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Maternal Newborn Nursing

19.1 Labor Dystocia

Maternal Newborn Nursing19.1 Labor Dystocia

Learning Objectives

By the end of this section, you will be able to:

  • Explain the uterine causes of dystocia during labor and birth
  • Explain the pelvic causes of dystocia during labor and birth
  • Explain the fetal causes of dystocia during labor and birth

Lack of progress during labor, which could make it prolonged or difficult is called dystocia is defined as difficult labor. The types of dystocia are uterine, pelvic, and fetal. Table 19.1 lists the most common risk factors for labor dystocia. Uterine dystocia is caused by lack of power, meaning that uterine contractions or the maternal pushing effort is inadequate to progress to birth. Pelvic dystocia is a problem of the passage, meaning that the pelvic outlet does not allow the passage of the fetus for birth. Fetal dystocia is a problem of the passenger, meaning that the fetus is unable to maneuver through the pelvis to descend and birth. These three types of dystocia create long, difficult labors. The common factors associated with labor dystocia are the following:

  • power: uterine contractions and laboring person’s pushing effort
  • passenger: fetal malposition or malpresentation
  • passage: inadequate pelvis inlet, midpelvis, or outlet
  • psyche: laboring person’s preparedness and anxiety regarding the labor and birth process
  • position of the laboring person
Cause Risk Factor
Power
  • induction of labor
  • prelabor rupture of membranes
  • preterm labor
  • prolonged latent phase
  • protracted active phase
  • prolonged second stage
  • epidural anesthesia
  • chorioamnionitis
  • postterm pregnancy
  • polyhydramnios
  • maternal fatigue
  • multiple gestation
  • uterine anomalies
  • grand multiparity
Passenger
  • estimated fetal weight large for gestational age
  • mispositioning or malpresentation of the fetus
Passage
  • age of laboring person (< 16 and > 40)
  • obesity
  • short stature
  • shape and size of pelvis
  • nulliparity
Psyche
  • anxiety
  • knowledge deficit
  • lack of support
Position
  • head of bed elevated < 30 degrees
  • laboring person lying on back
Table 19.1 The Most Common Risk Factors Associated with Labor Dystocia (Mohammed & El-Chaar, 2022)

Life-Stage Context

Labor Dystocia Increases with Age

Advanced maternal age (AMA) is a risk factor for uterine dystocia. The finding that uterine dystocia occurs more often in AMA persons is true; however, studies have shown that the risk of labor dystocia increases with maternal age (Waldenstrom & Ekeus, 2017). After age 25, the risk of labor dystocia increases continuously regardless of parity. Therefore, labor dystocia risk can occur prior to age 35. Labor dystocia increasing with age is related to a continuous decline in uterine performance after age 25.

Uterine Dystocia

The labor complication in which lack of cervical dilation occurs due to insufficient contraction strength, frequency, or duration is uterine dystocia (Wu et al., 2017).

Figure 19.2 shows monitor tracings associated with uterine dystocia. In a normal contraction pattern, the upper uterine muscles shorten during the contraction to elongate the lower uterine segment, which causes dilation, effacement, and descent of the fetal head. (Figure 19.3) shows how the muscle fibers of the uterus work together.

Three contraction patterns shown: Hypotonic uterine contraction pattern, Hypertonic uterine contraction pattern, and Normal uterine contraction pattern.
Figure 19.2 Fetal Monitor Tracings of Uterine Contraction Patterns These monitor tracings represent the common uterine contraction patterns seen in labor over 15 minutes. Tracing 1 represents an inadequate pattern, with too few contractions. Tracing 2 represents a tachysystole pattern, with too many contractions that lack strength and duration. Tracing 3 represents a normal contraction pattern, with five contractions. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)
Image of muscles running throughout the uterus.
Figure 19.3 Uterine Muscle Structure The muscle structure of the uterus enables contractions to shorten the upper uterine segment and stretch the cervix open. This is demonstrated by the white lines in the picture. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Multiple factors cause inadequate uterine contraction activity. Causes related to the pregnant person are chorioamnionitis, dehydration and malnutrition, exhaustion, and emotional stress. Chorioamnionitis can cause the uterine muscle to inadequately contract due to the inflammatory process of infection. Pregnant persons with long labors who are allowed little to eat or drink can become exhausted, hypoglycemic, and dehydrated, preventing the uterine muscles from contracting properly. Emotional stress occurs when fear, pain, or inability to relax releases stress hormones, such as cortisol, that inhibit proper oxytocin production (Aristizabal, 2019). A fetal cause of inadequate contraction patterns can be malposition. The fetus presenting in the occiput-posterior or occiput transverse position creates a larger diameter to pass through the pelvic inlet, making labor progression difficult. The role of the nurse is to encourage hydration, assist with frequent movement and position changes, and provide emotional support to alleviate fear and stress in the laboring person.

Multiple gestation, large for gestational age, and polyhydramnios (an excessive amount of amniotic fluid) distend the uterus and decrease the strength of the contractions, causing uterine dystocia. Grand multiparity and prolonged labor are associated with a uterus too tired or overstretched to contract efficiently. Uterine anomalies, such as bicornuate and unicornuate uteri, are associated with uterine muscle dysfunction. Epidural anesthesia may decrease uterine contraction strength and frequency and has been linked to a nonengaged fetal head (Penuela et al., 2019).

