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NCM 102

NURSING CARE OF THE CLIENT


WITH HIGH-RISK LABOR &
DELIVERY & HER
FAMILY

INTRAPARTUM COMPLICATIONS

occur in as many as 31% of all births


broad term for abnormal or difficult labor and delivery
arise from 3 main components of the labor process

DYSTOCIA
Abnormal or difficult labor
Is often an indication of operative delivery
with its associated complications.
Shoulder dystocia

TYPES (3Ps)
a) Uterine Dystocia ( Power) - uterine
contractions need to be strong, coordinated,
rhythmic and intermittent to be effective
b) Fetal Dystocia (Passenger)
malpresentation, malposition, or other fetal
factors such as macrosomia or shoulder
dystocia.
c) Pelvic Dystocia ( Passage) - fetus cannot
enter or pass the bony pelvis of the mother
due to contractions of the pelvis.

CAUSES

Abnormalities of expulsive forces.


Abnormal presentation.
Abnormalities of birth canal

RISK FACTORS
Maternal Risks

Prolonged labor

Uterine rupture

Damage to soft tissue


Fetal Risks

Cord prolapsed

Trauma to head

MANAGEMENT

Oxytocin administration if there is


inadequate contractions.
Cesarean delivery if there is abnormal fetal
position.

CEPHALOPELVIC
DISPROPORTION

implies disproportion between the head of the


baby ('cephalus') and the mother's pelvis.
Complications can occur if the fetal head is too
large to pass through the mother's pelvis or
birth canal.

It is one of the commonest cause of different


complications in labor, including prolonged
labor, fetal distress, and delayed second stage .
Cephalo-pelvic disproportion (CPD) is very
frequently diagnosed and is a very common
indication of cesarian sections.
But it is very difficult to diagnose CPD before
a woman has started her labor pains since it is
very difficult to anticipate how well the fetal
head and the maternal pelvis will adjust and
mould to each other.

CAUSES

Increased Fetal Weight:

Very large baby due to hereditary reasons a baby whose weight is estimated to be above
5 Kgs or 10 pounds.

Postmature baby - when the pregnancy goes


above 42 weeks.

Babies of women with diabetes usually tend


to be big.

Babies of mothers who have had a number


of children - each succeeding baby tends to be
larger and heavier.

CAUSES
Fetal Position:

Occipito-posterior position - In this position


the fetus faces the mothers abdomen instead of
her back.

Brow presentation

Face presentation.

Problems with the Pelvis:

Small pelvis.

Abnormal shape of the pelvis due to


diseases like rickets, osteomalacia or
tuberculosis.

Abnormal shape due to previous accidents.

Tumors of the bones.

Childhood poliomyelitis affecting the shape


of the hips.

Congenital dislocation of the hips.

Congenital deformity of the sacrum or


coccyx.

CAUSES
Problems with the Genital tract:

Tumors like fibroids obstructing the birth


passage.

Congenital rigidity of the cervix.

Scarring of the cervix due to previous


operations like conisation.

Congenital vaginal septum

COMPLICATIONS

Dystocia
PROM
Failure of the cervix to dilate or the fetus to
descend
Extensive caput and molding
Fetal intolerance
Potential for birth injury related to a difficult
and traumatic delivery

Problems with the Power: (Force of Labor)


1. Uterine Inertia sluggishness of contractions or the force of labor or
defined as difficult, painful, prolonged labor due to mechanical factors
- current term Dysfunctional Labor

failure of the mother`s expulsive effort during delivery


it may develop during the first or second stage of labor
Common Causes:
a. inappropriate use of analgesia (excessive or too early administration)
b. unusually large baby/multiple gestation
c. poor fetal position (posterior rather than anterior position)
d. pelvic bone contraction (leads to narrowing of the pelvic diameter so the
fetus cant pass)
e. primigravida
f. hypotonic, hypertonic and prolonged labor

TYPES
I. Primary Uterine Inertia

most common of the two types

degree of inertia range from complete


failure of the uterus to normal delivery with
retained placenta

CAUSES

weakness of the uterus


excessively large fetus
fatty infiltration of the myometrium
ketosis a metabolic disease related to fat
body condition, it may combine with fatty
uterus producing insufficient contractions
hypocalcemia
stress
uterine ruptures
uterine torsion

Management

monitor contractions and FHR


sedation in the form of short acting
barbiturates ( to promote rest, relieve pain and
abnormal uterine activity)
teach the patient proper muscle control

II. Secondary Uterine Inertia


direct result of dystocia
CAUSES:
malpresentation
prolonged unproductive labor
MANAGEMENT:
Augment labor if no CPD (amniotomy and
oxytocin)
If augmentation is used, the nurse should
explain that contraction are likely to be have
rapid onset and very painful. Assurance should
be given.

