CHAPTER 2

Nursing Care of the client with High-Risk Labor & Delivery

This chapter focuses on the assessment and nursing management of the different complications
of labor and delivery involving problems on the 4 Ps of labor: Passenger, Passageway, Power,
and Psyche.

Intended Learning Outcomes:

At the end of the lesson, students will be able to:

1. Identify High-risk Factors during labor and delivery

2. Cite problems associated with the passenger, passageway and powers of labor and delivery.
3. Identify assessment findings and general nursing care for client’s with placental problems
(e.g. Placenta previa, abruptio placenta).
4. Discuss psychological changes in mothers during the different phases and stages of labor
and delivery.

Lesson 1: Problems with the Passenger:

Duration: 6 hours

Key Terms:

• Malpresentation
• Malposition
• Fetal distress
• Breech

A. Fetal malposition
- Refers to positions other than an occipito-anterior position.
- Malpositions include occipito-posterior and occipito-transverse positions of fetal head in
relation to maternal pelvis.
- It is usually seen in multipara or those with lax abdominal wall. Fetal malpositions are
assessed during labor.

Left Occipito-anterior
- The most ideal for vaginal birth.
(A) A fetus in cephalic presentation, LOA position. View is from outlet. The fetus rotates
90 degrees from this position. (B) Descent and flexion (C) Internal rotation complete.
(D) Extension; the face and chin are born

Occipito-posterior Position
- Arrested labor may occur when the head does not rotate and/or descend. Delivery may
be complicated by perineal tears or extension of an episiotomy.
Maternal Risks:
• prolonged labor
• potential for operative delivery
• extension of episiotomy,
• 3rd or 4th degree laceration of the perineum.
Maternal symptoms:
• Intense back pain in labor
• Dysfunctional labor pattern
• prolonged active phase
• secondary arrest of dilatation
• arrest of descent
 (A) Fetus in cephalic presentation LOP position. View is from outlet. The fetus rotates 135
degrees from this position. (B) Descent and flexion. (C) In ternal rotation beginning.
Because of the posterior position, the head will rotate in a longer arc than if it were in an
anterior position. (D) Internal rotation complete. (E) Extension; the face and the chin are
born. (F) External rotation; the fetus rotates to place the shoulder in an anteroposterior
position

Occipito-transverse Position
- It is the incomplete rotation of OP to OA results in the fetal head being in a horizontal
or transverse position (OT).
- Persistent occiput transverse position occurs as a result of ineffective contractions
or a flattened bony pelvis.

Diagnosis:
• Abdominal examination – the lower part of the abdomen is flattened, fetal limbs are
palpable anteriorly and the fetal flank.
• Vaginal examination – the posterior fontanelle is toward the sacrum and the anterior
fontanelle may be easily felt if the head is deflexed.
• Ultrasound

Nursing Diagnoses: Impaired Gas Exchange, Pain, Fatigue, Anxiety

Nursing Management:

Impaired gas exchange

• Encourage the mother to lie on her side from the fetal back, which may help with
rotation.
• Knee-chest position may facilitate rotation.
 • Pelvic-rocking may help with rotation.

• Monitor FHB appropriately

• Be prepared for childbirth emergencies such as cesarean section, forceps-assisted
delivery, and neonatal-resuscitation.
Pain
• Encourage relaxation with contractions.
• Apply sacral counter – pressure with heel of hand to relieve back pain.
• Provide comfortable environment.
• Teach breathing exercises for use during early labor until client receives
pharmacologic relief.
• Monitor physical response for example, palpitations/rapid pulse

Fatigue
• Assess psychological and physical factors that may affect reports of fatigue level
• Monitor physical response for example, palpitations/rapid pulse
• Monitor fetal heart beat and contractions continuously.
• Refraining from intervening with client during contraction.
Anxiety
• Keep client and family informed progress.
• Provide support during labor through personal touch and contact. These methods
convey concern.
• Continue support and encouragement.
• Make the client feel she is somewhat in control of her situation.
• Provide client and family teaching.
• Identify client’s perception of the threat presented by the situation.

