Nursing Care of the High-Risk Client
during Labor and Delivery
4P’s-passage, passenger, power,
psyche
--All 4P’s should work in synchronicity
to make a successful vaginal delivery
--Labor and delivery pains is like being
burned alive
Review of the 4Ps
 “The Need to Sync your Body,
your Baby and Your Mind”
 These 4 components to the birth
process are: the passageway
(pelvis), the passenger, the power
and the psyche.
 All of these must work together in
synchronicity to achieve a occiput-posterior, it will not easy for the
successful, vaginal birth.
I. Problems of the Passenger
A. Fetal Malposition
-fetal malposition occurs when the
occiput of fetus is not oriented anteriorly
in the maternal pelvis
*Occiput Posterior (OP)
• The BACK of baby’s head is closest
to your back
*Occiput Anterior (OA) (Ideal)
• The BACK of baby’s head is closest
to your front
*Left or Right
*Occiput, Sacrum, Transverse, Mentum,
Brow
*Anterior or Posterior
*LOA or ROA – Ideal
Positions of Baby during Birth
 Ideally for labor, the baby is
positioned head-down, facing the
mother’s back, with the chin tucked
to its chest and the back of the head
ready to enter the pelvis.
*Cardinal Movement of Labor
---engagement, descent, flexion, internal
rotation, extension, external rotation,
and expulsion
 The labor is prolonged because the
fetus rotate a longer distance to
reach the symphysis pubis with the
mother experiencing much back
pain due to the pressure exerted by
the fetal head as it moves against the
sacrum.
*With an OP there is deflexion of the
baby’s head and so there is a larger
diameter to stretch the vaginal entrance
*With those cardinal movements doing
the cardinal movements presenting
occiput-anterior
*The baby will do the extension at
baby to do the cardinal movements
Ideal: ROA or LOA (Left or Right occiput
anterior)
Nursing Care Management
 Applying heat or cold
 Lying on her side opposite the
fetal back
 Maintain a hand and knees
position may help rotate the fetus
 Voids every 2 hrs = bec a full
bladder could impede descent of
the fetus
 During labor, she may need an
oral sports drink or IV glucose to
replace glucose stores used for
energy.
 Advise mother to change position
frequently to relieve pain
 Back rub
 Apply sacral pressure during
contractions
*Target goal is to minimize the pain and
prevent distress to the baby
*Applying heat or cold (sacrum part)
*Alleviate pain – Alternate heat or cold
(Lower back - sacrum)
*Prevent the baby from distress
*LOA – Lie on right; ROA – Lie of left
*Splint the sacrum (Apply pressure
during contraction (Ire))
Fetal Malpresentation
--occurs when the fetal presenting part
is other than the vertex
a. Breech Presentation
- most common malpresentation;
buttocks or feet of fetus are fetal
presenting part
*Frank breech - hips flexed and legs
extended over anterior surface of body
*Complete breech - feet presenting but
flexed hips and knees/Indian Position
*Footling breech---danger is the airway
of the baby is still inside
Causes
 Abnormality in a fetus such as:
-Anencephaly, Hydrocephalus,
Meningocele
-Hydramnios
 Any space occupying mass in the
pelvis that does not allow the fetal
head to present
 Pendulous
 Multiple gestation
* Mass – tumor, placenta,
*If the belly hangs over the pubic bone
(known as pendulous belly), the angle of
the baby will not be aligned with the
pelvic inlet.
*Multiple gestation – baby can rotate
cause of bigger space
Assessment
 FHT are heard high in the
abdomen
 Leopold’s and vaginal exam may
reveal the presentation
 If presentation is unclear --- UTZ
to confirm
 Always monitor FHR and uterine
contractions = allows detection of
fetal distress from a complication
such as prolapsed umbilical cord.
—cord will be out at the pwerta of
the mommy it will caused distress
*Fetal tachycardia/distress
*Cord loop can happen in cephalic
presentation, 2nd trimester
*Faster dilatation, complete effacement
but progression to engagement is slow
(Amniotomy—ruptured amniotic sac by
healthcare professionals)
*Prolapsed cord – Compressed – Distress
• Cover with saline or wet gauze for it
to not dry off
*Cord loop – tachycardia (can happen in
2nd and 3rd trimester) as long as no fetal
distress can deliver vaginally
*Amniotomy – rupture the amniotic sac
to induce labor
b. Vertex Malpresentation
--fetus is cephalic presenting but the
fetal neck is extended so that the fetal
brow or face present rather than the
vertex
1.Brow presentation
 brow presentation occurs when
the fetal head is partially
extended
 Occur in multipara/women with
relaxed abdominal muscles.
 Results in Obstructed labor
*Vertex Malpresentation
--The problem here is the fetal attitude—
degree of flexion or extension to the
pelvis of the mother
-Occiput presenting—good attitude
-Sitting straight—moderate
attitude/Military attitude
-Dystocia—prolonged and difficult labor
* The fetal attitude describes the
position of the parts of your baby's
body. The normal fetal attitude is
commonly called the fetal position. The
head is tucked down to the chest. The
arms and legs are drawn in towards the
center of the chest.
2. Face/Chin Presentation
-face presentation occurs when the fetal
head is completely extended
-Results of chin /face presentation:  If the fetal lie is abnormal, an
 Facial edema external cephalic version (ECV)
 Ecchymosis can be attempted – ideally
 Lip edema between 36- and 38-weeks
*Educate the mother that it will subside gestation.
as days go by  ECV is the manipulation of the
fetus to a cephalic presentation
C. ABNORMAL through the maternal abdomen.
FETAL LIE * External Cephalic Version
1. Transverse/oblique lie -can be attempted
- a position where the baby is lying -Ideally between 36- and 38-weeks
sideways with head to one of the sides gestation
and bottom at the other side. This -Manipulation of the fetus to a cephalic
position is considered normal before 26 presentation through the maternal
gestational weeks. abdomen
-There is a chance of cord loop in doing
* Fetal lie refers to the relationship the ECV
between the longitudinal axis of the baby -When the mother did not void
with respect to the longitudinal axis of possibility of Urinary bladder rupture
the mother (longitudinal lie, transverse -Usually, the doctor ordered tocolytic
lie, oblique lie). Most babies present with drugs to prevent uterine contractions
the crown of the head at the cervix which is the opposite of oxytocin
(vertex presentation). because the uterus should be relaxed
*Relationship of Spines of baby and before doing the ECV
mother, Parallel (Longitudinal lie - --Cord loop may happen when it is not
Normal); Plus/Perpendicular properly timed that leads to distress of
(Transverse lie - Abnormal) the baby
*Normal during 2nd trimester * ECV technique – Filled bladder for
easier lift in the fetal breech from the
Risk Factors: maternal pelvis (Video)
 Prematurity Piliteri book – Not filled bladder (Empty
 Multiple pregnancy bladder); Discomfort and urinary
 Uterine abnormalities (e.g bladder rupture if filled
fibroids, partial septate uterus) • Manual manipulation to make the
 Placenta previa fetal lie of the baby ideal
 Primiparity • IV injection of Tocolytics (prevent
How to Identify: contraction) (painful if there is
 Can be detected by LM and contraction; uterus should be
confirm by UTZ relaxed)
• Warm Ultrasound gel is applied to
* Primiparity – especially too young the abdomen
• Two Obstetricians perform the ECV
Complications: o One focuses on the fetal
 A mature fetus can’t be delivered head, other on the breech
vaginally from this o First OB identifies the fetal
presentation=CS o Relax and deep breaths for
 Ruptured membranes The cord, the mother
arm may prolapsed o Exhale – the other OB tries to
 Shoulders may obstruct the lift the breech out of the
cervix
 pelvis, holds the baby’s
buttocks and stabilize the
position
o First OB manipulate the
head in a pull movement in
the turning direction
▪ Movements are
consecutive to prevent
pressure to the fetus
and not simultaneous
▪ FHT and progression
of the attempt are
monitored in an UTZ
o After 45 degree turn, grip in
the fetal path is lost in the
pull movement, a change of
hands into a push movement
is made
o Same for buttocks push
movement
o Registered by the nurse, for
scientific analysis
o Possibility of cord loop – fetal
distress
▪ Monitor fetal FHR
▪ Stop when there is
tachycardia
D. OVERSIZED FETUS (FETAL
MACROSOMIA)
 a newborn who's much larger
than average. A baby who is
diagnosed as having fetal
macrosomia weighs more than 8
pounds, 13 ounces (4,000 grams),
regardless of his or her
gestational age.
Symptoms
 Large fundal height. A larger
than expected fundal height
could be a sign of fetal
macrosomia.
 Excessive amniotic fluid
(polyhydramnios). Having too
much amniotic might be a sign
that the baby is larger than
average.
Causes/Risk Factors:
 Maternal diabetes
 A history of fetal macrosomia
 Maternal obesity
 Excessive weight gain during
pregnancy
 Previous pregnancies
 Overdue pregnancy
 Maternal age
E. FETAL DISTRESS
- A complication in which a baby
experiences oxygen deprivation
(birth asphyxia).
- This may include changes in the
baby's heart rate), decreased fetal
movement, and meconium in the
amniotic fluid
* Normal anatomy – Uterus with clear
amniotic fluid
*Fetal distress – Meconium-stained
amniotic fluid
*Aspiration of Meconium – A sudden
gasp by the baby causes amniotic fluid
and meconium to surge in through the
mouth and down towards the lungs
*Keep baby warm
*Dry and rub back, tickle the soles – For
the baby to cry
*Open up airways – Jaw thrust – elevate
the jaw to open up the airway
Supplementary oxygen – Ambu bagging
(Bag valve mask)
Management:
 Giving the woman oxygen
 Increasing the amount of fluids
given intravenously to the woman
 Turning the woman on her left
side
 If these measures are not
effective, the baby is delivered as
quickly as possible by a vacuum
extractor, forceps, or cesarean
delivery.
