SESSION 7.

CESAREAN SECTION
· Cesarean section is a surgical procedure commonly used in the obstetric
practice.

· the fetal delivery is attained through an incision made over the abdomen
and uterus, after 28 weeks

of pregnancy.

If the removal of fetus is done before 28 weeks of pregnancy, the procedure

is known as hysterotomy.

· The use of cesarean delivery helps in avoiding difficult cases of vaginal

delivery, which may be

associated with considerable maternal and fetal mortality and morbidity.

INDICATIONS

· Cephalopelvic disproportion

· Placenta previa

· Estimated fetal weight >4 kg

· Hyperextension of fetal head

· Footling breech (danger of entrapment of head in an incompletely dilated

cervix)

· Severe Intrauterine Growth Restriction (IUGR)

· Clinician not competent with the technique of breech vaginal delivery

COMPLICATIONS

· Abdominal pain

· Injury to bladder, ureters, etc.

· Increased risk of rupture uterus and maternal death

· Neonatal respiratory morbidity

· Requirement for hysterectomy

· Thromboembolic disease

· Increased duration of hospital stay

· Antepartum or intrapartum intrauterine deaths in future pregnancies

· Patients with a previous history of cesarean delivery are prone to develop

complications, like

placenta previa and adherent placenta during future pregnancies

PROCEDURE

Preoperative Preparation

The following steps should be taken for preoperative preparation:

1. Empty stomach: The patient should be NPO for at

least 12 hours before undertaking a cesarean section.

In case the patient is full stomach, she should be

administered H2 receptor blocker (ranitidine 150 mg)

and an antiemetic (metoclopramide 10 mg) at least 2

hours prior to the surgery.

RATIONALE

To prevent the risk of aspiration at the time of administration of anesthesia

2. Patient position: The patient is placed with 15° lateral tilt on the
operating table.

RATIONALE

To reduce the chances of hypotension.

3. Anesthesia: While cesarean section can be

performed both under general or regional anesthesia,

nowadays regional anesthesia is favored.

RATIONALE

Spinal and epidural anesthesia have become the most commonly used
forms of regional anesthesia in the recent years.

4. Clinical examination: Before cleaning and draping the patient, it is a good

practice to check the fetal lie, presentation, position and fetal heart sounds
once again. Foley’s or plain rubber catheter must be inserted, following
which the cleaning and draping of the abdomen is done.

RATIONALE

To monitor the fetal heart tone of the fetus.

5. Preparation of the skin: The area around the proposed incision site must
be washed with antiseptic soap solution (e.g. savlon and/or betadine
solution).

· The antiseptic solution must be applied at least three times over the
incision site, using a high-level disinfected sponge-holding forceps and
cotton or gauze swab.

RATIONALE

Antiseptic skin cleansing before surgery is thought to reduce the risk of

postoperative wound infections

Steps of Surgery
6. A vertical or transverse incision can be given over the skin (Fig. 7.3). The
vertical skin incision can be either given in the midline or paramedian
location, extending just above the pubic symphysis to just below the
umbilicus.

RATIONALE

Previously, vertical skin incision at the time of cesarean section was favored,
as it was supposed to provide far more superior access to the surgical field
in comparison to the transverse incision. Also, the vertical incision showed
potential for extension at the time of surgery. However, it was associated
with poor cosmetic results and an increased risk of wound dehiscence and
hernia formation. Therefore, nowadays, transverse incision is mainly
favored due to better cosmetic effect, reduced postoperative pain and
improved patient recovery.

Two types of transverse incisions are mainly used, while performing

cesarean section:

(1) the sharp (Pfannenstiel) type and

(2) the blunt (Joel Cohen) type.

Sharp Pfannenstiel transverse incision: While giving this type of incision, a

slightly curved, transverse skin incision is made at the level of pubic hairline,
about an inch above the pubic symphysis and is extended somewhat
beyond the lateral borders of rectus abdominis muscle.

· The subsequent tissue layers, until the level of anterior rectus sheath are
opened by using a sharp scalpel.

7. Dissecting the Rectus Sheath

After dissecting through the skin, subcutaneous fat and fascia, as the
anterior rectus sheath is reached, sharp dissection may be required. A
scalpel can be used to incise the rectus sheath throughout the length of the
incision. The cut edges of the incised rectus sheath are held with the help of
allis forceps and then carefully separated out from the underlying rectus
muscle and pyramidalis.

RATIONALE

These muscles are then separated with the help of blunt and sharp
dissection to expose transversalis fascia and peritoneum.

8. Opening the Peritoneum

The transversalis fascia and peritoneal fat are dissected carefully to reach
the underlying parietal peritoneum. After placing two hemostats about 2
cm apart to hold the peritoneum, it is carefully opened.

RATIONALE

The layers of parietal peritoneum are carefully examined to be sure that

omentum, bowel or bladder is not lying adjacent to it.

9. Insertion of the Doyen’s Retractor

Following the identification of lower uterine segment, some surgeons prefer

to put a moistened laparotomy pack in each of the paracolic gutters. The
loose fold of the uterovesical peritoneum over the lower uterine segment is
then grasped with the help of forceps and incised transversely with the help
of scissors. The lower flap of the peritoneum is held with artery forceps and
the loose areolar tissue pushed down. The underlying bladder is then
separated by blunt dissection. Finally, the lower flap of peritoneum and the
areolar tissue is retracted by the Doyen’s retractor to clear the lower
uterine segment. The upper flap of the peritoneum is pushed up to leave
about 2 cm wide strip on the uterine surface, which is not covered with
visceral peritoneum.

