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    Module 5 Part 1

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    Module 5 Part 1

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    8 views65 pages

    Module 5 Part 1

    Uploaded by

    D A M N E R A

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 65

    Nursing Care of Client with High-Risk

    Labor and Delivery and Her Family


    Problems of the Passenger

    Fetal Malposition
    • Occipitoposterior position
    • The occiput is directed diagonally and posteriorly
    • ROP or LOP
    Problems of the Passenger

    Fetal Malposition
    • Occipitoposterior position
    • 1/10 pregnancies
    • Occurs in women with android, anthropoid, or a
    contracted pelves
    Assessment
    • Back pain
    fetal head rotates against sacrum
    ↓

    pressure and pain on lower back


    ↓

    sacral nerve compression


    • Dysfunctional labor pattern
    – Prolonged active phase; arrested descent

    • FHT heard best:


    – lateral sides of abdomen
    Diagnosis: Vaginal Examination or by Sonogram
    NSD Delivery
    • Average size fetus
    • (+) able to rotate
    • Good flexion
    • Forceful and effective uterine contractions
    NSD Delivery
    • COMPLICATIONS:
    – ↑ molding
    – ↑ caput
    –Umbilical cord prolapse
    • FORCEPS DELIVERY:
    NSD Delivery
    • FORCEPS DELIVERY COMPLICATIONS:
    – hemorrhage
    – cervical lacerations
    – infection in post-partum period
    Nursing Interventions
    • Counterpressure on the sacrum
    – back rub, change of position
    – fist / heel of hand at sacral area

    • Application of warm or cold compress on the sacrum


    • Lying on the side opposite the fetal back or
    maintaining hands- and-knees position
    – Squatting, left side-lying if ROP; right side-lying if LOP
    – Leaning forward over a birthing ball
    – helps fetus rotate
    Nursing Interventions
    • Encourage the woman to void every 2 hours
    during labor

    • Oral sports drink / IV glucose solution

    • Emotional support
    – panic attacks
    Fetal malpresentation
    • Vertex presentation / Asynclitism
    • A fetal head presenting at a different angle than
    expected

    • Face presentation
    • Brow presentation

    • Head diameter is often too large for birth to


    proceed
    Brow presentation
    • Risk factors:
    – Multiparity
    – Woman with relaxed abdominal muscles
    – Oligohydramnios
    – Obstructed labor

    • Medical management:
    – CS birth
    Signs and Symptoms
    • Bruising and extreme ecchymosis
    – Face
    – Anterior fontanelle

    • Nursing management:
    – Reassure parents child is well after birth
    Face presentation
    Lie: Longitudinal
    Attitude: Poor (fetus in complete extension)
    Presenting part: Chin / Mentum

    * Head diameter of fetus present to the pelvic inlet is


    often too large for birth to proceed
    Possible causes
    • Women with placenta previa
    • Women with contracted pelvis
    – Instead of flexing head → EXTEND
    • Relaxed uterus of a multipara
    • Prematurity
    • Hydramnios
    • Fetal malformation
    Assessment
    • Head more prominent than normal

    • X engagement on Leopold’s maneuver

    • Head and back are felt on the same side of the uterus

    • FHT is transmitted on the forward-thrust chest and


    heard on the side of the fetus where feet and arms
    are palpated
    • back is extremely concave
    Diagnostic procedures
    • Vaginal examination
    • Sonogram
    – Nose, mouth, and chin can be felt as
    presenting parts

    • Measurement of pelvic diameter


    – √ vaginal birth is possible
    Medical management
    • NSD
    – If chin is anterior
    – pelvic measurements are within normal limits
    – CX: long 1st stage of labor
    – fetus does not mold well

    • CS
    – if chin is posterior
    – long process for posterior-anterior rotation
    Nursing management
    • Observe infant closely for patent airway

    • If lip edema is so severe, lavage feedings


    – to obtain enough fluid until the infant can suck effectively
    – X suck for 1-2 days

    • The infant may be transferred to an ICU nursery for 24 hours

    • Reassure the parents that the edema is transient and will


    disappear in a few days
    2. Breech Presentation

    • Buttocks or feet are the presenting parts

    • Early in pregnancy (Breech) then turns (Cephalic)

    • Normally fetal head is widest = buttocks + legs


    (more space)
    Causes
    • Gestational age less than 40 weeks

    • Abnormality in fetus
    – Anencephaly
    – Hydrocephalus
    – Meningocele

    • Hydramnios

    • Congenital anomaly of the uterus


    – Septate uterus
    – traps uterus in breech presentation
    Causes
    • Space occupying mass in pelvis / Placenta previa
    tumor at pelvis
    ↓
    X head to present

