Dysfunctional Labor (Dystocia) Nursing Care Plan & Management

Description

Dysfunctional labor is difficult, painful, prolonged labor due to mechanical factors.

Etiology

Fetal factors (passenger) include unusually large fetus, fetal anomaly, malpresentation, and malposition
Uterine factors (powers) include hypotonic labor, hypertonic labor, precipitous labor, and prolonged labor.
Pelvic factors (passage) include inlet contracture, midpelvis contracture, and outlet contracture.
“Psyche” factors include maternal anxiety and fear and lack of preparation.

Pathophysiology

Uterine contractions are ineffective secondary to muscle fatigue or overstretching.

Assessment Findings

Clinical manifestations include irregular uterine contractions and ineffective uterine contractions in terms of contractile strength and duration.

Nursing Management

Optimize uterine activity. Monitor uterine contractions for dysfunctional patterns; use palpation and an electronic monitor.
Prevent unnecessary fatigue. Check the client’s level of fatigue and ability to cope with pain.
Prevent complications of labor for the client and infant.
- Assess urinary bladder; catheterize as needed.
- Assess maternal vital signs, including temperature, pulse, respiratory rates, and blood pressure.
- Check maternal urine for acetone (an indication of dehydration and exhaustion).
- Assess condition of fetus by monitoring FHR, fetal activity, and color of amniotic fluid.
Provide physical and emotional support.
- Promote relaxation through bathing and keeping the client and bed clean, back rubs, frequent position changes (sidelying), walking (if indicated), and by keeping the environment quiet.
- Coach the client in breathing and relaxation techniques.
Provide client and family education.

Exam

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Nursing Care Plan

Risk For Fluid Volume Deficit

Risk for fluid volume deficit: At risk for experiencing vascular, cellular, or intracellular dehydration.

Risk factors

Hypermetabolic state.
Vomiting.
Profuse diaphoresis.
Restricted oral intake.
Mild diuresis associated with oxytocin administration

Possibly evidenced by

[Not applicable].

Desired Outcomes

Patient will maintain fluid balance, as evidenced by moist mucous membranes, appropriate urine output, and palpable pulses.
Patient will be free of complications.

Nursing Interventions	Rationale
Monitor vital signs. Note reports of dizziness with change of position.	Increased pulse rate and temperature, and orthostatic BP changes may indicate decrease in circulating volume.
Assess lips and oral mucous membranes and degree of salivation.	Dry oral mucous membranes/lips and decreased salivation are further indicators of dehydration.
Note abnormal FHR response.	May reflect effects of maternal dehydration and decreased perfusion.
Keep accurate intake/output, test urine for ketones, and assess breath for fruity odor.	Decreased urine output and increased urine specific gravity reflect dehydration. Inadequate glucose intake results in a breakdown of fats and presence of ketones.
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 electrolytes, and serum glucose.	Increased Hematocrit suggests dehydration. Serumelectrolyte 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.

Risk For Maternal Injury

Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.

Risk factors

Alteration of muscle tone/contractile pattern.
Maternal fatigue.
Mechanical obstruction to fetal descent.

Possibly evidenced by

[Not applicable]

Desired Outcomes

Patient will accomplish cervix dilation at least 1.2 cm/hr for 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.

Nursing Interventions	Rationale
Review the 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 administration of narcotics or of epidural block anesthetics until the cervix is 4 cm dilated.	A hypertonic contractile pattern may occur in response to oxytocin stimulation; sedation/analgesia given too early (or in excess of needs) can inhibit or arrest labor.
Note the condition of cervix. Monitor for signs of amnionitis. Note elevated temperature or WBC; odor and color of vaginal discharge.	A rigid or unripe cervix will not dilate, impending fetal descent/labor progress. Development of amnionitis is directly related to length of labor, so that delivery should occur within 24 hr after rupture of membranes.
Assess uterine contractile pattern manually (palpation) or electronically via external, or internal monitor with internal uterine pressure catheter (IUPC).	Dysfunctional contractions lengthen labor increasing the risk of maternal/fetal complications. A hypotonic pattern is reflected by frequent, mild 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 an external monitor.
Evaluate the current level of fatigue, as well as activity and rest prior to onset of labor.	Excess maternal exhaustion contributes to secondary dysfunction, or may be the result of prolonged labor/false labor.
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.
Evaluate degree of hydration. Note amount and type of intake.	Prolonged labor can result in a fluid-electrolyte 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.
Graph cervical dilation and fetal descent against time (i.e., Friedman curve).	May be used on occasion to record progress/ prolongation of labor.
Review bowel habits and regularity of evacuation	Bowel fullness may hinder uterine activity and interfere with the fetal descent.
Encourage client to void every 1–2 hr. Assess for bladder fullness over symphysis pubis.	A full bladder may inhibit uterine activity and interfere with the fetal descent.
Place client in lateral recumbent position and encourage bed rest or sitting position/ambulation,as tolerated.	Relaxation and increased uterine perfusion may correct a hypertonic pattern. Ambulation may assist gravitational forces in stimulating normal labor pattern and cervical dilation.
Have emergency delivery kit available.	May be needed in the event of a precipitous labor and delivery, which are associated with uterine hypertonicity.
Remain with the client if possible, arrange for the presence of doula as appropriate; provide a quiet environment as indicated.	Decrease external stimuli may be important to allow sleep after administration of medication to a client in the hypertonic state. Also helpful in decreasing the level of anxiety, which can contribute to both primary and secondary uterine dysfunction.
Palpate the abdomen of thin client for the presence of pathological retraction ring between uterine segments. (These rings are not palpable through the vagina or through the abdomen, in the obese client).	In obstructed labor, a depressed pathological ring (Bandl’s ring) may develop at the juncture of lowerand upper uterine segments, indicating an impending uterine rupture.
Investigate reports of severe abdominal pain. Note signs of fetal distress, cessation of contractions, presence of vaginal bleeding.	May indicate developing uterine tear/acute rupture necessitating emergency surgery. Note: Hemorrhage is usually occult since it is intraperitoneal with hematomas of the broad ligament.
Prepare client for amniotomy, and assist with the procedure, when the cervix is 3–4 cm dilated.	Rupture of membranes relieves uterine overdistension (a cause of both primary and secondary dysfunction) and allows presenting part to engage and labor to progress in the absence of cephalopelvic disproportion (CPD). Note: Active management of labor (AML) protocols may support amniotomy once presenting part is engaged to accelerate labor/help prevent dystocia.
Administer narcotic or sedative, such as morphine, pentobarbital (Nembutal), or secobarbital (Seconal), for sleep as indicated.	May help distinguish between true and false labor. With false labor, contractions cease; with true labor, a more effective pattern may happen following a 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.
Use nipple stimulation to produce endogenous oxytocin or initiate infusion of exogenous oxytocin (Pitocin) or prostaglandins.	Oxytocin may be necessary to increase or institute myometrial activity for a hypotonic uterine pattern.It is usually contraindicated in hypertonic labor pattern because it can accentuate the hypertonicity, but may be tried with amniotomy if the latent phase is prolonged and if CPD and malpositions are ruled out.
Prepare for forceps delivery, as necessary.	Excessive maternal fatigue, resulting in ineffective bearing-down efforts in stage II labor, necessitates the use of forceps.
Assist with preparation for cesarean delivery, as indicated, e.g., malposition, CPD, or Bandl’s ring.	Immediate cesarean birth is indicated for Bandl’s ring or fetal distress due to CPD. Note: Once labor 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.