Professional Documents
Culture Documents
Client With High-Risk
Client With High-Risk
1.Passenger or Fetus
2.Passageway or pelvic bones and other
pelvic structure
3.Power or uterine contractions
4. Placenta
5. Psyche - client’s psychological state
HIGH RISK PREGNANT CLIENT DURING LABOR & DELIVERY
Fetal Skull
Its size is important as the fetus
travels
the birth canal
Its ability to change its shape is also important
- eases its passage during labor & delivery
in response to the pressure exerted by the
maternal pelvis & birth canal during labor &
delivery
PROBLEM of PASSENGER
Fetal Malposition
Position- is the relationship of the
presenting part to a specific
quadrant of a woman’s pelvis.
Birth Technique
If an infant will be born vaginally, a woman is
allowed to push after full dilatation is achieved.
-it is steadied and supported by a sterile towel
held against the infant’s inferior surface.
HIGH RISK PREGNANT CLIENTDURING LABOR & DELIVERY
Postpartum hemorrhage
The large placental area and over-
distended uterus place a mother at risk
for bleeding after delivery in many
multiple pregnancies.
PASSAGEWAY
Refers to the route that the fetus must travel
when leaving the uterus arriving at the external
perineal area of birth.
The route includes the maternal pelvis and soft
tissues
The maternal pelvis must be of adequate size for
the fetus to pass through.
The shape of the pelvis can determine the ability
and ease with which the fetus can pass through.
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.
CPD
A trial labor may be allowed to continue if
descent of the presenting part and dilation of the
cervix are occurring.
If labor doesn't progress or complications develop,
cesarean birth is the delivery 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.
CPD
. Monitor progress of the trial labor – if, after 6-12
hours, no progress of labor and if fetal distress
occurs, prepare for CS.
Assessment Findings:
Suspected if the 2nd
stage of labor is
prolonged, there is
arrest of descent or
when head appears in
perineum but retracts
instead of protruding
with each contraction.
(turtle sign)
Treatment :
Applying suprapubic pressure may
help the shoulder escape from
beneath the symphysis pubis.
Asking the woman to flex her thighs sharply on her
abdomen (McRobert's maneuver) widens the pelvic outlet
and may let the anterior shoulder be delivered.
a. HYPOTONIC Contractions
b. HYPERTONIC Contractions
c. UNCOORDINATED Contractions
Hypotonic Contractions
Hypotonic labor is an abnormal labor pattern, notable
during the active phase of labor, characterized by poor
and inadequate uterine contractions that are ineffective
to cause cervical dilation, effacement, and fetal
descent, leading to a prolonged or protracted delivery.
Termed when the number or frequency of contractions is
low, not increasing beyond two or three in a 10-minute
period, and the strength of contractions does not rise
above 25mmHg. The resting tone of the uterus remains
below 10mmHg during active phase.
Irregular and not painful (lack of intensity)
The cause of hypotonic labor is uterine inertia, also known
as hypotonic or hypocontractile uterine dysfunction.
Though the etiology of the inertia is unknown, these
conditions are commonly associated with hypocontractile
uterine dysfunction:
1. Uterine overdistension and overuse as seen in multifetal
gestation, fetal macrosomia, polyhydramnios and grand-
multiparity
2. Mechanical disruption of myometrial function from myoma
or distension of the bladder or bowel
3. Malpositioning and malpresentation of the fetus, where
there is absent reflex in uterine contraction, due to
inadequate contact of the presenting part onto the lower
uterine segment
4. Abnormal uterine axis as seen in a pendulous
abdomen. There is an exaggerated anteversion of the
uterus.
5. Other general/systemic causes may include maternal
anemia, maternal exhaustion, and improper use of analgesia
in labor.
Occur when analgesia has been administered too early
(before cervical dilatation of 3-4cm)
* due to cervix dilated for a long period both uterus and fetus
are at risk of INFECTION
Supportive Measures
1. Continuous reassurance to keep the mother calm. Maternal
stress increases endogenous adrenaline, which can inhibit uterine
contractions.
2. Encourage ambulation and avoid supine position. Although
these are not proven to improve contractions or prolonged labor
due to hypocontractility, they may improve the comfort of the
parturient.
