UTERINE PROLAPSED
If you a chronic
 Uterine prolapse is falling or sliding of the womb (uterus) from
its normal position into the vaginal area.
 Muscles, ligaments, and other structures hold the uterus in the
pelvis. If these muscles and structures are weak, the uterus
drops into the vaginal canal. This is called prolapse.
 This condition is more common in women who have had one
or more vaginal births.
Causes
1. Normal aging
2. Lack of estrogen after menopause
3. Anything that puts pressure on the pelvic muscles, including
chronic cough and obesity
4. Pelvic tumor (rare)
 Long-term constipation and the pushing associated with it
can make this condition worse.
Assessment
1. Feeling like you are sitting on a small ball
2. Difficult or painful sexual intercourse
3. Frequent urination or a sudden urge to empty the bladder
4. Low backache
5. Uterus and cervix that stick out through the vaginal opening
6. Repeated bladder infections
7. Feeling of heaviness or pulling in the pelvis
8. Vaginal bleeding
9. Increased vaginal discharge
Diagnostic Test
A pelvic examination
 The pelvic exam may also show that the bladder and front wall
of the vagina (cystocele), or rectum and back wall of the
vagina (rectocele) are entering the vagina. The urethra and
bladder may also be lower in the pelvis than usual.
Treatment
1. Lifestyle changes
 Weight loss is recommended in obese women with uterine
prolapse.
 Heavy lifting or straining should be avoided, because they can
worsen symptoms.
 Coughing can also make symptoms worse.
cough, ask your doctor how to prevent or treat it. If you smoke,
try to quit. Smoking can cause a chronic cough.
2. Vaginal passery
 Doctors may recommend placing a rubber or plastic donut-
shaped device, called a pessary, into the vagina.
 The device holds the uterus in place. It may be temporary or
permanent. Vaginal pessaries are fitted for each individual
woman. Some are similar to a diaphragm used for birth
control.
 Pessaries must be cleaned from time to time, sometimes by
the doctor or nurse. Many women can be taught how to insert,
clean, and remove the pessary herself.
Side effects of pessaries include:
1. Foul smelling discharge from the vagina
2. Irritation of the lining of the vagina
3. Ulcers in the vagina
4. Problems with normal sexual intercourse and penetration
3. Surgery
Surgery should not be done until the prolapse symptoms are worse
than the risks of having surgery. The specific type of surgery depends
on:
1. Degree of prolapsed
2. Desire for future pregnancies
3. Other medical conditions
4. The women's desire to retain vaginal function
5. The woman's age and general health
6.  Vaginal hysterectomy is used to correct uterine prolapse. Any
sagging of the vaginal
walls, urethra, bladder, or rectum can be surgically corrected
at the same time.
Complications
1. Ulceration and infection of the cervix and vaginal walls may
occur in severe cases of uterine prolapse.
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 2. Urinary tract infections and other urinary symptoms may occur Types
because of a cystocele. Constipation andhemorrhoids may 1. Complete rupture
occur because of a rectocele.  endometrium, myometrium and peritoneum layers
 uterine contractions will immediately stops
Prevention  2 distinct swellings will be visible on the woman’s abdomen
1. Tightening the pelvic floor muscles using Kegel a) The retracted uterus
exercises helps to strengthen the muscles and reduces the b) Extrauterine fetus
risk of uterine prolapse.  Signs of shock: rapid weak pulse, falling BP, cold clammy
2. Estrogen therapy, either vaginal or oral, in postmenopausal skin, dilatation of the nostrils, FHR fades and then are absent.
women may help maintain muscle tone in the vaginal area. 2. Incomplete rupture
3. Weight loss and avoiding heavy lifting can decrease the risk  leaving the peritoneum intact
for uterine prolapse.  the signs of rupture are less evident
 woman experience only a localized tenderness and a
UTERINE RUPTURE persistent aching pain over the area of the lower uterine
 Occurs when a uterus undergoes more strain than it is capable segment
of sustaining.  fetal and maternal distress
 Occur most commonly when a vertical scar from a previous  lack of contractions
CS or hysterectomy repair tears.
 Confirmed by Ultrasound Nursing care management
 An immediate emergency situation 1. Administer emergency fluid replacement therapy as ordered.
2. Anticipate the use of oxytocin to attempt to contract the uterus
Predisposing factors and minimize bleeding
1. Prolonged labor 3. Prepare the woman for possible laparotomy as an emergency
2. Abnormal presentation measure to control bleeding and achieve a repair
3. Multiple gestation 4. Advised not to conceive again after a rupture of the uterus---
4. Unwise use of oxytocin unless the rupture occurred in the inactive lower segment.
5. Obstructed labor 5. Perform a ceasarian hysterectomy (with consent) fear of the
6. Traumatic maneuvers of forceps or tractions removal of the damaged uterus or tubal ligation at the time of
 If uterine rupture occurs fetal death will follow UNLESS laparotomy ==== result in the loss of childbearing ability.
immediate CS is done.
