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High Risk Labor

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Kristy L

on 20 November 2012

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Transcript of High Risk Labor

Hypertonic Uterine Dysfunction •Risk factors:
-Nulliparous woman are more subject to abnormal early labor
•Assessment findings:
-Painful, frequent UCs with inadequate uterine relaxation between UCs with little cervical changes
-May be indeterminate or abnormal fetal heart rate related to prolonged labor and inadequate uterine relaxation Hypertonic Uterine Dysfunction •Uncoordinated uterine activity. Contractions are frequent and painful but ineffective in promoting dilation and effacement.
•Women who experience hypertonic uterine dysfunction are at risk for exhaustion related to the prolonged labor and the fetus is at risk for fetal intolerance of labor and asphyxia related to decreased placental profusion. Dystocia Long, difficult or abnormal labor
Diagnosed when there is an alteration in the progress of labor related to cervical dilation and /or descent of the fetus
Dysfunctional labor is abnormal UCs that prevent the normal progress of cervical dilation or descent of the fetus. Hypertonic Uterine Dysfunction •Medical Management:
-Evaluate labor progress
-Evaluate cause of labor dysfunction
-Hydrate to improve uterine perfusion and coordination of UCs
-Provide pain management to allow the woman to sleep and prevent exhaustion Hypertonic Uterine Dysfunction •Nursing Actions:
-Promote rest to try to break the pattern of frequent but ineffective UCs. The pattern typically becomes effective when the woman sleeps for a period of several hours and awakens in a normal labor pattern of active labor.
-Methods used to promote uterine rest are
•Administration of pain medication such as Demerol or morphine as per order to decrease labor contractions and allow the uterus to rest
•Promotion of relaxation
•Warm shower or bath
•Quiet environment
•Minimal interruptions to allow for long period of sleep Hypertonic Uterine Dysfunction Nursing Actions Continued:
-Hydrate the woman with IV or PO fluids if tolerated. Dehydration can result in dysfunctional labor.
-Assess FHR and UCs
-Evaluate labor progress with a sterile vaginal exam (SVE)
-Inform the woman and family of the progress of labor and explain interventions
-Inform the care provider of the woman’s response and progress in labor LiJen Lamb, Kristy Lenehan
Lucy Ryu and Crystal Sanchez HIGH RISK LABOR Risk factors for dystocia include:
•Congenital uterine abnormalities such as bicorniate uterus
•Malpresentation of the fetus such as occiput posterior or face presentation
•Cephalopelvic disproportion
•Tachysystole of the uterus with oxytocin
•Maternal fatigue and dehydration
•Administration of analgesia or anesthesia early in labor
•Extreme maternal fear or exhaustion, which can result in catecholamine release interfering with uterine contractility Hypotonic Uterine Dysfunction •Assessment Findings:
-Decreased frequency, strength, and duration of UCs
-Little or no cervical change
-Less than 0.5cm/hr progress in cervical dilation for a primiparous woman in active labor
-Less than 1.0cm/hr progress in cervical dilation for a multiparous woman in active labor
-Increased fear and anxiety levels Hypotonic Uterine Dysfunction •Risk factors
-Multiparous women often have more problems in the active phase
-Extreme fear may result in catecholamine release, interfering with uterine contractility Hypotonic Uterine
Dysfunction Hypotonic Uterine Dysfunction •Medical Management:
-Evaluate labor progression
-Determine the cause of the dysfunction
-Determine obstetrical interventions
•Augment labor with oxytocin
•Perform amniotomy (AROM-artificial rupture of membranes)
•Perform cesarean birth when other interventions have failed or when there are fetal signs of fetal intolerance of labor Hypotonic Uterine Dysfunction •Nursing Actions:
-Assess uterine activity
-Assess maternal and fetal status
-Stimulate uterine activity to achieve a normal labor pattern using the following methods:
•Ambulate and change the position of the woman to promote comfort and labor progress
•Hydrate with IV or PO as per orders as dehydration can result in dysfunctional labor
•Administer IV fluids to maximize maternal fluid volume, to correct maternal hypotension and improve placental perfusion
•Augment labor with oxytocin as per order Hypotonic Uterine Dysfunction Nursing Actions Continued:
-Evaluate labor progress with SVE
-Inform the woman and the family of the progress of labor and explain interventions
-Provide emotional support. Anxiety levels can increase due to prolonged labor; increase anxiety and fear can interfere with effective UCs
-Maintain good aseptic technique to minimize the risk of infection if ROM
•Minimize the vaginal exams
•Maintain perineal cleanliness
-Inform the care provider of the woman’s response and progress in labor LiJen Lamb, Kristy Lenehan
Lucy Ryu and Crystal Sanchez HIGH RISK LABOR •Occurs when the pressure of the UC is insufficient (IUPC pressure <25 mm Hg) to promote cervical dilation and effacement.
•The woman makes normal progress during the latent phase of labor, but during active labor the UCs become weaker and less effective for cervical changes and labor progress.
•Risk for exhaustion and infection related to the prolonged labor and the fetus is at risk for fetal intolerance of labor and asphyxia. Fetal Dystocia •Medical Management:
-Confirm the fetal position with vaginal exams and ultrasound
-Determine the type of obstetrical interventions such as use of vacuum extractor, forceps, or need for cesarean birth
•Nursing Actions:
-Perform Leopold’s maneuver to determine the fetal position
-Assess the location of the FHR
-Assess the fetal position with SVE
-Alert the primary care provider if there is any question regarding fetal presentation, position or absence of fetal descent Fetal Dystocia •Risk factors:
-Abnormal fetal presentation or position such as face, brow, or breech
-Fetal anomalies, such as hydrocephalus, and/or any other fetal anomaly that interferes with fetal descent through the birth canal
-Fetal macrosomia; birth weight greater than 4500 g
•Assessment Findings:
-FHR may be heard above the umbilicus versus in the lower uterine segment; this is a sign that the fetus may be in a position other than vertex
-The SVE reveals a buttocks or face when malpresentation is the cause of dystocia
-The presenting part is not engaged in the maternal pelvis
-There is no fetal descent through the pelvis Fetal Dystocia Pelvic Dystocia •Related to the contraction of one or more of the three planes of the pelvis
•A key point in the outcome of labor is dependent on the interrelationship of the size and shape of the pelvis, fetal size, presentation and position, and quality of the UCs
•Three contractions of the pelvic planes are:
-Inlet contraction occurs when the widest part of the pelvis is small
-Midpelvis contraction related to prominent ischial spines, convergent pelvic side walls, and a narrow sacrosciatic notch may result in arrest of descent of the vertex
-Outlet contraction can be estimated by measuring the transverse diameter of the pelvis Pelvic Dystocia •Risk factors:
-Small pelvis
-Abnormal pelvic shape
•Assessment Findings:
-Delayed descent of fetal head Pelvic Dystocia •Medical Management:
-Evaluate the pelvis for contraction of one or more of the planes of the pelvis
-Evaluate the descent and engagement of the fetal head
•Nursing Actions:
-Perform SVE to evaluate the progress of labor and fetal descent LiJen Lamb, Kristy Lenehan
Lucy Ryu and Crystal Sanchez HIGH RISK LABOR •May be caused by excessive fetal size, malpresentation, multifetal pregnancy, or fetal anomalies.
•Fetus can move through the birth canal most effectively when the head is flexed and is occiput anterior position. This allows the smallest diameter of the fetal head to enter the maternal pelvis and the most flexible part of the fetal body, the back of the neck, to adapt to the curve of the birth canal
•When the fetal position is other than flexed and vertex or the fetus is large in comparison to the maternal pelvis, labor may be difficult and vaginal birth a challenge

