Nancy Pares, RN, MSN
Metro Community College
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Identify the pathophysiology and nursing
process of various high risk labor factors in
the intrapartal period.
Review types of bleeding disorders and
associated nursing interventions
◦ Umbilical cord abnormalities, placenta previa,
abruption and DIC
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Threatened abortion
Imminent abortion
Incomplete abortion
Complete abortion
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Missed abortion
Recurrent pregnancy loss
Septic abortion
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Bed rest
Abstinence from coitus
D&C or suction evacuation
Rh immune globulin
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Assess the amount and appearance of any
vaginal bleeding
Monitor the woman’s vital signs and degree
of discomfort
Assess need for Rh immune globulin.
Assess fetal heart rate
Assess the responses and coping of the
woman and her family
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Maternal hypertension
Domestic violence
Abdominal trauma
Presence of fibroids
Uterine overdistension
Fetal growth restriction
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Advanced maternal age
Alcohol consumption
Cocaine use
Short umbilical cord
High parity
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Marginal
Central
Complete
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Multiparity
Increasing age
Placenta accreta
Defective development of blood vessels in the
decidua
Prior cesarean birth
Smoking
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Recent spontaneous or induced abortion
Large placenta
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Total
Partial
Marginal
Low-lying
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Succenturiate placenta
Circumvallate placenta
Battledore placenta
Prolapsed umbilical cord
Velamentous insertion
Occult
(hidden,
cannot be
seen or felt)
Complete
(cannot be
seen, but may
be felt)
Visible
(can be seen
protruding
from vagina)
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Velamentous insertion
◦ Developmental
abnormality which may
cause decreased fetal
perfusion
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Vasa previa
◦ Cord vessels over os
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Cord compression
◦ During descent
◦ Cord wrapping
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Cord prolapse
◦ Cord precedes fetus
◦ Check EFM
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Vasa previa
Cord length problems
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Describe the pathophysiology and nursing
process of abnormal labor patterns or fetal
malpositioning.
◦ Hypertonic, hypotonic, prolonged, precipitous
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Dystocia
Hypertonic contractions
Hypotonic contractions
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Characterized by uterine irritability, poor resting
tone, frequent contractions
Risks
◦ Maternal exhaustion, pain
◦ Infection
◦ Maternal/fetal injury
Management
◦ Rest, hydration, sedation
◦ Labor augmentation (oxytocin, AROM)
Contributing factors
◦ Primip, fetal position, flexion of fetal head, size
of baby
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Assessment
◦ Uterine activity, cx change, membranes, fetus, and
mom
◦ Fetal tolerance of labor
 EFM pg 578
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FHR
Variability
Periodic changes
See Perifacts online
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Risk for infection
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Acute pain
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Deficient knowledge
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Fatigue
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Anxiety
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Outcome statements –
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Hypertonic can evolve into normal pattern
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If ineffective continues: c/delivery
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RN responsible for reporting and
documenting data in time current
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Characterized by contractions that are inadequate in
frequency, duration, intensity
Risks
◦ Maternal exhaustion from long labor
◦ Infection
◦ Maternal/fetal injury
Management
◦ Rest, hydration, sedation
◦ Labor augmentation (oxytocin, AROM)
Contributing factors
◦ Large fetus,malpresentation,early or repeated maternal
sedation
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The same in all aspects of process to
hypertonic
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Labor that progresses rapidly (< 3hrs after
onset of uterine activity)
Contributing factors
◦ Grand multip, small fetus, relaxed pelvic muscles,
hx of same
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Risks
◦ Uncontrolled delivery
◦ ACOG allows for induction with contributing factors
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Assessment
◦ Thorough hx, EFM, fetal position changes, (U/S),
client responses, fetal tolerance
◦ Be alert for amniotic fluid emboli, uterine atony
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Nursing dx