 Impending rupture may be preceded by a pathologic INVERSION OF THE UTERUS
retraction ring and by strong uterine contractions without  Refers to the uterus turning inside out with either birth of the
cervical dilatation. fetus or delivery of the placenta
 TO PREVENT RUPTURE: anticipate the need of an  Occur if traction is applied to the umbilical cord to remove the
immediate CS placenta
 Occur if pressure is applied to the uterine fundus when the
Assessment uterus is not contracted.
1. Sudden, severe pain during a strong labor contractions  Occur if the placenta is attached at the fundus and during birth
2. Tearing sensation the fetus pulls the fundus down
 Occurs in degrees
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 a. The inverted fundus may lie within the uterine cavity or
the vagina
b. Total inversion it may protrude from the vagina
Assessment
1. Large amount of blood suddenly gushes from the vagina
2. If it continues: woman will show signs of blood loss:
hypotension, dizziness, paleness and diaphoresis
3. Fundus is not palpable in the abdomen
4. Uterus is not contracting
5. Bleeding continues
Nursing care management
1. Never attempt to replace an inversion == because handling of
the uterus may increase the bleeding.
2. Never attempt to remove the placenta if it is still attached ==
because this only creates a larger surface area for bleeding.
3. Start an IV fluid using a large gauge needle
4. Administer O2 via mask
5. Assess Vital signs
6. Be ready to give CPR == due to sudden blood loss, heart will
fail
7. Give general anesthesia, or possibly nitroglycerin or a tocolytic
drug to relax the uterus
8. Physician/midwife/nurse replaces the fundus manually
9. Administer oxytocin after manual replacement helps the uterus
to contract and to remain in its natural place
10. Antibiotic therapy == because the woman’s endometrium is
exposed, preventing infection
11. Informed her that CS will probably be necessary in any future
pregnancy == to prevent the possibility of future inversion
PROBLEMS of THE PASSAGEWAY
1. ABNORMAL SIZE OR SHAPE OF THE PELVIS
 Narrowing of the passageway/birth canal
 Happen in the inlet, outlet and midpelvis
 Types of pelvis
 Gynecoid
 Anthropoid- oval inlet, ape
 Android – male pelvis, hear shaped
 Platypelloid- compressed front-back, oval
 The narrowing causes: CPD and failure to progress in
labor.
Factors influencing the size and shape of the pelvis:
 Developmental factor: hereditary or congenital
 Racial factor
 Nutritional factor: Malnutrition results in small pelvis
 Sexual factor: as excessive androgen may produce
android pelvis
 Metabolic factor: as rickets and osteomalacia
 Trauma, diseases or tumors of the bony pelvis, legs or
spines
2. CEPHALOPELVIC DISPROPORTION/ CPD
 Is suggested by lack of engagement at the beginning of labor,
prolonged first stage and finally poor fetal descent.
 A disproportion between the size of the fetal head and the
pelvic diameters. This result in failure to progress labor.
 INLET CONTRACTION- Narrowing of the anteroposterior
diameter to less than 11 cmor of the transverse diameter
to 12 cmor less
Causes
 Rickets in early life
 Small pelvis
Effects:
 Floating vertex presentation with no descent during
labor
 Abnormal presentation\
 Prolapsed cord extremity
 Considerable molding of the fetal head
 Caput succedaneum formation
 Prolonged rupture of the membranes
 If allowed to continue, abnormal thinning of the lower
uterine segment may occur with development of
Bandl’s retraction ring or even uterine rupture.
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  CS is the treatment of choice in true inlet contraction
Management:
 If minor inlet contraction- spontaneous delivery
 If with moderate and severe degrees
√ induction of labor
√ CS
√ Trial Labor
 OUTLET CONTRACTION- Narrowing of the transverse
diameter at the outlet to less than 11 cm. This is the
distance between the ischial tuberosities, a measurement
that is easy to make during a prenatal visit.
 MID PELVIS CONTRACTION-
 The interspinous diameter is estimated by palpating
the ischial spines.
 Most frequent than inlet dyticia because the midpelvis
is maller than the inlet and positional abnormality is
more common at this level
 An estimated distance of >9 cm
Effects:
 Arrest of descent
 Poor application of the head to the cervix
 Abnormal rate of cervical dilatation
3. SHOULDER DYSTOCIA
 Occurs at the 2nd stage of labor when the infant head is born
but the shoulders are too broad to enter and be delivered thru
the pelvic outlet.
 Hazardous to the mother- can result in vaginal cervical tear
 Hazardous to the fetus==cord compression
 Occur with women with diabetetis, multipara, post dated
pregnancies
Risk Factors
1. Brachial plexus injury
2. Brain injury- due to lack of o2 r/t cord compression of
umbilical cord
3. Chest compression leading to the uncoordinated breathing
Management
1. Mc Robert’s Manuever- mother is sharlply flexing her
thighs on her abdomen
2. Suprapubic pressure
PROBLEMS of THE PSYCHE FACTORS
1. Inadequate Voluntary Expulsive Forces
2. Fear/ anxiety
 Psyche is the woman’s psychological outlook or refers to the
state or feeling that a woman brings into labor.
 A feeling of apprehension or Fright.
 Women without adequate support can have a labor experience
so frightening and stressful which can develop a post
traumatic stress syndrome.
Nursing care management
1. Encourage women to ask questions at prenatal visitsand to
attend preparation for childbirth classes help prepare them to
labor.
