HIGH RISK LABOR and DELIVERY

4 Ps
1.Passenger 2.Passageway 3.Power 4.Psych

PASSENGER
1. Fetal Lie
Transverse lie Longitudinal lie

2. Presentation
Cephalic Breech Shoulder

3. Position
Anterior Occiput LOA

4. Attitude
Relationship of fetal part to one another

5. Station
Relation to ischial spine

PASSAGEWAY
refers to the adequancy of pelvis and birth canal.

PELVIS
1. FALSE PELVIS can support pregnant uterus 2. TRUE PELVIS bony canal of the mothers pelvis

TYPES of PELVIS
1. GYNECOID round pelvic shape 2. ANDROID heart shape pelvis 3. PLATYPELLOID inlet oval in shape, with long transverse diameters 4. ANTROPOID inlet oval in shape with long anteroposterior diameter

POWER
PRIMARY POWER is uterine muscular contractions, which cause the changes of the first stage of labor complete effacement and dilatation of the cervix. SECONDARY POWER is the use of abdominal muscles to push during the second stage of labor.

PHASE OF CONTRACTION
1. Increment building up of contraction 2. Acme peak of the contraction 3. Decrement letting up of contraction

POWER compose of :
1. 2. 3. 4. 5. 6. Frequency Duration Intensity Regularity Effacement Dilatation

PSYCH
- Fighting for the labor experience.

FACTOR
1. 2. 3. 4. 5. Cultural Heritage Previous Experience Support System Self esteem Trauma

PASSENGER PROBLEM
A.FETAL MALPOSITION
1. OCCIPITOPOSTERIOR POSITION ( OPP )
ASSESSMENT 1. Assess type of pelvis 2. It can develop dysfunctional labor pattern and prolonged active phase. MANAGEMENT 1. Back rub or pressure on sacrum.

2. TRANSVERSE LIE - occurs in woman with pendulus abdomen, contraction of the pelvic brim, hydramions, congenital uterine structure, ovoid uterus. Ovoid Uterus more horizontal than vertical uterus ASSESSMENT 1. Leopolds Manuever 2. Confirmed by Sonogram NURSING MANAGEMENT CS Birth

3. LOP and ROP - most common malposition and painful ASSESSMENT 1. Leopolds Manuever 2. Ultrasound
NURSING MANAGEMENT 1. Put mother on squatting position to lessen low back pain.

B. FETAL MALPOSITION
1. VERTEX MALPRESENTATION Brow Presentation - rarest condition occurs with a multipara or weak abdominal muscle. ASSESSMENT 1. Through IE MEDICAL MANAGEMENT CS Birth

2. FACE PRESENTATION
Mentum Proportional to the pelvis Making difficult labor to proceed ASSESSMENT 1. IE 2. Leopolds Manuever NURSING MANAGEMENT CS Birth

3. BREECH PRESENTATION TYPES 1. Frank 2. Footling 3. Shoulder 4. Complete MATERNAL FETAL RISK 1. Dysfunctional Labor 2. Anoxia 3. Traumatic Injury 4. Spine or arm fracture

MANAGEMENT 1. Frequent monitoring of FHR and uterine contraction 2. Turn patient to the left side.

4. SHOULDER PRESENTATION
Occurs at the 2nd stage of labor Shoilder are too broad, scapula, horizontal or transverse position ASSESSMENT 1. Not often identified until head is born MANAGEMENT Apply pressure on suprapelvis area McRobert Manuever CS Birth

C. FETAL DISTRESS
CAUSE 1. Cord Compression 2. Placental Anomalies 3. Preexisting maternal disease Signs and Symptoms 1. Declaration of FHT 2. Meconium stain, amniotic fluid with vertex position

NURSING MANAGEMENT
1. Check the FHR on appropriate basis. 2. Conduct vaginal exam for presentation and position 3. Place the mother on the left side to prevent impede of blood circulation 4. Administer O2 check for prolapse cord 5. Support mother and family 6. Prepare emergency birth as indicated 100 beats per minutes

D. PROLAPSED CORD
CAUSES or FACTOR 1. Displacement of the cord in a downward position 2. When membrane ruptured 3. With enduring contraction 4. Associated with breech presentation 5. Unengaged labor 6. Premature labor/rupture

OBSTETRIC EMERGENCY If compression of cord occurs, fetal asphyxia and damage in CNS may occur or death. ASSESSMENT Vaginal examination to identify cord prolapse in the vagina

NURSING MANAGEMENT 1. Check FHT immediately when membrane rupture and again after next contraction or within 5 minutes before declaration 2. If fetal bradycardia, perform vaginal examination and check for prolapsed cord to determined the case. 3. If cord prolapsed into the vagina, exert upward pressure against presenting part, lift part of the cord reducing pressure on cord. 4. Get help to move the mother into a position where gravity assist in getting the presenting part of cord.

