Risky Labor and Birth

Prof. Dr. Gülşen Vural

 Risky Labor and Birth

• A pregnancy is considered high-risk when

there are potential complications that
could affect the mother, the baby, or both.
 Risk Labor and Births

• High-risk pregnancies require

management by a specialist to help
ensure the best outcome for the mother
and baby.
 Risk Factors For High-Risk
Pregnancy
• Maternal Age
• Drug Addiction
• Cigarette smoking
• Work condition
• Violance
 Risk Factors for High-Risk
Pregnancy
• Preeclampsia
• Gestational diabetes or Diabetus mellitus
Systemic disease
• Autoimmune disease
• Thyroid disease
• Infertility
• Obesity and HIV/AIDS.
 Risk Factors for High-Risk
Pregnancy
• Pregnancy-related issues
• Premature labor,
• Multiple births,
• Placenta previa and Fetal problems.
RISKS RELATED LABOR AND
BIRTH
• Dysfunctional Labor
• Maternal positioning
• Hypertonic contractions
• Hypotonic contractions
• Precipitous labor and birth
 DYSFUNCTIONAL LABOR
AND BIRTH
• Dysfunctional or
prolonged labor refers
to prolongation in the
duration of labor,
typically in the first
stage of labor.
 DYSFUNCTIONAL LABOR

• Diagnosis of delay in labor is dependent

on careful monitoring of uterine
contraction, cervical dilation and descent
of the fetus through the pelvis.
 Labor and Birth at Risk

Dystocia
• Dystocia is abnormal or difficult labor
• Leading indicator for primary cesarean
sections in the USA
• Early identification and prompt
interventions help to minimize risk to
mother and fetus
 Dystocia Factors

• Maternal positioning
• Powers
• Passenger
• Passageway
• Maternal stress (psyche).
 Maternal positioning

• Maternal position can interfere with

the decent of the fetus
• Maternal built
• Uterine abnormalities/congenital
malformations
 Hypertonic contractions

• Hypertonic contractions tend to occur

more frequently and during the latent
phase of labor
• They are more painful than usual, and
they make the woman frustrated with her
breathing techniques because they are
ineffective.
 Hypertonic contractions

• The lack of relaxation between

contractions may not allow optimal uterine
artery filling that could lead to fetal anoxia.
Hypertonic Contractions
• NURSING CARE OF HYPERTONIC
CONTRACTIONS
 Nursing Care

• Nurse should follow up frequency of uterin

contractions
• Monitorization of fetal heart sounds
• Fluid intake and amount of urine should be
monitirized
• Psychological support
 Nursing Care

• Anxiety should be handled

• Massage may be helpful
• Body hygiene
• Mother and father should be informed
about birth process
HYPOTONIC CONTRACTIONS
 Hypotonic Contractions

The number of uterine contractions in

hypotonic contractions is unusually slow
or infrequent.
 Hypotonic Contractions

• Hypotonic contractions increase the

woman’s risk for postpartal hemorrhage.
 Hypotonic Contractions

• In the first hour after birth following a labor

of hypotonic contractions, palpate the
uterus and assess the lochia.
 Hypotonic Contractions

• Hidration of mother important

• Fluid intake and amount of urination
should be monitorized
• Bladder drainage important
 Hypotonic Contractions

• Give information to mother on relaxation

techniques
• Restrict vaginal examination and
• Body hygien should given
PRECIPITOUS LABOR
 Precipitous Labor

• Precipitate labor occurs when a woman

gives birth with only a few and rapidly
occurring contractions.
 Reasons Of Precipitous Labor

• Grand multiparity
• Induction of labor by oxytocin or
amniotomy
• Subdural hemorrhage for the fetus may
occur from the rapid release of pressure
on the head.
 Reasons Of Precipitous Labor

• Having a large pelvis

• History of precipitous labor
 NURSING CARE

• Nurses should follow up carefully

mothers who has a precipitous history
• Servical dilatation and effecment should
be monitored carefully
• Dose of oxitosin should be given
carefully
 NURSING CARE

