DYSTOCIA-

a difficult labor which can arise from the

POWER, the PASSAGEWAY, the PASSENGER,
PSYCHE and medical interventions
-labor that lasts >24 hours)
COMMON CAUSES OF DYSFUNCTIONAL
LABOR
 Inappropriate use of analgesia (excessive or too early
administration)
 Pelvic bone contraction that has narrowed the pelvic
diameter so that a fetus cannot pass (rickets)
 Poor fetal position (posterior rather than anterior
positions)
 Extension rather than flexion of the fetal head
 Overdistention of the uterus, as with multiple
pregnancy, hydramnios, or an excessively oversized fetus
 Cervical rigidity ( unripe)
 Presence of a full rectum or urinary bladder that
impedes fetal descent
 Mother becomes exhausted from labor
 Primigravida status
COMPLICATIONS WITH THE POWER
(FORCE OF LABOR)
INERTIA- sluggishness of contractions, now known
as DYSFUNCTIONAL LABOR
 PRIMARY (occurring at the onset of labor) or
 SECONDARY (occurring later in labor)
UTERINE TONES
NORMAL VALUES:

RESTING TONE= 5-15 mm Hg

MILD CONTRACTION= 15-30 mm Hg
MODERATE CONTRACTION= 30-50 mm Hg
STRONG CONTRACTION= 50-75 mm Hg
 INEFFECTIVE UTERINE FORCE
HYPOTONIC CONTRACTIONS(2ary
inertia)/HYPOTONIC UTERINE INERTIA
 The number of contractions is low or infrequent ( not
increasing beyond 2 or 3 in a 10-minute period
 Resting tone of the uterus remains < 10 mm Hg,
& strength of contractions does not rise above 25
mm Hg
 Common in the ACTIVE PHASE
 Increases length of labor & uterus does not contract
effectively postpartally due to exhaustion, increasing
chance for postpartal hemorrhage
 Cervix is dilated for prolonged periods increasing risk
for infection of mother & fetus
Causes of Hypotonic Uterus
 administration of analgesia when cervix is not
dilated to 3 or 4 cm,
 bowel or bladder distention- prevents descent or firm
engagement,
 multiple gestation,
 LGA fetus,
 hydramnios,
 lax uterus due to grand multiparity
Complications
 Maternal/fetal infections- cervix is dilated for a
prolonged time
 Postpartum hemorrhage
 Fetal distress and death
 Maternal exhaustion
Management of Hypotonic Uterus
 UTZ to rule out CPD
 Walking, if not contraindicated
 OXYTOCIN to augment labor by strengthening
contractions & making them effective
 Amniotomy to speed up labor
 1st hour postpartum, palpate the uterus and assess
lochia q 15 minutes to ensure that postpartl
contractions are not also hypotonic & inadequate to
halt bleeding
OXYTOCIN for Hypotonic UI
 Do not leave pt alone
 Client must be in true labor- at least 3 cm
 No obstruction, uterine overdistention, multiple
gestation
 Monitor VS esp BP( most impt bec oxytocin may
cause hypo/hypertension
 Assist w/ delivery: after failed trial labor of 6 hours
 After delivery: observe for signs of injury & signs of
poor bonding dt difficult delivery
HYPERTONIC UTERUS( primary
inertia)
 Increase in resting tone to > 15 mm Hg, mostly
seen in the LATENT PHASE
 Muscle fibers do not repolarize or relax after a
contraction, thereby wiping it clean to receive a
new pacemaker stimulus
 More painful because the myometrium
becomes tender from constant lack of
relaxation & the anoxia of uterine cells that
results
HYPERTONIC UTERUS
 Lack of relaxation between contractions
may not allow uterine artery filling leading to
fetal anoxia
 **Any woman whose pain is out of
proportion to the quality of her
contractions should have both a uterine &
fetal external monitor applied for at least 15
mins to make sure that the resting phase of
contractions is adequate & that the fetal
pattern is not showing late deceleration
Management of Hypertonic
Uterus
 Rest & pain relief with a drug like morphine
sulfate & sedatives
 Change linen and client’s gown, darken the room
lights, decrease noise & stimulation
 If (+) for deceleration in FHR, abnormally long 1 st
stage of labor, or lack of progress with pushing (“2nd
STAGE ARREST”), CS may be necessary
 HYPOTONIC vs HYPERTONIC
CONTRACTIONS
CRITERIA HYPERTONIC HYPOTONIC

