Dystocia and Postpartum

ANGELES UNIVERSITY FOUNDATION COLLEGE OF NURSING

DYSTOCIA and POSTPARTUM HEMORRHAGE (case report)

Submitted by: Del Rosario, Jovella BSN III-12

Submitted to: Reenah Zarah N. Macarayo, RN, MN Clinical Instructor

DYSTOCIA  Dystocia is an abnormal or difficult childbirth or labor. It came from the Greek "dys" meaning "difficult, painful, disordered, abnormal " and "tokos" meaning "birth." It occurs in 1% of vaginal deliveries.

Birth Dystocia

ETIOLOGY

1. Uterine factors: Good contractions start at the fundus and move down towards the pelvis. If uterine activity is uncoordinated or contractions short or infrequent then labor will be difficult and prolonged. Primigravida mothers may be more at risk of dystocia as they have a degree of uterine uncoordination which is why their labours tend to be longer. Oxytocin can enhance and coordinate uterine contractions. 2. Fetal factors: Position or lie. E.G. transverse or breech, macrosomia, shoulder  dystocia (this results as a combination of fetal factors and pelvic pa ssage factors). 3. Pelvic passage factors: A pelvis with a round brim is very favourable in labour, however some women have a long and oval brim. A small pelvic brim should be suspected if the fetal head has not engaged into the pelvis by 37 weeks gestation. Other factors that can lead to cephalopelvic disproportion are scoliosis, kyphosis and historically rickets. Shoulder dystocia in part results from a small or abnormal pelvic inlet. RISK FACTORS • • • • • •

Diabetes mellitus Fetal macrosomia Maternal obesity Induction of labour  Prolonged labour  Oxytocin - too much can lead to hyperstimulation of the uterus

HYPERTONIC UTERINE DYSFUNCTION – frequent contractions of the uterus that generally occurs at the latent phase of labor. Causes: 



contraction of the mid-segment of the uterus is greater than the contraction of the fundus muscle fibers of the myometrium do not repolarize or relax after a contraction

Signs and Symptoms  

frequent and intense contractions that are ineffective very painful contractions

Medical Management:

1. Bed rest 2. Pain relief with drugs such as morphine sulfate 3. ceasarean birth if no progress in labor, deceleration in FHR, and long first stage of  labor  Nursing Management:

1. Decrease noise and stimulation 2. Monitor fetal heart rate and labor progress Complications:

1. restricted uterine artery filling 2. fetal anoxia

HYPOTONIC UTERINE DYSFUNCTION – low or infrequent contractions that usually occur at the active phase of labor. Causes:     

bowel or bladder distention overstretched uterus due to multiple gestation macrosomia hydramnios lax uterus due to grand multiparity

Signs and Sympotms:  

infrequent and non-forceful contractions usually painless, though some women may report it to b e very painful

Medical Management:

1. administration of oxytocin 2. amniotomy to improve labor  Complications:

1. 2. 3. 4. 5.

ineffective cervical dilatation prolonged labor  ineffective uterine contractions during the postpartal period possible postpartal hemorrhage uterine and fetal infections

Management for all cases of Dystocia:

1. Assisted delivery with the use of forceps 2. McRoberts maneuver - the patient hyperflexes her hips so they are against her  abdomen. Mothers in labour may not have enough energy to do this by themselves and may need the assistance of others in the room - which is usually the case. Posterolateral pressure is applied suprapubically with traction on the fetal head. This is the most effective procedure and should be performed first. 3. If this fails an episiotomy may be needed - but the need for a caesarean should be considered. 4. Wood's screw maneuver - turning anterior shoulder to posterior position.

Nursing Diagnosis: 1. Fear related to uncertainty of pregnancy outcome 2. Anxiety related to medical procedures necessary to ensure health of mother and fetus 3. Fatigue related to loss of glucose stores through work and during labor  4. Risk for ineffective tissue perfusion related to excessive blood loss with complication of labor  5. Risk for injury related to effect on mother and fetus of a labor complication and treatment required.

POSTPARTUM HEMORRHAGE Postpartum hemorrhage is defined as a loss of blood in the postpartum period of more than 500 mL. The average, spontaneous vaginal birth will typically have a 500 mL blood loss. In cesarean births the average blood loss rises to 800-1000 mL. There is a greater  risk of hemorrhage in the first 24 hours after the birth, called primary postpartum hemorrhage. A secondary hemorrhage occurs after the first 24 hours of birth. It is one of  the most important causes of maternal mortality associated with childbearing. Risk Factors         

Multiple Gestation Large baby Polyhydramnios Multipartity (particularly grand multiparity, more than 5 term pregnancies) Prolonged labor (uterine inertia) Labor induced with oxytocin General Anesthesia Placenta Previa / Abruptio Placentae Magnesium Sulfate infusion

4 MAJOR CAUSES: 1. Uterine Atony - relaxation of the uterus. The uterus is not contracting enough to control the bleeding at the placental site.

-Most frequent cause of postpartal hemorrhage Therapeutic Management:

1. 2. 3. 4. 5. 6.

Dilute intravenous infusion of oxytocin Intramuscular methergine Administer oxygen by face mask  Prostaglandin administration Blood replacement Iron therapy

Nursing Management:

1. Uterine massage 2. Supine position 3. Monitor Vital signs frequently

2. Lacerations- occur most often in different circumstances such as delivery with difficult or precipitate births, primigravidas, macrosomic babies, use of lithotomy positions and instrument. Nursing Management:

1. Maintain an air of calm and stand beside the woman 2. Adequate space to work, adequate sponges and suture supplies and a good light source. 3. For perineal lacerations, diet high in fluid and stool softener may be prescribed for  the first week after birth. 3. Retained Placental Fragments - the placenta does not deliver in its entirety; the fragments of it separate and are left behind. Medical Management:

1. DNC 2. Methotrexate may be prescribed Nursing Management:

1. Report any tendency for the discharge to change from lochia serosa or alba back  to rubra. 2. Be certain the client knows to continue the observation of the color of lochia discharge. 4. Disseminated Intravascular Coagulation - an acquired disorder of blood clotting in which fibrinogen level fails to below effective limits. It occurs when there is extreme bleeding and so many platelets and fibrin from the general circulation rush to the site that not enough are left in the rest of the body for further clotting. Medical Management:

1. Intravenous administration of heparin 2. Blood or platelet transfusion may be necessary 3. Fresh-frozen plasma or platelets. Nursing Mangement: 

Be certain a woman and her support person have a full explanation of what is happening.

Nursing Diagnosis:

1. 2. 3. 4.

Deficient fluid volume related to excess fluid blood loss after birth. Acute pain related to tissue trauma Risk for ineffective tissue perfusion related to loss of blood Risk for deficient diversional activity related to activity restrictions and bedrest.