NURSING CARE OF THE

CLIENT WITH HIGH-RISK

LABOR AND DELIVERY
HIGH RISK FACTORS

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

 Problems with the Passengers

 Birth complications may arise if:
• an infant is immature or preterm
 Maternal pelvis is so undersized (early adolescence)
• its diameters are smaller than the fetal skull diameters.
• umbilical cord prolapses
• more than one fetus is present
• a fetus is malpositioned or too large for the birth canal.
PASSENGER
> Refers to the fetus & its ability to
move
through the passage
> Affected by several fetal
features

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.

Fetal Malpositions are abnormal

position of the vertex in relation to the
maternal pelvis.
 1. Occipito-posterior
position
The most common
malposition
The head initially engages
normally but then the
occiput rotates posteriorly
rather than anteriorly.
The occipito-posterior (OP)
position results from a
poorly flexed vertex..
 5.2% of deliveries are persistent
occipito-posterior.

 It may occur because of a flat

sacrum, poorly flexed head or
weak uterine contractions which
may not push the head down into
the pelvis with sufficient strength to
produce correct rotation.
 Occipitoposterior Position
• The fetus presenting in posterior:
-may increased molding and
caput formation
-labor is somewhat prolonged
-experience pressure & pain in her
lower back due to sacral nerve
compression
Management:

 applying counter pressure on the sacrum by a back rub may

be helpful in relieving a portion of the pain

 often result in a long labour, close maternal and fetal

monitoring are required.
 allow to void approximately every 2 hours to keep her
bladder empty (impede fetal descent)

 adequate fluids be given to the mother. (regulate IVF)

 mother may get the urge to push before full dilatation
but this must be discouraged (cause perineal
Hematoma or laceration)

 forceps or caesarean section may be required.

2. Occipito-Transverse position
Head initially engages correctly but
fails to rotate and remains in
transverse position.

When a baby is in the left occiput

transverse position (LOT) or
right occiput transverse (ROT)
position during labor, it may lead
to more pain and a slower
progression.
 Management:
Alternatives for delivery include:
If the second stage is reached
the head must be manually
rotated with Kielland's forceps
or delivered using vacuum
extraction.
>failure of forceps delivery -
changed immediately to a
caesarean method
Fetal Malpresentation
Presentation – describes the
body part that will be first to
pass through the cervix and be
delivered.
Fetal Malpresentation is where
the baby is in difficult position
for delivery.
Types of fetal presentation:
Cephalic- head presents first(vertex)
Breech –buttocks or feet presents
first
Shoulder – shoulder, iliac crest,
hand, or elbow presents first
Fetal Malpresentation
1. VERTEX MALPRESENTATION
 a. Brow Presentation
 b. Face Presentation
 c. Occipital Presentation

 1.a.) Brow Presentation - head

moderately flexed
 1.b.) Face Presentation - head poorly
flexed
 1.c.) Occipital Presentation -
hyperflexion
Problems With Fetal Position,
Presentation, or Size
 Face Presentation
A fetal head presenting at a
different angle than expected
is termed asynclitism (face or
chin/mentum).
A face presentation is
confirmed by vaginal
examination when the nose,
mouth, or chin can be felt as
the presenting part.
 Face Presentation
A fetus in a posterior position, instead of
flexing the head as labor proceeds, may
extend the head, resulting in a face
presentation
 Italso may occur in the relaxed uterus of
a multipara or with prematurity,
hydramnios, or fetal malformation.
 UTZ is done to confirm the abnormal
presentation.
 Management:
 If the chin is anterior and the
pelvic diameters are within
normal limits (vaginal birth).
 CS -method of choice
 Face presentation may result to
facial edema and may be
purple from ecchymotic
bruising.
= Observe the infant closely for a
patent airway.
(lip edema is so severe that they
are unable to suck for a day or
two)
 Nursing care :
 Gavage feedings may be necessary to
allow them to obtain enough fluid until
they can suck effectively.
 They may be transferred to a NICU for 24
hours.
 Reassure the parents that the edema is
transient
 Risks of Face Presentation
Increased risk of CPD &
prolonged labor
Increase risk of
infection
Cephalhematoma
Edema of the face
Brow Presentation
 A fetus in brow presentation has the chin
untucked, and the neck is extended
slightly backward. It is similar to
face presentation, except the neck is less
extended
 the brow (forehead) is the part that is
situated to go through the pelvis first
 It is the rarest of the presentations. It occurs
in a multipara or a woman with relaxed
abdominal muscles.
 Cesarean birth will be necessary
 Brow presentations also leave an infant
with extreme ecchymotic bruising on the
face.
Risks of Brow Presentation
Fetus – increased mortality because of
cerebral and neck compression and
damage to trachea & larynx
- facial edema, bruising
Brow presentation constitutes an
absolute foeto-pelvic disproportion, and
vaginal delivery is impossible (except with
preterm birth or extremely low birth
weight). This is an obstetric emergency,
because labour is obstructed and there is
a risk of uterine rupture and foetal
distress.
Transverse Lie (SHOULDER PRESENTATION)
= fetus positioned horizontally across the
uterus, rather than vertically.
= the baby’s long axis is perpendicular
relative to the mother’s; in other words,
the baby is sideways

