HIGH RISK FACTORS pass through the maternal pelvis. 1.Passenger or Fetus Its ability to change its shape is also 2.Passageway or pelvic bones and other important pelvic structure - eases its passage during 3.Power or uterine contractions labor & delivery 4. Placenta - in response to the pressure exerted 5. Psyche - client’s psychological state by the maternal pelvis & birth canal HIGH-RISK LABOR AND during labor & delivery DELIVERYProblems of the Passenger 1. Fetal malposition Fetal Malposition 2. Fetal malpresentation Position- is the relationship of the Vertex presenting part to a specific quadrant of presentation a woman’s pelvis. Brow presentation Fetal Malpositions - are abnormal Face presentation position of the vertex in relation to the Occiput posterior maternal pelvis. 3. Fetal Distress Occipito-posterior position 4. Prolapse of the Cord - The most common TYPES OF PELVIS malposition 1. GYNECOID – normal female Occipito-transverse position pelvis - Head initially engages 2. ANDROID – male pelvis; narrow correctly but fails pelvic inlet and outlet to rotate and remains in 3. ANTHROPOID – narrow transverse position. transverse diameter and larger Positions in Vertex antero-posterior diameter Presentation (occiput) 4. PLATYPELLOID – inlet is oval Right occipito anterior and AP diameter is shallow Right occipito posterior 5. PASSENGER Right occipito transverse Description Left occipito anterior Refers to the fetus & its ability to Left occipito posterior move through the passage Left occipito transverse Affected by several fetal features Positions in Breech Presentation Fetal Skull (sacrum) Its size is important as the fetus Right sacroanterior travels the birth canal Right sacroposterior The head can flex or extend 45 Right sacrotransverse degrees and rotate 180 degrees, Left sacroanterior Left sacroposterior 11. Longer labor due to ineffective Left sacrotransverse contractions and slow or Positions in Face Presentation arrested fetal descent (mentum) 12. Cesarean birth if brow Right mentoanterior presentation persists Right mentoposterior 13. Fetus – increased mortality Right mentotransverse because of cerebral and neck Left mentoanterior compression and damage to Left mentoposterior trachea & larynx Left mentotransverse - facial edema, bruising Shoulder Presentation (acromion Risks of Face Presentation process) Increased risk of CPD & Right scapuloanterior prolonged labor Right scapuloposterior Increase risk of infection Right scapulotransverse Cesarean birth Left scapuloanterior Cephalhematoma Left scapuloposterior Edema of the face & throat Left scapulotransverse Fetal Malpresentation Fetal Malpresentation Types of breech Presentation: Presentation – describes the body part 1. Complete- thighs of the fetus that will be first to pass through the are tightly flexed on the cervix and be delivered abdomen; buttocks and flexed Fetal Malpresentation is where the legs present first baby is in difficult position for delivery 2. Frank – hips are flexed but Types of fetal presentation: legs are extended; buttocks 1. Cephalic- head presents first present first 2. Breech – buttocks or feet 3.Incomplete – one or both hips presents first partially of fully extended 3. Shoulder – shoulder, iliac crest, Nursing Management (Breech) hand, or elbow presents first Assess maternal & fetal status- to 4. Fetal Malpresentation promote maternal-fetal physical 5. Types of Cephalic: well being 6. 1. Vertex – head sharply flexed Continuous fetal monitoring- (Normal) increased risk for cord prolapse 7. 2. Brow- head moderately flexed CBR without BRP 8. 3. Face- head poorly flexed Teaching & information about the 9. 4. Mentum- hyperextension of breech presentation head; chin presents first Evaluation (Breech) 10. Risks of Brow Presentation The woman & partner understand Fetal Heart Rate PatternsA. Early the implications of breech Decelerations presentation = caused by fetal head compression Major complications are • Periodic DECREASE in FHR recognized early & corrective resulting from pressure on the measures are instituted fetal head during contractions. The mother and baby have safe B. Late Decelerations labor & birth = caused by uteroplacental insufficiency Fetal Malpresentation • Are smooth, uniform waveforms Shoulder Presentation – the fetus is that inversely mirror the