Gynecoid Anthropoid Android Sonogram Acceleration Deceleration Tocolytic Agent Rickets

-the occiput is directed diagonally and

posteriorly
- In the process of internal rotation, the

fetal head must rotate not through a 90-degree arc, which is necessary for the anterior position, but through an arc approx. 135-degree arc - Can be delivered spontaneously but with increase molding and caput

Risk Factors:
Women with android, anthropoid or contracted pelvis

1. 2.

Prolonged active phase

Arrested descent

3.

Fetal heart sounds heard best at the lateral sides of the abdomen

> Pressure and pain in the mothers lower back

* interventions:

> Counter pressure on the sacrum ( Back rub, apply fist or heel of hand to sacral area) > Heat or cold applications in the sacral area which ever feels best > lying on the side opposite the fetal back > Double hip squeeze ex: knee-chest position - partner, nurse or doula places hands over gluteal muscles and presses with palms of hands up and inward toward the center of the pelvis

 > knee press Measure to facilitate the rotation of the fetal head Lateral abdominal stroking: stroke the abdomen in

direction that the fetal head should rotate Hands and knees position: kneeling while leaning forward over a birth ball, padded chair seat,bed or over-the-bed table Squatting Pelvic rocking Stair climbing Lateral position: towards the fetus should turn

Caesarean if:
Contractions are ineffective
Fetus is larger than average

Fetus is not in good flexion

Maternal exhaustion

Transverse arrest
Persistent occipito posterior position

 Recommended practice to auscultate FHR according

to AAP/ACOG and AWHONN With no risk: * First stage (active phase) every 30 minutes * Second stage every 15 minutes With risk: * First stage (active phase) every 15 mintues * Second stage every 5 mintues

What controls the FHR?

1. Intrinsic rhythmicity of fetal heart rate 2. CNS 3. Fetal ANS

Baseline FHR average rate during a 10-minute segment that excludes periodic or episodic changes Variability of FHR irregular fluctations in the baseline FHR of two cycles per minute or greater _ one of the most realiable indicators of fetal well-being

Four ranges of variability

1. Absent or undetected variability
2. Minimal variability greater than undetected but no more than 5 beats/min

3. Moderate variability 6-25 beats/min

4. Marked variability greater than 25 beats/min

 If no variability is present, it indicates that the natural

pacemaker activity of the fetal heart (effects of the sympathetic and parasympathetic NS) has been affected.

e.g. Administration of narcotics or barbiturates

 Acceleration

- visually apparent abrupt increase in FHR above the baseline rate - the increase is 15 beats/min or greater and last 15 seconds or more with return to baseline less than 2 minutes from the beggining of the acceleration. - preterm (peak of 10 beats/min or more above baseline for atleast 10 seconds

 Deceleration
- abrupt decrease in FHR 1.

Early deceleration periodic decreases in FHR resulting from pressure on the fetal head during contractions - parasympathetic stimulation in response to vagal nerve compression brings about a slowing of FHR - rate rarely falls below 100 bpm, and it returns quickly to between 120-160 bpm - mirror of the contraction

 Late deceleration

those that are delayed until 30-40 seconds after the onset of a contraction and continue beyond the end of the contraction - it suggest uteroplacental insuffuciency or decreased blood flow through the intervillous spaces of the uterus during contraction If oxytocin is being used stop the infusion or slow the rate Change the womans position from supine to lateral Administer IVF or oxygen as prescribed

 Prepare for possible prompt birth of the infant if the

late decelerations persist or if FHR variability becomes absent or decreased. Report and document the findings promptly
Prolonged decelerations last longer than 2-3 minutes

but less than 10 minutes

_ may signify cord compression or maternal hypotension

 Variable deceleration decelerations that occur at

unpredictable times in relation to contractions

- may indicate cord compression Change the womans position from supine to lateral or trendelenburg position Administer IVF and oxygen as ordered Amnioinfusion Ultrasonography - intermittent sound waves of high frequency (above the audible range) are profected toward a uterus by a transducer placed on the abdomen or in the vagina

 Sonogram B-mode scanning is used - most frequently used - this mode allows pattern to merge and form a picture, similar to a black-and- white TV picture
Real-time mode ivolves the use of multiple waves that allow the screen picture to move - Fetal heart can be seen to move, and even movement of the extremities, such as bringing a hand to the mouth to suck a thumb, can be seen

Fetal Malpresentation
1. Brow presentation rarest of the presentation - occipitomental diameter presents - fetus in partial extension - infants will have extreme ecchymotic bruising in the face

