NCM 109 LEC MIDTERM COVERAGE

Gestational Conditions

Duration: 9 hours

Key Terms:
 Hyperemesis Gravidarum
 Ectopic Pregnancy
 H-mole
 Incompetent Cervix
 Abortion
 Placenta Previa
 Abruption Placenta
 Pregnancy
 Pre-eclampsia
 Induced Hypertension
 Eclampsia

A. Hyperemesis Gravidarum
Description and Etiology
- Hyperemesis gravidarum or pernicious vomiting of pregnancy is characterized by extreme nausea
and vomiting during the first half of pregnancy that is associated with dehydration, weight loss, and
electrolyte imbalance; the emesis is much more severe than in the common “morning sickness” of
early pregnancy and occurs in only 0.1 percent of pregnancies.
- Theories about the etiology include psychological as well as physiological factors but the actual
cause remains unknown; the condition is rare in developing countries; high levels of HCG, as are
found in gestational trophoblastic disease (H-mole), are associated with severe nausea, and
vomiting.
- The fetus is at risk for macrosomia (excessively large body), abnormal development, IUGR, or death
from lack of nutrition, hypoxia, and maternal ketoacidosis.

Assessment
- Intractable vomiting during the first 20 weeks of pregnancy.
- Dehydration with: weight loss of more 5 percent of pre pregnancy weight, poor skin turgor, dry
mucous membranes, possible hypotension, tachycardia, and increased lab values for hematocrit and
urine specific gravity.
- Signs and symptoms of electrolyte imbalance (acidosis): Ketosis, confusion, drowsiness, muscle
weakness, cramps, clumsiness, tremors, irregular heartbeat, decreased level of consciousness.
- Signs and symptoms of starvation: muscle wasting, ketonuria, jaundice, bleeding gums (vitamin
deficiency)

Priority Nursing Diagnoses:

- Deficient fluid volume
- Risk for injury
- Altered nutrition, less than body requirements
- Ineffective coping

Implementation
1. Client may need hospitalization with IV fluid therapy with glucose, electrolytes, and vitamins to
begin treatment and then continue at home once stabilized.
2. Monitor daily weight and measure intake and output; assess vital signs as appropriate, hydration,
and nutritional status.
3. Administer antiemetic medications such as phenothiazines or antihistamines as ordered to control
nausea and vomiting.
4. Encourage six small feedings a day after the acute nausea and vomiting has passed; clear liquids
such as lemonade and herbal teas, and salty foods like potato chips are sometimes better tolerated
at first.
5. Total Parenteral nutrition (TPN) may be required in severe cases when the client is unable to
tolerate oral feedings.
6. Monitor fetal growth with serial ultrasound.

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 7. Provide emotional support, help client to identify healthy coping mechanisms and support systems
she can rely on during pregnancy.
Evaluation:
- Client exhibits signs of adequate hydration: moist mucous membranes, good skin turgor, stable
vital signs, and intake equal to output.
- client can tolerate adequate nutrition for maternal and fetal requirements and gains appropriate
weight during pregnancy.

B. Ectopic Pregnancy
Description and Etiology
- Implantation of a fertilized ovum outside the uterus. Sites may include ovary or elsewhere in the
abdominal cavity; the most common site is implantation in a fallopian tube that has become
narrowed by scarring or adhesions
- Risk factors for tubal damage that may result in ectopic pregnancy:
 ascending infections
 pelvic inflammatory disease (PID)
 use of IUD contraception
 tubal surgery
- Tubular obstruction that prevents the transit of fertilized ovum to the uterus
- Medical emergency
- Visualized through laparoscopy
- Rule out – unilateral /bilateral pain – women in childbearing age
- Misdiagnosed as appendicitis
Assessment:
- Interview reveals last menstrual period (LMP) consistent with possible pregnancy and possible
subjective symptoms of pregnancy such as breast tenderness and nausea.
- Unilateral lower abdominal pain: may be slowly increasing or sudden and severe with abdominal
rigidity and referred right shoulder pain.
- Possible irregular vaginal bleeding or signs of hypovolemic shock if fallopian tube has ruptured;
prioritize care accordingly.
- Laboratory test: Beta-hCG confirms pregnancy
- Ultrasound confirms an extrauterine pregnancy.

Priority Nursing Diagnoses:

- Risk for deficient fluid volume
- Pain
- Fear
- Anticipatory grieving
Implementation:
1. Monitor blood pressure, pulse, and respiration every 15 minutes or more frequently if indicated.
2. Start an IV of ordered fluid with at least 18-gauge needle in case blood products need to be given.
3. Provide oxygen as indicated for shock.
4. Medicate for pain as ordered.
5. Obtain Laboratory tests: Beta-hCG, CBC, and blood group and type, cross-match if hemorrhage is
suspected.
6. Prepare the client for surgery (laparotomy); if possible, the pregnancy will be evacuated and the
tube preserved for future fertility if desired.
7. Provide routine preoperative care and teaching; offer emotional support to client and family.
8. Provide general postoperative care; facilitate grieving; provide RhoGAM for Rh-negative mothers
with a Rh-positive partner.

Evaluation:
- Client experiences evacuation of ectopic pregnancy
- Vital signs remain stable without signs of hypovolemic shock.
- Fertility is preserved as desired.
- Client and family begin grieving for their loss.

C. Gestational Trophoblastic disease (H-mole)

Description and Etiology
- Abnormal proliferation and degeneration of trophoblastic villi

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 - Characterize by abnormal development of the placenta
- The chorionic villi grow rapidly into fluid-filled grape-like clusters
- Predisposes patient to choriocarcinoma

2 Types:
1. Complete mole - Normal sperm fertilizes an ovum with no genetic material
2. Partial mole - 1 ovum is fertilized by 2 sperm = 69 chromosomes
- Spontaneously aborts in the first trimester

Assessment
 Vaginal bleeding – brown like prune juice and may contain some grape-like vesicles
 Size and date discrepancy – size of abdomen is greater than AOG
 Excessive nausea and vomiting – proliferation of trophoblastic villi – HCG
 Abnormal labs – high hCG levels and very low MSAFP (maternal serum alpha-fetoprotein) levels.

