Aripin, Alshammae N.
II BSN - H
Bleeding during Pregnancy Spontaneous Miscarrige
Bleeding during Pregnancy — deviation from normal
● any degree of this during pregnancy
is potential emergency due to
placenta has loosened and cut off
nourishment to the fetus
● amount of blood visualized may he Management:
only a fraction of the blood actually
being lost due to undilated cervix
and intact membranes contain
blood within the uterus
● significant blood loss or developing
hypovolemic shock is expected
Signs of Hypovolemic Shock — severe blood or other
fluid loss makes the heart unable to pump enough blood to the
body.
- occur when 10% of blood volume of approximately 2
units of blood have been lost
- fetal distress occur when 25% of blood volume is lost Management:
Signs and Symptoms of Hypovolemic Shock
1. Increased pulse rate
○ Heart attempts to circulate decreased blood
volume
2. Decreased Blood pressure
○ Less peripheral resistance is present
because of decrease blood volume
3. Increase RR
○ Respiratory system attempts to increase gas
exchange to better oxygenate decreased red
blood cell volume
4. Cold, clammy skin Management:
○ Vasoconstriction occurs to maintain blood
volume in central body core
5. Decreased Urine output
○ Inadequate blood is enetering kidneys
because of decreased blood volume
6. Dizziness or decrease level of conciousness
○ Inadequate blood is reaching cerebrum
because of decrease blood volume
7. Decreased Central Venous Pressure Management:
○ Decreased blood is returning to heart
because of reduced blood volume.
FIRST TRIMESTER BLEEDING
➢ Abortion
➢ Ectopic Pregnancy
Abortion — any interruption of pregnancy before a fetus is
viable ( AOV— 24 weeks or one that weighs at least 500g).
Early miscarriage occurs before 16 weeks
Late miscarriage occurs between 16 and 20 weeks
1.Threatened Miscarriage
○ Prior to end of the 20th weeks of AOG
○ Bleeding: slight or spotting (bright red)
○ Cervix: Closed
○ Pain: uterine cramping, slight to moderate
- Complete Bed Rest (CBR) without BRP
- Diet: Normal diet-high vitamins and protein
- Instruct cloent to avoid any kind of straining
- Keep pernieal pad count to determine blood loss
- Restrict contact
2.Imminent (Inevitable) Miscarriage
○ Cannot be stop when membranes rupture
and the cervix dilates
○ Bleeding: Moderate to Profuse
○ Cervix: Open
○ Pain: Moderate to severe
- CBR without BRP
- Keep all perineal pad count and save all tissues
samples
- Replace blood or fluid loss as necessary
- NPO, D&C
3.Incomplete Miscarriage
○ Some but not all of the conceptions products
is expelled
○ Cervix: open
○ Bleeding: active uterine bleeding and severe
abdominal cramping
- Prepare for complete abortion D&C
- IV line – fluid administration replacement, oxytoxin
4.Complete Miscarriage
○ Occurs when all products of conception are
expelled from the uterus
○ Pregnancy test (-) & symptoms no longer
present
- Bed rest and watch for bleeding, pain, and fever
5. Missed Miscarriage
○ Fetus dies in utero before 20 weeks AOG &
retained 2 months or longer
○ Cervix: Closed
○ Uterus stops growing: decrease in size
○ Painless vaginal bleeding
○ Discharges: Foul smelling, red or brownish
or may not occur
○ Fetus will undergo changes:
■ Fluffing – gray scale, thickening
and covering of fetal skull and
thorax
■ Maceration – softening
 Aripin, Alshammae N. II BSN - H
■ Mummification – leather like ○ 2 pads/hour
changes ○ Clots
■ Lithopedion formation – ● Infection
stoney-material ○ Fever
6. Recurrent Pregnancy Loss ○ Abdominal pain & tenderness
○ Repeated aborting (spontaneous of any ○ Endometritis
type)
○ 3 or more pregnancy at same age or 2. Dilation and Vacuum Extraction
per-viable stage ○ Paracervical block
■ Causes: ○ Cervix is dilated by dilators
1. Defective Spermatozoa ○ LAMINARIA – dried sterilized seaweeds –
2. Hormonal Influence cervix swells after 24hrs bacomes dilatable,
3. Nutritional status vacuum extraction is inserted and evacuate
4. Deviation of uterus – uterine contents in 15 minutes
mid-septum, ○ Antibiotics, oxytoxin, MGH after 4 hours
Biconuate-horns or poles ○ Bleeding same as menses
small space for
implantation 3. Suction Curettage
5. Psychological factor Complications:
(stress) ● Hemorrhage
6. Blood Incompatibility – ○ 2 pads/hour
ABO, Rh factor ○ Clots
● Infection
Induced Abortion ○ Fever
○ Abdominal pain & tenderness
– voluntary/deliberately terminating pregnancy ○ Endometritis

1. Therapeutic – medically indicated 4. Saline Induction

2. Criminal – intentionaly ○ Salt poisoning Abortion – done on 14th-
3. Septic – infected abortion, secondary to infection 16th weeks of AOG then D&E is used
■ Salt water kills the fetus
Purpose: ■ Uterus starts contracting usually
● Threat within the next 2 days, resulting in
● To prevent birth of infant with severe defects the delivery of the dead fetus
(malformation, chromosomal) ○ Saline & Prostanglandin Induction – done on
● Psychological Implication (rape or incest) 17th–24th weeks AOG
■ Mechanism:
Therapeutic Abortion: According to US Supreme court ruling ● Saline interferes with
(Jan 22, 1973) pregnancy may be terminated as follows: progesterone functioning
1. First Trimester Abortion – decision is left to the causing endometrial
woman and her physician sloughing
2. Second Trimester – state may not prohibit but may ● Needle is inserted into the
regulate practice for women's health. uterus through the
3. Third Trimester – state may choose to protect abdominal wall.
potential life of the fetus by prohibiting abortion except Procedure:
when there is a threat to mother’s life or health ● Some amniotic fluid is removed about 100-200mL and
4. Religious belief of the mother is always respected. replaced with 20% hypertonic saline sol. is injected
into the uterus to replace aspirated amniotic fluid
● Needle is removed – 12–36hrs following injection–
Procedures Used to Induced Abortion
Labor contractions begins; supplemented by oxytocin
drip
1. Menstrual Extraction – simplest type done on the
4th–6th weeks AOG
Complications:
○ Uterine lining is suction – client bleeds as
1. Hypernatremia – accidental injection of HSS to blood
normal menses
vessels in the uterus
○ Oxytoxin given orally
a. Signs & Symptoms
○ Follow-up check up & pregnancy test
- Increase pulse
Complications:
- Flushed face
● Hemorrhage
 Aripin, Alshammae N. II BSN - H
b. Mechanism: to equalize osmotic pressure,
fluid from tissue transfer to blood vessel B. Ovarian
which then leave the tissue dehydrated. a. Tubo-ovarian
b. Ovarian
2. Water Intoxication C. Cervical
a. Large amount oxytocin used, ADH effect D. Abdominal/Peritoneal
b. S/Sx: severe headache, confusion,
drowiness, edema, decrease urinary output
c. Rx: DIC & oxytocin drip
3. Hemorrhage
4. Infection – D5W - to balance or restore fluid

Prostaglandin Injection – hormone which is abortive

○ Administration:
■ IV drip
■ ½ - Ihr after adm. labor will
start
■ No oxytocin needed Causes:
■ S/E: nausea, vomiting, and 1. Adhesions in tubes - tubo-ovarian, fallopian tubes
diarrhea 2. Infection - chronic salphingitis. PID
■ Dx: anticholinergic, and 3. Congenital malformations - infantile uterus
antidiarrheal 4. Scars of tubal surgery - a failed tubal ligation
■ CI: HPN- vasoconstriction, 5. Uterine tumor pressing the tubes
respiratory disorder - 6. Endometriosis
bronchial constriction & 7. Tubal spasm
bronchospasm
● Vaginal suppository - given 3–4 hours Signs & symptoms of Ruptured ectopic:
■ as PRN until labor starts 1. Spotting bleeding - may or may not not be present
2. Abdominal rigidity
● Oral - not recommended - causes severe 3. Cullen's signs - bluish discolorations around the
nausea and vomiting, shaky, chills, & umbilicus
increased temperature. 4. Shoulder pain - blood irritating the phrenic nerve in
the diaphragm
Hysterotomy – done on 16th and 18th weeks AOG like 5. Mass in Cul-de-sac of Douglas (pouch) may be
cesarean section. palpated or bloody fluid may be aspirated
culdocentesis
Complications of Abortion 6. Excruciatinging pain at cervix when !E is done
1.  emorrhage
H 7. Knifelike pain either lower quadrant
2. Infection 8. WBC- 15,000/UL>, RBC - decrease, ESR – slight
3. Isoimmunization – production of antibodies against elevated
Rh-positive blood type 9. S/S of shock

ECTOPIC PREGNANCY
Signs & symptoms (early ectopic pregnancy)
● Implantation of a fertilized ovum outside the uterine 1. Amenorrhea or abnormal menses - spotting
cavity.
● Ectopic pregnancy has been called "a disaster of S/S - acute rupture
reproduction" for 2 reasons: 1. Shock
1. it remain a significant cause of maternal 2. Referred shoulder pain
death from hemorrhage 3. Evidence of acute blood loss
2. It reduces the woman's chance of
subsequent pregnancies because of damage S/S - Chronic rupture – occurs 50% in tubal ectopic
or destruction of the fallopian tube. pregnancy
Types according to sites 1. slow - internal bleeding
A. Tubal – most common 2. atypical or inconclusive symptoms as
a. fimbriae ○ Slight, dark, vaginal bleeding
b. ampullar - 60% ○ Renal or pelvic pressure or fullness
c. isthmic ○ Lower abdominal tenderness
d. interstitial ○ Slight fever
 Aripin, Alshammae N. II BSN - H
○ Leukocytosis
○ Cullen's sign Sign & Symptoms:
○ Decrease hgb & hct a. rapid enlargement of the uterus Like 3 mos.= 5 mos.
b. absence of fetal heart tones or movement & fetal
Diagnostic test: structures
● Ultrasound - reveal site of ectopic pregnancy c. hCG titers greater than expected for gestational age
● Culdocentesis - yields free blood that will not clot or (+ pregnancy test)
is already clotted d. hyperemesis gravidarum
● Laparoscopy - discloses extrauterine pregnancy e. signs of PIH before 20m weeks AOG
f. vaginal bleeding - dark-brown blood
Treatment g. passing out of grape-like clusters
1. Culdotomy - release clotted blood and product of "Latu-latu"appearance @ 16 weeks AOG – the client
extrauterine pregnancy. bleeds with molar expulsion.
2. Laparotomy - reveal correct diagnosis
3. Salpingostomy Diagnostic test
1. Ultrasound (sonogram) - reveals molar pregnancy,
Nursing Management show-dense growth [typically snow flake pattern] but
1. Monitor V/S, watch for signs of shock no fetal growth.
2. Nursing care to bleeding clients 2. Pregnancy test - (+) due to elevated hCG titer.
3. Observe nature of bleeding ● HCG= increase 1.2 mil. IU in 24 hrs.[normal
4. Administration of nacotics or analgesic as ordered = 400,000 lU
5. Prepare clients for diagnosis and treatment 3. Hct.& Hgb - decrease due to bleeding
6. Provide post operative care 4. ESR & WBC- increase due to infection

Management:
SECOND TRIMESTER BLEEDING 1. Evacuation by:
a. DC or Suction curettage
➢ H-mole b. Hysterotomy
➢ Incompetent Cervix c. Hysterectomy – above 45 yrs.old