RATIONALE
Doyen Retractor is used in abdominal OB/GYN,

retracting bladder, and cesarean section procedure. The retractor has a

round concave blade, the palm grip handle has a little hook at the end and a
thumb rest, the handle is designed to provide grip and comfort. It is used by
surgeons to either actively separate the edges of a surgical incision or
wound, or can hold back underlying organs and tissues, so that body parts
under the incision may be accessed.

10. Giving a uterine incision: An incision is made on the lower uterine

segment about 1 cm below the upper margin of peritoneal reflection and
about 2–3 cm above the bladder base. While making an incision in the
uterus, a curvilinear mark of about 10 cm length is made by the scalpel,
cutting partially through the myometrium. Following this, a small cut (about
3 cm in size) is made, using the scalpel in the middle of this incision mark,
reaching up to, but not through the membranes. The rest of the incision can
be completed either by stretching the incision, using the tips of two index
fingers along both the sides of the incision mark (Fig. 7.4A) or using
bandage scissors, to extend the incision on two sides (Fig. 7.4B).

RATIONALE

The uterine incision must be gently given, taking care to avoid any injury to
the underlying fetus.

The metzenbaum scissors are introduced into the uterus over the two
fingers, in order to protect the fetus. The uterine incision must be large
enough so as to allow the delivery of the head and trunk without the risk of
extension of the incision laterally into the uterine vessels. As the fetal
membranes bulge out through the uterine incision, they are ruptured. The
amniotic fluid, which is released following the rupture of membranes, is
sucked with the help of a suction machine.

RATIONALE
The use of metzenbaum scissors may be especially required in cases, where
the lower uterine segment is thickened andthe uterine incision cannot be
extended using the fingers. If the lower uterine segment is very thin, injury
to the fetus can be avoided, by using the handle of the scalpel or a
hemostat (an artery forceps) to open the uterus.

Location of the uterine incision: The incision in the uterus is commonly

given over the lower uterine segment.

The classical incision has been found to be associated with high risk of scar
rupture during future

pregnancies. As a result, lower segment transverse scars are nowadays

preferred.

The lower segment uterine scar is considered to be stronger than the upper
segment scar due to the reasons mentioned in Table 7.3.

11. Delivery of the Infant

In case of cephalic presentation, once the fetal presenting part becomes

visible through the uterine incision, the surgeon places his/her right hand
below the fetal presenting part and grasps it. In case of cephalic
presentation the fetal head is then elevated gently, using the palms and
fingers of the hand. The Doyen’s retractor is removed, once the
fetalpresenting part has been grasped. In order to facilitate delivery, fundal
pressure is applied by the assistant. Delivery is completed in the manner
similar to normal vaginal delivery. Once the baby’s shoulders have
delivered, an IV infusion containing 20 IU of oxytocin per liter of crystalloids
is infused at a rate of 10 mL/minute, until effective uterine contractions are
obtained. Following the delivery of the baby, the doctor will call out the
time of delivery and the sex of the baby. The cord is clamped and cut and
the baby handed over to the clinician.
RATIONALE

Delivery of the fetal head should be in the same way as during the normal
vaginal delivery. Fundal massage, following the delivery of the baby, helps in
reducing bleeding and hastens the delivery of placenta.

12. Placental Removal

Following the delivery of the placenta, the remnant bits of membranes and
decidua are removed using a sponge-holding forceps. The cut edges of the
uterine incision are then identified and grasped with the help of Green
Armytage clamps.(as seen below) The uterine angles are usually grasped
with allies forceps.

RATIONALE

At the time of cesarean, the placenta should be removed, using controlled

cord traction (Fig. 7.5) and not manual removal as this reduces the risk of
endometritis.

13. Closing the Uterine Incision

The main controversy related to the closure of the uterine incision is

whether the closure should be in the form of a single-layered or a double-
layered closure. Both single-layered and double-layered closure of uterine
incision are being currently practiced. If tubal sterilization has to be
performed, it is done following the closure of uterine incision. Following the
uterine closure, swab and instrument count is done. Once the count is
found to be correct, the abdominal incision is closed in layers.

RATIONALE

Though single- layered closure is associated with reduced operative time

and reduced blood loss in the short term, the risk of the uterine rupture
during subsequent pregnancies is increased. The current recommendation
is to close the uterus in two layers, as the safety and efficacy of closing
uterus in a single layer is presently uncertain. Individual bleeding sites can
be approximated with the help of figureof-eight sutures.

14. Peritoneal Closure

The current recommendation by (Royal College of Obstetrician and

Gynecologist)RCOG is that neither the visceral nor the parietal peritoneum
should be sutured at the time of cesarean section.

RATIONALE

This reduces the operative time and the requirement for the postoperative
analgesia.

15. Closure of the Rectus Sheath

Rectus sheath closure is performed after identifying the angles and holding
them with allies forceps. The angles must be secured using 1-0 vicryl
sutures. The rectus layer is closed with the help of continuous locked
sutures placed no more than 1 cm apart. Hemostasis must be checked at all
levels.

16. Closure of Subcutaneous Space

There is no need for the routine closure of the subcutaneous tissue space,
unless there is more han 2 cm of subcutaneous fat.

RATIONALE

To reduce the incidence of the wound infection.

17. Skin Closure

Clinicians should be aware that presently the

differences

between the use of different suture materials and

methods of skin closure at the time of cesarean

section are not certain.

Skin closure can be either performed, using

subcutaneous, continuous repair absorbable or

nonabsorbable stitches or using interrupted stitches

with nonabsorbable sutures or staples.

RATIONALE

Following the skin closure, the vagina is swabbed

dried and dressing applied to the wound.

POSTOPERATIVE CARE

1. After surgery is completed, the woman needs to be monitored in a

recovery area. When the effects of anesthesia have worn off, about

4–8 hours after surgery, the woman may be

transferred to the postpartum room.