Signs and Symptoms:

 Missed period
 Full feeling in the lower abdomen
 Lower quadrant tenderness
 (+) PT
 Referred shoulder pain
 Signs of acute rupture
 Vaginal bleeding

Complications:
 Hyperemesis gravidarum
 Severe PIH (occurs during the first half of pregnancy)
 Hyperthyroidism
 Trophoblastic pulmonary embolism

Priority Nursing Diagnoses:

 Deficient fluid volume
 Anticipatory grieving
 Fear
Implementation and Collaborative Care:
1. Monitor the client for signs of hemorrhage, PIH, or other complications including disseminated
intravascular coagulation (DIC)
2. Provide preop and post op D and C care
3. Start IV line
4. Provide client and family teaching:
 monitor hCG levels for 1 year – to rule out development of cancer choriocarcinoma
 Client should not become pregnant for 1 year following a molar pregnancy in case chemotherapy is
indicated
 Provide contraceptive counseling
5. Provide RhoGAM to appropriate clients
6. Report the ff symptoms:
 Irregular vaginal bleeding
 Persistent secretion from the breast
 Hemoptysis
 Severe persistent headache
7. Provide emotional support
8. Culdocentesis: aspiration of fluid in the culde sac; bloody aspirate indicates intraperitoneal bleeding
that results from tubular rupture.
Evaluation:
- Molar pregnancy is identified and evacuated.
- The client verbalizes the need for follow-up care and uses effective contraception during this period.
- Client remains cancer-free for 1 year.

D. Incompetent Cervix
Description and Etiology:
- Painless effacement and dilatation of the cervix that is not associated with contractions and usually
occurs in the second trimester resulting in spontaneous abortion or very preterm birth.
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 - Other possible contributing factors are cervical inflammation or previous cervical trauma.
- Cannot hold the fetus until term.
- Commonly occurs at approximately week 20 of pregnancy.
Assessment:
- Previous unexplained second-trimester pregnancy losses may indicate an undiagnosed incompetent
cervix.
- Cervical effacement and dilatation without contractions or pain; client may present for care
completely dilated with bulging membranes.
Priority Nursing Diagnoses:
- Risk for injury: fetal
- anticipatory grieving
Risk Factors:
 ↑ maternal age
 Hx of cervical trauma or habitual abortion
Manifestation:
 Show or increased pelvic pressure – usually first sign
 ROM
Implementation:
1. Provide emotional support and grief support group referral for client with pregnancy loss
2. Provide client teaching if client is to be managed on bedrest at home for a cervix just beginning to
efface.
3. Provide teaching about Cervical cerclage if this is the treatment method chosen.
- Cervical stitch
- Done @ 12 – 14 weeks
a. Shirodkar procedure – permanent – CS – future child birth
b. McDonald’s procedure – temporary – 37/38 wk. removed
- Maintain activity restrictions and vaginal rest
4. Monitor the cerclage client for signs and symptoms of preterm labor or infection. Client may be
placed in Trendelenburg position and be administered tocolytics; provide appropriate nursing
assessments and care related to the medication.
5. Instruct client to return if contractions begin., as the suture will need to be removed before vaginal
birth is accomplished.

Evaluation:
- the client has cervical cerclage placed without complications; pregnancy is continued until fetal
viability is reached.

E. Spontaneous Abortion
Description and Etiology
- Unintended termination of pregnancy at any time before the fetus has attained viability (20
weeks gestation), the lay term is “miscarriage”.
- The most common cause of bleeding in the first trimester and usually results from:
 chromosomal abnormalities in the embryo
 teratogen exposure
 inadequate implantation
 maternal endocrine disorders
Assessment:
- vaginal spotting or bleeding
- Pelvic cramping or dull backache
- Falling hCG levels indicate death of the embryo; ultrasound is used to identify the gestational
sac

Priority Nursing Diagnoses:

- Risk for deficient fluid volume
- Anticipatory grieving
- Pain
Types:
1. Threatened abortion- possible loss of the products of conception.
 Slight vaginal bleeding
 Closed cervical os
 Mild abdominal cramping

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  Can save a baby through bed rest and med
2. Inevitable/Imminent abortion – loss of the products of conception that cannot be
prevented.
 Vaginal bleeding
 ROM
 Cervical dilation
 Strong abdominal cramping
3. Incomplete abortion- expulsion of some parts and retention of other parts of conceptus in
utero.
 Passage of some products of conception
 Intense abdominal cramping
 Heavy vaginal bleeding
4. Complete Abortion – spontaneous expulsion of the products of conception after the fetus has
died in utero.
 Passage of products of conception
 ↓ in pain and vaginal bleeding after passage
5. Missed abortion – retention of all products of conception after the death of fetus in the
uterus.
 Nonviable embryo retained in utero for @ least 6 weeks
 Absent uterine contractions
 Irregular spotting
 Fetus still inside the uterus
6. Habitual abortion
 History of 3 or more consecutive spontaneous abortions
 Not carrying pregnancy to term.
 Requires extensive diagnostic investigation, including genetic and chromosomal studies.

Complications:
 Hemorrhage – incomplete abortion – uterus cannot contract effectively
 Infection – cervix open – microorganism have free access to the uterus
 Septic abortion – infection
 Isoimmunization – Rh incompatibility

Implementation
1. Instruct client with a threatened abortion about bedrest at home and when to return if
bleeding or cramping worsen.
2. Assess the amount of bleeding, instruct client to save all clots and tissue that may
passed for further examination.
3. Monitor blood pressure, pulse, and respirations frequently if bleeding is heavy; evaluate
for signs of impending shock.
4. Initiate intravenous therapy with at least an 18-gauge needle as ordered.
5. Assist with dilatation and curettage (D & C) as indicated for an incomplete abortion.
6. Provide emotional support, without false hope, to the client and family.
7. Give RhoGAM for Rh-negative clients with Rh-positive partners within 72 hours of
intervention.
Evaluation:
- Pregnancy is either maintained or products of conception are expelled without further
complication
- Client and family are assisted to mourn the pregnancy loss.