lying horizontally in the pelvis contractions, they may drop to Compound Presentation- prolapse of a below 100 beats/minute. limb of the fetus alongside the head in a C. Variable Decelerations cephalic presentation or of one or both = caused by umbilical cord arms in a breech presentation compression Fetal Distress • In severe cases the FHR may HYPOXIA - decelerate below 70beats/minute Late deceleration appear for more than 30 seconds, with a Fetal breathing stops slow return to baseline. Fetal movement ceases • Management: Fetal tone absent 1. place pt in left-lateral position • Causes of Fetal DistressCord 2. increased IV flow rate Prolapse/cord compression 3. administer O2 as per doctors order • PROM 4. discontinue oxytocin infusion (induce • Oligohydramnios labor) • Meconium Staining Nursing Intervention: • Maternal complication – DM, 1. continue monitoring contractions and anemia, infection record FHR. • Preterm/IUGR fetus 2. anticipate amnioinfusion for repetitive • How it is detected? Special test variable decelerations and monitoring procedures 3. If rate falls below 70beats/minute > X-ray pelvimetry reveals persists for more than 60 seconds, the malpositioning doctor may choose to intervene. > Ultrasonography shows pelvic masses 4. Prepare double set-up delivery that interfere with vaginal birth Prolapse of the Umbilical Cord > Auscultation of FHR (by fetoscope, A loop of the umbilical cord slips Doppler unit, or electronic fetal monitor) down in front of the presenting determines fetal intolerance of labor. fetal part Prolapse may occur anytime after presenting part in the woman's vagina the membranes rupture if the (to keep pressure off the cord) until presenting part is not fitted firmly delivered by CS. into the cervix. 5. If prolapsed cord is exposed to room Causes: Premature rupture of air (drying will begin- leading to atrophy membranes of the umbilical vessels). Fetal presentation other than • Don't push the cord back to cephalic vagina (may add to compression Tends to occur most often with by knotting/kinking), instead the ff conditions: cover exposed portion with sterile Placenta previa sponge soaked in sterile saline to Intrauterine tumors preventing the prevent drying. presenting part from engaging Nursing Interventions: A small fetus Inform client and watchers about CPD preventing firm engagement the additional procedures & Hydramnios techniques that may be ASSESSMENT: necessary during the delivery = cord may be felt as the process. presenting part initially during IE Prepare additional equipment & = identified on UTZ, CS is personnel for delivery necessary before rupture of Assisting with amniotomy, membranes. ultrasonography, forceps or = if rupture occurs, the cord will vacuum extraction application as slide down into the vagina needed (pressure exerted by amniotic Assisting with neonatal fluid) resuscitation, if necessary = cord may be visible at the vulva Explaining any newborn Management: 1. Position patient on characteristics related to the high Trendelenburg or knee chest (for fetal risk birth, such as forcep marks, head to fall back thus relieving pressure bruising on cord preventing compression and Encouraging parental interaction fetal anoxia) with neonates immediately after 2. Administer O2 at 10L/min to mother delivery (helpful to improve oxygenation of the • PASSAGERefers to the route fetus). that the fetus must travel when 3. A tocolytic agent is used (to reduce leaving the uterus arriving at the uterine activity and pressure on fetus) external perineal area of birth. 4. If fully dilated, the physician may PROBLEMS with the PASSAGEWAY: deliver infant quickly, if incomplete A. Abnormal Size or Shape of the dilatation, upward pressure on the Pelvis B. Cephalo-pelvic Disproportion passage C. Shoulder Dystocia except when • Refers to the route that the fetus fetus is in must travel when leaving the occiput uterus arriving at the external posterior perineal area of birth. position PROBLEMS with the PASSAGEWAY: c. Android- shaped pelvis occurs in A. Abnormal Size or Shape of the about 20% of females Pelvis It’s heart- B. Cephalo-pelvic Disproportion shaped, like C. Shoulder Dystocia the normal • Refers to the route that the fetus male pelvis must travel when leaving the Diameter is uterus arriving at the external somewhat perineal