SESSION 6.

VERSIONS

 Fetal presentation is altered by physically substituting one pole of a longitudinal

presentation for the other, or converting an oblique or transverse lie into a longitudinal
presentation.

1. EXTERNAL CEPHALIC VERSION (as seen on figure 6.30 A to D)

 Manipulations performed through the abdominal wall that yield a cephalic
presentation.
 External cephalic version (ECV) reduces the rate of non-cephalic presentation at birth
(Hofmeyr, 2015b).

INDICATIONS
 Breech presentation
 Transverse lie

CONTRAINDICATIONS
 early labor,
 oligohydramnios or rupture of membranes
 nuchal cord,
 structural uterine abnormalities
 fetal-growth restriction, and prior
 abruption or its risks (Rosman, 2013).
 Prior Cesarean Section

COMPLICATIONS
 risks for placental abruption
 preterm labor
 fetal compromise
 uterine rupture
 feto-maternal hemorrhage
 alloimmunization
 amnionic fluid embolism
 death may also complicate attempts at external version
 dystocia
 malpresentation
 non-reassuring fetal heart patterns
2. INTERNAL PODALIC VERSION
 A fetus is turned to a breech presentation using the hand placed into the uterus (Fig.
45-26).
 The obstetrician grasps the fetal feet to then effect delivery by breech extraction.

INDICATION
 the only indication is when the fetus in transverse lie in case of second baby in twin
gestation.

Technique for Internal Podalic Version

Prerequisites for Internal Podalic Version
Before undertaking the procedure of internal podalic version, the obstetrician must make sure
that the following conditions are fulfilled:
• Cervix must be completely dilated.
• Liquor/amniotic fluid
must be adequate for
intrauterine
manipulation.
• Fetal lie,
presentation and FHR
must be assessed by
an experienced
obstetrician before
undertaking the
procedure.

Actual Procedure
The procedure must
be ideally performed
under general
anesthesia with the
uterus sufficiently
relaxed.
• Under all aseptic
precautions, the
clinician introduces
one of his/her hands into the uterine cavity in a cone-shaped manner. (b)
• The hand is passed along the breech to ultimately grasp the fetal foot, which is identified by
palpation of its heel.
While the foot is gradually brought down, clinician’s other hand present externally over the
abdomen helps in
gradually pushing the cephalic pole upwards. (c)
• Rest of the delivery is completed by breech extraction.

Complications due to internal podalic version

Maternal Fetal
• Placental abruption
• Asphyxia
• Rupture uterus
• Cord prolapsed
• Increased maternal mortality and morbidity
• Intracranial hemorrhage

SESSION 7. CESAREAN SECTION

 Cesarean section is a surgical procedure commonly used in the obstetric practice.

 the fetal delivery is attained through an incision made over the abdomen and uterus,
after 28 weeks of pregnancy.

If the removal of fetus is done before 28 weeks of pregnancy, the procedure is known as
hysterotomy.

 The use of cesarean delivery helps in avoiding difficult cases of vaginal delivery, which
may be associated with considerable maternal and fetal mortality and morbidity.

INDICATIONS
 Cephalopelvic disproportion
 Placenta previa
 Estimated fetal weight >4 kg
 Hyperextension of fetal head
 Footling breech (danger of entrapment of head in an incompletely dilated cervix)
 Severe Intrauterine Growth Restriction (IUGR)
 Clinician not competent with the technique of breech vaginal delivery

COMPLICATIONS
 Abdominal pain
 Injury to bladder, ureters, etc.
 Increased risk of rupture uterus and maternal death
 Neonatal respiratory morbidity
 Requirement for hysterectomy
 Thromboembolic disease
 Increased duration of hospital stays
  Antepartum or intrapartum intrauterine deaths in future pregnancies
 Patients with a previous history of cesarean delivery are prone to develop
complications, like placenta previa and adherent placenta during future pregnancies
PROCEDURE RATIONALE
Preoperative Preparation
The following steps should be taken for preoperative
preparation:

1. Empty stomach: The patient should be NPO for

at least 12 hours before undertaking a cesarean To prevent the risk of aspiration at the
section. In case the patient is full stomach, she time of administration of anesthesia
should be administered H2 receptor blocker
(ranitidine 150 mg) and an antiemetic
(metoclopramide 10 mg) at least 2 hours prior to the
surgery.
2. Patient position: The patient is placed with 15° To reduce the chances of hypotension.
lateral tilt on the operating table.
3. Anesthesia: While cesarean section can be Spinal and epidural anesthesia have
performed both under general or regional become the most commonly used
anesthesia, nowadays regional anesthesia is forms of regional anesthesia in the
favored. recent years.
4. Clinical examination: Before cleaning and To monitor the fetal heart tone of the
draping the patient, it is a good practice to check the fetus.
fetal lie, presentation, position and fetal heart
sounds once again.
Foleys or plain rubber catheter must be inserted,
following which the cleaning and draping of the
abdomen is done.
5. Preparation of the skin: The area around the Antiseptic skin cleansing before
proposed incision site must be washed with surgery is thought to reduce the risk of
antiseptic soap solution (e. g. savlon and/or postoperative wound infections
betadine solution).