F. Placenta Previa
Description and Etiology
- The placenta is abnormally implanted near to or over the internal cervical os; as the cervix
softens and begins to efface and dilate, placental sinuses are opened causing progressive
hemorrhages.
- May be a low implantation near the cervix, a partial previa covering a part of the os, or a
complete placenta previa which covers the entire internal cervical os.
- Incidence of placenta previa is higher with multiple gestation and multipara
Assessment:
- Episodic painless vaginal bleeding after the 20 th week of pregnancy without contractions.
- Ultrasound identification of placental location.
Priority Nursing Diagnoses:
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 - Risk for deficient fluid volume
- Risk for injury
- Fear
Implementation and collaborative care:
1. Never perform a vaginal exam as this may create profuse hemorrhage.
2. Assist with a double set-up procedure if indicated.
3. Preterm clients should be maintained on bedrest with bathroom privileges until fetal maturity is
reached.
4. Monitor vital signs to rule out ascending infection or shock.
5. Assess blood loss by weighing peripads and bed pads that bloody (1g=1 ml).
6. Monitor Hgb and hct levels: obtain blood group and type, cross-match as needed.
7. Monitor fetal well-being with continuous or intermittent monitoring.
8. Maintain IV access with at least 18-gauge needle and provide replacements as ordered.
9. Provide emotional support to the client on bedrest.
10. Promote adequate nutrition with prenatal vitamins and iron as needed to prevent maternal
anemia.
11. Provide routine pre-operative and post-operative cesarean care if indicated.
Evaluation:
- Bleeding does not become excessive
- Client’s vital signs remain stable
- client delivers a healthy mature newborn.

G. Abruption Placenta
Description and Etiology
- Premature separation of the placenta away from the uterine wall during pregnancy.
- Types:
1. Partial separation
- Separate only at the margin
- Cause vaginal bleeding but perhaps little pain
2. A central (concealed) abruption may not result in vaginal bleeding but does cause
increasing uterine irritability and tenderness.
- Apparent hemorrhage
3. Complete (100%) separation from the uterine wall results in profuse hemorrhage
- Precipitating Factors:
1. Maternal hypertension
2. cocaine abuse
3. abdominal trauma

Assessment:
- A painful, rigid, board-like abdomen with vaginal bleeding is the classic sign of abruptio placenta;
the abdomen may increase in size as bleeding continues; ultrasound confirms the diagnosis.
- A central abruption causes severe pain from bleeding behind the placenta distending the uterine
muscle but there may be little or no vaginal bleeding, the uterus is very irritable and the fetus
shows consistent late decelerations.
- Bleeding behind the placenta is forced into the myometrium and may result in a Couvelaire
uterus; the uterus becomes bluish purple, extremely irritable, distended, and rigid; the uterus
does not contract efficiently after delivery leading to postpartum hemorrhage.
- Marginal placental separation may present with more bleeding but less pain than a concealed
abruption.
- Fetal outcome depends on the degree of placental separation and maturity of the fetus at the
time of birth.

Priority Nursing Diagnoses:

- Deficient fluid volume
- Risk for injury
- Risk for impaired gas exchange

Implementation and collaborative care:

1. Monitor maternal blood pressure, pulse, respiration for signs of impending shock.
2. Monitor fetus continuously for signs of distress: increased fetal movement, decreased FHR
variability, changes in baseline FHR, late decelerations.

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 3. Assess client for bleeding, uterine activity, and abdominal pain; place on external fetal monitor to
evaluate uterine irritability and fetal well-being; palpate uterine tone.
4. Measure client’s abdominal girth at the umbilicus for baseline size and repeat periodically to
evaluate occult bleeding.
5. Review Lab Values to estimate blood loss (hemoglobin and hematocrit) and monitor for the
potential development of disseminating intravascular coagulation (platelets, fibrinogen, fibrin
degradation products, PT, and PTT).
6. Monitor client for signs of developing coagulation defects: unusual bleeding from injection sites,
gums, development of petechiae.
7. Start and maintain IV fluids with at least an 18-gauge needle; monitor intake and output; a Foley
catheter may be inserted with expected urine output of 30-ml/hour or greater.
8. Provide oxygen as indicated at 8-12 L/min via tight face-mask.
9. Carefully monitor the client and fetus if vaginal delivery is attempted; prepare for an emergency
cesarean delivery if the fetus develops distress.
10. Provide on-going information and emotional support for client and family.

Evaluation:
- Maternal blood loss is minimized and fetal well-being is maintained.
- the client delivers a healthy infant without further complications.
- client delivers a healthy mature newborn.

H. Premature Rupture of Membranes

Description and Etiology
- Premature rupture of membrane refers to amniotic membrane rupture before labor begins; labor
will begin spontaneously within 24 hours of membrane rupture.
- Preterm rupture of membranes refers to membrane rupture prior to term gestation or before 37
weeks; risk factors: infection, incompetent cervix, and trauma.
- Prolonged rupture of membranes refers to membranes ruptured more than 12 hours before birth;
many caregivers will induce labor rather than risk prolonged rupture with possible ascending
infection.

Assessment:
- Gush of watery, clear, or meconium-stained fluid from the vagina with continued leakage.
- Amniotic fluid turns nitrazine paper blue indicating the alkaline pH; urine is almost always acidic
and does not change the yellow color of nitrazine paper.
- Amniotic fluid shows characteristic ferning pattern on microscopic examination; urine and vaginal
secretions do not display ferning.
- The unengaged fetus is at risk for a prolapsed cord when the membranes rupture.
Priority Nursing Diagnoses:
- Risk for infection
- Anxiety
- Risk for injury

Implementation and collaborative care:

1. Assess FHR when membranes rupture to rule out prolapsed cord; note time, color, and amount of
fluid; obtain a baseline maternal temperature.
2. Evaluate client’s temperature every 2 hours, other vital signs may be routine.
3. Avoid vaginal exams to prevent introduction of microorganisms that may cause an ascending
infection.
4. Monitor for development of uterine contractions and evaluate fetal well-being; decreased
amniotic fluid may cause variable decelerations of the FHT.
5. Monitor client for signs of chorioamnionitis (inflammation and infection of fetal membrane and
amniotic fluid); elevated temperature, abdominal tenderness, increased WBCs and erythrocyte
sedimentation rate.
6. Obtain vaginal culture for group B streptococcus as ordered.
7. Provide client teaching that amniotic fluid is continuously produced and that there is no such
thing as a “dry birth”.
8. Administer antibiotics as ordered.