 the abnormal presentation can be

confirmed by Leopold’s maneuvers.
 -an ultrasound may be taken to further
confirm the abnormal lie and to
provide information on pelvic size.
Transverse Lie
 often, the membranes rupture at the beginning
of labor. Because there is no firm presenting
part, the cord or an arm may prolapse, or the
shoulder may obstruct the cervix.
 Cesarean birth is necessary.
 BREECH PRESENTATION
= occurs when the buttocks or feet present first.
Complete Breech Presentation
Breech Presentation
 Breech presentation is more hazardous to
the fetus than a cephalic presentation,
because there is a higher risk of:
= Anoxia from a prolapsed cord
= Traumatic injury to the aftercoming head
(possibility of intracranial hemorrhage or
anoxia)
= Dysfunctional labor
= Early rupture of the membranes because of
the poor fit of the presenting part.
Assessment
• FHTs usually are heard high in the abdomen.
• Leopold’s maneuvers and a vaginal
examination usually reveal the presentation.
• UTZ clearly confirms a breech presentation

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

Problems With Fetal Position,

Presentation, or Size
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.
 Problems With Fetal Position,
Presentation, or Size
Oversized Fetus (Macrosomia)
= Macrosomia is a term that describes
a baby who is born much larger than
average for their gestational age,
which is the number of weeks in the
uterus.
 Size may become a problem in a
fetus who weighs more than 4000 to
4500g (approximately 9 to 10 lb).
 Babies of this size complicate up to
10% of all births (gestational
diabetes)
Oversized Fetus (Macrosomia)
 An oversized infant may cause uterine dysfunction
during labor or at birth because of overstretching of
the fibers of the myometrium.
 it can cause fetal pelvic disproportion or even uterine
rupture from obstruction
 Fetal macrosomia is more likely to be a result of
maternal diabetes, obesity or weight gain during
pregnancy than other causes.
Methods to check the baby’s size include:
 Measuring the height of the fundus. A larger than
normal fundal height could be a sign of macrosomia.
 Ultrasound. This test uses sound waves to view an
image of the baby in the uterus, it can estimate
whether the baby is too large in the womb.
 Check the amniotic fluid level. Too much amniotic
fluid is a sign that the baby is producing excess urine.
Larger babies produce more urine.
Management:
 CS- method of choice for delivery, if baby’s size
may complicate the birthing
Oversized Fetus (Macrosomia)
Macrosomia can cause these
problems during vaginal delivery:
 the baby’s shoulder may get stuck in
the birth canal
 the baby’s clavicle or another bone
gets fractured
 labor takes longer than normal
 forceps or vacuum delivery is
needed
 the baby doesn’t get enough
oxygen
Oversized Fetus (Macrosomia)
Macrosomia can cause these problems
during vaginal delivery with the mother
include:
 Injury to the vagina. As the baby is
delivered, he or she can tear the
mother’s vagina or the muscles between
the vagina and anus, the perineal
muscles.
 Bleeding after delivery. A large baby can
prevent the muscles of the uterus from
contracting like they should after
delivery. This can lead to excess
bleeding.
 Uterine rupture. If you’ve had a past
cesarean delivery or uterine surgery,
the uterus can tear during delivery. This
complication could be life-threatening.
Problems of the Passenger
Fetal Distress
• also called “nonreassuring fetal status,” is the term
medical professionals use to describe when a
fetus is not receiving adequate oxygen during
pregnancy or labor.
• refers to signs before and during childbirth
indicating that the fetus is not well.