◦ Risk for soft tissue injury
◦ Risk for infection
◦ Anxiety
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Abruptio placentae
Cervical, vaginal, or perineal lacerations
Postpartum hemorrhage
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Discuss the nursing process associated with
high risk labor conditions
◦ PPROM, PTL, Cord issues, EFM, Multiples, CPD,
Malposition, amniotic fluid issues, VBAC, induction
and incompetent cervix
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Malpositions
Cephalopelvic
disproportion
Macrosomia
Multiple gestation
Fetal distress
Uterine rupture
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Placenta previa
Abruptio placentae
Umbilical cord
prolapse
Polyhydramnios/
oligohydramnios
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Determine duration of PROM
Assess gestational age
Observe for signs and symptoms of infection
Assess hydration status
Assess fetal status
Assess childbirth preparation and coping
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Encourage resting on left side
Provide comfort measures
Provide education
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Identify risk for preterm labor
Assess change in risk status for preterm labor
Assess educational needs of the woman and
her loved ones
Assess the woman’s responses to medical
and nursing intervention
Teach about the importance of recognizing
the onset of labor
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Uterine contractions occurring every 10
minutes or less
Mild menstrual like cramps felt low in the
adbomen
Constant or intermittent feeling of pelvic
pressure
Rupture of membranes
Low, dull backache, which may be constant or
intermittent
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A change in vaginal discharge
Abdominal cramping with or without diarrhea
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Noninvasive
Easy to place
May be used before and following rupture of
membranes
Can be used intermittently
Provides a permanent, continuous recording
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The nurse must compare subjective findings
with monitor
The belt may become uncomfortable
The belt may require frequent readjustment
The mother may feel inhibited to move
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Provides pressure measurements for
contraction intensity and uterine resting tone
Allows for very accurate timing of UCs
Provides a permanent record of the uterine
activity
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Membranes must be ruptured and adequate
cervical dilation must be achieved
Invasive
Increases the risk of uterine infection or
perforation
Contraindicated in cases with active
infections
Use with a low-lying placenta can result in
placenta puncture
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Uses minimum instrumentation
Is portable
Allows for maximum maternal movement
Convenient and economical
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Can only provide the baseline fetal heart rate,
rhythms, and obvious increases and
decreases
Does not provide a permanent record
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Produces a continuous graphic recording
Can show the baseline, baseline variability,
and changes in the FHR
Noninvasive
Does not require rupture of membranes
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Is susceptible to interference from maternal
and fetal movement
May produce a weak signal
Tracing may become sketchy and difficult to
interpret
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Clearer tracings
Provides information about short term
variability
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Infection
Injury
Requires ruptured membranes and sufficient
cervical dilatation
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Is the fetal lie longitudinal or transverse?
What is in the fundus? Am I feeling buttocks
or head?
Where is the fetal back?
Where are the small parts or extremities?
What is in the inlet? Does it confirm what I
found in the fundus?
Is the presenting part engaged, floating, or
dipping into the inlet?
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Baseline FHR
◦ Mean FHR during 10 minute period
◦ Must be observed for 2 minutes
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Changes in FHR
◦ Episodic – not associated with uterine contractions
◦ Periodic – associated with uterine contractions
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Fetal tachycardia
◦ Baseline greater than 160 bpm for at least a 10minute period
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Fetal bradycardia
◦ Baseline less than 110 bpm for at least a 10-minute
period
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Tachycardia
Bradycardia
Accelerations
Sinusoidal
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Absent – amplitude undetected
Minimal – amplitude range detectable but ≤ 5
bpm
Moderate – amplitude range of 6-25 bpm
Marked – amplitude greater than 25 bpm
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Rate of descent
Episodic
Periodic
◦ Early
◦ Late
◦ Variable
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Determine the uterine resting tone
Assess the contractions
◦ What is the frequency?
◦ What is the duration?
◦ What is the intensity (if internal monitoring)?