Uterine dystocia can also occur in second stage labor. When the cervix is fully dilated and the fetal head has descended, most laboring persons feel an overwhelming urge to push. The fetus is born by the expulsive strength of the uterine contractions and the maternal pushing effort. Dystocia may occur because epidural anesthesia reduces the urge to push. Second stage dystocia can also result from the same risk factors that cause first stage uterine dystocia. New guidelines for second stage labor recommend that a nulliparous person push at least 3 hours and a multiparous person push at least 2 hours prior to diagnosing dystocia (American College of Obstetricians and Gynecologists [ACOG], 2024). The guidelines do not specify any difference in length with or without an epidural. The role of the nurse during the second stage, especially during dystocia, is to provide support and assist in the pushing process.

Pelvic Dystocia

A labor complication that occurs when the size of the fetal head is larger than the size of the maternal pelvis due to a small capacity of the pelvic inlet, midpelvis, or pelvic outlet is called pelvic dystocia. In a normal labor, the fetal head descends and engages in the pelvic inlet. As the fetus passes through the pelvis, the head flexes and rotates to the occiput-anterior (OA) position in the midpelvis. The fetal head enters the pelvic outlet in a flexed OA position and is born by the extension of the fetal head. If any part of the pelvis is too small for the fetal head, these cardinal movements cannot occur. At times, the power of the contractions can be adequate, but because of the inability of the fetal head to descend, cervical dilation and effacement stall (Cohen & Friedman, 2023).

Life-Stage Context

Pelvic Dystocia in Teens

Prior to the current study, adolescents were thought to have increased risk of pelvic dystocia because of the immaturity of their pelvis and thus were at higher risk for cesarean birth. Recent studies, however, have not confirmed this assumption.

A study was conducted of 43,537 nulliparous persons less than 25 years of age. The study examining adverse maternal and neonatal outcomes included 1,189 adolescents less than 16 years of age; 14,703 older adolescents ages 16 to 19; and 27,645 young adults ages 20 to 24. Study results found that younger adolescents had increased anemia, preterm delivery, postpartum hemorrhage, and preeclampsia. Older adolescents had increased anemia, preterm delivery, and blood transfusions.

Study results found that younger and older adolescents had decreased risk of cesarean birth. Older adolescents were less likely to have a cesarean birth due to failure to progress or cephalopelvic disproportion. For adolescents who spontaneously went into labor, the study showed their second stage of labor was shorter.

This study challenged the assumption of increased incidence of pelvic dystocia in younger adolescents. However, research on this population is limited, and the topic requires further study.

(Kawakita et al., 2016)

The normal pelvic inlet should allow the passage of a fetal head diameter of approximately 9.5 centimeters (cm) (Figure 19.4). Therefore, if the pelvic inlet is less than 10 cm, it could cause inability of the fetal head to engage and pass through the inlet.

Image of pelvis bone with pelvic inlet circled.
Figure 19.4 Pelvic Inlet The pelvic inlet must be adequate for the fetal head to enter and pass through to avoid pelvic dystocia. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Midpelvis dystocia is more common than pelvic inlet dystocia. The midpelvis is measured by the distance between the ischial spines and should average more than 9 cm (Figure 19.5). When the nurse is performing a cervical exam during labor, the ischial spines are the landmark for determining station. If the ischial spines are encroaching and prominent, the nurse is aware that a midpelvis dystocia could occur. With a smaller midpelvis, the fetal head engages but is unable to flex or rotate anteriorly. Molding and caput succedaneum are seen with this dystocia.

Image of pelvic bone with ischial spines extending out into the pelvic inlet. The interspinous measurement of 10 cm is labeled inside the pelvic inlet.
Figure 19.5 Midpelvis A midpelvis dystocia occurs when the ischial spines are prominent and encroaching. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Pelvic outlet dystocia is seen when the ischial tuberosity distance is less than 8 cm (Figure 19.6). When the pelvic outlet is contracted or too small, the fetal head can become malpositioned as the fetus attempts to turn the head to find the path of least resistance to progress through the pelvis. Extreme caput succedaneum can occur. Pelvic outlet dystocia can lead to prolonged pushing, forceps birth, or cesarean birth.

Image of pelvic bone with ischial spines extending out into the pelvic outlet.
Figure 19.6 Pelvic Outlet A pelvic-outlet dystocia occurs when the ischial tuberosities are encroaching and not allowing descent of the fetal head. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Fetal Dystocia

The labor complication in which the fetal head is unable to navigate through the pelvis is fetal dystocia. Reasons for fetal dystocia can be a persistent occiput posterior or transverse, face, or brow presentation. Occiput posterior or transverse positions can stall cervical dilation due to lack of even pressure exerted on the cervix. These positions can also lead to failure of the presenting part to descend. A face presentation occurs when the neck is hyperextended and the chin, also called the mentum, is presenting. This presentation, occurring in only 0.1 percent of births, is caused by prematurity, pendulous maternal abdomen, fetal malformations (anencephaly), and polyhydramnios (Mohammed & El-Chaar, 2022). Some face and brow presentations are seen with large fetuses and contracted pelvis inlets. A vaginal delivery is possible if the chin is directed at the maternal symphysis pubis (mentum anterior) (see Figure 15.8). It is impossible for a fetus to navigate the pelvis if the chin remains posterior and pointing toward the maternal back (mentum posterior); a cesarean birth is necessary (Mohammed & El-Chaar, 2022). The role of the nurse is to support and educate the laboring person and family regarding the possible changes in birth plan to a forceps or cesarean birth.

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