Medical Management
1. If there are signs of obstruction or the fetal heart rate is abnormal at any stage, deliver
by caesarean section.
2. If the membranes are intact, rupture the membranes with an amniotic hook or a Kocher
clamp.
3. If the cervix is not fully dilated and there are no signs of obstruction, augment labor with
oxytocin.
4. If the cervix is fully dilated but there is no descent in the expulsive phase, assess for signs
of obstruction.
5. If the cervix is fully dilated and if the leading bony edge of the head is above -2 station,
perform caesarean section; the leading bony edge of the head is between 0 station and -
2 station, deliver by Vacuum Extraction and Symphysiotomy
6. If the operator is not proficient in symphysiotomy, perform caesarean section;
7. If the bony edge of the fetal head is at 0 station, deliver by vacuum extraction or forceps.

SYMPHYSIOTOMY

A surgical procedure in which the cartilage

of the symphysis pubis is divided to widen
the pelvis allowing childbirth when there is a
mechanical problem.

Currently the procedure is rarely performed

in developed countries, but is still routine in
developing countries where cesarean
section is not always an option.

Forceps - provides traction or a

means of rotating the fetal head.
Risks: fetal ecchymosis or edema
of the face, transient facial
paralysis, maternal lacerations, or
episiotomy extensions.

Vacuum extraction -
Provides traction to shorten
the second stage of
labor.
Risks: newborn
cephalhematoma, retinal
hemorrhage and
intracranial hemorrhage.
B. Fetal Malpresentation
- refers to fetal presenting part other than vertex and includes breech, transverse, face,
brow, and sinciput.
- Malpresentations may be identified late in pregnancy or may not be discovered until the
initial assessment during labor.

Related Factors:
• The woman has had more than one pregnancy
• There is more than one fetus in the uterus
• The uterus has too much or too little amniotic fluid
• The uterus is not normal in shape or has abnormal growths, such as fibroids
• placenta previa
• The baby is preterm

Types of Malpresentation:

Vertex Malpresentation
1. Sinciput
- the larger diameter of the fetal head is presented.
- Labor progress is slowed with slower descent of the fetal head.

2. Brow
- The brow presentation is caused by partial extension of the fetal head so that the occiput
is higher than the sinciput.
Maternal Risks
• Longer labor caused by ineffective contractions and slow or arrested fetal descent.
• Dysfunctional labor patterns
• Cesarean birth if brow presentation persists or if the fetus is large
Fetal/neonatal risks
• mortality because of cerebral and neck compression and damage to the trachea and
larynx

Management
- If the fetus is alive or dead, deliver by caesarean section.
*Do not deliver brow presentation by vacuum extraction, outlet forceps or symphysiotomy.

3. Face
- The face presentation is caused by hyper-extension of the fetal head so that neither
the occiput nor the sinciput is palpable on vaginal examination.

Face presentation. Mechanism of birth in mentoanterior position

Top: the submentobregmatic diameter at the outlet
Bottom: the fetal head is born by movement of flexion
 Face presentation. Mechanism of birth in mentoposterior position.
Fetal head is unable to extend further. The face becomes impacted. This prevents descent
and labor is arrested.

Management
1. Chin-Anterior Position
If the cervix is fully dilated:
• Allow to proceed with normal childbirth;
• If there is slow progress and no sign of obstruction, augment labor with oxytocin;
• If descent is unsatisfactory, deliver by forceps.
If the cervix is not fully dilated and there are no signs of obstruction:
• augment labor with oxytocin.
2. Chin-Posterior Position
• If the cervix is fully dilated:
• Deliver by caesarean section.
• If the cervix is not fully dilated
• Monitor descent, rotation and progress. If there are signs of obstruction, deliver
by caesarean section.

Consider This!

Do not perform vacuum extraction for face

presentation.

Breech
• Breech presentation means that either the buttocks or the feet are the first body parts
that will contact the cervix.
• Breech presentations occurs in approximately 3% of the births and are affected by fetal
attitude.
• Breech presentations can be difficult births, with the presenting point influencing the
degree of difficulty.
1. Frank breech
• The baby's bottom comes first, and the legs are flexed at the hip and extended at
the knees (with feet near the ears).
• 65-70% of breech babies are in the frank breech position.

2. Complete Breech
• The baby's hips and knees are flexed so that the baby is sitting crosslegged, with
feet beside the bottom.

3. Footling Breech
• One or both feet come first, with the bottom at a higher position. This is rare at
term but relatively common with premature fetuses.
Maternal Risks
• Prolonged labor r/t decreased pressure exerted by the breech on the cervix.
• PROM may expose client to infection.
• Cesarean or forceps delivery.
• Trauma to birth canal during delivery from manipulation and forceps to free the fetal
head.
• Intrapartum or postpartum hemorrhage.

