Cmca Maternal

• High risk labor and delivery


  Refers to potential complications that can occur during labor and delivery, which nurses need to identify and respond to in order to improve maternal and neonatal outcomes
• Most pregnant women go into labor spontaneously and have a normal labor and spontaneous vaginal birth. However, many potential complications can occur.
• Normal labor


  Refers to the presence of regular uterine contractions that cause progressive dilatation and effacement of the cervix and fetal descent
• Characteristics of normal labor

  • 95% of women in labor will have 3-5 contractions per 10 minutes
  • Full cervical dilatation is usually achieved 4 hours after 4 cm dilatation
  • Strength of contractions is at least 25mmHg
• Stages of normal labor

  • Latent (0-3cm cervical dilatation, 10-30 sec contractions, 5-30 min frequency, mild intensity)
  • Active (4-7cm dilatation, 30-45 sec contractions, 3-5 min frequency, moderate to strong intensity)
  • Transitional (8-10cm dilatation, 60-90 sec contractions, 2-3 min frequency, a woman may experience a feeling of loss of control, anxiety, panic, or irritability)
• Dystocia


  A broad term referring to prolonged labor (any labor that lasts more than 24 hours) caused by an abnormality or a combination of abnormalities in the essential factors of labor
• Factors that can cause dystocia

  • Powers of labor (uterine contractions)
  • Passenger (fetal aspects/position)
  • Passage (pelvis)
  • Psychological response of the woman
• Causes of dystocia


  • Ineffective Uterine Force (Hypotonic, Hypertonic or uncoordinated contractions)
  • Dysfunctional labor and associated stages of labor
  • Precipitate Labor
  • Uterine rupture
  • Pelvic dystocia
  • Cephalopelvic disproportion (CPD)
  • Shoulder dystocia
  • Cord prolapse
  • Malposition
  • Malpresentation
  • Oversized Fetus
  • Inability to Bear Down Properly
  • Fear/Anxiety
• Uterine contractions


  The basic force moving the fetus through the birth canal, caused by the interplay of contractile enzymes, electrolytes, contractile proteins, hormones, and prostaglandins
• Normal uterine contractions


  • Polarity of uterus - upper segment contracts while lower segment relaxes
  • Pacemakers - two pacemakers situated at each cornua of the uterus that generate contractions in a coordinated fashion

  
• Hypotonic uterine dysfunction


  Contractions less than 2-3 in a 10-minute period, resting tone less than 10mmHg and does not rise above 25 mmHg, duration less than 20-30 seconds, occurring during the active stage of labor
• Hypertonic uterine contractions


  Single contraction >2 minutes, more painful, contractions that are >5 in 10 minutes, increase in resting tone to more than 15 mmHg, occurring more frequently during the latent phase of labor
• Uncoordinated uterine contractions


  More than one pacemaker (contraction point) may be initiating contractions, or receptor points in the myometrium may be acting independently of the pacemaker, making the contractions uncoordinated
• Prolonged latent phase of labor

  When true labor lasts for more than about 8 hours without entering into the active first stage for a multigravida, or more than 20 hours for a primigravida
• Protracted active phase of labor

  When true labor takes more than about 12-14 hours without entering into the second stage for a primigravida, or more than 6 hours for a multigravida, with cervical dilatation <1.2 cm/hr in nullipara or <1.5 cm/hr in multipara
• Prolonged deceleration phase


  When it extends beyond 3 hours in a nullipara and 1 hour in a multipara, with progress in dilation slowing after 8 cm and uterine contractions becoming dysfunctional
• Prolonged descent


  Occurs if the rate of descent is less than 1.0cm/hour in a nullipara or 2cm/hr in a multipara, or if the second stage lasts over 3 hours in a multipara
• Arrest of descent


  No descent has occurred for 1 hour in a multipara or 2 hours in a nullipara, with failure of the expected descent of the fetus
• Abnormal fetal head position

  • Cervix starts to swell and take on fluid
  • Uterine contractions become dysfunctional, even after oxytocin administration
• Management


  Cesarean delivery
• Prolonged descent


  1. Rate of descent is less than 1.0cm/hour in a nullipara or 2cm/hr in a multipara

  2. Second stage lasts over 3 hours in a multipara

  3. Contractions become infrequent and of poor quality and dilatation stops
• Management of prolonged descent

  1. Rest and fluid intake

  2. Rupture membranes if not already ruptured

  3. IV oxytocin

  4. Semi-fowler's, squatting, and kneeling position and encourage mother to push effectively
• Arrest of descent


  • No descent has occurred for 1 hour in a multipara or 2 hours in a nullipara
  • Failure of descent has occurred when expected descent of the fetus does not begin or engagement or movement beyond 0 station has not occurred
• Cause of arrest of descent

  Cephalopelvic disproportion (CPD)
• Pathologic retraction rings

  • Also known as Bandl's ring
  • A horizontal indention running across the abdomen or division of the two uterine segments that become very prominent which was caused by the continuous retraction of the upper segment and the over distention of the lower uterine segment
• Management of pathologic retraction rings

