Nursing Care of the client with high- against the sacrum by a lie attitu descri

risk labor & delivery & her family sacrum, a back rub. de ption
woman types
1. Problems of the Passenger may Footli longitu poor Neithe
A. Fetal Malposition -Abnormal experience ng dinal r the
pressure and thighs
positions of the vertex of the fetal
pain in her nor
head (with the occiput as the
lower back lower
reference point) relative to the because legs
maternal pelvis. of sacral nerve are
-Vertex malpresentation compression. flexed.
If one
foot
presen
t, it is a
single
i. Occipitoposterior Position footlin
-The fetal position is posterior rather Nursing Considerations g
than anterior. ➢ Advice to void every 2 hours to breech
-Tend to occur in women with keep her bladder empty ; if
android, anthropoid, or contracted • Full bladder could further impede both
pelvises. descent of the fetus. presen
-In these positions, during internal ➢ Determine last meal t, it is a
double
rotation, the fetal head must rotate • May require oral sports drink or IV
footlin
not through a 90-degree arc but glucose solution to replace glucose
g
through an arc of approximately 135 stores she is using to keep active in
breech
degrees. labor. .
-A posteriorly presenting head does B. Fetal Malpresentation frank longitu mode Attitud
not fit the cervix as snugly as one in - occurs when the part of the fetus dinal rate e is
an anterior position which is closest to pelvic inlet is not moder
the vertex of the fetal heart. ate
becaus
e the
hips
are
flexed,
but
the
i. Breech Presentation knees
-Most fetuses are in a breech are
presentation early in pregnancy. By extend
ed to
week 38, however, in approximately
rest on
97% of all pregnancies, a fetus turns
the
to a cephalic presentation. chest.
Complications and Management -Either the buttocks or the feet are The
Complications Management the first body parts that will contact buttoc
Increase the Confirm the cervix. ks
risk of umbilical position by Types: alone
cord prolapse vaginal
presen
examination or
t to
ultrasound.
the
Because the Applying cervix.
fetal head counterpressure
rotates on the
 comp longitu good The ✓ Fetal heart sounds heard high in ✓ Polyhydramnios
lete dinal (full fetus the abdomen. ✓ Fetal malformation
flexio has ✓ Leopold maneuvers and a vaginal Birth Technique
n) the
examination. ✓ If the chin is anterior and the
thighs
tightly ✓ Ultrasound pelvic diameters are
flexed ✓ FHR monitoring and uterine within normal limits, it may be
on the contractions : Early detection of fetal possible for the infant
abdom distress from a complication such as to be born without difficulty
en; prolapsed cord or arrest of descent. ✓ If the chin is posterior: CS
both Birth Technique
the Vaginally: The mother is allowed to
buttok push after full dilatation is achieved,
s and and the breech, trunk, and shoulders
th
are born. Nursing Considerations
tightly
flexed ✓ Assess for facial edema and
feet ecchymotic bruising
presen ✓ Observe the infant closely for a
t to Complications patent airway.
the ✓ Cord compression ✓ Gavage feedings may be necessary
cervix.
✓ Intracranial hemorrhage to allow them to obtain enough fluid
Nursing Considerations until they can suck effectively.
Factors
✓ Advice the following findings as
✓ Gestational age less than 40
normal:
weeks
• Frank breech position tends to
✓ Abnormalities such as
keep his or her legs extended and at
anencephaly, hydrocephalus, or
the level of the face for the first 2 or
meningocele
3 days of life.
✓ Polyhydramnios ✓ They may be transferred to a
• Footling breech may tend to keep
✓ Congenital anomaly of the uterus, the legs extended
neonatal intensive care unit
such as a mid septum, that traps the (NICU) for 24 hours.
in a footling position for the first few
fetus in a ✓ Reassure the parents that the
days.
breech position edema is transient and will
ii. Face Presentation
✓ Any space-occupying mass in the -An abnormal form of cephalic
disappear in a few days with no
pelvis (fibroid tumor of uterus or a p. aftermath.
presentation where the
previa) iii. Brow Presentation
presenting part is mentum.
