Inversion of the Uterus
- Refers to the turning inside out with either birth
of the fetus or delivery of the placenta
Cause:
 Traction of the umbilical cord
 Pressure on the fundus when uterus is not
contracted
 Placenta is attached to the fundus, because at
birth, passage pulls down the fundus
S/Sx:
 Large amount of blood suddenly gushes from
the vagina
 Fundus is not palpable in the abdomen
 Shows signs of blood loss such as:
1. Hypotension
2. Diziness
3. Paleness
4. Diaphoresis
Therapeutic Management:
1. Do not attempt to replace an inversion
- Rationale: handling of the uterus may increase
the bleeding
2. Do not remove the placenta if it is still attached
- Rationale: this creates a larger space for
bleeding
3. Do not administer oxytocic drugs
- Rationale: this only compounds the inversion
making the uterus more tensed & difficult to
replace
4. Start an IV line
- Rationale: to replace the blood lost
- If IV line is already present, open it to achieve
optimal flow
5. Administer O2 by mask
6. Assess vital signs
7. If a woman’s heart fails due to blood less, be
ready to perform CPR
8. Will be given general anesthesia,nitroglycerin,
tocolytic drug
- Rationale for Tocolytic: to relax the uterus
9. Replace the fundus manually
10. Administer oxytocin after manual replacement
- Rationale: to help the uterus contract
11. Antibiotic Therapy
- Rationale: to prevent infection
12. CS Birth may be necessary
REMEMBER THE ORDER:
1. Nitroglycerin
2. Tocolytic Drug – to relax the uterus
3. Put back uterus manually
4. Oxytocin – to help the uterus contract
5. Antibiotic – to prevent infection
Amniotic Fluid Embolism
- Occurs when the amniotic fluid is forced into an
open maternal uterine blood sinus
Cause:
 Some defect in the membranes
 After membrane rupture
 Premature separation of the placenta
Risk factors:
 Oxytocin administration
 Abruptio Placenta
 Hydramnios
S/Sx:
 Woman in strong labor, suddenly sits up, grasps
her chest because of sharp pain and inability to
breathe (due to pulmonary constriction)
 Pale, then turns bluish gray
- Rationale: pulmonary embolism & lack of blood
flow to the lungs
Therapeutic Management:
1. O2 administration by face mask or cannula
2. Within minutes, CPR is needed
- May be useless because it does not relive
pulmonary constriction
- Death can occur in minutes ☹
3. If she survives, she needs to be in the ICU
4. Guard prognosis of the fetus
- Rationale: Reduced placental perfusion results
from the severe drop in maternal BP
General Information:
 Prognosis depends on:
1. Size of the embolism
2. Speed of which the condition was detected
3. Skil and speed of emergency interventions
 If woman survives, risk for Disseminated
Intravascular Coagulation (DIC) is high
Problems with the Passenger
1. Umbilical Cord Prolapse
2. Multiple Getsation
3. Problems with the Fetal Size, Presentation, or
Size
Umbilical Cord Prolapse
- A loop of the umbilical cord slips down in front
of the presenting fetal part
 Disseminated Intravascular Coagulation (DIC)
- Here, the platelets and clotting factors
napundok ha usa ka part of the uterus, so give
ANTICOAGULANT to distribute platelet and
clotting factors
2 Types of Prolapse:
1. The cord is prolapsed but still within the uterus
2. The cord is visible at the vulva