Risk Factors:
Multipara, woman with relaxed abdominal muscles

Caesarean delivery is recommended if

Will not occur spontaneously correct

2. Face Presentation
- rare; chin or mentum presentation - the head diameter the fetus presents is often too large for birth to proceed - it is a warning signal because something is abnormal causing the presentation - instead of flexing the head as labor proceeds, may extend the head resulting to this presentation - long first stage of labor - attitude is poor

Risk Factors:

women with contracted pelvis or placenta previa, relaxed uterus for a multipara, prematurity, hydramnios, fetal malformation, CPD

Sonogram Vaginal Examination

-

the nose, mouth or chin can be felt as the presenting part

 1. A head that feels more prominent than normal

2. No engagement apparent on leopolds maneuver 3. Head and back are both felt in the same side of the uterus

4. Back is difficult to outline because it is concave

Effects to the baby and its interventions:

> facial edema and may be purple from ecchymotic

bruising *observe the infant closely for a patent airway > lip edema is so severe that the infant is unable to suck for a day or two * gavage feedings may be necessary to allow the infant to obtain enough fluid until he or she can suck effectively * the infant maybe transferred to an ICU nursery for 24H * reassure the parents that the edema is transient and will disappear in a few days

3. Sinciput military attitude 4. Transverse lie or Shoulder Presentation

-

the ovoid of the uterus is found to be more horizontal than vertical (obvious on inspection) - mature fetus cannot be delivered vaginally from this presentation - membranes rupture at the beginning of the labor - the presenting part usually becomes one of the shoulders (acromion process); an iliac crest; a hand; or an elbow - cesarean birth is necessary

Risk Factors:

Women with pendulous abdomen uterine masses (e.g. Fibroid tumors) contraction of the pelvic brim congenital anomalies of the uterus (placenta previa) hydramnios Infants with hydrocephalus or another abnormality that prevents the head from engaging May occur in prematurity Multiple gestation Short umbilical cord Grand multiparity

 Leopolds Maneuvers
Sonogram
Membranes rupture at the beginning of the labor The cord or an arm may prolapse Shoulders may obstruct the cervix

Breech Presentation- most common

malpresentation
Three Types

Complete Frank Footling- knee extends below the

buttocks - Foot extends below the buttocks

1. Complete
the fetus has thighs tightly flexed on the abdomen -both the buttocks and the tightly flexed feet present to the cervix - The gluteal muscles of the fetus maybe mistaken on vaginal examination for a head - The cleft between the buttocks maybe mistaken for the sagittal suture line
-

2. Frank Breech
-

attitude is moderate because the hips are flexed but the knees are extended to rest on the chest - the buttocks alone present to the cervix - infant may tend to keep the legs extended and at the level of the face for the first 2-3 days of life

3. Footling
- Neither the thighs nor lower legs are flexed - if one foot presents, it is a single-footling breech; if both presents, it is a doublefootling breech - may tend to keep the legs extended in a footling position for the first few days * Inform the parents of the possible posture of the infant so that they do not misinterpret the unusual posture of their infant

 Diagnosis is made by abdominal palpation

and vaginal examination

Confirmed by ultrasound scan

Risk Factors:
Preterm birth Abnormality in a fetus such as anencephaly, hydrocephalus, or meningocele Hydramnios or oligohydramnios Congenital anomalies of the uterus (e.g. Midseptum) Any space-occupying mass in the pelvis (e.g. Fibriod mass, placenta previa) Pendulous abdomen Multifetal gestation Unknown factors

Complications

Anoxia from a prolapsed cord Traumatic injury to the aftercoming head (possibility of intracranial hemorrhage or anoxia) Fracture of the spine or arm Dysfunctional labor Early rupture of the membranes because of the poor fit of the presenting part Aftercoming head can be trapped by an incompletely dilated cervix

Possible meconium staining because of the inevitable contraction of the fetal buttocks from cervical pressure. This is not due to fetal anoxia as a sign of fetal distress but this is expected because of the pressure in the buttocks. This can be aspirated however if the infant inhales amniotic fluid.

Assessment
* Fetal heart sounds are best heard at or

above the umbilicus * Leopolds maneuvers * Vaginal Examination * Ultrasound examination * Radiographic pelvimetry to determine which patients are suitable for trial of labor

Interventions

determine the cause of passage of meconium * if vaginal delivery is preferred, the woman is allowed to push after full dilatation is achieved -Vaginal birth is accomplished by mechanisms of labor that manipulate the buttocks and lower extremities as they emerge from the birth canal * Piper forceps sometimes are used to deliver the head

* Assess fetal heart rate and pattern to

External Cephalic Version

-

is used to attempt to turn the fetus from a breech or shoulder presentation to a vertex presentation for birth - usual time is 37-38 weeks but it may be done at 34-35 weeks - can decrease the number of cesarean births necessary

Procedure:
Fetal Heart Rate and possibly ultrasound are recorded

continuously to identify potential problems such as cord entanglement and placental separation A tocolytic agent may be administered to help relax the uterus The breech and the vertex of the fetus is located and grasp transabdominally by the examiners hands on the womans abdomen Gentle pressure is then exerted to rotate the fetus in a forward direction to a cephalic

Contraindications:
1.
2. 3.

