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 passage 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 be very painful

Medical Management:

1. administration of oxytocin
2. amniotomy to improve labor

Complications:

1. ineffective cervical dilatation

2. prolonged labor
3. ineffective uterine contractions during the postpartal period
4. possible postpartal hemorrhage
5. 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. Dilute intravenous infusion of oxytocin

2. Intramuscular methergine
3. Administer oxygen by face mask
4. Prostaglandin administration
5. Blood replacement
6. 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. Deficient fluid volume related to excess fluid blood loss after birth.
2. Acute pain related to tissue trauma
3. Risk for ineffective tissue perfusion related to loss of blood
4. Risk for deficient diversional activity related to activity restrictions and bedrest.