 The antiseptic solution must be applied at

least three times over the incision site, using
a high-level disinfected sponge-holding
forceps and cotton or gauze swab.
Steps of Surgery
6. A vertical or transverse incision can be given over
the skin (Fig. 7.3). The vertical skin incision can be
either given in the midline or paramedian location,
extending just above the pubic symphysis to just
below the umbilicus.
Previously, vertical skin incision at the
time of cesarean section was favored,
as it was supposed to provide far more
superior access to the surgical field in
comparison to the transverse incision.
Also, the vertical incision showed
potential for extension at
the time of surgery. However, it was
associated with poor
cosmetic results and an increased risk
of wound dehiscence and hernia
formation. Therefore, nowadays,
transverse incision is mainly favored
 due to better cosmetic effect, reduced
postoperative pain and improved
patient recovery.

Two types of transverse incisions are mainly used, while performing cesarean section:
(1) the sharp (Pfannenstiel) type and
(2) the blunt (Joel Cohen) type.

Sharp Pfannenstiel transverse incision: While giving this type of incision, a slightly curved,
transverse skin incision is made at the level of pubic hairline, about an inch above the pubic
symphysis and is extended somewhat beyond the lateral borders of rectus abdominis muscle.
 The subsequent tissue layers, until the level of anterior rectus sheath are opened by
using a sharp scalpel.
7. Dissecting the Rectus Sheath These muscles are then separated
After dissecting through the skin, subcutaneous fat with the help of blunt and sharp
and fascia, as the anterior rectus sheath is reached, dissection to expose transversalis
sharp dissection may be required. fascia and peritoneum.

A scalpel can be used to incise the rectus sheath

throughout the length of the incision.

The cut edges of the incised rectus sheath are held

with the help of allis forceps and then carefully
separated out from the underlying rectus muscle
and pyramidalis.
8. Opening the Peritoneum The layers of parietal peritoneum are
The transversalis fascia and peritoneal fat are carefully examined to be sure that
dissected carefully to reach the underlying parietal omentum, bowel or bladder is not lying
peritoneum. adjacent to it.
After placing two hemostats about 2 cm apart to
hold the peritoneum, it is carefully opened.

9. Insertion of the Doyen’s Retractor Doyen Retractor is used in abdominal

OB/GYN, retracting bladder, and
cesarean section procedure. The
retractor has a round concave blade,
the palm grip handle has a little hook
at the end and a thumb rest, the
handle is designed to provide grip and
comfort.

It is used by surgeons to either actively

separate the edges of a surgical
Following the identification of lower uterine segment, incision or wound, or can hold back
some surgeons prefer to put a moistened underlying organs and tissues, so that
laparotomy pack in each of the paracolic gutters. body parts under the incision may be
accessed.
The loose fold of the uterovesical peritoneum over
the lower uterine segment is then grasped with the
help of forceps and incised transversely with the
help of scissors.

The lower flap of the peritoneum is held with artery

forceps and the loose areolar tissue pushed down.

The underlying bladder is then separated by blunt

dissection. Finally, the lower flap of peritoneum and
the areolar tissue is retracted by the Doyen’s
retractor to clear the lower uterine segment.

The upper flap of the peritoneum is pushed up to

leave about 2 cm wide strip on the uterine surface,
which is not covered with visceral peritoneum.
10. Giving a uterine incision: An incision is made The uterine incision must be gently
on the lower uterine segment about 1 cm below the given, taking care to avoid any injury
upper margin of peritoneal reflection and about 2–3 to the underlying fetus.
cm above the bladder base.

While making an incision in the uterus, a curvilinear

mark of about 10 cm length is made by the scalpel,
cutting partially through the myometrium.

Following this, a small cut (about 3 cm in size) is

made, using the scalpel in the middle of this incision
mark, reaching up to, but not through the
membranes.
The rest of the incision can be completed either by
stretching the incision, using the tips of two index
fingers along both the sides of the incision mark
(Fig. 7.4A) or using bandage scissors, to extend the
incision on two sides (Fig. 7.4B).

The metzenbaum scissors are introduced into the
uterus over the two fingers, in order to protect the
fetus.
The uterine incision must be large enough so as to
allow the delivery of the head and trunk without the
risk of extension of the incision laterally into the
uterine vessels. As the fetal membranes bulge out
through the uterine incision, they are ruptured.
The use of metzenbaum scissors may
be especially required in cases, where
the lower uterine segment is thickened
andthe uterine incision cannot be
extended using the fingers. If the lower
uterine segment is very thin, injury to
the fetus can be avoided, by using the
handle of the scalpel or a hemostat (an
artery forceps) to open the uterus.

The amniotic fluid, which is released following the

rupture of membranes, is sucked with the help of a
suction machine.
Location of the uterine incision: The incision in the uterus is commonly given over the
lower uterine segment.

The classical incision has been found to be associated with high risk of scar rupture during
future pregnancies. As a result, lower segment transverse scars are nowadays preferred.

