WINTER

HIGH RISK
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Labor and Delivery

 WINTER
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Problems with the
Passenger
Fetal Malposition
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• Fetal position is the relationship of the
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presenting part of the fetus to a specific
section of the mother’s pelvis

• It can influence the progression of labor

and the possible need for surgical
intervention
• Occipitotransverse
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• It is the incomplete
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rotation of OP to OA
results in the fetal head
in horizontal position
• Occipitoposterior
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• Arrested labor can
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occur when the head
does not rotate and/or
descend
• Delivery may be
complicated be
perineal tears or
extension of an
episitomy
 Assessment Findings
• WINTER
Intense back pain
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• Poor dilatation and descent
• Depression in lower maternal abdomen
• Fetal heart rate heard laterally
• Anterior fontanelle in anterior
• Perineal laceration or episiotomy extension
 Management
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• Manual rotation Template
• Side-lying and knee-chest
• Forceps
 Fetal Malpresentation

Describes the fetal body part that will

be first to pass through the cervix and
be delivered

Affects the duration and difficulty of

labor
Vertex Malpresentation
Breech Presentation
Shoulder Presentation
 Nursing Interventions
• Observe closely for abnormal labor patterns
• Monitor FHR and contractions continuously
• Anticipate forcep-assisted birth
• Anticipate CS for incomplete breech or shoulder
presentation
• Position in Trendelenburg or knee-chest
position
• Manually raise the presenting part aseptically
 Fetal Distress
• Refers to fetal compromise that results in
a stressful and potentially lethal condition
• Normally during labor, the fetus is able to
respond appropriately as indicated by the
following:
– FHR ranging between 120-160 bpm
– Reassuring FHR pattern
• variability 6-10 bpm
• Accelerations with movement or activity
 Fetal Distress
• Causes:
– Prematurity; Post maturity
– Uteroplacental insufficiency
– Congenital malformation
– ABO or Rh Incompatibility
– Maternal complications such as diabetes,
heart disease or gestational hypertension
– Prolonged labor
– Oxytocin infusion
 Assessment Findings
• Nonreassuring FHR
• Fetal acidosis
• Meconium-stained amniotic fluid
• Decrease in or cessation of fetal
movement; increased with meconium
 Nursing Interventions
• Monitor FHR, fetal activity, fetal heart variability
• Immediately notify physician
• Prepare for possible placement of internal
monitor and fetal scalp pH sampling
• Position patient on left side to enhance
uteroplacental blood flow
• Administer oxygen via face mask as ordered
(6-8 Lpm)
• Expect to discontinue oxytocin infusion if in use
• Prepare for delivery as indicated
 Prolapsed Umbilical Cord
• Refers to the descent of the umbilical cord into
the vagina before the presenting part

• May occur anytime after membranes rupture,

especially if presenting part is not fitted firmly in the
cervix
 Prolapsed Umbilical Cord

• Is an emergency requiring prompt action

to save the fetus; the cord may be
compressed between the fetus and
maternal cervix or pelvis, compromising
fetoplacental perfusion
 Cause

 PROM
 Fetal presentation other than cephalic
 Placenta previa
 Intrauterine tumors preventing the presenting
part from engaging
 Small fetus
 CPD preventing firm engagement
 Hydramnios
 Multiple gestation
 Assessment Findings
• Cord maybe palpable at the perineum
during vaginal examination
• An UTZ helps confirm
• FHR pattern shows variable decelerations
 Treatment

• Focuses on relieving pressure on the cord

– Tredelenburg or knee-chest position to cause
fetal head to fall back from cord
– Elevating head up and off the cord with sterile
gloved hand inserted vaginally
 Treatment

• Focuses on relieving pressure on the cord

– Tredelenburg or knee-chest position to cause
fetal head to fall back from cord
– Elevating head up and off the cord with sterile
gloved hand inserted vaginally
 Treatment
• Administer oxygen to promote adequate fetal
oxygenation
• FHR monitoring
• If cord is exposed, saline-soaked sterile
dressings are applied over any portion of the
cord
• Vaginal delivery may be done if the patient’s
cervix is fully dilated; CS if cervical dilation is
incomplete
 Nursing Interventions
• Always auscultate FHT immediately after rupture
of membranes
• Assist with measures to relieve compression
• Administer O2 at 10 Lpm by face mask as
ordered
• Anticipate use of tocolytic to reduce uterine
activity and pressure of the fetus
• Monitor uterine contractions and FHR patterns
closely
 Nursing Interventions
• Cover any exposed areas of the cord with sterile
saline-soaked dressings
• Prepare patient for delivery
– Offer emotional support
 04

Problems with the

Passageway
Abnormal size and shape04
 04
Cephalopelvic Disproportion
• Refers to the narrowing of the birth canal
• Involves a disproportion between the size of the
normal fetal head and the pelvic diameters
• Results in failure to progress labor
• If fetus’s head doesn’t engage:
– head remains a floating entity = malposition
– Membranes rupture, possibility of cord prolapse
greatly increases
 Causes 04
• Physical size of the maternal pelvis is a
major contributor
• Outlet contraction
• Fetal factors
– Large fetal size (>4000g birth weight)
– Abnormal positions of the fetal head, fetal
abnormalities, malpresentations of the fetus
 Assessment Findings 04
• Lack of fetal head engagement in a
primigravida due to
– fetal abnormality, such as larger-than-usual
head
– pelvic abnormality, such as smaller-than-usual
pelvis
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Treatment
• If pelvic measurements are borderline or just
adequate, physician may allow trial labor
• Trial labor may be allowed to continue if
descent of the presenting part and dilation of
the cervix are occuring
• If labor doesn’t progress or complications
develop, CS is the delivery method of choice
 Nursing Interventions 04
• Instruct primiparous patient to maintain prenatal
visit schedule to have pelvic measurements
recorded
• Monitor progress of trial labor
• Provide emotional support
• Explain necessity of cesarean birth, if possible
• Offer support to patient’s support person
 Shoulder Dystocia 05
• Defined as the impaction of the anterior fetal
shoulder against the maternal pubic bone after
delivery of the head
 Nursing Interventions 05
• Note time of birth of the head
• Note all interventions to relieve pain
• Note which shoulder is impacted
• Call for help
• Provide suprapubic pressure when asked
• Sharply flex and abduct maternal legs onto the
abdomen (Mc Robert’s Maneuver)
• Anticipate neonatal resuscitation and maternal
postpartum hemorrhage
Mc Robert’s Maneuver 05
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THANK
Y O U !!!