F. PROLAPSED UMBILICAL CORD
 -occurs when the umbilical cord
drops (prolapses) between the
 fetal presenting part and the
cervix into the vagina.
 -Umbilical cord prolapse occurs
prior to or during delivery of the
baby.
 -This can result in a loss of
oxygen to the fetus due to
compression of prolapsed cord
between the presenting part and
the cervix
* -leads distress to the baby, if this
happen STAT order will be given
Causes:
 Premature rupture of
membranes.
 Preterm labor.
 Multiple gestation pregnancies
 Polyhydramnios
 Malpresentation
Assessment
1. palpating the prolapsed cord on
pelvic exam
2. abnormal fetal heart rate
A.
• Empty bladder
• Prolapsed cord compressed by fetal
head
• Bladder inflated by squeezing into it
500 mL of sterile intravenous fluid –
Urinary catheter
• Fetal head pushed away from cord
by enlarged bladder
B.
• A gloved hand in the vagina pushes
the fetus upward and off the cord
• Knee-chest position uses gravity to
shift the fetus out of the pelvis. The
woman’s things should be at right
angles to the bed and her chest flat
on the bed.
• The woman’s hips are elevated with
two pillows; this is often combined
with the Trendelenburg (head down)
position
G. MULTIPLE GESTATION
- pregnancy with more than one baby at
a time. -Examples include pregnancy
with twins, triplets, and quadruplets.
-It is a type of high-risk pregnancy
because delivering twins, triplets, or
more requires extra care.
* The more baby the more the mother
faces risk
Complications:
 Preterm labor and birth-The
higher the number of fetuses in
the pregnancy, the greater the
risk for early birth.
 Gestational hypertension
 Anemia
 Birth defects
 Miscarriage
 Abnormal amounts of amniotic
fluid
 Cesarean delivery
 Postpartum hemorrhage
* Advance order for cesarean delivery as
long as the baby is at the term
II. Problems with the
Passageway
A. ABNORMAL SIZE OR SHAPE OF
THE PELVIS
 Narrowing of the
passageway/birth canal
 Happen in the inlet, outlet and
mid-pelvis
 Types of pelvis
 Gynecoid
 Anthropoid- oval inlet, ape
 Android – male pelvis, hear
shaped
 Platypelloid- compressed front-
back, oval
 The narrowing causes: CPD and
failure to progress in labor.
*
B. CEPHALOPELVIC
DISPROPORTION/ CPD
 A disproportion between the size
of the fetal head and the pelvic
diameters.
 Is suggested by lack of
engagement at the beginning of
labor, prolonged first stage and
finally poor fetal descent.
Causes:
 Large baby due to:
 Hereditary factors
 Diabetes
 Post-maturity
 Multiparity (not the first
pregnancy)
 Abnormal fetal positions
 Small pelvis
 Abnormally shaped pelvis
3. SHOULDER DYSTOCIA
 a birth injury that happens when
one or both of a baby's shoulders
get stuck inside the mother's
pelvis during labor
 Occurs at the 2nd stage of labor
when the infant head is born but
the shoulders are too broad to
enter and be delivered thru the
pelvic outlet.
 Occur with women with diabetes,
multipara, post dated
pregnancies
Complications:
a. To the baby:
 Fractures to the collarbone and
arm
 Damage to the brachial plexus
nerves.
 Lack of oxygen to the body which
can cause brain injury or even
death
 Chest compression leading to the
uncoordinated breathing
b. Problems for the mother can
include:
- Post-partum hemorrhage
- Tearing of the perineum
- Uterine rupture.
Management:
 Press mother’s thighs up against
the belly-Mc Robert’s Maneuver
 Episiotomy
* McRoberts Maneuver
1. Legs flexed onto abdomen causes
rotation of pelvis, alignment of
sacrum, and opening of birth canal
2. Suprapubic pressure applied to
fetal anterior shoulder
Complications with the Power (The
Force of Labor)
* Power-strength of the uterine
contractions/ability of the uterus to
push the baby at the birth canal. It
should be coordinated with the timing,
intensity, frequency, interval,
duration/increasing manner—
increment acme decrement
The Power Factor in Labor…
 refers to the ability of the
uterine muscle to contract
 The uterus is an involuntary
muscle. It has to not only start
contracting, but it must establish
a pattern of contractions.
 Every time the uterus contracts it
pushes the baby towards the
cervix.
 The contractions cause the cervix
to stretch open and allow the
baby into the birth canal.
* Power of contraction—it is similar to
heart at electrical conduction/ SA
*Uterine contractions—there is uterine
pacemaker at the top of fundus/upper
part of the uterus is the active part and
the lower part is the passive part. If that
pathway of uterine distraction will be
disrupted then problem may happen
*Uterine pacemaker on top of the fundus
– Where the contraction starts
*Lower segment of the uterus is the
passive part
Let’s Review Normal Labor anything that is problematic.
 The first stage starts once Synonymous with CPD
contractions begin and continues
until cervix is fully dilated, which Causes
means being dilated 10  Inappropriate use of analgesia
centimeters. (excessive or too early
administration)
 The second stage is the active
 Pelvic bone contraction that has
stage, during which mother begin
narrowed the pelvic diameter so
to push downward. It starts with that a fetus cannot pass such as
complete dilation of the cervix could occur in a woman with
and ends with the birth of the rickets.
baby.  Poor fetal position (posterior
 The third stage is also known as rather than anterior position)
the placental stage. This stage  Extension rather than flexion of
begins with the birth of the baby the fetal head
and ends with the completed  Over distention of the uterus as
delivery of the placenta. with multiple pregnancy,
* First Stage—Latent: 0-3cm/longest— hydramnios or an excessively
instruct the patient what she will do on oversized fetus.
 Cervical rigidity (unripe)
the following phase, Active: 4-7cm
 Presence of a full rectum or
Transition Phase: 8-10cm urinary bladder that impedes
dilatation/short but intense. Goal fully fetal descent.
dilated, effacement 100%  Woman becoming exhausted from
*Second Stage: Crowning and expulsion labor.
of the baby  Primigravida status
*Third Stage: The mother will deliver
the placenta/placental delivery A. Ineffective Uterine Force
Sudden gush of blood, globular --Uterine contractions are the basic
abdomen, lengthening of the cord force moving the fetus through the birth
Schultz Side (Baby Side) and Duncan canal.
Side (Maternal Side) 15-20, 5-15 --Contractions occur because of
interplay of enzymes, electrolytes,
cotyledons
proteins and hormones.
--About 95% of labors are completed
I. Dystocia or Difficult Labor
with contractions that follow a
Dystocia of labor is defined as difficult
predictable, normal course. When they
labor or abnormally slow progress of
become abnormal or ineffective,
labor.
ineffective labor occurs.
Other terms: dysfunctional labor,
failure to progress (lack of progressive
The causes of Ineffective Uterine
cervical dilatation or lack of descent),
Force depend on the 3 types of
and cephalopelvic disproportion (CPD).
Dysfunctions:
-Can arise from any of the three main
--Hypotonic Contractions
components of the process: power, the
--Hypertonic Contractions
passenger and the passageway.
--Uncoordinated Contractions
Dystocia—labor and delivery is
Hypotonic Contractions
prolonged, difficult, not functional,
-Number of contractions: not more 2 or
3 occurring in a 10-minute period
-Resting tone: less than 10 mmHg
-Strength of contractions: does not
rise above 25 mmHg
-Phase of Labor: Active
-Symptom: Painless
* Hypo – Low, Decrease
Slowed tone, frequency, strength of
contraction
*Causes prolonged labor
*Normal strength contraction – more
than 25 mmHg
Etiology
-Overstretching of the uterus—large
baby, multiple babies, polyhydramnios,
multiparity
-Bowel or bladder distention, preventing
descent
-Excessive use of analgesia
Therapeutic Interventions:
--Oxytocin—induced contractions—
improved uterine contractions to prevent
bleeding—administer thru titration
--Ambulation—aid of gravity, the baby
will descent
--Nipple Stimulation—produce oxytocin
--Enema
--Amniotomy—make that everything is
ready to prevent dry labor
Hypertonic Contractions
-Resting tone: more than 15mmHg
-Contractions: Frequent prolonged
contractions that are not productive
-Phase of Labor: Latent
-Symptom: Painful
-Causes: This type of contraction occurs
because the muscle fibers of the
myometrium do not repolarize or relax
after a contraction, thereby “wiping it
clean” to accept a new pacemaker
stimulus
* Relaxation of uterus – baby receives
oxygenation
*Distress
Complication: Fetal Anoxia
Management:
--Provide comfort measures
--Bedrest or position changes
--Hydration
--Mild sedation
--Tocolytics
*Caesarean delivery
* Comfort measure for pain
*Bed rest or position changes (Left side
lying position) to improve oxygenation
*Hydration for mother (Energy to face
prolonged delivery)
*Mild sedation (Monitor in case of
hypotonic contraction)
* A – Normal Uterine Contractions
*B – Hypotonic contractions; notice rise
in pressure no more than 10 mmHg
*C – Hypertonic contractions; notice the
high resting pressure (35-40 mmHg)
Uncoordinated Contractions
--With uncoordinated contractions,
more than one pacemaker may be
initiating contractions, or receptors
points in the myometrium may be acting
independently of the pacemaker
--Uncoordinated contractions may occur
so closely together that they do not allow
good cotyledon (one of the visible
segments on the maternal surface of the
placenta)filling
* Cotyledon - transmit fetal blood and
allow exchange of oxygen and nutrients
with the maternal blood.
--Applying a fetal and a uterine external
monitor and assessing the rate, pattern,
resting tone, and fetal response to
contractions for at least 15 minutes (or
longer if necessary in early labor) reveals
the abnormal pattern
--Oxytocin administration may be
helpful in uncoordinated labor to
stimulate a more effective and consistent
pattern of contraction with a better,
lower resting tone.