3. Empty bladder, consider catheterization.
4. Maintain adequate hydration.
5. Adequate pain relief.
Medical management:
Amniotomy
Membrane rupture (amniotomy) stimulates contractions by the
release of prostaglandins and reflex stimulation of the uterus
when the presenting part becomes closely applied to the lower
uterine segment.
Oxytocin
Oxytocin is the medication of choice for augmenting
contractions.
Asssessment Findings ;
Onset of rhythmic uterine contractions
Possible rupture of membranes , passage of cervical
mucus plug, and a bloody discharge
Cervical effacement and dilation on vaginal exam
Treatment :
Such treatment consists of bed rest ; drug therapy with
tocolytic.
Terbutaline, a beta-adrenergic blocker, is the most
commonly used tocolytic (smooth muscle relaxation).
- Antidote is propranolol (Inderal)
Magnesium sulfate is typically the first drug used to stop
contractions.
- It's a central nervous system depressant that
prevents reflux of calcium into the myometrial cells,
thereby keeping the uterus relaxed.
- Antidote is Calcium gluconate.
Indomethacin (Indocin) is a prostaglandin synthesis
inhibitor; typically not used after 32 weeks gestation to
avoid premature closure of the ductus arteriosus.
- A nonsteroidal anti-inflammatory that decreases
production of prostaglandins which are lipid compounds
associated with the initiation of labor.
- There's no antidote; discontinue drug.
Nifedipine (Procardia) is a calcium channel blocker, it
decreases the production of calcium, a substance
associated with the initiation of labor.
- There's no antidote, DC the drug.
Nursing Intervention :
1. Closely observe the patient in preterm labor for signs
of fetal or maternal distress.
2. Provide guidance about the hospital stay, potential
for delivery of a premature infant, and the possible
need for neonatal intensive care.
3. Maintain bed rest; provide appropriate diversionary
activities.
4. Administer medications as ordered.
5. Monitor VS, FHR and uterine contractions.
6. Keep the patient in left side-lying position to ensure
adequate placental perfusion.
7. Administer fluids as ordered to ensure adequate
hydration.
8. If necessary during active premature labor, administer
O2 to the patient.
9. If labor is suppressed, begin discharge teaching with
the woman and family about tocolytic therapy, and
anticipate referral and follow up.
PRECIPITATE LABOR
Refers to labor that lasts 3 hours or less
More common in multiparous patients and in women
who have received oxytocin induction or amniotomy.
Causes :
Lack of maternal tissue resistance to the passage of the fetus.
Assessment Findings :
Strong uterine contractions with signs of premature placental
separation.
Cervical dilation during the active phase of more than 5
cm/hour in a nulliparous woman and greater than 10 cm/hour
in multiparas.
Management
Before delivery
Patient who had previous precipitate labour should be
hospitalized before expected date of delivery as she is more
prone to repeated precipitate labour.
During delivery
Inhalation anaesthesia: as nitrous oxide and oxygen is given to
slow the course of labour.
Tocolytic agents: as ritodrine (Yutopar) may be effective.
Episiotomy: to avoid perineal lacerations and intracranial
haemorrhage.
Plans for immediate delivery are necessary.
After delivery
Examine the mother and foetus for injuries.
Nursing Interventions :
1. Provide emotional and physical support to the woman
and family.
2. Continuously monitor uterine contractions and FHR
patterns
3. Encourage the woman to relax as possible
4. Explain all procedures and treatments being initiated.
5. Instruct the woman with a history of precipitate labor
that it may occur with future pregnancies; advise to
plan for such an occurrence in advance.
PLACENTA
● The spongy structure within the uterus from which the
fetus derives nourishment.
Placenta
The placenta is the organ created
during pregnancy to nourish thefetus, remove its
waste, and produce hormones to sustain the
pregnancy.
3. Placenta Circumvallata = a
thickened greyish –white ring the
fetal surface, created by a double
fold amnion & chorion
4. Placenta accreta =
the chorionic villi
are deeply
attached onto or
into the
myometrium
5. Velamentous insertion of
the cord = the cord
separates into small
vessels that reach the
placenta by spreading
across a flod of amnion.
