SUMMARY NOTES FOR MATERNAL AND
CHILD HEALTH CARE NURSING
HEMATOLOGIC DISORDER AND
PREGNANCY
True anemia is when hemoglobin concentration
is LESS than 11 g/dl (hematocrit <33%) on the first or
third trimester pregnancy or when hemoglobin
concentration is LESS than 10.5 g/dl (hematocrit <32%)
in the second tri. In cases of Pseudoanemia it often
develops is early pregnancy because blood volume
often expands ahead of RBC count.
A WOMAN WITH IRON DEFICIENCY ANEMIA
° Iron deficiency anemia is MOST COMMON anemia is
pregnancy.
Deficient in iron stores from a combination of:
1. Diet low on Fe
2. Heavy menstrual period
3. Unwise weight reducing programs
NOTE: iron is absorb in the duodenum, bounded to
transferrin and transports to liver, spleen, and bone
marrow and is converted into ferritin.
Two types of Anemia
• Microcytic (small RBC)
• Hypochromic (less hemoglobin than the average RBC)
Clinical signs (a woman may experience)
1. Fatigue
2. Poor exercise tolerance (associated with LBW and
preterm Birth)
3. Pica (associated with restless leg syndrome)
MANAGEMENT OR PREVENTION
1. Prenatal Vit. (27 mg of Fe as prophylactic)
2. Diet (Fe and vit. Ex. Green leafy veg, meat and
legumes)
Women with Fe deficiency anemia are prescribe
with (120- 200 mg Fe/day) FeSo4 or Fe gluconate.
Side effect: Constipation or Gastric Irritation. Stools are
black. Increase roughage in the diet and always take the
pills with food to reduce these symptoms
NOTE: Fe is best absorb in an acidic medium. Advice
women to take orange juice or Vit. C supplement. If
mother has difficulty with oral Fe therapy with IV Fe is
prescribed. RBC count should increase 0.5 and 1.5 to 3
and 4% by 2 weeks.
A WOMAN WITH FOLIC ACID DEFIENCY ANEMIA
Folic acid/folate/folacin, is one of the B vit. (9)
is needed for normal RBC formation and is associated
with the prevention of Nueral Tube (Spina Bufida) and
abdominal wall defect.
1
Occurs most often in:
1. Multiple pregnancy
2. Hemolytic disease
3. Hydantoin (anticonvulsant, interferes with folate
absorption)
4. Poor gastric absorption
Note: Develops into Megaloblastic anemia (enlarge
RBC). In CBC, the MCV is elevated compared to Fe
Deficiency. Takes weeks to develop, once full blown
may lead to Early Miscarriage/ Premature separation of
the placenta.
PREVENTION:
1. Take supplements of 400 ug/dl/ day
2. Folate rich food (green leafy veg., oranges and dried
beans).
A WOMAN WITH SICKLE CELL ANEMIA
Sickle Cell anemia is a recessively inherited hemolytic
anemia cause by abnormal amino acid in the beta chain
of hemoglobin.
Conditions on which the disease occurs:
 When the Amino acid valine (sickling
hemoglobin, Hbs) is replaces or substitutes
Amino acid Lysine (nonsickling hemoglobin,
HbC) in the beta chain.
 An individual with heterozygous gene (has 1
gene) has sickle cell trait (HbAS). If a person is
homozygous (has 2 genes substitution), sickle
cell disease (HbSS).
Pathologic Concept
The majority of the RBC are irrgular in shape and as
such cannot carry O2 normally compared to normal
rbc's. When 02 tension becomes reduce,the cellz clump
together resulting in blockage. And these cells undergo
hemolysis which leads to anemia.
Women with the disease often have:
• Preterm birth
• Growth restriction
•miscarriage
•LBW (when vessels to the placenta are block or
compromise)
•Fetal death Organs affected include liver, kidney,
heart, lungs and the brain.
Assessment
1. A woman who has the disease has a normal Hgb 6-8
mg/dl. •Hemolytic crisis: 5-6 mg/dl accompanied by rise
of indirect bilirubin.
2. Women with the disease has vascular stasis =
bacteriuria. Obtain clean catch sample.
3. Monitor nutritional status (consume sufficient Folic
acid) Ensure women to drink at least 8 glasses of
fluid/day since dehydration can lead to sickle cell crisis.
NOTE: Women should NOT take routine Fe supplement
as sickle cells cannot incorporate Fe in the same as
nonsickled cells.
4. Assess lower Ex for varicosities or pooling of blood
which leads to RBC destruction. (Encourage modified
Sims position for venous return or sitting with legs
elevated, avoid/reduce standing for long periods)
5. Fetal Health, US and Nonstress test. Blood flow
velocity is also measured.
6. Electrophoresis of RBC is obtained through
amniocentesis. Clinical symptoms of the disease are not
apparent until 3-6 months.
Therapeutic Management
1. Blood Transfusion - to replace sickled with nonsicked
and to remove increased bilirubin and to restore Hgb
level.
2. In labor, keep woman hydrated and to help resist
strenous excertion. If operative birth is needed, epidural
anesthesia is administered. NOT GENERAL ANESTHESIA
as in it can lead to hypoxia.
3. In post partal period, early ambulation and wearing
of pressure stockings or IPC boots reduce the risk of
thromboembolism.
If Sickle cell crisis occurs:
1. Administer O2
2. Fluid volume increase to lower circulatory viscosity.
A WOMAN WITH U.T.I.
Often asymptomatic in non-pregnant women. In
pregnant women, the ureters dilate form the effects of
progesterone, stasis can occur.
 Glycosuria that also occurs in pregnancy allows
to ideal bacterial growth medium.
 Infections can lead into pyelonephritis and is
associated with PROM and Preterm labor.
Occurs more often in Women with
Vesicoureteral reflux (back flow of urine into
the ureters.)
CAUSATIVE AGENT
1. E. coli
2. Strep. B (vaginal cultures should be obtained as it is
associated with Pneumonia in the NB.)
Assessment
1. Frequency and pain in urination. Maybe accompanied
by nausea, vomiting, malaise, pain. Pain in the Lumbar
area (right side due to compression and stasis, and is
tender to palpate)
2. Temp: 103° to 104° F / 39° to 4o° C
3. Urine culture: 100, 000 organisms/ml
Therapeutic Management
1. Amoxicillin/ Ampicillin/ Cephalosporin
CONTRAINDICATED:
• Sulfaminides can cause neonatal jaundice.
2
• Tetracycline can result to bone growth retardation
and staining of deciduous teeth.
2. Increase fluid intake (3- 4 L/ 24 hrs.). Drink a glass of
cranjuice berry/day
3. Void frequently (2-4 hrs.). Promote drainage by knee
chest position for 15 min every morning and evening.
4. Wear cotton for underwear and not synthetic fiber.
ENDOCRINE DISORDER AND
PREGNANCY
A WOMAN WITH HYPOTHYRODISM
Hypothyroidism or the underproduction of
thyroid hormones, is a rare condition in late adolescent
and especially in rare in pregnancy.
Women who has hypothyroidism has anovulatory or
she has difficulty INCREASING thyroid functioning to a
necessary pregnancy level which can lead to
miscarriage.
WOMEN WITH THIS CONDITION:
1. Fatigue
2. Tends to be obese
3. Myxedema (dry skin)
4. Low tolerance to cold.
Note: often associated with extreme incidence of
hyperemesis gravidarum.
MEDICATION
Levothyroxine (synthroid) to supplement the
lack of thyroid hormones. When pregnancy is planned,
women should consult health care provider to be
certain that her dose will be high enough to sustain
pregnancy. (Increased by 20 to 30 %)
Caution: Should be taken a DIFFERENT TIME from any
medications containing Fe, Ca or any soy products by
about 4 hrs. to ensure that there is no problem in
absorption.
NURSING CONSIDERATION
Be sure she does not continue in taking her
pregnancy dose after pregnancy. Levothyroxine levels
should be tapered back to the prepregnancy level so
she can breastfeed safely. Too much of the medication
could pass beyond the normal thyroid function and
develop HYPERTHYROIDISM.
A WOMAN WITH HYPERTHYROIDISM
Hyperthyroidism or the over production of
thyroid hormone. Sometimes called Graves’ disease. If
left undiagnosed may develop heart failure (due to
stress and cannot manage the increasing blood volume.
Symptoms include:
  Rapid heart rate
 Exophthalmos
 heat intolerance
 heat palpations
 Weight loss.
Women who has hyperthyroidism is more prone to:
1. Gestational hypertension
2. Fetal growth restriction
3. Preterm labor.
DIAGNOSED
 Nuclear medicine (involves the radioactive
uptake of 131I subtype)
NOTE: Should not be used during pregnancy because
fetal thyroid may incorporate this drug resulting in the
destruction of fetal thyroid.
 An assay of fetal cord will reveal T4 and TSH and
the need for infant therapy
TREATMENT FOR HYPERTHYROIDISM
PHARMATEUTICAL
 Thiomides (methimazole/Tapazole OR
propylthoracil/PTU) which reduces thyroid
activity.
Caution: drugs can cross the placenta which can lead
to congenital hypothyroidism and enlargement thyroid
gland.
CONSIDERATION: Should be given at the lowest possible
dose of the drug. Caution to keep careful records as
increase doses can lead to goiter. Goiter can cause
obstruction in the airway and make resuscitation
difficult.
Women who are receiving anti-thyroid
medication in smaller or minimal doses may breastfeed.
However those with large doses are advised not to BF as
it can be excreted to the breastmilk.
PREFERRED DRUG CHOICE: Methimazole is the drug of
choice as it can cross the placenta less easily
If left untreated or not regulated newborn may
appear jittery with tachypnea and tachycardia.
SUGRICAL treatment to reduce the functioning of the
thyroid gland but not the choice DURING pregnancy due
to the use of GENERAL ANESTHESIA.
A WOMAN WITH DIABETES MELLITUS
Diabetes mellitus is an endocrine disorder in
which the pancreas cannot produce adequate insulin to
regulate body glucose levels.
 Insulin was produced synthetically in 1921
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 Type 2 diabetes is occurring more frequently in
young adults.
NOTE: progesterone interferes with insulin activity and
therefore increases blood glucose levels. The estrogen
in contraceptives also has the potential for increasing
lipid and cholesterol levels and blood coagulation.
IUD have been associated with higher-than-usual rates
of pelvic inflammatory disease; because women with
diabetes have difficulty fighting infections
Pathophysiology and Clinical Manifestations
The primary problem of any woman with this
disorder is controlling the balance between insulin and
blood glucose levels to prevent hyperglycemia or
hypoglycemia, the conditions can be a threat to normal
fetal development. Infants of diabetic women are five
times more apt to be born with heart anomalies.
If a woman’s insulin level is insufficient, glucose
cannot be used by body cells (because of insulin
insufficiency). The cells register their glucose want, and
the liver quickly converts stored glycogen to glucose to
increase the serum glucose. When the level of blood
sugar rises to 150 mg/100 mL (normal is 80 to 120
mg/dL), the kidneys begin to excrete quantities of
glucose in the urine (glycosuria). May occur even lower
than 150 mg/100 mL during pregnancy. Because of
osmotic action, Because of osmotic action, large
quantities of fluid are lost in urine (polyuria).
Dehydration begins to occur; the blood serum
becomes concentrated and the blood volume may fall.
Reducing blood flow and such the cells receive
inadequate O2. Anaerobic metabolic reactions cause
large stores of lactic acid to pour out of muscles into the
bloodstream. Fat is mobilized from fat stores and
metabolized for energy. Ketone is produced and is
considered acidic (the best example is acetone). These
two acid sources lower the pH of the blood, and a
metabolic acidosis develops.
Protein breakdown reduces the supply of
protein to body cells. As cells die, they release
potassium and sodium, and this is lost from the body in
the extensive polyuria.
Long-term effects of diabetes mellitus are vascular
narrowing that leads to kidney, heart, and retinal
dysfunction.
Diabetes during Pregnancy
 Diabetes often occurs as type 1 or diabetes
which occurs in childhood and represents
failure of the pancreas to produce adequate
insulin for body requirements.
 Type 2 diabetes traditionally has occurred in
older adults and represents gradual failure of
insulin production that occurs with aging.
 Glomerular filtration of glucose is increased (the
glomerular excretion threshold is lowered),
 causing slight glycosuria. The rate of insulin
secretion is increased, and the fasting blood
sugar level is lowered.
 All women appear to develop an insulin
resistance as pregnancy progresses or insulin
does not seem as effective during pregnancy, a
phenomenon that is probably caused by the
presence of the hormone human placental
lactogen (chorionic somatomammotropin) and
high levels of cortisol, estrogen, progesterone,
and catecholamines.
 The continued use of glucose by the fetus may
lead to hypoglycemia (lowered serum glucose
levels) for the mother between meals; this is
most apt to occur overnight.
 An increase in the amount of amniotic fluid
occurs in at least 25% of diabetic women,
probably because of hyperglycemia in the fetus
that causes increased urine production.
(AMNIOCENTESIS is needed, this exposes a
woman to infection and possible preterm labor)
 When glucose regulation is poor, a woman is at
greater risk for pregnancy-induced
hypertension and infection (particularly
monilial infection) than other women. Infants of
women with poorly controlled diabetes tend to
be large (10 lb) because the increased insulin
the fetus must produce to counteract the
overload of glucose he or she receives acts as a
growth stimulant
 Prone to CPD, and increased risk of shoulder
dystocia and as such may be born through CS.
 Caudal regression syndrome (failure of the
lower extremities to develop), spontaneous
miscarriage, and stillbirth in infants.
Hypoglycemia, respiratory distress syndrome,
hypocalcemia, and hyperbilirubinemia.
Risk factors for gestational diabetes include:
• Obesity
• Age over 25 years
• History of large babies (10 lb or more)
• History of unexplained fetal or perinatal loss • History
of congenital anomalies in previous pregnancies
• History of PCOS
• Family history of diabetes (one close relative or two
distant ones)
• Member of a population with a high risk for diabetes
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Class Description
Type 1 Formerly known as insulin-dependent
diabetes mellitus.
A state characterized by the destruction
of the beta cells in the pancreas that
usually leads to absolute insulin
deficiency.
a. Immune-mediated diabetes mellitus
results from autoimmune destruction of
the beta cells.
b. Idiopathic type 1 refers to forms that
have no known cause
Type 2 Formerly known as non-insulin-
dependent diabetes mellitus.
A state that usually arises because of
insulin resistance combined with a
relative deficiency in the production of
insulin.
Gestational A condition of abnormal glucose
Diabetes metabolism that arises during pregnancy.
Possible signal of an increased risk for
type 2 diabetes later in life
Impaired
glucose A state between “normal” and “diabetes”
homeostasi in which the body is no longer using
s and/or secreting homeostasis insulin
properly.
a. Impaired fasting glucose:
A state when fasting plasma glucose is at
least 110 but under 126 mg/dL.
b. Impaired glucose tolerance:
A state when results of the oral glucose
tolerance test are at least 140 but under
200 mg/dL in the 2-hour sample
Assessment
 A fasting plasma glucose of 126 mg/dl or above
or a nonfasting plasma glucose of 200 mg/dl or
above meets the threshold for the diagnosis of
diabetes.
 After the oral 50-g glucose load is ingested, a
venous blood sample is taken for glucose
determination 60 minutes later.
Conditions on which how it is confirmed:
If the serum glucose level at 1 hour is
more than 140 mg/dL, the woman is scheduled
for a 100-g, 3-hour fasting glucose tolerance
test.
If two of the four blood samples
collected for this test are abnormal or the
fasting value is above 95 mg/dL, a diagnosis of
diabetes is made.

Therapeutic Management
1. Insulin
 Be certain she understands that re-regulation is
a necessity because of the changes in her
metabolism. Women with gestational diabetes
will be started on insulin therapy if diet alone is
unsuccessful in regulating glucose values.
 Women should eat almost immediately after
injecting these short-acting insulins to prevent
hypoglycemia before mealtimes. Oral
hypoglycemia agents are not used for
regulation during pregnancy because, unlike
insulin, they cross the placenta and are
potentially teratogenic to a fetus
 Help a woman plan her day based on the time
interval her insulin takes to reach its peak.