4.
5. 6. 7. 8.

Multiple gestation Severe oligohydramnios Placenta previa A cord that wraps around the neck Unexplained third-trimester bleeding Uterine anomalies Previous cesarean birth CPD

Interventions
> Before ECV is done, ultarsound scanning is required to determine the fetal position > Locate the umbilical cord; rule out placenta previa > Evaluate the adequacy of the maternal pelvis > Assess the amount of amniotic fluid, the fetal age and the presence of any anomalies > A non-stress test is performed to confirm fetal wellbeing > Assess fetal heart rate > Obtained informed consent

 > Checks maternal vital signs

> Assess the womans level of comfort because

the procedure may cause discomfort > Assess for vaginal bleeding > Women who are Rh-negative should receive Rh immunglobulin because the manipulation can cause fetomaternal bleeding

Fetal Distress *Fetal Heart Beat less than 120bpm or

greater than 160bpm * meconium-stained amniotic fluid * fetal hyperactivity * progressive decrease in baseline variability * severe variable deceleration * late deceleration

Interventions
Monitor fetal heart rate every 15 min
Place the mother in a lateral position;

elevate her legs Monitor maternal and fetal status Prepare for emergency cesarean section Administer oxygen at 8-10 LPM via face mask as ordered Discontinue oxytocin if infusing as ordered

Prolapsed Umbilical Cord

- occurs when the cord lies below the presenting part of the fetus - may be occult (hidden, not visible at any time during labor whether or not membranes are ruptured - it is most common to see frank (visible) prolapse directly after rupture of membranes. When gravity washes the cord in front of the presenting part - occurred in 1.9 of 1000 live births in 2002 - always an emergency situation, because the reduced blood flow to the fetus can quickly cause fetal harm

Risk Factors:
Premature rupture of membranes Amniotomy if the if the presenting part is high Malpresentation (breech) Long cord (longer than 100 cm) Transverse lie Unengaged presenting part A small fetus CPD preventing firm engagement] Hydramnios Multiple gestation

Assessment
Vaginal Examination they may be felt as the

presenting part FHB continuous monitoring fetal bradycardia with variable deceleration during uterine contraction If fetal hypoxia is severe, violent fetal activity may occur and cease Woman reports feeling the cord after the membranes rupture Cord is seen or felt in or protruding from the vagina

Interventions
> Always assess fetal heart sounds immediately after rupture of the membranes occuring either spontaneously or by amniotomy Cord prolapsed automatically lead to cord compression

> Management is aimed toward relieving pressure on the cord to prevent fetal anoxia

> The examiner put a sterile gloved hand into the vagina and hold the presenting part off the cord > Assist the woman into a position such as a modified Sims, Trendelenburg, or knee-chest position

The cord has prolapsed to the extent that it is exposed to room air > drying will begin > atrophy of the umbilical veins >Do not attempt to push any exposed cord back into the vagina (this may add to the compression by causing knotting or kinking) >Cover any exposed portion with a sterile saline compress to prevent drying

Cervix is fully dilated at the time of proplapse > A forceps- or vacuum-assisted birth can be performed for the fetus in cephalic presentation; other wise a cesarean birth is likely to be performed Dilatation is not complete > The birth method of choice is upward pressure on the presenting part applied by the practitioners hand in the vagina > The baby is delivered by cesarean

Emergency Interventions
Call for assistance Notify primary health care provider immediately Glove the examining hand quickly Place the woman in the appropriate situation If the cord is protruding from the vagina, wrap loosely in a sterile towel saturated with warm,

sterile normal saline solution Administer O2 via facemask at 8-10LPM until birth is accomplished

 Start IV fluids or increase existing drip

Continue to monitor FHR by internal fetal scalp electrode, if possible

Explain to woman and support person what is happening and the way it is managed
Prepare for immediate vaginal birth if cervix is

fully dilated or cesarean birth if it is not

 Dystocia - long, difficult , or abnormal labor - occurs in approximately 8%-11% of women during the

first stage of labor and is the primary cause of cesarean birth It is cause by the folowing: 1. Dysfunctional labor 2. Alterations in the pelvic structure 3. Abnormal position, presentation, and excessive size of the fetus 4. Maternal position during labor and birth 5. Psychological responses of the mother to labor related to past experiences, preparation, culture and heritage and support system