Evaluation:

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 - Client and fetus remain infection-free.
- Umbilical cord does not prolapse.
- Client delivers a healthy infant without complications associated with prematurity.

I. Pregnancy-Induced Hypertension
Description and Etiology
- Hypertensive disorder that begins during pregnancy; etiology is unknown, but pre-eclampsia is
associated with vasospasm and vascular endothelial damage.
- Condition is more common in young primigravidas, women over 35, younger than 20 years old,
multiple gestation, diabetes mellitus, hydatidiform mole, hydramnios, low socioeconomic status.
- The client is at risk for CVA, DIC, renal failure, and hepatic rupture.

Assessment:
- Symptoms usually develop during the third trimester except in cases of gestational trophoblastic
disease (H-mole); the client is at risk for seizures and other complications up to 48 hours after
delivery.
a. Mild Pre-eclampsia – hypertension of 140/90 or increase of 30/15 from baseline, proteinuria
trace to +1, mild to moderate pretibial edema with weight gain of 2-2.5 pound per week.
b. Severe Pre-eclampsia - hypertension greater than 160/110, proteinuria 3+ to 4+ or more
than 5 grams in a 24-hour urine specimen, sudden large weight gain with facial edema, pitting
pretibial edema and possible signs of central nervous system (CNS) irritation.
c. Eclampsia – most severe PIH, signs and symptoms of preeclampsia with presence of seizure;
Prior the event of seizure, experience aura – epigastric pain
d. Systemic Responses – CNS Irritability causes severe or continuous headache, hyperreflexia, or
visual disturbance (blurred vision); renal damage is indicated by oliguria (less than 30cc/hour);
portal hypertension may result in epigastric pain and may precede hepatic rupture.
e. Lab Values – increased hematocrit, serum uric acid, and BUN; increased liver enzymes (ALT,
AST). Decreased RBCs and platelets as condition worsens.

3 classic signs:

1. increased BP Assessment of Edema

• Non – pitting
2. proteinuria
• Pitting 1+ - indented slightly
3. edema
Priority Nursing • Pitting 2+ - moderate indentation Diagnoses:
- Deficient • Pitting 3+ - deep indentation fluid volume
• Pitting 4+ - so deep it remains after
- Anxiety
removal of the fingers
- Risk for injury

Implementation and collaborative care:

 The only cure for PIH is delivery; the goal of care is to deliver a healthy, viable infant while
safeguarding the mother’s health.
1. Bedrest at home is indicated if preeclampsia is mild; hospitalization if severe until fetus is mature
enough to be delivered; bedrest on left side, to facilitate uteroplacental perfusion.
2. A quiet, calm environment is maintained to decrease CNS stimulation; siderails should be up and
padded for clients with severe preeclampsia who are at risk of progressing to seizure.
3. A high protein diet without salt restriction is indicated; restricting salt intake may result in
hypovolemia and fetal distress; diuretics should not be used for the same reason.
4. Implement frequent assessment (every 15 minutes to 1-4 hours as indicated by client condition)
to include BP, pulse, and respirations, edema, deep tendon reflexes, and clonus checks; assess
client for headache, visual disturbances, and epigastric pain.
5. Foley catheter is inserted to monitor renal function; strict intake and output; evaluate urine for
protein; assess daily weight.
6. Monitor fetal well-being by continuous EFM, serial NSTs, BPP, or amniocentesis as indicated.
7. Administer Magnesium Sulfate as ordered for seizure prevention; monitor client for signs of
Magnesium Toxicity.
a. Monitor magnesium blood levels: 5-8 mg/dl is therapeutic range.
b. Decreased urine output (less than 30 cc/hr.) can increase the risk for toxicity as
magnesium sulfate is excreted by kidneys.
c. Depressed reflexes and respirations less than 12 to 14 per minute indicate magnesium
toxicity.

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 d. Keep calcium gluconate at the bedside for emergency administration to counteract
magnesium sulfate toxicity.
8. Prepare for induction of cesarean birth when fetus is mature or if maternal condition worsens.
9. Provide teaching and support to client and family about the condition and therapeutic
interventions; client with mild preeclampsia frequently do not feel ill and may have difficulty
maintaining bedrest.
10. The newborn should be evaluated for signs of depression related to magnesium sulfate.
11. Continue client to monitor client for PIH complications; seizures may occur for 48 hours after
delivery.

Evaluation:
- Client does not experience eclampsia or HELLP syndrome.
- Client delivers a healthy mature infant without further complications.

Problems with the Passenger:

Duration: 6 hours

Key Terms:

 Malpresentation
 Malposition
 Fetal distress
 Breech
A. Fetal malposition
- Refers to positions other than an occipito-anterior position.
- Malpositions include occipito-posterior and occipito-transverse positions of fetal head in relation to
maternal pelvis.
- It is usually seen in multipara or those with lax abdominal wall. Fetal malpositions are assessed during
labor.

Left Occipito-anterior
- The most ideal for vaginal birth.

(A) A fetus in cephalic presentation, LOA position. View is from outlet. The fetus rotates 90 degrees
from this position. (B) Descent and flexion (C) Internal rotation complete. (D) Extension; the face and
chin are born

Occipito-posterior Position
- Arrested labor may occur when the head does not rotate and/or descend. Delivery may be
complicated by perineal tears or extension of an episiotomy.
Maternal Risks:
 prolonged labor
 potential for operative delivery
 extension of episiotomy,
 3rd or 4th degree laceration of the perineum.
Maternal symptoms:
 Intense back pain in labor
 Dysfunctional labor pattern
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  prolonged active phase
 secondary arrest of dilatation
 arrest of descent

(A) Fetus in cephalic presentation LOP position. View is from outlet. The fetus rotates 135 degrees
from this position. (B) Descent and flexion. (C) In ternal rotation beginning. Because of the posterior
position, the head will rotate in a longer arc than if it were in an anterior position. (D) Internal rotation
complete. (E) Extension; the face and the chin are born. (F) External rotation; the fetus rotates to
place the shoulder in an anteroposterior position

Occipito-transverse Position
- It is the incomplete rotation of OP to OA results in the fetal head being in a horizontal or
transverse position (OT).
- Persistent occiput transverse position occurs as a result of ineffective contractions or a flattened
bony pelvis.