The lower segment uterine scar is considered to be stronger than the upper segment scar
due to the reasons mentioned in Table 7.3.
11. Delivery of the Infant
In case of cephalic presentation, once the fetal
presenting
part becomes visible through the uterine incision,
the
surgeon places his/her right hand below the fetal
presenting part and grasps it.
In case of cephalic presentation the fetal head is
then elevated gently, using the palms and fingers of
the hand.
Delivery of the fetal head should be in
the same way as during the normal
vaginal delivery.
Fundal massage, following the delivery
of the baby, helps in reducing bleeding
and hastens the delivery of placenta.

The Doyen’s retractor is removed, once the fetal

presenting part has been grasped.

In order to facilitate delivery, fundal pressure is

applied by
the assistant. Delivery is completed in the manner
similar
to normal vaginal delivery.

Once the baby’s shoulders have delivered, an IV

infusion containing 20 IU of oxytocin per liter of
crystalloids is infused at a rate of 10 mL/minute,
until effective uterine contractions are obtained.

Following the delivery of the baby, the doctor will

call out the time of delivery and the sex of the baby.
The cord is clamped and cut and the baby handed
over to the clinician.
12. Placental Removal
Following the delivery of the placenta, the remnant
bits of membranes and decidua are removed using
a sponge-holding forceps. The cut edges of the
uterine incision are then identified and grasped with
the help of Green Armytage clamps.(as seen
below)
The uterine angles are usually grasped with allies
forceps.
13. Closing the Uterine Incision
The main controversy related to the closure of the
uterine incision is whether the closure should be in
the form of a single-layered or a double-layered
closure.
Both single-layered and double-layered closure of
uterine
incision are being currently practiced.
If tubal sterilization has to be performed, it is done
following the closure of uterine incision.
Following the uterine closure, swab and instrument
count is done.
Once the count is found to be correct, the
abdominal
incision is closed in layers.
14. Peritoneal Closure
The current recommendation by (Royal College of
Obstetrician and Gynecologist)RCOG is that
neither the visceral nor the parietal peritoneum
should be sutured at the time of cesarean section.
15. Closure of the Rectus Sheath
At the time of cesarean, the placenta
should be removed,
using controlled cord traction (Fig. 7.5)
and not manual
removal as this reduces the risk of
endometritis.
Though single- layered closure is
associated with reduced operative time
and reduced blood loss in the short
term, the risk of the uterine rupture
during subsequent pregnancies is
increased. The current
recommendation is to close the uterus
in two layers, as the safety and efficacy
of closing uterus in a single layer is
presently uncertain. Individual bleeding
sites can be approximated with the help
of figureof-eight sutures.
This reduces the operative time and the
requirement for the postoperative
analgesia.
The rectus layer is closed with the help
of continuous locked sutures placed no
Rectus sheath closure is performed after identifying
the angles and holding them with allies forceps.
The angles must be secured using 1-0 vicryl
sutures.
16. Closure of Subcutaneous Space
There is no need for the routine closure of the
subcutaneous tissue space, unless there is more
than 2 cm of subcutaneous fat.
17. Skin Closure
Clinicians should be aware that presently the
differences
between the use of different suture materials and
methods of skin closure at the time of cesarean
section are not certain.
Skin closure can be either performed, using
subcutaneous, continuous repair absorbable or
nonabsorbable stitches or using interrupted stitches
with nonabsorbable sutures or staples.
POSTOPERATIVE CARE
1. After surgery is completed, the woman needs to
be
monitored in a recovery area.
When the effects of anesthesia have worn off,
about 4–8 hours after surgery, the woman may be
transferred to the postpartum room.
2. Fluids and oral food after cesarean section:
As a general rule, about 3 liters of fluids must be prolonged infusion of IV fluids can alter
replaced by IV infusion during the first
postoperative day, provided that the woman’s urine receives IV fluids for more than 48
output remains greater than 30 mL/hour.
If the urine output falls below 30 mL/hour, the
woman
needs to be reassessed to evaluate the cause of
oliguria.
In uncomplicated cases, the urinary catheter can be
more than 1 cm apart. Hemostasis
must be checked at all levels.
To reduce the incidence of the wound
infection.
Following the skin closure, the vagina
is swabbed dried and dressing applied
to the wound.
Monitoring of routine vital signs (blood
pressure,
temperature, breathing), urine output,
vaginal bleeding
and uterine tonicity (to check, if the
uterus remains
adequately contracted), needs to be
done at hourly
intervals for the first 4 hours.
Thereafter, the monitoring
needs to be done at every four hourly
intervals for the first
postoperative day at least. Adequate
analgesia needs to
be provided, initially through the IV line
and later with
oral medications.
The clinician needs to remember that
electrolyte balance. If the woman
hours, her electrolyte levels need to be
monitored every 48 hours.
Balanced electrolyte solution (e.g.
potassium chloride 1.5 g in 1 L IV
fluids) may be administered.
 removed by 12 hours postoperatively. Intravenous
fluids may need to be continued, until she starts
taking liquids orally.
3. Ambulation after cesarean section: The
women must be encouraged to ambulate as soon
as 6–8 hours following the surgery.
4. Dressing and wound care: The dressing must
be kept on the wound for the first 2–3 days after
surgery, so as to provide a protective barrier
against infection. Thereafter, dressing is usually not
required.
Walking also improves blood flow and
speeds wound healing. Failure to walk
may cause increased constipation and
gas pain and weakness, and puts the
patient at a higher risk for infections,
blood clots and lung problems such as
pneumonia.
The dressing must be changed while
using a sterile technique.
The surgical wound also needs to be
carefully inspected.

