UTERINE INVERSION

A.DESCRIPTION. The uterus turns completely or partially inside out; it occurs immediately

following delivery of the placenta or in the immediate postpartum period.

B. ETIOLOGY
1. Forced inversion is caused by excessive pulling of the cord or vigorous manual expression of
the placenta or clots from an atonic uterus.
2. Spontaneous inversion is due to increased abdominal pressure from bearing down, coughing,
or sudden abdominal muscle contraction.
Predisposing factors include straining after delivery of the placenta, vigorous kneading of the
fundus to expel the placenta, manual separation, and extraction of the placenta, rapid delivery
with multiple gestation, or rapid release of excessive amniotic fluid.

C.PATHOPHYSIOLOGY
1. The inverted uterus is unable to restore normal position or contract appropriately.
2. The woman is placed at increased risk for bleeding and infection.

D. ASSESSMENT FINDINGS. Clinical manifestations include:

1. Excruciating pelvic pain with a sensation of extreme fullness extending into the vagina.
2. Extrusion of the inner uterine lining into the vagina or extending past the vaginal introitus.
3. Vaginal bleeding and signs of hypovolemia.

E. NURSING MANAGEMENT. Promptly identify & assist with the resolution of uterine

inversion.
1. Recognize signs of impending inversion, and immediately notify the physicianand call for
assistance.
2. Immediate manual replacement of the uterus at the time of inversion will prevent cervical
entrapment of the uterus; if reinversion is not performed immediately, rapid and extreme blood
loss ma occur, resulting in hypovolemic shock.
3. Take steps to prevent or limit hypovolemic shock.
a. Insert a large gauge intravenous catheter for fluid replacement.
b. Measure and record maternal vital signs every 5 to 15 minutes to established a baseline and
document change.
c. Open an established intravenous line for optimal fluid replacement.
d. A fibrinogen level should be drawn to determine the risk of blood clot formation.
e. Prepare for anesthesia as needed.
f. Prepare to administer a cardiopulmonary resuscitation, if required.
4. If manual reinversion is not successful, prepare the client and family for possible general
anesthesia and surgery.
Premature Rupture Of Membrane(PROM)

A. DESCRIPTION. PROM is rupture of chorion and amnion before the onset of labor. The
gestational age of the fetus and estimates of viability affect management.

B. ETIOLOGY. The precise cause and specific predisposing factors are unknown.

C. PATHOPHYSIOLOGY.
1. PROM is associated with malpresentation, possible weak areas in the amnion and chorion,
subclinical infection, and possibly incompetent cervix.
2. Basic and effective defense against the fetus contracting an infection is lost the risk of
ascending intrauterine infection, known as chorioamnionitis, is increased.
3. The leading cause associated with PROM is infection.
4. When the latent period (time between rupture of membranes and onset of labor) is less than 24
hours, the risk of infection is low.
D.ASSESSMENT FINDINGS
1. Clinical manifestations
a. PROM is marked by amniotic fluid gushing from the vagina. The fluid may trickle or leak
from the vagina in the absence of contractions.
b. Pooling of amniotic fluid in the vagina will be visualized during a speculum examination.
c. Maternal fever, fetal tachycardia, and malodorous discharge may indicate infection.
2.Laboratory and diagnostic study findings. Rupture of the membranes is confirmed by the
following.
a. Ferning is evident.
b. Nitrazine test tape turns blue-green
E. NURSING MANAGEMENT
1.Prevent infection and other potential complications.
a. Make an early and accurate evaluation of membrane status, using sterile speculum
examination and determination of ferning. Thereafter, keep vaginal examinations to a minimum
to prevent infection.
b. Obtain smear specimens from vagina and rectum as prescribed to test for betahemolytic
streptococci, organisms that risk to the fetus.
c. Determine maternal and fetal status, including estimated gestational age. Continually assess
for signs of infection.
d. Maintain the client on bed rest if the fetal head is not engaged. This method may prevent cord
prolapsed if additional rupture and loss of fluid occur. Once the fetal head is engaged,
ambulation can be encouraged.
2. Provide client and family education.
a. Inform the client, if the fetus is at term, that the chances of spontaneous labor beginning are
excellent; encourage the client partner to prepare themselves for labor and birth.
b. If labor does not begin or the fetus is judged to be preterm or at risk for infection, explain
treatments that are likely to be needed.