cm
- If the bowel or bladder distention prevents descent or firm engagement
- Uterus that is overstretched by multiple gestation
- Larger than usual fetus
- Hydramnios
- Lax uterus from grand multiparity
8
Q
CAUSE OF HYPOTONIC CONTRACTIONS
A
- Early administration of analgesia
- Bowel or bladder distention
- Overstretched uterus due to multiple gestation
- Larger than usual fetus
- Hydramnios
- Relax uterus from grand multiparity
- Contractions are not painful
- Lack of intensity
- A subjective symptom
- Increase the length of labor
- Uterus does not contract
- Exhaustion
9
Q
Nursing MGT. For HYPOTONIC CONTRACTIONS
A
- 1st hour after birth-palpate the uterus
- Assess the lochia every 15 minutes to ensure that postpartal contractions are not also hypotonic and therefore inadequate to halt bleeding
- Oxytocin- check first vital signs bef., regulate flow of oxytocin.
- If complain of dizziness, headache-stop
- Sign of water retention may mean Oxytocin intoxication
- Palpate the uterus (should be firm)- 1st hours aft. Birth
- Assess lochia every 15 mins, if present then there’s U.C.
10
Q
HYPERTONIC CONTRACTION
A
- Resting tone: more than 25 mmHg
- Intensity: stronger
- Seen in Latent phase
- Occurs because the muscle fibers of the myometrium do not repolarize or relax after a contraction thereby “wiping it clean” to accept a new pacemaker stimulus
- Occur because more than one pacemaker is stimulating contractions
- More painful- because the myometrium becomes tender from constant lack of relaxation and the anoxia of uterine cell results
- Woman is frustrated or disappointed because she has ineffective breathing exercises
- Danger: lack of relaxation between contractions- may not allow uterine artery filling
11
Q
Cause of
HYPERTONIC CONTRACTION
A
- problem with myometrium that’s responsible for contraction
12
Q
Uncoordinated Contractions
A
- Myometrium keeps on contracting
- Uterine contraction appear closely together that they do not allow good cotyledon (blood exchange)
- More than 1 pacemaker may be initiating contractions
- Receptor points in the myometrium may be acting independently of the pacemaker
- Appear closely together that they don’t allow good cotyledon
- The woman don’t have time to rest or to use breathing exercises with contractions
13
Q
Uncoordinated Contractions MGT.
A
- Apply a fetal and uterine external monitor (tocodynamometer)
assessing the pattern, resting tone and fetal response to contraction for at least 15 minutes reveals abnormal pattern - Oxytocin administration to make uterine contraction regular
14
Q
Dysfunctional Labor and associated stages of Labor
A
- Dysfunction at the first stage of labor
- Protracted Active Phase
- Prolonged Deceleration Phase
- Secondary Arrest Dilatation
15
Q
Dysfunction at the first stage of labor
A
- Involves prolonged latent phase
- Protracted active phase
- Prolonged deceleration phase
- Secondary arrest dilatation
16
Q
Prolonged Latent Phase
A
- longer than 20 hrs in nullipara
- longer than 14 hrs in multipara
- occurs if cervix is not ripe
- occur with excessive use of analgesic early in labor
- uterus tends to be hypertonic state
- Relaxation between contractions is inadequate
- Contractions are mild ( less than 15 mmHg), ineffective
- One segment of the uterus may be contracting with more than another segment.
17
Q
Dysfunction at the first stage of labor MGT.