2. Encourage to share their experience after labor serves a
briefing time and helps them integrate the experience into their
totallife.
POSTPARTAL COMPLICATIONS
A. POST PARTAL HEMORRHAGE
 Excessive blood loss during or after the third stage labor.
 Accepted normal average blood loss is 500 ml in vaginal
delivery and 1000 ml at CS
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  The most dangerous time at which hemorrhage is likely to  Abnormal adhesions such as accreta, increta and
occur is during the first hour post partum percreta.
 Blood loss more than 500 cc. (normal blood loss 250- 350 cc) 3. Trauma- 20% of postpartum hemorrhage is due to trauma
 Leading cause of maternal mortality associated with anywhere in the genital tract which may be caused by
childbearing  Lacerations and episiotomy
 Hematoma
Incidence  CS
1. The overall incidence is 3-6% in all deliveries  Uterine rupture and uterine inversion
2. Vaginal delivery is associated with a 3.9% incidence of  Uterine perforation during forceps application or
postpartum hemorrhage curettage
3. Cesarean delivery is associated with a 6.4% incidence of 4. Thrombosis – clot formation and fibrin deposition on the
postpartum hemorrhage. placental site stop the oozing of blood vessels of the uterus.
4. Delayed postpartum hemorrhage occurs in 1-2 % of patients.  Disorders of the coagulation system and platelets,
whether preexistent or acquired can result in bleeding
or aggravate bleeding.
Causes (4T’S)  Acquired disorders - HELLP syndrome, DIC
The cause of postpartal hemorrhage can be remembered easily by  Preexistent coagulation disorder- thrombocytopenic
using the mnemonic 4T’s purpura
1. Tone- refers to the failure of the uterine myometrial muscle
fibers to contract and retract which can caused by the Types of Post partum Hemorrhage
following conditions 1. Early Post-partum hemorrhage – occurs during the first 24 hrs
 Overdistention -Macrosomnia, hydramnios, multiple after delivery
pregnancy Causes of early postpartum hemorrhage
 Fatigue- prolonged labor, precipitate labor,oxytocic o Uterine Atony – uterus is not well contracted, relaxed
drugs or boggy most frequent cause)
 Infection-chorioamnionitis, endomyometritis, o Lacerations of birth canal
septicemia o Inversion of the uterus
 Uterine structural abnormality o Hypofibrinogenemia
 Hypoxia due to hypoperfusion or Couvelaire uterus o Clotting defect
 Placental site in the lower uterine segment 2. Late Postpartum Hemorrhage- Occurs from 24 hours after birth to
 Distention with blood before or after placental delivery 4 weeks postpartum.
 Inhibition of contractions by drugs- anesthetic agents, CAUSES OF LATE POSTPARTAL HEMORRHAGE
nitrates, NSAIDS, Mg S04, nifedipine, beta- o Retained Placental Fragments
symptomimetics o Subinvolution of the uterus
2. Tissue- Presence of retained placental tissues prevents full o Infection
uterine contractions resulting in failure to seal off bleeding
vessels which can caused by
Nursing care management
 Preterm gestation especially in lessthan 24 1. Fundal massage
weeksgestation

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 2. Offer a bedpan or assist with ambulating to the bathroom at 1. Intravenous infusion of oxytocin (pitocin) to help uterus
least every 4 hours to keep of the woman’s bladder empty maintain tone
3. If a woman is experiencing respiratory distress from 2. The usual dose is 10-40U per 1000ml of5%dextrose solution
decreasing blood volume, mask administer oxygen by face 3. Intramuscular Methylergonovine ( methergin)
mask of 4 L/min rate 4. Bimanual massage
4. Supine position to allow adequate blood flow to herbrain and 5. Prostaglandin administration
kidneys. 6. Blood replacement
5. Obtain vital signs frequently 7. Hysterectomy

(1) UTERINE ATONY (2) RETAINED PLACENTAL FRAGMENTS

 Failure of the uterus to contract continuously after delivery.  The most common cause of post partal
 It is the most common cause of Post partal hemorrhage and hemorrhage.
often occurs following delivery of the baby and up to 24 hours  Have increased risk of recurrence of retained
after the delivery of the placenta., placental fragments in subsequent deliveries.
 Relaxation of the uterus  Incidence: occurs in 6% of vaginal deliveries.
 Causes
Causes  Partial separation of a normal placenta
1. Overdistention : hydramnios, multiple pregnancy, macrosomia  Manual removal of placenta
2. Complication of labor- Precipitate , prolonged labor  Abnormal adherent placenta- accreta,
3. Uterine relaxing agents: anesthesia, analgesia, terbutaline, increta ore perceta
magnesium sulfate, nitroglycerine  Abnormal placental adhesion
4. Oxytocin given during labor
5. High parity and advanced maternal age (3) SUBINVOLUTION OF THE UTERUS
6. Infection: amnionitis and chorioamnionitis  Occurs when there is a delay in the return of the
7. Presence of fibroid tumors that interfere with uterine uterustoits prepregnant size, shape and function
contractions  Causes
8. Over massage of the uterus that results in very strong uterine 1. Retained placental fragments
contractions and eventual fatigue 2. Infection- endometritis
9. Retained placental fragments 3. Uterine tumors
10. Prolonged third stage of labor Assessment
 Enlarged and boggy uterus
Assessment  Prolonged or reversal pattern in lochial discharge
1. If the uterus suddenly relaxes, there will be abrupt gush of  Foul odor in lochia if caused by infection
blood from the placental site.
