Abnormal labor

Outline:

Objectives.
Introduction.
Related definitions.
Factors that might complicate progress of labor.
Problems in the powers.
Problems in the passage.
Problems in the passenger.
Problems in placenta.
Problems in psychological status.
Common complication.
Nursing management for dystocia.
Obstetric emergencies & its management.

Objectives:

General objective:

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 By the end of this lecture each student should be able to obtain
comprehensive knowledge about abnormal labor & obstetric
emergencies.

Specific objectives:

At the end of this chapter the student should be able to:

1. Define related definitions correctly.
2. Mention factors that might complicate labor completely.
3. Clarify problems in powers.
4. Identify problems in passage.
5. Mention problems in placenta.
6. Explain problems in passenger.
7. Discuss nursing management for abnormal labor
8. Identify obstetric emergencies accurately.
9. Explain nursing management for emergencies according to
priority of care.

Abnormal labor

Introduction:

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 While many risk factors may appear in the prenatal period,
others will only become evident in admission in the birthing unit or
develop during birth and labor. The nurse plays a central role in
promptly recognizing suspected and obvious abnormalities. When life-
threatening condition arises rapid appraisal is necessary.
According to the national maternal mortality survey, obstructed
and prolonged labor accounted for 8% of deaths from direct obstetrical
causes (64.5%). And about 60% of maternal deaths occur in medical
facilities.

Related definitions

Immature labor: Termination of pregnancy between 20 -28 weeks

(fetal weight 500 1000 gm).

Premature labor: Termination of pregnancy between 28 - 38

weeks (fetal weight 1000 2500 gm).

Postmature labor: Prolongation of pregnancy 2 weeks or more

beyond the calculated date of delivery.

Prolonged labor: The labor last for more than 24 hour in PG & 16
hour in MG.

Precipitated labor: The labor last for about 1 3 hours.

Dystocia: Prolonged, painful, or difficult delivery results from

deviation from normal interrelationships between five essential factors of
labor (power, passage, passenger, placenta & psychological status).
OR Dystocia is defined as abnormal or difficult labor, whereas eutocia
describes normal labor or childbirth and oxytocia describes rapid labor.

Factors that might complicate progress of labor:

Uterine factors (abnormalities of the power);

1. Hypotonic uterine contraction.
2. Hypertonic uterine contraction.
3. Incoordinate uterine action.

o Pelvic factors (abnormalities of the passage);

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 1. Contracted pelvis ( inlet midpelvis outlet ) contracture.
2. Abnormal pelvic shape.
3. Soft tissues obstruction.

Fetal factors (abnormalities of the Passenger);

1. Unusually large fetus & Fetal anomaly.
2. Abnormal fetal number.
3. Abnormal fetal disposition.

Placental factors (abnormalities of the Placenta);

1. Unusually large placenta.
2. Abnormal shape.
3. Abnormal site of insertion.

Psychological status; refers to clients psychological state,

available support system, preparation for childbirth, experiences &
coping strategies.

Abnormalities in the power:

Power Indicates primary involuntary uterine muscle contraction and
secondary voluntary abdominal muscles contractions by bear down.

Abnormal uterine contraction:

Hypotonic uterine contraction;

It means weak contraction that caused by
Over stretching in the uterus by multiple pregnancy
Epidural anaesthesia.
Chorioamnioitis.
Mal presentation, mal position.
Maternal disease.
It result in prolonged labor

Signs & symptoms:

Weak contraction.
Exhaustion.
Dehydration.
Sever pain.
Cervical and vaginal edema.
Premature rupture of membranes (PROM).
Sings of fetal distress like abnormal fetal heart rate (FHR).

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 Hypertonic uterine contraction;
In which uterine contraction characterized by increase duration by
more than 90 second, decrease interval less than 60 second and
incomplete relaxation between contraction.
This condition caused by
disturbance in the fundal pacemaker.
fetal mal presentation or mal position.
over stimulation by Oxytocin.
It result in precipitated labor
Signs & symptoms:
Tetanic (long and painful) uterine activity.
Exhaustion.
Sever pain.
Signs of fetal distress.

Incoordinate uterine action;

- Contraction ring; It is a localized spasm of the circular muscle fibers
of the uterus. It usually occurs around a groove in the fetal body e.g.
neck. It not seen or felt abdominal.

- Retraction ring (Pathological or Bandles ring); occurs at the

junction of the upper and lower uterine segment, it occurs at the level of
umbilicus, it seen & felt as a sign of obstructed labor.

Factors leading to weak voluntary power are;

1. Weak abdominal muscles.
2. Obesity associated with weak abd. Muscles.
3. Epidural anesthesia.
4. Debilitating diseases as anemia, HD & diabetes.

PRECIPITATE LABOR:
The fetus is rapidly expelled from the birth canal. The duration of labor is
less than 3 hours sometimes.
Aetiology:
- Strong frequent uterine contractions.
- Laxity of the tissues of the birth canal, so more frequent in multiparae.
- High pain threshold, so the patient does not feel except the last few
strong contractions.
Complication:
A-Maternal: - Lacerations of the cervix, vagina or perineum.