1. Primary occurring at the onset of labor


2. Secondary occurring later in labor
Signs and Symptoms;
- irregular uterine contractions
- ineffective uterine contractions (strength/duration)

Management:
1. Monitor uterine contractions by palpation and with the use of
electronic monitor
2. Prevent unnecessary fatigues check the client level of fatigue
3. Prevent complications of labor
a. assess urinary bladder (catheterize as needed)
b. assess maternal VS
c. monitor condition of fetus by monitoring FHR, fetal
activity and color of amniotic fluid
4. Provide comfort measures
a. frequent position changes
b. walking
c. quiet/calm environment
d. breathing/relaxation technique

2. Ineffective Uterine Force

- ineffective uterine contractions which can result in ineffective


labor
types;
1. Hypotonic Contractions the number of contractions is usually
low or infrequent (not increasing beyond 2 or 3 in a 10 minute
period)
- occurs during the active phase of labor
- normal : 3-4/10 min period with duration of 30 seconds

Risk Factors
- bowel/bladder distention prevents
descent/engagement
- multiple gestation
-large fetus
- hydramnios
- multiparity

Signs and Symptoms: Painless less frequent Contraction

Management:
1. oxytocin administration to strengthen contractions and
increase effectiveness
2. Amniotomy (artificial rupture of membranes to further
speed labor
3. Palpate the uterus and assess lochia every 15 minutes to
prevent postpartum bleeding
4. monitor maternal VS and FHR
5. position changes to relieve discomfort and enhance
progress

2. Hypertonic Contractions
- intensity of the contractions may not stronger or very active and
frequent contractions but ineffective
- occurs more frequently and commonly seen in latent phase of
labor
- the muscle fibers of the uterus (myometrium) do not repolarize

Signs and Symptoms;


1. Painful nonproductive contractions
2. uterine tenderness
3. fetal anoxia/distress
4. dehydration due to excessive perspiration
5. fatigue and exhaustion

Management:
1. assess quality of contractions by uterine/fetal external monitor
applied at least 15 minutes interval
2. adequate rest
3. pain relief with morphine sulfate
4. changing linen/gowns
5. darkened room lights
6. decreasing environmental stimuli
7. CS delivery

PRECIPITATE LABOR

- define as labor that is completed in fewer than 3 hours (normal length


of labor; Primipara 14-20 hours, Multi 8-14 hours)
- a forceful contractions that can lead to premature separation of the
placenta (placing the mother and fetus at risk for hemorrhage)

Risk Factors:
1. likely to occur in multiparity mothers
2. women undergo premature separation of the placenta
3. previous history of precipitate labor

COMPLICATIONS:
Maternal

Infection

Laceration

Uterine atony

Hemorrhage

Abruption placenta
Neonatal

Intracranial hemorrhage

Aspiration of amniotic fluid

Infection

Signs and symptoms:


1. tachycardia (earliest sign)
2. restleness
3. hypotension (late sign)
4. signs of hypovolemic shock
5. vulvar pain and bruising

Nursing Management:
1. Inform mother at 28 weeks of pregnancy that labor may be
shorter than normal
2. Tocolytic agent administration to reduce the force and frequency
of contractions
3. Cold applications to limit bruising, pain and edema
4. In time of hemorrhage position the mother in modified
trendelenburg position
5. IVF replacement fast drip

6. Advice patient who have history of precipitate delivery that


it may happen again.
7. Patient who has history of precipitate delivery and those
grand multiparas must be brought to D.R before full
dilatation.

UTERINE RUPTURE

- rupture of the uterus during labor


- accounts for 5% of maternal death
- incidence rate is 1 in 1500 births
Risk Factors:
- commonly occur from a vertical scar during the previous CS
or hysterectomy repair tears
- prolong labor
- faulty presentation
- multiple gestation
- use of oxytocin
- traumatic maneuvers

- usually preceded by pathologic refraction ring (an indentation is apparent


across the abdomen over the uterus) and strong uterine contractions without any
cervical dilatation, the fetus is gripped by retraction ring and cannot descent)

Signs and Symptoms:


1. sudden severe pain during a strong labor contractions
2. report a tearing sensation
3. hemorrhage from a torn uterus into the abdominal cavity and into the
vagina
4. signs of shock (rapid, weak pulse, falling blood pressure, cold clammy
skin)
5. absent fetal heart sounds
6. localized tenderness and aching pain from the lower segment
7. fetal distress

UTERINE RUPTURE A spontaneous or traumatic rupture of


the uterus. It occurs in about 1 in 15,000 births with about 50%
- infant mortality.
-

Tearing of the muscles of the uterus


Occurs when the uterus can no longer withstand the strain
placed upon it.
A serious complication labor that can lead to materials and
fetal death.

Causes:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

11.
12.
13.
14.

Rupture of scar from previous CS


Prolonged labor obstructed labor
Malposition and malpresentation
Multiple gestation
Injudicious use of oxytocin
Forceps ad vacuum extraction
Internal inversion
Precipitate labor and delivery
Manual-removal of the placenta
Over-distention of the uterus
External trauma sharp or blunt.
Placenta increta or accrete
Adenomyosis
Gestational trophoblastic neoplasia

Adenomyosis

Types
1.
Complete Rupture

Woman suddenly experiences excruciating pain at the peak


of a contraction, then contraction stops.

Internal hemorrhage follow and vaginal bleeding may or


may not be present.

Swelling visible, abdomen, uterus and the extrauterine fetus.