Problems with the passageway

Abnormal size and shape of the pelvis

Complications: inlet contraction- ordinary due to rickets in the early life or congenitally small pelvis Assessment- AP diameter Narrows to less than 11cm; maximum transverse diameter is 12cm or less Management- pelvic measurements before 24th week of pregnancy CS birth

Outlet contraction
Outlet contraction is the distance between the ischial tuberosites
Assessment - Descent of the presenting part - Dilatation of the cervix Management frequently monitor fetal heart sounds encourage the client to void every 2hrs CS birth is indicated if adequate progress in labor cannot be documented after a definite period (612hrs), or fetal distress occurs

External cephalic version

fetus is being turned from breech to a cephalic position before birth Assessment- fetal heart rate and UTZ are recorded continuously Management- administer tocolytic agent to relax the uterus

cephalo pelvic disproportion (CPD)

CPD implies disproportion between the head of the baby (cephalus) and the mothers pelvis. complications can occur if the fetal head is too large to pass through the mothers pelvis or birth canal it is one of the most common cause of different complications in labor including prolonged labor, fetal distress and delayed second stage

 it is very frequently diagnosed and very common indication of CS birth it is very difficult to diagnose before a woman has started a labor pains since it is very difficult to anticipate how well the fetal head and the maternal pelvis will adjust and mold with each other

Causes of CPD
increase fetal weight Very large babies due to hereditary reasons. Weight is estimated to be about above 8kg or 10lbs. post mature babies when pregnancy goes above <12 weeks babies of women with DM that causes the baby to become big

 fetal position

occipito- posterior position where the fetus faces the mothers abdomen instead of her back brow presentation face presentation

problems with the pelvis small pelvis abnormal shape of the pelvis due to diseases like rickets, osteomalacia, or TB abnormal shape of the pelvis due to previous accidents tumor of the bones

 childhood poliomyelitis affecting the shape of the hips congenital dislocation of the hips congenital deformity of the sacrum and the coccyx congenital vaginal septum

Shoulder Dystocia (prolonged labor)

A specific case of dystocia whereby after the delivery of the head the anterior shoulder of the infant cannot pass below the symphisis pubis, a required significant manipulation to pass below the symphisis pubis. It is diagnose when the shoulders fail to deliver shortly after fetal head

 It is the chin that presses against the wall of the perineum It is an obstetrical emergency, and fetal demise can occur if the infant is not delivered, due to compression of the umbilical cord within the birth canal.

Signs
One often described feature is the turtle sign, which involves in the appearance and retraction of the fetal head (analogous to a turtle withdrawing into its shell), the erythematous, red puffy face indicative of facial flushing. This accours whwn the babys shoulder is obstructed by the maternal pelvis

Management
A- Ask for help. This involves requesting the help of an obstetrician, anesthesiologist and pediatrics for subsequent resuscitation of the infant L- leg hyperflexion or Mc roberts maneuver A-anterior shoulder disimpaction (supprapubic pressure) R-rubin maneuver M-manual delivery of posterior arm E-episiotomy R-roll over in all fours

Nursing or Medical Care of Client with Problems of the Passageway

Induction and augmentation of labor- augmentation is indicated when there are hypotonic and infrequent uterine complications.

Methods
a. Cervical ripening- cervical consistencyis changed from firm to soft. Common method is the application of prostaglandin gel to the interior surface of the cervix by a catheter or suppository b. Administration of oxytocin- IV infusion of oxytocin to initiate uterine contractions c. Active management of laboraggressive administration of oxytocin to shorten labor

2.) Forceps birth - applied after the fetal head reaches the perineum - Forceps are used to prevent pressure from being exerted on the fetal head 3.) Vacuum extraction - causes fever, laceration of the birth canal compared to forceps birth - contraindicated to preterm infants

Problems with the Power Classification a. Hypertonic Uterine dysfunction b. Hypotonic Uterine dysfunction c. Abnormal progress during labor d. Uterine Rupture e. Uterine Prolapse

a. Hypertonic Uterine dysfunction

Usually encounter in latent stage of labor.

Management: 1. Evaluation of pelvic size 2. Maintenance of fluid and electrolyte balance in IVF 3. Therapeutic rest, anlagesic, morphine and sedative. 4. Keep bladder empty. 5. Provide more space for the passage of fetus 6. Watch for danger sign

b. Hypotonic Uterine dysfunction

Uncoordinated poor maturity, lack of progress Characterized by weak and infrequent contraction which are insufficient to dilate the cervix Usaully occurs during active phase Uterus are easily undepable.