• At its most severe it may lead to neonatal brain

injury or stillbirth.
• This can occur due to maternal, fetal or placental
factors
Some common causes of fetal
distress include :
 Anemia
 Intrauterine growth restriction
(IUGR)
 Post-term pregnancy (pregnancy at
42 weeks or more)
 Meconium-stained amniotic fluid
 Oligohydramnios (low amniotic fluid)
 Pregnancy-induced hypertension
 Rhesus (Rh) Sensitization
 Cord Compression (uteroplacental
insufficiency
Assessment Findings:
• FHT above 160 or below 110/min
• Fetal hypermobility/hyperactivity

 Heart rate abnormalities that are

signs of fetal distress:
 Tachycardia (an abnormally fast
heart rate)
 Bradycardia (an abnormally slow
heart rate)
 Variable decelerations (abrupt
decreases in heart rate)
 Late decelerations (late returns to
the baseline heart rate after a
contraction)
 Management:

 Reposition mother to left lateral recumbent.

This relieves pressure on inferior vena cava, thereby, increasing
venous return resulting in increased perfusion of placenta and
fetus.
 Administer O2 per mask @ 5-10L/min. (adequate
Oxygenation)
 Monitor FHT continuously – hooked to EFM
 Notify the physician
 Prepare for emergency CS if indicated.
 Nursing Interventions:

 FHT monitoring in response to mother’s uterine

contraction
 Instruction on Left lateral position
 Ready for set-up: Induction of labor and CS
delivery
 Preparing fetal resuscitation equipment; infant
warmer, O2, suction machine
 Notify physician-Pediatrician
Problems with the Passengers
 Prolapse of the Umbilical Cord
• In umbilical cord prolapse, a loop of the umbilical
cord slips down in front of the presenting fetal part.
Prolapse may occur anytime after the membranes
rupture if the presenting part is not fitted firmly into
the cervix.
Prolapse of the Umbilical Cord
Prolapse of the Umbilical Cord
 Prolapse may occur at any time after the
membranes rupture if the presenting fetal part is not
fitted firmly into the cervix.
 It tends to occur most often with:
• Premature rupture of membranes
• Fetal presentation other than cephalic
• Placenta previa
• A small fetus
• Cephalopelvic disproportion preventing firm
engagement
• Hydramnios
• Multiple gestation
Assessment
 the cord may be felt as the
presenting part on an initial vaginal
examination during labor.
 identified on UTZ (CS is necessary
before rupture of the membranes
occurs)
 -if ruptured membrane occurs, the
cord slides down into the vagina
from the pressure exerted by the
amniotic fluid (deceleration FHR
pattern)
 -to rule out cord prolapse, always
assess FHSs immediately after
rupture of the membranes.
Therapeutic Management
 Management is aimed at relieving
pressure on the cord (fetal anoxia)
 This may be done by placing a gloved
hand in the vagina and manually
elevating the fetal head off the cord, or
by placing the woman in a knee–chest
or Trendelenburg position
Management
 Administering O2 at 10 L/min by face mask
 A tocolytic agent may be prescribed to
reduce uterine activity and pressure on the
fetus
 If the cord exposed to room air, drying will
begin (umbilical atrophy)
- Do not attempt to push any exposed cord back
into the vagina (may add compression)
- cover any exposed portion with a sterile saline
compress to prevent drying
 Management
 Ifthe cervix is fully dilated at the time of
the prolapse, forceps delivery is
recommended (prevent fetal anoxia)
 If dilatation is incomplete, upward
pressure on the presenting part, applied
by a practitioner’s hand in the woman’s
vagina, until the baby can be born by CS.
 Prolapse of the Umbilical Cord
Management
= Amnioinfusion
 is the addition of a sterile saline fluid into
the uterus to supplement the amniotic
fluid (prevents additional cord
compression)
 Nursing Interventions:

Prepare additional equipment & personnel

for delivery
Assist with amniotomy, forceps or vacuum
extraction application as needed.
Ready neonatal resuscitation equipment, if
necessary
Explanation of any signs related to the high
risk birth, such as forcep marks, bruising
Problems with the Passenger
 Multiple Gestation
A multiple birth is the culmination of one
multiple pregnancy, wherein the mother
delivers two or more offspring.
 additionalpersonnel are needed for the
birth (nurses, pediatricians or neonatal
nurse practitioners).
 increased
incidence of cord entanglement
and premature separation of the placenta.
Multiple Gestation
 Types of Multiple Gestation
Fraternal twins
 Two separate eggs are fertilized and implant
in the uterus. The babies are siblings who
share the same uterus — they may look
similar or different, and may either be the
same gender (2 girls or 2 boys) or of different
genders.
 A pregnancy with fraternal twins is
statistically the lowest risk of all multiple
pregnancies since each baby has its own
placenta and amniotic sac. You will
sometimes hear fraternal twins referred to as
'dizygotic' twins, referring to 2 zygotes
(fertilized eggs). Fraternal twins have
separate placentas and umbilical cords.
Identical twins
 are formed when a single
fertilized egg is split in half.
Each half (embryo) is
genetically identical, so the
babies share the same DNA.
 Identical twins may share the
same placenta and amniotic
sac, or they may have their
own placenta and amniotic
sac. You will sometimes hear
identical twins referred to as
'monozygotic', referring to
one zygote (fertilized egg).
Triplets and 'higher order multiples'
(HOMs)
 Triplets, quadruplets, quintuplets,
sextuplets or more can be a
combination both of identical and
fraternal multiples.
 For example, triplets can be either
fraternal (trizygotic), forming from 3
individual eggs that are fertilized
and implanted in the uterus; or they
can be identical, when one egg
divides into 3 embryos; or they can
be a combination of both.
Multiple Gestation
 Why it is a concern?
has increased risks for complications w/c
includes the following:
 Preterm labor and birth
 Low birth weights – less than 2500 grms
 need care in a neonatal intensive care unit
(NICU).
 Multiple birth babies have about twice the risk
of congenital (present at birth) abnormalities
including neural tube defects (such as spina
bifida), gastrointestinal, and heart
abnormalities.
Multiple Gestation
 the placenta of the first infant separates before
the second fetus is born.
 assess the woman carefully in the immediate
postpartal period, placing her at risk for
hemorrhage from uterine atony (lacking normal
tone).
 the risk for uterine infection increases if labor or
birth was prolonged.
 CS method of delivery.
 MULTIPLE GESTATIONS
Miscarriage
 A phenomenon called the vanishing twin syndrome
in which more than one fetus is diagnosed, but
vanishes (or is miscarried), usually in the first
trimester, is more likely in multiple pregnancies. This
may or may not be accompanied by bleeding. The
risk of pregnancy loss is increased in later trimesters
as well.
Abnormal amounts of amniotic fluid
 Amniotic fluid abnormalities are more common in
multiple pregnancies, especially for twins that share
a placenta.
Twin-to-twin transfusion syndrome (TTTS) is a
condition of the placenta that develops only with
identical twins that share a placenta. Blood vessels
connect within the placenta and divert blood from
one fetus to the other. It occurs in about 15 percent
of twins with a shared placenta.
 In TTTS, blood is shunted from one fetus to the
other through blood vessel connections in a
shared placenta.
 Over time, the recipient fetus receives too much
blood, which can overload the cardiovascular
system and cause too much amniotic fluid to
develop. The smaller donor fetus does not get
enough blood and has low amounts of amniotic
fluid.
Cesarean delivery
 Abnormal fetal positions increase the
chances of cesarean birth.

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.