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- Postpartum hemorrhage (due to lacerations and there is no time for
retractions). - Inversion of uterus.
- Rupture of symphysis pubis. - Acute anemia.
- Puerperal sepsis due to lacerations and unsuitable circumstances.
- Amniotic fluid embolism.
B-Fetal: - Asphyxia: the strong frequent uterine contraction interfere with
placental circulation.
- Intracranial hemorrhage due to rapid compression of the head.
- Rupture of the cord.
- Injury or death o the fetus due to falling.
Role of the nurse
Major objectives of care are as follows: - Preventing maternal trauma.
- Preventing transmission of infection. - Establishing the neonates airway
and maintaining respiration. - Minimizing blood loss.
- Reassuring the woman and securing medical help.
- The nurse must be prepared to evaluate the womans labor status, alert
the birth attendant and other staff as needed.
- The nurse must immediately assess or the womans labor patterns, stage
of cervical dilatation and effacement, and fetal station and presentation.
FHR should be auscultation at once and monitored for signs of apparent
fetal distress.
- Once the second stage is initiated, place the palm of the hand firmly
against the perineum and emerging fetal head.
- If time permits, turn the woman to aside lying or Sim,s position.
- When the head is born, suction the neonates mouth & nares.
- Clamp the cord, and complete the care as normal labor.

PROLONGED LABOUR:-
It is one in which regular uterine contraction with a dilation cervix have
been present or 18 hours more or for 12 hours since admission.
Causes:- Faults in the powers. - Faults in the passage.
- Faults in the passenger. - Faults in the patients psychology.
Complications:
* Maternal
- Maternal morbidity, dehydration, ketoacidosis.
- Puerperal infection, postpartum hemorrhage.
- Infection of urinary tract.
* Fetal:- Perinatal death due to Pneumonia, Intrauterine infection,
hypoxia and Stress from reduced placental circulation.
Nursing implications:
- Continuous monitoring of progress of labor and fetal condition.
Fetal heart assessment for signs of distress and uterine assessment for
titanic contractions and pathological ring is essential.

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- Close monitor of intake and output and vital signs for possibility of
uterine rupture.
- Comfort measures to relieve pain and encourage progress of labor.
- Give glaucose intravenous to avoid dehydration.
- Antibiotics to control infection.
- Intravenous oxytocin is started and fetal monitoring is closely observed

Abnormalities in the passage:

Abnormal pelvic size;

Contracted pelvis; means that the essential diameters of pelvis is
decreased by 1 cm or more. Small size lead to inlet, mid pelvis or outlet
contracture.
Cephalopelvic Disproportion:
Disproportion between the size of the fetal head and that of the maternal
pelvis with resultant difficult labor, and danger to the fetus.
Degrees of contracted pelvis:
Minor degree: The true conjugate is 9-10 cm. It corresponds to minor
disproportion.
Moderate degree: the true conjugate is 8-9 cm. It corresponds to moderate
disproportion.
Marked degree: the true conjugate is 6-8 cm. It corresponds to marked
disproportion.
Extreme degree: The true conjugate is less than 6 cm. Vaginal delivery is
not possible.
Diagnosis of disproportion
1-History
*Bone disease or fractures. *Previous difficult labor.
2-General examination
- Short stature less than 150 cm.
- Bone deformity or limping gait.
- Rachitic flat pelvis.
- A symmetrical due to poliomyelitis, pelvic turmors, or fracture.
3-Abdominal examination
- Pendulous abdomen.
- Malpresentation.
- Non-engagement of the fetal head after 37 weeks in primigravida.
4-Pelvic examination.
- Non engaged head.
- Palpable sacral promontory and prominent ischial spines.
- Convergent side walls.
- Narrow subpubic angle and arch.
- Unsatisfactory tests of disproportion.

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 5-During labor:
- Failure of the head to descend.
- Failure of the cervix to dilate progressively, even after the use of
oxytocin stimulation.
- Excessive moulding and caput formation.
6-Radiological diagnosis
By x-ray or CAT scan. Lateral view is satisfactory to get data about the
anteroposterior diameters of the pelvis, curve of the sacrum, sacrosciatic
notch and engagement of the head.
Management of disproportion
It depends on the degree of disproportion.
Indication for elective cesarean section (C.S):
- Marked disproportion.
- Moderate disproportion with other obstetric complications as
malpresentations, bad obstetric history, and previous c.s. or failed trial
labor.
- Associated medical problems as diabetes, hypertension.
- Preterm labour. - Contracted out let.

Abnormal pelvic shape;

Android pelvis (male pelvis): the brim heart shaped with straight
sacrum which prevent fetal rotation.

Platypelloid pelvis: the brim kidney shape with short anterior posterior
diameter which lead to difficult fetal engagement.

Anthropoid pelvis: the brim oval shaped with short transverse

diameter which lead to fetal mal position.

Soft tissues Obstruction;

1. Ovarian tumor.
2. Uterine fibroid,
3. Bicornuate, double uterus, septate uterus or didelphys.
4. Cervical polyps.
5. Vaginal stenosis.
6. Perineal tumors or cysts.

Abnormalities in passenger:
Congenital anomalies and fetal malpresentation can result in fetal distress
and deviation from the normal course of labor and birth. A variety of fetal
problems may have particular significance in the intrapartum period,

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 increasing maternal and fetal risk. Other problems include fetal anomalies
that influence the course of labor and birth; multifetal gestation, which
poses additional risks to fetal well being in the intrapartum period; which
not only affect the physiologic, but also the psychological process or
labor and birth.
1-Multifetal gestation:
Multifetal gestation includes twins pregnancy, triplets, or quadrates.
Prenatal care for woman with multifetal gestation as well as intrapartum
care is essential in preventing hazards that can affect both maternal and
fetal life and health.
Causes:
The aetiology of spontaneous monozygotic twins is unclear, Dizygotic
twins has the following predisposing factors:
- Age: its more common among women aged 20-39 years and dramatic
decrease after this age occurs.
- Fertility drugs: that stimulate the ovaries to produce many ovum. The
incidence is approximately 20%.
- Race predisposition: Its common among nigerian black women, while
it is less seen among Japanese women.
- Multiparity: it is more common among parous women than nulliparous
women.
Diagnosis:
- Multifetal pregnancy often suspected when the uterine size or fundal
height is greater than dates.
- Ultrasonographic estimation of two or more feta noutlines and
auscultation of more than one fetal heart is a positive sign.