RATIONALE

Monitoring of routine vital signs (blood pressure, temperature, breathing),

urine output, vaginal bleeding and uterine tonicity (to check, if the uterus
remains adequately contracted), needs to be done at hourly intervals for
the first 4 hours. Thereafter, the monitoring needs to be done at every four
hourly intervals for the first postoperative day at least. Adequate analgesia
needs to be provided, initially through the IV line and later with oral
medications.

2. Fluids and oral food after cesarean section: As

a general rule, about 3 liters of fluids must be

replaced by IV infusion during the first postoperative

day, provided that the woman’s urine output remains

greater than 30 mL/hour.

If the urine output falls below 30 mL/hour, the woman

needs to be reassessed to evaluate the cause of

oliguria.

In uncomplicated cases, the urinary catheter can be

removed by 12 hours postoperatively. Intravenous

fluids may need to be continued, until she starts

taking liquids orally.

RATIONALE

The clinician needs to remember that prolonged

infusion of IV fluids can alter electrolyte balance. If

the woman receives IV fluids for more than 48 hours,

her electrolyte levels need to be monitored every 48

hours.

Balanced electrolyte solution (e.g. potassium

chloride 1.5 g in 1 L IV fluids) may be administered.

3. Ambulation after cesarean section: The women

must be encouraged to ambulate as soon as 6–8

hours following the surgery.

RATIONALE
Walking also improves blood flow and speeds wound

healing. Failure to walk may cause increased

constipation and gas pain and weakness, and puts

the patient at a higher risk for infections, blood clots

and lung problems such as pneumonia.

4. Dressing and wound care: The dressing must be

kept on the wound for the first 2–3 days after

surgery, so as to provide a protective barrier against

infection. Thereafter, dressing is usually not required.

If blood or fluid is observed to be leaking through the

initial dressing, the dressing must not be changed.

The amount of blood/fluid lost must be monitored.

If bleeding increases or the bloodstain covers half

the dressing or more, the dressing must be removed

and replaced with another sterile dressing.

RATIONALE

The dressing must be changed while using a sterile technique.

The surgical wound also needs to be carefully inspected.

5. Length of hospital stay: Length of hospital stay

is likely to be longer after a cesarean section (an

average of 3–4 days) in comparison to that after a

vaginal birth (average 1–2 days).

RATIONALE

Women who are recovering well and have not

developed complications following cesarean may be

offered early discharge.

Multiple Choice:

Answer the following questions carefully.

1. Raya is pregnant and was told by her OB doctor that her baby is on face
presentation. In face presentation, when is cesarean birth necessary?

A. If the chin is anterior.

2. What is a contraindication to external cephalic version?

A. Hydramnios

3. Julanne a client who delivered by cesarean section 24 hours ago is using a

patient-controlled analgesia (PCA) pump for pain control. Her oral intake
has been ice chips only since surgery. She is now complaining of nausea and
bloating, and states that because she had nothing to eat, she is too weak to
breastfeed her infant. Which nursing diagnosis has the highest priority?

A. Altered nutrition, less than body requirements for lactation

B. Alteration in comfort related to nausea and abdominal distention

C. Impaired bowel motility related to pain medication and immobility

D. Fatigue related to cesarean delivery and physical care demands of infant

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

cesarean delivery. Which assessment finding would indicate a need to
contact the physician?

A. Fetal heart rate of 180 beats per minute

B. White blood cell count of 12,000

C. Maternal pulse rate of 85 beats per minute

D. Hemoglobin of 11.0 g/dL

5. Which of the following fetal positions is most favorable for cesarean

birth?

A. Vertex presentation

B. Transverse lie

C. Frank breech presentation

D. Posterior position of the fetal head

6. Carly a client is admitted to the L & D suite at 36 weeks’ gestation. She

has a history of C-section and complains of severe abdominal pain that
started less than 1 hour earlier. When the nurse palpates tetanic
contractions, the client again complains of severe pain. After the client
vomits, she states that the pain is better and then passes out. Which is the
probable cause of her signs and symptoms?

A. Hysteria compounded by the flu

B. Placental abruption

C. Uterine rupture

D. Dysfunctional labor

7. Manipulations performed through the abdominal wall that yield a

cephalic presentation.

A. External Cephalic Version

8. A fetus is turned to a breech presentation using the hand placed into the
uterus.

B. Internal Podalic Version

9. Which of the following are complications of Cesarean Section, SELECT ALL

THAT APPLY:

A. Injury to bladder and ureters

B. Increased risk of rupture uterus and maternal death

C. Neonatal respiratory morbidity

D. Requirement for hysterectomy

10.Which of the following are indications for Cesarean Section, SELECT ALL
THAT APPLY:

A. Cephalopelvic disproportion

B. Placenta previa
C. Estimated fetal weight >4 kg

D. Hyperextension of fetal head

11. Astra had a cesarean section and is 2 days post-op. What is an important
measure to reduce the size of the bladder and keep it away from the
surgical field during cesarean birth?

A. Administer an oxytocic to contract the bladder.

B. Restrict fluids in the woman for 4 hours before surgery.

C. Insert a urinary catheter to drain the bladder and decrease its size.

D. Give a diuretic to reduce the bladder to its smallest size.

12. Carrie is to administer ranitidine (Zantac) as ordered prior to a planned

cesarean birth to:

A. Promote uterine contractions.

B. Decrease gastric secretions.

C. Delay uterine contractions.

D. Neutralize urine acidity.

13. Carrie instructs Astra on deep breathing exercises as part of the

preoperative teaching plan. The rationale for this exercise is to:

A. Stimulate the diaphragm to contract.

B. Promote involution on a traumatized uterus.

C. Prevent stasis of mucus in the lungs.

D. Prevent pulmonary edema.

14. You are asked by your instructor regarding Cesarean Section. What is
the most important responsibility of the healthcare team before the surgery
starts?