Diagnosis:
 Abdominal examination – the lower part of the abdomen is flattened; fetal limbs are palpable
anteriorly and the fetal flank.
 Vaginal examination – the posterior fontanelle is toward the sacrum and the anterior fontanelle may
be easily felt if the head is deflexed.
 Ultrasound

Nursing Diagnoses: Impaired Gas Exchange, Pain, Fatigue, Anxiety

Nursing Management:

Impaired gas exchange

 Encourage the mother to lie on her side from the fetal back, which may help with rotation.
 Knee-chest position may facilitate rotation.
 Pelvic-rocking may help with rotation.

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  Monitor FHB appropriately
 Be prepared for childbirth emergencies such as cesarean section, forceps-assisted delivery, and
neonatal-resuscitation.
Pain
 Encourage relaxation with contractions.
 Apply sacral counter – pressure with heel of hand to relieve back pain.
 Provide comfortable environment.
 Teach breathing exercises for use during early labor until client receives pharmacologic relief.
 Monitor physical response for example, palpitations/rapid pulse

Fatigue
 Assess psychological and physical factors that may affect reports of fatigue level
 Monitor physical response for example, palpitations/rapid pulse
 Monitor fetal heart beat and contractions continuously.
 Refraining from intervening with client during contraction.

Anxiety
 Keep client and family informed progress.
 Provide support during labor through personal touch and contact. These methods convey
concern.
 Continue support and encouragement.
 Make the client feel she is somewhat in control of her situation.
 Provide client and family teaching.
 Identify client’s perception of the threat presented by the situation.

Medical Management
1. If there are signs of obstruction or the fetal heart rate is abnormal at any stage, deliver by caesarean
section.
2. If the membranes are intact, rupture the membranes with an amniotic hook or a Kocher clamp.
3. If the cervix is not fully dilated and there are no signs of obstruction, augment labor with oxytocin.
4. If the cervix is fully dilated but there is no descent in the expulsive phase, assess for signs of
obstruction.
5. If the cervix is fully dilated and if the leading bony edge of the head is above -2 station, perform
caesarean section; the leading bony edge of the head is between 0 station and -2 station, deliver by
Vacuum Extraction and Symphysiotomy
6. If the operator is not proficient in symphysiotomy, perform caesarean section;
7. If the bony edge of the fetal head is at 0 station, deliver by vacuum extraction or forceps.

SYMPHYSIOTOMY

A surgical procedure in which the cartilage

of the symphysis pubis is divided to widen
the pelvis allowing childbirth when there is a
mechanical problem.

Currently the procedure is rarely performed

in developed countries, but is still routine in
developing countries where cesarean
section is not always an option.

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 Forceps - provides traction or a
means of rotating the fetal head.
Risks: fetal ecchymosis or edema
of the face, transient facial
paralysis, maternal lacerations, or
episiotomy extensions.

Vacuum extraction -
Provides traction to shorten
the second stage of
labor.
Risks: newborn
cephalhematoma, retinal
hemorrhage and intracranial
hemorrhage.

B. Fetal Malpresentation
- refers to fetal presenting part other than vertex and includes breech, transverse, face, brow, and
sinciput.
- Malpresentations may be identified late in pregnancy or may not be discovered until the initial
assessment during labor.

Related Factors:
• The woman has had more than one pregnancy
• There is more than one fetus in the uterus
• The uterus has too much or too little amniotic fluid
• The uterus is not normal in shape or has abnormal growths, such as fibroids
• placenta previa
• The baby is preterm

Types of Malpresentation:

Vertex Malpresentation
1. Sinciput
- the larger diameter of the fetal head is presented.
- Labor progress is slowed with slower descent of the fetal head.

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 2. Brow
- The brow presentation is caused by partial extension of the fetal head so that the occiput is higher
than the sinciput.

Maternal Risks
• Longer labor caused by ineffective contractions and slow or arrested fetal descent.
• Dysfunctional labor patterns
• Cesarean birth if brow presentation persists or if the fetus is large
Fetal/neonatal risks
• mortality because of cerebral and neck compression and damage to the trachea and larynx

Management
- If the fetus is alive or dead, deliver by caesarean section.
*Do not deliver brow presentation by vacuum extraction, outlet forceps or symphysiotomy.

3. Face
- The face presentation is caused by hyper-extension of the fetal head so that neither the occiput nor
the sinciput is palpable on vaginal examination.

Face presentation. Mechanism of birth in mentoanterior position

Top: the submentobregmatic diameter at the outlet
Bottom: the fetal head is born by movement of flexion

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Face presentation. Mechanism of birth in mentoposterior position.
Fetal head is unable to extend further. The face becomes impacted.
This prevents descent and labor is arrested.
Management
1. Chin-Anterior Position
If the cervix is fully dilated:
 Allow to proceed with normal childbirth;
 If there is slow progress and no sign of obstruction, augment labor with oxytocin;
 If descent is unsatisfactory, deliver by forceps.
If the cervix is not fully dilated and there are no signs of obstruction:
 augment labor with oxytocin.
2. Chin-Posterior Position
 If the cervix is fully dilated:
 Deliver by caesarean section.
 If the cervix is not fully dilated
 Monitor descent, rotation, and progress. If there are signs of obstruction, deliver by caesarean
section.

Consider This!
Do not perform vacuum extraction for face
presentation.

Breech
 Breech presentation means that either the buttocks or the feet are the first body parts that will contact
the cervix.
 Breech presentations occurs in approximately 3% of the births and are affected by fetal attitude.
 Breech presentations can be difficult births, with the presenting point influencing the degree of
difficulty.