Knowing when insulin reaches its peak level
makes serum glucose monitoring meaningful
and alerts women to the time of the day when
they are most apt to be hypoglycemic.
 Be certain a woman is using an injection
technique for insulin of stretching the skin taut
and injecting at a 90- degree angle. Although
this is normally intramuscular injection
technique, insulin syringes have such short
needles (5/8 in) that this places the insulin in
the subcutaneous tissue.
2. Blood glucose Monitoring
 All women with diabetes need to do blood
glucose monitoring to determine whether
hyperglycemia or hypoglycemia exist.
 When a woman discovers that hypoglycemia is
present, she should ingest some form of
sustained carbohydrate such as a glass of milk
and some crackers. Taking a less-concentrated
fluid such as milk rather than orange juice and
including a complex carbohydrate helps prevent
a rebound phenomenon in which a high glucose
level is created that produces even more
pronounced hypoglycemia.
 If a woman discovers an elevated blood glucose
level, she should assess her urine for ketones.
She should inform her health care provider if
she finds ketones in two separate specimens.
Acidosis during pregnancy must be prevented
because maternal acidosis leads to fetal anoxia
because of fetal inability to use oxygen when
body cells are acidotic.
3. Insulin Pump Therapy
 An insulin pump is an automatic pump about
the size of an mp3 player. A syringe of regular
insulin is placed in the pump chamber and a
small gauge needle is attached to a length of
thin polyethylene tubing and implanted into the
5
subcutaneous tissue of a woman’s abdomen or
thigh
 Depending on the individual prescription, before
a snack and before a meal, a woman can dial or
press a button on the pump; the pump then
pushes the syringe barrel forward to administer
the bolus.
 The site of the pump insertion is cleaned daily
and covered with sterile gauze; the site is
changed every 24 to 48 hours to ensure that
absorption remains optimal.
 To assess whether the pump is delivering insulin
at the designated rate, a woman must do blood
glucose determinations about four times
throughout the day (fasting and 1 hour after
each meal
Several restrictions are necessary when using an insulin
pump. The pump must not be allowed to become wet;
therefore, a woman should remove the pump (not the
syringe and tubing) when showering and remove the
complete apparatus (pump, syringe, and tubing) to
bathe or swim (caution her not to leave it disconnected
for more than 1 hour).
BLEEDING DURING PREGNANCY
SPONTANEOUS MISCARRIAGE
Abortion is the medical term for any
interruption of a pregnancy before a fetus is viable. A
viable fetus is usually defined as a fetus of more than 20
to 24 weeks of gestation or one that weighs at least 500
g.
 When the interruption occurs spontaneously, it
is clearer to refer to it as a miscarriage.
A spontaneous miscarriage is an early miscarriage if
it occurs before week 16 of pregnancy and a late
miscarriage if it occurs between weeks 16 and 24.
Cause of spontaneous Miscarriage
1.Abnormal fetal development
2.Immunologic factors
3.Implantation abnormalities
4.Failure of the corpus luteum to produce
progesterone.
5. Systemic infection
6. Teratogenic drugs ( ex. Isotretinoin/
Accutane)
7. Alcohol
Assessment
 Vaginal spotting
Therapeutic Management
 Depending on the symptoms and the
description of the bleeding a woman gives
THREATENED MISCARRIAGE
Symptoms of a threatened miscarriage
 vaginal bleeding, initially only scant and usually
bright red
 slight cramping, but no cervical dilatation
Assessment
1. Fetal heart sounds assessed or an ultrasound
performed to evaluate the viability of the fetus.
2. Blood for human chorionic gonadotropin
hormone (hCG)
Management
1. Avoidance of strenuous activity for 24 to 48
hours is the key intervention.
2. Complete bed rest is usually NOT necessary.
Bed rest may stop the vaginal bleeding but only
because blood is pooling vaginally. When a
woman does ambulate again, the vaginal blood
collection will drain and bleeding will recur.
3. Be certain to convey concerned assurance that
miscarriages happen spontaneously, not
because of anything a woman did.
NOTE: Coitus is usually restricted for 2 weeks after the
bleeding episode to prevent infection and to avoid
inducing further bleeding.
As many as 50% of women with a threatened
miscarriage continue the pregnancy; for the other 50%
Misconception
 Estrogen in the form of diethylstilbestrol (DES)
was prescribed for this purpose, but there is no
conclusive evidence that this helped, and
because DES could be teratogenic, this practice
is no longer advocated
IMMINENT (INEVITABLE) MISCARRIAGE
A threatened miscarriage becomes an imminent
(inevitable) miscarriage if uterine contractions and
cervical dilation occur.
 A woman who reports cramping or uterine
contractions.
NOTE: Save any tissue fragments she has passed and
bring them with her so they can be examined.
Assessment:
1. Fetal heart sounds are detected and an
ultrasound reveals an empty uterus or
nonviable fetus.
Management
1. D&E (Dilatation and Evacuation) to ensure
that all the products of conception are
removed.
2. After a woman is discharged following the D&E,
a woman should assess vaginal bleeding by
recording the number of pads she uses.
Note: Saturating more than one pad per hour is
abnormally heavy bleeding.
6
COMPLETE MISCARRIAGE
 In a complete miscarriage, the entire products
of conception (fetus, membranes, and placenta)
are expelled spontaneously without any
assistance.
 The bleeding usually slows within 2 hours and
then ceases within a few days after passage of
the products of conception.
INCOMPLETE MISCARRIAGE
In an incomplete miscarriage, part of the
conceptus (usually the fetus) is expelled, but the
membrane or placenta is retained in the uterus.
NOTE: there is a danger of maternal hemorrhage as
long as part of the conceptus is retained in the uterus
because the uterus cannot contract effectively under
this condition.
Management:
1. The physician will usually perform a dilation and
curettage (D&C) or suction curettage to
evacuate the remainder of the pregnancy from
the uterus
MISSED MISCARRIAGE
 Also commonly referred to as early pregnancy
failure, the fetus dies in utero but is not
expelled.
Assessment
1. Discovered at a prenatal examination when the
fundal height is measured and no increase in
size can be demonstrated
2. When previously heard fetal heart sounds
cannot be heard.
3. An ultrasound can establish the fetus has died.
Often the embryo actually died 4 to 6 weeks
before the onset of miscarriage symptoms or
failure of growth was noted
4. Symptoms of a threatened miscarriage (painless
vaginal bleeding)
Management
1. D&E will be done
2. If the pregnancy is over 14 weeks, labor may be
induced by a prostaglandin suppository or
misoprostol (Cytotec) to dilate the cervix,
followed by oxytocin stimulation or
administration of mifepristone techniques used
for elective termination of pregnancy.
NOTE: There is a danger of allowing this normal
course (spontaneously within 2 weeks) to happen,
however, because disseminated intravascular
coagulation (DIC).
3. May need support in accepting the reality of the
situation and need counseling to accept a future
pregnancy.
RECURRENT PREGNANCY LOSE
A woman who had three spontaneous miscarriages that
occurred at the same gestational age where called in
the past as “habitual aborters”
 Now , “recurrent pregnancy loss” is used to
describe this miscarriage pattern
 Occurs about 1% in women who want to be
pregnant
Possible causes:
1. Defective spermatozoa
2. Endocrine factors (- protein bound iodine/PBI, -
butanol extractable iodine/BEI, globulin bound
iodine/GBI; poor thyroid function; luteal phase
defect.
3. Deviations of the uterus such as separate or
bicornuate uterus
4. Resistance to uterine artery blood flow
5. Chorioamnionitis or uterine infection
6. Autoimmune disorder (Lupus anticoagulant and
antiphospolipid antibodiesC
COMPLICATION OF MISCARRIAGE
 Infection and hemorrhage are the two most
likely complications of miscarriage.
Hemorrhage
 With complete miscarriage, fatal/serious
hemorrhage is rare
 With incomplete miscarriage, coagulation
defects may develop
Nursing interventions (incomplete miscarriage)
1. Monitor VS for any changes to detect possible
hypovolemic shock.
If excessive vaginal bleeding occurs, position woman flat
and provide fundal massage to the uterine fundus to try
and aid in contractions.
2. Applying pneumatic anti-shock garments can
help maintain blood pressure.
3. If bleeding does not stop, D &C may be
necessary or suction curettage to empty the
uterus of the material that is preventing it from
contraction and homeostasis
4. A transfusion may be necessary to replace
blood loss
5. Direct replacement of fibrinogen/ another
clotting factor may be needed to increase
coagulation ability.
Nursing Interventions (self-limiting complete
miscarriage)
1. Provide clear instructions on how much
bleeding is abnormal (more than 1 pad/hr.) and
what color changes should be expected (dark
color to serous fluid color)
2. Be certain that she knows that any unusual
odor passing of large clots is abnormal
7
3. If prescribe with medication such as
Methylergonovine maleate (methergine) to aid
in uterine contractions, review prescribe
medications and the importance of taking it.
Infection
 Tend to develop on women who have lost an
appreciable amount of blood. Infection is often
a reason for blood loss
 Causative agents: Escherichia Coli/Group A
streptococcus.
 Complications: parametritis, peritonitis,
thrombophlebitis and septicemia.
Nursing Interventions
1. Observe women closely to rule out this second
and possibly fatal complication.
2. Be certain the woman is familiar with the
common danger signs of infections
 Fever higher than 104 º F (38º C )
 Abdominal pain/tenderness
 Foul smelling vaginal discharge
Note: fever is the most important sign of infection
3. Caution women to wipe perineal area from
front to back after voiding and defecation to
prevent the spread of bacteria form the rectal
area
4. Be certain not advise woman not to use
tampons (stasis of fluid increase risk of
infection)
SEPTIC ABORTION
 A complication by infection
 Occurs most frequently in women who have
tried to self-abort/ pregnancy was aborted
illegally using a non-sterile instrument such as a
knitting needle
 Because the uterus is a warm, moist and dark
cavity once infectious organism are introduced
they grow rapidly.
Symptoms:
1. Fever
2. Crampy abdominal pain
3. Uterus is tender to palpation
Complications
1. Toxic shock syndrome
2. Septicemia
3. Kidney failure
4. Death
Nursing Interventions:
1. Need immediate intensive care, therapy and
assessment which may include the following:
 CBC
 Serum electrolyte
 Serum creatinine
 BT
 Cross matching
 Cervical, vaginal and urine cultures
2. And indwelling catheter may be inserted to
monitor urine output and asses kidney function
3. IVF therapy to restore fluid volume
 4. A combination of broad spectrum penicillin,
gentamicin, and clindamycin is commonly
prescribed.
5. A central venous pressure/pulmonary artery
catheter may be inserted to monitor left atrial
filling pressure and hemodynamic status.
6. D&C or D&E will be performed to remove
necrotic tissue form the uterus is important
7. DOPAMINE AND DIGITALIS may be necessary
to maintain sufficient cardiac output.
8. O2 may be given to maintain respiratory
function
Note: final results may leaf to infertility due to uterine
scarring. She may also need follow up social work
counseling to assess her home life.
ECTOPIC PREGNANCY
 is one in which implantation occurred outside
the uterine cavity
 95% occur in the fallopian tube on which
fertilization occurs in the fallopian tube
 2% of pregnancies are ectopic and it is the
second most frequent cause of bleeding early
in pregnancy
Fallopian tube sites:
1. Ampullar portion (80%)
2. Isthmus (12%)
3. Interstitial/fimbrial (8%)
Causes:
Obstruction
 Adhesion of the tube from a previous infection
(chronic salpingitis which leaves bilateral
scarring or pelvic inflammatory disease)
 Congenital malformation
 Scars from tubal surgery
 Uterine tumor pressing on proximal end of the
tube
Note: the zygote cannot travel the length of the tube. It
lodges at a stricture site along the tube and implants
there instead.
Factors:
1. Increasing rate of PID which can lead to tubal
scarring
2. Increased following in vitro fertilization
3. Women who smoke
4. Women who have had ectopic pregnancy may
higher chance of having subsequent ectopic
pregnancy
5. Congenital anomalies such as webbing (fibrous
bands)
Note: oral contraceptive used before pregnancy
reduces the incidence of ectopic pregnancy
Assessment
1. Early ultrasound or MRI.
2. If not revealed in an US or MRI, the zygote
grows (6-12 weeks of pregnancy/2-8 weeks
8
after a missed period) large enough that it
ruptures the slender fallopian tube
 If the implantation was in the interstitial
portion, rupture can cause serve
peritoneal bleeding
 It the ampullar portion, profuse
hemorrhage is less likely.
3. Rupture ectopic pregnancy may result to large
amounts of blood loss over time and is serious
regardless of site of implantation
4. Sharp, stabbing pain in one of her lower
abdominal quadrants at the time of the rupture
5. Scant vaginal spotting
Note: The amount of bleeding does not reveal the
actual amount present. However due to the products of
the conception from the ruptured tube and
accompanying blood may be EXPELLED INTO THE
PELVIC CAVITY
6. As the placenta dislodges, progesterone
secretions will halt and the uterine decidua
sloughs off, resulting in additional bleeding
7. A woman may experience hypotension due to
blood loss: light headedness, rapid pulse and
signs of hypovolemic shock.
Note: occasionally, a women may move and pull one of
here round ligaments which causes a momentary sharp
lower quadrant pain. However vaginal spotting does
rule out round ligament pain.
8. By the time the woman arrives at the hospital,
she may already be in severe shock as evidence
by weak thread pulse, rapid respiration and
falling BP
9. Leukocytosis may be present as a sign of trauma
10. Transvaginal ultrasound will demonstrate the
ruptured tube and blood collecting in the
peritoneum.
DIAGNOSTIC PROCEDURES
1. Falling hCG
2. Serum progesterone level
3. Laparoscopy or colposcopy
4. Ultrasound
If a woman awaits for a time before seeking help,
her abdomen gradually becomes rigid form peritoneal
irritation. A bluish-tinged hue in the umbilicus may
develop (Cullen signs).
ADDITIONAL ASSESSMENT
 She may have continuing extensive or dull
vaginal and abdominal pain; movement on the
cervix during IE can cause excruciating pain.
 She may also feel pain in her shoulders as well
from blood in the peritoneal cavity cause
irritation on the phrenic nerve
 A tender mass is usually palpable in douglas cul-
de-sac on vaginal examination.
Therapeutic Management
Note: Some ectopic pregnancy end before they rupture
and are reabsorbed over the next few days, requiring no
treatment.
1. IM or oral administration of METHOTREXATE.
(Advantage of this therapy is that the tube is
left intact with no surgical scarring to that
would cause a second ectopic pregnancy. ---- A
woman is treated until a (–) hCG titer is
achieved.
2. A hysterosalpingogram/US is usually performed
after this to assess that the pregnancy is no
longer present and also whether the tube
appears fully present.
Note: Amount of blood evident with ruptured ectopic
pregnancy is A POOR ESTIMATE OF THE ACTUAL BLOOD
LOSS.
 If pregnancy is not confirmed, Hgb level, BT,
cross-matching and hCG level are tested.
3. IVF using a large gauge catheter to restore
intravascular volume will be prescribe. BLOOD
then can be administered through the same
line.
4. If ruptured, ectopic pregnancy is laparoscopy to
ligate the bleeding vessel and to remove or
repair the damaged fallopian tube.
Note: rough suture lines may lead to another tubal
pregnancy, so either the tube will be removed or
suturing the tube will be done microsurgical techniques
(lose 5% of her fertility)
GESTATIONAL TROPHOBLASTIC
DISEASE/HYDATIDIFORM MOLE
 Considered as the abnormal proliferation and
then degeneration of the trophoblastic villi.
 Appears “clear fluid filled, grape sized vesicles”
 Associated with choriocarcinoma, a rapidly
metastasizing malignancy.
Most often occur in women:
1. Low protein diet
2. Older than 35 yrs. of age
3. Asian inheritance
4. Blood group A women who marry blood group
O men
TWO TYPES OF MOLAR GROWTH
Complete mole
 swell and become cystic
 If embryo form, it dies early at only 1-2 mm in
size.
 No fetal blood present
 Karyotype: 46XX/47XY (these components was
contributed only by the father or an empty
ovum.
