HIGH RISK LABOR AND DELIVERY A. DYSTOCIA OR DIFFICULT LABOR- Long , difficult or abnormal labor CAUSES 1.

Dysfunctional labor or uncoordinated uterine contraction 2. Alterations in pelvic structure 3. Fetal causes 4. Maternal position during labor and birth 5. Psychological responses of the mother to labor 1.DYSFUNCTIONAL UTERINE CONTRACTION - Abnormal uterine contractions that prevent the normal progress of cervical dilation, effacement or descent. -RISK FACTORS 1. Body build 2. Uterine abnormalities 3. Malpresentation and position of the fetus 4. CPD 5. Overstimulation with oxytocin 6. Maternal fatigue,dehydration 7. Inappropriate timing of analgesic or anesthetic administration HYPERTONIC UTERINE DYSFUNCTION - uterine contractions of poor quality that usualy occurs on the latent phase of labor and are usually uncoordinated. - Contractions are more frequent but the intensity may decrease - Painful contractions - Ineffective dilation and cervical effacement RISK OF HYPERTONIC LABOR PATTERNS A. MATERNAL RISK

1.Increased discomfort( uterine muscle cell anoxia) 2. Fatigue 3.Stress on coping abilities 4.Dehydration and increased incidence of infection B. FETAL-NEONATAL RISK 1. Nonreassuring fetal status 2. Caput succedaneum,cephalhematoma,exces sive molding CLINICAL THERAPY 1.Bedrest and sedation 2. Oxytocin infusion or amniotomy 3.CS delivery NURSING MANAGEMENT A.ASSESSMENT 1. Evaluate the relationship between the intensity of the pain and the degree of cervical dilation and effacement. 2.Asssess if anxiety is affecting labor progress B. NURSING DIAGNOSIS 1. Fear 2. Acute pain 3. Ineffective individual coping 4. Anxiety C. PLANNING AND IMPLEMENTATION 1. Provide comfort and support to the couple 2. Provide supportive measures: - change of position - quiet environment -use of music -back rub 3. Provide client education D. EVALUATION 1. The woman has increased comfort and decreased anxiety 2. The woman and her partner are able to cope with the labor. 3. The woman experiences a more effective labor pattern. HYPOTONIC LABOR PATTERNS

Occurs in the active phase of labor. Contractions are weak and inefficient or stop altogether.

3. Determine the maternal hydration status 4. Encourage the woman to void every 2 hours and check for distention. 5. Monitor for signs of infection 6. Limit vaginal examination. 7. Provide information regarding hypotonic labor pattern. D. EVALUATION 1. The woman maintains comfort during labor 2. The woman understand the type of labor pattern that is occuring and the treatment plan. PRECIPITATE LABOR 0 PRECIPITATE LABOR- Labor that lasts < 3 hours from the onset of contractions to the time of birth. Rapid descent of the presenting part, resulting in birth Unexpected, sudden and often unattended birth

RISK FACTORS 1. Multiple gestation 2. Large fetus 3. Grand multiparity 4. Bowel or bladder distention 5. CPD RISK OF HYPOTONIC LABOR PATTERN A. MATERNAL RISK 1. Maternal exhaustion 2. stress on coping abilities 3. postpartum hemorrhage 4. intrauterine infection B. FETAL-NEONATAL RISK 1. Nonreassuring fetal status 2. Fetal sepsis CLINICAL THERAPY 1.Stimulation of uterine contraction 2. Active Management of labor (AMOL)-labor is managed with amniotomy,timed cervical examination and oxytocin administration. 3. CS NURSING MANAGEMENT A. ASSESSMENT 1. Assess the contraction,VS and FHR 2. Signs of infection and dehydration 3. Coping mechanisms of the woman and her partner. B. NURSING DIAGNOSIS 1. Acute pain 2. Ineffective individual coping 3. Health seeking behavior C.PLANNING AND IMPLEMENTATION 1. Promote maternal and fetal well being 2. Assess for the presence of meconium

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RISK FACTORS 1. Multiparity 2. Large pelvis 3. Previous precipitous labor 4. Small fetus in a favorable position 5. Strong contraction RISK OF PRECIPITOUS LABOR A. MATERNAL RISK 1. Loss of coping abilities 2. Lacerations of the cervix,perineum, vagina 3. Postpartum hemorrhage B. FETAL-NEONATAL RISK 1. Nonreassuring fetal status 2. Cerebral trauma 3. Pneumothorax from rapid descent through the birth canal.

