Nursing Care of the client with high-risk labor& delivery & her family

2. Problems with the passageway

-Contraction or narrowing of the passageway or birth canal. The narrowing causes CPD, or a disproportion between the size
of the fetal head and the pelvic diameters, which then results in failure to progress in labor.
-May occur at the inlet, at the midpelvis, or at the outlet.
-Assessed via sonogram

A. Abnormal size or shape of the pelvis

i. Inlet contraction
- Narrowing of the anteroposterior diameter of the pelvis to less than 11 cm, or of the transverse diameter to 12 cm or
less.
- Caused by rickets in early life or by an inherited small pelvis.

ii. Outlet contraction

- Narrowing of the transverse diameter, the distance between the ischial tuberosities at the outlet, to less than 11 cm.

iii. Shoulder Dystocia

-Occurs at the second stage of labor, when the fetal head is born but the shoulders are too broad to enter and be born
through the pelvic outlet.

 Complications
 Can result in vaginal or cervical tears.
 Cord compression
 Can result in a fractured clavicle or a brachial plexus injury for the fetus.
 Separation of your pubic bones.

 Factors
 Diabetes
 Multiparas
 Postdate pregnancies

 Clinical sign
 Turtle sign- Fetal head retraction manifested by head bobbing, emerging and then pulling back
(conceptualised as similar to a turtle pulling its head into and out of its shell).

 Series of maneuvers that help resolve a shoulder dystocia

 McRoberts maneuver: Asking or assisting a woman to flex her thighs sharply on her abdomen widens the
pelvic outlet and may allow the anterior shoulder to be born.
 Applying suprapubic pressure may also help the shoulder escape from beneath the symphysis pubis and be
born.

iv. Cephalopelvic Disproportion (CPD)

-Occurs when there is mismatch between the size of the fetal head and size of the maternal pelvis, resulting in "failure
to progress" in labor for mechanical reasons.

 Suggested by:
 Lack of engagement at the beginning of labor
 Prolonged first stage of labor
 Poor fetal descent

 Factors:
 Gestational diabetes
 Post-term pregnancy
 Small pelvic outlet
 Congenital dislocation of the hips
 Occipital posterior disproportion

 Management:
 Close monitoring of the labor progress
 Discontinuation of Pitocin
 Cesarean section if indicated

 More than 65% of women who had been diagnosed with CPD in earlier pregnancies were able to deliver vaginally
in subsequent pregnancies (American Journal of Public Health).

3. Problems with the Powers

***Power refers to uterine contractions and maternal pushing efforts.

A. Dysfunctional Labor (Dystocia)

-Refers to difficult labor which is usually due to uterine dysfunction, fetal malpresentation/abnormality, or pelvic
abnormality.

 Factors:
 Advanced maternal age
 Obesity
 Overdistention of uterus
 Cephalopelvic disproportion (CPD)
 Overstimulation of the uterus
 Maternal fatigue
 Dehydration
 Fear or anxiety
 Lack of analgesic assistance

B. Premature labor
-Labor that occurs before the end of week 37 of gestation.
-It occurs in approximately 9% to 11% of all pregnancies and is responsible for almost two thirds of all infant deaths in the
neonatal period
-A woman is documented as being in actual labor rather than having false labor contractions if contractions have caused
cervical effacement over 80% or dilation over 1 cm.

 Factors
 Dehydration
 Urinary tract infection
 Periodontal disease
 Chorioamnionitis
 Large fetal size
 African American women
 Adolescents
 Inadequate prenatal care
 Strenuous jobs during pregnancy

 Assessment
 Ultrasound exam: analyzing changes in the length of the cervix
 Analysis of vaginal mucus for the presence of fetal fibronectin, a protein produced by trophoblast cells . If this
is present in vaginal mucus, it predicts that preterm contractions are ready to occur; absence of the protein
predicts that labor will not occur for at least 14 days.

 Therapeutic Management
-Medical attempts can be made to stop labor if the fetal membranes have not ruptured, fetal distress is absent,
there is no evidence that bleeding is occurring, the cervix is not dilated more than 4 to 5 cm, and effacement is not more
than 50%.
 Admission and bed rest to relieve the pressure of the fetus on the cervix.
 External fetal and uterine contraction monitors are attached to monitor FHR and the intensity of contractions.
 Intravenous fluid therapy
 Vaginal and cervical cultures and a clean-catch urine sample are prescribed to rule out infection.

 Pharmacologic Intervention
 Terbutaline: may be used as a tocolytic agent.
***Should not be used for over 48 to 72 hours of therapy because of a potential for serious maternal
heart problems and death.
***Should not be used in an outpatient or home setting: requires constant assessment.