A
- Involves the uterus to rest
- Providing adequate fluid for hydration
- Pain relief with a drug such as morphine sulfate
- Changing the linen and the woman’s gown
- Darkening room lights
- Decreasing noise and stimulation
18
Q
Nullipara Latent Phases
A
Latent phase
- average: 8.6 hrs
- Upper Normal: 20 hrs
Active Phase
- Average: 5.8 hrs
- Upper Normal: 12 hrs
Second Stage
- Average: 1hrs
- Upper Normal: 1.5 hrs
19
Q
Multipara Phases
A
Latent phase
- average: 5.3 hrs
- Upper Normal: 14 hrs
Active Phase
- Average: 2.5 hrs
- Upper Normal: 6 hrs
Second Stage
- Average: 0.25 hrs
- Upper Normal: none
20
Q
Dysfunction at the first stage of labor causes
A
- unripe cervix
- hypertonic contraction
21
Q
Dysfunction at the first stage of labor MGT.
A
- Instruct client to rest for uterus to rest
- Hydrate the client because if dehydrated, prolong labor, lead to blood viscosity and thrombophlebitis
- Morphine sulfate- relieve pain
- Change linen and woman gown to promote comfort
- Darken the room lights
22
Q
Protracted Active Phase
A
- associated with CPD and fetal malposition
- Cervical dilatation does not occur at a rate of at least 1.2 cm/hr in a nullipara or 1.5 cm/hr in a multipara
- active phase lasts longer than: 12 hrs in a primigravida and 6 hrs in a multigravida
- 4-7 cm dilatation (active phase)
- associated with cephalopelvic disproportion or fetal malposition (may be in posterior)
- due to rate of cervical dilatation
- may reflect myometrial activity
23
Q
PROLONGED DECELERATION PHASE
A
- Abnormal fetal head position
- Descent beyond 3 hours for nulli and 1 hour for multi
- CS is the mode of delivery
- Becomes prolonged when it extends
beyond 3
24
Q
SECONDARY ARREST DILATATION
A
- Occurred if there is NO progress in cervical dilatation for longer than 2 hours
- CS is necessary
25
Dysfunction at the Second Stage of Labor
1. Prolonged Descent
2. Arrest of Descent
3. Contraction Ring
4. Uterine Rupture
26
Prolonged Descent
- Nulli- less than 1 cm/hour, multi-less than 2 cm/hour
- Multi- normal is 2.5 hours but in prolonged descent it’s 3 hours
contractions become infrequent and poor quality
- Dilatation stops
- Occurs if the rate of descent is less than 1.0 cm/hr in a nullipara 2 cm/hr in a multipara
- Can be suspected if the second stage lasts over 3 hours in a multipara
27
Prolonged Descent MGT.
- Rest and fluid intake- if faulty contractions, CPD and poor fetal presentation has been r/o by UTZ ( rest and fluid intake)
- If membranes have not ruptured( ruptured them)
- Oxytocin/IV to induce the uterus to contract effectively
- Semi- fowler’s position, squatting, kneeling or more effective pushing may speed descent
28
Arrest of Descent
- Due to CPD
- Results when NO DESCENT has occurred for 1 hour in a multipara or 2 hours in a nullipara
29
Arrest of Descent expected when
- the descent of fetus does not begin
- Engagement or movement beyond 0 station has not occurred
- CPD = most likely cause for arrest of descent
- CS is necessary
- if there is no contraindications to vaginal birth, oxytocin may be used to assist labor
30
Contraction Ring
- hard band that forms across the uterus at the junction of the upper and lower uterine segments and interferes with fetal descent.
- Pathologic retraction ring/Bandl’s ring= common type of contraction ring
- Appears at the 2nd stage of labor
- Can be palpated at a horizontal indentation across the abdomen
- warning sign that there will be dysfunctional labor
- warning that client is at risk of uterine rupture
- report immediately to the doctor
31
Check the contour of Contraction ring to see...
- A WARNING SIGN that severe dysfunctional labor is occurring
- Formed by excessive retraction of the upper uterine segment, the uterine myometrium is much thicker above than below the ring
- IF OCCURS IN EARLY LABOR = usually caused by uncoordinated contractions
- In the pelvic division of labor = caused by obstetric manipulation or by administration of oxytocin
- Fetus and placenta are gripped and cannot advance
- Identified by ultrasound (UTZ)
32
Contraction Ring caused by
- If occurs early in labor- caused by uncoordinated contractions
- In pelvic division- caused by excessive oxytocin and obstetric manipulation
- Placenta cannot be delivered
33
Contraction Ring MGT.