✓ Pendulous abdomen (the uterus -A cephalic presentation in which the
may fall so far forward that the fetal head is midway between
head comes to lie outside the pelvic flexion and extension.
brim, causing a breech presentation) -Rarest of the presentations.
Factors
✓ Multiple gestation (the presenting
infant cannot turn to a vertex Assessment ✓ Occurs in a multipara or a woman
position) ✓ Vaginal examination: Nose, with relaxed abdominal
mouth, or chin can be felt muscles.
as the presenting part.
✓ UTZ
Factors
✓ Contracted pelvis
✓ Placenta previa Management
Assessment ✓ Relaxed uterus of a multipara ✓ Unless the presentation
spontaneously corrects, cesarean
✓ Prematurity
birth will be necessary to birth the
infant safely.
iv. Transverse Lie
-A fetal presentation in which the
fetal longitudinal axis lies
perpendicular to the long axis of the
uterus.
Factors
✓ Pendulous abdomens
✓ Uterine fibroid tumors
✓ Congenital abnormalities of the
uterus
✓ Polyhydramnios
✓ It may occur in infants with
hydrocephalus or another
abnormality that
prevents the head from engaging
✓ Prematurity
✓ Multiple gestations
✓ Short umbilical cord
Assessment
✓ Obvious on inspection: Ovoid of
the uterus is found to
be more horizontal than vertical.
✓ Can be confirmed by Leopold
maneuvers.
✓ An ultrasound may be taken to
further confirm the
abnormal lie and to provide
information on pelvic size.
v. Shoulder Presentation
-The presenting part is usually one of
the shoulders
(acromion process), an iliac crest, a
hand, or an elbow.
-Associated with a transverse lie
Assessment
✓ Contour of the mother’s abdomen
at term may appear
fuller side to side rather than top to
bottom.
Factors
✓ Pelvic contractions
✓ Placenta previa
✓ Relaxed abdominal walls from
grand multiparity
Birth Technique
✓ Cesarean birth
Differentiate:
✓ fetal MALPOSITION- fetal position
is posterior rather than anterior;
suggested by dysfunctional labor
pattern.
✓ fetal MALPRESENTATION-
describes any non-vrtex presentation
C. Prolapse of the Umbilical Cord
-A loop of the umbilical cord slips
down in front of the presenting fetal
part.
-An emergency situation: leads to
cord compression and decreased
oxygenation to the fetus.
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
✓ Polyhydramnios
✓ Multiple gestation
Assessment
✓ Vaginal exam: cord may be felt as
the presenting part
✓ Transvaginal UTZ
✓ FHR: unusually slow or a variable
deceleration
Therapeutic Management
***Goal: Relieve pressure on the
cord.
✓ Knee-chest position or
Trendelenburg position
✓ Administering oxygen at 10 L/min
by face mask
✓ Tocolytic agent : Reduce uterine
activity and pressure on the fetus.
✓ Amnioinfusion
✓ Do not attempt to push any
exposed cord back into the vagina
because this could add to the
compression by causing knotting or
kinking. Instead, cover any exposed
portion with a sterile saline
compress to prevent drying.
✓ FBS: supplies information as to
whether a fetus is becoming
acidotic.
2. Problems of the Passageway
-Contraction or narrowing of the
passageway or birth canal. The
narrowing causes CPD, or a
disproportion between the size of
the fetal head and the pelvic
diameters, which then results in
failure to progress in labor.
-May occur at the inlet, at the
midpelvis, or at the outlet.
-Assessed via sonogram
A.Abnormal size or shape of
the pelvis
Four different pelvic shapes

a. Gynecoid: This is the most
common type of pelvis in
females and is generally
considered to be the typical
female pelvis. Its overall shape
is round, shallow, and open.
