NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
INEFFECTIVE UTERINE FORCE 2. Hypertonic Contractions
- abnormal labor pattern, notable especially
during the active phase of labor, characterized
by poor and inadequate uterine contractions
that are ineffective to cause cervical dilation,
effacement, and fetal descent, leading to a
prolonged or protracted delivery. Hypotonic
labor is primarily a dysfunction of power. There
is inadequate propulsive power to cause fetal
descent, cervical dilatation, and eventual
expulsion of the fetus and placenta.
- Uterine contractions are the basic force that
moves the fetus through the birth canal. They
occur 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. In about 95% of labors,
contractions follow a predictable, efficient
course. When they have less strength than usual
or are rapid but ineffective, dysfunctional labor
occurs
Etiology/Cause
- Overdistension of the uterus.
- Developmental anomalies of the uterus e.g.
hypoplasia.
- Myomas of the uterus interfere mechanically
with contractions.
- Malpresentations, malpositions and
cephalopelvic disproportion. The presenting part
is not fitting in the lower uterine segment leading
to absence of reflex uterine contractions.
- Full bladder and rectum.
Types
1. Hypotonic Contractions
◼ Primary inertia: weak uterine contractions
from the start.
◼ Secondary inertia: inertia developed after a
period of good uterine contractions when it
failed to overcome an obstruction so the the
uterus is exhausted.
MODULE 2M: INTRAPARTAL COMPLICATIONS
◼ Colicky uterus: incoordination of the
different parts of the uterus in contractions.
◼ Hyperactive lower uterine segment: so the
dominance of the upper segment is lost.
Signs and Symptoms
Hypotonic Contractions
❖ There are only two or three contractions
occurring within a 10- minute period.
❖ The strength of contractions does not rise above
10 mmHg, and they occur mostly during the
active phase of labor.
❖ The number of uterine contractions in hypotonic
contractions is unusually slow or infrequent.
Hypertonic Contractions
❖ marked by an increase in resting tone to more
than 15 mmHg.
❖ They are more painful than usual, and they make
the woman frustrated with her breathing
techniques because they are ineffective.
Management
Nursing Management:
• Place the client in a lateral recumbent position
• Assess Uterine contraction pattern
• Encourage bed rest or sitting
position/Ambulation
• Monitor vital signs
• Explain to the woman and her partner that
although the contractions are very strong, they
are ineffective and are not achieving cervical
dilatation.
Medical Management:
• Uterine and fetal external monitor
should be applied at least 15 minutes to
check the resting phase of the
contractions and that the fetal pattern is
not showing a late deceleration
• Intravenous infusion
is frequently administered to maintain
hydration and electrolyte balance.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Pharmacologic Management:
• Administer short-acting tocolytics (eg,
terbutaline 0.25 mg IV once)
• Discontinuation of oxytocin if it is being used
• Administer analgesics to reduce pain
Surgical Management:
• Caesarean section
(is necessary if) there is late
deceleration, an abnormally long first
stage of labor or lack of progress with
pushing.
HYPOTONIC UTERINE CONTRACTION
- Occurs mostly during the ACTIVE PHASE of labor
- When uterine contractions are unusually slow or
infrequent
- Increased chance of postpartal hemorrhage
- Resting tone remains less than 10 mmHg
- . With hypotonic uterine contractions, the
number of contractions is unusually infrequent
(not more than two or three occurring in a 10-
minute period). The resting tone of the uterus
remains less than 10 mmHg, and the strength of
contractions does not rise above 25 mmHg (Fig.
23.1B). Hypotonic contractions occur during the
active phase of labor and tend to occur after the
administration of analgesia, especially if the
cervix is not dilated to 3 to 4 cm or if bowel or
bladder distention is preventing descent or firm
engagement. They also may occur in a uterus
that is overstretched by a multiple gestation, a
larger than usual single fetus, polyhydramnios,
or in a uterus that is lax from grand multiparity.
Such contractions are not exceedingly painful
because of their lack of intensity. Keep in mind,
however, that pain is a subjective symptom.
Some women, therefore, may interpret these
contractions as very painful.
- Hypotonic contractions will increase the length
of labor because more of them are necessary to
achieve cervical dilatation. If the uterus becomes
exhausted, this can cause it to not contract as
effectively during the postpartal period, thus
increasing a woman’s chance for postpartal
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hemorrhage. In the first hour after birth
following a labor of hypotonic contractions, it is
very important to palpate the uterine fundus,
obtain the woman’s blood pressure, and assess
the amount of lochia every 15 minutes for the
first hour to ensure postpartal contractions are
not also hypotonic and therefore not adequate
to halt postpartal hemorrhage.
Etiology/Cause
Hypotonic contractions occur after administration of
analgesia, bowel or bladder distention, if the uterus is
overstretched due to multiple gestation, a large fetus,
hydramnios, or a uterus that is lax from grand
multiparity.
- Hydramnios
- Overstretched uterus by a multiple gestation
- Bowel or Bladder distention
- Administration of analgesia if cervix is not dilated
to 3 to 4 cm
Types
1. Poor and inadequate uterine contractions that
are inadequate in causing cervical dilatation,
effacement, and fetal descent, resulting in a
prolonged or protracted delivery, especially
during the active phase of labor.
2. There are only two or three contractions
occurring within a 10- minute period.
3. The contractions in the uterus are feeble,
infrequent and have short durations. (no more
than two or three in a 10-minute span).
4. The contractions have a strength of less than 10
mmHg and are most common during labor's
active phase.
Signs and Symptoms
❖ The number of uterine contractions in hypotonic
contractions is unusually slow or infrequent.
❖ Number of Contractions: There are only two or
three contractions occurring within a 10-minute
period.
❖ The strength of contraction: does not rise above
10 mmHg, and they occur mostly during the
active phase of labor.
❖ Resting tone remains less than 10 mmHg
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Management
Nursing Management:
Always remember that it is significant to assess the
mother and fetus to exclude other causes of abnormal
labor progression, such as cephalopelvic disproportion
(CPD) a n d fetal malpositioning.
• Optimize uterine activity. In monitoring uterine
Pharmacologic Management:
contractions for dysfunctional patterns, the
nurse can use palpation and an electronic
monitor.
• Checking the client’s level of fatigue and ability
to cope with pain is important to prevent
unnecessary fatigue.
• Prevent complications of labor for the client and
infant such as:
Assessing the urinary bladder
Assessing maternal vital signs, including
temperature, pulse, respiratory rates,
and blood pressure.
Checking maternal urine for acetone (an
Surgical Management:
indication of dehydration and
exhaustion).
Assessing the condition of the fetus by
monitoring FHR, fetal activity, and color
of amniotic fluid.
• Promote relaxation by, giving back rubs,
promoting comfortable position (sidelying),
coaching the client in breathing and relaxation
techniques, and keeping the environment quiet.
• In the first hour after birth following labor of
hypotonic contractions, palpate the uterus and
assess the lochia every 15 minutes to ensure that
there are no postpartal hypotonic contractions
and inadequate to halt bleeding.
Medical Management:
• Amniotomy aids in the stimulation of
contractions by releasing prostaglandins and
reflex stimulation of the uterus when the
presenting part becomes closely applied to the
lower uterine segment. This should be
attempted when vaginal delivery is probable and
if cervical dilatation is less than 4 cm, there is
adequate fetal descent (station -2 or lower), and
MODULE 2M: INTRAPARTAL COMPLICATIONS
the presenting part is well applied to the lower
uterine segment.
• The combination of amniotomy and oxytocin
augmentation is more effective in the
management of hypotonic labor than
amniotomy alone when instituted early in the
active phase of labor.
• The use of intravenous oxytocin to stimulate
contractions can be followed provided there are
no contraindications. Oxytocin is the medication
of choice for augmenting contractions. The
dosage regimen should be titrated to effect for
achieving adequate uterine contractions. The
usual protocol is 5 units of oxytocin in 500mls of
5% Dextrose intravenous infusion, starting with
10 drops/min and gradually titrating the rate to
achieve a contraction rate of at least 3 per
minute.
• Assisted vaginal delivery using forceps, vacuum,
or breach extraction may be indicated if
ineffective efforts for bearing down are
observed and if the cervix is already fully dilated,
and vaginal delivery is indicated and probable.
• Cesarean section delivery is performed if all
other measures have failed to stimulate the
uterine contractions such as when oxytocin is
contraindicated, and if there is maternal
exhaustion, fetal distress, or even before full
cervical dilation.
HYPERTONIC UTERINE CONTRACTION
- Hypertonic labor is characterized by more
frequent, ineffective, and painful contractions,
which does not allow the uterus to relax
between contractions . It is most noticeable
during the latent phase of labor.
- Hypertonic uterine contractions are marked by
an increase in resting tone to more than 15
mmHg (Fig. 23.1C). However, the intensity of the
contraction may be no stronger than that
associated with hypotonic contractions. In
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
contrast to hypotonic contractions, these occur
frequently and are most commonly seen in the
latent phase of labor. Hypertonic contractions
may occur because more than one uterine
pacemaker is stimulating contractions or
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 can lead
to fetal anoxia early in the latent phase of labor.
Applying a uterine and a fetal external monitor
to any woman whose pain seems out of
proportion to the quality of her contractions will
help identify that the resting phase between
contractions is adequate and that the FHR is not
showing late deceleration
- If decelerations in the FHR, an abnormally long
first stage of labor, or lack of progress with
pushing (i.e., “second-stage arrest”) occurs,
cesarean birth may be necessary. Although this
is disappointing, be certain the woman and her
support person understand that, although
contractions are strong, they are ineffective and
are not achieving cervical dilatation
Etiology/Cause
- Uterine hyperstimulation is a complication that
can occur with excessive use of Pitocin during
labor. Pitocin is a medication administered to
pregnant women to induce or speed up labor. It
is a synthetic form of oxytocin – the hormone a
mother's body produces naturally during labor.
Signs and Symptoms
❖ Hypertonic contractions are marked by an
increase in resting tone to more than 15 mmHg.
❖ Hypertonic contractions tend to occur more
frequently and during the latent phase of labor.
MODULE 2M: INTRAPARTAL COMPLICATIONS
❖ They are more painful than usual, and they make
the woman frustrated with her breathing
techniques because they are ineffective.
Management
Nursing Management:
• Assess uterine contraction pattern; provide rest
(analgesia); provide comfort measures; monitor
maternal vital signs; frequently monitor fetal
status. Lateral position; administer oxygen by
mask.