If blood or fluid is observed to be leaking through

the initial dressing, the dressing must not be
changed.

The amount of blood/fluid lost must be monitored.

If bleeding increases or the bloodstain covers half

the dressing or more, the dressing must be
removed and replaced with another sterile
dressing.
5. Length of hospital stay: Length of hospital stay Women who are recovering well and
is likely to be longer after a cesarean section (an have not developed complications
average of 3–4 days) in comparison to that after a following cesarean may be offered
vaginal birth (average 1–2 days). early discharge.

Multiple Choice:
Answer the following questions carefully.

1. Raya is pregnant and was told by her OB doctor that her baby is on face presentation.
In face presentation, when is cesarean birth necessary?
A. If the chin is anterior.
B. If the chin is posterior.
C. If the pelvic diameters are within normal limits.
D. If the pelvic diameters are higher than normal.

2. What is a contraindication to external cephalic version?

A. Hydramnios
B. Nulliparity
C. Vaginal birth
D. Cesarean birth

3. Julianne a client who delivered by cesarean section 24 hours ago is using a patient-
controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only
since surgery. She is now complaining of nausea and bloating, and states that because
she had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis
has the highest priority?
A. Altered nutrition, less than body requirements for lactation
B. Alteration in comfort related to nausea and abdominal distention
C. Impaired bowel motility related to pain medication and immobility
D. Fatigue related to cesarean delivery and physical care demands of infant

4. Karina is performing an assessment of a client who is scheduled for a cesarean

delivery. Which assessment finding would indicate a need to contact the physician?
A. Fetal heart rate of 180 beats per minute
B. White blood cell count of 12,000
C. Maternal pulse rate of 85 beats per minute
D. Hemoglobin of 11.0 g/dL

5. Which of the following fetal positions is most favorable for cesarean birth?
A. Vertex presentation
B. Transverse lie
C. Frank breech presentation
D. Posterior position of the fetal head

6. Carly a client is admitted to the L & D suite at 36 weeks’ gestation. She has a history of
C-section and complains of severe abdominal pain that started less than 1 hour earlier.
When the nurse palpates tetanic contractions, the client again complains of severe pain.
After the client vomits, she states that the pain is better and then passes out. Which is
the probable cause of her signs and symptoms?
A. Hysteria compounded by the flu
B. Placental abruption
C. Uterine rupture
D. Dysfunctional labor

7. Manipulations performed through the abdominal wall that yield a cephalic

presentation.
A. External Cephalic Version
B. Internal Podalic Version
C. External Podalic Version
D. Internal Cephalic Version

8. A fetus is turned to a breech presentation using the hand placed into the uterus.
A. External Cephalic Version
B. Internal Podalic Version
C. External Podalic Version
D. Internal Cephalic Version

9. Which of the following are complications of Cesarean Section, SELECT ALL THAT
APPLY:
A. Injury to bladder and ureters
B. Increased risk of rupture uterus and maternal death
C. Neonatal respiratory morbidity
D. Requirement for hysterectomy

10.Which of the following are indications for Cesarean Section, SELECT ALL THAT
APPLY:
A. Cephalopelvic disproportion
B. Placenta previa
C. Estimated fetal weight >4 kg
D. Hyperextension of fetal head

11. Astra had a cesarean section and is 2 days post-op. What is an important measure to
reduce the size of the bladder and keep it away from the surgical field during cesarean
birth?
A. Administer an oxytocic to contract the bladder.
B. Restrict fluids in the woman for 4 hours before surgery.
C. Insert a urinary catheter to drain the bladder and decrease its size.
D. Give a diuretic to reduce the bladder to its smallest size.

12. Carrie is to administer ranitidine (Zantac) as ordered prior to a planned cesarean birth
to:
A. Promote uterine contractions.
B. Decrease gastric secretions.
C. Delay uterine contractions.
D. Neutralize urine acidity.

13. Carrie instructs Astra on deep breathing exercises as part of the preoperative
teaching plan. The rationale for this exercise is to:
A. Stimulate the diaphragm to contract.
B. Promote involution on a traumatized uterus.
C. Prevent stasis of mucus in the lungs.
D. Prevent pulmonary edema.

14. You are asked by your instructor regarding Cesarean Section. What is the most
important responsibility of the healthcare team before the surgery starts?
A. Assessing the woman’s hygiene.
B. Inserting a urinary catheter.
C. Decreasing the stomach secretions.
D. Securing an informed consent and ensuring that it is obtained.