- Administration of morphine sulfate or inhalation of amyl nitrite to relieve contraction ring
- Tocolytic agent =to stop contraction
- CS
- Manual removal of the placenta under general anesthesia= if contraction ring does not allow the placenta to be delivered.
34
Complications of Contraction Ring
- Uterine rupture will lead to fetal death
- Neurologic damage to the fetus
- Massive hemorrhage due to separation or removal of placenta
35
Uterine Rupture
- Occurs when a uterus undergoes more strain than it is capable of sustaining.
- Confirmed by Ultrasound
- An immediate emergency situation
- Can lead to fetal death
36
Uterine Rupture Predisposing Factors
- Prolonged labor
- Abnormal presentation
- Multiple gestation
- Unwise use of oxytocin
- Obstructed labor
- Traumatic maneuvers of forceps or tractions
37
Types of Uterine Rupture
1. Complete
2. Incomplete
38
Complete Uterine Rupture
- Involves the Endometrium, myometrium and peritoneum layers
- Uterine contractions will immediately stop
- 2 distinct swellings will be visible on the woman’s abdomen
- The retracted uterus
- Extrauterine fetus
- When auscultated, it fades or absent
- Signs of shock: rapid weak pulse, falling BP, cold clammy skin, dilatation of the nostrils, FHR fades and then are absent.
39
Incomplete Uterine Rupture
- Leaving the peritoneum intact
- Signs of rupture are less evident
- Localized tenderness - woman experience only a localized tenderness and a persistent aching pain over the area of the lower uterine segment
- Fetal and maternal distress
- Lack contraction
40
Uterine Rupture MGT.
- Administer emergency fluid therapy due to blood loss (gauge should be large)
- Anticipate oxytocin use of oxytocin since there’s no uterine contraction (to attempt to contract the uterus and minimize bleeding)
- Prepare for laparotomy to control bleeding and achieve repair
- Advise not to conceive again to prevent another rupture unless the rupture occurred in the inactive lower segment
- Do hysterectomy if uterus is severely damage- will not conceive again
- Perform a cesarian hysterectomy (with consent) fear of the removal of the damaged uterus or tubal ligation at the time of laparotomy result in the loss of childbearing ability.
- Do not forget to assess the contour and report immediately to prevent uterine rupture- CS will be done immediately
41
Precipitate Labor
- Occur when uterine contractions are so strong that a woman gives birth with only a few rapidly occurring contractions.
- Labor that is completed in fewer than 3 hours.
- Precipitate dilatation
- Occur with: grand multiparity, or after induction of labor by oxytocin or amniotomy
- Contractions are forceful that may lead to:
premature separation of the placenta, Hemorrhage, lacerations
42
Risks of Precipitate Labor
- fetus may exp subdural hemorrhage
- brief labor for multiparous woman with 28 weeks AOG
43
Normal Precipitate labor
Latent
- Nulli: 8.6 hrs
- Multi: 5.3 hrs
Labor
- Nulli: 14 to 15 hrs
- Multi: 8 to 9 hrs
44
2 Classifications of Precipitate Labor
- Precipitate Dilatation
- Precipitate Descent
45
Precipitate Dilatation
cervical dilatation is progressing at a rate of 5 cm or more per hour in nulliparas and 10 cm per hour in multiparas
46
Precipitate Descent
fetal descent is progressing at a rate of 5 cm per hour or more in nulliparas and 10 cm per hour or more in multiparas.
47
Assessment on women exp Precipitate Labor
- Similar to woman with normal labor pattern but they appear suddenly without warning.