Maternal and fetal implications:

Although the rates of morbidity to those women with multiple gestation
the mortality rates is just slightly higher.
Intrapartum complications associated with multifetal gestation:
- Pregnancy induced hypertension.
- Abruption-placenta.
- Placenta-previa.
Role of nurse
- The nurse should evaluate fundal height on her first assessment and
perform abdominal examination to identify fetal extremities.
- Report immediately suspicion of multiple gestations.
- Intrapartum care includes close observation of vital signs.
Assessment of signs of pregnancy induced hypertension, including
edema, proteinuria and hypertension. Close monitoring of fetal heart
rates guided by ultrasonography is useful.
- Assessment of progress of labor and early detection of dystocia.

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- Immediate newborn care and identification of the two twins,
weighing them and keep them warm all the time. Avoidance of
invasive procedure and gentle suctioning is essential.

Fig. 1 Different position for twins

2-Abnormal fetal position and presentation

Abnormal fetal presentation and position can lead to dystocia and
ineffective uterine contractions. It includes the follows:

A-Occipitoposterior position:
In this position the fetal occiput and small posterior fontanel are located
in the posterior segment of maternal pelvis, and the brow and face are in
the anterior segment.
Incidence: It occurs in 15-30% of labor, most of fetuses rotate during
labor.
Aetiology:- Android pelvis. - Anthropoid pelvis.
- Cephalopelvic disproportion. - Pendulous abdomen.
- Multiple pregnancy.
Diagnosis: During abdominal assessment the fetal back is not
identified well, while fetal small parts are easily identified, fetal heart rate
may best heard at maternal flank, far from the midline. The anterior
fontanel is readily felt in the anterior segment of the maternal pelvis, FHS
are heard very well through fetal chest by ultrasonography shows the
position of the fetus.
Maternal, fetal and neonatal implications:
- Cervical dilatation and fetal descent is often slow.
- Labor is significantly prolonged.
- Excessive backache and coupling of uterine contraction.
- Premature rupture of membrane.

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 - Midpelvis arrest.
- Higher rate of instrumental delivery.
Nursing implications:
- The nurse should encourage the woman to use positions that may help
fetal rotation.
- The nurse should monitor intake and output as dehydration is possible
from prolonged labor and assess of urine for ketone bodies is important.
- Evacuate the bladder and assessment of urine for ketone bodies is
important.
- Encourage the woman to prevent frustration and assess fetal heart
closely especially at the second stage of labor.
- Avoid unnecessary P.V.
- Change the mothers position to help rotation of the presenting part
and relieve backache as in squatting, knee chest position manual
rotation of the presenting part is done to be followed by midpelvis
forceps.

B- Breech presentation
Breech presentations are more common cause of dystocia and in many
settings contribute significantly to the incidence of caesarean section
breech presentation is associated with ineffective cervical dilatation due
to the soft buttocks. The soft buttocks passes easily through incomplete
dilated cervix and the head becomes trapped leading to hypoxia and may
be asphyxia.
Incidence: Breech presentation is common in the second trimester,
but most usually rotates at labor, it is found in approximately 3-4% of
singleton pregnancy.
* Before 34 weeks, it is 25%.
* After 34 weeks 33%.
Aetiology:- Uterine anomalies as bicornuate uterus or separate uterus.
- Fetal anomalies as hydrocephalus or abdominal tumors.
- Multiple gestation.
- Premature fetus and low birth weight, as free movement is more, it
occurs in 20% where fetal weight is 1000 gm.
- Multiparty is associated with breech presentation.
- Cord around neck.
Classification: Breech presentation is classified into
- Frank breech (extended knees, flexed hips). It occurs in 65%.
- - Incomplete or flooting breech (extended knees, extended hips).
it occurs in 25% of breech presentation.
- Complete breech (flexed knees, flexed hips). It occurs in 10% of breech
presentation.

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 C. Single
footling breech presentation,

Fig.2 Types of breech presentation

Diagnosis:
Abdominal examination shows the vertex is present in the fundus and
ballot able and fetal heart sound is auscultate above the umbilical level,
bimanual examination shows absence of fontanels and presence of sacral
bone, feets or soft buttocks, by ultrasonagraphy confirme diagnosis.
Nursing implications:
- During the course of intrapartum assessment early detection is essential
for better management.
- Patient support and clarification of the condition is essential.
- Intravenous infusion is started for possible cesarean section.
- Preparation for tocolytic administration to give time to better
assessment.
- Electronic fetal monitoring is indicated particularly in meconium
stained amniotic fluid.
- Pediatric nurse and medical staff should attend the labor.
Maternal, fetal, and neonatal implications:
- Premature rupture of membranes.
- Cord prolapsed.
- Maternal infection.
- Prolonged labor.
- Traumatic delivery vaginal and perineal lacerations.
Factors affecting mode of delivery in breech
presentation: criteria for vaginal delivery:
- Frank or complete breech with hyperextension of fetal head.
- Fetal weight estimated as less than 3500gm.
- Adequate pelvic size.