 Pelvic size or adequacy can be check by

combination of pelvimetry and fetal sonography.
PROBLEMS with the PASSAGEWAY

 A. Abnormal Size or Shape of the

Pelvis
 B. Cephalo-pelvic Disproportion
 C. Shoulder Dystocia
TYPES OF PELVIS
GYNECOID – normal female pelvis
ANDROID – male pelvis; narrow pelvic inlet
and outlet
ANTHROPOID – narrow transverse diameter
and larger anterio-posterior diameter
PLATYPELLOID – inlet is oval and AP
diameter is shallow
 CEPHALOPELVIC
DISPROPORTION

 Refers to the narrowing of the

birth canal which can occur at
the inlet, midpelvis, or outlet.
 Involves a disproportion
between the size of the normal
fetal head and the pelvic
diameters.
 Results in failure to progress in
labor
 CPD
Causes :
 The physical size of the maternal pelvis is a major
contributor – small pelvis is a factor.
- Inlet contraction occurs when the narrowing of the
anteroposterior or diameter is less than 11 cm or the
maximum transverse diameter is 12cm or less
 In primigravidas, the fetal head normally engages
at weeks 36-38 of pregnancy
- When this event occurs before labor begins, its
assumed that the pelvic inlet is adequate.
 CPD
Assessment Findings :
 Lack of fetal head engagement in a primigravida
due to a fetal abnormality, such as larger than
usual head, or a pelvic abnormality such as smaller
than usual pelvis.

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.

3. Remember that it may be difficult for women

to undertake a labor they know they may be
unable to complete
- Be alert to the feeling of the patient
* Some women having a trial labor feel as if
they're on trial, with feelings of self-
consciousness and being judged
* If dilation doesn't occur, they may feel
discouraged and inadequate, as if they're at
fault.
Problems with the Passageway
Shoulder Dystocia
 The problem occurs at the second stage of labor
when the fetal head is born but the shoulders are too
broad to enter and be delivered through the pelvic
outlet.
-it can result in vaginal or cervical tears.
-the cord is compressed between the fetal body and
the bony pelvis.
-

Shoulder Dystocia
 Causes :
- Occur in women
with diabetes, and in
post-date pregnancies,
poor fetal position,
multiple pregnancy,
and large fetus.
 Hazardous to the
Mother = because it
can result in vaginal
or cervical tearing.
Hazardous to the Fetus = the force of birth can result in a
fractured clavicle or a brachial plexus injury for the
fetus.


 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.

 CS is necessary if maternal and fetal condition is in

complication.
Problems with the POWERS

 Can arise from any of the 3 components of labor

process
 1. Forces that propels the fetus (uterine contraction)
 2. the passenger (the fetus)
 3. the passageway (the birth canal)
DYSFUNCTIONAL LABOR
> refers to a sluggishness in the force of contractions.
 Dysfunctional labor can occur at any point in labor but is
generally classified as primary (occurring at the onset of
labor) or secondary (late in labor).
Causes:
 It may be related to problems with the passenger,
passage and/or power.

 Problems related to the passenger include fetal

malposition or malpresentation or an unusually large fetus.
- Problems related to passage include pelvic contractures,
cervical rigidity
- Problems related to power include uterine contractions that
are hypotonic, hypertonic, or uncoordinated.
 Inappropriate use of analgesics or anesthetics (excessive or
too early administration)
 Presence of full rectum or urinary bladder (impedes fetal
descent)
 Mother becoming exhausted from labor
Ineffective uterine force will lead to
abnormal contractions:

 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.

Assisted vaginal delivery may be performed using forceps,

vacuum, or breach extraction provided the cervix is fully
dilated, and vaginal delivery is indicated and probable.

Operative delivery by cesarean section should be

considered early when the assessment indicates a CPD or
fetal malpositioning/malpresentation.
 Management

 Hypotonic contractions involves improving the

strength of contractions
- If contractions are too weak or infrequent to be
effective, labor may need to be induced or
augmented to make uterine contractions stronger.
- Cervical ripening via stripping of membranes or
application of prostaglandin gel or laminaria may
be done to prepare for the induction of labor.
HYPERTONIC UTERINE
CONTRACTION
What is hypertonic labor?
 Uterine hyperstimulation or hypertonic uterine
dysfunction is a potential complication
of labor induction.

 The woman complains of pain; intensity of

contractions may be no stronger than with
hypotonic contractions.
HYPERTONIC UTERINE
CONTRACTION
 Aremarked by an increase in resting
tone to more than 15mmHg, most
common during the latent phase.
 Theuterus don't rest between
contractions, high resting pressure of
40-50mmHg.
 Occur because (1) the muscle fibers of
the myometrium don't repolarize after a
contraction thereby “wiping it clean” to
accept a new pacemaker stimulus
(myometrial contractility)
 (2) Oxytocin administration.