Partial mole
9
 Swollen and misshapen
 May grow up to 9 weeks but then macerates
 Karyotype: 69XX/69XY (three chromosomes for
every pair: one set supplied by the ovum that
was fertilized by 2 sperms or a single ovum that
was fertilized a sperm in which meiosis did not
occur or vice versa)
 Rarely leads to choriocarcinoma
Assessment
1. Rapid growth, uterus tends to expand faster
than the usual or the uterus reaches its land
marks (over the symphysis pubis at 12 weeks,
and 20-24 weeks at the umbilicus) before the
expected time.
Note: this can often be misdiagnosed with multiple
gestation or miscalculated due date.
2. DIAGNOSTIC PROCEDURE: Serum/Urine test
for hCG, 1-2 million IU – Normal: 400, 000 IU.
Results will continue to be strongly positive up
until day 100 of pregnancy
Note: this can often be misdiagnosed with multiple
pregnancy with more than 1 placenta or miscalculated
due date.
3. SYMPTOMS OF GHPN: Edema, proteinuria and
high blood pressure is present before 20 weeks
of pregnancy
4. Ultrasound: dense growth with snowflake
pattern but NO FETAL HEART SOUND AND NO
FETAL GROWTH because there is no viable
fetus.
5. At 16 weeks when still not identified by US, it
will be identified itself by vaginal bleeding:
spotting dark brown blood resembling prune
juices or as a profuse fresh flow.
6. Bleeding is accompanied by clear fluid filed
vesicles.
Note: it is important for the mother to bring any clots
or tissues passed during miscarriage to the hospital to
be analyzed.
Therapeutic Management
1. D&C or evacuation of abnormal trophoblast
cells
2. Following this, baseline pelvic examination is
performed and a serum test for beta subunits of
hCG.
Note: serum hCG level is assessed every 2 weeks until
levels are normal again. Then the serum level is
assessed every 4 weeks for the next 6-12 months
Conditions: if the level plateaus or increase, it means
malignant transformation is occurring. If hCG levels
becomes (-), a woman is theoretically free of any risk of
malignancy.
3. During this period while waiting for hCG to
decline, oral contraceptives such as estrogen or
progesterone so that a + pregnancy will not be
 confused with the increasing hCG that occurs in
malignancy.
Note: By 12 months a woman may begin to plan a
second pregnancy.
4. METHOTREXATE: as a prophylactic course for
gestational trophoblastic disease. If metastasis
occurs, a second agent such as DACTINOMYCIN
Consideration: METHOTREXATE may interfere with
WBC synthesis or formation (i.e. leukopenia), and as
such prophylactic use must be weighted carefully.
5. Provide counseling to allow patient to express
their anger and sense of unfairness for this type
of event.
Note: a woman who has had an incidence of gestational
trophoblastic disease may have an increased risk of
second molar pregnancy.
PREMATURE CERVICAL DILATION/CERVICAL
INSUFFICIENCY
 Previously termed an incompetent cervix, refers
to the cervix that dilates prematurely and
therefore cannot retain fetus until term.
 Usually occurs at 2o weeks where the fetus is
still immature to survive
Symptoms include:
1. Show (pink stained vaginal discharge)
2. Increase pelvic pressure
3. Rupture membranes
4. Amniotic fluid discharge which then leads to
uterine contractions.
No particular cause but is associated with
 Increased maternal age
 Congenital structural defects
 Past trauma to the cervix ( i.e. cone biopsy or
repeated D&C
Diagnosed: early US or after pregnancy is lost.
Therapeutic management
1. After the loss of the first child due to
premature cervical dilatation, a surgical
operation termed as cervical cerclage can be
performed to prevent this from happening in a
second pregnancy.
2. As soon as us confirms of the 2 nd pregnancy is
healthy approximately 12-14 weeks purse string
sutures are place in the cervix by vaginal route
under regional anesthesia
Types of procedures used:
McDonalds Procedure
 Nylon sutures are place horizontally and
vertically across the cervix and pulled tight to
reduce the cervical canal a few millimeters in
diameter.
Shirodkar Technique
 Sterile tape is threaded in a purse string manner
under the submucous layer of the cervix and
sutured in place to achieve a closed cervix.
Note: This procedures are done to strengthen the cervix
and prevent it from dilating until the end of pregnancy.
10
These procedures are accomplished by vaginal route or
transabdominal route.
3. After surgery, woman must remain on CBR in a
slight or modified tredulenburg’s position for a
few days to decrease pressure on the sutures.
Note: Sexual activity may be resume in most instances
after this rest period.
4. Sutures are removed at weeks 37-38 weeks of
pregnancy so the fetus can be born vaginally. If
transabdominal approach, the sutures are left
in place and CS is performed.
If woman at prenatal visits is discovered to have cervical
dilatation but with membranes still intact, an emergent
cerclage suture is place in the cervix even at that point
as a prophylaxis against preterm birth.
PLACENTA PREVIA
 A condition of pregnancy in which the placenta
is implanted abnormally in the lower parts of
the uterus.
 MOST COMMON CAUSE OF PAINLESS
BLEEDING IN THE 3RD TRIMESTER.
 5 per 1000 pregnancy
Degrees of Placenta previa
1. Total placenta previa (implantation that totally
obstructs the cervical os)
2. Partial placenta previa (implantation that
occludes only a portion of the cervical os)
3. Marginal placenta previa/implantation (the
placentas edge approaches the cervical os)
4. Low lying placenta previa (implantation is lower
rather than in the upper portion)
Note: the degree to which the placenta covers the
cervical os is generally estimated by percentage; 100%.
75%, 30%
Factors associated with placenta previa:
1. Increased parity
2. Advance maternal age
3. Past CS births
4. Past D&C/uterine curettage
5. Multiple gestation
6. Male fetus
Possible causes: it is thought to occur when the
placenta is forced to spread to find an adequate
exchange surface
There is a possibility of increase risk for
congenital anomalies or fetal growth restriction if the
implantation does not supply optimum fetal O2 and
nutrients.
Assessment
1. Routine sonogram or ultrasounds
2. Vaginal bleeding characterize by painless,
abrupt, bright red and sudden enough to
frighten a woman
Note: Bleeding in this condition does not start up until
lower uterine segment starts to separate from the
upper segment late in pregnancy and the cervix begins
to dilate (30 weeks of pregnancy)
Not associated with increased activity
Therapeutic Management
Immediate Care measure
1. Bed rest in a side lying position
 Woman’s estimation of her blood loss
 Accompanying pain
 Color of blood
 Duration of the pregnancy
 Time of bleeding
 What she has done for the bleeding
 Prior episodes of bleeding
 Prior surgeries for incompetent cervix
2. Inspect the perineum for bleeding and estimate
the amount of blood loss
Note: noting the number of perineal pads should also
be done. An apt or kleihauer-Betke test (strip test
procedure to differentiate between maternal and fetal
blood is present)
3. Obtain baseline VS to determine any signs or
symptoms of hypovolemic shock are present.
Note: Continue to assess BP every 5 to 15 minutes or
continuously with an electronic cuff.
4. NEVER ATTEMPT a pelvic or rectal examination
5. Attach external monitoring equipment to
record FHR and UC.
6. Hgb, Hct, PT, PTT, plt count, fibrinogen, BT and
cross matching as well as antibody screen will
be assessed to establish baseline.
7. Monitor Urine output
8. Administer IVF as prescribe
Note: use large-gauge catheter to allow blood
replacement at the same line.
Conditions on which type of Delivery is used
 If the previa is under 30%, it may be possible for
the fetus to be born pass it.
 If more than 30% and the fetus is mature, the
safest birth for both mother and baby is CS
Continuing Care Measures
1. If labor has begun, continuing or of the fetus is
being compromised (measured by the response
FHR to contractions) BIRTH MUST BE ACHIEVED
REGARDLESS OF GESTATIONAL AGE
2. A woman may remain in bed rest for 24-48 hrs.
for close observation
3. Fetal heart sounds, Hct and Hgb are assessed
continuously
4. BETHAMETHASONE (IM): a steroid to hasten
fetal lung maturity may be prescribed for the
mother to encourage the maturity of the fetal
lungs if the fetus is less than 34 weeks of
gestation.
Note: Given 12-24 hours before birth if fetus is less than
34 weeks of gestation and to prevent RDS. Upon
interaction with tocolytic agents it may lead to cardiac
decompensation. Be alert!
11
Birth
 Birth decisions will generally be made
immediately as it is important birth to be in a
controlled setting in case more than usual blood
loss occurs at birth
 If the placenta previa is found to be total, CS is
the appropriate birth
 If partial, the amount of blood loss, the
condition of the fetus and a woman parity will
influence the decision
 For CS, where US reveals placental location, a
transverse uterine incision may still be possible.
Note: woman who may have placenta previa are
more prone to postpartum hemorrhage because
the placental site of the lower uterine segment does
not contract. A second complication to this
condition is endometritis.
PREMATURE SEPARATION OF THE PLACENTA
(ABRUPTIO PLANCENTAE)
 The placenta appears to have been implanted
to correctly. Suddenly however it begins to
separate and bleeding results.
 MOST COMMON CAUSE OF PERINATAL
DEATH because it can lead to extensive
bleeding.
 Separation generally occurs late in pregnancy;
even as late as during the 1 st or 2nd stage of
labor.
Consideration: Always be alert to both the amount and
kind pain and vaginal bleeding a woman is having
during labor
Causes: Unknown but it is associated with
1. Increased parity
2. Advance maternal age
3. Short umbilical cord
4. Chronic Hypertensive disease
5. GHPN
6. Direct trauma ( i.e. violence or automobile
accidents)
7. Vasoconstriction form cocaine and cigarette use
8. Thrombophilic conditions
Other causes:
 Chorioamnionitis
 Rapid decrease of uterine volume (i.e.
polyhydramnios where sudden release of
amniotic fluid occurs.
Assessment
1. Sharp, stabbing pain high in the uterine fundus
as the initial separation occurs.
2. Tenderness can be felt on uterine palpations
3. Heavy bleeding
Note: external bleeding will only be evident if the
placenta separates first at the edges and so blood
escapes into the uterus and then the cervix. In contrast,
if the center of the placenta separates first, blood can
pool under the placenta, although bleeding is just as
intense.
4. Signs of hypovolemic shock will follow
5. Uterus becomes tense and is rigid to touch
 6. if blood infiltrates into the uterine musculature,
couvelaire uterus or uteroplacental apoplexy,
forming a broadlike, hard uterus
7. Fibrinogen levels become diminished as
bleeding progresses
8. When bleeding begins, assess pain whether
accompanied by it, the amount and kind of
bleeding and her actions to detect if trauma
could have led to the separation.
Therapeutic Management
1. IVF for fluid replacement (large gauge catheter
should be used)
2. O2 by mask should be given to limit fetal anoxia
3. Monitor fetal heart sounds and record maternal
VS every 5 to 15 minutes to establish baseline
and observe progress
4. Baseline fibrinogen should also be acquired (to
be followed up to the time of birth)
5. Keep woman in a lateral and NOT in supine.
6. DO NOT PERFORM any pelvic, vaginal or
abdominal examination
DEGREES OF SEPARATION
Grade Criteria
0 No symptoms of separations are apparent from
maternal or fetal signs
1 Minimal separation but enough to cause
vaginal bleeding and changes in maternal VS
2 Moderate separation; there is evident fetal
distress; uterus is tense and painful on
palpation
3 Extreme separation; hypovolemic shock and
fetal distress will result
7. Unless the separation is minimal (grade 1-2),
the pregnancy must be ended
8. If NVSD is not imminent, CS is the birth method
of choice
9. FIBRINOGEN OF CYCLOPRECIPITATE can be
used to elevate a woman’s fibrinogen level prior
to and concurrently with surgery.
PROGNOSIS
 Fetal-depends upon the extent of separation
and degree of fetal hypoxia
 Maternal- depends upon promptly given
treatment
PRETERM LABOR
 Is labor that occurs before the end of week 37
of gestation
 Always potentially serious because it results in
the birth of an infants, the infant will me
IMMATURE
 Responsible for 2/3 of the neonatal death
 Persistent uterine contractions occur (even if
mild or widely space should be considered in
labor)
12
Note: a woman is documented to be in actual labor
rather than having false labor contractions if
contractions have cause cervical effacement over 80%
and dilation over 1 cm
Preventive measure:
1. Maintaining a general health during pregnancy
is the best preventive measure to avoid preterm
birth.
2. Knowing the signs of labor can help woman
identify if preterm birth is beginning (some
women wait before they seek help for preterm
labor as they diagnose them as back pain or
extremely hard Braxton Hicks contractions.)
Causes: usually unclear but it is associated however
with:
1. Dehydration
2. Urinary tract infection
3. Periodontal disease
4. chorioamnionitis
5. Large fetal size
6. African American, adolescent and those who
received inadequate prenatal care
7. Strenuous jobs during pregnancy and works
that leads to extreme fatigue.
8. Intimate partner violence and trauma
Assessment
Common Symptoms:
1. Persistent, low and dull backache
2. Vaginal spotting
3. Abdominal tightening
4. A feeling of pelvic pressure
5. Increased Vaginal discharge
6. Uterine contractions
7. Intestinal cramping
Diagnostic:
 Ultrasound (analyzing the changes in the length
of the cervix)
 Fibronectin Analysis (found or obtained in the
vaginal mucus characterized as a protein
produced by the trophoblastic cells.
Conditions:
 If present, it predicts that preterm
contractions are ready to occur.
 If absent, labor will not occur for at
least 14 days
Therapeutic management
1. Medical attempts can be made if:
 Fetal membranes have NOT ruptures
 Fetal distress is absent
 No evidence that bleeding is occurring
 Cervix is not dilated to more 4-5 cm and
effacement is not more than 50%
2. Place on bed rest to relieve pressure of the
fetus on the cervix.
3. External fetal and uterine contraction monitors
are attached to monitor FHR and the intensity
of contractions.
4. IVF therapy to keep her hydrated
Note: being hydrated halts uterine contractions. If a
woman is dehydrated the pituitary gland is activated to
secrete ADH which might cause the pituitary gland to
release oxytocin as well as strengthening uterine
contractions.
5. Vaginal and cervical cultures and clean catch
urine to rule out infection. If infection is present
the woman is prescribed with antibiotic that is
especially effect for group B streptococcus
Drug Administration
Terbutaline- is a drug approved to prevent and treat
bronchospasm but may be used, off-label as a tocolytic
agent.
Note: Terbutaline carries a black box and should NOT be
used for over 48-72 hours of therapy because of the
potential for serious maternal health problems and
death. And should not be used in an outpatient setting.
Magnesium sulfate- given IV, is primarily used to treat
preeclampsia and prevent eclamptic seizures. MgSo4 is
also use for fetal neuroprotection which is given prior to
32 weeks to help prevent cerebral palsy in premature
infants
Betamethasone- for the formation of lung surfactant
appears to accelerate, thus reducing the possibility of
RDS or BPD.
Note: if pregnancy is under 34 weeks, a woman may be
given 2 doses of 12 mg betamethasone IM 24 hours
apart OR 4 doses of 6 mg dexamethasone IM 12 hours
apart.
Fetal assessment
1. Assessing the FHR and activity
2. If contractions have ceased and there is
evidence of fetal well-being, women arrested
with preterm labor can be safely care for at
home.
3. Drink enough fluid
4. Limit strenuous activities
5. Maintain adequate nutrition
6. DO NOT SMOKE
7. Record daily fetal kick count or count to 10 test
Labor that can be halted
 Ruptured membranes can be thought of as the
“point of no return” (increased chances of risk
for infection if labor is halted)
 if fetus is very immature, CS birth may be
planned to reduce fetal head pressure and
reduce the possibility of intraventricular
hemorrhage although this is controversial since
infants born of CS have higher incidence of
respiratory difficulty, which is already at risk for
preterm infants
 Increase risk for chord prolapse, AROM is not
done as a RULE IN PRETERM LABOR UNTIL THE
FETAL HEAD IS FIRMLY ENGAGED.
 Analgesics are administered with caution
because immature infants will have enough
difficulty breathing at birth without the burden
of being sedated from a drug such as
MEPERIDINE.
