high risk - problem with

(DYSTOCIA)

Difficult Labor

(Power

passenger,

Passageway

Psyche)

Difficult Labor can arise from problems occurring from

the main components of the LABOR PROCESS (4)

❑Problems of passenger

❑Problems with the passageway

❑Problems with powers

❑Placental problems

❑Problems with psyche factors

LABOR OR BIRTH COMPLICATIONS (5)

▪ Identifying women in labor who are developing a complication

▪Assisting with CS births and careful assessment during labor

▪Being alert to preliminary symptoms of uterine rupture (accounts for

substantial number of maternal deaths during labor)

The National 2020 Health Goals relate to attempts to decrease

maternal complications and prevent infant injury related to birth in which

nurses can help through (3)

❑ Continuous assessment of laboring woman and her fetus

❑ Provide emotional support for the mother and her family

things to ponder in high risk (2)

▪ Fetal and uterine monitors are tools to detect deviations

▪Requires frequent adjustment of the equipment to achieve clear tracing

▪It is important to explain the importance of the apparatus to the laboring woman and her partner to gain their cooperation

assessment for high risk (3)

fetal and uterine monitors

tools to detect deviations (2)

induction and labor procedures

• Pain related to (2)

uncertainty of pregnancy outcome

Fear related to

glucose stores through work and duration of labor

2. prolonged labor

Fatigue related to loss of (2)

medical procedures and apparatus necessary to ensure health

of woman and fetus

Anxiety related to

excessive loss of blood with

complications of labor

Risk for ineffective tissue perfusion related to

lack of knowledge or lack of preparation for labor

Ineffective coping related to (2)

labor involving multiple gestation of

pregnancy

Risk for injury (maternal/fetal) related to

nonviable monitoring pattern of fetus

Anticipatory grieving related to

▪ Outcomes to be included in planning can be difficult to identify

because it may not be what the woman desires

▪Encourage the couple to clarify their priorities when complication

arise is helpful

Outcome Identification and Planning (2)

1. increase fhr

2. strengthen Uterine contractions

Priorities will be to: (2)

May reveal unhappiness but focus is more on

positive outcome and look the couple for signs

that they are able to begin interacting with their

child after their distressful experience

Outcome Evaluation

1. cervical dilation

2. expulsion

3. placental

4. maternal homeostatic stabilization

stages of labor (4)

cervical dilation

begins with onset of regular contraction and ends with complete dilation

1. latent 0 3

2. active 4 7

3. transitional 8 10

cervical dilation stages

explusion

begins with complete cervical dialtion and ends with delivery of baby

placental

immediately after fetus is borna nd ends when placenta is delivered

maternal homeostatic stabilization stage

begins after the delivery of placenta and continues for one to four hours after delivery

▪OCCIPITOPOSTERIOR POSITION

(1/10

of all labors)

▪OCCIPITOPOSTERIOR POSITION

complains of back pain

android,

anthropoid and

contracted pelvis

FETAL MALPISION OCCURS MORE IN WOMEN WITH (3)

gynecoid (female)

android (male)

anthropoid (narrow)

platpelloid (wide

pelvic shapes (4)

▪Prolonged active phase

▪Arrested descent

▪Fetal heart sounds heard best at the lateral

sides of the abdomen

fetal malposition suggested through (3)

fetal malposition

▪May experience INTENSE pressure and pain

in the lower back

–sacral nerve compression

▪May experience INTENSE pressure and pain

in the lower back (fetal head rotates

against the sacrum)

1. ROP

2. LOP

most common malposition

LOA

Most favorable position

FETAL MALPOSITION

▪Posteriorly presenting head does not fit the

cervix as snugly as one in anterior position

1. vaginal exam

2. ultrasound

Fetal malposition is confirmed by (2)

▪Fetus is of average size

▪Good flexion

▪Forceful uterine contraction

▪Rotate through a large arc

▪Arrive at good birth position for the pelvic outlet

▪Results only to increased molding and caput formation

Fetal Malposition SUCCESSFUL vaginal delivery if:(6)

▪Assume hands and knees position, squatting or lying on her side

▪ Shifting from right to left or lunging or swinging body right to left while

elevating her left foot on a chair

fetal malposition management

Not Evidence-based and tiring to the mother (2)

▪Most women choose epidurals

▪ Peanut ball between the woman’s legs has been found to open the cervix

and reduce total labor time

Fetal management RATIONALE (2)

▪Apply counter pressure on the sacrum by a back rub

▪ Rebozo method (Cohen & Thomas, 2015) – jiggling and massaging the

uterus maybe helpful when assisting the fetus to rotate to a better position

▪ Void every 2 hours (full bladder impedes descent)

▪ IV or oral glucose (to replace used glucose stores to keep active in labor)

▪ CS delivery if resulted to uterine dysfunction (maternal exhaustion)

▪ If born vaginally, the baby is born looking at the ceiling or “sunny side up)

forcep

vacuum extraction

episiotomy

Fetal Malposition MANAGEMENT (9)

Rebozo method

jiggling and massaging the

uterus maybe helpful when assisting the fetus to rotate to a better position

crowning

•low forceps or outlet forceps usually

applied after

internal rotation

▪Forceps to aid fetus for

•low forceps or outlet forceps

(2) usually applied after crowning

oCervical lacerations

oHemorrhage

oinfection

might lead to (3)

