Chapter 23

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  • Topic: Childbirth, Obstetrics, Pelvis
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Chapter 23 high risk pregnant client during labor and delivery

Four main components of the labor process
1. passenger or fetus
2. passage way or pelvic bones and other pelvic structure
3. powers or uterine contractions
4. clients psyche or psychological state

Problems with the passenger
-Problem may arise if preterm, also during multiple gestation.

Fetal malposition 

1. Occipitoposterior position
ROP or LOP
Second stage of labor
Complains of severe back pain from the pressure of the fetal head pressing against other sacrum

Fetal malpresentation

1. Asynctilism vertex malpresentation
Fetal head presenting at a different angle than expected

2. Brow presentation
Rare
Occurs in multiparty
Woman with relaxed abdominal muscles
Results in obstructed labor
CS is necessary
Infant can have extreme ecchymotic bruising in the face
Reassure parents that child is well after birth.

3. Face presentation
Rare
Occurs, the head diameter the fetus presents to the pelvis is often too large for birth to proceed Head that feels more apparent than normal
Confirmed for vaginal examination when the nose, mouth or chin can be felt as the presenting part. Sonogram - pelvic diameters are measured
Babies born: facial edema and purple ecchymotic bruising, observe for patent airway, severe lip edema - unable to suck for a day or two,necessary for gavage feeding, edema will disappear in a few days

4. Shoulder presentation
Fetus lies horizontally
Presenting part is usually:
-one of the shoulders (acromiom process)
-An iliac crest
-A hand
-Or an elbow
May be caused by:
-Relapsed abdominal walls from grand multiparity - which allows for the unsupported uterus to fall forward -Placenta previa
 Most infants are born by CS why?
-Membranes have ruptured at the beginning of labor
-No firm presenting part
Occurs in women with:
-pendulous abdomen
-Uterine masses that obstruct the lower uterine segment
-Contraction of the pelvic brim
-Congenital anomalies
-Hydramnios
Occurs in infants with:
-Hydrocephalus or any abnormality which prevents the infant from engaging. -Obvious on inspection, confirmed through leopolds

5. Breech presentation
Most common form of malpresentation
 It's fetus assumes this position in early pregnancy
But by week 38, fetus normally turns to a cephalic presentation

3 types
1. Complete breech
Thighs and knees are flexed
2. Frank breech
Thighs are flexed on hips, knees are extended
3. Footing breech
Foot extends below the buttocks or knees extends below the buttocks

Causes
Gestational age less than 40 weeks
Fetal anomalies
Maternal anomalies
Multiple gestation
Unknown factors

Fetal risk
Anoxia
Traumatic injury
Fracture of the spine or arm
Dysfunctional labor
Early rupture of the membranes because of the poor fit of the presenting part.

Assessment
FHT are heard hi in the abdomen
Abdominal palpation
Vaginal examination
Ultrasound
Scan

External cephalic version
Turning of a fetus from a breech to a cephalic
Position before birth
Maybe done as early as 34 to 35 weeks
Usual time is 37 to 38 weeks of pregnancy

Before attempting :
Ultrasound
Locate umbilical cord
Rule out placenta previa
Evaluate the adequacy of maternal pelvis
Assess the amount of the amniotic fluid, the fetal age, and presence of anomalies NST performed to confirm fetal we'll being

Contraindications
Uterine anomalies
Previous CS birth
CPD cephalopelvic disproportion
Placenta previa
Multifetal gestation 
Polihydrammios
Todo lyric agent is given to relax

Nurses role
Continuous monitor of FHT
Check maternal vs
Assess woman's level of discomfort

Fetal anomalies
Hydrocephalus
Anencephaly - absence of cranium
Prolapsed umbilical cord
-loop of the umbilical cord slips down in front of the presenting part Occurs when the cord lies below the presenting part of the fetus

Tends to occur most often in the following
PROM
Fetal presentation other than...
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