NCP Dysfunctional Labor Dystocia

Dysfunctional Labor/Dystocia
Dystocia refers to difficult labor which is usually due to uterine dysfunction, fetal malpresentation/abnormality, or pelvic abnormality.
(Refer to CPs: Labor: Stage I—Latent Phase; Labor: Stage I—Active Phase.)
Report of fatigue, lack of energy
Lethargy, decreased performance
BP may be elevated.
May have received magnesium sulfate (MgSO4) for pregnancy-induced hypertension.
Bowel or bladder distension may be evident.
Ego Integrity
May be extremely anxious, fearful
May have received narcotic or peridural anesthesia early in labor process.
May have noted false labor at home.
Infrequent or irregular contractions, mild to moderate in intensity (fewer than three contractions in a 10-min period).
May occur prior to the onset of labor (primary latent-phase dysfunction) or after labor is well established (secondary active-phase dysfunction).
Latent Phase of Labor May Be Prolonged: 20 hr or longer in nullipara (average is 81⁄2 hr), or 14 hr in multipara (average is 51⁄2 hr).
Myometrial resting tone may be 8 mm Hg or less, and contractions may measure less than 30 mm Hg or may occur more than 5 min apart; or resting tone may be greater than 15 mm Hg, with contractions rising to 50–85 mm Hg with increased frequency and decreasing intensity.
May have had external version after 34 weeks’ gestation in attempt to convert breech to cephalic presentation.
Fetal descent may be less than 1 cm/hr in nullipara or less than 2 cm/hr in multipara (protracted descent), or no progress over 1 or more hr for nullipara or for 30 min in multipara after complete cervical dilation (arrest of descent).
Vaginal examination may reveal fetus to be in malposition (i.e., breech; chin, face, or brow position).
Cervix may be rigid/“not ripe.”
Dilation may be less than 1.2 cm/hr in primipara or less than 1.5 cm/hr for multipara, in active phase (protracted active phase), or absence of cervical changes over a 2-hr period (secondary arrest of labor).
Failure to deliver within 2 hr, or 3 hr with regional anesthesia for primipara, or 1 hr/2hr with regional anesthesia for multipara (prolonged stage II).
May be primigravida or grand multipara.
Uterus may be overdistended owing to hydramnios, multiple gestation, a large fetus, or grand multiparity.
May have identifiable uterine tumors.
Prenatal Testing: May have confirmed polyhydramnios, large fetus, or multiple gestation.
Nonstress Test/Contraction Stress Test (NST/CST): Assesses fetal well-being.
X-ray Pelvimetry or Ultrasound: Evaluates pelvic architecture, fetal presentation, position, and formation.
Fetal Scalp Sampling: Occasionally done to detect or rule out acidosis.
  1. Identify and treat abnormal uterine pattern.
  2. Monitor maternal/fetal physical response to contractile pattern and length of labor.
  3. Provide emotional support for the client/couple.
  4. Prevent complications.
NURSING DIAGNOSIS:                                                               Injury, risk for maternal
Risk Factors May Include:                                                             Alteration of muscle tone/contractile pattern, mechanical obstruction to fetal descent, maternal fatigue
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Accomplish cervix dilation at least 1.2 cm/hr for
CRITERIA—CLIENT WILL:                                                     primipara, 1.5 cm/hr for multipara in active phase, with fetal descent at least 1 cm/hr for primipara, 2 cm/hr for multipara.
ACTIONS/INTERVENTIONS                                   RATIONALE
Review history of labor, onset, and duration.                                         Helpful in identifying possible causes, needed
diagnostic studies, and appropriate interventions.
Uterine dysfunction may be caused by an atonic or a
hypertonic state. Uterine atony is classified as
primary when it occurs before the onset of labor
(latent phase) or secondary when it occurs after well-
established labor (active phase).
Note timing/type of medication(s). Avoid admin-                                 A hypertonic contractile pattern may occur in
istration of narcotics or of epidural block anesthetics                            response to oxytocin stimulation; sedation/
until cervix is 4 cm dilated.                                                                     analgesia given too early (or in excess of needs) can
inhibit or arrest labor.
Evaluate current level of fatigue, as well as activity                              Excess maternal exhaustion contributes to
and rest prior to onset of labor.                                                               secondary dysfunction, or may be the result of
prolonged labor/false labor.
Assess uterine contractile pattern manually                                           Dysfunctional contractions prolong labor,
(palpation) or electronically via external, or internal                             increasing the risk of maternal/fetal complications.
monitor with internal uterine pressure catheter                                      A hypotonic pattern is reflected by frequent, mild
(IUPC).                                                                                                   contractions measuring less than 30 mm Hg via IUPC
or “soft as chin” per palpation. A hypertonic pattern
is reflected by increased frequency, an elevated
resting tone per palpation or greater than 15 mm Hg
via IUPC, and possibly decreased intensity of
contractions. Note: Intensity of contractions cannot be
measured by external monitor.