Phase of Labor Latent Active

Symptoms Painful Painless

Medication

Oxytocin Unfavorable Favorable reaction

reaction
Sedation Helpful Little value
CONTRACTION RING
 It is a hard band that forms across the uterus at the
junction of the upper and lower uterine segments and
interferes with fetal descent.

 BANDL’S RING or PATHOLOGIC RETRACTION

RING- a type of contraction ring that usually appears at
the 2nd stage of labor & can be palpated as a horizontal
indentation across the abdomen.
 It is a warning sign that severe dysfunctional labor is
occurring as it is formed by excessive retraction of the
upper uterine segment; the myometrium is much
thicker above than below the ring.
 It is caused by uncoordinated contractions due to CPD,
manipulation or the use of oxytocin.
 The fetus and the undelivered placenta are gripped by
the retraction ring and cannot advance beyond this
point.
BANDL’s RING
Management
 Administration of IV morphine sulfate or
inhalation of amyl nitrate
 Tocolytics to halt the contractions
 Cesarian birth to ensure safety of the fetus and
manual removal of the placenta under general
anesthesia
Complications:
Uterine rupture
Neurologic damage to the fetus
 PRETERM/PREMATURE LABOR

Definition:
labor that occurs before the
end of 37 weeks of gestation
 Associated with:
 Dehydration
 Urinary tract infection
 Periodontal disease
 Chorioamnionitis
 Large fetal size
 Strenuous jobs during pregnancy
 Shift work
 Intimate partner violence and trauma
Assessment
 Persistent uterine contractions (4 contractions every 4
minutes or less)
 Low abdominal cramping with or without diarrhea
 Intermittent sensation of pelvic pressure, urinary
frequency
 Persistent, dull low backache
 Increased vaginal discharge, may be pink-tinged
 Leaking amniotic fluid
 Cervical effacement > 80% & dilatation > 1 cm
 PTL
Management
 Lab test to detect presence of fetal
fibronectin to predict impending delivery;
if absent, labor will not occur for at least 14
days
 UTZ of cervix to determine shortening
 Patient is admitted & placed in complete
bed rest (preferably left side-lying) to
relieve pressure of the fetus on the cervix
Management cont’d
 IV fluid to maintain hydration which may help
stop contractions (dehydration stimulates PG to
secrete oxytocin)
 Vaginal, cervical & urine cultures to rule out
infection
 Increase fluid intake since a full bladder inhibits
contractions
 TOCOLYTICS- to halt labor
 Discharge- once contractions have stopped and
maternal and fetal conditions have stabilized
 No MEPERIDINE(DEMEROL)
 TOCOLYTIC AGENTS to halt labor
Drug Type/purpose Major side Nursing concerns
effects

RITRODRINE ß-adrenergic Maternal or fetal Assess VS, breath

(YUTOPAR) receptor tachycardia, sounds, FHR,
agonist/tocolysis shortness of contractions & maternal
breath, pulmonary response
edema, tremors,
N/V,hyperglycemi
a, hypokalemia

TERBUTALINE ß- SAME AS ABOVE SAME AS ABOVE

(BRETHINE) adrenergic/tocolysi
s; antidote:
PROPANOLOL
Drug Type/purpose Major side effects Nursing concerns