2. Follow-up management for detection of malignant

GESTATIONAL TROPHOBLASTIC DISEASE changes of complications.
(Hydatidiform Mole or Molar Pregnancy) a. HCG levels
b. # every 2 weeks until titers are negative for 3
consecutive results
Pathophysiology:
■ # once monthly x 6 mos
● The embryo & the placenta deteriorate & loose its
■ # every 2 mos X 6 mos
identity
■ # every 6 mos X 1 year.
● A rapidly growing throphoblastic tissue develop
● if hCG are negative – free of risk of developing malignancy.
Note: continual rising of HCG (3x) indicates pathologic
2 Types of Molar Growth:
condition- D&C is to be done if the uterus is intact then tissue
1. Complete mole
can be examined (biopsy)
a. no fetus
3. Prophylactic treatment of choriocarcinoma
b. all trophoblastic villi
a. Methotrexate - drug of choice, but this drug
c. embryo dies early
interferes with WBC formation (Leukopenia)
d. no fetal blood found
b. Dactinomycin - drug used if metastasis
occurs.
2. Partial mole ■ if untreated, death results
a. Some villi formed
b. Presence of gth week fetal mass & fetal 4. CXR - to detect metastasis to the other systems of the
blood in the villi body as to the lungs
c. Rarely lead to choriocarcinoma a. to be done until hCG titers are negative.
b. then every 2 months x 1 yr.
Predisposing Factors: 5. Oral contraception – used to:
1. Malnutrition - low protein intake a. prevent another molar pregnancy
2. Age - woman under 20 & above 35 yrs.old b. suppress Endogenous Pituitary Leutenizing
● low socio economic status Hormones (LH)which will distort hCG titer
3. Chromosomal abnormalities assay.
4. Hormonal imbalance - use of Clomiphene citrate 6. Provide Emotional Support
(clomic) and women of asian heritage
 Aripin, Alshammae N. II BSN - H
Nursing Intervention
INCOMPETENT CERVIX After the cerclage:
- observe for spotting of fresh blood - expected during
A defect in the cervix that makes it unable to remain closed the 1st–2nd day (application of suture induces
through pregnancy. bleeding)
- Common cause of late abortions or premature - placed on bedrest or slight T-position - to decrease
labor. pressure on the new sutures.
- Occurs at 20th weeks AOG - sexual activity may resumed after rest period

Causes:
1. Trauma - traumatic delivery as forcep extraction THIRD TRIMESTER BLEEDING
- forceful D&C
2. Congenital anomaly ➢ Placenta Previa
- infantile uterus ➢ Abruptio Placenta
3. Endocrine factor - low progesterone

Criteria before Management:

(in the current pregnancy) all must be present
a. Membranes (BOW) must be intact
b. Cervix is not > 3cm.dilated
c. Cervix is not > 50% effaced
Management
Supportive
1. Bedrest
2. Monitor VIS & FHT
3. Psychological support & reassurance
4. Health teaching:
● Uterine contraction
● Rupture of Membrane
● Assess presence of fever
● Bleeding and pain
● Abstain coitus
Surgery
1. Cervical Cerclage – a purse string suture is placed
in the cervix.
- done to prevent premature dilatation of the
cervix, holds pregnancy inside the uterus.
Types of Cerclage Techniques:
a. Shirodkar-Barter technique
● sterile tape is threaded in a purse-string
manner under the submucous layer of the
cervix
● suture implaced to achieve a closed cervix
b. McDonald technique
○ nylon sutures are placed horizontally &
vertically across the cervix pulled tight to
reduced the canal
○ remove if fetus reached almost fullterm -
38th -39th weeks AOG.
Transabdominal approach
● a permanent purse-string (cerclage) is placed at the
lower end of the uterus or remaining cervix.
● the suture is left in placed and C/S is performed.
● success of both types: 80% - 90%.
PLACENTA PREVIA
– Improperly implantated placenta in the lower uterine
segment near or covering the internel cervical os
– 30% › than average placenta implanted at the funds - site &
size related (surface area)
– degree of placenta covers the internal os is estimated by
70-100%, 75% etc.
– 2nd trimester 45% of placenta are implanted at lower
uterine segment
Classification of Placenta Previa
● Incomplete or Partial Placenta Previa – Occurs
when the placenta asymmetrically envers only part of
the internal os
● Marginal Placenta Previa – only an edge of the
placenta approaches the internal os
Causes:
1. Unknown
2. Can be attributed to the following conditions:
● Fibroid tumor in the uterus
● Uterine scars from previous surgery (c/s,
past uterine curettage)
● Abnormal uterine position or shape
● Multiparity - multiple gestation
● Age - very young & very old
● Cigarette smoking
Assessment/ Physical Exam:(7 months AOG)
1. Painless uterine bleeding
2. Uterine tone - normal but relax completely bet.cont.
3. Pain - painless non-tenderness uterus- may
experience labor
4. Fetal position
 Aripin, Alshammae N. II BSN - H
○ Fundal height is greater – placenta hinders ● Hemorrhage is apparent or visible when bleeding
descent of presenting parts separates or dissects the membranes from the
○ leopold's maneuver reveals malposition of endometrium and blood flows out through the vagina.
fetus – transverse or breech
Relatively Concealed Abruption
Diagnostic tests: Partial separation concealed bleeding
● Ultrasound - safe, accurate, & non invasive method of ● Concealed Hemorrhage – the bleeding occurs behind
visualizing the placenta the placenta but the margins remain intact, Causing
● Amniocentesis formation of a hematoma
○ asses fetal lung maturity LS ratio 1:2
○ If lung maturity is reached, Cs delivery-done Concealed Abruption
Complete separation – concealed bleeding
● No vaginal exam uless patient is place on double
preparation procedure Incidence and Etiology
1. Cause is unknown
Laboratory tests: 2. Following factors that increase risk:
- hemoglobin ○ Maternal use of cocaine - leading case of
- hematocrit abruptio placenta
- Rh factor ○ Cigarette smokin
- urinalysis ○ Maternal HPN; Multigravida
- blood typing ○ PROM; Advance maternal age
○ History of previous premature separation;
Nursing Care Management abortion, stillbirth, pre-natal hemorrhage;
Goal: to ensure an adequate blood supply to a woman & fetus. premature labor
1. Inspect perineum for bleeding ○ Abdominal trauma; short umbilical cord
2. Test strip procedure - to detect blood is fetal or
maternal origin DEGREES OF SEPARATION
3. No IE or rectal exam in painless bleeding.
Grade Description
4. Monitor vis (TR,B/P), 180, FHT
5. IF therapy- use larger bôre needle (LR, vol. 0 No symptoms were apparent
Expander) from maternal or fetal side;
6. O2 administration - incase of fetal distress diagnosis of placental
7. Keep NPO separation is made during
8. Betamethasone - steriod that hasten fetal lung delivery; placenta shows
maturity in < 34 weeks gestation. recent adherent clots on
maternal surface
Management of placenta previa (In General)
● delivery - if fetus reached maturity 1 Minimal separation
a. if > 30% previa enough to cause vaginal
○ Abdominal by C/S bleeding and change
b. If <30% previa surfaces in the maternal VS;
○ Vaginal delivery no fetal distress or
■ if delivery is not attained hemorrhagic shock occurs
within 6 hours – C/S is
indicated
PLACENTA ABRUPTIO 2 Moderate separation with
evidence of fetal distress;
- is the premature separation of part or all of the uterusresult is tense, painful
placenta from its site of implantation on palpation
- can be an abnormal separation of a normally
implanted placenta 3 Extreme separation without
- occurs at >20 weeks of AOG immediate intervention;
maternal shock and fetal
Classification of Abruptio Placenta death will result
External Abruption
Marginal Abruption w/ external bleeding
Assessment/Physical exam
- Symptoms vary with degrees of placental separation
(ABRUPTIO PLACENTA)
 Aripin, Alshammae N. II BSN - H
● Vaginal bleeding- may be concealed 3. DIC
● Uterine contractions (hypertonic) 4. Acute renal failure
● Increased abdominal girth 5. Infection
● Signs of shock 6. Postpartal hemorrhage
● Fetal distress or fetal demise 7. Death
❖ In severe concealed bleeding, blood may
infiltrate the uterine musculature -
COUVELAIRE uterus or uteroplacental
apoplexy - hard, boardlike uterus - orange or
bronze color - uterus becomes tense and
rigid to touch
❖ In extensive bleeding, DIC syndrome
occurs; the woman's reserve blood
fibrinogen may be used up in her body's
attempt to accomplish effective clot
formation

Signs of Concealed hemorrhage

● Increase in fundal height
● Hard boardlike abdomen
● Persistent abdominal pain

Systemic signs of hemorrhage

- Persistent late deceleration in FHT
- Slight or absent vaginal bleeding

Laboratory tests:
● Hemoglobin level
● Blood typing & cross-matching
● Fibrinogen level - tests for DIC (5 ml of blood to stand
for 5 mins; if clot formed- DIC negative; no clot
formation - positive to DIC

Nursing Care/Management
1. Admit to hospital
2. Administered oxygen by mask ( fetal anoxia)
3. Monitor FHT, VS and record
4. Determine baseline fibrinogen
5. Keep in lateral position -prevent pressure at vena
cava; further compromise Tetal circulation
6. No IE, pelvic exam, enema
7. Depending on degree of separation if labor starts -
rupturing BOW may help speed delivery or
administration of oxytocin.

Purpose of rupturing BOW

a. Prevents development of couvelaire uterus, prevents
pooling of blood in the myometrium of uterus.
b. Prevent DIC
c. Speed up delivery
8. If delivery do not occur, cesarean section is the
method of choice
9. Cause of maternal death:
● Massive hemorrhage which lead to hock;
circulatory collapse or renal failure
● Infection

Fetal Complications:
1. Prematurity
2. Hypoxia – result in irreversible damage & anemia