Medical Management:
• Prostoglandin E2 is administered before labor to
minimize risk of uterine hyperstimulation and to
minimize the effects on Fetal Heart Rate.
• Administration of tocolytic treatment with β2-
adrenergic drugs has shown to stabilize uterine
contractions while also effectively lowering Fetal
Heart Rate.
• The usage of a balloon catheter to induce labor
rather than Prostoglandin E2 lowers the risk of
uterine hyperstimulation and its effect on fetal
heart rate.
Pharmacologic Management:
• Hypertonic uterine dysfunction is difficult to
treat, but repositioning, short-acting tocolytics
(eg, terbutaline 0.25 mg IV once),
discontinuation of oxytocin if it is being used, and
analgesics may help.
Surgical Management:
• Assisted vaginal delivery
may be performed using forceps,
vacuum, or breech extraction provided
the cervix is fully dilated, and vaginal
delivery is indicated and probable.
• Operative delivery by cesarean section
should be considered early when the
assessment indicates a CPD or fetal
malpositioning/malpresentation.
However, in the absence of an early
indication, cesarean section is
performed if all other measures have
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
failed to stimulate the uterine Types
contractions; when oxytocin is The first stage starts with uterine contractions leading to
contraindicated (including cephalopelvic complete cervical dilation and is divided into latent and
disproportion), if there is maternal active phases.
exhaustion, fetal distress (category III
1. Latent phase:
fetal heart tracing), or before full cervical
◼ Irregular uterine contractions occur along
dilation. Cesarean birth would be
with cervical effacement and dilatation that
necessary if there is late deceleration, an
is slow and progressive.
abnormally long first stage of labor or
2. Active phase
lack of progress with pushing.
An higher rate of cervical dilatation and fetal
COMPARISON OF HYPOTONIC AND descent indicates the active phase. The
HYPERTONIC CONTRACTIONS acceleration, maximum slope, and deceleration
Criteria Hypertonic Hypotonic phases are all part of the active phase, which
Most common Latent Active normally begins around 3-4 cm cervical dilation.
phase of
occurrence Management
Symptoms Painful Limited pain Nursing Management:
Medications • Nursing care for patients with dysfunctional
used
labor revolves around identifying and treating
Oxytocin Unfavorable Favorable
abnormal uterine patterns, preventing
reaction reaction
Sedation Helpful Little value unnecessary fatigue, monitoring maternal/fetal
physical response to contractile pattern,
providing emotional support for the client/
DYSFUNCTIONAL LABOR – 1ST STAGE couple, and preventing complications for the
- Dysfunctional or prolonged labor refers to a client and infant.
labor that lasts longer than expected, usually in
Medical Management:
the first stage. The intensity, duration, and
frequency of uterine contractions, cervical • For those in the latent phase, the treatment of
dilatation, and the descent of the fetus through choice is rest for several hours. During this
the pelvis are all used to diagnose labor delay. interval, uterine activity, fetal status, and
cervical effacement must be evaluated to
Etiology/Cause determine if progress to the active phase has
- Dysfunctional labor can be due to abnormalities
occurred. Approximately 85% of patients so
in uterine contraction and/or lack of ability of the
treated progress to the active phase.
mother to forcibly expel the fetus, a large fetus
Approximately 10% will cease to have
and/or an unusual orientation of the fetus in the
contractions, and the diagnosis of false labor
uterus, or abnormalities in the pelvis such that
may be made. For the approximately 5% of
the passage is blocked or too small.
patients in whom therapeutic rest fails and in
patients for whom expeditious delivery is
indicated, oxytocin infusion may be used.

Pharmacologic Management:

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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
• Options for managing the latent phase of labor
include observation, sedation with
antihistamines or mild narcotics, and labor
augmentation.
Surgical Management:
• Cesarean delivery for dystocia should not be
performed in women who remain in latent labor
for being induced with sedatives.
DYSFUNCTIONAL LABOR – 2ND STAGE
- Failure to progress in labor is a situation in which
labor stalls out or stops. This can relate to the
cervix not dilating enough, the baby’s head not
engaging with the mother’s pelvis, differences
between the size of the baby’s head and
mother’s pelvis, or with contractions not being
sufficiently strong or frequent to push the baby
out, among other factors.
- The active phase usually starts at 3-4 cm cervical
dilation and is subdivided into the acceleration,
maximum slope, and deceleration phases. The
second stage of labor is defined as complete
dilation of the cervix to the delivery of the infant.
Etiology/Cause
- Dysfunctional labor can be due to abnormalities
in uterine contraction and/or lack of ability of the
mother to forcibly expel the fetus, a large fetus
and/or an unusual orientation of the fetus in the
uterus, or abnormalities in the pelvis such that
the passage is blocked or too small.
Types
1. Prolonged latent phase
◼ Friedman defined prolonged latent phase as
> 20 hours in a nulliparous woman, and > 14
hours in a multiparous woman.
2. Protracted active phase dilation
Protracted labor is abnormally slow cervical
dilation or fetal descent during active labor.
3. Secondary arrest of dilation
◼ This is diagnosed when there has been no
change in cervical dilation for at least 2
hours. This time criterion is the same for
nulliparas and multiparas and is based in
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part on the certainty with which cervical
dilation can be determined on digital
examination.
4. Prolonged deceleration phase
◼ progress in dilation slows after 8 cm and
uterine contractions become dysfunctional,
even after oxytocin administration. In this
situation, the cervix starts to swell and take
on fluid. In this situation, a C-section may be
needed.
5. Protracted descent
◼ abnormally slow cervical dilation or fetal
descent during active labor.
6. Arrest of descent
◼ the head of the fetus is in the same place in
the birth canal during the first and second
examinations, which your doctor performs
one hour apart. This signifies that the baby
hasn't moved farther down the birth canal
within the last hour.
Signs and Symptoms
❖ The abnormally slow descent of the fetus during
the second stage of labor
❖ Abnormally slow dilation of the cervix during
active labor
❖ Lodging of the shoulders of the fetus once the
head has been delivered (shoulder dystocia)
Management
Nursing Management:
• Monitor uterine contractions for dysfunctional
patterns
• Check the patient’s level of fatigue and ability to
cope with pain
• Assess urinary bladder, catheterize as needed.
• Assess maternal vital signs Assess condition of
fetus by monitoring fetal heart rate, fetal
activity, and color of amniotic fluid
• Coach the client in breathing and relaxation
techniques
• Provide back rubs
• Nipple stimulation to produce endogenous
oxytocin
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
• Assess for malpositioning of fetus using
Leopold’s Maneuvers
Medical Management:
• Prepare for forceps delivery as necessary:
Excessive maternal fatigue, resulting in
ineffective bearing-down efforts in stage II labor,
indicates the use of forceps.
• Apply vacuum extractor as indicated: Vacuum
extractor may be used to rotate and expedite
delivery of fetus.
Pharmacologic Management:
• Administer narcotic or sedative such as
morphine, pentobarbital, or secobarbital
• Infusion of exogenous oxytocin (Pitocin) or
prostaglandins.
Surgical Management:
• Amniotomy: Rupture of membranes relieves
uterine overdistension and allows presenting
part to engage and labor to progress in the
absence of cephalopelvic disproportion.
• Cesarean Delivery: Immediate cesarean birth is
indicated for Bandl’s ring or fetal distress due to
CPD.
CONTRACTION RING
- A contraction ring is a spasmodic contraction of
the lower portion of the uterus which usually
occurs during the first phase of labour, but
persists into the second stage. The ring then
contracts round the child's neck and prevents
the child descending, thus delaying and
preventing delivery. It is a cause of obstructed
labor or dysfunctional labor.
Etiology/Cause
- Tonic uterine contraction
- Inco-ordinated uterine contractions
Types
1. Bandl’s Ring
◼ An end result of tonic uterine contraction
and retraction following obstructed labor. It
always occurs at the junction of upper and
MODULE 2M: INTRAPARTAL COMPLICATIONS
lower segments and progressively moves
upwards.
2. Constriction Ring
◼ A manifestation of localized inco-ordinated
uterine contractions caused by undue
irritability of the uterus . The constriction
ring usually occurs at the junction of upper
and lower segment, and the position does
not alter.
Signs and Symptoms
❖ Maternal exhaustion
❖ Fetal anoxia
Management
Nursing Management:
The nursing care for patients with dysfunctional labor
revolves around identifying and treating abnormal
uterine patterns, monitoring maternal/fetal physical
response to contractile pattern and length of labor,
providing emotional support for the client/couple and
preventing complications.
In conducting the nursing interventions, the nurse must
perform the following:
1. Optimize uterine activity. Monitor uterine
contractions for dysfunctional patterns; use
palpation and an electronic monitor.
2. Prevent unnecessary fatigue. Check the client’s
level of fatigue and ability to cope with pain.
3. Prevent complications of labor for the client and
infant.
Assess urinary bladder; catheterize as
needed.
Assess maternal vital signs, including
temperature, pulse, respiratory rates,
and blood pressure.
Check maternal urine for acetone (an
indication of dehydration and
exhaustion).
Assess the condition of the fetus by
monitoring FHR, fetal activity
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Medical Management:
• In cases when amniotic banding is constricting
the umbilical cord or cutting off the blood supply
to a baby's limb, a doctor can attempt to
surgically remove the bands before your baby is
born.
Pharmacologic Management:
• The classical treatment is morphia, anesthesia,
adrenaline, and inhalation of amyl nitrite which,
sometimes, relaxes the contraction ring
dramatically, and spinal anesthesia. If those
means prove unsuccessful, weight traction
attached to a scalp forceps is advised.
Surgical Management:
• In cases when amniotic banding is constricting
the umbilical cord or cutting off the blood supply
to a baby's limb, a doctor can attempt to
surgically remove the bands before your baby is
born.
PRECIPITATE LABOR
- Characterized as rapid labor and delivery that
can be completed in less than 3 hours. This can
be predicted from a labor graph. During the
active phase of dilatation, the rate is greater than
5 cm/hr (1cm every 12 minutes) in a nullipara or
10 cm/hr (1cm every 10 minutes) in a multipara.
However, this can result in maternal injury (i.e
cervical or perineal lacerations) and place the
fetus at risk for traumatic or asphyxia insults.