▪Vacuum extraction

•disk shaped cup

placed over vertex of

head and vacuum

applied

▪Episiotomy

•surgical incision to

allow more room

1. shoulder/transverse

2. face/brow

3. normal

4. breech complete

5. breech footling

6. breech frank

FETAL PRESENTATIONS

BREECH presentation

Presenting part is buttocks

BREECH presentation

Most of the fetuses are in this presentation

early in pregnancy and by 38th week 97% turns

to cephalic presentation

38

97

Most of the fetuses are in this presentation

early in pregnancy and by __th week __% turns

to cephalic presentation

a. Developing dysplasia of the hip

b. Anoxia from prolapsed cord

c. Traumatic injury to aftercoming head

d. Fracture of spine/arm

e. Dysfunctional labor

f. Early rupture of membrane because of poor fit

of the presenting part

g. Meconium staining

More hazardous than cephalic presentation because

of RISKS (7)

Meconium staining is expected

BREECH PRESENTATION

Inevitable contraction of fetal buttocks from cervical

pressure

Meconium excretion

BREECH PRESENTATION

Can lead to meconium aspiration if the infant inhales the

amniotic fluid

a. Gestational age less than 40

b. Fetal anomaly

c. Hydramnios (amniotic fluid disorder/

polyhydramnios---too much amniotic fluid builds up

during pregnancy)

d. Uterine anomaly

e. Space-occupying mass in the pelvis

f. Pendulous abdomen

g. Multiple gestation

h. Unknown factors

BREECH presentation (8)_

a. FHB heard high in the abdomen

b. Leopold’s maneuver and vaginal examination

c. Complete breech may be mistaken into head (fully

engaged)

d. Ultrasound may confirm presentation

e. It will still follow the same mechanisms of labor

(flexion, descent, internal rotation, expulsion and

external rotation)

BREECH PRESI assessment (5)

ultrasound

how to confirm breech

(flexion, descent, internal rotation, expulsion and

external rotation)

mechanisms of labor 5

Always monitor FHR and uterine contractions

continuously

BREECH presentation

MANAGEMENT

monitor (2)

✓ Push after full dilatation

✓ Support sterile with sterile towel against infant’s

inferior surface

VAGINAL DELIVERY breech 2

1. Trunk of infant is straddled over care giver’s forearm

2. Two fingers of the right hand are then placed in the infant’smouth

3. The left hand is slid into the woman’s vagina, palm down along

   the infant’s back, and pressure is applied to the occiput to flex

   the head fully

4. Gentle traction applied to the shoulders (upward and outward)

   delivers the head

AID IN THE BIRTH OF THE HEAD (4)

External rotation

(bring head to its best

outlet diameter)

✓ arm of the posterior shoulder maybe drawn down by

passing two fingers over the infant’s shoulder and down

the arm to the elbow

✓ sweep flexed arm across infant’s face and chest and out

✓ other arm is delivered the same way

✓ External rotation allowed to occur

BREECH presentation

MANAGEMENT

▪ If not born readily (4)

head

BREECH presentation

DANGER

▪ __ delivery the most hazardous

✓ umbilicus precedes the head

✓ loop of cord passes down alongside the head

✓ pressure of the head against the pelvic brim compresses the

cord

BREECH

head delivery the most hazardous (3)

1. head\

2. intracranial hemorrhage

BREECH DANGER (2)

Intracranial

hemorrhage

Pressure changes occur

instantaneously (result to

tentorial tears – gross

motor and mental

incapacity or lethal

damage to the fetus)

tentorial tears

Pressure changes occur

instantaneously (result to

Frank breech birth

legs extended at level of head for first 2-3 days

Footling breech

legs remains in the same position for first few days

ASYNCLITISM

head presenting at a

different angle than

expected

1. chin or mentum

2. too large for birth to proceed

FACE PRESENTATION

head presenting at a

different angle than

expected (2)

▪ Heads feel prominent than normal

▪ No engagement on Leopold's

▪ Head and back felt at the same side

▪ Back extremely concave

▪ Usually a warning signal that something is abnormal

▪ Posterior position

FACE presentation

ASSESSMENT (6)

FACE presentation

No engagement on Leopold's

FACE presentation

Head and back felt at the same side

FACE presentation

Back extremely concave

✓ Fetal heart tones heard on the side of the fetus where feet

and arms can be palpated

✓ Nose, mouth and chin can be palpated during vaginal

examination

Back extremely concave (2)

nose mouth and chin

(3) can be palpated during vaginal

examination for FACE presi

✓ Head extends

✓ Occurs in women with contracted pelvis or Placenta previa

✓ Relaxed uterus of multipara women/ prematurity/

hydramnios/fetal malformation

FACE PRESI ASSESSMENT

Posterior position (3)

1. ✓ Facial edema

2. Lip edema

FACE presentation

▪ EFFECT ON

FETUS (2)

ecchymotic

bruising)

Facial edema

(purple from

Lip edema

(unable to suck

for a day or two)

Facial edema

(purple from

ecchymotic

bruising)

ULTRASOUND

FACE presentation

___ is done to confirm

pelvic diameter

FACE presentation

IF INDICATED ___ is measured

cs

If chin is posterior

pwede vaginal

If chin is anterior

BROW presentation

Most rare

BROW presentation

Occurs in multipara or woman with relaxed

abdominal muscles

BROW presentation

Results in obstructed labor

BROW presentation

Head becomes jammed in the brim of the pelvis as

the occipitomental diameter presents

BROW presentation

CS is necessary

occipitomental diameter

BROW presentation

Head becomes jammed in the brim of the pelvis as

the __ presents

vertico mental

occipito frontal diameters

brow presi

shortens =

lengthens =

middle of frontal suture

brow presentation

on vaginal exam, fingers touches the

vertigo-mental diameter

transverse at the brim

Brow presi

the ___ of the head is trying to engage the ___

TRANSVERSE LIE

Tumors that obstruct the lower uterine segment

✓ contraction of pelvic brim

✓ congenital abnormalities of the uterus

✓ hydramnios

✓ multiple gestation

✓ short umbilical cord

Tumors that obstruct the lower uterine segment (5)