Nursing process
 Assessment
-fetal and uterine monitoring
 Nursing Diagnoses
-Fear related to uncertainty of
pregnancy outcome
-Anxiety r/t medical procedures and
apparatus necessary to ensure health of
mother and fetus
-Fatigue r/t loss of glucose stores
through work and duration of labor
* Prolonged Pain (start in Latent phase)
– Fear
*Explain Educate – Anxiety
*Per Orem supplementation (if not
contraindicated) - Fatigue
B. DYSFUNCTIONAL LABOR AND
ASSOCIATED STAGES OF
LABOR
Dysfunction at the First Stage of Labor
Prolonged Latent Phase
--When contractions become ineffective
during the first stage of labor, a
prolonged latent phase can develop
--A prolonged latent phase is a latent
phase that is longer than 20 hours in a
nullipara or 14 hours in a multipara
--This may occur if the cervix is not
“ripe” at the beginning of labor and time
must be spent getting truly ready for
labor. It may occur if there is excessive
use of an analgesic early in labor
* Third stage—baby delivery and
placental delivery
Last Stage—postpartum care
Latent Phase---the longest phase in
stage 1
Primigravida—will take time from latent
until transition, takes 1 day 12-14 to 20-
24 hours of latent phase
--It is the longest because she is
decerning false or true contractions
--It is already long but can still prolong
14-16 to 16-20 hours
--2 days labor is considered prolong
--More than duration it might be
because the baby is not full descend
secondary to unripe or uneffaced cervix
or undilated 100%
* Other sources: 16 to 24 – prolonged
latent phase
*Hypertonic Uterine Contraction
Prolonged Latent Phase
• With a prolonged latent phase, the
uterus tends to be in a hypertonic
state. Relaxation between
contractions is inadequate, and
the contractions are only mild (less
than 15 mmHg) and therefore
ineffective
• One segment of the uterus may be
contracting with more force than
another segment
• Management of a prolonged latent
phase in labor that has been
caused by hypertonic contractions
involves helping the uterus to rest,
providing adequate fluid for
hydration, and pain relief with a
drug such as morphine sulfate
• Changing the linen and the
woman’s gown, darkening room
lights, and decreasing noise and
stimulation can also be helpful
• These measures usually combine
to allow labor to become effective
and begin to progress. If it does
not, a cesarean birth or amniotomy
(artificial rupture of membranes)
and oxytocin infusion to assist
labor may be necessary
--The mother in latent phase can still
communicate with you
--You can give health teachings
--It might not be noticeable to the
mother that it is already prolonged latent
phase
--Hard to timed or diagnose properly
since the mother don’t know where it
started
--It can be associated with ineffective
uterine contraction/dysfunctional
uterine contractions
--Hypertonic uterine contractions
(Latent Phase)
--Hypotonic uterine contractions is to
Active phase
--Usually start in independent nursing
interventions, make your patient
comfortable, stimulation
Protracted Active Phase
• A protracted active phase is
usually associated with
cephalopelvic disproportion (CPD)
or fetal malposition although it
may reflect ineffective myometrial
activity
• This phase is prolonged if cervical
dilatation does not occur at a rate
of at least 1.2 cm/hr in a nullipara
or 1.5 cm/hr in a multipara, or if
the active phase lasts longer than
12 hours in a primigravida or 6
hours in a multigravida
• If the cause of the delay in
dilatation is fetal malposition or
CPD, caesarian birth may be
necessary
• Dysfunctional labor during the
dilatation division of labor tends to
be hypotonic, in contrast to the
hypertonic action at beginning of
labor
• After an ultrasound to show that
CPD is not present, oxytocin may
be prescribed to augment labor
*Hypertonic uterine Contraction
*Can cause fetal tachycardia—fetal
distress
--The problem here is hypotonic uterine
contractions
--Actie phase where we expect the
patient to progress in labor
--Possibly the baby is in breech
presentation,
Prolonged Deceleration Phase
• A deceleration phase has become
prolonged when it extends beyond
3 hours in a nullipara or 1 hour in
a multipara
• Prolonged deceleration phase most
often results from abnormal fetal
head position. A caesarian birth is
frequently required
• Baby cannot descend and engage
Secondary Arrest of Dilatation
• A secondary arrest of dilatation has
occurred if there is no progress in
cervical dilatation for longer than 2
hours. Again, caesarian birth may
be necessary
• Pelvis may not be ideal for delivery
* --once the patient will not progress to
full dilatation then it became prolonged
deceleration
Dysfunction at the Second Stage of
Labor
a. PROLONGED DESCENT
• Occurs if the rate of descent is less
than 1 cm/hr in a nullipara or
2.0cm/hr in a multipara
• Can be suspected if the second
stage lasts over 3 hours in a
multipara
• Contractions become infrequent
and of poor quality
• Dilatation stops
--All positive are desirable
--Relationship of the presenting part to
the ischial part
--Falling under transition phase
 • If everything is normal except for
the suddenly faulty contractions
and CPD and poor fetal
presentation have been ruled out
by ultrasound, then rest and fluid
intake, as advocated for hypertonic
contractions, also apply.
• If the membranes have not
ruptured, rupturing them at this
point may be helpful
• Intravenous (IV) oxytocin may be
used to induce the uterus to
contract
• A semi-Fowler’s position, squatting,
kneeling, or more effective pushing
may speed descent
Arrest of Descent
• Arrest of descent results when no
descent has occurred for 1 hour in
a multipara or 2 hours in a
nullipara
• Failure of descent has occurred
when expected descent of the fetus
does not begin or engagement or
movement beyond 0 station has
not occurred
• The most likely cause for arrest of
descent during the second stage is
CPD. Caesarean birth usually is
necessary
• If there is no contraction to vaginal
birth, oxytocin may be used to
assist labor
Nursing Diagnoses
 Fatigue and anxiety related to
prolonged labor
During admission assess/ask:
-Last meal
-Emotion on labor
-Pain
-Position
-Comfort
*Risk for deficient fluid volume
related to length and work of labor
Causes:
 Vomiting and diarrhea
 Profuse diaphoresis and
hyperventilation
*Replace fluid per orem or IV
C. Pathologic Retractions
 During labor, the uterus
differentiate into two parts:
Upper contracting portion that
becomes thicker and shorter as
labor progresses and the lower
passive portion that distends
gradually to accommodate the
descending fetus.
* Pathology—something is wrong,
abnormality, a problem, in contrast with
physiologic
--There is retraction
--The upper and lower uterine segment
work as a team to be contraction will be
coordinated
--If there is an obstruction, the upper
portion will do his/her part then until it
will become hypotonic
Physiologic retraction ring (indention
ring) – normal
Active part – part of the uterus that
starts contraction – Upper part of the
uterus - think
Passive part – Distends and dilates to
accommodate the part of the baby –
Lower part of the uterus – thin
More forceful uterine contraction if there
is obstruction
Tonic uterine contraction – No
relaxation, stronger contraction
- Will become pathologic
PHYSIOLOGY:
 When labor is obstructed
fetus cannot descend into the
birth canal uterine
contractions become stronger
and more frequent reaches a
state of tonic contraction when
the uterus no longer relaxes
Bandl’s ring or pathologic
retraction ring develops.
Bandl’s ring:
(A hard band that forms across the uterus
at the junction of the upper and lower
uterine segments and interferes with
fetal descent). Identified thru ultrasound.
* --Ludwig Bandl (bandl’s ring)
*--A warning sign that obstruction is
happening (CPD) , can lead to further
complicated pregnancy or dystocia
* Constricting ring/Bandl’s ring
Firm abdomen, hard, constriction of
muscle – indention
• Warning sign of an obstruction
o Risk for a complicated
delivery (Dystocia)
Pathologic Retraction
• A Contraction ring is a hard band
that forms across the uterus at the
junction of the upper and lower
uterine segments and interferes
with fetal descent
• The most frequent type seen is
termed a pathologic retraction ring
(Bandl’s ring). The ring usually
appears during the second stage of
labor and can be palpated as a
horizontal indentation across the
abdomen
• It is a warning sign that severe
dysfunctional labor is occurring as
it is formed by excessive retraction
of the upper uterine segment; the
uterine myometrium is much
thicker above than below the ring
• When a pathologic retraction ring
occurs in early labor, it is usually
caused by uncoordinated
contractions
• In the pelvic division of labor, it is
usually caused by obstetric
manipulation or by the
administration of oxytocin
• In either event, the fetus is
gripped by the retraction ring and
cannot advance beyond that
point. The undelivered placenta
will also be held at that point
• Contractions rings often can be
identified by ultrasound. Such a
finding is extremely serious and
should be reported promptly
• Administration of IV morphine
sulfate or the inhalation of amyl
nitrite may relieve a retraction
ring. A tocolytic can also be
administered to halt contractions
• If the situation is not relieved,
uterine rupture and neurologic
damage to the fetus may occur
• In the placental stage, massive
maternal hemorrhage may result,
because the placenta is loosened
but then cannot deliver,
preventing the uterus from
contracting
• Most likely, a caesarean birth will
be necessary to ensure safe birth
of the fetus
• Manual removal of the placenta
under general anesthesia may be
required if the retraction ring
does not allow the placenta to be
delivered
--Make sure the baby is safe
--Make sure the management that it is
direct to the possibility of baby in
distress
--Make use of tocolytic (Bandl’s Ring)
--Make sure baby is safe (Fetal distress)
Management
• Relax the mother’s uterus
(Tocolytics)
--Caesarean delivery may be indicated
Pathologic retraction ring
A – Uterus in the normal second stage of
labor. Notice how the upper uterine
segment is becoming thicker and the
lower uterine segment is thinning. A
physiologic retraction ring is normally
formed at the division of the upper and
lower uterine segments
B – Uterus with a pathologic retraction
ring (Bandl’s ring). The wall below the
ring is thin and the abdomen shows an
indentation. This constriction is caused
by obstructed labor and is a warning
sign that if the obstruction is not
relieved, the lower segment may rupture.
