1. Introduction
3bRlH90

2. High Risk Intrapartum Nursing –Part I
Developed by D. Ann Currie RN, MSN
2012

3. Complications of Labor
Preterm Labor
Premature Rupture of Membranes
Dystocia
Labor Dysfunctions
Precipitous Labor and Birth
Fetal MalPositions
Fetal Malpresentations
Shoulder Dystocia
Prolapsed Umbilical Cord
Cephalopelvic Disproportion
Placenta Problems
Lacerations

4. Preterm Labor (PTL)
Define as a labor that occurs between weeks of pregnancy
Prematurity is the number one cause of neonatal mortality in USA.
Preterm births occurs in 11-12% of births

5. Preterm Labor-Risk Factors
Many factors may place a woman at risk for preterm labor: such as
antepartum hemorrhage
trauma
infections
lower socioeconomic status
Multiple gestation
See text for other causes

6. Preterm Labor Clinical Manifestations of PTL: Abdominal Pain Back Pain
Pelvic Pain
Menstrual –like Cramps
Increased Vaginal Discharge
Pelvic Pressure
Urinary Frequency
Diarrhea

7. Preterm Labor Treatment
Bedrest
Pelvic Rest
Hydration
Medications:
Tocolytics:
Beta agonists- terbutaline
Magnesium Sulfate
Calcium Channel Blockers-
Nifedipine (Procardia EL)
Indomethacin (Indocin)
Others: Antibiotics

8. No Treatment of PTL if the following conditions exit:
Fetal Demise
Lethal Fetal Anomaly
Severe Preeclampsia/ eclampsia
Hemorrhage/Abruptio placenta
Chorioamnionitis
Severe Fetal Growth Restriction
Fetal Maturity
Acute Nonreassuring Fetal Heart Pattern

9. Nursing
Teach all pregnancy clients the clinical manifestations of PTL and to report to their health care provider if they occur.
Teach self care measures to prevent PTL
Teach and assist in treatment of PTL
Prevent complications of Treatment-
Prolong bedrest
Tocolytic medications

10. Premature Rupture of Membranes (PROM)
PROM is defined as rupture of membranes one hour prior to labor starting.
Premature Premature Rupture of Membrane is rupture of membranes prior to 37 weeks. (PPROM)
Complications associated with PPROM:
Preterm labor
Infections
Oliohydramnios
Abruptio Placenta
Fetal Problems-IUGR, Pulmonary Hypoplasia, and other

11. Dystocia
Defined as an abnormal labor pattern that may occur because of abnormalities in the power, the passenger, or the passage.
It may encompass many things in labor.

12. Labor Dysfunctions Primary Labor dysfunction:
Hypertonic Labor Pattern is ineffectual uterine contractions of poor quality occurring in the latent phase of labor. UC are painful but do not dilate or efface the cervix.
It may cause:
Increased discomfort
Fatigue
Stress
Dehydration
Infection
Nonreassuring Fetal Heart Pattern

14. Primary Labor Dysfunction Hypertonic Labor Pattern
Management:
Rest
Hydration
Sedation - Sedatives such as :
Seconal
Dalmane
Morphine Sulfate

15. Secondary Labor Dysfunction Hypo tonic Labor Pattern
This is poor uterine contractions- irregular or low amplitude.
If not caused by CPD
Management:
Oxytocin (Pitocin)
Augmentation

16. Precipitous Labor and Birth
It is when the entire process of labor and birth occurs within 3 hours.
Precipitous Labor is when cervical dilation is 5cm or more per hour for a primigravida and 10 cm per hour for a multipara.
Precipitous birth is a sudden birth
It may be unattended or nurse attended birth.