Fetal Risks:
• Compression or prolapse of umbilical cord.
• Entrapment of fetal head in incompletely dilated cervix.
• Aspiration and asphyxia at birth.
• Birth trauma from manipulation and forceps to free the fetal head.

Management
1. External Cephalic Version.

- Tocolytics, such as Terbutaline 0.25 mg IM, can be used before ECV to help relax the
uterus.
- If ECV is successful, proceed with normal childbirth. If ECV fails or is not advisable,
deliver by caesarean section.
- Attempt external version if:
• Breech presentation is present at or after 37 weeks (before 37 weeks, a
successful version is more likely spontaneously revert back to breech
presentation)
• Vaginal delivery is possible
• Membranes are intact and amniotic fluid is adequate;
• There are no complications (e.g. fetal growth restriction, uterine bleeding,
previous caesarean delivery, fetal abnormalities, twin pregnancy, HPN, fetal
death).

2. Vaginal Breech Delivery

- Safe and feasible under the following conditions:
 • complete or frank breech
• adequate clinical pelvimetry
• fetus is not too large
• no previous caesarean section for cephalopelvic disproportion
• flexed head

3. Cesarean Section
- Recommended in cases of:

• Double footling breech

• Small or malformed pelvis
• Very large fetus
• Previous cesarean section for cephalopelvic disproportion
• Hyperextended or deflexed head.

Transverse

- Fetus lies horizontally in the pelvis so that the longest fetal axis is perpendicular to that of
the mother.
- The presenting part is usually one of the shoulders (acromion process), an iliac crest, a
hand, or an elbow.

Management:
1. External version – If an infant is preterm and smaller than usual, an attempt to turn the
fetus to a horizontal lie may be made.
2. Cesarean birth - most infants in transverse lie must be born by cesarean birth, however,
because they cannot be turned and cannot be born normally form this “wedged” position.

Nursing Diagnoses:
• Anxiety
• Fear
• Risk for infection
• Risk for injury
Nursing Care of Clients with Malpresentations

Anxiety
• Provide client and family teaching,
• Be available to client for listening and talking
• Provide client support and encouragement.
• Encourage client to acknowledge and express feelings.
• Encourage breathing exercises to relieve anxiety.

Fear
• Provide client and family teaching,
• Note for degree of incapacitation.
• Stay with the client or make arrangements to have someone else be there.
• Provide opportunity for questions and answer honestly.
• Explain procedures within level of client’s ability to understand and handle.

Risk for Injury

• Observe closely for abnormal labor patterns.
• Monitor fetal heart beat and contractions continuously
• Be prepared for childbirth emergencies such as cesarean section, forceps-assisted
delivery, and neonatal-resuscitation.
• Maintain sterility of equipment.
• Anticipate forceps-assisted birth.
• Anticipate cesarean birth for incomplete breech or shoulder presentation.

Risk for infection

• Stress proper hand washing techniques of all caregivers.
• Maintain sterile technique.
• Cleanse incision site daily and prn.
• Change dressings as needed.
• Encourage early ambulation, deep breathing, coughing, and position change.

C. Fetal Distress
Causes:
• Compression of the umbilical cord
• Uteroplacental insufficiency caused by placental abnormalities or maternal condition
(prolonged labor, HPN, DM,infections
• Prolonged labor-CPD, breech presentation, failure of the cervix to dilate

Signs and Symptoms:

• Meconium-stained amniotic fluid
• Changes in fetal heart rate baseline:
- tachycardia
- bradycardia
• Decreased or absence of variability of heart rate
• Late deceleration pattern
• Severe variable deceleration pattern
 Nursing Care
Assessment
1. Assess FHR baseline, variability and pattern of periodic changes
2. Assess contraction pattern and maternal response to labor

Nursing Diagnoses:
• Decreased cardiac output (fetal)
• Impaired gas exchange
• Anxiety

Planning and Implementation

Late deceleration:
1. Reposition mother on her left side
2. Administer O2 by face-mask at 8-10 lpm
3. Increase IV fluids
4. Discontinue oxytocin infusion, if labor is being induced
5. Notify the physician immediately
❖ Goal is to improve maternal blood flow to the placenta

Severe variable decelerations or prolonged bradycardia

1. Reposition the mother on either side
2. If not corrected, reposition to opposite side
3. Administer O2 by face-mask at 8-10 L/min
4. Trendelenburg or knee-chest position, if not corrected
5. Apply upward digital pressure on the presenting part to relieve pressure on the
umbilical cord.
❖ The goal is to relieve pressure on the umbilical cord
6. Provide appropriate information and emotional support
7. Maintain continuous monitoring of FHR and uterine activity, and labor progress.