area of birth. narrowed, Shape of pelvis making fetal -also can determine the ability and ease passage with which the fetus can pass difficult a. Gynecoid- shaped pelvis is the most d. Platypelloid- shaped pelvis occurs in common type of pelvis about 5% of females Occurs in It’s oval or about 50% of flat females The fetus Round shape may have with difficulty adequate rotating diameters to sufficiently to allow easy match the passage of shape of the fetal skull pelvis at the b. Anthropoid- shaped pelvis occurs in appropriate about 25% of females diameters It’s oval with CEPHALOPELVIC DISPROPORTION longer • Refers to the narrowing of the anteroposteri birth canal which can occur at the or diameter inlet, midpelvis, or outlet. This type of • Involves a disproportion between pelvis may the size of the normal fetal head pose and the pelvic diameters. difficulty in • Results in failure to progress in may also be frightened and feel labor helpless Causes : • The physical size of the maternal pelvis is a major contributor – small pelvis is a factor. • Outlet contraction can also be a contributing factor - There's a narrowing of the transverse diameter Treatment : • If the pelvic measurements are borderline or just adequate, especially the inlet measurement , and the fetal lie and position are good, the physician may allow a trial labor (to determine whether labor can progress normally). • If labor doesn't progress or complications develop, cesarean birth is the method of choice. • Nursing Intervention: • 1. Instruct the primi patient to maintain her prenatal visit schedule so that pelvic measurements are taken and recorded before week 24 of pregnancy. • 2. Monitor progress of the trial labor – if, after 6-12 hours, no progress of labor and if fetal distress occurs, prepare for CS. • 3. If the trial labor fails and cesarean birth is scheduled, provide an explanation about why it's necessary and is best for the neonate. • 4. Provide support for the patient's significant person; he Shoulder Dystocia Hypotonic uterine • The problem occurs at the contractions second stage of labor when the Uncoordinated uterine fetal head is born but the contractions shoulders are too broad to enter 2. Premature labor and be delivered through the 3. Precipitate labor & birth pelvic outlet. 4. Uterine prolapse/inversion Causes : 5. Uterine rupture - Occur in women with diabetes, and DYSFUNCTIONAL LABOR in post-date pregnancies, poor fetal • Also known as “inertia” ; refers to position, multiple pregnancy, and large a sluggishness in the force of fetus. contractions. • Hazardous to the Mother = • Dysfunctional labor can occur at because it can result in vaginal or any point in labor but is generally cervical tearing. classified as primary (occurring at • Hazardous to the Fetus = the onset of labor) or secondary compressed between the fetal (late in labor). body and the bony pelvis, Causes: possibly resulting in a fractured • It may be related to problems clavicle or a brachial plexus with the passenger, passage or injury. power. Assessment Findings > malposition or malpresentation or an • Suspected if the 2nd stage of unusually large fetus. labor is prolonged, there is arrest > pelvic contractures, cervical rigidity of descent or when head appears > uterine contractions that are in perineum but retracts instead hypotonic, hypertonic, or uncoordinated. of protruding with each • Presence of full rectum or urinary contraction. (turtle sign) bladder (impedes fetal descent) • Treatment : • Mother becoming exhausted from • Initially = Applying suprapubic labor pressure may help the shoulder Hypotonic Contractions escape from beneath the • Termed when the number or symphysis pubis. frequency of contractions is low, • CS is necessary if maternal and not increasing beyond two or fetal condition is in complication. three in a 10-minute period, and Problems with the POWERS the strength of contractions does Problems with the Powers not rise above 25mmHg. The 1. Dystocia or difficult labor resting tone of the uterus remains Hypertonic uterine below 10mmHg during active contractions phase. • Irregular and not painful (lack of - If contractions are too weak or intensity) infrequent to be effective, labor may causes: need to be induced or augmented to • Occur when analgesia has been make uterine