LEARNING CONTENT 

WOMEN EXPERIENCING PROBLEMS DURING LABOR

DYSFUNCTIONAL LABOR

 Dysfunction can occur at any point in labor, but it is generally classified as primary (occurring at the onset of labor) or
secondary (occurring later in labor).

 The risk of maternal postpartal infection, hemorrhage, and infant mortality is higher in women who have a prolonged
labor than in those who do not

 Prolonged labor appears to result from several factors. It is most likely to occur if a fetus is large. Hypotonic, hypertonic,
and uncoordinated contractions all play additional roles

INEFFECTIVE UTERINE FORCE

 Normal uterine contraction occurs because of the interplay of the contractile enzyme adenosine triphosphate and the
influence of major electrolytes such as calcium, sodium, and potassium, specific contractile proteins (actin and myosin),
epinephrine and norepinephrine, oxytocin (a posterior pituitary hormone), estrogen, progesterone, and prostaglandins.
About 95% of labors are completed with contractions that follow a predictable, normal course. When they become
abnormal or ineffective, ineffective labor occurs.

HYPOTONIC CONTRACTIONS

 The number of contractions is unusually low or infrequent (not more two or three occurring in a 10-minute period).

 Hypotonic contractions are most apt to occur during the active phase of labor. They may occur after the administration
of analgesia, especially if the cervix is not dilatated to 3 to 4 cm or if bowel or bladder distention prevents descent or
firm engagement

 They may occur in a uterus that is overstretched by a multiple gestation, a larger-than-usual single fetus, hydramnios, or
in a uterus that is lax from grand multiparity

 Hypotonic contractions increase the length of labor, because more of them are necessary to achieve cervical dilatation

 This can cause the uterus to not contract as effectively during the postpartal period because of exhaustion, increasing a
woman’s chance for postpartal hemorrhage

 Monitor for bleeding after birth

HYPERTONIC CONTRACTIONS

 An increase in resting tone to more than 15 mm Hg

 Hypertonic ones tend to occur frequently and are most commonly seen in the latent phase of labor

 it occurs because the muscle fibers of the myometrium do not repolarize or relax after a contraction, thereby “wiping it
clean” to accept a new pacemaker stimulus

 They tend to be more painful than usual, because the myometrium becomes tender from constant lack of relaxation
and the anoxia of uterine cells that results

 A danger of hypertonic contractions is that the lack of relaxation between contractions may not allow optimal uterine
artery filling; this could lead to fetal anoxia early in the latent phase of labor

 If deceleration in the fetal heart rate (FHR) or an abnormally long first stage of labor or lack of progress with pushing
(“second-stage arrest”) occurs, cesarean birth may be necessary

 Although the contractions are strong, they are ineffective and are not achieving cervical dilatation
UNCOORDINATED CONTRACTIONS

 With uncoordinated contractions, more than one pacemaker may be initiating contractions, or receptor points in the
myometrium may be acting independently of the pacemaker

 Uncoordinated contractions may occur so closely together that they do not allow good cotyledon (one of the visible
segments on the maternal surface of the placenta) filling

 Oxytocin administration may be helpful in uncoordinated labor to stimulate a more effective and consistent pattern of
contractions with a better, lower resting tone.

DYSFUNCTIONAL LABOR AND ASSOCIATED STAGES OF LABOR

 Dysfunction that occurs with the first stage of labor involves a prolonged latent phase, protracted active phase,
prolonged deceleration phase, and secondary arrest of dilatation.

Prolonged Latent Phase

 When contractions become ineffective during the first stage of labor, a prolonged latent phase can develop

 A prolonged latent phase is a latent phase that is longer than 20 hours in a nullipara or 14 hours in a multipara

 This may occur if the cervix is not “ripe” at the beginning of labor and time must be spent getting truly ready for labor
 It may occur if there is excessive use of an analgesic early in labor
 With a prolonged latent phase, 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) and therefore ineffective

Management:

 Helping the uterus to rest, providing adequate fluid for hydration, and pain relief with a drug such as morphine sulfate

 Changing the linen and the woman’s gown, darkening room lights, and decreasing noise and stimulation can also be
helpful

 Cesarean birth or amniotomy (artificial rupture of membranes) and oxytocin infusion to assist labor may be necessary 

Protracted Active Phase

 Usually associated with cephalopelvic disproportion (CPD) or fetal malposition, although it may reflect ineffective
myometrial activity

 This phase is prolonged if cervical dilatation does not occur at a rate of at least 1.2 cm/hr in a nullipara or 1.5 cm/hr in a
multipara, or if the active phase lasts longer than 12 hours in a primigravida or 6 hours in a multigravida.