Evaluation
1. The fetal heart rate remains in normal range with adequate variability and absence
of ominous periodic changes
2. The client verbalizes that anxiety is decreased
3. Family coping strategies are strengthened

D. Prolapse Umbilical Cord

Cause: fetus is not firmly engaged

Contributing factors:
1. ROM before engagement
2. Small fetus
3. Breech presentation
4. Multifetal pregnancy
5. Transverse lie
6. Polyhydramnios
7. Long cord
8. Spontaneous or artificial rupture of membranes before presenting part is engaged

Assessment
1. Identify the client at risk for prolapsed umbilical cord
2. Assess for the following:
- Fetal hypoxia
- irregular FHR
- Umbilical cord can be felt on cervix/vagina
- Variable deceleration
- Cord may be protruding from the vagina
- Fetal distress
- Fetal bradycardia

Nursing Diagnoses
• Risk for impaired gas exchange
• Risk for injury
• fear

Nursing Management

1. Note: The nurse’s #1 priority action is to assess the Fetal Heart Rate
2. Primary goal :
✓ to remove the pressure from the cord

Planning and Implementation

1. Place mother on knee-chest or trendelenburg position
2. Push fetal presenting part upward
Note!
• Do not push cord back to uterus
3. Administer O2 by face mask at 8-10 lpm
4. Maintain continuous electronic fetal monitoring
5. Prepare for rapid delivery vaginally or by CS
6. If cord protrudes through the vagina, apply sterile saline soaked dressing to
prevent drying.

Evaluation
1. The fetal heart rate remains within normal range and without ominous signs
2. The fetus is safely delivered
3. The client and family verbalized understanding of the implications of prolapsed
umbilical cord and the need for emergency management
 Lesson 2: Problems with the Passageway

Duration: 3 hours

Key Terms:
• Abnormal size or shape of the pelvis
• Cephalopelvic disproportion
• Shoulder Dystocia

A. Abnormal size or shape of the pelvis

- Pelvis is said to be contracted when its diagonal conjugate is less than 11.5cm
and its bi-ischial diameter is less than 8cm.

1. Inlet Contracture
• Inlet dystocia – anteroposterior dm less than 10cm and greatest transverse dm that is
less than 12 cm or diagonal conjugate less than 11.5cm
• due to several conditions including rickets and flat pelvis
• Important sign in primi: lack of engagement between 36 and 38th week of pregnancy
• Influences fetal position and presentation

2. Midpelvis Contracture

• Occurs when the sum of the interspinous and posterior sagittal diameters of the midpelvis
is less than 13.5cm or an interischial spinous dm less than 8cm.
• Midpelvis dystocia – most common pelvic dystocia
• Fetus is able to engage but due to narrowed dm of the midplevis the fetal head is
prevented from rotating internally fr transverse to AP dm.

3. Outlet Contracture
• occurs when the bi-ischial dm (distance between ischial tuberosities) is less than 8cm

Causes
• Increased Fetal Weight
• Fetal Position
• Problems with the Pelvis
Categories:
Maternal: size & shape of bony pelvis
Fetal: size, shape, presentation, position
Diagnosis
• Clinical Pelvimetry

Measurement of transverse diameter of the outlet and pubic angle

- Trial of labor (TOL): the physician may allow labor to continue or even stimulate
labor with oxytocin when pelvic measurements are borderline to see if the fetal head
will descend making vaginal delivery possible; if progressive changes in dilatation and
station do not occur, a cesarean delivery is performed.
B. Cephalo-Pelvic Disproportion
- Fetal head is too large to pass through the bony pelvis.
Sign: Fetal head does not descend even though there are strong contractions
Maternal Risks:
• Prolonged labor
• Exhaustion
• Hemorrhage
• Infection
Fetal Risks:
• Hypoxia
• Birth trauma
Diagnosis: Ultrasound
- estimation of the baby's size can be made
- an assessment of potential CPD can be made

Management: Cesarian section is the only option to deliver the baby

C. Shoulder Dystocia
- Difficulty in bringing out shoulder
- Fetal head is born but the shoulders are too broad to enter and be delivered through the
pelvic outlet

Manifestations
• Prolonged second stage of labor
• Arrest of descent
• Turtle sign

Maternal Risks:
• Vaginal or cervical lacerations
• Postpartum hemorrhage

Neonatal Risks:
• Hypoxia
• Fractures of clavicle
• Brachial plexus injury - is a group of nerves that come from the spinal cord in the
neck and travel down the arm. These nerves control the muscles of the shoulder,
elbow, wrist and hand, as well as provide feeling in the arm. Some brachial plexus
injuries are minor and will completely recover in several weeks. Other injuries are
severe enough and could cause some permanent disability in the arm.