1. Frank breech
 The baby's bottom comes first, and the legs are flexed at the hip and extended at the knees
(with feet near the ears).
 65-70% of breech babies are in the frank breech position.

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 2. Complete Breech
 The baby's hips and knees are flexed so that the baby is sitting cross-legged, with feet beside
the bottom.

3. Footling Breech
 One or both feet come first, with the bottom at a higher position. This is rare at term but
relatively common with premature fetuses.

Maternal Risks
 Prolonged labor r/t decreased pressure exerted by the breech on the cervix.
 PROM may expose client to infection.
 Cesarean or forceps delivery.
 Trauma to birth canal during delivery from manipulation and forceps to free the fetal head.
 Intrapartum or postpartum hemorrhage.

Fetal Risks:
 Compression or prolapse of umbilical cord.
 Entrapment of fetal head in incompletely dilated cervix.
 Aspiration and asphyxia at birth.
 Birth trauma from manipulation and forceps to free the fetal head.

Management
1. External Cephalic Version.

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 - Tocolytics, such as Terbutaline 0.25 mg IM, can be used before ECV to help relax the uterus.
- If ECV is successful, proceed with normal childbirth. If ECV fails or is not advisable, deliver by
caesarean section.
- Attempt external version if:
 Breech presentation is present at or after 37 weeks (before 37 weeks, a successful version is
more likely spontaneously revert back to breech presentation)
 Vaginal delivery is possible
 Membranes are intact and amniotic fluid is adequate;
 There are no complications (e.g. fetal growth restriction, uterine bleeding, previous
caesarean delivery, fetal abnormalities, twin pregnancy, HPN, fetal death).

2. Vaginal Breech Delivery

- Safe and feasible under the following conditions:
 complete or frank breech
 adequate clinical pelvimetry
 fetus is not too large
 no previous caesarean section for cephalopelvic disproportion
 flexed head

3. Cesarean Section
- Recommended in cases of:
 Double footling breech
 Small or malformed pelvis
 Very large fetus
 Previous cesarean section for cephalopelvic disproportion
 Hyperextended or deflexed head.

Transverse

- Fetus lies horizontally in the pelvis so that the longest fetal axis is perpendicular to that of the mother.
- The presenting part is usually one of the shoulders (acromion process), an iliac crest, a hand, or an
elbow.

Management:
1. External version – If an infant is preterm and smaller than usual, an attempt to turn the fetus to a
horizontal lie may be made.
2. Cesarean birth - most infants in transverse lie must be born by cesarean birth, however, because they
cannot be turned and cannot be born normally form this “wedged” position.

Nursing Diagnoses:
 Anxiety
 Fear
 Risk for infection
 Risk for injury

Nursing Care of Clients with Malpresentations

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Anxiety
 Provide client and family teaching,
 Be available to client for listening and talking
 Provide client support and encouragement.
 Encourage client to acknowledge and express feelings.
 Encourage breathing exercises to relieve anxiety.

Fear
 Provide client and family teaching,
 Note for degree of incapacitation.
 Stay with the client or make arrangements to have someone else be there.
 Provide opportunity for questions and answer honestly.
 Explain procedures within level of client’s ability to understand and handle.

Risk for Injury

 Observe closely for abnormal labor patterns.
 Monitor fetal heart beat and contractions continuously
 Be prepared for childbirth emergencies such as cesarean section, forceps-assisted delivery, and
neonatal-resuscitation.
 Maintain sterility of equipment.
 Anticipate forceps-assisted birth.
 Anticipate cesarean birth for incomplete breech or shoulder presentation.

Risk for infection

 Stress proper hand washing techniques of all caregivers.
 Maintain sterile technique.
 Cleanse incision site daily and prn.
 Change dressings as needed.
 Encourage early ambulation, deep breathing, coughing, and position change.

C. Fetal Distress
Causes:
• Compression of the umbilical cord
• Uteroplacental insufficiency caused by placental abnormalities or maternal condition (prolonged
labor, HPN, DM, infections
• Prolonged labor-CPD, breech presentation, failure of the cervix to dilate

Signs and Symptoms:

• Meconium-stained amniotic fluid
• Changes in fetal heart rate baseline:
- tachycardia
- bradycardia
• Decreased or absence of variability of heart rate
• Late deceleration pattern
• Severe variable deceleration pattern
Nursing Care
Assessment
1. Assess FHR baseline, variability, and pattern of periodic changes
2. Assess contraction pattern and maternal response to labor

Nursing Diagnoses:
 Decreased cardiac output (fetal)
 Impaired gas exchange
 Anxiety

Planning and Implementation

Late deceleration:
1. Reposition mother on her left side
2. Administer O2 by face-mask at 8-10 lpm
3. Increase IV fluids
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 4. Discontinue oxytocin infusion, if labor is being induced
5. Notify the physician immediately
 Goal is to improve maternal blood flow to the placenta
Severe variable decelerations or prolonged bradycardia
1. Reposition the mother on either side
2. If not corrected, reposition to opposite side
3. Administer O2 by face-mask at 8-10 L/min
4. Trendelenburg or knee-chest position, if not corrected
5. Apply upward digital pressure on the presenting part to relieve pressure on the umbilical cord.
 The goal is to relieve pressure on the umbilical cord
6. Provide appropriate information and emotional support
7. Maintain continuous monitoring of FHR and uterine activity, and labor progress.
Evaluation

1. The fetal heart rate remains in normal range with adequate variability and absence of ominous
periodic changes
2. The client verbalizes that anxiety is decreased
3. Family coping strategies are strengthened

D. Prolapse Umbilical Cord

Cause: fetus is not firmly engaged

Contributing factors:
1. ROM before engagement
2. Small fetus
3. Breech presentation
4. Multifetal pregnancy
5. Transverse lie
6. Polyhydramnios
7. Long cord
8. Spontaneous or artificial rupture of membranes before presenting part is engaged

Assessment
1. Identify the client at risk for prolapsed umbilical cord
2. Assess for the following:
- Fetal hypoxia
- irregular FHR
- Umbilical cord can be felt on cervix/vagina
- Variable deceleration
- Cord may be protruding from the vagina
- Fetal distress
- Fetal bradycardia
Nursing Diagnoses
• Risk for impaired gas exchange
• Risk for injury
• fear

Nursing Management

1. Note: The nurse’s #1 priority action is to assess the Fetal Heart Rate
2. Primary goal:
 to remove the pressure from the cord

Planning and Implementation

1. Place mother on knee-chest or Trendelenburg position
2. Push fetal presenting part upward
Note!
• Do not push cord back to uterus
3. Administer O2 by face mask at 8-10 lpm
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 4. Maintain continuous electronic fetal monitoring
5. Prepare for rapid delivery vaginally or by CS
6. If cord protrudes through the vagina, apply sterile saline-soaked dressing to prevent drying.