 Cesarean is opted if birth fetal malposition or CPD is the reason

 If 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

 Prolonged deceleration phase most often results from abnormal fetal head position
 A cesarean birth is frequently required 

Secondary Arrest of Dilatation

 A secondary arrest of dilatation has occurred if there is no progress in cervical dilatation for longer than 2 hours

 C/S is advisable

 
DYSFUNCTION AT THE SECOND STAGE OF LABOR

Prolonged descent

 Fetus occurs if the rate of descent is less than 1.0 cm/hr in a nullipara or 2.0 cm/hr in a multipara

 It can be suspected if the second stage lasts over 3 hours in a multipara

 The contractions become infrequent and of poor quality and dilatation stops

 If everything is normal except for the suddenly faulty contractions and CPD and poor fetal presentation have been ruled
out by ultrasound, then rest and fluid intake

 If the membranes have not ruptured, rupturing them at this point may be helpful

 Intravenous (IV) oxytocin may be used to induce the uterus to contract effectively

 semi-Fowler’s position, squatting, kneeling, or more effective pushing may speed descent.

Arrest of Descent

 Arrest of descent results when no descent has occurred for 1 hour in a multipara or 2 hours in a nullipara

 Failure of descent has occurred when expected descent of the fetus does not begin or engagement or movement
beyond 0 station has not occurred

 Major caused is CPD

 Cesarean birth is advisable

 If normal delivery, used of oxytocin is needed

 CONTRACTION RINGS

 A contraction ring is a hard band that forms across the uterus at the junction of the upper and lower uterine segments
and interferes with fetal descent

 The most frequent type seen is termed A PATHOLOGIC RETRACTION RING(BANDL’S RING).

 The ring usually appears during the second stage of labor and can be palpated as a horizontal indentation across the
abdomen

 It is a warning sign that severe dysfunctional labor is occurring as it is formed by excessive retraction of the upper
uterine segment; the uterine myometrium is much thicker above than below the ring

 If it occurs during the early labor, it is caused by uncoordinated contraction

 In the pelvic division of labor, it is usually caused by obstetric manipulation or by the administration of oxytocin

 Fetus is gripped by the retraction ring and cannot advance beyond that point. The undelivered placenta will also be held
at that point.

 UTZ is used to determine contraction rings & considered as serious problems

 Administration of IV morphine sulfate or the inhalation of amyl nitrite may relieve a retraction ring

 A tocolytic can also be administered to halt contractions.

 Complications if not treated: uterine rupture and neurologic damage to the fetus may occur

 In the placental stage, massive maternal hemorrhage may result, because the placenta is loosened but then cannot
deliver, preventing the uterus from contracting

 C/S is advised for safe delivery

 Manual removal of placenta under G.A if the retraction ring does not allow the placenta to be delivered
LEARNING CONTENT 

PRECIPITATE LABOR

 Precipitate labor and birth occur when uterine contractions are so strong that a woman gives birth with  only a few,
rapidly occurring contractions.

 It is often defined as a labor that is completed in fewer than 3 hours.

 Precipitate dilatation is cervical dilatation that occurs at a rate of 5 cm or more per hour in a primipara or 10 cm or more
per hour in a multipara

 Likely to occur with grand multiparity, or it may occur after induction of labor by oxytocin or amniotomy
 It can lead to: premature separation of the placenta, subdural hemorrhage to fetus, & lacerations of the birth canal.
 Tocolytic may be administered to reduce the force and frequency of contractions

INDUCTION AND AUGMENTATION OF LABOR

 When labor contractions are ineffective, several interventions, such as induction and augmentation of labor
with oxytocin or amniotomy (artificial rupture of the membranes), may be initiated to strengthen them

 Induction of labor means that labor is started artificially

 Augmentation of labor refers to assisting labor that has started spontaneously but is not effective

 The primary reasons for inducing labor include the presence of pre-eclampsia; eclampsia; severe hypertension;
diabetes; Rh sensitization; prolonged rupture of the membranes; intrauterine growth restriction; and post maturity (a
pregnancy lasting beyond 42 weeks)—all situations that increase the risk for a fetus to remain in utero

 Augmentation of labor or assistance to make uterine contractions stronger may be necessary if the contractions are
hypotonic or too weak or infrequent to be effective

 Use cautiously for women with a multiple gestation, hydramnios, grand parity, maternal age older than 40 years, or
previous uterine scars.

 Before induction of labor is begun, the following 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

 Cervical ripening, or a change in the cervical consistency from firm to soft, is the first step the uterus must complete in
early labor

 To “ripen” a cervix, various methods can be instituted. One is known as “stripping the membranes,” or separating the
membranes from the lower uterine segment manually, using a gloved finger in the cervix

 The use of hygroscopic suppositories (suppositories of seaweed that swell on contact with cervical secretions) is also a
time-honored method

 A more commonly used method of speeding cervical ripening is the application of a prostaglandin gel, such as
misoprostol: cytotec, to the interior surface of the cervix by a catheter or suppository, or to the external surface by
applying it to a diaphragm and then placing the diaphragm against the cervix

 Additional doses may be applied every 6 hours. Two or three doses are usually adequate to cause ripening.
  Women should remain in bed in a side-lying position to prevent leakage of the medication, and the FHR should be
monitored continuously for at least 30 minutes after each application

INDUCTION OF LABOR BY OXYTOCIN

 Administration of oxytocin (synthetic form of naturally occurring pituitary hormone) initiates contractions in a uterus at
pregnancy term

 Oxytocin is always administered intravenously, so that, if hyperstimulation should occur, it can be quickly discontinued

 Usually a form of oxytocin, such as Pitocin, is mixed in the proportion of 10 IU in 1000 mL of Ringer’s lactate

