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General information: Any labor or delivery that is prolonged and difficult. Usually results form a change in the interrelationships among the 5 Ps (factors in labor and delivery): >passenger >passage >powers >placenta >psyche of mother. Cesarean birth is needed if disproportion is great. Problems with presentation: any presentation unfavorable for delivery (e.g. breech, shoulder , face, transverse lie. Posterior presentation that does not rotate or cannot be rotated with ease.

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Problems with maternal soft tissue A full bladder may impede the progress of labor, as can myomata uteri, cervical edema, scar tissue, and congenital anomalies. Emptying the bladder may allow labor to continue; the other conditions may necessitate caesarean birth. 2. Dysfunctional uterine contractions Contraction may be too weak, too short, too far apart, ineffectual Classification A.) Primary: inefficient pattern present from beginning of labor; usually prolonged latent phase. B.) Secondary: efficient pattern that changes to efficient or stops; may occur in any stage.

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Assessment findings: Progress of labor is slower than expected rate of dilatation, effacement, descent for specific client. Length of labor prolonged; prolonged latent phase (>20 hrs in nullipara pt. or >4 h in a multipara pt), protacted active phase dilatation np. <1-2cm, mp <1.5cm; protacted descengt <1 cm per hr change in station in the nullipara pt. or <2 cm per hour in the mp pt. Maternal exhaustion/ distress Fetal distress Arrest of descent: no progress in fetal station greater than 1 hour Nursing intervention: Individual as to cause Provide comfort measures for client Provide client, supportive descriptions of all actions taken Administer analgesia if ordered Monitor mother/ fetus continuously

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Ineffective uterine contraction or power Maternal position and during labor and birth Previous psychological response to past experience of labor and delivery Alteration of fetal size, position, presentation, and number of fetuses. Alteration in pelvic structure Insufficient contractions are produced Compromised efforts due to analgesia Occurrence of extended and painful labor This interacts with the labor progress Complications to the fetus: Neonatal asphyxia Fetal injuries and fractures Fetal distress Complications to the mother: Vaginal laceration Infection Maternal exhaustion Post partum hemorrhage Maternal vaginal laceration Vaginal hemorrhage: decrease blood volume Acute pain Poor dilatation and effacement of the cervix Poor descent of the fetus

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Signs/ symptoms: Pain Increase heart rate, pulse, body temp. Increased BP Diaphoresis Body weakness Exhausted appearance SOB Nasal flaring Anxiety Restlessness Vaginal hemorrhage

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Medical Management: Treatment for contraction abnormalities involves stimulation of labor through the use of oxytocin. An intrauterine pressure catheter may be used. Management for maternal passageway or fetal passage problems involves delivery in the safest manner for the mother and fetus. If the problem is related to the inlet or midpelvis, a CS delivery is indicated. B. If the size of the outlet is the problem, a forceps or vacuum extraction maybe perform. Surgical Management: 1. Caesarean in necessary for delivery of the fetus

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Acute pain related difficulty in labor. Promoting comfort: Relaxation technique such as breathing techniques during labor Changing position Support person Pain medications Anxiety related to threat of change in health status of self and fetus. Decreasing anxiety: Give brief explanation to the women about the nature of contraction associated with induce labor Provide anticipatory guidance regarding use of meds, procedures and equipment. Prepare for caesarean if necessary Powerlessness Provide rest period Relaxation technique Support person Nursing diagnosis:

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Deficient knowledge related to measures that can be used to enhance labor and facilitate birth. Teach proper breathing techniques used during labor Educate about the complication of the delivery Explain client that caesarean is necessary due to difficult labor. Ineffective individual coping related to inadequate support system. Support mechanism: Stay with the patient during labor process Encourage patient to discuss about her condition

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