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1. INLET CONTRACTION
 Is narrowing of the pelvis
Anteroposterior diameter <11cm
Transverse diameter- 12cm/less
Cause: Rickets in early life
Inherited pelvis
Rickets- caused by lack of calcium
If engage does not occur:
 Fetal abnormality (larger than the usual
head)
 Pelvic abnormality (smaller than the usual
head)
2. OUTLET CONTRACTION
 Is a narrowing of the transverse diameter, the
distance between the ischial tuberosities at the
outlet, to less than 11 cm
Management:
1. Trial labor
2. Forceps birth
3. Vacuum extraction
IV. ANOMALIES OF THE PLACENTA AND
CORD
1. PLACENTA SUCCENTURIATA
 A placenta that has one or more accessory lobes
connected to the main placenta by blood
vessels.
 No fetal abnormality is associated
 Small lobes maybe retained in the uterus after
birth.
 The placenta appears torn at the edge or torn
blood vessels extend beyond the edge of the
placenta.
2. PLACENTA CIRCUMVALLATA
 No chorion covers the fetal side of the placenta.
 A whitish ring composed of decidua is seen
around the placenta from its fetal surface.
 No abnormalities are associated, but it should
be noted.
3. BATTLEDORE PLACENTA
 Cord is inserted near the placenta margin rather
than in the center.
 Rare
 No known clinical significance
4. VELAMENTOUS INSERTION of the CORD
 The cord, instead of entering the placenta
directly, separates into small vessels that reach
the placenta by spreading across a fold of
amnion.
 Mostly in multiple gestation
 Associated with fetal anomalies─ not enough
blood supply
5. VASA PREVIA
 Is defined as “fetal vessels crossing or running
in close proximity to the inner os.”
 Painless bleeding may occur
 These vessels course within the membranes
and are at risk of rupture when the supporting
membranes rupture.
 Cesarean birth is necessary
6. PLACENTA ACCRETA
 Unusually deep attachment of the placenta to
the uterine myometrium, so deep that the
placenta will not loosen and deliver.
 Attempts to remove manually causes extreme
hemorrhage.
 Hysterectomy (to remove the uterus)
 Methotrexate (to destroy the still-attach tissue)
 Decidua (normal)- Placenta attaches to the
uterus until labor, when it separates with
the help of contractions.
 Placenta increta- the placental chorionic
villi invade deeply into the uterine
myometrium.
 Placenta accrete- the placental chorionic
villi adheres to the superficial layer of the
uterine myometrium.
 Placenta percreta- the placental chorionic
villi grows through the uttering
myometrium and often adhere to
abnormal structures (e.g. bladder &
intestine).
B. ANOMALIES OF THE CORD
Umbilical Cord
 It is the connection between placenta and fetus.
LENGTH: 50-60 cm
DIAMETER: 2 cm
SHAPE: tortous, showing false notes
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Contents: 2 umbilical arteries, one umbilical vein SHORT CORD

embedded in Wharton’s jelly and surrounded by  Poses a risk for numerous delivery
amniotic membrane complications and birth injuries.
 Evaluated through ultrasound
Attachments: it is attached to fetal surface of  Close monitoring for mother & child
placenta near its center, the other attachment is through prenatal tests or admission for
to central aspect of fetal abdominal wall continuous monitoring
Complications include:
Function: It provides a developing baby with 1. Placental abruption- baby’s movement
blood, oxygen, nutrients and waste disposal. pulls on the cord enough to cause the
- It contains umbilical vessels that connect placenta to pull away from the uterus,
the fetus to the placenta. resulting in severe bleeding.
1. TWO-VESSEL CORD Management:
 The cord has a single artery and a vein.  Rapid C-section to prevent the child
 Also called as a Single Umbilical Artery (SUA) from experiencing dangerous
 Causes: oxygen deprivation and sustaining
1. An artery doesn’t grow properly in the permanent brain damage.
womb. 2. Abnormal fetal lie
2. “ “ “ divide in two as it normally Management:
would.  Rapid C-section to prevent the child
RISK FACTORS: from experiencing dangerous
 Being older than age 40 oxygen deprivation and sustaining
 Having a history of diabetes / high blood permanent brain damage.
sugar episodes during pregnancy
 Pregnant w/ multiple babies, like twins/ LONG CORD
triplets phenytoin  Unusually long cord may be easily
Diagnosis compromised
 During prenatal period- ultrasound  It may tend to twist or form a knot.
May cause birth defects  May cause NUCHAL CORD
 Heart problems
 Kidney problems GIANT UMBILICAL CORD
 Spinal defects  Diameter: 5 cm
May be associated with;  Length: approx. 30 cm
 Genetic abnormality known as VATER.  Glistening surface
 This stands for vertebral defects, anal  Hydropic consistency
atresia, transesophageal fistula w/
esophageal atresia & radial dysplasia. SUPINE HYPOTENSION (Vena Cava syndrome)
2. UNUSUAL CORD LENGTH  Occurs when the venous return to the heart is
a. Cord absence (achordia) impaired by the weight of the uterus of the vena
b. Excessively short umbilical cord (<35 cm) cava.
 Abnormal presentations
 Fetal Heart Rate injuries  The syndrome results in partial occlusion of the
 Abruptio placenta vena cava and aorta and in reduced cardiac
 Rupture-hemorrhage-fetal death return, cardiac output and blood pressure.
 Anomalies of parturition ASSESSMENT
 Inversion of the uterus 1. Pallor
 2. Faintness, dizziness, breathlessness
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3. Tachycardia, hypotension  Monitor for unusual pain