• Mothers should be supported

psychologically
• Infection may be a risk in postpartum
period
• Postpartum maternal bleeding should be
monitored carefully
 PASSENGER

• Problems related to passenger in labor

• Persistent occiput posterior position
• Breech presentation
• Shoulder dystocia
• Multiple gestation
• Macrosomia
 PASSAGEWAY

• Contraction of one or more of the three

planes of the maternal pelvis: inlet,
midpelvis, and outlet.
 Passageway
• Problems related with
passageway
• Obstruction in the
birth canal like
Placenta Previa,
Uterine fibroids, Full
bladder and cervical
swelling.
 Maternal Psyche

Emotions
•Fear,
• Anxiety,
•Helplessness,
•Exhaustion and feeling alone cause
psychological stress.
 Management

• Provide physical and emotional support

• Comfort measures should taken and
• Pain management important.
 NURSING DIAGNOSIS FOR
HIGH RISK LABOR
• Risk For Maternal Injury
• Risk For Fetal Injury
• Risk For Fluid Volume Deficit
• Ineffective Individual Coping
 PRETERM LABOR AND BIRTH

• Preterm labor: cervical changes and

uterine contractions occurring between
20 and 37 week of pregnancy.
 Preterm Labor and Birth
Risk Factors
• Infections
• Low Socioeconomic status
• Smoking
• Little or no prenatal care
• Domestic violence
 Preterm Labor and Birth

• Current multifetal pregnancy

• History of a preterm birth
• Uterine and cervical abnormalities
 Preterm Labor and Birth

Uterine contractions
• Pattern more frequent than every 10
minutes persisting for 1 hour or more
Discomfort
• Dull, intermittent low back pain
• Menstrual like cramps
 Preterm Labor and Birth

• Suprapubic pain or pressure

• Pelvic pressure or heaviness
• Urinary frequency
 Preterm Labor and Birth

• Change in discharge
• Rupture of amniotic membranes
 Preterm Labor and Birth

Prevention
• Educate woman about early symptoms
of preterm labor
• Counseling about risk reduction should
be individualized for each pregnant
woman
 Preterm Labor and Birth

• Women with symptoms of preterm labor

should pay attention to what activities or
situations contribute to symptoms and
modify behavior accordingly.
 Preterm Labor and Birth
Lifestyle modifications
• Activities resulting in preterm labor
Sexual activity
Carrying heavy loads
 Preterm Labor Management
• Bed rest
• Tocolytics
• Glucocorticoid to help accelerate fetal
lung maturity
 Preterm Labor and Birth

Management of inevitable preterm birth

•4cm dilation inevitable preterm birth
•Births in tertiary centers better neonatal
and maternal outcomes
•Women at risk improved outcome at
tertiary center
•Administer Glucocorticoids before transfer
 Prolonged Pregnancy

• Prolonged pregnancy is defined

as pregnancy which progresses beyond
42 weeks.
 Prolonged Pregnancy

• Continues beyond 42 weeks

gestation
• Risk for fetal/neonatal problems
• Increase risk for cesarean birth due to
utero-placental insufficiencies
 Post Term Labor and Birth

Maternal risks related to Fetal

Macrosomia
• Dystocia of labor
• Infection
• Post partum hemorrhage
 Post Term Labor and Birth
Fetal Risks
• Asphyxia
• Meconium aspiration
• Hypoglycemia
• Respiratory distress
• Macrosomia
• Brachial plexus injuries
 Post Term Labor and Birth

• Birth injury resulting in brachial plexus

damage or cerebral palsy
• Neonatal acidaemia
• Low five-minute Apgar scores
• Neonatal encephalopathy.
 Post Term Labor and Birth

Management
•Induction of labor
•Monitor fetus for signs of
uteroplacental insufficiencies
 Induction/Augmentation of Labor

• The stimulation of uterine contractions

by medical and surgical intervention
means to produce delivery before the
onset of spontaneous labor.
 Induction/Augmentation of Labor

Important Points for induction

• Post term pregnancy
• Prolonged rupture of membranes
• Gestational hypertension
• Preeclampsia
• Diabetes
• Fetal demise
Induction/Augmentation of Labor

