Group A2-Nursing Care Algorithms (Written Output)

INTRAPARTAL COMPLICATIONS
NCM 110: Nursing Informatics

Nursing Care Algorithms
Group A2
Balbuena, Katya Alexandra S
Gabun, Johncen Brian L
Hamoy, Heaven Khrys T.
Igot, Marvie Raymon R.
Jayson, Ellen Rose O.
Joe, Rinoah Airish P.
Lear, Niekkah Mae P.
Limboy, Roanna Therese G.
Locsin, Aaliyah Bjorn B.
Locsin, Ninna Cherizze M.
Magan, April Pai A.
Oliver, Diamae S.
Osnan, Jasper G.
Pangilinan Carlin Gyandev P.
Rosal, Cromwell Ernest B.
Sabanal, Pauline A.
Samson, Therese Hannah S.
Santana, Caiera Marie D.
Surface, Leila Teresita G.
Tabale, Ivan Joey S.
Tagsip, Anne May G.
Takahashi, Jhanika H.
Villacampa, Meghan Maureen L.
Villamor, Angela Mae C.
Vinluan, TJ Marian S.
Yee, Joshua S.
Date Submitted: March 4, 2022

Submitted to: Dr. Emiliano Suson II
TABLE OF CONTENTS
INTRAPARTAL COMPLICATIONS PAGE NUMBER
Hypertonic Contractions ............................................................................................ 3

Dysfunctional Labor
- 1st stage........................................................................................................... 5
- 2nd stage......................................................................................................... 8
Precipitate Labor........................................................................................................ 10
Uterine Rupture.......................................................................................................... 13
Uterine Inversion........................................................................................................ 16
Amniotic fluid embolism............................................................................................ 18
Preterm Labor............................................................................................................. 21
Premature rupture of membranes.............................................................................24
Post term pregnancy................................................................................................... 27
Fetal Death.................................................................................................................. 29
Prolapse of umbilical cord......................................................................................... 33
Multiple Gestation...................................................................................................... 35
Fetal Anomalies.......................................................................................................... 38
Hydramnios................................................................................................................ 41
Occipito-posterior Presentation................................................................................ 44
Face,breech, brow Presentation................................................................................ 47
Transverse lie.............................................................................................................. 51
Macrosomia............................................................................................................... 54
Shoulder Dystocia...................................................................................................... 57
2
High Risk Mothers
(Hypertonic Contractions)
Simple description about the condition
Hypertonic contractions is when there is a rise in resting tone of greater than

15mmHg occurs more frequently during latent phase of labor.
Assessment
● Interview:
1. Evaluate the degree of dehydration and the amount of intake
2. Ask the patients pain scale from 1-10
3. Client will express that the contraction occurs frequently and painful
● Inspection:
1. Assess for the frequency of uterine contractions and the resting phase
between contractions
2. Monitor for the Vital signs of the mother
3. Assess rupture membrane
4. Assess for pelvis size or shape
● Palpation:
1. Palpating in assessing uterine contractile pattern manually or electronically
via external, or internal monitor with internal uterine pressure catheter
(IUPC).
● Percussion: N/A
● Auscultation:
1. Auscultate the fetal heart rate to confirm that it is not showing late
deceleration.
3
Nursing Care Algorithm Collaborative Nursing Action
Prevention
To avoid birth complications:
1. Apply a uterine and fetal external

monitor to assess the resting phase
between contractions whether they
are enough or not.
2. Frequently monitor fetal status and

auscultate the fetal heart rate to
confirm that it is not showing late
deceleration
Management
1. Administer analgesia as prescribed

by the physician as this promotes
pain relief.
2. Administer oxygen by mouth as this

will help manage breathing during
labor.
3. Discontinue the use of oxytocin.

4. Provide comfort measures.
References and Resources
Belleza, R. M. N. (2021, April 22). Care of the Woman with Complications during Labor.
Nurseslabs. Retrieved February 27, 2022, from
https://nurseslabs.com/care-woman-complications-labor/#:%7E:text=Hypertonic%20co
ntractions%20are%20marked%20by,techniques%20because%20they%20are%20ineffe
ctive.
Uterine Contractions’ Pattern in Active Phase of Labor as a Predictor of Failure to Progress .

(2014, March 24). NCBI. Retrieved March 1, 2022, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4825395/
4
High Risk Mothers
(Dysfunctional Labor 1st Stage )
Dysfunctional or prolonged labor refers to a labor that lasts longer in the latent,
protracted active phases, prolonged deceleration phases and secondary arrest of dilation.
This is usually in the first stage.
Assessment
● Interview
1. Ask for the expected due date
2. When was the first contractions begin
3. Past and present pregnancy record
4. Obtain information about the patient’s health and medical history
5. For her current pregnancy ask about the gravida, and parity status
6. Ask the patient’s pain scale
● Inspection
1. Inspect the patients if any underlying abnormalities in uterine contractions,
inability to forcibly expel the fetus because of its size and/or an unusual
orientation of the fetus in the uterus, or abnormalities in the pelvis such as a
blocked or too small passage
2. Inspect the conjunctiva of the eyes and also the mucous membranes of her
mouth to see paleness that suggests anemia
3. Abdominal inspection using leopold’s maneuver
4. Presence of vaginal bleeding
5. Signs of maternal distress
● Palpation
1. Palpate if the fetus is usually large and unable to pass through the birth canal.
or the fetus is positioned incorrectly
2. Assess the mother’s abdomen to know the fundal height
3. Palpate the bladder area to identify if the patient is full bladder
● Percussion
1. Percuss the bladder area to identify if the patient is full bladder
● Auscultation
1. Auscultate the mother’s abdomen to know the fetal heart tone of the fetus
2. Auscultate for the mother’s heart rate
5
Prevention
1. Encourage the use of trained labor

support companions, delay hospital
admission until the active phase of
labor.
2. If possible, avoid elective labor

induction before 41 weeks' gestation,
use epidural analgesia sparingly to
prevent dysfunctional or prolonged
labor.
Management
1. Prepare the patient for cesarean or

forceps delivery.
2. Assess the client’s uterine

contractions pattern through
palpating or electronically via
external or internal monitor.
3. Evaluate the patient through cervical

and abdominal examination to know
the complication.
4. Administer oxytocic drugs, which

produces rhythmic uterine
contractions and can cause the gravid
uterus to contract.
5. As needed, administer a narcotic or

sedative to aid sleep.
6. Perform amniotomy to the client

when the cervix is 3–4 cm dilated.
6
Arantza Abril, S. C. (n.d.). Essential obstetric and newborn care Chapter 7: Labour dystocia
and malpresentations. Retrieved on March 1, 2022 from Medecins Sans Frontiers:
https://medicalguidelines.msf.org/viewport/ONC/english/7-1-prolonged-labour-
51417461.html
Boatin, A., & Eckert, L. e. (2017, December 4). Dysfunctional labor: Case definition &
guidelines for data collection, analysis, and presentation of immunization safety data.
Retrieved on March 1, 2022 from NCBI:https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC5710983/
Labor Dystocia. (2016, January 27). Retrieved from Agency for healthcare research and
quality. Retrieved on March 1, 2022 from https://effectivehealthcare.ahrq.gov
/products/labor-dystocia/research-protocol
Martin, P. (2019, June 2). 4 Dysfunctional Labor (Dystocia) Nursing Care Plans.
Retrieved on March 1, 2022 from Nurseslabs:https://nurseslabs.com/4-
dysfunctional-labor-dystocia- nursing-care-plans/#:~:text=The%20nursing
%20care%20for%20patients, client%2Fcouple%20and%20preventing%20complications.
7
High Risk Mothers
(Dysfunctional Labor 2nd Stage)
In the second stage, abnormal labor patterns are classified as either protraction or
arrest disorders. Prolonged stages of labor imply that tasks are being completed, although at
a slower rate than would be anticipated. Arrest disorders signify a total stop of labor
progress.
Assessment
● Interview:
1. Interview the patient about:
■ Pain scale rating
■ Medication history
■ History of labor, onset, and duration
● Inspection:
1. Determine whether any maternal variables, such as dehydration, acidosis,
anxiety, or vena caval syndrome, exist.
2. Record the frequency of uterine contractions.
3. Assess the fetal descent in the delivery canal in regard to the ischial spines.
● Palpation:
1. Manually (through palpation) or electronically (by external or internal
monitor with internal uterine pressure catheter) evaluate the uterine
contractile pattern (IUPC).
● Percussion:
1. Percuss to identify the position, size, and consistency of every fetal part.
2. Check to see if the uterus is in the midline of the abdomen. It's often rotated
to the right or left.
● Auscultation:
1. Count the number of fetal heartbeats for one minute every 30 minutes during
the active phase of labor and every 5 minutes during the second stage.
8
Prevention & Management
1. Encourage bed rest or sitting

