COMPLICATIONS WITH THE POWER (THE FORCE OF LABOR)

DYSFUNCTIONAL LABOR

Normal labor is characterized by progress. Dysfunctional labor is one that does not result in
normal progress of cervical effacement, dilation, and fetal descent. Dystocia is a general term that
describes any difficult labor or birth. Dysfunctional labor often is prolonged but may be unusually short
and intense. It is generally classified as primary (occurring at the onset of labor) or secondary (occurring
later in labor).

An operative birth (assisted with a vacuum extractor or forceps, or cesarean birth) may be
needed if dysfunctional labor does not resolve or fetal or maternal compromise occurs. Signs of
compromise include persistent nonreassuring fetal heart rate (FHR) patterns, fetal acidosis, and
meconium passage. Maternal exhaustion or infection may occur, especially with long labors.

Common Causes of Dysfunctional Labor

 Inappropriate use of analgesia (excessive or too early administration)

 Pelvic bone contraction that has narrowed the pelvic diameter so that a fetus cannot pass, such
could occur in a woman with rickets
 Poor fetal position (posterior rather than anterior position)
 Extension rather than flexion of the fetal head
 Overdistention of the uterus, as with multiple pregnancy, hydramnios, or an excessively
oversized fetus
 Cervical rigidity (unripe)
 Presence of a full rectum or urinary bladder that impedes fetal descent
 Woman becoming exhausted from labor
 Primigravida status

INEFFECTIVE UTERINE FORCE

Uterine contractions are the basic force moving the fetus through the birth canal. They occur
because of the interplay of the contractile enzyme adenosine triphosphate and the influence of major
electrolytes such as calcium, sodium, and potassium, specific contractile proteins (actin and myosin),
epinephrine and norepinephrine, oxytocin (a posterior pituitary hormone), estrogen, progesterone, and
prostaglandins. About 95% of labors are completed with contractions that follow a predictable, normal
course. When they become abnormal or ineffective, ineffective labor occurs.

Two patterns of ineffective uterine contractions are hypotonic dysfunction and hypertonic
dysfunction. Hypotonic dysfunction is more common than hypertonic dysfunction. The characteristics
and management of each are different, but either results in poor labor progress if it persists.

Hypotonic Contractions

Hypotonic contractions are coordinated but too weak to be effective. They are infrequent and brief (not
more two or three occurring in a 10-minute period) and can be indented easily with fingertip pressure at
the peak. The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions
does not rise above 25 mm Hg.
 Hypotonic labor dysfunction, or secondary arrest, usually occurs during the active phase of
labor, when progress normally quickens. The active phase usually begins at about 4 cm of cervical
dilation. Uterine overdistention is associated with hypotonic dysfunction because the stretched uterine
muscle contracts poorly.

They may occur after the administration of analgesia, especially if the cervix is not dilatated to 3
to 4 cm or if bowel or bladder distention prevents descent or firm engagement. They may also occur in a
uterus that is overstretched by a multiple gestation, a larger-than-usual single fetus, hydramnios, or in a
uterus that is lax from grand multiparity. Such contractions are not exceedingly painful, because of their
lack of intensity. Keep in mind, however, that the strength of a contraction is a subjective symptom.
Some women may interpret these contractions as very painful.

Hypotonic contractions increase the length of labor, because more of them are necessary to
achieve cervical dilatation. This can cause the uterus to not contract as effectively during the postpartal
period because of exhaustion, increasing a woman’s chance for postpartal hemorrhage. In the first hour
after birth following a labor of hypotonic contractions, palpate the uterus and assess lochia every 15
minutes to ensure that postpartal contractions are not also hypotonic and therefore inadequate to halt
bleeding.

Management depends on the cause. Many women respond to simple measures. Administration
of adequate intravenous (IV) or oral fluids corrects maternal fluid and electrolyte imbalances or
hypoglycemia. Maternal position changes, particularly different upright positions, favor fetal descent
and promote effective contractions. The woman who actively changes positions typically has better
labor progress and is more comfortable than the woman who remains in one position. Standing or
sitting in a shower provides the comfort of warm water and an upright position. Pain management
techniques such as epidural block may have outcomes that reduce the effectiveness of contractions,
requiring interventions specific to that factor. Effective pain management may, however, improve the
progress of labor.

The nurse should use therapeutic communication to help the woman identify anxieties or beliefs
about labor and its progress. Identifying her anxieties is the first step to managing them effectively so
that the stress response does not slow her labor. For example, the nurse might ask, “What do you think
is making your labor slow?” or “How do you feel your labor is going?”