Causes in hypotonic uterine dysfunction

Over distention of the uterine,multiple pregnancy and hyramnios Malpresentation and malposition Pelvic bone contraction Unripe cervix Congenital abnormalities of the uterus Unknown cause

Complications

Maternal and Fetal infection Post partum hemorrhage Fetal distress and death Maternal exhaustion

Management
1. Re-evaluate the pelvic size to rule out fetopelvic disproportion 2. Amniotomy 3. Obmentation labor 4. If contracted pelvis is the cause , CS is performed.

C. Abnormal Progress During labor

Indication Nullipara Prolonged latent phase >20 h Average second stage 50 min Multipara >14 h 20 min >1 h (>2 h) < 1.5 cm/h < 2 cm/h >2 h >1 h >30 min

Prolonged second stage >2 h (>3 h) without (with) epidural Protracted dilation Protracted descent Arrest of dilation* Arrest of descent* Prolonged third stage < 1.2 cm/h < 1 cm/h >2 h >2 h >30 min

*Adequate contractions >200 Montevideo units [MVU] per 10 minutes for 2 hours. (Please refer to the Pathophysiology for information regarding adequate contractions.)

d. Uterine Rupture
is a potentially catastrophic event during childbirth by which the integrity of the myometrial wall is breached. In an incomplete rupture the peritoneum is still intact. With a complete rupture the contents of the uterus may spill into the peritoneal cavity or thebroad ligament. A uterine rupture is a life-threatening event for mother and baby. A uterine rupture typically occurs during early labor, but may already develop during late pregnancy. Uterine dehiscence is a similar condition, but involves fewer layers, less bleeding, and less risk.

e. Uterine prolapse
is a form of female genital prolapse (also called pelvic organ prolapse or prolapse of the uterus (womb). Treatment is surgical, and the options include hysterectomy or a uterus-sparing techniques such as Hysteropexy or Manchester procedure. The uterus (womb) is normally held in place by a hammock of muscles and ligaments. Prolapse happens when the ligaments supporting the uterus become so weak that

PLACENTAL PROBLEMS
PLACENTA ACCRETA Placenta accreta is a severe obstetric complication involving an abnormally deep attachment of the placenta, through the endometrium and into the myometrium (the middle layer of the uterine wall). There are three forms of placenta accreta, distinguishable by the depth of penetration. The placenta usually detaches from the uterine wall relatively easily, but women who encounter placenta accreta during childbirth are at great risk of hemorrhage during its removal. This commonly requires surgery to stem the bleeding and fully remove the placenta, and in severe forms can often lead to a hysterectomy or be fatal.

There are multiple variants, defined by the depth of their attachment to uterine wall:
Type Description An invasion of the myometrium which does not penetrate the entire thickness of the muscle. This form of the condition accounts for around 75% of all cases. Percent

placenta accreta

75-78%

placenta increta

Occurs when the placenta further extends into the myometrium, penetrating 17% the muscle.

placenta percreta

The worst form of the condition is when the placenta penetrates the entire myometrium to the uterine serosa (invades through entire uterine wall). 5-7% This variant can lead to the placenta attaching to other organs such as the rectum or bladder

DIAGNOSIS
Placenta accreta is very rarely recognized before birth, and is very difficult to diagnose. A Doppler ultrasound can lead to the diagnosis of a suspected accreta and an MRI will give more detail leading to further suspicion of such an abnormal placenta. However, both the ultrasound and the MRI rarely confirm an accreta with certainty. While it can lead to some vaginal bleeding during the third trimester, this is more commonly associated with the factors leading to the condition. In some cases the second trimester can see elevated maternal serum alpha-fetoprotein levels, though this is also an indicator of many other conditions. During birth, placenta accreta is suspected if the placenta has not been delivered within 30 minutes of the birth. Usually in this case, manual blunt dissection or placenta traction is attempted but can cause hemorrhage in accreta.

RISK FACTORS
The condition affects around 10% of cases of placenta previa, and is increased in incidence by the presence of scar tissue i.e. Asherman's syndrome usually from past uterine surgery, especially from a past Dilation and curettage, (which is used for many indications including miscarriage, termination, and postpartum hemorrhaging), myomectomy, or caesarean section. A thin decidua can also be a contributing factor to such trophoblastic invasion. Some studies suggest that the rate of incidence is higher when the fetus is female.

TREATMENT The safest treatment is a planned caesarean section and abdominal hysterectomy if placenta accreta is diagnosed before birth. If it is important to save the woman's uterus (for future pregnancies) then resection around the placenta may be successful. Conservative treatment can also be uterus sparing but may not be as successful and has a higher risk of complications. Techniques include leaving the placenta in the uterus intrauterine balloon catheterization to compress blood vessels embolisation of pelvic vessels If the woman decides to proceed with a vaginal delivery, blood products for transfusion should be prepared.