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 - Gestational age of 36-42 weeks.
- Birth attendants experienced in vaginal breech delivery and
pediatric
support available in the event of neonatal problems.

Cesarean delivery:
- Absence of labor when fetal status requires delivery.
- Premature fetus that requires minimal stress.
- Previous history of perinatal death or infant with residual birth trauma.
- Inadequate pelvis suggested by previous birth.

C-Brow presentation:
Brow presentation occurs when the fetus is in a head down position with
the head straight or slightly extended so that the brow and orbital ridges
are the presenting part of the skull
Aetiology: - Multiparty with small fetus.
- Neck tumors as thyroid tumors.
- Cephalopelvic disproportion.
Diagnosis:- Fetal brow on vaginal examination.
Maternal, fetal, and neonatal implications:
If the maternal pelvis is adequate the delivery can proceed normally.
Vaginal delivery with persistent brow presentation usually results in
perineal and vaginal lacerations. There is increased risk of head, neck,
larynx, and damage to the central nervous system. Trauma from forceps
application is also common.
Nursing implications:
- Close monitoring of the progress of labor and fetal status
throughout labor.
- Insertion of fetal scalp electrode is contraindicated.
- Assurance and parents. Support is very important as labor may be
prolonged.
- Preparation for emergency cesarean delivery or forceps application
is important.
- Assurance a bout any possible face swelling or lacerations to the
parents.

D-Face presentation:
Face presentation occurs when the fetus is in a head down position the
head hyper extended.
Incidence: It occurs in 0.2%.
Aetiology: - Multifarious women.
- Small pelvis. - Large infant.
- Congenital goiter or anencephaly.

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 - Weakness in maternal abdominal wall.
Diagnosis: Face presentation is diagnosed on vaginal examination
where the facial features of the fetus are palpable.
Maternal, fetal, and neonatal implications:
- Vaginal delivery can occur in 80% of cases if maternal pelvis is
adequate and the presentation is mento-anterior. While if the chin is
posterior and no further extension is possible the delivery is arrested.
Cesarean section may be expected.
- Prolonged labor is expected. Fetal membranes usually rupture early in
labor. Newborn face is swollen, lacerated and moulding is pronounced.
Edema of the larynx is common cause of respiratory distress.

Nursing implications:
- Application of fetal electrodes is contraindicated to prevent fetal
injury. - The nurse should be prepared for emergency delivery an
resuscitation efforts if the infant is compromised.
- If cesarean delivery is planned after a considerable time the parents
should be prepared to the facial appearance of the infant which usually
resolute at the fifth day.

E-shoulder presentation:
Shoulder presentation occurs when the fetuss long axis is perpendicular
to the maternal axis in a transverse lie.
Incidence: It occurs in about 0.3% of singleton pregnancy. It is more
common in twins and when fetal weight exceeds 4000 gm.
Aetiology: - Multiparty. - Lax abdominal muscles.
- Preterm labor. - Low lying placenta.
- Inlet contracture. - Macrosomic infant.
Diagnosis:
- Abdominal examination shows abnormal transverse appearance.
ultrasongraphy confirms the diagnosis.
Maternal, fetal, and neontal implications:
Labor can be dysfunctional. Pathological ring and even rupture uterus can
result if diagnosis is missed.
There is increased risk of cord prolapsed and prolapse off the shoulder
into the vagina.
Nursing implications:
Abdominal examination is performed to confirm the diagnosis and proper
notification. Preparation to external version or cesarean section is done.

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 Fig. 3 Fetal presentation

Abnormal fetal size;

Macrosomia, which is defined as a fetal weight of 4500 g or
more (common in diabetic mother).
Fetuses with anomalies such as hydrocephaly, enlarged abdomen, or
neck masses can also present with dysfunctional labors.

Abnormal Fetal position;

Abnormal denomonators; Sacrum(S), Scapula(Sc), Mentum(M) &
Fronto(F).
e.g. if Sacrum is denomonator, the fetal position may be RSA, LSA,
RSP,LSP.

Abnormalities in placenta:
Abnormal placental size;
large placenta (most common in diabetic mother) lead to dystocia in 3rd
stage.

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 Abnormal placental shape;
Placenta succenturiata: placenta with one or more accessory lobes.
Placenta bipartita or tripartita: two or three separate areas of
placental tissue, there is one umbilical cord which divided &
sending branch to each lobe.
Placenta circumvallata: chorion is still continuous with the edge of
the placenta but its attachment is folded back to the fetal surface.

Placenta velamentosa: insertion of cord into the membranes, blood

vessels between cord and placenta across the membranes. When
membrane rupture result in hemorrhage( Vasa previa).

Battledore placenta: the umbilical cord is inserted at or near the

placental margin.

Abnormal site of placental insertion;

placenta previa; that means abnormal situated placenta in lower

uterine segment (LUS). It may be partly in LUS, marginalis to cervix,
partly over internal Os or central lie over Os.

Placenta accerta: abnormally adherence placenta to the uterine

wall.
- Placenta increta, the villi invade the myometrium..
- Placenta percreta, the villi penetrate the myometrium.

Problems in psychological status:

Psychological factors that affect tolerance of pain;

1. Culture; some cultures encourage loud & vigorous expression of
pain.

2. Previous experience; previous bad experience do always

adversely affect a womans ability to deal with pain.