  1. Administration of IV morphine or inhalation of amyl nitrite may relieve a retraction ring

  2. Tocolytics can be administered to stop labor and contractions

  3. Manual removal of the placenta under general anesthesia may be required if the retraction ring does or allow the placenta to be delivered

  4. Cesarean Delivery will be necessary to ensure safe birth of the fetus
• Precipitate labor and birth

  • Cervical dilatation 5 cm/hour in primipara or 10 cm/hour in multipara
  • Labor that is completed in fewer than 3 hours
• Classification of precipitate labor

  • Precipitate Dilatation - cervical dilatation is progressing at 5 cm or more per hour in nulliparas, 10 cm or more per hour in multiparas
  • Precipitate Descent - fetal descent is progressing at 5 cm or more per hour in nulliparas, 10 cm or more per hour in multiparas
• Causes/risk factors of precipitate labor

  • Grand multiparity
  • Induced labor through amniotomy or oxytocin
  • Previous history of precipitate labor
  • Baby's size is smaller than the average size
  • Use of prostaglandin to induce labor
  • Absence of painful sensation causing the woman to be unaware that vigorous labor is occurring
• Signs and symptoms of precipitate labor


  • Similar to women with normal labor pattern but appears suddenly without warning
  • Patient complains of sudden intense urge to push
  • Sudden increase in bloody show
  • Sudden bulging of the perineum
  • Sudden crowning of the presenting part
• Management of precipitate labor

  1. Anticipatory guidance (prevention) - prenatal care (early detection)

  2. If accelerated labor occurs during oxytocin administration, stop infusion immediately and turn woman on her side

  3. Tocolytics may be administered to reduce force and frequency of contractions

  4. Do not leave patient alone

  5. Prepare for delivery: birthing area be ready before full dilatation

  6. Ask woman to pant and not to push when head is already crowning to prevent rapid expulsion
• Complications of precipitate labor

  • Maternal: Laceration of birth canal & uterine rupture, Premature separation of placenta, Postpartum hemorrhage, Amniotic fluid embolism
  • Fetal: Hypoxia, Subdural hemorrhage due to sudden change of intracranial pressure, Injuries (fall)
• Uterine rupture


  • Tearing of uterine muscles occurs when the uterus can no longer withstand the strain
  • Rare but often a fatal complication of labor
• Causes of uterine rupture

  • Rupture of scar from previous CS
  • Prolonged labor, obstructed labor, malposition and malpresentation
  • Over distention of the uterus from multiple gestation or hydramnios
  • Injudicious use of oxytocin, forceps and vacuum extraction
  • Precipitate labor and delivery
  • Manual removal of the placenta
  • External trauma –sharp or blunt
  • Gestational trophoblastic neoplasia
• Signs and symptoms of uterine rupture

  • Impending uterine rupture –pathologic retraction ring
  • During the peak of contraction, the woman complains of a sudden sharp tearing pain, then felt relieved as the uterus loses the capacity to contract or contractions are too weak
• Types of uterine rupture

  • Complete Rupture - Woman experiences a sudden excruciating pain at the peak of a contraction, and then contractions stop altogether. Two swellings will be visible in the abdomen: the uterus and the extra-uterine fetus. Internal hemorrhage soon follows and vaginal bleeding may or may not occur because blood from torn uterine vessels pools in the peritoneal cavity. Placental separation results in fetal hypoxia/death
  • Incomplete Rupture - Localized tenderness and persistent pain over the abdomen. Contractions may still continue or stop but no progress in cervical dilatation will be observed. Vaginal bleeding may or may not occur because blood pools in the peritoneal cavity. As blood supply to the fetus is cut off, fetal distress occurs and FHT soon becomes absent. A sign of maternal shock occurs as manifested by rapid and thread pulse, hypotension, air hunger, and cold clammy skin
• Management of uterine rupture

  1. Anticipate need for immediate CS delivery

  2. Blood transfusion and IVF administration to correct shock

  3. O2 therapy (mask) at 8L/m

  4. Prepare client for emergency laparotomy

  5. Provide emotional support

  6. For ruptured upper segment –BTL. For extensive damage, hysterectomy is performed

  7. Post op care –no extensive physical activity for 6-8 weeks
• Uterine prolapse

  Falling or sliding of the uterus from its normal position in the pelvic cavity into the vaginal canal
• Causes/risk factors of uterine prolapse

  • Weakened ligaments and connective tissues that hold the uterus in place
  • Multiparity
  • Obesity
  • Insufficient prenatal care
  • Birth of large infant
  • Prolonged 2nd stage of labor
  • Bearing-down efforts
  • Extraction of baby before full dilatation
  • Instrument birth
  • Poor healing of perineal tissue postpartally

  
• Signs and symptoms of uterine prolapse

  • A feeling as if "sitting on a small ball" or as if something is falling out of your vagina
  • Difficult or painful sexual intercourse
  • Low backache
  • Tissue protrusion from the vaginal opening
  • Sensation of heaviness or pulling in your pelvis
  • Vaginal bleeding