position/ambulation,as tolerated.
2. Teach the client to assume

hands-and-knees position, or lateral
Sims’ position on side opposite that
to which fetal occiput is directed, if
fetus is in OP position.
3. Encourage taking in oral fluids to

prevent dehydration.
4. Note frequency of uterine

contractions.
5. Provide a safe and quiet environment

to prevent stress
Martin, P. B. (2019, June 1). 4 Dysfunctional Labor (Dystocia) Nursing Care Plans.
Nurseslabs. Retrieved March 1, 2022, from https://nurseslabs.com/4-dysfunctional
-labor-dystocia-nursing-care-plans/
R. (2018, August 20). Dysfunctional Labor (Dystocia) Nursing Care Plan & Management.
RNpedia. Retrieved March 1, 2022, from https://www.rnpedia.com/nursing-notes/
maternal-and-child-nursing-notes/dysfunctional-labor/
9
High Risk Mothers
(Precipitate Labor)
Precipitate labor or also called as rapid labor happens when uterine contractions are
excessively intense, and a woman gives birth with only a few rapidly occurring contractions
that finish in less than 3 hours.
Assessment
● Interview
1. Interview the patient about:
- The time between contractions in terms of recovery.
- Feeling of pushing down or the need to defecate (bowel movement)
- Sudden onset of intense and irregular contractions during labor
- Presence of pelvic pressure during early stage of labor
● Inspection
1. Signs of tearing and laceration of the cervix and vagina.
2. Excessive bleeding from the vagina or uterus (postpartum hemorrhage).
3. Signs of both fetal and maternal infection, such as fever, foul smell from
amniotic fluid, and unusual vaginal discharge smell.
● Palpation
1. When the uterus is soft to palpate and relax (Uterine atony).
● Percussion
1. N/A
● Auscultation
1. One of the indications of fetal and maternal infection is tachycardia. Hence,
auscultation must be done to mothers and the fetus that has higher risk in
precipitate labor.
2. Monitor the mother's blood pressure since hypertensive problems are one of
the risk factors for developing precipitate labor.
10
Prevention
Precipitate labor is unpreventable. However,

patients that are at high risk for this
condition must do the following:
1. Plan for adequate transportation to
the nearest hospital or alternative
birthing center.
2. The birthing room should be adjusted

into birth readiness before full
dilation is achieved.
Management
1. Aid patient in initiating intravenous

therapy, considering Electrolytes may
be needed to replenish the fluids
from blood volume loss.
2. Support the patient in preparing for a

proper procedure to prevent
postpartum hemorrhage after
precipitous labor.
3. Prepare tocolytic medication such as

beta adrenergic and calcium
antagonist to slow down labor as
suggested by the attending physician.
4. Ensure a clean and sterile

environment for delivery.
5. Check for the presence of an intact

amniotic sac.
6. Teach the patient the proper

breathing exercises for delivering the
baby.
7. If present, the bulb suction the

amniotic fluid from the infant’s
mouth.
11
8. Encourage the patient to lie down in
a left side-lying position.
Dulay, A. T. (2020, October 5). Intra-Amniotic Infection. Retrieved February 28, 2022, from
MSD Manual Professional Edition website:
https://www.msdmanuals.com/professional/gynecology-and-obstetrics/abnormalities-of
-pregnancy/intra-amniotic-infection#:~:text=Infection%20increases%20risk%20of%20
obstetric,and%20maternal%20or%20fetal%20tachycardia.
‌
Gill, P., Patel, A., & Van, J. W. (2021, July 19). Uterine Atony. Retrieved February 28, 2022,
from Nih.gov website: https://www.ncbi.nlm.nih.gov/books/NBK493238/
Herndon, J. (2018). What You Need to Know About Precipitous or Rapid Labor. Retrieved
February 28, 2022, from Verywell Family website:
https://www.verywellfamily.com/what-you-should-know-about-precipitous-labor-4174
105
NurseStudyNet. (2021, September 13). Nursing Stat Facts. Retrieved February 28, 2022, from
NurseStudy.net website: https://nursestudy.net/precipitous-labor-nursing-care-plans/
‌
WebMD Editorial Contributors. (2021, March 14). What is Precipitous Labor? Retrieved
February 28, 2022, from WebMD website:
https://www.webmd.com/parenting/what-is-precipitous-labor
‌
12
High Risk Mothers
(Uterine Rupture)
Uterine rupture is when the uterus tears spontaneously that may result in the fetus to
be expelled into the peritoneal cavity. It can cause a hemorrhage or blood loss to the mother
and can suffocate the infant.
Assessment
● Interview
> Is the client feeling a ripping uterine/abdominal pain?
> Does the uterine contraction don’t cease?
> Is the client bleeding?
● Inspection
1. Hemodynamic Stability - a client with uterine rupture should be checked if
she has a stable pumping heart and good circulation of blood. Blood pressure
and heart rate should be assessed for hypotension and tachycardia if vaginal
bleeding occurs.
2. Laparotomy - is a surgical incision into the abdominal cavity. This is a
procedure done to confirm uterine rupture.
3. Urine Examination - a client with uterine rupture should be examined for
hematuria or the presence of blood in the urine.
4. Obstetric Ultrasonography - blood loss and subsequent morbidity and
mortality can be avoided if the ectopic pregnancy is detected before it
ruptures.
● Palpation
1. In women with a suspected uterine rupture, palpating the abdomen to locate
the most painful spot and guarding can be beneficial. A uterine rupture
should induce pain in the middle of the abdomen. A woman with uterine
rupture will have a tender abdomen.
● Percussion
1. When percussing a client with uterine rupture, there is a dull and tenderness
upon percussing the client’s abdomen.
● Auscultation
1. A client with uterine rupture must be auscultated on the abdomen to assess
the fetal heart rate.
13
(Prevention & Management)
Dependent
1. Administer emergency fluid

replacement and IV oxytocin as
ordered by the physician
2. Maintain a patent airway while

administering oxygen as ordered by
the physician.
Interdependent
3. Assess for hypertonicity or

symptoms of uterine muscle
weakness in the mother's labor
pattern.
4. Identify the indicators of an

impending rupture and contact for
help as soon as possible.
5. If the symptoms are severe, an

emergency laparotomy is performed
to try to deliver the fetus as soon as
possible and restore homeostasis.
6. During surgery, monitor maternal

blood pressure, pulse and respiration
7. Monitor Fetal Heart tones
8. To stop the bleeding and mend the

rupture, a laparotomy would be
required.
9. Tell the client that after a uterine

rupture, the client should not try to
conceive again unless the rupture is
in the inactive lower section.
10. Inform the partner and family about
14
how and where they will receive
information about the mother and
newborn.
Togioka, B. M. (2021). Uterine rupture. StatPearls [Internet]. Retrieved February 27,

2022, from https://www.ncbi.nlm.nih.gov/books/NBK559209/
Cai, Y. Q., Liu, W., Zhang, H., He, X. Q., & Zhang, J. (2020). Laparoscopic repair of uterine
rupture following successful second vaginal birth after caesarean delivery:A case report.
World journal of clinical cases, 8(13), 2855–2861. https://doi.org/10.12998/wjcc.v8.i1
3.2855
Duggal, B. S., & Khanna, S. (2006). Second trimester uterine rupture - an unusual case.
Medical journal, Armed Forces India. Retrieved February 27, 2022, from
Uterine rupture nursing management. RNpedia. (2018). Retrieved February 27, 2022,
from https://www.rnpedia.com/nursing-notes/maternal-and-child-nursing-notes
/uterine-rupture/
Belleza , M. (2021). Labor Complications Nursing Care & Management. Nurseslabs.