3. Preparation for delivery; learn the mother a variety of skills to

master pain.

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4. Support system; the birth experiences of a womans family &
friends can be an important source of support if they convey realistic
information about labor pain & its control.

5. Fear & anxiety.

Fear & anxiety increase muscle tension general fatigue increase
pain perception and decrease coping skills to relieve pain which
increase maternal anxiety, exhaustion and loss the power to bear down
during 2nd stage ( secondary power).

Common complication:

Maternal and fetal distress.

Infection - Ruptured uterus.
PROM. - Cord prolapse.

Nursing management for dystocia:

Prevention :

During pregnancy;
- Early detection of high risk women.
- Discover contracted pelvis and mal presentation.
- Improve standards of maternity services ( prenatal care, family planning
programs).
- Follow up and health education during pregnancy about diet, exercises,
hygiene, activity and danger signs during pregnancy.
- The multipara must be delivered in hospital.

During labor;
- Proper assessment for mother in admission through complete history
taking, physical examination and investigation.
- Close observation for progress of labor.
- Avoid misuse of Oxytocin.
- Frequent empty the bladder.
- Comfort measures and hydration.

Mangement:

1. 1st stage:

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 Complete assessment for mother in admission to detect the cause
of dystocia.
*Complete history
*A careful physical examination must be performed.
- General examination; ht., wt., .
- Abdominal examination with Leopold maneuvers in order to
ascertain the presentation of the fetus and to estimate the fetal weight.
- The pelvic examination focuses on determination of the pelvis
capacity using clinical pelvimetry.
- Vaginal examination to assess CD, station, effacement, fetal
position & presentation.
*Investigations; C.B.C, RH, blood group, urine analysis, sonar,.

2. Close observation using electronic monitoring for

- Progress of labor (cervical dilatation, fetal decent, uterine
contraction and condition of membranes).
- Fetal condition (FHR).
- Maternal condition especially for dehydration, pallor, exhaustion,
cervical & vaginal edema and sever pain, signs of shock and recording
for any abnormality.

3. Management of dystocia depends on underlying factors related

to the maternal condition and fetal status.

4. Provide comfort measures to relieve pain and help client to adapt

comfortable position.
5. IV fluids to maintain hydration and observe intake & output.
6. Encourage frequent evacuation of bladder evacuate the rectum
by enema.
7. Administer the prescribed drugs (antibiotics, analgesics).

2- 2nd stage:

8. Prepare the mother for instrumental delivery e.g. Forceps or

Vacuum extraction or CS if necessary.

Instrumental delivery:
- Preparation for place, equipment & appratus.
- Preparation for mother; postioning, sterlization, evacuate the
bladder and anesthesia.
- Close observation for FHR, vital signs & contraction.

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- Assist the doctor during delivery; follow fetal decent, supporting
the perineum, cutting the episiotomy
- Suctioning & oxygenation for baby at birth.
Cesarean section:
- Preparation for place, equipment & appratus
- Preparation for mother; remove any jewelry, assess vital signs,
catheterization, IV line, collect specimen for lab, singed consent and
anesthesia.
- Assist the doctor during delivery.
- Suctioning & oxygenation for baby at birth.

3 3rd stage:

9. If the placenta has not been delivered within 45 to 60 min of

delivery, manual removal may be necessary.
- The entire hand is inserted into the uterine cavity, separating the
placenta from its attachment, then extracting the placenta.

10. The placenta should be examined for completeness because

fragments left in the uterus can cause delayed hemorrhage or
infection.
- If the placenta is incomplete, the uterine cavity should be explored
manually under general anesthesia to detect retained placental
fragments.

4 4th stage:

11. Observation for mother include vital signs, uterus, lochia,

perineum, wound condition, intake & output

12. Uterine massage in case of instrumental delivery

13. Perineal & breast care.

14. IV fluids with oxytocic drugs.

15. Physical & neurological examination for baby.

- Eye, cord & diaper care.
- Reassure the mother if there is any injury result from delivery.

16. Encourage breast feeding as early as possible after delivery.

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 Obstetric emergencies

Abruption of the placenta:

An abruption is a death threat to the fetus and a hazard to the mother.

When the placenta separates from its bed (probably because of the rupture
of a malformed blood vessel), the damage to the fetus follows not just
because of the barrier that the clot makes between the placental bed and
villi but also because the release of prostaglandins causes a major degree
of uterine spasm. This interferes with perfusion of the placenta, which
remains attached. Blood tracking into the myometrium often goes as far as
the peritoneum over the uterus, causing much pain and shock, with spasm
of the uterine muscle.
Clinical features of abruption of the placenta
Symptoms
0 Abdominal pain
Severe shock with symptoms beyond vaginal blood loss
Vaginal bleeding usually old blood
Signs
Shock
Spasm of uterus described as woody
Tender uterus
Fetal parts hard to feel
Often no fetal heart is heard
Emergency treatment of abruption
Treat the shock
Give oxygen
Insert intravenous lines
Arrange a cross match of 6 units of blood
Give morphine (if fetus dead)
Deliver the fetus
By caesarean section (if fetus is alive and gestation is mature)
By rupturing membranes (if cervix is ripe or fetus is dead)

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 Treat disseminated intravascular coagulopathy
Urgent haematological consultation
Check platelet count
Give cryoprecipitate (fresh frozen plasma)
Transfuse with fresh blood if available

Fig. 4 Abruptio placenta

Placenta previa:

The blastocyst occasionally implants in the lower part of the uterus.