 Backache
2. Vaginal bleeding which is extremely large and the client
mayexhibit symptoms of shock andblood loss.
Therapeutic Management
Therapeutic management

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  Initially the physician may order Ergonovine Maleate . 8. The uterus was explored after birth for a retained placenta or
2mg to stimulate uterine contractions for 2 weeks.If abdominal bleeding site (infection was introduced with
bleeding continues after 2 weeks, D and Cis performed exploration)
 Treating the cause
 Removal of uterine tumors and antibiotics for Assessment- localized in the vagina, vulva, perineum
infection  Pain
 Evacuation of the retained placental fragments  Fever
by D and C  Edema
 Redness
Nursing care management  Firmness
1. Uterine Massage –first nursing action  Tenderness
2. Ice compress  Burning on urination
3. Oxytocin administration  Wound discharge
4. Empty bladder
 Temperature >100.4 (38C) after 1st 24 hours on any of the
5. Bimanual compression to explore retained placental
first 10 postpartum days.
fragments
Prevention
6. Hysterectomy (last alternative)
1. Use sterile gloves, instruments during labor, birth and
postpartal period.
2. Proper perineal care by the client,(front-back)
II. POSTPARTAL PUERPERIAL INFECTION 3. Handwashing
 Reproductive tract infection developing after delivery 4. The client should have her own bedpan and perineal supplies
 May spread to the peritoneum (peritonitis) or the circulatory and should not share them.
system (septicemia) 5. Antibiotics ( ampicillin, gentamicin, 3rd generation
cephalosporins (cefixime)
Risk Factors 6. No antibiotics during breastfeeding ==== observe infant for the
1. Ruptrure of the membrane more than 24 hours before birth presence of white plaque or thrush (oral candida) ===because
2. Placental fragments retained within the uterus ( the tissue the portion of the maternal antibiotic passes into the breastmilk
necroses and serves as an excellent bed for bacterial growth) and cause overgrowth of fungal organisms ===== a
3. Postpartal hemorrhage ( the woman’s general condition is decreased in microorganisms in the bowel caused by an
weakened) antibiotic passed in breast milk may lead to insufficient Vitamin
4. Pre-existing anemia ( the body’s defense against infection is K formation and decreased blood clotting ability.
lowered)  Hot sitz bath 2x a day.
5. Prolonged and difficult labor, particularly instrument births Management: antibiotic after culture and sensitivity testing of the
( trauma to the tissue may leave lacerations or fissures for isolated organisms
easy portals of entry for infection)  Group B streptococci
6. Internal fetal heart monitoring ( contamination may have been  Eschirichia coli
introduced in the placement of the scalp electrode)  Staphylococcus == cause of toxic syndrome similar to
7. Local vaginal infection was present at the time of birth (direct puerperial infection
spread of infection has occurred) 1. ENDOMETRITIS

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 An infection of the endometrium, the lining of the uterus. 2. WOUND INFECTION/INFECTION OF THE PERINEUM
 Bacteria gain access through the vagina and enter the uterus at  Suture line from her perineum, episiotomy or laceration repair
the time of birth or during the postpartal period. == portal of entry for bacterial invasion.
 Assessment
Assessment 1. Pain
1. Temperature elevation on the third and 4 th postpartal day == 2. Heat
occurs at the same time during breast filling 3. Feeling of pressure
2. Increase WBC 20,000-30,000cells.mm3 (NORMAL) 4. One or two stitches may be sloughed away
3. Chills 5. Open suture with drainage
4. Loss of appetite o Notify the physician on the localized symptom
5. General malaise o Culture the discharge using cotton tipped applicator
6. Uterus not well contracted and painful to touch touched to the secretions.
7. Strong afterpains
8. Lochia is dark brown, foul odor 3. UTI/ URINARY TRACT INFECTION
==== if accompanied with high fever == lochia may be
scant or absent Assessment
 Placental fragments confirmed by UTZ 1. Burning on urination
2. Hematuria- blood in the urine
Danger of endometritis 3. Feeling of frequency / she always has to void
 Tubal scarring 4. Sharp pain in voiding that she may refuse doing so –
 Interference with future fertility compounding to urinary stasis
Management 5. Low grade fever
1. Antibiotic == Clindamycin (Cleocin) === determined by a 6. Lower abdominal pain
culture of the lochia. Diagnosis -urinalysis
2. Vaginal culture using a sterile swab rather than from a perineal Management
pad 1. Sulfa drugs - commonly prescribed but contraindicated if
3. Oxytocic agent === methylergonovine == to encourage uterine breastfeeding
contraction 2. Amoxicillin/ ampicillin to treat infection- for 5-7 days to
4. Increase fluid intake eradicate infection completely
5. Analgesic === for afterpains 3. Drink large amounts of water- a glass every hour to help flush
6. Sitting in a fowler’s position or walking == encourage lochia infection from the bladder
drainage by gravity == helps prevent pooling of infected 4. Oral analgesic - Tylenol, Acetaminophen to reduce pain from
secretions. urination
== Wear gloves when changing perineal pad 5. Temporarily D/C breastfeeding depending on Antibiotic
7. Early recognition of signs: prescribed
o Normal color
o Quantity and odor of discharge 4. PERINEAL HEMATOMA
o Size, consistency, tenderness of a normal postpartal  Collection of blood in the subcutaneous layer tissue of the
uterus perineum.