4. Sweating, cool & damp skin
5. Fetal distress After procedure:
INTERVENTION a. Prepare for a nonstress test to evaluate
 Position the client on her side particularly fetal well-being
left lateral recumbent position─ to shift the b. Monitor uterine activity, bleeding,
weight of the fetus off the vena cava until her ruptured membrane & decreased fetal
S/S subside and V/S stabilize activity
 Monitor V/S and FHR c. Rh (-) patient─ perform Kleihauer-Betke
test─ to detect the presence and
OBSTETRICAL PROCEDURES amount of fetal blood in the maternal
A. BISHOP SCORE circulation and identify if additional Rh
─ determines maternal readiness for labor (6 immune globulin is needed.
cm > indicates readiness for labor induction)
 Dilatation D. EPISIOTOMY
 Effacement  It is an insertion made into the perineum
 Consistency to enlarge the vaginal outlet and
 Position facilitate delivery.
 Station of presenting part ─ check the site for lacerations, bleeding
and infection;
B. ELECTIVE INDUCTION OF LABOR R(edness)
 Oxytocin (Pitocin, Syntocinon) infusion E(dema)
 Amniotomy─ artificial rupture of E(cchymosis)
membrane D(rainage/discharge)
─done when 0 0r + station A(pproximation of wound)

