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MODULE 1M: INTRAPARTAL COMPLICATIONS

INEFFECTIVE UTERINE FORCE 2. Hypotonic Contractions

DEFINITION a. Number of uterine contractions is
unusually infrequent (not more than 2
- Occurs when uterine contractions become
or 3 in 10 mins)
abnormal or ineffective as uterine
b. Resting tone is less than 10mmHg
contractions are the basic force behind
c. Strength of contractions do not rise
moving the fetus through the birth canal.
above 25 mmHg
- Less strength than usual; ineffective;
d. Occurs during active phase of labor;
dysfunctional labor occurs.
limited pain
- Characterized by poor and inadequate
e. Tend to occur:
uterine contractions that are ineffective to
i. After Rx of Analgesia,
cause cervical dilation, effacement, and fetal
especially if the cervix is not
descent, leading to a prolonged or protracted
dilated to 3 or 4 cm
delivery
ii. If bowel or bladder distention
ETIOLOGY/CAUSE is preventing descent or firm
engagement.
- Abnormalities/Ineffective: f. May occur:
o Major electrolytes i. In a Uterus that is
▪ Calcium overstretched by multiple
▪ Sodium gestation.
▪ Potassium ii. Larger than usual single fetus
o Contractile proteins iii. Polyhydramnios
▪ Actin and Myosin iv. Relaxed uterus from grand
o Oxytocin multiparity.
o Epinephrine and Norepinephrine 3. Uncoordinated
o Estrogen, Progesterone and a. More than one pacemaker may be
Prostaglandin initiating contractions
- Excess maternal nervousness, sickness b. Receptor points in the myometrium;
and/or emotions may be acting independently of the
- Pathological changes of uterine cervix and pacemaker.
uterus c. Can interfere with the blood supply to
- Cephalopelvic disproportion the placenta
- Hydramnios, Multiple pregnancy, d. Can make it difficult for a woman to
Oligohydramnios rest between contractions or breathe
- Postdate pregnancy effectively
- Excess anesthesia
- Overdistension of the uterus SIGNS AND SYMPTOMS
- Developmental anomalies of the uterus e.g.
- Prolonged pushing of the mother
hypoplasia.
- Exhaustion
- Myomas of the uterus interfere mechanically
- Delivery of the fetus is delayed
with contractions.
- Malpresentations, malpositions and MANAGEMENT
cephalopelvic disproportion. The presenting
part is not fitting in the lower uterine segment 1. Medical
leading to absence of reflex uterine a. Uterine and fetal external monitor
contractions. should be applied at least 15 minutes
- Full bladder and rectum. to check the resting phase of the
contractions and that the fetal pattern
COMPLICATIONS is not showing a late deceleration
b. Intravenous infusion is frequently
- Fetal anoxia
administered to maintain hydration
TYPES and electrolyte balance.
2. Pharmacologic
1. Hypertonic uterine contractions a. Administer short-acting tocolytics
a. Increased resting tone to more than (e.g., terbutaline 0.25 mg IV once)
15 mmHg b. Administer analgesics to reduce pain
b. Occurs frequently c. Oxytocin
c. Occurs in latent phase of labor; 3. Surgical
painful a. Cesarean Section
d. May occur d/t more than one
pacemaker is stimulating CRITERIA HYPERTONIC HYPOTONIC
contractions Most common
e. Or because muscle fibers of the phase of Latent Active
myometrium do not repolarize or occurrence
relax after contraction. Symptoms Painful Limited pain
Medications
Unfavorable Favorable
used:
reaction reaction
- Oxytocin
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NURSING INTERVENTIONS b. Secondary Inertia

i. Contractions are effective for
1. Perform labor watch a time but begin to lose
2. Do back rubs intensity
3. Fundal massage ii. Occurs later in labor
4. Nipple stimulation
5. In the first hour after birth: SIGNS AND SYMPTOMS
a. Obtain blood pressure
b. Assess lochia every 15 minute - Slow and weak contractions
- Infrequent contractions
6. Place the client in a lateral recumbent
position - Prolonged active phase
- Exhaustion of the mother
7. Assess Uterine contraction pattern
8. Encourage bed rest or sitting - Painless
- Resting tone remains less than 10 mmHg
position/Ambulation
9. Monitor vital signs MANAGEMENT
10. Explain to the woman and her partner that
although the contractions are very strong, 1. Medical and Pharmacologic
they are ineffective and are not achieving a. Amniotomy
cervical dilatation. b. Oxytocin
c. Ambulation
NURSING DIAGNOSES d. Enema
- Ineffective coping r/t exhaustion as e. Prostaglandin
2. Surgical
evidenced by report of painful uterine
contractions a. Cesarean section
b. Vaginal delivery by forceps/ vacuum/
PROLONGED LABOR breech extraction
- Could lead to postpartum infection,
hemorrhage and problems in infant NURSING INTERVENTIONS
- HYPOTONIC: 1. Palpate uterine fundus
o Number of contractions is infrequent
2. Obtain blood pressure
less than 10 mmHg resting tone
3. Assess lochia every 15 minutes for 1st hours
(Active phase)
- HYPERTONIC: 4. Nipple stimulation
o Increase in resting tone to more than 5. Catheterization
15 mmHg; intensity is no stronger 6. Optimize uterine activity. In monitoring
than associated with hypotonic uterine contractions for dysfunctional
(Latent phase) patterns, the nurse can use palpation and an
electronic monitor.
HYPOTONIC UTERINE FORCE 7. Checking the client’s level of fatigue and
DEFINITION ability to cope with pain is important to
prevent unnecessary fatigue
- Uterine contractions are unusually slow or
8. Prevent complications of labor for the client
infrequent
and infant such as:
- Resting tone remains less than 10 mmHg
a. Assessing the urinary bladder
- Only 2 to 3 contractions within a 10-minute
b. Assessing maternal vital signs,
period
including temperature, pulse,
- The strength of contractions does not rise
respiratory rates, and blood pressure.
above 10 mmHg
c. Checking maternal urine for acetone
- Occurs mostly during the ACTIVE PHASE of
(an indication of dehydration and
labor
exhaustion).
- Increased chance of postpartal hemorrhage
d. Assessing the condition of the fetus
ETIOLOGY/CAUSE by monitoring FHR, fetal activity, and
color of amniotic fluid.
- Administration of analgesia (painkiller) if 9. Promote relaxation by, giving back rubs,
cervix is not dilated to 3 to 4 cm promoting comfortable position (side-lying),
- Bowel or bladder distention coaching the client in breathing and
- Overstretched uterus by a multiple gestation, relaxation techniques, and keeping the
- Macrosomic fetus, environment quiet
- Hydramnios 10. In the first hour after birth following labor of
TYPES hypotonic contractions, palpate the uterus
and assess the lochia every 15 minutes to
1. DYSFUNCTIONAL LABOR ensure that there are no postpartal hypotonic
a. Primary Inertia contractions and inadequate to halt bleeding.
i. Contractions are inadequate 11. If considering cesarean birth, instruct the
from labor onset mother about the procedure.
ii. Occur at the onset of labor
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NURSING DIAGNOSES
- Fatigue: compromised concentration related
to prolonged labor
HYPERTONIC UTERINE FORCE
DEFINITION
- Can lead to fetal anoxia
- Increased resting tone to more than 15
mmHg.
- Intensity of contractions may be no stronger
than hypotonic contractions.
- Occur more frequently than hypotonic
contractions.
- Most commonly seen in LATENT PHASE of
labor.
ETIOLOGY/CAUSE
- May occur because more than one
pacemaker is stimulating contractions
- Muscle fibers of the myometrium do not
repolarize or relax after a contraction
- Excessive use of Pitocin during labor
SIGNS AND SYMPTOMS
- Contractions are more painful
- Tender uterus
- Fetal distress
- Prolonged first stage of labor
- Pain
- Fatigue
- Poor and inadequate uterine contractions
that are inadequate in causing cervical
dilatation, effacement, and fetal descent,
resulting in a prolonged or protracted
delivery, especially during the active phase of
labor.
- There are only two or three contractions
occurring within a 10-minute period.
- The contractions in the uterus are feeble,
infrequent and have short durations. (no
more than two or three in a 10-minute span).
- The contractions have a strength of less than
10 mmHg and are most common during
labor's active phase.
MANAGEMENT
1. Medical and Pharmacologic
a. Prostaglandin E2 is administered
before labor to minimize risk of
uterine hyperstimulation
b. Morphine sulfate to slow down
contractions (Tocolytics)
c. Administration of tocolytic treatment
with β2-adrenergic drugs
2. Surgical
a. Cesarean section
b. Assisted Vaginal delivery (forceps,
vacuum, breech extraction0
NURSING INTERVENTIONS
1. Emotional support
2. Bedrest or position changes (lateral position)
3. Hydration mild sedation
4. Deep breathing exercises
5. Back rubs
6. Labor watch
7. Fetal external monitor
8. Assess uterine contraction pattern
9. Provide rest (analgesia)
10. Provide comfort measures
11. Monitor maternal vital signs
12. Frequently monitor fetal status.
13. Administer oxygen by mask.
NURSING DIAGNOSES
- Acute pain: resting tone of 33mmHg related
hypertonic uterine contractions
- Impaired gas exchange: fetal anoxia related
to hypertonic uterine contractions
- Risk for maternal injury r/t alteration of
muscle tone/contractile pattern.
DYSFUNCTIONAL LABOR
DEFINITION
- Dysfunctional labor is difficult, painful,
prolonged labor due to mechanical factors
- Refers to prolongation in the duration of
labor, typically in the first stage of labor.
- AKA INERTIA:
o Sluggishness of contractions
o Force of labor is less than usual
- Diagnosis of delay in labor is dependent on
careful monitoring of uterine contraction
intensity, duration, and frequency, cervical
dilation and descent of the fetus through the
pelvis.
- Difficulty in labor or abnormally slow
progress of labor.
- Prolonged labor is most likely to occur if:
o Fetus is large
o Contractions are:
▪ Ineffective Uterine force
• Hypertonic
• Hypotonic
• Uncoordinated
- PATHOPHYSIOLOGY
o Uterine contractions are ineffective
secondary to muscle fatigue or
overstretching
ETIOLOGY/CAUSE
- Fetal Factors (Passenger)
o Unusually large fetus, fetal anomaly,
malpresentation, and malposition
- Uterine Factors (Power)
o Hypotonic labor, hypertonic labor,
precipitous labor, and prolonged
labor
- Pelvic Factors (Passageway)
o Inlet contracture, midpelvis
contracture, outlet contracture;
unripe cervix; CPD
- “Psyche” Factors
o Maternal anxiety and fear and lack of
preparation; primigravida; Excessive
analgesic/anesthetic
ASSESSMENT FINDINGS
Clinical manifestations include irregular
uterine contractions and ineffective uterine
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contractions in terms of contractile strength and ▪ Pain relief with drug:

duration • Morphine sulfate
▪ Decrease noise
TYPES
2. Protracted Active Phase
1. Primary Inertia o Associated with fetal malposition or
a. Contractions are inadequate from cephalopelvic disproportion (CPD)
labor onset ▪ Diameter of fetal head is
b. Occur at the onset of labor larger than woman's pelvic
2. Secondary Inertia diameter
a. Contractions are effective for a time o Prolonged if cervical dilatation does
but begin to lose intensity not occur at a rate of:
b. Occurs later in labor ▪ Nullipara: 1.2 cm/hr
▪ Multipara: 1.5 cm/hr
NURSING INTERVENTIONS o Prolonged if active phase lasts longer
1. Optimize uterine activity than:
a. Monitor uterine contractions for ▪ Primigravida: 12 hours
dysfunctional patterns; use palpation ▪ Multigravida: 6 hours
and an electronic monitor o 4 cm: full dilation
2. Prevent unnecessary fatigue. Check the o MANAGEMENT:
client’s level of fatigue and ability to cope with ▪ If the cause is fetal
pain malposition or CPD:
3. Prevent complications of labor for the client • Cesarean birth
and infant: ▪ If CPD is not present (as seen
a. Assess urinary bladder; catheterize in ultrasound):
as needed. • Rx oxytocin (augment
b. Assess maternal vital signs, including action of labor)
temperature, pulse, respiratory rates, ▪ Dysfunctional labor during the
and blood pressure. dilatational division of labor
c. Check maternal urine for acetone (an tends to be Hypotonic
indication of dehydration and • Hypertonic: beginning
exhaustion). of labor
d. Assess condition of fetus by 3. Prolonged Deceleration Phase
monitoring FHR, fetal activity, and o Active phase exceeds beyond:
color of amniotic fluid ▪ Nullipara: 3 hours
4. Provide physical and emotional support ▪ Multipara: 1 hour
a. Promote relaxation through bathing o Associated with abnormal fetal head
position
and keeping the client and bed clean,
o MANAGEMENT:
back rubs, frequent position changes
▪ Cesarean birth.
(side-lying position), walking (if
4. Secondary Arrest of Dilatation
indicated), and by keeping the
o No progress in cervical dilatation for
environment quiet
2 hours or more
b. Coach the client in breathing and
o MANAGEMENT:
relaxation techniques
▪ Cesarean birth
5. Provide client and family education
DYSFUNCTIONAL LABOR: 2ND STAGE
DYSFUNCTIONAL LABOR: 1ST STAGE SIGNS AND SYMPTOMS
TYPES
- Exhausted uterus
1. Prolonged Latent Phase
- Uterus doesn't relax
o Longer than:
- Deceleration of FHR
▪ 20 hours in nullipara (never
- Abnormally long stages of labor
given birth)
- Fetal hypoxia
▪ 14 hours in multipara
(multiple pregnancies) TYPES
o May occur if Cervix is not “RIPE” at
the beginning of labor. 1. Prolonged Descent
o Uterus tends to be in hypertonic o Contractions become infrequent and
state, of poor quality
o Relaxation is inadequate, and o Suspected to have occurred if 2nd
contractions are mild (less than 15 stage lasts over 2 hours in a
mmHg) multipara
o Onset of labor: 4cm o Effacement has occurred but then the
o MANAGEMENT: contractions become infrequent and
▪ Help uterus rest of poor quality.
▪ Provide adequate fluid for ▪ Dilatation stops.
hydration o Rate of descent:
o ▪ Nullipara: Less than 1cm/hr
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▪ Multipara: less than 2 cm/hr TYPES

o MANAGEMENT:
▪ Rest 1. Bandl’s Ring
▪ Rupture of membranes a. An end result of tonic uterine
▪ Induce oxytocin contraction and retraction following
▪ May speed descent: obstructed labor. It always occurs at
the junction of upper and lower
• Semi-fowler
segments and progressively moves
• Squatting kneeling
upwards.
• More effective
2. Constriction Ring
pushing
a. A manifestation of localized in
2. Arrest of Descent
coordinated uterine contractions
o ARREST of descent occurs when No
caused by undue irritability of the
descent has occurred:
uterus. The constriction ring usually
▪ Nullipara: for 2 hours
occurs at the junction of upper and
▪ Multipara: 1 hour
lower segment, and the position does
o FAILURE of descent occurs when:
not alter.
▪ Expected descent of fetus
does not begin SIGNS AND SYMPTOMS
▪ Engagement beyond station 0
does not occur - Maternal exhaustion
o CAUSE: - Fetal anoxia
▪ cephalopelvic disproportion MANAGEMENT
(CPD)
o MANAGEMENT: 1. Medical
▪ Oxytocin for NSVD a. Surgical removal of the bands before
▪ Cesarean Section the birth of the baby
2. Pharmacologic
MANAGEMENT a. Morphia
1. Medical b. Anesthesia
a. Oxytocin c. Adrenaline
b. Dinoprostone d. Inhalation of amyl nitrite
2. Surgical e. Spinal anesthesia
a. Amniotomy f. Weight traction attached to a scalp
b. Cesarean Section forceps is advised if unsuccessful

NURSING INTERVENTIONS NURSING INTERVENTIONS

1. Check cervical dilatation 1. Identifying and treating abnormal uterine

2. Monitor uterine contractions patterns
3. Stimulate the nipple 2. Monitoring maternal/fetal physical response
4. Check blood pressure to contractile pattern and length of labor
5. Check FHT 3. Providing emotional support for the
6. Emotional Support client/couple and preventing complications
7. Back rubs 4. Optimize uterine activity. Monitor uterine
8. Semi-Fowler (to speed up descent) contractions for dysfunctional patterns; use
palpation and an electronic monitor.
NURSING DIAGNOSES 5. Prevent unnecessary fatigue. Check the
client’s level of fatigue and ability to cope with
- Fatigue: slow sluggish response related to
pain.
prolonged labor
6. Prevent complications of labor for the client
- Risk for fetal injury r/t fetal malpresentation
and infant.
CONTRACTION RING a. Assess urinary bladder; catheterize
DEFINITION as needed.
b. Assess maternal vital signs, including
- It is a spasmodic contraction of the lower temperature, pulse, respiratory rates,
portion of the uterus which usually occurs and blood pressure.
during the first phase of labour, but persists c. Check maternal urine for acetone (an
into the second stage. The ring then indication of dehydration and
contracts round the child's neck and prevents exhaustion).
the child descending, thus delaying and d. Assess the condition of the fetus by
preventing delivery. It is a cause of monitoring FHR, fetal activity, and
obstructed labor or dysfunctional labor. color of amniotic fluid.
ETIOLOGY/CAUSE 7. Provide physical and emotional support.
a. Promote relaxation through bathing
- Tonic uterine contraction and keeping the client and bed clean,
- Inco-ordinated uterine contractions back rubs, frequent position changes
(sidelying), walking (if indicated), and
by keeping the environment quiet.
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b. Coach the client in breathing and - Subdural hemorrhage (fetus)

relaxation techniques
SIGNS AND SYMPTOMS
8. Provide client and family education
NURSING DIAGNOSES - Painful
- Sudden onset of strong contractions
- Risk of fetal injury r/t prolonged labor - An intense feeling to bear down and push
PRECIPITATE LABOR MANAGEMENT
DEFINITION
1. Medical
- Rapid labor and birth of less than 3-hour a. Check for history of precipitate labor
duration (Labor completed in 3 hours) b. Induce labor with a low rupture of
- Caused by lack of resistance of uterus/cervix membranes and a controlled delivery
to passage of fetus or intense uterine with care.
contractions c. Woman should be cautioned during
- Hazards to mother are perineal laceration the 28th week.
and postpartum hemorrhage, and infection d. Cardiotocography
- Hazards to infants are anoxia and i. The heart rate of your baby is
intracranial hemorrhage measured using
- PRECIPITATE DILATATION that occurs at a cardiotocography (CTG).
rate of: ii. It also focuses solely on the
o Primipara: 5 cm or more per hour womb's contractions at the
o Multipara: 10 cm or more per hour same time (uterus).
- PRECIPITATE BIRTH occurs when: iii. It is used to monitor the baby
o Uterine contractions are so strong a for any signs of distress both
woman gives birth with only a few, before birth (antenatally) and
rapidly occurring contractions. throughout labor
o Labor that is completed in fewer than e. Note bulging of membranes
3 hours f. Crowning
- Rapid contractions g. Urge to bear down
o Uterine contractions are so strong h. Promote fetal oxygenation
resulting in rapid occurring i. Stop Pitocin induction
contractions j. Give oxygen
- PRECIPITATE LABOR Can be predicted k. IV fluids
with a labor graph if, during the ACTIVE l. Prepare for delivery
PHASE of dilatation the rate is: 2. Pharmacologic
o Nullipara: Greater than 5 cm/hr (1 a. Tocolytic drugs
cm every 12 minutes) i. Bolus of subcutaneous
o Multipara: 10 cm/hr (1 cm every 6 terbutaline or intravenous
minutes) ritodrine, should be given to
the mother if a syntocinon
ETIOLOGY/CAUSE
infusion is being
- Grand multiparity administered.
- Abnormally strong uterine and abdominal 3. Surgical
contractions a. Cesarean Section after diagnosis of
- Abnormally low resistance of the soft pass of placental abruption
the birth canal
NURSING INTERVENTIONS
- Absence of painful sensations
- Induction of labor by oxytocin 1. Monitor Vital signs
- Maternal Risk Factors: 2. Encourage oral intake
o Laceration in perineum 3. Provide supplemental fluids as indicated
o Premature separation of placenta 4. Provide a quiet environment and privacy
- Fetal Risk Factors: within parameters of the situation.
o Subdural hemorrhage that may result 5. Note client’s level of consciousness and
from the pressure at the head mentation
6. Remain with mother and monitor closely
ASSESSMENT FINDINGS
7. Keep mother and partner informed
- Rapid cervical dilation throughout process of labor and birth
- Accelerated fetal descent 8. Support and guide fetal head through birth
- History of rapid labor canal when birth occurs
- Rapid uterine contractions with decreased Precipitous Delivery Outside Hospital
periods of relaxation between contractions Setting: Nursing Interventions
COMPLICATIONS 1. Remain with patient
- Premature separation of the placenta 2. Prepare sterile or clean environment
- Lacerations of the perineum 3. Instruct client to pant when head crowns
o Women at risk for hemorrhage
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MODULE 1M: INTRAPARTAL COMPLICATIONS
4. Support infant’s head; apply slight pressure
to control delivery
5. Deliver fetal head between contractions
6. Slip nuchal cord, if present, over head
7. Rotate infant externally as head emerges
8. Delivery shoulders, then trunk
9. Clear airway and facilitate mucus drainage
10. Dry baby rapidly and place on mother’s
abdomen
11. Do not pull-on cord. Hold placenta as
delivered
12. Wrap baby in blanker and put to breast
13. Check for bleeding and fundal tone
14. Arrange for transport to hospital
NURSING DIAGNOSES
- Impaired Tissue Integrity related to
episiotomy as evidenced by redness and
pain on surgical site
UTERINE RUPTURE
DEFINITION
- Occurs most often in women who have a
previous cesarean scar.
- Fetal death occurs unless Cesarean birth is
accomplished.
- Uterine rupture is an immediate emergency
(d/t vascularity of the uterus at the end of
pregnancy = highly vascular)
- Spontaneous or traumatic rupture of the
uterus
- Rupture of uterus during labor
- Considered rare but is always possible to
happen
- Classified into 2 types: complete and
incomplete rupture
- Diagnosis: based on the presenting
symptoms
ETIOLOGY/CAUSE
- May be caused by injury from obstetric
instruments such as uterine sound or curette
used in abortion
- May result from obstetric intervention, such
as excessive fundal pressure, forceps
delivery, violent bearing-down, tumultuous
labor and fetal shoulder dystocia
- Spontaneous uterine rupture is most likely to
occur after previous uterine surgery, grand
multiparity combined with the use of oxytocic
agents, cephalopelvic disproportion,
malpresentation, or hydrocephalus.
- Commonly occurs to women who have
previous Cesarean scars
- RISK FACTORS:
o Prolonged labor
o Abnormal presentation
o Multiple gestation (2 or more fetuses
inside uterus)
o Unwise use of oxytocin
o Obstructed labor
o Traumatic maneuvers of forceps or
traction
ASSESSMENT FINDINGS
- Rupture of the scar from a previous cesarean
delivery or hysterectomy
- Prolonged or obstructed labor (shoulder
dystocia)
- Forceps delivery of fetus with abnormalities
(hydrocephalus)
- Application of forceps and extraction before
cervical OS has completely dilated
- Injudicious use of oxytocin
- Excessive manual pressure applied to the
fundus during delivery
- Violent, bearing down
Complete Rupture: Assessment
- Clinical manifestations vary from mild to
severe, depending on the site and extent of
the rupture, degree of extrusion of the uterine
contents, and intraperitoneal evidence or
absence of spilled amniotic fluid and blood.
- Sudden sharp abdominal pain during
contractions
- Abdominal tenderness
- Cessation of contractions
- Bleeding into the abdominal cavity and
sometimes into the vagina
- Fetus easily palpated; FHT cease
- Signs of shock:
o Rapid, weak pulse
o Cold, clammy skin
o Pallor
o Flaring of nostrils due to air hunger
Incomplete Rupture: Assessment
- Develops over a period of few hours
- Abdominal pain during contractions
- Contractions continue, but cervix fail to dilate
- Vaginal bleeding may be present
- Rising pulse rate and skin pallor
- Loss of FHT
COMPLICATIONS
- DANGER SIGNS OF PREGNANCY
o Cramping, contractions (uterine)
o Rupture of membranes
o Absence of fetal movement
o Muscle irritability
o Pain (epigastric, abdominal, uterine)
o Spotting or vaginal bleeding
o Urine frequency or Oliguria
o Persistent vomiting
o Uterine Rupture:
▪ Assess for:
• Loss of uterine
contour
• Palpable fetal part
TYPES
1. COMPLETE
a. Going through the:
i. Endometrium
ii. Myometrium
iii. Peritoneum
iv. Uterine contractions will
immediately stop.
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v. Two indistinct swellings will be
visible on the woman’s
abdomen:
1. The retracted uterus
2. Extrauterine fetus
vi. Signs of hypovolemic shock
begin:
1. Rapid, weak pulse
2. Falling BP
3. Cold and clammy skin
4. Dilation of the nostrils
from air starvation
5. Fetal heart sounds
fade and then are
absent
2. INCOMPLETE
a. Leaving the peritoneum intact.
b. Signs of rupture are less evident
c. SIGNS & SYMPTOMS:
i. Localized tenderness
ii. Persistent aching over area of
lower uterine segment
iii. Lack of contractions
iv. Fetal and maternal distress.
PROCEDURES
- Ultrasound
SIGNS AND SYMPTOMS
- Sudden severe pain during strong labor
contractions
- “Tearing” sensation
- Pain: severe abdominal pain
- Contractions would stop
- Fetal HR is absent
- BP falls down
- Pulse is rapid but weak
MANAGEMENT
1. Medical and Therapeutic
a. Emergency replacement therapy
b. IV oxytocin to contract uterus and
minimize bleeding
2. Pharmacologic
a. Rx emergency replacement therapy
b. IV Oxytocin
i. To contract the uterus and
minimize bleeding
3. Surgical
a. Laparotomy
i. To control bleeding and birth
of the fetus (emergency
measures)
b. Cesarean hysterectomy
i. Removal of the damaged
uterus (removing the uterus
first to remove the baby)
1. No uterus = not
capable to conceive
anymore
c. Tubal ligation
i. Results in the loss of
childbearing capability
NURSING INTERVENTIONS
1. Monitor for the possibility of uterine rupture
a. In the presence of predisposing
factors, monitor maternal labor
pattern closely for hypertonicity or
signs of weakening uterine muscle.
b. Recognize signs of impending
rupture, immediately notify the
physician, and call for assistance
c. Take note of blood loss and if it is
complete/incomplete
2. Assist with rapid intervention
a. If the client has signs of possible
uterine rupture, vaginal delivery is
generally not attempted
b. If symptoms are not severe, an
emergency cesarean delivery may be
attempted, and the uterine tear
repaired
c. If symptoms are severe, emergency
laparotomy is performed to attempt
immediate delivery of fetus and then
establish homeostasis
3. Implement the following preparations of
surgery
a. Monitor maternal blood pressure,
pulse, and respirations; also monitor
fetal heart tones
b. If the client has central venous
pressure catheter in place, monitor
pressure to evaluate blood loss and
effects of fluid and blood replacement
c. Insert a urinary catheter for precise
determinations of fluid balance
d. Obtain blood to assess possible
acidosis
e. Administer oxygen, and maintain
patent airway
4. Prevent and manage complications. Take
these steps in order to prevent or limit
hypovolemic shock
a. Oxygenate by providing 8 to 10 L/min
using a closed mask
b. Restore circulating volume using one
or more IV lines
c. Evaluate the cause, response to
therapy, and fetal condition
d. Remedy the problem by preparing
the client for surgery and
administering antibiotics
5. Provide physical and emotional support
a. Provide support for the client’s
partner and family members once
surgery has begun
b. Inform the partner and family how
they will receive information about the
mother and newborn and where to
wait
NURSING DIAGNOSES
- Deficient Fluid Volume: vaginal bleeding r/t
uterine rupture
INVERSION OF THE UTERUS
DEFINITION
- AKA UTERINE INVERSION
- The uterus turns completely or partially
inside out; it occurs immediately following
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delivery of the placenta or in the immediate TYPES