 Oxytocin drip should be incremented/ gradually increased in flow rate: max 20gtts/min

 After cervical dilatation reaches 4 cm, artificial rupture of the membranes may be performed to further induce labor,
and the infusion may be d/c, but in some cases may still continue until full dilatation

 Monitor: woman’s pulse and blood pressure every 15 minutes. Monitor uterine contractions and FHR conscientiously

 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, if more than, than stop oxytocin

 Excessive stimulation of the uterus by oxytocin may lead to tonic uterine contractions with fetal death or rupture of the
uterus

 Anti-dote: beta-adrenergic receptor drug such as terbutaline sulfate (Brethine) or magnesium sulfate may be prescribed
to decrease myometrial activity

 Monitor for oxytocin toxicity: headache and vomiting due to water intoxication

o seizures, coma, and death

LEARNING CONTENT 

UTERINE RUPTURE

 Rupture of the uterus during labor, although rare, is always a possibility

 Uterine rupture occurs when a uterus undergoes more strain than it is capable of sustaining.

 Rupture occurs most commonly when a vertical scar from a previous cesarean birth or hysterotomy repair tears (it
occurs in less than 1% of women who have a low transverse cesarean scar from a previous pregnancy;  about 4% to 8%
of women who have a classic cesarean incision)

 Contributing factors may include prolonged labor, abnormal presentation, multiple gestation, unwise use of oxytocin,
obstructed labor, and traumatic maneuvers of forceps or traction

 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

 If a uterus should rupture, the woman experiences a sudden, severe pain during a strong labor contraction, which she
may report as a “tearing” sensation.

 Rupture can be complete: going through the endometrium, myometrium, and peritoneum layers, or incomplete,
leaving the peritoneum intact

 With a complete rupture, uterine contractions will immediately stop

 Two distinct swellings will be visible on the woman’s abdomen: the retracted uterus and the extrauterine fetus

 Hemorrhage from the torn uterine arteries floods into the abdominal cavity and possibly into the vagina. Signs of shock
begin, including rapid, weak pulse; falling blood pressure; cold and clammy skin; and dilatation of the nostrils from air
hunger. Fetal heart sounds fade and then are absent

 If the rupture is incomplete: the signs of rupture are less evident. With an incomplete rupture, a woman may
experience only a localized tenderness and a persistent aching pain over the area of the lower uterine segment

 Changes in the woman’s vital signs will gradually reveal fetal and maternal distress

 Uterine rupture can be confirmed by ultrasound

 Because the uterus at the end of pregnancy is such a vascular organ, uterine rupture is an immediate emergency
situation

 Management: Administer emergency fluid replacement therapy as ordered.

o Use of IV oxytocin to attempt to contract the uterus and minimize bleeding

o Possible laparotomy

o A woman’s prognosis depends on the extent of the rupture and the blood loss.

o Most women are advised not to conceive again after a rupture of the uterus unless the rupture occurred in the
inactive lower segment.

INVERSION OF THE UTERUS/ UTERINE PROLAPSE

 Uterine inversion refers to the uterus turning inside out with either birth of the fetus or delivery of the placenta

 It may occur if traction is applied to the umbilical cord to remove the placenta or if pressure is applied to the uterine
fundus when the uterus is not contracted

 It may also occur if the placenta is attached at the fundus so that, during birth, the passage of the fetus pulls the fundus
down
  Inversion occurs in various degrees. The inverted fundus may lie within the uterine cavity or the vagina, or, in total
inversion, it may protrude from the vagina

 When an inversion occurs, a large amount of blood suddenly gushes from the vagina. The fundus is not palpable in the
abdomen.

 Hypovolemic shock is always possible is bleeding does not stop

Management:

o Never attempt to replace an inversion, because handling of the uterus may increase the bleeding

o Never attempt to remove the placenta if it is still attached, because this only creates a larger surface area for
bleeding

o Oxytocin is not advisable because it will make the uterus more tense thus more difficult to replace

o IVF therapy use large gauze needle ready for BT

o Administer oxygen by mask

o Administer general anesthesia or possibly nitroglycerin or a tocolytic drug to relax the uterus and be replaced
by doctor or nurse manually

o Administer oxytocin after replacement to start contract & lessen bleeding and remain in its natural place

o Antibiotic is needed since there is exposure of uterus

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

 It can cause immediate death

 This condition may occur during labor or in the postpartal period

 It is not preventable because it cannot be predicted

 A woman’s 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. 

Manifestations & Management:

 Mother in labor, suddenly grasps her chest because of sharp pain and inability to breathe as she experiences pulmonary
artery constriction

 Color chance to pale then to bluish gray

 O2 administration

 CPR but may not be effective

 If mother survive: ICU monitoring

 C/S is done

PROLAPSE OF THE UMBILICAL CORD

 umbilical cord prolapses, a loop of the umbilical cord slips down in front of the presenting fetal part

 Cord prolapse automatically leads to cord compression, because the fetal presenting part presses against the cord at
the pelvic brim causing fetal anoxia
  Prolapsed cord is always an emergency situation, because the reduced blood flow to the fetus can quickly cause fetal
harm.

