Chapter 23 high risk pregnant client during labor and delivery Four main components of the labor process 1.
passenger or fetus 2. passage way or pelvic bones and other pelvic structure 3. powers or uterine contractions 4.
clients psyche or psychological state Problems with the passenger -Problem may arise if preterm, also during multiple gestation. Fetal malposition 1. Occipitoposterior position ROP or LOP Second stage of labor Complains of severe back pain from the pressure of the fetal head pressing against other sacrum Fetal malpresentation 1. Asynctilism vertex malpresentationFetal head presenting at a different angle than expected 2. Brow presentation Rare Occurs in multiparty Woman with relaxed abdominal muscles Results in obstructed labor CS is necessary Infant can have extreme ecchymotic bruising in the face Reassure parents that child is well after birth. 3. Face presentation Rare Occurs, the head diameter the fetus presents to the pelvis is often too large for birth to proceed Head that feels more apparent than normal Confirmed for vaginal examination when the nose, mouth or chin can be felt as the presenting part.
Sonogram – pelvic diameters are measuredBabies born: facial edema and purple ecchymotic bruising, observe for patent airway, severe lip edema – unable to suck for a day or two,necessary for gavage feeding, edema will disappear in a few days 4. Shoulder presentation Fetus lies horizontally Presenting part is usually: -one of the shoulders (acromiom process) -An iliac crest -A hand -Or an elbow May be caused by: -Relapsed abdominal walls from grand multiparity – which allows for the unsupported uterus to fall forward -Placenta previa Most infants are born by CS why? -Membranes have ruptured at the beginning of labor No firm presenting part Occurs in women with: -pendulous abdomen -Uterine masses that obstruct the lower uterine segment -Contraction of the pelvic brim -Congenital anomalies -Hydramnios Occurs in infants with: -Hydrocephalus or any abnormality which prevents the infant from engaging. -Obvious on inspection, confirmed through leopolds 5. Breech presentation Most common form of malpresentation It’s fetus assumes this position in early pregnancy But by week 38, fetus normally turns to a cephalic presentation 3 types 1. Complete breech Thighs and knees are flexed 2.
Frank breechThighs are flexed on hips, knees are extended 3. Footing breech Foot extends below the buttocks or knees extends below the buttocks Causes Gestational age less than 40 weeks Fetal anomalies Maternal anomalies Multiple gestation Unknown factors Fetal risk Anoxia Traumatic injury Fracture of the spine or arm Dysfunctional labor Early rupture of the membranes because of the poor fit of the presenting part. Assessment FHT are heard hi in the abdomen Abdominal palpation Vaginal examination Ultrasound Scan External cephalic version Turning of a fetus from a breech to a cephalic Position before birthMaybe done as early as 34 to 35 weeks Usual time is 37 to 38 weeks of pregnancy Before attempting : Ultrasound Locate umbilical cord Rule out placenta previa Evaluate the adequacy of maternal pelvis Assess the amount of the amniotic fluid, the fetal age, and presence of anomalies NST performed to confirm fetal we’ll being Contraindications Uterine anomalies Previous CS birth CPD cephalopelvic disproportion Placenta previa Multifetal gestation Polihydrammios Todo lyric agent is given to relax Nurses role Continuous monitor of FHT Check maternal vs Assess woman’s level of discomfortFetal anomalies Hydrocephalus Anencephaly – absence of cranium Prolapsed umbilical cord -loop of the umbilical cord slips down in front of the presenting part Occurs when the cord lies below the presenting part of the fetus Tends to occur most often in the following PROM Fetal presentation other than cephalic Placenta previa Intrauterine tumors preventing the presenting part Signs Fetal bradycardia Woman feels the cord after membranes rupture Cord is seen or felt or protruding in the vagina Nurses intervention Call for assistance Notify primary health care provider immediatelyGlove the examining hand quickly and insert two fingers into the vagina to the cervix Administer oxygen to the woman by mask at 8 to 10L/min until birth is accomplished Problems with the passageway Abnormal size or shape of the pelvis Cephalopelvic disproportion also called fetopelvic disproportion Excessive fetal size 4000g Origin of maternal CPD if: Maternal pelvis is too small Abnormally shaped pelvis Deformed pelvis Macrosomia is associated with Maternal DM Obesity Multiparity Large size of one or both parents Shoulder dystocia Condition in which e head is born but the anterior shoulder cannot pass under the pubic arch CausesCPD due to macrosomia Maternal pelvis abnormality Signs Slowing of the progress of labor Formation of a caput succedaneum that increases in size When the head emerges it restracts against the perineum ( turtle sign) Fetal risk Birth injuries Maternal risk Excessive blood loss due to: uterine atony or rupture Lacerations Extension of the episiotomy Endometritis McRobert’s maneuver The woman’s leg are flexed apart with her knees on her abdomen Causes the sacrum to straighten and the symphysis pubis rotates to the mother’s head Angle of pelvic inclination is increased freeing the shoulder.Applying suprapubic pressure Help shoulder escape Complications with the power or the force of labor Dystocia Long difficult or abnormal labor Primary cause of cesarean birth Cause Dysfunctional labor Alterations in the pelvic structure Fetal causes Abnormal position presentation Anomalies Excessive size Number of fetuses Hypotonic More common Initially makes normal progress, active stage then contractions weak and inefficient and stop altogether Uterus is easily intended Risenot more than 10mmhg Management Perform ltrasound or X-ray to rule out CPD Assess FHT and pattern Normal findings: AmbulatoryEnema Hypertonic contractions Anxious first time mothers Occur in latent stage Force of the contraction Uterus is unable to apply downward pressure Uterus may not relax Women maybe exhausted Management Therapeutic rests Warm bath Administration of analgesics Contraction rings Types Constriction rings Pathological contraction rings Sonography or ultrasound Administration of IV morphine sulfate – halt contractions, todo lyric to halt contractions If not relieved, uterine rupture and death of fetus may occur Massive maternal hemorrhage may occur Preterm labor Associated with: Hydration UTI ChorioamnionitisWork on strenuous jobs or perform shift work that leads to extreme fatigue Symptoms Recognized by woman Persistent dull low backache Vaginal spotting Precipitate Labor and birth Lasts less than 3 hours from onset of contractions to the time of birth Uterine rupture Uterus undergoes more strain than its capable of straining Causes Separation of the scar of a previous classic cesarean birth Uterine trauma Congenital uterine anomaly Causes Intense spontaneous uterine contractions Labor stimulation Over distended uterus Malpresentation External or internal version Difficult forceps-assisted delivery Classification Complete rupture