NCM109J

CARE OF MOTHER, CHILD AT RISK (MATERNAL)

HIGH-RISK LABOR AND DELIVERY

HIGH-RISK LABOR AND DELIVERY • Disproportion between the maternal pelvis and
fetal presenting part (CPD)
• POWERS • Poor fetal position
• PASSENGER • Overdistention of the uterus
• PASSAGEWAY • Presence of a full rectum or urinary bladder that
• PLACENTA impedes fetal descent
• PSYCHE/PSYCHOLOGICAL STATE
CLASSIFICATIONS - PROBLEMS WITH THE POWER
PROBLEM WITH THE POWERS
Ineffective or abnormal uterine contractions are classified
• Dystocia according to strength:
• Premature Labor • Hypotonic Uterine dysfunction
• Precipitate Labor & Birth • Hypertonic Uterine dysfunction
• Uterine inversion • Uncoordinated contractions
• Uterine rupture
• Amniotic fluid embolism HYPOTONIC UTERINE DYSFUNCTION

PROBLEMS WITH THE POWER (THE FORCE OF LABOR) • Unusually infrequent number of contractions (not
more than 2 or 3 in 10 mins)
• Dystocia - any difficult or obstructed labor or birth • Occurs during active labor
• Inertia - sluggishness of contractions or the force • Increase the length of labor
of labor
Inertia = Dysfunctional labor (current term) CAUSES

THE FORCE OF LABOR • Analgesia administration

• Bowel and bladder is distended
• Effective uterine activity - characterized by • Overstretched uterus
coordinated contractions
• Multiparity
• Coordinated contractions - are strong & numerous
enough to propel the fetus past the resistance of HYPERTONIC UTERINE DYSFUNCTION
the woman’s pelvis
• Occurs during latent phase of labor
DYSTOCIA
• Characterized by strong, ineffective contraction
• Difficult labor or birth • Lack of relaxation between contractions →
insufficient uterine arterial filling → fetal anoxia
• Refers to any labor which does not normally
advance
COMPARISON OF HYPOTONIC AND HYPERTONIC CONTRACTIONS
• A dysfunctional labor may result from problems
with powers of labor, the passenger, the passage,
the psyche, or a combination of these. CRITERIA HYPOTONIC HYPERTONIC
▪ Coordinated but ▪ Uncoordinate
weak d, irregular
FACTORS ▪ Become less Short and of
frequent and poor intensity,
• Forces are inadequate (Faculty power) short in duration but painful
CONTRACTIONS ▪ Easily indented at and cramp-
e.g., inertia - the sluggishness of uterine peak like
contractions ▪ Woman may
• Abnormal position of the passenger (infant) have minimal ▪ Strong
discomfort contraction in
• Abnormal passageway (birth canal) because the the
contraction are midsection of
COMMON CAUSES OF DYSFUNCTIONAL LABOR weak the uterus
(than in
fundus)
• Maternal fatigue
• Maternal inactivity ▪ Anoxic uterine
muscles
• Inappropriate use of analgesia

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NCM109J
CARE OF MOTHER, CHILD AT RISK (MATERNAL)
HIGH-RISK LABOR AND DELIVERY

▪ Lack of measures ▪ Include

relaxation because they partner or
may have family.
anxiety that will
heighten the
woman's anxiety.

SYMPTOMS Painless Painful

UNCOORDINATED UTERINE CONTRACTIONS

▪ Higher than • More than one contraction occurs at the same

UTERINE RESTING normal, time due to myometrium acts independently from
TONE Not elevated important to
distinguish from
each other.
abruptio
placenta MANAGEMENT
▪ Active. Typically ▪ Latent. Usually
occur after 4 cm occurs before • Fetal and uterine external monitor applied every
PHASE OF LABOR dilatation 4 cm dilation 15 mins.
▪ Secondary ▪ Primary • Oxytocin to stimulate labor
dysfunction dysfunction