Many women need measures such as amniotomy and oxytocin infusion to promote labor
progress. The birth attendant evaluates the woman’s labor to confirm that she is having hypotonic active
labor rather than a prolonged latent phase of labor or false labor. The latent phase of labor occurs
within the first 3 cm of cervical dilation. The maternal pelvis and fetal presentation and position are
evaluated to identify abnormalities. Reducing undesired maternal effects of a prolonged latent phase
such as exhaustion or infection is a goal of the birth.

HYPERTONIC CONTRACTIONS

Hypertonic labor dysfunction is less common than hypotonic dysfunction and more often affects
women in early labor with their first baby. Contractions are uncoordinated and erratic in their
frequency, duration, and intensity. The contractions are painful but ineffective. Hypertonic dysfunction
usually occurs during the latent phase of labor. Basal intrauterine pressure is usually high.
 Hypertonic uterine contractions are marked by an increase in resting tone to more than 15 mm
Hg. 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. They may occur
because more than one pacemaker is stimulating contractions. They tend to be more painful than usual,
because the myometrium becomes tender from constant lack of relaxation and the anoxia of uterine
cells that results. A woman may become frustrated or disappointed with her breathing exercises for
childbirth, because such techniques are ineffective with this type of contraction.

A danger of hypertonic contractions is that the lack of relaxation between contractions may not
allow optimal uterine artery filling; this could lead to fetal anoxia early in the latent phase of labor. Any
woman whose pain seems out of proportion to the quality of her contractions should have both a
uterine and a fetal external monitor applied for at least 15 minutes to ensure that the resting phase of
the contractions is adequate and that the fetal pattern is not showing late deceleration. If deceleration
in the fetal heart rate (FHR) or an abnormally long first stage of labor or lack of progress with pushing
(“second-stage arrest”) occurs, cesarean birth may be necessary.

Management of hypertonic labor depends on the cause. Relief of pain is the primary
intervention to promote a normal labor pattern. Warm showers and baths promote relaxation and rest,
often allowing a normal labor pattern to ensue. Systemic analgesics or, occasionally, low-dose epidural
analgesia may be required to achieve this purpose.

Oxytocin is not usually given because it can intensify the already high uterine resting tone.
However, very low doses of oxytocin sometimes are given to promote coordinated uterine contractions.
Tocolytic drugs (drugs that inhibit uterine contractions) may be ordered to reduce uterine resting tone
and improve placental blood flow. The decision to order uterine stimulant or relaxant drugs is very
individualized, based on each woman’s labor pattern.

Nursing care to promote effective pushing helps the mother make each effort more productive.
Most women, even women who have had epidural analgesia, can detect the urge to push with today’s
techniques. The practice of laboring down, or delayed pushing—encouraging the woman to wait until
she feels the reflexive urge to push—has shown a lower incidence of adverse effects than pushing
immediately on full cervical dilation.

Upright positions such as squatting add gravity to the woman’s pushing efforts. Semisitting, side-
lying, and pushing while sitting on the toilet are other options. If she prefers to lie in bed on her side, she
should pull her upper leg toward her chest with each push. Leaning forward while in the sitting or
squatting position maintains the best alignment of the fetal head with the pelvis.

The woman who fears injury because of the sensations she feels when pushing may respond to
accurate information about the process of fetal descent. If she understands that sensations of tearing
often accompany fetal descent but her tissues can expand to accommodate the baby, she may be more
willing to push with contractions. Epidural analgesia for labor uses a mixture of a local anesthetic agent
and an epidural opioid analgesic to provide pain control without the major loss of sensation that is likely
if local anesthetic is used alone. However, if a woman cannot feel the urge to push at all or cannot feel it
strongly after the fetus has descended, she can be coached to push with each contraction.
 The woman who is exhausted may push more effectively if she is encouraged to rest and push
only when she feels the urge, or she may push with every other contraction. Oral and IV fluids can
provide energy for the strenuous work of second-stage labor. Reassuring her about fetal well-being and
the fact that she has no absolute deadline to meet helps her work with her body’s efforts most
effectively. This reassurance also helps the woman who may be emotionally readying herself to “let go”
of her fetus in exchange for a newborn as she labors.

COMPARISON OF HYPOTONIC AND HYPERTONIC CONTRACTIONS

Criteria Hypertonic Hypotonic

Phase of labor Latent Active
Symptoms Painful Limited pain
Medications used:
Oxytocin Unfavorable reaction Favorable reaction
Sedation Helpful Little value

UNCOORDINATED CONTRACTIONS

Normally, all contractions are initiated at one pacemaker point high in the uterus. A contraction
sweeps down over the organ, encircling it; repolarization occurs; relaxation or a low resting tone is
achieved; and another pacemaker activated contraction begins. 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. Because they
occur so erratically such as one on top of another and then a long period without any, it may be difficult
for a woman to rest between contractions or to use breathing exercises with contractions.