Specific problems with the Passageway

Pelvis Dystocia can occur whenever there are contractures of the pelvic diameters that reduce the capacity of the bony pelvis, including inlet, midpelvis, outlet or any combinations of the these planes Pelvic contractures may be caused by congenital abnormalities, maternal malnutrition, neoplasms, or lower spinal disorders

Inlet Contraction
- the diagonal conjugate is less than 11.5cm - incidence of shoulder or face presentation is increased -weak uterine contractions may be noted during the first stage of labor

Risk Factors: * Rickets in early life *Inhereted small or flat pelvis

 Engagement in primigravida

>occurs 36-38th week of pregnancy >if engagement does not occur, then either a fetal abnormality (larger-than-usual head) or a pelvic abnormality ( smaller-than-usual pelvis) should be suspected Engagement in multigravida > occurs when the labor begins

Interventions

Every primigravida should have pelvic measurements taken and recorded before week 24 of pregnancy Based on these measurements and the assumption the fetus will be of average size, birth decision can be made.

Outlet Contraction

- interischial diameter is 8cm or less

- woman with this problem have a long, narrow pubich arch and an android pelvis (causes fetal descent to be arrested) - easy to assess during prenatal visit and reassessed during labor transverse diameter is the distance between the ischial tuberosities

Assessment of Pelvic Adequacy

Evaluation of pelvic adequacy using internal conjugate

and ischial tuberosity diameters is generally done during pregnancy, so that, by weeks 32 to 36 of pregnancy, the nurse-midwife or physician is alerted that a cephalopelvic disproportion could occur > woman with this potential problem are cautioned not to attempt a home birth or use a birthing center without nearby hospital facilities available

 Suprapubic angle
* place the fingers vaginally and press up against the pubic arch. If the angle is too steep, the fetal head can lock behind it and perineal tissue may tear during birth as the fetal head is pushed posteriorly If the fingers cannot be separated in this position, the angle is unusually steep (>90 degrees)

Cephalopelvic Disproportion
- also called fetopelvic disproportion - is often related to excessive fetal size (i.e., 4000g or more) - the fetus cannot fit in through the maternal pelvis to be born vaginally - occurred at a rate of 15.8 % per 1000 live births in 2002

 Excessive fetal size, or macrosomia can be

associated with maternal DM, obesity, multiparity, or the large size of one or both parents
If the maternal pelvis is too small, abnormally

shaped, or deformed, CPD may be of maternal origin

Shoulder Dystocia
- fetal head is born but the anterior shoulder

cannot pass under the pubic arch - .24%-2.0% of all vaginal births are complicated by this problem - it occurs in the second stage of labor - hazardous to the mother because it can result in vaginal or cervical tears

 - it is often not identified until the head has already

been born and the wide anterior shoulder locks beneath the symphysis pubis - hazardous to the fetus if the cord is compresses between the fetal body and the bony pelvis - the force of birth can result in a fractured clavicle or humerus or a brachial plexus damage for the fetus - the mothers primary risk stems from excessive blood loss as a result of uterine atony or rupture, lacerations, extension of the episiotomy,or endometritis

Risk Factors:
Woman with diabetes
Multiparas Post-date pregnancies Fetopelvic disproportion due excessive

fetal size (>4000g) Maternal pelvic abnormalities

Suspect

Prolonged stage of labor

2nd

Arrest of descent External rotation does not occur A Turtle sign-head emerges and retracts against the perineum

Formation of a caput succedaneum that increases in size

Interventions
Ask the woman to flex her thighs sharply on her abdomen - McRoberts Maneuver this causes
the sacrum to straighten, and the symphisis pubis rotates toward the mothers head; the angle of pelvic inclination is decreased, freeing the shoulder

Apply suprapubic pressure to the anterior

shoulder using the Mazzanti or Rubin maneuver in an attempt to push the shoulder under the symphysis pubis Squatting position or lateral recumbent position

 Mazzanti technique pressure is applied directly, posteriorly and laterally above the symphysis pubis
Rubin technique pressure is applied obliquely posteriorly against the anterior shoulder

 > When shoulder dystocia is diagnosed, the nurse helps the

woman assume the position(s) that may facilitate birth of the shoulders > Assist the primary health care provider with these maneuvers > Provide encouragement and support to reduce anxiety and fear > Examine newborn for fracture of the clavicle or humerus, as well as brachial plexus injuries > Maternal assessment should focus on early detection of hemorrhage and trauma to the soft tissue of the birth canal

Dysfunctional labor - an abnormal uterine contractions that prevent the normal progress of cervical dilation, effacement,or descent

Risk factors:
Body build (e.g., 30 pounds or more overweight; short

stature Uterine abnormalities (e.g. Congenital malformations; overdistention, as with multiple gestation or hydramnios) Malpresentation and positions of fetus CPD Overstimulation of oxytocin Maternal fatigue, dehydration and electrolyte imbalance, and fear Inappropriate timing of analgesic or anesthetic administration

1.