Risks
• Cesarean delivery
• Instrumented assisted delivery
• Epidural analgesia
• Fetal stress and admission to
neonatal intensive care unit.
 Induction Contraindications

• Complete plasenta previa

• Abruptio placenta
• Transverse lie of fetüs
• Prolapsed umbilical cord
 Induction Contraindications

• Previous myomectomy
• Herpes Simpleks Virus
• Previous caesarean section
 Mechanical method

• Application of Local pressure to the

cervix stimulating the release of
prostaglandins to ripen the cervix
• Foley catheter inserted into endocervical
canal to ripen & dilate cervix.
 Amniotomy

• An amniotomy is a procedure performed to

release fluid from the amniotic sac to
induce labor during childbirth.
Amniotomy
• Nurses and midwife
can do Amniotomy.
 Amniotomy

• There are certain complications

associated with an amniotomy. These
include:
• Fetal blood loss
• Infection
• Fetal scalp trauma
• Chorioamnionitis
NURSING CARE
 Nursing Care

• The initial nursing care

• Place a dry underpad under the women’s
buttokcs
• Chart the amount, color and odor of fluid
• Follow up nature of contractions
• Follow up fetal heart rate
PHARMACOLOGICAL
 Pharmacological

• Some drugs can be given to women for

induction of labor
• Prostaglandins and
• Oxytocin
 Oxytocin (Pitocin)

• It should start low dose and should be

gradually increased
• The dose is generally increased every 15
to 30 minutes until regular contractions of
moderate strength and lasting
approximately 60 to 90 seconds are
occurring every 2 to 3 minutes.
NURSING CARE
 Oxytocin (Pitocin)
• Continuous fetal monitor to evaluate
contraction pattern and FHR
• Prior to starting induction verify term
pregnancy and vertex position
• If hyperstimulation occurs turn
Oxytocin infusion off to let the uterus
rest and notify provider.
 Nursing Care

• Adequate hydration and patient positioning

• Frequent nursing presence at the bedside
to fully assess uterine activity and fetal
heart rate response.
 Nursing Care

• Once active labor is established, consider

decreasing oxytocin to the lowest amount
necessary for maintenance.
• Dosing should be documented
PREMATURE RUPTURE OF
MEMBRANES (PROM)
Premature Rupture of Membranes

Rupture of amniotic sac and leakage

of amniotic fluid beginning at least 1
hour before onset of labor at any
gestational age.
 Etiology

• Sexually transmitted infections, such as

chlamydia and gonorrhea
• Previous preterm birth
• Vaginal bleeding
• Cigarette smoking during pregnancy
 Preterm Premature Rupture of
Membranes (PPROM)
• Diagnosed after
woman
complains of
sudden gush or
slow leak of
vaginal fluid
 Nursing Care

• Nursing assessment and intervention are

described
• Preterm labor,
• Side effects of tocolytic therapy,
• Maternal/fetal infection,
• Fetal compromise
 Nursing Care

• Side effects of extended bed rest,

maternal stress,
• Educational needs, and routine prenatal
care.
 Amnioinfusion

• Warm sterile IV
solution is infused
into the uterus
through an
intrauterine
pressure catheter
to increase the
amniotic fluid
volume.
 Amnioinfusion

• Contraindications: vaginal bleeding of

unknown origin, umbilical cord prolapse,
amnionitis, uterine hypertonicity and
sever fetal distress
 Amnioinfusion

• Follow hospital policy for infusion

• Complications: abruption, cord prolapse,
fetal hypothermia
 Nursing care

• Explain the procedure to patient

• Assist in dorsal recumbent position
• Connect the cateter to the monitor cable
• Monitor FHR
FORCEPS-VACUUM ASSISTED BIRTH
 Forceps-Vacuum Assisted
Birth
• An assisted birth is when forceps or a
ventouse suction cup are used to help
deliver the baby.
 Forceps-Vacuum Assisted Birth

Indications of the procedure

• Prolonged second stage
• Fetal distress
• Abnormal presentations
• Arrest of rotation
• Delivery of head in a breech
presentation
Forceps
 Birth Related Interventions