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.

ABNORMAL LABOR PATTERNS

Six abnormal labor patterns were identified and classified by Friedman (1989) according to the
nature of the cervical dilation and fetal descent. These patterns may result from a variety of causes,
including ineffective uterine contractions, pelvic contractures, CPD, abnormal fetal presentation or
position, early use of analgesics, nerve block analgesia or anesthesia, and anxiety and stress.

Progress in either the first or the second stage of labor can be protracted (prolonged) or
arrested (stopped). Abnormal progress can be identified by plotting cervical dilation and fetal descent on
a labor graph (partogram) at various intervals after the onset of labor and comparing the resulting curve
with the expected labor curve for a nulliparous or multiparous labor. If a woman exhibits an abnormal
labor pattern, the primary health care provider should be notified.

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, as defined by Friedman, 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. 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
on a monitor printout) 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.

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.

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.

DYSFUNCTION AT THE SECOND 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. 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.
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.

CONTRACTION RINGS

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
dysfunction 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.

Causes of Contraction Rings

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 as well as the undelivered placenta.

Relieving Contraction Rings

Contraction rings often can be identified by ultrasound. Such a finding is extremely serious and
should be reported promptly. 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.

Complications caused by Contraction Rings

 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.

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. 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.

Predicting,Relieving, and Cautions on Precipitate 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. 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.

INDUCTION AND AUGMENTATION OF LABOR

When labor contractions are ineffective, several interventions, such as induction and
augmentation of labor with oxytocin or amniotomy (artificial rupture of the membranes), may be
initiated to strengthen them.

Induction of labor means that labor is started artificially. Induction may be necessary to initiate
labor before the time when it would have occurred spontaneously because a fetus is in danger or
because labor does not occur spontaneously and the fetus appears to be at term.

Primary Reasons for Inducing Labor

  presence of pre-eclampsia
 eclampsia
 severe hypertension
 diabetes
 Rh sensitization
 prolonged rupture of the membranes
 intrauterine growth restriction
 postmaturity (a pregnancy lasting beyond 42 weeks)
 all situations that increase the risk for a fetus to remain in utero.

Augmentation of labor refers to assisting labor (making uterine contractions stronger)

that has started spontaneously but is not effective. It may be necessary if the contractions are
hypotonic or too weak or infrequent to be effective.

Risks for Initiation and Augmentation of Labor

 risk of uterine rupture

 decrease in the fetal blood supply from poor cotyledon filling
 premature separation of the placenta

it is used cautiously with women with a multiple gestation, hydramnios, grand parity,
maternal age older than 40 years, or previous uterine scars.

Before induction of labor is begun, the following conditions should be present:

 The fetus is in a longitudinal lie.

 The cervix is ripe, or ready for birth.
 A presenting part is engaged.
 There is no CPD.
 The fetus is estimated to be mature by date, demonstrated by a lecithin–sphingomyelin ratio
or ultrasound biparietal diameter to rule out preterm birth

Cervical Ripening

Cervical ripening, or a change in the cervical consistency from firm to soft, is the first
step the uterus must complete in early labor. Until this has occurred, dilatation and coordination
of uterine contractions will not occur. To determine whether a cervix is “ripe,” or ready for
dilatation, Bishop (1964) established criteria for scoring the cervix. Using this scale, if a woman’s
total score is 8 or greater, the cervix is considered ready for birth and should respond to
induction.
Various Ripening Methods

To “ripen” a cervix, various methods can be instituted. One is known as “stripping the
membranes,” or separating the membranes from the lower uterine segment manually, using a
gloved finger in the cervix. This is an easy procedure performed during an office visit. Possible
complications of this mechanical method include bleeding from an undetected low-lying
placenta, inadvertent rupture of membranes, and the possibility of infection if membranes
should rupture.

The use of hygroscopic suppositories (suppositories of seaweed that swell on contact

with cervical secretions) is also a time-honored method. These suppositories can be inserted to
gradually and gently urge dilatation (laminaria technique). They are held in place by gauze
sponges saturated with povidone-iodine or an antifungal cream. Documentation of how many
dilators and sponges were placed is important, so it can be documented afterward that none
remain.