Causes :
Unknown
Possible contributors include a woman with DM, with certain
diseases such as syphillis or erythroblastosis, and a placenta
wider in diameter.
Treatment :
Complete visual inspection of the placenta is necessary after
birth
With succenturiata, manual removal of the placenta is
indicated
With accreta, methotrexate may be given (to destroy the
remaining attached tissue); hysterectomy may be necessary
Nursing Interventions :
1. Make sure that the placenta is inspected after delivery
2. Assist with manual removal of placenta succenturiata
3. Prepare the pt for possible CS birth
4. Offer emotional support and explain all treatments to
pt and family
5. Monitor the pt closely in the immediate postpartum
period.
PLACENTAL PROBLEMS
PLACENTA PREVIA - implantation in the lower uterine
segment where it encroaches on the internal os. One of
the most common causes of bleeding during 2nd half of
pregnancy.
Types:
1. Low implantation = the placenta implants in the lower
uterine segment
2. Partial = the placenta partially occludes the cervical
os
3. Total = the placenta totally occludes the cervical os.
PLACENTA PREVIA
The placenta is usually attached to the upper part of the
uterus, away from the cervix, the opening which the baby
passes through during delivery.
Placenta previa is the attachment of the placenta to the
wall of the uterus in a location that completely or partially
covers the uterine outlet (opening of the cervix).
Diagnostic Test :
Transvaginal ultrasound scanning (to determine
placental position)
Radiologic test such as retrograde catheterization or
radioisotope scanning (to locate the placenta)
Laboratory studies- decreased maternal hemoglobin
levels (due to blood loss)
Pelvis examination
Diagnostic findings:
Management
Moderate Separation
- may develop abruptly or progress from mild to
extensive separation with external hemorrhage
Severe Separation
- external hemorrhage occurs, along with shock and
possible fetal cardiac distress.
Causes :
Contributing factors include hydramnios, cocaine use,
decreased blood flow to the placenta, and trauma to
the abdomen
Abruptio Placenta
The inverted fundus may lie within the uterine cavity of the
vagina or, in total inversion, protrude from the vagina.
Causes :
May occur after the birth of the neonate, especially if
traction is applied to the uterine fundus when the uterus is not
contracted.
Grades of inversion
Uterine inversion is graded by its severity. This includes:
Incomplete inversion - the top of the uterus (fundus) has
collapsed, but the uterus hasn’t come through the cervix.
Complete inversion - the uterus is inside-out and coming out
through the cervix.
Prolapsed inversion - the fundus of the uterus is coming out of
the vagina.
Total inversion - both the uterus and vagina protrude inside-
out (this occurs more commonly in cases of cancer than
childbirth).
Assessment Findings :
A large sudden gush of blood from the vagina.
Non-palpable fundus in the abdomen
Signs and symptoms of shock if the loss of blood
continues
* hypotension.
* pallor
* dizziness and diaphoresis
Possible exsanguination if bleeding continues
unchecked
Risk factors:
Nursing Interventions :
1. Initiate IV therapy as ordered – if the woman has an IV
line in place, increased the flow rate to achieve optimal
flow of fluid to restore fluid volume.
2. Administer oxygen by mask as ordered
3. Keep in mind that administering an oxytoxic only
compounds the inversion
4. Never attempt to remove the placenta if it's still attached
because this will create more bleeding.
5. Monitor VS at least every 15 minutes.
6. Assist with the measures to relax the uterus
7. Provide emotional support and explanation what's
happening and procedures being done
8. Be prepared to perform CPR if the woman's heart fails
from the sudden blood loss.
9. Anticipate administering antibiotic as ordered
UTERINE RUPTURE
Occurs when the uterus undergoes more strain than it's
capable of sustaining and then ruptures.
Rupture can be complete, going through endometrium,
myometrium, and peritoneum, or incomplete, leaving the
peritoneum intact.
The viability of the fetus depends on the extent of the
rupture and the time that elapses between the rupture
and abdominal extraction.
The woman's prognosis depends on the extent of the
rupture and blood loss.
Causes :
Usually occurs from a previous cesarean birth, such as
when a vertical scar from a previous incision is present.
Can also occur from hysterectomy repair.