A. Assessing the woman’s hygiene.

B. Inserting a urinary catheter.

C. Decreasing the stomach secretions.

D. Securing an informed consent and ensuring that it is obtained.

15. The nurse administers Ringer’s solution intravenously for what purpose?

A. To avoid urinary tract infection.

B. To ensure that the woman is fully hydrated.

C. To reduce bladder size.

D. To decrease urine specific gravity.

16. Dr. Callum a surgeon plans to perform a low segment incision rather
than a classic incision. This type of incision is more advantageous because:

A. The procedure is faster with the incision being made simultaneously

through the abdomen and uterus.

B. The procedure is made with a vertical incision to decrease the chances of

reopening.

C. It is made horizontally and high on the woman’s abdomen.

D. The likelihood of a postpartal uterine infection is decreased.

17. Katrine was asked by her instructor that if oxytocin is ordered

postoperatively for the client who has had a cesarean birth, the most
important nursing intervention would be to:

A. Monitor the woman’s blood pressure.

B. Prevent infection at the incision site.

C. Implement measures to promote comfort.

D. Assess for increased lochia discharge.

18. Charie was asked which of the following interventions would be most
helpful to assist a woman to void after a cesarean birth?

A. Withholding prescribed analgesic.

B. Letting the woman void every 4 hours.

C. Running water from the tap within woman’s hearing distance.

D. Pouring cold water over her perineal area.

19. Ramina has undergone a cesarean birth is to be discharged. You would

instruct the woman to notify her health care provider if she develops which
of the following?

A. Drainage at her incision line.

B. No bowel movement for 2 days.

C. Decrease in lochia.
D. Pain on the incision site.

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

postoperatively?

B. Pneumonia

SESSION 8
Nursing Care of a Family Experiencing a Postpartum Complication

UTERINE ATONY

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

postpartum hemorrhage; it tends to

occur most often in Asian, Hispanic, and Black woman (Grobman, Bailit,
Rice, et al., 2015).

Factors that predispose a woman to poor uterine tone or the inability of her
uterus to maintain a contracted

state are summarized in Box 25.3. When caring for a woman in whom any
of these conditions are present, be

especially conscientious in your observations and be on guard for signs of

uterine bleeding.

Nursing Diagnoses and Related Interventions

Nursing Diagnosis:

Deficient fluid volume related to excessive blood loss after birth.

Outcome Evaluation:
Patient’s blood pressure and heart rate remains within usual defined limits;
lochia flow is less than one

saturated perineal pad per hour.

· If the uterus suddenly relaxes, there will be an abrupt gush of blood

vaginally from the placental site.

This can occur immediately after birth but is more likely to occur gradually,
over the first postpartum

hour, as the uterus slowly loses its tone.

· If the loss of blood is extremely copious, a woman will quickly begin to

exhibit symptoms of

hypovolemic shock such as a falling blood pressure; a rapid, weak, or

thready pulse; increased and

shallow respirations; pale, clammy skin; and increasing anxiety.

· If the blood loss is unnoticed seepage, there is little change in pulse and
blood pressure at first

because of circulatory compensation. Suddenly, however, the system is able

to compensate no more,

and the pulse rate rises rapidly and becomes weak.

· Blood pressure then drops abruptly. With slow bleeding, a woman

develops these symptoms over a

period of hours; the end result of continued seepage, however, can be as

life threatening as a sudden

profuse loss of blood (Andrighetti, 2013).

It is difficult to estimate the amount of blood a postpartal woman is losing

because it is difficult to estimate the
amount of blood

· It takes to saturate a perineal pad (between 25 and 50 ml). By counting the

number of perineal pads

saturated in given lengths of time, such as half-hour intervals, a rough

estimate of the amount of blood

loss can be formed.

· Five pads saturated in half an hour is obviously a different situation from

five pads saturated in 8 hours.

· A woman will have lost approximately 250 ml of blood, and if either

scenario is allowed to continue

unattended, she will be in grave danger of hypovolemia.

· Be certain that when you are counting perineal pads, you differentiate
between saturated and used.

Weighing perineal pads before and after use and then subtracting the
difference is an accurate technique to

measure vaginal discharge:

· 1 g of weight is comparable to 1 ml of blood volume,

· if a pad weights 50 g more after use, the woman has lost 50 ml of blood.

Note:

1. Always be sure to turn a woman on her side when inspecting for blood
loss to be certain a large

amount of blood is not pooling undetected beneath her.

2. The best safeguard against uterine atony is to palpate a woman’s fundus

at frequent intervals to be
assured her uterus is remaining contracted. Under usual circumstances, a
well-contracted uterus feels

firm and is easily recognized because it feels like no other abdominal organ.
If you are unsure whether

you have located a woman’s fundus on palpation, it means the uterus is

probably in a state of

relaxation.

3. Frequent assessments of lochia (to be certain the amount of the flow is

under a saturated pad per hour

and that any clots are small), as well as vital signs, particularly pulse and
blood pressure, are equally

important determinations.

Therapeutic Management

In the event of uterine atony, the first step in controlling hemorrhage is to

attempt fundal massage to

encourage contraction. Unless the uterus is extremely lacking in tone, this

procedure is usually effective in

causing contraction, and, after a few seconds, the uterus assumes its
healthy, grapefruit-like feel (World Health

Organization [WHO], 2015).

With uterine atony, even if the uterus responds well to massage, the
problem may not be completely resolved

because, as soon as you remove your hand from the fundus, the uterus may
relax and the lethal seepage will

begin again.
1. To prevent this, remain with a woman after massaging her fundus and
assess to be certain her

uterus is not relaxing again. Continue to assess carefully for the next 4
hours.