Vacuum-assisted
• Vacuum applied to fetal head, negative
pressure to assist birth of head
– Prerequisites
• Vertex presentation
• Ruptured membranes
• Absence of Cefalo Pelvic Disproportion
EPISIOTOMY
 Episiotomy
• Incision made in the perineum to enlarge
the vaginal outlet
Type of episiotomy
• Locations- midline, Right or Left
• Mediolateral.
 Episiotomy

• Alternative measures
• Warm compresses
• Massage with oil have been successful in
stretching perineal area.
Types of Episiotomy
 Nursing Care Of Episiotomy

• Local wound care and pain management

• Warm baths
• Sitz baths (women should sit in water that
covers her vulvar area) a few times a day.
 Nursing Care Of Episiotomy

• Say mother change her pads every 2 to 4

hours
• Wound area should be clean and dry
• Pat the area dry with a clean towel after
bathe
 Nursing Care Of Episiotomy

• After woman urinate or have a bowel

movement, spray warm water over the
area and pat dry with a clean towel or
baby wipe
• Say woman NOT use toilet paper.
 Nursing Care of Episiotomy

• Say mother to take stool softeners and

drink lots of water
• This will prevent constipation
• Eating lots of fiber will also helpful
• Mother health care provider can suggest
foods with plenty of fiber.
 Nursing Care Of Episiotomy

• Teach Kegel egzersizes to mother.

Kegel Exercises
• Bladder should be empty, then women should
sit or lie down
• Tighten her pelvic floor muscles and hold
tight and count to 8
• Relax the muscles and count to 10
• Repeat 10 times, 3 times a day (morning,
afternoon, and night).
CESAREAN BIRTH
 Cesarean Birth

• The delivery of
the fetus through
an incision in the
abdomen and
uterus.
 Cesarean Birth indications

• Recognition of
fetal distress due
to Electronic fetal
monitoring
• Preserve life of
mother and fetus
• Failed labor
 Cesarean Birth
Complications and risks
• Anesthesia
• Surgical complications
• Impaired bonding
• Post partum complications
NURSING CARE OF CESAREAN
 Nursing Care

• Follow up of vital signs of mother and baby

• Pain control
• Wound care
• Women who are recovering well after CS
and who do not have complications can
eat and drink when they feel hungry or
thirsty
 Nursing Care

• Urinary catheter care

• Education for discharge
• Prevetion of infection
• Early ambulation of mother
• Initiation of breastfeeding
OBSTETRIC EMERGENCIES
 Obstetric Emergencies

• Umbilical cord prolapse

• Placenta Previa
• Placental abruption
• Uterine rupture
• Shoulder Dystocia
• Fetal Demise
 Umbilical cord prolapse
• Umbilical cord
prolapse is a
complication that
occurs prior to or
during delivery of the
baby
Umbilical cord prolapse
• In a prolapse, the umbilical cord drops
(prolapses) through the open cervix into
the vagina ahead of the baby.
 Cord Prolapse
Contributing factors
•Long cord (longer than 100 cm)
•Malpresentation (breech)
•Transverse lie
•Unengaged presenting part
•Hydramnios
Cord Prolapse
MANAGEMENT
 Management

• Hold the presenting part off the umbilical

cord until delivery
• Change patients position to relieve cord
pressure
• Monitor fetal heart rate
• Emotional support
• Preper woman for c/sec
Cord Prolapse
Cord Prolapse
 Placenta Previa

• Placental
implantation in the
lower uterine
segment
• Position can
create a barrier for
vaginal delivery of
the fetus
 Placenta Previa

• Vaginal bleeding after the 20th week of

gestation is characteristic of placenta
previa
• Usually the bleeding is painless, but it can
be associated with uterine contractions
and abdominal pain.
 Placenta Previa

• Bleeding may range in severity from light

to severe.
 Placental Abruption
• Premature separation of placenta
Management
• Based on gestational age, extent of
hemorrhage and maternal-fetal oxygenation
perfusion
• Maintain maternal cardiovascular status
• Prompt delivery
• Cesarean birth if fetus still alive; vaginal birth
if fetal demise
THAK YOU