1.

PROBLEMS WITH THE POWER OF LABOR

(Mendez, Edrea A.)

• Power of Labor - refers to forces (primary and secondary) acting to expel fetus.
 Inertia is a time-honored term to denote that sluggishness of contractions, or the force of labor, has occurred.
A more current term used is dysfunctional labor (Strehlow & Uzelac, 2007).
 Dysfunction labor is generally classified as: primary (occurring at the onset of labor) or secondary (occurring
later in labor).

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.
 Uterine Contraction includes: fundal dominance, polarity, coordination, effectiveness, frequency, duration,
intensity, interval, resting tone(tonus).

Figure 1: Normal Uterine Contraction

Figure 2: Contraction Cycle

 When the uterine contractions become abnormal or ineffective, ineffective labor occurs.
 Cause of Ineffective Uterine Force depends on the three type of uterine dysfunction: Hypertonic, Hypotonic,
and Uncoordinated Contractions.

A. HYPOTONIC UTERINE CONTRACTIONS

 This is a common type of abnormal uterine contraction, which may present from the beginning of labour or
may develop subsequently after a variable period of effective contractions.
 Most apt to occur during the active phase of labor.
 The number of contractions is unusually low or infrequent (not more two or three occurring in a 10-minute
period).
 The resting tone of the uterus remains less than 10 mm Hg, and the strength of contractions does not rise
above 25 mm Hg.
 The contractions are synchronous but weak or infrequent or both.
 Figure 3: Hypotonic Uterine Contraction

Etiology:

 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 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.

Signs and Symptoms:

 Patient feels less pain during uterine contraction.

 Palpation reveals less hardening of the uterus.
 Uterine wall is easily indentable at the acme of pain.
 Uterus becomes relaxed after the contraction; fetal parts are well palpable and fetal heart rate remains good.
 Internal examination reveals: poor dilatation of the cervix, membranes usually remain intact, and associated
presence of contracted pelvis, malposition, deflexed head or malpresentation may be evident.

Complications:

 Prolonged labour
 Infection
 Possibility of postpartum hemorrhage due to atonic uterus

Management:

 Careful evaluation of the case is to be done.

 In normal condition prepare for vaginal delivery.
 Plan for caesarean section if mother have contracted pelvis, malpresentation or evidence of fetal and maternal
distress.
 Reassure the mother to keep up the morale and prevent psychological depression.
 Change posture of woman.
 Empty the bowel by enema and encourage mother to frequently empty the bladder.
 Maintain hydration.
 Oxytocin administration.

B. HYPERTONIC UTERINE CONTRACTIONS

 Tend to occur frequently and are most commonly seen in the latent phase of labor.
 Marked by an increase in resting tone to more than 15 mm Hg.
 It typically has elevated resting pressures, increased contraction frequency, and decreased coordination, as
well as a delayed fall to baseline uterine tone.
 It is the condition in which the tone of the uterus is high during and between contractions with severe
backache.
  A woman may become frustrated or disappointed with her breathing exercises for childbirth, because such
techniques are ineffective with this type of contraction.
 In the absence of obstruction, the hypertonic uterine action results in precipitate labor whereas it results in
Bandl’s ring formation in the presence of any obstruction.

 Precipitate Labor – an overactive labor in which the baby is expelled soon after the start of the
labour.
 Tonic Uterine Contraction and Retraction (Bandl’s Ring Formation) – predominantly due to
obstructed labor; the pattern of uterine action is normal, the upper uterine segment actively while
the lower segment remains passive.

Figure 4: Hypertonic uterine Contraction

Etiology:

 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.

Sign and Symptoms:

 Painful contractions related to uterine muscle anoxia.

 Dilatation and effacement of the cervix do not occur.
 Prolonged latent phase. Stay at 2-3 cm, do not dilate as should.
 Fetal distress occurs early

Complication:

 Fetal Anoxia

Management:

 Provide comfort measure.

 Bedrest
 Hydration
 Tocolytics
 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 or an abnormally long first stage of labor or lack of progress with
pushing (“second-stage arrest”) occurs, cesarean birth may be necessary.
 Explain to the woman and her support person need to understand that, although the contractions are
strong, they are ineffective and are not achieving cervical dilatation.
 C. 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.
 It 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.