The gynecoid pelvis is thought to be
the most favorable pelvis type for a
vaginal birth. This is because the
wide, open shape give the baby
plenty of room during delivery.
b. Android: This type of pelvis
bears more resemblance to
the male pelvis. It’s narrower
than the gynecoid pelvis and is
shaped more like a heart or a
wedge.
The narrower shape of the android
pelvis can make labor difficult
because the baby might move more
slowly through the birth canal. Some
pregnant women with an android
pelvis may require a Csection.
c. Anthropoid: An anthropoid pelvis
is narrow and deep. Its shape is
similar to an upright egg or oval.
The elongated shape of the
anthropoid pelvis makes it roomier
from front to back than the android
pelvis. But it’s still narrower than the
gynecoid pelvis. Some pregnant
women with this pelvis type may be
able to have a vaginal birth, but their
labor might last longer.
d. Platypelloid: The platypelloid
pelvis is also called a flat pelvis. This
is the least common type. It’s wide
but shallow, and it resembles
an egg or oval lying on its side.
The shape of the platypelloid pelvis
can make a vaginal birth difficult
because the baby may have
trouble passing through the pelvic
inlet. Many pregnant women with a
platypelloid pelvis need to have a C-
section.
i. Inlet contraction
- Narrowing of the anteroposterior
diameter of the pelvis to less than 11
cm, or of the transverse diameter to
13 cm or less.
- Caused by rickets in early life or by
an inherited small pelvis.
ii. Outlet contraction
- Narrowing of the transverse
diameter, the distance between the
ischial tuberosities at the outlet, to
less than 11 cm.
iii. Shoulder Dystocia
-Occurs at the second stage of labor,
when the fetal head
is born but the shoulders are too
broad to enter and be
born through the pelvic outlet.
Complications
✓ Can result in vaginal or cervical
tears.
✓ Cord compression
✓ Can result in a fractured clavicle or
a brachial plexus injury for the fetus
(most common)
✓ Separation of your pubic bones.
Factors
✓ Diabetes
✓ Multiparas
✓ Postdate pregnancies
Clinical sign
✓ Turtle sign- Fetal head retraction
manifested by head bobbing,
emerging and then pulling back
(conceptualised as similar to a turtle
pulling its head into and out of its
shell).
Series of maneuvers that help
resolve a shoulder dystocia
✓ McRoberts maneuver: Asking or
assisting a woman to flex her thighs
sharply on her abdomen widens the
pelvic outlet and may allow the
anterior shoulder to be born.
✓ Applying suprapubic pressure may
also help the shoulder escape from
beneath the symphysis pubis and
be born.
iv. Cephalopelvic Disproportion
(CPD)
-Occurs when there is mismatch
between the size of the fetal head
and size of the maternal pelvis,
resulting in "failure to progress" in
labor for mechanical reasons.
Suggested by:
✓ Lack of engagement at the
beginning of labor
✓ Prolonged first stage of labor
✓ Poor fetal descent
Factors:
✓ Gestational diabetes
✓ Post-term pregnancy
✓ Small pelvic outlet
✓ Congenital dislocation of the hips
✓ Occipital posterior disproportion
**More than 65% of women who
had been diagnosed with CPD
in earlier pregnancies were able to
deliver vaginally in
subsequent pregnancies (American
Journal of Public Health).
3.Problems with the Powers
A.Dysfunctional Labor (Dystocia)
- Refers to difficult labor which is
usually due to uterine dysfunction,
fetal malpresentation/abnormality,
or pelvic abnormality.
Factors:
✓ Maternal fatigue
✓ Advanced maternal age
✓ Dehydration
✓ Obesity
✓ Fear or anxiety
✓ Overdistention of uterus
✓ Lack of analgesic
✓ Cephalopelvic disproportion (CPD)
assistance
✓ Overstimulation of the uterus
B.Premature labor
-Labor that occurs before the end of
week 37 of gestation.