postpartum period
- Uterus turning inside out either birth of fetus
or delivery of placenta
- A rare case occurring in 1 in 20,000
births
- Uterus turning inside out with either:
o Birth of the fetus
o Delivery of the placenta
- PATHOPHYSIOLOGY:
o The inverted uterus is unable to
restore normal position or contract
o The woman is placed at increased
risk for bleeding and infection
1. 1st degree (also called INCOMPLETE) –
The fundus is within the endometrial cavity
2. 2nd degree (also called COMPLETE) – The
fundus protrudes through the cervical os
3. 3rd degree (also called PROLAPSED) –
The fundus protrudes to or beyond the
introitus
4. 4th degree (also called TOTAL) – Both the
uterus and vagina are inverted
a. Contraction is not in place
b. Bleeding is expected
c. Emergency case

ETIOLOGY/CAUSE SIGNS AND SYMPTOMS

- Forced Inversion - Sudden gush of a large amount of blood from

o Caused by excessive pulling of the the vagina.
cord or vigorous manual expression - Fundus is impalpable in the abdomen
of the placenta or clots from an atonic - Signs of blood loss:
uterus o Hypotension
- Spontaneous Inversion o Dizziness
o Due to increased abdominal pressure o Paleness
from bearing down, coughing, or o Diaphoresis
sudden abdominal muscle - Abdominal pain
contraction - A mass in the pain
- RISK FACTORS:
MANAGEMENT
o Traction is applied to the uterine
fundus when the uterus is not 1. NEVER attempt to replace an inversion
contracted a. Handling of the uterus could increase
o Placenta is attached to the fundus so bleeding and would be difficult to
that passage of the fetus at birth pulls replace the inversion later on prior to
the fundus downward. manually replace it back
o Labor lasting longer than 24 hours 2. NEVER attempt to remove the placenta if
o A short umbilical cord still attached (could create a larger surface
o Prior deliveries area for bleeding)
o Use of muscle relaxants during labor 3. DISCONTINUE oxytocin (if Rx) if infused
o Abnormal or weak uterus a. If the uterus continues to contract,
o Previous uterine inversion makes the uterus more tense and
o Placenta accreta, in which the difficult to replace.
placenta is too deeply embedded in 4. Medical
the uterine wall a. Manual replacement of the Fundus
- Predisposing Factors: b. Rx Oxytocin AFTER manual
o Straining after delivery of the replacement of the fundus
placenta i. Helps uterus to contract
o Vigorous kneading of the fundus to ii. Helps uterus remain in natural
expel the placenta place.
o Manual separation and extraction of 5. Pharmacologic
the placenta a. Uterotonic drugs
o Rapid delivery with multiple b. General anesthesia
gestation, or rapid release of c. Nitroglycerin
excessive amniotic fluid d. Tocolytic drug IV
i. To relax the uterus to
ASSESSMENT FINDINGS appropriately replace the
- Excruciating pelvic pain with a sensation of fundus manually
extreme fullness extending into the vagina. e. Oxytocin is administered again if
- Extrusion of the inner uterine lining into the fundus is replaced so that uterus will
vagina or extending past the vaginal introitus. contract and further prevent blood
- Vaginal bleeding and signs of hypovolemia loss
f. Antibiotic prophylaxis (therapy)
COMPLICATIONS i. To mitigate risk for infection
- Bleeding cannot be halted d/t position of the d/t exposure of uterine
endometrium.
uterus (cannot be contracted)
o Exsanguination may occur: 6. Surgical
a. Cesarean section
▪ Blood loss to the point of
b. Huntington Procedure
death.
c. Haultain procedure
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i. For future pregnancies to - Occurs when amniotic fluid is forced into an

prevent repeat inversion. open maternal uterine blood sinus after a
membrane rupture or partial premature
NURSING INTERVENTIONS
separation of the placenta.
1. Insertion of IV line using a large gauge - Not common: 1 in 20,000 births incidence
needle. Make sure line is appropriate to - Occurs during labor or in the postpartal
blood replacement period
a. Large gauge needle is used in case - NOT PREVENTABLE because it is
of blood transfusion unpredictable
i. As pregnant women are ante, o If not detected right away, it depends
intra and postnatally at risk of on the speed and skill of emergency
hemorrhage interventions
ii. There is a need to regulate - VERY DANGEROUS and NEEDS
blood flow IMMEDIATE EMERGENCY
iii. Blood has larger molecules INTERVENTIONS since it depends on the
therefore there is a need for prognosis and size of embolism and if it is
large gauge needle for blood detected early
transfusion and not to lead to o Since emboli is a moving clot thus it
blood clots by using smaller will travel to other parts
gauge needles ▪ Lungs = pulmonary
iv. D5LR – IV fluids common for embolism
pregnant clients
ETIOLOGY/CAUSE
2. Administer oxygen and assess v/s that would
indicate if there is drastic emergency - Humoral or anaphylactoid response to
interventions are needed. amniotic fluid in the maternal circulation
3. Promptly identify and assist with the - Previously thought:
resolution of uterine inversion. o Meconium
4. Recognize signs of impending inversion, and o Shed fetal skin cells
immediately notify the physician and call for - Fetal/Neonatal Implications
assistance. o meconium, lanugo, and vernix in fluid
5. Immediate manual replacement of the uterus maybe deposited in the pulmonary
at the time of inversion will prevent cervical arterioles
entrapment of the uterus, if reinversion is not - Predisposing factors
performed immediately, rapid, and extreme o Intrauterine fetal death
blood loss may occur, resulting in o High parity
hypovolemic shock. o Abruptio placenta
6. If manual reinversion is not successful, o Oxytocin augmentation
prepare the client and family for possible o Advanced maternal age
general anesthesia and surgery. - RISK FACTORS:
7. Take steps in order to prevent or limit o Induction of Labor
hypovolemic shock. o Multiple Pregnancy
8. Insert a large gauge intravenous catheter for o Polyhydramnios
fluid replacement.
TYPES
9. Measure and record maternal vital signs
every 5 to 15 minutes to establish a baseline 1. Typical AFE:
and document change. a. Phase 1 – respiratory and circulatory
10. Open an established intravenous line for disorders
optimal fluid replacement. b. Phase 2 – coagulation disturbances
11. A fibrinogen level should be drawn to of maternal hemostasis
determine the risk for formation of a blood c. Phase 3 – acute renal failure and
clot. acute respiratory distress syndrome
12. Prepare for anesthesia as needed. (ARDS), and leading to
13. Prepare to administer CPR, if required. (If a cardiopulmonary collapse
woman's heart fails from blood loss) 2. Atypical AFE:
a. Uterine Hemorrhage
NURSING DIAGNOSES b. Adult respiratory syndrome
(ARDS) – as form of atypical AFE
- Risk for Infection related to decreased
c. Paradoxical AFE
hemoglobin.
d. Cesarean section – related atypical
AMNIOTIC FLUID EMBOLISM AFE
DEFINITION
SIGNS AND SYMPTOMS
- Escape of amniotic fluid into maternal
circulation via either a defect in the - Sudden dyspnea
membranes after ROM or partial abruptio - Cyanosis
placenta - Tachypnea (pulmonary artery constriction
occurs)
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- Paleness SIGNS OF MOTHER ON ACTUAL LABOR

- Hemorrhage - Persistent uterine contraction (every 20
- Chest pain mins)
- Coughing with pink frothy sputum - Uterine contractions that cause cervical
- Increasing restlessness and anxiety effacement over 80%
- Chills - Cervical dilation over 1 cm
- Shock out of proportion to blood loss - Persistent, dull and low backache
- Seizures - Light spotting/ vaginal bleeding
- Hypotension - Pressure in the pelvis
- Fetal distress - Menstrual – like cramping