Maternal Complications:
1. Hemorrhage
2. Hypovolemic shock

PROBLEMS WITH LABOR
Stages of Labor
● First stage of labor: Begins at the onset of true
labor/regular contractions (= every 5 mins lasting
30 seconds) until the mother’s cervix is fully
dilated 10 cm and effaced 100%
○ Latent phase - starts when regular uterine
contractions set in and ends at the
beginning of the active phase
○ Active phase - which begins when rapid
cervical dilation begins and ends when
the mother’s cervix is fully dilate
● Second stage of labor: Begins when the mother’s
cervix is fully dilated until the baby is delivered
○ Problem: Passenger (LGA)
● Third stage of labor: Begins when the baby is
delivered until the placenta is delivered
● Fourth stage of Labor: 1–2 hours after delivery
Dystocia – prolonged labor
1. Hypertonic & Hypotonic Uterine Contractions
2. Abnormal progress in Labor
3. Retraction Ring
Factors:
- Forces are inadequate (faulty power)
○ E.g Inertia – sluggishness of contractions
- Abnormal position of passenger
- Abnormal passageway (birth canal)
Premature labor – less than 37 weeks ; more than 20
weeks
1. Precipitate labor & birth – less than 3 hours of
delivery
2. Uterine Inversion – uterine fundus collapses into the
endometrial cavity, turning the uterus partially or
completely inside out
3. Uterine Rupture – uterus tears or breaks open
Amniotic fluid embolism – Amniotic fluid enters circulatory
system/ lungs = hypoxia
DYSTOCIA
➢ Hypotonic Uterine Contractions
➢ Hypertonic Uterine Contractions
➢ Dysfunction of Labor progress (by stage)
➢ Retraction Ring
Dysfunctional labor
- Occur at any point in labor, but it is generally
classified as primary (occurring at the onset of
labor) or secondary (occurring later in labor).
- Denotes Sluggishness of contractions
Aripin, Alshammae N. II BSN - H
- Most likely to occur if a fetus is large or if the
contractions are hypotonic, hypertonic or
uncoordinated contractions
Common Causes of Dysfunctional Labor
● Maternal fatigue
● Maternal inactivity
● Inappropriate use of analgesia (excessive or too early
administration)
● Disproportion between maternal pelvis and fetal
presenting part
● Poor fetal position (posterior rather than anterior)
● Overdistention of the uterine (multiple, hydramnios,
LGA)
● Presence of full rectum or urinary bladder that
impedes fetal descend
PROBLEMS WITH THE POWER
(The Force of Labor)
● Ineffective or abnormal uterine
contractions are classified according to
strength:
○ Hypotonic Uterine Dysfunction
○ Hypertonic Uterine Dysfunction
○ Uncoordinated Contractions
Ineffective Uterine Force
- Uterine contractions are the basic force moving
the fetus through the birth canal.
- They occur because of the interplay of the
contractile enzyme adenosine triphosphate and in
the influence of major electrolytes.
- When contractions become abnormal or ineffective,
dysfunctional labor occurs.
- Classified as hypotonic, hypertonic and uncoordinated
uterine contractions
Hypotonic Contractions (secondary dysfunction)
- Resting tone of the uterus: ↓ 10 mmHg (not
elevated)
- Number of contractions is unusually low or
infrequent (not more than 2 or 3 occurring in a
10-minute period).
- Strength of contractions does not rise above 25
mmHg.
- Coordinated but weak contractions– woman may feel
discomfort due to weak contractions
- Become less frequent and short in duration
- Easily indented at peak
- Not painful due to the lack of intensity. (But others
may find it already painful).
● May occur:
- During the active phase of labor, after 4 cm
dilation.

- After the administration of analgesia, if
the cervix is not dilated to 3-4 cm
- Bowel or bladder distention prevents
descent or firm engagement.
- Overstretched uterus by multiple
pregnancies
- LGA, polyhydramnios, or in uterus that is
lax from grand multiparity
● Increases the length of labor because more of them
are necessary to achieve cervical dilatation,
increasing the risk of postpartum hemorrhage due
to uterus becomes exhausted causing not to
contract effectively during postpartal period
Therapeutic Management:
- Amniotomy (may increase risk for infection)
- Oxytocin augmentation
- C/S if no progress
NURSING RESPONSIBILITIES:
In the first hour after birth following a labor of hypotonic
contractions, palpate the uterus and assess lochia every 15
minutes to ensure that postpartum contractions are not
also hypotonic and therefore inadequate to halt bleeding.
● Interventions related to amniotomy and oxytocin
augmentation
● Encourage position changes
● An abdominal binder may help direct the fetus
towards mother’s pelvis if her abdominal wall is very
lax
Hypertonic Contractions (primary dysfunction)
- Occurs because the muscle fibers of the
myometrium do not repolarize or relax after a
contraction, thereby “wiping it clean” to accept a
new pacemaker stimulus.
- Resting tone of the uterus: ↑ 15 mm Hg
- Intensity of the contraction may be no stronger than
hypotonic contractions. More painful than usual,
because the muscle fibers of the myometrium
become tender from constant lack of relaxation and
the anoxia of the cells that results.
- Uncoordinated, irregular, short and poor intensity but
painful and cramplike
- Strong contractions in the midsection of the uterus
(than in fundus)
- Anoxic uterines muscles
- Lack of relaxation
● May occur:
- Frequently in the latent phase of labor,
before 4 cm dilation.
- Because more than one pacemaker is
stimulating contractions.
● Danger: lack of relaxation between contractions may
not allow optimal uterine artery filling, this could
lead to fetal anoxia early in the latent phase of labor.
Aripin, Alshammae N. II BSN - H
● If deceleration in the FHR or an abnormally long first
stage of labor or lack of progress with pushing occurs
(second-stage arrest) C/S birth may be necessary.
Therapeutic Management:
- Correct cause if can be identified
- Light sedation to promote rest
- Hydration
- Tocolytics to reduce high uterine tone and promote
placental perfusion
NURSING RESPONSIBILITIES:
If pain seems to be out of proportion to the quality of her
contractions should have both a uterine and a fetal external
monitor applied for at least 15 minutes to ensure that the
resting face is adequate and the fetal pattern is not
decelerating.
● Promote uterine blood flow; side-lying position
● Promote rest, general comfort and relaxation
● Pain relief
Coordinated contractions
- One pacemaker points high in the uterus.
Contraction encircles the organ → repolarization
occurs → relaxation or low resting tone is achieved →
another pacemaker is activated contraction begins.
Uncoordinated Contractions
- More than one contractions may be initiating the
uterus or receptor points in the myometrium may be
acting independently of the pacemaker.
- May occur that they do not allow good cotyledon
(one of the visible segments on the maternal surface
of the placenta) filling.
- Difficult to rest between contractions or use
breathing exercises.
NURSING RESPONSIBILITIES:
Apply fetal and uterine external monitors and assess the
rate, pattern, resting tone and fetal response to
contractions for at least 15 minutes to reveal the abnormal
pattern. Oxytocin may be administered to stimulate a more
effective and consistent pattern of contractions with a better,
low resting tone.
Complications:
● Mother: Exhaustion and dehydration
● Infant: Injury and death
Dysfunction at the first stage of labor
Prolonged latent phase
- Latent phase that is longer than 20 hours
nullipara or 14 hours for multipara.
● May occur:
 Aripin, Alshammae N. II BSN - H
○ If the cervix is not “ripe” at the beginning
of labor, time must be spent getting ready Dysfunction at the Second Stage Labor
for true labor.
○ Excessive use of analgesics early in
labor.
Prolonged Descent
- Prolonged latent phase tends to be in a hypertonic
● Occurs if the rate of descent is:
state.
○ less than 1.0 cm/hr in a nullipara or
- Relaxation between contractions is inadequate,
○ 2.0 /hr in a multipara.
and the contractions are only mild (⬇ than 15 mmHg)
● It can be suspected if the second stage lasts over
therefore ineffective.
3 hours in a multipara

MANAGEMENT:
NURSING RESPONSIBILITIES:
● Help the uterus rest
- If CPD and poor fetal presentation have been ruled
● Providing adequate fluid,
out by ultrasound, then rest and fluid intake.
● Pain relief (morphine sulfate),
- If membranes have not ruptured, rupture them.
● Dimming the lights
- Semi-fowler’s position, squatting, kneeling, or
● Changing linen and patient’s gown
more effective pushing may speed the descent.
● Decreasing noise
Arrest of Descent
If not effective, C/S or amniotomy and oxytocin infusion (to ● When no descent occured for 2 hours in nullipara
regulate uterine contractions) to assist labor may be necessary. or 1 hour in multipara.
● Descent of the fetus does not begin or engagement
or movement beyond 0 station.
Protracted Active Phase
● Cause of the arrest during the second stage is
CPD.
● Associated with cephalopelvic disproportion or
fetal malposition.
Contraction Rings
● Phase is prolonged if cervical dilatation does not
occur at a rate of at least:
- 1.2 cm/hr in a nullipara or 1.5 cm/hr in a
multipara (1cm/hr in nulli, 1.2cm/hr in multi)
- If the active phase lasts longer than 12
hours in a primigravida or 6 hours in a
multigravida. (Should be 4-8 hours)
● If the cause of delay in dilatation is CPD or fetal
malposition, C/S may be necessary.
● Tends to be hypotonic during the dilatation
division of labor.

NURSING RESPONSIBILITIES:
After an ultrasound to show that CPD is not present,
oxytocin may be prescribed to augment labor.
● A hard band that forms across the uterus at the
Prolonged deceleration phase junction of the upper and lower uterine segments
and interferes with fetal descent.
● The fetus is gripped by the retraction ring and
● May be prolonged:
cannot advance beyond.
- Extends beyond 3 hours nullipara or 1
● Most frequently type seen:
hour in multipara.
A. Pathologic retraction ring (Bandl’s ring)
● The cervix dilates very quickly, but towards the
a. Common in obstructed labor;
end of the active phase, cervix dilation slows
retraction ring is indented deeply
down.
and palpable as a mass in the
● Most often results from abnormal fetal head
middle of the abdomen.
position. C/S frequently required.
b. Grip fetus and placenta
❖ Assessement:
Secondary Arrest of Dilatation - Usually appears during the 2nd stage of
labor and can be palpated as a horizontal
● Occurs when there is no progress in cervical dilatation indentation across the abdomen.
for longer than 2 hours - Uncoordinated contractions early in labor
● Management: C/S may be necessary
 Aripin, Alshammae N. II BSN - H
- It is a warning sign that severe ● Contractions may be forceful that they lead to
dysfunctional labor is occurring as it is premature separation of the placenta, placing the
- CAUSED: by excessive retraction woman at risk for hemorrhage, and also sustain

⚠️
of the upper uterine segment. laceration of the birth canal.
- DANGER : Signifies impending ● Risk to the fetus:
rupture of the lower uterine ○ subdural hemorrhage may result from the
segment and neurologic damage to rapid release of pressure on the head.
fetus may occur if the obstruction is
not relieved. NURSING RESPONSIBILITIES:
● In the pelvic division of labor, it is usually caused - Tocolytics may be administered to reduce the force
by obstetric manipulation or by the administration and frequency of the contractions.
of oxytocin.
● In the placenta stage, massive maternal Cervical Ripening
hemorrhage may result, because the placenta is
loosened but then cannot deliver, preventing the
● Change in cervical from firm to soft, is the first step
uterus from contracting.
that the uterus must complete in early labor.
● Until this has occurred, dilatation and coordination of
B. Constriction Ring
uterine contractions does not occur.
a. Can occur at any point of in the
● Scoring of the cervix is a way to determine if the
myometrium and anytime during
cervix is “ripe,” or ready for dilatation.”bishop score”
labor
● If the total score is 8 or greater, the cervix is
b. When pathologic occur during early
considered ready for birth.
labor, it is usually from
uncoordinated contractions
Methods to ripen a cervix:
- Stripping or separating the membranes from the
NURSING RESPONSIBILITIES:
lower uterine segment manually, using a gloved
- Administering IV morphine sulfate or the inhalation
finger in the cervix.
of amyl nitrite may relieve a retraction ring.
Risk: possible bleeding from an
- Administration of tocolytics to halt contractions.
undetected low-lying placenta, infection.
- C/S or Manual removal of the placenta may be
- Hygroscopic suppositories - inserted to gradually
required if the retraction ring does not allow the
and gently urge dilatation.
placenta to be delivered,
- Most common: application of prostaglandin gel
● if not attended leads to:
misoprostol (Cytotec), to the inferior surface of the
○ Mother: Uterine rupture and
cervix by a catheter or suppository if no CPD or
postpartum hemorrhage
placenta previa
○ Infant: Death
● F= Q6, D=2 or 3 doses – adequate to cause
Curative Management Care:
ripening
- Antibiotics
■ Side lying position to prevent leaking and
- Sedative – stop abnormal contractions
monitor FHR for at least 30 mins after each
- Short acting Barbiturates – to promote rest/relaxation
application
- Monitor FHB
■ Side effects: vomiting, fever, diarrhea,
- NPO – prepare for surgery (C/S)
hypertension.
- Trial labor – in borderline or adequate pelvis
■ Administration of oxytocin may be
started 6 to 12 hours after the LAST
PREMATURE LABOR prostaglandin dose (beginning it sooner
➢ Precipitate Labor and Birth might lead to hyperstimulation of the uterus)
➢ Uterine Rupture ■ Contraindicated: women have had past
➢ Uterine Inversion C/S births.