-It occurs in approximately 9% to
11% of all pregnancies and is
responsible for almost two thirds of
all infant deaths in the neonatal
period
-A woman is documented as being in
actual labor rather than having false
labor contractions if contractions
have caused cervical effacement
over 80% or dilation over 1 cm.
Factors
✓ Dehydration
✓ Urinary tract infection
✓ Periodontal disease
✓ Chorioamnionitis
✓ Adolescents
✓ Inadequate prenatal care
✓ Strenuous jobs during
Pregnancy
Assessment
✓ Ultrasound exam: analyzing
changes in the length of the
cervix
✓ Analysis of vaginal mucus for the
presence of fetal fibronectin,
a protein produced by trophoblast
cells . If this is present in
vaginal mucus, it predicts that
preterm contractions are ready
to occur; absence of the protein
predicts that labor will not
occur for at least 14 days.
Therapeutic Management
- Medical attempts can be made to
stop labor if :
✓ the fetal membranes have not
ruptured
✓ fetal distress is absent
✓ there is no evidence that bleeding
is occurrin
✓ the cervix is not dilated more than
4 to 5 cm
✓ effacement is not more than 50%.
✓ Admission and bed rest to relieve
the pressure of the fetus on the
cervix.
✓ External fetal and uterine
contraction monitors are attached to
monitor FHR and the intensity of
contractions.
✓ Intravenous fluid therapy
✓ Vaginal and cervical cultures and a
clean-catch urine sample are
prescribed to rule out infection.
Pharmacologic Intervention
✓ Terbutaline: may be used as a
tocolytic agent
***Should not be used for over 48
to 72 hours of therapy because of a
potential for serious maternal heart
problems and death.
***Should not be used in an
outpatient or home setting: requires
constant assessment.
✓ Magnesium sulfate, given IV, is
used primarily to treat preeclampsia
and prevent eclamptic seizures.
***It was traditionally given to
prevent preterm labor as well.
✓ Corticosteroid such as
betamethasone the formation of
lung
surfactant: Reduce the possibility of
respiratory distress syndrome or
bronchopulmonary dysplasia.
C.Precipitate labor and birth
-Predicted from a labor graph if,
during the active phase of dilatation,
the rate is greater than 5 cm/hr (1
cm every 12 minutes) in a nullipara
or 10 cm/hr (1 cm every 6 minutes)
in a multipara.
Terminologies
Precipitate dilatation
-Cervical dilatation that occurs at a
rate of 5 cm or more per hour in a
primipara or 10 cm or more per hour
in a multipara.
Precipitate birth
-Uterine contractions are so strong a
woman gives birth with only a few,
rapidly occurring contractions, often
defined as a labor that is completed
in fewer than 3 hours.
Factors
✓ Grand multiparity
✓ After induction of labor by
oxytocin
Complications
✓ Contractions can be so forceful
they lead to premature
separation of the placenta or
lacerations of the perineum
✓ Risk for hemorrhage
Nursing Consideration
✓ Caution a multiparous woman by
week 28 of pregnancy that
because a past labor was so brief,
her labor this time also may be brief
so that she has time to plan for
adequate transportation to the
hospital or alternative birthing
center.
D.Uterine prolapse
-The uterus has descended into the
vagina due to overstretching of
uterine supports and trauma to the
levator ani muscle.
-Pelvic floor muscles and ligaments
stretch and weaken until they no
longer provide enough support for
the uterus.
Assessment Finding
✓ Vaginal pressure and low back
pain
****described as like you're sitting
on a small ball — and the sensation
that something has fallen out of your
vagina.
Factors
✓ Insufficient prenatal care
✓ Birth of a large infant
✓ Prolonged second stage of labor
✓ Bearingdown efforts or extraction
of a baby before full dilatation
✓ Instrument birth
✓ Poor healing of perineal tissue
postpartally
Management
✓ Surgery to repair uterine supports
or placement of a pessary, a plastic
uterine support.