MANAGEMENT ETIOLOGY/CAUSE
1. IMMEDIATE - Dehydration – can start early uterine
a. Immediate delivery contractions
b. Rx Oxygen with face mask or cannula - UTI (Urinary Tract Infection)
c. CPR may be necessary (but may be - Periodontal disease
ineffective) - Chorioamnionitis
d. Admit to ICU - Large fetal size
2. Surgical - Possible cause can be classified
a. Cesarean section according to:
3. Pharmacologic o Medical History
a. Uterotonics ▪ Weight, height, cervical
b. Therapy with fibrinogen to counteract anomalies, chronic illness
the DIC. o Obstetric History
NURSING INTERVENTIONS ▪ Previous preterm labor and
birth
1. Administration of oxygen ▪ History of loss pregnancy
2. Blood transfusion ▪ Incompetent cervix
3. Heparin injection ▪ Previous spontaneous
4. Insertion of CVP (central venous pressure) abortion
line o Present Pregnancy
5. Monitoring of cardiopulmonary status ▪ Uterine distention
6. Endotracheal intubation (to maintain ▪ Abdominal surgery during
pulmonary function) pregnancy
▪ Uterine bleeding
NURSING DIAGNOSES ▪ Dehydration
- Risk for Disseminated Intravascular ▪ Infection/ inflammation
Coagulation (DIC) ▪ Preeclampsia
- Risk for maternal and fetal injury related to ▪ Preterm premature rupture of
polyhydramnios membranes (PPROM)
▪ Excess contractions
PRETERM LABOR ▪ Extra babies (Multiple
DEFINITION gestation)
- Refers to the occurrence of regular uterine ▪ Ischemia
contractions accompanied by cervical ▪ Placental abruption (Abruptio
effacement and dilation that begins after 20 Placentae)
weeks’ gestation and before the end of ▪ Uterine clock
week 37 of gestation ▪ Hormonal permission
- It is considered to be established if regular ▪ Trauma
contractions can be documented at least 4 in ▪ Fetal death
20 minutes or 8 in 60 minutes with ▪ Hydramnios
progressive change in the cervical score in ▪ Placenta Previa
the form of effacement of 80% or more and ▪ Incompetent Cervix
cervical dilatation >1cm. ▪ Uterine Structural Anomalies
- Occurs approximately 9-11% of all ▪ Intrauterine Infection
pregnancy ▪ Congenital Adrenal
- Serious complication - consider infant inside Hyperplasia
the baby (pre-term labor) o Lifestyle and Demographics
o 37 - 40 weeks = TERM ▪ Stress (physical and
o More than 40 weeks= POST TERM emotional)
o Less than 37 weeks = PRETERM ▪ Alcohol or Narcotic drug
- PATHOPHYSIOLOGY: contractions
o The uterus begins the process of
contraction prior to term gestational
age
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- Factors that can contribute to early b. Note: If contractions are detected

contractions early and treatment begun early,
o Nature of client’s job/ work if it is there is a higher rate of labor
strenuous/ hectic schedule work that stoppage
could lead to stress or fatigue 3. Conservative Treatment
ASSESSMENT FINDINGS a. Bed rest in left lateral position
b. Hydration with IV therapy and
- Clinical manifestations of preterm labor are continuous fetal and uterine
basically the signs of true labor that occur contraction monitoring
when the gestational age of the fetus is c. Tocolytic therapy not needed if
greater than 20 and less than 37 weeks contractions stops
- Low back pain d. Discharge planning includes
- Suprapubic pressure i. Completely bed rest or limited
- Vaginal pressure activity
- Rhythmic uterine contractions ii. Stress management
- Cervical dilation and effacement iii. Promotion of nutrition
- Possible rupture of membranes iv. Increased intake to 10
- Expulsion of the cervical mucus plug cups/day
- Bloody show v. No sexual activity or breast
To know that medical attempts can stop labor manipulation
4. Pharmacologic
- No evidence of bleeding a. Tocolytic Therapy
- Absence of fetal distress (no bradycardia or i. BETA-SYMPATHOMIMETIC
tachycardia) DRUGS – act to halt
- If cervix is not dilated not more than 4 to 5 contractions by coupling with
cm and effacement is not more than 50% adrenergic receptors on the
- If amniotic fluid is still intact (amniotic bag/ outer surface of the
membranes has not ruptured) membrane of myometrial
cells - ideal tocolytic drug is
How would you know that labor can’t be one that acts entirely on beta2
stopped? If cannot be stopped, assist the
receptor sites and so does not
mother in delivery
cause any cardiac or
- Amniotic fluid has been ruptured (Point of gastrointestinal symptom
no return - Labor progresses) 1. Ritodrine HCl
- Cervical dilation is more than 3-4 cm and (Yutopar)
effacement is more than 50% 2. Terbutaline Sulfate
o Mother and baby is risk for (Brethine) – ‘tocolytic
infection agent’ to halt labor;
should not be used
TYPES (CLASSIFICATIONS)
over 48-72 hours and
1. Extremely preterm: <28 weeks in an outpatient or
2. Very preterm: 28-32 weeks home setting
3. Moderate to late preterm: 32-37 weeks a. VERY
COMMON =
SIGNS AND SYMPTOMS used to
- Ruptured membranes pregnant
- Cervix is more than 50% effaced and more women who
than 3-4 cm dilated are on preterm
- Cesarian birth if fetus is very immature labor
- Regular or frequent contractions 3. Magnesium Sulfate –
- Constant low, dull backache used for fetal
- Pelvic or abdominal pressure neuroprotection prior
- Mild abdominal cramps to 32 weeks to help
- Vaginal spotting prevent cerebral palsy
- Watery, mucus-like or bloody vaginal in premature infants
discharge (given in smaller
doses than in PIH)
MANAGEMENT a. Used for pre-
eclampsia and
1. BEST KEY PREVENTION: Maintaining
general health during pregnancy eclampsia
(DRUG OF
2. Focus and Method: Focus of medical
CHOICE)
treatment is prevention of delivery of a
b. For early
preterm infant
contractions
a. Method depends on the cervical
dilation and contraction pattern
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c. Muscle span of 7 days, the

relaxant = dose may be repeated
relaxes uterine
muscles that
leads to
stopping/
halting the
uterine
contractions
Mechanism Of Action of Beta-Mimetic Agents
▪ Stimulate the beta2-receptors
which causes uterine relation
Note:
• Use of these drugs for
a prolonged period of
time can result in a
decreased response
of the drug
• Initially, administered
IV “piggy-back” via
infusion control then
weaned either to SQ
or to PO
Side Effects:
• Increased PR
• Decreased BP
• Increased plasma
volume
• Decreased Serum
Potassium
• Hyperglycemia
• Hyperinsulinemia
b. Steroid Therapy
i. NSAIDS (Non-Steroidal
Anti-Inflammatory Drug)
and Inomethacin (Indocin)
Mechanism of Action
• Prostaglandin
antagonist used to
inhibit uterine
contractions
Side Effects
• Headache
• Prolonged bleeding
time
• Nausea
• Syncope
• Vomiting
• Blurred Vision
ii. Betamethasone
(Corticosteroid) – if
pregnancy is under 34 weeks,
woman may be given steroid
to attempt to hasten fetal lung
maturity
1. Preferred choice as it
leads to lower rates of
respiratory distress
syndrome or
bronchopulmonary
dysplasia in newborns
2. If woman has not
given birth with the
but it is not advisable
because it may cause
glucose regulation
3. AFFECTS the fetus
4. To hasten fetal lung
maturity
5. If lung surfactant is not
fully formed then the
fetus is out, it could
result in other
problems (RDS:
respiratory distress
syndrome)
6. Given in 2 doses: 24
hours apart: IM: 12
mg/dose
a. 24 hours
because effect
will take place
after 24 hours
after giving the
medication
7. Dexamethasone:
substitute to
Betamethasone
a. Given in 4
doses: 6
mg/dose: 12
hours apart
NURSING INTERVENTIONS
1. Obtain a thorough obstetric history
2. Obtain specimens for CBC and U/A
3. Determine frequency, duration, and intensity
of uterine contractions
4. Determine cervical dilation and effacement
5. Assess status of membranes and bloody
show
6. Evaluate the fetus for distress, size, and
maturity
7. Perform measures to manage or stop
preterm labor
a. Place on complete bedrest in side-
lying position
b. Prepare for possible U/S,
amniocentesis, tocolytic drug therapy
and steroid therapy
c. Administer Tocolytic (contraction-
inhibiting) medications as prescribed
d. Assess S/E such as hypotension,
dyspnea, chest pain, and FHR
exceeding 180 beats/min
8. Provide emotional and physical support
(adequate hydration)
Therapeutic Management:
1. Complete bed rest - (Hospital)
a. Serving of bedpans
2. Hydration
a. Increase fluid intake (Home setting)
3. Providing and administering IV fluids
(Hospital setting)
4. Doctor could order a vaginal/cervical
culture/ urine sample to rule out infection
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Medical attempts can be done to stop labor if the ff - Too much fluid
are present: - Multiple gestation
- Previous cervix surgery and biopsies
Conditions: Fetal membranes are intact, absence - Multigravida and had PPROM and PROM
of fetal distress, no evidence that bleeding is
occurring, cervix is not dilated to more than 4-5 cm, ASSESSMENT AND DIAGNOSTIC TESTS
effacement is not more than 50 % FINDINGS