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Determine
Determine
Determine
present
Determine
changes
the baseline
FHR variability
whether a sinusoidal pattern is
whether there are periodic
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Variable decelerations
Late decelerations of any magnitude
Absence of variability
Prolonged deceleration
Severe (marked) bradycardia
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Notify MD/Midwife and document
Change position
Increase IV fluids
Provide oxygen
Tocolytics
Prepare for cesarean or vacuum birth
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Direct stimulation to fetal scalp to elicit an
acceleration
Uncompromised fetuses will elicit
acceleration of at least 15 bpm for 15
seconds
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Evaluate for shared
amnion and chorion
Higher incidence of
PTL
Cojoining
abnormalities
1:1 ratio of nurse to
baby in delivery
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Perinatal
abnormalities 5 x
greater
Maternal
complications
increase
Financial concerns
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Fetuses can
assume a variety
of positions in
utero
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Spontaneous abortions
Gestational diabetes
Hypertension
Acute fatty liver disease
Pulmonary embolism
Maternal anemia
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Hydramnios
PROM
Incompetent cervix
IUGR
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Preterm labor
Uterine dysfunction
Abnormal fetal presentations
Instrumental or cesarean birth
Postpartum hemorrhage
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Shortness of breath and/or dyspnea on
exertion
Backaches
Round ligament pain
Heartburn
Pelvic or suprapubic pressure
Pedal edema
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Perineal damage
Hemorrhage
Increased risk of cesarean birth
Anxiety
Emotional fatigue
Persistence of normal discomforts
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Decreased perfusion
Oligohydramnios
Small-for-gestational-age (SGA)
Macrosomia
Increased risk for meconium staining
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Persistent occiput-posterior (OP) position
Brow presentation
Face presentation
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May be able to
deliver
vaginally
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Frank
Single or double footling (incomplete)
Complete
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Head trauma
Increased risk for infant mortality
Neonatal complications
Cord prolapse
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Shoulder presentation (Transverse Lie)
Compound presentation
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Options for
delivery are
external version
or cesarean
section
Anterior shoulder impinged
behind the symphysis
McRoberts maneuver
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Mc Roberts maneuver
Suprapubic pressure
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Woods corkscrew
◦ Push ant chest wall of
fetus and turn 180
degrees
Rubin maneuver
push against scapula of
ant. Shoulder to rotate
forward 180
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CPD
◦ Contributing factors
 Irregular shaped pelvis
 Fetal macrosomia
 Hx of crushed or fx
pelvix
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Macrosomia
◦ Passenger too big
◦ Can lead to shoulder
dystocia
◦ Maternal diabetes
◦ Excessive mat wt
gain
◦ Adv. Mat age
◦ Erb’s palsy
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Cephalopelvic disproportion
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Uterine rupture
Maternal soft tissue damage
Cord prolapse
Extreme molding
Trauma to fetal skull and CNS
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Dysfunctional labor
Uterine rupture
Perineal lacerations
Postpartum hemorrhage
Puerperal infection
Shoulder dystocia
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One previous cesarean birth and a low
transverse uterine incision
An adequate pelvis
No other uterine scars or previous uterine
rupture
An available physician who is able to do a
cesarean
In-house anesthesia personnel
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Uterine rupture
Stillbirths
Hypoxia
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Sexual intercourse/lovemaking
Self or partner stimulation of the woman’s
nipples and breasts
Use of herbs
◦ Blue/black cohosh
◦ Evening primrose oil
◦ Red raspberry leaves
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Use of homeopathic solutions
◦ Caulophyllum or pulsatilla
◦ Castor oil, enemas
◦ Acupressure/acupuncture
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Mechanical dilatation with balloon catheter
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Advantages
◦ Labor usually occurs in 24-48 hours
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Disadvantages
◦ Can be painful
◦ Uterine contractions
◦ Bloody discharge
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Advantages
◦ Cervical ripening
◦ Shorter labor
◦ Lower requirements for oxytocin during labor
induction
◦ Vaginal birth is achieved within 24 hours for most
women
◦ Incidence of cesarean birth is reduced
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Risks
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Uterine hyperstimulation
Nonreassuring fetal status
Higher incidence of postpartum hemorrhage
Uterine rupture
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Risks
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Hyperstimulation of the uterus
Uterine rupture
Water intoxication
Nonreassuring fetal heart rate patterns
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Amniotic fluid embolism
Hydramnios (polyhydramnios)
Oligohydramnios
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Serial cervical ultrasound assessments
Bed rest
Progesterone supplementation
Antibiotics
Anti-inflammatory drugs
Cerclage procedures
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Summarize indications, complications and
nursing interventions for birth related
procedures.