Precipitate Labor Induction and Augmentation of Labor

● Induction of labor means started artificially.

● When uterine contractions are so strong that a
● May be necessary to initiate labor before the time
woman gives birth with only a few, rapidly occurring
when it would have occurred spontaneously because
contractions.
a fetus is in danger or because labor does not occur
● Labor that is completed in fewer than 3 hours.
spontaneously and the fetus appears to be term.
● Precipitate dilatation - cervical dilatation that occurs
at a rate of 5 cm or more per hour in a primipara or
10 cm or more per hour in a multipara.
 Aripin, Alshammae N. II BSN - H
Primary reasons: pre-eclampsia, eclampsia, severe - Direct communication with peritoneal cavity
hypertension, diabetes, Rh sensitization, prolonged rupture of ● Uterine contraction will immediately stop.
the membranes, IUGR, postmaturity. ● Two distinct swellings will be visible on
● Augmentation of labor refers to assisting labor that the woman’s abdomen: retracted uterus
has started spontaneously but is not effective. and the extrauterine fetus.
● Necessary if contractions are hypotonic or too weak ● Hemorrhage from torn uterine arteries floods
or infrequent to be effective. into the abdominal cavity and possibly into
● Augmentation carries a risk of uterine rupture, in ⬇ the vagina.
fetal blood supply from poor cotyledon filling, or ● Signs of shock, rapid weak pulse; falling BP,
premature separation of the placenta, it is used cold and clammy skin; dilatation of the
CAUTIOUSLY with women with multiple gestation, nostrils from air hunger. FHR fades then
older than 40 years, previous uterine scars. absent.
- Incomplete (leaving the peritoneum intact)
Induction of Labor by Oxytocin ● Rupture into the peritoneum covering the
uterus but not into the peritoneal cavity
● Less evident
● Initiates contractions in a uterus at pregnancy term.
● May experience only a localized
● IV administration. If hyperstimulation occurs,
tenderness and a persistent aching pain
discontinue.
over the area of the lower uterine
● When administering the infusion, “piggy back” the
segment.
oxytocin to a solution to a maintenance IV solution,
● FHR sounds, lack of contractions, vital signs
such as Ringer’s lactate.
will reveal fetal and maternal distress. Can
● Use an infusion pump to regulate the infusion
be confirmed by ultrasound
rate, so that the rate will not change even if the
woman changes position.
● Usually begins at a rate of 0.5 to 1 mU/min. If no Factors Contributory
response, gradually increase infusion every 15-60
- Strained uterus - Prolonged labor
minutes by 1-2 mU/min until contractions begin.
- Beyond its capacity - Faulty presentation
● Do not increase the rate to more than 20 mU/min
- Previous C/S repair - Multiple gestation
without checking for further instructions, because an - Hysterotomy - Unwise use of
administration rate greater than this is likely to cause oxytocin
tetanic contractions. - Obstruction of labor
● After cervical dilatation reaches 4 cm, artificial - Traumatic maneuvers
rupture of the membranes may be performed to using forceps
further induce labor and infusion may be
discontinued. Assessment:
● Peripheral vessel dilatation side effects of oxytocin ● Impending rupture may be preceded by a pathologic
may increase risk of extreme hypotension. Take retraction ring and by strong uterine contractions
the patient's bp every 15 minutes. without any cervical dilatation.
● If stopping oxytocin infusion does not stop the ● If a uterine ruptures, a woman feels sudden severe
hyperstimulation, a beta adrenergic receptor drug pain, which may be reported as a tearing sensation.
such as terbutaline sulfate (brethine) or ● To prevent rupture, when these symptoms are
magnesium sulfate may be prescribed. present, anticipate the need for an immediate C/S.

Uterine Rupture Manifestations: (vary with the degree of rupture)

● Complete or incomplete separation of uterine tissue
as a result of a tear in the wall of the uterus from
the stress of labor
● Occurs when a uterus undergoes more strain than
it is capable of sustaining.
● Rupture occurs most commonly when a vertical
scar from a previous cesarean scar from a previous
pregnancy. NURSING RESPONSIBILITIES:
● When uterine rupture occurs, fetal death will follow
unless immediate C/S can be accomplished.
Rupture can be:
- Complete (going through the 3 layers of the uterus):
- Abdominal pain
- Chest pain
- Rigid abdomen
- Absent fetal heart rate
- Signs of maternal shock
- Contractions may stop or fail to progress
- Fetus palpated outside the uterus (complete rupture)
- Monitor for and treat signs of shock
- Administer emergency fluid replacement therapy as
ordered. (Anticipate use of IV oxytocin)
- Prepare patients for a possible laparotomy to control
bleeding and achieve repair.

● Most women are advised not to conceive again,
unless the rupture occurred in the inactive lower
segment.
● Physicians with consent, may perform C/S,
hysterectomy (removal of damaged uterus) or
tubal ligation at the time of laparotomy. Both
procedures result in loss of childbearing ability.
Inversion of the Uterus
● Uterus completely or partly turning inside out with
either birth of the fetus or delivery of the placenta
● Fundus is formed thru the cervix, turned inside out
● Usually occurs during delivery or after delivery of
the placenta
● Cause:
○ Attachment of placenta at fundus – sudden
delivery of fetus without support – fundus is
pulled down if
○ Strong fundal push in an non-contracted
state
○ Attempts to deliver placenta before
separation
● Inverted fundus may lie within the uterine cavity or the
vagina, or, in total inversion, it may protrude from the
vagina.
● If the loss of blood continues unchecked for longer
than a few minutes: hypotension, dizziness, paleness,
diaphoresis. Because the uterus is not contracted in
this position, bleeding continues, and exsanguination
could occur within a period as short as 10 minutes.
Assessment:
- The inferior of the uterus protrude from vagina
- Sudden gush of blood
- Fundus no longer palpable
- Uterus is not contracted
- Severe pain
- Hemorrhage with signs of shock
DEGREE OF INVERSION
Management:
● Monitor for hemorrhage and signs of shock and treat
shock
Aripin, Alshammae N. II BSN - H
● Prepare the client for a return of uterus to correct
position via vagina
○ if unsuccessful, laparotomy with replacement
to the correct position is done
● Hydrostatic Reduction of acute uterine inversion
○ Reverse Trendelenburg lithotomy position
○ A bag of warmed fluid is hung at least one
meter above the patient and allowed to flow
by gravity or with light pressure through
tubing connected to a silastic ventouse cup
in the vagina; the seal between the perimeter
of the cup and the vagina prevents
significant leakage.
○ The resulting intravaginal hydrostatic
pressure may force the inverted fundus back
to its normal position
○ Two to 5 liters of fluid may be needed
NURSING RESPONSIBILITIES:
- Never attempt to replace an inversion, because it may
increase the bleeding.
- Never attempt to remove the placenta if it’s still
attached, because this only creates a larger surface
area for bleeding.
- Do not administer oxytocin because it compounds the
inversion or makes the uterus more tense and difficult
to replace.
- IV fluid line should be started (use a large gauge
needle, because blood will need to be replaced).
- Administer oxygen by mask, and assess VS.
- Be prepared to perform CPR if the woman’s heart
should fail from the sudden blood loss.
- Woman will be immediately given general anesthesia
or possible nitroglycerin or a Tocolytic drug IV, to relax
uterus
- Physician or nurse midwife then replaces fundus
manually.
- Administration of oxytocin after manual replacement.
- Because the uterine endometrium was exposed, a
woman will need antibiotic therapy to prevent
infection.
AMNIOTIC FLUID EMBOLISM
● Solid particles from amniotic fluid enter maternal
circulation
● Amniotic fluid is forced into circulation thru open
maternal sinuses
Signs & Symptoms: (as any embolism)
- fatal womans sits up and grab chest due to pain and
inability to breath
 Aripin, Alshammae N. II BSN - H
Causes: Unknown
- Causes an allergic-like reaction that can be fatal
- The inflammatory response leads to organ damage,
particularly to the lungs and heart

Management:
Depending on the situation, steps that might be taken include:
● Cardiopulmonary resuscitation (CPR)
● Oxygen administration or ventilator
● Multiple blood transfusions
● Steroids
● Cardiac catheterization
● Urgent delivery of the baby
● Hysterectomy (if required to stop the source of the
bleeding)

PROBLEMS WITH THE PASSENGER
CORD PROLAPSE – a loop of umbilical cord slips down in
front of the presenting part.
- May occur at any time after ROM if the presenting
fetal part is not fitted firmly into the cervix
- Tends to occur most often with:
● Premature ROM
● Fetal presentation other than cephalic
● Placenta previa
● Intrauterine tumors preventing the presenting
part from engaging
● Small fetus
● CPD preventing firm engagement
● Polyhydramnios
● Multiple gestation
Assessment
- The client has a feeling that something is coming
through the vagina.
- Umbilical cord is visible or palpable.
- Fetal heart rate is irregular and slow.
- Fetal heart monitor shows variable decelerations or
bradycardia after rupture of the membranes.
Intervention
● Elevate the fetal presenting part that is lying on the
cord by applying finger pressure with a gloved hand to
relieve cord pressure.
● Place the client into extreme Trendelenburg's or
modified Sims' position or a knee-chest position (to
cause the fetal head to fall back from the cord).
● Administer oxygen, 8 to 10 L/minute, by face mask to
the client.
● Tocolytic agents may be prescribed to reduce uterine
activity and pressure on the fetus.
● Monitor fetal heart rate and assess the fetus for
hypoxia.
● Prepare to start intravenous fluids or increase the rate
of administration of an existing appropriate solution.
● Prepare for immediate birth.
● Document the event, actions taken, and the client's
response.
MULTIPLE GESTATION – Pregnancies with two or more
fetuses
Complications:
● Fetus :
○ Abnormal fetal presentation
○ Cord entanglement
○ Premature separation of the placenta
○ Cord prolapse (the babies are usually small
therefore firm head engagement may not occur)
● Mother :
○ Anemia
○ Gestational Hypertension
○ Uterine dysfunction (prolonged labor)
○ Overstretched uterus
Aripin, Alshammae N. II BSN - H
Management:
- Assess hematocrit level and bp closely during labor or
while waiting for C/S arrangements
- Support breathing exercise to minimize the need for
analgesia or anesthesia (this minimize any respiratory
difficulties the infants may have at birth because of
immaturity)
- Assess FHR
- Internal Podalic Version – done to accomplish a
breech delivery of second twin where feet are
grasped by the delivering provider
PROBLEMS WITH THE POSITION,
PRESENTATION OR SIZE
A. Fetal Malposition
● Persistent occiput posterior - is directed diagonally
and posteriorly, ROP or LOP
● Tend to occur in women with:
○ android pelvis
○ anthropoid, or
○ contracted pelvis
○ a posteriorly presenting head does not fit the
cervix as snugly as one in anterior position
TYPES OF PELVIS
Gynaecoid Pelvis (Rounded or slightly oval inlet)
- Is a typical female pelvis. Ideal for vaginal delivery
- Found in 80 % of Asian women; 50-70 % white
women
- Straight pelvic sidewalls with roomy pelvic cavity
- Good sacral curve
- Subpubic arch is wide 90 degrees
Android Pelvis (Heart shaped)
- Present in most male and also in few females
- 0.6 % in Asian women; 2-8% in white women
- Heart shaped (or triangular) pelvic inlet - due to
prominent sacrum
- Pelvis funnels from above downwards (convergent
sidewalls)
- Prominent ischial spines
- Sacrum inclining forward
- Narrow subpubic arch
Platypelloid Pelvis (Flat/ kidney shape)
- Uncommon in both sexes
- Pelvic inlet appears slightly flattened (kidney shape)
 Aripin, Alshammae N. II BSN - H
- Transverse diameter is greater than A diameter
PELVIC MIDPLANE DIAMETERS
- Sacral promontory pushed forwards

Anthropoid Pelvis (Long oval)

- Present in some males and females
- 15% in Asian women; 15-30% in white women
- Pelvic inlet is long oval
- AP diameter > transverse diameter
- Long & narrow sacrum
- Women with this type tend to be tall
- Less labor complications
PELVIC INLET DIAMETERS

ANTEROPOSTERIOR DIAMETER

● Measured at the level of the ischial spines • also

called the midplane or plane of least pelvic
dimensions
● During labor, the degree of fetal, head descent into
the true pelvis may be described by station, and
the midpelvis and ischial spines serve to mark zero
station.