2. If a woman’s uterus does not remain contracted, contact her primary

care provider so interventions to

increase contraction such as administering:

o a bolus or a dilute intravenous infusion of oxytocin (Pitocin) can be

prescribed to help the

uterus maintain tone (Lang, Zhao, & Robertson, 2015).

3. Be aware, however, that oxytocin has a short duration of action:

o approximately 1 hour, so symptoms of uterine atony can recur quickly if it

is administered only

as a single dose.

o If oxytocin is not effective at maintaining tone,

1. Carboprost tromethamine (Hemabate), a prostaglandin F2a derivative,

or

methylergonovine maleate (Methergine), an ergot compound, both given

intramuscularly, are second possibilities.

2. Misoprostol (Cytotec), a prostaglandin E1 analogue, may also be

administered

rectally to decrease postpartum hemorrhage.

· Carboprost tromethamine may be repeated every 15 to 90 minutes up to

8 doses;
· Methylergonovine maleate may be repeated every 2 to 4 hours up to 5
doses.

· A second dose of misoprostol should not be administered unless a

minimum of 2 hours has

elapsed.

4. Check that all of these drugs are readily available for use on a hospital
unit in the event of postpartum

hemorrhage. Because prostaglandins tend to cause diarrhea and nausea as

a side effect, assess for this

after administration; some women will need to be administered antiemetic

to limit these side effects

(Bateman, Tsen, Liu, et al., 2014).

5. Be aware that all of these medications can increase blood pressure and
so must be used cautiously

in women with hypertension. Assess blood pressure prior to administration

and about 15 minutes afterward to

detect this potentially dangerous side effect.

Additional measures that can be helpful to combat uterine atony include:

· Elevate the woman’s lower extremities to improve circulation to essential

organs.

· Offer a bedpan or assist the woman to the bathroom at least every 4 hours
to be certain her

bladder is emptying because a full bladder predisposes a woman to uterine

atony. To reduce

the possibility of bladder pressure, insertion of a urinary catheter may be

prescribed.

· Administer oxygen by face mask at a rate of about 10 to 12 L/min if the

woman is experiencing

respiratory distress from decreasing blood volume. Position her supine (flat)
to allow adequate

blood flow to her brain and kidneys.

· Obtain vital signs frequently and assess them for trends such as a
continually decreasing blood

pressure with a continuously rising pulse rate.

When planning continuing care after sudden blood loss

· Remember that a woman may be so exhausted from labor and the effect
of the blood loss that she

resents frequent uterine and blood pressure assessments.

· Explain that you realize these measures are disturbing, but that they are
important for her welfare.

· Obtain measurements as quickly and gently as possible to cause a

minimum of discomfort and

disruption, allowing the woman time to rest.

Bimanual Compression

If fundal massage and administration of uterotonics (drugs to contract the

uterus) are not effective at stopping uterine bleeding, a sonogram may be

done

to detect possible retained placental fragments. The woman’s primary care

provider may attempt bimanual compression (Weeks & Mallaiah, 2016).

· The primary care provider inserts one hand into a woman’s vagina

while pushing against the fundus through the abdominal wall with the

other hand.

· If this is ineffective, the woman may be returned to the birthing room, so

that her uterine cavity can be explored manually.

· Under sonogram visualization, a balloon catheter may be introduced

vaginally and inflated with sterile water until it puts pressure against the

bleeding site.

· Vaginal packing is inserted during this procedure to stabilize the

placement of the balloon.

· Be certain to document the presence of the packing so it can be removed

before agency discharge

because retained packing serves as a growth medium for microorganisms

that could lead to postpartal

infection (Vintejoux, Ulrich, Mousty, et al., 2015).

Multiple Choice (10 points)

Answer the following questions carefully.

1. The mother had delivery an hour ago, the nurse must identify that the
patient exhibits hypovolemic shock when:

A. High blood pressure, tachycardic, skin warm to touch

B. Low blood pressure, weak pulse, cold clammy skin

C. High blood pressure, tachycardic, shallow respiration

D. Low blood pressure, weak pulse, skin warm to touch

2. The nurse is caring for a mother who has undergone post-operative

delivery. To be able to prevent complication, the nurse must know how to
estimate the amount of blood a postpartal woman after delivery, EXCEPT:

A. Counting the number of perineal pads saturated in given lengths of time,

such as half-hour intervals, a rough

estimate of the amount of blood loss can be formed.

B. Weighing perineal pads before and after use and then subtracting the
difference.

C. A woman will have lost approximately 250 ml of blood, and if either

scenario is allowed to continue

unattended, she will be in grave danger of hypovolemia.

D. Assuming that the mother will consume five pads the whole shift.

3. During the assessment, the nurse noticed that the mother had
uncontrolled blood loss, the nurse should position the mother in:

A. Lithotomy Position

B. Side lying Position

C. Sitting Position

D. Prone Position

4. These are conditions that leave the uterus of the woman unable to
contract readily, EXCEPT:
A. Well-contracted uterus

B. Labor initiated or assisted with an oxytocin agent

C. Prior history of postpartum hemorrhage

D. Secondary maternal illness such as anemia

5. The nurse noticed that the mother in the delivery room is having
hypovolemic shock after giving birth. The nursing diagnosis would be:

A. Risk for excess fluid volume

B. Deficient fluid volume

C. Risk for infection

D. Risk for Pain

6. The patient was brought to OB ward after delivery with a history of

multiple gestation. The nurse knows that this is one of the risk factors of
uterine atony. What is the initial nurse action?

