The client with high-risk labor & delivery & her family

1. Problem with the powers

a. Dystocia or difficult labor
✓ Hypertonic uterine dysfunction
• the contractions are too frequent and there is a high resting tone in the uterus and the
contractions are excessively painful.
• MORE COMMON
• NO BASAL HYPERTOUS
• UTERINE CONTRACTION HAVE A NORMAL GRADIENT PATTERN
• PRESSURE DURING CONTRACTION IS
INSUFFICIENT TO DILATE TO THE
CERVIX
✓ Hypotonic uterine dysfunction
• a dysfunction in the propulsive power of the
uterus that presents as an abnormal labor pattern
resulting in prolonged or protracted delivery,
which is a common indication for primary
cesarean section.
• EITHER BASAL TONE IS ELEVATED
• PRESSURE GRADIENT IS DISTORTED
✓ Abnormal progress in labor
• CPD- Cephalopelvic disproportion
✓ Retraction ring (Bandl’s ring)
- a constriction located at the junction of the thinned lower uterine segment and the thick
retracted upper uterine segment that is associated with obstructed labor

b. Premature Labor
- occurs between the 20th and 37th week of pregnancy
- Infant born after 20 weeks and before the end of 37 weeks gestation; weight of less than
2500g (5lbs, 8oz/2.5kg) @ birth
- when uterine contractions cause the cervix, the mouth of the uterus or womb, to open
earlier than normal.
- (factors) carrying twins, shortened cervix, smoking cigarettes, too much amniotic fluid
(polyhydramnios)
- Etiology - exact cause: rarely known 1) Low socioeconomic level 2) Poor nutritional
status 3) Lack of prenatal care 4) Multiple/multifetal pregnancy 5) Previous early birth 6)
Race (non-white) 7) Cigarette smoking 8) Age of mother (highest incidence: < 20 y.o) 9)
Order of birth (1st pregnancies and beyond 4th pregnancy) 10) Closely spaced
pregnancies 11) Abnormalities of mother’s reproductive system (intrauterine septum,
incompetent cervix) 12) Infections (esp. UTI) 13) Obstetric complications (PROM,
premature separation of placenta) 14) Early induction of labor 15) Elective C/S
 - (s/s) Regular or frequent sensations of abdominal tightening (contractions) , constant low,
a sensation of pelvic or lower abdominal pressure, mild abdominal cramps, vaginal
spotting or light bleeding, vaginal discharge: watery, mucus-like, or bloody

- (complications) can pose a number of health concerns for your baby, such as low birth
weight, breathing difficulties, underdeveloped organs and vision problems. Children who
are born prematurely also have a higher risk of cerebral palsy, learning disabilities and
behavioral problems.

c. Precipitate (rapid) Labor and birth

- when a baby is born within 3hrs of regular contractions starting.
- (signs) Contractions start suddenly and come very close together right away. Unlike
typical labor, there isn’t a break between contraction, Continuously painful and strong
contractions with little to no build up in intensity level and You feel an urge to push.
Some people describe it as feeling like you need to poop.
- (factors) given birth before, had precipitous labor before, baby is on the smaller side,
uterus is exceptionally strong and efficient at contractions, birth canal is soft and flexible,
high blood pressure, labor is induced with prostaglandins and been exposed to certain
drugs such as cocaine.
- (complications) heavy bleeding or postpartum hemorrhage, shock (not enough blood and
oxygen get to your organs and tissue), higher risk of perineal tears and vaginal lacerations
,retained placenta or placenta getting stuck in the uterus , delivery in an unsterilized area,
like a car, emotional distress and not. receiving necessary antibiotics for certain infections
(Group B strep) before delivery, which puts your baby at risk for infection.

d. Uterine inversion (inverted uterus)