● TRANSVERSE DIAMETER (interspinous diameter)

- Midplane normally is the largest plane and has the
longest diameter.
● Anatomical Conjugate(11cm)
- Distance between midpoint of sacral promontory to inner
- The interspinous diameter (station O, when the
margin of upper border of symphysis pubis. BPD of fetal head passes this diameter) is 10 cm or
- It measures about 11 cm. slightly greater, is usually the smallest pelvic
diameter,
● Obstetric Conjugate (10 cm)
- Distance between midpoint of sacral promontory to FEMALE PELVIS AND MEASUREMENTS
prominent bony projection in midline of inner surface of
symphysis pubis.
- Shortest diameter of inlet, measures about 10 cm.
- Can't be clinically estimated, diagonal conjugate
necessary.
- Obstetric Conjugate = Diagonal conjugate - 2 cm

● Diagonal Conjugate (12cm)

- Distance between lower border of symphysis pubis to mid
point of sacral promontory.
- Measure by bimanual examination.

TRUE PELVIS
● Transverse Diameter of inlet (13 cm)
- Distance between 2 farthest points on pelvic brim over
- Lies below the pelvic brim
ilio-pectineal lines. - Consists of the pelvic inlet, midpelvis and pelvic
- Measures about 13 cm. outlet
- This divides brim into anterior and posterior segments. - True pelvis for birth

● Oblique Diameter of inlet (12 cm) FALSE PELVIS

- There are two oblique diameters right & left.
- Each extends from one sacro-iliac joint to opposite ilid
pectineal eminence.
- It measures 12 cm
- Is the shallow portion above the pelvic brim
- Supports the abdominal viscera
- Supports the uterus during the late months of
pregnancy and aids in directing

B. Fetal Malpresentation
- Fetal head presenting at a different angle than
expected is termed Asynclitism
A. Vertex Presentation
1. Face presentation (Chin or Mentum) - the head is
extended, and the fetal occiput is near the fetal spine
(full extension)
Babies born after face presentation will have:
○ facial edema - ecchymotic bruising
○ lip edema - infant unable to suck
■ reassure parents that edema is
transient will disappear in few days
2. Sincipito presentation – "military position"
- Occipitofrontal diameter (2nd widest antero -
posterior)
3. Brow presentation (the rarest type) - fetal head is
partly extended. (poor flexion - extension)
B. Breech Presentation
Note: Majority of fetuses are in breech presentation early in
pregnancy at by week 38 AOG fetuses normally turn to
cephalic presentation and "retain most comfortable position"
- Head is widest in single diameter; buttocks plus
- Legs = take up more space
Uterus
● Fundus - largest part 97% of all pregnancies, fetuses
turn so that the buttocks and LE are in the fundus
those who failed to turn are breech
Aripin, Alshammae N. II BSN - H
Prevention
● woman to assume 15 minute knee-chest position for
3X a day during pregnancy so breech presentation
will be less likely to occur
Types of Breech presentation :
1. Complete breech – feet and legs are flexed on thigh;
thighs flexed on abdomen and buttocks; feet are
presenting parts
2. Frank breech – legs are extended and lie against
abdomen and chest; feet at levels of shoulder;
buttocks are the presenting parts
3. Footling
a. double footling - legs are unflexed and
extended; presenting part – feet
b. single footling - one leg is unflexed 8
extended; presenting part - one of the feet
4. Kneeling - one or both legs extended at the hips and
flexed at the knees
Causes of Breech presentation:
- Age of Gestation under 40 weeks
- Abnormality in the fetus – anencephaly,
hydrocephalus, meningocele
- Hydramnios – free fetal movement
- Pendulous abdomen - lax abdominal muscle
- Any space-occupying mass in uterus e.g.mid septum
– traps fetus in position
- Multiple gestation - can't turn to vertex position
Risk of breech presentation:
● Anoxia from a prolapsed cord
● Traumatic injury to the after coming head –
intracranial hemorrhage or anoxia
● Fracture of the spine or arms
● Dysfunctional labor
● Presenting part does not fit cervix
● Early rupture of BOW
● Risk of infection
● meconium aspiration – although meconium leakage is
not a sign of fetal distress but expected from buttocks
pressure
Assessment:
- FHT - heard high in the abdomen
- Leopold's maneuver and vaginal examination - reveal
breech presentation
- Ultrasound - to confirm
Hazards/Risks part of a breech birth:
● Cord compression - because the umbilicus precedes
the head, a loop of cord passes down alongside the
head and pressure of the head compress the loop
cord
● Intracranial hemorrhage - because of pressure
changes.
 Aripin, Alshammae N. II BSN - H
● Tentorial tears - causes gross motor and mental ● Simpson's - Used as outlet forcep
incapacity or lethal damage to the fetus ● Baxton - With hinge in the right blade used to rotate
● Abruptio placenta fetal head to a more favorable position such as
● Erb-Duchene paralysis (Erb's palsy) - injury to the REPOROA
brachial plexus ● Tarnier's - Axis traction forceps
○ SIS: Loss of sensation at arm and paralysis Pre-requisites:
○ Atrophy of deltoid and biceps and brachial - Pelvis should be adequate - no CPD
muscles - Fetal head must be deeply engaged (+3 to +4 station)
- Cervix must be completely dilated and effaced
Management - Accurate diagnosis position and station must be made
Presentation – vertex presentation
1. Maneuvers - Membranes (BOW) must be ruptured
○ Internal podalic version – Direct - Some form of anesthesia must be used e.g. pudendal
manipulation of the baby inside the uterine block - to achieve pelvic relaxation and reduce pain
cavity to the breech position. - Rectum and bladder must be empty
○ External podalic version/External - Vacuum Extraction
cephalic version (ECV) – refers to a
procedure by which an obstetrician or Types of Forceps Application:
midwife turns the baby from the breech to I. Low-forceps operation
the cephalic position by manipulating the ○ Easy delivery; forceps are applied after the
baby through the maternal abdomen. head has rendered the perineal floor with
sagittal suture in anterior-posterior of the
A. Mobilization of the breech outlet - vertex at introitus
B. Manual forward rotation using both hands, one to
push the breech and the other to guide the vertex II. Mid forceps operation
C. Completion of forward roll ○ Forceps are applied before the criteria for
D. Backward roll low forceps are met but after engagement
has taken place - vertex at ischial spine
Breech Position: Turning the Baby
● The baby is in breech position. III. High forceps operation
● The healthcare provider feels for the baby's head and ○ Forceps are applied before engagement has
bottom and turns the baby around. taken place (only used in modern OB - rarely
● The baby is in position for normal delivery. done) biparietal diameter above ischial spine

2. Forceps Delivery Complications:

○ OB forceps - steel or metal instruments (2 Maternal:
blades left and right with lock), used if the ● Lacerations - vagina, cervix -> hemorrhage & infection
fetal head reaches the perineum ● Rupture of uterus
○ Maybe high forceps (non-engaged head) or ● Injury to bladder and rectum
mid-forceps (level of ischial spines) Fetus:
○ Maybe used with pudendal block ● Cephalhematoma
● Brain damage
Indications: ● Skull fracture
- To shorten 2nd stage of labor - When woman ● Facial paralysis
is unable to push with contractions in pelvic ● Cord compression
division of labor ● Facial marks - temporary 24- 48 hours only
- After regional anesthesia
- Cessation of progress of labor Nursing Management:
- Failure of fetal head to rotate ● Prepare patient
- Fetal distress ● Explain the procedure
- Prolapsed cord ● Explain outcome ASAP especially on outcome of
- FHT 100 BPM or 160 bpm procedure e.g. marks, bruising
- Meconium stain in cephalic presentation
3. Vacuum Extraction
5 common types of OB forceps - used in place of forceps (duration - 30 minutes)
● Kielland's - With short handles and a marked cephalic - delivery of a fetus in vertex presentation with the use
curve use like Baxton of a cap suction device that is applied to fetal scalp for
● Piper - Used to deliver the head in breech traction e.g ventouse vacuum extraction
presentation
 Aripin, Alshammae N. II BSN - H
Complications:
● Scalp ecchymoses - expected - posterior fontanelle COMPOUND AND SHOULDER PRESENTATION
● cephalhematoma - prolonged used >30 minutes -
damage to scalp
Shoulder Presentation (Transverse lie)
- Long axis of the fetus is perpendicular to the long axis
Advantages over forceps:
of the mother
● Use of little anesthesia (fetus less depressed at birth)
- Shoulder presents over the pelvic inlet
● Fewer laceration (non-invasive)

Etiology:
Disadvantages
- Pendulous abdomen
● Marked caput - >7 days after birth - assure mother
- Uterine masses that obstruct lower uterine segment
● Tentorial tear - from extreme pressure
- Contraction of the pelvic brim
Contraindicated if:
Congenital abnormalities of the uterus
- Scalp blood sampling was done - bleeds
● Hydrocephalus
- Preterm - soft skull
● Polyhydramnios
● Prematurity
4. Cesarean Delivery
● Multiple gestation
● Surgical extraction of the fetus via the uterine incision
● Short umbilical cord
through the abdomen - trans-abdominal incision of the uterus
Scheduled Cesarean Birth Nursing Care of Clients with Malpresentation
- Screen for abnormal fetal presentation
Indications: - Perform abdominal palpation on all patients in labor
● Transverse lie - Palpate presenting part when performing vaginal
● Genital herpes exams
● CPD - Report abnormal findings to the physician
● Avoidance of post procedure stress incontinence
Compound Presentation
Benefits: - Compound presentation means that a fetal hand is
- reduces transfer of HIV, hepatitis C, herpes 2 from coming out with the fetal head.
mother to NB - Prolapse or concurrent presentation of an extremity
- “once a cesarean always a cesarean" no longer with the presenting part
applies
This is a problem because:
Emergency Cesarean Birth ● The amount of baby that must come through the birth
canal at one time is increased.
Done for reasons such as:
● There is increased risk of mechanical injury to the arm
● placenta previa
and shoulder, including fractures, nerve injuries and
● abruptio placenta
soft tissue injury.
● fetal distress
● failure to progress in labor
Etiology: Unknown
● Factors that predisposed to a loose-fitting part:
Risks:
○ Small or premature babies
- the woman may not be a candidate for anesthesia
Management:
- psychologically unprepared
- A compound presentation may be resolve if the fetus
- fluid and electrolyte imbalance
can be encouraged to withdraw the hand
- emotionally and physically exhausted from labor
- If the fetus and the arm are relatively small in
comparison to maternal pelvis, vaginal delivery is
Other Indications:
possible but some risk of injury to the arm
● Uterine inertia
- If the fetus and the arm are relatively large in
● Previous C/S
comparison to maternal pelvis, obstructed labor will
● Severe toxemia
occur and C/S will be needed
● Placental accident (eclampsia)
● DM
C. Fetal Size
● Old primi
● Prolapsed cord - Oversized fetus (Macrosomia)
● Post-term pregnancy - Weighs > than 4000–4500 g (9–10 lbs)
● Failed forceps delivery
Large babies associated with : DM, multiparity
 Aripin, Alshammae N. II BSN - H
● Oversized infant may cause uterine dysfunction
during labor or at birth because to the overstretching
of the fiber of the myometrium

Large infant born vaginally has high risk of:

● Cervical nerve palsy
● Diaphragmatic nerve injury
● Fractured clavicle - because of shoulder dystocia
● Postpartum + risk of hemorrhage because of the
overdistended uterus.