Retrieved February 27, 2022, from https://nurseslabs.com/labor-complications/
MSD Manuals. (2021). Uterine rupture - gynecology and obstetrics. MSD Manual
Professional Edition. Retrieved February 27, 2022, from https://www.msdmanuals.com/
professional/gynecology-and-obstetrics/abnormalities-and-complications-of-labor
-and-delivery/uterine-rupture
Onc. 3.3 Uterine rupture - Essential obstetric and newborn care. (n.d.). Retrieved
February 28, 2022, from https://medicalguidelines.msf.org/viewport/ONC/english/3-3
-uterine-rupture-51416296.html
15
High Risk Mothers
(Uterine Inversion)
When the uterine fundus collapses into the endometrial cavity, the uterus is turned
partially or entirely inside out, resulting in uterine inversion. It's a rare consequence of
vaginal or cesarean birth, but it's a life-threatening obstetric emergency when it does happen.
Assessment
● Interview
- Ask if the client is feeling any pain in the lower abdomen region
- Ask if the client is feeling dizzy, lightheaded, weak, or drowsy
● Inspection
- Vaginal bleeding is present which may result in shock
- Take note of the client’s blood pressure, uterine inversion can cause hypotension
- Take note of the heart rate
- See if the skin is cold and clammy
● Palpation
- a smooth, round mass projecting from the cervix or the vaginal canal is present
- Uterus is not in the proper position when the abdomen is palpated
● Percussion : N/A
● Auscultation
- Listen to the client’s breathing, rapid breathing may be a sign of shock with is
caused by excessive bleeding due to the inversion of the uterus
16
1. Discontinue uterotonic drugs and

give uterine relaxants as indicated
since the uterus should be relaxed for
its replacement.
2. Collaborate with anesthesiology

staff, this is in case the client needs to
be brought to the operating room if
manual replacement is unsuccessful.
3. Call for immediate assistance from

obstetric staff and operating room
personnel this is also in case manual
replacement is unsuccessful in which
case the client needs to be brought to
the operating room.
4. Collaborate with the client’s OB

GYN to help come up with a
healthcare plan for the client.
5. Assist the OBGYN in manually

replacing the uterine fundus.
Macones, G., MD,MSCE. (2021, November 1). Puerperal uterine inversion. UptoDate.
Retrieved on March 3, 2022 from
https://www.uptodate.com/contents/puerperal-uterine-inversion#H3
17
High Risk Mothers & High Risk Infants
(Amniotic Fluid Embolism)
Amniotic fluid embolism is a rare but serious condition that occurs when amniotic
fluid or fetal material, such as fetal cells, enters the mother's bloodstream during pregnancy.
Amniotic fluid embolism is most likely to occur during labor or shortly after birth.
Assessment
● Interview
1. Ask if the patient is able to breathe well.
2. Ask if the patient is feeling any headache, chest pain or is feeling nauseous.
● Inspection
1. Take note of the breathing pattern, changes in blood pressure, blood oxygen
saturation and heart rate.
2. Check the color of the skin and mucous membranes. (Bluish discoloration of
the skin and mucous membranes may happen due to a lack of oxygen in the
blood)
● Palpation: N/A
● Percussion: N/A
● Auscultation
1. Auscultate for mother’s breath sounds.
2. Fetal distress, such as a slow heart rate, or other fetal rate abnormalities.
18
Amniotic fluid embolism is not preventable

because it is unpredictable.
1. Monitor the patient’s vital signs.
2. Monitor the fetus and watch out for

signs of distress.
3. Position the patient with proper body

alignment for maximum breathing
pattern.
4. Give Rx Oxygen with a face mask or

cannula.
5. Prepare for transfusion of red blood

cells (as needed to replace lost
blood).
6. Administer medications as prescribed

by the physician.
● Vasopressors - used to maintain
blood pressure.
● Inotropes - used to improve
contractility.
● Steroids - may be recommended
because the process may be immune
mediated.
● Uterotonics - to limit postpartum
bleeding.
7. Maintain normal blood volume

through administration of plasma and
intravenous fluids.
8. Assist in endotracheal intubation (to

maintain pulmonary function).
9. Assist in Fibrinogen Therapy to

counteract DIC (disseminated
intravascular coagulation).
19
10. Assist in emergent cesarean delivery
in arrested mothers who are
unresponsive to resuscitation.
Amniotic Fluid Embolism - NORD (National Organization for Rare Disorders). (2019, June
27). NORD (National Organization for Rare Disorders); NORD.
https://rarediseases.org/rare-diseases/amniotic-fluid-embolism/ ‌
Delgado, A. (2019, November 26). Amniotic Fluid Embolism. Healthline; Healthline Media.
https://www.healthline.com/health/pregnancy/amniotic-fluid-embolism ‌
Mayo Clinic Staff. (2020, August 18). Amniotic fluid embolism - Diagnosis and treatment -
Mayo Clinic. Mayoclinic.org; https://www.mayoclinic.org/diseases-conditions/
amniotic-fluid-embolism/diagnosis-treatment/drc-20369328 ‌
Moldenhauer, J. S. (2021, July 6). Amniotic Fluid Embolism. MSD Manual Professional
Edition; MSD Manuals. https://www.msdmanuals.com/professional/gynecology-
and-obstetrics/abnormalities-and-complications-of-labor-and-delivery/amniotic-fluid-e
mbolism ‌
Moore, L. E. (2019, May 13). Amniotic Fluid Embolism Treatment & Management: Medical
Care, Surgical Care. Medscape.com; Medscape.
https://emedicine.medscape.com/article/253068-treatment ‌
20
High Risk Mothers
(Preterm Labor)
It is a labor that happens before the end of week 37 of pregnancy. It affects

approximately 9% to 11% of all pregnancies. This is always a potentially dangerous case as
this can lead to preterm birth.
Assessment
● Interview
1. Obtain the client's full obstetric, medical, surgical and social history.
2. Obtain history of events leading up to the beginning of labor.
3. Review history for symptoms of labor or other diagnosis which may present
with similar symptoms and review risk factors.
● Inspection
1. Inspect for continuing signs and symptoms.

- Persistent, dull, and low backache
- Vaginal spotting
- Feeling of pelvic pressure or abdominal tightening
- Menstrual-like cramping
- Increased vaginal discharge
- Uterine contractions
- Intestinal cramping
2. Inspect any changes in the length of the cervix by ultrasound exam and
analysis of vaginal mucus for the presence of fetal fibronectin.
● Palpation
1. A physical exam is done to assess firmness, abdominal tenderness, fetal size,

and position.
2. Abdominal palpation to detect uterine activity (frequency, duration and
strength)
21
● Auscultation
1. Assessing the fetal heart rate (FHR) and activity and monitoring the effect of
preterm labor medications on the fetus.
2. During labor, either external ultrasound or intermittent auscultation will be
used to monitor the fetal heart rate.
Prevention
1. Assess the client’s condition and

evaluate signs of labor.
2. Assess client’s knowledge of preterm

labors.
3. Encourage bed rest in a side-lying

position to relieve the pressure of the
fetus on the cervix.
4. Attach external fetal and uterine

contraction monitors to monitor FHR
and the intensity of contractions.
5. Give intravenous fluid therapy to keep

the client well hydrated.
6. Perform vaginal and cervical cultures

(prescribed) to rule out infection.
7. Encourage the client to maintain

adequate nutrition and to not smoke
cigarettes.
Management
1. Administer tocolytics to temporarily

slow the client’s contractions.
2. Administer corticosteroid such as

betamethasone to reduce the possibility
of respiratory distress syndrome.
22
3. Administer magnesium sulfate
(intravenously) for fetal neuroprotection
(prior to 32 weeks) to help prevent
cerebral palsy in premature infants.
4. Obtain client’s consent for ultrasound.
5. If an infection is present, administer an

antibiotic that is especially for group B
streptococcus (prescribed by the doctor).
Payne, J. (2016). Premature Labour. Preterm labour causes and issues. Patient.info. Retrieved
March 1, 2022, from https://patient.info/doctor/premature-labour-pro
Preterm labor - Diagnosis and treatment - Mayo Clinic. (2022, February 8). Mayo Clinic.
https://www.mayoclinic.org/diseases-conditions/preterm-labor/diagnosis-treatment/drc-
20376848#:%7E:text=Ultrasound.,Uterine%20monitoring.
Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal & Child Health Nursing: Care of the
Childbearing & Childrearing Family (8th ed., Vol. 1). Lippincott Williams & Wilkins.
Suman V, Luther EE. Preterm Labor. [Updated 2021 Aug 11]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK536939/
23
High Risk Mothers
(Premature Rupture of Membranes)
Premature rupture of membranes (PROM) is the rupture of gestational membranes