Etiology/Cause
- Grand multiparity
- Abnormally strong uterine and abdominal
contractions
- Abnormally low resistance of the soft pass of the
birth canal
- Absence of painful sensations
- Induction of labor by oxytocin
Signs and Symptoms
❖ Painful
❖ Sudden onset of strong contractions
❖ An intense feeling to bear down and push
MODULE 2M: INTRAPARTAL COMPLICATIONS
Management
Nursing Management:
• Monitor Vital signs
• Encourage oral intake
• Provide supplemental fluids as indicated
• Provide a quiet environment and privacy within
parameters of the situation.
• Note client’s level of consciousness and
mentation
Medical Management:
• Check for history of precipitate labor
• Induce labor with a low rupture of membranes
and a controlled delivery with care.
• Woman should be cautioned during the 28th
week.
• Cardiotocography
o The heart rate of your baby is measured
using cardiotocography (CTG).
o It also focuses solely on the womb's
contractions at the same time (uterus).
o It is used to monitor the baby for any
signs of distress both before birth
(antenatally) and throughout labor.
Pharmacologic Management:
• A tocolytic, such as a bolus of subcutaneous
terbutaline or intravenous ritodrine, should be
given to the mother if a syntocinon infusion is
being administered.
Surgical Management:
• Performing a cesarean delivery immediately
after the diagnosis of placental abruption may
have contributed to a reduction in the rate of
vaginal births.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
UTERINE RUPTURE
- During a uterine rupture, the endometrium,
myometrium, and peritoneum of the uterus
divide completely (Togioka & Tonismae, 2021). It
can also be described as a condition wherein the
woman’s uterus will tear through the uterine
wall and serosa. The hole resulting from the tear
could possibly lead to the entry of the fetus,
amniotic fluid, or umbilical cord into the
peritoneal cavity or broad ligament. This mainly
occurs in pregnant women but can also manifest
in women who are not pregnant.
Etiology/Cause
- In pregnant women, those who had previously
undergone cesarean deliveries were most likely
to experience a uterine rupture. Another reason
is having an overdistended uterus or the uterus
being larger than normal. Different procedures
may also cause this condition inadvertently
(Porter & Kaplan, 2011). Specifically, these are an
external or internal fetal version, an iatrogenic
perforation, and excessive use of drugs which
stimulate uterine contractions. In non-pregnant
women, the uterus may have a uterine rupture if
it is exposed to trauma, an infection, or cancer
(Herrera, Hassanein & Bansal, 2011)
Types
When it comes to uterine ruptures, a complete tear
through the epithelial layer until the serosal outer layer
is usually expected. However, sometimes the
perimetrium is left intact. In a complication such as
uterine rupture, there are two types which are both
equally concerning and require immediate attention
(Gibbins et al., 2015):
1. A complete uterine rupture
◼ refers to the tear going through the
endometrium, myometrium, and
peritoneum. Due to the damage done to the
myometrium (which is the smooth muscle
layer), uterine contractions stop. Two
swellings will also be made visible on the
woman’s abdomen.
MODULE 2M: INTRAPARTAL COMPLICATIONS
2. An incomplete uterine rupture
◼ is when the outer layer of the uterus is left
untorn. This makes it difficult to immediately
identify a uterine rupture as signs of rupture
won’t be easily seen.
Signs and Symptoms
❖ When uterine rupture occurs, immediate care
should be provided to the mother. This is mainly
because the signs and symptoms of uterine
rupture can lead to morbidity or mortality. These
include fetal bradycardia, noticeable signs of
hypovolemia, loss of fetal station, and severe or
constant abdominal pain (Guiliano et al., 2014).
Cases wherein the fetus entered the peritoneal
cavity due to uterine rupture have led to an
increase towards possible fetal and maternal
death. This is treated right away through a
laparotomy which helps control bleeding and the
birth of the fetus.
Management
Nursing Management:
• Monitor maternal blood pressure, pulse, and
respirations of the mother and the fetal heart
tones.
• Help with the patients physical and their
emotional support when needed
• Check cervical dilation
• Monitor uterine contractions
Medical Management:
• Look for circulatory accommodations
• Blood product might be used such as fibrinogen
or platelets
• Initiate cardiopulmonary resuscitation if the
patient arrest. If no response perform a
perimortem cesarean delivery
Pharmacologic Management:
• Rx emergency replacement therapy
• IV Oxytocin- contracts the uterus and minimize
bleeding
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Surgical Management:
• Laparotomy- to control bleeding and birth of the
fetus
• Cesarean hysterectomy- removal of the uterus at
the time of cesarean delivery
INVERSION OF THE UTERUS
- When the uterine fundus collapses into the
endometrial cavity, the uterus is turned partially
or entirely inside out, resulting in uterine
inversion. It's an uncommon consequence of
vaginal or cesarean birth, but it's a life-
threatening obstetric emergency when it does
happen. If not detected and treated
immediately, uterine inversion can result in
severe bleeding and shock, which can lead to
maternal death.
Etiology/Cause
The main cause of uterine inversion remains unclear.
However, it is linked to the following risk factors:
- labor lasting longer than 24 hours
- a short umbilical cord
- prior deliveries
- use of muscle relaxants during labor
- abnormal or weak uterus
- previous uterine inversion
- placenta accreta, in which the placenta is too
deeply embedded in the uterine wall
- fundal implantation of the placenta, in which the
placenta implants at the very top of the uterus
Types
1. 1st degree (also called incomplete) – The fundus
is within the endometrial cavity
2. 2nd degree (also called complete) – The fundus
protrudes through the cervical os
3. 3rd degree (also called prolapsed) – The fundus
protrudes to or beyond the introitus
4. 4th degree (also called total) – Both the uterus
and vagina are inverted
Signs and Symptoms
❖ Dizziness
❖ Abdominal pain
❖ A mass in the vagina
MODULE 2M: INTRAPARTAL COMPLICATIONS
❖ Low blood pressure.
Management
Nursing Management:
• Insertion of IV line using a large gauge needle.
• Assess vital signs.
• Prepare to perform CPR if a woman's heart fails
from blood loss.
• Rx Oxygen mask.
Medical Management:
• Immediate uterine repositioning is essential for
acute puerperal inversion.
• Measures to reposition the uterus may include:
• Preparing theatres for a possible laparotomy.
• Attempting prompt repositioning of the uterus.
This is best done manually and quickly,
as delay can render repositioning
progressively more difficult. Reposition
the uterus (with the placenta if still
attached) by slowly and steadily pushing
upwards towards the umbilicus,
commonly referred to as Johnson's
method.
Pharmacologic Management:
• Administer uterotonic drugs- Atony is common
after restoration of the normal uterine position.
• Antibiotic prophylaxis -administration of a single
dose of a first-generation cephalosporin.
Surgical Management:
Huntington procedure
• Locate the cup formed by the inversion
• Place a clamp, such as an Allis or Babcock clamp,
on each round ligament entering the cup,
approximately 2 cm deep in the cup.
• Gently pull on the clamps to exert upward
traction on the inverted fundus.
• Repeatedly clamp in 2 cm increments along the
ligament and exert traction until the inversion is
corrected.
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Haultain procedure
• Make an incision (approximately 1.5 inches in
length) in the posterior surface of the uterus to
transect the constriction ring and thus increase
the size of the previously constricted area.
• Manual reduction can be performed through the
vagina or by placing a finger abdominally
through the myometrial incision to below the
fundus and then exerting pressure on the fundus
to reduce the inversion.
• The incision is repaired when the uterus has
been returned to a normal position.
AMNIOTIC FLUID EMBOLISM
- Amniotic fluid embolism (AFE) is one of the
catastrophic complications of pregnancy that
occurs when amniotic fluid is forced into an open
maternal uterine blood sinus after a membrane
rupture or partial premature separation of the
placenta (Balinger, Chu Lam, Hon, et al., 2015).
Etiology/Cause
- Etiology largely remains unknown, but may
occur in healthy women during labour, during
cesarean section, after abnormal vaginal
delivery, or during the second trimester of
pregnancy. It may also occur up to 48 hours post-
delivery. It can also occur during abortion, after
abdominal trauma, and during amnio-infusion.
Previously, it was thought particles such as
meconium or shed fetal skin cells in the amniotic
fluid entered the maternal circulation and
reached the lungs as small emboli. A more likely
cause of symptoms is a humoral or
anaphylactoid response to amniotic fluid in the
maternal circulation. Although it is associated
with induction of labor, multiple pregnancy, and
perhaps polyhydramnios (i.e., excess amniotic
fluid), it is not preventable because it cannot be
predicted.
MODULE 2M: INTRAPARTAL COMPLICATIONS
Types
1. Typical AFE:
◼ Phase 1-respiratory and circulatory disorders
◼ Phase 2-coagulation disturbances of
maternal hemostasis
◼ Phase 3-acute renal failure and acute
respiratory distress syndrome (ARDS), and
leading to cardiopulmonary collapse.
2. Atypical AFE:
◼ Uterine Hemorrhage
◼ Adult respiratory syndrome (ARDS)- as form
of atypical AFE
◼ Paradoxical AFE
◼ Cesarean section- related atypical AFE
Signs and Symptoms
❖ Acute or sudden shortness of breath (dyspnea)
❖ Excess fluid in the lungs (pulmonary edema)
❖ Sudden low blood pressure
❖ Sudden failure of the heart to effectively pump
blood (cardiovascular collapse)
❖ Life-threatening problems with blood clotting
(disseminated intravascular coagulopathy)
❖ Bleeding from the uterus, cesarean incision or
intravenous (IV) sites
❖ Altered mental status, such as anxiety or a sense
of doom
❖ Chills, shivering, sweating
❖ Rapid heart rate or disturbances in the rhythm of
the heart rate
❖ Fetal distress, such as a slow heart rate, or other
fetal heart rate abnormalities
❖ Seizures
❖ Loss of consciousness
Management
Nursing Management:
• Admit the patient with amniotic fluid embolism
(AFE) into the intensive care unit (ICU).
Medical Management:
• Initiate cardiopulmonary resuscitation (CPR) if
the patient arrests. If she does not respond to
resuscitation, perform a perimortem cesarean
delivery.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
• Treat hypotension with crystalloid and blood
products. Use pressors as necessary.
• Avoid excessive fluid administration. During the
initial phase, right ventricular function is
suboptimal. Excess fluid may over distend the
Right ventricle which could increase the risk of a
right sided myocardial infarction.