Hypertonic Uterine Dysfunction

- the muscle fibers of the myometrium do not repolarize or relax after the contraction, to accept a new pacemaker stimulus - tend to be more painful and frequent contractions but do not cause cervical dilatation or effacement - marked by an increase in resting tone to more than 15 mmhg - occur in the latent stage and are usually uncoordinated

 - the force of the contraction may be in the midsection

of the uterus rather than in the fundus, and teh uterus is therefore unable to apply downward pressure to push the presenting part against the cervix - the uterus may not relax completely between contractions

Fetal Anoxia danger of hypertonic uterine

contraction
- results if there is lack of relaxation between contractions which may not allow optimal uterine artery filling Interventions: Monitor maternal and fetal status Uterine and fetal external monitor applied for 15 minutes Therapeutic rest warm bath or shower Administer analgesics such as morphine, meperidine, or nalbuphine inhibit uterine contractions, reduce pain and encourage sleep

After a 4- to 6- hour rest, theses women are likely to awaken in active labor with a normal uterine contraction pattern
> Decrease noise and stimulation > Change the linen and clients gown > Darken the room lights

Cesarean if:
Abnormally long first stage of labor
Lack of progress with pushing (second stage arrest)

Deceleration in the fetal heart rate

2. Hypotonic Uterine Contraction

- more common type; also called secondary uterine inertia - the woman initially makes normal progress into the active stage of labor; then the contractions become weak and inefficient or stop together - uterus is easily indented, even at the peak of contractions - intrauterine pressure during the contraction (usually < 25mmhg) is insufficient for progress of cervical effacement and dilatation - occur during the active phase of labor - not exceedingly painful

Risk factors:

Administration of analgesia especially if the cervix is not dilatated 3-4 cm or if the bladder is distended that prevents the descent of the fetus Multiple gestation the uterus is overstretched A larger-than-usual fetus Hydramnios Uterus that is lax from grand multiparity CPD Malpositions

Complications:
Increase length of labor > uterus is exhausted > not contract as effectively during the post partal period > post partal hemorrhage
Cervix is dilated for a long period of time risk for infection

Interventions
> Perform ultrasound or an x-ray examination to rule out CPD > Assess FHR and pattern, characteristics of amniotic fluid if membranes are ruptured, and maternal well-being > If findings are normal, ambulation, hydrotherapy,enema, striping or rupture of membranes, nipple stimulation, and oxytocin infusion can be used to augment labor > Infusion of oxytocin to augment labor by strengthening contractions and increasing the effectiveness > Amniotomy may be done to further speed labor > In the first hour after birth, palpate the uterus and assess lochia Q15 minutes to ensure that post partal contractions are not also hypotonic

Interventions
Monitor and assess the rate, pattern, resting

tone, and fetal response to contractions for atleast 15 mins (or longer if necessary for early labor) Oxygen therapy as ordered Administer oxytocin to stimulate a more effective and consistent pattern of contractions

Uncoordinated Contractions
- more than one pacemaker may be initiating contractions, or receptor points in the myometrium may be acting independently of the pacemaker. - do not allow good cotelydon filling - occur so eratically (difficult for a woman

to rest between contraction or breathing technique with contractions)

DYSFUNCTIONAL LABOR AND ASSOCIATED STAGES OF LABOR

1. DYSFUNCTION WITH THE FIRST STAGE OF LABOR

Prolonged Latent Phase - major dysfunction that can occur in the first stage of labor - a latent phase that is longer than 20 hours in a nullipara or 14 hours in a multipara

Risk Factors:

The cervix is not ripeat the beginning of labor, excessive use of analgesic early in labor
Uterus tends to be in hypertonic state Contractions are only mild therefore ineffective Relaxation between contractions is inadequate One segment of the uterus may be contracting than the other segment

Interventions
> Administer morphine sulfate as ordered to relax hypertonicity
> Administer IVF as ordered or encourage fluid intake to prevent dehydration > Amniotomy

> Oxytocin infusion

> Cesarean delivery if NSVD is not possible

Protracted Active Phase

- usually associated with CPD or fetal malposition Cervical dilatation does not occur at a rate of atleast 1.2cm/h in a nullipara or 1.5cm/h in a multipara - active phae last longer than 12h in a primigravida or 6h in multigravida. - contraction is hypotonic - Cesarean birth if fetal malposition and CPD is present - If CPD is not present, oxytocin may be administered to augment labor