MgSO4 CNS Lethargy, heat sensation, Assess RR, DTR,

Depressant/Tocol respiratory depression, hourly urinary output,
ysis depressed reflexes, cardiac serum Mg levels
arrest if high serum levels (>
10-12 mg/dl)

BETAMETHASONE Corticosteroid/ Increased risk of infection & Must be given 24 to

(CELESTONE) or stimulates fetal poor wound healing, 48 hours before
DEXAMETHASONE lung maturation hypoglycemia, increased risk delivery to be
by stimulating of pulmonary edema when effective; commonly
surfactant given with a ß-adrenergic used between 24 to
production agent 34 weeks AOG unless
fetal lung maturity
can be documented
PRECIPITATE LABOR
Definition:
 it is a labor that is completed in < 3 hours
 It occurs when uterine contractions are so strong
that the woman gives birth with only a few, rapidly
occurring contractions.
Causes:
grand multiparity,
induction of labor by OXYTOCIN or AMNIOTOMY
PRECIPITATE LABOR
Causes:
 grand multiparity,
 Large pelvis
 Small fetus
 induction of labor by OXYTOCIN or
 AMNIOTOMY
PRECIPITATE LABOR
Symptoms:
 rate of dilatation in the active phase:
 > 5 cm/hr (1 cm/12 mins) in a nullipara
 10 cm/hr (1 cm/6 mins) in a multipara;
 tocolytics may be administered
PRECIPITATE LABOR
Maternal Complications:
 premature separation of the placenta leading to
hemorrhage,
 infection
 lacerations on the birth canal
 Uterine rupture
 Amniotic fluid embolism
Fetal Complications
 Fetal hypoxia, anoxia
 Erb-Duchenne palsy
 Injuries like falling to the
floor in unattended
childbirth
 Subdural hemorrhage on the
fetus due to sudden release
of pressure on the head,
 hemorrhage
 PRECIPITATE LABOR
Management:
 TOCOLYTICS
 In multiparous women with history of a brief
past labor, advise to prepare for
appropriately timed transport starting
on her 28th week of gestation(BIRTH
PLAN)
 Never leave client
 Monitor FHT q15 min
 Provide emotional support: inform client of what is
happening
 Assist with the delivery, advising the client to pant
or blow and NOT to push
 Never hold the baby back
 Support the perineum with a towel to prevent
lacerations and also subdural
hemorrhage(MODIFIED RITGEN’S
MANEUVER)
 Deliver baby in-between contractions
 Inspect the perineum for possible lacerations
 INVERSION OF THE
UTERUS
Definition:
turning inside
out of the uterus
with either birth
of the fetus or
the delivery of
the placenta
 INVERSION OF THE
UTERUS
Predisposing Factors
 Pulling or traction on the umbilical cord to remove
the placenta
 Vigorous pressure is applied to the fundus while the
uterus is not contracted
 The placenta is attached at the fundus and the
passage of the fetus during birth pulls it down
 INVERSION OF THE UTERUS
Types of Inversion
 1. Complete or Total Inversion
 The uterus is visible outside the vaginal introitus
 Life threatening because of severe hemorrhage &
shock
 2. Partial Inversion
 The inverted fundus may lie within the uterine
cavity
 It is not visible but may be palpated
 It hampers or impedes contractions & control of
hemorrhage
 INVERSION OF THE UTERUS
Assessment
 Sudden gushing of blood from the vagina
 Signs of blood loss: hypotension, dizziness,
paleness or diaphoresis
 Because bleeding is continuous,
exsanguination could occur within 10
minutes
 INVERSION OF THE UTERUS
Management
 Never attempt to replace an inversion since handling of
the uterus will worsen the hemorrhage
 Never attempt to remove the placenta if it is still
attached
 Oxytocic drugs makes the uterus more tense thus, more
difficult to replace
 Start an IV line (use a large-gauge needle to be used in
BT) & open it to achieve optimal flow to restore fluid
volume
Management cont’d
 Administer O2 by mask
 Assess VS
 Prepare to administer CPR
 General anesthesia, nitroglycerin or a
tocolytic is administered to relax the
uterus
 Physician or midwife will then replace the
fundus manually
 After replacement, administer Oxytocin
 Antibiotic therapy to prevent infection
 CS is recommended for succeeding
pregnancies
PROBLEMS WITH
THE PASSENGER
PROLAPSE OF THE UMBILICAL CORD
Definition
 A loop of the umbilical cord slips down in
front of the presenting fetal part
 It may occur any time after the membranes
have ruptured if the presenting part is not
fitted firmly into the cervix
Cord Prolapse
Predisposing Factors
 Premature rupture of membranes
 Fetal presentation other than cephalic
 Placenta previa
 Intrauterine tumors preventing the presenting
part from engaging
 A small fetus
 CPD preventing firm engagement
 Hydramnios
 Multiple gestation
CORD COMPRESSION
 Cord Prolapse
Assessment
 The cord may be felt as the presenting part on an
initial vaginal examination during labor
 UTZ evidence ( a CS is necessary before rupture of
membranes)
 variable deceleration pattern becomes apparent
 The cord may be visible at the vulva
 To r/o prolapse, assess FHR immediately after
rupture of membranes
Management
 cord prolapse will lead to cord compression because
the presenting part will press against the cord at the
pelvic brim
 Place the mother’s hips higher than her head:
knee-chest position
 Trendelenberg position
Management
 Amnioinfusion-to  Nursing Consideration
reduce compression on  Monitor FHR and
the cord with infusion of uterine contractions
5ooml warmed NSS. continuously.
 Used for only a short  Monitor maternal temp
time until the cervix is every hour
fully dilated or a  Placed the bag of fluid
cesarean birth can be in a radian warmer to
arranged. prevent chilling
 Can also be performed
for women with
oligohydramnios
Management
1. Prevention:
 Always assess FHT after membranes rupture
 Place woman on bed rest after membranes rupture
2. Reduce pressure on the cord by:
 Place in Knee-chest or Trendelenburg position, or
place folded towel under the hips
 Put on sterile gloves and insert 2 fingers into the
vagina, then push presenting part upward
3. If cord is exposed to air, cover with saline-
moistened sterile compress to prevent drying.
 Drying of cord leads to atrophy & constriction of BV
Management
4. Never replace the cord back into the vagina
as it may result in kinking and knotting
obstructing blood flow
5. Administer O2 at 10 LPM to improve O2
supply to fetus
6. Deliver baby ASAP:
 Vaginal delivery if cervix is fully dilated & no fetal
distress
 CS if cervix is not fully dilated & if fetal distress is
present
Cesarean Section
Management
 Place a gloved hand in the vagina and manually
lift the fetal head off the cord
 Administer O2 at 10 LPM by face mask to the
mother to increase oxygenation to the fetus
 Tocolytic agent may be administered to reduce
uterine activity & pressure on the fetus
 Maintain continuous electronic fetal monitoring
 Prepare for rapid delivery vaginally or by CS
Emergency Management
 FETAL MALPOSITION
The ideal position is flexed with
the occiput in the R or L Anterior
quadrant (ROA/LOA)
Types of Malposition