15. The nurse administers Ringer’s solution intravenously for what purpose?
A. To avoid urinary tract infection.
B. To ensure that the woman is fully hydrated.
C. To reduce bladder size.
D. To decrease urine specific gravity.

16. Dr. Callum a surgeon plans to perform a low segment incision rather than a classic
incision. This type of incision is more advantageous because:
A. The procedure is faster with the incision being made simultaneously through the abdomen
and uterus.
B. The procedure is made with a vertical incision to decrease the chances of reopening.
C. It is made horizontally and high on the woman’s abdomen.
D. The likelihood of a postpartal uterine infection is decreased.

17. Katrine was asked by her instructor that if oxytocin is ordered postoperatively for the
client who has had a cesarean birth, the most important nursing intervention would be
to:
A. Monitor the woman’s blood pressure.
B. Prevent infection at the incision site.
C. Implement measures to promote comfort.
D. Assess for increased lochia discharge.

18. Charie was asked which of the following interventions would be most helpful to
assist a woman to void after a cesarean birth?
A. Withholding prescribed analgesic.
B. Letting the woman void every 4 hours.
C. Running water from the tap within woman’s hearing distance.
D. Pouring cold water over her perineal area.

19. Ramina has undergone a cesarean birth is to be discharged. You would instruct the
woman to notify her health care provider if she develops which of the following?
A. Drainage at her incision line.
B. No bowel movement for 2 days.
C. Decrease in lochia.
D. Pain on the incision site.

20. Which of the following is a complication of pain that occurs postoperatively?

A. Constipation
B. Pneumonia
C. Hypotension
D. Fever
 SESSION 8. UTERINE ATONY

Nursing Care of a Family Experiencing a Postpartum Complication

UTERINE ATONY
Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartum hemorrhage;
it tends to occur most often in Asian, Hispanic, and Black woman (Grobman, Bailit, Rice, et al.,
2015).
Factors that predispose a woman to poor uterine tone or the inability of her uterus to maintain a
contracted state are summarized in Box 25.3. When caring for a woman in whom any of these
conditions are present, be especially conscientious in your observations and be on guard for signs
of uterine bleeding.
 Nursing Diagnoses and Related Interventions
Nursing Diagnosis:
Deficient fluid volume related to excessive blood loss after birth.

Outcome Evaluation:
Patient’s blood pressure and heart rate remains within usual defined limits; lochia flow is less than
one saturated perineal pad per hour.
 If the uterus suddenly relaxes, there will be an abrupt gush of blood vaginally from the
placental site. This can occur immediately after birth but is more likely to occur gradually,
over the first postpartum hour, as the uterus slowly loses its tone.
 If the loss of blood is extremely copious, a woman will quickly begin to exhibit symptoms
of hypovolemic shock such as a falling blood pressure; a rapid, weak, or thready pulse;
increased and shallow respirations; pale, clammy skin; and increasing anxiety.
 If the blood loss is unnoticed seepage, there is little change in pulse and blood pressure
at first because of circulatory compensation. Suddenly, however, the system is able to
compensate no more, and the pulse rate rises rapidly and becomes weak.
 Blood pressure then drops abruptly. With slow bleeding, a woman develops these
symptoms over a period of hours; the end result of continued seepage, however, can be
as life threatening as a sudden profuse loss of blood (Andrighetti, 2013).

It is difficult to estimate the amount of blood a postpartal woman is losing because it is difficult to
estimate the amount of blood
  It takes to saturate a perineal pad (between 25 and 50 ml). By counting the number of
perineal pads saturated in given lengths of time, such as half-hour intervals, a rough
estimate of the amount of blood loss can be formed.
 Five pads saturated in half an hour is obviously a different situation from five pads
saturated in 8 hours.
 A woman will have lost approximately 250 ml of blood, and if either scenario is allowed to
continue unattended, she will be in grave danger of hypovolemia.
 Be certain that when you are counting perineal pads, you differentiate between saturated
and used.
Weighing perineal pads before and after use and then subtracting the difference is an accurate
technique to measure vaginal discharge:
 1 g of weight is comparable to 1 ml of blood volume,
 if a pad weights 50 g more after use, the woman has lost 50 ml of blood.
Note:
1. Always be sure to turn a woman on her side when inspecting for blood loss to be certain
a large amount of blood is not pooling undetected beneath her.
2. The best safeguard against uterine atony is to palpate a woman’s fundus at frequent
intervals to be assured her uterus is remaining contracted. Under usual circumstances, a
well-contracted uterus feels firm and is easily recognized because it feels like no other
abdominal organ. If you are unsure whether you have located a woman’s fundus on
palpation, it means the uterus is probably in a state of relaxation.
3. Frequent assessments of lochia (to be certain the amount of the flow is under a saturated
pad per hour and that any clots are small), as well as vital signs, particularly pulse and
blood pressure, are equally important determinations.