Evaluation
1. The fetal heart rate remains within normal range and without ominous signs
2. The fetus is safely delivered
3. The client and family verbalized understanding of the implications of prolapsed umbilical cord
and the need for emergency management

Problems with the Passageway

Duration: 6 hours

Key Terms:
 Abnormal size or shape of the pelvis
 Cephalopelvic disproportion
 Shoulder Dystocia

A. Abnormal size or shape of the pelvis

- Pelvis is said to be contracted when its diagonal conjugate is less than 11.5cm and its bi-
ischial diameter is less than 8cm.

1. Inlet Contracture
 Inlet dystocia – anteroposterior dm less than 10cm and greatest transverse dm that is less than 12
cm or diagonal conjugate less than 11.5cm
 due to several conditions including rickets and flat pelvis
 Important sign in primi: lack of engagement between 36 and 38 th week of pregnancy
 Influences fetal position and presentation

2. Midpelvis Contracture

 Occurs when the sum of the interspinous and posterior sagittal diameters of the midpelvis is less than
13.5cm or an interischial spinous dm less than 8cm.
 Midpelvis dystocia – most common pelvic dystocia
 Fetus is able to engage but due to narrowed dm of the midplevis the fetal head is prevented from
rotating internally from transverse to AP dm.

3. Outlet Contracture
 occurs when the bi-ischial dm (distance between ischial tuberosities) is less than 8cm

Causes
 Increased Fetal Weight
 Fetal Position
 Problems with the Pelvis

Categories:
Maternal: size & shape of bony pelvis
Fetal: size, shape, presentation, position

Diagnosis
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  Clinical Pelvimetry

Measurement of transverse diameter of the outlet and pubic angle

- Trial of labor (TOL): the physician may allow labor to continue or even stimulate labor with
oxytocin when pelvic measurements are borderline to see if the fetal head will descend making
vaginal delivery possible; if progressive changes in dilatation and station do not occur, a cesarean
delivery is performed.

B. Cephalo-Pelvic Disproportion
- Fetal head is too large to pass through the bony pelvis.
Sign: Fetal head does not descend even though there are strong contractions
Maternal Risks:
 Prolonged labor
 Exhaustion
 Hemorrhage
 Infection
Fetal Risks:
 Hypoxia
 Birth trauma
Diagnosis: Ultrasound
- estimation of the baby's size can be made
- an assessment of potential CPD can be made

Management: Cesarian section is the only option to deliver the baby

C. Shoulder Dystocia
- Difficulty in bringing out shoulder
- Fetal head is born but the shoulders are too broad to enter and be delivered through the pelvic outlet

Manifestations
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  Prolonged second stage of labor
 Arrest of descent
 Turtle sign

Maternal Risks:
 Vaginal or cervical lacerations
 Postpartum hemorrhage

Neonatal Risks:
 Hypoxia
 Fractures of clavicle
 Brachial plexus injury - is a group of nerves that come from the spinal cord in the neck and
travel down the arm. These nerves control the muscles of the shoulder, elbow, wrist and hand, as
well as provide feeling in the arm. Some brachial plexus injuries are minor and will completely
recover in several weeks. Other injuries are severe enough and could cause some permanent
disability in the arm.

Nursing Care
Assessment and identification of the client at risk for shoulder dystocia
 Obesity
 Increased fundal height
 History of macrosomia
 Maternal diabetes or gestational diabetes
 Prolonged second-stage of labor
 Multipara
 Post-date pregnancies

Nursing Diagnoses
 Risk for Injury
 Fear
 Deficient knowledge

Planning and Implementation

1. Assist with positioning during delivery: Mc Robert’s Maneuver

 Woman flexes thighs on her abdomen

 Position changes the angle of the pelvis, increases pelvic diameters, and facilitates delivery of the
shoulders

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2. Assess for maternal and newborn injury following delivery

Evaluation
- Client and fetus experience a safe delivery without injury.
- The client indicates that fear is diminished.
- Client is able to verbalize increased understanding of pelvic disproportion and dystocia, its
causes, and implications for delivery.

Problems with the Powers

Duration: 6 hours

Key Terms:

 Difficult labor
 hypertonic uterine dysfunction
 hypotonic uterine dysfunction
 abnormal progress in labor
 retraction rings
 Premature labor
 Precipitate labor and birth
 Uterine prolapse
 Uterine rupture

A. Difficult Labor
1. Hypertonic Uterine Dysfunction
- Usually encountered in the latent phase
- Contractions are too frequent but uncoordinated
- Tend to be more painful

Maternal Risks: prolonged or non-progressive labor, pain, and fatigue.

Fetal Risks: Hypoxia caused by decreased uteroplacental blood flow.

Medical Management: Therapeutic rest – sedation aimed at stopping contractions, promoting rest,
and allowing normal labor pattern to develop.

Nursing Management:
1. Evaluation of pelvic size
2. Monitor intake and output.
3. Maintenance of fluid and electrolytes.
4. Keep bladder empty.
5. Encourage side lying position.
6. Watch for danger signals: fetal distress, passage of meconium-stained amniotic fluid

2. Hypotonic Uterine Contractions

- characterized by weak and infrequent contractions which are insufficient to dilate the cervix.

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 - Usually occurs during the active phase.