Pharmacological Management
• Drugs are used in amniotic fluid embolism (AFE)
to stabilize the patient. Pressors are used to
maintain blood pressure, and inotropes are used
to improve contractility. Use of steroids has been
suggested because the process may be immune
mediated. Uterotonics may be used to limit
postpartum bleeding.
Surgical Management
• Perform emergent cesarean delivery in arrested
mothers who are unresponsive to resuscitation.
PRETERM LABOR
- Preterm labor happens when your cervix opens
after week 20 and before week 37 of pregnancy
due to consistent contractions. Premature birth
can be the outcome of preterm labor. The higher
the risk of your baby's health if he or she is born
prematurely. In the neonatal intensive care unit,
many premature babies (preemies) require
special attention. Preemies can suffer from long-
term mental and physical problems as well.
Etiology/Cause
- There are a number of reasons for preterm birth.
For no apparent reason, a woman may go into
labor early. There may be a medical reason for
early labor and delivery at other times. Like
premature rupture of membranes, bleeding
during pregnancy, and weak cervix.
MODULE 2M: INTRAPARTAL COMPLICATIONS
Types
Preterm occurs when babies are born alive before 37
weeks of pregnancy. There are sub-categories of preterm
birth based on gestational age:
• Extremely preterm which is less than 28 weeks
• Very preterm is 28 to 32 weeks,
• Moderate to late preterm occurs between 32 to
37 weeks.
Signs and Symptoms
❖ Regular or frequent contractions
❖ Constant low, dull backache
❖ Pelvic or abdominal pressure
❖ Mild abdominal cramps
❖ Vaginal spotting
❖ Preterm rupture of membranes
❖ Watery, mucus-like or bloody vaginal discharge
Management
Nursing Management
• When tests reveal immature fetal lung
development, cervical dilatation is less than 4
cm, and there are no contraindications to
continuing the pregnancy, premature labor is
suppressed. For patients with preterm labor, the
nurse should keep a watchful eye out for
indicators of fetal or maternal discomfort and
give complete supportive care.
Medical Management
• Pelvic exam. Your health care provider might
evaluate the firmness and tenderness of your
uterus and the baby's size and position.
• Ultrasound. A transvaginal ultrasound might be
used to measure the length of your cervix. An
ultrasound might also be done to check for
problems with the baby or placenta, confirm the
baby's position, assess the volume of amniotic
fluid, and estimate the baby's weight.
• Uterine monitoring. Your health care provider
might use a uterine monitor to measure the
duration and spacing of your contractions.
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Pharmacological Management
• Exogenous progesterone, corticosteroids, and
tocolytics (-adrenergic agonists, magnesium
sulfate, calcium channel blockers, prostaglandin
inhibitors, nitrates, and oxytocin receptor
blockers) this is to prolong pregnancy as safely as
possible to permit fetal development and
maturation
Surgical Management
• Cervical cerclage might be recommended if
you're less than 24 weeks pregnant, you have a
Nursing Management:
history of early premature birth, and an
ultrasound shows your cervix is opening or your
cervical length is less than 25 millimeters.
PREMATURE RUPTURE OF MEMBRANES
- Premature rupture of membranes (PROM) is the
rupture or breaking open of gestational
membranes that surrounds the baby, amniotic
sac, prior to the onset of labor. When the sac
ruptures, the pregnant woman has an increased
risk for infection and has a higher chance of
having the baby born prematurely.
Etiology/Cause
- There is a variety of mechanisms that cause
prelabor rupture of membranes. Rupture of the
membranes before the end of pregnancy (term)
can be caused by a physiologic weakening of the
membranes or from the force of contractions.
Some causes or risk factors may be infections of
the uterus, cervix, or vagina; too much stretching
of the amniotic sac which can happen if there is
too much fluid, or if there is more than one baby
putting pressure on the membranes; smoking; if
the mother has had cervix surgery or biopsies;
and if the mother was pregnant before and had
a PROM or PPROM.
MODULE 2M: INTRAPARTAL COMPLICATIONS
Types
1. Preterm premature rupture of membranes
◼ Amniotic sac ruptures before 37 weeks of
pregnancy
2. Spontaneous rupture of membrane
◼ Rupture of membranes after or with the
onset of labor occurring prior to 37 weeks.
Management
❖ Leaking or a gush of watery fluid from the vagina
❖ Constant wetness in underwear
Management
• Prevent infection and other tissues from
occurring.
Using sterile speculum examination and
ferning determination, make an early
and accurate assessment of membrane
health. To avoid infection, restrict
vaginal inspections to be a bare
minimum after that.
Take smear samples from the vaginal
and rectum as directed to check for beta
hemolytic streptococci, a bacteria that
puts the fetus at risk.
Determine the status of the mother and
fetus, including the approximate
gestational age. Examine for indications
of infection on a regular basis.
If the fetal head is not engaged, keep the
client in bed. If there is another rupture
and fluid loss, this approach may avoid
cord prolapse. Ambulation can be
promoted once the fetal head is
engaged.
• Provide client and family education.
If the fetus is at term, tell the client that
the possibilities of spontaneous labor
starting are high; encourage the client
and partner to prepare for labor and
birth.
Explain the therapies that will likely be
required if labor does not start or if the
fetus is determined to be premature or
at risk of infection.
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• Fever, discomfort, an elevated fetal heart rate,
and/or laboratory testing are all indicators of
infection and should be monitored.
Medical Management
• Determine if the cervix is suitable for labor
induction.
If the patient’s cervix is in good shape,
there’s no need to wait. As a result,
intravenous oxytocin should be used to
induce labor as soon as feasible.
Pharmacological Management
• Give corticosteroids to the mother.
This might help the fetus’ lungs grow
since lung immaturity is a major problem
of premature babies. This medication,
on the hand, may hide a uterine
infection.
• Antibiotics
This is to avoid or treat infections.
• Tocolytics
These are medications that are used to
prevent premature labor.
Surgical Management
• If PPROM is stable, women with the condition
generally deliver at 34 weeks. Early delivery is
required if there is evidence of abruption,
chorioamnionitis, or fetal compromise.
MODULE 2M: INTRAPARTAL COMPLICATIONS
PROLAPSE OF THE UMBILICAL CORD
- The umbilical cord connects to the placenta. It
delivers nutrients and serves as the baby’s
lifeline to the mother. Prolapse of the umbilical
cord happens when the cord between the baby’s
body and pelvic bones are compacted, reducing
the baby’s blood supply. This occurrence will
hinder oxygen supply to the baby. This condition
occurs when the umbilical cord falls out between
the fetal presenting part and the cervix into the
vagina
Etiology/Cause
- Premature rupture of the membranes
◼ The most common cause of prolapse. When
the membranes rupture earlier than
expected or undergo an amniotomy
procedure, the baby’s head may be high up
in the uterus, allowing the umbilical cord to
fall out through the cervix.
- Fetal Presentation other than cephalic
- Placenta previa
- Intrauterine tumors preventing the presenting
part from engaging
- CPD preventing firm engagement
- Prematurity / A small fetus
◼ Premature infants are vulnerable to
malpresentation and they tend to be
smaller. (a higher volume of amniotic fluid in
relation to the baby’s size)
- Multiple gestation pregnancies (twins,triplets,
etc.)
◼ Upon exiting the mother’s womb, the baby
may possibly push the other baby’s cord out.
- Polyhydramnios
◼ Excessive amniotic fluid may push the cord
forcefully due to the pressure of the fluid
exiting the mother.
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Types
Cord prolapse may be subdivided into three types the
following are:
1. Overt cord prolapse
◼ After the membranes are ruptured, the
umbilical cord descends through the cervix
into the vaginal canal.
2. Funic Presentation
◼ The loop of the umbilical cord lies between
the fetal presenting part and the still-intact
fetal membranes covering the cervical os.
3. Occult prolapse
◼ Occult cord prolapse results when the cord’s
location is alongside the presenting part, but
it cannot be detected by the examiner.
Signs and Symptoms
An umbilical cord prolapse may occur with no outward
physical signs on the mother and no fetal heart trace but
upon examination, an ill-fitting or unengaged presenting
part should alert one to the possibility of cord prolapse.
Another sign/symptom can be:
❖ Seeing/feeling the umbilical cord before the
baby is delivered. This is the most obvious sign of
a cord prolapse.
❖ Fetal distress from lack of oxygen.
❖ Prolonged fetal heart rate deceleration on the
fetal monitor.
Management
Nursing Management
• Inform the neonatal team for possible neonatal
resuscitation.
Medical Management
• Funic Decompression - Until delivery is possible,
relieving the pressure on the cord by elevation of
the fetal presenting part, is the cornerstone of
management in cord prolapse. It is done
manually by the medical provider through the
placement of their finger or hand in the vaginal
vault and gentle elevation of the presenting part
off the umbilical cord.
Pharmacologic Management
• Consider Tocolysis (e.g. terbutaline) - If delivery
is imminently unavailable, this treatment can
relax the uterus and stop contractions which can
relieve the pressure off the cord. It may also
allow sufficient time for transfer to a location
where delivery is feasible. This can be
particularly useful when there are fetal heart
rate abnormalities while preparing for a C-
section.
Surgical Management
• Lower Segment Cesarean Section (LSCS) -
Cesarean delivery, also known as “C-section”, is
a surgical procedure wherein a baby is delivered
by making an incision in the mother’s abdomen
and another in the mother’s uterus.

• Identify prolapsed cord and apply immediate

intervention.
• Assess fetal viability.
• Call for assistance.
• Change the patient’s position to trendelenburg
or modified sims position.
• Relieve pressure from cord.
• Prepare for emergency delivery or cesarean
birth.
• Administer oxygen by mask by 10-12 L/min.
• Fill maternal bladder with 500-700 cc NS
• Continuous fetal monitoring.

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MULTIPLE GESTATION
- considered a complication of pregnancy because
a woman’s body must adjust to the effects of
more than one fetus. It begins with single ovum
and spermatozoon. In the process of fusion, or in
one of the first cell divisions , the zygote divides
into one of the first cell divisions , the zygote
divides into two identical individuals. Single -
ovum twins usually have one placenta , one
chorion, two amnions , and two umbilical cords.
Etiology/Cause
- The use of fertility drugs to induce ovulation
often causes more than egg to be released from
the ovaries and can result in twins, triplets , or
more.