1. OCCIPITOPOSTERIOR
POSITION
 It occurs in 1/10 of all labors and
during internal rotation the head must
rotate through 135 degrees instead of 90
degrees
 Failure to rotate is termed PERSISTENT
OCCIPUT POSTERIOR
 Common in women with android,
anthropoid or contracted pelves
OCCIPITOPOSTERIOR
Occipitoposterior Position
Symptoms:
 prolonged active phase,
 arrested descent,
 FHT heard best at the lateral sides of the abdomen,
 intense back pain during labor
ROP/LOP
 Maternal risks: prolonged labor,
potential for CS birth, 3rd or 4th degree
lacerations
 Fetal risks: umbilical cord prolapse,
increased molding, caput formation
2. OCCIPUT TRANSVERSE
POSITION
 Due to ineffective contractions or a
flattened bony pelvis
 Vaginal delivery is possible with oxytocin
administration and application of forceps
for delivery
Management:
 Encourage mother to lie on her opposite
side from the fetal back which may
help with rotation
 Other positions: Hands and knees
position, squatting, pelvic rocking
Management
 Apply sacral counter-pressure with the
heel of the hand or do back rubs to relieve
back pain
 Apply heat or cold, as desired by the
patient
Occipitotransverse
 Encourage voiding every 2 hours
 In prolonged labor, provide sports drink or IV
glucose to replenish glucose stores
 Provide constant encouragement and inform
the client & family of progress
 Prepare for a forceps delivery
 FETAL MALPRESENTATION
1. BREECH PRESENTATION
2. VERTEX MALPRESENTATIONS
a. FACE PRESENTATION
b. BROW PRESENTATION
c. SINCIPITAL PRESENTATION
(MILITARY ATTITUDE)
FETAL MALPRESENTATIONS
3. SHOULDER PRESENTATION
(TRANSVERSE LIE)
4. COMPOUND PRESENTATION
 1. BREECH PRESENTATION
 Most fetuses are in breech presentation early in
pregnancy but by week 38, turn into a cephalic
presentation

