MIDTERM LECTURE
pass through the maternal pelvis.
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 LABOR AND
DELIVERYProblems of the Passenger
1. Fetal malposition
2. Fetal malpresentation
 Vertex
presentation
 Brow presentation
 Face presentation
 Occiput posterior
3. Fetal Distress
4. Prolapse of the Cord
TYPES OF PELVIS
1. GYNECOID – normal female
pelvis
2. ANDROID – male pelvis; narrow
pelvic inlet and outlet
3. ANTHROPOID – narrow
transverse diameter and larger
antero-posterior diameter
4. PLATYPELLOID – inlet is oval
and AP diameter is shallow
5. PASSENGER
Description
 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
 The head can flex or extend 45
degrees and rotate 180 degrees,
which allows smallest diameters
to move down the birth canal and
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
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.
Occipito-posterior position
- The most common
malposition
Occipito-transverse position
- Head initially engages
correctly but fails
to rotate and remains in
transverse position.
Positions in Vertex
Presentation (occiput)
 Right occipito anterior
 Right occipito posterior
 Right occipito transverse
 Left occipito anterior
 Left occipito posterior
 Left occipito transverse
Positions in Breech Presentation
(sacrum)
 Right sacroanterior
 Right sacroposterior
 Right sacrotransverse
 Left sacroanterior
 Left sacroposterior
 Left sacrotransverse
Positions in Face Presentation
(mentum)
 Right mentoanterior
 Right mentoposterior
 Right mentotransverse
 Left mentoanterior
 Left mentoposterior
 Left mentotransverse
Shoulder Presentation (acromion
process)
 Right scapuloanterior
 Right scapuloposterior
 Right scapulotransverse
 Left scapuloanterior
 Left scapuloposterior
 Left scapulotransverse
 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:
1. Cephalic- head presents first
2. Breech – buttocks or feet
presents first
3. Shoulder – shoulder, iliac crest,
hand, or elbow presents first
4. Fetal Malpresentation
5. Types of Cephalic:
6. 1. Vertex – head sharply flexed
(Normal)
7. 2. Brow- head moderately flexed
8. 3. Face- head poorly flexed
9. 4. Mentum- hyperextension of
head; chin presents first
10. Risks of Brow Presentation
11. Longer labor due to ineffective
contractions and slow or
arrested fetal descent
12. Cesarean birth if brow
presentation persists
13. Fetus – increased mortality
because of cerebral and neck
compression and damage to
trachea & larynx
- facial edema, bruising
Risks of Face Presentation
 Increased risk of CPD &
prolonged labor
 Increase risk of infection
 Cesarean birth
 Cephalhematoma
 Edema of the face & throat
 Fetal Malpresentation
 Types of breech Presentation:
1. Complete- thighs of the fetus
are tightly flexed on the
abdomen; buttocks and flexed
legs present first
2. Frank – hips are flexed but
legs are extended; buttocks
present first
3.Incomplete – one or both hips
partially of fully extended
 Nursing Management (Breech)
 Assess maternal & fetal status- to
promote maternal-fetal physical
well being
 Continuous fetal monitoring-
increased risk for cord prolapse
 CBR without BRP
 Teaching & information about the
breech presentation
 Evaluation (Breech)
 The woman & partner understand
the implications of breech
presentation
 Major complications are
recognized early & corrective
measures are instituted
  The mother and baby have safe
labor & birth
Fetal Malpresentation
Shoulder Presentation – the fetus is
lying horizontally in the pelvis
Compound Presentation- prolapse of a
limb of the fetus alongside the head in a
cephalic presentation or of one or both
arms in a breech presentation
Fetal Distress
HYPOXIA -
 Late deceleration appear
 Fetal breathing stops
 Fetal movement ceases
 Fetal tone absent
• Causes of Fetal DistressCord
Prolapse/cord compression
• PROM
• Oligohydramnios
• Meconium Staining
• Maternal complication – DM,
anemia, infection
• Preterm/IUGR fetus
• How it is detected? Special test
and monitoring procedures
> X-ray pelvimetry reveals
malpositioning
> Ultrasonography shows pelvic masses
that interfere with vaginal birth
> Auscultation of FHR (by fetoscope,
Doppler unit, or electronic fetal monitor)
determines fetal intolerance of labor.