Occurs most often in these Situations:
 Premature Rupture of Membranes (PROM)
 Fetalpresentation other than cephalic
 Placenta Previa
 Intrauterine tumors preventing presenting part
from engaging
 Small fetus
 Cephalopelvic Disproportion (CPD)
 Multiple Gestation
Assessment:
 Ultrasound
- If seen in ultrasound = CS birth needed
 May be felt as the presenting part
 Mostly discovered after PROM, when FHR
pattern becomes apparent
 Cord may be visible in the vulva
Therapeutic Management:
Goal: relieve pressure on the cord
1. Place a gloved hand in the vagina
Manually elevate the fetal head off the cord
Place the woman in knee-chest or Trendelenburg
Position
- Rationale: to allow the fetal head to fall back
from the cord
2. Administer O2 at 10L/min by face mask
3. Tocolytic Drug to reduce uterine activity
4. Amnioinfusion to relieve pressure in the cord
5. Do not attempt to put back the cord in the
vagina because this will lead to kinking
6. If cervix is fully dilated, choose to birth the
infant
- Rationale: to prevent anoxia
7. If cervix is not fully dilated, upward pressure on
the presenting part
- Rationale: To keep pressure off the cord until
baby is born by CS
P.S. ALWAYS REMEMBER FOR CORD PROLAPSE:
1. Apply wet gauze on the prolapsed cord
2. Do Ritgen’s Maneuver
3. Obtain FHR
4. Check the temperature of the mother after 1 hr (do
this hourly)
 Amnioinfusion
- Addition of sterile fluid into the uterus to
supplement amniotic fluid
General Information:
 Neither shortens or prolongs labor
 Only prevents additional cord compression
 Initially, 500 mL is infused
 Continue to monitor:
1. FHR
2. Uterine Contractions
3. Temperature (hourly)
 Due to continuous flow of infusing solution in
the vagina, change bed linens frequently
 If vaginal leakage stops = fetal head is firmly
engaged, and all fluid infused is in the uterus
 This is dangerous because = hydramnios =
uterine rupture
How Amnioinfusion is done:
1. Sterile catheter introduced thru the cervix, into
the uterus after PROM
2. IV tubing is attached and a warmed solution of
NSS or LR is rapidly infused
3. Position of Woman: Lateral Recumbent
Position
- Rationale: To prevent supine hypotension
syndrome
 Fetal Blood Sampling
- Fetal scalp is nicked by a scalpel in this
procedure
- You can obtain the ff in this procedure:
1. PO2
2. PCO2
3. pH
4. Bicarbonate Excess
5. Hematocrit Level of Fetus
General Information:
 Usually only pH results are necessary
 Normal pH: 7.25
 pH Needs to be Remeasure in 30 mins:
between 7.21-7.25
 Fetal Acidosis: 7.20 and the fetus will be
hypoxic
How Fetal Blood Sampling is Done:
1. Cervical Dilatation of 3-4cm after PROM, head is
visualized using amnioscope
2. Scalp is cleaned using providone-iodine sprayed
with silicon
 Silicon – causes blood to form beads, caught by
capillary tube
3. Small scalpel introduced vaginally, into the
cervix and the fetal scalp is nicked
Multiple Gestation
General Information:
 Twins: opt for CS birth to reduce risk of anoxia
in 2nd fetus
 Increased incidence of cord entanglement and
PROM
 Increased risk of cord prolapse because the
babies heads are small so firm engagement
does not occur
 Anemia and PIH can occur
 First stage of labor does not differ greatly from
that of a woman with single gestation
 Abnormal presentation may occur because of
multiple foetuses
  Common occurrences: 6. If uterine relaxation is needed: administer
1. Uterine Dysfunction from prolonged labor nitroglycerin
2. Distended uterus
3. Unusual fetal poresentation 7. Assess women during postpartal period
4. PROM - Rationale: To determine distended uterus and uterine
infection

Problems with Fetal Position, Size, or Presentation

1. Occipitoposterior Position
2. Breech Presentation
 Most twin pregnancies present with both
3. Face
vertex
4. Brow
 Possible presentations for twins:
1. Both vertex 5. Transverse Lie
2. Both breech
3. One vertex, one breech
4. One vertex, one transverse lie 6. Oversized Fetus (Macrosomia
 After the first infant is born, both ends of the 7. Shoulder Dystocia
cord are tied or clamped permanently, because 8. Fetal Anomalies
cord clamps could slip off

Occipitoposterior Position

- Rationale: Prevents haemorrhage thru an open - Occiput is directed diagonally & posteriorly
cord end if babies shared one placenta either to the right (ROP) or left (LOP)

