HIGH RISK LABOR AND DELIVERY

• 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)
  • Active (4-7cm dilatation, 30-45 sec contractions, 3-5 min frequency)
  • Transitional (8-10cm dilatation, 60-90 sec contractions, 2-3 min frequency)
• 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)
  • Pelvic dystocia
  • Cephalopelvic disproportion
  • Shoulder dystocia
  • Cord prolapse
  • Malposition
  • Malpresentation
  • Oversized fetus
  • Inability to bear down properly
  • Fear/anxiety
• Common causes of dystocia include primigravidastatus, pelvic bone contraction, poor fetal position, extension rather than flexion of the fetal head, overdistension of the uterus, a non-ripe cervix, presence of a full rectum or urinary bladder, and the woman becoming exhausted from labor
• 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 - upper segment contracts while lower segment relaxes
  • Pacemakers - two pacemakers at each cornua generate contractions in a coordinated fashion
• Hypotonic uterine dysfunction


  Contractions less than 2-3 in a 10-minute period, with resting tone less than 10mmHg and duration less than 20-30 seconds
• Hypertonic uterine contractions


  Single contraction >2 minutes, more than 5 contractions in 10 minutes, and increase in resting tone to >15 mmHg
• Uncoordinated uterine contractions


  More than one pacemaker initiating contractions, or receptor points acting independently
• Prolonged latent phase of labor

  True labor lasting more than 8 hours (14 hours for multigravida, 20 hours for primigravida) without entering active first stage
• Protracted active phase of labor

  True labor taking more than 12-14 hours (6 hours for multigravida, 12 hours for primigravida) without entering second stage
• Prolonged deceleration phase


  Extends beyond 3 hours in nullipara or 1 hour in multipara, with slowed progress in dilation and dysfunctional contractions
• Prolonged descent


  Rate of descent less than 1cm/hour in nullipara or 2cm/hour in multipara, or second stage lasting over 3 hours in multipara
• Arrest of descent


  No descent for 1 hour in multipara or 2 hours in nullipara, with failure of the fetus to engage or move beyond 0 station
• Prolonged labor


  • Cervical dilation slows to less than 1 cm/hour in nulliparas or 2 cm/hour in multiparas
  • Uterine contractions become dysfunctional, even after oxytocin administration
  • Cervix starts to swell and take on fluid
• Prolonged descent


  Rate of descent is less than 1 cm/hour in nulliparas or 2 cm/hour in multiparas
• Prolonged second stage


  Lasts over 3 hours in a multipara
• Arrest of descent


  No descent for 1 hour in a multipara or 2 hours in a nullipara
• Pathologic retraction ring


  Horizontal indentation running across the abdomen, caused by continuous retraction of the upper uterine segment and over-distension of the lower uterine segment

  
• Precipitate labor


  Cervical dilation of 5 cm/hour in nulliparas or 10 cm/hour in multiparas

  Labor completed in fewer than 3 hours
• Psyche factors in labor

  Inability to bear down properly

  Fear/anxiety about labor process