NURSING OF CLIENT WITH HIGH RISK

LABOR AND DELIVERY

PASSENGER 1. Transverse Lie Position
• Fetal malposition Occurs:
• Fetal mal-presentation
• Woman with pendulous abdomen
• Fetal Distress
• Uterine fibroids or tumor
• Prolapse of the umbilical cord
• Contraction of the pelvic brim
CONSIDERATIONS: • Congenital abnormalities
• Polyhydramnios
• Attitude
• Hydrocephalus
• Fetal Lie
• Prematurity
a. Transverse • multipara

b. longitudinal Assessment:

• Fetal presentation • Obvious on inspection

a. cephalic • Confirmed by LM
b. Breech
Fetal Presentation
c. Compound
d. Shoulder Portion of the body of the fetus that is
• Fetal Position foremost in the birth canal or in closest
• Leopold’s Maneuver proximity to it.
Fetal Attitude a. Cephalic
b. Breech
• Fetal posture of habitus
c. Shoulder
• Relationships of the fetal head to
d. Compound
fetal back or extremities
• “Universal flexion” Fetal presentation picture(insert)
Fetal head
• widest part of the body
• Most difficult to pass thru vagina
• Passage depends on bones, sutures,
fontanelles
Fetal Lie
• Relationship of the long axis of the
fetus to the long axis of the maternal
abdomen
Breech Fetal Position
Types: • Relationship of the chosen portion of
the fetal presenting part inn the
• Complete
reference to one of the 4 quadrants
• Frank
or transverse diameter of birth canal.
• Footling
Episiotomy
Etiology:
- Shortens the second stage of labor
• Gestational Age: < 40 weeks
especially in first time mother/
• Fetal anomaly (anencephaly and
patients
hydrocephalus)
• Polyhydramnios Determining points:
• Congenital anomaly of the brain
• Occiput (cephalic/ vertex
• Tumor
presentation)
• Pendulous abdomen (relax uterus)
• Mentum or chin (face presentation)
• Multiple Gestation
• Sacrum (breech presentation)
Assessment: • Acromion or scapula (shoulder
presentation)
• FHT heard on higher abdomen
• LM- detected different parts Diagnosis of Fetal presentation and
• Vaginal Examination- fetus may position
completely engaged but is
• Abdominal Palpation: Leopold’s
mistakenly detected
Maneuver
Birthing Techniques: • Vaginal exam
• Auscultation
• Steadied and supported by a sterile
• Sonography or ultrasound
towel
• Rarely: plain radiographs, CT-Scan or
• Delivery of shoulders
MRI
• Delivery of head
• A Hazardous part Vaginal Exam
• Danger: Compression of the cord
• Palpation of the various Fetal
and intracranial hemorrhage
sutures and fontanels
• Gentle traction by going up and
• Face and breech presentation
don
are identified.
• Straddling of the shoulders
• 2 fingers are the inserted into the Internal Examination
infant’s mouth
• Insert two fingers into the vagina
Cephalic Presentation • Assessing surgical suture of the head.
• Identifying hat station or to which
1. Vertex / Occiput
extent the presenting part has
2. Sinciput/ Military
descended.
3. Brow
4. Face
Insert pictures
Occipito-Posterior Position True Pelvis
“Sunny Sside up” • Internal
• Narrow
Management
3 parts
Position: Squatting
1. Inlet
Left Lateral if ROP
2. Midpelvis
PASSAGEWAY 3. outlet