COMPLICATION
▪Correct
cause if can
be identified. • Mother: exhaustion and dehydration
▪ Amniotomy (may ▪ Light sedation • Fetus; injury and death
THERAPEUTIC increase the risk to promote
MANAGEMENT of infection) rest.
▪ Oxytocin ▪ Hydration. CLASSIFICATION ACCORDING TO TIME
▪ Cesarean birth if ▪ Tocolytics to
no progress reduce high Classified according to time when it occurs:
uterine tone
and promote
placental • Primary dysfunction - occurring at the onset of
perfusion. labor or prolong latent phase of labor.
▪ Interventions ▪ Promote
related to uterine blood
• Secondary dysfunction - occurring later in labor or
amniotomy and flow; side- prolonged active phase of labor fetus does not
oxytocin lying position. descend; cervix not dilated.
augmentation. ▪ Promote rest,
▪ Encourage general
position comfort, and ABNORMAL PROGRESS IN LABOR
changes. relaxation.
▪ An abdominal ▪ Pain relief DYSFUNCTION AT THE FIRST STAGE:
binder may help ▪ Emotional
direct the fetus support:
toward the 1. Prolonged Latent Phase
mother’s pelvis if ▪ Accept the • Latent phase longer than 20 hours in nullipara, 14
her abdominal reality of the hours in multipara (Friedman, 1978)
wall is very lax. woman's pain
▪ Ambulation if no and • May occur if:
NURSING CARE contraindication frustration. o Cervix is not ripe at the beginning of labor
and if ▪ Reassure her o Excessive analgesia
acceptable to that she is not
the woman. being childish • Uterus tends to be in hypertonic state
▪ Emotional ▪ Explain reason • Relaxation between contractions is inadequate
support; allow for measures
her to express to break
feelings of abnormal 2. Protracted Active Phase
discouragement. labor patterns • Usually associated with CPD or fetal malpositions
▪ Explain and their
measures taken goals or
• This phase is prolonged if cervical dilatation does
to increase expected not occur at a rate of:
effectiveness of results. o 1.2cm/hr or more in nullipara
contractions. ▪ Allow her to o 1.5cm/hr in multipara or
▪ Include her express her
partner or family feelings • If the active phase last over
in emotional during and o 12 hours in primipara
support after labor.

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NCM109J
CARE OF MOTHER, CHILD AT RISK (MATERNAL)
HIGH-RISK LABOR AND DELIVERY

o 6 hours in multipara • Pathological Retraction Ring (Bandl’s Ring) -

3. Prolonged Decceleration Phase common in obstructed labor; retraction ring is
• A deceleration has become prolonged when it indented deeply and palpable as a mass in the
extends beyond middle of the abdomen
o 3 hours in nullipara o Danger sign - signifies impending rupture of the
o 1 hour in multipara lower uterine segment if the obstruction is not
• Results from abnormal fetal head position relieved
• Management: Cesarean delivery
Pathologic retraction ring or bandl’s ring
4. Secondary arrest of Dilatation
• Junction of upper & lower uterine segment
• Occurs when there’s no progress in cervical • Sign - severe dysfunctional labor occurs
dilatation for more than 2 hours. • Forewarning of a uterine rupture
• Grip fetus and placenta
5. Prolonged Descent • Assessment
o Horizontal indentation across abdomen
• Occurs if the rate of descent is: o Uncoordinated contractions early in labor
o Less than 1.0cm/hr in a nullipara • Dilatation phase - caused by obstetrical
o Less than 2.0cm/hr in a multipara manipulation and administration of oxytocin
o
b. Constriction Ring
DYSFUNCTION AT THE SECOND STAGE:
• Can occur at any point in the myometrium and
1. Arrest of Descent
anytime during labor; when pathologic occur
• Occurs when no descent has occured for during early labor, it is usually from uncoordinated
o 1 hour in multipara contractions.
o 2 hours in nullipara
• Failure of descent has occurred when expected PATHOPHYSIOLOGY
descent of the fetus does not begin:
• Cause: CPD • Fetus is grasped by the ring and can’t advance or
descent
2. Contraction Rings • If the fetus is delivered, the placenta can be held
after delivery.
a. Pathologic retraction ring (band’l ring)
• Ring usually appears as horizontal indentation MANAGEMENT
across the abdomen.
• Cause: excessive retraction of the upper uterine • Observe abdomen - report immediately
segment. • Administer IV morphine sulfate and amyl nitrate
• C/S - or manual extraction of placenta if not
attended leads to Mother (uterine rupture and
postpartum hemorrhage); fetus (death)

