HIGH RISK LABOR and DELIVERY

4 PsPassengerPassagewayPowerPsych

PASSENGER1. Fetal LieTransverse lieLongitudinal lie

2. PresentationCephalicBreechShoulder

3. PositionAnteriorOcciputLOA

4. AttitudeRelationship of fetal part to one another

5. StationRelation to ischial spine

PASSAGEWAY refers to the adequancy of pelvis and birth canal.

PELVISFALSE PELVIS can support pregnant uterusTRUE PELVIS bony canal of the mothers pelvis

TYPES of PELVISGYNECOID round pelvic shapeANDROID heart shape pelvisPLATYPELLOID inlet oval in shape, with long transverse diametersANTROPOID inlet oval in shape with long anteroposterior diameter

POWERPRIMARY 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

Increment building up of contractionAcme peak of the contractionDecrement letting up of contraction

POWER compose of :FrequencyDurationIntensityRegularityEffacementDilatation

PSYCHFighting for the labor experience.

FACTORCultural HeritagePrevious ExperienceSupport SystemSelf esteemTrauma

PASSENGER PROBLEMFETAL MALPOSITIONOCCIPITOPOSTERIOR POSITION ( OPP ) ASSESSMENTAssess type of pelvisIt can develop dysfunctional labor pattern and prolonged active phase.

MANAGEMENTBack rub or pressure on sacrum.

2. TRANSVERSE LIEoccurs in woman with pendulus abdomen, contraction of the pelvic brim, hydramions, congenital uterine structure, ovoid uterus.Ovoid Uterus more horizontal than vertical uterus

ASSESSMENTLeopolds ManueverConfirmed by Sonogram

NURSING MANAGEMENTCS Birth

3. LOP and ROP- most common malposition and painful

ASSESSMENTLeopolds ManueverUltrasound

NURSING MANAGEMENT1. Put mother on squatting position to lessen low back pain.

B. FETAL MALPOSITIONVERTEX MALPRESENTATIONBrow Presentation- rarest condition occurs with a multipara or weak abdominal muscle.

ASSESSMENTThrough IE

MEDICAL MANAGEMENTCS Birth

2. FACE PRESENTATIONMentumProportional to the pelvisMaking difficult labor to proceed

ASSESSMENTIE Leopolds Manuever

NURSING MANAGEMENTCS Birth

3. BREECH PRESENTATION

TYPESFrankFootlingShoulderComplete

MATERNAL FETAL RISKDysfunctional LaborAnoxiaTraumatic InjurySpine or arm fracture

MANAGEMENT

Frequent monitoring of FHR and uterine contractionTurn patient to the left side.

4. SHOULDER PRESENTATIONOccurs at the 2nd stage of laborShoilder are too broad, scapula, horizontal or transverse position

ASSESSMENTNot often identified until head is born

MANAGEMENTApply pressure on suprapelvis areaMcRobert ManueverCS Birth

C. FETAL DISTRESSCAUSECord CompressionPlacental AnomaliesPreexisting maternal disease

Signs and SymptomsDeclaration of FHTMeconium stain, amniotic fluid with vertex position

NURSING MANAGEMENT

Check the FHR on appropriate basis.Conduct vaginal exam for presentation and positionPlace the mother on the left side to prevent impede of blood circulationAdminister O2 check for prolapse cordSupport mother and familyPrepare emergency birth as indicated 100 beats per minutes

D. PROLAPSED CORD

CAUSES or FACTORDisplacement of the cord in a downward positionWhen membrane rupturedWith enduring contractionAssociated with breech presentationUnengaged laborPremature labor/rupture

OBSTETRIC EMERGENCYIf compression of cord occurs, fetal asphyxia and damage in CNS may occur or death.

ASSESSMENTVaginal examination to identify cord prolapse in the vagina

NURSING MANAGEMENTCheck FHT immediately when membrane rupture and again after next contraction or within 5 minutes before declarationIf fetal bradycardia, perform vaginal examination and check for prolapsed cord to determined the case.If cord prolapsed into the vagina, exert upward pressure against presenting part, lift part of the cord reducing pressure on cord. 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 pelvisComplications:inlet contraction- ordinary due to rickets in the early life or congenitally small pelvisAssessment- AP diameter Narrows to less than 11cm; maximum transverse diameter is 12cm or lessManagement- pelvic measurements before 24th week of pregnancyCS birth

Outlet contraction Outlet contraction is the distance between the ischial tuberositesAssessment - Descent of the presenting part - Dilatation of the cervixManagement frequently monitor fetal heart soundsencourage the client to void every 2hrsCS birth is indicated if adequate progress in labor cannot be documented after a definite period (6-12hrs), 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 continuouslyManagement- 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 canalit 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 birthit 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 CPDincrease fetal weightVery large babies due to hereditary reasons. Weight is estimated to be about above 8kg or 10lbs.post mature babies when pregnancy goes above

fetal positionoccipito- posterior position where the fetus faces the mothers abdomen instead of her backbrow presentationface presentation

problems with the pelvissmall pelvisabnormal shape of the pelvis due to diseases like rickets, osteomalacia, or TBabnormal shape of the pelvis due to previous accidentstumor of the bones

childhood poliomyelitis affecting the shape of the hipscongenital dislocation of the hipscongenital deformity of the sacrum and the coccyxcongenital 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 perineumIt 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.