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Disappointment
Guilt
Conflict between expectation and need for
intervention
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External Cephalic Version (ECV)
Podalic Version (Internal)
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Maternal/fetal assessments
NST
Lab studies
Psychological support
Education
Monitor VS
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EFM
Mediation administration – Beta-mimetics,
RhoGAM
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Labor induction
Labor augmentation
Allow access to fetus and uterus to
◦ Apply an internal fetal heart monitoring scalp
electrode
◦ Insert an intrauterine pressure catheter
◦ Obtain a fetal scalp blood sample
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Prevent the possibility of variable
decelerations
Treat nonperiodic decelerations
Meconium dilution
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Types
◦ Midline
◦ Mediolateral
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Support
Assist with communication of woman’s needs
Pain relief measures
Assessment
Education
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Heart disease
Acute pulmonary edema or pulmonary
compromise
Certain neurological conditions
Intrapartal infection
Prolonged second stage
Exhaustion
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Premature placental separation
Prolapsed umbilical cord
Nonreassuring fetal status
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Outlet forceps
Midforceps
Breech forceps
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Ecchymosis, edema, or both along the sides
of the face
Caput succedaneum or cephalhematoma
Transient facial paralysis
Low Apgar scores
Retinal hemorrhage
Corneal abrasions
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Ocular trauma
Other trauma (Erb’s palsy, fractured clavicle)
Elevated neonatal bilirubin levels
Prolonged infant hospital stay
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Lacerations of the birth canal
Periurethral lacerations
Extension of a median episiotomy into the
anus
More likely to have a third- or fourth-degree
laceration
Report more perineal pain and sexual
problems in the postpartum period
Postpartum infections
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Cervical lacerations
Prolonged hospital stay
Urinary and rectal incontinence
Anal sphincter injury
Postpartum metritis
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Explains procedure to woman
Monitors contractions
Informs physician/CNM of contraction
Encourages woman to avoid pushing during
contraction
Assessment of mother and her newborn
Reassurance
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Prolonged second stage of labor
Nonreassuring heart rate pattern
Used to relieve the woman of pushing effort
When analgesia or fatigue interfere with
ability to push effectively
Borderline CPD
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Procedure
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Suction cup placed on fetal occiput
Pump is used to create suction
Traction is applied
Fetal head should descend with each contraction
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Inform woman about procedure
Pumps the vacuum
Supports the woman
Assesses the mother and neonate for
complications
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Scalp lacerations and bruising
Shoulder dystocia
Subgaleal hematomas
Cephalhematomas
Intracranial hemorrhages
Subconjunctival hemorrhages
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Neonatal jaundice
Fractured clavicle
Erb’s palsy
Damage to the sixth and seventh cranial
nerves
Retinal hemorrhage
Fetal death
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Perineal trauma
Edema
Third- and fourth-degree lacerations
Postpartum pain
Infection
More sexual difficulties in the postpartum
period
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Complete placenta previa
CPD
Placental abruption
Active genital herpes
Umbilical cord prolapse
Failure to progress in labor
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Proven nonreassuring fetal status
Benign and malignant tumors that obstruct
the birth canal
Breech presentation
Previous cesarean birth
Major congenital anomalies
Cervical cerclage
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Severe Rh isoimmunization
Maternal preference for cesarean birth
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Stress and anxiety
Sense of loss of vaginal birth experience
Fear
Relief
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Preoperative teaching
◦ Coughing and deep breathing
◦ Splinting
◦ What to expect
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Assisting with the epidural
Monitoring maternal vital signs and fetal
heart rate
Inserting an indwelling urinary catheter
Preparing the abdomen and perineum
Making sure that all necessary personnel and
equipment are present
Positioning the woman on the operating table
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Supporting the couple
Instrument count
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Normal newborn post-delivery care
Monitoring vital signs
Checking the surgical dressing
Palpating the fundus and checking lochia
Monitoring intake and output
Administration of oxytocin and pain
management