Note condition of cervix. Monitor for signs of                                      A rigid or unripe cervix will not dilate, impeding
amnionitis. Note elevated temperature or WBC;                                   fetal descent/labor progress. Development of
odor and color of vaginal discharge.                                                       amnionitis is directly related to length of labor, so
that delivery should occur within 24 hr after rupture
of membranes.
Note effacement, fetal station, and fetal presentation.                            These indicators of labor progress may identify a
contributing cause of prolonged labor. For example,
breech presentation is not as effective a wedge for
cervical dilation as is vertex presentation.
Graph cervical dilation and fetal descent against                                   May be used on occasion to document progress/
time (i.e., Friedman curve).                                                                    prolongation of labor.
Place client in lateral recumbent position and                                        Relaxation and increased uterine perfusion may
encourage bedrest or sitting position/ambulation,                                  correct a hypertonic pattern. Ambulation may
as tolerated.                                                                                             assist gravitational forces in stimulating normal labor
pattern and cervical dilation.
Encourage client to void every 1–2 hr. Assess for                                 A full bladder may inhibit uterine activity and
bladder fullness over symphysis pubis.                                                  interfere with fetal descent.
Assess degree of hydration. Note amount and type                               Prolonged labor can result in a fluid-electrolyte
of intake. (Refer to ND: Fluid Volume risk for deficit.)                         imbalance as well as depletion of glucose reserves,
resulting in exhaustion and prolonged labor with
increased risk of uterine infection, postpartal
hemorrhage, or precipitous delivery in the presence
of hypertonic labor.
Review bowel habits and regularity of evacuation.                                Bowel fullness may inhibit uterine activity and
interfere with fetal descent.
Remain with client if possible, arrange for presence                             Reduction of outside stimuli may be necessary to
of doula as appropriate; provide quiet environment                               allow sleep after administration of medication to
as indicated.                                                                                             client in the hypertonic state. Also helpful in
reducing level of anxiety, which can contribute to
both primary and secondary uterine dysfunction.
Have emergency delivery kit available.                                                  May be needed in the event of a precipitous labor
and delivery, which are associated with uterine
Palpate abdomen of thin client for presence of                                      In obstructed labor, a depressed pathological ring
pathological retraction ring between uterine segments.                         (Bandl’s ring) may develop at the juncture of lower
(These rings are not palpable through the vagina,                                  and upper uterine segments, indicating impending
or through the abdomen, in the obese client).                                         uterine rupture.
Investigate reports of severe abdominal pain. Note                               May indicate developing uterine tear/acute
signs of fetal distress, cessation of contractions,                                    rupture necessitating emergency surgery. Note:
presence of vaginal bleeding.                                                                  Hemorrhage is usually occult since it is
intraperitoneal with hematomas of the broad
Prepare client for amniotomy, and assist with the                                  Rupture of membranes relieves uterine
procedure, when cervix is 3–4 cm dilated.                                             overdistension (a cause of both primary and
secondary dysfunction) and allows presenting part to
engage and labor to progress in the absence of CPD.
Note: Active management of labor (AML) protocols
may support anmniotomy once presenting part is
engaged to accelerate labor/help prevent dystocia.
Use nipple stimulation to produce endogenous                                      Oxytocin may be necessary to augment or institute
oxytocin, or initiate infusion of exogenous oxytocin                             myometrial activity for hypotonic uterine pattern.
(Pitocin) or prostaglandins. (Refer to CP: Labor:                                  It is usually contraindicated in hypertonic labor
Induced/Augmented.)                                                                              pattern because it can accentuate the hypertonicity,
but may be tried with amniotomy if latent phase is
prolonged and if CPD and malpositions are ruled
Administer narcotic or sedative, such as morphine,                               May help distinguish between true and false labor.
pentobarbital (Nembutal), or secobarbital (Seconal),                            With false labor, contractions cease; with true
for sleep as indicated.                                                                              labor, more effective pattern may ensue following
rest. Morphine helps promote heavy sedation and
eliminate hypertonic contractile pattern. A period of
rest conserves energy and reduces utilization of
glucose to relieve fatigue.
Prepare for forceps delivery, as necessary.                                             Excessive maternal fatigue, resulting in ineffective
bearing-down efforts in stage II labor, necessitates
use of forceps.
Assist with preparation for cesarean delivery, as                                   Immediate cesarean birth is indicated for Bandl’s
indicated, e.g., malposition, CPD, or Bandl’s ring.                                ring or fetal distress due to CPD. Note: Once labor
(Refer to CP: Cesarean Birth.)                                                                is diagnosed, if delivery has not occurred within
12 hr, and amniotomy and oxytocin have been
used appropriately, then a cesarean delivery is
recommended by some protocols.