Results in separation of the placenta from te uterus, cutting off
blood supply to the fetus resulting in hypoxia and fetal

2. Incomplete Rupture
Symptoms are:
- localized tenderness and persistent pain over the abdomen
- Contractions may continue or stop
- Vaginal bleeding may or may not be present
- No progress in cervial dilatation
Signs of materials shock and fetal distress disappear.

Management:
1.
Blood transfusion and administration of IVF- correct shock
2.
Administer mask oxygen
3.
Emergency laparotomy to deliver the baby
4.
Provide emotional support
5.
Post-op care (after Hysterectomy)

Explain need to avoid driving for 3-6 weeks

Explain need to avoid jogging, sexual intercourse, dancing


and lifting heavy objects for 6-8 weeks.

BANDLS RING
During labor the uterus differentiate into two parts:
1.
The upper contracting portion that becomes thicker and
shorter as labor progresses.
2.
The lower passive portion that distend gradually to
accommodate the descending fetus.
- this division is called Physiologic retraction ring.

When labor is obstructed, the fetus cannot descent into the birth
canal. Because of this uterine contractions become stronger
and more frequent in an effort to overcome the obstruction
until it reaches a state of tonic contraction when the uterus no
longer relaxes. It is in this stage that Bandls ring of pathologic
retraction ring develops. The retraction of the upper segment
and the over distention of the lower uterine segment could
result in the division of the two uterine segment to become
very prominent.

Bandls ring is seen as a horizontal indention running across the


abdoment.

Management:
1.
Morphine Sulfate relax the uterus
2.
CS immediate delivery of the fetus and prevent uterine
rupture
3.
If develop during the placental stage woman is placed
anesthesia and placenta is removed manually.

Nursing Management:
1. Administer emergency fluid replacement therapy as ordered
2. Anticipate use of intravenous oxytocin to attempt to contract
the uterus and minimize bleeding
3. prepare mother from a Laparotomy as an emergency measure
to control bleeding and effect a repair
4. Physician may perform hysterectomy (removal of a
damaged uterus) or BTL at the time of Laparotomy
5. monitor VS and FHR
6. administer BT as ordered

UTERINE INVERSION

- uterus turns completely or partially inside out, it occurs immediately


following delivery of the placenta or in the immediate postpartum
period
- incidence rate is 1 in 15, 000 births
Causes:
- occurs after birth of the infant if traction is applied to umbilical
cord to remove placenta
- pressure is applied to the uterine fundus when uterus is not
contracted
- occurs when placenta attached at the fundus (the passage of the
fetus pulls the fundus down)

Signs and Symptoms:


1. sudden gushes of blood from vagina
2. fundus is not palpable
3. show signs of blood loss (hypotension, dizziness and paleness)
4. bleeding
Nursing Management;
1. recognize signs of impending inversion and immediately notify the
physician
2. never attempt to replace the inversion because handling may
increase the bleeding
3. never attempt to remove the placenta if it still attached

4. take steps to prevent or limit hypovolemic shock


a. use large gauge IV catheter for fluid replacement
b. measure and record maternal VS every 5 to 15 minutes to
establish baseline changes
5. administer oxygen by mask
6. be prepared to perform CPR if the heart fails due to sudden
blood loss
7. the mother will be given general anesthesia or nitroglycerin or a
tocolytic drug IV to immediately relax the uterus
8. physician/nurse midwife replaces the fundus manually (push the
uterus back inside)

AMNIOTIC FLUID EMBOLISM

- occurs when amniotic fluid is force to enter the maternal blood


circulation because of some defect in the membranes or after
membranes rupture (not preventable because it cannot be
predicted)
- incidence rate is 1 in 8000 births

Risk factors:
1. oxytocin administration
2. abruption placenta
3. hydramnios

Signs and Symptoms:


1. sharp pain on the chest
2. dyspnea (secondary to pulmonary artery constriction)
3. mother becomes pale and cyanotic due to pulmonary embolism and
lack of blood flow to the lungs
Nursing Management:
1. immediate management is oxygen administration by face mask or
cannula
2. prepare the mother for CPR (may be ineffective because these
procedures do not relieve the pulmonary constriction)
3. Endotracheal intubation to maintain pulmonary function
4. The mother should be transferred to ICU

Complication:
1. DIC disseminated intravascular coagulation
- bleeding to all portion of body (eyes, nose,
gums, IV sites)
- therapy with fibrinogen to counteract DIC

PROBLEMS WITH THE PASSENGER


1. PROLAPSE OF UMBILICAL CORD

descent of the umbilical cord into the vagina ahead of


the fetal presenting part with resulting compression of the
cord (cord compression)
- emergency situation , immediate delivery is
attempted to save the baby
- incidence rate is 0.2-0.6% of births or 1 of 200
pregnancies

Associative Factors:
1. premature rupture of membranes (the fetal fluid may rush and carry
the cord along toward the birth canal)
2. breech presentation
3. placenta previa
4. intrauterine tumors preventing the presenting part from engagement
5. small fetus
6. CPD preventing engagement
7. hydramnios
8. multiple gestation

