A difficult labor—dystocia—can arise from any of the four
main components of the labor process: (a) the power, or the
force that propels the fetus (uterine contractions); (b) the
passenger (the fetus); (c) the passageway (the birth canal);
or (d) the psyche (the woman’s and family’s perception of
the event)
Inertia is a time-honored term to denote sluggishness of
contractions, or that the force of labor, is less than usual. A
more current term is dysfunctional labor
Dysfunction can occur at any point in labor, but it is
generally classified as primary (i.e., occurring at the onset
of labor) or secondary (i.e., occurring later in labor). The
risk of maternal postpartal infection, hemorrhage, and infant
mortality is higher in women who have a prolonged labor
than in those who do not.
Common Causes of Dysfunctional Labor
• Primigravida status
• Pelvic bone contraction that has narrowed the pelvic
diameter so a fetus cannot pass (cephalopelvic disproportion
[CPD]) such as could occur in a woman with rickets
• Posterior rather than anterior fetal position or extension
rather than flexion of the fetal head
• Failure of the uterine muscle to contract properly or
overdistention of the uterus, as with a multiple pregnancy,
polyhydramnios, or an excessively oversized fetus
• A nonripe cervix
• Presence of a full rectum or urinary bladder that impedes
fetal descent
• A woman becoming exhausted from labor
• Inappropriate use of analgesia (excessive or too early
administration)
INEFFECTIVE UTERINE FORCE
Uterine contractions are the basic force that moves the fetus
through the birth canal.
Hypotonic Contractions
the number of contractions is unusually infrequent (not
more than two or three occurring in a 10- minute period).
The resting tone of the uterus remains less than 10 mmHg,
and the strength of contractions does not rise above 25
mmHg
Hypertonic Contractions
Hypertonic uterine contractions are marked by an increase
in resting tone to more than 15 mmHg
danger of hypertonic contractions is that the lack of
relaxation between contractions may not allow optimal
uterine artery filling; this can lead to fetal anoxia early in
the latent phase of labor
Uncoordinated Contractions
Uncoordinated contractions can occur so closely together
that they can interfere with the blood supply to the placenta.
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
breathe effectively with contractions.
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 (1978), is
a latent phase that lasts longer than 20 hours in a nullipara
or 14 hours in a multipara
Protracted Active Phase
A protracted active phase is usually associated with fetal
malposition or cephalopelvic disproportion (CPD) (the
diameter of the fetal head is larger than the woman’s pelvic
diameters),
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
Prolonged Deceleration Phase A deceleration phase has
become prolonged when it extends beyond 3 hours in a
nullipara or 1 hour in a multipara. A prolonged deceleration
phase most often results from abnormal fetal head position.
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
2 hours in a multipara
Arrest of Descent
Arrest of descent results when no descent has occurred for 2
hours in a nullipara or 1 hour in a multipara. Failure of
descent occurs when expected descent of the fetus does not
begin or engagement or movement beyond 0 station does
not occur. The most likely cause for arrest of descent during
the second stage is CPD.
PRECIPITATE LABOR
 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.
Precipitate birth occurs when uterine contractions are so
strong a woman gives birth with only a few, rapidly
occurring contractions, often defined as a labor that is
completed in fewer than 3 hours
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.
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 labor is started artificially.
Augmentation of labor refers to assisting labor that has
started spontaneously but is not effective
At one time, induction could be completed if a fetus was
proven to have adequate lung surfactant by amniocentesis at
term but less than 39.
American College of Obstetricians and Gynecologists
(ACOG) has issued a statement (ACOG, 2013) indicating
that fetal lung maturity should not be used and inductions
should be avoided until 39 weeks unless medically
indicated. Conditions that might make induction necessary
before that time include preeclampsia, eclampsia, severe
hypertension, diabetes, Rh sensitization, prolonged rupture
of the membranes, and intrauterine growth restriction
Cervical Ripening
Cervical ripening, or a change in the cervical consistency
from firm to soft, is the first change of the uterus in early
labor because, until this has happened, dilatation and
coordination of uterine contractions will not occur.
Induction of Labor by Oxytocin
After a cervix is “ripe,” administration of oxytocin (a
synthetic form of naturally occurring pituitary hormone) can
be used to initiate labor contractions if a pregnancy is at
term
danger of hyperstimulation is that a fetus needs 60 to 90
seconds between contractions in order to receive adequate
oxygenation from placenta blood vessels
For administration, oxytocin (Pitocin) is commonly mixed
in the proportion of 10 International Units in 1,000 ml of
Ringer’s lactate.
Augmentation by Oxytocin
Augmentation of labor may be used if labor contractions
begin spontaneously but then become weak, irregular, or
ineffective (i.e., hypotonic)
UTERINE RUPTURE
Rupture of the uterus during labor, although rare, is always
a possibility. It occurs most often in women who have a
previous cesarean scar. 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.
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 downward
AMNIOTIC FLUID EMBOLISM
Amniotic fluid embolism occurs when amniotic fluid is
forced into an open maternal uterine blood sinus after a
membrane rupture or partial premature separation of the
placenta
Problems With the Passenger
complications may arise if an infant is immature or preterm
or if the maternal pelvis is so undersized that its diameters
are smaller than the fetal skull, such as occurs in early