Secondary Arrest of Dilatation

-

There is no progress in cervical dilatation for more than 2 hours DYSFUNCTION AT THE SECOND STAGE OF LABOR

Prolonged Descent - occurs if the rate of descent is less than 1cm/h in a nullipara or 2cm/h in a multipara

Interventions
> Encourage rest and fluid intake
> Rupturing of the membrane may be helpful > IV oxytocin administration for effective

contraction > Place client in semi-Fowlers position, squatting, kneeling > Encourage more effective pushing ( if no CPD or Fetal Malpresentation )

Arrest of Descent
hour in multipara and 2 hours in nullipara Risk Factor: CPD
> Cesarean birth > If no contraindication for NSVD, oxytocin may be administered to assist labor
- no descent has occured for 1

Contraction Rings
Two Types
1. Pathologic Retraction Ring
2. Constriction Ring

Pathologic Retraction Ring

- Bandls ring - most common - occurs at the juncture of the upper and lower uterine segments that forms as a warning sign that severe dysfunctional labor is occuring - usually appears during the second stage of labor as a horizontal indentation across the abdomen - it is formed by excessive retraction of the upper uterine segment - the uterine myometrium is much thicker above than below the ring

Constriction Ring

- occur at any point in the myometrium

and at any time during labor

When a pathologic ring occurs in early labor, it is usually caused by uncoordinated contractions. In the pelvic division of labor, usually caused by obstetric manipulation or by the administration of oxytocin

Complications
Uterine rupture Death of the fetus Massive maternal hemorrhage (placenta is loosened but then cannot be delivered preventing the uterus to contract)

Interventions

> Observe abdomen during FHB monitoring > Administration of IV morphine sulfate or the inhalation of amyl nitrite > Administration of tocolytic agent to halt contractions > cesarean birth to ensure safety of the fetus > Manual removal of the placenta under general anesthesia > Report promptly any untoward findings

Precipitate Labor and Birth

- a labor that lasts less than 3 hors from the onset of contractions to the time of birt - occur when uterine contrations are so strong that the woman gives birth with only a few, rapidly occuring contractions - can be predicted from a labor graph (during active phase, the rate is > 5cm/h or 1cm/12 minutes in a nullipara, 10 cm/h or 1 cm/6 minutes in multipara ) - occured at the highest rate (21.9) among women age 35-39 and at the lowest rate (11.7) among women younger than 20 years

Risk Factors: Grand multiparity, induction of labor

by oxytocin or amniotomy, history of precipitous labor, hypertonic uterine contractions that ate tetanic in intensity

Complications:

Premature separation of the placenta > mother at risk for hemorrhage Uterine rupture Lacerations of the birth canal Amniotic fluid embolism Sudden release of the pressure on the head > fetus at risk for intracranial hemorrhage Fetal hypoxia caused by decrease periods of uterine relaxation between contractions

Interventions

> Monitor maternal and fetal status > Assess the previous delivery of client > Administer a tocolytic agent to reduce the force and frequency of contraction > Caution a multiparous woman by week 28 of pregnancy that her labor might be shorter than a previous one > Woman with prior precipitate labor should alerted that they may deliver this way again > Both multiparas and woman with histories of precipitate labor should have the birthing room converted to birth readiness before full dilatation

Uterine Rupture

- occurs when a uterus undergoes more strain than it is capable of sustaining - accounts for as many as 5% of all maternal deaths - impending rupture may be preceded by a pathologic retraction ring and by strong uterine contractions without any cervical dilatation - can be complete, going through the endometrium, myometrium, and peritoneum layers, or incomplete, leaving the peritoneum intact. - fetal death will follow unless immediate cesarean birth can be accomplished

Risk Factors:

* Prolonged labor

* Abnormal presentation * Multiple gestation * Unwise use of oxytocin * Obstructed labor * Traumatic maneuvers of forceps or traction * Vertical scar from previous cesarean birth or hysterotomy

Signs and symptoms

1. Pathologic ring 2. A sudden, severe pain during a strong labor contraction ( woman may report a tearing sensation) 3. with a complete rupture, uterine contractions will immediately stop 4. two distinct swellings is visible in the womans abdomen The retracted uterus The extrauterine fetus

 5. Hemorrhage from the torn uterine arteries floods into the abdominal cavity and possibly into the vagina > shock begins

Rapid, weak pulse Falling blood pressure Cold and clammy skin Dilatation of the nostrils from air hunger