prior to the onset of labor, approximately 37 weeks of gestation.
Assessment
● Interview
1. When is the patient’s estimated due date?
2. Is the patient contracting?
3. Is the patient bleeding vaginally?
4. Did the patient have sexual intercourse recently?
5. Does the patient have a fever?
● Inspection
1. Ultrasonography: confirm gestational age, estimated fetal weight,
presentation, amniotic fluid index and fetal anatomy (if not fully evaluated
yet).
2. Speculum Vaginal Examination: Evaluate for cervical dilation and
effacement
3. Microscopic Examination: Ferning of the dried fluid
4. Nitrazine Paper: Presence of blood contamination
5. Evidence of fluid pooling in the vagina or leaking from the cervical os when
the patient coughs
● Palpation
1. Applying fundal pressure with evidence of fluid pooling
24
1. Maternal health should be monitored

in determination of the
appropriateness of expectant
management
2. Fetal monitoring should be

performed at least daily until delivery
3. Maintain the patient on bed rest if the

fetal head is not engaged. This
method may prevent cord prolapse if
additional rupture and loss of fluid
occur. Once the fetal head is
engaged, ambulation can be
encouraged
4. Maternal and fetal infection may

prompt PROM and must be treated
quickly to avoid fetal compromise
5. Monitor for signs of fetal

compromise to include changes in
fetal heart rate because PROM may
be an indicator of fetal distress
6. Antibiotics should be administered to

patients with PPROM because they
prolong the latent period and
improve outcomes
7. Corticosteroids should be given to

patients with PPROM (24 weeks-32
weeks gestation) to decrease the risk
of intraventricular hemorrhage,
respiratory distress syndrome, and
necrotizing enterocolitis
25
Dayal, S., Hong, P. (2021). Premature Rupture of Membranes. StatPearls. Retrieved from
Habte, A., Dessu, S., & Lukas, K. (2021). Determinants of Premature Rupture of Membranes
Among Pregnant Women Admitted to Public Hospitals in Southern Ethiopia, 2020: A
Hospital-Based Case–Control Study. Retrieved from
Medina, T. M., Hill, A. D., (2006). Preterm Premature Rupture of Membranes: Diagnosis and
Management. American Family Physician. Retrieved from
https://www.aafp.org/afp/2006/0215/p659.html#:~:text=The%20diagnosis%20of%20P
ROM%20requires,recently%2C%20or%20has%20a%20fever.
Jazayeri, A., (2018). Premature Rupture of Membranes. Medscape. Retrieved from

https://emedicine.medscape.com/article/261137-overview#a1
26
High Risk Mothers
(Post Term Pregnancy)
Also known as prolonged pregnancy, this condition happens when a pregnancy has
reached an age of gestation of more than 42 weeks.
Assessment
● Interview
1. Ask the client for presence of any of the following risk factors during
antenatal period:
○ High blood pressure
○ History of antepartum hemorrhage
○ Limited fetal movements
○ Intrauterine growth restriction
○ Medical conditions that could cause concern
○ Premature rupture of membranes
○ > 40 years maternal age and a first pregnancy
2. What are your expectations and preferred choices for childbirth?
● Inspection
1. Ultrasound to check fetal size and orientation
2. Assess the amount of amniotic fluid to rule out for oligohydramnios
3. Evaluation of placenta before inducing labor
● Palpation
1. Conduct abdominal palpation to assess fetal heart rate and fetal position
● Auscultation
1. Auscultate abdomen to confirm evaluation of fetal heart rate and fetal
position
27
Prevention
To avoid birth complications:
1. Assist in inducing the labor.
2. Get ready for the client’s chance of

having difficult childbirth.
3. Inform the pediatric staff of the

possible birth-injured newborn.
Management
1. Observe fetal status from time to

time.
2. Assess fetal heart rate and position.
3. Discuss possible options of

interventions that may be done.
4. Provide physical and emotional care.
5. Give necessary patient and family

education regarding the condition.

Norwitz, E.R. (2022). Patient education: Postterm pregnancy (Beyond the Basics).
UpToDate. https://www.uptodate.com/contents/postterm-pregnancy-beyond-the-basic
s#H4
Prolonged Pregnancy (Postterm Pregnancy) Nursing Management. (2018).

RNpedia. https://www.rnpedia.com/nursing-notes/maternal-and-child-nursing-notes/
prolonged-pregnancy/
Prolonged pregnancy: Care beyond 40 weeks gestation. (2019). King Edward

Memorial Hospital: Obstetrics & Gynaecology. https://www.kemh.health.wa.gov.au/~/
media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-Guide
lines/Prolonged-Pregnancy.pdf?thn=0
Richa, S. (2018). Post-term Pregnancy (Prolonged Pregnancy). An Evidence-based Clinical

Textbook in Obstetrics & Gynaecology for MRCOG-2 (1st ed., p 3).
28
High Risk Infants
(Fetal Death)
Fetal death is referred to as the spontaneous intrauterine death of a fetus during any
time of a pregnancy. It is specifically referred to as stillbirths when fetal death happens later
in pregnancy at 20 weeks/5 months of gestation or more. However, a more updated
definition of fetal death is the delivery of a fetus showing no signs of life evidenced by
absence of breathing, heartbeat, pulsation of umbilical cord, or movements of voluntary
muscles.
Assessment
● Interview
1. Ask the mother when she started feeling decreased fetal movement.
2. Ask mother the AOG while also checking records.
3. Ask the mother’s for any complications or experienced risk factors of fetal
demise.
INFANT
● Inspection
1. No definite fetal movement of voluntary muscles
2. No pulsation of the umbilical cord
3. Monitor uterine activity
4. Inspect fetal heart rate monitor for 20 minutes using non-stress test to
determine proper heart rate.
● Palpation
1. Palpate abdomen if size corresponds to the age of gestation/reduced fetal
height.
● Percussion: N/A
● Auscultation
1. Determine adequacy of blood flow through the placenta and umbilical cord
vessels in women who are likely to be impaired using a doppler ultrasound. It
29
uses high-frequency sound waves to determine the blood flow through
vessels.
2. FHR shows no presence of heart beat
MOTHER
● Inspection
1. Inspect hands and nails for color and surface characteristics.
2. Assess pain scale from 1-10.
3. Monitor the patient's temperature for any signs of infection, because keeping
a stillborn fetus inside the body can cause this and even blood clotting.
4. Assess lochia or bleeding from the vagina.
5. With the help of the ultrasound to check for signs of movement and life
within the womb.
● Palpation
1. Assess pulse rate of the mother
2. Palpate the abdomen for tenderness, rigidity, guarding, masses or other
abnormalities.
● Percussion: N/A
● Auscultation:
1. Monitor maternal heart rhythm.
2. Monitor maternal fetal heart rate.
30
1. Dilation and evacuation can be

offered in the second trimester. Labor
induction is also appropriate at later
gestational age, based on patient
preference, or if the option for
dilation and evacuation is
unavailable.
2. Before 28 weeks gestation,

misoprostol appears to be the most
effective method of induction.
Typical dosage is 200-400 mcg
vaginally every 4-12 hours.
3. Monitor and document uterine

activity before and during labor or
labor induction. Including vital signs
per misoprostol induction.
4. Monitoring of uterine activity with a

fetal demise is at the discretion of the
provider. If no uterine activity
monitoring is desired, the provider
should annotate in a progress note.
5. Note abnormalities during patient

assessment.
6. Document admission and fetal

demise record.
7. The most important tests in the

evaluation of a stillbirth are fetal
autopsy, examination of the placenta,
cord and membranes and karyotype
evaluation.
8. Provide supportive care and allow for