Other causes include :
> prolonged labor, faulty presentation, multiple
gestation, use of oxytocin, traumatic maneuvers using
forceps or traction.
Assessment Findings :
Indentation appearing across the abdomen over
the uterus (pathologic retraction ring)
Strong uterine contractions without any cervical
dilation.
Indications of complete uterine rupture
- sudden, severe pain during a
strong labor contraction
- report of a tearing sensation
- cessation of uterine contractions
- hemorrhage
Treatment :
Focuses on the following measures :
- Fluid replacement
- IV oxytocin to contract the uterus and minimize
bleeding
A cesarean birth will be done to ensure safety of
neonate
Manual removal of the placenta under general
anesthesia may be necessary.
A laparotomy may be necessary as an emergency
measure to control bleeding and repair the rupture;
hysterectomy or tubal ligation may be performed.
It's inadvisable for a woman to conceive again after
uterine rupture, unless it occurred in the inactive
lower segment.
Nursing Interventions :
1. Administer emergency fluid replacement therapy
as ordered.
2. Anticipate the use of IV oxytocin to contract the
uterus and minimize bleeding.
3. Prepare the woman for a possible laparotomy as
an emergency measure – explanation is necessary.
4. Immediately provide information to the support person
and inform them about the fetal outcome, the extent
of the surgery, and the woman's safety.
5. If applicable, offer emotional support for the loss of this
child or loss of future children (if hysterectomy or tubal
ligation is performed).
6. Allow them to express their emotions without feeling
threatened.
AMNIOTIC FLUID EMBOLISM
Refers to the escape of amniotic fluid into maternal
circulation
Amniotic fluid embolism is a rare but serious condition that
occurs when amniotic fluid — the fluid that surrounds a
baby in the uterus during pregnancy — or fetal material,
such as fetal cells, enters the mother's bloodstream.
Results from a defect in the membranes after rupture or
from partial abruptio placenta
The fetus is at risk for possible deposition of meconium and
vernix in the pulmonary arterioles
Causes ;
Predisposing factors include intrauterine fetal death,
abruptio placenta, oxytocin administration, and
advanced maternal age
Assessment Findings :
Sudden dyspnea
Hemorrhage
Cyanosis
Increasing restlessness and anxiety
Treatment :
Administration of oxygen, blood and heparin
Close monitoring of cardiopulmonary status
Immediate delivery of the infant
Insertion of central venous pressure line
Nursing Interventions :
1. Administer O2 via face mask and monitor VS every 15
minutes for changes.
2. Anticipate the need for endotracheal intubation to
maintain pulmonary function
3. Prepare to initiate CPR
4. Arrange to transfer the patient to intensive care unit and
prepare for immediate delivery of the fetus by CS
5. Provide emotional support to the family
CLIENTS PSYCHOLOGICAL
STATE
The maternal response and psychological readiness for labor
(feelings of anticipation, excitement or apprehension).
PSYCHE
Refers to the feelings that the woman brings to labor, a
major component is the psychological readiness for
labor.
Factors affecting psychological readiness:
1. Presence of support systems positively affects the
woman's ability to manage labor
2. The degree of preparation for childbirth is important,
asking questions and attending education classes can
help the woman prepare for the event.
Maternal Psychological Responses
during Labor
1st Stage
Mother feels anticipation, excitement, or
apprehension
During active phase, becomes serious, and may ask
for pain medication or use breathing techniques
During the transitional, may lose control, thrash in bed,
groan,or cry out.
2nd Stage
Maternal behavior changes from coping with
contractions to actively pushing
The patient may become exhausted
3rd Stage
Mother focuses on the neonate's condition
Patient may feel discomfort from uterine
contractions before expelling the placenta.
4th Stage
Mother's attention focused on neonate, begins to
adjust to the role of mother
The primary activity is promoting maternal-neonatal
bonding.
Problems with Psyche factor
Inability to bear down properly.
Health teachings :
- on proper breathing techniques
- proper position during labor process
- attentive to physician coaching/instruction
Fear/ anxiety
- Thorough explanation of the treatment/procedure
being done to pt, as well as pts and fetal condition
- Encourage verbalization of feelings
- Be available to patient needs
- Provide with diversionary activities to refocus attention