1. Place woman on best rest upon admission - CONFIRMATORY SIGNS

2. Initiate IV therapy o A sudden gush of clear fluid from
vagina, with continued minimal
Nursing Assessment During Tocolytic Therapy leakage
1. Evaluate the following during Tocolytic o Amniotic fluid causes an alkaline
Therapy: reaction on the paper (appears blue)
a. Fetal status if tested with Nitrazine paper
b. Respiratory Status (Pulmonary o Presence of a high level of
Edema) alphafetoprotein (AFP) in the vagina
c. Muscular tremors o Increased WBC count and C-reactive
d. Hypotension protein
e. Urinary control COMPLICATIONS
f. Contraction pattern
g. Palpitations - Fetal Risk Complications
h. Dizziness/Lightheadedness o Seal to the fetus is lost and uterine
2. Diagnostic Evaluation prior to Tocolytic and fetal infection may occur
Administration o Increased pressure on the umbilical
a. CBC cord
b. Electrolytes o Inhibiting fetal nutrient supply
c. Baseline ECG o Cord Prolapse – could interfere with
d. Glucose, BUN fetal circulation
e. PT and PTT o Development of a Potter-like
syndrome or distorted facial features
NURSING DIAGNOSES and pulmonary hypoplasia from
pressure
- Acute pain reports of or discomfort r/t uterine
contractions TYPES
- Risk for Infection r/t early dilatation of cervix
1. Preterm premature rupture of membranes
PREMATURE RUPTURE OF THE – Amniotic sac ruptures before 37 weeks of
MEMBRANES (PROM) pregnancy
DEFINITION 2. Spontaneous rupture of membrane –
- Rupture of fetal membranes with loss of Rupture of membranes after or with the onset
amniotic fluid during pregnancy before 37 of labor occurring prior to 37 weeks.
weeks SIGNS AND SYMPTOMS
- rupture or breaking open of gestational
membranes that surrounds the baby, - Leaking or a gush of watery fluid from the
amniotic sac, prior to the onset of labor. vagina with continued minimal leakage
When the sac ruptures, the pregnant woman - Constant wetness in underwear
has an increased risk for infection and has a
MANAGEMENT
higher chance of having the baby born
prematurely. 1. Medical
- Rupture of fetal membranes with loss of a. Determine if the cervix is suitable for
amniotic fluid during pregnancy before 37 labor induction
weeks i. If the patient’s cervix is in
o PREMATURE - bag of water is good shape, there’s no need
ruptured (spontaneous/artificial) to wait. As a result,
- Associated with infection of membranes and intravenous oxytocin should
cause is unknown (risk for infection) be used to induce labor as
o Spontaneous rupture: natural soon as feasible.
rupture of membranes 2. Surgical
o Artificial rupture: using material to a. Early delivery
rupture the bag of water i. If there is evidence of
abruption, chorioamnionitis,
ETIOLOGY/CAUSE
or fetal compromise
- Associated with infection of the membranes 3. Pharmacologic
(chorioamnionitis) a. Corticosteroids – This might help
- Physiologic weakening of the membranes or the fetus’ lungs grow since lung
from the force of contractions immaturity is a major problem of
- Infections of the uterus, cervix, or vagina premature babies. This medication,
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on the hand, may hide a uterine
infection.
b. Antibiotics – This is to avoid or treat
infections
c. Tocolytics –
d. These are medications that are used
to prevent premature labor.
NURSING INTERVENTIONS
1. If it is ruptured, Assess signs of infection
2. Assess the cloudy/clear and color
(yellow/greenish)
a. Meconium staining: stool/meconium
of the baby while inside the uterus
i. Yellow green/greenish is
present in amniotic fluid
3. Monitor fetal heart tone
4. Assess for fetal distress and cord prolapse
5. If fetus is matured at the time of rupture and
labor does not begin within 24 hours
a. Induction of Labor contractions by IV
administration of oxytocin
b. Place woman on bed rest
c. Administered a corticosteroid to
hasten fetal lung maturity
d. Prophylactic administration of broad-
spectrum antibiotics
e. A woman with no signs of infection
may be administered a tocolytic
agent
NURSING DIAGNOSES
- Anxiety: Apprehensiveness and awareness
of physiological symptoms r/t perceived
threat to one’s health and the fetus
PROLAPSE OF THE UMBILICAL CORD
DEFINITON
- Descent of the umbilical cord into the vagina
ahead of the fetal presenting part with
resulting compression of the cord between
the presenting part and maternal pelvis
o A loop of the umbilical cord slips
down in front of the presenting fetal
part
- May occur at any time after the membranes
rupture
- Tends to occur most often with:
o Premature rupture of membranes
o Fetal presentation other than
cephalic
o Placenta previa
o Intrauterine tumors preventing the
presenting part from engaging
o Small fetus
o CPD preventing firm engagement
o Polyhydramnios
o Multiple gestation
- It is an emergency situation therefore,
immediate delivery will be attempted to save
the fetus
- Occurs in 1 of 200 pregnancies
- Needs emergency action
ETIOLOGY/CAUSE & PATHOPHYSIOLOGY
- Occurs frequently in prematurity
- Rupture of membranes with the fetal
presenting part unengaged
- Shoulder or footling breech presentations
- May follow rupture of the amniotic
membranes due to the fluid rush that may
carry the cord along toward the birth canal
PATHOPHYSIOLOGY
- Compression of the cord results in the
compromise or cessation of fetoplacental
perfusion
ASSESSMENT FINDINGS
- Vaginal examination
o Cord felt as presenting part
- Fetal distress may occur as the cord is
compressed between the presenting part
and the bony prominence
o FHR is unusually slow or decelerating
with contractions or between
contractions
o Fetal bradycardia is present
- Prolapsed cord is ALWAYS an emergency
- Can lead to:
o Cord compression
o Decreased oxygenation
- Cord may be protruding from the vagina
- Cord may be palpated in the vaginal canal or
cervix
TYPES
➢ Overt Cord Prolapse
o Umbilical cord ahead of fetal
presenting part
➢ Occult (Nonovert) Cord Prolapse
o Umbilical cord alongside fetal
presenting part
➢ Cord (Funic Presentation)
o Occurs when the cord prolapses
beneath the presenting component,
either with or without membrane
rupture
o Occurs when the cord can be felt
protruding below the presenting
section before the membranes have
torn
SIGNS AND SYMPTOMS
• Can occur with no obvious physical
indications and normal fetal heart tracing
• On a pelvic exam, the prolapsed cord can be
seen or felt
• Bradycardia
MANAGEMENT
➢ MEDICAL
o Delivery of the fetus as soon as
possible
➢ PHARMACOLOGICAL
o Tocolytic drug
▪ To reduce uterine activity and
pressure on the fetus
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Amnioinfusion
o •
▪ Addition of sterile fluid into the
uterus to supplement the
amniotic fluid and reduce
compression on the cord
➢ SURGICAL
o Cesarean section if a serious
obstetric emergency necessitates
NURSING INTERVENTIONS
• Do assessment
o Assess fetal heart tone
o Assess characteristics and
consistency
▪ Check meconium staining
and if amniotic fluid is
greenish or brownish
▪ Check for any signs of
infection
• Aim to relieve the pressure compressing on
the cord and reduce anoxia
• Manually elevating the fetal head off the cord
• Place woman in:
o Knee – chest position - this uses
gravity to shift the fetus out of the
pelvis. The woman’s thighs should be
at right angles to the bed and her
chest flat on the bed
o Trendelenburg position – this causes
fetal head to fall back from the cord.
Often combined with the woman’s
hips are elevated with two pillows
• Rx Oxygen at 10 L/min by face mask
• Cover any exposed portion with sterile saline
compress to prevent drying
o Drying occurs = constriction of
umbilical vessels = fetal anoxia
• C: call for help
• O: organize delivery
• R: relieve pressure on the cord
• D: delivery
• Assess laboring client often if the fetus is
preterm or small for gestational age, if the
presenting part is not engaged, and if the
membranes are ruptured
• Periodically evaluate FHR, esp. right after
rupture of member (spontaneous or surgical)
and again in 5 to 10 minutes
• Notify physician and prepare for emergency
cesarean birth if prolapsed cord is identified
• If client is fully dilated, the most emergent
delivery route may be vaginal. In this case,
encourage the client to push and assist with
the delivery as follows:
1. Lower the head of the bed and elevate
the client’s hips on a pillow or place the
client in the knee – chest position to
minimize pressure from the cord
2. Assess cord pulsations constantly
3. Gently wrap gauze soaked in sterile
normal saline solution around the
prolapsed cord
• A gloved hand in the vagina pushed fetus
upward and off the cord
If the cord is exposed to the cold air, there
may be reflex constriction of the umbilical
vessels (restricts O2 flow to the fetus)
NURSING DIAGNOSIS
- Risk for Fetal Injury r/t interruption of blood
flow secondary to prolapsed cord
MULTIPLE GESTATION
DEFINITON
- Pregnancies with 2 or more fetuses
- Often end before full term (woman may have
not practiced breathing exercises)
- First stage of labor does not differ greatly
from that of a woman with a single gestation
pregnancy
- Can lead to:
o Anemia
o Gestational HTN
- Most twin pregnancies with both twins in
vertex
- If physician thinks about the risk of delivery
twins normally → opts for cesarean birth as
2nd fetus will have a risk for anoxia
- Physician’s skills are considered
ETIOLOGY/CAUSE
- Can happen randomly
- Family history of twins, triplets or more
ASSESSMENT FINDINGS
• Hematocrit level
• Blood pressure
RISK FACTORS
• In vitro fertilization
TYPES
• Fraternal twins
o 2 separate eggs are fertilized and
implanted in the uterus
o Babies are siblings who share the
same uterus
o May look different and may either be
the same gender or not
o Statistically the lowest risk of all
• Identical twins
o A single fertilized egg is split in half
o Each half embryo is genetically
identical so babies share the same
DNA thus sharing the same
characteristics
o May share the same placenta and
amniotic sac or have their own
placenta and amniotic sac
• Triplets and higher order multiples
(HOMs)
o Can be a combination of both
identical and fraternal multiples
In terms of presentation
• Vertex: most common
• Vertex and Breech: 2nd most common
• Breech and Vertex: 3rd most common
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• Breech and Breech: 4th most common o Amniotic fluid index is above 24
cm
SIGNS AND SYMPTOMS o Pockets of fluid large than 8 cm on
- Uterus is larger than expected for the dates ultrasound
in pregnancy - Can lead to:
- Increased morning sickness o Fetal malpresentation
- Increased appetite ▪ Transverse lie
- Excessive weight gain o Premature rupture of membranes
- Fetal movements felt in different parts of ▪ Further leads to:
abdomen at the same time • Infection
• Prolapsed cord
MANAGEMENT • Preterm birth
➢ MEDICAL ETIOLOGY/CAUSE
o Maternal and fetal testing to monitor
the health of the fetuses - Accumulation of amniotic fluid suggests
o More frequent prenatal visits difficulty in fetus’s ability to:
➢ PHARMACOLOGIC o Swallow
o Analgesia o Absorb
o Anesthesia o Excessive urine production
o NO OXYTOCIN: to avoid
CAUSES
compromising circulation of unborn
twin - Gestational diabetes
o Corticosteroid medicines may be - Baby’s urine output
given to help mature the lungs of the - Birth defect that affects baby’s GI tract or
fetuses as lung maturity is a major CNS
problem for premature babies
o Tocolytic medicines may be given if RISK FACTORS
mom experiences preterm labor • Women with diabetes
➢ SURGICAL • Hyperglycemia causes excessive fluid shifts
o Cesarean section into the amniotic space
o NSVD is possible on twins
• Fetus with anencephaly
NURSING INTERVENTIONS
DIAGNOSTIC TEST FINDINGS
- Urge woman to spend early hours of labor
• Ultrasound: to determine pockets of fluid
engaged in activity
o Playing cards TYPES
o Reading to pass time quickly
- Support the woman’s breathing exercises to • Mild hydramnios – cannot cause any
minimize need for analgesia or anesthetic complication and has no symptoms
- Provide physician referrals such as maternal • Severe hydramnios – there is problem with
– fetal medicine specialist for special testing. the fetus
This is to increase the quality care and safety • Oligohydramnios – AFI (amniotic fluid
given to the mother and child intake) less than 7cm or absence of a fluid
- Encourage or increase rest of the client pocket 2 -3 cm in depth
- Increased nutrition especially for mothers
SIGNS AND SYMPTOMS
carrying 2 or more fetuses need more
calories, protein and other nutrients including • Unusually rapid enlargement of the uterus
folic acid. • Extreme shortness of breath (dyspnea)
• Lower extremity varicosities
NURSING DIAGNOSIS
• Hemorrhoids
- Ineffective breathing pattern: dyspnea • Increased weight gain
related to enlarged uterus resulting in
abnormal breathing pattern MANAGEMENT