Risk for Prolapse cord, infection  ice pack 1st 24 hours to prevent bleeding
 Bloody amniotic fluid─ abruptio & hematoma
placenta, fetal trauma  sitz bath after 24 hours
 Polyhydramnios─ DM, congenital  shower; do not bath in tub to prevent
disorder infection
 Oligohydramnios─ intrauterine growth E. FORCEPS BIRTH
retardation (IUGR)  Forceps: instrument used to shorten the
2nd stage of labor
C. External Caphalic version  Applied to head or presenting part to
 Manipulation of the fetus from an allow physician to control traction on
abnormal position into a normal infant’s head
presentation  Indicated in ineffective pushing,
 Indicated for an abnormal presentation malposition & large infants
that exist after the 34th week  Check for possible injury, e.g. intracranial
hemorrhage, facial bruising, fatal palsy,
INTERVENTIONS hematoma of perineal area of the
 Monitor V/S mother
 Tocolytic & IV therapy is administered to
relax uterus F. VACUUM EXTRACTION
 Monitor BP to identify vena cava
compression
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 A cup is placed on the presenting part
through w/c suction is applied to pull
infant down
 Infant may develop caput succedaneum
but is otherwise unharmed.
 Not to be done longer than 25 min.
 Assess for cerebral trauma─
cephalhematoma
 Caput succedaneum is normal & will
resolve in 24 hrs.
G. AMNIOTOMY
 Done to induce or stimulate labor / to
permit internal electrolyte fetal
monitoring
RISKS:
1. Prolapse of the UC- cord will slip down in
a gush of fluid
2. Infection- vaginal organisms have free
access (Chorioamnionitis)
3. Abruptio Placentae- uterus is distended
when the membranes rupture.
INDUCTION & AUGMENTATION of LABOR
- Are considered when ending the pregnancy
benefits the women/fetus and when labor &
vaginal birth are considered safe.
RISKS:
1. Uterine hyperstimulation- can reduce
placental perfusion & fetal oxygenation
2. Uterine rupture- over distention
3. Maternal water intoxication- caused by
oxytocin’s antidiuretic affects
4. Greater risk for CS birth
TECHNIQUES
 Determining whether induction is indicated
 Cervical ripening- softens the cervix & make
it more likely to dilate
a. Medical methods
b. Mechanical methods
 Oxytocin administration- a powerful drug
and it is impossible to predict a woman’s
response to it.
Nursing Considerations:
 Observing fetal response
 Observing mother’s response
CESAREAN BIRTH
 Birth accomplished through an abdominal
incision into the uterus.
 One of the oldest types of surgical procedures
known.
 It is always slightly more hazardous than vaginal
birth (done only when medically necessary)
 One of the safest types of surgical with few
complications compared with other surgical
procedures.
INDICATIONS
 Maternal factors:
1. Active genital herpes/ HPV
2. AIDS/ HIV
3. Maternal Disease (DM, Heart Disease/
Cervical cancer)
4. Dystocia
5. Cephalopelvic disproportion (CPD)
6. Cervical cerclage
7. Disabling conditions (severe hypertension)
8. Failed induction/ failure to progress in labor
9. Previous surgical procedure
10. Elective- no indicated risk
RISKS:
 Infection
 Hemorrhage
 UTI/trauma
 Thrombophlebitis/ embolism
 Paralytic ileus
 Atelectasis
 Anesthesia complications
 Placental factors
1. Placenta previa
2. Premature separation of the placenta
3. Umbilical cord prolapse
 Fetal factors
1. Compound conditions (macrosomic fetus in
a breech lie)
2. Extreme low birth weight
3. Fetal distress
4. Major fetal anomalies (hydrocephalus)
5. Multigestation/ conjoined twins
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6. Transverse fetal lie
RISKs:
 Inadvertent preterm birth
 Transient tachypnea- delayed
absorption of lung fluid
 Persistent pulmonary hypertension
 Injury (laceration, bruising, fractures,
other trauma)
TYPES:
1. Scheduled/ elective
2. Emergent
PREOPERATIVE ASSESSMENT
- A nursing assessment of a pregnant woman
about to undergo CS birth is also important to
obtain health history that would become
essential later on.
- Assess the woman about past surgeries,
secondary illnesses, allergies to foods/drugs,
reaction to anesthesia & medications that
could increase any surgical risk.
- The woman should be in the best possible
physical and psychological state before
undergoing any surgery.
- An obese woman with poor nutritional status
is at risk for a slow wound healing.
- Tissue that contains extra fatty cells would be
difficult to suture and the incision will heal
much slower and predispose the woman to
infection and dehiscence.
- An obese woman would also have difficulty in
initiating ambulation & turning after surgery
as it will increase the risk for
pneumonia/thrombophlebitis
- A woman w/ protein/vitamin deficiency is also
at risk for poorer healing because these are
needed for new cell formation at the incision
site.
- Age can also affect surgical risk because it can
cause decreased circulatory and renal
function
- A woman who has secondary illness is also at
greater risk depending on the extent of the
disease because the secondary illness may
affect the woman’s ability to adapt to the
demands of the surgery.
- The general medication history of the woman
must also be assessed because there are drugs
that could increase the surgical risk by
interfering w/ the defects of surgery more
than a woman with normal blood volume.
1. STRESS RESPONSE
- Such response minimize blood supply to
the lower extremities causes
Thrombophlebitis.
2. INTERFERENCE W/ BODY DEFENSES
- Important line of defense are lost
- Adherence to aseptic technique during
surgery & the days following surgery
3. INTERFERENCE W/ CIRCULATORY FUNCTION
- Pelvic vessels are congested w/ blood
waiting to supply the placenta.
- Extensive blood loss can lead to
hypovolemia and lowered blood pressure.
4. INTERFERENCE W/ BODY ORGAN FUNCTION
- When body organ is handled, cut or
repaired in surgery, it may respond w/ a
temporary disruption in function.
- Bladder must be displaced anteriorly-
bladder may not sense filling usually after
surgery
- Paralytic ileus- intestine
5. INTERFERENCE W/ SELF-IMAGE or ESTEEM
- Scar
- Marks her woman less than others
Nursing Care of a Woman Anticipating a Cesarean
Birth
PREOPERATIVE INTERVIEW
 The woman’s knowledge about the procedure
 The length of hospitalization anticipated
 Postsurgical equipment to be used
 Special precautions necessary for her infant
PREOPERATIVE DIAGNOSTIC PROCEDURES
 V/S determination
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 Urinalysis
 CBC
 Coagulation profile (prothrombin time (PT),
partial thromboplastin time (PTT0
 Serum electrolytes and Ph
 Blood typing and crossmatching
 Ultrasound- to determine fetal presentation and
maturity

PREOPERATIVE TEACHING
 Teach to prevent complications
a. Deep breathing
b. Incentive spirometry
c. Turning
d. Ambulation

IMMEDIATE PREOPERATIVE CARE MEASURES

 Informed consent
 Overall hygiene
 Gastrointestinal tract preparation
 Baseline intake & output
 Hydration
 Preoperative medication
 Patient chart & presurgery checklist
 Transport to surgery
 Role of the support person

INTRAOPERATIVE CARE MEASURES

 Administration of anesthesia
 Skin preparation
 Surgical incision

TYPES of UTERINE INCISION

Classic cesarean incision
Low transverse incision
Low vertical incision

TYPES of SKIN INCISION for CS

 Vertical
 Pfannenstiel

Nursing Consideration
 Providing emotional support
 Teaching
 Promoting safety
 Providing postoperative care
 Presenting vaginal birth after CS