Therapeutic Management
In the event of uterine atony, the first step in controlling hemorrhage is to attempt fundal massage
to encourage contraction. Unless the uterus is extremely lacking in tone, this procedure is usually
effective in causing contraction, and, after a few seconds, the uterus assumes its healthy,
grapefruit-like feel (World Health Organization [WHO], 2015).
FUNDAL MASSAGE
PROCEDURE SCRIPT FOR RETURN
DEMONSTRATION
1. Explain the necessity for the procedure and Nurse: Good day Ma’am, I am nurse
provide privacy. (state your name), I will be your nurse for
RATIONALE: the day. I will render a fundal massage to
Help to decrease anxiety, and providing privacy control vaginal bleeding and encourage
enhances self-esteem. uterine contraction.
2. Ask the patient to void (unless bleeding is Nurse: Before we begin the procedure
extensive and more rapid actions seems Ma’am, I would to assist you to
necessary). Ask her to lie supine with knees void/urinate to lessen the pressure and
flexed. avoid discomfort. (Optional, unless
RATIONALE: bleeding is extensive).

After the patient have voided.

An empty bladder prevents displacement of the
uterus and ensures accurate assessment of
uterine tone.
Proper positioning enhances visualization and
effectiveness of procedure.
3. Put on gloves. Place one hand on the
abdomen just above the symphysis pubis. Place
the other hand around the top of the fundus. (As
shown below)
Nurse: Ma’am, may I assist you to lie on
the bed with your knees flex.
Nurse: Ma’am, I am going to start to
massage your fundus by placing may one
hand on your abdomen just above your
symphysis pubis while my other hand is
around the top of your fundus

RATIONALE:
This anchors the lower uterine segment and
allows you to locate and assess the fundus.
4. Rotate the upper hand to massage the uterus Nurse: Ma’am, I am now rotating my
until it is firm, being careful not to over massage. upper hand to carefully massage your
(As seen below) uterus in order to encourage uterine
contraction.

RATIONALE:
Massage should be done only when the uterus
is not firm and aggressive massage may lead to
a partial or complete uterine prolapse.
 5. When the uterus is firm, press the fundus Nurse: I can now feel that the uterus is
between the hands using the slight downward firm, I will now press your fundus between
pressure against the lower hand. my hands with slight downward pressure
RATIONALE: against my lower hand.
Gently squeezing with downward pressure helps
to expel blood or clots collected in the uterine
cavity.
6. Remove and observe the woman’s perineum Nurse: Ma’am, please allow me to check
for the passage of clots and the amount of your perineum, in order to remove the
bleeding. passage of clots and estimate the amount
RATIONALE: of your vaginal bleeding.
This helps to assess the degree of bleeding.
7. Massage the uterus one more time to be Nurse: Ma’am, we are almost done, I will
certain it remains firm, cleanse the perineum and do a fundal massage one more time just
apply a clean perineal pad. Discard gloves and to make sure that your uterus is firm.
soiled pads according to agency policy.
RATIONALE: Nurse: (After the fundal massage) Ma’am,
This helps to promote comfort and hygiene while I am now done with the procedure. I am
reducing the risk for infection. now cleaning your perineum and
afterwards I will apply a clean perineal
pad.
8. Document the result of the procedure. After the procedure I will document the
Continue to assess the fundus and lochia result of the procedure and I will continue
according to agency policy, Notify the primary to assess the fundus and lochia and I will
care provider if the fundus does not remain firm notify the primary care provider if the
or if bleeding continues. fundus does not remain firm or if the
RATIONALE: bleeding continues.
Documentation provides a means for evaluation.
Continued assessment allows for early
identification and prompt intervention with
additional measures such as oxytocin to prevent
hemorrhage.
With uterine atony, even if the uterus responds well to massage, the problem may not be
completely resolved because, as soon as you remove your hand from the fundus, the uterus may
relax and the lethal seepage will begin again.
1. To prevent this, remain with a woman after massaging her fundus and assess to be
certain her uterus is not relaxing again. Continue to assess carefully for the next 4 hours.
2. If a woman’s uterus does not remain contracted, contact her primary care provider so
interventions to increase contraction such as administering:
o a bolus or a dilute intravenous infusion of oxytocin (Pitocin) can be prescribed
to help the uterus maintain tone (Lang, Zhao, & Robertson, 2015).
3. Be aware, however, that oxytocin has a short duration of action:
o approximately 1 hour, so symptoms of uterine atony can recur quickly if it is
administered only as a single dose.
o If oxytocin is not effective at maintaining tone,
Carboprost tromethamine (Hemabate), a prostaglandin F2a derivative,
or methylergonovine maleate (Methergine), an ergot compound, both
given intramuscularly, are second possibilities.
Misoprostol (Cytotec), a prostaglandin E1 analogue, may also be
administered rectally to decrease postpartum hemorrhage.
  Carboprost tromethamine may be repeated every 15 to 90 minutes up to 8
doses;
 Methylergonovine maleate may be repeated every 2 to 4 hours up to 5 doses.
 A second dose of misoprostol should not be administered unless a minimum of 2
hours has elapsed.
4. Check that all of these drugs are readily available for use on a hospital unit in the event of
postpartum hemorrhage. Because prostaglandins tend to cause diarrhea and nausea as a side
effect, assess for this after administration; some women will need to be administered antiemetic
to limit these side effects (Bateman, Tsen, Liu, et al., 2014).
4. Be aware that all of these medications can increase blood pressure and so must be
used cautiously in women with hypertension. Assess blood pressure prior to administration and
about 15 minutes afterward to detect this potentially dangerous side effect.
Additional measures that can be helpful to combat uterine atony include:
 Elevate the woman’s lower extremities to improve circulation to essential organs.
 Offer a bedpan or assist the woman to the bathroom at least every 4 hours to be
certain her bladder is emptying because a full bladder predisposes a woman to
uterine atony. To reduce the possibility of bladder pressure, insertion of a urinary
catheter may be prescribed.
 Administer oxygen by face mask at a rate of about 10 to 12 L/min if the woman is
experiencing respiratory distress from decreasing blood volume. Position her
supine (flat) to allow adequate blood flow to her brain and kidneys.
 Obtain vital signs frequently and assess them for trends such as a continually
decreasing blood pressure with a continuously rising pulse rate.

