1. COMPLICATIONS
WITH THE
POWER
(THE FORCE OF THE
LABOR)
UNIVERSITY OF NORTHERN PHILIPPINES
GRADUATE SCHOOL
MASTER OF ARTS IN NURSING

2. A.INEFFECTIVE UTERINE FORCE
 Uterine contractions are the basic force moving the
fetus through the birth canal.
 Contractions occur because of interplay of
enzymes, electrolytes, proteins and hormones.
 About 95% of labors are completed with
contractions that follow a predictable, normal
course. When they become abnormal or ineffective,
ineffective labor occurs.

3. Hypotonic Contractions
Hypertonic Contractions
Uncoordinated Contractions
THE CAUSES OF INEFFECTIVE UTERINE FORCE
DEPEND ON THE 3 TYPES OF DYSFUNCTION:

4. HYPOTONIC CONTRACTIONS
 Number of contractions:
not more 2 or 3 occurring in a 10-minute
period.
 Resting tone: less than 10 mm Hg
 Strength of contractions: does not rise
above 25 mm Hg.
 Phase of Labor: Active
 Symptom: Painless

5. ETIOLOGY:
 Overstretching of the uterus – large baby,
multiple babies, polyhydramnios, multiparity.
 Bowel or bladder distention, preventing
descent.
 Excessive use of analgesia.

6. THERAPEUTIC INTERVENTIONS:
 Oxytocin
 Ambulation
 Nipple stimulation
 Enema
 Amniotomy

7. HYPERTONIC CONTRACTIONS
 Resting tone: more than 15 mm Hg.
 Contractions: Frequent prolonged contractions that
are not productive.
 Phase of Labor: Latent
 Symptom: Painful
 Cause: This type of contraction 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.

8. COMPLICATION: FETAL ANOXIA
 Management:
 Provide comfort measures
 Bedrest or position changes
 Hydration
 Mild sedation
 Tocolytics
 Caesarean delivery

10. Uncoordinated Contractions
 With uncoordinated contractions, more than one
pacemaker may be initiating contractions, or
receptor points in the myometrium may be acting
independently of the pacemaker.
 Uncoordinated contractions may occur so closely
together that they do not allow good cotyledon (one
of the visible segments on the maternal surface of
the placenta) filling.

11. Uncoordinated Contractions cont’d
 Applying a fetal and a uterine external monitor and
assessing the rate, pattern, resting tone, and fetal
response to contractions for at least 15 minutes (or
longer if necessary in early labor) reveals the
abnormal pattern.
 Oxytocin administration may be helpful in
uncoordinated labor to stimulate a more effective
and consistent pattern of contractions with a better,
lower resting tone.

12. B. DYSFUNCTIONAL LABOR AND ASSOCIATED
STAGES OF LABOR
Dysfunction at the First Stage of Labor
Prolonged Latent Phase
 When contractions become ineffective during the first
stage of labor, a prolonged latent phase can develop.
 A prolonged latent phase is a latent phase that is longer
than 20 hours in a nullipara or 14 hours in a multipara.
 This may occur if the cervix is not “ripe” at the beginning
of labor and time must be spent getting truly ready for
labor. It may occur if there is excessive use of an
analgesic early in labor.

13. Prolonged Latent Phase cont’d
 With a prolonged latent phase, the uterus tends to be in a
hypertonic state. Relaxation between contractions is inadequate,
and the contractions are only mild (less than 15 mm Hg) and
therefore ineffective.
 One segment of the uterus may be contracting with more force
than another segment.
 Management of a prolonged latent phase in labor that has been
caused by hypertonic contractions involves helping the uterus to
rest, providing adequate fluid for hydration, and pain relief with a
drug such as morphine sulfate.
 Changing the linen and the woman’s gown, darkening room
lights, and decreasing noise and stimulation can also be helpful.
 These measures usually combine to allow labor to become
effective and begin to progress. If it does not, a cesarean birth or
amniotomy (artificial rupture of membranes) and oxytocin
infusion to assist labor may be necessary.

