Problem with the passage Outlet contraction

The third reason dystocia can occur is a contraction or Outlet contraction is a narrowing of the transverse diameter,
narrowing of the passageway or birth canal. This can happen the distance between the ischial tuberosities at the outlet, to
at the inlet, at the midpelvis, or at the outlet. The narrowing less than 11 cm.
causes CPD, or a disproportion between the size of the fetal
head and the pelvic diameters, which then results in failure to Trial labor
progress in labor. If a woman has a borderline (just adequate) inlet measurement
Inlet contraction and the fetal lie and position are good, her primary care
provider may allow her a “trial” labor to determine whether
Inlet contraction is narrowing of the anteroposterior diameter of labor will progress normally.
the pelvis to less than 11 cm, or of the transverse diameter to
12 cm or less.  The trial labor continues as long as descent of the
presenting part and dilatation of the cervix continue to
 It usually is caused by rickets in early life or by an occur. With a trial labor, monitor fetal heart sounds
inherited small pelvis. and uterine contractions frequently.
 Urge the woman to void every 2 hours so her urinary
Rickets is caused by a lack of calcium and is therefore rare in bladder is as empty as possible, allowing the fetal
developed countries but can occur among immigrants who head to use all the space available.
were raised where milk supplies were not plentiful
 If, after a definite period (6 to 12 hours), adequate
 In primigravidas, the fetal head normally engages progress in labor cannot be documented, or if at any
between weeks 36 and 38 of pregnancy time fetal distress occurs, the trial labor will be
discontinued and the woman will be scheduled for a
If this occurs any time before labor begins, it is proof the pelvic cesarean birth.
inlet is adequate as lightening, by definition, means the fetal
head has sunk below the inlet. It may be difficult for women to undertake labor they know they
may not be able to complete because the effort subjects them
Following the general rule that “what goes in, comes out,” a needlessly to pain.
head that engages or proves it fits into the pelvic brim will
probably also be able to pass through the midpelvis and  Emphasize, but do not overstress, that it is best for
through the outlet. their baby to be born vaginally.
 If the trial labor fails and cesarean birth is scheduled,
If engagement does not occur in a primigravida, then either a provide an explanation as to why cesarean birth is
fetal abnormality (larger than usual head) or a pelvic necessary and why it has become the best route for
abnormality (smaller than usual pelvis) should be suspected. the birth of their baby.

 As a rule, engagement does not occur in Some women undergoing a trial labor feel as if they
multigravidas until labor begins. For these women, themselves are on trial. When dilatation does not occur, they
previous vaginal birth of a full-term infant without begin to feel discouraged and inadequate, as if they are at
problems is proof their birth canal is adequate. fault.

Every primigravida should have pelvic measurements taken The support person may be as frightened and feel as helpless
and recorded before week 24 of pregnancy so, based on these as she does and so momentarily stops being a support person.
measurements and the assumption the fetus will be of average
size, a birth decision can be made.  You can assure a woman and her support person
that a cesarean birth is just an alternative, not an
 If CPD exists, because the fetus may not engage but inferior, method of birth for them. Because labor
instead remains “floating,” the possibility of cord is not progressing, it is the method of choice to
prolapse can lead to a secondary concern. allow them to achieve their goal of a healthy
mother and healthy child.
External cephalic version In years past, babies were routinely born with forceps. Today,
the technique is rarely used (in only about 4% to 8% of births)
External cephalic version is the turning of a fetus from a because it can lead to rectal sphincter tears in the woman,
breech to a cephalic position before birth. which can lead to dyspareunia, anal incontinence, or
increased urinary stress incontinence
 It may be done as early as 34 to 35 weeks,
although the usual time is by 37 to 38 weeks of Although no longer used routinely, forceps may be necessary
pregnancy with any of the following conditions:
For the procedure, FHR and possibly ultrasound are recorded  A woman is unable to push with contractions in the
continuously. pelvic division of labor such as might happen with a
woman who received regional anesthesia or who has
 A tocolytic agent may be administered to help
a spinal cord injury.
relax the uterus.
 Cessation of descent in the second stage of labor
 The breech and vertex of the fetus are located
occurs.
and grasped transabdominally by the examiner’s
 A fetus is in an abnormal position.
hands on the woman’s abdomen
 Gentle pressure is then exerted to rotate the  A fetus is in distress from a complication such as a
fetus in a forward direction to a cephalic lie. prolapsed cord.

Although not always successful, the use of external version Although forceps appear as if they would put forceful pressure
can decrease the number of cesarean births necessary from: on the fetal head, the pressure registers on the steel blades
rather than the head so they can actually reduce pressure,
 breech presentations thus avoiding a complication such as subdural hemorrhage.
 Contraindications to the procedure include multiple
Before forceps are applied:
gestation,
 severe oligohydramnios,  Membranes must be ruptured.
 small pelvic diameters,  CPD must not be present.
 a cord that wraps around the fetal neck,  The cervix must be fully dilated.
 Unexplained thirdtrimester bleeding, which might be  The woman’s bladder must be empty.
a placenta previa.  Record the FHR before forceps application because
there is a danger that the cord could be compressed
External version can be uncomfortable for a woman because
between the forceps blade and the fetal head,
of the feeling of pressure. Women who are Rh negative should
receive Rh immunoglobulin after the procedure in case  assess FHR again immediately after application.
minimal bleeding occurs. The woman’s cervix needs to be carefully assessed after
Forceps birth forceps birth to be certain no lacerations have occurred

Obstetrical forceps are steel instruments constructed of two  To rule out bladder injury, record the time and amount
blades that slide together at their shaft to form a handle. of the first voiding.
 Assess the newborn to be certain no facial palsy
 One blade is slipped into the woman’s vagina next to exists from pressure.
the fetal head, and the other is slipped into place on  A forceps birth may leave a transient erythematous
the other side of the head. mark on the newborn’s cheek. This mark will fade in 1
 Next, the shafts of the instrument are brought to 2 days with no long-term effects.
together in the midline to form the handle.
 The primary care provider then applies pressure on
the handle to manually extract the fetus from the birth
canal.
Vacuum extraction

A fetus, if positioned far enough down the birth canal, may be

born by vacuum extraction

 With the fetal head at the perineum, a soft, disk-

shaped cup is pressed against the fetal scalp and
over the posterior fontanelle.
 When vacuum pressure is applied, air beneath the
cup is suctioned out and the cup then adheres so
tightly to the fetal scalp that traction on the vacuum
cord leading to the cup extracts the fetus

Vacuum extraction has advantages over forceps birth in that

little anesthesia is necessary, thus leaving the fetus with less
respiratory depression at birth.

 One disadvantage over natural birth is that more

perineal lacerations may occur.
 Its major disadvantage is that it causes a marked
caput on the newborn head that may be noticeable as
long as 7 days after birth.
 Tentorial tears from extreme pressure also have
occurred.

A woman may need reassurance that the caput swelling is

harmless for her infant and will decrease rapidly.

Vacuum extraction should not be used as a method of birth if

fetal scalp blood sampling was used because the suction
pressure can cause severe bleeding at the sampling site.

Moreover, vacuum extraction is not advantageous for preterm

infants because of the softness of the preterm skull.