 6. If the rupture is incomplete, a woman may experience a localized tenderness and a persistent aching pain over the area of the lower uterine segment
7. Maternal and Fetal distress

Interventions
> Close monitoring of the fetal heart sound and uterine contractions
> Administer emergency fluid replacement

therapy as ordered > Anticipate use of IV oxytocin to attempt to contract the uterus and minimize the bleeding > Prepare the woman for a possible laparotomy as an emergency measure to control bleeding and achieve a repair

 > Advise woman not to conceive again after a rupture of the uterus, unless the rupture occurred in the inactive lower segment
> Cesarean hysterectomy ( removal of the damaged uterus) > Tubal ligation at the time of laparotomy > Allow time to the woman and support person to express emotions without feeling threatened

Inversion of the Uterus

-

refers to the turning inside out of the uterus either during birth of the fetus or delivery of the placenta - occurring in about 1 in 15,000 births - inverted fundus may lie within the uterine cavity or the vagina - it may also protrude from the vagina

Risk Factors:
* If traction is applied to the umbilical cord to remove the placenta * If pressure is applied to the uterine fundus when the uterus is not contracted * If the placenta is attached to the fundus

Signs and Symptoms

1. A large amount of blood suddenly gushes from the vagina 2. The fundus is not palpable in the abdomen 3. a depression in the fundal area of the uterus 4. Woman has severe pain If blood loss is not checked, the woman may show signs of blood loss Hypotension Dizziness Paleness Diaphores

Interventions
> Assess vital signs > Never attempt to replace an inversion > Never attempt to remove the placenta if it is still attached >Start IV fluid line use a large-gauge needle > Administer oxygen via facemask > Be prepared to perform cardiopulmonary resuscitation (CPR) if the womans heart should fail

> The woman will immediately be given general anesthesia or possibly nitroglycerin or a tocolytic drug intravenously, to relax the uterus > Administer antibiotic therapy if needed > Inform the woman that cesarean birth will probably be necessary in any future pregnancy > Monitor for hemorrhage and signs of shock > Laparotomy with replacement is done

Preterm Labor
- cervical changes and uterine contractions occurring between 20 weeks and 37 weeks of pregnancy - may be associated with infection Preterm birth any birth that occurs before the completion of 37 weeks of pregnancy Preterm labor and preterm birth are the most serious complications of pregnancy because they lead to about 90% of neonatal deaths Preterm birth are 2nd only to congenital anomalies as a cause of infant death

Important Key Points

Preterm birth and Low birth weight are often used

interchangeably but they have distincly different meaning Preterm birth describes length of gestation regardless of the weight of the baby - more dangerous health condition because length of time in the uterus correlates with immaturity of body systems Low birth weight describes the weight at a time of birth - far easier to measure than preterm birth that is why other use this term for preterm birth

Risk Factors for Preterm Labor

Demographic Risks

Nonwhite race Age (<17 yr, >35 yr) Low socioeconomic status Unmarried Less than high school education

Biophysical Risks
Previous preterm labor and birth Second trimester abortion (More than two spontaneous or therapeutic); still births Grand multiparity; short interval between pregnancies

( 1 year since last birth); familty history of preterm labor and birth Progesterone deficiency Uterine anomalies Cervical incompetence Exposure to DES or other toxic substance Medical diseases (DM, HPN, anemia)

 Small stature (<119 cm in height; <45.5 kg or underweight

for height)

Current pregnancy risks: * multifetal pregnancy * hydramnios * bleeding * placental problems *gestational hypertension * PROM * Fetal anomalies *Inadequate plasma volume expantion; anemia

 Behavioral-Psychosocial Risks
* Poor nutrition; weight loss or low weight gain * Smoking (> 10 cigarettes a day) * Substance abuse (e.g., alcohol, ellicit drugs, especially cocaine) * Inadequate prenatal care * Commutes more than 1 hours each day *Excessive physical activity (heavy physical work, prolonged standing, heavy lifting, young child care) *Excessive lifestyle stressors

Assessment
* Infection is thought to be the major etiologic

factor

* Painful or painless uterine contraction * Abdominal cramping (may be accompanied by diarrhea) * Low back pain * Pelvic pressure or heaviness * Change in the character and amount of usual discharge; may be thicker or thinner, bloody, brown or colorless, and may be odorous * Rupture of amniotic membranes

Signs and Symptoms of Preterm Labor Uterine Activity

1. Uterine contractions more frequent than every 10 minutes persisting for 1 hour or more 2. Uterine contractions may be painful or painless

 Discomforts
1. Lower abdominal cramping similar to gas pains; may be accompanied by diarrhea 2. Dull, intermittent low back pain (below the waist) 3. Painful menstrual-like cramps 4. Suprapubic pain or pressure 5. Pelvic pressure or heaviness 6. Urinary frequency