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  Caused by the injury to the blood vessels in the perineum  The postpartum woman is especially susceptible for the
during birth. formation of thrombi because of increased fibrinogen and
 Occur during rapid spontaneous birth an perineal varicosities. prothrombin levels which increases blood coagulability.
 May occur at the site of episiotomy or laceration repair if a vein  Thrombi have a tendency to occlude circulation and are a
was punctured during repair. good medium of bacterial growth.
 Present minor bleeding and discomfort.
Incidence
Assessment 1. DVT- 3 to:1000
1. Severe pain in the perineal area 2. Pulmonary embolism- 2700 to 7000
2. Feeling of pressure between legs
3. With hematoma == purplish discoloration with swelling 2cm or Risk Factors
8cm in diameter 1. Varicosities of the legs
4. Tenderness during palpation 2. Obesity
5. Palpates as firm globe 3. Over 30 years old
4. Multiparity
Nursing care management 5. Use of estrogen supplement
1. Report the presence of hematoma: size, degree of woman’s 6. History of thromboembolic disease
discomfort 7. Anesthesia, surgery
2. Assess the size by measuring it in centimeters with each 8. Smoking
inspection. 9. Trauma to extremities
3. Describe a hematoma (small, large) 10. DM
4. Describe the lesion
5. Administer mild analgesic == pain relief
6. Apply an ice pack (covered with towel to prevent thermal injury Causes
to the skin) 1. Injury to blood vessels usually occurs during delivery,
7. If the hematoma is large or continues to increase === returned indwelling catheterization and infection
the woman in the delivery room to have the site incised and 2. Increased clotting that normally occurs during pregnancy and
vessel be ligated under local anesthesia. after delivery and with the use of oral contraceptives
 If an episiotomy incision line is opened to drain a 3. Blood stasis that occurs as a result of varicose veins, bed rest
hematoma, it may be left open and packed with gauze after CS and prolonged inactivity
rather than resutured.
 Packing is usually removed within 24-48 hours Dignosis
Instruct the client before discharge that she has to keep 1. Doppler ultrasound
the area dry 2. X-ray dye injection called venogram.

5. THROMBOEMBOLIC DISORDERS TYPES ACCORDING TO LOCATION

 Thrombi or blood clots are formed when there is stasis of
circulation or repair of damaged tissue.
1. Superficial thrombophlebitis/ Phlebothrombosis/ Venous
thrombosis
 Inflammation affecting the superficial veins of the extremities,
the veins that are near the skin and visible to the eye. Main
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 symptom is tenderness and pain in the affected vein followed
by edema
 Location of the clot can be seen by the eye on inspection of
the painful and reddened area in the affected leg. These blood
clots are large and hard enough to be felt by palpation
2. Deep Vein Thrombophlebitis/DVT
 This is inflammation of a vein located deep with in a muscle
tissue. Since the vein affected is surrounded by muscles,
blood clot may break free during muscular movement and
travel in the circulation.
 The main danger is of the emboli (moving blood clot is called
embolus, stationary blood clot is thrombus) reaching the lungs
and obstruct pulmonary blood flow resulting in pulmonary
embolism. There is more swelling in deep vein thrombosis
than in superficial vein thrombosis.
TYPES ACCORDING TO VEINS AFFECTED
1. Femoral Thrombophlebitis
 Infection of the veins of the legs femoral, popliteal veins
Manifestations
a. Homan’s sign- calf pain when the foot is dorsiflexed
b. Milk leg or phlegmasia alba dolens- the leg is shiny white
in appearance because of extreme swelling and lack of
circulation
c. Swelling of affected leg, pain stiffness
d. Fever
e. infection of the ovarian, uterine and pelvic veins
manifestations are
 Fever and chills
 Pain in the lower abdomen or flank
 Palpable parametrail mass in some cases.
Management
1. Early ambulation after delivery
2. Use of support stocking in woman with varicosities to
promote circulation and prevent stasis. Instruct the patient
to put stocking before rising from bed in the morning.
3. Provide adequate hydration
4. Avoid trauma to extremities
- pad stirrups well
- avoid pressure on the l vessels
- If post CS encourage leg exercises to promote venous
return while patient is not yet able to get out of bed
5. Avoid activities that contribute to venous stasis such as
prolonged bed rest,standing and sitting.
2. Superficial Venous Thrombosis
 Involving small clots in the absence of infection usually
resolves without anticoagulant treatment.
 The management is directed towards relief of pain and
resolution of clot which include
 Application of heat to relieve pain
 Aspirin and ibuprofen- anti inflammatory drugs to relieve
pain and prevent inflammation
 If the woman is receiving heparin, aspirin should never be
given to her.