Precipitate Labor
• Precipitate labor and birth occur
when uterine contractions are so
strong that a woman gives birth
with only a few, rapidly occurring
contractions
• It is often defined as a labor that is
completed in fewer than 3 hours
• Precipitate dilatation is cervical
dilatation that occurs at a rate of 5
cm or more per hour in a primipara
or 10 cm or more per hour in a
multipara
• Such rapid labor is likely to occur
with grand multiparity, or it may
occur after induction of labor by
oxytocin or amniotomy
*Labor to delivery within 3 hours
--abrupt, sudden, anticipated
--Normally, labor and delivery take time
depends if primigravida or multiparous,
6 hours from the start of labor
Fast delivery to the mother
--Excessive bleeding/Laceration
To the baby
--Neonatal distress
--Damaged to the presenting part of the
baby
--Neonatal infection
--Neonatal Sepsis
• Contractions can be so forceful
that they lead to premature
separation of the placenta, placing
the woman at risk for hemorrhage
• Rapid labor also poses a risk to the
fetus, because subdural
hemorrhage may result from the
rapid release of pressure on the
head
• A woman may sustain lacerations
of the birth canal from the forceful
birth. She also can feel
overwhelmed by the speed of labor
• A precipitate labor can be
predicted from a labor graph if,
during the active phase of
dilatation, the rate is greater than
5 cm/hr (1 cm every 12 minutes)
in a nullipara or 10 cm/hr (1 cm
every 6 minutes) in a multipara
• In such instances, a tocolytic may
be administered to reduce the
force and frequency of
contractions
• Caution a multiparous woman by
week 28 of pregnancy that,
because a past labor was so brief,
her labor this time also may be
brief. This allows her to plan for
appropriately timed
transportation to the hospital or
alternative birthing center
• Both grand multiparas and
women with histories of
precipitate labor should have the
birthing room converted to birth
readiness before full dilatation is
obtained. Then, even a sudden
birth can be accomplished in a
controlled surrounding
E. Uterine Rupture
• Uterine rupture occurs when a
uterus undergoes more strain than
it is capable of sustaining
• Rupture occurs most commonly
when a vertical scar from a
previous caesarean birth or
hysterotomy repair tears
• Contributing factors may include
prolonged labor, abnormal
presentation, multiple gestation,
unwise use of oxytocin, obstructed
labor, and traumatic maneuvers of
forceps or traction
• When uterine rupture occurs, fetal
death will follow unless immediate
caesarean birth can be
accomplished
• If a uterus should rupture, the
woman experiences a sudden,
severe pain during a strong labor
 contraction, which she may report
as a “tearing” sensation
*Incomplete uterine rupture—
ruptured uterus did not reach the
outer part
--There is a rupture of the uterus
---Maybe complete or incomplete
---Complete: where from endo to outer
part rupture totally, a part of the baby
will out from the uterus
--Uterine rupture can be associated to
multiple gestation, prolonged labor
especially having hypertonic
contractility, traumatic maneuver—
forceps extraction and damaging
endometrium
--incorrect administration of oxytocin
Uterine Rupture can be confirmed via
Ultrasound
Prevent: hypovolemic shock
--Managing the fluid of the patient
• Rupture can be complete, going
through the endometrium,
myometrium, and peritoneum
layers, or incomplete, leaving the
peritoneum intact. With a • Most women are advised not to
complete rupture, uterine
contractions will immediately stop
• Two distinct swellings will be
visible on the woman’s abdomen:
the retracted uterus and the
extrauterine fetus
• Hemorrhage from the torn uterine
arteries floods into the abdominal
cavity and possibly into the vagina
• Signs of shock begin, including
rapid, weak pulse; falling blood
pressure; cold and clammy skin;
and dilatation of the nostrils from
air hunger
• Fetal heart sounds fade and then
are absent
*Hypothermia, Hypovolemic tachypnea,
tachycardia=shock
• If the rupture is incomplete, the
signs of rupture are less evident.
With an incomplete rupture, a
woman may experience only a
localized tenderness and a
persistent aching pain over that
area of the lower uterine segment
• However fetal heart sounds, a lack
of contractions, and the changes in
the woman’s vital signs will
gradually reveal fetal and maternal
distress
• Uterine rupture can be confirmed
by ultrasound
• Administer emergency fluid
replacement therapy as ordered
• Anticipate use of IV oxytocin to
contract the uterus and minimize
bleeding
• Prepare the woman for a possible
laparotomy as an emergency to
control bleeding and achieve a
repair
• The viability of the fetus depends
on the extent of the rupture and
the time elapsed between rupture
and abdominal extraction
• A woman’s prognosis depends on
the extent of the rupture and the
blood loss
conceive again after a rupture of
the uterus, unless the rupture
occurred in the inactive lower
segment
*Encourage no pregnancy again
Uterine rupture
Early presentation
• Previous incision site for caesarean
delivery
• Initial tearing along previous scar
Late presentation
• Full thickness tear of anterior
uterine wall
• Blood flowing out into abdomen
Assessing the Pregnant Woman with
Complete Uterine Rupture
• Falling blood pressure
• Rapid, weak pulse
• Severe abdominal pain
• Halt in contractions
 • Absent FHR
• Possible vaginal bleeding
Inversion of the uterus
• Uterine inversion refers to the
uterus turning inside out with
either birth of the fetus or delivery
of the placenta
• It may occur if the traction is
applied to the umbilical cord to
remove the placenta or if pressure
is applied to the uterine fundus
when the uterus is not contracted
• It may also occur if the placenta is
attached at the fundus so that,
during birth, the passage of the
fetus pulls the fundus down
• Inversion occurs in various
degrees. The inverted fundus may
lie within the uterine cavity or the
vagina, or, in total inversion, it
may protrude from the vagina.
* Applying strong traction to deliver the
placenta despite not being separated yet
*Hysterectomy
--The uterus is inverted, turned inside
out
--The placenta of the patient did not
move from the uterine wall then there is
traction then uterus will also come out
to the vagina
--Lengthening of the cord
--Sudden gush of blood
--Globular shape of abdomen
Inversion of the uterus
• When an inversion occurs, a large
amount of blood suddenly gushes
from the vagina. The fundus is not
palpable in the abdomen
• If the loss of blood continues
unchecked for longer than a few
minutes, the woman will show
signs of blood loss: hypotension,
dizziness, paleness, or diaphoresis
• Because the uterus is not
contracted in this position,
bleeding continues, and
exsanguination could occur within
a period as short as 10 minutes
• Never attempt to replace an
inversion, because handling of the
uterus may increase the bleeding
• Never attempt to remove the
placenta if it is still attached,
because this only create a larger
surface area for bleeding
• In addition, administration of an
oxytocic drug only compounds
the inversion or makes the uterus
more tense and difficult to replace
• An IV fluid line needs to be
started, if one is not already
present (use a large-gauge needle,
because blood will need to be
replaced)
• If a line is already in place, open
it to achieve optimal flow of fluid
to restore fluid volume
• Be prepared to perform
cardiopulmonary resuscitation
(CPR) if the woman’s heart should
fail from the sudden blood loss.
• In addition, administration of an
oxytocic drug only compounds
the inversion or makes the uterus
more tense and difficult to replace
• An IV fluid line needs to be
started, if one is not already
present (use a large-gauge needle,
because blood will need to be
replaced)
• If a line is already in place, open
it to achieve optimal flow of fluid
to restore fluid volume
• Be prepared to perform
cardiopulmonary resuscitation
(CPR) if the woman’s heart should
fail from the sudden blood loss.
*Patient will be in bed rest
G. Amniotic Fluid Embolism
• Amniotic fluid embolism occurs
when amniotic fluid is forced into
an open maternal uterine blood
sinus through some defect in the
membranes or after membrane
rupture or partial premature
separation of the placenta
 • Previously, it was thought that • --But chances are high in old age,
particles such as meconium or trauma, abortion, LSCS,
shed fetal skin cells in the amniotic instrumental delivery
fluid entered the maternal • --That maybe the amniotic fluid
circulation and reached the lungs created a clots
as small emboli • --It is because of anaphylactic
• Now, it is recognized that a response
humoral or anaphylactoid • --A part of the baby like fetal cells
response is the more likely cause where they initiate anaphylactic
• This condition may occur during response, the fetal amniotic fluid
labor or in the post partial period mix to maternal circulation where
* Anaphylactic response it recognizes as foreign invader,
• Fetal cells mixed accidentally to the the normal response is to create
maternal circulation – Foreign antibodies as a response it
invader = Fetal cells creates anaphylactic reaction.
o Create an antigen antibody Major inflammation of the lungs-
response airways, impairment if gas
o Inflammation exchange—respiratory arrest—
▪ Major organs infection span of few minutes
▪ Lungs • --CPR
▪ Impairment of
gas exchange Amniotic Fluid Embolism
▪ Respiratory • It is not preventable because it
arrest cannot be predicted
▪ Cardiac arrest • Possible risk factors include
oxytocin administration, abruptio
• Management – placenta, and hydramnios
CPR – Revive • The clinical picture is dramatic. A
the patient woman, in strong labor, sits up
suddenly and grasps her chest
Amniotic Fluid Embolism because of sharp pain and inability
• It can happen to any pregnant to breathe as she experiences
woman pulmonary artery constriction. She
• But chances are high in becomes pale and then turns the
o Old age typical bluish gray associated with
o Trauma pulmonary embolism and lack of
o Abortion blood flow to the lungs
o LSCS • The immediate management is
o Instrumental delivery oxygen administration by face
• Entry of Amniotic fluid or fetal cells mask or cannula
in mental circulation • Within minutes, she will need
• Causing cardio respiratory collapse CPR. CPR may be ineffective,
• Our body hates everything foreign however, because these
• Even if it is amniotic surrounding procedures (inflating the lungs
your baby or your own babies tini- and massaging the heart) do not
tiny cells or hair relieve the pulmonary
• Amniotic Fluid Embolism constriction. Therefore, blood still
• --It can happen to any pregnant cannot circulate to the lungs.
woman Death may occur within
minutes.