patient/ family expression of grief.
31
Intrauterine Fetal Demise. Birth Injury Justice Center. (2022). Retrieved on March 1, 2022
from Intrauterine Fetal Demise - Learn More About Causes (childbirthinjuries.com)
Intrauterine Fetal Demise Guideline. Alaska Native Medical Center: Mother Baby Unit.
(2018). Retrieved from https://anmc.org/wp-content/uploads/ANMCWomens
HealthGuidelines3-13-2018/31-45/Intrauterine%20Fetal%20Demise%20guideline.pdf
Wayne, G. (2019). 5 Perinatal Loss Nursing Care Plans. Nurselabs. Retrieved from 5 Perinatal
Loss Nursing Care Plans - Nurseslabs
Fetal Death Data. (2020). National Center for Health Statistics. Retrieved on March 1, 2022
from https://www.cdc.gov/nchs/nvss/fetal_death.htm
32
High Risk Infants
(Prolapse of Umbilical Cord)
When the umbilical cord prolapses into the vaginal canal before your baby enters the
birth canal, it is known as umbilical cord prolapse. The chord is squeezed between your
baby's body and your pelvic bones when this happens. This lowers your baby's blood flow,
resulting in oxygen deficiency.
Assessment
● Interview
- “Do you feel any pain in your abdomen? If yes, Can you rate it from 1 to 10
as 10 is the most painful”
● Inspection
- An Ultrasound or a fetal doppler can also identify or diagnose an Umbilical
cord prolapse, however, these devices cannot fully determine the fetal cord
compression.
● Palpation
- During pelvic or vaginal exam, the nurse can feel the umbilical cord, and
when he or she does feel it, from there one will know if the umbilical cord
has already prolapsed.
● Auscultation
- One of the signs of the prolapse of the umbilical cord is when the fetal heart
rate is below the normal range or the fetus is experiencing bradycardia (FHR
is below 120 bpm). One can assess this when using a stethoscope in
auscultating the abdomen of the mother and listening for the Fetal heart rate
of the baby.
33
Dependent
1. Assist the mother in preparing for a

vaginal examination or in a funic
decompression to release the pressure
of the presenting part on the cord as
instructed by the physician.
2. Administer Tocolytic drugs to

minimize uterine activity and to
delay labor and lessen fetal pressure.
3. Administer Oxygen to supply the

necessary amount since fetal
oxygenation is compromised to the
prolapse of the umbilical cord.
4. Prepare to assist in a cesarean

delivery ordered by the attending
physician.
Interdependent
1. Collaborate with a Nutritionist or a

dietician for the mother's diet plan
and lifestyle modifications.
2. Talk with a loved one on how the

mother can cope up with the stress
given by the complication.
Belleza, R. M. N. (2021). Labor Complications. Nurseslabs. Retrieved on March 1, 2022

from https://nurseslabs.com/labor-complications/#:%7E:text=Once
%20the%20cord%20has%20prolapsed,baby%20to%20prevent%20fetal%20anoxia.
RNPedia (2018). Cord Prolapse Nursing Management. RNpedia. Retrieved on March 1, 2022
from https://www.rnpedia.com/nursing-notes/maternal-and-child-nursing
-notes/cord-prolapse/
34
High Risk Mothers
(Multiple Gestation)
As the name suggests, multiple gestation is when a mother carries more than one
baby or fetus at a time. This occurs when more than one egg is fertilized or when one egg is
fertilized but eventually splits into 2 or more babies. This may not be a condition in itself,
but these cases increase the risk for complications for both the mother and children.
Assessment
● Interview
1. ” Have you recently experienced an increase in discomfort like backaches,
morning sickness, or shortness of breath?”
2. “How is your appetite? Would you say that you have a bigger appetite than
usual lately?”
3. “Have you felt movements in your belly from different areas at the same
time?”
● Inspection
1. One way to determine a gestation is to observe whether or not the patient’s
uterus is larger than it should be, with respect to her current age of gestation.
2. Inspect for excessive weight gain, especially in early pregnancy.
3. The best way to determine how many fetuses are within the mother’s womb
is through an ultrasound where it can vividly be seen.
● Palpation: N/A
● Percussion: N/A
● Auscultation
1. A multiple gestation can be made clear through auscultation. In a case of
multiple pregnancy, multiple hearts may be heard on different regions of the
mother’s abdomen when auscultating.
35
Dependent
1. Administer tocolytic agent as per

physician’s order in the case that
preterm labor occurs to slow and/or
stop contractions.
2. Maternal and Fetal testing for

monitoring of the status and
condition of both mother and child.
3. Prepare to assist the doctor in an
imperative case of cesarean section
delivery.
4. Administer corticosteroid medicines
to help lung maturation of fetuses.
Lung immaturity is a common
problem in premature labor, a
common complication of multiple
pregnancy.
Interdependent
1. Collaborate with a nutritionist and/or

dietician to help address the mother’s
need for more calories and nutrients .
2. Refer the client to a maternal-fetal

medicine specialist for special
testing, ultrasound evaluations, and
coordinations in the case of needed
action due to complications.
3. Advise the mother on the importance

of frequent prenatal checkups for
close monitoring on both mother and
child.
36
Multiple Birth: Twins, Triplets, Complications & Symptoms. (2020, December 20). Cleveland
Clinic. https://my.clevelandclinic.org/health/articles/9710-expecting-twins-or-triplets
Gurevich, R. (2021, June 14). Risks of a Twin Pregnancy for Mother and Babies. Verywell
Family. https://www.verywellfamily.com/twin-pregnancy-risks-1960314
37
High Risk Infants
(Fetal Anomalies)
Fetal anomalies refer to unusual or unexpected conditions in a baby's development

during pregnancy. Fetal anomalies may also be known as congenital anomalies or birth
defects.
Assessment
● Interview
➢ Family Medical History
➢ Personal Medical History
➢ Vaccination Status
➢ Infection Screening
● Inspection
1. Maternal blood screen is a simple blood test. It measures the levels of two
proteins, human chorionic gonadotropin (hCG) and pregnancy associated
plasma protein A (PAPP-A). If the protein levels are abnormally high or low,
there could be a chromosomal disorder in the baby.
2. Perform an ultrasound scan to check for fetal anomalies as part of the routine
prenatal testing, usually between weeks 18 and 23 of your pregnancy. The
scan enables to view the baby's development, including: The formation of the
baby's head, brain and facial features.
3. A maternal serum screen: identify if a mother is at increased risk for having
a baby with certain birth defects, such as neural tube defects or chromosomal
disorders.
4. Fetal echocardiogram: evaluate the baby’s heart for heart defects before
birth and provide a more detailed image of the baby’s heart than a regular
pregnancy ultrasound.
● Palpation
1. Palpate the umbilical cord during a pelvic or vaginal exam
● Percussion: N/A
● Auscultation: N/A
38
1. The client should have signed informed

consent. Since it is impossible to treat the
fetus without going through the pregnant
woman either physically or
pharmacologically, any fetal intervention
has implications for the pregnant
woman’s health and necessarily her
bodily integrity and, therefore, cannot be
performed without her explicit informed
consent.
2. Conduct fetal research, to have a

research subject advocate who does not
have direct ties to the experimental
protocol so that this individual can act as
an independent advocate for the pregnant
woman, especially when the proposed
intervention poses significant risks to the
pregnant woman.
3. Have support services collaborate with

the client and the family. The complex
emotional stressors that pregnant women
and their families may experience when
considering fetal interventions may
necessitate access to such support
services.
4. A diverse group of professionals should

be custom made in organizations and
governance of centers providing fetal
interventions.
5. Fetal care centers should be encouraged

to establish collaborative research
networks (especially for rare diseases
39
and procedures) and to support
multicenter trials to accumulate more
robust short- and long-term maternal and
fetal outcome data on all categories of
fetal intervention.
Birth Defects and Congenital Anomalies | Diagnosis & Treatments. (2022). Boston Children’s
Hospital. Retrieved from
https://www.childrenshospital.org/conditions-and-treatments/conditions/b/birth-defects
-and-congenital-anomalies/diagnosis-and-treatments
During Pregnancy: Prenatal Testing. (2020). Diagnostic. Birth Defects. Centers for Disease
Control and Prevention. Retrieved from
https://www.cdc.gov/ncbddd/birthdefects/diagnosis.html#:~:text=First%20Trimester%
20Screening&text=The%20maternal%20blood%20screen%20is,chromosomal%20diso
rder%20in%20the%20baby.
Fetal anomaly. Mercy. (2019, August 30). Retrieved February 27, 2022, from
https://www.mercy.net/service/fetal-anomaly/
Maternal–fetal intervention and Fetal Care Centers. ACOG. (n.d.). Retrieved February 27,
2022, from
https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2011/08/ma
ternal-fetal-intervention-and-fetal-care-centers
McLean, S. D., (2017). Congenital Anomalies. Obgyn Key. Fastest Obstetric, Gynecology and
Pediatric Insight Engine. Retrieved on March 2, 2022 from
https://obgynkey.com/congenital-anomalies-3/
40
High Risk Infants
(Hydramnios)
Polyhydramnios is a condition that affects a pregnant woman's uterus. In this condition,