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

Methodsa. 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 suppositoryb. Administration of oxytocin- IV infusion of oxytocin to initiate uterine contractionsc. Active management of labor- aggressive 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 head3.) Vacuum extraction- causes fever, laceration of the birth canal compared to forceps birth- contraindicated to preterm infants

Problems with the PowerClassification Hypertonic Uterine dysfunction Hypotonic Uterine dysfunction Abnormal progress during labor Uterine Rupture Uterine Prolapse

a. Hypertonic Uterine dysfunctionUsually encounter in latent stage of labor.

Management:Evaluation of pelvic sizeMaintenance of fluid and electrolyte balance in IVFTherapeutic rest, anlagesic, morphine and sedative.Keep bladder empty.Provide more space for the passage of fetusWatch for danger sign

b. Hypotonic Uterine dysfunctionUncoordinated poor maturity, lack of progressCharacterized by weak and infrequent contraction which are insufficient to dilate the cervixUsaully occurs during active phaseUterus are easily undepable.

Causes in hypotonic uterine dysfunctionOver distention of the uterine,multiple pregnancy and hyramniosMalpresentation and malpositionPelvic bone contractionUnripe cervixCongenital abnormalities of the uterusUnknown cause

ComplicationsMaternal and Fetal infectionPost partum hemorrhageFetal distress and deathMaternal exhaustion

ManagementRe-evaluate the pelvic size to rule out fetopelvic disproportionAmniotomyObmentation laborIf contracted pelvis is the cause , CS is performed.

C. Abnormal Progress During labor

IndicationNulliparaMultiparaProlonged latent phase>20 h>14 hAverage second stage50 min20 minProlonged second stage without (with) epidural>2 h (>3 h)>1 h (>2 h)Protracted dilation< 1.2 cm/h< 1.5 cm/hProtracted descent< 1 cm/h< 2 cm/hArrest of dilation*>2 h>2 hArrest of descent*>2 h>1 hProlonged third stage>30 min>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 Ruptureis a potentially catastrophic event duringchildbirthby which the integrity of themyometrialwall is breached. In an incomplete rupture theperitoneumis 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 earlylabor, but may already develop during late pregnancy.Uterinedehiscenceis a similar condition, but involves fewer layers, less bleeding, and less risk.

e. Uterine prolapseis a form offemale genital prolapse(also called pelvic organ prolapse or prolapse of the uterus (womb).Treatment is surgical, and the options includehysterectomyor a uterus-sparing techniques such as HysteropexyorManchester 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 the uterus cannot stay in place and slips down from its normal position. These ligaments are theround ligament,uterosacral ligaments,broad ligamentand theovarian ligament. The utereosacral ligaments are by far the most important ligaments in preventing uterine prolapse.

PLACENTAL PROBLEMSPLACENTA ACCRETAPlacenta accretais a severeobstetriccomplication involving an abnormally deep attachment of theplacenta, through the endometriumand into themyometrium(the middle layer of theuterine 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 childbirthare at great risk ofhemorrhageduring its removal. This commonly requiressurgeryto stem the bleeding and fully remove the placenta, and in severe forms can often lead to ahysterectomyor be fatal.

There are multiple variants, defined by the depth of their attachment to uterine wall:

TypeDescriptionPercentplacenta accretaAn invasion of the myometrium which does not penetrate the entire thickness of themuscle. This form of the condition accounts for around 75% of all cases.75-78%placenta incretaOccurs when the placenta further extends into the myometrium, penetrating the muscle.17%placenta percretaThe worst form of the condition is when the placenta penetrates the entire myometrium to the uterineserosa(invades through entire uterine wall). This variant can lead to the placenta attaching to other organs such as the rectum orbladder5-7%

DIAGNOSISPlacenta accreta is very rarely recognized before birth, and is very difficult to diagnose. A Dopplerultrasoundcan lead to the diagnosis of a suspected accreta and anMRIwill 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 serumalpha-fetoproteinlevels, 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 FACTORSThe condition affects around 10% of cases ofplacenta previa, and is increased in incidence by the presence ofscar tissuei.e.Asherman's syndromeusually from past uterine surgery, especially from a pastDilation and curettage,(which is used for many indications including miscarriage, termination, and postpartum hemorrhaging), myomectomy,orcaesarean section. A thindeciduacan also be a contributing factor to suchtrophoblasticinvasion. Some studies suggest that the rate of incidence is higher when thefetusis female.