Causes
 Overdistention of the uterus
 Malpresentation and malposition
 Pelvic bone contraction
 Unripe or rigid cervix
 Congenital abnormalities of the uterus
 Unknown causes

Risks:
 Maternal and fetal infections
 Postpartum hemorrhage
 Fetal distress and death
 Maternal exhaustion

Management:
1. Re-evaluate pelvic size to rule out fetopelvic disproportion
2. Vaginal delivery
• Amniotomy if membranes are not yet ruptured
• Augmentation of labor
3. CS if pelvis is contracted
4. Provide supportive nursing care

3. Abnormal Progress in Labor

- The partograph is used to identify deviations from normal progress in labor by plotting cervical
dilatation and descent of the fetal head over time.
a. Prolonged Latent Phase
 Exceeding 20 hours in nulliparas and more than 14 hours in multiparas
Causes:
1. Poor cervical condition (unripe, rigid, and firm)
2. Excessive sedation
3. Conduction of analgesia
Management:
 Therapeutic rest (use of sedative)
 Active intervention (oxytocin stimulation)

b. Protraction Disorders
- The most common abnormalities during the active phase.
- Caused by the same factors that contribute to prolonged latent phase.

Types:
1. Protracted active phase - <1.2 cm dilatation per hour in nullipara; <1.5 cm per hour in
multipara
2. Protracted Descent - <1 cm feta descent per hour in nullipara; < 2cm descent in multipara

Management:
 Re-asses pelvic size, presentation, position to rule out fetopelvic disproportion
 Expectant management if without CPD
 Provide support to the mother.

c. Arrest Disorders
- Active phase disorder characterized by lack of descent and dilatation even uterine
contractions are occurring normally.
Types:
1. Arrest of dilatation – no progress in cervical dilatation for more than 2 hours in nulliparas
and 1 hour in multiparas
2. Arrest of Descent – no progress of fetal descent for more than 1 hour in nulliparas and
primiparas
3. Failure of Descent – absence of fetal descent in the second stage of labor.

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 d. Prolonged Second Stage
- Median duration in nulliparas is 20 minutes and 50 minutes in multiparas
- Common causes: persistent occiput posterior, and epidural anesthesia
- Prolonged if more than:
 Nullipara: 2 hours without conduction analgesia, 3 hours with conduction analgesia
 Multipara: 1 hour without conduction analgesia, 2 hours with conduction analgesia

4. Retraction Rings
- Physiologic retraction ring: boundary between upper uterine segment and lower uterine
segment that normally forms during labor.
 Upper segment contracts and becomes thicker as muscle fibers shorten
 Lower segment distends and becomes thinner
- Bandl’s Ring: A Pathological retraction ring that forms when labor is obstructed caused by
CPD or other complications.
 Upper segment continues to thicken
 Lower segment continues to distend
 Risk of uterine rupture
 CS is indicated
- Constriction Ring
 Retraction ring forms and impedes fetal descent.
 Relaxation of the constriction ring with analgesics, anesthetics, or both allows vaginal
delivery.

B. Precipitate labor and birth

- Occurs within 3 hours from onset of contraction to delivery of baby
- Occurs without warning
Classifications:
 Precipitate dilatation – 5cm or more/hour dilatation in nulliparas and 10 cm/hour in
multiparas.
 Precipitate descent - –fetal descent is progressing at a rate of 5cm or more/hour in nulliparas and 10
cm/hour in multiparas.
Predisposing Factors
 Multiparity
 Large pelvis
 Lax unresisting maternal tissue
 Small baby in good position
 Induction of labor
 Absence of painful sensation
Maternal Risks
 Laceration of birth canal and uterine rupture
 Postpartum hemorrhage
 Amniotic fluid embolism
Fetal Risks
 Hypoxia
 Intracranial hemorrhage
 Erb-Duchenne palsy
 Premature separation of placenta
 Injuries
Signs and Symptoms
 Patient complains of a sudden, intense urge to push
 Sudden increase in bloody show.
 Sudden bulging of the perineum
 Sudden crowning of the presenting part
Management
1. Anticipatory guidance for prevention
2. During oxytocin admin, stop infusion right away and turn woman on her side
3. Call for help, do not leave the patient alone.
4. Obtain sterile delivery pack if in a health care facility
5. Deliver the baby

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C. Uterine rupture
- Tearing of the muscles of the uterus
- Rare but serious complication, occurring in 1 in 1,500 to 2,000 births.
Causes:
 Rupture of scar from previous CS
 Prolonged labor, obstructed labor, malposition, malpresentation
 Overdistention of the uterus
 Injudicious use of oxytocin, forceps and vacuum extraction
 Precipitate labor and delivery
 Manual removal of the placenta
 External trauma
 Placenta increta or accrete
 Adenomyosis
 Gestational trophoblastic neoplasia

Signs and Symptoms

 Impending uterine rupture is often manifested by a pathologic retraction ring in
obstructed labor.
 Sudden sharp tearing pain during the peak of contraction, after which, relief is felt as
uterus loses the capacity to contract

Types:
1. Complete
 Sudden excruciating pain at the peak of a contraction, the contractions stop altogether
 Two swellings will be visible
 Internal hemorrhage
 Vaginal bleeding may or may not occur
 Separation of the placenta – leads to hypoxia and fetal death

2. Incomplete rupture
 Localized tenderness
 Persistent pain over the abdomen
 Contractions may still continue or stop
 No progress in cervical dilatation
 Vaginal bleeding may or may not be present
 Signs of maternal shock and fetal distress

Medical Management
1. Complete Rupture: management of shock: Blood transfusion and administration of IVF,
Administer mask oxygen at 8 lpm.
2. Incomplete Rupture: Hysterectomy, emergency laparotomy to deliver the baby

Nursing Assessment:
1. Sudden, sharp, lower abdominal pain
2. Tearing sensation
3. Signs of shock
4. Cessation of contractions
5. FHR ceases
6. Blood loss is often concealed
7. Fetal parts may be easily palpated through abdominal wall

Priority Nursing Diagnoses

 Risk for Injury
 Impaired Gas Exchange
 Deficient fluid volume

Planning and Implementation

a. Prevention is best
1. Identify clients at risk.

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 2. Avoid hyperstimulation of uterus during induction.

Evaluation
- Client and infant are delivered without injury
- Client’s fluid volume is restored to normal.

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