HYDRAMNIOS ➢ MEDICAL
o CBC test to assess client’s overall
DEFINITON health
o Biophysical profile test to assess the
- Too much amniotic fluid builds up in the
health of a baby
uterus which makes its size become larger
➢ PHARMACOLOGICAL
than normal
o Tocolytic drugs: to slow or halt
- Normal range of amniotic fluid: 500 to 1000
labor, suppression of uterine
mL (at term)
contractions
- Excessive fluids
o Provide Indomethacin (Indocin): a
- Polyhydramnios
medication used to treat arthritis,
o More than 2000 mL
gout, bursitis and tendonitis pain,
 NCM 109: CARE OF MOTHER AND CHILD AT RISK (ACUTE & CHRONIC)
MODULE 1M: INTRAPARTAL COMPLICATIONS
edema, and joint stiffness. This will
assist in lowering fetal urine output
and amniotic fluid volume.
▪ SHOULD NOT BE used after
31 weeks of pregnancy
➢ SURGICAL
o Amnioreduction: to remove some of
the excess fluids or for testing and
treatment
o Needling of membranes: to allow
slow controlled release of fluids
NURSING INTERVENTIONS
- Encourage bed rest
- Encourage high fiber diet
- Suggest a stool softener if diet alone is
ineffective
- Assess vital signs as well as edema in lower
extremities
- Provide close monitoring to the client
- Administration of medication as prescribed
by the physician to facilitate the reduction of
AFV and fetal urine production
NURSING DIAGNOSIS
- Risk for maternal and fetal injury r/t
hydramnios
OCCIPITO – POSTERIOR POSITION
DEFINITON
- Fetal position is posterior rather than anterior
- Occiput is directed diagonally and
posteriorly, either to the right (ROP) or to the
left (LOP)
- Aka: sunny side up baby
- Most common fetal malposition
- The baby is head-down, facing the mother’s
abdomen, and the baby's occipital bone is
against the back of the mother's pelvis. In this
position, the baby’s back is extended along
the mother’s spine and the baby’s chin is
lifted making the head seem larger than it is
because the head measures larger from the
back compared to measuring from the front.
- A posterior presenting head: does not fit the
cervix increases risk for umbilical prolapsed
cord
- If a posteriorly presenting fetus has an
average size, good flexion with forceful
contractions & successful rotation
through the large arc, fetus arrives at a
good birth position:
o Prolonged labor due to greater arc
rotation
o Satisfactory birth with increasing
molding and caput formation
o Increase pressure and pain in
maternal’s lower back as there is a
sacral nerve compression due to
rotation of fetal head against the
sacrum
- If posteriorly presenting fetus has: larger
than average size, bad flexion, impossible
rotation through a 135-degree arc:
o Woman becomes exhausted
o Transverse arrest – fetal head arrest
in transverse position, rotation may
not occur at all
o Fetus must be born by cesarean birth
o Some women are able to pass a
persistent occipito-posterior position
through their pelvis: baby born
“sunny side up” looking up the
ceiling
ETIOLOGY/CAUSE
- Occur in women with android, anthropoid or
contracted pelvis
- Mother is more likely to have a baby in an OP
position at delivery if:
o Primigravid
o 35 years or older
o Obese
o Hand prev. OP delivery
o 41 weeks or more
o Baby weighs 4000g or more
o Placenta attached to the front of
uterus
TYPES
• Right occipito-posterior position
o Most common
o Baby’s head is down and back is at
the right side
• Left occipito-posterior position
o Less common
o Baby is facing forward slightly to the
left or looking toward the mother’s
right thigh
PROCEDURES
Rotation from a posterior position can be aided by:
➢ Non – evidenced: have the woman assume
a hands and knees position, squatting or
lying on her side
o Lunging: swinging her body right to
left while elevating left foot on a chair
to widen the pelvic path and make
fetal rotation easier
▪ not proven to be effective
▪ tiring for women in labor
➢ Epidurals for deliveries: open pelvis, and
reduce total labor time
➢ FHR sounds are heard best at lateral
sides of abdomen: as suggested by
prolonged active phase, arrested descent
SIGNS AND SYMPTOMS
- Posterior baby belly shape: mom has an odd-
looking shape
- Posterior position baby kicks: pregnant
woman might feel the baby’s kicks and
movements more to the front
- Occipito posterior position felt upon
palpation: irregularities or protrusions are
most likely feeling the baby’s front
- Baby’s heartbeat: muffled heartbeat is heard
almost anywhere in the belly
- Posterior baby back pain: when labor starts,
mom usually feel pain in her back
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MANAGEMENT
➢ MEDICAL
o Manual rotation from the OP to
occiput anterior position is performed
o Unmodified Scanzoni maneuver with
simultaneous traction and rotation
o Antepartum Ultrasonography can
help accurately diagnose fetal
malposition
➢ PHARMACOLOGICAL
o Epidurals for their deliveries to help
relieve the intense back pressure and
pain
o Entonox gas or nitrous oxide mixed
with oxygen is given for pain as this
gas allows for mobility to change
positions because it does not stay in
the body very long
➢ SURGICAL
o Cesarean delivery when OP can
cause labor dystocia
o Forceps Assisted Delivery are used
to help fetus rotate but the mother
must be observed closely for
hemorrhage from cervical lacerations
NURSING INTERVENTIONS
If a posteriorly presenting fetus has an average size,
good flexion with forceful contractions & successful
rotation through the large arc, fetus arrives at a good
birth position:
Nursing Interventions:
✓ Apply counterpressure by a back rub to
relieve mother’s back pain
✓ REBOZO method of jiggling and massaging
a uterus is helpful when assisting the fetus to
rotate into a better position
✓ During prolonged labor, be certain woman
void approx. 2 hours as full bladder impedes
the descent of the fetus
✓ Provide oral sports drink or IV glucose
solution to replace glucose stores she is
using to keep active in labor
If posteriorly presenting fetus has: larger than
average size, bad flexion, impossible rotation
through a 135-degree arc:
Nursing Interventions
✓ Provide frequent assurance and support
when women from getting worried during
prolonged labor
✓ If forceps are used to help fetus rotate:
observe woman closely form hemorrhage
from cervical lacerations or infections in the
postpartum period
- Assist mother in forward leaning positions to
help encourage the baby to rotate forward as
well
NURSING DIAGNOSIS
- Risk for maternal and fetal injury r/t occipito
– posterior position
FACE, BREECH, BROW PRESENTATION
FACE PRESENTATION
DEFINITON
- Type of cephalic presentation in which the
presenting component is the mentum (chin)
- Asynclitism – fetal head presenting at a
different angle than expected
CHARACTERISTICS
- Head feels more prominent than normal
- No engagement apparent on Leopold’s
maneuver
- Head and back are both felt on the same side
of the uterus
- Back is difficult to outline because it is
concave
o If back is extremely concave, fetal
heart tones transmitted to the forward
– thrust chest and heard on the side
of the fetus where feet and arms can
be palpated
- Head diameter the fetus presents to the
pelvis is often too large for birth to proceed
ETIOLOGY/CAUSE
- A fetus in posterior position, instead of flexing
the head as a labor proceeds, may extend
the head
Possibly as a result of:
• Contracted pelvis
• Placenta previa
• Relaxed uterus of a multipara
• Prematurity
• Hydramnios
• Fetal malformation
EFFECTS
Newborn Effects:
• Facial edema
• Color of edema: purple from ecchymotic
bruising
• Lip edema is severe – infant unable to suck
for a day or two
TYPES
• Mentum Anterior (MA): chin is facing the
front of the mother and will be the presenting
part of the face.
• Mentum Posterior (M IP): chin is facing the
mother’s back. Baby’s head, neck and
shoulders enter the pelvis at the same time
• Mentum Transverse (MT): baby’s chin is
facing the side of the birth canal.
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SIGNS AND SYMPTOMS
- Fetus facial features (orbital ridges, nose,
malar eminences, mentum, mouth and
gums) and back can be felt during palpations
MANAGEMENT
➢ MEDICAL
o If cesarean delivery is not feasible ff.
maneuvers can be attempted
▪ Maneuver to convert face to
vertex presentation
▪ Rotation maneuver to bring
chin anteriorly
▪ Internal podalic version
➢ PHARMACOLOGICAL
o Oxytocin (Pitocin) may be used with
normal fetus and abnormally slow
progress, as long as FHR patterns
remain reassuring
➢ SURGICAL
o If chin is posterior, cesarean birth is
the method of choice
NURSING INTERVENTIONS
- If chin is anterior and pelvic diameters are
normal infant may be born without difficulty
- Observe infant for patent airway
- Labor management involves monitoring of
FHR and labor course as FHR abnormalities
and prolonged or arrested labor occur more
commonly
BREECH PRESENTATION
DEFINITON
- Fetus in a longitudinal lie with the buttocks or
feet closest to the cervix
- Most fetuses are in breech presentation early
in pregnancy. However, by week 38, a fetus
normally turns to a cephalic presentation
- In breech birth, the same stages of flexion,
descent, internal rotation, expulsion and
external rotation occur as in a vertex birth
CHARACTERISTICS
- FHS are heard high in the abdomen
ETIOLOGY/CAUSE
- Mother had several pregnancies
- Mom had premature birth in the past
- Too much or too little amniotic fluid
- Abnormally shaped uterus
- Placenta previa
EFFECTS & DANGERS
FETAL EFFECTS:
• Developing dysplasia of the hip
• Anoxia from a prolapsed cord
• Traumatic injury to the aftercoming head (a
possibility of intracranial hemorrhage or
anoxia)
• Fracture of the spine or arm
• Dysfunctional labor
• Early rupture of the membranes because of
the poor fit of the presenting part
DANGERS:
• Birth of the head: umbilicus precedes the
head; a loop of cord passes down alongside
the head. The pressure of the head against
the pelvic brim automatically compresses
this loop of cord
• Intracranial hemorrhage: if infant is born
suddenly to reduce the duration of the cord
compression
• Hypoxia: if infant is born gradually to
reduce the possibility of intracranial injury
• Tentorial tears
AFTER BIRTH
• Frank Breech Presentation: Infant tends to
keep his or her legs extended and at the level
of the face for the first 2 or 3 days of life
• Footling Breech Presentation: tend to
keep the legs extended in a footling position
for the first few days
TYPES
• Frank Breech: buttocks are in place to come
out first during delivery. Legs are straight up
in front of the body, with the feet near the
head.
o most common type of breech
• Complete Breech: buttocks are down near
the birth canal. Knees are bent, and feet are
near the buttocks
• Footling Breech: one leg or both legs are
stretched out below the buttocks. Leg or legs
are in place to come out first during delivery
SIGNS AND SYMPTOMS
- Subcostal tenderness
- Ballotable head in the fundal area
- Softer irregular mass in the pelvis
- Fetal heartbeat loudest above the umbilicus
MANAGEMENT
➢ MEDICAL
o External cephalic version is done to
turn a fetus from breech or transverse
to a vertex position before labor
begins
➢ SURGICAL
o Planned cesarean birth is the usual
method of birth because of difficulty
with birth of the head
▪ But its hazardous to a fetus
(risk for displacing of hips)
and traumatic injury
NURSING INTERVENTIONS
- Monitor FHR and uterine contractions
BROW PRESENTATION
DEFINITON
- The chin untucked, and the neck is extended
slightly backward
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- Similar to face presentation except, the neck RISK FACTORS

is less extended
Women with these following conditions:
- Suggests the brow (forehead) is the part that
is situated to go through the pelvis first • Pendulous abdomen
ETIOLOGY/CAUSE • Uterine fibroid tumors that obstruct the lower
uterine segment
- Multipara • Contraction of the pelvic brim
- Woman with a relaxed abdominal muscle • Congenital anomalies of the uterus
- Obstructed labor • Hydramnios
EFFECTS TYPES
NEWBORN EFFECTS: • Left Shoulder Presentation: baby’s left
• Extreme ecchymotic bruising on the face shoulder faces the birth canal
o Dangerous for cord prolapse
TYPES • Right Shoulder Presentation: baby’s right
shoulder faces the bottom of the uterus
• Transient Brow: during conversion of vertex
• Back Down Presentation: baby lies on her
to face
back with neither shoulder facing in the
• Persistent Brow: only extremely rare that
direction of the birth canal
will happen
o Impossible for labor since there is no
SIGNS AND SYMPTOMS way the baby can exit

- Fetus’ facial features (anterior fontanelle and SIGNS AND SYMPTOMS

face) can be palpated except for the mouth
and the chin
MANAGEMENT
➢ SURGICAL
o Cesarean birth is performed to deliver
infant safely
NURSING INTERVENTIONS
- Labor management involves monitoring of
FHR and labor course as FHR abnormalities
and prolonged or arrested labor occur more
commonly
NURSING DIAGNOSIS
- Risk for fetal injury r/t fetal malpresentation
(delivery through breech presentation)
TRANSVERSE LIE
DEFINITON
- Baby lies horizontally
CHARACTERISTICS:
- Ovoid of the uterus is found to be more
horizontal than vertical (can be confirmed by
Leopold’s maneuver)
- Membranes rupture at the beginning of labor
- No firm presenting part
- Cord or arm may prolapse
- Shoulder may obstruct the cervix
ETIOLOGY/CAUSE
- Infants with hydrocephalus
- Abnormality that prevents the head from
engaging
- Multiple gestation (2nd twin)
- Short umbilical cord
- Prematurity if the infant has room for free
movement
- Intense back pain in labor
- Dysfunctional labor pattern
MANAGEMENT
➢ PHARMACOLOGICAL
o ASA recommends spinal block or
epidural for most cesarean births so
that the infant receives little
medication and woman may still
actively participate in the delivery
➢ SURGICAL
o Cesarean birth may necessary
NURSING INTERVENTIONS
- Assess FHR manually or electronically
- Note frequency of uterine contractions. Notify
physician if the frequency is 2 mins or less
- Identify maternal factors such as
dehydration, acidosis, anxiety or vena caval
syndrome
- Monitor fetal descent in the birth canal in
relation to ischial spines
- Assess for the deep, transverse arrest of the
fetal head
- Note color and amount of amniotic fluid when
membrane rupture
- Observe for visible cord prolapse when
membranes rupture and occult cord prolapse
as indicated
May do:
- Leopold’s maneuver to confirm abdominal
presentation
- Ultrasound for pelvic size
NURSING DIAGNOSIS
- Anxiety r/t perceived threats to self and
wellbeing of the fetus
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MACROSOMIA - Assess for symmetry of mouth while crying