- In vitro- fertilization (IVF) can lead to multiple
pregnancy if more than one embryo is
transferred to the uterus. Identical multiple also
may result if the fertilized egg splits after
transfer.
- Women older than age 35 are more likely to
release two or more eggs during a single
menstrual cycle than younger women. So older
women are more likely than younger women to
become pregnant with multiple.
Types
1. Fraternal twins
◼ ‘dizygotic’ twins referring two zygotes
(fertilized eggs)
◼ two separate eggs
◼ may look the same or different
◼ Same or different
◼ baby has its own placenta and amniotic sac.
2. Identical twins
◼ ‘monozygotic ‘ referring to one zygote (
fertilized egg)
◼ single fertilized egg is split in half
◼ each half (embryo) genetically identical
◼ Babies share same DNA means they may
share same characteristics
◼ share same placenta amniotic sac or they
may have their own placenta and amniotic
sac
MODULE 2M: INTRAPARTAL COMPLICATIONS
3. Triplets and ‘higher order multiples’ (HOMs)
◼ Triplets, quadruplets ,sextuplets or more can
be a combination both of identical and
fraternal multiples.
◼ example: triplets can be either fraternal (
trizygotic) forming from 3 individuals egg
that fertilized and implanted the uterus ; or
they can be identical , when one egg divides
into 3 embryos ; or they can be a
combination of both.
Signs and Symptoms
The following are the most common symptoms of
multiple pregnancy. However, each woman may
experience symptoms differently. Symptoms of multiple
pregnancy may include:
❖ Uterus is larger than expected for the dates in
pregnancy
❖ Increased morning sickness
❖ Increased appetite
❖ Breast tenderness than women who are
pregnant with a single fetus.
❖ Excessive weight gain, especially in early
pregnancy
❖ Fetal movement felt in different parts of
abdomen at same time
Management
Nursing Management:
• Advice the mother for frequent prenatal visits
this is to detect problems as early as
possible. The mothers’s nutritional
status and weight should also be
monitored
• Increase nutrition
Carrying two or more fetuses need more
calories,protein and other nutrients,
including iron. Higher weight gain is also
recommended for multiple pregnancy.
• Increase rest
Higher -order multiple pregnancies
often require bedrest starting in the
middle of the second trimester.
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Preventive bed rest has not been shown
to prevent preterm birth in multiple
pregnancy.
• Referrals
Referrals to a maternal -fetal medicine
specialist called a perinatologist , for
special testing or ultrasound
evaluations, and to coordinate care of
complications , may be necessary
Medical Management:
• Pregnancy blood testing
levels of human chorionic gonadotropin
(hCG) may be quite high with multiple
pregnancy
• Alpha-fetoprotein
levels of a protein released by the fetal
liver and found in the mother’s blood
may be high when more than one fetus
is making the protein
• Ultrasound
a diagnostic imaging technique that uses
high-frequent sound waves to create
images of blood vessels, tissues , and
organs. Ultrasound can be done with a
vaginal transducer, especially in early
pregnancy .
Pharmacologic Management:
• Tocolytic medications
May be given if preterm labor occurs, to
help slow or stop contractions of the
uterus . These may be given orally, in an
injection , or intravenously. Tocolytic
medications often used include
magnesium sulfate.
• Corticosteroid medications
a medication may be given to help
mature the lungs of the fetuses. Lung
immaturity is a major problem of
premature babies.
MODULE 2M: INTRAPARTAL COMPLICATIONS
Surgical Management:
• Cervical cerclage
Cerclage ( a procedure used to suture
shut the cervical opening) is used for
women with an incompetent cervix. This
is a condition in which the cervix is
physically weak and unable to stay
closed during pregnancy . Some women
with higher - order multiple may require
cerclage in early pregnancy.
HYDRAMNIOS
- There is too much amniotic fluid around the baby
during pregnancy in this complication. It’s also
called polyhydramnios.
- It occurs when the excess fluid is more than
2,000 ml or an amniotic fluid index above 24 cm.
- It can cause fetal malpresentation because the
additional uterine space can allow the fetus to
turn to a transverse lie. It can also lead to
premature rupture of the membranes from the
increased pressure, leading to the additional
risks of infection, prolapsed cord, and preterm
birth.
Etiology/Cause
- Amniotic fluid is formed by a combination of the
amniotic membrane cells and from fetal urine. It
is swallowed, absorbed into the fetal
bloodstream through the intestinal membrane,
and then transmitted to the placenta. Although
polyhydramnios can occur separate from fetal
involvement, accumulation of amniotic fluid
suggests difficulty with the fetus's ability to
swallow or absorb or excessive urine production.
Inability to swallow occurs in anencephalic
infants with a tracheoesophageal fistula with
stenosis or intestinal obstruction (Bishop &
Ebach, 2015). Excessive urine output appears in
the fetuses of diabetic women (hyperglycemia in
the fetus causes increased urine production)
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Signs and Symptoms
❖ Rapid enlargement of the uterus.
❖ The overly distended uterus pushes up against
the diaphragm with extreme shortness of
breath.
❖ Lower extremity varicosities and hemorrhoids
because good venous return from the lower
extremities is blocked by extensive uterine
pressure.
❖ The increased amount of fluid will cause
increased weight gain.
Management
Nursing Management:
• Encourage bed rest
• Encourage high fibre diet
• Suggest a stool softener if diet alone is
ineffective
• Assess vital signs as well as edema in lower
extremities
Medical Management:
• Monitor fluid levels
• Remove excess amniotic fluid.
Pharmacologic Management:
• Administer Indomethacin- decreased
urinary output.
Surgical Management:
• Tocolysis -To slow or halt labor, suppression of
uterine contractions
• “Needling” of membranes - To allow slow
controlled release of fluids
• Amniocentesis -to reduce the volume of the
amniotic fluid
MODULE 2M: INTRAPARTAL COMPLICATIONS
OCCIPITO-POSTERIOR POSITION
- This term refers to the fact that the back of your
baby's skull (the occipital bone) is in the back (or
posterior) of your pelvis. You may also hear this
position referred to as "face-up" or "sunny-side
up."
- Occipitoposterior position is a delivery
presentation wheir, the baby's head is down, but
it is facing the mother's front instead of her back.
Etiology/Cause
- The occipitoposterior position in the main is
caused by the adaptation of the head to a pelvis
having a narrow fore pelvis and an ample
anteroposterior diameter and therefore may be
considered “physiologic.”
Types
1. Right Occipitoposterior
◼ In the right occiput posterior position (ROP),
the baby is facing forward and slightly to the
right (looking toward the mother's left
thigh). This presentation may slow labor and
cause more pain.
2. Left Occipitoposterior
The baby is facing forward and slightly to the left
(looking toward the mother's right thigh). This
fetal presentation can lead to more back pain
(sometimes referred to as "back labor") and slow
progression of labor.
3. Direct Occipitoposterior
◼ In direct occipito-posterior, the head can be
delivered by flexion supposing that the
uterine contractions are strong and there is
no contracted pelvis.
Signs and Symptoms
Symptoms:
❖ Back labor
❖ Prolonged labor
Signs:
❖ Abdominal examination
◼ The mother may complain of backache and
she may feel that her baby’s bottom is very
high up against her ribs.
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◼ Upon inspection: There is a saucer-shaped
depression at or just below the umbilicus.
This depression is created by the ‘dip’
between the head and the lower limbs of the
fetus.
◼ Upon palpation: While the breech is easily
palpated at the fundus, the back is difficult
to palpate as it is well out to the maternal
side, sometimes almost adjacent to the
maternal spine. Limbs can be felt on both
sides of the midline.
◼ Upon auscultation: The fetal back is not well
flexed so the chest is thrust forward,
therefore the fetal heart can be heard in the
midline. However, the heart may be heard
more easily at the flank on the same side as
the back.
❖ Vaginal examination
◼ The findings will depend upon the degree of
flexion of the head; locating the anterior
fontanelle in the anterior part of the pelvis is
diagnostic. The direction of the sagittal
suture and location of the posterior
fontanelle will help to confirm the diagnosis.
Management
Nursing Management:
• Apply counterpressure by a back rub to relieve
mother’s back pain.
• During a long labor, be certain that the mother
voids approximately every 2 hours to keep her
bladder empty.
• REBOZO method of jiggling and massaging the
uterus.
• Provide frequent assurance and support when
the mother is getting worried during prolonged
labor.
Medical Management:
• Manual rotation during vaginal exam.
o Flex fetal head
➢ Place hand in posterior pelvis
behind occiput
➢ Wedge head into flexion
MODULE 2M: INTRAPARTAL COMPLICATIONS
o Rotate head
➢ Perform during contraction with
mother pushing
➢ OP: Examiner pronates
dominant hand on exam
➢ ROP: Examiner pronates left
hand clockwise
➢ LOP: Examiner pronates right
hand counter clockwise
Pharmacologic Management
• Administer narcotic or sedative
• Administer antibiotic
Surgical Management
• Cesarean section
• Vacuum delivery
• Forceps delivery
FACE, BREECH, BROW PRESENTATION
Face Presentation
- In a face presentation, the fetal head and neck
are hyperextended, causing the occiput to come
in contact with the upper back of the fetus while
lying in a longitudinal axis. The presenting
portion of the fetus is the fetal face between the
orbital ridges and the chin.
Breech Presentation
- In a breech presentation, the baby’s feet or
buttocks are positioned to come out of the
vagina first. The baby’s head is up closest to the
chest of the mother and its bottom is closest to
the vagina.
Brow presentation
- One of many abnormal positions that can lead to
labor and delivery complications and subsequent
birth injuries. A fetus in brow presentation has
the chin untucked, and the neck is extended
slightly backward. It is similar to face
presentation, except the neck is less extended.
As the term “brow presentation” suggests, the
brow (forehead) is the part that is situated to go
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
through the pelvis first. Vaginal delivery can be Signs and Symptoms
difficult or impossible with brow presentation, Breech Presentation
because the diameter of the presenting part of
❖ Fetal heartbeat primarily above the umbilicus
the head may be too big to safely fit through the
❖ Head ballotable in the fundal area
pelvis.