 Magnesium sulfate, given IV, is used primarily to treat preeclampsia and prevent eclamptic seizures.
***It was traditionally given to prevent preterm labor as well.
 Corticosteroid such as betamethasone the formation of lung surfactant: Reduce the possibility of respiratory
distress syndrome or bronchopulmonary dysplasia.
***During the time labor is being chemically halted, therefore, if the pregnancy is under 34 weeks, a
woman may be given two doses of 12 mg betamethasone intramuscularly 24 hours apart or four doses of 6
mg dexamethasone intramuscularly 12 hours apart. Although the effect of betamethasone lasts for about 7
days, it takes about 24 hours for the drug to begin its effect, so it is important labor be halted for at least 24
hours. If the fetus is not born within the 7-day time span, the dose of betamethasone may be repeated.
C. Precipitate labor and birth
-Predicted from a labor graph if, during the active phase of dilatation, the rate is greater than 5 cm/hr (1 cm every 12
minutes) in a nullipara or 10 cm/hr (1 cm every 6 minutes) in a multipara.

 Terminologies
 Precipitate dilatation
-Cervical dilatation that occurs at a rate of 5 cm or more per hour in a primipara or 10 cm or more per hour in
a multipara.

 Precipitate birth
-Uterine contractions are so strong a woman gives birth with only a few, rapidly occurring contractions, often
defined as a labor that is completed in fewer than 3 hours.

 Factors
 Grand multiparity
 After induction of labor by oxytocin

 Complications
 Contractions can be so forceful they lead to premature separation of the placenta or lacerations of the
perineum
 Risk for hemorrhage

 Nursing Consideration
 Caution a multiparous woman by week 28 of pregnancy that because a past labor was so brief, her labor this
time also may be brief so that she has time to plan for adequate transportation to the hospital or alternative
birthing center.

D. Uterine prolapse
-The uterus has descended into the vagina due to overstretching of uterine supports and trauma to the levator ani muscle.
-Pelvic floor muscles and ligaments stretch and weaken until they no longer provide enough support for the uterus.

 Assessment Finding
 Vaginal pressure and low back pain

 Factors
 Insufficient prenatal care
 Birth of a large infant
 Prolonged second stage of labor
 Bearingdown efforts or extraction of a baby before full dilatation
 Instrument birth
 Poor healing of perineal tissue postpartally

 Management
 Surgery to repair uterine supports or placement of a pessary, a plastic uterine support.
***Women with pessaries in place need to return for a pelvic examination every 3 months to have the
pessary removed, cleaned, and replaced and the vagina inspected; otherwise, vaginal infection or erosion of
the vaginal walls can result. Surgical replacement is also possible.

E. Uterine rupture
-Rupture of the uterus during labor, although rare, is always a possibility.
-It occurs most often in women who have a previous cesarean scar.

 Types
i. Complete
-Going through the endometrium, myometrium, and peritoneum layers
-Uterine contractions will immediately stop

ii. Incomplete
-Leaving the peritoneum intact

 Factors
 Prolonged labor
 Abnormal presentation
 Multiple gestation
 Unwise use of oxytocin
 Obstructed labor
  Traumatic maneuvers of forceps or traction

 Assessment
 Confirmed by UTZ
 Complete uterine rupture
 Sudden, severe pain during a strong labor contraction, which she may report as a “tearing” sensation.
 Abdominal assessment: swelling from the retracted uterus and the extrauterine fetus.
 Hemorrhage from the torn uterine arteries floods into the abdominal cavity and possibly into the vagina.
 Signs of hypotensive shock begin, including a rapid, weak pulse; falling blood pressure; cold and clammy
skin; and dilation of the nostrils from air starvation.
 Incomplete uterine rupture
 If the rupture is incomplete, the signs of rupture are less evident
 Localized tenderness and a persistent aching pain over the area of the lower uterine segment.

 Complication
 When uterine rupture occurs, fetal death will follow unless immediate cesarean birth can be accomplished.
 The viability of the fetus depends on the extent of the rupture and the time elapsed between rupture and
abdominal extraction.
 A woman’s prognosis depends on the extent of the rupture and the blood loss.

 Management
 Administer emergency fluid replacement therapy as prescribed.
 Anticipate the use of IV oxytocin to attempt to contract the uterus and minimize bleeding.
 Prepare the woman for a possible laparotomy as an emergency measure to control bleeding and birth the
fetus.
 Options such as cesarean hysterectomy or tubal ligation, both of which will result in loss of childbearing ability
will be considered.
 Utilize clergy or counselors as needed to help the couple begin the coping process. They are not only grieving
for the loss of a child but also the cost of unexpected surgery and perhaps loss of fertility.
 Most women are advised not to conceive again after a rupture of the uterus, unless the rupture occurred in
the inactive lower segment.

