COMPLICATIONS

DURING LABOR
AND DELIVERY
(Part I)

Prolonged Labor (failure to progress)

Malpresentation
Premature Rupture of Membrane

Prepared By:
KrizeleAnn M. Santos,RN
Luz C. Echaluce,RM
Milagros F. Blanza,RM

Outline
I. Definition (brief description of the said
problem/case)
II. Causes
III. Signs/Symptoms(Test/Diagnostics)
IV. Treatment/Management
V. Nursing Consideration(nursing care as nurse
and midwife)

PROLONGED LABOR(failure to
progress)
also known as failure to progress, occurs when labor lasts for approximately 20
hours or more if you are a first-time mother, and 14 hours or more if you have
previously given birth. A prolonged latent phase happens during the first stage of
labor.
Note: Normal labor is define as presence of regular painful uterine contractions
becoming progressively stronger and more frequent accompanied by effacement
and progressive dilatation of the cervix and decent of the presentating part.

Latent Phase
Latent phase is the preparatory phase of the uterus and the cervix before the
actual onset of labor.
Normal latent phase is about :
8 hours in primi
4 hours in multi
In a partograph the labor process divided into:
Alert Line - start at the end of the latent phase and end with the full
dilatation of cervix (10cm) in 7 hours. ( 1cm/hr. dilatation)
Action Line - its drawn four hours to the right of the alert line. An interval of
4 hours is allowed to diagnose delay in active phase and then appropriate
intervention is done.
Labour is considered abnormal when cervicograp crosses the alert line
Latent Phase that ends with the cervix is 3 cm dilated.
Active Phase starts with cervical dilatation of 4 cm. Cervix should dilate at least 1
cm per hour

Causes
Unripe cervix
Malposition and malpresentation
Cephalopelvic disproportion
Premature rupture of the membranes
Abnormal uterine contraction
Contracted pelvis
Congenital malformation of the baby

First Stage

Failure to dilate the cervix is due to:

Fault in power abnormal uterine contraction such as
-uterine inertia
-in coordinate uterus contraction
Fault in passage
-contracted pelvis
-cervical dystocia
-pelvic tumor or even full bladder
Fault in passenger
-malpresentation
-congenital abnormalities of the fetus
Others: Early administration of sedatives and analgesics before active labor
begins.

Second Stage
Sluggish or non descent of the presenting part in 2nd stage due to:
Fault in power
-uterine inertia
-inability to bear down

-epidural analgesia
-constriction ring (Bandls Ring)
Fault in passage
-CPD(Cephalopelvic Disproportion)
-android pelvis
-contracted pelvis
-soft tissue pelvic tumor
-undue resistance to the pelvic floor
Fault in passanger
-malposition and malpresentation (Big baby)
-congenital malformation of the baby

Signs/Symptoms(Tests/Diagnostics)
First stage of labor is considered prolonged when the duration is more
than 12 hrs. the rate of cervical dilatation is <1 cm/hr in primi and <1.5 cm/hr in
multi. The rate of descent if the presenting part is <1 cm/hr in primi and <2Cm/hr
in multi.
The second stage is considered prolonged if it lasts for more than 2
hrs in primi, and 1 hr in multi.
Labor extends for more than 18 hours.
Dehydration may be present. Mouth may be dry due to prolonged mouth
breathing.
Pain may be more on the back radiating to the thighs rather than inside the
abdomen. This is due to pressure over the muscles and ligaments.
Labor pains may initially be severe, frequent and prolonged but later
decrease and become very mild as the muscles become fatigued.
Pulse rate is often high.
Ketosis may develop due to prolonged starvation.

Diagnostic Features

 Sluggish or non descent of the presenting part even after full dilatation of
the cervix
Variable degrees of molding and caput formation in cephalic presentation
Identification of the cause of prolongation

Dangers
Fetal
The fetal risk is increased due to the combined effects of:
Hypoxia
Intrauterine Infection
Intracranial stress or hemorrhage
Increased operative delivery

Maternal
There is increased incidence of:
Distress
Postpartum hemorrhage
Trauma to the genital tract
Increased operative delivery
Puerperal sepsis

Treatment/Management
Prevention
Antenatal or early intranatal detection of the factors likely to produce
prolonged labor
Use of partograph
Change of posture in labor other than supine to increase the uterine
contractions
Avoidance of labor dehydration

Treatment

 Vaginal examination is done to verify the fetal presentation, position and

station
Clinical pelvimetry is done, if only uterine activity is suboptimal
Amniotomy and or oxytocin infusion is adequate
Caesarean section is done when vaginal delivery is unsafe

Nursing Consideration
Observation
Temperature should be taken 4 hourly.
Infection may develop where there has been prolonged rupture of
membranes.
Vaginal swabs may be taken and broad spectrum antibiotics commented
when infection is suspected.
Pulse and blood pressure are recorded hourly or more frequently if the
womans condition requires.
Fluid balance
An accurate record should be kept.
Note of urinary output is important
The mother is offered the opportunity to empty her bladder every 2 hours.
A full bladder may affect the uterine action in labour and if she is unable to
void, a catheter should be inserted.
Fetal well-being
Fetal heart should be to monitored continuously
The use of oxytocin and epidural analgesia combined with maternal and fetal
indications for induction have been cited as reasons for using electronic
monitoring.
Fetal blood sampling may be used to support decision to continue with labor,
or intervene.