- Is a complication during childbirth where your uterus turns partially or completely inside
out.
- With healthy deliveries, your baby exits your uterus (womb) and travels through your
vaginal canal to be born. Shortly after, you’ll deliver the placenta, an organ that allows
you to share nutrients with your baby during pregnancy. The placenta is called
“afterbirth” once it leaves your body. Your uterus maintains its shape throughout
delivery.
- (risk factors) short umbilical cord, rapid or prolonged labor and delivery, use of
medicines that relax your uterus, first birth (not the same as your first pregnancy), a fetus
that is heavier than average (fetal macrosomia), retained placenta (the placenta isn’t
delivered within 30 minutes of your baby being born), severe preeclampsia (a pregnancy-
related condition that may result in high blood pressure) and placenta accreta
spectrum (the placenta grows so deeply into your uterine wall that it doesn’t separate
during childbirth).
- (s/s) vaginal bleeding that may be mild or severe, pain in your lower belly and a feeling
of downward pressure, a smooth round mass bulging from your vagina, dropping blood
pressure, feeling dizzy, light-headed, weak, confused, tired or drowsy, rapid heartbeat
and shallow breathing, cold and clammy skin, muscle cramps(abdomen/belly, arms,
hands, feet and legs) and thirst.
 ✓ (causes) Aging: Over time, losing muscle mass can put more strain on your muscles.
These changes can lead to more frequent muscle cramps as you age.
✓ Dehydration: Losing body fluids while exercising (especially in hot temperatures) can
cause muscles to cramp.
✓ Hypothyroidism: Having a thyroid gland that is less active than normal can lead to
muscle cramps.
✓ Low electrolyte levels: Low levels of substances such as calcium or potassium in the
blood can cause muscle cramps.
✓ Medication: Taking certain medicines, including pseudoephedrine (a drug used to treat
nasal congestion) and statins (medications that treat high cholesterol), can cause
involuntary muscle cramping.
✓ Nerve disorders: In rare cases, issues such as a pinched nerve or spinal cord injury can
cause nerve compression (pressure on nerves), which can lead to muscle cramps.
✓ Physical strain: Overusing your muscles during exercise or strenuous activities can lead
to cramps.
✓ Pregnancy: Often, women who are pregnant experience leg cramps due to low
electrolyte levels, circulation changes, and pressure on the nerves caused by the growing
baby
✓ Tight muscles: Inactivity and not enough stretching can cause muscles to contract
(clench) involuntarily.
- (DEGREES)
✓ 1st degree (incomplete): The top of your uterus has collapsed inside your uterine
cavity.
✓ 2nd degree (complete): The top part of your uterus folds into the opening of your
uterus (cervix), like a sock that is turned inside out.
✓ 3rd degree (prolapsed): The top part of your uterus enters the deepest part of your
vaginal canal.
✓ 4th degree (total): Both your uterus and your vagina protrude outside your body.

Most people with uterine inversion fall into the 2nd or 3rd-degree categories.

CREDE MANEUVER

- A provider may pull on the umbilical cord — the organ that connects your baby to the
placenta — while placing gentle pressure on your abdomen to coax the placenta out.
Process:

✓ Your placenta has implanted on the top of your uterus (fundal placental
implantation). The placenta may attach to your uterine wall at the top, side, front or
back during pregnancy. Most often, it connects at the top.
✓ Your uterus doesn’t contract after delivery (uterine atony). Usually, your uterus
contracts after your baby is born. The squeezing helps deliver the placenta and
reduces the size of your blood vessels so that they don’t bleed as easily.

e. Uterine rupture
 - a tear in the wall of the uterus, most often at the site of a previous c-section incision. In a
complete rupture, the tear goes through all layers of the uterine wall and the consequences
can be dire for mother and baby.
- (common) who try a vaginal delivery after having had a cesarean than in those who have
a planned cesarean.
- (s/s) abdominal pain, vaginal bleeding, a rapid pulse or other evidence of internal bleeding,
referred pain in the chest caused by irritation to the diaphragm from internal bleeding and
slowed or stopped labor
The diagnosis is confirmed when the mother undergoes a cesarean delivery and a defect is
seen in the uterine wall.
- (causes) It happen at the site of a scar from a previous c-section. And ruptures tend to
occur during labor because a scar is most likely to give way under the stress of
contractions.
- (risk factors) labor induction, labor augmentation w/ oxytocin, had more than 3 children, an
overly distended uterus (from too much amniotic fluid or carrying multiples or a big baby),
advancing maternal age and a prolonged labor.

Trauma to the uterus, from such things as a car accident or a procedure such as external cephalic
version or a difficult forceps delivery, may also cause a uterine rupture, as can a difficult manual
removal of the placenta.