 Instruct to avoid massaging the area
3. DVT/ Deep Vein Thrombosis
 Requires intensive management to prevent serious
complications like pulmonary embolism
Management
1. Hospitalization during acute phase
2. Bedrest until signs and symptoms disappear. Gradual
ambulation after disappearance of signs and symptoms but
the patient must wear elastic stockings to improve circulation
in the leg and prevent venous stasis
3. Leg elevation
4. Anticoagulant therapytoprevent venous stasis
Heparin- Mother may breastfeed as it is not passed to
breastmilk.
Keep antagonist, sulfate, available.
Dicumarol- passed on breastmilk, so mother must stop
breastfeeding.
Keep antagonist, Vitamin K available.
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 5. Monitor PTT level or APTT Apply warm wet compress 12. Past or present evidence of emotional problems- woman with
dressing to promote circulation and for comfort Administer history of PPD and Post partum Psychosis have 50% chance
prescribed antibiotic to combat infection and analgesic to of recurrence.
relieve pain
6. Surgery may be used if the affected vein is likely to present a A. POSTPARTAL BLUES
long term threat of producing blood clots.  Almost every woman notices some immediate feelings ( 1-10
days) of sadness ( postpartal blues)
2 major complications associated with the hypercoagulable state Onset- 1-10 days afterchild birth
brought by pregnancy Incidence- 70% of all births
1. Thrombophlebitis- Infection of the lining of the vein with
formation of thrombi (thrombo for the presence of clots and Etiology
phlebitis meaning inflammation of the lining of blood vessels. 1. Probable hormonal changes
a. Venous Thrombosis/ phlebothrombosis-if the 2. Stress of life changes
inflammation is minor and involves only superficial Symptoms:Sadness, Tears
veins of the extremities. Contact to Reality: Maintained Consistently
-Location of the clot can be seen by the eye on Therapy
inspection of the painful nd reddened area in the 1. Support
affected leg. Thses blood clots are large and hard 2. Empathy
enough to be felt by palpation Nursing Role- Offering compassion and understanding
b. Thromboplebitis - if theinflammation involves deep
veins B. POSTPARTAL DEPRESSION
2. Pulmonary embolism - may occur when these thrombi  This occurs as a response to the anticlimactic feeling after birth
formed in the deep leg veins are carried by circulation to the and probably is related to hormonal shifts as estrogen,
pulmonary artery and obstruct blood flow to the lungs. It is rare progesterone and corticotrophin-releasing hormone levels in her
but when it happensit is life threatening body decline
Onset- 1-12 months after birth
Incidence- 10% of all births
IV. POSTPARTAL PSYCHIATRIC DISORDER Risk factors /Etiology
Risk Factors 1. History of previous depression
1. Unwanted pregnancy 2. Hormonal response
2. Feeling unloved by mate 3. Troubled childhood
3. Below 20 years old 4. Stress in the home or at work
4. Single mother 5. Lack of self esteem- maybe a major contributing factor
5. Medical indigence 6. Lack of effective support people/ social support
6. Low self esteem Symptoms
7. Dissatisfaction with extent of education 1. Anxiety
8. Economic problems with housing and income 2. Feeling of loss
9. Poor relationship with husband or boyfriend 3. Feeling of sadness
10. Being part of a family with 6 or more siblings 4. Extreme fatigue
11. Limited parental support 5. Inability to stop crying
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 6. Increased anxiety about her own and infants health
7. Insecurity/ unwillingness to make decisions
8. Psychosomatic symptoms- nausea, vomiting, and diarrhea
9. Depressive/ manic mood fluctuations
Contact with Reality- Intact but can be disoriented sense of suicidal
thoughts and depersonalization when severe
Therapy/ Management
1. Counseling
2. Discovery of the problem as soon as symptoms develop is a
nursing priority
3. Antidepressant therapy
4. Postpartal return visit and well child visit
Nursing Role -Referring to counseling
C. POST PARTAL PSYCHOSIS
 As many as 1 in 500 presents enough symptoms in the year after
birth of a child to be considered psychiatrically ill.
 Because the illness coincides with the postpartal period it has
been called postpartal psychosis.
 Probably a response to the crisis of childbearing
 The majority of these women will have had symptoms of mental
illness before pregnancy.
 Precipitated by death in the family, illness, loss of husbands job, a
divorce or some other major crisis
Onset- within 1st month after birth
Incidence- 1%-2% of all births
Etiology
1. Possible activation of previous mental illness
2. Hormonal changes
3. Family history of bipolar disorder
Symptoms
1. Exceptionally sad
2. Has lost contact with reality/ Delusions/ hallucinations to harm
self and infant
3. Sensory input is so disturbed to comprehend or explain what a
correct perception is
Therapy / Management
1. Referral to psychiatric counselor /Psychotherapy
2. Antipsychotic medication/ Drug therapy
 Note-Do not leave alone because disturbed perception
might lead to harm herself
 Never leave alone with the infant
Contact with Reality- Loss of touch with reality, severe regressive
breakdown, high risk of suicide and/or infantacide
Nursing Role
1. Referring to counseling
2. Safeguard mother from injury to self or to newborn
Nursing Care of a Family with a High-risk Newborn
Newborn priorities in first days of life
1. Initiation and maintenance of respirations
2. Establishment of extrauterine circulation
3. Control of body temperature
4. Intake of adequate nourishment
5. Establishment of waste elimination
6. Prevention of infection
7. Establishment of an infant-parent relationship
8. Developmental care or care that balances physiologic needs
and stimulation for best development
Initiation and maintenance of respirations
• Establish respiration immediately to prevent:
a. Respiratory acidosis
b. Falling of blood pH and bicarbonate
c. Cerebral hypoxia
Causes of asphyxia/acidosis while inside the utero
asphyxia a condition arising when the body is deprived of oxygen,
causing unconsciousness or death; suffocation.