Stretching and thinning of the uterine muscle of the lower segment in the
third trimester may sheer off part of the placental attachment. This is
accompanied by painless bleeding.
Clinical aspects of placenta praevia
Symptoms
Vaginal bleeding bright red, painless, recurrent
Signs
Soft, pain free uterus
Easy to feel fetus often high head, breech, or transverse lie
No fetal distress
Do not do a digital vaginal examination
A speculum examination in an inpatient to exclude any local
bleeding is acceptable
Four stages of severity of placenta praevia:
I placenta encroaches on lower segment but does not reach internal os

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 II placenta reaches internal os but does not cover it
III placenta covers internal os before dilatation but not when dilated
IV placenta completely covers internal os even when dilated

Fig. 5 Types of placenta previa

- If placenta praevia is confirmed the woman should stay in hospital

for at least 48 hours after the bleeding has stopped. Management is
conservative, even to the level of giving blood transfusions for severe
bleeds, until the fetus is mature (at about 36 weeks).
- If the placenta is anterior and only just engaging in the lower segment,
the membranes may be ruptured and a vaginal delivery expected, as the
head coming down into the mother's pelvis will compress the bleeding
placental bed against the back of the pubis symphysis. The same cannot
be said for any degree of posterior placenta praevia.

Ruptured uterus;

It means abrupt tearing of the uterus either complete (all layers of uterus
include peritoneum) or incomplete (include endometrium &
myometrium).
Causes:
- Over distension of uterus.

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- Hypertonic contraction.
- Obstructed labor.
- Grandmultipara.
- Abdominal trauma.
- Trauma with obstetric instruments.
Sings & symptoms:
- Internal and/or external blood loss.
- Abdominal pain.
- Tachycardia.
- The infant easily felt through the abdominal wall.
Ng care:
1. Anti shock measures (oxygen mask, one or more IV line to
restore circulation, drug therapy, administer antibiotics and prepare the
client for surgery).
2. Preparation for surgery (monitor V.S & FHR, if she has CVP
catheter monitor pressure to evaluate blood loss, insert urinary
catheter to measure intake & output and obtain blood to assess
possible acidosis).
3. Operation; - The placenta and fetus are removed and
hysterectomy is performed.
- If ruptured scar with clean cut edges or if patient young or child
less the tear is sutured and the pregnancy avoided for one year and CS
is done 2 weeks before expected date of delivery (EED).

Cord prolapse;

It is descent of the cord into the vagina infront the presenting part after
ROM.
Cord presentation is decent of the cord infront the presenting part before
ROM, while occult prolapse the cord is beside the presenting part.
Causes:
- Multiple birth.
- Malpresentation (eg. breech).
- Increased liquor volume.
- Placenta previa.
- Long cord.
Ng care:
1. Place client in knee chest position to decrease pressure on cord
or trendlenburg position and hips elevated with pillows with side lying
position.
2. Assess the cord for pulsation, apply firm upward manual
pressure to the presenting part of the fetus with sterile gloved hand to
elevate it and relieve pressure from the cord.

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 3. Gently wrap gauze soaked in sterile normal warm saline solution
around the prolapsed cord.
4. Frequent evaluate FHR and signs of distress.
5. Prepare for CS and support the woman (when cervix is dilated
CS will performed, when cervix is fully dilated NVD with forceps).

Fig. 6 Cord prolapse

PROM ( premature rupture of membranes):

It refers to rupture of membranes (chorion & amnion) 1 hour or more

before the onset of labor.
Causes:
- Malpresentation.
- Possible weak areas in the membranes.
- Infection.
- Incompetent cervix.
- Vit. C deficiency.
- Smoking.
Nursing mangement:
Pregnancy of 34 wks or more, induction of labor if spontaneous
labor has not begun by approximately 12 hrs after PROM (potential
for CS).
Pregnancy less than 34 wks:
1. Complete bed rest.
2. Hydration.
3. Sedation & tocolytics.
4. High vaginal swab for culture.
5. Corticosteroids to improve fetal lung maturity.
6. Antibiotics to guard against infection.
7. Observation for maternal infection e.g. fever, tachycardia,
increase WBCs, uterine tenderness &foul smelling.
N.B. when pregnancy reaches 34 wks, labor is induced with oxytocin.

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 Shock:

Shock is a complex syndrom involving a reduction in blood flow to the

tissues with resulting dysfunction of organs & cells. It entails progressive
collapse of the circulatory system and if left untreated can result in death.
Shock can be classified as follows:
Hypovolemic; the result of a reduction in intravascular volume.
Cardiogenic; impaired ability of the heart to pump blood.
Distributive; an abnormality in the vascular system that
produces a maldistribution of the circulatory system, this include
septic & anaphylactic shock.

*Hypovolemic shock: this is caused by any loss of circulating fluid

volume as in hemorrhage or sever vomiting.
Effect of shock on organs: - Brain; the level of consciousness
deteriorates. Lungs; gas exchange is impaired as the physiological dead
space increases within the lungs. Kidneys; the renal tubules become
ischaemic owing to the reduction in blood supply. Gastrointestinal
tract; the gut becomes ischaemic and its ability to function as a barrier
against infection wanes. Liver; drug & hormone metabolism ceases as
does the conjugation of bilirubin.
Nursing management:
1. Call for help.
2. Maintain the airway; if the mother is severely collapsed she
should be turned on to her side & 40 % O2 administered. If she is
unconscious an airway should be inserted.
3. Replace fluids; two wide-bore intravenous cannulae should be
inserted to enable fluids and drugs to be administered swiftly. Blood
should be taken for cross-matching prior to commencing intravenous
fluids.
4. Warmth.
5. Arrest hemorrhage.