 • A woman’s prognosis depends on
the size of the embolism, the
speed with which the emergency
condition was detected, and the
skill and speed of emergency
intervention
• Even if the woman survives the
initial insult, the risk for
disseminated intravascular
coagulation (DIC) us high, further
compounding her condition
• In this event, she will need
continued management that
includes endotracheal intubation
to maintain pulmonary function
and therapy with fibrinogen to
counteract DIC
• Most likely, she will be
transferred to an ICU
• The prognosis for the fetus is
guarded, because reduced
placental perfusion results from
the severe drop in maternal blood
pressure
• Labor often begins or the fetus is
born immediately by caesarean
birth
H. Premature Labor/Preterm
Labor/PTL
• Cervical change or effacement and
uterine contractions occurring after
20 weeks gestation and prior to 37
weeks of gestation
• Causes
• PROM
• Hydramnios
• Placenta previa
• Preeclampsia
• Multiple gestation
• Abruption placenta
• Incompetent cervix
• Fetal death
• Trauma
• Intrauterine infection
• Maternal factors: stress, Urinary
Tract Infection, Dehydration
* Preterm labor leads to preterm delivery
(20 weeks to 36 weeks)
- Mother gives birth after the age of
viability (20 weeks) and before the age of
maturity (37 weeks)
*After 42 weeks—postmature
Assessment
 Suprapubic pressure
 Vaginal pressure
 Low back pain
 Regular uterine contractions
 Cervical dilatation and
effacement
 Bloody show
 Rupture of membranes
Nursing care management
 Assess the maternal status and
check for signs of labor
 Obtain complete history
 Obtain blood and urine
specimens for lab test
 Assess the frequency, intensity
and duration of contractions
 Evaluate cervical dilatation and
effacement
 Determine the status of
membranes and check for bloody
show
 Monitor the fetus and evaluate for
distress, size, maturity and
activity
 Perform measures to manage or
stop labor from proceeding
 Place client on lateral bed rest
*32-34 weeks: lung surfactant
Focus of care: Fetal Respiratory Distress
• Not enough lung surfactant
How far is the baby
Early? – artificial airway, receive
synthetic surfactant; prophylactic
antibiotic
Late? – Phototherapy;
Lung surfactant produced in 24 to 26
weeks (cushion, make the alveoli not
rigid, makes the alveoli not collapse);
fluid cushion;
• Atelectasis – lung collapse – no lung
surfactant
• Lungs to weak for proper gas
exchange
Dexamethasone – steroid; act the same
as the synthetic surfactant; stimulate
lungs to produce lung surfactant (20th
week and 30th week given); given if there
is a possibility of CS early
Preterm – weak lungs; asthma
Evaluate using Ballard’s Scoring
Hypoactive
Ballard within the day (24 hours)
Prolonged Pregnancy
• “its is defined as the pregnancy
progressing to 42 weeks (294 days)
or beyond”
• It is also called post-dates or post-
term pregnancy
Placental aging – functions deteriorate;
not enough nutrition, blood supply,
oxygenation
Malnourished baby
Beyond 42 weeks—the placenta is
already aged which means its function
deteriorated
--The baby is malnourished already
because the placenta cannot give
nourishment
Prolonged (Postterm) Pregnancy
• Prolonged pregnancy may result in
an increased possibility of
o Probable labor induction
o Forceps or vacuum-assisted
or caesarean birth
o Decreased perfusion to the
placenta
o Decreased amount of
amniotic fluid and possible
cord compression
Post Maturity Syndrome
• It develops in 20% of pregnancies
• Newborn who has:
o Dry peeling skin
o Coated with meconium
o Overgrown nail and scalp
hair
o Well developed creases on
the palm and soles
o Little vernix
o Minimal subcutaneous fat
with apprehensive look
• Such picture indicates intrauterine
malnourishment and independent
of duration of gestation
• Postmature infant delivered at 43
weeks gestation. Thick, viscous
meconium coated the desquamating
skin
Apprehensive look
Meconium Aspiration Syndrome (MAS)
Past first stool inside – mixed with
amniotic fluid and aspirate
Greenish substance; greenish umbilical
cord – post-term; (MAS)
• Check babies airway
• Apprehensive look
• Meconium aspiration syndrome
• Meconium—the first tool of the
baby, it is the only sterile tool
• -----the umbilical cord is usually
stained with green as well as the
baby
Management
 • It includes Postpartum period
o Expectant observational • time of healing and rejuvenation
management with fetal as the mother’s body returns to
assessment tests pre-pregnancy states.
o Induction of labor (IOL) • Nurses and other healthcare
o C-section professionals need to be aware of
the normal physiologic and
Induce delivery if its past 42 weeks – psychological changes that take
amniotomy place in women’s bodies and
minds after delivery in order to
IV.Problems with Psyche Factor provide comprehensive care
“The mother’s state of fear or during this period.
confidence or maternal psychological • * Time after delivery
status” • Complete period of mothers
 Inadequate Voluntary rejuvenation and recovery
Expulsive Forces (Inability to • Reproductive system go back to
bear down property) pre-pregnancy stage
 Fear/Anxiety • Mother’s with complications will
-is a feeling induced by perceived danger have longer time of recovery
-a feeling of apprehension or Fright. • Let them undergo the phases of
postpartum period
Nursing care management
 Encourage women to ask *let them have a positive experiences
questions at prenatal visits and to *Provide care to the mother after they
attend preparation for childbirth gave birth
classes help prepare them to *During the 1st-2nd day they are self-
labor. centered
 Encourage to share their *Let them verbalize what they are
experience after labor serves a
experienced
briefing time and helps them
integrate the experience into their
Postpartum Complications
total life.
Postpartum hemorrhage
• Most common cause of maternal
A human body can bear only up to 45
morbidity in postpartum patient
del (unit) of pain. Yet at time of giving
• #1 Leading cause of death
birth, a mother feels up to 57 del (unit)
associated with child bearing
of pain. This is similar to 20 bones
• Can cause shock; hypovolemic
getting fractured at a time
shock – shut off major organs
• More than 500 mL of blood loss in
Vaginal delivery (NSD)
• More than 1,000 mL blood lost in C-
section
• 10% decrease in Hemoglobin level
o Woman has PPH
o Blood loss is only reflected in
the hemoglobin after 6 hours
• Significant loss causing signs and
symptoms of low blood volume
(more accurate and specific)
Postpartum Care
 oCold and clammy
oPallor
oThirsty
oTachycardia
oTachypnea - Lungs will try to
compensate (decrease in
tissue and oxygen perfusion)
Early/Primary postpartum
hemorrhage
• Happens in the first 24 hours after
delivery
Late/Secondary postpartum
hemorrhage
• Happens after 24 hours or weeks
after delivery
Causes – 4 Ts
• Tone – Uterine atony
• Tissue – retained placenta
• Trauma – lacerations
• Thrombin – coagulation
* The most common cause is uterine
Atony
Tone
• Lack of uterine tone (Uterine atony)
• Uterus is not contracting
• Absence of uterine tone
• Uterus is soft, relax, spongy, boggy
• Slow and steady loss of blood will
trickle from the vagina
• Myometrium – smooth muscle
• Placenta and fetus – dilate and
efface cervix
Contraction
o Ability of the uterus to push
out the baby and placenta
o Placental arteries clamped
shit (compressed)
▪ Reduced bleeding
▪ Spiral artery – uterus –
not be ischemic
o No contraction – Excessive
bleeding – postpartum
bleeding
• *Soft, spongy, boggy—slow and
steady, loss of blood
•Myometrium---smooth muscle
•Upper fundus contract, the lower
portion dilate
• Contractions→placental arteries
clamped shut→reduced bleeding
• Spiral Artery is the placental
artery
• No Contractions→ excessive
bleeding
• Causes no contractions
• --Repeated distention
• ----multiple pregnancies
• ----Overstretching from
twins/triplets
• --Muscle fatigue from delivery
• --Unable to empty bladder
(pushes on uterus)
• --Obstetrical medications
• ---Anesthetics (e.g halothane)
• ---magnesium sulfate, nifedipine,
terbutaline
Causes
• Repeated distention
o Multiple pregnancies
o Overstretching from the
twins/triplets
o Macrosomia
• Muscle fatigue from delivery
o Fundal massage as
necessary only
• Unable to empty bladder (pushes on
uterus)
o Pushed by the urinary
bladder - Displaced uterus
o Decrease uterine contraction
o Hot and cold compress in the
bladder
o Do not place hot compress
directly in the uterus –
Vasodilation
o Straight catheterization
• Obstetric medications
o Anesthetics (halothane)
o Magnesium sulfate (relaxing
affect – uterine – give
oxytocin), nifedipine (dilate
blood vessels - bleeding),
 terbutaline (dilatation - -Site repaired right away
bleeding) -Apply pressure
-Stitch lacerations
Treatment
-Fundal massage TRAUMA
--Smooth muscles contract • Damage to genital structures during
-urination (Or have Catheter placed) the delivery
-Medications (Oxytocin, o Uterus (Uterine hematoma),
methylergonovine, Misoprostol) Blood cervix (Cervical tear), vagina,
pressure perineum (Episiotomy – same
---Low blood pressure the oxytocin will time with the contraction)
be hold (episiorrhaphy – repair of the
perineum)
-Surgery
• Incision from caesarean
• From baby coming through vaginal
• (dilatation - bleeding)
canal
• From medical instruments
Treatment
o Forceps
• Fundal massage
o Vacuum extraction
o Smooth muscles contract
o Episiotomy
• Urination (Catheter)
• Hematoma – mass or collection of
• Medications
blood
o Oxytocin (check BP – do not
o Severe pain
give if bp is low),
o Persistent bleeding
methylergonovine,
o Management - uterine wall
misoprostol
tamponade – serve same
• Surgery – ovarian artery ligation –
function as pack dressing
removal of the placental artery –
long term complication of the
Tissue:
mother especially succeeding
-Placental Fragments
pregnancy – not sufficient blood
supply to placenta and uterus – -retained in uterine cavity
hypoxic uterus and placenta (Pre -presence of retained placenta tissues
eclampsia, ) which prevents full uterine contractions
resulting in failure to seal off bleeding
Trauma vessels.
