High Risk Conditions During Labor and Delivery

Fetal Malposition

Definition

Malpositions are abnormal positions of the vertex of the fetal head (with the
occiput as the reference point) relative to the maternal pelvis.

Cause

 Excess amniotic fluid

 Abnormal shape and size of the pelvis
 Uterine tumour
 Placenta praevia
 Slackness of uterine (after previous pregnancies)
 Multiple pregnancy

Sign and Symptoms

 Vaginal bleeding
 Unsatisfactory progress of labour
 Abdominal pain
 Premature rupture of membranes

Diagnosis

 Listen to the fetal heart rate immediately after a contraction: count the fetal
heart rate for a full minute at least once every 30 minutes during the active
phase and every 5 minutes during the second stage; if there are fetal heart
rate abnormalities) less than 100 or more than 180 beats per minute), suspect
fetal distress.

Medical / Surgical Management

 Oxytocin administration
 If the are signs of obstruction or the fetal heart rate is abnormal at any stage,
deliver by caesarean section.
  The fetal head is between 1/5 and 3/5 above the symphysis pubis or the
leading bony edge of the head is between 0 station and -2 station. Deliver by
vacuum extraction and symphysiotomy.
 Craniotomy
 Episiotomy

Nursing Management

 If the cervix is fully dilated but there is no descent in the expulsive phase,
assess for signs of obstruction

Prognosis

Fetal malposition is associated with increased morbidity of both mother and

infant if not treated accurately.
Fetal Distress

Definition

Fetal distress is an emergency pregnancy, labor and delivery complication in

which a baby experiences oxygen deprivation (birth asphysia).

Cause

 Abnormal fetal presentation

 Forceps and vacuum extractor misuse
 Placental abruption
 Preeclampsia
 Prolonged and arrested labor
 Umbilical cord problems
 Uterine rupture

Sign and Symptoms

 Decreased movement felt by the mother

 Meconium staining
 Tachycardia and bradycardia
 Abnormal fetal heart rate
 Fetal hyperactivity
 Fetal metabolic acidosis
 Vaginal bleeding

Diagnosis

 Clinical examination in each antenatal visit is the primary and main

assessment of fetal well-being. This includes detection of fetal heart sound,
fetal size, fundal level and amount of amniotic fluid.
 Fetal scalp blood sampling

Medical / Surgical Management

 Tocolytics
  Cesarian delivery

Nursing Management

 Administer oxygen at 8-10 / min via face mask

 Discontinue oxytocin
 Place patient in a lateral position, elevate legs
 Monitor maternal and fetal status
 Intrauterine resuscitation
 Amniotic infusion

Prognosis

Determination of the prognosis in fetal distress has always been difficult for
the obstetrician. Compounding the problem is the variation in opinion as to what
clinical findings actually comprise fetal distress. Fetal bradycardia with a persistent
fetal heart rate of less than 100 per minute has been widely accepted as the cardinal
sign of fetal difficulty in utero. Many authors have considered meconium staining of
the amniotic fluid in vertex presentation in association with slowing of the fetal heart
as suggestive of fetal distress, Others have shown willingness to regard meconium
staining alone in a vertex presentation as a sign of impending fetal difficulty.
Umbilical Cord Prolapse

Definition

It is a complication that occurs prior to or during delivery of the baby. In a

prolapse, the umbilical cord drops (prolapses) through the open cervix into the
vagina ahead of the baby. The cord can them become trapped against the baby’s
body during delivery.

Cause

 Premature rupture of the membranes

 Premature delivery of the baby
 Delivery more than one baby per pregnancy (twins, triplets, etc.)
 Excessive amniotic fluid
 Breech delivery
 An umbilical cord that is longer than usual

Signs and Symptoms

 Umbilical cord seen or felt during vaginal examination

 Fetal bradycardia
 Client reports feeling the cord within the vagina

Diagnosis

 Fetal heart monitoring

 A pelvic examination
 Palpate (feel) the cord with his or her fingers

Medical / Surgical Management

 Consider tocolysis (e.g Terbutaline)

 Amnioinfusin
 Delivery is usually via emergency caesarean section
Nursing Management

 Avoid handling the cord

 Manually elevate the presenting part
 Knee chest position

Prognosis

The fetal prognosis was bad; neonatal mortality was 41.3% at 5 minutes of life
against 9.8% in the control group. The factors aggravating the fetal prognosis were
the long delay between the occurrence of the umbilical cord prolapse and childbirth,
the delivery mode and the small birth.
Cephalopelvic Disproportion

Definition

It occurs when a baby’s head or body is too large to fit through the mother’s
pelvis. It is believed that rue cpd is rare, but many cases of “failure to progress”
during labor are given a diagnosis of cpd. When an accurate diagnosis of cpd has
been made, the safest type of delivery for mother and baby is a cesarean.