Nursing Care
Assessment and identification of the client at risk for shoulder dystocia
• Obesity
• Increased fundal height
• History of macrosomia
• Maternal diabetes or gestational diabetes
• Prolonged second-stage of labor
• Multipara
 • Post-date pregnancies

Nursing Diagnoses
• Risk for Injury
• Fear
• Deficient knowledge

Planning and Implementation

1. Assist with positioning during delivery: Mc Robert’s Maneuver

• Woman flexes thighs on her abdomen

• Position changes the angle of the pelvis, increases pelvic diameters, and facilitates
delivery of the shoulders

2. Assess for maternal and newborn injury following delivery

Evaluation
- Client and fetus experience a safe delivery without injury.
 - The client indicates that fear is diminished.
- Client is able to verbalize increased understanding of pelvic disproportion and
dystocia, its causes, and implications for delivery.

Lesson 3: Problems with the Powers

Duration: 2 hours

Key Terms:

• Difficult labor
• hypertonic uterine dysfunction
• hypotonic uterine dysfunction
• abnormal progress in labor
• retraction rings
• Premature labor
• Precipitate labor and birth
• Uterine prolapse
• Uterine rupture

A. Difficult Labor
1. Hypertonic Uterine Dysfunction
- Usually encountered in the latent phase
- Contractions are too frequent but uncoordinated
- Tend to be more painful

Maternal Risks: prolonged or non-progressive labor, pain, and fatigue.

Fetal Risks: Hypoxia caused by decreased uteroplacental blood flow.

Medical Management: Therapeutic rest – sedation aimed at stopping contractions,

promoting rest, and allowing normal labor pattern to develop.

Nursing Management:
1. Evaluation of pelvic size
2. Monitor intake and output.
3. Maintenance of fluid and electrolytes.
4. Keep bladder empty.
5. Encourage side lying position.
6. Watch for danger signals: fetal distress, passage of meconium stained amniotic fluid

2. Hypotonic Uterine Contractions

- characterized by weak and infrequent contractions which are insufficient to dilate the
cervix.
- Usually occurs during the active phase.

Causes
• Overdistention of the uterus
 • Malpresentation and malposition
• Pelvic bone contraction
• Unripe or rigid cervix
• Congenital abnormalities of the uterus
• Unknown causes

Risks:
• Maternal and fetal infections
• Postpartum hemorrhage
• Fetal distress and death
• Maternal exhaustion

Management:
1. Re-evaluate pelvic size to rule out fetopelvic disproportion
2. Vaginal delivery
• Amniotomy if membranes are not yet ruptured
• Augmentation of labor
3. CS if pelvis is contracted
4. Provide supportive nursing care

3. Abnormal Progress in Labor

- The partograph is used to identify deviations from normal progress in labor by plotting
cervical dilatation and descent of the fetal head over time.
a. Prolonged Latent Phase
• Exceeding 20 hours in nulliparas and more than 14 hours in multiparas
Causes:
1. Poor cervical condition (unripe, rigid and firm)
2. Excessive sedation
3. Conduction of analgesia
Management:
• Therapeutic rest (use of sedative)
• Active intervention (oxytocin stimulation)

b. Protraction Disorders
- The most common abnormalities during the active phase.
- Caused by the same factors that contribute to prolonged latent phase.