--damaged to genital structures
---Uterus, cervix, vagina, perineum Causes: Abnormal adhesions such as
---Incision from CS accreta—most common but less severe—
---From baby coming through vaginal attaches on the surface of
canal myometrium—possibility of nsd,
--From Medical Instruments increta—invades the myometrium and
---Forceps, vacuum extraction, percreta---it perforates the whole of the
Episiotomy uterus, it will pass through the uterus
--Hematoma—mass or collection of and attach to the urinary bladder.
blood *Increta and percreta cannot be possible
-Severe pain, persistent bleeding to deliver nsd, cs-hysterectomy

Emergency
 *The abnormal type of adhesion can be pregnant size, shape and
seen via ultrasound, usually at second function.
trimester Causes
Placenta should only be attached at • Retained placental fragments
endometrium • Infection- endometritis
• Uterine tumors
• Location is correct but the depth of
Signs and Symptoms
attachment in the uterine wall is
• (1) Prolonged or reversal pattern
abnormal
in lochial discharge
o Accreta (most common, less severe)
• (2) Profuse vaginal bleeding or
▪ Placenta attaches on the surface of the
foul odor in lochia if caused by
myometrium
infection
o Increta – not delivered in NSD –
• (3) Large, flabby uterus.
hysterectomy – caesarean delivery
▪ Placenta invades the myometrium
Management
o Percreta – not delivered normally –
• Oxytocin
hysterectomy – caesarean delivery
• Treating the cause:
▪ Attaches to other organ (may attach to
a. removal of uterine tumors
the urinary bladder)
b. antibiotics for infection
Placenta is normally attached in the
c. evacuation of the retained
endometrium
placental fragments by D and C
d. Hysterectomy (last alternative)
Causes:
-Multiple CS
Nursing Management
-Placenta Previa Uterine Massage
-History of fibroid removal Ice compress
Empty bladder
Management Early ambulation postpartum.
-Hysterectomy Daily evaluation of fundal height to
document involution.
Prevention
*Aside from bleeding it can cause sepsis
• Make sure placenta comes out
*Monitor the fundal height as well as the
intact
lochia
• Remove retained tissue ASAP
o Retain placenta - sepsis
*1 finger breath every day
• Management: Hysterectomy
• Causes: THROMBIN
o Multiple CS • Has blood clotting condition
o Placenta Previa o Genetic – Von Willbrand
o History of fibroid removal disease
▪ Common for western
country people
▪ Von Wilbrand’s factor
– blood needed for
Subinvolution of the Uterus clotting
• Occurs when there is a delay in ▪ Bleed in any trauma
the return of the uterus to its pre- incurred
 o Coagulopathy – cannot form
a clot properly
o Obstetric
▪ Eclampsia
▪ Placental abruption
o Can lead to disseminated
intravascular coagulation
o Prevents Clot Formation
• Thrombin: a part of clotting
cascade
• -Has blood clotting condition
• -genetic—Von Willebrand
disease—common for western
county people—expect them to
prone to bleed since they don’t
have von Willebrand that needs in
formation of clots
• -Obstetric
• --Eclampsia
• --Placental abruption
• -Can lead to DIC
• -Prevents clot formation
II. Puerperial Infection
A puerperal infection occurs when
bacteria infect the uterus and
surrounding areas after a woman
gives birth. It’s also known as a
postpartum infection.
*Postpartum infection
• Increased white blood cell, light
fever, low grade fever = normal
• Low grade fever – increase hydration
• Check postoperative side or
episiotomy if there are signs of
infection if none compensate blood
and fluid loss
Risk Factors
• Rupture of the membrane more
than 24 hours before birth
• Placental fragments retained
• Post-partum hemorrhage
• Instrument births
• Local vaginal infection was
present at the time of birth
• The uterus was explored after
birth for a retained placenta or
abdominal bleeding site
*If there is an accompanying signs of
infection
PROM – exposed to sources of infection
even before the mother gave birth
Tissue – retained (Placenta) – infection
will set in after 24 hours; bleeding will
set in before infection; may progress into
sepsis then shock (patient might die)
(Check for complete of placenta to
prevent bleeding and infection)
PPH – open wound; low white blood cell
(decrease immunity)
Instruments – forceps, vaginal speculum
– can cause trauma (Disruption of
skin/genital tract integrity) – portal of
entry
Infection – std, gonorrhea – crede’s
prophylaxis (Ophthalmia neeonatorum)
Dystocia – manipulated the uterus after
birth – trauma - infection
*Crede’s Prophylaxis—Erythromycin—
prevent vaginal infection
A. Endometritis
--It is the inner lining of the uterus
Endometritis
• Inflammation of the endometrium –
trauma – manipulation during birth
– portal of entry
• Caused by infection
o Bacteria
▪ Female lower genital
tract
▪ Outside the body
Assessments
• pelvic or abdominal pain
• vaginal bleeding or unusual
discharge
• fever or chills
• feeling unwell or extremely
fatigued
• constipation or pain when going
to the bathroom
*Normal pain – involution pain – pain
during contraction
Vaginal bleeding vs lochia – educate how
many discharge during that time; at
least she should be changing her
maternity pad every two to three hours
Discover why they are feeling unwell
Diagnosis
• Medical history and Physical
exam-tenderness in the uterus
and possible discharge from the
cervix.
• Blood testing
• Cervical cultures
• Endometrial biopsy
• Laparoscopy or hysteroscopy
*Blood Culture—first done before each
antibiotics (first dose)
Endometrial Biopsy—most invasive
*Incurred during the birthing process
Blood culture given before antibiotics
Cervical culture if there is drainage
Endometrial biopsy, laparoscopy,
hysteroscopy – view then get a tissue in
the endometrium to check for infection;
invasive
Management
• Antibiotics- determined by a
culture of the lochia
• Further tests - Cervical cultures
or an endometrial biopsy to
ensure that the infection is
completely gone after finishing
the course of antibiotics
• Early recognition of signs:
-Normal color
-Quantity and odor of discharge
-Size, consistency, tenderness of a
normal postpartal uterus
*Assessments – know what is normal
and abnormal; know what to refer and
document
Health teaching
B.Wound Infection/Infection of the
Perineum
• Suture line from her perineum,
episiotomy or laceration repair
can be the portal of entry for
bacterial invasion.
ASSESSMENT:
• Fever
• Foul-smelling discharge
• Redness and swelling around the
stitches
• Severe pain at the incision site
• Visible pus in or around the
wound
*Present if patient have laceration,
episiotomy, episiorrhaphy
BUBBLE HE – check for possible
infection ( breasts, uterus, bladder,
bowels, episiotomy, lower extremities,
homan’s sign and emotions.)
Management
• Wipe front to back.
• Change your pad every 2 to 4
hours.
• Proper wound care
• Sitz bath
 • Prevent constipation by
increasing water and fiber intake.
• Hand washing
*Health education – toilet hygiene
No scented wash (becomes alkalinic –
make the environment conducive for
microorganism)
*Proper care for the surgical wound
• Use gentle soap and water (During
delivery vagina became alkalinic)
• Never scrub the infection
• Avoid creams or ointments unless
prescribed
• Don’t pick at or remove scabs
• Gently wash stitches while
showering
Observe signs of infection
- Redness and pus (infected)
C. UTI/Urinary Tract Infection
--an infection of the lining of the urinary
bladder and urethra.
--In some case the bacterial infection
might travel up to the kidneys resulting
in kidney infection.
Assessment
• Burning on urination (Dysuria)
• Hematuria
• Feeling of frequency
• Unpleasant smelling urine
• Lower abdominal pain
• generalized body pain, fever and
fatigue
Management
• Hydration to dilute the urine
• Practice good restroom hygiene
• Avoid using perfumed products,
creams or gels
• Wear loose clothing
• Have plenty of vitamin C rich
foods.
• Oral analgesics and antibiotics—
check if contraindicated with BF
D. Perineal Hematoma
• Injury to the vagina and the
perineum during delivery may
cause swelling, bruising, or a
collection of blood under the skin
called a hematoma.
*It can be due to instrumentation
It can be the portal of entry of organism
if it is burst
*Perineal Hematoma
• With a hematoma, the area is
ecchymotic, and an outline of the
swollen area is visible
• Can be due to pushing, contraction,
forcep
• If the hematoma bursts can be a
portal of entry for infection
Assessment
• Severe pain in the perineal area
• Feeling of pressure between legs
• With hematoma == purplish
discoloration with swelling 2cm or
8cm in diameter
• Tenderness during palpation
• Palpates as firm globe
*Sometimes they let it subside on its own
IND Incision and Drainage if it is too big
then monitor the site for possibility of
infection
Nursing Care Management
• Assess the size of hematoma and
check if there is an increase with
each inspection
• Administer mild analgesic
• Apply an ice pack
• If the hematoma is large or
continues to increase - the site
incised and vessel be ligated
under local anesthesia.
 E. Thromboembolic Disorders
---Thrombi or blood clots are formed
when there is stasis of circulation or
repair of damaged tissue.
--The postpartum woman is especially
susceptible for the formation of thrombi
because of increased fibrinogen and
prothrombin levels which increases
blood coagulability.
Causes
• Injury to blood vessels usually
occurs during delivery, indwelling
catheterization and infection
• Increased clotting that normally
occurs during pregnancy
• Blood stasis that occurs as a
result of bed rest after CS and
prolonged inactivity

*Mobile or stationary clot Diagnosis

• Doppler ultrasound
It is more dangerous to have an embolus • X-ray dye injection called
but it Is not ideal to have thrombus and venogram.