 Fetal head is the widest single diameter but the

buttocks plus the legs take up more space
3 types:
 Complete Breech
 Frank Breech
 Footling Breech- single or double
Types of Breech Presentation
Meconuim staining due to
pressure on the buttocks is NOT a
sign of fetal distress but can lead
to meconium aspiration
Risks
 Anoxia from a prolapsed cord
 Traumatic injury to the aftercoming head
(intracranial hemorrhage or anoxia); entrapment
 Fracture of the spine or the arm
 Dysfunctional labor
Risks:
 Early rupture of the membranes due to
poor fit of the presenting part
 CS or forceps delivery
 Trauma to the birth canal due to
manipulation and forceps
 Intrapartum or postpartum hemorrhage
Assessment
 FHT are heard high in the abdomen
 Diagnosed by Leopold’s maneuver
and UTZ
Management
 Monitor FHT & contractions continuously
 Piper forceps may be applied o the head to
prevent damaging the infant’s neck.
 Cesarean Section to lessen the risks
External Cephalic version
 The manipulation of the fetus through the
abdominal wall to a vertex presentation
 external fetal monitoring
 -IV fluids, Brethine is given via piggyback
 -version is discontinued if undue fetal or
maternal stress is noted
External Cephalic Version
Internal Podalic Version
 Indication:
 Retained Second twin in a transverse lie
 Shoulder Presentation
Internal Podalic Version
2. VERTEX MALPRESENTATIONS
a. FACE PRESENTATION

 A fetal head presenting at a different angle

than expected is termed ASYNCLITISM
(FACE and BROW)
Face Presentation
Assessment:
 A head that feels more prominent than
normal, with no engagement apparent on
Leopold’s maneuver suggests face
presentation
 Head and back are felt on the same side of
the uterus with LM
 Back is difficult to palpate because it is concave
 Mouth, nose or chin is felt by vaginal
examination as the presenting part
Diagnosis:
 UTZ,
 Leopold’s Maneuver
Risks:
 prolonged labor,
 Cesarean section,
 facial edema and bruising of the infant
Management:
 External fetal heart rate monitoring ONLY