PROBLEMS WITH THE PASSAGE
➢ Abnormal size or shape of the pelvis
➢ Cephalopelvic Disproportion
➢ Shoulder Dystocia
Abnormal size or shape of the pelvis
- Factor that dystocia can occur is the contraction or
narrowing of the passageway of the birth canal
- This can happen at the inlet, at the midpelvis, or at
the outlet
THE NARROWING CAUSES:
Cephalopelvic Disproportion – a disproportion
between the size of the fetal head and the pelvic diameters –
will result in failure to progress in labor
Inlet Contraction
● Narrowing of the anteroposterior diameter to less
than 11 cm, or the transverse diameter to 12 cl or
less
● A head that engages – it fits into the pelvic brim and
able to pass thru the midpelvis and outlet
● If engagement does not occur in primi – fetal
abnormality (larger than-usual head) or pelvic
abnormality (smaller than-usual pelvis)
● As a rule, engagement does not occur in multigravida
until labor begins
● CPD – fetus does not engage and remains floating,
malposition may occur – may complicate the situation
Management:
- Primigravida should have pelvic measurements taken
and recorded before 24 weeks of pregnancy
● Based on the measurements, birth decisions
can be made
Outlet Contraction
● Narrowing of the transverse diameter at the outlet
to less than 11 cm. distance between the ischial
tuberosities.
● Measurement can make during a prenatal visit - can
be anticipated before labor begins.
Management:
- Trial labor if the woman has a borderline (just
adequate)inlet measurement and the fetal lie and
position are good.
- The physician allow woman a "trial" labor to determine
labor can progress normally.
External Cephalic Version – Turning of a fetus from breech
to a cephalic position before birth.
● Tocolytic drug may be given to help relax the uterus
CRITERIA BEFORE FORCEPS ARE APPLIED:
● membranes must be ruptured
● CPD must not be present
Aripin, Alshammae N. II BSN - H
● The cervix must be fully dilated.
● A woman's bladder must be empty
● Vacuum Extraction
Shoulder Dystocia – Delayed or difficult birth of the
shoulders that may occur as they impacted above the maternal
symphysis pubis.
● After head is born, it retracts against the perineum,
much like a turtle's head drawing into its shell ("turtle
sign")
● Shoulder dystocia is an urgent situation
○ because umbilical cord can compressed
between the fetal body and maternal pelvis
Methods to relieve impacted fetal shoulders:
1. McRobert's maneuver - woman flexes her thights
sharply against her abdomen, which straightens the
pelvic curve
● Legs flexed onto abdomen causes rotation of
pelvis, alignment of sacrum, & opening of
birth canal
● Suprapubic pressure applied to fetal anterior
shoulder
2. Suprapubic pressure - by pressing the fetal anterior
shoulder downward to displace it from above the
mother's symphysis.
● fundal pressure should not be used because
it will push the anterior shoulder even more
firmly against the mother's symphysis
PROBLEMS OF THE PSYCHE
- Most women perceive labor is a stressful event.
- Perceived threat caused by:
● pain
● fear,
● Nonsupport, or
● personal situation > can result in excessive
stress and may interfere with the normal
labor progress.
Responses to excessive or prolonged stress interfere with
labor in several ways:
● Increased glucose consumption reduces the energy
supply available to the contracting uterus.
● Secretion of catecholamines (epinephrine and
nor-epinephrine) by adrenal glands stimulate uterine
beta receptors, which inhibit uterine contractions.
● Adrenal secretion of catecholamines diverts blood
supply from the uterus and placenta to skeletal
muscle.
● Labor contractions and maternal pushing efforts are
less effective because these powers are working
against the resistance of tense abdominal and pelvic
muscles.
● Pain perception is increased and pain tolerance is
decreased, which further increases maternal anxiety
and stress.
 Aripin, Alshammae N. II BSN - H
Nursing Management:
- Establishing a trusting relationship with the woman
and her SO
- Making the environment comfortable by adjusting
temperature and light
- Promoting physical comfort
- Providing accurate information
- lmplementing nonpharmacologic and pharmacologic
pain management

Questions:
● Why is psychological support during labor important
for effective physiologic function?

Answer:
● Psychological support reduces stress that otherwise
can consume energy the uterus needs, inhibit uterine
contractions, reduce placental blood supply, impair
the woman's pushing efforts, and increase the
woman's pain experience.
 Aripin, Alshammae N. II BSN - H
POSTPARTUM BLEEDING ● Inspect blood loss - blood seeps at back
● Palpate fundus
I. Early PPH or Immediate: occurs within 1st 24 hrs ● Frequent assessment of lochial discharge/ VS
after delivery. ● Empty bladder every 4 hrs
a. Uterine atony B. Therapeutic
b. Trauma to the birth canal during labor & delivery ○ Massage uterus
- Lacerations ○ Apply cold (ice) compress
- Hematomas ○ Refer for administration of (Methergin)

Normal delivery average blood loss: 300-350ml Medical Management:

Postpartum hemorrhage: 1. Administer oxytocin agent - S/E: HPN BP
= >500 ml within 24 hrs.period after vaginal delivery 140/90mmhg. Do not administer
= > 1000 ml after cesarean birth 2. Blood replacement - >500 ml needs BT;
auto-transfusion
Late Postpartum hemorrhage: 3. Bimanual massage
- occurs after 24 hours and the remaining days of the 6 4. Prostaglandin Administration (IM/IV) - strong uterus
weeks puerperium. contractions
a. Retained placental fragments 5. Hysterectomy - removal of uterus last resort
b. Bleeding disorders
Lacerations
Reason of Postpartum bleeding - Tearing at birth canal - expected consequence of
1. Uterine Atony chidbearing; more common in:
2. Lacerations ● Primipara
3. Retained placental fragments ● Large babies >9 Ibs
4. Uterine Inversion Structures affected:
5. D I C (Disseminated Intravascular Coagulation) 1. Cervical
2. Vagina
Uterine Atony 3. Perineal
- Loss of uterine muscle tone, uterus fails to contract
completely; to seal off open uterus vessel after 1st degree – vaginal mucosa, skin of perineum, fourchette
delivery. 2nd degree – vagina, perineal skin, fascia, levator anterior
Causes: muscle & perineal body
a. Conditions that distended the uterus beyond average 3rd degree – entire perineum, external sphincter of rectum
capacity 4th degree – entire perineum, rectal sphincter and some
○ Multiple gestation mucous membranes of rectum
○ Hydramnios (AF> 2000 cc)
○ Large baby (>9lbs.) Management:
○ Presence of uterine myomas (fibroid tumor) 1. Repair
b. Conditions that leave the uterus too exhausted to 2. Pack
contract readily 3. No enema/ suppositories/ rectal temperature
○ Deep anesthesia/ analgesics 4. Prevent constipation
○ Labor & oxytocin agent – Cervical lacerations R/O uterine atony
○ Maternal age >30 years
○ High parity Retained Placental Fragments
○ Dystocia - Placenta failed to be delivered entirely and fragments
○ Secondary illness as anemia or parts are left behind inside the uterus
○ Endometritis
c. Conditions with varied placental site or attachment Assessment:
○ Placenta previa 1. Bleeding depends on size of placental fragments
○ Placenta accreta ● Large - immediate uterus does not contract
○ Placenta abruptio ● Small- (6-10 day post-partum) - abrupt
○ Retained placental fragments discharge of blood clots
Assessment: 2. On examination, uterus not fully contracted
1. Uterus suddenly relaxes 3. Doctor orders for serum HCG determination- reveals
2. Occurs gradually - as lethal as sudden gush of blood; that part of a placenta is still present.
following delivery; postpartum period.
Management:
Nursing Management: 1. Severe bleeding - blood transfusion
A. Prevention 2. D & C
 Aripin, Alshammae N. II BSN - H
3. Placenta accreta - methotrexate - to destroy ● Methotrexate
placental tissues
4. Advise patient to observe lochial discharge (alba, Hematomas
serosa, rubra) - Collection of blood within the subcutaneous layer of
perineum, skin has no sign of trauma.
Anomalies of the Placenta Causes:
1. Injury to blood vessel - labor/ delivery
2. Rapid spontaneous deliveries - precipitate delivery
Normal Weight : 500gms.
3. Perineal varicosities
– 1/6 of fetal weight
4. Episiotomy repair site
● Diameter: 15-20 cm
5. Anesthesia infiltration
● Thickness: 1.5 - 3 cm

Assessment:
Placenta is expectedly increase size in: (½ of fetal weight)
- Feeling of pressure between legs
1. DM
- Pain, discomfort, tenderness
2. Erythroblastosis fetalis
- Minor bleeding
3. Scar on septum - placenta spread to look for space to
- Swelling/ bluish discoloration 1-4cm.
implant

Management:
A. Placenta Succenturiata
1. Small - warm/cold compress- ice pack absorb in 3-4
- No fetal abnormality
days
- Has one or more accessory lobes connected
2. Large - incision and evacuation
to placenta by blood vessel
3. Analgesia
- Small lobes maybe retained-maternal
bleeding POSTPARTUM HEMORRHAGE

CONDITIONS THAT INCREASE A WOMAN'S RISK FOR

B. Placenta Circumvallata
- Fetal side of placenta is covered to some
extent with chorion; no abnormality
C. Placenta Marginata
- The fold of chorion reaches just to the edges
of the placenta; no abnormality
D. Battledore placenta
- Cord is inserted marginally rather than
centrally
- Rare but with no known clinical significance
POSTPARTUM HEMORRHAGE
● Distend the Uterus Beyond Average Capacity
● Caused Cervical or Uterine Lacerations
● Varied Placental Site or Attachment
● Conditions That Leave the Uterus Unable to Contract
Readily
● Inadequate Blood Coagulation
HEMORRHAGE
- Bleeding of 500 ml or more after delivery
- Primary cause of maternal mortality that demands prompt
recognition and intervention.
ASSESSMENT
● Early: occurs during 24 hours after delivery
● Late: Occurs after 24 hours following delivery

E. Velamentous insertion of the cord Causes

- Cord instead of entering the placenta
centrally, separates into small vessels
reaches the placenta by spreading across a
fold of amnion
- Found in multiple pregnancies
- Predispose to maternal hemorrhage
F. (1) Placenta accreta
- chorionic villi of the placenta form abnormal
attachment to the myometrium of the uterus
(2) Placenta Inccreta
- placenta invades the myometrium
(3) Placenta Percreta
- placenta penetrates the myometrium and
into the serosa
Management
● Manual extraction
● Hysterectomy
- Uterine Atony
- Laceration of the cervix or vagina
- Hematoma development in the cervix, perineum, or labia
- Retained placental fragments
Predisposing Factors
● Previous hx of postpartum hemorrhage
● Placenta previa
● Abruptio placenta
● Overdistention of the uterus
● Infection
● Dystocia
INTERVENTION
● Massage fundus for Uterine Atony
— One hand remains cupped against the uterus at the level of the
symphysis pubis to support the uterus
— The other hand is cupped to massage and gently compress the
fundus toward the lower uterine segment.
● Monitor the VS and fundus every 5-15 minutes; monitor
for early signs of hemorrhaging and shock.
● Remain with the client if hemorrhage or signs of shock
occurs
 Aripin, Alshammae N. II BSN - H