 Prolapse may occur at any time after the membranes rupture if the presenting fetal part is not fitted firmly into the
cervix. It tends to occur most often with:

 Premature rupture of membranes

 Fetal presentation other than cephalic

 Placenta previa

 Intrauterine tumors preventing the presenting part from engaging

 A small fetus

 Cephalopelvic disproportion preventing firm engagement

 Hydramnios

 Multiple gestation

Assessment:

 It can be assessed upon vaginal examination

 The cord may be visible in the vulva
 UTZ can detect the position of the cord

Management:

 Relive the pressure on the cord to avoid compression and fetal anoxia by:

o Inserting glove hands and elevate the fetal head

o Position of mother: knee chest or Trendelenburg position, which causes the fetal head to fall back from the
cord

 Oxygen at 10 L/min by face mask

 Tocolytic agent may be prescribed to reduce uterine activity and pressure on the fetus
 Amnioinfusion may also use to relieve pressure on the cord
 If cord is already expose to room air thus becoming dry, Cover the exposed cord with sterile gauze with sterile saline

 Forceps Delivery will be used to deliver fetus quickly if complete dilation is present

 If dilatation is incomplete, C/S is the choice of delivery. While waiting for delivery, apply pressure at the vaginal opening
using hands.

 MULTIPLE GESTATION

 Twins may be born by cesarean birth to decrease the risk that the second fetus will experience anoxia

 this also is often the situation in multiple gestations of three or more, because of the increased incidence of cord
entanglement and premature separation of the placenta

 If a woman with a multiple gestation will be giving birth vaginally, she is usually instructed to come to the hospital early
in labor.

 Multiple pregnancies often end before full term, so the woman may not yet have practiced breathing exercises.

 To this day, C/S is the choice of delivery for multiple gestations to avoid probem during labor and delivery

 Normal delivery can be done if the there is good fetal position

  In normal delivery: Oxytocin can be used after the delivery of 1 st baby, to make initiate uterine contraction for the
second labor of the 2nd baby, also   shortening the time span between births

LEARNING CONTENT

PROBLEMS WITH FETAL POSITION, PRESENTATION, OR SIZE 

Normall

Occipitoposterior Position

 The occiput (assuming the presentation is vertex) is directed diagonally and posteriorly, either to the right (ROP) or to
the left (LOP)

 Labor is longer than usual

 Back pain is more severe due to sacral nerve compression

 Applying counterpressure on the sacrum by a back rub may be helpful in relieving a portion of the pain

 Applying heat or cold, whichever feels best, also may help

 Lying on the side opposite the fetal back or maintaining a hands-and-knees position may help the fetus rotate

 NSD is possible

Face Presentation

 Normal Delivery can be done

 Babies born after a face presentation have a great deal of facial edema and may be purple from ecchymotic bruising

 Observe the infant closely for a patent airway

 In some infants, lip edema is so severe that they are unable to suck for a day or two- gavage feeding can be done

 Assure parents that edema will disappear

Brow presentation

 Unless the presentation spontaneously corrects, cesarean birth will be necessary to birth the infant safely

 Brow presentations also leave an infant with extreme ecchymotic bruising on the face

Breech Presentation

 Presenting part: foot, buttocks

 Meconium staining is higher incidence due to pressure in the fetus buttocks in the cervix

 In a breech birth, the same stages of flexion, descent, internal rotation, expulsion, and external rotation occur as in a
vertex birth

 Normal delivery can be done but difficulty arises during the delivery of the fetal head.

 Forceps Delivery or the use of Piper forceps is commonly used to deliver the head to avoid damage in the neck of the
baby.

 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 pressure of the head against the pelvic brim automatically compresses this loop of cord.

 A second danger of a breech birth is intracranial hemorrhage

 With a breech birth, pressure changes occur instantaneously. Tentorial tears, which can cause gross motor and mental
incapacity or lethal damage to the fetus, may result.

 With the difficulty of NSD, Caesarean birth is often opted

 

Transverse Lie

 Transverse lie occurs in women with pendulous abdomens, with uterine fibroid tumors that obstruct the lower uterine
segment, with contraction of the pelvic brim, with congenital abnormalities of the uterus, or with hydramnios.

 A mature fetus cannot be delivered vaginally from this presentation instead C/ S is the choice

Oversized Fetus (Macrosomia)

 Size may become a problem in a fetus who weighs more than 4000 to 4500 g (approximately 9 to 10 lbs.)

 most frequently born to women who enter pregnancy with diabetes or develop gestational diabetes

 Large babies are also associated with multiparity, because each infant born to a woman tends to be slightly heavier and
larger than the one born just before

 a large infant born vaginally has a higher than-normal risk of cervical nerve palsy, diaphragmatic nerve injury, or
fractured clavicle because of shoulder dystocia

 may cause uterine dysfunction during labor or at birth because of overstretching of the fibers of the myometrium

 C/S delivery is the choice

Shoulder Dystocia

 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

 This is hazardous to the woman because it can result in vaginal or cervical tears

 The force of birth can result in a fractured clavicle or a brachial plexus injury for the fetus