CURATIVE MANAGEMENT CARE

• Antibiotics
• Sedative - stop abnormal contractions
• Short-acting barbiturates - to promote relax/rest
• Monitor FHB
• NPO - Prepare for Surgery (CS)
• Assist in delivery; vaginal or CS
• In a difficult labor (if fetus is larger than the birth • Trial labor - in borderline or adequate pelvis.
canal), round ligaments of the uterus become
tense and may be palpable on the abdomen

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NCM109J
CARE OF MOTHER, CHILD AT RISK (MATERNAL)
HIGH-RISK LABOR AND DELIVERY

PRECIPITATE LABOR/DELIVERY • Administer IV

• Administer oxygen
• Occurs when uterine contractions are so strong • If heart failure develops - immediate general
that the woman delivers with only a few rapidly anesthesia or administer nitroglycerin/tocolytics
occurring contractions • Administer antibiotics
• Cervical dilatation occurs 5cm/hr (primipara) or
10cm/hr (multipara) UTERINE RUPTURE

PREMATURE LABOR/DELIVERY • Complete or incomplete separation of the uterine

tissue as a result of a tear in the wall of the uterus
• Occurs before the end of 37 weeks AOG or before from the stress of labor
fetus weighs 2,500 grams.
• Complete: direct communication between the
• Results in a premature infant, ⅔ neonatal death is uterine and peritoneal cavities
due to LBW. • Incomplete: where the peritoneum overlying the
uterus is intact.
POST-TERM LABOR OR DELIVERY
FACTORS
• Post-gestational, post-mature
• Pregnancy beyond normal AOG - (38-32 weeks) • Strained uterus beyond its capacity
• Pregnancy beyond normal AOG (38-42 weeks) • Previous C/S, repair or hysterotomy
• Occurs approximately 10% of all pregnancies.
CONTRIBUTORY
INVERSION OF THE UTERUS
• Prolonged labor
• Uterus is completely or partly turns inside out • Faulty presentation
• Fetus is formed through the cervix, turned inside • Multiple gestation
out. • Unwise use of oxytocin
• This usually occurs during delivery or after the • Obstruction labor
delivery of the placenta
• Traumatic maneuvers using forceps
CAUSES
ASSESSMENT
• Strong, fundal push in a non-contracted state
• Impeding rupture suggested by pathologic
• Taction is applied to the umbilical cord.
retraction ring, strong uterine contractions with
• Attachment of placenta at fundus - sudden cervical dilatation
delivery of fetus without support - fundus is pulled
• When uterus rupture, S/S: sudden severe pain
down.
during strong labor
ASSESSMENT
MANIFESTATIONS VARY WITH THE DEGREE COMPLETE
RUPTURE
• The interior of the uterus protrude from vagina
• Sudden gush of blood • Halt in contractions
• Fundus no longer palpable • Possible vaginal bleeding
• Uterus is not contracted • Severe abdominal pain
• Severe pain • Signs of hypotensive shock
• Hemorrhage with signs of shock • Absent fetal heart sound

MANAGEMENT INCOMPLETE RUPTURE

• Monitor for hemorrhage and signs of shock and

• Localized tenderness
treat shock
• Persistent lower uterine segment pain
• Prepare the client for a return of the uterus to the
• Lack of contractions
correct position via the vagina
• Fetal distress
• Discontinue oxytocin
• Maternal distress

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NCM109J
CARE OF MOTHER, CHILD AT RISK (MATERNAL)
HIGH-RISK LABOR AND DELIVERY

MANAGEMENT

• Monitor for and treat signs of shock (administer

oxygen, IV fluids, and blood products)
• Administer IV oxytocin
• Prepare client for immediate
o Ceasarean Section, or
o Hysterotomy with hysterectomy
• Provide emotional support for the client and
partner

Denoga, Trixie Kate B. 5