● Ask another nurse to notify HCP if hemorrhage or signs of URINARY TRACT INFECTION
shock occur - A woman who is catheterized at the time of childbirth
● Assess and estimate blood loss by pad count (1 gram= 1 or during the postpartum period is prone to
mL of blood)
● Turn the client to assess for pooled blood underneath her
development of a urinary tract infection.
● Assess LOC Assessment
● Administer fluids and monitor I & O ● Burning urination
● Monitor hemoglobin and hematocrit
● Hematuria
● Maintain asepsis
● Prepare for administration of oxytocin (Pitocin) if ● Feeling of frequent voiding
prescribed ● Pain is sharp on voiding
● Prepare for the administration of IV and BT if prescribed ● Low grade fever
● Prepare surgical; intervention (D&C or hysterectomy)
● Discomfort from lower abdominal pain
● Obtain clean catch urine specimen
POSTPARTAL PUERPERAL INFECTION
Therapeutic Management
● Theoretically, the uterus is sterile during pregnancy - Broad-spectrum antibiotic such as amoxicillin or
and until the membranes rupture. ampicillin will be prescribed
● After rupture, pathogens can invade. - Encourage a woman to drink large amounts of fluid
● The risk of infection is even greater if tissue edema - Oral analgesic, such as acetaminophen (Tylenol)
and trauma are present. If infection occurs, the - Health teaching about the antibiotics
prognosis for complete recovery depends
INFLAMMATORY CONDITIONS
CONDITIONS THAT INCREASE A WOMAN'S RISK FOR
POSTPARTAL INFECTION VULVITIS
- Rupture of the membranes more than 24 hours before ● Burning or itching
birth ● Possible small cracks in the skin
- Placental fragments retained within the uterus ● Vaginal discharge - Exudate
- Postpartum hemorrhage - possibly profuse and purulent
- Pre-existing anemia ● Redness and swelling
- Prolonged and difficult labor, particularly instrument Management:
births - Cortisone ointment may be used to decrease vulvar
- Internal fetal heart monitoring itching
- Local vaginal infection was present at the time of birth - Advise clients to wear cotton underwear or
- The uterus was explored after birth for a retained cotton-crotch pantyhose.
placenta or abnormal bleeding site.
VAGINITIS
ENDOMETRITIS ● Unusual vaginal discharges (leukorrhea)
● Endometritis is an infection of the endometrium, the ● Vaginal itching, irritation burning
lining of the uterus. ● Dyspareunia, pelvic pain, dysuria
Assessment Management:
- Fever 3rd or 4th day postpartum - Hygienic measures
- Chills, loss of appetite, and general malaise - Symptomatic treatment
- Uterus usually is not well contracted and is painful to - Treatment of cause
the touch
- Strong afterpains
CERVICITIS
- Lochia usually is dark brown and has a foul odor.
● Leukorrhea
- Ultrasound may be ordered to confirm the presence of
● Low back pain
placental fragments
● Hypogastric pain
● Dyspareunia
Therapeutic Management
● Dysmenorrhea
● administration of an appropriate antibiotic, such as
● Dysuria
clindamycin (Cleocin)
● Urinary frequency and urgency
● Obtain the culture from the vagina-sterile swab
● Metrorrhagia
● Methylergonovine
● Cervical dystocia
● Additional fluid
Management
● Analgesic
- Treat acute infections with appropriate antibiotics.
● Fowler’s position, encourage walking
- Cervical Cautery
● Health teaching about the signs and symptoms
• Cryotherapy
 Aripin, Alshammae N. II BSN - H
PELVIC INFLAMMATORY DISEASE (PID) - Apply a bed cradle and keep bed clothes off affected
leg
- Never massage the legs
● Microorganisms ascending from the vagina and cervix
- Monitor for manifestations of pulmonary embolism
into the endometrium and fallopian tubes.
- Apply hot packs
- Apply elastic stockings
Common symptoms:
- Administer analgesics and antibiotics if prescribed
- Lower abdominal pain
- Heparin sodium IV may be prescribed for femoral or
- Cervical discharge
pelvic thrombophlebitis.
- Irregular vaginal bleeding
- Abdominal pain, nausea, vomiting
- Fever, malaise
POSTPARTUM PSYCHIATRIC DISORDER
- Leukocytosis
- Malodorous, purulent vaginal discharge POSTPARTUM DEPRESSION
- Extreme fatigue
MANAGEMENT - An inability to stop crying increased anxiety about her
● Place patient on semi-fowler's position to facilitate - Own or her infant's health
drainage - Insecurity (unwillingness to be left alone or inability to
● Avoid use of tampons make decisions)
● Support with proper nutrition - Psychosomatic symptoms (nausea and vomiting,
● Administer drugs - non GC (tetracycline); GC diarrhea
(penicillin G) - and either depressive or manic mood fluctuations.
● Control spread of infection
● Use warm douches and heat compresses to abdomen Management
as Rx ● Discovery of the problem – nsg priority
● Give moral support and understanding ● Conscientious observation and discussion
● Counseling, antidepressant therapy
THROMBOEMBOLIC DISORDER

THROMBOPHLEBITIS
● A clot forms in a vessel wall as a result of
inflammation of the vessel wall.
TYPES
1. Superficial thrombophlebitis
● Palpable thrombus that feels bumpy and
hard
● Tenderness and pain in the affected lower
extremity
● Warm and pinkish red color over the
thrombus area.
2. Femoral thrombophlebitis
● Malaise
● Chills and fever
● Possible Positive Homan's Sign
● Diminished peripheral pulses
● Shiny white skin over affected area
● Pain, stiffness, and swelling of the affected
lea
3. Pelvic Thrombophlebitis
● Severe chills
● Dramatic Body Temperature
● Pulmonary Embolism may be the first sign
Management
- Assess the lower extremities for edema, tenderness,
varices, and increased skin temperature.
- Maintain bed rest
- Elevate legs
 Aripin, Alshammae N. II BSN - H
GYNECOLOGIC PROBLEMS Nursing Interventions:
● Controlling pain
MENSTRUAL DISORDERS ○ Administer pain reliever [prostaglandin
inhibitors.
○ Apply heating pad to lower back or abdomen
DYSMENORRHEA
○ Assess response to pain control measures
● Painful menstruation symptoms begin with
○ Surgery - presacral and ovarian neurectomy
menstruation and experience discomfort several
[cutting of nerve fibers]
hours before the onset of flow.
● Health education
○ Explain possible causes of dysmenorrhea
2 Types:
○ Teach to use prescribed medications and the
1. Primary - unknown cause; emotional or psychological
S/E
factor
○ Encourage clients to reduce stress through
- associated with ovulatory cycle
adequate sleep, good nutrition & exercise.
- usually appears 6-12 mos. after menarche
● Psychological counseling
when ovulation is established

2. Secondary - factors extrinsic to uterus as AMENORRHEA

endometriosis, pelvic infection
- acquired menstrual pain that develops later ● Absence of menstrual cycle [periods]
in life after 25 yrs.
- it is associated with pelvic pathology 1. Primary
- Menarche does not occur by age 16
Etiology: - Caused by embryonic maldevelopment,
1. Endocrine - release/ Increased prostaglandin hormonal
production by the endometrium. 2. Secondary
2. Anatomical - obstructive [Infantile uterus] - Menstruation stops – 6 mos. in woman
3. Constitutional - chronic illness [anemia) whom normal menstruation has been
4. Hormonal & psychological factors - stress & established.
anxiety - Excessive exercise or inadequate nutrition
5. Caused by lesions, such as - endometriosis, pelvic w/ decrease body fat stores
infection, congenital abnormality, uterine fibroids, 3. Anovulation secondary to polycystic ovary disease
ovarian cyst. occurs in obese women.
4. Hormonal causes - pituitary tumor and thyroid
Clinical Manifestations: disease
● Nausea & vomiting 5. Medications - phenothiazines and oral
● Diarrhea contraceptives
● Headache, chills 6. Other causes: normal pregnancy & lactation,
● Tiredness & nervousness menopause, psychogenic stress, hypothalamic
● Low back ache distress
● Pain - caused by increased uterine contractility & 7. Constitutional disease [ DM, TB, Obesity]
hypoxia
- Characteristics of pain: colicky or dull Diagnostic Evaluation:
(lower mid abdominal region), spasmodic or ● Progesterone challenge test.
constant. ○ Positive result - bleeding occurs; chronic
anovulation is most likely.
Diagnostic Evaluation: ○ Negative result - no bleeding occurs.
- Pelvic Ultrasound ● Thyroid stimulating hormone - decrease in
- Serum or Urine pregnancy test Hyperthyroidism
- Laparoscopy & Hysteroscopy ● Prolactin level (increased) w/ pituitary tumor.
● Hormones levels- LH & FSH - to detect ovarian failure
Management: ● Genetic karyotyping
● Primary dysmenorrhea: ● Pregnancy test
○ Local heat application - to increase blood
flow and decrease spasm. Management:
○ Exercise 1. Hormonal replacement therapy
○ Nonsteroidal anti-inflammatory agents 2. Nutritional, exercise or psychological counseling as
○ Oral contraceptives indicated
○ D&C - Decreased exercise
 Aripin, Alshammae N. II BSN - H
- Weight reduction if obese
TYPES OF PMS
3. Discontinue causative medications.
Description Management
Complications:
- It has been theorized that prolonged amenorrhea may PMS A ● Vit. B6 at
lead to atypia and cancer of the endometrium 200 - 800
because of unopposed estrogen stimulation on the Feelings of overwhelm, more mg/day
endometrium. sensitive than usual (especially to ● Progestero
perceived rejection or criticism), ne therapy
Nursing Diagnosis: feeling on edge or irritable ● Limit intake
● Altered Nutrition: Less Than Body requirements r/t to of dairy
poor dietary habits &/or vigorous exercise. Hormonal imbalance (link here] products
(relative excess of estrogen to ● Outdoor
Metrorrhagia progesterone), inadequate exercise
neurotransmitter
synthesis: low serotonin, adrenal
● Bleeding between regular menstrual periods fatigue and cortisol dysregulation.
● Common in pill users
● Assess for etiology as disease, tumors, etc S/Sx: anxiety, irritability, elevated
estrogen, decreased progesterone
Menorrhagia
PMS B ● Na intake
● Vit. E (600
● Excessive bleeding during regular prior Abdominal bloating, u) reduce
● "Heavy Menses" Breast tenderness/swelling. breast
weight gain of over 3 pounds symptoms
Causes: Endometrial distress, inflammatory disease, & ● Methylxant
emotional stress Estrogen excess, increased stress hine as
which causes the adrenal gland to coffee, tea,
Management: secrete an excess of both the choco,
● Assess underlying cause correct hemoglobin stress hormone cortisol and cola, and
deficiency with iron supplement and or hormonal aldosterone which causes salt nicotine
supplement and water retention. ● Refined
sugar to 5
Oligomenorrhea [Hypomenorrhea] S/S: water and salt retention = tbsp/ day
bloating, mastalgia, weight gain, ● Prostaglan
aldosterone, Mg, and prostaglandin din
● Markedly diminish menstrual flow
- nearing amenorrhea inhibitors