 Although there is no evidence-based data, asking a woman to flex her thighs sharply on her abdomen (McRoberts’
maneuver) may widen the pelvic outlet and allow the anterior shoulder to be born

 Applying suprapubic pressure may also help the shoulder escape from beneath the symphysis pubis and be born

EXTERNAL CEPHALIC VERSION

 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

 For the procedure, FHR and possibly ultrasound are recorded continuously

 Tocolytics may be given

 Contraindications to the procedure include multiple gestation, severe oligohydramnios, contraindications to vaginal
birth, a cord that wraps around the fetal neck, and unexplained third-trimester bleeding, which might be a placenta
previa. External version can be uncomfortable for a woman because of the feeling of pressure 

Forceps Birth Obstetrical

 Obstetrical forceps are steel instruments constructed of two blades that slide together at their shaft to form a handle

 Today, the technique is rarely used (about 4% to 8% of births) because it can lead to rectal sphincter tears in the woman
which lead to dyspareunia, anal incontinence, or increased urinary stress incontinence in women

 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.

 Although forceps appear as if they would put forceful pressure on the fetal head, the pressure registers on the steel
blades rather than the head so they actually reduce pressure

 The woman’s cervix needs to be carefully assessed after forceps birth to be certain that no laceration has occurred

 To rule out bladder injury, record the time and amount of the first voiding.

 Assess the newborn to be certain that no facial palsy or subdural hematoma exists. 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.

PROBLEM WITH THE PASSAGE

 Another reason that dystocia can occur is a contraction or narrowing of the passageway or birth canal. This can happen
at the inlet, at the midpelvis, or at the outlet.

 The narrowing causes CPD, or a disproportion between the size of the fetal head and the pelvic diameters. This results
in failure to progress in labor. 

Inlet Contraction

 Inlet contraction is narrowing of the anteroposterior diameter to less than 11 cm, or of the transverse diameter to 12
cm or less.

 Often caused by rickets

 For primigravida: if fetal head was engaged during 36-38th weeks of gestation then pelvic inlet size is adequate

 A head that engages or proves it fits into the pelvic brim will probably also be able to pass through the midpelvis and
through the outlet

 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

 For multigravida:  previous birth of a full-term infant vaginally without problems is proof that their birth canals are
adequate

 With CPD, because the fetus does not engage but remains “floating,” malposition may occur, further complicating an
already difficult situation. Should the membranes rupture, the possibility of cord prolapse increases greatly. 

Outlet Contraction

 Outlet contraction is narrowing of the transverse diameter at the outlet to less than 11 cm.

 This is the distance between the ischial tuberosities, a measurement that is easy to make during a prenatal visit, so the
narrow diameter can be anticipated before labor begins.
LEARNING CONTENT

POSTPARTAL HEMORRAHGE

 Hemorrhage, one of the most important causes of maternal mortality associated with childbearing, poses a possible
threat throughout pregnancy and is also a major potential danger in the immediate postpartal period

 Traditionally, postpartal hemorrhage has been defined as any blood loss from the uterus greater than 500 mL within a
24-hour period

 In specific agencies, the loss may not be considered hemorrhage until it reaches 1000 mL

 Hemorrhage may occur either early (within the first 24 hours) or late (any time after the first 24 hours during the
remaining days of the 6-week puerperium).

 The greatest danger of hemorrhage is in the first 24 hours because of the grossly denuded and unprotected uterine
area left after detachment of the placenta

 There are five main causes for postpartal hemorrhage: uterine atony, lacerations, retained placental fragments,
uterine inversion, and disseminated intravascular coagulation

UTERINE ATONY

 Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartal hemorrhage

 The uterus must remain in a contracted state after birth to keep the open vessels at the placental site from bleeding

 Be especially cautious in your observations and be on guard for signs of uterine bleeding. This is especially important
because many postpartal women are discharged within 48 hours after birth 

Therapeutic Management:

 Uterine massage to encourage contraction

 Uterine massage may not completely resolve uterine atony:

o Stay with the mother even after massaging

o Check if uterus will relax again

o Check for the fundic height, and lochia

 Oxytocin Infusion- drug of choice

o Other drugs: Carboprost tromethamine (Hemabate), a prostaglandin F2a derivative, or methylergonovine

maleate (Methergine), an ergot compound, given intramuscularly

 empty the bladder- A full bladder pushes an uncontracted uterus into an even more uncontracted state.

o Empty every 4 hours

o IFC can be inserted

 Continuous blood loss- position women on supine position

o O2 administration

o Monitor for signs of hypovolemic shock: initial- increase RR, PR, cold clammy skin, pale color; late- decrease
RR, PR, thready pulse, Decrease BP, changes in LOC
  Bimanual Massage- if there are retained placental fragments, the physician or nurse-midwife inserts one hand into a
woman’s vagina while pushing against the fundus through the abdominal wall with the other hand:

o Uterine packing may be inserted during this procedure to help halt bleeding

o Use anesthesia since it is painful

o If uterine packing is used, be certain this is documented in a woman’s chart so it can be removed before agency
discharge. Retained packing serves as a growth medium for microorganism invasion that could lead to a
postpartal infection

 Prostaglandin Administration- Intramuscular injection of prostaglandin F22 is another way to initiate uterine

contractions. Observe for nausea, diarrhea, tachycardia, and hypertension, all of which are possible adverse effects of
prostaglandin administration

 Blood Replacement

 Hysterectomy or Suturing- sutures or balloon compression may be used to halt bleeding

 Embolization of pelvic and uterine vessels by angiographic techniques may be successful

 Hysterectomy 

CERVICAL LACERATIONS

 Lacerations of the cervix are usually found on the sides of the cervix, near the branches of the uterine artery.

