Care of the Woman with Complications during Labor

Labor is not one of the much-anticipated processes during pregnancy because of the pain that a woman would have to go through. When a disease or condition complicates the labor process, it is already up to the skills of the healthcare providers to clear the way for a safe labor despite the painful sensations the woman must go through.

Ineffective Uterine Force

Ineffective labor occurs when uterine contractions become abnormal or ineffective, as uterine contractions are the basic force behind moving the fetus through the birth canal.

Hypotonic Contractions

• The number of uterine contractions in hypotonic contractions is unusually slow or infrequent.
• There are only two or three contractions occurring within a 10-minute period.
• The strength of contractions does not rise above 10 mmHg, and they occur mostly during the active phase of labor.
• Hypotonic contractions occur after administration of analgesia, bowel or bladder distention, if the uterus is overstretched due to multiple gestation, a large fetus, hydramnios, or a uterus that is lax from grand multiparity.
• Hypotonic contractions increase the woman’s risk for postpartal hemorrhage.
• In the first hour after birth following a labor of hypotonic contractions, palpate the uterus and assess the lochia every 15 minutes to ensure that there are no postpartal hypotonic contractions and inadequate to halt bleeding.

Hypertonic Contractions

• Hypertonic contractions are marked by an increase in resting tone to more than 15 mmHg.
• Hypertonic contractions tend to occur more frequently and during the latent phase of labor.
• They are more painful than usual, and they make the woman frustrated with her breathing techniques because they are ineffective.
• The lack of relaxation between contractions may not allow optimal uterine artery filling that could lead to fetal anoxia.
• A uterine and fetal external monitor should be applied for at least 15 minutes to check the resting phase of the contractions and that the fetal pattern is not showing a late deceleration.
• Cesarean birth would be necessary if there is late deceleration, an abnormally long first stage of labor or lack of progress with pushing.
• Explain to the woman and her partner that although the contractions are very strong, they are ineffective and are not achieving cervical dilatation.

Uncoordinated Contractions

• More than one pacemaker may be initiating contractions with uncoordinated contractions, or receptor points in the myometrium may be acting independently of the pacemaker.
• It would be difficult for the woman to rest between contractions because they occur erratically.
• A fetal and uterine external monitor must be attached to the woman to assess the rate, pattern, resting tone, and fetal response to contractions for at least 15 minutes.
• Oxytocin administration can also be done to stimulate a more effective and consistent pattern of contractions with a better, lower resting tone.

Dysfunctional Labor

• Dysfunctional labor during the first stage involves prolonged latent phase, protracted active phase, prolonged deceleration phase, and secondary arrest of dilatation.
• Prolonged latent phase can be managed through helping the uterus to rest, providing adequate fluid for hydration and pain relief.
• Oxytocin is prescribed during a protracted active phase to augment labor.
• Cesarean birth would also be necessary in a prolonged deceleration phase.
• In secondary arrest of dilatation, there is no progress with cervical dilatation for more than 2 hours, and then cesarean birth would be necessary.
• Dysfunction during the second stage of labor involves prolonged descent and arrest of descent.
• If the rate of descent is less than 1 cm/hr in a nullipara or 2.0 in a multipara, then there is prolonged descent of the fetus.
• Encourage the woman to rest and increase her fluid intake.
• Intravenous oxytocin may also be administered to induce the uterus to contract effectively.
• A semi-Fowler’s position, squatting, kneeling, or more effective pushing may speed up the descent.
• When no descent occurs for 1 hour in a multipara and 2 hours in a nullipara, there is an arrest of descent.
• The most likely cause of arrest of descent in the second stage of labor is CPD, so cesarean birth is necessary.
• Oxytocin could also assist labor if there is no contraindication to vaginal birth.