Signs and Symptoms;


1. the umbilical cord seen or felt during vaginal exam
2. reports feeling of cord into the vagina

Management: (relieve compression on the cord and fetal anoxia)


1. periodically evaluate FHR especially after the rupture of
membranes (fetal distress)
2. Physician will place a glove hand in the vagina and manually
elevate the fetal head off the cord
3. Reduce pressure on the cord by:

Placing on knee chest or trendelenburg position, or place a folded


towel under the hips
4. administer oxygen at 10 Liters/minute by facemask to improve
oxygenation of the fetus
5. do not attempt to push any exposed cord back into the vagina (adds
to compression and cord kinking

6. cover any exposed portion of the cord with sterile gauge


soaked in NSS around the prolapsed cord
7. if the cervix is fully dilated at the time of prolapsed (the most
emergent delivery route is NSD and encourage mother to push)
8. if not fully dilated, mother is delivered via CS (upward
pressure on the presenting part to keep pressure off the cord)

MULTIPLE GESTATION

focus on her needs as well as those of her


babies.
Twins may be born by cesarean birth to
decrease the risk that the second fetus will
increased incidence of cord entanglement and
premature separation of the placenta

Complication

Anemia
PIH

Management

If giving birth vaginally, instruct to come to


the hospital early in labor.
Breathing exercise in early hours of labor
During labor, support the womans breathing
exercises to minimize the need for analgesia or
anesthesia; this helps to minimize any
respiratory difficulties the infants may have at
birth because of their immaturity.
If possible, monitor each FHR by a separate
fetal monitor during labor.

Because the babies are usually small, firm


head engagement may not occur, increasing
the risk for cord prolapse after rupture of the
membranes.
Because of the multiple fetuses, abnormal fetal
presentation may occur.
Uterine dysfunction from a long labor, an
overstretched uterus, unusual presentation, and
premature separation of the placenta after the birth of
the first child may also be more common.

After the birth of the first child, the lie of the


second fetus is determined by external
abdominal palpation or ultrasound.
If the presentation is not vertex, external
version may be attempted to make it so
If this is not successful, a decision for a breech
birth or cesarean birth must be made

PROBLEMS WITH POSITION,


PRESENTATION OR SIZE:

1. OCCIPITO-POSTERIOR POSITION
- LOA (LEFT OCCIPITO-ANTERIOR) IS THE MOST IDEAL
AND COMMON FETAL POSITION
- LOP (left occipito-posterior) is located on left and posterior
quadrant pelvis
- ROP (right occipito-posterior) is located at the right and
posterior quadrant pelvis
ROP in this position, during the internal rotation, the fetal head must
rotate not through a 90 degree arc but through an arc of approximately
135 degrees

Risk Factors:
1. Women with android/anthropoid pelvis.

A posterior position is suggested by


a dysfunctional labor pattern such as a
prolonged
active phase,
arrested descent,
or fetal heart sounds heard best at the lateral
sides of the abdomen.

Signs and Symptoms;


- Intense lower back pain (lumbosacral pain) due to
compression of sacral nerves during rotation
- Shooting leg pains
Nursing Management;
1. provide back rub
2. change of position (squatting position) may help fetus to
rotate
3. encourage voiding every 2 hours to keep bladder empty
(because full bladder impedes descent of the fetus)
4. apply hot/cold compress
5. delivered via CS

2. BREECH PRESENTATIONS presenting


parts are usually buttocks and feet
Complications:
1. anoxia (due to prolapsed umbilical cord)
2. intracranial hemorrhage
3. fracture of the pine/extremities
4. dysfunctional labor

An infant who was born from a frank breech


position tends to keep his or her legs extended
and at the level of the face for the first 2 or 3
days of life.
The infant who was a footling breech may tend
to keep the legs extended in a footling position
for the first few days.
Be sure to point out to the parents that this is
normal, so that they do not misinterpret the
unusual posture of their infant as more than it
is.

Risk Factors:
1. gestational age under 40 weeks
2. abnormality in the fetus such as anencephaly, hydrocephalus
3. hydramnios (allows for free fetal movement)
4. congenital anomaly of the uterus
5. multiple gestation

Signs and Symptoms;


1. Fetal heart sounds usually heard high in the abdomen (URQ,
ULQ)
2. fetal distress
Diagnosis; Leopolds maneuver, vaginal exams and ultrasounds
will reveal breech presentations

Nursing Management;
1. External version is being used to avoid some CS deliveries for a
breech presentations
VERSION is a method of changing the fetal presentation usually
from breech to cephalic.
- done after 37 weeks of gestation but before the onset of labor
- begins with non-stress test and BPF to determine of the fetus
is in good condition and if there is adequate amount of amniotic
fluid
- mother is given tocolytic drug to relax her uterus during
version

- UTZ is used to guide the procedure while physician pushes the


fetal buttocks upward out of the pelvis while pushing the fetal
head downward toward the pelvis in either clockwise or
counterclockwise direction

3. the head may also be delivered using forceps delivery to


control the flexion and rate of descent

4. CS delivery

Birth of the head is the most hazardous part of


a breech birth.
Because the umbilicus precedes the head, a
loop of cord passes down alongside the head.
The pressure of the head against the pelvic
brim automatically compresses this loop of
cord.