 Vaginal delivery if the chin is ANTERIOR & the
pelvis is adequate

 CS is the chin is POSTERIOR or signs of fetal

distress are present
 b. BROW PRESENTATION
 Rarest type, occurs in multipara or woman with
relaxed abdominal muscles
 Often leads to obstructed labor because the head
becomes jammed in the brim of the pelvis
 CS is recommended
 Causes extreme ecchymotic bruising of the face
Brow Presentation
 b. SINCIPITAL PRESENTATION
(MILITARY ATTITUDE)
Labor progress is slowed with
slower descent of the fetal head
Sinciput & Chin Presentation
 3. SHOULDER PRESENTATION
(TRANSVERSE LIE)
 Occurs in women with pendulous abdomens,
uterine fibroid tumors, contraction of the pelvic
brim, congenital anomalies of the uterus,
hydramnios, fetus with hydrocephalus or
anything that prevents engagement, prematurity,
multiple gestation or short umbilical cord.
 Obvious on inspection because the uterus is more
horizontal
 Diagnosed by LM, confirmed by UTZ
 Mature fetus cannot be delivered vaginally; CS is
recommended
 Cord or arm may prolapse
 3. SHOULDER
PRESENTATION
 4. COMPOUND PRESENTATION
 More than 1 part of the fetus presents; most
commonly hand or arm prolapsing with the head
 Risk of cord compression and prolapse is
increased
 Method of delivery depends on size, presence of
distress and progress of labor
Compound presentation
 FETAL DISTRESS
 Insufficient O2 supply to meet the demands of
the fetus
Causes:
 UC compression
 Uteroplacental insufficiency due to anomalies or
maternal condition
Fetal Distress
Signs and Symptoms:
 Meconium-stained AF (excluding breech
presentations)
 Changes in FHR baseline : tachycardia (>160)-
early sign of distress
 Bradycardia (<110)- late sign of distress
 Decreased or absence of variability of the
heart rate
-HR varies <2 to 5 bpm causing a
flattened appearance of the heart rate
-indicates depression of the
autonomic nervous system that
controls HR
-fetal sleep, sedation or hypoxia may affect
variability
 Late deceleration pattern
-FHR slows following the peak of a contraction &
slowly returns to baseline rate during the resting
phase
-due to uteroplacental insufficiency
-ominous sign
 Severe variable deceleration pattern
-FHR repeatedly decelerates <90bpm for over 60
sec before returning to baseline
-due to interference of blood flow from cord
compression
-leads to fetal hypoxia and low APGAR scores
Nursing Care
 Assess FHR baseline, variability & pattern of changes
 Asses UC & maternal responses to labor
 Correct fetal hypoxia
 For LD: reposition on her left side
 Administer O2 at 8-10 LPM
 Increase IVF
 Discontinue oxytocin if labor is induced
 Notify physician
 For VD or prolonged bradycardia:
reposition on either side
 If not corrected, reposition to opposite side
 Administer O2 by face mask at 8-10 LPM
 Trendelenberg or knee-chest position
 Perform vaginal examination & apply upward
pressure on the presenting part to relieve
pressure on the UC
 Provide appropriate information and support
PROBLEMS WITH THE
PASSAGEWAY
ABNORMAL SIZE AND SHAPE
OF THE PELVIS
INLET CONTRACTION

 It is the narrowing of the anteroposterior

diameter of the pelvis to < 11 cm, or the
transverse diameter to 12 cm or less
 Usually caused by rickets in early life or
inherited pelvic size
 “what goes in comes out”- a head that
engages proves it fits into the pelvic brim &
will probably be able to fit through the
midpelvis and outlet
 It makes engagement difficult (in primis, at
36-38 wks; in multis, during labor)
 It influences fetal position and
presentation
 Primigravidas must have pelvic
measurements done before 24 weeks
OUTLET CONTRACTION
 Narrowing of the transverse diameter of
the outlet to < 11 cm (distance between the
ischial tuberosities)
*TRIAL LABOR
 Done when the inlet has a borderline
measurement (just adequate) and the fetal lie &
position is good
 It is allowed to continue as long as descent and
dilatations continue to occur.
 Urge her to void every 2 hours
Trial Labor
 After rupture of membranes, assess FHR;
if head is still high, increased risk for UC
prolapse
 If after a definite period (6-12 hours)
adequate progress is not apparent, CS is
done
 CEPHALOPELVIC
DISPROPORTION (CPD)
 Fetal head is too large to pass through the
bony pelvis
 Symptom: fetal head does not descend
even if there are strong contractions
 CPD
 Risks: prolonged labor, exhaustion,
hemorrhage, infection, fetal hypoxia and
distress
 CS is necessary
SHOULDER DYSTOCIA