NURSING DIAGNOSIS:                                                               Injury, risk for fetal
Risk Factors May Include:                                                             Prolonged labor, fetal malpresentations, tissue hypoxia/acidosis, abnormalities of the maternal pelvis, CPD
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Display FHR within normal limits, with good
CRITERIA—FETUS WILL:                                                        variability, no late decelerations noted.
CLIENT WILL:                                                                              Participate in interventions to improve labor pattern and/or reduce identified risk factors.
ACTIONS/INTERVENTIONS                                   RATIONALE
Assess FHR manually or electronically. Note vari-                               Detects abnormal responses, such as exaggerated
ability, periodic changes, and baseline rate. If in free-                           variability, bradycardia, and tachycardia, which
standing birth center, check FHTs between contrac-                              may be caused by stress, hypoxia, acidosis, or
tions using Doptone. Count for 10 min, break for                                  sepsis.
5 min, and count again for 10 min. Continue this
pattern throughout the contraction to midway
between it and the following contraction.
Note uterine pressures during resting and con-                                      Resting pressure greater than 30 mm Hg or
tractile phases via intrauterine pressure catheter, if                               contractile pressure greater than 50 mm Hg
available.                                                                                                 reduces or compromises oxygenation within
intervillous spaces.
Identify maternal factors such as dehydration,                                       Sometimes, simple procedures (such as turning
acidosis, anxiety, or vena caval syndrome.                                            client to lateral recumbent position) can increase
circulating blood and oxygen to uterus and placenta
and may prevent or correct fetal hypoxia.
Note frequency of uterine contractions. Notify                                      Contractions occurring every 2 min or less do not
physician if frequency is 2 min or less.                                                  allow for adequate oxygenation of intervillous
Assess for malpositioning using Leopold’s maneuvers                         Determining fetal lie, position, and presentation
and findings on internal examination (location of                                  may identify factor(s) contributing to
fontanelles and cranial sutures). Review results of                                dysfunctional labor.
Monitor fetal descent in birth canal in relation to                                  Descent that is less than 1 cm/hr for a primipara,
ischial spines.                                                                                          or less than 2 cm/hr for a multipara, may indicate
CPD or malposition.
Arrange transfer to acute care setting if malposition                              Risk of fetal/neonatal injury or demise increases
is detected in client in free-standing birth center                                   with vaginal delivery if presentation is other than
without adequate surgical/high-risk neonatal                                         vertex.
Prepare client for the most expedient method of delivery                      Such presentations increase the risk of CPD, owing
if fetus is in brow, face, or chin presentation.                                         to a larger diameter of the fetal skull entering the
pelvis (11 cm in brow or face presentation, 13 cm in
chin presentation, versus 9.5 cm for vertex
presentation), often necessitating assisted delivery
via forceps or vacuum, or cesarean delivery because
of failure to progress and ineffective labor pattern.
Assess for deep transverse arrest of the fetal head.                                Failure of the vertex to rotate fully from an OP to an
occiput OA position may result in a transverse
position, arrested labor, and the need for cesarean
Have client assume hands-and-knees position, or                                  These positions encourage anterior rotation by
lateral Sims’ position on side opposite that to which                             allowing fetal spine to fall toward the client’s
fetal occiput is directed, if fetus is in OP position.                                 anterior abdominal wall (70% of fetuses in OP
position rotate spontaneously).
Note color and amount of amniotic fluid when                                      Excess amniotic fluid causing uterine overdis-
membranes rupture.                                                                                tention is associated with fetal anomalies.
Meconium-stained amniotic fluid in a vertex
presentation results from hypoxia, which causes
vagal stimulation and relaxation of the anal
sphincter. Noting characteristics of amniotic fluid
alerts staff to potential needs of newborn, e.g.,
airway/ventilatory support.
Observe for visible cord prolapse when membranes                              Cord prolapse is more likely to occur in breech
rupture, and occult cord prolapse as indicated by                                  presentation, because the presenting part is not
variable decelerations on monitor strip, especially if                             firmly engaged, nor is it totally blocking the os, as
fetus is in breech presentation.                                                                in vertex presentation.
Note odor and change in color of amniotic fluid                                    Ascending infection and sepsis with accompanying
with prolonged rupture of membranes.                                                   fetal tachycardia may occur with prolonged rupture
of membranes.
Administer antibiotic to client, as indicated.                                           Prevents/treats ascending infection and will protect
fetus as well.
If fetus fails to rotate from OP to OA position (face                              Delivering the fetus in a posterior position results
to pubis), prepare for delivery in posterior position.                              in a higher incidence of maternal lacerations.
Alternatively, apply vacuum extractor as indicated.                               Vacuum extractor may be used to rotate and expedite
delivery of fetus.