❖ Softer irregular mass in the pelvis
Etiology/Cause ❖ Subcostal tenderness
There are many different reasons why a baby may
Face Presentation
present brow-first, face-first or breech-first. It could be
due to: ❖ deflexed/ hyperextended neck
❖ Soft tissue with an orifice
- if a woman has had several pregnancies
❖ Facial features of the chin, mouth nose, and
- if a woman has had a premature birth in the past
cheekbones can be felt
- if the uterus has too much or too little amniotic
fluid, meaning the baby has extra room to move Brow Presentation
around in or not enough fluid to move around in
- if the woman has an abnormally shaped uterus ❖ Chin is untucked
or has other complications, such as fibroids in ❖ Neck extended slightly backward
the uterus Management
- if a woman has placenta previa Nursing Management:
- Fetal Macrosomia (large baby)
- Cephalopelvic disproportion, or CPD(a mismatch • FHR Monitoring
in size between the mother’s pelvis and the • Examine patient and document of a partograph
baby’s head) • Examine the patient to exclude cord prolapse in
- Multiple nuchal cords (umbilical cord wrapped the event of membrane rupture.
around baby’s neck more than once)
Medical Management:
- Multiparity (the mother has previously given
birth) • ECV may be offered to the patient if there are no
- Maternal obesity contraindications.
• Inform the patient ECV may risk complications of
Types
future pregnancies.
Types of breech presentation
• Inform the patient of less complications with a
1. Frank breech: successful vaginal birth.
◼ The baby’s buttocks are aimed at the vaginal
Pharmacologic Management:
canal with its legs sticking straight up in front
of their body and the feet near their head. • Terbutaline may be used to prevent uterine
2. Complete breech contractions and relax the uterus if need be.
◼ The baby’s buttocks are pointing downward
and both the hips and the knees are flexed Surgical Management:
(folded under themselves). • Emergency C-sections are performed when the
3. Footling breech: baby or mother are at risk.
◼ One or both of the baby’s feet point
downward and will deliver before the rest of
their body.

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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
TRANSVERSE LIE
- A transverse lie position in pregnancy means that
the baby is horizontal in your belly. The position
of the baby becomes an issue as your due date
approaches. The optimal position for vaginal
delivery is the head down or vertex position.
Etiology/Cause
Some of the more common reasons why a baby may be
in the transverse lie position include the following:
- Abnormality of the uterus
- Having a cyst or fibroid blocking your cervix
- Pelvic structure
- Polyhydramnios (too much amniotic fluid) or low
fluid levels
- Position of the placenta
- Second (or more) pregnancy
- Twin or multiple pregnancy
Signs and Symptoms
❖ Abdominal examination— In transverse position,
the presenting part of the fetus is typically the
shoulder. During abdominal examination, the
head or the buttocks cannot be felt at the
bottom of the uterus and the head is usually felt
in the side.
❖ Vaginal examination— A shoulder may be felt
during a vaginal examination. An arm of the fetus
may even slip forward and the hand or elbow
may be felt during pelvic examination.
❖ Confirmation - An ultrasound scan of the uterus
confirms the transverse lie position.
Management
Nursing Management:
• Adequate prenatal care to diagnose the case
antenatally.
• Develop a delivery plan.
Medical Management:
• Manually rotate the fetus into a head-first
presentation.
• Pushing on the mother’s abdomen to roll the
fetus.
MODULE 2M: INTRAPARTAL COMPLICATIONS
• Reaching into the mother’s uterus to move the
fetus.
Pharmacologic Management:
• If it is needed to do internal and external
versions, medications are also involved.
Surgical Management:
• The medical team may also perform an
amniotomy in order to induce labor after turning
the baby.
• If the version is unsuccessful, a C-section may be
necessary
MACROSOMIA
- Macrosomia is used to describe a newborn who's
much larger than average or has an excessive
birth weight. A baby who is diagnosed as having
fetal macrosomia weighs more than 8 pounds,
13 ounces (4,000 grams), regardless of his or her
gestational age.
- An accurate diagnosis of fetal macrosomia can
be made only by measuring birth weight after
delivery; therefore, the condition is confirmed
only retrospectively, ie, after delivery of the
neonate.
Etiology/Cause
- Having a family history of fetal macrosomia.
- Excessive weight gain during pregnancy.
- Obesity during pregnancy.
- Multiple pregnancies.
- A pregnancy lasting more than 40 weeks.
- A mother with an above-average height and
weight.
- Maternal diabetes
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Signs and Symptoms
During pregnancy, fetal macrosomia can be difficult to
detect and diagnose. Among the signs and symptoms
are:
❖ Large Fundal Height
◼ A larger-than-expected fundal height may
indicate fetal macrosomia.
❖ Excessive amniotic fluid (polyhydramnios)
◼ The amount of amniotic fluid in a baby
reflects his or her urine output, and a larger
baby produces more urine.
Management
Nursing Management:
• Antenatally, intervention is aimed at identifying
and preventing macrosomia and sudden fetal
death.
• Intrapartally, screening and monitoring are used
to identify cephalopelvic disproportion and
shoulder dystocia in order to avoid birth trauma
and fetal asphyxia.
• A thorough assessment should be performed
during the neonatal period to identify
respiratory distress, birth trauma, problems with
metabolic transition, and congenital anomalies.
Medical Management
• The doctor may advise to have the baby
delivered via C-section.
Pharmacologic Management
• Prescriptions for diabetes medications are
provided.
• Blood sugar levels should be checked three times
per day, or as directed.
Surgical Management
• Elective cesarean section for women whose
pregnancies are complicated by macrosomia if
the estimated fetal weight is greater than 5000 g
without underlying glucose intolerance or 4500
g with underlying glucose intolerance.
• In women with macrosomic pregnancies,
assisted vaginal delivery, such as forceps or
MODULE 2M: INTRAPARTAL COMPLICATIONS
vacuum-assisted deliveries, should be
performed with extreme caution.
SHOULDER DYSTOCIA
- Shoulder dystocia is a birth injury (also called
birth trauma) is an obstetric complication of
cephalic vaginal deliveries during which the fetal
shoulders do not deliver after the head has
emerged from the mother’s introitus. It occurs
when one or both shoulders become impacted
against the bones of the maternal pelvis.
Etiology/Cause
- Fetal macrosomia: (Your baby weighs more than
8 pounds, 13 ounces.)
- Your baby is in the wrong position.
- Your pelvic opening is too small.
- You are in a position that limits the room in your
pelvis.
- Being overweight
- Deliveries past due date
Signs and Symptoms
❖ Signs include retraction of the baby's head back
into the vagina, known as "turtle sign" which
involves the appearance and retraction of the
baby's head, and a red puffy face . Shoulder
dystocia is not identified until the head has
already been born and the wide anterior
shoulder locks beneath the symphysis pubis.
Management
Nursing Management
• Assess maternal vital signs, including
temperature, pulse, respiratory rates, and blood
pressure.
• Assess the condition of the fetus by monitoring
FHR, fetal activity, and color of amniotic fluid.
• Assess the condition of the fetus by monitoring
FHR, fetal activity, and color of amniotic fluid,
and coach the client in breathing and relaxation
techniques.
Medical Management
• Assist the and ask the client to flex her thighs
sharply on her abdomen to perform McRoberts
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Maneuver to widen the pelvic outlet and allow Management
the anterior shoulder to be born. Nursing Management:
• Apply Suprapubic pressure to help the shoulder
• Identify and treat abnormal uterine pattern
escape from beneath the symphysis pubis and be
• Monitor maternal/fet al physical response to
born.
contractile pattern
• Perform further maneuvers such as the internal
• observe the length of labor
maneuvers.
• Provide emotional support for the client and
Pharmacologic Management prevent complication s.
• Note signs of fetal distress, cessation of
• The client may be given medicines to reduce
contractions, presence of vaginal bleeding.
your pain or to prevent or treat a bacterial
• Assist with preparation for cesarean delivery, as
infection. She may also need treatment to stop
indicated.
severe bleeding.
Medical Management:
Surgical Management
• Treatment is often multimodal, and includes
• When the labor is very long, and medical
dietary changes, pelvic floor physical therapy or
management is not progressing as it should, or
biofeedback, and ultrasound-guided botulinum
causing complications for the mother or the
injection.
baby, an emergency C-section is performed in
order to deliver the baby safely. A Pharmacologic Management:
symphysiotomy is performed as an alternative to
an emergency C-section. Symphysiotomy is the • Administration of narcotic or sedative, such as
artificial division and separation of the pubic morphine, pentobarbital (Nembutal), or
symphysis in order to facilitate vaginal delivery. secobarbital (Seconal), for sleep as indicated.

Surgical Management:
INLET CONTRACTION
- Inlet contraction is the narrowing of the • Surgery is generally reserved for refractory
anteroposterior diameter of the pelvis to less cases.
than 11 cm, or of the transverse diameter to 12
cm or less.

Etiology/Cause
- Inlet Contraction is usually caused by rickets in
early life or by an inherited small pelvis. Rickets
is caused by a lack of calcium and is therefore
rare in developed countries but can occur among
immigrants who were raised where milk supplies
were not plentiful.

Signs and Symptoms

❖ Anteroposterior diameter is less than 11 cm
❖ Transverse diameter is to 12 cm or less
❖ Diagonal Conjugate is less than 11.5 cm
❖ If there is no engagement in primigravidas, then
either a fetal abnormality or a pelvic abnormality
should be suspected

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OUTLET CONTRACTION
- The pelvic outlet is composed of two triangular
areas that share the same base but are not in the
same plane. The anterior triangle is formed by
the pubic arch. The apex of the posterior triangle
is the tip of the sacrum, and the sides are the
sacral sciatic ligaments and ischial tuberosities.
The anteroposterior diameter, from the inferior
edge of the pubic symphysis to the tip of the
sacrum, usually measures approximately 11.5
cm. The transverse diameter, the distance
between the inner edges of the ischial
tuberosities, measures approximately 10 cm.
Etiology/Cause
Causes in the pelvis
• Developmental (congenital):
◼ Small gynaecoid pelvis (generally contracted
pelvis).
◼ Small android pelvis.
◼ Small anthropoid pelvis.
◼ Small platypelloid pelvis (simple flat pelvis).
◼ Naegele’s pelvis: absence of one sacral ala.
◼ Robert’s pelvis: absence of both sacral alae.
◼ High assimilation pelvis: The sacrum is
composed of 6 vertebrae.
◼ Low assimilation pelvis: The sacrum is
composed of 4 vertebrae.
