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Chapter 23 Continuation
Chapter 23 Continuation
- Refers to the turning inside out with either birth - Occurs when the amniotic fluid is forced into an
of the fetus or delivery of the placenta open maternal uterine blood sinus
Cause: Cause:
Traction of the umbilical cord Some defect in the membranes
Pressure on the fundus when uterus is not After membrane rupture
contracted Premature separation of the placenta
Placenta is attached to the fundus, because at
birth, passage pulls down the fundus Risk factors:
Oxytocin administration
S/Sx: Abruptio Placenta
Large amount of blood suddenly gushes from Hydramnios
the vagina
Fundus is not palpable in the abdomen S/Sx:
Shows signs of blood loss such as: Woman in strong labor, suddenly sits up, grasps
1. Hypotension her chest because of sharp pain and inability to
2. Diziness breathe (due to pulmonary constriction)
3. Paleness Pale, then turns bluish gray
4. Diaphoresis - Rationale: pulmonary embolism & lack of blood
flow to the lungs
Therapeutic Management:
1. Do not attempt to replace an inversion Therapeutic Management:
- Rationale: handling of the uterus may increase 1. O2 administration by face mask or cannula
the bleeding 2. Within minutes, CPR is needed
- May be useless because it does not relive
2. Do not remove the placenta if it is still attached pulmonary constriction
- Rationale: this creates a larger space for - Death can occur in minutes ☹
bleeding 3. If she survives, she needs to be in the ICU
4. Guard prognosis of the fetus
3. Do not administer oxytocic drugs - Rationale: Reduced placental perfusion results
- Rationale: this only compounds the inversion from the severe drop in maternal BP
making the uterus more tensed & difficult to
replace General Information:
Prognosis depends on:
4. Start an IV line 1. Size of the embolism
- Rationale: to replace the blood lost 2. Speed of which the condition was detected
- If IV line is already present, open it to achieve 3. Skil and speed of emergency interventions
optimal flow
If woman survives, risk for Disseminated
5. Administer O2 by mask Intravascular Coagulation (DIC) is high
6. Assess vital signs
7. If a woman’s heart fails due to blood less, be Problems with the Passenger
ready to perform CPR 1. Umbilical Cord Prolapse
8. Will be given general anesthesia,nitroglycerin, 2. Multiple Getsation
tocolytic drug 3. Problems with the Fetal Size, Presentation, or
- Rationale for Tocolytic: to relax the uterus Size
9. Replace the fundus manually
Umbilical Cord Prolapse
10. Administer oxytocin after manual replacement - A loop of the umbilical cord slips down in front
- Rationale: to help the uterus contract of the presenting fetal part
Occipitoposterior Position
- Rationale: Prevents haemorrhage thru an open - Occiput is directed diagonally & posteriorly
cord end if babies shared one placenta either to the right (ROP) or left (LOP)
General Information:
Transverse Lie Fetal head normally engages: 36-38 weeks AOG
- Confirmed thru Leopold’s Maneuver & Engagement does not occur in multigravidas
Ultrasound until labor begins
- A mature fetus cannot be delivered vaginally in Every primigravida must have pelvic
this position measurements checked before 24 weeks of
- CS Birth is necessary pregnancy
Cause: CPD: fetus does not engage & malposition may
Pendulous abdomen from uterine fibroid occur
tumors, obstructing the lower uterine segment If membranes rupture, cord prolapse incidence
Contraction of the pelvic brim is increased
Congenital abnormalities
Hydrocephalus Outlet Contraction
Multiple gestation - Narrowing of the transverse diameter at the
outlet to <11cm
Oversized Fetus (Macrosomia)
- Weighs >4 000 to 5 000g (9-10lbs.) Trial Labor
- CS Birth is necessary - Done to determine whether labor can progress
- If delivered vaginally, there is risk for these in normally
infants: Indication:
Cervical Nerve Palsy Borderline inlet measurement
Diaphragmatic Nerve Injury Fetal lie and position are good
Fractured Clavicle
Therapeutic Management:
Shoulder Dystocia 1. Monitor FHR
- Occurs at the 2nd Stage of Labor, when fetal 2. After Rupture of Membranes: assess FHR
head is born but the shoulders are too broad to
enter and be born through the pelvic outlet External Cephalic Version
- Hazardous to the Mother: it can result in - Turning of the fetus from breech to cephalic
vaginal and cervical lacerations position before birth
- Hazardous to the Fetus: it can result in clavicle - Can be done at 34-35 weeks of pregnancy
or brachial plexus injury - Usual time it is done is at 37-38 weeks of
- Not identified until the head has already been pregnancy
born and the wide anterior shoulder locks
beneath the symphysis pubis
Contraindications to ECV: 4. Record the time and amount of 1st voiding
Multiple Gestation - Rationale: to rule out bladder injury
Oligohydramnios
Midforceps Birth
- If fetal head is engaged <+2 station Anomalies of the Placenta and the Cord
1. Placenta Succenturiata
2. Placenta Circumvallata
How Are the Forceps Used: 3. Placenta Marginata
1. One blade, slide in the vagina next to the fetal 4. Battledore Placenta
head 5. Placenta Accreta
2. Another blade, slipped into place on the other 6. Vasa Previa/Placenta Previa
side of the head 7. Two-Vessel Cord
8. Unusual Cord Length
Necessary Conditions to Qualify for Forceps Birth:
Unable to push with contractions (spinal cord General Information:
injury/regional anesthesia) Normal Placenta: 500 g
Cesaation of descent in 2nd stage of labor Diameter: 15-20cm
Fetus abnormal position Thickness: 3cm
Fetus is in distress from a complication Diabetes, Syphilis & Erythroblastosis placenta
(prolapsed cord) is unusally large
If the uterus has scars: placenta may be wide in
diameter because it was forced to spread out to
find implantation space
Before forceps are applied, make sure:
Membranes have been ruptured
CPD must not be present Placenta Succenturiata
Cervix is fully dilated - Has one or more accessory lobes attached or
Bladder is empty connected to the main placenta, by blood
vessels
Therapeutic Management: - No fetal abnormality is associated with this
1. Anesthetic - Important to be recognized because small lobes
- Pudendal Block
may be retained in the uterus after birth =
- Rationale: reduce pain and facilitate pelvic
haemorrhage
relaxation
- Inspection: placenta appears torn at the edge
2. Record FHR before forceps application
- Rationale: there is danger that the cord could
be compressed between the forceps blade and Placenta Circumvallata
the fetal head - Some extent of Chorion covers the fetal side of
the placenta
3. Assess woman’s cervix
- Rationale: to check for lacerations Placenta Marginata
- Chorion reaches just to the end of the placenta
Battledore Placenta
- Cord is inserted marginally rather than centrally
Placenta Accreta
- Unusually deep attachment of the placenta to
the uterine myometrium so deeply the placenta
will not loosen and deliver
- Manual Removal=haemorrhage
- Hysterectomy or treatment with methotrexate:
to destroy the still-attached tissue
Two-vessel Cord
- Normal Cord: 2 arteries, 1 vein
- Absence of one artery: Congetial heart & kidney
anomalies
- Drying distorts the appearance of the vessels
- Document the number of vessels present