Vaginal Discharge
1. Change in character or amount of usual discharge: thicker(mucoid) or thinner (watery), bloody or colorless, increased amount, odor 2. Rupture of amniotic membranes

Interventions
Focus on stopping the labor 1. Identify and treat infection 2. Bed rest a form of care of unknown effectiveness - with negative effect Monitor fetal status Administer fluids Administer medications as prescribed ( tocolytic and antenatal glucocorticoids) Education about the signs and symptoms of preterm labor

 > Encourage client to go on prenatal visit to detect

signs of preterm labor > If symptoms occur when the woman is engaged in any of activities, the woman should consider what she was doing when symptoms began, and then consider stopping those activities until 37 weeks of pregnancy > Individualized counselling about lifestyle modification > There are no specific rules for which activities are safe for pregnant women and which are not

Factors influencing the impact of preterm labor treatment:

Stability of the support system
Financial status Availability of child support and assistance

with household maintenance

 Medications Used in Preterm labor

1. Ritodrine 2. Magnesium sulfate

3. Terbutaline
4. Nifedipine 5. indomethacin

Predicting Preterm Labor and Birth

Biochemical Markers
Fetal fibronectin Salivary estriol

Endocervical Length

 * up to 94% - negative result

* < 46 % - positive result

Salivary estriol
- a form of estrogen produced by the fetus that is present in plasma at 9 weeks of gestation - have been shown to increase before preterm birth - specimen are collected by the woman in the home - the testing is done every 2 weeks for about 10 weeks

 * 98% - negative predictive value * 7% to 25% - positive predictive value

Endocervical length
- studies have suggested that a shortened cervix precedes preterm labor - can be determined by ultrasound measurement - women whose cervical length is 35 mm at 24 to 28weeks of gestation are more likely to have a preterm birth than women whose cervical length exceeds 40mm

 Fetal fibronectins

- are glycoproteins found in plasma and produced during fetal life - specimen is the cervical mucus - appear in cervical canal early in pregnancy and then again in late pregnancy - appearance between 24 and 34 weeks of gestation predicts labor - done during vaginal examination - can predict who will not go into pretem labor , but not who will

 Factors influencing the psyche of the client

in labor and the effect of fear, anxiety on labor progress

> Hormones and neurotransmitters released in response to stress can cause dystocia > Sources of stress vary for each woman, but pain and absence of support person are two recognized factors

 An idealized perception of labor and birth may be a

source of guilt and and a sense of failure especially when the pregnancy is unplanned or is a product of shaky or terminated relationship
Unresolve fears increase a womans stress and can

inhibit the process of labor as a result of the inhibiting effects of catecholamines associated with the stress response on uterine contractions

 > Confinement to bed and restriction of maternal movement can be a source of stress
> When anxiety is excessive, it can inhibit normal

cervical dilatation and result in prolonged labor and increased pain perception > Anxiety causes increased level of stress-related hormones > Increase hormones> acts on smooth muscles of the uterus> reduce uterine contractility> dystocia

Interventions
> Answer her questions or find out the answers
> Provide support for her and her support person and

family > Serve as a clients advocate (women equate emotional support with information giving)- give empowerment > Assures the woman that she is not expected to act in any particular way and that the process will end in the birth of the baby

 > Women with a history of sexual abuse

* Memories can be triggered during labor by

intrusive procedures such as vaginal examinations; loss of control; being confined to bed and restrained by monitors , IV lines, and epidurals; being watched by students; and experiencing intense sensations in the uterus and genital area, especially at the time when the woman must push the baby out

 > Women who are survivors of abuse may fight the

labor process by reacting in panic or anger toward care providers, may take control of everyone and everything related to their childbirth, may surrender by being submissive and dependent, or may retreat by mentally dissociating themselves from the sensations of labor and birth

Interventions
> Encourage the woman to associate the sensations

they are experiencing with the process of childbirth and not with their past abuse > Sense of control should be maintained by explaining all procedures and why they are needed, validating her needs and paying close attention to her requests > Proceeding at the womans pace by waiting for her permission to touch her > Accept her often extreme reactions to labor

 > Protect her privacy limit the exposure of her body and

number of persons involve in her care

It is recommended that all laboring woman

be cared for in this manner , because it is not unusual for a woman to choose not to reveal a history of sexual abuse

 What sets us apart from other species is that

we humans are driven by ambition. Some ambitions are specific, while others are vague. A life without ambition is a waste. Aim small, miss small. These aim quotes remind us to neverr stop marching towards our goal.

Thank You Very Much

God Bless