FACE PRESENTATION

Face (chin, or mentum) presentation is rare,


but when it does occur,
the head diameter the fetus presents to the
pelvis is often too large for birth to proceed.

Signs
head that feels more prominent than normal
head and back are both felt on the same side of
the uterus with Leopolds maneuvers
FHT heard on the side of the fetus where feet
and arms can be palpated
confirmed by vaginal examination when the
nose, mouth, or chin can be felt as the
presenting part

Factors
A fetus in a posterior position, instead of
flexing the head
Contracted pelvis or placenta previa.
Relaxed uterus of a multipara or
with prematurity, hydramnios, or fetal
malformation.

Management
an ultrasound is done to confirm it; if
indicated, the pelvic diameters are measured.
If the chin is anterior and the pelvic diameters
are within normal limits, it may be possible for

the infant to be born without difficulty (perhaps after a long


first stage of labor, because the face does not mold well to
make a snugly engaging part).
If the chin is posterior, cesarean birth is usually the method of
choice; otherwise, it would be necessary to wait for a long
posterior-to-anterior rotation to occur.
Such rotation could result in uterine dysfunction or a
transverse arrest.

Babies born after a face presentation have a


great deal of facial edema and may be purple
from ecchymotic bruising.
Observe the infant closely for a patent airway.
In some infants, lip edema is so severe that
they are unable to suck for a day or two.
Gavage feedings may be necessary to allow
them to obtain enough fluid until they can suck
effectively.
They may be transferred to a NICU for 24 hours. Reassure the
parents that the edema is transient and will disappear in a few
days, with no aftermath.

BROW PRESENTATION

rarest of the presentations.


It occurs in a multipara or a woman with
relaxed abdominal muscles.
Unless the presentation spontaneously
corrects, cesarean birth will be necessary to
birth the infant safely.
Brow presentations also leave an infant with
extreme ecchymotic bruising on the face.

On seeing this bruising over the same area as


the anterior fontanelle, or soft spot,
parents may need additional reassurance that
the child is well after birth.

TRANSVERSE LIE

occurs in women with pendulous abdomens,


with uterine fibroid tumors that obstruct the
lower uterine segment,
with contraction of the pelvic brim,
with congenital abnormalities of the uterus,
or with hydramnios.

occur in infants with hydrocephalus or another


abnormality that prevents the head from
engaging.
It may also occur in prematurity if the infant
has room for free movement,
In multiple gestation (particularly in a second
twin), or if there
is a short umbilical cord.

A mature fetus cannot be delivered vaginally


from this presentation. Often, the membranes
rupture at the beginning of labor.
Because there is no firm presenting part, the
cord or an arm may prolapse, or the shoulder
may obstruct the cervix.
CESAREAN BIRTH IS NECESSARY.

Oversized Fetus (Macrosomia)

4000 to 4500 g (approximately 9 to 10 lb).


Occurs in pregnant women with DM or
developed gestational DM
Multiparity
IF THE INFANT IS SO OVERSIZED THAT
HE OR SHE CANNOT BE BORN
VAGINALLY, CESAREAN BIRTH
BECOMES THE BIRTH METHOD OF
CHOICE.

Shoulder Dystocia

The problem occurs at the second stage of


labor, when the fetal head is born but the
shoulders are too broad to enter and be born
through the pelvic outlet.
occur in women with diabetes,
in multiparas, and in post-date pregnancies.

Management
asking a woman to flex her thighs sharply on
her abdomen (McRoberts maneuver) may
widen the pelvic outlet and allow the anterior
shoulder to be born.
Applying suprapubic pressure may also help
the shoulder escape from beneath the
symphysis pubis and be born

PROBLEMS WITH THE


PASSAGE

Contraction or narrowing of the passageway or


birth canal.
This can happen at the inlet, at the midpelvis,
or at the outlet.
The narrowing causes CPD, or a disproportion
between the size of the fetal head and the
pelvic diameters.
This results in failure to progress in labor.

INLET CONTRACTION
narrowing of the anteroposterior diameter
to less than 11 cm, or of the transverse
diameter to 12 cm or less.
It usually is caused by rickets in early life or
by an inherited small pelvis.

Every primigravida should have pelvic


measurements taken and recorded before week
24 of pregnancy.
Based on these measurements and the
assumption the fetus will be of average size, a
birth decision can be made.
With CPD, because the fetus does not engage
but remains floating, malposition may occur,
further complicating an already difficult
situation. Should the membranes rupture, the
possibility of cord prolapse increases greatly.

OUTLET CONTRACTION
narrowing of the transverse diameter at the
outlet to less than 11 cm.

MANAGEMENT
TRIAL LABOR
to determine whether labor can progress
normally. A trial labor continues as long as
descent of the presenting part and dilatation of
the cervix continue to occur.

Monitor fetal heart sounds and uterine


contractions continuously, if possible
Urge the woman to void every 2 hours so that
her urinary bladder is as empty as possible,
allowing the fetal head to use all the space
available.