◼ Split pelvis: splitted symphysis pubis
• Metabolic:
◼ Rickets.
◼ Osteomalacia (triradiate pelvic brim).
◼ Traumatic: as fractures.
◼ Neoplastic: as osteoma.
Causes in the spine
- Lumbar kyphosis.
- Lumbar scoliosis.
- Spondylolisthesis: The 5th lumbar vertebra with
the above vertebral column is pushed forward
while the promontory is pushed backwards and
the tip of the sacrum is pushed forwards leading
to outlet contraction.
MODULE 2M: INTRAPARTAL COMPLICATIONS
Causes in the lower limbs
- Dislocation of one or both femurs.
- Atrophy of one or both lower limbs.
Signs and Symptoms
❖ inter ischial tuberous diameter is 8 cm or less
❖ Arresting of the head in the pelvic inlet
❖ Uterine contractions abnormality.
❖ Signs of urinary bladder compression.
❖ Edema of the cervix, and vaginal walls,
productions of fistulas.
❖ Pushing occurs in the location of the fetal head
in the inlet
Management
Nursing Management:
• Review the history of labor, onset, and duration.
• Obtain baseline lab investigations.
• Assess uterine contractile pattern manually
(palpation) or electronically, depending on the
availability.
• Evaluate the current level of maternal
fatigue/emotional stress.
• Observe any signs of infection.
• Monitor vitals.
• Evaluate the degree of hydration. Note down the
quantity and type of intake.
• Place the client in a lateral recumbent position
and encourage bed rest or sitting
position/ambulation, as tolerated.
• Note signs of fetal distress, cessation of uterine
contractions, and presence of vaginal bleeding.
• Alert the obstetrician of any warning signs.
Medical Management:
• Therapeutic rest and analgesia may be provided
during a prolonged first stage of labor.
Pharmacologic Management:
• Administration of oxytocin.
• Administer narcotic or sedative, as indicated
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
Surgical Management:
• In the case of maternal/fetal compromise,
immediate intraoperative delivery is indicated.
SUCCENTURIATE PLACENTA
- A succenturiate placenta is a condition
characterized by the development of one or
more accessory lobes in the membranes that are
separate from the main placental body and are
usually connected by vessels of fetal origin. It is
a smaller variant of a bilobed placenta. Only the
communicating membranes support the vessels.
- A placenta succenturiata (Fig. 23.13A) is a
placenta that has one or more accessory lobes
connected to the main placenta by blood vessels.
No fetal abnormality is associated with this type.
However, it is important it be recognized
because the small lobes may be retained in the
uterus after birth, leading to severe maternal
hemorrhage. On inspection, the placenta
appears torn at the edge, or torn blood vessels
extend beyond the edge of the placenta. If the
remaining lobes are recognized and removed
from the uterus manually, the uterus will
contract as usual with no adverse maternal
effects.
Etiology/Cause
Factors that leads to succenturiate placentas are the
following:
- Advanced maternal age
- In vitro fertilization (IVF)
- Implantation over leiomyomas, in areas of
previous surgery, in the cornu, or over the
cervical os.
Signs and Symptoms
Signs
❖ Hemorrhage from vessels from vessels attaching
main placental mass to succenturiate lobe
❖ Velamentous attachment
❖ Retained products
Symptoms
❖ Vaginal Bleeding
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Management
Nursing Management:
• Assist the patient in a side lying position when
she starts to bleed.
• Monitor baseline vital signs especially the blood
pressure, and the uterine contractions to
manage the labor of the patient.
Medical Management:
• Intravenous treatment
The use of intravenous treatment to
inject blood into the mother's
bloodstream is encouraged in order to
assist her recover from her bleeding.
Performing vaginal examinations is not
recommended since they might result in
bleeding, which is dangerous to both the
mother and the baby.
Pharmacologic Management:
• The patient must be administered a
corticosteroid for the development of the fetus’
lungs.
Surgical Management:
• Cesarean Section
Because of its risk factors, such as pelvic
infection and preeclampsia , a centuriate
placenta raises the likelihood of a
cesarean delivery for a patient.
CIRCUMVALLATE PLACENTA
- A circumvallate placenta is a rare condition that
occurs when the amnion and chorion fetal
membranes of the placenta fold backward
around the edges of the placenta. It is an
abnormality in the shape of the placenta where
the chorionic plate, which is the part of the
placenta that’s on the fetal side, is smaller than
the basal plate, resulting in hematoma retention
in the placental margin.
- Ordinarily, the chorion membrane begins at the
edge of the placenta and spreads to envelop the
fetus; no chorion covers the fetal side of the
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
placenta. In placenta circumvallata, the fetal side
of the placenta is covered to some extent with
chorion (Fig. 23.13B). The umbilical cord enters
the placenta at the usual midpoint, and large
vessels spread out from there. However, they
end abruptly at the point where the chorion
folds back onto the surface. (In placenta
marginata, the fold of chorion reaches just to the
edge of the placenta.) Although no abnormalities
are associated with this type of placenta, its
presence should be noted.
Etiology/Cause
The exact cause of Circumvallate placenta is still
unknown, however it is associated with the following:
- Poor pregnancy outcomes due to increased risk
of vaginal bleeding beginning in the first
trimester
- Premature rupture of the membranes (PROM)
- Preterm delivery
- Placental insufficiency
- Placental abruption
Signs and Symptoms
A circumvallate placenta does not always cause
symptoms during pregnancy. However, a doctor may be
able to notice some signs that a woman has a
circumvallate placenta. These signs may include:
❖ Vaginal bleeding
◼ A circumvallate placenta leads to a higher
chance of persistent vaginal bleeding during
the first trimester.
◼ It is found that the incidence of vaginal
bleeding was higher in these women than in
those in the control group during all three
trimesters
Management
Nursing Management:
• Assessing the fetal heart sounds to monitor the
wellbeing of the fetus and advise the mother to
improve her lifestyle such as eating a balanced
diet, taking in nutrient supplements, and getting
plenty of rest to give both herself and the fetus
sufficient.
MODULE 2M: INTRAPARTAL COMPLICATIONS
Medical Management:
Ultrasound
• One of the main concerns of a circumvallate
placenta is the decreased birth weight of the
baby. Therefore, to help monitor this, the doctor
may recommend checking the growth of the
baby using ultrasound.
• If the fetus is not growing fast enough, the
doctor may recommend early delivery. A vaginal
delivery will usually be possible, but a cesarean
section might be the best option if the baby is
not tolerating labor.
• In order to treat oligohydramnios from a
circumvallate placenta, the doctor may conduct
a procedure known as Amnioinfusion, in which
the amniotic sac is replaced with other fluid. This
reduces the risk of umbilical cord shrinking and
underdevelopment of the fetus’ body organs.
Pharmacologic Management:
• There is no treatment for a circumvallate
placenta, and doctors often do not diagnose it
until after the birth.
Surgical Management:
Emergency Cesarean Section
• If there is severe blood loss and placental
abruption as a result of circumvallate placenta,
an emergency C-section might be conducted in
order to save the life of both mother and the
baby.
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NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
PLACENTA ACCRETA
- Placenta accreta, a dangerous pregnancy illness,
occurs when the placenta grows too far into the
uterine wall. The placenta usually separates from
the uterine wall after childbirth. In placenta
accreta, part or all of the placenta stays
attached. This can result in a lot of blood loss
after birth. Placenta accreta is considered a high-
risk pregnancy complication. If the condition is
diagnosed during pregnancy, you'll likely need an
early C-section delivery followed by the surgical
removal of your uterus (hysterectomy).
- Placenta accreta is an unusually deep
attachment of the placenta to the uterine
myometrium, so deep that the placenta will not
loosen and deliver (Silver, 2015). Attempts to
remove it manually may lead to extreme
hemorrhage because of the deep attachment.
Hysterectomy to remove the uterus or
treatment with methotrexate to destroy the still-
attached tissue may be necessary.
Etiology/Cause
Placenta accreta is thought to be caused by scarring or
other abnormalities with the lining of the uterus. Several
risk factors have been linked to placenta accreta,
including:
- Multiple cesarean sections (c sections)
◼ Women who have had multiple cesarean
sections have a higher risk of developing
placenta accreta. This results from scarring
of the uterus from the procedures. The more
cesarean sections a woman has over time,
the higher her risk of placenta accreta.
- Placenta previa
◼ This condition occurs when the placenta is
located at the bottom of the uterus, blocking
the opening of the cervix. The lower part of
the uterus is less suited for the placenta to
implant. In patients with placenta previa and
a history of prior cesarean section(s), the risk
for placenta accreta increases with the
number of cesarean sections the patient has
had.
MODULE 2M: INTRAPARTAL COMPLICATIONS
- History of fibroid removal
◼ If the woman has had a fibroid (a non-
cancerous growth or tumor of the uterine
muscle) removed, the scarring could lead to
placenta accreta.
Types
There are three types of this condition. The type is
determined by how deeply the placenta is attached to
the uterus.
1. Placenta accreta
◼ The placenta firmly attaches to the wall of
the uterus. It does not pass through the wall
of the uterus or impact the muscles of the
uterus. This is the most common type of the
condition.
2. Placenta increta
◼ This type of the condition sees the placenta
more deeply imbedded in the wall of the
uterus. It still does not pass through the wall,
but is firmly attached to the muscle of the
uterus.
3. Placenta percreta
◼ The most severe of the types, placenta
percreta happens when the placenta passes
through the wall of the uterus. The placenta
might grow through the uterus and impact
other organs, such as the bladder or
intestines.
Signs and Symptoms
❖ There are often no signs or symptoms of
placenta accreta during pregnancy. In some
cases, though, bright red vaginal bleeding
without pain during the third trimester or a little
earlier could be a sign.
❖ This type of bleeding may also be a sign of
placenta previa, which is when the placenta lies
low in the uterus and covers all or part of the
cervix. Occasionally, placenta accreta is detected
during a routine ultrasound. Speak to your
healthcare provider right away if you notice any
vaginal bleeding during your pregnancy.
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Management
Nursing Management:
• Assess baseline vital signs especially the blood
pressure. The physician would order monitoring
of the blood pressure every 5-15 minutes.
• Assess fetal heart sounds to monitor the
wellbeing of the fetus.
• Monitor uterine contractions to establish the
progress of labor of the mother.
• Weigh perineal pads used during bleeding to
calculate the amount of blood lost.