14. Protracted Active Phase
 A protracted active phase is usually associated with
cephalopelvic disproportion (CPD) or fetal malposition,
although it may reflect ineffective myometrial activity.
 This phase is prolonged if 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, or if the active phase lasts longer than 12 hours in a
primigravida or 6 hours in a multigravida.
 If the cause of the delay in dilatation is fetal malposition or
CPD, cesarean birth may be necessary.
 Dysfunctional labor during the dilatational division of labor
tends to be hypotonic, in contrast to the hypertonic action at
the beginning of labor.
 After an ultrasound to show that CPD is not present, oxytocin
may be prescribed to augment labor.

15. Prolonged Deceleration Phase
 A deceleration phase has become prolonged when
it extends beyond 3 hours in a nullipara or 1 hour in
a multipara.
 Prolonged deceleration phase most often results
from abnormal fetal head position. A cesarean birth
is frequently required.
Secondary Arrest of Dilatation
 A secondary arrest of dilatation has occurred if
there is no progress in cervical dilatation for longer
than 2 hours. Again, cesarean birth may be
necessary.

16. DYSFUNCTION AT THE FIRST STAGE OF LABOR
Prolonged Descent
 Prolonged descent of the fetus occurs if the rate of
descent is less than 1.0 cm/hr in a nullipara or 2.0
cm/hr in a multipara. It can be suspected if the
second stage lasts over 3 hours in a multipara.
 With both a prolonged active phase of dilatation
and prolonged descent, contractions have been of
good quality and proper duration, and effacement
and beginning dilatation have occurred, but then
the contractions become infrequent and of poor
quality and dilatation stops.

17. Prolonged Descent cont’d
 If everything is normal except for the suddenly
faulty contractions and CPD and poor fetal
presentation have been ruled out by
ultrasound, then rest and fluid intake, as advocated
for hypertonic contractions, also apply.
 If the membranes have not ruptured, rupturing them
at this point may be helpful.
 Intravenous (IV) oxytocin may be used to induce
the uterus to contract.
 A semi-Fowler’s position, squatting, kneeling, or
more effective pushing may speed descent.

18. Arrest of Descent
 Arrest of descent results when no descent has
occurred for 1 hour in a multipara or 2 hours in a
nullipara.
 Failure of descent has occurred when expected
descent of the fetus does not begin or engagement
or movement beyond 0 station has not occurred.
 The most likely cause for arrest of descent during
the second stage is CPD. Cesarean birth usually is
necessary.
 If there is no contraindication to vaginal birth,
oxytocin may be used to assist labor.

20. C. PATHOLOGIC RETRACTION
 A contraction ring is a hard band that forms across the
uterus at the junction of the upper and lower uterine
segments and interferes with fetal descent.
 The most frequent type seen is termed a pathologic
retraction ring (Bandl’s ring). The ring usually appears
during the second stage of labor and can be palpated
as a horizontal indentation across the abdomen.
 It is a warning sign that severe dysfunctional labor is
occurring as it is formed by excessive retraction of the
upper uterine segment; the uterine myometrium is
much thicker above than below the ring.

21. C. PATHOLOGIC RETRACTION cont’d
 When a pathologic retraction ring occurs in early
labor, it is usually caused by uncoordinated
contractions.
 In the pelvic division of labor, it is usually caused by
obstetric manipulation or by the administration of
oxytocin.
 In either event, the fetus is gripped by the retraction
ring and cannot advance beyond that point. The
undelivered placenta will also be held at that point.
 Contraction rings often can be identified by
ultrasound. Such a finding is extremely serious and
should be reported promptly.

22. C. PATHOLOGIC RETRACTION cont’d
 Administration of IV morphine sulfate or the inhalation of
amyl nitrite may relieve a retraction ring. A tocolytic can
also be administered to halt contractions.
 If the situation is not relieved, uterine rupture and
neurologic damage to the fetus may occur.
 In the placental stage, massive maternal hemorrhage
may result, because the placenta is loosened but then
cannot deliver, preventing the uterus from contracting.
 Most likely, a cesarean birth will be necessary to ensure
safe birth of the fetus.
 Manual removal of the placenta under general
anesthesia may be required if the retraction ring does
not allow the placenta to be delivered.

24. FIGURE (A) NORMAL SHAPE OF PREGNANT ABDOMEN DURING LABOUR, IN A
WOMAN LYING ON HER BACK; (B) BANDL’S RING IN THE ABDOMEN OF A
WOMAN WITH OBSTRUCTED LABOUR.