After rupture of the membranes, assess FHR


carefully; if the fetal head is still high, there is
an increased danger of prolapsed cord and
anoxia to the fetus.
If after a definite period (6 to 12 hours)
adequate progress in labor cannot be
documented, or if at any time fetal distress
occurs, the woman will be scheduled for a
cesarean birth.

EXTERNAL CEPHALIC VERSION


turning of a fetus from a breech to a cephalic
position before birth.
done as early as 34 to 35 weeks, although the
usual time is 37 to 38 weeks of pregnancy

FORCEP BIRTH

A woman is unable to push with contractions in the


pelvic division of labor such as might happen with a
woman who receives regional anesthesia or has a
spinal cord injury.
Cessation of descent in the second stage of labor
occurs.
A fetus is in an abnormal position or is immature.
A fetus is in distress from a complication such as a
prolapsed cord.

Before forceps are applied,


Membranes must be ruptured.
CPD must not be present.
The cervix must be fully dilated.
The womans bladder must be empty.

VACUUM EXTRACTION
a disk-shaped cup is pressed against the fetal
scalp, over the posterior fontanelle. When
vacuum pressure is applied, air beneath the cup
is suctioned out and the cup then adheres so
tightly to the fetal scalp that traction on the
cord leading to the cup extracts the fetus

THERAPEUTIC MANAGEMENT OF
PROBLEMS OR POTENTIAL PROBLEMS IN
LABOR AND BIRTH

1. Induction of labor done when labor


contractions are ineffective
- means that labor is started artificially

Indications;
1. pre-eclampsia
2. eclampsia
3. severe hypertension/DM
4. Rh sensitization
5. prolong rupture of membranes
6. post maturity

Requirements for labor induction;


1. fetus must be in longitudinal lie
2. cervix must be ripe
3. presenting part must be engaged
4. No CPD
5. fetus is matured by date, LS ratio or sonogram (bi-parietal
diameter)

Pharmacological Methods:
1. Cervical Ripening softening of the cervix/consistency

- is the FIRST STEP the uterus must complete in early


labor

- necessary for dilatation and uterine contractions


Criteria:
Scoring of cervix for readiness in elective conductions (if
the scale is 8 or above, the woman is considered ready for
birth and induction)

Scoring
Factor

Dilatation (cm)

1-2

3-4

5-6

Effacement (%) 0-30

40-50

60-70

80

Station

-3

-2

-1, 0

+1, +2

Consistency

Firm

Medium

Soft

Position

Posterior

Mid-Posterior

Anterior

Prostaglandin Gel commonly used method of speeding


cervical ripening and is applied to the inferior surface of
the cervix
- applied before labor induction
- can also be applied on the external surface by
applying the gel to the diaphragm then placing the
diaphragm against the cervix
- apply every 6 hours for 2-3 doses

Nursing Considerations;
1. Place women in flat position to prevent leakage of medication
2. the woman remains on bed rest for 1 to 2 hours and is monitored for
uterine contractions
3. monitor FHR continuously for at least 30 minutes after each
application up to 2 hours
4. IV line with saline is initiated in case uterine hyperstimulation
occurs such as contractions longer than 90 seconds or more than 5
contraction in 10 minutes
5. explain the side effects vomiting, fever, diarrhea and hypertension
6. oxytocin induction can be started 6-12 hours after the last
prostaglandin dose

2. Induction of Labor by Oxytocin a synthetic form of


pituitary hormone initiates contractions in uterus
Nursing Considerations;
1. Given IV (to hasten effect), IV form of oxytocin needs to
be diluted
2. the drug is traditionally mixed in the proportion of 10 IU
in 1000ml of Ringers Lactated (LR)
3. Administer the medication by piggyback attach to D5W
as the main IV line (if oxytocin needs to be discontinued, the
main line will be maintain)

4. when cervical dilatations reaches 4 cm, artificial rupture of


membranes is performed to further induce labor and oxytocin
infusion is discontinued
5. Monitor FHR/uterine contractions and cervical dilatation
during the procedure
6. side effects: extreme hypotension due to peripheral
vasodilatation, headache, vomiting
7. monitor VS every 15 minutes
8. complications to watch; fetal distress and uterine rupture

ANOMALIES OF THE PLACENTA AND


CORD

1. Anomalies of the placenta


a. Placenta Succenturiata has one or more
accessory lobes connected to the main placenta by blood
vessels
- no fetal abnormality associated with it
- can lead to maternal hemorrhage
(small lobes retain in the uterus after birth)

b. Placenta Circumvallata fetal side of the placenta is covered with


chorion (normally, no chorion covers the fetal side of the placenta)
- no abnormalities is associated with this types of
placental anomaly

c. Battledore Placenta the cord is inserted marginally rather than


centrally
- rare/unknown clinical significance
d. Velamentous Insertion of the Cord situation in which the cord
instead of entering the placenta directly, separated into small vessels that
reach the placenta by spreading across a fold of amnion

VASA PREVIA
the umbilical vessels of a velamentous cord
insertion cross the cervical os and therefore
deliver before the fetus

Before inserting any instrument such as an internal


fetal monitor, be certain to identify structures to
prevent accidental tearing of a vasa previa as tearing
would result in sudden fetal blood loss.