NOTE: if a woman wants pharmaceutical pain
management, epidural is preferable.
13
 Woman must rest on her side to help prevent
supine hypotension syndrome or interference
of uterine contraction
 Episiotomy is done to remove the excess
pressure on the head and reduce possibility of
subdural or intraventricular hemorrhage.
 Cord is not clamped immediately because this
extra amount of blood can help reduce
possibility of preterm anemia.
PREMATURE RUPTURE OF MEMBRANES
 Is considered as the ruptured of fetal
membranes with the loss of amniotic fluid before
37 weeks of pregnancy.
 Occurs 5-10% of pregnancy
Cause: unknown but it is strongly associated with
infection of the membranes (i.e. chorioamnionitis)
Complications:
1. Risk for uterine and fetal infections may occur
2. Increase pressure on the umbilical cord from
the loss of amniotic fluid which also diminishes
fetal supply or cord prolapse
3. Potter-like syndrome (i.e. distorted like facial
features and pulmonary hypoplasia from
uterine pressure)
Assessment
1. History
2. Sudden gush of clear fluid from her vagina with
continued minimal leakage
3. Vaginal speculum examination is done to
observe for vaginal pooling of fluid.
4. To determine the difference between urine and
amniotic fluid, Nitrazine paper is used.
Conditions:
 Amniotic fluid cause an alkaline reaction on the
paper which appears blue
 Urine causes an acidic reaction on the paper which
remains yellow
5. Fluid can also be test for ferning or the typical
appearance of a high estrogen fluid on
microscopic examination.
6. Ultrasound
7. Culture may also be done for N. gonorrhea,
group B streptococcus and chlamydia.
8. Blood studies specifically WBC and C- reactive
protein, increase with membranes rupture.
Note: AVOID DOING ROUTINE VAGINAL EXAMINATION
BECAUSE OF THE RISK FOR INFECTION RISES
SIGNIFICANTLY
Therapeutic Management
1. If labor does not begin within 24 hours and the
fetus is mature enough by amniocentesis to
survive in extrauterine environment, labor
contractions can be induced by IV
administration of OXYTOCIN
2. If the fetus is not at a point of viability, woman
is offered immediate delivery
3. If she declines, she is place on bed rest
4. If she reaches viability, a corticosteroid is
administered to hasten fetal lung maturity
 5. Prophylactic administration of broad spectrum
penicillin antibiotics.
6. A woman with no signs of infection may be
administered with tocolytic agent if labor
contractions begin.
7. Amnionfusion to reduce pressure on the fetal
cord and to allow safer term birth.
POLYHYDRAMNIOS
 Amniotic fluid volume at term is: 500-1000 ml
 Polyhydramnios occurs when there is excess
fluid of more than 2000 ml or an amniotic index
above 24 cm.
This condition results in:
1. Fetal malpresentation (additional uterine space)
2. PROM (increased pressure
3. Preterm birth
4. Cord prolapse
5. Risk for infection
Amniotic fluid is formed from a combination of
the cells of the amniotic membrane and from fetal
urine. It is evacuated by being swallowed by the fetus,
absorbed across the intestinal membrane into the fetal
bloodstream and transferred across the placenta.
Accumulation of fluid suggest
1. Difficulty in the infants ability to swallow,
absorbed (infants who are anencephalic, those
who have tracheoesophageal fistula with
stenosis and those who have intestinal
obstruction)
2. excessive urine production (hyperglycemia)
Assessment
1. rapid enlargement of the uterus
2. Small parts of the fetus becomes difficult to
palpate because the uterus is unusually tense.
3. Auscultation of the FHR becomes difficult
because of the depth of the increased amount
of amniotic fluid.
4. Extreme Shortness of breath because the uterus
5. She may develop varicosities and hemorrhoids
because lower extremities venous return is
blocked by extensive uterine pressure.
6. Increase weight gain
7. Diagnostic procedure: Ultrasound
Therapeutic Management
1. Bed rest (helps to increase uteroplacental
circulation and reduce pressure on the cervix,
which helps prevent preterm labor)
2. Teach woman that it is important to report
signs of rupture membrane or uterine
contractions.
3. Help her avoid constipation by encouraging her
to eat high fiber diet. Suggest stool softeners if
diet alone is ineffective (straining to defecate
could increase uterine pressure and cause a
ROM)
4. Assess VS and lower extremities for edema
frequently.
5. Amniocentesis can be performed to remove
extra fluid (must be repeated almost daily to be
effective)
14
6. If contractions begin, tocolysis may be
necessary to halt preterm labor
7. To prevent the sudden loss of fluid and
accompanying cord prolapse during labor,
membranes are needled (a thin needle is
inserted vaginally to pierce them to allow a
slow, controlled release of fluid.)
OLIGOHYDRAMNIOS
 Refers to pregnancy with less than the average
amount of amniotic fluid.
Causes: a bladder/renal disorder in the fetus that is
interfering with the voiding. It also can occur in server
growth restriction
This condition results in the following
1. Muscle weak at birth
2. Lungs can fail to develop (hypoplastic lungs)
3. Potter syndrome ( i.e. distorted features of the
face occurs
Assessment: Oligohydramnios is suspected when the
uterus fails to meet the expected growth rate.
Diagnostic: US when pockets of amniotic fluid are less
than the average.
POSTTERM PREGNANCY
 A pregnancy that exceeds 38-42 weeks is
prolonged ( i.e. postterm pregnancy,
postmature or postdate)
 Considered as postmarure or dysmature
 Occurs at 3-12 % of all pregnancies
Note: included in this group are those pregnancy who
extend beyond their due date set because of a faulty
due date. Woman who have long menstrual cycle (i.e.
40-45 days) do not ovulate on day 14 as in typical
menstrual cycle. They ovulate 14 days from the end of
their menstrual period or on day 26 or 31, their children
will be considered late by 12 or 17 days.
Causes: the trigger that initiates labor did not turn on,
this condition occurs:
1. When woman is receiving high doses of
salicylates (for sinus headaches and rheumatoid
arthritis) which interferes with the synthesis of
prostaglandin (responsible for the initiation of
labor)
2. Associated with myometrial quiescence or a
uterus that does not respond to normal
stimulation.
Complications associated with postterm pregnancy
 Meconium aspiration (is more likely to occur as
fetal intestinal content reach the rectum)
 Lack of growth (placenta seem to have
adequate functioning ability only 40-42 weeks)
Note: after this it acquire calcium deposits and exposes
the fetus to decrease blood perfusion and a lack of
oxygen, fluid and nutrients.
 If OLIGOHYDRAMNIOS occurs, it can lead to
deceleration of FHR due to cord compression.
Management
1. If labor has not begun by 41 weeks, a NON
STRESS TEST & a BIOPHYSICAL PROFILE
Conditions of the results:
 If these are normal, it suggest due date was
miscalculated
 If these test are abnormal, or the physical
examination or biparietal diameter measured
on US suggest the fetus is term side and labor
will be induced.
2. Prostaglandin gel or misoprostol (cytotec)
3. Oxytocin infusion
Note: if oxytocin is ineffective, CS birth maybe
necessary.
4. Monitor FHR closely during labor to be certain
placental insufficiency is not occurring from
aging of the placenta.
ISOIMMUNIZATION (RH INCOMPATIBILITY)
RH incompatibility occurs when an Rh- negative
mother (one negative for D antigen or one with a dd
genotype) carries a fetus with an Rh-positive blood type
(DD or Dd genotype)
Conditions:
For such situations to occur, the father of the child must
be either homozygous (DD) or heterozygous (Dd)
 if the father is homozygous, the couple’s
children will be Rh positive
 If the father is heterozygous, the couple’s
children will have a 50% chance of being Rh
positive.
Because of this incompatibility, the mother forms
antibodies against the invading substance (in this case
it’s the fetal blood). The Rh factor to which is exists as a
portion of the RBC so these maternal antibodies cross
the placenta and cause hemolysis of the fetal RBC----
deficient RBC means less O2 can reach the cells due to
insufficient cells for transport.
Note for this conditions:
1. Procedures such as amniocentesis and
percutaneous umbilical blood sampling can
establish a connections between the maternal
and fetal blood which theoretically should not
exist.
2. As the placenta separates at birth, active
exchange of maternal and fetal blood from
damage villi occurs.
Note: maternal antibodies are formed within 72 hours
after birth
Assessment
1. Anti-D antibody titer at first pregnancy visit
 Normal: 0
 Minimal: 1:8
Note: test is repeated at 28 weeks of pregnancy
Conditions:
 if normal no therapy is needed
 If a woman’s anti-D titer is elevated at a fist
assessment (1:16 or +) it shows, Rh
sensitization. To which the fetus is in toxic
environment and as such be monitored every 2
weeks by ---
15
DOPPLER VELOCITY (detects when anemia is present or
fetal RBC are being destroyed)
 If velocity remains high, fetus is not developing
anemia and most likely is an Rh (-) fetus
 If velocity is low, it means fetus is in danger and
immediate birth must be carried out provided
that the fetus is term.
Therapeutic management
1. RhIG, a commercial preparation of passive Rh
(D) antibodies against Rh factor, is administered
to women who are Rh negative at 28 weeks of
pregnancy.2
Note: RhoGAM is given by injection to the mother in the
fisrt 72 hours after birth of an Rh (+) child and is
destroyed in 2 weeks to 2 months.
COMPLICATIONS WITH THE POWER
(THE FORCE OF LABOR)
Inertia is a time honored term to denote sluggishness of
contractions, or that the force of labor is less than
normal.
 A more current term is dysfunctional labor
 Classified into 2: primary ( occurring at the
onset of labor and secondary ( occurring later in
labor)
Note: prolonged labor increases the chance of the risk
of maternal hemorrhage, infection and infant mortality.
Factors which can influence prolonged labor:
 Fetus is large
 If contractions are hypertonic, hypotonic or
uncoordinated contractions.
INEFFECTIVE UTERINE FORCE
Uterine contractions- are the basic force moves
the fetus through the birth canal.
These contractions occur through an interplay of:
1. Contractile enzymes of ATP
2. Major electrolyte: Ca, Na, and K
3. Contractile proteins actin and myosin
4. Epinephrine
5. Norepinephrine
6. Estrogen
7. Progesterone
8. Oxytocin
9. Prostaglandins
Different types of contractions:
1. Hypotonic Contractions- the number of
contractions is unusually infrequent (not more
than 2-3 contractions/ 10 minutes)
 Resting tone: -10 mmHg
 Strength: not rise above 25 mmHg
 NOT exceedingly painful/limited pain
Occur:
 during the active phase of labor
 After the administration of Analgesia especially
if cervix is 3-4 cm or bladder is distended
 Overstretched uterus (polyhydramnios,
multiple gestations, large fetus)
 Lax uterus (grand multiparty)
Note: hypotonic contractions will increase the length of
labor which can lead to exhaustion of the uterus. This
can cause the uterus to not contract effectively during
postpartal period and as such the mother is in risk for
postpartal hemorrhage.
Important nursing interventions:
1. In the 1st hour after birth, palpate the
fundus.
2. Obtain woman’s BP
3. Assess the lochia every 15 minutes for the
first hour to ensure postpartal
contractions are NOT ALSO HYPOTONIC.
Medications used: Oxytocin has favorable reaction
where sedation has little value
2. Hypertonic Contractions- are marked by increasing
resting tone of more than 15mmHg, however the
intensity of the contractions maybe no stronger
than that associated with hypotonic contractions
Occur:
 Latent phase of labor
 More than one uterine pacemaker
 Muscle fibers of the myometrium do not
repolarize
 More painful than usual because the
myometrium becomes tender form the
constant lack of relaxation and the anoxia of
the uterine cells results.
Note: lack of relaxation between contractions may not
allow optimal uterine artery filling: this can lead to fetal
anoxia in the latent phase of labor.
Important nursing interventions:
1. Apply uterine and fetal external monitor
to women whose pain seems out of
proportion to the quality of contraction.
2. If deceleration of FHR, an abnormally long
first stage of labor, lack of progress with
pushing occurs and as such CS maybe
necessary.
Medications used: Oxytocin has a unfavorable reaction
and sedation is very helpful
3. Uncoordinated Contractions-more than one
pacemaker may be initiating contractions or receptor
points in the myometrium may be acting independently
of the pace maker.
 Occur so closely together, it infers with the
placental blood supply
 Erratic, such a one on top of the other and
period without any
 It may be difficult for a woman to breathe
effectively with contractions or rest in between
contractions.
16
Important Nursing interventions:
1. Apply fetal and uterine external monitors and
assessing the rate, pattern, resting tone and
fetal response to contractions for 15 minutes
revels the abnormal pattern.
2. Oxytocin administrations-to stimulate a more
consistent and effective pattern of contraction
with better lower resting tone.
DYSFUNCTIONAL LABOR AND ASSOCIATED STAGES OF
LABOR
Dysfunction at the first stage of labor
 Prolonged latent phase
 Protracted active phase
 Prolonged deceleration phase
 Secondary arrest dilatation
Prolonged Latent Phase- when contractions become
ineffective during the first stage of labor.
 A prolonged latent phase, as defined by
Friedman (1978), is a latent phase that is longer
than 20 hours in a nullipara or 14 hours in a
multipara
 the uterus tends to be in a hypertonic state
 Relaxation between contractions is
inadequate, and the contractions are only mild
(less than 15 mm Hg on a monitor printout)
Occurs:
1. “Not” ripe cervix at the beginning of labor
(excessive use of an analgesic early in labor)
Management
1. Helping the uterus to rest
2. Providing adequate fluid for hydration
3. Pain relief with a drug such as morphine sulfate
4. Changing the linen and the woman’s gown
5. Darkening room lights
6. Decreasing noise and stimulation can also be
helpful.
7. If it does not, a cesarean birth or amniotomy
(artificial rupture of membranes) and oxytocin
infusion to assist labor may be necessary.
Protracted Active Phase- is usually associated with
cephalopelvic disproportion (CPD) or fetal malposition,
although it may reflect ineffective myometrial activity.
 tends to be hypotonic
This phase is prolonged:
 If cervical dilatation does not occur at a rate of
at least 1.2 cm/hour in a nullipara or 1.5 cm/hr
in a multipara
 if the active phase lasts longer than 12 hours in
a primigravida or 6 hours in a multigravida
Management:
1. If the cause of the delay in dilatation is fetal
malposition or CPD, CS may be necessary
2. After an ultrasound to show that CPD is not
present, oxytocin may be prescribed to
augment labor
Prolonged Deceleration Phase- A deceleration phase
has become prolonged when it extends beyond 3 hours
in a nullipara or 1 hour in a multipara
 Most often cause by fetal head position
 CS is frequently required.
Secondary Arrest of Dilation- there is no progress in
cervical dilatation for longer than 2 hours
 CS may be necessary
Dysfunction at the second stage of labor
 Prolonged descent
 Arrest of descent
Prolonged Descent- occurs if the rate of descent is less
than 1.0 cm/hr in a nullipara or 2.0 cm/hr in a multipara
Note: It can be suspected if the second stage lasts over
3 hours in a multipara
 contractions have been of good quality and
proper duration, and effacement and beginning
dilatation have occurred, but then the
contractions become infrequent and of poor
quality and dilatation stop
Management:
1. rest and fluid intake, as advocated for
hypertonic contractions
2. If the membranes have not ruptured, rupturing
them at this point may be helpful
3. IV oxytocin may be used to induce the uterus to
contract effectively
4. A semi-Fowler’s position, squatting, kneeling,
or more effective pushing may speed descent
Arrest of Descent- no descent has occurred for 1 hour
in a multipara or 2 hours in a nullipara.
 occurred when expected descent of the fetus
does not begin or engagement or movement
beyond 0 station has not occurred
 cause for arrest of descent during the second
stage is CPD
 Cesarean birth usually is necessary
 If there is no contraindication to vaginal birth,
oxytocin may be used to assist labor
PRECIPITATE LABOR
 Precipitate dilatation occurs when cervical
dilatation occurs at a rate of 5cm or more per
hour in nullipara and 10cm or more per hour in
multipara.
 Precipitate birth occurs when uterine
contractions are so strong a woman gives birth
to only a few rapidly occurring contractions.