 If the artery is torn, the blood loss may be so great that blood gushes from the vaginal opening

 Occurs immediately after delivery of the placenta

Therapeutic Management

 Repair of a cervical laceration is difficult, because the bleeding can be so intense that it obstructs visualization of the
area

 Suturing

 Stay with the mother and explain properly

 If the cervical laceration appears to be extensive or difficult to repair, it may be necessary for the woman to be given a
regional anesthetic to relax the uterine muscle and to prevent pain

VAGINAL LACERATIONS

Therapeutic Management

 Suturing

 Some oozing often occurs after a repair, so the vagina may be packed to maintain pressure on the suture line

 IFC maybe inserted

 If packing is inserted, document in a woman’s nursing care plan when and where it was placed, so you can be certain it
will be removed after 24 to 48 hours or before discharge

 Prolonged packing may cause infection

PERINEAL LACERATIONS
Lacerations of the perineum usually occur when a woman is placed in a lithotomy position for birth, because this position
increases tension on the perineum.

Classification Description of Involvement:

 First degree Vaginal mucous membrane and skin of the perineum to the fourchette

 Second degree Vagina, perineal skin, fascia, levator ani muscle, and perineal body

 Third degree Entire perineum, extending to reach the external sphincter of the rectum

 Fourth degree Entire perineum, rectal sphincter, and some of the mucous membrane of the rectum.

Therapeutic Management

 Perineal lacerations are sutured and treated as an episiotomy repair.

 Document the degree of lacerations

 Diet high in fluid and a stool softener

 Enema or rectal suppository is not recommended for 3 rd-4th degree laceration because the hard tips of equipment could
open sutures near to or including those of the rectal sphincters

RETAINED PLACENTAL FRAGMENTS

 Occasionally, a placenta does not deliver in its entirety; fragments of it separate and are left behind

 Retained placenta fragments causes the uterus not to contact effectively

 To detect the complication of retained placenta, every placenta should be inspected carefully after birth to see that it is
complete

 Can be detected thru UTZ

 If retained are large enough bleeding may be immediate after delivery

 If the retained are small bleeding may not be detected until postpartum day 6 to 10

Therapeutic Management

 D&C

 Balloon occlusion and embolization of the internal iliac arteries may minimize blood loss.

 Methotrexate may be prescribed to destroy the retained placental tissue

 be certain a woman knows to continue to observe the color of lochia discharge and to report any tendency for the
discharge to change from lochia serosa or alba back to rubra

SUBINVOLUTION

 Subinvolution is incomplete return of the uterus to its prepregnant size and shape.

 With subinvolution, at a 4- or 6- week postpartal visit, the uterus is still enlarged and soft

 Rresult from a small retained placental fragment, a mild endometritis (infection of the endometrium), or an
accompanying problem such as a uterine myoma that is interfering with complete contraction

Therapeutic Management
  Oral administration of methylergonovine

 Oral antibiotic for endometritis

 Instruction of discharges

LEARNING CONTENT

PERINEAL HEMATOMAS

 A perineal hematoma is a collection of blood in the subcutaneous layer of tissue of the perineum. The overlying skin, as
a rule, is intact with no noticeable trauma.

 Such blood collections can be caused by injury to blood vessels in the perineum during birth.

 Occur after rapid, spontaneous births and in women who have perineal varicosities

 It appears as an area of purplish discoloration with obvious swelling

 The area is tender to palpation

Therapeutic Management

 Mild analgesic

 Ice pack

 Site maybe incised and the bleeding vessel ligated under local anesthesia

o If an episiotomy incision line is opened to drain a hematoma, it may be left open and packed with gauze rather
than re-sutured

o Packing is usually removed within 24 to 48 hours

o Keeping it clean and dry & using a sitz bath once or twice a day

PUERPERAL INFECTION

 Infection of the reproductive tract is another leading cause of maternal mortality

 Theoretically, the uterus is sterile during pregnancy and until the membranes rupture.

 A puerperal infection is always potentially serious, because, although it usually begins as only a local infection, it can
spread to involve the peritoneum (peritonitis) or the circulatory system (septicemia)

 group B streptococci, Escherichia coli, Staphylococcal infections are common

ENDOMETRITIS

 Endometritis is an infection of the endometrium, the lining of the uterus

 Bacteria gain access to the uterus through the vagina and enter the uterus either at the time of birth or during the
postpartal period

Assessment:

 Fever in 3rd-4th portpartal day

 WBC result is not used to determine since there is an increase WBC after birth

 Temp 0f 38 C for 2 consecutive days (except the first 24hr after birth) suggestion infection

 Depending on the severity of the infection, a woman may have accompanying chills, loss of appetite, and general
malaise.
 