Fetal Heart Rate PatternsA. Early
Decelerations
= caused by fetal head compression
• Periodic DECREASE in FHR
resulting from pressure on the
fetal head during contractions.
B. Late Decelerations
= caused by uteroplacental
insufficiency
• Are smooth, uniform waveforms
that inversely mirror the
contractions, they may drop to
below 100 beats/minute.
C. Variable Decelerations
= caused by umbilical cord
compression
• In severe cases the FHR may
decelerate below 70beats/minute
for more than 30 seconds, with a
slow return to baseline.
• Management:
1. place pt in left-lateral position
2. increased IV flow rate
3. administer O2 as per doctors order
4. discontinue oxytocin infusion (induce
labor)
Nursing Intervention:
1. continue monitoring contractions and
record FHR.
2. anticipate amnioinfusion for repetitive
variable decelerations
3. If rate falls below 70beats/minute
persists for more than 60 seconds, the
doctor may choose to intervene.
4. Prepare double set-up delivery
Prolapse of the Umbilical Cord
 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.
 Causes: Premature rupture of
membranes
 Fetal presentation other than
cephalic
  Tends to occur most often with
the ff conditions:
 Placenta previa
 Intrauterine tumors preventing the
presenting part from engaging
 A small fetus
 CPD preventing firm engagement
 Hydramnios
 ASSESSMENT:
 = cord may be felt as the
presenting part initially during IE
 = identified on UTZ, CS is
necessary before rupture of
membranes.
 = if rupture occurs, the cord will
slide down into the vagina
(pressure exerted by amniotic
fluid)
 = cord may be visible at the vulva
Management: 1. Position patient on
Trendelenburg or knee chest (for fetal
head to fall back thus relieving pressure
on cord preventing compression and
fetal anoxia)
2. Administer O2 at 10L/min to mother
(helpful to improve oxygenation of the
fetus).
3. A tocolytic agent is used (to reduce
uterine activity and pressure on fetus)
4. If fully dilated, the physician may
deliver infant quickly, if incomplete
dilatation, upward pressure on the
presenting part in the woman's vagina
(to keep pressure off the cord) until
delivered by CS.
5. If prolapsed cord is exposed to room
air (drying will begin- leading to atrophy
of the umbilical vessels).
• Don't push the cord back to
vagina (may add to compression
by knotting/kinking), instead
cover exposed portion with sterile
sponge soaked in sterile saline to
prevent drying.
Nursing Interventions:
 Inform client and watchers about
the additional procedures &
techniques that may be
necessary during the delivery
process.
 Prepare additional equipment &
personnel for delivery
 Assisting with amniotomy,
ultrasonography, forceps or
vacuum extraction application as
needed
 Assisting with neonatal
resuscitation, if necessary
 Explaining any newborn
characteristics related to the high
risk birth, such as forcep marks,
bruising
 Encouraging parental interaction
with neonates immediately after
delivery
• PASSAGER
refers to the route that the fetus
must travel when leaving the uterus
arriving at the external perineal area
of birth.
PROBLEMS with the PASSAGEWAY:
A. Abnormal Size or Shape of the
Pelvis
B. Cephalo-pelvic Disproportion
C. Shoulder Dystocia
• Refers to the route that the fetus
must travel when leaving the
uterus arriving at the external
perineal area of birth.