Note: It is often defined as a labor that is completed in
fewer than 3 hours
Most likely to occur due to:
1. Grand multiparity
2. Induction of labor by oxytocin
Contractions are so forceful it can lead to:
1. Premature separation of the placenta
2. Laceration
3. Risk for hemorrhage
17
4. For the fetus: risk for subdural hemorrhage
Assessment
 Can be predicted through labor graph (h if,
during the active phase of dilatation, the rate is
greater than 5 cm/hr (1 cm every 12 minutes) in
a nullipara or 10 cm/hr (1 cm every 6 minutes)
in a multipara)
Management:
1. Tocolytic may be administered to reduce the
force and frequency of contraction
2. Caution a multiparous woman by week 28 of
pregnancy that, because a past labor was so
brief, her labor this time also may be brief
3. Both grand multiparas and women with
histories of precipitate labor should have the
birthing room converted to birth readiness.
INDUCTION AND AUGMENTATION OF LABOR
 Induction of labor-labor is started artificially.
 Augmentation of labor- refers to assisting labor
that has started spontaneously but is not
effective.
Induction may be necessary because a fetus is in danger
or because labor does not occur spontaneously and the
fetus appears to be at term.
Note: Assessing fetal lung maturity should not be as an
indication for induction and that it should be avoided
until 39 weeks unless medically indicated
Conditions include:
 pre-eclampsia
 eclampsia
 severe HPN
 DM
 Rh sensitization
 prolonged rupture of the membranes
 IUGR
 Postterm infants
Augmentation of labor or assistance may be necessary if
the contractions are hypotonic or too weak or
infrequent to be effective.
Increases the risk for:
 risk for uterine rupture
 decrease fetal blood supply
 premature separation of the placenta
Use with Caution if woman has:
 multiple gestation
 hydramnios
 grand parity
 maternal age older than 40 years of age
 previous uterine scars
Before inductions, this conditions should be present
 The fetus is in a longitudinal lie
 The cervix is ripe, or ready for birth.
 A presenting part is engaged.
 There is no CPD.
 The fetus is estimated to be mature by date,
demonstrated by a lecithin–sphingomyelin ratio
or ultrasound biparietal diameter to rule out
preterm birth.
CERVICAL RIPENING– is the change of cervical Administration of oxytocin (synthetic form of naturally
consistency from firm to soft, and should be completed occurring pituitary hormone) initiates contractions in a
at the first stage of labor uterus at pregnancy term.
To determine whether a cervix is “ripe,” or  Always IV, so that, if hyperstimulation should
ready for dilatation, Bishop established criteria for occur, it can be quickly discontinued
scoring the cervix.  half-life: 3 minutes
Scoring of the Cervix for Readiness for Elective Induction Dilution methods:
Note: Using this scale, if a woman’s total score is 8 or Score
greater, the cervix is considered ready for birth and Scoring Factor 0 1 2 3
should respond to induction Dilatation 0 1–2 3–4 3–4
(cm)
To “ripen” a cervix
Effacement 0–30 40–50 60–70 80
1. “stripping the membranes,” or separating the
(%)
membranes from the lower uterine segment
Station –3 –2 –1–0 1–2
manually, using a gloved finger in the cervix
Consistency Firm Medium Soft
Possible complications of this mechanical method:
Position Posterior Mid- Anterior
 Bleeding
position
 Inadvertent rupture of membranes
1. Oxytocin, such as Pitocin, is mixed in the
 Possible infection
proportion of 10 IU in 1000 mL of Ringer’s
2. hygroscopic suppositories (suppositories of
lactate.
seaweed that swell on contact with cervical
2. An alternative dilution method is to add 15 IU of
secretions
oxytocin to 250 mL of an IV solution; this yields
 inserted to gradually and gently urge
a concentration of 60 mU/1 mL
dilatation (laminaria technique)
Note: Physician’s orders for administration of oxytocin
 held in place by gauze sponges
for induction usually designate the number of milliunits
saturated with povidone-iodine or an
to be administered per minute.
antifungal cream
 Documentation on how many dilators
Nursing Consideration:
and sponges were place are important.
1. When administering the infusion, “piggyback”
3. Application of prostaglandin gel, such as
the oxytocin solution to a maintenance IV
misoprostol
solution such as LRS.
 interior surface of the cervix by a
2. Always attach the oxytocin solution to the
catheter or suppository
infusion port closest to the woman
 the external surface by applying it to
3. Use an infusion pump to regulate the infusion
a diaphragm and then placing the
rate, so that the rate will not change even if a
diaphragm against the cervix
woman changes position.
 Additional doses may be applied
Administration:
every 6 hours. Two or three doses
 Infusions are usually begun at a rate of 0.5 to 1
are usually adequate to cause
mU/min
ripening
 If there is no response, the infusion is gradually
 SE: vomiting, fever, diarrhea, and
increased every 30 to 60 minutes by small
hypertension
increments of 1 to 2 mU/min until contractions
 Caution: women with asthma, renal
begin
or cardiovascular disease, or
 Many women respond with as little as 4
glaucoma
mU/min; most women respond at 16 mU/min.
 Contraindication: Past CS
 DO NOT INCREASE RATE TO MORE THAN 30
Nursing Interventions:
milliunits/min without checker further
 Bed rest in a side-lying position to
instructions (greater rate of administration can
prevent leakage.
cause tetanic contractions)
 FHR should be monitored
Note: After cervical dilatation reaches 4 cm, artificial
continuously for at least 30 minutes
rupture of the membranes may be performed to further
after each application
induce labor, and the infusion may be discontinued at
 Oxytocin induction may be started 6
that point.
to 12 hours after the last
SE: peripheral vessel dilatation, extreme hypotension,
prostaglandin dose
decreased urine blood flow which leads to water
 Monitor side effects and
intoxications.
hypersensitivity to the medication
Nursing Interventions to SE
INDUCTION OF LABOR BY OXYTOCIN
1. take the woman’s pulse and blood pressure
every 15 minutes

18
 2. Monitor uterine contractions and FHR
conscientiously
Water intoxication- is first manifested by headache and
vomiting. Water intoxication in its most severe form can
lead to seizures, coma, and death because of the large
shift in interstitial tissue fluid.
Nursing Intervention for this includes:
1. If you observe these danger signs in a woman
during induction of labor, report them
immediately and halt the infusion
2. Keep an accurate intake and output record
3. test and record urine specific gravity
throughout oxytocin administration to detect
fluid retention
Contractions should occur no more often than
every 2 minutes, should not be stronger than 50 mm
Hg pressure, and should last no longer than 70
seconds. The resting pressure between contractions
should not exceed 15 mm Hg by monitor.
If contractions become more frequent or longer in
duration than these safe limits, or if signs of fetal
distress occur
 Stop the IV infusion and seek help immediately.
 oxygen administration
 If stopping the oxytocin infusion does not stop
the hyperstimulation, a beta-adrenergic
receptor drug such as terbutaline sulfate
(Brethine) or magnesium sulfate may be
prescribed to decrease myometrial activity
 After birth, observe infant closely for
hyperbilirubinemia and jaundice.
Danger: Excessive stimulation of the uterus by oxytocin
may lead to tonic uterine contractions with fetal death
or rupture of the uterus
AUGMENTATION BY OXYTOCIN
 Precautions regarding oxytocin augmentation
are the same as for primary induction of labor
 A uterus may be very responsive or respond
very effectively to oxytocin
Nursing management:
 Be certain that the drug is increased in small
increments ONLY
 that fetal heart sounds are well monitored
during the procedure
UTERINE RUPTURE
 occurs when a uterus undergoes more strain
than it is capable of sustaining
 occurs when a uterus undergoes more strain
than it is capable of sustaining
 5% of all maternal death
Contributing factors include:
1. Prolonged labor
2. Abnormal presentation
3. Multiple gestation
4. Unwise use of oxytocin
5. Obstructed labor
19
6. Traumatic maneuvers of forceps/tractions.
Note:
 When uterine rupture occurs, fetal death will
follow unless immediate cesarean birth can be
accomplished
Impending rupture may be preceded by a pathologic
retraction ring and by strong uterine contractions
without any cervical dilatation.
Types of Uterine rupture
 Complete (going through the endometrium,
myometrium, and peritoneum layers)
 incomplete (leaving the peritoneum intact)
Assessment
 Severe pain during labor contractions (Report of
tearing sensations)
With a complete rupture, uterine contractions will
immediately stop. Two distinct swellings will be visible:
the retracted uterus and the extrauterine fetus
1. Hemorrhage from the torn uterine arteries
flood
2. Signs of shock begin: including rapid, weak
pulse; falling blood pressure; cold and clammy
skin; and dilatation of the nostrils from air
hunger.
3. Fetal heart sounds fade and then are absent
With incomplete, the signs of rupture are less evident
1. Localized tenderness and a persistent aching
pain over the area of the lower uterine
segment.
2. fetal heart sounds, a lack of contractions, and
the changes in the woman’s VS will gradually
reveal fetal and maternal distress
3. confirmed by ultrasound
Therapeutic Management
1. Administer emergency fluid replacement
therapy as ordered.
2. Anticipate use of IV oxytocin to attempt to
contract the uterus and minimize bleeding.
3. Prepare the woman for a possible laparotomy
as an emergency measure to control bleeding
and achieve a repair
Fetal Prognosis depends on the extent of the rupture
and the time elapsed between rupture and abdominal
extraction
Maternal Prognosis depends on the extent of the
rupture and the blood loss
4. Advised not to conceive again after a rupture of
the uterus, unless the rupture occurred in the
inactive lower segment.
5. Perform a cesarean hysterectomy (removal of
the damaged uterus) or tubal ligation at the
time of the laparotomy; both procedures result
in loss of childbearing ability (WITH CONSENT)
Additional Nursing Interventions:
1. offer information to the support person and to
inform him or her about fetal outcome
2. Allow them time to express these emotions
without feeling threatened.
 3. Explaining to them about the death of the fetus
is very difficult; utilize clergy or counselors as
needed to help begin the coping process
INVERSION OF THE UTERUS- refers to the uterus
turning inside out with either birth of the fetus or
delivery of the placenta
 occurring in about 1 in 20,000 births
Causes:
1. tractions is applied to the umbilical cord
2. Pressure is applied to the uterine fundus when
uterus is not contracted.
3. Placenta is attached to the fundus
Assessment
1. Large amounts of blood suddenly gush
2. Fundus is not palpable in the abdomen
3. If blood loss continues; hypotension, dizziness,
paleness and diaphoresis
4. Exsanguination may occur within 10 minutes.
Therapeutic 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. administration of an oxytocic drug (oxytocin)
only compounds the inversion or makes the
uterus more tense and difficult to replace and
as such should be discontinued
4. IV fluid line needs to be started, if one is not
already present (use a large-gauge needle,
because blood will need to be replaced)
5. Administer oxygen by mask, and assess vital
signs. Be prepared to perform cardiopulmonary
resuscitation (CPR)
6. The woman will immediately be given general
anesthesia or possibly nitroglycerin or a
tocolytic drug intravenously, to relax the uterus
7. The physician or nurse, midwife then replaces
the fundus manually.
8. Antibiotic therapy to prevent infection.
AMNIOTIC FLUID EMBOLISM- occurs when amniotic
fluid is forced into an open maternal uterine blood sinus
through some defect in the membranes or after
membrane rupture or partial premature separation of
the placenta.
Cause of symptoms: humoral or anaphylactooid
response to amniotic fluid in the maternal circulation.
 This condition may occur during labor or in the
postpartal period.
 The incidence is about 1 in 20,000 births;
It is not preventable because it cannot be predicted.
Risk factors:
 oxytocin administration
 induction of labor
 multiple pregnancy
 abruptio placentae
 hydramnios
Assessment
20
1. suddenly and grasps her chest because of sharp
pain
2. inability to breathe as she experiences
pulmonary artery constriction
3. pale
4. turns the typical bluish gray
Therapeutic Management
1. O2 administration by face mask or cannula.
2. She will need CPR however CPR may be
ineffective, (inflating the lungs and massaging
the heart)
Note: CPR does NOT relieve the pulmonary constriction.
Therefore, blood still cannot circulate to the lungs.
Death may occur within minutes. Prognosis depends on
the size of the embolism, the speed with which the
emergency condition was detected, and the skill and
speed of emergency interventions
If the woman survives the initial insult, the risk for
disseminated intravascular coagulation (DIC)
 she will need continued management that
includes endotracheal intubation to maintain
pulmonary function
 therapy with fibrinogen to counteract DIC
The prognosis for the fetus is guarded, because reduced
placental perfusion results from the severe drop in
maternal blood pressure. Labor often begins or the
fetus is born immediately by cesarean birth
PROBLEMS WITH THE PASSENGER
PROLAPSE OF THE UMBILICAL CORD- a loop of the
umbilical cord slips down in front of the presenting fetal
part.
 incidence is about 0.5% of cephalic births
 15-20% in breech or transverse lie
It tend to occur with:
 PROM
 Fetal presentation other than cephalic
 Placenta previa
 Intrauterine tumors preventing the presenting
part from engaging
 Small fetus
 CPD
 Hydramnios
 Multiple gestation
Assessment
1. may be felt as the presenting part on an initial
vaginal examination
2. ultrasound
3. Cord prolapse is only first discovered only when
after the membranes have ruptured, when FHR
is invariably slow or variable deceleration
4. On inspection, cord is visible in the vulva
Note: To rule out cord prolapse, always assess fetal
heart sounds immediately after rupture of the
membranes
Therapeutic Management
Note: Cord prolapse automatically leads to cord
compression, because the fetal presenting part presses
against the cord at the pelvic brim and as such decrease
oxygenation of the fetus.
Management is aimed at relieving pressure on
the cord, thereby relieving the compression and the
resulting fetal anoxia
1. Placing a gloved hand in the vagina and
manually elevating the fetal head off the cord.
2. By placing the woman in a knee–chest or
Trendelenburg position, which causes the fetal
head to fall back from the cord.
3. Administering oxygen at 10 L/min by face mask
to the woman is also helpful to improve
oxygenation to the fetus.
4. A tocolytic agent may be prescribed to reduce
uterine activity and pressure on the fetus.
5. Cover any exposed portion with a sterile saline
compress to prevent drying. DO NOT attempt to
push any exposed cord back into the vagina.
This may add to the compression by causing
knotting or kinking
6. If dilatation is incomplete, the birth method of
choice is upward pressure on the presenting
part, applied by a practitioner’s hand in the
woman’s vagina, to keep pressure off the cord
until the baby can be born by CS.
Amnioinfusion- is the addition of sterile fluid into the
uterus to supplement the amniotic fluid.
 Prevents additional cord compression.
Procedure:
1. Sterile double lumen catheter is introduced
through the cervix into the uterus after rupture
of the membranes.
2. It is attached to intravenous tubing, and a
solution of warmed normal saline or lactated
Ringer’s solution is rapidly infused. Initially,
approximately 500 mL is infused.
Note: to prevent chilling of the woman and fetus. This
can be done by placing the bag of fluid on a radiant
heat warmer or by using a blood/fluid warmer before
administration
3. Throughout the procedure, urge a woman to lie
in a lateral recumbent position to prevent
supine hypotension syndrome.
Note: Help maintain strict aseptic technique during
insertion and while caring for the catheter.
4. Continuously monitor FHR and uterine
contractions internally during the infusion.
5. Record maternal temperature hourly to detect
infection.
6. Change her bed frequently.
7. Also assess that there is constant drainage.
Note: If vaginal leakage should stop, it usually means
that the fetal head is firmly engaged and all fluid being
infused is being held in the uterus. This can lead to
polyhydramnios and uterine rupture.
21
Fetal Blood Sampling- The oxygen saturation, partial
pressures of oxygen (PO2) and carbon dioxide (PCO2),
pH, bicarbonate excess, and hematocrit of fetal blood
may all be determined during labor if a sample of
capillary blood is taken from the fetal scalp as it
presents at the dilated cervix.
Procedure:
1. After cervical dilatation of 3 to 4 cm and rupture
of the membranes, the fetal head is visualized
by the use of an amnioscope
2. The scalp is cleaned with povidone-iodine and
sprayed with silicon
3. A small scalpel is introduced vaginally into the
cervix, and the fetal scalp is nicked
4. The silicon causes blood to form in beads, which
are caught by a capillary tube.