• Cord compression
• Maternal anesthesia
• Placenta previa
• Abruptio placenta
Factors predisposing infants to respiratory difficulty in the 1 st few days
of life
• Low birth weight
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 • Maternal history of diabetes EFFECT: could push meconium down into an infant’s airway
• Premature rupture of membranes compromising respiration
• Maternal use of barbiturates or narcotics close to birth  GIVE oxygen by mask without pressure
• Meconium staining  Wait for a laryngoscope to be passed and the trachea
• Irregularities detected by fetal heart monitor during labor to be deep suctioned before giving oxygen under
• Cord prolapse pressure
• Lowered apgar score (<7) AT 1-5 MINUTES  If for deep suctioning:
• Postmaturity  Place an infant on the back and slide a folded towel or
• Small for gestational age pad under the shoulders to raise them slightly to the
• Breech birth head is in a neutral position.
• Multiple birth  Slide a catheter (French 8- French 12) over the infant’s
• Chest, heart or respiratory tract anomalies tongue to the back of the throat
 Do not suction for longer than 10 seconds – to avoid
Resuscitation removing excessive air from an infant’s lungs
If breathing is ineffective  circulatory shunts ( ductus  Use a gentle touch
arteriosus) fails to close  bradycardia or cardiac arrhythmias can occur
because: because of vagus stimulation from vigorous suctioning
There is increase pressure in the left side than at the right side of the  An infant who still makes no effort at spontaneous respiration
heart requires immediate laryngoscopy to open the airway.
Blood circulates through a patent ductus arteriosus left to right or from  (process)Laryngoscopedeeptracheal
aorta to pulmonary artery suctioningendotracheal tube insertion Oxygen
administration by a positive pressure bag and mask with
RESULT: newborn struggles to breathe and circulate 100% oxygen at 40 to 60 breaths/minute
blood  uses available serum glucose hypoglycemic
Resuscitation is done for those newborns who fails to take first breath • Primary apnea – period of halted respiration
- a pause in respiration longer
Resuscitation process than 20 seconds with an
a. Establish and maintain an airway accompanying bradycardia)after 1
 bulb syringe suction (mouth then nose) or 2 minutes)
 Rub the back ( be sure that the baby is dry)  Resuscitation attempts are generally successful
 If a newborn has to attempt to raise body Secondary apnea – respiratory effort will
temperature because of chilling, this will become weaker, heart rate will fall, stops breathing
increase the need for oxygen which the baby  Resuscitation attempts become difficult and ineffective
cannot supply because breathing has not yet
initiated. • Size of laryngscope:
 warmed, blow-by oxygen by face mask or positive pressure 0 – 1 = newborn
mask may be administered
• If meconium stained: • Size of endotracheal tube
 DO NOT stimulate an infant to breathe by rubbing the Infants under 100 g = 2.5mm
back or administering air or oxygen under pressure Over 3000g = 4.0 mm
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b. Lung expansion
- Once an airway has been established, newborn’s lungs need
to be expanded
- Lungs are inflated by the first breath
- Cry – proof of lung expansion
- 40 cm H20 = pressure to open the lung alveoli for the first time
- 15- 20 cm H2o – pressure to continue inflating alveoli
• The levels of oxygen should not fluctuate
effect: can cause bleeding from immature cranial vessels
• No pressure above what is necessary
Effect: excessive force can rupture lung alveoli
 To be certain that oxygen is reaching the lungs with
resuscitation- monitor the newborn’s oxygen level with pulse
oximetry and auscultating the chest.
 If air can be heard on only one side or sounds are not
symmetric
reason: the endotracheal tube is probably at the bifurcation of the
trachea and blocking one of the main stem bronchi.
 When oxygen is given under pressure, the stomach quickly
fills with oxygen
 If air can be heard on only one side or sounds are not
symmetric
reason: the endotracheal tube is probably at the bifurcation of the
trachea and blocking one of the main stem bronchi.