25. D. PRECIPITATE LABOR
 Precipitate labor and birth occur when uterine
contractions are so strong that a woman gives birth with
only a few, rapidly occurring contractions.
 It is often defined as a labor that is completed in fewer
than 3 hours.
 Precipitate dilatation is cervical dilatation that occurs at
a rate of 5 cm or more per hour in a primipara or 10 cm
or more per hour in a multipara.
 Such rapid labor is likely to occur with grand
multiparity, or it may occur after induction of labor by
oxytocin or amniotomy.

26. D. PRECIPITATE LABOR cont’d
 Contractions can be so forceful that they lead to
premature separation of the placenta, placing the
woman at risk for hemorrhage.
 Rapid labor also poses a risk to the fetus, because
subdural hemorrhage may result from the rapid release
of pressure on the head.
 A woman may sustain lacerations of the birth canal from
the forceful birth. She also can feel overwhelmed by the
speed of labor.
 A precipitate labor can be predicted from a labor graph
if, during the active phase of dilatation, the rate is
greater than 5 cm/hr (1 cm every 12 minutes) in a
nullipara or 10 cm/hr (1 cm every 6 minutes) in a
multipara.

27. D. PRECIPITATE LABOR cont’d
 In such instances, a tocolytic may be administered to
reduce the force and frequency of contractions.
 Caution a multiparous woman by week 28 of pregnancy
that, because a past labor was so brief, her labor this
time also may be brief. This allows her to plan for
appropriately timed transportation to the hospital or
alternative birthing center.
 Both grand multiparas and women with histories of
precipitate labor should have the birthing room
converted to birth readiness before full dilatation is
obtained. Then, even a sudden birth can be
accomplished in a controlled surrounding.

28. E. UTERINE RUPTURE
 Uterine rupture occurs when a uterus undergoes more
strain than it is capable of sustaining.
 Rupture occurs most commonly when a vertical scar
from a previous cesarean birth or hysterotomy repair
tears.
 Contributing factors may include prolonged labor,
abnormal presentation, multiple gestation, unwise use of
oxytocin, obstructed labor, and traumatic maneuvers of
forceps or traction.
 When uterine rupture occurs, fetal death will follow
unless immediate cesarean birth can be accomplished.
 If a uterus should rupture, the woman experiences a
sudden, severe pain during a strong labor contraction,
which she may report as a “tearing” sensation.

29. E. UTERINE RUPTURE cont’d
 Rupture can be complete, going through the
endometrium, myometrium, and peritoneum layers, or
incomplete, leaving the peritoneum intact. With a
complete rupture, uterine contractions will immediately
stop.
 Two distinct swellings will be visible on the woman’s
abdomen: the retracted uterus and the extrauterine
fetus.
 Hemorrhage from the torn uterine arteries floods into the
abdominal cavity and possibly into the vagina.
 Signs of shock begin, including rapid, weak pulse; falling
blood pressure; cold and clammy skin; and dilatation of
the nostrils from air hunger.
 Fetal heart sounds fade and then are absent.

30. E. UTERINE RUPTURE cont’d
 If the rupture is incomplete, the signs of rupture are less
evident. With an incomplete rupture, a woman may
experience only a localized tenderness and a persistent
aching pain over the area of the lower uterine segment.
 However, fetal heart sounds, a lack of contractions, and
the changes in the woman’s vital signs will gradually
reveal fetal and maternal distress.
 Uterine rupture can be confirmed by ultrasound.
 Administer emergency fluid replacement therapy as
ordered.

31. E. UTERINE RUPTURE cont’d
 Anticipate use of IV oxytocin to attempt to contract the
uterus and minimize bleeding.
 Prepare the woman for a possible laparotomy as an
emergency measure to control bleeding and achieve a
repair.
 The viability of the fetus depends on the extent of the
rupture and the time elapsed between rupture and
abdominal extraction.
 A woman’s prognosis depends on the 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.