A. Check for body temperature

B. Palpate the fundus

C. Assess for skin integrity

D. Warm compress

7. The nurse assesses that the mother’s uterus is not relaxing despite
continuously massaging her fundus for 4 hours. The nurse notifies her
physician and learn that the nurse should prepare for administering:
A. Oxytocin (Pitocin) incorporated to current intravenous fluid as ordered.

B. Oxygen 4-6 LPM as ordered

C. 2 Packed of RBC as ordered

D. Paracetamol IV as ordered

8. Nurse Digna is aware that the oxytocin (Pitocin) has a short duration of
action and notices that it is not working on contracting the mother’s uterus.
What should the nurse prepare to administer after referring the situation to
her physician?

A. Prepare to administer another dose of oxytocin (Pitocin) as ordered

B. Prepare to administer oxygen 6-10 LPM as ordered

C. Prepare to administer methylergonovine maleate (Methergine)

intramuscularly as ordered

D. Prepare to administer hydralazine as ordered

9.The nurse administered methylergonovine maleate intramuscular to

patients with uterine atony. What are the nurse precautions in giving this
medication?

A. Assess for patient’s body temperature

B. Assess for patient’s pulse

C. Assess for patient’s blood pressure

D. Assess for patient’s fluid input.

10. The nurse administered carboprost tromethamine to the mother with

uterine atony, the physician ordered to repeat the dose every 30 minutes
interval. The nurse knows that carboprost tromethamine can be
administered repeatedly for:

A. Up to 14 doses

B. Up to 12 doses

C. Up to 10 doses

D. Up to 8 doses

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

A. Carboprost tromethamine (Hemabate)

B. Misoprostol (Cytotec)

C. Methylergonovine maleate (Methergine)

D. Oxytocin (Pitocin)

12. During the patient’s combat to uterine atony, the nurse responsibilities
are, EXCEPT:

A. Administer oxygen via face mask 10-12 LPM

B. Elevation of lower extremities

C. No bathroom privileges, offer bedpan for bladder emptying

D. Check vital signs every 4 hours

13. The patient had completed the dose for the administration of
uterotonics, however her body doesn’t respond to the treatment provided.
Her physician would likely attempt bimanual compression. The nurse knows
this procedure is done:

A. By placing one hand on the abdomen just above the symphysis pubis.

B. By inserting one hand into the woman’s vagina while pushing against
the fundus

C. By removing tissue inside the uterus

D. By removing thin layer of tissue that lines the uterus

14. The physician referred the patient from the birthing room to be
examined and admitted in the tertiary hospital for further evaluation. The
patient’s uterus is not responding to bimanual compression done by the
primary care provider. The nurse knows that the next procedure that the
gynecologist would be:

D. Using sonogram for visualization, a balloon catheter may be introduced

vaginally and inflated with sterile water until it puts pressure against the
bleeding site.

15. After the bimanual compression using a balloon catheter, the physician
facilitated vaginal packing that is inserted to stabilize the placement. The
nurse responsibility is to:

B. Document the presence of vaginal packing

SESSION 9. BALLOON TAMPONADE

DESCRIPTION
· A balloon technology that is being use to tamponade the postpartum
uterus to control postpartum

hemorrhage.

· This involves inserting a rubber or silicone balloon into the uterine cavity
and inflating the balloon with

normal saline.

· The open tip permits continuous drainage of blood from the uterus.

· Balloon ruptures when more than 50 mL was instilled into the balloon,
thus a 34F Foley with a 60-ml

balloon can be used.

· If bleeding subsides, the catheter is typically removed after 12 to 24 hours.

INDICATION

· Postpartum hemorrhage due to uterine atony, when uterotonics fail to

control bleeding.

· An intrauterine balloon is used to reduce intrauterine bleeding and avoid

hemostasis hysterectomy.

· In a BEmONC facility, an intrauterine balloon can be used to stabilize the

patient before referring her

to a CEmONC facility.

CONTRAINDICATIONS

· Uterine rupture

· Purulent infection of the vagina, cervix or uterus

TYPES OF BALLOON TAMPONADE

1. CONDOM OR GLOVE TAMPONADE (as seen on

the other column)

· This is a balloon made of a rubber glove,

condom, or other device that is attached to a

rubber urinary catheter and is inserted into

the uterus under aseptic conditions.

· This device is attached to a syringe and filled

with sufficient saline solution, usually 300 ml

to 500 Ml, to exert enough counter-pressure

to stop bleeding.

· When the bleeding stops, the care provider

folds and ties the outer end of the catheter to

maintain pressure. An oxytocin infusion is

continued for 24 hours.

· If bleeding persists, add more saline solution.

If bleeding has stopped and the woman is in

constant pain, remove 50 ml to 100 Ml of the

saline solution.

· The balloon is left in place for 24 to 48 hours;

it is gradually deflated over two hours, and

then removed. If bleeding starts again during

the deflating period, re-inflate the balloon

tamponade and wait another 24 to 48 hours

before trying to deflate a second time.

· A balloon tamponade may arrest or stop

bleeding in 77.5% to 88.8% or more cases

without any further need for surgical

treatment.

2. BAKRI POSTPARTUM BALLOON/ BT-CATH (as

seen on the other column)

· This specialized device works as an

intrauterine tamponade.

· It is costly and may not be suitable for lowerresource settings.

· It is inserted and inflated to tamponade the

endometrial cavity and stop bleeding.

Insertion requires two or three team members.

· The first performs abdominal sonography

during the procedure.

· The second places the deflated balloon into

the uterus and stabilizes it.