adolescence or in women with altered bone growth from a
disease such as rickets. It also can occur if the umbilical
cord prolapses, if more than one fetus is present, or if a
fetus is malpositioned or too large for the birth canal.
PROLAPSE OF THE UMBILICAL CORD
n umbilical cord prolapse, a loop of the umbilical cord slips
down in front of the presenting fetal part. Prolapse may
occur at any time after the membranes rupture if the
presenting fetal part is not fitted firmly into the cervix.
Management is aimed, therefore, at relieving pressure on
the cord, thereby relieving the compression and the
resulting fetal anoxia. This may be done by placing a gloved
hand in the vagina and manually elevating the fetal head off
the cord, or by placing the woman in a knee–chest or
Trendelenburg position, to cause the fetal head to fall back
from the cord.
Amnioinfusion
Amnioinfusion is the addition of a sterile fluid into the
uterus to supplement the amniotic fluid and reduce
compression on the cord.
amnioinfusion is used for only a short time until the cervix
is fully dilated or a cesarean birth can be arranged
PROBLEMS WITH FETAL POSITION,
PRESENTATION, OR SIZE
Occipitoposterior Position
occiput (assuming the presentation is vertex) is directed
diagonally and posteriorly, either to the right (right
occipitoposterior [ROP]) or to the left (left occipitoposterior
[LOP]). In these positions, during internal rotation, the fetal
head must rotate not through a 90-degree arc.
Face Presentation
A fetal head presenting at a different angle than expected is
termed asynclitism. Face and brow presentations are
examples. Face (chin, or mentum) presentation is rare, but
when it does occur, the head diameter the fetus presents to
the pelvis is often too large for birth to proceed.
Brow Presentation
A brow presentation is the rarest of the presentations. It
occurs in a multipara or a woman with relaxed abdominal
muscles.
Transverse Lie
Transverse lie occurs in women with pendulous abdomens,
with uterine fibroid tumors that obstruct the lower uterine
segment, with contraction of the pelvic brim, with
congenital abnormalities of the uterus, or with
polyhydramnios.
Oversized Fetus (Macrosomia)
Size may become a problem in a fetus who weighs more
than 4,000 to 4,500 g.,(approximately 9 to 10 lb). Babies of
this size complicate up to 10% of all births and are most
frequently born to women who enter pregnancy with
diabetes or who develop gestational diabetes
Shoulder Dystocia
Shoulder dystocia is a birth problem that is increasing in
incidence because the weight and therefore the size of
newborns is increasing..,shoulders are too broad to enter
and be born through the pelvic outlet.
Shoulder dystocia is most apt to occur in women with
diabetes, in multiparas, and in postdate pregnancies.
Fetal Anomalies
Fetal anomalies of the head such as hydrocephalus (i.e.,
fluid-filled ventricles) or anencephaly (i.e., absence of the
cranium) are a final category of fetal factors that can
complicate birth because the fetal presenting part does not
engage the cervix well.
INLET CONTRACTION
Inlet contraction
is narrowing of the anteroposterior diameter of the pelvis to
less than 11 cm, or of the transverse diameter to 12 cm or
less. It usually is caused by rickets in early life or by an
inherited small pelvis.
OUTLET CONTRACTION
Outlet contraction is a narrowing of the transverse
diameter, the distance between the ischial tuberosities at the
outlet, to less than 11 cm.
TRIAL LABOR
If a woman has a borderline (just adequate) inlet
measurement and the fetal lie and position are good, her
primary care provider may allow her a “trial” labor to
determine whether labor will progress normally.
External cephalic version is the turning of a fetus from a
breech to a cephalic position before birth. It may be done as
early as 34 to 35 weeks, although the usual time is by 37 to
38 weeks of pregnancy
ANOMALIES OF THE PLACENTA
3rd stage of labor.
The placenta and cord are always examined for the presence
of anomalies after birth. The normal placenta weighs
approximately 500 g and is 15 to 20 cm in diameter and 1.5
to 3.0 cm thick. Its weight is approximately one sixth that of
the fetus
Placenta Succenturiata
A placenta succenturiata is a placenta that has one or more
accessory lobes connected to the main placenta by blood
vessels. No fetal abnormality is associated with this type
Placenta Circumvallata
Ordinarily, the chorion membrane begins at the edge of the
placenta and spreads to envelop the fetus; no chorion covers
the fetal side of the placenta. In placenta circumvallata, the
fetal side of the placenta is covered to some extent with
chorion.
(In placenta marginata, the fold of chorion reaches just to
the edge of the placenta.)
Battledore Placenta
In a battledore placenta, the cord is inserted marginally
rather than centrally. This anomaly is rare and has no known
clinical significance either.
Velamentous Insertion of the Cord
Velamentous insertion of the cord is a situation in which the
cord, instead of entering the placenta directly, separates into
small vessels that reach the placenta by spreading across a
fold of amnion
Vasa Previa
In vasa previa, the umbilical vessels of a velamentous cord
insertion cross the cervical os and therefore deliver before
the fetus. The vessels may tear with cervical dilatation, just
as a placenta previa may tear.

Placenta Accreta
Placenta accreta is an unusually deep attachment of the
placenta to the uterine myometrium, so deep that the
placenta will not loosen and deliver

ANOMALIES OF THE CORD

Two-Vessel Cord
A normal cord contains one vein and two arteries. The
absence of one of the umbilical arteries is associated with
congenital heart and kidney anomalies because the insult
that caused the loss of the vessel may have also affected
other mesoderm germ layer structures.

Unusual Cord Length

Although the length of the umbilical cord rarely varies,
some abnormal lengths may occur. An unusually short
umbilical cord can result in premature separation of the
placenta or an abnormal fetal lie. An unusually long cord
may be easily compromised because of its tendency to twist
or knot