A more commonly used method of speeding cervical ripening is the application of a

prostaglandin gel, such as misoprostol, to the interior surface of the cervix by a catheter or
suppository, or to the external surface by applying it to a diaphragm and then placing the
diaphragm against the cervix). Additional doses may be applied every 6 hours. Two or three
doses are usually adequate to cause ripening. Women should remain in bed in a side-lying
position to prevent leakage of the medication, and the FHR should be monitored continuously
for at least 30 minutes after each application (perhaps up to 2 hours after vaginal insertion).
Side effects are vomiting, fever, diarrhea, and hypertension, so these should also be monitored.

Oxytocin induction may be started 6 to 12 hours after the last prostaglandin dose
(beginning it sooner might lead to hyperstimulation of the uterus. Even with their side effects,
prostaglandins are well accepted by women. Caution: women with asthma, renal or
cardiovascular disease, or glaucoma. Contraindication: for women who have had past cesarean
births.

Induction of Labor by Oxytocin

Administration of oxytocin (synthetic form of naturally occurring pituitary hormone)

initiates contractions in a uterus at pregnancy term. Oxytocin is always administered
intravenously, so that, if hyperstimulation should occur, it can be quickly discontinued. Because
the half-life of oxytocin is approximately 3 minutes, the falling serum level and effects are
apparent almost immediately after discontinuation of IV administration.
Dilution

Usually a form of oxytocin, such as Pitocin, is mixed in the proportion of 10 IU in 1000

mL of Ringer’s lactate. Ten international units of oxytocin is the same as 10,000 milliunits (mU),
so each milliliter of this solution contains 10 mU of oxytocin. An alternative dilution method is to
add 15 IU of oxytocin to 250 mL of an IV solution; this yields a concentration of 60 mU/1 mL.
Physician’s orders for administration of oxytocin for induction usually designate the number of
milliunits to be administered per minute. Be sure to know the dilution prescribed and recognize
the concentration in each milliliter.

Administration

When administering the infusion, “piggyback” the oxytocin solution to a maintenance IV

solution such as Ringer’s lactate. Then, if the oxytocin needs to be discontinued quickly during
the induction, the main IV line can still be maintained. Always attach the oxytocin solution to the
infusion port closest to the woman. This way, if it is stopped, little solution remains in the tubing
to still infuse. Use an infusion pump to regulate the infusion rate, so that the rate will not
change even if a woman changes position. A physician should be immediately available during
the entire procedure to ensure safety.

Risks & Side-Effects

Infusions are usually begun at a rate of 0.5 to 1 mU/min. If there is no response, the
infusion is gradually increased every 15 to 60 minutes by small increments of 1 to 2 mU/min
until contractions begin. Many women respond with as little as 4 mU/min; most women respond
at 16 mU/min. Do not increase the rate to more than 20 mU/min without checking for further
instructions, because an administration rate greater than this is likely to cause tetanic
contractions .

Aggressive induction (an increment of 6 mU/min instead of the usual 1 to 2 mU/min)

has been suggested as a way to shorten labor and may be used in some research facilities. After
cervical dilatation reaches 4 cm, artificial rupture of the membranes may be performed to
further induce labor, and the infusion may be discontinued at that point. For other women, the
infusion is continued through full dilatation.

Peripheral vessel dilatation, a side effect of oxytocin, may cause extreme hypotension.
To ensure safe induction, take the woman’s pulse and blood pressure every 15 minutes. Monitor
uterine contractions and FHR conscientiously.

Danger Signs of Oxytocin Administration:

 Nausea and Vomiting

 Dizziness, Headache
 Tachycardia
 Hypotension
 Hypertonic Contractions
  Fetal Tachycardia or Bradycardia
 Decreased urine output

Contractions should occur no more often than every 2 minutes, should not be stronger
than 50 mm Hg pressure, and should last no longer than 70 seconds. The resting pressure
between contractions should not exceed 15 mm Hg by monitor. If contractions become more
frequent or longer in duration than these safe limits, or if signs of fetal distress occur, stop the IV
infusion and seek help immediately.

Anticipate the need for oxygen administration. Excessive stimulation of the uterus by
oxytocin may lead to tonic uterine contractions with fetal death or rupture of the uterus. If
stopping the oxytocin infusion does not stop the hyperstimulation, a beta-adrenergic receptor
drug such as terbutaline sulfate (Brethine) or magnesium sulfate may be prescribed to decrease
myometrial activity.

Oxytocin has an antidiuretic side effect that can result in decreased urine flow, possibly
leading to water intoxication. Water intoxication is first manifested by headache and vomiting.
If you observe these danger signs in a woman during induction of labor, report them
immediately and halt the infusion. Water intoxication in its most severe form can lead to
seizures, coma, and death because of the large shift in interstitial tissue fluid. Keep an accurate
intake and output record, and test and record urine specific gravity throughout oxytocin
administration to detect fluid retention. Limit the amount of IV fluid being given to 150 mL/hr by
ensuring that the main IV fluid line is infusing at a rate not greater than 2.5 mL/min.