• Refers to the passing thru uterus, If pelvis too small, home birth not done
cervix, vaginal canal.
Pelvic Inlet
• Single most important determinant
to mechanism of labor Antero-posterior diameter (/front to back)-
12.5 cm (diagonal conjugate
4 TYPES OF PELVIC
True Conjugate
Gynecoid
Actual opening of the outlet
• rounded, oval shape
• Easy vaginal delivery Subtract with symphysis pubis (1.5 cm) from
• Considered “normal female pelvis” diagonal conjugate (12.5-1.5 = 11.0)
Android Complete flexion = 9.5 cm diameter
• Vaginal delivery difficult Transverse diameter (across) – 13.5
• “true male pelvis”
Midpelvis narrowest part of pelvis that fetus
Anthropoid must pass through ischial spines
• Oval Pelvic Oitlet
• Assisted birth usually with forceps
Trouble passing through pelvic opening,
20=-25 %
pelvis too small or poor fetal attitude
Platypelloid
Soft Tisuue
• <5 % of women
• Flattened pelvis
Structures of Pelvis
• Bones held together by ligaments
• Supports and protects organs
False Pelvis: broader, hip bones
 POWERS utilize other measures such as forceps,
vacuum extraction, episiotomy
Uterine contx’x: primary force moving fetus
thru maternal pelvis during first stage of Prolonged Labor or Failure to progress:
labor
Labor lasting more than 18-24 hours or fails
Maternal Efforts: woman adds voluntary to make changes in dilation or effacement
pushing in labor to propel fetus through
Cervical Dilation: Primigravida (1.2 cm/hr
pelvis
Multigravida (1.5 cm /hr.)
PSYCHE
Dscent (i=1 cm/hr in primigravida and 2
Prepared for childbirth: childbirth classes -
cm/hr. in multigravida)
prenatal care.
Etiology:
Previous childbirth experience-
complicated? • CPD
• Malpresentation
Support from significant other- separated?
• Labor Dysfunction
Marital Strain? FOB involved? Abuse?
Therapeutic Interventions:
Emotional Status- anxious/depressed, drug
use, psych hx Depends on the cause:
Culture- background may influence • Provide comfort measures
response to pain • Conservation of energy
• Psychological support
Some moan, some stoic, some verbally
• Position change
expressive
PRECIPITUS LABOR OR DELIVERY (POWER)
Fear/ Anxiety exacerbate pain- uterine
dysfunction UNEXPECTED FAST DELIVERY
PROBLEMS OF PASSAGEWAYS: Etiology:
Cephalopelvic Disportion (CPD) • Lack of resistance of maternal tissue
t passage fetus
Causes:
• Intense uterine contractions
• Large baby for small pelvis • Small baby in a favorable position
• Usually diagnosed when there is an
Complications/Risk:
arrest in descent
• If the baby delivers too fast, does not
Symptoms:
all the cervix to dilate and efface
Stations remains the same and does not which lead to cervical lacerations
descend • Uterine rupture
• Fetal hypoxia and fetal intracranial
Treatment and Nursing Care:
hemorrhage
Usually do a C-section • Labor last less than 3 hours

Delivery
RAPID DELIVERY OUTSIDE NORMAL SETTING Goal:
• Everything is out of control stop the labor, suppress uterine activity
• Mom is frightened, angry, feels
Drug Therapy: Tocolytics
cheated
• Nursing Care: Uses: stop or arrest labor
• Do not leave the mother alone
Criteria for use, don’t give if:
• Try to make the place clean (do not
break down table) • Patient is in active labor, cervix has
dilated to 4 cm or more
PREMATURE RUPTURE OF MEMBRANES
• Presence of severe [pre-eclampsia
(POWER)
• Fetal complications/Fetal Demise
Spontaneous rupture of membranes • Hemorrhage is present
• Ruptured membranes
Etiology:
B-Adrenergic Agonist
• Infections
• Fetal abnormalities Yutopar (ritodine) or Brethine (terbutaline
• Incompetent cervix sulfate)
• Sexual intercourse
SIDE EFFECTS OR WARNING SIGNS:
Major Risk: ascending intrauterine infection
• Palpitations
Other Risk: precipitation Labor • Tachycardia (pulse-120)
• Tremors, nervousness, restlessness
Treatment:
• Headache, severe dizziness
Wait and watch, bedrest, no intercourse • Hyperglycemia
Assess: time membranes rupture and if TOXIC EFFECTS- PULMONARY EDEMA
labor started
Rales, crackles, dyspnea noted On routine
Check: Temperature nursinf=g chest examination
Describe: character of amniotic fluid Tocolytic Drugs
Check: WBC Nursing Care:
Provide: psychological support • Stop the medication
• Start oxygen
PRETERM LABOR
Antidote:
Labor that occurs 20 weeks but before 37
weeks
Etiology:
Urinary tract ninfections
Premature rupture of membranes
Calcium Channel Blokers: AMNIOTIC FLUID EMBOLISM
Decrease smooth muscle contraction by Escape of amniotic fluid into the maternal
blocking the slow calcium channels at cell circulation
surface
(usually enters maternal circulation through
Side Effects: open sinus at placental site)
• Hypotension, tachycardia Fatal: contains debris, lanugo, vernix,
• Facial flushing meconium
• Headache
Signs and Symptoms:
PROLAPSE OF UMBILICAL CORD
• Dyspnea
Prolapse through the cervical canal • Chest pain
alongside • Cyanosis
• Shock
Etiology:
Therapeutic interventions:
Occurs anytime
Deliver the baby
Nursing Care:
RUPTURED UTERUS
• Get the pressure off the cord
• Place in Trendelenburg or knee- Spontaneous or traumatic rupture of uterus
chest position
Etiology:
• elevate
Rupture of previous C-section scar
Amnioinfusion:
Prolonged labor
Warmed
Injudicious use of Pitocin(overstimulation)
Treat:
Excessive maternal pressure
• Oligohydramnios
• Meconium-stained amniotic fluid INDUCTIkkON OF LABOR
• Cord compression and variable
Stimulation of uterine contractions before
decelerations
spontaneous
Nursing Care:
(picture labor readiness)
• Assess maternal and fetal vital signs
Polyhydramios
• Assess contractions
• Provide comfort measures Excessive amniotic fluid usually >2000 ml
• Palpate FHT, Do not attempt to
replace cord
• Give O2 per gams at 10 L
• Cover exposed cord with sterile wet
gauze