PMS C ● Refined
Polymenorrhea [Hypermenorrhea] sugar 5
Desire for carbohydrates, general tbsp/ day
● Frequent menstruation occurring at intervals of less increase in appetite, fatigue, ● Alcohol
than 3 weeks headaches. ● Na 3
grams/ day
PREMENSTRUAL SYNDROME Low serotonin [carbohydrate ● Animal fat
A group of symptoms that includes headache, irritability, ingestion temporarily raises vegetable
depressions, breast tenderness, and bloating that are clearly serotonin- that's why sweets make oil
related to onset of menstruation. us feel good in the moment). adrenal
fatigue causes low cortisol levels
Etiology: which can cause sugar cravings.
– Hormonal imbalance
● Prostaglandins / Endorphins S/Sx: - Premenstrual craving for
– Psychological / environmental factors sweets, appetite and food binges,
● attitudes & beliefs r/t menstruation palpitations, fatigue, fainting spells.
● nutrition & pollution headache, shakes, altered GIT,
● Women in their 30's prostaglandin, Vit. B, Zinc, Vit. C and
● Occur in 25%-50% of menstruating women Mg
 Aripin, Alshammae N. II BSN - H

PMS D ● Therapy Parasitic or wandering

depends on - Pedunculated tumor attached to other tissues
Low mood paired with lethargy, serum
forgetfulness, and confusion. evaluation Intraligamental subserosal
- tumor into the broad ligaments; implant on pelvic
Underactive thyroid and low ligament; displace uterus
serotonin.
Cervical = rare
S/Sx: depression, withdrawn,
insomnia, forgetfulness, confusion, Sarcomatous (malignant)
altered estrogen, and progesterone - rapidly enlarging and hemorrhagic
level B. and Mg

Clinical Manifestation:
● Necrosis, ulceration, foul smelling vaginal discharges
MYOMAS
Secondary Changes ( Degeneration)
● Circumscribed growth encapsulated
● Other name: fibromyomas, fibroma, fibroids, 1. Hyalinization
leiomyomas ● When tumor outgrows
● Benign tumors Clinical manifestation: Mature or old myoma are white
● Composed mainly of smooth muscles with some containing soft gelatinous area of hyaline change -
fibrous connective tissue asymptomatic
2. Cystic = Follows hyalinization; tumor liquefies
3. Calcification = Common in larger tumor
4. Fatty = Follow hyaline and cystic
5. Infectious = appears with PID; common in
pedunculated, submucosal tumors
6. Carneous = red, associated with hemorrhage into
tumor and hemorrhage

Cause:
- Estrogen seems to activate the growth of uterine
fibroids.
- In fact, during the first trimester of pregnancy, about
one-third of all fibroids grow larger, but then shrink
after birth.
- Generally, uterine fibroids shrink after menopause, but
hormone therapy after menopause may cause their
symptoms to continue.

Clinical manifestation:
Classifications (Location)
● Heavy bleeding
Intramural ● Anemia
- Uterine walls; surrounded by myometrium ● Fatigue and weakness
Clinical manifestation: ● Painful intercourse
● Uterus size ● Pain, bleeding, or a discharge from the vagina if
● Vaginal bleeding between periods myomas become infected
● Dysmenorrhea ● A feeling of pressure or a lump in the abdomen, in
rare cases
Subserous ● Difficulties urinating, dribbling at the end of urination,
Directly beneath (under) the serosa; pedunculated; to I or urine retention if a myoma blocks the flow of urine.
wander; to multiply and enlarge Urinary tract infections are more likely to develop in
women with myomas
Submucous
- Beneath the endometrium; they grow thin and Other causes:
displace endometrium over their surface and ● Race: more common among African American
become the site of necrosis and infection women.

● Age: A study concluded that white women younger
than 35 years of age had faster-growing tumors than
white women older than age 45. In addition, waiting lo
gel pregnant until age 30 or older places women at
higher risk of developing uterine fibroids.
● Early menstruation: Having your first period at an
early age increases the risk of developing fibroids.
● Caffeine and alcohol: A connection between alcohol
and caffeine intake and an increased risk of
developing uterine fibroids was uncovered in a 2016
study.
● Genetic factors: Researchers found that some
specific genetic alterations are linked to fibroid
growth.
● General health status: Obesity and high blood
pressure also may play a role in fibroid development
and growth.
● Diet: A diet rich in red meat appears to increase your
chance of developing tilbroids
Management:
● Depend on symptoms, age, location, and size of the
tumor; onset of complication and desire to get
pregnant
● Fibroid - D and C
● Small tumor - myomectomy (removal of tumor without
removal of the uterus)
● Large tumor - hysterectomy
● Radiation and chemotherapy
Nursing Care:
● Full explanation - removal of uterus - menses,
pregnancy, sexual activity
● Reassurance
● Surgery - pre and post op care
Other treatment:
● Hormonal contraception
● An intrauterine device
● Antifibrinolytic
● Nonsteroidal agents.
● If you don't want to have children, endometrial
ablation is another option.
○ During this procedure, the endometrium is
destroyed using cold or heat.
● Medications called gonadotropin-releasing hormone
agonist for GNRH agonists) can shrink fibroids, but
they grow back once treatment stops.
● Myomectomy, a procedure where a thin tube called
an endoscope is passed into the uterus through the
cervix. The fibroid is shaved and removed while
leaving the uterus intact. It can reduce fibroids,
but they may grow back.
● MRI-guided ultrasound surgery uses ultrasound
waves to shrink fibroids and reduce heavy bleeding.
ENDOMETRIOSIS
● chocolate cysts
Aripin, Alshammae N. II BSN - H
● Abnormal growth of extra-uterine endometrial
cells; after in the cul-de-sac of the peritoneal cavity,
uterine ligaments and ovaries
● Excessive endometrial cell production plus reflex
of blood during menses.
Incidence:
- multiparous
- familial tendency
● Endometriosis is a disease that affects females in
their reproductive years.
● The endometrium is the tissue that lines the inside of
the uterus, which builds up and sheds each month in
the menstrual cycle.
● It causes a chronic inflammatory reaction that may
result in the formation of scar tissue (adhesions,
fibrosis within the pelvis and other parts of the body.
Several lesion types have been described:
● Superficial endometriosis found mainly on the pelvic
peritoneum
● Cystic ovarian endometriosis (endometrioma) found in
the ovaries
● Deep endometriosis found in the recto-vaginal
septum, bladder, and bowel
● In rare cases, endometriosis has also been found
outside the pelvis.
Ovarian Endometriosis
● Nodules implant in the lining of ovaries.
● When tissue around these areas hardens it can
develop and proliferate into the fallopian tubes
and bowels
Deep Infiltrating Endometriosis
● The nodules implant at least 5 mm below the
peritoneum.
● Structures penetrated can include the uterosacral
ligaments, bowel, bladder and ureters
Peritoneal Endometriosis
● The peritoneum is the lining of the abdomen.
Peritoneal endometriosis occurs when endometrial
cells travel to and implant in the peritoneal wall.
 Aripin, Alshammae N. II BSN - H
➢ With endometriosis this tissue is found in locations
outside of the uterus, and develops into nodules, Nursing Care:
lesions, tumors, growths, or implants. 1. Secure Consent
➢ Each month the tissue builds up, breaks down, and 2. Explain every procedure
sheds. Menstrual blood flows from the uterus and out 3. Follow up care and check up
of the body through the vagina, but the blood and 4. Surgery - pre-op and post-op care
tissue shed from endometrial growths has no way of
leaving the body. OVARIAN CYSTS
➢ This results in internal bleeding, breakdown of the
blood and tissue from the lesions, and inflammation ● Non-neoplastic tumors of the ovaries
- and can cause pain, infertility, scar tissue ● The word "cyst" means a fluid-filled cavity, usually
formation, adhesions, and bowel problems. with a lining.

Cause: Clinical Manifestation:

● Retrograde menstruation is when menstrual blood May or may not be present
containing endometrial cells flows back through the = but is symptoms occur
fallopian tubes and into the pelvic cavity at the time 1. pelvic pains - often
that blood is flowing out of the body through the cervix one sided
and vagina during periods. 2. pressure in the
● Cellular metaplasia is when cells change from one lower abdomen
form to another. Cells outside the uterus change into 3. backache &
endometrial-like cells and start to grow. menstrual irregularities
● Stem cells can give rise to the disease, which then
spreads through the body via blood and lymphatic Treatment:
vessels Surgical excision of the
cycle
Clinical Manifestation: based on location Nursing care:
eg. Lungs - S/S grave and serious - Explain procedure
1. Uterine displacement - nodules at cul-de-Sac - Observe for S/S of tumor growth
2. Dyspareunia - lesions at uterosacral ligaments and - Follow up care
posterior fornix of vagina
3. Incapacitating pain on defecation
FISTULAS
4. Infertility
5. "Chocolate cyst” in uterine surface
6. Abnormal uterine bleeding ● Abnormal tube like passages within body tissues
● Abnormal tortuous opening between two internal
Treatment /Management: hollow organs or between an internal hollow organ
● Estrogen/ progesterone - based oral contraception and the exterior of the body/skin.
● Danazol - synthetic androgen - shrinks abnormal
tissues Types of Fistula:
● Laparotomy with excision by laser surgery 1. Ureterovaginal - between ureter and vagina
● Salpingo-oophorectomy 2. Rectovaginal - between rectum and vagina
● Hysterectomy 3. Vesicovaginal - between urinary bladder & vagina

POLYPS

● Pedunculated tumors from the mucosa and

extending into the opening of a body cavity

Types of Polyps:
● Uterine
○ Hypermenorrhea
○ Metrorrhagia
○ DUB
● Cervical
○ Bleeding following vaginal sexual activity and
may become infected
Treatment:
● Surgical excision - polypectomy
 Aripin, Alshammae N. II BSN - H
B. Surgery
○ Fistulotomyl fistulectomy
○ Diagnosed early - time of delivery to be
repaired immediately
○ Post-op heals 2 - 3 months for inflammation
to subside
○ Maintain adequate nutrition, vitamins, &
protein
○ Administer chemotherapeutic agents
○ Done in healthy tissues
○ Post-menopausal - oral estrogen ® for
healthier viable tissues
○ Perineal hygiene

Post-operative care:
● Recto-vaginal:
● Limit bowel activity - clear liquids for few days and
diet resolve gradually
● Warm perineal irrigations, heat lamp treatments
● Bedrest

Vesicovaginal:
● Proper bladder drainage - FBC - l & O
● Gentleness in administration of bladder and bowel
irrigations
Cause:
● Obstetrical injury
○ pelvic surgery (hysterectomy and vaginal
reconstructive surgery - common)
○ extension of carcinoma or complication of
treatment for CA

Clinical manifestation:
● Trickling of urine into vagina
● Fecal incontinence and flats passed thru vagina and
malodorous
● Irritation and excoriation of vulvar tissues

Diagnostic test:
1. Methylene Blue test - Dye test
● Dye is instilled into bladder
● Dye in vagina - vesicovaginal fistula
● None in ureteovaginal fistula
2. Indigo Carmine test
● Injected IV
● Appears in vagina is ureterovaginal fistula
3. IVP - for location of fistula
4. Cystoscopy
● Determine numbers and locations of fistulas

Treatment:
A. If to heal without surgery (rare)
○ maintain cleanliness - sitz bath; deodorant
douches/ wash
○ use of perineal pads; plastic or rubber pants
○ prevent excoriations - use of bland creams
dust of cornstarch - soothes
○ use of feminine morale boosters as:
attractive hairdo, nail polish; perfumes new
beaded jacket; latest fashion, etc