 When oxygen is given under pressure, the stomach quickly
fills with oxygen
• If resuscitation continues for over 2 minutes,
 insert an orogastric tube and leaving the distal end open
reasons:
o will help deflate the stomach
o decreases the posibilility of vomiting and aspiration of
stomach contents from overdistention
o Administration of narcotic ( morphine or mepedridine
(Demerol) during labor causes respiratory depression.
o Narcan (narcotic antagonist)- Naloxone
o injected into the umbilical vessel
o Or injected intramuscularly into a thigh
o Relieves depression
o Dose: 0.01 to 0.1 mg/kg body weight
Other drugs used in resuscitation
Atrophine
- Reduces bronchial secretions
- Reduces vagus nerve effects
- Relives bradycardia
Calcium chloride- Increases heart contractility
Dopamine- Increases systemic blood perfusion by increasing blood
pressure through beta agonist action
Epinephrine- Strengthens or initiates cardiac contractions
Increases heart rate and blood pressure
Sodium bicarbonate/
Tromethamine- Corrects metabolic acidosis
Do not give this unless ventilation is adequate or acidosis can be
increased by retained CO2
Lidocaine- Counteracts ventricular arrhythmias
arrhythmia is a problem with the rate or rhythm of your heartbeat.
Ventricular arrhythmias are abnormal heartbeats that originate in
your lower heart chambers, called ventricles
c. Ventilation Maintenance
- An increase respiratory rate in a newborn is the first sign of
obstruction or respiratory compromise.
- If RR is increased = undress the baby’s chest and look for
retractions
• Interventions:
 Places under a warmer and remove the clothing from the
chest= this prevents acidosis
 Place the infant in supine and elevate the bed at 15 degrees=
this allows the abdominal contents to fall away from the
diaphragm, offering additional breathing space.
 Suction secretions
 Monitor oxygen level
2. Establishment of extrauterine circulation
• If an infant has NO audible heartbeat or if the cardiac rate is
below 80 beats/minute
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 Action: closed chest massage should be started Hypovolemia refers to the loss of extracellular fluid
 hold an infant with fingers  Tachypnea
supporting the back and  Pallor
depress the sternum with two  Tachycardia
fingers  Decreased arterial blood pressure
 Depress the sternum  Decreased central venous pressure
approximately 1/3 of its depth (1  Decreased tissue perfusion of peripheral tissue
or 2 cm) at a rate of 100  Metabolic acidosis
times/min.
 Lung ventilation at a rate of 4. Regulating Temperature
30x/min • All high risk infants have difficulty maintaining a normal
 Ratio: 1:3 temperature.
 If heart sounds are not resumed above 80 bpm after 30 • Maintain a neutral temperature environment
seconds of combined positive pressure ventilation and cardiac • If the environment is TOO HOT, metabolism decreases
compression • If the environment is TOO COLD, increases metabolism
Action: spray epinephrine 0.1 to 0.3 ml/kg (1:10,000) into • The increased metabolism requires increased oxygen
endotracheal tube to stimulate cardiac function. • Without oxygen
----hypoxic
3. Maintaining Fluid and Electrolyte Balance ----vasoconstriction of blood vessels occurs
-----decreased pulmonary perfusion(if prolong)
• Lactated Ringers solution or 5% dextrose are commonly used • ------PO2 lever falls and PCO2 increases
to maintain fluid and electrolytes levels. • Decrease PO2
• Sodium, potassium and glucose are needed. effect: may open fetal right to left shunts
• Rate of fluid administration must be carefully monitored surfactant production may stop
WHY? Can lead to patent ductus arteriosus or heart failure To prevent newborn from becoming chilled after birth:
• Use of radiant warmer may increase in water loss from  Wipe an infant dry
convection and radiation.  Cover the head with a cap
Therefore: the newborn requires fluid than  Place the baby immediately under a prewarmed radiant
he or she is placed in a double walled incubator. warmer or in a warmed incubator ( 97.8 F/36.5C)
• Monitor urine output and specific gravity to determine  Skin-skin
dehydration.
 A Urine Output of <2ml/kg/hr or a specific gravity >1.luid 5. Establishing adequate nutritional intake
intake.015 to 1.020 suggests inadequate Infants with severe asphyxia at birth receive IVF
 If an infant has hypotension without hypovolemia, a Reason: for them not to be exhausted from sucking or until
vasopressor such as dopamine may be given to increase BP necrotizing enterocolitis has been ruled out.
and improve cell perfusion. • If RR is rapid and with NEC
 If hypovolemia is present, the cause is fetal blood loss from Action: gavage feeding
placenta previa or twin-twin transfusion. preterm infants should be breastfed/ manually
express breastmilk
• If hypovolemia is present observe the ff:
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  Expressed breastmilk should be stored in a nonshiny plastic
bags or bottles to avoid the infant being exposed to
polycarbonate
6. Establishing waste elimination
• Immature infants void within 24 hours of birth
Reason: BP may not be adequate to optimally supply their kidneys
• Immature infants pass stool late than term
Reason: meconium has not yet reached the end of the intestine at
birth
7. Preventing infection
• Infection from prenatal, perinatal and postnatal causes
• PROM
• pneumonia
• Skin lesions
Viruses that causes infection
• Be certain that the parents of a high risk newborns are kept
informed
• If an infant dies despite newborns resuscitation attempts,
parents need to see the infant without being covered by a
myriad of equipment
9. Anticipating Developmental Needs
• High risk newborns need special care to ensure that the
amount of pain they experience during the procedures is
limited to the least amount possible’
• Follow up of high risk infants at home
Dystocia
-Inertia
- Ineffective Uterine Contraction
*Hypotonic
*Hypertonic
*Uncoordinated
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