 Occasionally, the placenta of 1st infant separates

before the 2nd fetus is born = sudden profuse
bleeding because the uterus cannot contract
normally because it is still full w/ the 2 nd infant
 If a common placenta is involved: FHR of the General Information:
other infant will register distress immediately  Fetal head must rotate at 135
 Rotation can be aided by:
 Twins need to be born at once if they are to 1. Hands & Knees Position
survive. For this reason, CS birth is opted for 2. Squatting
already 3. LOP: lying to the right side
4. ROP: lying to the left side
 Fraternal Twins: possible to have different
fathers because 2 egg cells were fertilized by 2  Lunging
sperm cellss - Shifting the weight from right to left
- Swinging the body from right to left while
elevating the left foot on a chair
Therapeutic Management:
 Lunging increases pelvic path to facilitate
1. Urge to engage in activity during 1st stage of
rotation
labor like playing cards or reading
2. Practice breathing exercises to minimize the  Posterior Positions tend to occur in women
need for analgesia who:
3. Presence of 2nd Baby: do not administer 1. Android Pelvis
oxytocin 2. Anthropoid Pelvis
- Rationale: this might compromise circulation to 3. Contracted Pelvis
the 2nd baby
 Posterior Position is suggested by:
4. External abdominal palpation to determine the 1. Prolonged active face
presentation of the 2nd baby 2. Arrested Descent
- If not vertex presentation, it can be corrected 3. FHR heard on the lateral side of the
manually
abdomen
- If manual correction is unsuccessful opt for CS
 Posterior presenting head: does not fit the
or breech birth
cervix = caput succedaneum
5. If 2nd baby is to be born vaginally: administer  Ineffective contractions & large fetus, rotation
oxytocin of 135 degrees is impossible
- Rationale: to aid in uterine contractions,
shortening span time between births
  Conditions that needs CS Birth if Occipito
posterior Position is Present:
1. Ineffective contractions
2. Uterine dysfunction due to maternal
exhaustion
3. Fetal head arrest in transverse position
S/Sx in Woman:
 Pain in the lower back due to sacral nerve
compression
Therapeutic Management:
1. Apply counter pressure on the sacrum by back
rub
2. Apply cold or heat
3. Lying on the side opposite to the fetal back /
Hand Kneea helps the fetus rotate
4. Allow to void every 2 hrs. to keep bladder
empty
- Rationale to facilitate descent
5. Oral sports drink or IV glucose solution
- Rationale: To replace glucose stores used for
energy
6. Great deal of support to prevent panick
7. Frequent reassurance that although their
pattern of labor is not the ideal one, it is within
safe, and controlled limits
8. Forceps used to rotate the fetus can pose these
risks:
1. Cervical Lacerations
2. Hemorrhage
3. Infection in postpartal period
Breech Presentation
General Information:
 Normally: 38 weeks AOG, fetus is already in
cephalic presentation
 Fundus is the largest part of the uterus
 Frank Breech: keeps his legs extended for 2-
3days of life, at the level of the face
 Footling Breech: keeps his legs extended in a
footling position for a few days
Dangers of Breech Presentation:
1. Anoxia from a prolapsed cord
2. Traumatic Injury to the aftercoming head
(possibility of intracranial haemorrhage or
anoxia)
3. Fracture of the spine or arm
4. Dysfunctional labor
5. Early rupture of the membranes because of
poor fit of presenting part
6. Birth of the head: most hazardous
- Rationale: The umbilicus precedes the head ,
and a loop of cord passes alongside the head
and it compresses the cord
7. Intracranial haemorrhage
8. Tentorial Tears
- Rationale: causes gross motor and mental
incapacity or lethal damage to the fetus may
result
Assessment:
 FHR is heard high in the abdomen
 Leopold’s Maneuver
 Vaginal Examination
Causes of Breech Presentation:
 Gestational age <40 wks
 Abnormality in fetus such as:
- Anencephaly
- Hydrocephalus
- Meningocele
 Hydramnios
 Congenital anomaly of the uterus (mid septum,
trapping the fetus in breech position)
 Space-occupying mass (fibroid tumor)
 Pendulous abdomen- lax abdomen
- Rationale: uterus may fall far forward that the
fetal head lies outside the pelvic brim=breech
presentation
 Multiple Gestation
 Unknown Factors
Therapeutic Management:
1. Always monitor FHR and contractions
- Rationale: to detect early signs of fetal distress
2. To aid the birth of the head:
Trunk of infant is straddled on physicians arm
Right Hand of Physician: 2 fingers are placed inside
infant’s mouth
Left Hand of Physician: slid into the vagina, palm down
along infant’s back
Pressure is applied to flex the head fully
Gentle Traction (upward and outward) applied to the
shoulders to deliver the head
- A Piper forceps may be used to control flexion
and rate of descent
Face Presentation
 Asynclitism
- Fetal head presenting at a different angle \
General Information:
 Face or Mentum Presentation is rare
 Face presentation is evident during Leopold’s
manuerver, when the head feels more
prominent than normal, with no engagement
apparent
 Fetal back is difficult to outline in this
presentation because it is concave
 If fetal back is extremely concave: FHR is heard
on the side where arms and feet are palpated
 If chin is anterior: delivery can be done w/o
difficulty
  If chin is posterior: CS birth is needed Cause:
 Diabetes
 Babies have a great deal of facial edema and  Multiparity
purple from ecchymotic bruising  Post-date Pregnancies