 *lack of relaxation between contractions

does not allow optimal uterine artery
filling, which may lead to FETAL ANOXIA.

 Fetal Anoxia = inadequacy of O2 in the

fetus
Management of hypertonic labor:

Hypertonic uterine dysfunction is difficult to treat, but

repositioning, short-acting tocolytics
(eg, terbutaline 0.25 mg IV once), discontinuation
of oxytocin if it is being used, and analgesics may help.

Tocolytics = medications that suppresses uterine

contractions

promote comfort (changing the linen and the mother's

gown, darkening room lights, and decreasing
noise/stimuli).

- if decelerating FHT or lack of progress with pushing,

CS delivery may be necessary.
Uncoordinated Uterine Contractions

 Occur erratically, such as one on top of another followed

by a long period without any.

 The lack of a regular pattern to contractions makes it

difficult for the woman to use breathing exercises bet
contractions.

 Occurs because more than one pacemaker may initiate

contractions.
 Uncoordinated Contractions
management:
 - Oxytocin administration to stimulate a more effective
and consistent pattern of contractions

 - if HPN occurs, stop oxy drip and notify physician.

 Nursing Interventions :
1. Explain the events to the patient and her support person;
explain that the contractions are ineffective
2. Provide comfort measures, including nonpharmacologic pain
relief measures.
3. Continuously monitor uterine contractions and FHR patterns.
4. Offer fluids as appropriate; institute IV therapy to supply
glucose to replace depleted stores from prolonged labor.

5. Assist with measures to induce or augment labor; monitor

oxytocin infusion if used.

6. Encourage frequent voiding to prevent bladder distention

from interfering with labor contractions.
 RETRACTION RING
 A pathologic constricting ring (Bandl's ring) that occurs at the
juncture of the upper and lower uterine segments.
 Bandl's ring (also known as pathological retraction ring) is the
abnormal junction between the two segments of the human
uterus, which is a late sign associated with obstructed labor(
dysfunctional labor).
 A ridge sometimes felt on the uterus above the pubes, marking th
e line of separation between the upper contractile and lower dilata
ble segments of the uterus. If the ring is normal, as in a normal del
ivery, it is called the physiologic retraction ring; if the ring persists,
as in prolonged labor, it is called the pathologic retraction ring.
 The Bandl’s ring is seen and felt abdominally as a transverse
groove that may rise to or above the umbilicus.
Cause :
 What causes Bandl's ring?
 It is unclear but it is believed that prolonged labor may play a role
in the development of a constriction ring.
 Dystocia has also been implicated.
 Early labor – it is usually from uncoordinated contractions; by obstetric
manipulation or the result of oxytocin administration.
 Can be identified by sonogram.
Treatment :
 A tocolytic may be administered to halt contractions. A
cesarean birth is advised to ensure safety of neonate.
 Nursing Interventions :
 1 Continue monitoring FHR patterns and contractions.
 2. Monitor Intake and output, refer if UO is below 30cc/hr.
3. Explain the events to the patient and support person,
explain the need for alternative method of delivery.

4. Encourage patient to verbalize feelings to ease tension

and relieved anxiety.
 PREMATURE LABOR
 Also known as “preterm labor”; the onset of rhythmic
uterine contractions that produce cervical changes after
fetal viability but before fetal maturity.
 Usually occurs between 20 and below 37 weeks
gestation.
 Fetal prognosis depends on birth weight and length of
gestation.
 Premature labor increases the risk of neonate morbidity or
mortality from excessive maturational deficiencies.
Maternal causes :
 - Cardiovascular and renal disease
 - DM
 - Infection
 - Abdominal surgery or trauma
 - Incompetent cervix
 - Placental abnormalities
 - Premature rupture of membranes
 Fetal causes :
 - Infection
 - Hydramnios

 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.