***Women with pessaries in place
need to return for a pelvic
examination every 3 months to have
the pessary removed, cleaned,
and replaced and the vagina
inspected; otherwise, vaginal
infection or erosion of the vaginal
walls can result. Surgical
replacement is also possible.
Pessary
The device fits into the vagina and
provides support to vaginal tissues
displaced by pelvic organ prolapse.
E.Uterine rupture
-Rupture of the uterus during labor,
although rare, is always a possibility.
-It occurs most often in women who
have a previous cesarean scar.
Types
i.Complete
-Going through the endometrium,
myometrium, and peritoneum layers
-Uterine contractions will
immediately stop
ii.Incomplete
-Leaving the peritoneum intact
Factors
✓ Prolonged labor
✓ Abnormal presentation
✓ Multiple gestation
✓ Unwise use of oxytocin
✓ Obstructed labor
✓ Traumatic maneuvers of forceps
or traction
Assessment
✓ Confirmed by UTZ
✓ Complete uterine rupture
*Sudden, severe pain during a strong
labor contraction, which she may
report as a “tearing” sensation.
*Abdominal assessment: swelling
from the retracted uterus and the
extrauterine fetus.
*Hemorrhage from the torn uterine
arteries floods into the abdominal
cavity and possibly into the vagina.
*Signs of hypotensive shock begin,
including a rapid, weak pulse; falling
blood pressure; cold and clammy
skin; and dilation of the nostrils from
air starvation.
✓ Incomplete uterine rupture
• If the rupture is incomplete, the
signs of rupture are less evident
• Localized tenderness and a
persistent aching pain over the area
of the lower uterine segment.
Complication
✓ When uterine rupture occurs, fetal
death will follow unless immediate
cesarean birth can be accomplished.
✓ The viability of the fetus depends
on the extent of the rupture and
the time elapsed between rupture
and abdominal extraction.
✓ A woman’s prognosis depends on
the extent of the rupture and the
blood loss.
Management
✓ Administer emergency fluid
replacement therapy as
prescribed.
✓ Anticipate the use of IV oxytocin
to attempt to contract the
uterus and minimize bleeding.
✓ Prepare the woman for a possible
laparotomy as an emergency
measure to control bleeding and
birth the fetus.
✓ Options such as cesarean
hysterectomy or tubal ligation, both
of which will result in loss of
childbearing ability will be
considered.
✓ Utilize clergy or counselors as
needed to help the couple
begin the coping process. They are
not only grieving for the
loss of a child but also the cost of
unexpected surgery and
perhaps loss of fertility.
✓ Most women are advised not to
conceive again after a rupture of the
uterus, unless the rupture occurred
in the inactive lower segment.
4.Problems with the Placenta
✓ Placenta, commonly referred to as
the afterbirth, is a disc of tissue that
connects a mother's uterus to the
umbilical cord, and is ultimately
responsible for delivering nutrients
and oxygen to a fetus.
-Normal placenta weighs
approximately 500 g and is 15 to 20
cm in diameter and 1.5 to 3.0 cm
thick. Its weight is approximately
one sixth that of the fetus.
-A placenta may be unusually
enlarged in women with diabetes.
-If the uterus has scars or a septum,
the placenta may be wide in
diameter because it was forced to
spread out to find implantation
space.
***Implantation in the lower uterine
segment
***Premature detachment of
placenta
A.Placenta Succenturiata
-Is a placenta that has one or more
accessory lobes connected to
the main placenta by blood vessels.
-No fetal abnormality is associated
with this type.
-Complication: Small lobes may be
retained in the uterus after
birth, leading to severe maternal
hemorrhage.
-Assessment: On inspection, the
placenta appears torn at the
edge, or torn blood vessels extend
beyond the edge of the
placenta.