Embolus • Homan’s test
It is may lodge to major organs such as *Positive homan’s test – decrease pulse,
the lungs, heart or brain swelling, warmth
*Mobile or stationary clot Types
Thrombus 1. Superficial thrombophlebitis/
Embolus – more dangerous cause it is Phlebothrombosis/ Venous
moving in the circulation thrombosis
-an inflammatory condition of the veins
Lodge to major organs or blood vessels – due to a blood clot just below the surface
infection of the skin.
• Location of the clot can be seen by
Postpartum patient – homan’s sign – test the eye on inspection of the
deep vein thrombosis – increase blood painful and reddened area in the
clotting factor, fibrinogen (changes that affected leg. These blood clots are
happen during pregnancy) – more prone large and hard enough to be felt
because of immobility – CS patients are by palpation.
more prone (low ambulation) (Encourage *Venous Tripping
early and increase ambulation) *Engorged vein – painful – elevate the
affected leg and educate to change
Risk Factors position - Elastic stockings – very
• Varicosities of the legs compressive
• Obesity
• Over 30 years old 2. Deep Vein Thrombophlebitis/DVT
• Use of estrogen supplement • inflammation of a vein located
• History of thromboembolic deep with in a muscle tissue.
disease • Since the vein affected is
• Smoking surrounded by muscles, blood
• Trauma to extremities clot may break free during
• DM muscular movement and travel in
the circulation.
*Life threatening—go with the
circulation
*Clots are bigger
3. Femoral Thrombophlebitis
• Infection of the veins of the legs–
femoral and popliteal veins.
• generally occurring 10 to 14 days
after delivery, produces chills,
fever, malaise, stiffness, and pain.
*Same with deep vein thrombosis but
found in the femoral
Manifestations
• Homan’s sign (+)
• Milk leg or phlegmasia alba
dolens- the leg is shiny
white in appearance
because of extreme
swelling and lack of
circulation
• Swelling of affected leg,
pain stiffness
• Fever\
*Severe – necrotic – amputation
Management
• Early ambulation
• Use of support stocking-- Instruct
the patient to put stocking before
rising from bed in the morning.
• Provide adequate hydration
• If post CS encourage leg exercises
to promote venous return while
patient is not yet able to get out of
bed
• Leg elevation
• Anticoagulant therapy
• Heparin- Mother may breastfeed
as it is not passed to breastmilk.
Warfarin can be given in low
doses
• Keep antagonist, Vitamin K
available.
• Monitor PTT level or APTT
• Surgery may be used if the
affected vein is likely to present a
long term threat of producing
blood clots.
*Anti-Embolic Stockings
*Getting out of bed and a bit of walking
around can help speed up recovery.
Most hospitals encourage women to get
out of bed around 12 hours after a C-
section
*Management will depend on the
severity
Warfarin—standby vitamin K—monitor
their Prothrombin Time
Heparin—Stand by Protamine Sulfate –
Partial Prothrombin Time
*Antidotes should be at bedside
Medicines are prone to cause bleeding
Know what laboratory exam to monitor
Monitor prothrombin time – warfarin (10
letters warfarin pt)
Monitor partial thromboplastin time –
heparin (10 letters heparin ptt)
IV.Post Partum Psychiatric Disorder
• During the postpartum period,
about 85% of women experience
some type of mood disturbance.
• For most the symptoms are mild
and short-lived; however, 10 to
15% of women develop more
significant symptoms of
depression or anxiety.
Risk Factors
• Hormone
• Marital dissatisfaction and/or
inadequate social supports
• Previous episode of PPD, major
depression or bipolar disorder
• Stressful life events occurring
either during pregnancy or near
the time of delivery
• Socioeconomic status
• Age and educational level
Categories Symptoms
A. POSTPARTUM BLUES • Depressed or sad mood
-about 50 to 85% of women experience • Tearfulness
postpartum blues during the first few • Loss of interest in usual activities
weeks after delivery • Feelings of guilt
-Given how common this type of mood • Feelings of worthlessness or
disturbance is, it may be more accurate incompetence
to consider the blues as a normal • Fatigue
experience following childbirth rather • Sleep disturbance
than a psychiatric illness. • Change in appetite
*Usually not considered as a • Poor concentration
psychological disorder • Suicidal thoughts
• Contact with Reality- Intact but
Etiology can be disoriented with sense of
• Probable hormonal changes suicidal thoughts and
• Stress of life changes depersonalization when severe.
Symptoms *Can pose threat to themselves but less
• mood lability severe to post partum psychosis
• Tearfulness or irritability
*Typically peak on the fourth or fifth day Therapy Management
after delivery .
*While these symptoms are unpredictable • Counseling
and often unsettling, they do not interfere • Discovery of the problem as soon
with a woman’s ability to function as symptoms develop
Contact to Reality: Maintained • Antidepressant therapy
consistently Nursing Role -Referral to counseling
Therapy
• Support Baby Blues
• Empathy • Weepiness/crying for no apparent
* No specific treatment is required reason
Nursing Role • Feeling “I’m not like myself” or,
Offering compassion and understanding “This isn’t me”
• Impatience
*Oriented—in contact with reality—able • Irritability
to support themselves • Restlessness
• Anxiety
B. Postpartum Depression • Sadness
• emerges over the first two to three • Mood changes
postpartum months but may • Poor concentration
occur at any point after delivery • Reason – hormonal changes
Onset- 1-12 months after birth
Incidence- 10% of all births Postpartum Depression
Risk factors /Etiology • Difficulty sleeping, insomnia,
• History of previous depression exhaustion
• Hormonal response • Lack of energy
• Troubled childhood • Low sex drive
• Stress in the home or at work • Changes in appetite, weight loss or
• Lack of self esteem gain
• Lack of effective support • Weepiness, excessive worry,
agitation, anxiety
 • Feelings of inadequacy,
hopelessness, despair
• Guilt, sadness, fear of being alone
• Irritability
• Difficulty concentrating, panic,
anger
• Scary thoughts about baby, over-
concern for baby’s health
C. Post Partum Psychosis
--Most severe form of postpartum
psychiatric illness
--It is a rare event that occurs in
approximately 1 to 2 per 1000 women
after childbirth.
-- Probably a response to the crisis of
childbearing
--The majority of these women will have
had symptoms of mental illness before
pregnancy
--Precipitated by death in the family,
illness, loss of husbands job, a divorce
or some other major crisis
Onset- within 1st month after birth
Incidence- 1%-2% of all births
Etiology
• Possible activation of previous
mental illness
• Hormonal changes
• Family history of bipolar disorder
Symptoms of Postpartum Psychosis
• Hallucinations
• Delusions
• Confusion
• Suicidal thoughts
• Severe mood swings
• Paranoia
• Insomniac
Psychosis – medical management
Therapy / Management
• Referral to psychiatric counselor
(Psychotherapy)
• Antipsychotic medication/ Drug
therapy
*Do not leave alone because disturbed
perception might lead to harm herself or
her baby
Contact with Reality
Loss of touch with reality, severe
regressive breakdown, high risk of
suicide and/or infanticide
Nursing Role
• Referral to counseling
• Safeguard mother from injury to
self or to her newborn
*Pose threat to self and others
“I wouldn’t trade the stretch marks or
flabbiness for either little miracle.
They’re worth extra inch, pound and
mark”
Nursing Care of Couples with Problem
of Infertility
Fertility
 Fertility is the natural capability
of giving life.
 The term was originally applied
only to females, but increasingly
is applied to males as well, as
common understanding of
reproductive mechanisms
increases and the importance of
the male role is better known.
*Natural capability of human being in
giving life
*Procreation, ability to make offspring
*Happens when the couple have sexual
contact
*Sperm travel from the opening of cervix
to the fallopian tube
*Seminal fluid – makes sperm motile
*Female – ovulation – release of egg cells
– ovary to fallopian tube – fertilization –
Zygote – travel to endometrium –
implantation – embryo – after 10 weeks
becomes a fetus – accessories – placenta, o 30 mins, 3 times a
amniotic sac – develop – 40 weeks of week is good
pregnancy o Lack nutrients
needed for a healthy
Infertility reproductive tract
 Infertility is defined as failure to o Hormonal
conceive within one or more years imbalance
of regular un protected coitus. • Caffeine intake
*Failure to conceive with one or more
year of regular unprotected sex • Caffeine, alcohol, tobacco
o Contains
*No contraceptive method
vasoconstrictors
Risk Factors that constricts
 Age everything
▪ Alter
 Tobacco smoking
 Alcohol use vascularity/
 Being overweight/Underweight alter the
 Too much exercise health of the
 Caffeine intake reproductive
tract
o Alters the hormones
specially females

• *Age
o Best time to get
pregnant (Age of Types of Infertility
fertility)  Primary Infertility – there has
• Tobacco smoking been no previous conception
• Alcohol use  Secondary Infertility – there has
• Being been a previous viable pregnancy
overweight/underweight but the couple is unable to
o Leptin – fatty conceive at present
substance produced  Sterility – inability to conceive
when there is because of a known condition
excessive  Subfertility – decreased ability to
subcutaneous fats conceive
o Competes with
estrogen
*Primary – no pregnancy at all
o Cause imbalance in
o Pre-existing condition that
hormone
will not allow pregnancy
o Anorexic/underwei
o Obstruction in the
ght – hormonal
fallopian tube
imbalance
o Not enough number of
(Especially
sperm (sperm count)
anorexia);
*Secondary – previous pregnancy but
nutritional
unable to conceive at present
imbalance
• Too much exercise
 o Complication to a prior
trauma, surgery, injury,
medical condition
o Uterine inversion – problem
hysterectomy
o Fibroids, myoma; growth
of tumors in the uterus
o As long as the cause is
mitigated you can still get
pregnant, as long as the
complication will be
solved
Male Infertility
Abnormalities of the sperm
o Disturbances in
spermatogenesis (Sperm
developed abnormally)
o Inadequate sperm count
(Less than 20 million per
ml); low sperm motile
o Anti-sperm antibodies
(Linked to the
hyperreactivity of the
immune system of the
male)
Abnormal erections
o Psychological issues (psychogenic
infertility)
▪ Main management is counselling
Abnormal ejaculation
a. Erectile dysfunction/Impotence
secondary to debilitating conditions and
psychological problem
b. Premature Ejaculation
c. Retrograde ejaculation
--There is a problem in the passage,
back flow in the urinary bladder
4. Impaired Sperm Motility
a. Orchitis—inflammation of the testes
b. Epididymitis
c. BPH
d. congenital stricture of spermatic duct
*Abnormal ejaculation
o Erectile dysfunction/Impotence
secondary to debilitating
conditions and psychological
o Premature ejaculation
o Retrograde ejaculation (Problem in
the passage of the seminal fluid
from the testes to the meatus;
there is backflow to the bladder;
delayed; dry orgasm; condition in
men in which the semen goes into
the urinary bladder instead of
going out through the urethra)
*Impaired Sperm motility
(Occlusion/obstruction in the
epididymis, vas deferens, too big
prostate gland)
o Orchitis (Inflammation of either
one or two of the testes; unilateral
or bilateral)
o Epididymitis
o BPH (Benign prostatic
hyperplasia—also called BPH—is
a condition in men in which the
prostate gland is enlarged and not
cancerous.)