17. Precipitous Labor and Birth
Complications: Abruptio placenta
Lacerations
Fetal Risks:
MAS,
Brachial Palsy,
Intracranial
Trauma
Management: Closely monitor
Scheduled induction in
control environment with
physician available

18. Fetal Mal position
Occiput posterior position (OP) is the most common mal position.
The client experiences intense BACK PAIN while in labor.
Complications:
Pain
3rd or 4th degree lacerations
or extension of episiotomy
Arrest of decent
C/S

19. Occiput Posterior Position (OP)
Position- Side –lying
Hand-and-knee position
Pelvic Rocking
Counter Pressure in small of back
Physician may have to assist in turn baby with forceps or vacuum extraction

20. Fetal Malpresentations :
Breech
Brow
Face
Shoulder
Complex

21. Breech Presentations

22. Breech Presentations
Breech Presentation is the most common malpresentation
About 4% of all Births
Frank Breech is the most common type of Breech. It is characterized by flexed hips and extended knees.
Footling Breech is characterized by one or both feet presenting.
Complete Breech

23. Breech Presentations Complications
Head Entrapment
Prolapsed Cord
MAS
Fetal Asphyxia and Hypoxia
Increased Risk for perinatal morbidity and morality.

24. Breech Presentation-during vaginal exam the nurse may feel the fetal anal sphincter

25. Piper Forceps should be on Delivery Table

26. Brow Presntations
Brow Presentations are the least common of all presentations.
In a Brow presentation the forehead is the presenting part.
Results in a prolonged labor or secondary arrest of labor.
C/S is best for delivery
Complications:
Extension of episiotomy or lacerations
Birth injuries to fetus: cerebral or neck
compression
Damage to the trachea and larynx.
Infant Mortality

27. Face Presentation

28. Face Presentation

29. Face Presentation A Mentoanterior position can be delivered vaginally.
A Mentoposerior position can not be delivered vaginally.
Complications of a face presentation:
Prolonged labor
Infection
C/S
Facial Trauma

30. Shoulder Presentation

31. Shoulder Presentation
Transverse Lie
Vaginal Birth is impossible
Cesarean Birth
Possibility of Prolapsed Cord if Membranes Rupture

32. Shoulder Dystocia An Obstetric Emergency Occurs with :
Macrosomic fetuses.
Obese woman or excessive weight
gain during pregnancy.
Woman of short statue.
Management:
McRoberts maneuver
Client should bring back legs/
thighs against abdomen
The nurse will apply suprapubic
anterior pressure to release anterior
shoulder.

33. Prolapsed Umbilical Cord

34. Prolapsed Umbilical Cord
When the umbilical cord precedes the fetal presenting part.
The cord may fall or be washed down through the cervix into the vagina or Trapped between the presenting part and the maternal pelvis
Occult cord prolapse may lay beside or just ahead of the fetal head

35. Prolapsed Umbilical Cord
Ant time the presenting part is not well engaged or firmly against the cervix, a prolapsed cord can occur.
This is an emergency because the cord can be compressed causing hypoxia and possible fetal death.
Prevent cord compression by manually preventing presenting part compressing the cord
Position- Knee-Chest position
( gynopectorus position) or Tendelburg

36. Prolapsed Umbilical Cord
Immediate Cesarean Section is needed
Remember to cover client when going through hall.

37. Placenta Problems Abruptio Placenta Placenta Previa
Placenta and Umbilical Cord Variations
Placenta Adherence :
Placenta Accreta
Placenta Increta
Placenta Percreta

39. Placenta Adherence- Retained Placenta
Placenta Accreta: is when the chorionic villi attaches directly to the myometrium. This is the most common form of placenta adherence.
Placenta Increta is when the placenta invades the myometrium.
Placenta Percreta is when the placenta penetrates the myometrium.
Complication is maternal hemorrhage.
Depending on the amount and depth of involvement will determine treatment

40. Lacerations
First Degree Laceration is limited to the fourchette, perineal skin, and vaginal mucous membrane.
Second Degree Laceration involves the perineal skin, vaginal mucous membrane, underlying fascia, and the muscles of the perineal body.

41. Lacerations
Third Degree Laceration extends through the perineal skin, vagina mucous membranes , and perineal body and involves the anal sphincter and may extend up the anterior wall of the rectum.
Fourth Degree Laceration extends through the rectal mucosa to the lumen of the rectum.

42. 3th and 4th Degree Lacerations
Care:
Get order for ice pack
Pain medications
Stool Softener
Pericare
Sitzbath
Remember nothing in rectum-
No Suppostories
No Enemas
No Rectal Exams

43. The End of Part I

44. QUESTIONS

45. THANK YOU

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