*Septic shock: this is a distributive form of shock, where an

overwhelming infection develops. In general population, infections from
Gram negative organisms such as Escherichia coli, Proteus or
Pseudomonas pyocyaneus are predominant, which are pathogens in the
female genital tract.
This may occur following: - Prolonged rupture of fetal membranes.
- Obstetric trauma. Septic abortion. Retained placental tissue.
Clinical signs: - Sudden tachycardia. Pyrexia - Rigors.

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 - Tachypnoea. Signs of shock including hypotension.
- Hemorrhage may be present.
Nursing management:
1. Replacement of fluid volume will restore perfusion of the vital
organs.
2. Satisfactory oxygenation is also needed.
3. Measures are needed to identify the source of infection & to
protect against reinfection by maintaining high standards of care in
clinical procedures.
4. A full infection screening; as high vaginal swab, midstream
spacimen of urine and blood cultures.
5. Infusion sites & indwelling catheter should be checked for signs
of contmination.
6. Rigorous treatment with intravenous antibiotics after blood
cultures have been taken.

Amniotic fluid embolism:

Occasionally, when the uterus is contracting strongly and there is an

opening between the amniotic sac and the uterine veins, a bolus of
amniotic fluid is pumped into the circulation. This passes through the
heart, and an accumulation of amniotic cells becomes trapped in the
pulmonary circulation. The amniotic fluid may cause local disseminated
intravascular coagulation, which may spread. This rare condition can
occur late in the last trimester or during labor.
Amniotic fluid embolism used to be diagnosed on histology only after a
postmortem examination but is now sometimes diagnosed before death.
Symptoms:
-0 Collapse while having strong contractions.
- Shock without any blood loss.
- Sudden dyspnoea, and the production of frothy sputum.
Treatment is supportive, with steroids, intravenous plasma expansion,
and urgent delivery. This obstetric emergency is rare and has a bad
prognosis for both mother and fetus, usually owing to delay in diagnosis.
Inversion of uterus:

Very rarely, if misapplied pressure has been used on the uterine fundus or
traction on the cord of a non-separated placenta in a multiparous woman,
the uterus can dimple and invert. This is a very shocking event as the
fundus turns inside out and goes through the cervix into the vagina.
Treatment requires an experienced obstetrician, who will try to return the
uterus under general anaesthesia. This can be very difficult.

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Fig. 7 Acute uterine inversion

Shoulder dystocia:
Macrosomic infants will often be detected antenatally, but if the infant's
fat face remains squashed against perineum and delivery fails to occur,
consider that the shoulders may be too broad to descend through the
pelvis. Meanwhile, the cord is being compressed against the mother so
the infant will die before transfer.
Nursing action:
(1) Call for any assistance that can reach you in less than 2-3 minutes.
(2) Flex the mother's knees up to her chest, preferably using two helpers.
(3) Arrange that the mother's buttocks slightly overhang the end of the
bed, and, if needed, cut a wide episiotomy to fit your hand beside the
head.
(4) Have an assistant apply suprapubic pressure while you attempt to
move the infant's head posteriorally, aiming to bring the top shoulder out
from under the pubis. If this fails, try gently rocking the infant up and
down to ease one or other shoulder into the pelvis (much like pulling a
wine cork).
(5) If this fails, insert a hand into the vagina to locate the infant's posterior
arm. Sweep the arm towards the infant's chest until the hand can be
reached and drawn across the chest and out of the vagina. Now rotate the
infant's body so the exposed axilla lies under the pubis, and apply
downwards pressure to deliver the torso. Expect a flat infant, possibly
with shoulder injuries including fractures, and a mother with pelvic floor
trauma.

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Undiagnosed twin
If the woman in labor is large, with no antenatal records (including no
ultrasound) to exclude multiple gestation, it is prudent not to give
syntocinon until the birth is completed and an empty belly palpated. An
undiagnosed twin will then usually deliver spontaneously within 15
minutes, with only the usual risks associated (eg. PET, malposition, post-
partumhemorrhage).

If syntocinon has been given with the first twin's shoulder, however,
transverse lie should be excluded, then membranes ruptured. The infant is
then turned to be extracted in the breech position by grasping and
delivering each foot in turn, before the uterus has time to contract

around it and separate its placenta. The first scenario is obviously

preferable.

Undiagnosed breech
The worst event is a breech premature infant whose body can slip through
a partly dilated cervix, unlike its larger head, which can then crush the
cord. Even at term, breech infants have a higher risk of cord prolapse,
intracranial haemorrhage (due to abrupt pressure changes in the rapid
descent of an aftercoming head), brachial and cervical trauma, and
internal injuries. Breech deliveries ideally occur with LSCS facilities on
standby, and a paediatrician in the room, precluding most rural centres. In
the acute setting, however, the principles of delivery are:
Nursing action:
(1) Have the woman in lithotomy position with buttocks slightly
overhanging the edge of the bed. Empty bladder via IDC.
(2) As the anus becomes visible over the perineum, consider an
episiotomy.
(3) Allow the breech to deliver unaided to the level of the knees
/umbilicus.
(4) Deliver the legs by lateral abduction and flexion of the knees, and
check there is sufficient length to the exposed portion of cord.
(5) Rotate the sacrum anteriorally, and from this point on, support some
of the weight of the infant's body to minimise traction on the neck. Hold
the infant at all times by bony parts such as thighs or pelvis, to reduce the
risk of liver trauma. Drape the infant to reduce heat loss.
(6) As the scapulas appear, deliver the shoulders, holding the infant by its
pelvis to rotate the body as required.
(7) The arms are delivered by using a finger to sweep them across the
infant's chest and out past the torso.