· The third member instills fluid to inflate the

balloon, rapidly infusing at least 150 Ml

followed by further instillation over a few

minutes for a total of 300 to 500 Ml to arrest

hemorrhage. It is reasonable to remove the

balloon after approximately 12 hours

3. RUSCH UROLOGICAL HYDROSTATIC BALLOON and SENGSTAKEN-

BLAKEMORE ESOPHAGEAL CATHETER (as seen on the other

column)

· The Rusch urologic hydrostatic balloon

catheter and the Sengstaken-Blakemore

esophageal catheter have been used to

control hemorrhage unresponsive to

uterotonics.

· Both work by creating pressure within the

uterus to stop bleeding.

· However, they are both expensive and not

available in many low-resource countries.

AORTIC COMPRESSION (as seen below on figure

9)

· Aortic compression is a life-saving

intervention when there is a heavy bleeding,

whatever the cause. It may be considered at

several different points during management

of PPH.

· Aortic compression does not prevent or delay

any of the other steps to be taken to clarify

the cause of PPH and remedy it.

· While preparing for a necessary intervention,

blood is conserved by cutting off the blood

supply to the pelvis by the compression.

Step-by-step technique

1. Explain the procedure to the woman, if she is

conscious, and reassure her.

2. Stand on the left side of the woman.

3. Place right fist just above and to the left of the

woman‘s umbilicus.

4. Lean over the woman so that your weight

increases the pressure on the aorta. You should be

able to feel the aorta against your knuckles. Do not

use your arm muscles; this is very tiring.

5. Before exerting aortic compression, feel the

femoral artery for a pulse using the index and third

fingers of the left hand.

6. Once the aorta and femoral pulse have been

identified, slowly lean over the woman and increase

the pressure over the aorta to seal it off. To confirm

proper sealing of the aorta, check the femoral pulse.

7. There must be no palpable pulse in the femoral

artery if the compression is effective. Should the

pulse become palpable, adjust the right fist and the

pressure until the pulse is gone again.

8. The fingers should be kept on the femoral artery

as long as the aorta is compressed to make sure that

the compression is efficient at all times.

Note 1: Aortic compression may be used to stop bleeding at any stage. It is

a simple life-saving skill to learn.

Note 2: Ideally, the birth attendant should accompany the woman during
transfer

District or referral hospital

1. Display a PPH management protocol poster in the maternity or case

room.

2. Apply Active Management of Third Stage of Labor (AMTSL)

3. Remember the ABCs.

4. Perform any of the procedures described above that are applicable.

5. If these procedures have not stopped the bleeding, consider: Use of

intrauterine tamponade for diagnosis

and treatment Apply anti-shock garment, if not already done. Give blood
transfusion, if resources available
(consider asking family members to donate blood). Perform surgical repair
of vaginal and cervical tears.

6. If unable to control the bleeding or if expertise or specialized resources

are unavailable, prepare the

woman for referral and transfer to next level health care facility.

Tertiary care or university hospital

1. Display a PPH management protocol poster in the maternity or case

room.

2. Apply AMTSL.

3. Remember the ABCs.

4. Perform any of the procedures described above that are applicable.

5. Replace lost fluid volume with fresh blood or blood products.

6. If these procedures have not stopped the bleeding, consider the

following procedures depending on the

severity of the bleeding and the condition of the woman:

7. Laparotomy to apply compression sutures using B-Lynch or Cho

techniques Systematic pelvic

devascularization : Uterine and utero-ovarian artery ligation, Interventional

radiology: Uterine artery

embolization

8. Selective arterial embolization may be useful in situations where

preservation of fertility is desired. The

procedure requires immediate access to radiological expertise. The time

required to organize and complete
the procedure in an emergency may make it a non-viable option. Rare
complications include blood vessel

perforation, hematoma formation, infection, allergic reactions to contrast

dyes used as part of the procedure,

and uterine necrosis. Hysterectomy (sub-total or total)

Although a last resort, hysterectomy must be considered prior to the

progression of hemorrhage to the point

of cardiovascular collapse. Sub-total hysterectomy may be effective for

bleeding due to uterine atony, and is

associated with less morbidity and mortality. However, it may not be

effective in controlling bleeding from

trauma to the lower segment, cervix, or upper vaginal tract.

MULTIPLE CHOICE (10 points)

Answer the questions carefully.

1. Which of the following management should be performed in the setting

of postpartum hemorrhage following a vaginal delivery? SELECT ALL THAT
APPLY

A. Evaluate birth canal for lacerations

B. Evaluate the placenta for possible retained fragments

C. The uterus should be manually explored, and placental fragments

removed

D. Ergot alkaloids for patients with hypertension

2. During evaluation of postpartum hemorrhage following a vaginal delivery,
which of the following maneuvers or medications might be used?

A. Bimanual uterine compression

B. Ergot alkaloids for patients with hypertension

C. Carboprost tromethamine in patients with mild asthma

D. Call for help

3. A 34-year-old G3P3 begins having brisk bright red bleeding following

completion of a vaginal delivery in your birthing facility. What should be
immediately considered? SELECT ALL THAT APPLY

A. Call for help

B. Bimanual uterine compression

C. Place large-bore intravenous lines and begin volume resuscitation

D. Fundal Massage

4. The client is experiencing an early postpartum hemorrhage. Which item

in the client’s care plan requires revision for care?

A. Inserting an indwelling urinary catheter

B. Fundal massage

C. Administration of oxytocic drugs

D. Perineal pad count

5. To avoid any complications associated with labor, the nurse must have a
keen eye for assessment.In the fourth stage of labor, the nurse observed
that the client has a full bladder. The nurse knows that this increases the
risk of what postpartum complication?

A. Shock

B. Disseminated Intravascular Coagulation (DIC)

C. Hemorrhage

D. Infection

6. The client is at the end of the first postpartum day. The nurse is assessing
the client’s status. Which finding requires further evaluation at this time?