2. Problems of the Passenger

a. Fetal Malposition
- Refers to positions other than an occipitoanterior position.
- Malpositions include occipitoposterior or occipitotransverse positions of fetal malposition
in relation to maternal pelvis.
- It is usually seen in multipara or those with lax abdominal wall. Fetal malposition is
assessed during Labor
- Maternal risks: prolonged labor, potential for operative delivery, extension oof
episiotomy, 3rd or 4th degree laceration of the perineum.
- Maternal symptoms: Intense back paim in labor, Dysfunctional labor pattern, prolonged
active phase, secondary arrest of dilatation, and arrest of descent

✓ Types of fetal malposition

- Diagnosis: Abdominal examination- the lower part of the abdomen is flattened, fetal
limbs are palpable anteriorly and fetal flank. Vaginal examination- the posteriorfintanelle
is toward the sacrum and the anterior fontanelle may be easily felt if the head is deflexed.
Ultrasound
- Nursing Care: 1.) Encourage the mother to lie on her side from the fetal back, which
may help with rotation. 2.) Pelvic- rocking may help with rotation. 3.) Knee- chest
position may facilitate rotation. 4.) Apply sacral counter- pressure with heel of hand to
relieve back pain. 5.) Continue support and encouragement: Keep client and family
informed progress, and praise client’s efforts to maintain control.
- Management: 1.) If there are signs of obstruction or the fetal heart rate is abnormal at
any stage, deliver by caesarean section. 2.) If the membranes are intact, rupture the
membranes with an amniotic hook or kocher clamp. 3.) If the cervix is not fully dilated
and there are no signs of obstruction, augment labor with oxytocin. 4.) If the cervix is
fully dilated but there is no descent in the
expulsive phase, assess for signs of
obstruction.
b. Fetal malpresentation
- Refers to fetal presenting part other than vertex and includes breech, transverse, face,
brow, and sinciput.
- Malpresentations may be identified late in pregnancy or may not be discovered until the
initial assessment during labor.
- (Factors) The woman has had more than one pregnancy, There is more than one fetus in
the uterus, The uterus has too much or too little amniotic fluid, The uterus is not normal
in shape or has abnormal growths, such as fibroids, placenta previa, and the baby is
preterm.

1. Vertex mal-presentation
- The vertex presentations are further classified according to the position of the
occiput, both right, left, or transverse and anterior or posterior: Left Occipito-
Anterior (LOA), Left Occipito-Posterior (LOP), Left Occipito-Transverse
(LOT)
- Vertex presentation indicates that the crown of the head or vertex of the baby is
presenting towards the cervix.
2. Breech presentation
2. Shoulder presentation / Transverse

✓ Compound presentation

✓ Management:
• External/ podallic version -
• Forcep delivery- Forceps delivery is a kind of assisted vaginal delivery, a way that
your healthcare team can assist you when labor has stalled. It’s only used when vaginal
delivery is in its final stages but not progressing, and when you or your baby’s health
are at risk from prolonged labor. Forceps are a medical tool that looks like metal salad
tongs. A trained healthcare provider can use the forceps to grasp your baby inside the
birth canal and help guide them out.
• Vacuum delivery- During the second stage of labor, when you’re actively trying to
push your baby out, sometimes the process of childbirth seems to stall. You’re trying,
but the baby isn’t coming. This can go on for hours. While you’re in labor, your
healthcare team will monitor your vital signs and your baby’s heart rate to stay alert to
 any signs of fetal distress. If you or your baby’s health is in danger from prolonged
labor, and labor isn’t progressing, your healthcare team will look for ways to assist you
in delivering your baby.

• Cesarean Delivery- Cesarean section, C-section, or Cesarean birth is the surgical

delivery of a baby through a cut (incision) made in the mother's abdomen and uterus.
Health care providers use it when they believe it is safer for the mother, the baby, or
both.
The incision made in the skin may be:
- Up-and-down (vertical). This incision extends from the belly button to the pubic
hairline.
- Across from side-to-side (horizontal). This incision extends across the pubic
hairline. It is used most often, because it heals well and there is less bleeding.
The type of incision used depends on the health of the mother and the fetus. The incision in the
uterus may also be either vertical or horizontal.
• Obstetrical surgery -
c. Prolapse umbilical cord
- Umbilical cord prolapse is a complication that occurs during labor, usually just before or
during delivery. It happens when the umbilical cord drops (prolapses) out of its normal
position and comes out of your cervix before your baby. In a typical delivery, your baby
comes out first, followed by the umbilical cord. But, in a prolapse, the umbilical cord
drops through your cervix and into your vagina before your baby does. When this
happens, the umbilical cord can get squished between your baby’s body and your cervix
or vagina.
Types of umbilical cord prolapse (Umbilical cord prolapse can be overt or occult
(nonovert).)
 - An overt prolapse means that the cord slips down into your cervix and vagina ahead of
your baby during delivery.
- In an occult umbilical cord prolapse, the cord slips out alongside (not before) your baby.
- (Factors) Fetal congenital disorders, Placenta previa, Irregularly shaped umbilical cord (too
long, very thin, etc.), Assisted vaginal delivery (using a vacuum or forceps during delivery), Low
birth weight (weighing less than 5 pounds, 8 ounces, or 2.5 kilograms, at birth), Having had five
or more babies already (multiparous), Irregular cord insertion (velamentous cord insertion), High
fetal station (fetal station is the baby’s position relative to your pelvis during labor),
Macrosomia (your baby is larger than average newborns), Procedures like amniotomy (your
provider breaks your water) or inserting a balloon to ripen your cervix.