• Assist the woman in a side lying position when
bleeding occurs.
Medical Management:
• Intravenous therapy. This would be prescribed
by the physician to replace the blood that was
lost during bleeding.
• Avoid vaginal examinations. This may initiate
hemorrhage that is fatal for both the mother and
the baby.
• Attach external monitoring equipment. To
monitor the uterine contractions and record
fetal heart sounds, an external equipment is
preferred than the internal monitoring
equipment.
• Ultrasound. Early detection of placenta previa is
always possible through ultrasonography. It is
the most common and initial diagnostic test that
could confirm the diagnosis.
Surgical Management:
• Cesarean delivery. Although the best way to
deliver a baby is through normal delivery, if the
placenta has obstructed more than 30% of the
cervical os it would be hard for the fetus to get
past the placenta through normal delivery.
Cesarean birth is then recommended by the
physician.
MODULE 2M: INTRAPARTAL COMPLICATIONS
BATTLEDORE PLACENTA
- Battledore placenta (Marginal cord insertion) is a
condition in which the umbilical cord is inserted
at or near the placental margin rather than in the
center. The cord can be inserted as close to 2 cm
from the edge of the placenta (velamentous cord
insertion).
- In a battledore placenta, the cord is inserted
marginally rather than centrally This anomaly is
rare and has no known clinical significance
either.
Etiology/Cause
- The incidence is 7% to 9% of singleton
pregnancies and 24% to 33% in twin
pregnancies. Complications associated with
battledore placenta are preterm labor, fetal
distress, and intrauterine growth restriction.
Signs and Symptoms
This condition rarely causes complications in singleton
gestations prior to the 3rd stage of labor, during which,
the marginal cord insertion can be avulsed during
placental delivery . In monochorionic twin gestations, a
marginal cord insertion may lead to unequal sharing of
the placental mass and therefore lead to discordant fetal
weight.
Associated with:
❖ Fetal Distress
❖ IUGR
❖ Preterm Labor
❖ Reduction Birth Weight
Management
Nursing Management:
• Assess and monitor vital signs of the patient.
• Brief the patient with ultrasound procedure and
preparation is done.
• Ensuring the pregnant is well-hydrated and has
adequate oxygen for fetal distress.
Medical Management:
• Ultrasonography and should include placental
cord insertion site and transvaginal ultrasound
may be considered in with marginal insertion of
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the cord or otherwise known as battledore
placenta.
• Tocolysis is done to delay preterm labor by
temporarily stopping contractions.
Surgical Management:
• Perform Cesarean hysterectomy. Performing
hysterectomy minimizes the risk of hemorrhage
which is also the safest option for the mother ,
however, this involves the complete removal of
the uterus. Hence, it is crucial to discuss this
procedure with the patient.
VASA PREVIA
- In Vasa previa, the umbilical vessels of a
velamentous cord insertion cross the cervical os
and therefore deliver before the fetus. These
vessels are at risk of rupture during cervical
dilation and may cause serious complications to
the fetus. However, prenatal diagnosis of this
condition can allow the safe birth of the newborn
and avoid fetal blood loss.
- In vasa previa, the umbilical vessels of a
velamentous cord insertion cross the cervical os
and therefore deliver before the fetus (Suzuki &
Kato, 2015). The vessels may tear with cervical
dilatation, just as a placenta previa may tear.
Before inserting any instrument such as an
internal fetal monitor, be certain to identify
structures to prevent accidental tearing of a vasa
previa because tearing would result in sudden
fetal blood loss. If sudden, painless bleeding
occurs with the beginning of cervical dilatation,
either placenta previa or vasa previa is
suspected. It can be confirmed by ultrasound. If
vasa previa is identified, the infant needs to be
born by cesarean birth.
Etiology/Cause
There are two main causes of vasa previa:
- Velamentous cord insertion - where the cord
inserts directly into the membranes, leaving
unprotected vessels running to the placenta
- Bilobate placentas - vessels crossing between
lobes of the placenta such as in succenturiate
MODULE 2M: INTRAPARTAL COMPLICATIONS
Types
There are three types of Vasa Previa, namely:
1. Type 1 Vasa Previa
◼ this is a type of Vasa Previa where there is a
single placental lobe with velamentous cord
insertion.
2. Type 2 Vasa Previa
this is a type of Vasa Previa where in which the
vessels traversing the cervix are connected
between the lobes of a multilobed placenta
3. Type 3 Vasa Previa
◼ this is a type of Vasa Previa where fetal
vessels follow a boomerang orbit, without
velamentous cord insertion or
bilobed/accessory placenta.
Signs and Symptoms
The classic signs and symptoms of Vasa Previa are the
following:
❖ Painless vaginal bleeding
❖ Rupture of membranes
❖ Fetal bradycardia
Management
Nursing Management:
• Assess fetal heart sounds so the mother would
be aware of the health of her baby.
• Allow the mother to vent out her feelings to
lessen her emotional stress.
• Assess any bleeding or spotting that might occur
to give adequate measures.
• Answer the mother’s questions honestly to
establish a trusting environment.
• Include the mother in the planning of the care
plan for both the mother and the baby.
Medical Management:
• Intravenous therapy. This would be prescribed
by the physician to replace the blood that was
lost during bleeding.
• Avoid vaginal examinations. This may initiate
hemorrhage that is fatal for both the mother and
the baby.
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• Attach external monitoring equipment. To
monitor the uterine contractions and record
fetal heart sounds, an external equipment is
preferred than the internal monitoring
equipment.
Pharmacologic Management:
• Corticosteroids- for the maturity of the baby’s
lungs
Surgical Management:
• Cesarean delivery. Although the best way to
deliver a baby is through normal delivery, if the
placenta has obstructed more than 30% of the
cervical os it would be hard for the fetus to get
past the placenta through normal delivery.
Cesarean birth is then recommended by the
physician.
TWO VESSEL CORD
- A normal cord contains one vein and two
arteries. The absence of one is also known as
Single Umbilical artery and is associated with
congenital heart and kidney anomalies.
Physicians usually identify a two-vessel cord
during a prenatal ultrasound.
- A normal cord contains one vein and two
arteries. The absence of one of the umbilical
arteries is associated with congenital heart and
kidney anomalies because the insult that caused
the loss of the vessel may have also affected
other mesoderm germ layer structures.
Inspection of the cord as to how many vessels
are present must be made immediately after
birth, before the cord begins to dry, because
drying distorts the appearance of the vessels.
Document the number of vessels conscientiously
because an infant with only two vessels needs to
be observed carefully for other anomalies during
the newborn period.
Etiology/Cause
The patient is thought to be more at risk if she is:
- Caucasian
- Over the age of 40
- Carrying more than one baby (Multiple
Pregnancy)
- Diabetic
- High blood pressure
Management
Nursing Management:
• Immediate inspection of the cord as to how
many vessels are present must be performed
after birth before the cord starts to dry.
• Obtain personal medical history
• Obtain family medical history
• Monitor vital signs
• Assist patient during tests
• Observe carefully for other anomalies during the
newborn period
Medical Management:
• Doctors can identify a two-vessel cord during a
prenatal ultrasound.
• The doctor may instruct the mother to go
amniocentesis.
• Fetal echocardiogram (viewing the chambers
and workings of the fetal heart)
• Screening for genetic abnormalities in
pregnancy, like an aneuploidy screening
• Karyotyping
Pharmacologic Management:
• Avoid medications such as Phenytoin because it
can affect fetal growth which can be harmful to
the growing fetus inside the womb.
Surgical Management:
• Normal Spontaneous Vaginal Delivery
• Cesarean delivery

MODULE 2M: INTRAPARTAL COMPLICATIONS YUSON, DREA

NCM 109: Care of Mother and Child at-risk or with Problems (Acute and Chronic)
UNUSUAL CORD LENGTH
- The cord may be too long or too short. Length
rarely varies. Short cord can result in premature
separation from the placenta or an abnormal
fetal lie. A long cord may be easily compromised
because of its tendency to twist or knot.
- Although the length of the umbilical cord rarely
varies, some abnormal lengths may occur. An
unusually short umbilical cord can result in
premature separation of the placenta or an
abnormal fetal lie. An unusually long cord may be
easily compromised because of its tendency to
twist or knot. Occasionally, a cord actually forms
a knot, but the natural pulsations of the blood
through the vessels and the muscular vessel
walls usually keep the blood flow adequate. It is
not unusual for a cord to wrap once around the
fetal neck (nuchal cord) but, again, with no
interference to fetal circulation
Etiology/Cause
- Short umbilical cord is caused by the premature
separation of placenta and abnormal fetal lie.
While the exact cause of the long umbilical cord
is unknown. Studies have indicated that a long
cord is more common with single pregnancies
than multiple pregnancies (such as twins and
triplets)
Types
1. Short umbilical cord
◼ A short umbilical cord is usually defined as an
umbilical cord that measures less than 35 cm
in length. Excessively short cords have been
associated with a delay in the second stage
of labor, irregular fetal heart rate, placental
abruption, rupture of the umbilical cord,
inversion of the uterus, and cord herniation.
2. Long umbilical cord
◼ Long cords have alternatively been defined
as umbilical cords longer than 70 cm and 100
cm. Excessively long umbilical cords are
associated with cord prolapse, torsion, true
knot entanglement around the fetus, and
delivery complications.
MODULE 2M: INTRAPARTAL COMPLICATIONS
Signs and Symptoms
Short Umbilical Cord
❖ Decreased blood flow to the fetus
❖ Nonreassuring fetal heart rate
Long Umbilical Cord
❖ Obstruction of blood flow
❖ Compression of the umbilical cord
❖ Fetal distress
❖ Decreased fetal heart rate
Management
Nursing Management:
• Establish rapport with patient
• Obtain patient health history and lifestyle
patterns (such as alcohol consumption or
smoking)
• Monitor baseline vital signs
• Monitor fetal heart rate
• Provide health teaching that left side lying
position is the most ideal when lying down
Medical Management:
• Physicians would request a routine ultrasound in
order to determine umbilical cord abnormalities.
• Prenatal tests such as biophysical or non-stress
test
• Continuous monitoring of the mother
Pharmacologic Management:
• Oxygen therapy in cases of umbilical cord
prolapse which is associated to long umbilical
cord
Surgical Management:
• Cesarean Delivery may be indicated
• Normal Spontaneous Vaginal Delivery
YUSON, DREA