5. The incision is then compressed until the
bleeding has stopped
6. After the procedure, the woman must be
observed after two or three contractions to be
certain that no new fetal scalp bleeding occur.
Conditions:
 If the fetus is hypoxic, the pH will fall (become
acidotic). A scalp blood pH greater than 7.25 is
considered normal for a fetus during labor. A
pH between 7.21 and 7.25 should be
remeasured in 30 minutes.
 A scalp blood pH lower than 7.20 is acidotic and
signifies a level of fetal distress.
Note: Fetal blood sampling involves no pain for the
woman, but it may involve an uncomfortable sensation
of pressure because of the examining hand in the
vagina.
MUTIPLE GESTATION
 Pregnancies of two or more fetuses
 Twins may be born by cesarean birth to
decrease the risk that the second fetus will
experience anoxia
 Multiple gestations of three or more, because
of the increased incidence of cord
entanglement and premature separation of the
placenta
Multiple gestation also increases the chance of:
1. Anemia
2. PIH
The Birthing process:
1. instructed to come to the hospital early in labor
2. Urge the woman to spend the early hours of
labor engaged in an activity such as playing
cards or reading, to make the time pass more
quickly
3. Multiple pregnancies often end before full
term, the early hours of labor can be practice
for breathing exercises.
4. During labor, support the woman’s breathing
exercises to minimize the need for analgesia or
anesthesia
5. 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
Common Complications:
 abnormal fetal presentation
 Uterine dysfunction from a long labor
 overstretched uterus
 unusual presentation
 premature separation of the placenta after the
birth of the first child
Most twin pregnancies present
1. both vertex
2. vertex and breech
3. breech and vertex
4. breech and breech
After the first infant is born, both ends of the baby’s
cord are tied or clamped permanently, rather than with
cord clamps, which could slip
Rationale: this prevents hemorrhage through an open
cord end if additional infants have shared the placenta.
 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
 If the infant will be born vaginally, an oxytocin
infusion may be begun at this point to assist
uterine contractions, thereby shortening the
time span between births.
 If uterine relaxation is needed, nitroglycerin, a
uterine relaxant, may be administered.
Caution: the placenta of the first infant separates before
the second fetus is born, and there is sudden, profuse
bleeding at the vagina. This creates a risk for the
woman. The uterus cannot contract as it normally
would, because it is still full with the second twin, so it is
difficult to halt the bleeding
Postpartal period:
1. Assess the woman carefully in the immediate
postpartal period, because the uterus that has
been overly distended owing to the multiple
gestation may have more difficulty contracting
than usual
2. Assess since this condition places her at risk for
hemorrhage from uterine atony (lacking normal
tone)
3. infants need careful assessment to determine
their true gestational age and whether a
phenomenon such as twin-to-twin transfusion
could have occurred
PROBLEMS WITH FETAL POSITION,
PRESENTATION, OR SIZE
OCCIPITOPOSTERIOR POSITION
22
In approximately one tenth of all labors, the fetal
position is posterior rather than anterior. That is, the
occiput (assuming the presentation is vertex) is directed
diagonally and posteriorly, either to the right (ROP) or
to the left (LOP).
 In these positions, during the fetal internal
rotation , fetal head rotates through a 135º
 Rotation can be aided by having the woman
assume a hands and knees position, squatting,
or lying on her side (left side for ROP, right side
for ROP)
 Shifting the weight form right to left or
“lunging” or swinging her body right to left
while elevating her left foot on a chair widens
the pelvic path and make rotation easier. (not
evidence based)
 Posterior positions tend to occur in women
with android, anthropoid or contracted
pelvises.
 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
 A posteriorly presenting head DOES NOT fit
the cervix as snugly as one in an anterior
position.
Note: Increases the risk of umbilical cord prolapse,
the position of the fetus is confirmed by vaginal
examination or by ultrasound.
 Because the fetal head rotates against the
sacrum, a woman may experience pressure
and pain in her lower back (owing to sacral
nerve compression)
Nursing Interventions for PRESSURE AND PAIN
1. Applying counterpressure on the sacrum by a
back rub may be helpful in relieving a portion of
the pain.
2. Applying heat or cold, whichever feels best, also
may help.
3. Lying on the side opposite the fetal back or
maintaining a hands-and-knees position may
help the fetus rotate
During Labor process
1. be certain a woman voids approximately every
2 hours to keep her bladder empty
2. she may need an oral sports drink or IV glucose
solution to replace glucose stores used for
energy
In these instances, the fetus must be born by cesarean
birth.
 If contractions are ineffective
 if the fetus is larger than average or not
in good flexion, rotation through the
135- degree arc may not be possible
 rotation may not occur at all (persistent
occipitoposterior position
3. Provide frequent reassurance that, although
their pattern of labor is not “textbook,” it is
within safe, controlled limits.
 4. If forceps are used to help the fetus rotate, this
places a woman at risk for cervical lacerations,
hemorrhage, and infection in the postpartum
period
BREECH PRESENTATION
 Most fetuses are in a breech presentation early
in pregnancy. However, by week 38, a fetus
normally turns to a cephalic presentation
 Although the fetal head is the widest single
diameter, the fetus’s buttocks (breech), plus the
legs, actually take up more space
 The fact that the fundus is the largest part of
the uterus this results in approximately 97% of
all pregnancies, the fetus turns so that the
buttocks and lower extremities are in the
fundus.
Types of breech presentations:
1. Complete
2. Frank
3. Footling
Causes of breech presentation
1. Gestational age less than 40 weeks
2. Abnormality in a fetus such as anencephaly,
hydrocephalus or meningocele.
3. Hydramnios
4. Congenital anomaly of the uterus such as mid
septum
5. Any space-occupying mass in the pelvis
6. Pendulous abdomen
7. Multiple gestations
8. Unknown factors
Breech presentation is more hazardous to a fetus than a
cephalic presentation, because there is a higher risk of:
 Anoxia from cord prolapse
 Traumatic injury to aftercoming head
 Fracture in the spine or arm
 Dysfunctional labor
 Early rupture of membranes.
The inevitable contraction of the fetal buttocks from
cervical pressure often causes meconium to be
extruded into the amniotic fluid before birth.
Assessment
1. Fetal heart sounds usually are heard high in the
abdomen.
2. Leopold’s maneuvers and a vaginal
examination usually reveal the presentation.
Note: If the breech is complete and firmly engaged, the
tightly stretched gluteal muscles of the fetus may be
mistaken on vaginal examination for a head
3. If the presentation is unclear, ultrasound clearly
confirms a breech presentation.
4. Always monitor FHR and uterine contractions
continuously, if possible, during this time.
Birthing Techniques:
1. As the breech spontaneously emerges from the
birth canal, it is steadied and supported by a
sterile towel held against the infant’s inferior
surface
23
2. If they are not born readily, the arm of the
posterior shoulder may be drawn down by
passing two fingers over the infant’s shoulder
and down the arm to the elbow, then sweeping
the flexed arm across the infant’s face and
chest and out.
3. The other arm is delivered in the same way
4. To aid in birth of the head, the trunk of the
infant is usually straddled over the physician’s
right forearm
5. Two fingers of the physician’s right hand are
placed in the infant’s mouth.
6. The left hand is slid into the woman’s vagina,
palm down, along the infant’s back. Pressure is
applied to the occiput to flex the head fully
7. Gentle traction applied to the shoulders
(upward and outward) delivers the head. An
aftercoming head may also be delivered by the
aid of Piper forceps to control flexion and the
rate of descent
Note: The difficulty with birth of the head is the reason
why planned cesarean birth is the usual method of
birth for many breech-presentation infants today
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
 A second danger of a breech birth is
intracranial hemorrhage. The infant who is
born suddenly to reduce the duration of cord
compression may suffer an intracranial
hemorrhage. In contrast, the infant who is born
gradually to reduce the possibility of
intracranial injury may suffer hypoxia
Newborns observations:
 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.
FACE PRESENTATION
 A fetal head presenting at a different angle than
expected is termed asynclitism.
 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.
 A fetus in a posterior position, instead of flexing
the head as labor proceeds, may extend the
head, resulting in a face presentation; this
usually occurs in a woman with a contracted
pelvis or placenta previa
It also may occur:
 Relaxed uterus of a multipara
 Prematurity
 Hydramnios
  fetal malformation
Characteristics of Fetal presentation under assessment:
1. A head that feels more prominent than normal,
with no engagement apparent on Leopold’s
maneuvers, suggests a face presentation.
2. It is also suggested when the head and back are
both felt on the same side of the uterus with
Leopold’s maneuvers
3. The back is concave in this presentation
4. Fetal heart tones may be transmitted to the
forward-thrust chest and heard on the side of
the fetus where feet and arms can be palpated.
5. A face presentation is confirmed by vaginal
examination when the nose, mouth, or chin
can be felt as the presenting part
6. an ultrasound is done to confirm it; if indicated,
the pelvic diameters are measured
Conditions:
 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
After Birth Assessment:
1. Babies born after a face presentation have a
great deal of facial edema and may be purple
from ecchymotic bruising
2. Observe the infant closely for a patent airway.
3. In some infants, lip edema is so severe that
they are unable to suck for a day or two
(transient and will disappear in a few days, with
no aftermath)
Nursing Intervention: Gavage feedings may be
necessary to allow them to obtain enough fluid until
they can suck effectively.
BROW PRESENTATION
 A brow presentation is the rarest of the
presentations.
 It occurs in a multipara or a woman with
relaxed abdominal muscles
 It almost invariably results in obstructed labor,
because the head becomes jammed in the brim
of the pelvis as the occipitomental diameter
presents
 CS may be necessary
 May lead to extreme ecchymotic bruising (over
the same areas as the anterior fontanelle or soft
spots)
TRANSVERSE LIE
Occurs in women with:
1. pendulous abdomens
2. uterine fibroid tumors
3. congenital abnormalities of the uterus
4. hydramnios
5. hydrocephalus
24
6. and other abnormalities that prevent the head
from engaging
7. prematurity
8. short umbilical cord
9. multiple gestation
Assessment:
1. Inspection: the ovoid of the uterus is found to
be more horizontal than vertical.
2. Leopold’s maneuver
3. US: confirm the abnormal lie and to provide
information on pelvic size
Birthing Technique-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. CS birth is necessary
OVERSIZED FETUS/ MARCROSOMIA
 Size may become a problem in a fetus who
weighs more than 4000 to 4500 g
(approximately 9 to 10 lb.)
 most frequently born to women who enter
pregnancy with diabetes or develop gestational
diabetes
 Large babies are also associated with
multiparity
 may cause uterine dysfunction during labor or
at birth because of overstretching of the fibers
of the myometrium
 Widen shoulders may cause fetal disproportion
or even uterine
 If the infant is so oversized that he or she
cannot be born vaginally, cesarean birth
becomes the birth method of choice.
Note: The large size of a fetus may be missed in an
obese woman, because the fetal contours are difficult
to palpate and obesity does not necessarily indicate a
larger-than-usual pelvis.
Diagnostic Procedure: Pelvimetry or ultrasound can be
used to compare the size of the fetus with the woman’s
pelvic capacity
Complications for large infants:
1. Risk for cerebral palsy
2. Diaphragmatic nerve injury
3. Fracture clavicle
Complications for Women with large infants
1. Risk for hemorrhage
SHOULDER DYSTOCIA -is a birth problem that is
increasing in incidence along with the increasing
average weight of newborns.
 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
 hazardous to the woman because it can result
in vaginal or cervical tears
 hazardous to the fetus if the cord is compressed
between the fetal body and the bony pelvis
  Force of birth can result in a fractured clavicle
or a brachial plexus injury for the fetus.
Risk Factor: most likely to occur in women
1. Diabetes
2. Multiple paras
3. Post-date pregnancy
Note: The problem often is not identified until the head
has already been born and the wide anterior shoulder
locks beneath the symphysis pubis
Assessment:
1. suspected earlier if the second stage of labor is
prolonged, if there is arrest of descent
2. if, when the head appears on the perineum
(crowning), it retracts instead of protruding
with each contraction (a turtle sign)
Management:
1. Asking a woman to flex her thighs sharply on
her abdomen (McRobert’s maneuver) may
widen the pelvic outlet and allow the anterior
shoulder to be born.
2. Applying suprapubic pressure may also help the
shoulder escape from beneath the symphysis
pubis and be born.
FETAL ANOMALIES- Fetal anomalies of the head such as
hydrocephalus (fluid-filled ventricles) or anencephaly
(absence of the cranium) can also complicate birth
because the fetal presenting part does not engage the
cervix well.
PROBLEMS WITH THE PASSAGE
INLET CONTRACTIONS- narrowing of the
anteroposterior diameter to less than 11 cm, or of the
transverse diameter to 12 cm or less.
Cause: Rickets or inherited small pelvis
 In primigravidas, the fetal head normally
engages between weeks 36 to 38 of pregnancy.
If this occurs before labor begins, it is proof that
the pelvic inlet is adequate
 If engagement does not occur in a primigravida,
then either a fetal abnormality (larger-than-
usual head) or a pelvic abnormality (smaller-
than-usual pelvis) should be suspected
 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. If 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. (This is the
distance between the ischial tuberosities)
25
 A measurement that is easy to make during a
prenatal visit, so the narrow diameter can be
anticipated before labor begins.
 It is also easily reassessed during labor
TRIAL LABOR
 continues as long as descent of the presenting
part and dilatation of the cervix continue to
occur
Nursing Management
1. Monitor fetal heart sounds and uterine
contractions continuously
2. Urge the woman to void every 2 hours so that
her urinary bladder is as empty as possible
3. After rupture of the membranes, assess FHR
carefully
4. If the fetal head is still high, there is an
increased danger of prolapsed cord and anoxia
to the fetus.
5. 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.
6. Emphasize, but do not overstress, that it is best
for their baby to be born vaginally.
7. If the trial labor fails and cesarean birth is
scheduled, provide an explanation about why
cesarean birth is necessary and now is the best
route for the birth of their baby
8. provide an explanation about why cesarean
birth is necessary and now is the best route for
the birth of their baby
9. You can assure a woman and her support
person that a cesarean birth will be an
alternative, not an inferior, method of birth for
them.
EXTERNAL CEPHALIC VERSION
 is the turning of a fetus from a breech to a
cephalic position before birth
 It may be done as early as 34 to 35 weeks,
although the usual time is 37 to 38 weeks of
pregnancy.
Procedure:
1. FHR and possibly ultrasound are recorded
continuously
2. A tocolytic agent may be administered to help
relax the uterus
3. The breech and vertex of the fetus are located
and grasped transabdominally by the
examiner’s hands on the woman’s abdomen
4. Gentle pressure is then exerted to rotate the
fetus in a forward direction to a cephalic lie
Contraindications to this procedure include:
 Multiple gestation
 Serve Oligohydramnios
Contraindication to vaginal birth
 Nuchal Cord
 Unexplained 3rd trimester bleeding
 Placenta previa
Note: Can be uncomfortable because of the feeling
pressure. Women who are Rh (-) receive Rh
immunoglobulin after the procedure.
FORCEPS BIRTH
 Obstetrical forceps are steel instruments
constructed of two blades that slide together at
their shaft to form a handle.
 A forceps birth is a forceps outlet procedure in
which the forceps are applied after the fetal
head reaches the perineum
 low forceps birth (head is at a 2 station or
more)
 midforceps birth (less than 2 station)
PROCEDURE:
1. One blade is slipped into the woman’s vagina
next to the fetal head, and then the other is
slipped into place on the other side of the head.
2. Next, the shafts of the instrument are brought
together in the midline to form the handle.
3. The physician then applies pressure on the
handle to manually extract the fetus from the
birth canal.
Complications/Effects of the procedure:
1. Rectal sphincter tear
2. Dyspareunia
3. Incontinence
4. Stress urinary incontinence
Forceps may be necessary, however, if any of the
following conditions occur:
 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
Note: the pressure registers on the steel blades rather
than the head so they actually reduce pressure. This
avoids subdural hemorrhage in a fetus as the fetal head
reaches the perineum.