Precipitate Labor

• Precipitate labor occurs when uterine contractions are so strong that a woman gives birth with only a few and rapidly occurring contractions.
• Grand multiparity facilitates this kind of labor, or it can also happen after induction of labor by oxytocin or amniotomy.
• Subdural hemorrhage for the fetus may occur from the rapid release of pressure on the head.
• The woman may also obtain lacerations of the birth canal due to forceful birth.
• If the rate is greater than 5 cm per hour in a nullipara or 10 cm/hr in a multipara, precipitate labor is already occurring.
• Caution a multipara by her 28^th week that her labor might still be brief if she has had a brief labor in the past to allow the woman to plan her transportation.
• A birthing room must be converted to birth readiness before full dilatation is obtained.

Practice Quiz: Care of the Woman with Complications during Labor

Quiz time!

1. A pregnant woman is experiencing a prolonged labor. What is the most common cause for the arrest of descent during the second stage of labor?

A. CPD
B. Maternal calcium deficiency
C. The fetus is asleep during labor
D. The maternal outlet is narrow

2. To assess a laboring client for ineffective uterine force, the nurse would:

A. Monitor contraction duration, strength, and resting tone.
B. Assess for glucose in the specimen of amniotic fluid.
C. Watch the client for elevated respiratory rates during contractions.
D. Check the electrolyte panel for the level of carbon dioxide.

3. Labor may be induced in which of the following women?

A. A woman with presenting part engaged.
B. A woman with a fetus in transverse lie.
C. A woman with CPD.
D. A woman with a premature fetus.

4. A multiparous woman arrived 2 hours ago in active labor with 4 cm of cervical dilation and states that she has a strong urge to push. Which answer most likely describes what is occurring?

A. She may need analgesic or sedation.
B. She may have CPD.
C. She is having a breech birth.
D. She is having a precipitous delivery.

5. What is the effect of precipitate labor in a fetus?

A. Fetal anoxia
B. Subdural hemorrhage
C. Arrest of descent
D. Late deceleration

Answers and Rationale

1. Answer: A. CPD

• A: Cephalopelvic disproportion is the most common cause of arrest of descent.
• B: Maternal calcium deficiency does not affect the descent of the fetus into the birth canal.
• C: The fetus is never asleep during labor because contractions are allowing it to move through the birth canal.
• D: A narrow maternal outlet would require cesarean birth since descent would not only be arrested, it would be impossible.

2. Answer: A. Monitor contraction duration, strength, and resting tone.

• A: The contraction duration, strength, and resting tone must be assessed to determine ineffective uterine force.
• B: Glucose in the amniotic fluid could not detect ineffective uterine force.
• C: Elevated respiratory rates are not indicative of ineffective uterine force.
• D: Ineffective uterine force cannot be detected with the level of carbon dioxide.

3. Answer: D. A woman with a premature fetus.

• D: A woman with a premature fetus could still be induced without any difficulty.
• A: When the presenting part is already engaged, this means that descent has been achieved and the fetus is on its way to being expelled so induction is not necessary.
• B: A fetus in a transverse lie is not allowed to be born via vaginal delivery and therefore must not be induced.
• C: CPD is not meant for vaginal birth, so induction would be impossible.

4. Answer: D. She is having a precipitous delivery.

• D: A precipitous delivery occurs when the woman is feeling the urge to push even though she has not achieved full cervical dilation.
• A: Analgesic or sedation should not be administered to a woman undergoing labor if she has a strong urge to push.
• B: Women with CPD would not be allowed to push because they are only allowed to give birth via cesarean section.
• C: A breech delivery does not need the aid of pushing since it should be delivered via cesarean section.

5. Answer: B. Subdural hemorrhage

• B: Subdural hemorrhage occurs due to the rapid release of pressure on the head.
• A: Fetal anoxia is caused by hypertonic contractions.
• C: Arrest of descent is one of the dysfunctions of the second stage of labor.
• D: Late deceleration occurs due to a dysfunctional labor.

Complications during labor can be foreseen by the health care providers while other conditions may not. Proper preparation of both the woman and the team that would take care of her during labor and delivery is necessary to avoid compromising both the mother and the fetus and to provide an optimum level of safety while they are inside the healthcare facility until the postpartum period.