the uterus collects too much amniotic fluid (the liquid that surrounds the baby in the womb),
which causes the uterus to expand beyond its normal size.
Assessment
● Interview
Ask the client for presence of any of the following signs and symptoms during the
duration of pregnancy:
➢ Shortness of breath or the inability to breathe
➢ Heartburn
➢ Swelling in the lower extremities and abdominal wall
➢ Constipation
➢ Uterine discomfort or contractions
➢ Fetal malposition, such as breech presentation
● Inspection
1. Examine the woman's uterus to see if it appears unusually large for the date
of pregnancy.
2. Measure of fundal height which is the distance between the pubic bone and
the top of the uterus during prenatal check ups.
3. Detailed ultrasound to detect or rule out birth abnormalities and other issues
● Palpation
1. Assess the growth of the baby by feeling the uterus through the tummy.
● Percussion: (N/A)
● Auscultation
1. Auscultate mother’s breath sounds and heart rate.
2. Auscultate fetal heart rate.
41
Prevention:
1. Place the mother on close monitoring
for any worsening signs and
symptoms.
2. Prepare mother for a biophysical
profile test including a nonstress test
with fetal heart monitoring and
ultrasound to measure heart rate,
muscle tone, movement, breathing,
and the amount of amniotic fluid
around the baby.
3. Prepare the mother for admission if
there is any evidence of worsening
maternal and/or fetal health due to
hydramnios.
Management:
1. Obtain consent from the patient to
perform amniocentesis after
explaining the procedure’s purpose,
benefits and risks. The healthcare
team will have to monitor the patient
every 1-3 weeks following treatment.
2. Administer prescribed medications
for the management of AFV and fetal
urine production. Additionally, pain
and/or constipation medication can
be prescribed to alleviate abdominal
pain.
3. Assess the patient's vital signs and
pain characteristics at least 30
minutes after administration of
medicine.
4. Treat the underlying conditions that
could be related to polyhydramnios.
5. Encourage progressive activity
through self-care, relaxation
techniques and exercise as tolerated.
42
Dulay, A. T. (2020, October). Polyhydramnios - Gynecology and Obstetrics. MSD

Manual Professional Edition. Retrieved March 1, 2022, from
https://www.msdmanuals.com/professional/gynecology-and-obstetrics/abnormalit
ies-of-pregnancy/polyhydramnios
C. Rn, A. B. (2021, September 2). Polyhydramnios Nursing Care Plans Diagnosis and
Interventions. NurseStudy.Net. Retrieved on March 2, 2022 from
https://nursestudy.net/polyhydramnios-nclex-nursing-review/
Mayo Foundation for Medical Education and Research. (2020, December 8).
Polyhydramnios. Mayo Clinic. Retrieved March 1, 2022, from
https://www.mayoclinic.org/diseases-conditions/polyhydramnios/diagnosis-treat
ment/drc-20368494
Polyhydramnios: Symptoms, causes, treatment & outlook. Cleveland Clinic. (2019).

Retrieved March 1, 2022, from
https://my.clevelandclinic.org/health/diseases/17852-polyhydramnios
U.S. National Library of Medicine. (2020, October 5). Hydramnios: Medlineplus

medical encyclopedia. MedlinePlus. Retrieved March 1, 2022, from
https://medlineplus.gov/ency/patientinstructions/000599.htm
43
(Occipito-posterior Presentation)
The occipito-posterior (OP) fetal head position during the first stage of labour occurs in
10-34% of cephalic presentations. It is caused by the adaptation of the head to a pelvis
having a narrow fore pelvis and an ample anteroposterior diameter and therefore may be
considered “physiologic.”
Assessment
● Interview
1. Obtain history from prenatal and birth records,and through interviews from
family or caregivers.
2. Ask about if she's feeling any uncomfortable or any pain in her abdomen area
or her uterine cavity.
● Inspection
1. Note her expression of pain or discomfort
2. Inspect the client’s abdomen and the shape around it, notice any abnormal
bumps, shapes or abdomen if it looks flat below the level of the umbilicus
3. Check if there is a presence of saucer shaped depression.
4. Assess the position of the fetal head and fetal movement may be detected in
the middle line.
● Palpation
1. Palpate lightly around the Umbilical level to the pubis symphysis and around
the abdomen and note where the head presentation of the infant is and where
it is.
2. While the breech is easily palpated at the fundus, the back is difficult to
palpate as it is well out to the maternal side, sometimes almost adjacent to the
maternal spine.
3. Palpate both sides of the midline if the limbs can be felt.
● Percussion: N/A
● Auscultation
1. The fetal back is not well flexed so the chest is thrust forward, therefore the
fetal heart can be heard in the midline. However, the heart may be heard
more easily at the flank on the same side as the back.
44
Prevention
1. Manual Rotation to manage

persistent occiput posterior position.
2. Epidural anesthesia will be ordered

to prevent possible prolonged labor.
3. Vacuum extraction has been

associated with lower incidence of
trauma to both the mother and the
infant.
Management
1. If an operative delivery is required

for the safe delivery of a healthy
baby then the mother’s informed
consent is required.
2. C-section - This is done when the

above method does not help to
deliver the baby through the vagina.
3. Assisting the client to change their

position may help to overcome the
urge to bear down as needed.
4. Provide oral sports drink or IV

glucose solution to replace glucose
stores she is using to keep active in
labor. as ordered by the physician.
5. Administration of ergometrine for

prevention of Postpartum
hemorrhage (PPH).
6. Oxytocin infusion to induce labor

and for forceps/vacuum delivery.
7. Obstetricians will do an ultrasound

scan to diagnose the position and to
compare the baseline data.
45
Belleza, R. M. N. (2021). Problems with Fetal Position, Presentation, Size, & Passage.
Nurseslabs. Retrieved on February 26, 2022, from
https://nurseslabs.com/problems-fetal-position-presentation-size-passage/
Guittier, MJ., Othenin-Girard, V., Irion, O. et al.(2014).Maternal positioning to correct

occipito-posterior fetal position in labour: a randomized controlled trial. BMC Pregnancy
Childbirth 14, 83 . https://doi.org/10.1186/1471-2393-14-83
46
(Face, Breech, Brow Presentation)
● Face Presentation
- The fetal head and neck are hyperextended in face presentation, causing the
occiput to come into touch with the fetus' upper back while laying on a
longitudinal axis.
● Breech Presentation
- Breech presentation occurs when the fetus is in longitudinal position, with the
buttocks or feet closest to the cervix. Leopold's Maneuver and vaginal
examination can confirm this.
● Brow Presentation
- When the chin is untucked and the neck is stretched rearward to some extent,
this is known as brow presentation. The forehead, which derives its name
from the word "brow," is the first portion of the female reproductive system
to pass through the cervix.
Assessment
● Interview
1. Obtain an informed consent
2. Review prenatal records
3. Ask the patient if fetal kicks can be felt and where it was located.
● Inspection
1. Inspect the contour, shape, and size of the mother’s abdomen. Obtain fundal
height.
2. Perform vaginal examination. Assess for the position of the fetal head and
dilation of the cervix.
● Palpation
1. Perform Leopold’s maneuver after 36 weeks. Palpate to determine the fetal
parts, position, and presentation as to whether it is vertex, face, brow, or
breech.
■ Palpation of a face presentation shows a perceivable indention of the
neck fold between the occiput and the back.
■ Palpation of a brow presentation is characterized as having the fetal
47
occiput higher than the sinciput and having more than 1/2 of the head
above the symphysis pubis.
■ Palpation of a breech presentation is characterized by a hard, round
mobile mass that can be felt at the fundus, and being unable to palpate
for a presenting part at the lower abdomen.
● Percussion: N/A
● Auscultation
1. Monitor the mother’s blood pressure and pulse rate.
2. Listen for the fetal heart rate.
■ Locate for the fetus’s back on either side of the mother's abdomen, or
directly at the middle of the abdomen.
3. Monitor respiratory rate of the fetus.
■ Face presentation can cause blockage of the airway causing
respiratory distress to the fetus.