When planning continuing care after sudden blood loss

 Remember that a woman may be so exhausted from labor and the effect of the blood loss
that she resents frequent uterine and blood pressure assessments.
 Explain that you realize these measures are disturbing, but that they are important for her
welfare.
 Obtain measurements as quickly and gently as possible to cause a minimum of discomfort
and disruption, allowing the woman time to rest.

Bimanual Compression
If fundal massage and administration of uterotonics (drugs to contract the uterus)
are not effective at stopping uterine bleeding, a sonogram may be done to detect
possible retained placental fragments. The woman’s primary care provider may
attempt bimanual compression (Weeks & Mallaiah, 2016).
 The primary care provider inserts one hand into a woman’s vagina while
pushing against the fundus through the abdominal wall with the other
hand.
 If this is ineffective, the woman may be returned to the birthing room, so
that her uterine cavity can be explored manually.
 Under sonogram visualization, a balloon catheter may be introduced
vaginally and inflated with sterile water until it puts pressure against the
bleeding site.
 Vaginal packing is inserted during this procedure to stabilize the placement of the balloon.
  Be certain to document the presence of the packing so it can be removed before agency
discharge because retained packing serves as a growth medium for microorganisms that
could lead to postpartal infection (Vintejoux, Ulrich, Mousty, et al., 2015).
Multiple Choice (10 points)
Answer the following questions carefully.

1. The mother had delivery an hour ago, the nurse must identify that the patient exhibits
hypovolemic shock when:
A. High blood pressure, tachycardic, skin warm to touch
B. Low blood pressure, weak pulse, cold clammy skin
C. High blood pressure, tachycardic, shallow respiration
D. Low blood pressure, weak pulse, skin warm to touch
2. The nurse is caring for a mother who has undergone post-operative delivery. To be
able to prevent complication, the nurse must know how to estimate the amount of blood
a postpartal woman after delivery, EXCEPT:
A. Counting the number of perineal pads saturated in given lengths of time, such as half-hour
intervals, a rough estimate of the amount of blood loss can be formed.
B. Weighing perineal pads before and after use and then subtracting the difference.
C. A woman will have lost approximately 250 ml of blood, and if either scenario is allowed to
continue unattended, she will be in grave danger of hypovolemia.
D. Assuming that the mother will consume five pads the whole shift.

3. During the assessment, the nurse noticed that the mother had uncontrolled blood loss,
the nurse should position the mother in:
A. Lithotomy Position
B. Side lying Position
C. Sitting Position
D. Prone Position

4. These are conditions that leave the uterus of the woman unable to contract readily,
EXCEPT:
A. Well-contracted uterus
B. Labor initiated or assisted with an oxytocin agent
C. Prior history of postpartum hemorrhage
D. Secondary maternal illness such as anemia

5. The nurse noticed that the mother in the delivery room is having hypovolemic shock
after giving birth. The nursing diagnosis would be:
A. Risk for excess fluid volume
B. Deficient fluid volume
C. Risk for infection
D. Risk for Pain

6. The patient was brought to OB ward after delivery with a history of multiple gestation.
The nurse knows that this is one of the risk factors of uterine atony. What is the initial
nurse action?
A. Check for body temperature
B. Palpate the fundus
C. Assess for skin integrity
D. Warm compress
7. The nurse assesses that the mother’s uterus is not relaxing despite continuously
massaging her fundus for 4 hours. The nurse notifies her physician and learn that the
nurse should prepare for administering:
A. Oxytocin (Pitocin) incorporated to current intravenous fluid as ordered.
B. Oxygen 4-6 LPM as ordered
C. 2 Packed of RBC as ordered
D. Paracetamol IV as ordered

8. Nurse Digna is aware that the oxytocin (Pitocin) has a short duration of action and
notices that it is not working on contracting the mother’s uterus. What should the nurse
prepare to administer after referring the situation to her physician?
A. Prepare to administer another dose of oxytocin (Pitocin) as ordered
B. Prepare to administer oxygen 6-10 LPM as ordered
C. Prepare to administer methylergonovine maleate (Methergine) intramuscularly as ordered
D. Prepare to administer hydralazine as ordered

9.The nurse administered methylergonovine maleate intramuscular to patients with

uterine atony. What are the nurse precautions in giving this medication?
A. Assess for patient’s body temperature
B. Assess for patient’s pulse
C. Assess for patient’s blood pressure
D. Assess for patient’s fluid input.