Types:
1. Protracted active phase - <1.2 cm dilatation per hour in nullipara; <1.5 cm
per hour in multipara
2. Protracted Descent - <1 cm feta descent per hour in nullipara; < 2cm descent
in multipara

Management:
• Re-asses pelvic size, presentation, position to rule out fetopelvic disproportion
• Expectant management if without CPD
• Provide support to the mother.
 c. Arrest Disorders
- Active phase disorder characterized by lack of descent and dilatation even
uterine contractions are occurring normally.
Types:
1. Arrest of dilatation – no progress in cervical dilatation for more than 2 hours
in nulliparas and 1 hour in multiparas
2. Arrest of Descent – no progress of fetal descent for more than 1 hour in
nulliparas and primiparas
3. Failure of Descent – absence of fetal descent in the second stage of labor.

d. Prolonged Second Stage

- Median duration in nulliparas is 20 minutes and 50 minutes in multiparas
- Common causes: persistent occiput posterior, and epidural anesthesia
- Prolonged if more than:
• Nullipara: 2 hours without conduction analgesia, 3 hours with conduction
analgesia
• Multipara: 1 hour without conduction analgesia, 2 hours with conduction
analgesia

4. Retraction Rings
- Physiologic retraction ring: boundary between upper uterine segment and
lower uterine segment that normally forms during labor.
• Upper segment contracts and becomes thicker as muscle fibers shorten
• Lower segment distends and becomes thinner
- Bandl’s Ring: A Pathological retraction ring that forms when labor is obstructed
caused by CPD or other complications.
• Upper segment continues to thicken
• Lower segment continues to distend
• Risk of uterine rupture
• CS is indicated
- Constriction Ring
 Retraction ring forms and impedes fetal descent.
 Relaxation of the constriction ring with analgesics, anesthetics, or both
allows vaginal delivery.

B. Premature Labor – contractions occurring between 20 to 37 weeks gestation.

Signs and symptoms:
1. Contractions occurring every 10 minutes or less with or without pain.
2. Low abdominal cramping with or without diarrhea.
3. Intermittent sensation of pelvic pressure, urinary frequency.
4. Low backache (constant or intermittent).
5. Increased vaginal discharge, may be pink-tinged.
6. Leaking amniotic fluid

Immediate actions to be taken by clients experiencing suspected premature

labor.
1. Empty bladder
2. Assume a left side-lying position.
 3. Drink 3-4 cups of water.
4. Palpate abdomen for uterine contractions; if 10 minutes apart or closer, contact
healthcare provider.
5. Rest for 30 minutes and slowly resume activity, if symptoms disappear.
6. If symptoms do not subside within 1 hour

Medical Management
1. Bedrest
2. Continued monitoring of uterine activity and FHR.
3. Administration of tocolytic agents, drugs to stop contractions, if labor continues
a. Ritodrine (Yutopar)
b. Terbutaline (Brethine)
c. Magnesium sulfate
2. Administration of betamethasone (Celestone) or dexamethasone to stimulate fetal
lung maturity.

Nursing Assessment and Diagnoses

1. Identify clients at risk for premature labor
2. Priority nursing diagnoses: Deficient knowledge; fear, ineffective coping

Planning and implementation

1. Provide client and family teaching regarding signs and management of premature
labor
2. Promote bed rest encouraging left lateral position
3. Monitor uterine activity and FHR
4. Administer tocolytics and monitor for adverse reactions
5. Provide emotional support encouraging client and family to express feelings and
concerns.

Evaluation
1. The client can identify signs and symptoms of premature labor that need to be
reported to the healthcare provider.
2. The client can identify self-care measures to initiate, if premature labor is suspected.
3. The client’s coping strategies are strengthened.
4. Client and fetus are delivered safely.

C. Precipitate labor and birth

- Occurs within 3 hours from onset of contraction to delivery of baby
- Occurs without warning
Classifications:
• Precipitate dilatation – 5cm or more/hour dilatation in nulliparas and 10
cm/hour in multiparas.
• Precipitate descent - –fetal descent is progressing at a rate of 5cm or
more/hour in nulliparas and 10 cm/hour in multiparas.
Predisposing Factors
• Multiparity
• Large pelvis
• Lax unresisting maternal tissue
 • Small baby in good position
• Induction of labor
• Absence of painful sensation
Maternal Risks
• Laceration of birth canal and uterine rupture
• Postpartum hemorrhage
• Amniotic fluid embolism
Fetal Risks
• Hypoxia
• Intracranial hemorrhage
• Erb-Duchenne palsy
• Premature separation of placenta
• Injuries

Signs and Symptoms

• Patient complains of a sudden, intense urge to push
• Sudden increase in bloody show.
• Sudden bulging of the perineum
• Sudden crowning of the presenting part
Management
1. Anticipatory guidance for prevention
2. During oxytocin admin, stop infusion right away and turn woman on her
side
3. Call for help, do not leave the patient alone.
4. Obtain sterile delivery pack if in a health care facility
5. Deliver the baby