 Maternal:Lacerations of the cervix, vagina and

perineum.
 Shock.
 Inversion of the uterus.
 Postpartum haemorrhage:
 The mother is at risk for hemorrhage secondary to
premature separation of the placenta and for
lacerations due to the force and rapidity of the birth.
 Fetal: Intracranial haemorrhage due to sudden compression
and decompression of the head.
 Foetal asphyxia due to:
 strong frequent uterine contractions reducing placental
perfusion,
 lack of immediate resuscitation.
 Avulsion of the umbilical cord.
 Foetal injury due to falling down.

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.

 The placenta is attached to the wall of the uterus

by bloodvessels that supply the fetus with oxygen
and nutrition and remove waste from
the fetus and transfer it to the mother.
 The fetus is attached to the placenta by
the umbilical cord. Through the cord, the
fetus receives nourishment and oxygen
and expels waste.

 On one side of the placenta, the

mother's blood circulates, and on the
other side, fetal blood circulates.
PLACENTAL ANOMALIES
 Involve abnormalities in the size of the placenta or the
blood vessels connected to it.

 * The normal placenta weighs about 500gms, is 15-20 cm

in diameter and 2-3cm thick; is flat, cakelike round or
oval.
 * The maternal side is lobulated; and fetal side is shiny.
Several Types of Placental Anomalies:
1. Battledore placenta = the cord is
inserted marginally rather than
centrally.

2. Placenta succenturiata = one or

more accessory lobes are
connected to the main placenta
by blood vessels.

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).

 On rare occasions, the placenta lies low in the uterus,

partly or completely blocking the cervix -- a condition
called placenta previa.
 As the uterus grows, the placenta usually moves
higher in the uterus, away from the cervix.

 But if it remains near the cervix as your due

date nears -- which happens in about 1 in 200
pregnancies -- you're at risk for bleeding,
especially during labor as the cervix thins
(effaces) and opens (dilates).
Assessment Findings :
 Vaginal bleeding after the 20th week of gestation
usually the bleeding is painless, but it can be
associated with uterine contractions.
 Painless, bright red vaginal bleeding(common after
20th week gestation esp during 3rd trimester)
 Initially scant bleeding is noted, beginning before the
onset of labor
 Palpation may reveal a soft nontender uterus
 Abdominal exam using LM reveals various
malpresentations (due to interference with the descent
of the fetal head caused by the placenta's abnormal
location)
 Types of Placenta Previa


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:

 Ultrasound, CT Scan, MRI


 Management

 Cesarean delivery (C-section) is required for complete

placenta previa and may be necessary for other types of
placenta previa.

 Women with placenta previa in the 3rd trimester of

pregnancy are advised to avoid sexual intercourse
and exercise and to reduce their activity level.
 Women with placenta previa who experience
heavy bleeding may require blood transfusions and
intravenous fluids.

 In some cases, tocolytic drugs (medications that

slow down or inhibit labor), such as terbutaline
(Brethine) are necessary.
Management :
 Limitation of maternal activities
 Monitoring of all relevant VS
 Vaginal delivery is considered only when the bleeding is
minimal and the placenta is marginal or when the labor is
rapid
 Immediate CS delivery performed as soon as the fetus
matures or in the case of intervening severe hemorrhage
 Rectal or vaginal exam shouldn't be performed (can
stimulate uterine activity) unless equipment is available
CS/vaginal delivery.
 Nursing Interventions :
1. Teach the pt to immediately identify and report signs and
symptoms of placenta previa
(bleeding, cramping)
2. If the pt with placenta previa shows active bleeding,
continuously monitor VS, intake and output, amount of
bleeding, as well as FHR
3. Anticipate the need for electronic fetal monitoring and
aplication as indicated
4. Have O2 available for use (fetal distress occur)
5. If the patient is Rh-negative, administer RhoGAM after
every bleeding episode
6. Instruct patient for complete bed rest
7. Prepare the patient and family for possible CS delivery,
and the birth of a preterm neonate through explanation
8. If the fetus isn't mature, expect to administer an initial
dose of betamethasone (to aid in promoting fetal lung
maturity); explain that additional doses may be given
again in 24hrs,and in 1-2 weeks
9. Provide emotional support during labor
10. Tactfully discuss the possibility of neonatal death
- tell the mother the neonate's survival depends on
gestational age, and amount of blood lost
11. During the postpartum period, monitor pt for signs of
hemorrhage and shock caused by uterus's diminished
ability to contract.
12. Encourage the pt and her family to verbalize their
feelings.
ABRUPTIO PLACENTAE

 Refers to the premature separation of the normally

implanted placenta from the uterine wall
 Usually occurs after 20-24 weeks of pregnancy but
may occur as late as during first or second stage of
labor.
 Common in multigravidas – usually age 35 and older
 Diagnosis is confirmed when there's heavy maternal
bleeding, which necessitates termination of
pregnancy
Degrees of Placental separation in Abruptio placenta
 Mild Separation
 - begins with small areas of separation and internal
bleeding (concealed hemorrhage) between the
placenta and uterine wall.