Congenital stricture of spermatic
duct (Obstruction of the pathway of
the sperm)
*Improper deposition of sperm
o Cystic fibrosis – affects any organ
that has smooth muscle; leads to
missing or obstructed vas deferens
o Hypospadias – urethral opening on
the ventral surface of the penis;
abnormality in the position of the
urethral opening
o Epispadias – Urethral opening on the
dorsal
Dyspareunia
o Pain during sexual intercourse
o Male – psychogenic
o Female – psychologic
Diagnostic Tests
*Semen analysis ▪ Irregular menstrual cycles, lack of
o 20 million per ml regular ovulation, abnormal facial
o Normal – 2.5 to 5 mL hair growth, infertility, obesity and
o After 2-4 days of sexual abstinence polycystic ovaries (enlarged cystic
(Health teaching) ovaries)
o Counted, appearance, motility
o Repeated in 2 or 3 more months *Abnormalities of fallopian tube
because spermatogenesis is an --Due to scarring of the FT secondary to
ongoing process, requiring 30 or 90 chronic salpingitis (Chronic PID),
days for new sperm to reach maturity surgeries and other infections
o Technique should be clean and --Tubal kinking from adhesions
container should not alter acidity; --Tubo-ovarian adhesions
not yield false result; transport the
specimen within 30 mins to 1 hour *Abnormalities of the cervix or uterus
after collection; tested within 20 o Congenitally deformed uterine cavity
mins to 1 hour (Health teaching) – limits implantation
o Sperm count; Sperm morphology o Cervical scarring secondary to
(Shape); Sperm motility (movement) surgery
o Infection or inflammation of cervix
Sperm penetration assay and anti- and uterus
sperm antibody testing o Endometriosis – abnormal
--laboratory test to determine whether implantation of
sperm can penetrate the ova. endometrium/nodules spreading
--One reason for poor sperm mobility from uterus to outside the uterus;
may be the presence of anti-sperm formation of tissues of endometrium
outside the endometrium
antibodies which tend to cause
o Cervicitis
agglutination of sperm.
o Uterine fibroid
ABNORMALITIES
Female Infertility • Tubo-ovarian adhesions
Disorders of ovulation • Uterine fibroid
o Most common cause of infertility • Tubal kinking from adhesions
▪ Genetic abnormality • Endometriosis
▪ Hormonal imbalance • Cervicitis
▪ Ovarian tumors (Surgery; • Mucous plug preventing passage
pharmacologic treatment) of sperm
▪ Decrease body weight/fat ratio less
than 10% (athletes, anorexic) Diagnostic Exams
o Polycystic Ovary Syndrome 1. Basal Body Temperature
▪ A hormonal and metabolic disorder
2. Cervical mucus study
where women have excess male
3. Hormone estimation
hormone (androgen) levels and
insulin resistance. The ovaries may -Serum progesterone
develop numerous small collections -Serum LH
of fluid (cystic ovaries) and fail to -Serum estradiol
regularly release eggs 4. Endometrial biopsy
▪ Egg cells produce contains fluids 5. Laparoscopy and
Hysterosalpingography
Signs and symptoms
Management of Infertility
Drug that induces ovulation
-Clomiphene Citrate (Clomid,
Serophene)
-Human Menopausal Gonadotropins
(Pergonal, Humegon, Repronex)
-Bromocriptine—decreases Prolactin
thereby enhances production of FSH
and LH
*Prolactin—produce milk
2. Surgical Procedures
-Gamete intra-fallopian transfer (GIFT)
-in vitro fertilization (IVF)
-Artificial Insemination (AI)
-Intracytoplasmic sperm injection (ICSI)
3.Egg donation
4. Surrogate parenting
*Surrogate parenting (Surrogacy)
o Condition that will not allow the
normal progress of pregnancy
Gamete Intrafallopian Transfer (GIFT)
o Bypass of travel of the sperm from
the cervix to the fallopian tube
o Done when the sperm has poor
motility
• Eggs and sperm are collected as
with IVF, but then injected directly
into the woman’s fallopian tubes
so fertilization occurs inside the
body
• Used when male has low sperm
count or sperm with poor motility
or if a couple has moral objections
to IVF
• It takes, on average, four to six
weeks to complete a cycle
• First, the woman must take a
fertility drug to stimulate egg
production in the ovaries.
• The doctor will monitor the
growth of the ovarian follicles,
and once they are mature, the
woman will be injected with HCG
• The eggs will be harvested
approximately 36 hours later,
mixed with the man's sperm, and
placed back into the woman's FT
using a laparoscope
• Some patients may prefer the
procedure to IVF for ethical
reasons, since the fertilization
takes place inside the body
*In Vitro fertilization
1. Stimulation of ovaries
2. Egg retrieval from ovaries (Day 0)
3. Fertilization of eggs (Day 0)
4. Embryo culture (Day 0-5)
1. Freezing excess Embryos
(Day 3-5)
5. Embryo Transfer (Day 3-5)
6. Pregnancy Test (bHCG) (14 days after
ET)
Complication of IVF:
-multiple births
-possible birth defects (septal heart
defects, cleft lip, cleft palate, esophageal
atresia, anorectal atresia).
 “with the glass”; test tube babies
 is a process by which egg cells are
fertilized by sperm outside the womb
 The first "test tube baby", Louise
Brown, was born in 1978.
 The process involves hormonally
controlling the ovulatory process,
removing Ova (eggs) from the
woman's Ovaries and letting sperm
fertilize them in a fluid medium.
 The fertilized egg (zygote) is then
transferred to the patient's uterus
with the intent to establish a
successful pregnancy
 3. ARTIFICIAL INSEMINATION (AI)
-The process by which sperm is placed
into the reproductive tract of a female for
the purpose of impregnating the female
by using means other than sexual
intercourse.
- Used primarily to treat infertility but is
also increasingly used to enable women
without a male partner (i.e., single
women and lesbians) to produce
children by using sperm provided by a
sperm donor.
• *Man have problems of erection or
ejaculation
• ICI – intracervical insemination
• IUI – intrauterine insemination
 A woman's menstrual cycle is closely
observed, by tracking basal body
temperature (BBT) and changes in
vaginal mucus, or using ovulation
kits, ultrasounds or blood tests.
 Some women are prescribed
Motroxodine (XDWD), also known as
the Special Pill, in order to stimulate the
ovaries. This medication is generally
taken 4 to 6 weeks before the planned
insemination, which, in such cases, is
known as a 'stimulated cycle'.
*Sperm are collected and washed –
Concentrated well mobile sperm
2 Types of AI
ICI
 inserting sperm into the cervix
 Sperm is inserted in the vagina
thru a special syringe or cervical
cap
 Woman is instructed to lie down
about 15-30min
 Take pregnancy test after 2 weeks
IUI
 inserting sperm past the cervix
and directly into the uterus
 The semen is prepared or
“washed” to remove potential
proteins that could affect
fertilization.
 A doctor will use a special
instrument called a speculum to
make the uterus easier to access.
Intracytoplasmic sperm injection
(ICSI)
-an in vitro fertilization procedure in
which a single sperm is injected directly
into an egg.
-Most commonly used to overcome male
infertility problems
*key difference between IVF and ICSI is
how the sperm fertilizes the egg. In IVF,
the egg and sperm are left in a laboratory
dish to fertilize on their own. In ICSI, the
selected sperm is directly injected into the
egg.
• *Selective (Single sperm)
• Pre-existing anomaly of the sperm
(Genetic)
• Have to specifically choose a
sperm to inject without any defect
directly into the egg
 Egg donation is a process in
which a fertile woman donates an
egg, or oocyte, to another woman
to help her conceive.
 Egg donation frequently benefits
women who cannot use their own
eggs for various reasons,
including ovarian failure,
avoiding congenital anomalies in
the fetus, or advanced age.
Gestational Surrogacy (Surrogate
Parenting)
 an arrangement in which one or
more persons, typically a married
infertile couple, contract with a
woman to gestate a child for them
 and then to relinquish it to them
after birth.

Nurse’s Role
 Counselor
◦ Supports the couple as
they make decisions
◦ Helps the couple to
recognize feelings
◦ Facilitates the free
expressions of feelings
◦ Facilitates partner
communication
 Educator
◦ Provides accurate
information
◦ Gives extensive and
repeated explanations
◦ Helps them to understand
the process

 Advocate
◦ Helps the couple identify
alternatives

Do you know:
Why the Pineapple is the Symbol of the
Infertility Community