4. Anomalies of the placenta

-Placenta, commonly referred to as the afterbirth, is a disc of tissue that connects a mother's uterus to the umbilical cord,
and is ultimately responsible for delivering nutrients and oxygen to a fetus.
-Normal placenta weighs approximately 500 g and is 15 to 20 cm in diameter and 1.5 to 3.0 cm thick. Its weight is
approximately one sixth that of the fetus.
-A placenta may be unusually enlarged in women with diabetes.
-If the uterus has scars or a septum, the placenta may be wide in diameter because it was forced to spread out to find
implantation space.

A. Placenta Succenturiata
-Is a placenta that has one or more accessory lobes connected to the main placenta by blood vessels.
-No fetal abnormality is associated with this type.
-Complication: Small lobes may be retained in the uterus after birth, leading to severe maternal hemorrhage.
-Assessment: On inspection, the placenta appears torn at the edge, or torn blood vessels extend beyond the edge of the
placenta.

B. Placenta Circumvallata
-Ordinarily, the chorion membrane begins at the edge of the placenta and spreads to envelop the fetus; no chorion covers
the fetal side of the placenta. In placenta circumvallata, the fetal side of the placenta is covered to some extent with chorion.
The umbilical cord enters the placenta at the usual midpoint, and large vessels spread out from there. However, they end
abruptly at the point where the chorion folds back onto the surface.
-Although no abnormalities are associated with this type of placenta, its presence should be noted.

C. Battledore Placenta
-The cord is inserted marginally rather than centrally. This anomaly is rare and has no known clinical significance either.
D. Velamentous Insertion of the Cord
-A situation in which the cord, instead of entering the placenta directly, separates into small vessels that reach the placenta
by spreading across a fold of amnion.
-Factor:
 Most frequently found with multiple gestations.
 Fetal anomalies .
-An infant born with this type of placenta needs to be examined carefully at birth.

E. Vasa Previa
-The umbilical vessels of a velamentous cord insertion cross the cervical os and therefore deliver before the fetus. The vessels
may tear with cervical dilatation, just as a placenta previa may tear.
-Complication: Possible tearing would result in sudden fetal blood loss.
-It can be confirmed by ultrasound.
-If vasa previa is identified, the infant needs to be born by cesarean birth.

F. Placenta Accreta
-An unusually deep attachment of the placenta to the uterine myometrium, so deep that the placenta will not loosen and
deliver.
-Attempts to remove it manually may lead to extreme hemorrhage because of the deep attachment.
-Management: Hysterectomy to remove the uterus or treatment with methotrexate to destroy the still-attached tissue may
be necessary.

5. Anomalies of the cord

-The umbilical cord is a bundle of blood vessels that develops during the early stages of embryological development. It is
enclosed inside a tubular sheath of amnion and consists of two paired umbilical arteries and one umbilical vein.
-Allows for the transfer of oxygen and nutrients from the maternal circulation into fetal circulation while simultaneously
removing waste products from fetal circulation to be eliminated maternally.

A. Two-Vessel Cord
-The umbilical cord contains only two blood vessels — one vein and one artery. Also known as single umbilical artery.
-Inspection of the cord as to how many vessels are present must be made immediately after birth, before the cord begins to
dry, because drying distorts the appearance of the vessels.
-Document the number of vessels conscientiously because an infant with only two vessels needs to be observed carefully for
other anomalies during the newborn period.

B. Unusual Cord Length

-Although the length of the umbilical cord rarely varies, some abnormal lengths may occur.
-Short umbilical cord can result in premature separation of the placenta or an abnormal fetal lie.
-Long cord may be easily compromised because of its tendency to twist or knot. Occasionally, a cord actually forms a knot,
but the natural pulsations of the blood through the vessels and the muscular vessel walls usually keep the blood flow
adequate. It is not unusual for a cord to wrap once around the fetal neck (nuchal cord) but, again, with no interference to
fetal circulation.

6. Problems with the psyche factors

-Psyche: The emotional state of the mother during her labor which can also have an overall effect on progress of labor.
 Factors:
 Levels of stress and underlying anxiety during the process
 The progress of labor and birth can be adversely affected maternal fear and tension.
 Support system (partner, family, etc.)
 Welcoming and supportive environment.

 Problems:
 Norepinephrine and epinephrine may stimulate both alpha and beta receptors of the myometrium and interfere
with the rhythmic nature of labor.
 Women experiencing increased pain or high levels of anxiety release catecolamines, which can have an inhibitory
effect on uterine contractility leading to abnormal labor progression.

 Therapeutic Management
 To ensure adequate progress:
 Adequate analgesia
 Emotional support.