d. Fetal distress
- Fetal distress describes a condition when the fetus shows signs of distress during late
pregnancy or labor. Most healthcare providers have replaced the term fetal distress with
non-reassuring fetal status (NRFS). There are many reasons why the fetus could show
signs of distress, such as labor, reactions to medications or issues with the umbilical cord
or placenta. Fetal distress can be dangerous and cause complications for both you and the
fetus. Your obstetrician looks for signs of distress as part of your pregnancy care.
The most common signs of fetal distress are:
- Changes in the fetal heart rate (lower or higher rate than normal).
- The fetus moves less for an extended period of time.
- Low amniotic fluid.
Common cause of fetal distress is the fetus not getting enough oxygen. The fetus gets oxygen
from you. You breathe oxygen into your lungs, then your blood carries it to the placenta. It’s
handed off to the placenta and transferred to the fetus's blood. Anything that interrupts this
process may lead to fetal distress.
Other conditions that may lead to non-reassuring fetal status are: Too frequent contractions
(tachysystole), Fetal anemia, Oligohydramnios (low amniotic fluid) Pregnancy-induced
hypertension (high blood pressure when you didn't have it before pregnancy), Preeclampsia,
Abnormally low blood pressure, Late-term pregnancies (41 weeks or more), Fetal growth
restriction (very small baby), Placental abruption, Placental previa, Umbilical cord compression,
chronic condition like diabetes, kidney disease or heart disease, and expecting identical twins.

3. Problems with the Passageway

a. Abnormal size or shape of the pelvis

- 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.
- 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.
- Anthropoid. An anthropoid pelvis is narrow and deep. Its shape is similar to an upright
egg or oval.
- 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.

b. Cephalopelvic disproportion
- This condition occurs when your baby’s head doesn’t clear the opening of your pelvis
during childbirth. Cephalopelvic disproportion is a rare complication that can stall
delivery.
Causes: Being past their due date, Excessive maternal weight gain during pregnancy. Family
history of large babies, Conditions in the birthing parent like diabetes or gestational diabetes,
Multiparity, meaning that you’ve given birth at least one time before, Biological parents have
obesity (a BMI greater than 30) or overweight (a BMI greater than 25), Birthing in adolescence,
when your pelvis isn’t skeletally mature, Pelvic malformations that may cause bony growths
affecting the opening. Malformations may also result in bones that are out of place, Petite
birthing parent whose pelvic opening is too small, Previous trauma, such as a fractured pelvis.
This can make it difficult for the joints to spread.
Cephalopelvic disproportion is more likely to happen with a:
- Flat (platypelloid) pelvic opening: A person with this type of pelvis has an oval opening
that’s wide from side to side but narrow from top to bottom.
- Heart-shaped (android) pelvis: The pelvic opening is wide on top and narrows toward the
bottom.
c. Shoulder dystocia
- Shoulder dystocia occurs when one or both of your baby’s shoulders get stuck inside your
pelvis during childbirth. The word dystocia comes from the Greek words “dys,” meaning
difficult, and “tokos,” meaning birth.
Causes:
- Fetal macrosomia: baby weighs more than 8 pounds, 13 ounces.
- baby is in the wrong position.
- pelvic opening is too small.
- a position that limits the room in your pelvis.
4. Placental problems
a. Implantation in the lower uterine segment
- Placenta previa means the placenta has implanted at the bottom of the uterus, over the
cervix or close by, which means the baby can’t be born vaginally.
- Treatment aims to ease the symptoms and prolong the pregnancy until at least 36 weeks.
- Complications: Major haemorrhage (bleeding) for the mother, Shock from loss of blood,
Fetal distress from lack of oxygen, Premature labour or delivery, Health risks to the baby,
if born prematurely, Emergency caesarean delivery, Hysterectomy, if the placenta fails to
come away from the uterine lining, Blood loss for the baby, and Death.
Causes: Low implantation of the fertilised egg, Abnormalities of the uterine lining, such as
fibroids, Scarring of the uterine lining (endometrium), Abnormalities of the placenta, Multiple
babies, such as twins, Multiple pregnancies - a woman who has already had six or more
deliveries has a risk of one in 20.