MALPRESENTATION
Malpresentation- where the fetus is lying longitudinally, but presents in any
manner other than vertex
BREECH
FACE
BROW
SHOULDER
COMPOUND
Malposition- where the fetus is lying longitudinally and the vertex is
presenting, but it is not in the Occipito Anterior position
Occipito Transverse
Occipito Posterior

BREECH PRESENTATION
presentation of the fetal buttocks, knees, or feet in labor; the feet may be alo
ngside the buttocks (complete breech presentation); the legs
may be extended against the trunk and the feet lying against the face (frank breech
presentation); or one or both feet or knees may be prolapsed into the
maternal vagina (incomplete breech presentation).

Types of Breech Presentation

I.

Frank (Extended) Breech Presentation

II.

Complete (Flexed) Breech Presentation

III.

Footling Breech Presentation

FACE PRESENTATION
-head is hyper extended
-presenting part is face
- denominator is chin (mentum)
- between glabella & chin
- presenting diameter is submentobregmatic (9.5cm)

Diagnosis
Is caused by hyperextension of the fetal head so that neither the occiput nor
the sinciput are palpable on the vaginal examination.
On abdominal examination, a groove may be felt between the occiput and
the back.
On the vaginal examination, the face is palpated, the examiners finger
enters the mouth easily and the bony jaws are felt.
The chin serves as reference point in describing the position of the head.

BROW PRESENTATION
The brow presentation is caused by partial extension of the fetal head so that
the occiput is higher than the sinciput.
Causes same like face presentations,although some arise as a resut of
exagerated extension OP

Diagnosed in labor by vaginal examination:palpating anterior

frontanele,supraorbital ridge and nose.

MGT: Only can be achieved by deliver by caesarean section

SHOULDER PRESENTATION

Occurs as a result of transverse lie or oblique lie

Predisposing factors = placenta previa,high parity,pelvic tumour,uterine

anomaly

On abdominal examination, neither the head nor the buttocks can be felt at
the symphysis pubis and the head is usually felt in the flank

On vaginal examination, a shoulder may be felt, but not always. Delay in

diagnosis risk cod prolapse and uterine rupture

Delivery should be by Caesearean Section.

COMPOUND PRESENTATION
Occurs when an arm prolapses alongside the presenting part. Both the
prolapsed arm and the fetal head present in the pelvis simultaneously
Management:

Replacement of the prolapsed arm

Assist the woman to assume the knee-chest position

Push the arm above the pelvic brim and hold it there until a contraction
pushes the head into the pelvis.

Proceed with management for normal childbirth

If the procedure fails or if the cord prolapses, deliver by caesarean section

PREMATURE RUPTURE OF
MEMBRANE (PROM)
Spontaneous rupture of membrane any time beyond 22nd weeks of
pregnancy but before the onset of labor
Incidence: 10% of all pregnancies
Two types-:
Term PROM
Preterm PROM
Term PROM - rupture of membranes beyond 37th weeks of gestation but
before the onset of labour - incidence: 8% of all pregnancies
Preterm PROM - rupture of membranes before 37 completed weeks of
gestation - incidence: 2 to 3% of all pregnancies

Possible Causes
Increased friability of the membranes
Decreased tensile strength of membranes
Polyhydramnios
Cervical incompetence
Multiple pregnancy
Infections e.g. chorio-amnionitis, UTI & lower genital tract infections
Cervical length < 2.5 cm
Prior preterm labour
Low BMI (< 19 kg/m2 )

Diagnosis
HISTORY
Patient complains of discharge of clear fluid (liquor) vaginally
EXAMINATION
Speculum examination shows liquor draining through cervical os
DIFFERENTIAL DIAGNOSIS
Hydrorrhoea gravidarum a state where periodic watery discharge occurs
probably due to successive decidual glandular secretion
Incontinence of urine

Investigations
Examination of collected fluid from posterior fornix:
a. Fern test, crystallization of liquor when dried on a slide
b. Nile blue sulphate (0.1%) test for orange fetal cells
c. Litmus test or Nitrazine paper test for detection of pH (pH becomes 6 to
6.2))

Management
Management of PROM depends on:
1. Gestational age of fetus
2. Whether the patient is in labour or not
3. Any evidence of sepsis
4. Prospect of fetal survival in that institution, if delivery occurs
(Maternal pulse, temperature and fetal heart rate monitored 4 hourly and
start prophylactic broad spectrum antibiotics)