 Problem occurs at the 2nd stage of labor,

when the fetal head is born but the
shoulders are to broad to enter and be born
through the pelvic outlet
 Usually due to:
 fetal macrosomia,
 maternal diabetes,
 multipara and
 postdate pregnancies
SHOULDER DYSTOCIA
 Symptoms:
 prolonged 2nd stage of labor
 arrest of descent,
 when the head appears on the perineum it
retracts instead of protruding with each
contraction (TURTLE SIGN)
 Maternal risks:
 lacerations,
 postpartum hemorrhage
 Fetal Risks:
 hypoxia,
 fractures to the clavicle,
 injury to neck and head
Management:
 McROBERT’S MANEUVER- ask pt to
flex her thighs sharply on her abdomen to widen
the pelvic outlet and allow the anterior shoulder
to be born
 Suprapubic pressure may be applied to help the
shoulder escape from beneath the symphysis
pubis and be born
 ANOMALIES OF THE
PLACENTA

Normal placenta:
 weighs 500 g
 15 to 20 cm in diameter,
 1.5 to 3 cm thick,
 weight is about 1/6 of the weight of the
fetus
1. PLACENTA SUCCENTURIATA
 It has 1 or more accessory lobes connected
to the main placenta
 The small lobes may be retained in the uterus
leading to hemorrhage and therefore must be
removed
 The placenta appears torn at the edge
PLACENTA SUCCENTURIATA
2. PLACENTA CIRCUMVALLATA

 The fetal side of the placenta is covered to

some extent by the chorion
 The placenta is cup-shaped with raised
margins with the whitish opaque chorion
covering the periphery
PLACENTA CIRCUMVALLATA
 3. BATTLEDORE PLACENTA

 The cord is inserted marginally

rather than centrally giving the
appearance of a tennis racket
BATTLEDORE PLACENTA
 4. VELAMANTOUS INSERTION OF
THE CORD

 The cord, instead of entering the placenta

directly, separates into small vessels that
reach the placenta by spreading cross a
fold of amnion
 Usually found with multiple gestation & is
associated with anomalies
Velamentous insertion of the cord
 5. VASA PREVIA

The umbilical vessels of a

velamentous cord insertion cross
the cervical os & deliver before the
fetus
VASA PREVIA
 6. PLACENTA ACCRETA
 It is the unusually deep attachment of the
placenta to the uterine myometrium
 Attempts to remove it will lead to massive
hemorrhage because of the deep attachment
 Hysterectomy or treatment with methotrexate to
destroy the still-attached tissue may be necessary
PLACENTA ACCRETA
PROBLEMS WITH THE
PSYCHE
Factors influencing the psyche of the
client in labor
 Fear & anxiety
 Perception of the problem
 Self-image
 Preparation for childbirth
 Support systems
 Coping ability
The Effects of fear and anxiety on labor
progress:
 Epinephrine secretion in response to stess
 Vascular changes divert blood from the
uterus to skeletal muscles
 Decrease in O2 & glucose supply to support
effective contractions
 Labor progress is slowed
Nursing assessment
 Determine past experiences with
preparations for, and expectations of labor
and birth
 Determine the client’s coping behaviors
and their effectiveness
Management
 Establish a trusting relationship with the client &
family
 Remain at bedside during labor
 Encourage relaxation
 Keep client & family informed about
progress and procedures
 Encourage positive coping behaviors and
discourage negative behaviors
 Promote self-image by praising efforts
.........the END!!!........