•Complications of fetal dystocia are:
-Neonatal asphyxia related to prolonged labor
-Fetal injuries, such as bruising
-Maternal lacerations
-Cephalopelvic disproportion (CPD): the size, shape, or position of the fetal head prevents it from passing through the lateral aspect of the maternal pelvis. (often necessitates a cesarean birth) Precipitous Labor •Medical Management:
-Prepare for and stand by for precipitous birth
•Nursing Actions:
-Remain in the room with the woman since birth is often very rapid with precipitous labor
-Monitor FHR and UCs every 15 minutes
-Monitor labor progress and cervical change closely with sterile vaginal exams
•Assess the cervix if the woman states she feels pressure or feels like “the baby is coming” it may be a sign of impending birth
-Support the woman and the family. This type of labor can be frightening, overwhelming and painful
-Anticipate potential maternal postpartum complications such as hemorrhage and lacerations
-Anticipate potential neonatal complications such as hypoxia and CNS depression related to rapid birth
-Prepare for delivery Precipitous Labor •Risk factors:
-Grand multiparity
-History of precipitous labor
•Assessment Findings:
-Hypertonic UCs that are occurring every 2 minutes or more frequently, lasting greater than 60 seconds and strong
-FHR pattern may be indeterminate or abnormal and nursing actions are based on FHR pattern
-Rapid cervical dilation such that labor is less than 3 hours Precipitous Labor Inadequate Expulsive Forces •Occurs in the second stage of labor when the woman is not able to push or bear-down
•The fetus is at higher risk for asphyxia related to prolonged second stage of labor
•The woman with a prolonged seconds stage, beyond 4 hours, is at risk for operative vaginal birth and perineal trauma

•Risk factors:
-Maternal exhaustion
-Epidural anesthesia because woman may not feel the urge to push Inadequate Expulsive Forces •Assessment Findings:
-Inadequate or ineffective pushing with little or no descent of the fetal head with expulsive pushing efforts
-Potential for indeterminate or abnormal FHR

•Medical Management:
-Evaluate the woman’s progress, maternal-fetal status, and likelihood of vaginal birth
-Augment with oxytocin
-Assist birth with vacuum or forceps
-Perform cesarean birth when other interventions are ineffective or signs of fetal intolerance to labor Inadequate Expulsive Forces •Nursing Actions:
-Assess fetal descent
-Evaluate fetal response to expulsive pushing
-Facilitate the second stage of labor by doing the following:
•Coaching the woman in bearing-down efforts
•Minimizing the Valsalva maneuver (by using open glottis push strategies)
•Maintaining adequate pain relief for the woman with labor epidurals
•Changing the maternal position to a more upright position to facilitate fetal descent
•Supporting the woman’s involuntary pushing efforts LiJen Lamb, Kristy Lenehan
Lucy Ryu and Crystal Sanchez HIGH RISK LABOR •Labor that lasts fewer than 3 hours from onset of labor to birth
•Women who experience a precipitous labor often have higher anxiety and pain levels related to the rapid and intense labor experience
•Precipitous labor and/or birth places the woman at risk for postpartum hemorrhage related to uterine atony or lacerations. The fetus/neonate is at risk for hypoxia and at risk for CNS depression related to hypoxia from the rapid birth
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