B.Placenta Circumvallata
-Ordinarily, the chorion membrane
begins at the edge of the placenta
and spreads to envelop the fetus; no
chorion covers the fetal side of the
placenta.
-In placenta circumvallata, the fetal
side of the placenta is covered to
some extent with chorion. The
umbilical cord enters the placenta at
the usual midpoint, and large
vessels spread out from there.
-Although no abnormalities are
associated with this type of placenta,
its presence should be noted.
C.Battledore Placenta
-The cord is inserted marginally
rather than centrally. This anomaly is
rare and has no known clinical
significance either.
D.Velamentous Insertion of the
Cord
-A situation in which the cord,
instead of entering the placenta
directly, separates into small vessels
that reach the placenta by spreading
across a fold of amnion.
✓ Factor:
-Most frequently found with
multiple gestations.
-Fetal anomalies
✓ An infant born with this type of
placenta needs to be
examined carefully at birth.
E.Vasa Previa
-The umbilical vessels of a
velamentous cord insertion cross the
cervical os and therefore deliver
before the fetus. The vessels may
tear with cervical dilatation, just as a
placenta previa may tear.
✓ Complication: Possible tearing
would result in sudden
fetal blood loss.
✓ It can be confirmed by ultrasound.
✓ If vasa previa is identified, the
infant needs to be born by cesarean
birth.
F.Placenta Accreta
-An unusually deep attachment of
the placenta
to the uterine myometrium, so deep
that the placenta will not loosen and
deliver.
-Attempts to remove it manually
may lead to extreme hemorrhage
because of the deep attachment.
-Management: Hysterectomy to
remove the uterus or treatment with
methotrexate to destroy the still-
attached tissue may be necessary.
-The umbilical cord is a bundle of
blood vessels that develops during
the early stages of embryological
development. It is enclosed inside a
tubular sheath of amnion and
consists of two paired umbilical
arteries and one umbilical vein.
-Allows for the transfer of O2 and
nutrients from the maternal
circulation into fetal circulation while
simultaneously removing waste
products from fetal circulation to be
eliminated maternally.
5.Anomalies of the cord
A.Two-Vessel Cord
-The umbilical cord contains only
two blood vessels — one vein and
one artery. Also known as single
umbilical artery.
-Inspection of the cord as to how
many vessels are present must be
made immediately after birth,
before the cord begins to dry,
because drying distorts the
appearance of the vessels.
-Document the number of vessels
conscientiously because an infant
with only two vessels needs to be
observed carefully for other
anomalies during the newborn
period.
B.Unusual Cord Length
-Although the length of the umbilical
cord rarely varies, some abnormal
lengths may occur.
-Short umbilical cord can result in
premature separation of the
placenta or an abnormal fetal lie.
-Long cord may be easily
compromised because of its
tendency to twist or knot.
Occasionally, a cord actually forms a
knot, but the natural pulsations of
the blood through the vessels and
the muscular vessel walls usually
keep the blood flow adequate. It is
not unusual for a cord to wrap once
around the fetal neck (nuchal cord)
but, again, with no interference to
fetal circulation.
6. Problems with the psyche factors
-Psyche: The emotional state of the
mother during her labor which can
also have an overall effect on
progress of labor.
✓ Factors:
-Levels of stress and underlying
anxiety during the process
-The progress of labor and birth can
be adversely affected maternal fear
and tension.
-Support system (partner, family,
etc.)
-Welcoming and supportive
environment.
✓ Problems:
-Norepinephrine and epinephrine
may stimulate both alpha and beta
receptors of the myometrium and
interfere with the rhythmic nature of
labor.
-Women experiencing increased pain
or high levels of anxiety release
catecolamines, which can have an
inhibitory effect on uterine
contractility leading to abnormal
labor progression.
✓ Therapeutic Management
-To ensure adequate progress:
-Adequate analgesia
-Emotional support.