10. The nurse administered carboprost tromethamine to the mother with uterine atony,
the physician ordered to repeat the dose every 30 minutes interval. The nurse knows that
carboprost tromethamine can be administered repeatedly for:
A. Up to 14 doses
B. Up to 12 doses
C. Up to 10 doses
D. Up to 8 doses

11. This drug is administered rectally to decrease postpartum hemorrhage.

A. Carboprost tromethamine (Hemabate)
B. Misoprostol (Cytotec)
C. Methylergonovine maleate (Methergine)
D. Oxytocin (Pitocin)

12. During the patient’s combat to uterine atony, the nurse responsibilities are, EXCEPT:
A. Administer oxygen via face mask 10-12 LPM
B. Elevation of lower extremities
C. No bathroom privileges, offer bedpan for bladder emptying
D. Check vital signs every 4 hours

13. The patient had completed the dose for the administration of uterotonics, however
her body doesn’t respond to the treatment provided. Her physician would likely attempt
bimanual compression. The nurse knows this procedure is done:
A. By placing one hand on the abdomen just above the symphysis pubis.
B. By inserting one hand into the woman’s vagina while pushing against the fundus
C. By removing tissue inside the uterus
D. By removing thin layer of tissue that lines the uterus
14. The physician referred the patient from the birthing room to be examined and
admitted in the tertiary hospital for further evaluation. The patient’s uterus is not
responding to bimanual compression done by the primary care provider. The nurse
knows that the next procedure that the gynecologist would be:
A. Placing one hand on the abdomen just above the symphysis pubis.
B. Inserting one hand into the woman’s vagina while pushing against the fundus
C. Removing tissue inside the uterus
D. Using sonogram for visualization, a balloon catheter may be introduced vaginally and inflated
with sterile water until it puts pressure against the bleeding site.

15. After the bimanual compression using a balloon catheter, the physician facilitated
vaginal packing that is inserted to stabilize the placement. The nurse responsibility is to:
A. Remove the vaginal packing
B. Document the presence of vaginal packing
C. Add more vaginal packing
D. Prepare to administer oxytocin (Pitocin)

NAME OF STUDENT: _______________________________________________________

LEVEL & BLOCK: SCHOOL YEAR & TERM:

_____________________________ ___________________________
OVERALL RATING
 SESSION 8. UTERINE ATONY MANAGEMENT: FUNDAL MASSAGE
PERFORMANCE EVALUATION CHECKLIST 3

PROCEDURE PERFORMED PERFORMED UNABLE TO

INDEPENDENTLY WITH PERFORM
ASSISTANCE REMARKS
4-5 2-3 0-1

ASSESSMENT

1. Assess the woman with factors that predispose

to poor uterine tone or inability of her uterus to
maintain a contracted state such as conditions
that increase for postpartum hemorrhages.

2. Obtain the mother’s blood pressure and heart

rate. Blood pressure drops abruptly due to
vaginal bleeding.

3. Check for loss of blood that leads to

hypovolemic shock (falling blood pressure; a
rapid, weak, or thready pulse; increased and
shallow respirations; pale, clammy skin; and
increasing anxiety)

4. Estimate the amount of blood by counting

number of perineal pads saturated in given
lengths of time, such as half-hour intervals, a
rough estimate of the amount of blood loss can
be formed.

PLANNING

5. Explain the necessity for the procedure and

provide privacy.

6. Position the woman on her side when

inspecting for blood loss to be certain a large
amount of blood is not pooling undetected
beneath her.

7. Palpate a woman’s fundus at frequent intervals

to be assured her uterus is remaining contracted.
IMPLEMENTATION

8. Explain the necessity for the procedure and

provide privacy.
 9. Ask the patient to void (unless bleeding is
extensive and more rapid action seems
necessary). Ask her to lie supine with knees
flexed.

10. Put on gloves. Place one hand on the

abdomen just above the symphysis pubis. Place
the other hand around the top of the fundus.

11. Rotate the upper hand to massage the uterus

until it is firm, being careful not to overmassage

12. When the uterus is firm, press the fundus

between the hands using slight downward
pressure against the lower hand.

13. Remove and observe the woman’s perineum

for the passage of clots and the amount of
bleeding.

14. Massage the uterus one more time to be

certain it remains firm, cleanse the perineum, and
apply a clean perineal pad. Discard gloves and
soiled pads according to agency policy.
DOCUMENTATION

15. Document the results of the procedure.

Continue to assess the fundus and lochia
according to agency policy. Notify the primary
care provider if the fundus does not remain firm
or if bleeding continues.

REMARKS:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

_____________________ ______________________
CONFORME: STUDENT’S SIGNATURE CLINICAL
INSTRUCTOR