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 (8) At this stage bring the sacrum again to face anteriorally, and raise the
infant's body to hang vertically, upside-down. Take care not to allow the
head to suddenly swing free, nor to overextend the neck.
(9) If the infant is held in one hand by its ankles, the forefinger of the
free hand can then be put into its mouth to maintain flexion of the neck as
the head is delivered in a slow and controlled manner. If forceps are
required, an assistant needs to hold the child's ankles.

Fig. 8 breach delivery

Postpartum hemorrhage:

After a normal delivery a woman commonly loses up to 300 ml of blood.

As her blood volume has increased because of fluid retention during
pregnancy, this is a loss, which can be coped with readily. However, a loss
of >500 ml measured clinically in the first 24 hours is considered to be a
primary postpartum hemorrhage. The attending practitioners commonly
underestimate Blood loss. The mother should be watched carefully and
treatments given to prevent any further loss.
Management of primary postpartum hemorrhage
Preventive
Intramuscular oxytocin at the end of the second stage of labor
Curative
Repeat oxytocic administration
Rub up a contraction
Check completeness of the placenta if it is not delivered or a
lobule is missing, prepare for manual removal
Bimanual compression
Intramyometrial prostaglandin E2 or carboprost
Surgical ligation uterine arteries, internal iliac arteries, or braces
(or Lynch) suture of uterus
Hysterectomy
- A rare cause of continuing primary postpartum hemorrhage is a rupture
of the uterus. This needs diagnosis and treatment with either hysterectomy
or abdominal resuturing.

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 Infection:

After delivery the genital tract has several sites of potential ingress of
bacteria. The placental bed itself is a large raw area, and ascending
infection from the lower genital tract may be assisted by previous
intrauterine procedures for example, forceps delivery. Infection of the
cervix or, uncommonly, of the episiotomy site, may also occur; the breast
can also be a site of infection in the puerperium.
Treating infections
Infections manifest themselves by local inflammation (swelling
and tenderness) and a raised temperature
Treatment is local heat to the area, analgesia, and broad
spectrum antibiotics until the results of bacteriological swabs are
available
Co-amoxiclav and erythromycin are both good choices because
they deal with penicillinase-producing staphylococci and
streptococci, especially group B
Metronidazole is often added for uterine infections
If the infection persists, anaemia may follow, which may
ultimately require a blood transfusion

Fig. 9 Common sites of infection

Psychological condition:

Pregnancy and childbirth are times of high psychological stimulation.

Any pre-existing psychological disorder may be exaggerated at this time
and requires treatment. Many women go through mood swings (blues) in
relation to childbirth, which can usually be managed by sympathetic
support. If postnatal depression persists for a week or so, mild
antidepressants may be needed, and the Edinburgh postnatal depression

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 questionnaire may be helpful in diagnosing the condition. If the condition
continues, formal psychiatric help is needed.

Three levels of psychiatric state associated with

childbirth
Postpartum blues (1 in 5 mothers)
Transient and treatable by reassurance
Puerpural depression (1 in 10 mothers)
Low mood, lack of energy, guilt, irritability, and insomnia
Treated by counseling (midwives and health visitors)
Antidepressants refer to GP if depression continues
Puerpural psychosis (1 in 500 mothers)
Affective, depressive, or manic behavior; insomnia; confusion;
perplexity
Refer to psychiatrist and admit to mother and baby unit
- At the extreme of the spectrum of disease a puerperal psychosis may
occur; both the mother and her baby should be admitted to a dedicated
maternity/psychiatric unit as both are at risk. Here the mother can have
expert psychiatric nursing and medical care while looking after her own
baby. There is a 25% risk of recurrence in a future pregnancy.

The golden rules of obstetric emergencies

The first principles of dealing with obstetric emergencies are the same as
for any emergency (see to the airway, breathing, and circulation), but
remember that in obstetrics there are two patients; the fetus is very
vulnerable to maternal hypoxia.

(1) Apply oxygen with the woman rolled into the left lateral position (by
at least a bag of IV fluid under the right hip) even if the woman is
unconscious and being intubated. Compression of the vena cava /aorto-
iliacs by the gravid uterus reduces venus return, resulting in hypotension
and reduced blood flow to the fetus; and increases lower abdomen venous
pressure which may be transmitted to the retro-placental space, increasing
the risk of placental separation and hemorrhage.
(2) In general, it is best to concentrate on the resuscitation and transfer of
the mother, as the infant is safer in utero. Fetal hemoglobin oxygen-
binding-capacity maintains adequate oxygenation until maternal partial
pressures are < 60, contrasting starkly to the difficulties in ventilating an
infant with premature lungs.
(3) In the young and healthy, tachecardia and hypotension are very late
features of shock and need to be considered extremely seriously.
(4) Be alert that the emergency may (uncommonly) not be due to the

31
pregnancy, as this may alter management. For example, a pregnant
woman with palpitations and collapse may have PAT or cardiomyopathy
and be better treated in the A&E dept. than the maternity ward.

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