PLACENTA INCRETA placenta increta placenta accreta with penetration of the myometrium. PLACENTA PERCRETA A placenta that invades the uterine wall. In placenta percreta, the vascular processes of the chorion (the chorionic villi), a fetal membrane that enters into the formation of the placenta, may invade the full thickness of the myometrium. This can cause an incomplete rupture of the uterus. The chorionic villi can go right on through both the myometrium and the outside covering of the uterus (serosa), causing complete and catastrophic rupture of the uterus.

Problem w/ psyche

3 types
1.) post partum blues 2.)post partum depression without psychotic features 3.)post partum depression with psychotic features

Etiology Predisposing Factors

History of puerperal psychosis or bipolar old name is manic depressive disorder Delirium and hallucination Rapid mood change Agitation or confusion Potential for suicide or infanticide

2.)post partum depression

3 perspective
Biological theory- alteration in hypothalamus function psychological theory- poor support system and poor relationship with the partners Sociocultural theories- low level of social gratification support, control both at work and in parenting rate

Assessment of post partum blues

Fatigue Weeping Anxiety Mood instability with onset 1-10 days lasting 2weeks

Manifestation of post partum depression with psychosis

Post partum depression plus hallucination, dillution, auditory illution Hyperactivity Management 1.) Identify post partum mood disorder Be aware for the signs and symptoms Teach the client and family about the disorder

2.) support and treat the client and family

Develop specific therapeutic goal Maintain prescribe medication schedule Keep communication open with the health care provider and coordinate with the social services Include family participation involvement in planning of care

3.) support effort at parentnewborn bonding

Provide support for the mother to continue care for the newborn Plan for continuity of care for the newborn, mother and family

Problem related to sexual response and reproduction

UTI
2 types
Cystitis lower part, urethra and bladder Pyelonephritis upper part, ureter and kidney

Infertility
2 types Primary infertility no pregnancy at all Secondary infertility theres a 1st pregnancy and no more next pregnancy High risk

Truck drivers Fitted pants

Female infertility
Thyroid disorder Adrenal disease Significant liver and kidney disease Hypothalamic pituitary factor Hypopituitary cell Hypothalamic dysfunction Kallman syndrome hyperprolactinemia

 Any ovarian factors Polycystic ovarian syndrome Inovulation Diminished ovarian reserve Lutheal dysfunction Premature menopouse Gonadal dysgenesis Ovarian neoplasm Tubal or peritoneal factor Tubal dysfunction

 Uterine factors Uterine malformation Uterine fibroid Ashermans syndrome Cervical factors Cervical stenosis Anti sperm antibodies Insufficient cervical mucous Vaginal factors Vaginismus Vaginal obstraction

 Genetic factors Androgen insensitivity syndrome

Male Infertility Factors

1. Pretesticular Causes
Endocrine problem like diabetes and thyroid disorder Hypothalamic disorder Cushing Syndrome Hyperprolactinemia Hypopituitarycele Drug and alcohol

2. Testicular Causes
Genetic defects of white chromosome White chromosome micro deletion Abnormal set of chromosomes Neoplasm such as semiloma Idiopathic failure

Varicocele Trauma Hydrocele Mumps leading to orchitis Testicular dysgenesis syndrome

3. Post-testicular Causes
Vasdeferens obstruction Infection Prostatitis Ejaculation/retrograde Hypospadia

 Impotence Acrosomal defect or egg penetration defect Low sperm count in men

Diagnostic Test

1. Paternal Test
A. Comprehensive installing physical exam B. Semen analysis (20million/cm) Progressive sperm motility more than 50% Ejaculation volume of more than 2ml Poor Prognosis Motility less than 50% Ejaculation less than 2ml

2. Maternal Test
A. Sims Huchner Test It is a post-coital test commonly 2 hours after the last and the woman will remain in supine position for 15 mins. Normal strength is 8-10cm with 50-20 million sperm if less than, low sperm count. Check problem with secretion Unreliable

Endometrial biopsy Hormonal testing Thyroid testing Laparoscopy Measurement of the progesterone in the 2nd half of pregnancy Pap smear Pelvic exam Special X-ray test

Management For Fertility Medications

1. Clomid (Clomiphene Citrate) Action: Use external only, spermatogenesis in case of low sperm count. Stimulate ripening and release ova from the ovary.

Management of Unovulation
Due to hyperprolactinemia 1.Parlodel (Bromocriptine Mesylate) Action: Anti-hyperprolactinemia, use clomid Side Effects: Multiple pregnancies 2.Restoration Tubal Patency (Tuboplasty)

1. 2. 3. 4.

Hysterosalpingonacele Artificial insemination Invitro fertilization Alternative and complementary treatment Acupuncture Diet and supplement Healthy Lifestyle