 A pudendal block, is necessary for forceps
application to achieve pelvic relaxation and
reduce pain.
 Usually, an episiotomy is performed to prevent
perineal tearing due to pressure on the
perineum.
Before the forceps are applied.
 Membranes must be ruptured.
 CPD must not be present.
 The cervix must be fully dilated.
 The woman’s bladder must be empty.
Nursing Management
1. Record FHR before forceps application
26
Rationale: there is a danger that the cord could be
compressed between the forceps blade and the fetal
head
2. assess FHR again immediately after application
3. Record the time and amount of the first voiding
Rationale: to rule out bladder injury
4. Assess the newborn to be certain that no facial
palsy or subdural hematoma exist.
Note: A forceps birth may leave a transient
erythematous mark on the newborn’s cheek. This mark
will fade in 1 to 2 days with no long-term effects.
ANOMALIES OF THE PLACENTA AND
CORD
ANOMALIES OF THE PLACENTA
• The normal placenta weighs approximately 500
g and is 15 to 20 cm in diameter and 1.5 to 3.0
cm thick. Its weight is approximately 1/6 that of
the fetus.
• A placenta may be unusually enlarged in
women with diabetes.
• In certain diseases, such as syphilis or
erythroblastosis, the placenta may be so large
that it weighs half as much as the fetus.
• If the uterus has scars or a septum, the placenta
may be wide in diameter because it was forced
to spread out to find implantation space.
PLACENTA SUCCENTURIATA
• is a placenta that has one or more accessory
lobes connected to the main placenta by blood
vessels
• No fetal abnormality is associated with this,
important that it be recognized, because the
small lobes may be retained in the uterus after
birth, leading to severe maternal hemorrhage.
INSPECTION: the placenta appears torn at the edge, or
torn blood vessels extend beyond the edge of the
placenta. The remaining lobes are removed from the
uterus manually to prevent maternal hemorrhage from
poor uterine contraction.
PLACENTA CIRCUMVALLATA- the fetal side of the
placenta is covered to some extent with chorion.
Normal: no chorion covers the fetal side of the placenta
• The umbilical cord enters the placenta at the
usual midpoint, and large vessels spread out
from there.
• They end abruptly at the point where the
chorion folds back onto the surface, however
PLACENTA MAGINATA- the fold of chorion reaches just
to the edge of the placenta.
BATTLEDORE PLACENTA- the cord is inserted marginally
rather than centrally. This anomaly is rare and has no
known clinical significance either.
VELAMENTOUS INSERTION OF THE CORD- is a situation
in which the cord, instead of entering the placenta
directly, separates into small vessels that reach the
placenta by spreading across a fold of amnion.
• This form of cord insertion is most frequently
found with multiple gestation.
• Because it may be associated with fetal
anomalies, an infant born with this type of
placenta should be examined carefully
VASA PREVIA - the umbilical vessels of a velamentous
cord insertion cross the cervical os and therefore deliver
before the fetus
• may tear with cervical dilatation, just as a
placenta previa may tear
• 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.
• If sudden, painless bleeding occurs with the
beginning of cervical dilatation, either placenta
previa or vasa previa is suspected.
Note: It can be confirmed by ultrasound. If vasa previa
is identified, the infant needs to be born by cesarean
birth.
PLACENTA ACCRETA- is an unusually deep attachment
of the placenta to the uterine myometrium so deeply
the placenta will not loosen and deliver
• may lead to extreme hemorrhage because of
the deep attachment
• Hysterectomy or treatment with methotrexate
to destroy the still-attached tissue
ANOMALIES OF THE CORD
TWO-VESSEL CORD- The absence of one of the
umbilical arteries is associated with congenital heart
and kidney anomalies, because the insult that caused
the loss of the vessel may have affected other
mesoderm germ layer structures as well
• Inspection of the cord as to how many vessels
are present must be made immediately after
birth, before the cord begins to dry, because
drying distorts the appearance of the vessels.
• Document the number of vessels present
conscientiously.
Note: An infant with only two vessels needs to be
observed carefully for other anomalies during the
newborn period.
UNUSUAL CORD LENGTH
 An unusually short umbilical cord can result in
premature separation of the placenta or an
abnormal fetal lie.
 An unusually long cord may be easily
compromised because of its tendency to twist
or knot
 A cord actually forms a knot, but the natural
pulsations of the blood through the vessels and
27
the muscular vessel walls usually keep the
blood flow adequate.
 It is not unusual for a cord to wrap once around
the fetal neck (nuchal cord) but, again, with no
interference to fetal circulation
POSTPARTUM HEMORRHAGE
Hemorrhage
 Is one of the primary causes of maternal
mortality associated with childbearing
 POSTPARTUM HEMORRHAGEE – defined as the
blood loss of more than 500 ml or more
following vaginal birth.
 Occurs in 5-15% of postpartal woman
 In CS: hemorrhage is defined as blood loss of
more than 1000 ml or 10 % decrease in
hematocrit level.
 May occur in early (within 24 hours ff. birth) or
late (24 hours to 6 weeks after birth)
 GREATEST DANGER IS IN THE FIRST 24 HOURS
because of the grossly denuded and
unprotected uterine area left after detachment
of the placenta
FOUR MAIN REASONS FOR POSTPARTUM
HEMORRHAGE
1. UTERINE ATONY
2. TRAUMA (lacerations, hematomas, uterine
inversion, uterine rupture
3. RETAINED PLACENTAL FRAGMENT
4. DISSEMINATED INSTRVASCULAR COAGULATION
OR DIC
Note: Generally referred to as the four T’s of
postpartum: Tone, trauma, tissue, and thrombin
UTERINE ATONY – or the relaxation of the uterus, is the
most frequent cause of postpartum hemorrhage.
Conditions that increases a woman’s risk for a
postpartal hemorrhage:
1. Conditions that distend the uterus beyond
average capacity: multiple gestation,
polyhydramnios, a large baby (>9 Ibs) and the
presence of uterine myomas ( fibroid tumors)
2. Conditions that could have cause uterine
lacerations: an operative birth, a rapid birth.
3. Conditions with varied placental site or
attachment: placenta previa, placenta accreta,
premature rupture of the placenta, retained
placental fragments.
4. Conditions that leave the uterus unable to
contract readily: deep anesthesia or analgesia,
labor initiated or assisted oxytocin agent, high
parity or high maternal age of over 35 years of
age, previous uterine surgery, prolonged or
difficult labor, chorioamnionitis or
endometritis secondary to maternal illness
 such as anemia, prior history of postpartum
hemorrhage, prolonged use of MgSO4 or other
tocolytic agent.
5. Conditions that lead to inadequate blood
coagulation: fetal death and DIC.
Therapeutic Management:
1. Attempt fundal massage to encourage
contraction usually effective in causing
contractions and after a few seconds the uterus
assumes its health grape-fruit like feel
Note: problem may not be completely resolved, as
soon as you remove you hand from the fundus the
uterus may relax and the lethal seepage will begin
again.
2. Remain with woman after massaging the fundus
and continue to assess carefully for the next 4
hours.
3. If the uterus does not remain in contracted,
administer a bolus or dilute IV infusion of
oxytocin (Pitocin)
Note: be aware, that oxytocin has a short duration of
action, approximately 1 hour so symptoms of uterine
atony can occur quickly.
4. If oxytocin is ineffective at maintaining tone:
 Carboprost tromethamine (hemebate)
every 15-90 minutes up to 8 doses.
 Methylergonovine maleate (methergine) a
prostaglandin F2a derivative maybe
repeated every 2-4 hours up to 5 doses.
 Misoprostol (cytotec), a prostaglandin E1
analogue, may also be administered rectally
to decrease postpartum hemorrhage.
Second doses should not be administered
unless minimum of 2 hours has elapsed.
Note:
Prostaglandin side effects: nausea and diarrhea, assess
after administration, some may need to be
administered with antiemetic to limit these SE.
ALL OF THESE MEDICATIONS (mentioned above) can
increase blood pressure and must be USED CAUTIOSLY
in women with hypertension. Assess BP prior to
administration and q15 minutes afterwards.
5. Elevate a woman’s lower extremities
6. Offer bedpan or assist a woman to the
bathroom every 4 hours to be certain her
bladder is emptying (full bladder predisposes a
woman to uterine atony)
7. Administer oxygen mask at a rate of 10-12/L
minute if woman is experiencing respiratory
distress from decreasing BV. POSITION HER
SUPINE OR FLAT
8. Obtain VS frequently and assess for trends such
as continuously decreasing BV with rising PR.
Bimanual Compression – after a sonogram is done to
determine or detect possible retained placental
28
fragments, the woman primary health care provider
may attempt bimanual compression.
 Insets one hand into the vagina while pushing it
against the fundus through the abdominal wall
with the other hand.
 A balloon catheter may be introduced vaginally
and inflated with sterile water until it puts
pressure on bleeding site
 Vaginal packing is inserted during this
procedure to stabilize placement of the balloon.
 Document the presence and note the number
of the packing so it can be removed before
agency discharge.
Blood replacement
 Replace blood loss with postpartal hemorrhage
is often necessary.
 BT and cross matching is done when a woman
is admitted to labor.
 Iron therapy may be prescribed to ensure good
hemoglobin formation
Note: Extensive blood loss is a precursor to postpartal
infection.
 Observe any woman who has experienced more
than normal blood loss for changes such as
scant or odorous lochia discharge
 Monitor temperature closely in the postpartal
period to detect the earliest sign of developing
infection.
Hysterectomy or Suturing
 With extreme bleeding embolization of the
pelvic and uterine vessels by angiographic
techniques may be necessary.
 Ligation of the uterine arteries or hysterectomy
may be necessary.
NURSING DIAGNOSIS
Deficient fluid volume related to blood loss
 May exhibit symptoms of hypovolemic shock
such as failing BP, a rapid weak and thready PR,
increase shallow RR, pale and clammy skin and
increase anxiety
 Counting the number of perineal pads saturated
in given lengths if time, such as half-hour
intervals, a rough estimate of the amount of
blood loss can be formed.
 Be certain when you are counting perineal pads,
you differentiate between saturated and used.
 Weighting perineal pads before and after use
and then subtracting the difference is an
accurate technique to measure vaginal
discharge.
 Always turn the woman on her side when
inspecting for blood.
 Best safeguard against uterine atony is to
palpate a woman’s fundus at frequent intervals
 to be assured her uterus is remaining
contracted.
 Frequent assessment of the lochia as well as VS,
particularly PR and BP.
LACERATIONS – small lacerations or tears of the birth
canal are common and may be considered a normal
consequence of childbearing.
Most common to occur:
1. Primigravida
2. Difficult or precipitate births
3. Birth of a large infant
4. Use of lithotomy position and instruments
Note: ANYTIME THE UTERUS FEELS FIRM BUT
BLEEDING PERSISTS, SUSPECT LACERATION AT ONE
OF THESE THREE SITES CAUSING THE BLEEDING.
Cervical Lacerations- usually found on the sides of the
cervix at the side of the uterine artery
 If the artery is torn, blood loss may be so great
that blood gushes form the vaginal opening
 Brighter than the venous blood lost in uterine
atony
 Ordinarily this bleeding ordinarily occurs
immediately after the detachment of the
placenta.
Therapeutic Management
1. Requires sutures and can be difficult because if
bleeding is intense, this blocks visualization of
the area.
2. Try to maintain an air of calm and if possible,
stand beside a woman at the head of the table.
3. If cervical lacerations appears to be extensive or
difficult to repair, it may be necessary for the
women to be given a regional anesthetic to
relax the uterine muscles and to prevent pain.
Vaginal Lacerations- easier to locate and assess than
cervical lacerations.
Therapeutic Management
Note: vaginal tissues is friable, making vaginal
lacerations difficult to suture.
1. A balloon tapenade may be effective if suturing
does not achieve homeostasis
2. Vagina may be packed to maintain pressure on
the suture lines.
3. Indwelling catheter (Foley catheter) because
packing causes such pressure on the urethra
that it interferes with voiding.
4. Document where, when and how many were
placed so it can be certain to remove after 24-
48 hours.
Perineal Lacerations – are more apt to occur when a
woman is placed in a lithotomy position (lithotomy
position increases the pressure on the perineum)
CLASSIFICATION OF PERINEAL LACERATIONS
29
 FIRST DEGREE- vaginal mucous membrane to
the skin of the perineum to the fourtechette
 SECOND DEGREE- vagina, perineal skin, fascia,
levator ani muscle to the perineal body
 THIRD DEGREE – entire perineum, extending to
the reach of the external sphincter of the
rectum.
 FOURTH DEGREE- entire perineum, rectal
sphincter to the mucous membranes of the
rectum
Therapeutic Management
1. Are sutured and treated the same as episiotomy
repair
2. A diet of high fluid and stool softeners may be
prescribed
3. Any woman who has had 3rd or 4th degree
laceration should NOT HAVE an enema or a
rectal suppository prescribed or have temp.
taken rectally
Note: 4th degree lacerations can lead to long term
dyspareunia, rectal incontinence, or sexual
dissatisfaction.
UTERINE INVERSION - is the prolapse of the fundus of
the uterus through the cervix so that the uterus turns
inside out.
RETAINED PLACENTAL FRAGMENTS
 A placenta does not detach in its entirety;
fragments of it separates and are left still
attached to the uterus.
 Portions retained keeps the uterus from
contracting fully, uterine bleeding occurs.
 MOST LIKELY TO HAPPEN WITH PLACENTA
SUCCENTURIATE. PLACENTA ACCRETA may also
be retained.
 Associated with: Previous CS, In vitro
fertilization
 Occurs at an incidence of 1 out of 3000 births
 Can be identified with US during pregnancy
 Removing deep embedded placenta can lead to
severe postpartal hemorrhage.
 To identify the complications of a retained
placental fragment, every placenta should be
inspected carefully after birth to be certain it is
complete.
 Can be detected by ultrasound
 A blood serum sample that contains hCG
hormone reveals that part of the placenta is still
present.
Assessment
1. Bleeding will be apparent
2. If the fragment is small, bleeding may not be
detected until postpartum day 6-10, when the
woman notices an abrupt discharge and a large
amount of vaginal bleeding
3. On examination, uterus is not fully contracted
Therapeutic Management
 1. D&C to remove the retained placental fragment
2. If cannot be removed METHOTREXATE may be
prescribed to destroy retained placental
fragments.
3. Continue to observe the color of the lochia and
to report any tendency for the discharge to
change form lochia serosa or Alba back to
rubra.
4. In some instances, placenta accreta is deeply
attached that balloon inclusion and
embolization of the internal iliac arteries may
be necessary to minimize blood loss.
Hysterectomy in other cases must also be
performed.
DISSEMINATED INTRAVASCULAR COAGULATION – is
the deficiency of the clotting ability due to vascular
injury.
 May occur in any woman in the postpartal
period
 Associated with PROM, missed early
miscarriage, or fetal death in the utero.
SUBINVOLUTION
 Is the incomplete return of the uterus to its pre
pregnant size and shape
 At 4-6 weeks of postpartal visit, the uterus is
still enlarged and soft.
 Lochia discharge is still present (4-6 weeks
postpartum)
 May result from a: small retained placental
fragment, a mild endometritis, uterine myoma
that is interfering with the contraction
Therapeutic Management
1. Oral administration of Methylergonovine
maleate, 0.2 mg QID/day or daily, is the usually
prescription to improve uterine tone and
complete involution
2. If the uterus feels tender to palpations
suggesting endometritis is present. An oral
ANTIBIOTIC also will be prescribed.
3. Be certain that a woman knows the normal
process of involution and lochia discharge.
4. A chronic loss of blood form subinvolution will
result in anemia and a lack of energy, conditions
that possibly could interfere with infant
bonding or lead to infection.
PERINEAL HEMATOMAS
 Is the collection of blood in the subcutaneous
layer of tissue in perineum
 Are more likely to occur in women with rapid,
spontaneous birth and in women with perineal
varicosities.
 May occur in the site of the episiotomy or
laceration repair if a vein was punctured during
suturing
 Usually represent MINOR BLEEDING
Assessment
30
1. If patient reports any pain in the perineal area
or a feeling of pressure between her legs,
inspect this to see IF A HEMATOMA could be
causing this.