34. F. INVERSION OF THE UTERUS
 Uterine inversion refers to the uterus turning inside out
with either birth of the fetus or delivery of the placenta.
 It may occur if traction is applied to the umbilical cord to
remove the placenta or if pressure is applied to the
uterine fundus when the uterus is not contracted.
 It may also occur if the placenta is attached at the
fundus so that, during birth, the passage of the fetus
pulls the fundus down.
 Inversion occurs in various degrees. The inverted
fundus may lie within the uterine cavity or the vagina, or,
in total inversion, it may protrude from the vagina.

35. F. INVERSION OF THE UTERUS cont’d
 When an inversion occurs, a large amount of blood
suddenly gushes from the vagina. The fundus is not
palpable in the abdomen.
 If the loss of blood continues unchecked for longer than
a few minutes, the woman will show signs of blood loss:
hypotension, dizziness, paleness, or diaphoresis.
 Because the uterus is not contracted in this
position, bleeding continues, and exsanguination could
occur within a period as short as 10 minutes.
 Never attempt to replace an inversion, because handling
of the uterus may increase the bleeding.
 Never attempt to remove the placenta if it is still
attached, because this only create a larger surface area
for bleeding.

36. F. INVERSION OF THE UTERUS cont’d
 In addition, administration of an oxytocic drug only
compounds the inversion or makes the uterus more
tense and difficult to replace.
 An IV fluid line needs to be started, if one is not already
present (use a large-gauge needle, because blood will
need to be replaced).
 If a line is already in place, open it to achieve optimal
flow of fluid to restore fluid volume.
 Administer oxygen by mask, and assess vital signs.
 Be prepared to perform cardiopulmonary resuscitation
(CPR) if the woman’s heart should fail from the sudden
blood loss.

37. F. INVERSION OF THE UTERUS cont’d
 The woman will immediately be given general
anesthesia or possibly nitroglycerin or a tocolytic drug
intravenously, to relax the uterus.
 The physician or nurse-midwife then replaces the
fundus manually.
 Administration of oxytocin after manual replacement
helps the uterus to contract and remain in its natural
place.
 Because the uterine endometrium was exposed, a
woman will need antibiotic therapy to prevent infection.
 She needs to be informed that cesarean birth will
probably be necessary in any future pregnancy, to
prevent the possibility of repeat inversion.

39. G. AMNIOTIC FLUID EMBOLISM
 Amniotic fluid embolism occurs when amniotic fluid is
forced into an open maternal uterine blood sinus
through some defect in the membranes or after
membrane rupture or partial premature separation of
the placenta.
 Previously, it was thought that particles such as
meconium or shed fetal skin cells in the amniotic fluid
entered the maternal circulation and reached the
lungs as small emboli.
 Now, it is recognized that a humoral or anaphylactoid
response is the more likely cause.
 This condition may occur during labor or in the
postpartal period.

40. G. AMNIOTIC FLUID EMBOLISM cont’d
 It is not preventable because it cannot be predicted.
 Possible risk factors include oxytocin
administration, abruptio placentae, and hydramnios.
 The clinical picture is dramatic. 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.
 The immediate management is oxygen administration
by face mask or cannula.

41. G. AMNIOTIC FLUID EMBOLISM cont’d
 Within minutes, she will need CPR. CPR may be
ineffective, however, because these procedures
(inflating the lungs and massaging the heart) do not
relieve the pulmonary constriction. Therefore, blood
still cannot circulate to the lungs. Death may occur
within minutes.
 A woman’s prognosis depends on the size of the
embolism, the speed with which the emergency
condition was detected, and the skill and speed of
emergency interventions.
 Even if the woman survives the initial insult, the risk
for disseminated intravascular coagulation (DIC) is
high, further compounding her condition.

42. G. AMNIOTIC FLUID EMBOLISM cont’d
 In this event, she will need continued management
that includes endotracheal intubation to maintain
pulmonary function and therapy with fibrinogen to
counteract DIC.
 Most likely, she will be transferred to an ICU.
 The prognosis for the fetus is guarded, because
reduced placental perfusion results from the severe
drop in maternal blood pressure.
 Labor often begins or the fetus is born immediately by
cesarean birth.

43. Thank you!!!
BARROGA, Marilyn Richelle
DIGUEL, Brenda Lee
GRAGERA, Jennifer C.
MASIGMAN, Mary Ann
PAESTE, Gloria
SERRANO, Cecille
VALENTON, Kathleen Anne Marie