Cause: Therapeutic Management:

 Relaxed uterus due to multiparity/prematurity 1. McRobert’s Maneuver (although not proven)
 Hydramnios - Flex thighs sharplyn on her abdomen
 Fetal malformation - Rationale: To widen the pelvic outlet and allow
anterior shoulder to be born
Assessment:
 Ultrasound for confirmation 2. Apply suprapubic pressure
 Vaginal examination - Rationale: to help shoulder escape from
beneath the symphysis pubis and be born
Therapeutic Management:
1. Observe infant closely for patent airway Problems with Passage
- In some cases, lip edema is sever that sucking is 1. Inlet Contraction
impossible 2. Outlet Contraction
2. Gavage feedings, until baby can suck effectively 3. Trial Labor
3. Transfer to NICU for 24hrs. 4. External Cephalic Version
4. Reassure parents that edema is transient 5. Forceps Birth
6. Vacuum Extraction
Brow Presentation Inlet Contraction
- Rarest of all presentations - Narrowing of the anteroposterior diameter to
- Results in obstructed labor, because the head <11cm or the transverse diameter to 12 cm or
becomes jammed in the brim of the pelvis, as less
the occipitomental diameter presents Cause:
- CS birth is necessary  Rickets
Cause: Relaxed abdominal muscled from multiparity  Inherited small pelvis

General Information:
Transverse Lie  Fetal head normally engages: 36-38 weeks AOG
- Confirmed thru Leopold’s Maneuver &  Engagement does not occur in multigravidas
Ultrasound until labor begins
- A mature fetus cannot be delivered vaginally in  Every primigravida must have pelvic
this position measurements checked before 24 weeks of
- CS Birth is necessary pregnancy
Cause:  CPD: fetus does not engage & malposition may
 Pendulous abdomen from uterine fibroid occur
tumors, obstructing the lower uterine segment  If membranes rupture, cord prolapse incidence
 Contraction of the pelvic brim is increased
 Congenital abnormalities
 Hydrocephalus Outlet Contraction
 Multiple gestation - Narrowing of the transverse diameter at the
outlet to <11cm
Oversized Fetus (Macrosomia)
- Weighs >4 000 to 5 000g (9-10lbs.) Trial Labor
- CS Birth is necessary - Done to determine whether labor can progress
- If delivered vaginally, there is risk for these in normally
infants: Indication:
 Cervical Nerve Palsy  Borderline inlet measurement
 Diaphragmatic Nerve Injury  Fetal lie and position are good
 Fractured Clavicle
Therapeutic Management:
Shoulder Dystocia 1. Monitor FHR
- Occurs at the 2nd Stage of Labor, when fetal 2. After Rupture of Membranes: assess FHR
head is born but the shoulders are too broad to
enter and be born through the pelvic outlet External Cephalic Version
- Hazardous to the Mother: it can result in - Turning of the fetus from breech to cephalic
vaginal and cervical lacerations position before birth
- Hazardous to the Fetus: it can result in clavicle - Can be done at 34-35 weeks of pregnancy
or brachial plexus injury - Usual time it is done is at 37-38 weeks of
- Not identified until the head has already been pregnancy
born and the wide anterior shoulder locks
beneath the symphysis pubis
Contraindications to ECV: 4. Record the time and amount of 1st voiding
 Multiple Gestation - Rationale: to rule out bladder injury
 Oligohydramnios