contractions stronger. administered too early (before - Cervical ripening via stripping of cervical dilatation of 3-4cm) membranes or application of • Overstretched uterus by a prostaglandin gel or laminaria may be multiple gestation done to prepare for the induction of • Larger fetuses labor. • Lax uterus from grand multiparity • Hypertonic contractions • Bowel or bladder distention = involves promoting rest, providing * due to cervix dilated for a long period analgesia with a drug such as morphine both uterus and fetus are at risk of sulfate, possibly inducing sedation(for INFECTION woman to rest). HYPERTONIC UTERINE - promote comfort (changing the linen CONTRACTION and the mother's gown, darkening room • Are marked by an increased in lights, and decreasing noise/stimuli). resting tone to more than - if decelerating FHT or lack of progress 15mmHg, with pushing, CS delivery may be • The uterus don't rest between necessary. contractions, high resting • Uncoordinated Contractions = pressure of 40-50mmHg. - Oxytocin administration to stimulate a • complains of pain more effective and consistent pattern of • *lack of relaxation between contractions contractions does not allow - if HPN occurs, stop oxy drip and optimal uterine artery filling, notify physician. which may lead to FETAL Nursing Interventions : ANOXIA. 1. Explain the events to the patient and Uncoordinated Uterine Contractions her support person; explain that the • Occur erratically, such as one on contractions are ineffective top of another followed by a long 2. Provide comfort measures, including period without any. nonpharmacologic pain relief measures. • The lack of a regular pattern to 3. Continuously monitor uterine contractions makes it difficult for contractions and FHR patterns. the woman to use breathing 4. Offer fluids as appropriate; institute IV exercises bet contractions. therapy to supply glucose to replace Management depleted stores from prolonged labor. • Hypotonic contractions involves 5. Assist with measures to induce or improving the strength of augment labor; monitor oxytocin infusion contractions if used. 6. Encourage frequent voiding to • Magnesium sulfate is typically the prevent bladder distention from first drug used to stop interfering with labor contractions. contractions. PREMATURE LABOR - It's a central nervous system • Also known as “preterm labor”; depressant that prevents reflux of the onset of rhythmic uterine calcium into the myometrial cells, contractions that produce cervical thereby keeping the uterus relaxed. changes after fetal viability but - Antidote is Calcium gluconate. before fetal maturity. • Nifedipine (Procardia) is a • Usually occurs between 20 and calcium channel blocker, it below 37 weeks gestation. decreases the production of • Premature labor increases the calcium, a substance associated risk of neonate morbidity or with the initiation of labor. mortality from excessive - There's no antidote, DC the drug. maturational deficiencies. Nursing Intervention : • Maternal causes : 1. Closely observe the patient in preterm - Cardiovascular and renal disease labor for signs of fetal or maternal - DM distress. - Infection 2. Provide guidance about the hospital - Abdominal surgery or trauma stay, potential for delivery of a - Incompetent cervix premature infant, and the possible need • Fetal causes : for neonatal intensive care. - Infection 3. Maintain bed rest; provide appropriate - Hydramnios diversionary activities. - Multiple pregnancy 4. Administer medications as ordered. Assessment Findings: 5. Monitor VS, FHR and uterine • Onset of rhythmic uterine contractions. contractions 6. Keep the patient in left side-lying • Possible rupture of membranes , position to ensure adequate placental passage of cervical mucus plug, perfusion. and a bloody discharge 7. Administer fluids as ordered to ensure • Cervical effacement and dilation adequate hydration. on vaginal exam 8. If necessary during active premature Treatment: labor, administer O2 to the patient. drug therapy with tocolytic agent 9. If labor is suppressed, begin • Terbutaline, a beta-adrenergic discharge teaching with the woman and blocker, is the most commonly family about tocolytic therapy, and used tocolytic (smooth muscle anticipate referral and follow up. relaxation). - Antidote is propranolol (Inderal)