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Outline:
Objectives.
Introduction.
Related definitions.
Factors that might complicate progress of labor.
Problems in the powers.
Problems in the passage.
Problems in the passenger.
Problems in placenta.
Nursing management for dystocia.
Objectives:
General objective:
Introduction :
Dystocia of labor is defined as difficult labor or abnormally
slow progress of labor. Other terms that are often used
interchangeably with dystocia are dysfunctional labor, failure
to progress (lack of progressive cervical dilatation or lack of
descent), and cephalopelvic disproportion (CPD).
DYSTOCIA
- literally means difficult labor
- Dystocia: Prolonged, painful, or difficult delivery results
Related definitions
Immature labor :Termination of pregnancy between 20 -28
weeks (fetal weight 500 1000 gm).
Premature labor :Termination of pregnancy between 28 - 38
weeks (fetal weight 1000 2500 gm).
Postmature labor :Prolongation of pregnancy 2 weeks or
more beyond the calculated date of delivery.
Prolonged labor: The labor last for more than 24 hour in PG &
16 hour in MG.
Chorioamnioitis.
Mal presentation, mal position.
Maternal disease.
It result in prolonged labor
Exhaustion.
Dehydration.
Sever pain.
Cervical and vaginal edema.
PRECIPITATE LABOR:
The fetus is rapidly expelled from the birth canal. The
duration of labor is less than 3 hours sometimes.
Aetiology:
- Strong frequent uterine contractions.
- Laxity of the tissues of the birth canal, so more frequent in
multiparae.
- High pain threshold, so the patient does not feel except the
last few strong contractions.
Complication:
A-Maternal: - Lacerations of the cervix, vagina or perineum.
- Postpartum hemorrhage (due to lacerations and there is no
time for retractions). - Inversion of uterus.
- Rupture of symphysis pubis. - Acute anemia.
- Puerperal sepsis due to lacerations and unsuitable
circumstances.
- Amniotic fluid embolism.
B-Fetal: - Asphyxia: the strong frequent uterine contraction
interfere with placental circulation.
- Intracranial hemorrhage due to rapid compression of the
head.
- Rupture of the cord.
- Injury or death of the fetus due to falling.
Ovarian tumor.
Uterine fibroid,
Bicornuate, double uterus, septate uterus or didelphys.
Cervical polyps.
Vaginal stenosis.
Perineal tumors or cysts.
Abnormalities in passenger:
Congenital anomalies and fetal malpresentation can result in
fetal distress and deviation from the normal course of labor
and birth.
1-Multifetal gestation:
Multifetal gestation includes twins pregnancy, triplets, or
quadrates.
Causes:
- Age: its more common among women aged 20-39 years and
dramatic decrease after this age occurs.
- Fertility drugs: that stimulate the ovaries to produce many
ovum.
- Multiparity: it is more common among parous women than
nulliparous women.
Maternal and fetal implications:
Intrapartum complications associated with multifetal
gestation:
- Pregnancy induced hypertension.
- Abruption-placenta.
- Placenta-previa.
1. Abnormal Presentation
Vertex Sinciput Brow Face
a. Brow presentation , Face presentation , . Shoulder
presentation (Transverse Lie)
Causes of transverse lie include: multiparity (lax
abdominal wall), preterm fetus, placenta previa, uterine
anomaly, excessive amnionic fluid, and contracted pelvis
d. Breech presentation
Predisposing factors include uterine relaxation, great
parity, multiple foetuses, hydramnios, anencephaly,
previous breech delivery, uterine anomalies, tumors in
the pelvis
Complications: cord prolapse, increased perinatal
morbidity and mortality due to difficult delivery, low birth
3. Abnormal Development
Hydrocephalus
Large transverse diameter of the cranium
overdistends the lower uterine segment
causes uterine rupture
The size of the head must be reduced (e.g.
cephalocentesis) to allow the fetus to pass
through the birth canal
Enlarged abdomen usually results from greatly
distended bladder, ascites, or enlargement of
the kidneys or liver.
Macrosomia
Defined as fetal weighing 4500 gms or more
Abnormalities in placenta:
Abnormal placental size ;
large placenta (most common in diabetic mother) lead to
dystocia in 3rd stage.
Abnormal placental shape ;
Placenta succenturiata: placenta with one or more accessory
lobes.
Placenta bipartita or tripartita: two or three separate areas
of placental tissue, there is one umbilical cord which divided
& sending branch to each lobe.
Management of Dystocia
Problems with the Powers
Hypertonic labor contractions
Bed rest and sedation to promote relaxation and reduce pain
Measures to rule out fetopelvic disproportion and fetal
malpresentation
Evaluate of fetal tolerance to labor pattern, such as
monitoring of FHR patterns
Assess for signs of maternal infection
Adequate hydration through IV therapy
Precipitous labor
Close monitoring of woman with previous history of this
Breech presentation
Assessment for possible associated conditions such as
placenta previa, hydramnios, fetal anomalies, and multiple
gestation
Ultrasound to confirm fetal presentation
External cephalic version possible at 37 weeks
Tocolytics to assist with external cephalic version
Trial labor for 4 to 6 hours to evaluate progress if version is
unsuccessful
Planning for cesarean birth if no progress is seen or fetal
distress occurs
During labor;
-Proper assessment for mother in admission through complete history
taking, physical examination and investigation.
Mangement:
1st stage:
Complete assessment for mother in admission to detect the cause of
dystocia.
*Complete history
Mangement:
*Investigations; C.B.C, RH, blood group, urine analysis, sonar,.
Close observation using electronic monitoring for
Progress of labor (cervical dilatation, fetal decent, uterine contraction
and condition of membranes).
Fetal condition (FHR).
Maternal condition especially for dehydration, pallor, exhaustion,
cervical & vaginal edema and sever pain, signs of shock and recording
for any abnormality.
Management of dystocia depends on underlying factors related to the
maternal condition and fetal status .
2- 2nd stage:
Prepare the mother for instrumental delivery e.g .Forceps or Vacuum
extraction or CS if necessary.
Instrumental delivery:
Preparation for place, equipment & appratus.
Preparation for mother; postioning, sterlization, evacuate the bladder
and anesthesia.
Close observation for FHR, vital signs & contraction.
Assist the doctor during delivery; follow fetal decent, supporting the
perineum, cutting the episiotomy
Suctioning & oxygenation for baby at birth.
2- 2nd stage:
Cesarean section:
- Preparation for place, equipment & appratus
Preparation for mother; remove any jewelry, assess vital signs,
catheterization, IV line, collect specimen for lab, singed consent and
anesthesia.
3rd stage:
the placenta.
3rd stage:
4th stage:
Observation for mother include vital signs, uterus, lochia, perineum,
wound condition, intake & output
Uterine massage in case of instrumental delivery
References
Ricci S.Susan. Essentials of Maternity, Newborn and Womens Health
Nursing.2nd ed., Philadelphia: Lippincott co. 2010.
Michele, R., Marcia, L. & Patricia, A. Olds` Maternal-Newborn Nursing &
Womens Health across the Lifespan. 9th edition. Pearson 2010.
Neville, F., Joseph, C. & Calvin, J. Essentials of Obstetrics and
Gynecology, 5th edition. Philadelphia: Lippincott co. 2010.