PLACENTA ACCRETA
unusual deep attachment of the placenta to
the uterine myometrium
placenta cannot be loosen and deliver

TYPES:
a) Placenta Accreta - invasion of the
myometrium that does not penetrate the
entire thickness of the muscle. It is the most
common type.
b) Placenta Increta - the placenta extends
into the muscles of the uterine wall
c) Placenta Percreta placenta penetrates
the entire uterine wall. It can lead to the
placenta attaching to other organs such as
the bladder.

PREDISPOSING FACTORS:
placenta previa
previous CS delivery
advance maternal age
placental location overlying previous uterine
scar
previous multiple pregnancies
previous uterine surgery
previous D&C
rate of incidence is higher when the fetus is
female according to studies

COMPLICATION:

rupture uterus
MANAGEMENT:

bedrest

curettage

oversewing of placenta bed

occluding the blood vessel that supply the


pelvis

scheduled delivery by CS

Methotrexate to destroy the still


attached tissue

Hysterectomy

Postpartum Complications
Postpartum hemorrhage major cause of maternal
death, occurs in 4% of deliveries
- defined as blood loss greater than 500 ml after
vaginal birth or 1000 ml after CS
Classifications:
According to severity:
a. Mild 750 1250 ml
b. Moderate 1250 1750 ml
c. Severe 2500 ml
1.

According to time:
1. Early Postpartum hemorrhage occurs within 24 hours of birth
2. Late postpartum hemorrhage occurs after 24 hours until 6 weeks after
birth

Major Risk: Hypovolemic Shock (low volume)


- occurs when the circulating blood volume is decreased which
interrupts blood flow to body cells
- manifested as:
a. Tachycardia (first sign)
b. hypotension
c. cold and clammy skin
d. mental changes such as anxiety, confusion, restleness
e. decrease urine output

Conditions that increase risk for PP hemorrhage


1. Over distension of the uterus

Multiple births
Hydramnios
Macrosomia

2. Trauma r/t forceps, uterine manipulation


3. Prolonged labor
4. Uterine infection
5. Trauma removing placenta

Causes of Postpartum hemorrhage

1.

Uterine Atony: Uterus without tone or lack of


normal muscle tone (90% of cases)
- uterine atony allows blood vessels at the
placenta site to bleed freely and usually massively.
- uterine muscle unable to contract around blood
vessels at placental site

Risk Factors:
1. Deep anesthesia
2. >30 years old
3. prolonged use of magnesium sulfate
4. previous uterine surgery
5. Over exhaustion
Symptoms:
1. uterus is difficult to feel and is boggy (soft)
2. lochia is increased and may have large blood clots
3. Blood may gush or come out slowly

Nursing Management:
1. Massage the uterus until firm
2. have mother to urinate or catheterize because bladder distension
pushes the uterus upward or in the side and interferes with the
ability of the uterus to contract
3. Encourage mother to breastfeed because sucking stimulation
causes the release of oxytocin from PPG
4. Administration of IV oxytocin or Methylergonovine
(Methergine) to control uterine atony
5. Hysterectomy is performed to remove the bleeding uterus that
does not respond to other measures

2. Lacerations tearing of the birth canal


- normally occurs as a result of child bearing
Risk factors:
a. difficult or precipitate births
b. primigravidas
c. birth of a large infant
d. use of a lithotomy position and instruments
(forceps)

Sites of lacerations:
1. Cervical Lacerations
- characterized by gushes of bright red blood from the vaginal
opening if uterine artery is torn
- difficult to repair because the bleeding may be so intense that it
can obstruct visualization of the area.
2. Vaginal Lacerations
- rare case but easier to assess
- oozing of blood after repair, vaginal packing is necessary to
maintain pressure from the suture line
- catheterize the mother because packing causes pressure on
urethra
- packing is removed after 24-48 hours (at risk for infection)

3. Perineal Lacerations
- usually occurs when mother is placed on lithotomy positions
(increases pressure on perineum)
Classifications:
a. First Degree vaginal mucous membranes and skin of the
perineum to the fourchette
b. Second Degree vagina, perineal skin, fascia and perineal body
c. Third Degree entire perineum and reaches the external sphincter
of the rectum
d. Fourth Degree entire perineum, rectal sphincter and some of the
mucous membrane of the rectum

Management (Perineal)
1. sutured and treated using episiotomy repair
2. diet high in carbohydrate and a stool softener is prescribed for
the first week postpartum to prevent constipation which could
break the sutures
3. do not take rectal temperatures because the hard tips of
equipment could open sutures

3. Retained Placental Fragments placenta does not deliver its


entire fragments and left behind leading to uterine bleeding
Causes:
a. Placenta Succenturiata a placenta with accessory lobe
b. Placenta Accreta a placenta that fuses with myometrium because of an
abnormal basalis layer
Signs and Symptoms:
1. if Large fragments
- Patient bleeds immediately at delivery
- Uterus is boggy
2. if Small fragments
- bleeding occurs at 6th 10th day PP
- Can cause subinvolution