 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

 Separation can be acute or chronic. Separation results

in bleeding into the decidua basalis behind the
placenta. Most often, etiology is unknown.

 Placental abruption can deprive the baby of oxygen

and nutrients and cause heavy bleeding in the mother.
 Risk factors for abruptio placentae include the following:
 Older maternal age
 Hypertension (pregnancy-induced or chronic)
 Placental ischemia (ischemic placental disease) manifesting
as intrauterine growth restriction
 Intra-amniotic infection (chorioamnionitis)
 Other vascular disorders
 History of abruptio placentae
 Abdominal trauma
 Acquired maternal thrombotic disorders
 Tobacco use
 Premature rupture of membranes
 Cocaine use (risk of up to 10%)
 Assessment findings
> may result in bright or dark red blood exiting through the cervix
(external hemorrhage).
> Blood may also remain behind the placenta (concealed
hemorrhage).

>Severity of symptoms and signs depends on degree of separation

and blood loss. As separation continues, the uterus may be painful,
tender, and irritable to palpation.

 Hemorrhagic shock may occur, as may signs of DIC.

Diagnostic findings : Ultrasound
 Management
 Sometimes prompt delivery and aggressive
supportive measures (term pregnancy or for
maternal or possible fetal instability).

 Trial of hospitalization and modified activity (CBR

w/out BRP’s) if the pregnancy is not near term and
if mother and fetus are stable.
 Medication (Corticosteroids) is given to help your
baby's lungs mature, in case early delivery
becomes necessary.

 Prompt cesarean delivery is usually indicated.

 For severe bleeding, you might need a blood
transfusion.
 Management:
 Monitoring maternal VS, FHR, uterine contractions, and
vaginal bleeding
 CS is indicated for moderate to severe placental
separation
 Vaginal delivery(depending on degree of separation)
 Fluid and electrolyte replacement therapy, blood
transfusion
 Evaluation of maternal laboratory values
 Nursing Interventions :
1. Assess extent of bleeding and monitor fundal ht. every
30 minutes for changes.
(if the level of the fundus increases, suspect abruptio
placenta)
2. Determine the amount of blood loss – count the number
of pads the pt used.
3. Begin electronic fetal monitoring to assess FHR
4. Monitor for maternal VS, I and O, and amount of
vaginal bleeding every 10-15minutes
5. Have equipment for emergency CS delivery available.
6. Reassure the pt of her progress through labor and
keep her informed of the fetus's condition.
7. Tactfully discuss the possibility of neonatal death.
8. Encourage the pt and her family to verbalize feelings
9. Help them to develop effective coping strategies –
referring them to counseling.
 UTERINE INVERSION
 Uterine inversion means the placenta fails to detach from
the uterine wall, and pulls the uterus inside-out as it exits.
 With this condition, the uterus actually turns inside out (rare
phenomenon occurring in 1 to 15,000 births).

 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:

1.Long labour (more than 24 hours).

2. Short umbilical cord.
3. Pulling too hard on the umbilical cord to
hasten delivery of the placenta,
particularly if the placenta is attached to
the fundus.
4. Placenta accreta (the placenta has
invaded too deeply into the uterine wall).
 Treatment :
 IV fluids and blood component therapy to replace fluid
volume and blood loss
 General anesthesia, or tocolytic may be administered to
relax the uterus
 After administration, the physician will attempt to
manually replace or rearrange the uterus
 Once replaced, oxytocin is given to promote uterine
contractions
 Due to uterine exposure, antibiotic is indicated
postpartally
 As a last resort, the patient may require an emergency
hysterectomy.

 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