2. Appears in the area as a purplish discoloration
with obvious swelling.
3. A small as 2 cm or as large as 8 cm in diameter
4. It palpates as a firm globe and feels tender
Therapeutic Management
1. Report presence, its estimated size and degree
of discomfort to her primary care provider
2. Describe the definitive size such as “5 cm” or
the size of a quarter etc. rather than
documenting it as “large” or “small”
3. Administer mild analgesics as prescribed for
pain relief
4. Applying an ICE PACK (covered in towel to
prevent thermal injury to the skin) may prevent
further bleeding.
 Usually hematoma is absorbed over the
next 3-4 days
 If one is large and continues to increase
in size, the site is incised and the
bleeding vessel ligated under local
anesthesia.
5. If incision is done, be certain to record the
packed gauze that was placed so it can be
remove in 24 to 48 hours.
6. Be certain woman knows suture line care she
needs to do at home such as keeping it clean
and dry and perhaps using a sitz bath once or
twice a day.
PUERPERAL INFECTIONS
 Infection of the reproductive tract in the
postpartal period is another major cause of
maternal mortality.
 Is always potentially serious because, although
it usually begins only as a local infection, it has
the potential to spread to the peritoneum
(peritonitis) or the circulatory system
(septicemia), conditions that can be fatal in a
woman whose body is already stressed form
childbirth.
CONDITIONS THAT INCREASES A WOMAN’S RISK FOR
POSTPARTAL INFECTION
1. Rupture of the membranes for more than 24
hours before birth
2. Retained placental fragments within the uterus
3. Postpartal hemorrhage
4. Preexisting anemia
5. Prolonged and difficult labor, particularly with
instrument births
6. Internal fetal heart monitoring electrode
7. Local vaginal infection present at the time of
birth
8. Uterus explored after birth for a retained
placenta or abnormal bleeding site.
Note: if infection should occur the prognosis for
complete recovery depends on such factors as the
woman’s general health, virulence of the
microorganism and portal of entry, the degree of
uterine involution at the time of the invasion and the
presence of the laceration of the reproductive tract
Common culture microorganism include:
1. Group B streptococcus
2. Staphylococci
3. Aerobic gram-negative bacilli such as E. coli
NURSING DIAGNOSIS
Risk for infection related to loss of uterine sterility with
child birth
 To prevent infection any articles introduced into
the birth canal during labor, birth and
postpartal period should be sterile.
 Be certain to instruct postpartal woman proper
perineal care
 Use good hand washing technique before,
during and after patient care to prevent cross
contamination.
 Each woman should have her own perineal
supply and should not share.
 Intravenous antibiotics usually are not
prescribed for a postpartal infection. Frequently
used antibiotics include ampicillin, gentamicin,
and third-generation cephalosporin such a
cefixime (suprax)
 If the woman will be continuing therapy at
home, stress that she must take the full course
to prevent the infection to reoccur.
 Alert them to observe for problems with the
infant such as oral candidiasis in the infants
mouth.
 Assess for bruising due to the decrease of Vit. K
producing bacteria in the bowel cause by
antibiotic therapy passed to breast milk.
Social isolation related to precautions necessary to
protect baby and others from exposure to infectious
microorganism.
 The baby of a mother with an increase
temperature (100.4 º F/ 38ºC) for two
consecutive 24-hour period exclusive of the first
24 hours keep in the incubator her room until
the cause of the infection is determined.
 IF THE CAUSE OF THE FEVER IS RELATED TO
CHILD BIRTH AND CLOSE INFECTIONS: there is
no danger of the baby contracting the disease
so the woman may care for her child as long as
she maintains the degree of prescribed bed rest
necessary.
 IF THE INFECTION INVOLVES DRAINAGE:
mother should wash her hands thoroughly
before holding her baby and should avoid
placing the baby on the bottom sheet. Instead
furnish clean sheets for her to spread over her
covers.
31
 If the mother is too ill, the infant should be fed
by a supplementary milk formula. Urge her to
manually express or pump breast milk during
this time to maintain milk production.
ENDOMETRITIS
 Is the infection of the endometrium, the
ling of the uterus
 Infection is usually associated with
chorioamnionitis and a cesarean birth.
Assessment:
1. Fever of endometritis usually manifests itself in
the 3rd and 4th postpartal day
Note: rather than relying on the WBC count to
determine presence of infection (postpartal woman:
20,000-30,000 cells/mm3) Infection is suspected,
instead in postpartal woman who have a temperature
over (100.4 º F/ 38ºC) for 2 consecutive 24 hour period.
2. DO NOT be led astray by attributing an elevated
temperature at this time to breast filling.
3. Chills
4. Loss of appetite
5. General malaise
6. Uterus is not well contracted and painful to
touch (may feel strong after pains)
7. Lochia is dark brown and foul in odor (if
accompanied by fever however, lochia in
contrast may be scant or absent
8. A sonogram may be prescribed to confirm
presence of placental fragment which could be
the possible cause of the infection.
Therapeutic Management
1. Antibiotic such as clindamycin (cleocin) as
determined by the culture (If infection is
limited to the endometrium, the course of the
infection will be about 7-10 days)
2. An oxytocic agent such as Methylergonovine
may also be prescribed to encourage uterine
contraction.
3. Urge woman to drink additional fluids to
combat fever
4. If strong after pains and abdominal discomfort
are present, ask if she need analgesic for pain
relief.
5. Sitting on a semi-fowlers position or walking
encourages lochia drainage by gravity and helps
prevent pooling in infected secretions.
6. Be certain to wear gloves in helping the woman
change her perineal pads and the changing of
bed lines. USE OF HAND WASHING TECHNIQUES
BEFORE AND AFTER HANDLING OF PADS
Note: endometritis is that it can lead to tubal scarring
and interference with future fertility.
INFECTION OF THE PERINEUM
Assessment
1. Pain, heat and feeling of pressure
 2. Elevated temperature may be or not be present
depending upon the systemic effect and the
spread of the infection.
3. Inspection of the suture line will reveal
inflammation
4. Stiches may have slough away, so an area of the
suture lines is open with purulent drainage
present.
Therapeutic Management
1. Either systemic or topical antibiotic is ordered
even before culture report is returned.
2. An analgesic may be prescribed to alleviate
discomfort
3. It may necessary to remove perineal sutures to
open area and allow for drainage.
4. Sitz baths, moist warm compresses, or hubbard
tank treatments may be prescribed to hasten
drainage and cleanse perineal area.
5. Change perineal pads frequently
6. Woman should wipe front to back after
urinating or a bowel movement to prevent
bringing contamination forward to the rectum.
7. Be certain to not place the infant at the bottom
bed sheet of the woman’s bed where the baby
could contact pathogenic bacteria.
8. Encourage the woman to ambulate and ask for
analgesics if needed.
PERITONITIS- or the infection of the peritoneal cavity
that usually occurs as an extension of the endometritis.
 IS ONE OF THE GRAVEST COMPLICATIONS OF
CHILDBEARING AND IS A MAJOR CAUSE OF
DEATH FROM PUERPERAL INFECTION.
 Infection spreads from the uterus into the
lymphatic system or directly through the
fallopian tube into the peritoneal cavity.
 May abscess may be formed form the cul-de-
sac of Douglas (lowest point of the peritoneal
cavity and gravity causes infected material to
localized in this area.
Assessment
1. Rigid abdomen
2. Abdominal pain (usually soft during postpartal
period: occurrence of guarding is one of the first
symptoms of peritonitis)
3. High fever
4. Vomiting
5. Rapid pulse
6. Appearance of acutely ill
Therapeutic Management:
1. Insertion of the NGT to prevent vomiting and to
rest the bowel (peritonitis is accompanied by
paralytic ileus)
2. IVF or TPN will be necessary
3. A woman may need analgesics for pain relief
and intravenous antibiotic to treat infection
32
Note: peritonitis can interfere with future fertility as it
can lead to scarring and adhesions.
THROMBOPHLEBITIS
Phlebitis is the inflammation of the lining of the blood
vessels. Thrombophlebitis is the inflammation with the
formation of blood clots.
 Serves as an extension of endometrial infection
Classified as either:
 SVD (superficial vein disease)
 DVT (deep vein thrombosis)
It tends to occur because:
 A woman’s fibrinogen level is still elevated from
pregnancy, leading to increased blood clotting.
 Dilatation of lower extremity veins is still
present as a result of pressure of the fetal head
during pregnancy and birth.
 The relative inactivity of the period or a
prolonged time spent in delivery or birthing
room stirrups leads to pooling, stasis, and
clotting of blood in the lower extremities.
 Obesity from increased weight before
pregnancy and pregnancy weight gain can lead
to relative inactivity and lack of exercise.
 The woman smokes cigarettes.
Note: Women most prone to thrombophlebitis are
those who are obese, have varicose veins, have had a
previous thrombophlebitis, are older than 35 years of
age with increased parity, or have a high incidence of
thrombophlebitis in their family.
Management
1. Use of good aseptic technique during birth
helps to prevent thrombophlebitis
2. Ambulation and limiting the time a woman
remains in obstetric stirrups encourages
circulation
3. If stirrups of examining or delivery tables are
used, be certain they are well padded, to
prevent any sharp pressure against the calves of
the legs.
4. If a woman had varicose veins during
pregnancy, wearing support stockings for the
first 2 weeks after birth can help increase
venous circulation and prevent stasis.
5. If these are prescribed, be certain a woman
knows to put them on before she rises in the
morning.
Note: If she waits until she is already up and walking,
venous congestion has already occurred and the
stockings are less effective.
6. Urge her to remove the support stockings twice
daily and assess her skin underneath for
mottling or inflammation.
7. An exercise program will also be important in
helping women lose their pregnancy weight.
 Beginning such activities as walking can also be
important
FEMORAL THROMBOPHLEBITIS
 the femoral, saphenous, or popliteal veins are
involved
 Although the inflammation site in
thrombophlebitis is a vein, an accompanying
arterial spasm often occurs, diminishing arterial
circulation to a leg. This decreased circulation,
along with edema, gives the leg a white or
drained appearance.
It was formerly believed that breast milk drained into
the leg, giving it its white appearance. The condition
was, therefore, formerly called milk leg or phlegmasia
alba dolens (“white inflammation”).
Assessment:
1. Elevated temperature, chills, pain, and redness
in the affected leg about 10 days after birth.
2. swell below the lesion at the point at which
venous circulation is blocked
3. Skin becomes so stretched from swelling that it
appears shiny and white.
4. Homans’ sign (pain in the calf of the leg on
dorsiflexion of the foot) may be positive;
Note: a negative Homans’ sign does not rule out
obstruction.
5. The diameter of the leg at thigh or calf level
may be increased compared with the other leg.
6. Doppler ultrasound or contrast venography
usually is ordered to confirm the diagnosis.
Therapeutic Management
1. bed rest with the affected leg elevated
2. Administration of anticoagulants, and
application of moist heat.
3. A bed cradle keeps pressure of the bedclothes
off the affected leg, both to decrease the
sensitivity of the leg and to improve circulation.
4. Provide good back, buttocks, and heel care.
5. Check for bed wrinkles so that a woman does
not develop the secondary problem of a
pressure ulcer while on bed rest.
NEVER MASSAGE THE SKIN OVER THE CLOT; THIS
COULD LOOSEN THE CLOT, CAUSING PULMONORAY OR
CEREBRAL EMBOLISM
6. Heat supplied by a moist, warm compress can
help decrease inflammation.
NOTE: Be certain to test water temperature by dipping
your inner wrist in it before soaking a dressing, to be
sure it is not too warm (because edema decreases
sensation in a woman’s leg, she can burn easily)
7. Always cover wet, warm dressings with a
plastic pad to hold in heat and moisture.
33
8. A commercial pad with circulating heating
coils or chemical hot packs may be positioned
over the plastic to ensure that soaks stay warm.
NOTE: Be certain the weight of a hot pack or pad does
not rest on the leg, causing an obstruction to flow of
blood.
9. Check a woman’s bed frequently when moist
compresses are used, to be certain the mattress
does not become wet from seeping water
10. Helping a woman use her time on bed rest is to
offer reading material about newborns.
11. The pain of thrombophlebitis is usually severe
enough to require administration of an
analgesic.
12. An appropriate antibiotic to reduce the initial
infection is prescribed. Often, an anticoagulant
(coumarin derivative or heparin) or a
thrombolytic agent:
 streptokinase
 Urokinase (is prescribed to dissolve the
clot through the activation of
fibrinolytic precursors and prevent
further clot formation.)
13. Blood coagulation levels to determine the
effectiveness of the drug therapy are measured
daily
NOTE: Depending on the drug prescribed, a baseline
activated partial thromboplastin time (aPTT) or
prothrombin time (PT) is obtained.
MEDICATION:
Heparin, an anticoagulant, can be administered
by continuous intravenous infusion or intermittently by
intravenous or subcutaneous injection
 Be certain she has demonstrated good injection
technique before discharge and understands
the importance of required blood work
(coagulation studies) so that she schedules
these appropriately.
Protamine sulfate, the antagonist for heparin, should
be readily available any time heparin is administered

Breastfeeding:
 A woman can continue to breastfeed while
receiving heparin.
 If she does not wish to breastfeed, she can be
switched to warfarin (an oral coumarin
derivative) before hospital discharge. The
antidote to warfarin is vitamin K.
NOTE: A woman has to discontinue breastfeeding
during therapy with coumarin, because coumarin-
derived anticoagulants are passed in breast milk.
 If the thrombophlebitis does not seem to be
severe and the woman wants to restart
breastfeeding after the course of anticoagulant
(about 10 days)encourage her to manually
express breast milk at the time of normal
feedings, to maintain a good milk supply
Lochia:
 Lochia usually increases in amount in a woman
who is receiving an anticoagulant. Be sure to
keep a meaningful record of the amount of this
discharge so
 assess for other possible signs of bleeding, such
as bleeding gums, ecchymotic spots on the skin,
or oozing from an episiotomy suture line
Note: Women taking anticoagulants are not normally
prescribed salicylic acid (aspirin) for pain, because
salicylic acid prevents blood clotting by preventing
platelet aggregation and clot formation.
With proper treatment, the acute symptoms of
femoral thrombophlebitis last only a few days, but the
full course of the disease takes 4 to 6 weeks before it is
resolved. Anticoagulant therapy may need to be
continued for 3 to 6 months. The affected leg may
never return to its former size and may always cause
discomfort after long periods of standing.
PELVIC THROMBOPHLEBITIS
 involves the ovarian, uterine, or hypogastric
veins
 usually follows a mild endometritis and occurs
later than femoral thrombophlebitis
34
 Often around the 14th or 15th day of the
puerperium.
 Risk factors are the same as for femoral
thrombophlebitis.
Assessment
1. extremely ill, with high fever, chills, and general
malaise
2. It necroses the vein and results in a pelvic
abscess
3. When it becomes systemic it result in a lung,
kidney, or heart valve abscess.
Therapeutic management
1. total bed rest and administration of antibiotics
and anticoagulants
2. Disease runs a long course of 6 to 8 weeks. If an
abscess forms, it can be located by sonogram
and incised by laparotomy
3. Formation of an abscess is associated with a
high mortality rate. A woman may need surgery
to remove the affected vessel before she
attempts to become pregnant again.
4. teach women preventive measures to reduce
the risk of recurrence with future pregnancies:
 not wearing constricting clothing such
as garters or tight stockings on the
lower extremities
 resting with the feet elevated
 ambulating daily during pregnancy
PULMONARY EMBOLUS
 obstruction of the pulmonary artery by a blood
clot; it usually occurs as a complication of
thrombophlebitis
Signs of pulmonary embolus:
1. sudden, sharp chest pain
2. tachypnea; tachycardia
3. orthopnea (inability to breathe except in an
upright position)
4. Cyanosis (the blood clot is obstructing the
pulmonary artery, blocking blood flow to the
lungs and return to the heart).
Considered EMERGENCY SITUATION
Management for Pulmonary Embolus
1. oxygen administered immediately and is at high
risk for cardiopulmonary arrest
2. transferred to an intensive care unit for
continuing care