D. Uterine prolapse
- Vigorous massage of the fundus and pulling on the umbilical cord to speed
placental separation may cause prolapse of the cervix and lower uterine segment
through the vagina.
- Uterine inversion: turning inside out of the uterus
1. Complete inversion
• Inverted uterus is visible outside the introitus
• Life-threatening because of severe hemorrhage and shock
• Uterus must be immediately replaced manually to stop blood loss
2. Partial inversion
• Not visible but can be palpated
• Uterine fundus is partially inverted hampering contraction and control of
hemorrhage
• Corrected by the physician using a bimanual technique

E. Uterine rupture
- Tearing of the muscles of the uterus
- Rare but serious complication, occurring in 1 in 1,500 to 2,000 births.
Causes:
 Rupture of scar from previous CS
  Prolonged labor, obstructed labor, malposition, malpresentation
 Overdistention of the uterus
 Injudicious use of oxytocin, forceps and vacuum extraction
 Precipitate labor and delivery
 Manual removal of the placenta
 External trauma
 Placenta increta or accrete
 Adenomyosis
 Gestational trophoblastic neoplasia

Signs and Symptoms

 Impending uterine rupture is often manifested by a pathologic retraction ring in
obstructed labor.
 Sudden sharp tearing pain during the peak of contraction, after which, relief is
felt as uterus loses the capacity to contract

Types:
1. Complete
 Sudden excruciating pain at the peak of a contraction, the contractions stop
altogether
 Two swellings will be visible
 Internal hemorrhage
 Vaginal bleeding may or may not occur
 Separation of the placenta – leads to hypoxia and fetal death

2. Incomplete rupture
 Localized tenderness
 Persistent pain over the abdomen
 Contractions may still continue or stop
 No progress in cervical dilatation
 Vaginal bleeding may or may not be present
 Signs of maternal shock and fetal distress

Medical Management
1. Complete Rupture: management of shock: Blood transfusion and administration of
IVF, Administer mask oxygen at 8 lpm.
2. Incomplete Rupture: Hysterectomy, emergency laparotomy to deliver the baby

Nursing Assessment:
1. Sudden, sharp, lower abdominal pain
2. Tearing sensation
3. Signs of shock
4. Cessation of contractions
5. FHR ceases
6. Blood loss is often concealed
7. Fetal parts may be easily palpated through abdominal wall
 Priority Nursing Diagnoses
1. Risk for Injury
2. Impaired Gas Exchange
3. Deficient fluid volume

Planning and Implementation

a. Prevention is best
• Identify client’s at risk.
• Avoid hyperstimulation of uterus during induction.

Evaluation
1. Client and infant are delivered without injury
2. Client’s fluid volume is restored to normal.

Lesson 4: Problems with the Psyche

Duration: 1 hour

Key Terms:
• Fear
• Anxiety
• Coping

A. Factors influencing the psyche of the client in labor

1. Fear and anxiety
2. Perception of the problem
3. Self-image
4. Preparation for childbirth
5. Support systems
6. Coping ability

B. The effect of fear and anxiety on labor progress

1. Epinephrine secretion in response to stress
2. Vascular changes divert blood from the uterus to skeletal muscles
3. Decrease in oxygen and glucose supply with accumulation of lactic acid in uterine
muscle.
4. Higher perception of pain
5. Decrease in available energy supply to support effective contractions
6. Labor progress is slowed

C. Nursing Assessment
1. Determine client’s past experiences with, preparation for, and expectations of labor
and birth.
2. Determine client’s current coping behaviors and their effectiveness with the current
situation.
D. Priority Nursing Diagnoses
1. Ineffective coping
2. Fear
3. Anxiety
4. Deficient knowledge

E. Planning and Implementation

1. Establish a trusting relationship with the client and family.
2. Remain at the bedside with the client and family during labor
3. Encourage relaxation
4. Keep the client and family informed about progress and procedures.
5. Encourage positive coping behaviors and discourage negative behaviors
6. Promote self-image by praising efforts.

F. Evaluation
1. Client coping strategies are strengthened.
2. Client’s fear and anxiety are reduced.
3. Client verbalizes increased understanding of the labor and birth process

Teacher’s Insight:

Complications may develop at any time during the course of labor in a client who
has been otherwise healthy throughout her pregnancy. Hence, regular assessment
and monitoring is very vital.