- Patient complains of a sudden, intense urge to push
- Sudden increase in bloody show
- Sudden bulging of the perineum
- Sudden crowning of the presenting part
48
Precipitate Labor: Maternal Complications
- Laceration of birth canal and uterine rupture
- Postpartum hemorrhage can lead to abruptio placenta
- Amniotic fluid embolism where the fluid enters in maternal circulation and travel to circulation (chest pain, tachycardia, dyspnea, bleeding, hypotension)
49
Precipitate Labor: Fetal Complications
- Subdural hematoma
- Fetal hypoxia
- Intracranial hemorrhage
- Risk for fall
- Erb Duchenne palsy- type of fracture affecting the clavicle
- Premature separation of placenta
- Injuries as a falling to the floor in unattended birth
50
Precipitate Labor MGT.
- Adequate prenatal care
- Warn woman who has history of precipitate labor, stay home or near hospital
51
Inversion of Uterus
- uterus turning inside out with either birth of the fetus or delivery of the placenta (3rd stage of labor)
- Occur if traction is applied to the umbilical cord to remove the placenta
52
Classifications of Inverted Uterus
- First (incomplete) The inverted fundus extends to, but not beyond, the cervical ring
- Second (incomplete) The inverted fundus extends through the cervical ring but remains within the vagina
- Third (complete) The inverted fundus extends down to the introitus
- Fourth (total) The vagina is also inverted
53
What causes Inverted Uterus
- Pulling placenta when not ready to deliver or when not detached
- Pulling placenta when uterus is not contracting or no strong uterine contraction
54
Inverted Uterus Assessment
- Large amount of blood
- Blood loss, dizziness, paleness and diaphoresis
- Fundus is not palpable
- Uterus is not contracting
- Bleeding continuous
55
Inverted Uterus MGT.
- Never attempt to replace an inversion because the uterus may increase bleeding
- Never attempt to remove the placenta if it is still attached- could lead to inversion and increase blood loss
- Start IV fluid
- Administer oxygen
- Assess vital signs
- Be ready to give CPR due to sudden blood loss, heart will fail
- Give general anesthesia- nitroglycerin or tocolytic drug to relax the uterus
- Physician /midwife/nurse replaces fundus manually
- Administer oxygen after manual replacement helps the uterus to contract and to remain in its natural place
- Antibiotic therapy- because Woman’s endometrium is exposed, prevent infection
- Inform her the CS will probably be necessary in any future pregnancy to prevent possibility of future inversion
56
Preterm Labor is Caused by...
- PROM
- Hydramnios
- Placenta previa
- Preeclampsia
- Multiple gestation
- Abruption placenta
- Incompetent cervix
- Fetal death
- Trauma
- Intrauterine infection
- Maternal factors: stress, Urinary Tract Infection, Dehydration
57
Preterm Labor MGT.
- Obtain blood and urine specimens for lab test
- Assess the frequency, intensity and duration of contractions
- Determine the status of membranes and check for bloody show (check if green or somewhat)
- Monitor the fetus and evaluate for distress, size, maturity and activity
- Evaluate cervical dilatation and effacement
- Give tocolytic medication as ordered (terbutaline, ritodrine)
- Give emotional and psychosocial support
58
Prolonged Labor
- Pregnancy which extends beyond 42 weeks AOG 37-40 weeks is normal-after 40 weeks the placenta can no longer support the growing fetus CAUSES
- Large fetus
- Hypotonic
- Hypertonic
- Uncoordinated contractions
59
Risk on Prolonged Labor
- Postpartal Infection
- Hemorrhage
- Infant Mortality
60
Prolonged Labor Assessment
- Weight loss and decreased uterine size
- Excessively large fetus
- Meconium-stained amniotic fluid
- Abnormal FHT pattern?
61
Prolonged Labor MGT.
- Evaluate fetus-remove stain to prevent DOB
- Prevent birth complications
- Give emotional and physical support
- Educate the patient and her family