Prepare for cesarean delivery of breech presentation                             Vaginal delivery of an infant in breech position is
if fetus fails to descend, labor progress ceases, or                                  associated with injury to the fetal spinal column,
CPD is identified.                                                                                    brachial plexus, clavicle, and brain structures,
increasing neonatal mortality and morbidity. Risk of
hypoxia caused by prolonged vagal stimulation with
head compression, and trauma such as intracranial
hemorrhage, can be alleviated or prevented if CPD is
identified and surgical intervention follows
NURSING DIAGNOSIS:                                                               Fluid Volume risk for deficit
Risk Factors May Include:                                                             Hypermetabolic state, vomiting, profuse diaphoresis, restricted oral intake, mild diuresis associated with oxytocin administration
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Maintain fluid balance, as evidenced by moist
CRITERIA—CLIENT WILL:                                                     mucous membranes, appropriate urine output, and palpable pulses.
Be free of complications.
ACTIONS/INTERVENTIONS                                   RATIONALE
Keep accurate intake/output, test urine for ketones,                               Decreased urine output and increased urine
and assess breath for fruity odor.                                                            specific gravity reflect dehydration. Inadequate
glucose intake results in a breakdown of fats and
presence of ketones.
Monitor vital signs. Note reports of dizziness with                                Increased pulse rate and temperature, and
change of position.                                                                                  orthostatic BP changes may indicate decrease in
circulating volume.
Assess lips and oral mucous membranes and degree                             Dry oral mucous membranes/lips and decreased
of salivation.                                                                                            salivation are further indicators of dehydration.
Note abnormal FHR response.                                                               May reflect effects of maternal dehydration and
(Refer to ND: Injury, risk for fetal.)                                                       decreased perfusion.
Encourage oral fluids as appropriate.                                                      Clear liquids such as fruit juices and broths provide
not only fluids but also calories for energy
production. Note: PO fluids are not recommended if
surgical intervention is contemplated.
Review laboratory data, e.g.: Hb/Hct, serum                                         Increased Hct suggests dehydration. Serum
electrolytes, and serum glucose.                                                             electrolyte levels detect developing imbalances;
serum glucose levels detect hypoglycemia.
Administer fluids intravenously.                                                             Parenteral solutions containing electrolytes and
glucose can correct or prevent maternal and fetal
imbalances and may reduce maternal exhaustion.
NURSING DIAGNOSIS:                                                               Coping, Individual, ineffective
May Be Related To:                                                                        Situational crisis, personal vulnerability, unrealistic expectations/perceptions, inadequate/exhausted support systems
Possibly Evidenced By:                                                                   Verbalizations and behavior indicative of inability to cope (loss of control, inability to problem-solve and/or meet role expectations), irritability, reports of tension/fatigue
DESIRED OUTCOMES/EVALUATION                                    Verbalize understanding of what is happening.
Identify/use effective coping techniques.
ACTIONS/INTERVENTIONS                                   RATIONALE
Determine progress of labor. Assess degree of pain                              Prolonged labor with resultant fatigue can reduce
in relation to dilation/effacement.                                                            the client’s ability to cope/manage contractions.
Increasing pain when the cervix is not dilating/
effacing can indicate developing dysfunction.
Extreme pain may indicate developing anoxia of
the uterine cells.
Acknowledge reality of client’s reports of pain/                                    Discomfort and pain may be misunderstood in the
discomfort.                                                                                              presence of lack of progression that is not recognized
as a dysfunctional problem. Feeling listened to and
supported can help client relax, reducing discomfort
and enhancing ability to cope with situation.
Determine anxiety level of client and partner. Note                              Excess anxiety increases adrenal activity/release of
evidence of frustration.                                                                           catecholamines, causing endocrine imbalance. Excess
epinephrine inhibits myometrial activity. Stress also
depletes glycogen stores, reducing glucose available
for adenosine triphosphate (ATP) synthesis, which is
needed for uterine contraction.
Discuss possibility of discharge of client to home                                 Too early admission fosters a sense of longer/
until active labor is established.                                                              prolonged labor for client. Client may be able to relax
better in familiar surroundings. Provides opportunity
to divert/refocus attention and to attend to tasks
that may be contributing to level of
Provide comfort measures and reposition client/                                    Reduces anxiety, promotes relaxation and sense of
encourage ambulation as appropriate. Demonstrate/                              control, assisting client to cope positively with the
encourage use of relaxation techniques, including                                 situation.
patterned breathing.
Provide encouragement for client/couple efforts                                   May be useful in correcting misconception that
to date.                                                                                                     client is overreacting to labor or is somehow to blame
for alteration of anticipated birth plan.
Give factual information about what is happening.                                Reduces the “unknowns” to assist with reduction of
anxiety and provides data necessary to make
informed decisions.
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