Dependent
1. Convert the brow presentation to a

face presentation by moving the head
and inserting the fingers through the
cervix between contractions.
2. Prepare to assist in External cephalic

version (ECV) ordered by the
attending physician.
3. Administer tocolytic drug as ordered

by the physician.
4. Administer oxytocin as ordered by

the physician. Oxytocin causes
strong contractions that thin and open
(dilate) the cervix, pull the baby
down and out of the birth canal, push
the placenta out, and stop bleeding at
the placenta's location.
5. Prepare to support the attending
48
physician with a cesarean birth as
ordered.
6. Assist the attending physician to

deliver the baby vaginally if the
external cephalic version is
successful.
Interdependent
1. Monitor the mother's blood pressure,

pulse, and breathing during
operation.
2. Inform the patient’s spouse and

family of where and how they'll get
information on the mother and her
baby.
Makajeva, J., & Ashraf, M. (2022, January 14). Delivery, Face And Brow Presentation. NCBI.
Retrieved March 1, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK567727/
Marino, T. (2021, December 22). Face and Brow Presentation. Medscape. Retrieved February
28, 2022, from https://emedicine.medscape.com/article/262341-overview
Médecins Sans Frontières. (2019b). 7.10 Brow presentation - Essential obstetric and newborn
care. Retrieved March 1, 2022, from
https://medicalguidelines.msf.org/viewport/ONC/english/7-10-brow-presentation-5141
7609.html
Médecins Sans Frontières. (2019). 7.9 Face presentation - Essential obstetric and newborn
care. Retrieved March 1, 2022, from
https://medicalguidelines.msf.org/viewport/ONC/english/7-9-face-presentation-514175
89.html
Mistry, M. (2018, November 12). Obstetric Examination - Presentation - Lie - OSCE.

TeachMeObGyn. Retrieved March 1, 2022, from
https://teachmeobgyn.com/history-taking-examinations/examinations/obstetric/
OpenLearn Create. (2019). Antenatal Care Module: 11. Assessing the Fetus: View as single
page. Retrieved March 1, 2022, from
49
https://www.open.edu/openlearncreate/mod/oucontent/view.php?id=41&printable=1#:
%7E:text=Listen%20near%20the%20mother’s%20sides,to%20hear%20the%20fetal%
20heartbeat
Superville, S. Siccardi, M. (2021, December 12). Leopold’s Maneuver. NCBI. Retrieved,

March 1, 2022 from https://www.ncbi.nlm.nih.gov/books/NBK560814/
50
(Transverse Lie)
This complication refers to the fetal presentation wherein the fetus lies horizontally
across the uterus, rather than vertically. This is one of the most serious abnormal
presentation as it has a high risk for fetal injury or result in a ruptured uterus. During
pre-labor, the doctor will try to reposition the fetus ideal to spontaneous normal delivery,
however, if the procedure fails – the physician may recommend C-Section instead.
Assessment
● Interview
1. Obtain Ultrasound and other medical records of the mother to confirm the
complication
2. Ask the patient if she had multiple pregnancies (twins, triplets, etc.) before.
3. If the mother is pregnant before, politely inquire if she has a low-lying
placenta (placenta previa) during her previous pregnancy.
● Inspection
1. Fetal shoulders can be felt during vaginal examination and elbow during
pelvic examination
2. Note any signs of discomfort such as difficulty in breathing, premature
contractions, or pain in the abdomen. These symptoms indicate
polyhydramnios which can cause transverse lie presentation.
● Palpation
1. The head of the baby can be palpated at the lower uterine pole inlet
2. Fetal head is felt in the flank or side of the mother
3. During palpation, the nurse can feel the fetal back facing the birth canal with
the shoulders pointing towards the passage.
● Percussion: N/A
● Auscultation
1. Locate the fetal heartbeat.
2. Monitor the blood pressure of both mother and child
51
Dependent:
1. Advise the patient to sleep on her
side with a pillow between the legs -
it can help create optimal positioning
for a baby to turn as prescribed by
the physician
Interdependent:
1. The patient is advised to have an
ultrasound because ultrasound scan
of the uterus confirms the transverse
lie position
2. A transverse baby may turn or be

turned into a head-down position
before birth, but if not, a c-section
will almost certainly be required to
ensure the child’s safety.
3. The doctor or midwife may advise

exercises or positions the mother can
do to promote repositioning.
4. A cesarean section may be

recommended id the baby does not
turn or if other measures are not
successful in turning the baby
5. External cephalic version involves

the doctor placing their hands on the
tummy and applying pressure to help
the baby rotate into a head-down
position.
52
Cheriyedath, S. M. (2019, February 26). What is a Transverse Baby? News-Medical.Net.

https://www.news-medical.net/health/What-is-a-Transverse-Baby.aspx
C-Section (Cesarean Birth): Procedure & Risks. (2018, June 22). Cleveland Clinic.
https://my.clevelandclinic.org/health/treatments/7246-cesarean-birth-c-section#risks--b
enefits
Hiramatsu, Y. (2020). Lower-Segment Transverse Cesarean Section. The Surgery Journal,

06(S 02), S72–S80. https://doi.org/10.1055/s-0040-1708060
Marcin, A. (2020, February 28). Can You Turn a Transverse Baby? Healthline.
https://www.healthline.com/health/pregnancy/transverse-baby#concerns
Marsh, L. (2019, December). What happens when my baby is in transverse lie? Baby Centre
UK.
https://www.babycentre.co.uk/x25017771/what-happens-when-my-baby-is-in-transvers
e-lie#:~:text=Your%20baby%20is%20more%20likely,any%20abnormalities%20of%20
the%20womb
Silva, J. C. (2018, October 2). What are the risks of having too much amniotic fluid? Medical
News Today.
https://www.medicalnewstoday.com/articles/323232#:%7E:text=Women%20with%20p
olyhydramnios%20often%20have,is%20too%20much%20amniotic%20fluid
Slide show: Fetal presentation before birth. (2020, August 11). Mayo Clinic.
https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/multimedia/fet
al-positions/sls-20076615?s=6
Superville, S. (2021, December 21). Leopold Maneuver. NCBI.

https://www.ncbi.nlm.nih.gov/books/NBK560814/#:~:text=In%20the%20transverse%2
0lie%20on,posterior%20to%20the%20sacroiliac%20joint
Weiss, R. (2021, June 14). What Happens If Your Baby Is Transverse? Verywell Family.
https://www.verywellfamily.com/transverse-lie-fetal-position-2758446
53
High Risk Infants
(Macrosomia)
Macrosomia is a term that describes an infant who is born much larger than average
for their gestational age (i.e, infant weight is above 90th percentile on an intrauterine growth
chart for that gestational age). A macrosomic baby appears deceptively healthy at birth
because of the weight, but a gestational age examination often reveals immature
development.
Assessment
● Interview
1. Obtain medical history of the mother (e.g., gestational hypertension, obesity).
2. Obtain obstetrical history to determine multiparity, previous LGA infant, or
post-term pregnancy.
● Inspection
1. Note the woman’s uterus whether it appears to be unusually large for the date
of pregnancy.
2. Upon birth, assess the infant’s skin color for ecchymosis, jaundice, and
erythema.
3. Assess motion of infant’s upper extremities.
4. Assess asymmetry of the infant’s anterior chest or unilateral lack of
movement.
5. Assess infant’s eyes for evidence of unresponsive or dilated pupils.
6. Assess for activities of the infant such as jitteriness, lethargy, and
uncoordinated eye movements.
● Palpation
1. When measuring fundal height, a larger than expected fundal height is
palpated.
● Percussion: N/A
● Auscultation
1. With the use of an ultrasound, an excessive amount of amniotic fluid is
detected and is indicative that the baby is larger than average.
54
Fetal macrosomia is unpredictable. The

diagnosis is made only after the baby has
been weighed after delivery. Promoting good
health and a healthy pregnancy can improve
the odds:
1. Encourage the mother to incorporate

exercise in her routine and eat a
low-glycemic index diet during
pregnancy.
2. Advise the mother to have a

preconception appointment. If the
mother is obese, she might also be
referred to another health care
provider — such as a registered
dietitian or an obesity specialist —
who can help her reach a healthy
weight before pregnancy.
3. Advise the mother to monitor her

weight and work with her health care
provider to determine how much
weight loss or weight gain is right for
her.
4. A C-Section delivery may be

necessary if the mother has diabetes,
the baby weighs 11 pounds or more,
or the mother had given birth to a
baby with shoulder dystocia.
Akanmode, A. & Mahdy, H. (2021, August 25). Macrosomia. National Center for
Biotechnology Information. Retrieved February 27, 2022 from
Brennan, D. (2021, March 10). What Is Fetal Macrosomia?. WebMD. Retrieved February 27,
2022 from https://www.webmd.com/parenting/what-is-fetal-macrosomia
Fetal Macrosomia. (2018, July 2). Cleveland Clinic. Retrieved February 27, 2022 from
55
https://my.clevelandclinic.org/health/diseases/17795-fetal-macrosomia
Mayo Clinic Staff. (2020, May 29). Fetal macrosomia. Mayo Clinic. Retrieved February 27,
2022 from
https://www.mayoclinic.org/diseases-conditions/fetal-macrosomia/symptoms-causes/sy
c-20372579#:~:text=Prevention,reduce%20the%20risk%20of%20macrosomia.
56
(Shoulder Dystocia)
Shoulder Dystocia is a complication of vaginal delivery in which the baby’s shoulder