Cause

 Large baby due to herediatary factors

 Diabetes
 Postmaturity
 Multiparity
 Abnormal fetal positions
 Small pelvis
 Abnormal shape pelvis

Signs and Symptoms

 Prolonged labor
 Fetal distress
 A lot of amniotic fluid
 Large fundal height (distance between pubic bone and the top of the uterus)

Diagnosis

 Ultrasound is used in estimating fetal size but not totally reliable for
determining fetal weight.
 Physical examination that measures pelvic size can often be most accurate
method for diagnosing cpd.
 Mri to visualize the baby’s head and your pelvis

Medical / Surgical Management

  Symphysiotomy (the surgical division of public cartilage)
 Caesarean section

Nursing Management

 During the trial of labor, you can help to open your pelvis and move the labor
along by changing positions with the help of your nurse, doula, or partner.
 You can try: sitting, squatting, changing sides or going on your hands and
knees. If labour continues, forceps or a vacuum may be needed to help
deliver the baby.

Prognosis

Cpd is uncommon and complications are even rarer. But when a baby is too
big to get through the mom’s pelvis or labor is very long and obstructed, it can lead
to delivery problems and birth injuries. Some of the complications of cephalopelvic
disproportion are (prom) premature rupture of membranes

Premature Labor

Definition

It occurs when regular contractions result in the opening of your cervix after
week 20 and before week 37 of pregnancy.

Cause

 Previous preterm labor or premature birth, particularly in the most recent

pregnancy or in more than one previous pregnancy
 Pregnancy with twins, triplets or other multiples
 Shortened cervix
 Problems with the uterus or placenta
 Smoking cigarettes or using illicit drugs
 Certain infections, particularly of the amniotic fluid and lower genital tract
 Some chronic conditions, such as high blood pressure, diabetes, autoimmune
disease and depression
 Stressful life events, such as the death of a loved one
  Too much amniotic fluid (polyhydramnios)
 Vaginal bleeding during pregnancy
 Presence of a fetal birth defect
 An interval of less than 12 months – or of more than 59 months- between
pregnancies
 Age of mother, both young and older
 Black, non-hispanic race ethnicity

Signs and Symptoms

 Regular of frequent sensations of abdominal tightening (contractions)

 Constant low, dull backache
 A sensation of pelvic or lower abdominal pressure
 Mild abdominal cramps
 Vaginal spotting or light bleeding
 Preterm rupture or membranes – in a gush or a continuous trickle or fluid after
the membrane around the baby breaks or tears
 A change in type of vaginal discharge – watery, mucus-like or bloody
 Flu-like symptoms

Diagnosis

 Pelvic examination to see if your cervix has started to change.

 A trans-vaginal ultrasound exam may be done to measure the length of your
cervix
 Uterine monitoring

Medical / Surgical Management

 Corticosteroids. Corticosteroids can help promote your baby’s lung maturity.

 Magnesium sulfate. Your doctor might offer magnesium sulfate if you have a
high risk of delivering between 24 and 32 of pregnancy
 Tocolytics. Your health care provider might give you a medication called a
tocolytic to temporarily slow your contractions.
 Cervical cerclage.

Nursing Management
  Educate patient and caregivers regarding warning signs and symptoms,
healthy diet and lifestyle to help prevent repeat preterm labor.
 Encourage patient to properly manage chronic conditions to prevent further
labor symptoms.

Prognosis

Some women with premature labor and early dilation of the cervix are put on
bed rest until the pregnancy progresses. Most babies born prior to 24 weeks have
little change of survival. Only about 50% will survive and the other 50% may die or
have permanent problems.

Precipitate Labor and Birth

Definition

Precipitous labor, also called rapid labor, is defined as giving birth after less
than 3 hours or regular contractions. I sometimes it’s also called precipitous labor if
labor lasts anywhere under 5 hours. Although it might seem like a good thing, rapid
labor can also carry risks and drawbacks.

Cause

 History of precipitate labor

 A baby who is smaller than the average size
 A very smooth birth canal
 When prostaglandin is used to induced labor
 If you have conceived using fertility treatments

Sign and Symptoms

 The sudden pattern of strong contractions that are very close to one another
and don’t let you rest or recover between each one
 Pain that feels like one long contraction
 A sudden feeling or having to push down like a bowel movement; this can
also feel like strong pressure in the pelvis

Diagnosis
  Review medical history and risk factors for preterm labor and evaluate your
signs and symptoms.