Contraindications to vaginal birth: Vacuum Extraction

 Cord Coil - Done if the fetus is far enough down the birth
 Unexplained 3rd Trimester bleeding canal
- Could indicate placenta previa - Advantageous than forceps birth because little
anesthesia is needed
- Advantage: Fewer lacerations on the birth canal
Forceps Birth - Disadvantage: Caput Succedaneum that could
- A forceps outlet procedure in which the forceps last up to 7 days
are applied after the fetal head reaches the
perineum How Is vacuum Extraction done:
 Obstetrical Forceps 1. Disk-shaped cup is nplaced on the fetal head ,
- Steel instruments constructed by two blades over the posterior fontanelle when the head is
that slide together at their shafts to form a already at the perineum
handle
2. Pressure is applied and air beneath the cup is
 Low Forceps Birth suctioned
- May be used to indicate that the fetal head is at 3. The cup adheres tightly on the fetal scalp,
+2 station or more pulling the fetus out

 Midforceps Birth
- If fetal head is engaged <+2 station Anomalies of the Placenta and the Cord
1. Placenta Succenturiata
2. Placenta Circumvallata
How Are the Forceps Used: 3. Placenta Marginata
1. One blade, slide in the vagina next to the fetal 4. Battledore Placenta
head 5. Placenta Accreta
2. Another blade, slipped into place on the other 6. Vasa Previa/Placenta Previa
side of the head 7. Two-Vessel Cord
8. Unusual Cord Length
Necessary Conditions to Qualify for Forceps Birth:
 Unable to push with contractions (spinal cord General Information:
injury/regional anesthesia)  Normal Placenta: 500 g
 Cesaation of descent in 2nd stage of labor  Diameter: 15-20cm
 Fetus abnormal position  Thickness: 3cm
 Fetus is in distress from a complication  Diabetes, Syphilis & Erythroblastosis placenta
(prolapsed cord) is unusally large
 If the uterus has scars: placenta may be wide in
diameter because it was forced to spread out to
find implantation space
Before forceps are applied, make sure:
 Membranes have been ruptured
 CPD must not be present  Placenta Succenturiata
 Cervix is fully dilated - Has one or more accessory lobes attached or
 Bladder is empty connected to the main placenta, by blood
vessels
Therapeutic Management: - No fetal abnormality is associated with this
1. Anesthetic - Important to be recognized because small lobes
- Pudendal Block
may be retained in the uterus after birth =
- Rationale: reduce pain and facilitate pelvic
haemorrhage
relaxation
- Inspection: placenta appears torn at the edge
2. Record FHR before forceps application
- Rationale: there is danger that the cord could
be compressed between the forceps blade and  Placenta Circumvallata
the fetal head - Some extent of Chorion covers the fetal side of
the placenta
3. Assess woman’s cervix
- Rationale: to check for lacerations  Placenta Marginata
- Chorion reaches just to the end of the placenta
  Battledore Placenta
- Cord is inserted marginally rather than centrally

 Velamentous Insertion of the Cord

- Instead of entering the placenta directly,
seprates into small vessels that reach the
placenta by spreading across a fold of amnion
- Cause: multiple gestation

 Vasa Previa/ Placenta Previa

- The umbilical vessels of the velamentous cord
insertion cross the cervical os and therefore
deliver before the fetus
- Confirmed by ultrasound
- DO NOT DO INTERNAL EXAMINATION (IE)
- S/Sx: sudden, painless bleeding w/ the
beginning of cervical dilatation

 Placenta Accreta
- Unusually deep attachment of the placenta to
the uterine myometrium so deeply the placenta
will not loosen and deliver
- Manual Removal=haemorrhage
- Hysterectomy or treatment with methotrexate:
to destroy the still-attached tissue

 Two-vessel Cord
- Normal Cord: 2 arteries, 1 vein
- Absence of one artery: Congetial heart & kidney
anomalies
- Drying distorts the appearance of the vessels
- Document the number of vessels present

 Unusual Cord Length

- Easily compromised because it can be formed
into knots
- Nuchal Cord: Wrapped around the neck

READ PAGE 649 for KEY POINTS FOR REVIEW! 😊