b. Premature detachment of placenta

- Placental abruption is a complication of pregnancy that happens when the placenta
separates from your uterus before delivery. The placenta is a temporary organ that
 connects a growing fetus to your uterus during pregnancy. It attaches to the wall of your
uterus, usually on the top or side and acts as a lifeline that gives nutrients and oxygen to
the fetus through the umbilical cord. The placenta also removes waste from the fetus's
blood.
- In placental abruption, the placenta may completely detach or partially detach. This can
decrease the amount of oxygen and nutrients to the fetus and cause heavy bleeding in the
birthing parent. Placental abruption is a serious condition that requires medical treatment.
Types of Placental Abruption:
- A partial placental abruption occurs when the placenta does not completely detach from
the uterine wall.
- A complete or total placental abruption occurs when the placenta completely detaches
from the uterine wall. There is usually more vaginal bleeding associated with this type of
abruption.
- Revealed placental abruptions have moderate to severe vaginal bleeding that you can see.
- Concealed placental abruptions have little or no visible vaginal bleeding. Blood is
trapped between the placenta and uterine wall.
S/S: Abdominal pain, Uterine contractions that are longer and more intense than average labor
contractions, Uterine tenderness, Backache or back pain, and Decreased fetal movement.
Complications: Placental abruption can be life-threatening to the fetus and sometimes to you.
Complications from a placental abruption include:
- For baby: Premature birth, Low birth weight, Growth problems, Brain injury from lack of
oxygen, and Stillbirth.
- For birthing parent: Blood loss, Blood clotting issues, Blood transfusion, Hemorrhage,
and Kidney failure.
Risk Factors: Trauma or injury to your uterus (like a car accident, fall or blow to the stomach),
Previous placental abruption, Multiple gestations (twins or triplets), High blood
pressure (hypertension), gestational diabetes or preeclampsia, If you smoke or have a history of
drug use, Short umbilical cord, Maternal age 35 or greater, Uterine fibroids, Thrombophilia (a
blood clotting disorder), Premature rupture of membranes (the water breaks before the fetus is
full term), and Rapid loss of the amniotic fluid.

5. Problems with the psyche factors

- Psychological stress and anxiety can cause tension and tightness in the pelvic floor muscles,
making it difficult to relax and bear down effectively during labor.
a. Inability to bear down properly
 - pregnant mother whose psychosocial ability has significantly changed due to shocking and
depressing experiences which has the propensity to diminish the quality of care she could
give to herself and her unborn baby.

b. Fear/anxiety
- Is a feeling induced by perceived danger; a mental shackle that a pregnant mother may feel
due to past experiences, or the fear of being not enough (as a caregiver), the fear of not having
enough means to provide her needs as well as the child's, fear of being alone. Or feeling of
nervousness during the procedure.

Nursing Interventions:

• providing emotional support and encourage verbalization of feelings to reduce anxiety.

• Promoting comfort by touching and reassurance as a basic nursing intervention.
• Promote comfort by cool, damp washcloths on the women’s face.
 • Check maternal vital signs to identify the sign of hypertension or hypotension.
• Check regularity, interval, frequency, and duration of contraction by palpation with finger
tips.
• Assess level, location, duration, intensity of pain, and factors that intensify or relieve
pain.
• Administer oxytocin as order and indicated after placental expulsion.

Factors/Causes:

• Anger
• Poor impulse control
• Emotional detachment or numbness
• Hyper alertness, hyperarousal, and exaggerated startle reflex
• Social withdrawal
• Self-destructive behaviour
• Survivor's guilt
• Relationship problems
• Avoidance of people, places, and things associated with the traumatic experience
• Depersonalization (sense of loss of identity as a person)
• Relationship problems
• Difficulty falling or staying asleep
• Decreased self-esteem

Diagnostic/Lab test:
• Hamilton Rating Scale for Depression (Ham-D)
• Ultrasonography
• Regardless of circumstances, a woman with suicidal or psychotic symptoms should
immediately see a psychiatrist for treatment.