Medical / Surgical Management

 Tocolytics. Your health care provider might give you a medication called a
tocolytic to temporarily slow your contractions.

Nursing Management

 Lie down either on your back or side

 Remain in a clean space
 Take deep breaths and think about calming things

Prognosis

Although very fast labor might initially sound appealing, there are some
difficulties with it, as well as some potential problems. Physically, precipitous labor
can cause: increased risk of vaginal and / or cervical tearing or laceration

Uterine Rupture

Definition

Is a rare, but serious childbirth complications that can occur during vaginal
birth. It causes a mother’s uterus to tear so her baby slips into her abdomen. This
can cause severe bleeding in the mother and can suffocate the baby.

Cause

 During labor, pressure builds as the baby moves through the mother’s birth
canal. This pressure can cause the mother’s uterus to tear.
 Often, it tears along the site of a previous cesarean delivery scar. When a
uterine rupture occurs, the uterus’s contents – including the baby- may spill
into the mother’s abdomen.

Sign and Symptoms

 Excessive vaginal bleeding

 Sudden pain between contractions
  Contractions that become slower or less intense
 Abnormal abdominal pain or soreness
 Recession or the baby’s head into the birth canal
 Bulging under the pubic bone
 Sudden pain at the site of a previous uterine scar
 Loss of uterine muscle tone
 Rapid heart rate, low blood pressure and shock in the mother
 Abnormal heart rate in the baby
 Failure of labor to progress naturally

Diagnosis

 Abdominal pain
 Vaginal bleeding
 Nonreassuring fetal heart pattern
 Signs of hypovolemic shocks (with complete uterine rupture)
 Palpation of fetal parts under the skin

Medical / Surgical Management

 Blood transfusion
 Oxygen therapy for the baby at birth
 Hysterectomy
 Laparotomy with cesarean delivery

Nursing Management

 Monitor for possibly of uterine rupture

 Assist with rapid intervention
 Prevent and manage complication’s
 Provide physical and emotional support

Prognosis

Doctors will improve the baby’s chances of survival by administering critical

care, such as oxygen 6.2% of uterine ruptures are associated with perinatal death.
14-33% of women with uterine rupture require an emergency hysterectomy. In a
systematic review of vbac the maternal mortality rate recited to spontaneous uterine
rupture was 0%. Similarly, in a dutch nationwide study there were no pregnancy-
related deaths due to uterine rupture.

Uterine Prolapse

Definition

It occurs when pelvic floor muscles and ligaments stretch and weaken and no
longer provide enough support for the uterus. As a result, the uterus slips down into
or protrudes out of the vagina. Uterine prolapse can occur in women of any age. But
it often affects postmenopausal women who`ve had one or more vaginal deliveries.

Cause

 Pregnancies
 Difficult labor and delivery or trauma during childbirth
 Delivery of a large baby
 Being overweight or obese
 Lower estrogen level after menopause
 Chronic constipation or straining with bowel movements
 Chronic cough or bronchitis
 Repeated heavy lifting

Sign and Symptoms

 Sensation of heaviness or pulling in your pelvis

 Tissue protruding from your vagina
 Urinary problems, such as urine leakage (incontinence) or urine retention
 Trouble having a bowel movement
 Feeling as if you`re sitting on a small ball or as if something is falling out of
your vagina
 Sexual concerns, such as sensation of looseness in the tone of your vaginal
tissue

Diagnosis
  Pelvic examination. During the pelvic exam your doctor is likely to ask you: to
bear down as if having a bowel movement
 Bearing down can help your doctor assess how far the uterus has slipped into
the vagina. To tighten your pelvic muscles as if you`re stopping a stream of
urine. This test checks the strength of your pelvic muscles.

Medical / Surgical Management

 Analgesics for pain

 Blood transfusion
 Oxygen therapy
 Repair uterine prolapse
 Hysterectomy

Nursing Management

 Treat and prevent constipation

 Avoid heavy lifting and lift correctly
 Control coughing
 Avoid weight gain
 Self-care measures. If your uterine prolapse causes few or no symptoms,
simple self-care measures may provide relief or help prevent worsening
prolapse. Self-care measures include performing kegel exercises to
strengthen your pelvic muscles, losing weight and treating constipation.
 Pessary. A vaginal pessary is a plastic or rubber ring inserted into your vagina
to support the bulging tissues. A pessary must be removed regularly for
cleaning.

Prognosis

Minor prolapse of the uterus or bladder can be corrected with strengthening

exercises of the pelvic floor muscles. Once prolapse has progressed to a more
advanced stage, it will continue and worsen without surgical treatment or pessary
support.