Therapeutic Management

 Administration of an appropriate antibiotic, such as clindamycin

 Oxytocic agent such as methylergonovine, may be prescribed to encourage uterine contraction

 Sitting in a Fowler’s position or walking encourages lochia drainage by gravity

 Assess normal color, quantity, and odor of lochia discharge and the size, consistency, and tenderness of a normal
postpartal uterus

INFECTION OF THE PERINEUM

 If a woman has a suture line on her perineum from an episiotomy or a laceration repair, a  portal of entry exists for
bacterial invasion

 Pain, heat, and a feeling of pressure in the suture line

 May have fever or none

 Suture line reveals the inflammation. One or two stitches may be sloughed away, or an area of the suture line may be
open with purulent drainage present

Therapeutic Management

 Remove perineal sutures- to open and drain

 Packing gauze can be used for drainage
 Systemic or topical antibiotic
 Analgesic
 Sitz baths, moist warm compresses
 Change perineal pads frequently
 Proper perineal washing
 Encourage the woman to ambulate

PERITONITIS

 Infection of the peritoneal cavity, usually occurs as an extension of endometritis

 It is one of the gravest complications of childbearing and is a major cause of death from puerperal infection

 The infection spreads through the lymphatic system or directly through the fallopian tubes or uterine wall to the
peritoneal cavity

 An abscess may form in the cul-de-sac of Douglas, because this is the lowest point of the peritoneal cavity and gravity
causes infected material to localize there

 Rigid abdomen, abdominal pain, high fever, rapid pulse, vomiting, and the appearance of being acutely ill 

Therapeutic Management

 Peritonitis is often accompanied by paralytic ileus (blockage of inflamed intestines)

 This requires insertion of a nasogastric tube to prevent vomiting and rest the bowel

 Analgesics for pain relief

THROMBOPHLEBITIS
  inflammation of the lining of a blood vessel with the formation of blood clots

 When thrombophlebitis occurs in the postpartal period, it is usually an extension of an endometrial infection

 Thrombophlebitis is classified as superficial vein disease (SVD) or deep vein thrombosis (DVT)

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.

 Ambulation and limiting the time a woman remains in obstetric stirrups encourages circulation in the lower extremities,
promotes venous return, and decreases the possibility of clot formation, also helping to prevent thrombophlebitis.

 Stirrups of examining or delivery table should be well padded, to prevent any sharp pressure against the calves of the
legs.

 Wearing support stockings for the first 2 weeks after birth can help increase venous circulation and prevent stasis

o Put them on before she rises in the morning

o Remove the support stockings twice daily and assess her skin underneath for mottling or inflammation that
would suggest inflammation of her veins

o Beginning such activities as walking can also be important. An exercise program will also be important in
helping women lose their pregnancy weight

FEMORAL THROMBOPHLEBITIS

 The femoral, saphenous, or popliteal veins are involved

 Decreased circulation, along with edema, gives the leg a white or drained appearance

 If femoral thrombophlebitis develops, a woman notices an elevated temperature, chills, pain, and redness in the
affected leg about 10 days after birth

 Homans’ sign (pain in the calf of the leg on dorsiflexion of the foot) may be positive

 Doppler ultrasound or contrast venography usually is ordered to confirm the diagnosis. 

Therapeutic Management

 Treatment consists of bed rest with the affected leg elevated

 Administration of anticoagulants: heparin and warfarin/comadine

 Strict bed rest can be enforced

 Provide good back, buttocks, and heel care

 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 a pulmonary or cerebral embolism

 Heat supplied by a moist, warm compress can help decrease inflammation

 Always cover wet, warm dressings with a plastic pad to hold in heat and moisture

 Analgesic

 Heparin therapy: can be given subcutaneously

o Protamine sulfate: antidote

o Check PTT

o Safe for BF

 Warfarin Therapy:

o Antidote to warfarin is vitamin K

o Discontinue breastfeeding

 Lochia usually increases in amount in a woman who is receiving an anticoagulant

 Assess for other possible signs of bleeding for anti-coagulant therapy such as easy bruising, ecchymosis,
Item 1

This is the turning of uterus inside out

Uterine inversion

Item 2

 Patient Kristina G1P1 with AOG of 38 weeks, went to the ER department complaining of persistent uterine contraction for 3
hours and in severe pain. Upon further assessment: Cervical Dilation of 2cm, 0 effacement, based on tocodynamometer: her
contraction frequency is 10 every 10 mins lasting for 5 mins for each contraction

Which of the following medicine would be indicated for patient Kristina

Morphine sulfate

Item 3

 Patient Kristina G1P1 with AOG of 38 weeks, went to the ER department complaining of persistent uterine contraction for 3
hours and in severe pain. Upon further assessment: Cervical Dilation of 2cm, 0 effacement, based on tocodynamometer: her
contraction frequency is 10 every 10 mins.