- Erb – Duchenne palsy: Assess for adduction
DEFINITON
of the affected arm with internal rotation and
- Neonate is born larger than the average for elbow extension
their gestational age - Klumpke paralysis: Assess for absent grasp
- Oversized fetus on the affected side.
- Size may become a problem in a fetus who - Assess for respiratory distress w/ diminished
weighs more than 4000 to 4500 g (approx. 9 breath sounds
– 10 lbs.) - Provide pulmonary hygiene to avoid
- Most are born due to women who enter pneumonia during recovery phase
pregnancy with diabetes or develop - Prepare client for intensive intrapartum
gestational diabetes and also associated assessment
with multiparity
NURSING DIAGNOSIS
ETIOLOGY/CAUSE
- Risk for maternal injury r/t delivery of baby
- Gestational diabetes with macrosomia
- Maternal obesity SHOULDER DYSTOCIA
- Genetics
- Post – term pregnancy DEFINITON
- Mother with history of macrosomia
- Happens when one or both of a baby’s
- Maternal age
shoulders get stuck inside the mother’s
EFFECTS pelvis during labor and birth
- Anterior shoulder of the baby is unable to
MATERNAL EFFECTS:
pass under the maternal public arch
• Uterine dysfunction during labor or birth - Occurs at the second stage of labor when
because of overstretching of the fibers of the the fetal head is born but the shoulders are
myometrium too broad to enter and be born through the
• Uterine rupture from obstruction pelvic outlet
• Increased risk of hemorrhage during - It is not identified until the head has already
postpartal period because of the been born and the wide anterior shoulder
overdistended uterus may not contract as locks beneath the symphysis pubis
readily as usual ETIOLOGY/CAUSE & PATHOPHYSIOLOGY
• Perineal lacerations
- Advanced maternal age
FETAL EFFECTS: - Diabetes maternal obesity
- Large baby (macrosomia)
• Fetal pelvic disproportion
- Postdate pregnancy
NEWBORN EFFECTS IF BORN VAGINALLY - Multiparity

• Cervical nerve palsy PATHOPHYSIOLOGY

• Diaphragmatic nerve injury
- The plane of the fetal shoulder aligns
• Fractured clavicle perpendicular to the pubis instead of at an
SIGNS AND SYMPTOMS angle. This causes the shoulder to become
wedged under the pubic arch
- Fundal height is higher than 42 cm
- Biparietal diameter is higher than 10 cm EFFECTS
- Excessive abdominal fluid MATERNAL EFFECTS
MANAGEMENT
• Vaginal tears
➢ MEDICAL • Cervical tears
o Antenatal testing to monitor baby’s
FETAL EFFECTS
well – being
o Ultrasound to take measurements of • Cord is compressed between the fetal body
parts of the baby’s body and the bony pelvis
➢ SURGICAL • Fractured clavicle (result of forced birth)
o Infant is oversized, and cannot be • Brachial plexus injury (result of forced birth
born via vaginal delivery so cesarean
birth is the method of choice ASSESSMENT FINDINGS

NURSING INTERVENTIONS - Birth process may seem unnecessarily

- Continuous fetal monitoring is labor is
allowed to progress
- Assess the infant for crepitus, hematoma or
deformity over the clavicle, and asymmetrical
if absent
prolonged
- Fetal head retracts against the mother’s
perineum as soon as the head is delivered
(turtle sign)
- External rotation does not occur
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- Second stage of labor is prolonged •

Relieves obstruction
- There is arrest of descent ▪ A - Apply suprapubic
- Head appears on the perineum (crowning) pressure and Anterior
shoulder disimpaction or do
PROCEDURES
Rubin maneuver
MANEUVERS • Downwards and
laterally
• McRoberts Maneuver: least invasive ▪ R - Release posterior
maneuver to disimpact the shoulders. shoulder
Position the patient in the extreme lithotomy • Deliver arm or if not
position with the hips completely flexed (knee then shoulder
– chest position); this may free the anterior ▪ M - Maneuver of Woods
fetal shoulder (Screw maneuver)
1. Place the client in McRoberts Maneuver ▪ E - Episiotomy
(i.e., thighs pulled up against the abdomen ▪ R - Roll onto all fours (hands
with hips abducted). on knees)
o The woman flexes her thighs sharply o Last resort options (fetal and
against her abdomen this is to widen maternal morbidity): fracture the
the pelvic outlet and allow the anterior clavicle of the fetus and Zavanelli
shoulder to be born maneuver
o A supported squat has a similar effect ➢ SURGICAL
and adds gravity to her pushing o Episiotomy
efforts o Cesarean section
2. Apply suprapubic measure by an
assistant pushes the fetal anterior NURSING INTERVENTIONS
shoulder downward to displace it from
- Assist the patient to flex her thighs sharply on
above the mother’s symphysis pubis.
her abdomen to widen the pelvic outlet to
Fundal pressure should not be used,
allow the anterior shoulder of the fetus to be
because it will push the anterior shoulder
born
more firmly against the mother’s
- Teach mothers about optimal weight gain in
symphysis
pregnancy and assist mothers with diabetes
o Helps shoulder escape from beneath
to prevent hyperglycemia through diet
the symphysis pubis and be born
management and medication use
• Moderate Suprapubic Pressure: Often
- Mnemonics: BE CAEM
disimpact the anterior shoulder. Desperate
o Breath, do not push; lower head of
traction on the fetal head is not likely to
bed
facilitate delivery and might lead to trauma,
o Elevate legs, into McRoberts position
delivery of an infant with shoulder dystocia
– sharp hip flexion while in supine
often results in fracture of the clavicle or
position
humerus to accomplish delivery
o Call for help
• Rubin Maneuver
o Apply suprapubic pressure –
o Inserting fingers and rotating the fetal
downward & lateral to release
shoulder toward the fetal chest (to
anterior shoulder
adduct fetal shoulder girdle)
o Enlarge vaginal opening with
• Woods Corkscrew Maneuver episiotomy to facilitate extra
o Physician pushes on posterior maneuvers
shoulder to release anterior shoulder o Maneuvers
• Zavenelli Maneuver ▪ Delivery of posterior arm
o Flexing fetal head and pushing ▪ Pressure against baby’s
baby’s head back into the vagina posterior shoulder either
SIGNS AND SYMPTOMS anteriorly or posteriorly &
anterior rotation (Woods
- Second stage of labor is prolonged corkscrew or Rubin
- Shoulder lock beneath symphysis pubis maneuver)
- Infant’s head will protrude but their body ▪ Mother on hands & knees –
retracts with each contraction “all fours” (Gaskin maneuver)
MANAGEMENT ▪ Replacement of baby’s head
to vagina followed by
➢ MEDICAL cesarean delivery (Zavanelli
o ALARMER mnemonic maneuver)
▪ A - Ask for help
NURSING DIAGNOSIS
• Call staff
▪ L - Legs hyperflexed - Risk for maternal injury r/t shoulder dystocia
(McRoberts maneuver)
• Patient legs go all the
way back
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INLET CONTRACTION ➢ SURGICAL

o Cesarean section if there is failed trial
DEFINITON
of labor
- Narrowing of the anteroposterior diameter to
NURSING INTERVENTIONS
less than 11 cm or of the transverse diameter
to 12 cm or less - For primigravida: pelvic measurements
should be taken and recorded before week
ETIOLOGY/CAUSE
24 of pregnancy
CAUSES - If CPD exist, because fetus is “floating” the
possibility of cord prolapse can lead to a
• Rickets (lack of calcium) secondary concern
• Inherited small pelvis - Assess uterine contractile pattern manually
(palpation) or electronically
ASSESSMENT FINDINGS
- Evaluate current level of maternal fatigue/
NORMAL CONDITIONS emotional stress
- Observe nay signs of infection
✓ Primigravids - Monitor v/s
o Fetal head – engages between 36 to - Evaluate the degree of hydration
38 weeks. If it occurs before labor - Place client in a lateral recumbent position
begins, this means that pelvic inlet is and encourage bed rest
adequate as lightening (fetal head - Prepare a client for amniotomy and assist
has sunk below the inlet) with the procedure when indicated
o Fetal head engages or fits into the
pelvic brim. This means that fetal NURSING DIAGNOSIS
head will be able to pass through the
- Risk for fetal injury r/t abnormalities of the
midpelvis and outlet
maternal pelvis
✓ Multigravids
o Engagement does not occur until OUTLET CONTRACTION
labor begins
DEFINITON
ABNORMAL CONDITIONS
- Narrowing of the transverse diameter at the
✓ Primigravids outlet less than 11 cm
o Engagement does not occur - Transverse diameter: distance between
o Because of: ischial tuberosities at the outlet
▪ Fetal abnormality (larger than o This measurement is made by
usual head) manually at a prenatal visit or at the
▪ Pelvic abnormality (smaller beginning at the labor
than usual pelvis)
ETIOLOGY/CAUSE
SIGNS AND SYMPTOMS
- Shape, classifications and clinical
MOTHER assessment of the adult female pelvis are the
starting points for the etiology and diagnosis
- Abnormal uterine contraction
of pelvic abnormalities
- Positive Vasten’s sign (disproportion
between fetal head and symphysis pubis is SIGNS AND SYMPTOMS
prominent)
- Urinary bladder compression SIGNS
- Edema of the cervix and vaginal wall - Leakage of urine
- Overextension of lower uterine segment - Visible bulge out of the vagina
FETUS SYMPTOMS
- Failure of engagement - Fecal incontinence
- Increase in malposition - Feeling of a bulge out of the vagina
- Extreme molding - Lower back pains or feeling of pressure in the
- Formation of a large caput succedaneum pelvis
- Asynclitism - Sensation of fullness
MANAGEMENT - Urinary incontinence
- Urinary retention
➢ MEDICAL
o Obstetric partogram MANAGEMENT
o Labor augmentation w/ amniotomy ➢ MEDICAL
and oxytocin infusion o Clinical pelvimetry
➢ PHARMACOLOGICAL o Examination of the pelvic size and
o Oxytocin to stimulate labor shape for evidence of pelvic
contraction
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➢ PHARMACOLOGICAL NURSING INTERVENTIONS

o Oxytocin stimulates the uterine
- Monitor baseline v/s, particularly BP and
muscles to contract while also
uterine contractions to manage patient’s
increasing the production of
labor
prostaglandins which help increase
- When patient begins to bleed, assist her in a
the contractions even more
side lying position
➢ SURGICAL
o Cesarean delivery NURSING DIAGNOSIS
NURSING INTERVENTIONS - Ineffective tissue perfusion r/t excessive
blood loss secondary to premature
- Examine maternal outlet thoroughly, paying
separation of the placenta
special attention to the angle of the pubic
arch and the distance between the ischial PLACENTA CIRCUMVALATA
tuberosities
- Kegel exercise can help relieve symptoms DEFINITON
and manage patients who are asymptomatic - Fetal side of the placenta is covered to some
NURSING DIAGNOSIS extent with chorion
- Normally, chorion membrane begins at the
- Risk for impaired fetal gas exchange r/t edge of the placenta and spreads to envelop
placental insufficiency the fetus
PLACENTA SUCCENTURIATA o No chorion covers the fetal side of the
placenta → normal
DEFINITON
CHARACTERISTICS
- Placenta has one or more accessory lobes
connected to the main placenta by blood • Umbilical cord enters the placenta at the
vessels usual midpoint
- No fetal abnormality • Large vessels spread out from there
- A morphological abnormality of the placenta Placenta Marginata – fold of chorion reaches just to
where 1 or more lobes are present outside the edge of the placenta
the placental body
EFFECTS
ETIOLOGY/CAUSE
- Placenta will not loosen and deliver
- Accessory love of placenta is formed by non
– involution of the chorionic villi, meaning ETIOLOGY/CAUSE
some of the chorionic villi fial to disappear
- No known cause and there does not seem to
- Chorionic villi arise from embryonic
be anything that a woman can do to stop a
membrane (chorion)
placenta circumvalata from forming
- Disc shape of the placenta is due to the result
- However, the ff. increases the risk of certain
of remodeling of placental tissue during its
pregnancy complications
growth → some chorionic villi disappear,
o Low birth weight
leaving behind a disc – shaped placenta
o Placental abruption
EFFECTS o Oligohydramnios
o Miscarriage and preterm birth
MATERNAL EFFECTS
SIGNS AND SYMPTOMS
• Severe maternal hemorrhage because of the
retained small lobes - Retarded fetus growth
- Vaginal bleeding
ASSESSMENT FINDINGS - Premature rupture of membranes (PROM)
CHARACTERISTICS UPON INSPECTION MANAGEMENT
• Placenta appears torn at the edge ➢ MEDICAL
• Torn blood vessels extend beyond the edge o Amnioinfusion to treat
of the placenta oligohydramnios caused by
circumvallate placenta
SIGNS AND SYMPTOMS
o Early delivery
- No specific signs and symptoms associated o Ultrasound
with accessory lobe of placenta as they are ➢ PHARMACOLOGICAL
found during a routine ultrasound o IV fluids to the mother to increase
examination blood pressure and prevent too much
blood loss
MANAGEMENT
➢ SURGICAL ➢ SURGICAL
o Remaining lobes are manually o Cesarean section
removed from the uterus o Cervical cerclage
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MODULE 1M: INTRAPARTAL COMPLICATIONS