gets caught above the mother’s pubic bone. This prevents the physician from fully
delivering the baby and can extend the length of time for delivery. Shoulder dystocia is
considered an obstetrical emergency.
Assessment
● Interview
1. Assess maternal height, pre-pregnant weight, current weight, and BMI
2. Assess for maternal history for shoulder dystocia risk factors (e.g., maternal
obesity, prior macrosomia, previous shoulder dystocia, and excessive
maternal weight gain)
● Inspection
1. Difficulty with the delivery of face or chin
2. Slow crowning of the fetal head
3. The head recoils against the perineum (turtle sign)
4. There is no spontaneous external rotation and restitution
5. Failure of the shoulders to descend
6. Failure to deliver with maternal expulsive efforts
7. Inability to continue the birth of the fetal shoulders with gentle pressure alone
● Palpation
1. Perform abdominal palpation to assess fetal position, and weight
2. Measure fundal height
● Auscultation
1. Attempt auscultation of fetal heart if repeat maneuvers are unsuccessful
57
Shoulder dystocia is an obstetric emergency

that requires preparation and training for
proper management by delivering providers.
Not only does the baby need to be delivered
quickly, but care must also be taken to
mitigate the risk of injury to the mother and
infant.
1. Ensure resuscitation personnel are

aware of possible complicated
delivery.
2. Check that resuscitation equipment is
ready and operational.
3. Be prepared to assist and perform

primary and secondary maneuvers.
Clinicians managing shoulder
dystocia must have a strong
understanding of both sets of
maneuvers.
- McRoberts maneuver
Perform the maneuver by flexing the
patient’s thighs toward her shoulders
while she is lying on her back.
Suprapubic pressure may be
applied at the same time to further
help dislodge the infant’s shoulder.
- Rubin’s maneuver
Perform the maneuver by placing a
hand into the vagina and applying
pressure to the posterior aspect of the
most accessible fetal shoulder
towards the fetal chest.
- Woods corkscrew maneuver

The obstetrician pushes on the
posterior surface of the posterior
shoulder in a corkscrew fasion in an
attempt to release the trapped
anterior shoulder and minimize the
58
diameter of the shoulder girdle.
- Jacquemier’s maneuver
This maneuver consists of delivery of
the whole posterior arm followed by
posterior shoulder delivery.
- Wide episiotomy
Enlarge vaginal opening with
episiotomy to help provide additional
room for the physician’s hand and
facilitate extra maneuvers.
- Zavanelli maneuver
The fetal head is rotated to its
pre-restitution attitude, flexed, and
elevated up to the vagina and back
into the uterus.
- Symphysiotomy
With the patient in the lithotomy
position, a Foley catheter is placed.
The urethra is retracted laterally with
the Foley catheter. The skin and
subcutaneous tissues are incised with
a scalpel to the level of the pubic
symphysis as well as the anterior
fibers of the pubic symphysis. It is
recommended only as a last resort
when all the other measures have
failed or in cases where immediate
access to an operating room facility
for Zavanelli is nor available.
4. Assist to perform a C-Section and

other surgical procedures as indicated
by the physician to release fetal
shoulders. These are done only in
severe cases of shoulder dystocia that
are not resolved by other methods.
59
Bothou, A., Apostolidi, D., Tsikouras, P., Iatrakis, G., Sarella, A., Iatrakis, D. Zervoudis, S.
(2021). Overview of techniques to manage shoulder dystocia during vaginal birth.
European Journal of Midwifery, 5(October), 1-6. https://doi.org/10.18332/ejm/142097
Donald, D., Roshan, A., Canela, C., & Varacallo, M. (2022, February). Shoulder Dystocia.
National Center for Biotechnology Information. Retrieved February 28, 2022 from
Jevitt, C. Morse, S., & O’Donnell, Y. (2008, January). Shoulder dystocia: nursing prevention
and posttrauma care. National Library of Medicine. Retrieved March 1, 2022 from
https://pubmed.ncbi.nlm.nih.gov/18287897
Khan, L. (2019, June). Shoulder Dystocia. TeachMe ObGyn. Retrieved March 1, 2022 from
https://teachmeobgyn.com/labour/emergencies/shoulder-dystocia/
Mistry, M. (2018, November). Obstetric Examination. TeachMe ObGyn. Retrieved March 1,

2022 from
https://teachmeobgyn.com/history-taking-examinations/examinations/obstetric/
Nall, R. (2012, March). Management of Shoulder Dystocia. Health;ine. Retrieved March 1,

2022 from https://www.healthline.com/health/pregnancy/delivery-shoulder-dystocia
Registered Nurse Initiated Activities. (2011). Obstetrical Emergencies - Shoulder Dystocia.

Retrieved MArch 1, 2022 from
http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Standards/Compet
encies/8BCoreCompDSTOBEmergShoulderDystocia.pdf
Sparkman, L. (2020, August). Nursing Maneuvers For Shoulder Dystocia. Relias. Retrieved
March 1, 2022 from https://www.relias.com/blog/nursing-maneuvers-shoulder-dystocia
The Roya Hospital For Women. (2016, July). Shoulder Dystocia. Quality & Patient Care
Committee. Retrieved March 1, 2022 from
https://www.seslhd.health.nsw.gov.au/sites/default/files/documents/shoulderdystocia2.p
df
Zhang, C., Wu, Y, Li, S., & Zhang, D. (2018, March).

Maternalhttps://www.seslhd.health.nsw.gov.au/sites/default/files/documents/shoulderdy
stocia2.pdf prepregnancy obesity and the risk of shoulder dystocia: a meta-analysis.
Department of Epidemiology and Health Statistics, School of Public Health of Qingdao
University. Retrieved February 28, 2022 from
https://pubmed.ncbi.nlm.nih.gov/28766922/
60

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INTRAPARTAL COMPLICATIONS

NCM 110: Nursing Informatics

Date Submitted: March 4, 2022

INTRAPARTAL COMPLICATIONS PAGE NUMBER

Hypertonic Contractions ............................................................................................ 3

Simple description about the condition

Hypertonic contractions is when there is a rise in resting tone of greater than

To avoid birth complications:

1. Apply a uterine and fetal external

2. Frequently monitor fetal status and

1. Administer analgesia as prescribed

2. Administer oxygen by mouth as this

3. Discontinue the use of oxytocin.

References and Resources

Uterine Contractions’ Pattern in Active Phase of Labor as a Predictor of Failure to Progress .

Simple description about the condition

1. Encourage the use of trained labor

2. If possible, avoid elective labor

1. Prepare the patient for cesarean or

2. Assess the client’s uterine

3. Evaluate the patient through cervical

4. Administer oxytocic drugs, which

5. As needed, administer a narcotic or

6. Perform amniotomy to the client

Simple description about the condition

Prevention & Management

1. Encourage bed rest or sitting

2. Teach the client to assume

3. Encourage taking in oral fluids to

4. Note frequency of uterine

5. Provide a safe and quiet environment

References and Resources

Simple description about the condition

Precipitate labor is unpreventable. However,

2. The birthing room should be adjusted

1. Aid patient in initiating intravenous

2. Support the patient in preparing for a

3. Prepare tocolytic medication such as

4. Ensure a clean and sterile

5. Check for the presence of an intact

6. Teach the patient the proper

7. If present, the bulb suction the

References and Resources

Simple description about the condition

1. Administer emergency fluid

2. Maintain a patent airway while

3. Assess for hypertonicity or

4. Identify the indicators of an

5. If the symptoms are severe, an

6. During surgery, monitor maternal

7. Monitor Fetal Heart tones

8. To stop the bleeding and mend the

9. Tell the client that after a uterine

10. Inform the partner and family about

References and Resources

Togioka, B. M. (2021). Uterine rupture. StatPearls [Internet]. Retrieved February 27,

Belleza , M. (2021). Labor Complications Nursing Care & Management. Nurseslabs.

Simple description about the condition

Prevention & Management

1. Discontinue uterotonic drugs and

2. Collaborate with anesthesiology

3. Call for immediate assistance from

4. Collaborate with the client’s OB

5. Assist the OBGYN in manually