A. Uterus in the midline position

B. Firm, round uterus

C. Fundus 2 fingerbreadths above the umbilicus

D. Fundus 1 fingerbreadth below the umbilicus

7. Postpartum assessment of the newly delivered client includes checking

the uterine fundus for firmness and position. On the second day
postpartum, you expect the client’s fundus to be:

A. Slightly boggy and below the umbilicus

B. Soft and either deviated to the right or left side of the abdomen

C. Firm and two to three fingerbreadths below the umbilicus

D. Firm and two to three fingerbreadths above the umbilicus

8. Katrina a postpartum nurse is preparing to care for a woman who has just
delivered a healthy newborn infant. In the immediate postpartum period
the nurse plans to take the woman's vital signs:

A. Every 30 minutes during the first hour and then every hour for the next
two hours.

B. Every 15 minutes during the first hour and then every 30 minutes for
the next two hours.

C. Every hour for the first 2 hours and then every 4 hours

D. Every 5 minutes for the first 30 minutes and then every hour for the next
4 hours.

9. Karina a postpartum nurse is taking the vital signs of a woman who

delivered a healthy newborn infant 4 hours ago. The nurse notes that the
mother's temperature is 100.2*F. Which of the following actions would be
most appropriate?

A. Retake the temperature in 15 minutes

B. Notify the physician

C. Document the findings

D. Increase hydration by encouraging oral fluids

10. Maxima is caring for a client during the immediate recovery phase or
fourth stage of labor. Which

action is most important for the nurse to take at this time? SELECT ALL THAT
APPLY

B. Check the uterine fundus

C. Check for the lochia

SESSION 10. INVERSION OF THE UTERUS

DESCRIPTION

· Puerperal inversion of the uterus is one of the classic hemorrhagic

disasters encountered in obstetrics.

Unless promptly recognized and managed appropriately, associated

bleeding often is massive.

· Uterine inversion occurs rarely, approximately 1 in every 25,000 deliveries.

It is often iatrogenic,

meaning it is caused by health care providers, often resulting from overly

vigorous umbilical cord

traction.

· Uterine inversion is more common in grand multiparous women.

Risk factors include alone or in combination:

(1) fundal placental implantation

(2) uterine atony

(3) cord traction applied before placental separation

(4) abnormally adhered placentation such as with the accrete syndromes

TYPES

1. INCOMPLETE INVERSION-when the fundus of the uterus has turned

inside out but the inverted fundus has

descended through the cervix.

2. COMPLETE INVERSION-when the inverted fundus has passed completely

through the cervix within the

vaginal canal.

DEGREES OF INVERSION

1. FIRST DEGREE INVERSION- the uterus is partially turned out

2. SECOND DEGREE INVERSION-the fundus has passed through the cervix

but not outside the vagina

3. THIRD DEGREE INVERSION-the fundus is prolapsed outside the vagina.

4. FOURTH DEGREE INVERSION- the uterus, cervix and vagina are

completely turned inside out and are visible.

PREVENTION

· Do not employ any method to expel the placenta when the uterus is
relaxed

· Patient should not be instructed to change her position.

· Pulling the cord simultaneously with fundal pressure should be avoided

· Manual removal of placenta should be done in proper manner.

CLINICAL MANIFESTATIONS

· Excruciating pelvic pain with a sensation of extreme fullness extending

into the vagina.

· Extrusion of the inner uterine lining into the vagina or extending past the
vaginal introitus.

· Vaginal bleeding and signs of hypovolemia.

MANAGEMENT

***Never attempt to replace an inversion because handling of the uterus

could increase the bleeding.

***Never attempt to remove the placenta if it is still attached because this

would create a larger surface area for bleeding.

MULTIPLE CHOICE (10 points)

1. Which of the following techniques during labor and delivery can lead to
uterine inversion?

B. Strongly tugging on the umbilical cord to deliver the placenta and

hasten placental separation.

2. When the Uterus is firm and contracted after delivery but there is vaginal
bleeding, the nurse should suspect?

A. lacerations of the soft tissues of cervix and vagina

B. uterine rupture

C. uterine inversion

D. uterine hypercontractility

3. A 33 y/o woman was rushed to ER , physical examination reveals the

presence of a smooth, round and round and pale mass protruding from the
vagina. What has most likely occurred in this patient?

A. Uterine atony
B. Uterine inversion

C. Voluntary uterine extension

D. Volatile uterine flexion

4. The following are risk factors of uterine involution, EXCEPT:

D. multifetal pregnancy

5. A 30 y/o woman delivers a 9 lb newborn. After placenta is delivered, a

firm pale mass is noted in the lower vagina. There is also moderate vaginal
bleeding during abdominal examination, uterus cannot be palpated. What
is the likely diagnosis?

A. Uterine inversion

6. Which of the following techniques during labor and delivery can lead to
uterine inversion?

B. Strongly tugging on the umbilical cord to deliver the placenta and

hasten placental separation

7. A procedure which is usually done by placing one hand in the vagina and
pushing against the body of the uterus while the other hand compresses
the fundus from above through the abdominal wall.

B. Bimanual uterine compression

8. Karylle a nurse educator on the postpartum unit is reviewing risk factors

for postpartum hemorrhage with a group of nurses. Which of the following
should be included in the discussion? SELECT ALL THAT APPLY

A. Precipitous delivery

B. Lacerations

C. Inversion of the uterus

E. Retained placental fragments

9. While assessing a primipara during the immediate postpartum period,

the nurse in charge plans to use both hands to assess the client’s fundus to:

A. Prevent uterine inversion

10. When the Contractions stop, and bleeding is primarily into the
abdominal cavity, the nurse should suspect?

B. uterine rupture