Management:
1. Dilatation and Curettage (D&C) will be performed to remove
placental fragments and to stop bleeding
2. administration of Methotrexate to destroy the retained
placental tissue
3. instruct the mother to observe the color of lochia discharge
4. check the completeness of the placenta after birth

4. Disseminated Intravascular Coagulation (DIC)


- deficiency in clotting ability caused by vascular injury
characterized by bleeding the IV sites, nose, gums etc.
Associative Factors:
a. premature separation of the placenta
b. missed early miscarriage
c. fetal death in utero

MEDICAL MANAGEMENT:
Heparin Therapy ( Anticoagulant) to halt
the clotting; thus aid coagulation
throughout the rest of the body
Blood or Platelets Transfusion - it can be
delayed until after heparin therapy so the
new blood factors are also not consumed by
the coagulation process.

NURSING MANAGEMENT:
Explain her condition to the patient if she is
unaware of it in order to instill and maintain
confidence.
Fetal assessment in order to evaluate the
sufficiency of placental circulation.
Referring to the physician all blood
coagulation studies.

5. Perineal Hematoma is a collection of blood in the


subcutaneous layer tissue of the perineum caused by injury to blood
vessels after birth
Risk Factors:
a. rapid spontaneous birth
b. perineal varicosities
c. episiotomy or laceration repair sites
Signs and Symptoms:
1. severe pain in the perineal area
2. feeling of pressure between the legs
3. purplish discoloration/swelling on perineum
4. concealed bleeding

Management:
1. assess the size by measuring it in centimeters
2. administer a mild analgesic as pain relief
3. apply an ice pack (covered by towel to prevent thermal
injury to the skin)
4. incision and drainage of the site of hematoma and is
packed with gauze

Puerperal Infection
- Infection of the reproductive tract associated with giving birth
- Usually occurs within 10 days of birth
- Another leading cause of maternal death
- Predisposing factors:
a. Prolonged rupture of membranes (>24 hours)
b. C-section
c. Trauma during birth process
d. Maternal anemia
e. Retained placental fragments

- Infection may be localized or systemic


a. Local infection can spread to peritoneum (peritonitis) or circulatory
system (septicemia).
b. Fatal to woman already stressed with childbirth
Assessment findings:
1. Temp of 100.4 for more than 2 consecutive days, excluding the first 24
hours.
2. Abdominal, perineal, or pelvic pain
3. Foul-smelling vaginal discharge
4. Burning sensation with urination
5. Chills, malaise
6. Rapid pulse and respirations
7. Elevated WBC, positive culture and sensitivity
(Remember, 20-25,000 is normal after deliveryMASKING infection)
8. inflammation of the suture line with pus

PREVENTION:
well balanced diet
avoid coitus in late pregnancy
separation of infected patient from noninfected patients
strict aseptic technique
proper perineal care
good handwashing technique to prevent
cross- contamination

Nursing interventions
1. Force fluids; may need more than 3L/day
2. Administer antibiotics after culture and sensitivity of the organism
(Group B streptococci and E. Coli) and other meds as ordered
3. Treat symptoms as they arise
4. Encourage high calorie, high protein diet
5. Position patient in a semi-Fowlers to promote drainage and prevent
reflux higher into reproductive tract
6. Use of sterile equipments on birth canal during labor, birth and
postpartum
7. Educate the mother about proper perineal care including wiping from
front to back
8. remove the suture to drain the area
9. hot sitz bath or warm compress
10. instruct the mother to observe for problem in their infant (such as oral candida)
This occur due to portion of maternal antibiotic passes into breast
11. Milk and can cause the overgrowth of fungal organism in an infant

Endometritis
- refers to the infection of the endometrium, the lining of the uterus at
the time of birth or during Postpartal period

Signs and Symptoms:


1. fever on the third or fourth day postpartum(increase in oral
temperature above 38C for 2 consecutive 24 hour periods, excluding
the first 24 hours period after birth)
2. chills, loss of appetite and general body malaise
3. uterine tenderness
4. foul smelling lochia

Management:
1. ATBC administration such as Clindamycin after culture
2. oxytocin is given to encourage uterine contraction
3. encourage increase fluid intake to combat fever
4. analgesic as ordered for pain relief due to after pains and
abdominal discomforts
5. encourage client to ambulate or in Fowlers position to
promote lochia drainage and prevent pooling of infected
secretions
6. IV therapy

Perineal Infection
- localized infection of the suture line from an episiotomy site

Signs and Symptoms:


1. feeling of heat, pain and pressure on the suture line
2. 1 or 2 stitches are sloughed away
3. purulent discharges on suture lines
Management:
1. removal of perineal sutures to open and allow for drainage

2. Topical, systemic ATBC as ordered


3. Analgesic to alleviate discomfort
4. Provide Sitz bath or warm compress to hasten drainage and
cleanse the area
5. Remind the mother to change perineal pads frequently to
prevent contamination/infection
6. Teach proper perineal care wiping from front to back after
bowel movement (to prevent bringing the feces to the healing
area)