TREATMENTThe safest treatment is a plannedcaesarean sectionand abdominalhysterectomyif 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 includeleaving the placenta in the uterusintrauterine balloon catheterization to compress blood vesselsembolisation of pelvic vesselsIf the woman decides to proceed with a vaginal delivery, blood products for transfusion should be prepared.

PLACENTA INCRETAplacenta incretaplacenta accretawith penetration of the myometrium.PLACENTA PERCRETAA 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 types1.) post partum blues2.)post partum depression without psychotic features3.)post partum depression with psychotic features

EtiologyPredisposing FactorsHistory of puerperal psychosis or bipolar old name is manic depressive disorderDelirium and hallucinationRapid mood changeAgitation or confusionPotential for suicide or infanticide

2.)post partum depression3 perspectiveBiological theory- alteration in hypothalamus functionpsychological theory- poor support system and poor relationship with the partnersSociocultural theories- low level of social gratification support, control both at work and in parenting rate

Assessment of post partum bluesFatigueWeepingAnxietyMood instability with onset 1-10 days lasting 2weeks

Manifestation of post partum depression with psychosisPost partum depression plus hallucination, dillution, auditory illutionHyperactivityManagement1.) Identify post partum mood disorderBe aware for the signs and symptomsTeach the client and family about the disorder

2.) support and treat the client and familyDevelop specific therapeutic goalMaintain prescribe medication scheduleKeep communication open with the health care provider and coordinate with the social servicesInclude family participation involvement in planning of care

3.) support effort at parent-newborn bondingProvide support for the mother to continue care for the newbornPlan for continuity of care for the newborn, mother and family

Problem related to sexual response and reproduction

UTI2 typesCystitis lower part, urethra and bladderPyelonephritis upper part, ureter and kidney

Infertility 2 typesPrimary infertility no pregnancy at allSecondary infertility theres a 1st pregnancy and no more next pregnancy

High riskTruck driversFitted pants

Female infertilityThyroid disorderAdrenal diseaseSignificant liver and kidney diseaseHypothalamic pituitary factorHypopituitary cellHypothalamic dysfunctionKallman syndromehyperprolactinemia

Any ovarian factorsPolycystic ovarian syndromeInovulationDiminished ovarian reserveLutheal dysfunctionPremature menopouseGonadal dysgenesisOvarian neoplasmTubal or peritoneal factorTubal dysfunction

Uterine factorsUterine malformationUterine fibroidAshermans syndromeCervical factorsCervical stenosisAnti sperm antibodiesInsufficient cervical mucousVaginal factorsVaginismusVaginal obstraction

Genetic factorsAndrogen insensitivity syndrome

Male Infertility Factors

1. Pretesticular CausesEndocrine problem like diabetes and thyroid disorderHypothalamic disorderCushing SyndromeHyperprolactinemiaHypopituitaryceleDrug and alcohol

2. Testicular CausesGenetic defects of white chromosomeWhite chromosome micro deletionAbnormal set of chromosomesNeoplasm such as semilomaIdiopathic failure

VaricoceleTraumaHydroceleMumps leading to orchitisTesticular dysgenesis syndrome

3. Post-testicular CausesVasdeferens obstructionInfectionProstatitisEjaculation/retrogradeHypospadia

ImpotenceAcrosomal defect or egg penetration defectLow sperm count in men

Diagnostic Test

1. Paternal TestComprehensive installing physical examSemen analysis (20million/cm)Progressive sperm motility more than 50%Ejaculation volume of more than 2mlPoor PrognosisMotility less than 50%Ejaculation less than 2ml

2. Maternal TestSims Huchner TestIt 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 secretionUnreliable

Endometrial biopsyHormonal testingThyroid testingLaparoscopyMeasurement of the progesterone in the 2nd half of pregnancyPap smear Pelvic examSpecial X-ray test

Management For Fertility MedicationsClomid (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

Parlodel (Bromocriptine Mesylate)Action: Anti-hyperprolactinemia, use clomidSide Effects: Multiple pregnancies

Restoration Tubal Patency (Tuboplasty)

Hysterosalpingonacele Artificial inseminationInvitro fertilizationAlternative and complementary treatmentAcupunctureDiet and supplementHealthy Lifestyle