Inco-ordinate Uterine Action:

 Spastic lower segment - there is reversal of uterine action, increased tone in lower uterine segment and
weakly acting upper uterine segment.
 Colicky uterus - various parts of uterus contract independently with feeling of pain at fundus and lower
segment; the contractions are very painful and felt predominantly in the hypogastrium region.
 Constriction ring - there is localized spastic constriction of a ring of circular muscle fibres of the uterus.
 Generalized tonic contraction (Uterine tetany)- condition in which there is pronounced retraction
involving whole of the uterus up to the level of internal os resulting in no physiological differentiation
of active upper segment and passive lower segment of the uterus.
 Cervical dystocia - cervix fails to dilate despite of normal uterine contraction.

Management:

 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 to stimulate a more effective and consistent pattern of
contractions with a better, lower resting tone.

C. PROLONGED LABOR

 Refers to labor that has slowed significantly, and lasts longer than expected. Exact definitions of prolonged
first and second stages of labor conflict.
 When the duration of the first and second stages of labor combined is greater than 20 hours for a woman’s
first pregnancy and greater than 14 hours for women who have previously given birth.

Management of Prolonged Labor:

 Intensive monitoring
 Oxytocin drip
 Episodin or Buscopan
 Cesarean Section

Figure 5: The normal parameters for the stages of labor

DYSFUNCTION AT THE FIRST STAGE OF LABOR

 Dysfunction that occurs with the first stage of labor involves a prolonged latent phase, protracted active
phase, prolonged deceleration phase, and secondary arrest of dilatation.

1. Prolonged Latent Phase

 When contractions become ineffective during the first stage of labor, a prolonged latent phase can
develop.
 It 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.
- Friedman (1978)
 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: 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.
2. Protracted Active Phase
 It 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.
3. 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.
4. 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

 Labor Dysfunction that occurs with the second stage of labor involves prolonged descent and arrest of
descent.
1. 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 (Cheng et al., 2007).
  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 effectively
 A semi-Fowler’s position, squatting, kneeling, or more effective pushing may speed descent.
2. 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.

Figure 5: The graph showing abnormal types of labor

Figure 7:Abnormal Labor Pattern (Friedman, 1983)

REFERENCES:

Pillitteri, Adele. (2007) Maternal & Child Health Nursing :Care Of The Childbearing & Childrearing Family.
Philadelphia, PA : Lippincott Williams & Wilkins

Nastor A., Natata N. (n.d.). The 4 P’s of Labor and Delivery. Retrieved from
https://www.academia.edu/8145196/4_Ps_of_Labor_and_Delivery
Shehata A. (2015). Normal Uterine Action. Retrieved from
https://www.slideshare.net/aymanshehata2010/normal-uterine-action
Gragera J. (2013). Complications with the Power. Retrieved from https://www.slideshare.net/jen316/complications-
with-the-power

DWA N. (2019). Abnormal Uterine Contraction. Retrieved from

https://www.scribd.com/presentation/266996773/Abnormal-Uterine-Contraction

Campana A. (2019). Prolonged Labour. Retrieved from

https://www.gfmer.ch/Obstetrics_simplified/prolonged_labour.htm

Mazumdar M. (n.d.) Prolonged Labor. Retrieved from http://gynaeonline.com/prolonged_labor.htm

Reiter&Walsh (n.d.) Prolonged Labor, Arrested Labor, and Birth Injury. Retrieved from
https://www.abclawcenters.com/practice-areas/prenatal-birth-injuries/traumatic-birth-injuries/prolonged-and-
arrested-labor/

Harrington, L. (2008). Normal Labour and Delivery. Retrieved from

https://www.glowm.com/section_view/heading/Normal%20Labor%20and%20Delivery/item/127

Reiter&Walsh (n.d.) Stages of Labor: What is Considered a ‘Normal’ Labor? What’s a ‘Failure to Progress?’.
Retrieved from https://www.abclawcenters.com/stages-of-labor-normal-failure-to-progress/