NURSING INTERVENTIONS MANAGEMENT

- Advice mom to have healthy lifestyle and to ➢ MEDICAL
have a well – balanced diet o MRI to aid in the visualization of
- Encourage mother to see doctor early and critical components required to
regularly successfully diagnose
- Advice mom to stop smoking, drinking, and o Ultrasound to allow the healthcare
intaking any other substance that could provider visualize the depth of the
potentially hard and interfere with baby’s placenta in the uterine wall
growth ➢ SURGICAL
- Advice mom to avoid stressful activities o Hysterectomy
- Monitor v/s o Cesarean section
➢ PHARMACOLOGICAL
NURSING DIAGNOSIS
o Methotrexate and Mifepristone to
- Deficient fluid volume: increased pulse rate, remove the still attached tissue while
and decreased BP r/t placental abruption leaving the uterus intact

PLACENTA ACCRETA NURSING INTERVENTIONS

DEFINITON - Do not attempt to remove manually because

it could lead to extreme hemorrhage
- Unusually deep attachment of the placenta to - Explain the side effects of hysterectomy well
the uterine myometrium to the point that the - Prepare the patient for C- section or
placenta will not loosen or deliver hysterectomy
- Removal possess risk to extreme - If patient is prescribed by Methotrexate,
hemorrhage due to the deep attachment of instruct them to drink at least 2L of fluid per
the placenta day to counteract the drug’s uric acid
ETIOLOGY/CAUSE formation
- Provide emotional and physical support to
- Suggested to be related to abnormalities in the patient
the lining of the uterus
- Factor that may increase the risk of placenta NURSING DIAGNOSIS
accrete includes: - Fear r/t pregnancy outcomes secondary to
o Prev. uterine surgery placenta accreta
o Placental position
o Maternal age (more common for BATTLEDORE PLACENTA
moms past age 35)
DEFINITON
o Number of childbirths
- Cord is inserted marginally rather than
TYPES
centrally
• Placenta Accreta - Attachment can be 2cm off the edge of the
o Causes no symptoms placenta
o Vaginal bleeding at 3rd trimester may - Rare anomaly and has no known clinical
be related significance
o Uses Ultrasound to detect ETIOLOGY/CAUSE
• Placenta Increta
o Placenta is more deeply embedded in - Multiple pregnancy
the uterine wall
SIGNS AND SYMPTOMS
o It is still not passing through the wall,
but is firmly attached to the uterine - Vaginal bleeding
muscle - Slow FHR
• Placenta Percreta - Umbilical cord is within 2cm from the
o Occurs when the placenta passes placental margin
through the uterine wall - Darker fetal blood
o Placenta has the potential to grow
through the uterus and affect other MANAGEMENT
organs ➢ MEDICAL
o Most severe type o Early delivery as recommended
SIGNS AND SYMPTOMS o MRI to diagnose Battledore placenta
o Ultrasound to visualize the location of
- Causes no symptoms the umbilical cord
- Vaginal bleeding at 3rd trimester may be ➢ SURGICAL
related o Perform cesarean hysterectomy:
- Detected through ultrasound hysterectomy reduces the risk of
hemorrhage and the safest option for
the mother
 NCM 109: CARE OF MOTHER AND CHILD AT RISK (ACUTE & CHRONIC)
MODULE 1M: INTRAPARTAL COMPLICATIONS
NURSING INTERVENTIONS
- Assess fetal heart tone (fetal anoxia)
- Assist in the provision of prompt treatment
and interventions
- Get ready for a D&C (Dilation & Curettage)
or a hysterectomy
- Provide physical and emotional support to
the client and family members
NURSING DIAGNOSIS
- Risk for fetal injury r/t intrauterine growth
restriction
VASA PREAVIA
DEFINITON
- Some of the blood vessels that connect the
umbilical cord to the placenta lie over or near
the entrance to the birth canal
- Umbilical vessels of a velamentous cord
insertion cross the cervical OS
- Delivers before the fetus
Characteristics is similar with placenta previa
- Cervix tears upon cervical dilation
- Sudden painless bleeding occurs with the
beginning of cervical dilation
ETIOLOGY/CAUSE
- Placenta previa
- Low lying placenta
- Previous CS
- Velamentous insertion of cord
o Umbilical cord inserts into the
amniotic sac instead of the placenta
- In vitro
- Multiple pregnancy
- Bilobed, multilobed or succenturiate placenta
o Vasa previa happens if the blood
vessels that run between these lobes
end up lying against the cervix
TYPES
- Low lying placenta: placenta implants in the
lower portion instead of the upper portion of
the uterus
- Marginal implantation: placenta’s edge is
nearing the cervical OS
- Partial placenta previa: portion of the
cervical OS is already covered by the
placenta
- Total placenta previa: the placenta
occludes the entire cervical OS
SIGNS AND SYMPTOMS
- Sudden painless bleeding
- Rupture of membranes
- Fetal bradycardia
- Bright red bleeding
MANAGEMENT
➢ MEDICAL
o IV therapy to replace the blood that
was lost during bleeding
o Avoiding vaginal examinations
Attach external monitoring equipment
o
to monitor uterine contractions and
record fetal heart sounds
➢ PHARMACOLOGICAL
o Antenatal corticosteroids:
administered 48 hours before a
scheduled C-section at less than 37
weeks of gestation
o Betamethasone and
Dexamethasone: most extensively
researched corticosteroids that are
generally preferred for antenatal
treatment to hasted fetal organ
maturation
➢ SURGICAL
o Infants needs to be born by cesarean
birth
NURSING INTERVENTIONS
- Identify structures before inserting any
instrument such as internal heart monitor to
prevent accidental tearing of vasa previa as
this could result in sudden fetal blood loss
- Assess baseline v/s esp. BP
- Assess fetal heart sounds to monitor
wellbeing of the fetus
- Monitor uterine contractions to establish the
progress of labor of the mother
- Weigh perineal pads used during bleeding to
calculate the amount of blood lost
- Assist woman in a side lying position when
bleeding occurs
NURSING DIAGNOSIS
- Deficient fluid volume r/t active blood loss
secondary to disrupted placental
implantation
TWO – VESSEL CORD
DEFINITON
- A variation of umbilical cord anatomy in
which 1 artery in the umbilical cord is missing
- NORMAL CORD: AVA: 2 arteries 1 vein
- ABNORMAL CORD: absence of one of the
umbilical arteries
ETIOLOGY/CAUSE
CAUSES → largely unknown
- Congenital heart and kidney anomalies
because the insult that caused the loss of the
vessel may have affected other mesoderm
germ layer structures as well
THEORIES PROPOSED TO EXPLAIN THE
DEVELOPMENT OF 2 – VESSEL CORDS
- Secondary atresia or atrophy of prev. normal
umbilical artery
- Regression of performed artery
- Primary agenesis of one of the umbilical
arteries
- Persistence of the original allontoic artery of
the body stalk
- Congenital heart and kidney anomalies
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MODULE 1M: INTRAPARTAL COMPLICATIONS

RISK FACTORS UNUSUAL CORD LENGTH

- Caucasian women DEFINITON
- People diagnosed with diabetes
- Longer or shorter than 55 cm or 20 inches
- Advanced maternal age
- Unusually short umbilical cord (< 35 cm) can
- Multiparity
result in premature separation of the
- Being pregnant with a girl
placenta or abnormal fetal lie
- Taking medications that may affect the fetal
- Unusually long umbilical cord (> 100cm) may
growth
be easily compromised because of its
- Hypertension/ toxemia
tendency to twist or knot
- Antepartum hemorrhage
- Poly/oligo hydramnios ETIOLOGY/CAUSE
TYPES SHORT UMBILICAL LONG UMBILICAL
CORD CORD
TYPE # of CONSISTS FREQUENCY
- Premature - Fetal activity
PATENT OF
separation of pulls on the cord
VESSELS
the placenta and stretches it
I 2 1 UA Common
- Abnormal fetal out
(allantoic)
lie
and left UV
II 2 1 UA Rare
COMPLICATIONS
(vitelline)
and left UV SHORT UMBILICAL LONG UMBILICAL
III 3 1 UA and Very rare CORD CORD
both UV - Fetal movement - Easily
IV 2 1 UA and Very rare disorder compromised
right UV - Intrauterine because of its
constraint tendency to
SIGNS AND SYMPTOMS - Abruptio twist or knot
placenta
- No s/s but typically occurs during routine 2nd
trimester ultrasound, done between 18 and
TYPES
22 weeks of pregnancy
SHORT UMBILICAL LONG UMBILICAL
MANAGEMENT CORD CORD
➢ MEDICAL - If umbilical cord - Can increase
o Micturating cystourethrogram as a is less than 35 the risk of
small proportion of infants with VUR cm at term serious labor
- Others consider and delivery
will have a normal renal ultrasound
40 – 45 cm to be issues
o Thorough antenatal scan and fetal short
echocardiogram - If cord is short,
o Consider chromosome analysis baby might not
➢ PHARMACOLOGICAL be moving or
o Avoid medications like Phenytoin growing enough
because they interfere with fetal signaling a
growth and be harmful to the potential health
developing fetus issue
➢ SURGICAL
o Advised to deliver baby via Cesarean SIGNS AND SYMPTOMS
section
SHORT UMBILICAL LONG UMBILICAL
NURSING INTERVENTIONS CORD CORD
- Decreased - Obstruction of
- Observe infant carefully for other anomalies blood flow to blood flow
- Inspect cord immediately after birth fetus - Compression of
- Educate mother - Non-reassuring the umbilical
- Encourage mother to verbalize feelings fetal heart rate cord
- Deep breathing exercises - Fetal distress
- CORD INSPECTION AFTER BIRTH - Decreased FHT
o Must be made immediately after birth
o Inspect cord before the cord begins to MANAGEMENT
dry because drying distorts the ➢ MEDICAL
appearance of the vessels o Ultrasound
NURSING DIAGNOSIS ➢ PHARMACOLOGICAL
o Tocolysis is an obstetrical procedure
- Preterm birth may be r/t the fetus with a that uses medications to delay the
known birth defect as evidenced by the delivery of fetus
thinning out and opening of the cervix
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MODULE 1M: INTRAPARTAL COMPLICATIONS

➢ SURGICAL
o Safe vaginal delivery may be possible
but if umbilical cord complications is
present, emergency cesarean
section is done
NURSING INTERVENTIONS
- Oxygen therapy
- Left side lying position
- Monitor FHT
- Monitor fetal position and pay attention to
any signs of fetal distress
NURSING DIAGNOSIS

• Impaired gas exchange: low FHT r/t cord coil