PROBLEMS with the PASSAGEWAY:
A. Abnormal Size or Shape of the
Pelvis
 B. Cephalo-pelvic Disproportion the normal
C. Shoulder Dystocia male pelvis
• Refers to the route that the fetus  Diameter is
must travel when leaving the somewhat
uterus arriving at the external narrowed,
perineal area of birth. making fetal
 Shape of pelvis passage
-also can determine the ability and ease difficult
with which the fetus can pass d. Platypelloid- shaped pelvis occurs in
a. Gynecoid- shaped pelvis is the most about 5% of females
common type of pelvis  It’s oval or
 Occurs in flat
about 50% of  The fetus
females may have
 Round shape difficulty
with rotating
adequate sufficiently to
diameters to match the
allow easy shape of the
passage of pelvis at the
fetal skull appropriate
b. Anthropoid- shaped pelvis occurs in diameters
about 25% of females CEPHALOPELVIC DISPROPORTION
 It’s oval with • Refers to the narrowing of the
longer birth canal which can occur at the
anteroposteri inlet, midpelvis, or outlet.
or diameter • Involves a disproportion between
 This type of the size of the normal fetal head
pelvis may and the pelvic diameters.
pose • Results in failure to progress in
difficulty in labor
passage Causes :
except when • The physical size of the maternal
fetus is in pelvis is a major contributor –
occiput small pelvis is a factor.
posterior • Outlet contraction can also be a
position contributing factor
c. Android- shaped pelvis occurs in - There's a narrowing of the transverse
about 20% of females diameter
 It’s heart- Treatment :
shaped, like
• 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).
• If labor doesn't progress or
complications develop, cesarean
birth is the 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.
• 2. Monitor progress of the trial
labor – if, after 6-12 hours, no
progress of labor and if fetal
distress occurs, prepare for CS.
• 3. If the trial labor fails and
cesarean birth is scheduled,
provide an explanation about why
it's necessary and is best for the
neonate.
• 4. Provide support for the
patient's significant person; he
may also be frightened and feel
helpless
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.
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 =
compressed between the fetal
body and the bony pelvis,
possibly resulting in a fractured
clavicle or a brachial plexus
injury.
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 :
• Initially = Applying suprapubic
pressure may help the shoulder
escape from beneath the
symphysis pubis.
• CS is necessary if maternal and
fetal condition is in complication.
Problems with the POWERS
Problems with the Powers
1. Dystocia or difficult labor
 Hypertonic uterine
contractions
 Hypotonic uterine
contractions
 Uncoordinated uterine
contractions
2. Premature labor
3. Precipitate labor & birth
4. Uterine prolapse/inversion
5. Uterine rupture
DYSFUNCTIONAL LABOR
• Also known as “inertia” ; 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 or
power.
> malposition or malpresentation or an
unusually large fetus.
> pelvic contractures, cervical rigidity
> uterine contractions that are
hypotonic, hypertonic, or uncoordinated.
• Presence of full rectum or urinary
bladder (impedes fetal descent)
• Mother becoming exhausted from
labor
Hypotonic Contractions
• 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)
causes:
• Occur when analgesia has been
administered too early (before
cervical dilatation of 3-4cm)
• Overstretched uterus by a
multiple gestation
• Larger fetuses
• Lax uterus from grand multiparity
• Bowel or bladder distention
* due to cervix dilated for a long period
both uterus and fetus are at risk of
INFECTION
HYPERTONIC UTERINE
CONTRACTION
• Are marked by an increased in
resting tone to more than
15mmHg,
• The uterus don't rest between
contractions, high resting
pressure of 40-50mmHg.
• complains of pain
• *lack of relaxation between
contractions does not allow
optimal uterine artery filling,
which may lead to FETAL
ANOXIA.
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.
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 contractions
= involves promoting rest, providing
analgesia with a drug such as morphine
sulfate, possibly inducing sedation(for
woman to rest).
- 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 Contractions =
- 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.
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.
• 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
• Fetal causes :
- Infection
- Hydramnios
- Multiple pregnancy
Assessment 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:
drug therapy with tocolytic agent
• 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.
• 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.