CLINICAL THERAPY 1.Close monitoring for the last few weeks of pregnancy. NURSING MANAGEMENT A. ASSESSMENT 1. Identify woman who are at risk of precipitous labor. 2.During labor: a. accelerated cervical dilation and fetal descent. b. Intense uterine contractions with little uterine relaxation between contractions B. NURSING DIAGNOSIS 1.Risk for injury 2. Acute pain C. PLANNING AND IMPLEMENTATION 1.Closely comfort monitor the woman and prepare an emergency birth pack. 2. Promote comfort and rest - side lying position - quiet environment - administer sedatives 3. Stop oxytocin infusion 4. Administer oxygen administration 5. Give information and support before and after the birth. D. EVALUATION 1. The woman and her baby are closely monitored. 2. The woman maintains optimal comfort. PRETERM LABOR 0 ] PRETERM LABOR- Labor that occurs between 20 and 37 completed eeks of pregnancy. RISK FACTORS A.DEMOGRAPHIC FACTORS: -Non white race -Age -Low socioeconomic status -unmarried -Educational attainment

B. BIOPHYSICAL RISKS -Previous preterm labor and birth -> 2 1st trimester abortion -Grand multiparity -Uterine anomalies -DES exposure -Medical condition -known cervical incompetence C. BEHAVIORAL PSYCHOSICIAL RISK -poor nutrition -smoking -substance abuse -inadequate prenatal care -excessive physical activity - stress IMPLICATIONS A. MATERNAL IMPLICATIONS 1.Psychologic stress 2. Physiologic stress B. FETAL-NEONATL IMPLICATIONS 1.Increased morbidity and mortality CLINICAL THERAPY 1.Women are taught to recognize the symptoms associated with preterm labor and predictors of preterm birth *PREDICTORS* a.FETAL FIBRONECTINS-Glycoprotein found in plasma and produced during fetal life. - Normally found in the plasma and the decidua. b.Abnormal cervical length- short cervix -35 mm at 24 to 28 weeks AOG c.History of previous preterm birth d.Presence of bacterial vaginal stenosis C> 2.Maintain good uterine blood flow, detecting uterine contractions, and quieting the fetus. 3.Administration of tocolytics. A.B-mimetic drugs relaxes the smooth muscle

-Ritrodine (Yutopar), terbutaline sulfate B. Magnesium sulfate- initial drug of choice for therapy c. Calcium channel blocker Nifedipine D.Prostaglandin synthesis inhibitorsIndomethacin(Indocin) -should be used < 72 hours - indicated to pregnancies< 32 weeks AOG 4. Administration corticosteroids (dexamethasone) CONTRAINDICATIONS TO TOCOLYSIS A.MATERNAL 1. Severe PIH 2. Active vaginal bleeding 3. Intrauterine infection 4.Cardiac disease 5. Dilation of >6cm B. FETAL 1. Estimated gestational age of >34 weeks 2. Fetal death 3. acute fetal distress 4. Chronic IUGR NURSING CARE FOR WOMEN RECEIVING TOCOLYTIC THERAPY 0 Explain the purpose and side effect of tocolytic therapy. 0 Position woman on her side 0 Monitor maternal VS,lung sound and respiratory effort,FHR,and labor status 0 Assess the mother and the fetus for adverse reaction 0 Measure I and O and daily weight 0 Limit fluid intake to 15002500ml 0 Provide psychosocial support 0 Encourage diversional activities and relaxation techniques

NURSING MANAGEMENT A. ASSESSMENT 1. Uterine contractions that occur every 10 minutes or less with or without pain. 2. Mild menstruallike cramps felt low in the abdomen 3. Pelvic pressure 4. rupture of membranes 6. Constant or intermittent low dull backache 7. Change in the vaginal discharge 8. Abdominal cramping with or without diarrhea B.NURSING DIAGNOSIS 1,Fear 2. Ineffective individual coping C. PLANNING AND IMPLEMENTATION 1. Home care a. Complete physical assessment b. Increase the womans awareness of the manifestations of preterm labor c. Teach the woman to evaluate contraction activity 2, Hospital care a. promote bed rest b. monitoring of VS c. measure I and O d. Monitor FHR and uterine contraction e. side lying position f. avoid or minimize performing IE g. provide emotional support h. keep the couple informed of the progress of labor,treatment regimen and the fetal status. D. EVALUATION 1. The woman is able to discuss the cause,identification and treatment of preterm labor 2. The woman states that she feels comfortable in her ability to cope with her situation and has resources to call on. 3. The woman can describe appropriate self care measures. 4. The woman succesfully gives birth to a healthy infant.