    • Pendulous abdomen
    – Relax abdominal muscles

    • Multiple gestation

    • UNKNOWN
    Types of Breech Presentation

    • COMPLETE
    – thighs tightly flexed on the abdomen
    – Buttocks + feet = tightly flexed to the cervix

    • FRANK
    – thighs are extended to rest on chest
    – buttocks alone present to the cervix

    • FOOTLING
    – single-footling breech
    – double-footling breech
    Breech Presentation
    Assessment:

    • Fetal heart sounds?

    • Continuous monitoring of FHR and uterine


    contractions during delivery
    – early detection of fetal distress from prolapsed cord or
    arrest of descent
    Maternal and Fetal Risks
    (Possible Complications)
    • Anoxia
    – prolapsed umbilical cord
    • Traumatic injury to the aftercoming head
    – possibility of intracranial hemorrhage / anoxia
    • Fracture of the spine or arm
    • Dysfunctional labor
    buttocks, legs, feet
    ↓

    exert less pressure on cervix


    ↓

    less dilatation
    Maternal and Fetal Risks
    (Possible Complications)
    • Early rupture of the membranes
    – poor fit of the presenting part

    • Meconium excretion leading to meconium


    aspiration
    – inevitable contraction of fetal buttocks from
    cervical pressure
    Diagnosis
    • Leopold’s maneuver
    • Vaginal exam
    • Ultrasound
    – confirmation of presentation
    – information about pelvic diameters
    – fetal skull diameters
    – evidence of possible placenta previa causing such
    presentation
    Birth Techniques:

    VAGINAL BIRTH

    • The patient is allowed to push after full dilatation is achieved, and the
    breech, trunk, and shoulders are born.

    • As the breech spontaneously emerges from the birth canal, it is steadied


    and supported by a sterile towel held against the infant’s inferior surface.

    • If the shoulders are not readily born, the arm of the posterior shoulder
    may be drawn down by passing two fingers over the infant’s shoulder and
    down the arm to the elbow, then sweeping the flexed arm across the
    infant’s face and chest and out. The other arm is delivered in same way.
    • To aid in the delivery of the head, the trunk of the infant is usually
    straddled over the physician’s right forearm. Two of the fingers of the
    physician’s right hand are placed in the infant’s mouth.

    • The left hand is slid into the mother’s vagina, palm down, along the
    infant’s back.

    • Pressure is applied to the occiput to flex the head fully.

    • Gentle traction applied to the shoulders (upward and outward) delivers


    the head.

    • An aftercoming head may also be delivered with the aid of Piper forceps
    to control flexion and the rate of descent.
    Forceps Delivery
    Possible Complications with Vaginal
    Birth
    • Cord compression
    – pressure of the fetal head against the pelvic brim
    • Intracranial hemorrhage
    – sudden delivery → pressure changes occur instantly
    • Hypoxia (gradual delivery)
    • Tentorial tears leading to gross motor & mental incapacity or lethal
    damage to the fetus

    Elective Cesarean Birth


    • Usual method of birth for breech-presentation infants
    • Because of difficulty with birth of head
    Nursing Interventions
    • Perform initial physical assessment of the infant to
    determine a possible reason for the breech presentation.

    • Explain to the parents that unusual posture of the infant


    few days after birth is normal and is related with the
    infant’s breech presentation intrauterine.

    ** frank = keep legs extended at level of face for 1st 2-3


    days of life
    ** footling = legs extended in footling position 1st few days
    3. Transverse Lie
    • less than 1% of fetuses

    Diagnosis:
    • Leopold’s Maneuver
    – uterus more horizontal than vertical
    • Sonogram
    – further confirmation and pelvic size

    Medical Management: Cesarean Birth


    Risk factors
    • Pendulous abdomens
    • Uterine masses (tumors)
    – obstruct the lower uterine segment
    • Contraction of the pelvic brim
    • Congenital abnormalities of the uterus
    • Hydramnios
    • Hydrocephalus
    • Placenta previa
    • Limit fetus’s ability to turn
    • Grand multiparity
    – Relaxed abdominal walls
    • Short umbilical cord; Multiple gestations (2nd twin)
    • Prematurity
    • small=has room for free movement
    Signs and symptoms
    • Countour of abdomen is distorted

    • Fuller side at side rather than top / bottom

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