Women may worry that induced labor will be more painful or “so different” from
normal labor that breathing exercises will be worthless, or that it will progress so fast it will be
harmful to the fetus. Induced labors do tend to have a slightly shorter first stage than the
average unassisted labor. However, this is an advantage to a woman, not a disadvantage. Once
contractions begin by this method, they are basically normal uterine contractions. You can
assure the woman of this, so that she does not fight the contractions or become unnecessarily
tense, which could prevent her from using her breathing techniques effectively. Induction of
labor with oxytocin can predispose a newborn to hyperbilirubinemia and jaundice. Observe the
infant closely for these conditions during the first few days of life.

Augmentation by Oxytocin

Augmentation of labor is required if labor contractions begin spontaneously but then

become so weak, irregular, or ineffective (hypotonic) that assistance is needed to strengthen
them. Precautions regarding oxytocin augmentation are the same as for primary induction of
labor. A uterus may be very responsive or respond very effectively to oxytocin used as. Be
certain that the drug is increased in small increments only and that fetal heart sounds are well
monitored during the procedure.

Active Management of Labor

 A technique of active management of labor began in Europe and has spread to some
centers in the United States. It includes the aggressive administration of oxytocin (increases of 6
mU/min rather than 1 or 2 mU/min) to shorten labor to 12 hours, which presumably reduces
the incidence of cesarean birth and postpartal infection. The maximum dosage of oxytocin used
may be as high as 36 to 40 mU/min. Active management is controversial because it violates the
tradition of birth as a normal, procedure-free process. Because it can shorten labor, it has the
potential to reduce the number of postpartal fevers that occur from infection or dehydration.

UTERINE RUPTURE

Rupture of the uterus during labor, although rare, is always a possibility. It accounts for
as many as 5% of all maternal deaths. 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:
  prolonged labor
 abnormal presentation
 multiple gestation
 unwise use of oxytocin
 obstructed labor
 traumatic maneuvers of forceps or traction

When uterine rupture occurs, fetal death will follow unless immediate cesarean birth
can be accomplished. In these instances, fetal outcome can be optimal. Impending rupture may
be preceded by a pathologic retraction ring and by strong uterine contractions without any
cervical dilatation. To prevent rupture when these symptoms are present, anticipate the need
for an immediate cesarean birth. 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.

Rupture can be complete, going through the endometrium, myometrium, and

peritoneum layers, or incomplete, leaving the peritoneum intact.

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 (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.

Incomplete Rupture

 Signs of rupture are less evident.

 localized tenderness
 persistent aching pain over the area of the lower uterine segment.
 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. Because the uterus at the end of
pregnancy is such a vascular organ, uterine rupture is an immediate emergency situation,
comparable to splenic or hepatic rupture.
 Administer emergency fluid replacement therapy as ordered. 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. The physician, with consent, may perform a
cesarean hysterectomy (removal of the damaged uterus) or tubal ligation at the time of the
laparotomy; both procedures result in loss of childbearing ability.

A woman may have difficulty giving her consent at this time, because it is unknown
whether her present baby will live. If blood loss was acute, she may be nonresponsive because
of decreased cerebral perfusion from hypotension. If this has happened, the woman’s support
person must be the one who gives this consent, relying on the information provided by the
operating surgeon to decide whether a functioning uterus can be saved. Be prepared to offer
information to the support person and to inform him or her about fetal outcome, the extent of
the surgery, and the woman’s safety as soon as possible.

Initially, a woman and her support person will probably be thankful that her life was
saved. However, they may become almost immediately angry that the rupture occurred,
especially if the fetus died and the woman will no longer be able to have children. Allow them
time to express these emotions without feeling threatened. Explaining to them about the death
of the fetus is very difficult; utilize clergy or counselors as needed to help begin the coping
process. The parents may want to plan a funeral, as oftentimes the babies are full term. They
are grieving for the loss of both the child and their fertility as a couple. The couple is also dealing
with an unexpected surgery to the mother, causing stressors that they did not plan for both
financially and emotionally.

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 is a rare phenomenon, occurring in about 1 in 20,000 births. 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.

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.

Management

 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 creates a larger
surface area for bleeding.
 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.
 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.

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. The incidence is about 1
in 20,000 births. It is not preventable because it cannot be predicted.

Possible risk factors:

 oxytocin administration
 abruptio placentae
 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.

Management

 The immediate management is oxygen administration by face mask or cannula.

 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.

 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.