After 30 mins, patient Kristina was crying and screaming of severe uterine pain, then suddenly stop complaining of pain, and her
uterine contraction stop, she become diaphoretic with cold clammy skin, and sudden paleness in her skin and her uterus has
already retracted. The Patient has possible had:

Uterine rupture

Item 4

 A mother in full term is experiencing uncoordinated contraction receives an oxytocin drip to enhanced and regulate her
contraction, this is an example of:

Augmentation of labor

Item 5

 Patient Kristina G1P1 with AOG of 38 weeks, went to the ER department complaining of persistent uterine contraction for 3
hours and in severe pain. Upon further assessment: Cervical Dilation of 2cm, 0 effacement, based on tocodynamometer: her
contraction frequency is 10 every 10 mins.

. Upon assessment of the Physician, she noticed that patient Kristina has a horizontal indentation across her abdomen. Patient is
might be experiencing:

Bandl’s ring

Item 6

 A labor that is started artificially thru medicine administration or cervical ripening

Induction of labor

Item 7

 The doctor orders: Oxygen 10L/min thru Face mask, the reason for this is to give additional oxygen to the:

Unborn child

Item 8
 In UTZ, it reveals that patient Kristina has a Uterine Rapture, which of the following will be performed to the patient:

Emergency abdominal surgery

Item 9

 A mother experience uterine inversion, after manually replacing / inserting back the uterus, the nurse should:

Increase oxytocin regulation as ordered

Item 10

 After the delivery of the placenta, you noticed that “something “protrudes in the vagina of the mother followed by sudden gush
of blood, your next action is:

Refer to the physician

Item 11

 Patient Kristina G1P1 with AOG of 38 weeks, went to the ER department complaining of persistent uterine contraction for 3
hours and in severe pain. Upon further assessment: Cervical Dilation of 2cm, 0 effacement, based on tocodynamometer: her
contraction frequency is 10 every 10 mins.

. After admitting patient Kristina, she verbalized that is in so much pain that her abdomen feels like tearing apart. Your next
action is to:

Refer to the physician on duty

Item 12

 Patient Ana, G5P5, with AOG of 38 weeks, come to the ER, in true labor, with cervical dilation of 5cm, and effacement of 70%.
During the internal examination, the physician notices a white shiny organ in her outer cervix. The physician said that Ana is
experiencing cord prolapse.

As a nurse, you are aware that cord prolapse can cause:

Hypoxia to the fetus

Item 13

 A labor that is completed in fewer than 3 hours:

Precipitate labor

Item 14

 Patient Ana, G5P5, with AOG of 38 weeks, come to the ER, in true labor, with cervical dilation of 5cm, and effacement of 70%.
During the internal examination, the physician notices a white shiny organ in her outer cervix. The physician said that Ana is
experiencing cord prolapse.

Upon knowing that Patient has a cord prolapse, your next actions is to:

Position mother on knee chest position

Item 15

 Patient Kristina G1P1 with AOG of 38 weeks, went to the ER department complaining of persistent uterine contraction for 3
hours and in severe pain. Upon further assessment: Cervical Dilation of 2cm, 0 effacement, based on tocodynamometer: her
contraction frequency is 10 every 10 mins, lasting each contraction for 5 minutes.

Base on the data above, patient Kristina is experiencing:

Hypertonic uterine contraction

Normal contraction: 3-5 times in every 10 minute period. Each contraction lasts 40-60 seconds; this is known as duration of
contractions

Item 1

 A baby in face presentation delivered thru NSD manifest lip edema, which of the following is your next interventions:

Assess for the sucking reflex of the baby

Item 2

 A mother with fetal position of Occipito- posterior will likely to experience more pain due to:

Compression of the sacral nerve

Item 3

 Fetus in breech presentation are at risk of experiencing Meconium Aspiration due to:

Increase pressure in the fetus buttock in the cervix

Item 4

 This is a uterine contraction wherein more than one pacemaker may be initiating contractions, or receptor points in the
myometrium may be acting independently of the pacemaker

Uncoordinated contraction

Item 5

 A fetus in breech presentation can be manually reposition is into cephalic presentation thru:

External cephalic version

Item 6

 McRoberts’ maneuver may be performed to mother experiencing:

Shoulder dystocia

Item 7

 . This is a failure of the cervix to dilatate for more than 2 hours during the 1st stage of labor

Secondary arrest of dilatation

Item 8

 A macrosomia fetus delivered thru Caesarian Section is due to:

CPD

Item 9

 A women with Pelvic Inlet with a transverse diameter of 10 cm my experience dystocia due to:

CPD

Item 10

 . A mother in labor has a fetal- Occipito posterior Position, as a nurse, you expect that the mother will experience

More painful and prolong labor and delivery

Item 11
 Which of the following is true with breech presentation delivery

All of the choices: Fetus may experience intracranial damage, foot, buttock may be presenting part, the fetus is at risk of cord
compression

Item 12

 Fetus in shoulder presentation is always born thru caesarian delivery

True

Item 13

 Which of the following position could lead to more painful labor and prolong delivery:

If the baby is facing forward and slightly to the left (looking toward the mothers right thigh)

Item 14

 A baby was born in face presentation thru NSD, which of the following is expected with the baby:

Presence of bluish discoloration in the face

Item 15

 Which of the following is true about hypotonic contraction during labor

Hypotonic contractions increase the length of labor, because more of them are necessary to achieve cervical dilatation