PREPARED BY;

MARJORIE GALICIA ROMANO

Clinical Instructor
 PROBLEMS WITH THE PASSANGER
A. Fetal malposition: the ideal fetal position is flexed
with occiput in the right or left anterior quadrant of
the maternal pelvis
1. Types of malpositions
a. Occiput posterior (OP) position
1) Right or left OP position occurs in about 25% of
all term pregnancies but usually rotates to
occiput anterior (OA) as labor progresses
2) Failure to rotate is termed persistent occiput
posterior
3) Maternal risk include prolonged labor, potential for
operative delivery, extension of the episiotomy, 3rd-
or 4th- degree of laceration of the perineum
 4) Maternal syptoms include intense back pain
in labor, dysfunctional labor pattern, prolonged
active phase, secondary arrest of dilation, and/or
arrest of descent
Possible Problem
Prolonged active phase
Arrested descent
Risk Factors
Android pelvis
Antrhopid pelvis
Contracted pelvis
b. Occiput tranverse (OT) position
1) Incomplete rotation of OP position to OA
results in the fetal head being in a horizontal or
tranverse position (OT)
2) Persistent occiput tranverse position occurs as
a result of ineffective contractions or a flattened
bony pelvis
3) In the absence of abnormal pelvic structure,
vaginal delivery can be accomplished by
stimulating contractions with oxytocin (Pitocin)
and application of forceps for delivery
2. Nursing care
a. Encourage the mother to lie on her side opposite from the
fetal back, which may help with rotation
b. Knee-chest position may facilitate rotation
c. Pelvic rocking may help with rotation
d. Apply sacral counter-pressure with heel of the hand to
relieve back pain
e. Continue support and ecouragement
1) Keep client and family informed of progress
2) Encourage relaxation with contractions
3) Praise client’s efforts to maintain control
f. Anticipate forceps/manual rotation and forceps- assisted
birth
MEDICAL MANAGEMENT
a. Forceps: metal instruments applied to the fetal head to
facilitate delivery
1) Provides traction or means of rotating the fetal
head
2) Risk are fetal ecchymosis or edema of the face,
transient facial paralysis, maternal
lacerations, or episiotomy extensions
b. Vacuum extraction: a suction cup applied to the fetal
head to facilitate delivery
1) Provides traction to shorten the second stage of
labor
2) Risk are newborn cephalhematoma, retinal
hemorrhage, and intracranial hemorrhage
 FETAL MALPRESENTATION
1. Vertex malpresentations are caused by failure of the fetus
to assume a flexed attitude
a. Brow presentation
1) Fetal forehead is the presenting part
2) 50% convert to vertex or face presentation
b. Face presentation
1) Increased risk of prolonged labor and operative
delivery
2) Anticipate vaginal delivery if pelvis is adequate
and the chin (mentum) is in the anterior
position
3) Anticipate cesarean delivery if mentum is
posterior or signs of fetal distress occur
4) Fetal monitor electrode should not be placed
on the presenting part (infants face); requires
external fetal heart rate monitoring.
5) Edema and bruising of the face, eyes, and lips
are common occurrences – client’s should be
prepared for this possibility before seeing the
infant for the first time
Caput succedaneum
A--Complete flexion. B-- Moderate flexion. C--Poor flexion. D--
Hyperextension
TYPES OF ATTITUDE
(a) Complete flexion. This is normal attitude in cephalic
presentation. With cephalic, there is complete flexion at
the head when the fetus "chin is on his chest." This
allows the smallest cephalic diameter to enter the
pelvis, which gives the fewest mechanical problems with
descent and delivery.
(b) Moderate flexion or military attitude. In cephalic
presentation, the fetus head is only partially flexed or
not flexed. It gives the appearance of a military person
at attention. A larger diameter of the head would be
coming through the passageway.
(c) Poor flexion or marked extension. In reference to
the fetus head, it is extended or bent backwards. This
would be called a brow presentation. It is difficult to
deliver because the widest diameter of the head enters
the pelvis first. This type of cephalic presentation may
require a C/Section if the attitude cannot be changed.
(d) Hyperextended. In reference to the cephalic
position, the fetus head is extended all the way back.
This allows a face or chin to present first in the pelvis. If
there is adequate room in the pelvis, the fetus may be
delivered vaginally.
Sincipital presentation (Military Attitude)
1) Larger diameter of the fetal head is presented
2) Labor progress is slowed with slower descent of the
fetal head
Breech Presentation
There are three types of breech presentation
1. Complete breech: sacrum is the presenting part, knees
flexed
2. Frank breech: sacrum is the presenting part, legs are
extended
3. Incomplete: (footling) one or both feet are presenting,
increasing the risk of umbilical cord prolapse
What causes a breech presentation?
The causes of breech presentations are not fully
known. However, a breech birth is more
common :
In subsequent pregnancies
In pregnancies of multiples
When there is history of premature delivery
When the uterus has too much or too little amniotic
fluid
In an abnormal shaped uterus or a uterus with
abnormal growths, such as fibroids.
For women with placenta previa
 Maternal Risk
1) Prolonged labor due to decrease
pressure exerted by breech on the
cervix
2) Cesarean or forceps delivery
3) Trauma to birth canal during delivery
from manipulation and forceps to free
fetal head
4) Intra partum or postpartum
hemorrhage
Delivery of Breech Presentation by Forceps
Vaginal delivery versus cesarean for breech
birth?
Most health care providers do not believe a vaginal
delivery is possible for a breech birth, although some
will wait to make that decision until a woman is in
labor. However, the following are often necessary in
order for a vaginal birth to be attempted:
The baby is full-term and in the frank breech
presentation
The baby does not show signs of distress while its heart
rate is closely monitored
The process of labor is smooth and steady; the cervix is
widening and the baby is moving down
The health care provider estimates that the baby is
not too big or the mother's pelvis too narrow for the
baby to pass safely through the birth canal
 Anesthesia is available and a cesarean delivery can be
performed on short notice
Piper forceps - applied to the after coming
fetal head
EXTERNAL CEPHALIC VERSION
Manipulation of the fetus through the abdominal wall from
a breech or shoulder presentation to a vertex
presentation:
May be done as early as 34 to 35 wks or usual time is 37
to 38 wks
Client is placed on external fetal monitor and possibly
UTZ are recorded continuously
IV fluids are started
Terbutaline is administered via piggybacked IV line to
relax the uterine muscle
FHR is closely monitored during version attempt
Version is discontinued if undue maternal or fetal
distress is noted
 VERSION
The breech and vertex of the fetus are grasped
transabdominally by the examiner’s hands on
the woman’s abdomen.
Gentle pressure is then exerted to rotate the
fetus in a forward direction to a cephalic lie.
The use of external version can decrease the
number of cesarean section from breech
presentation.
Contraindication
Multiple gestation
Severe oligohydramnios
Contraindications to vaginal births - The mother
has a condition (such as a heart problem) that
prevents her from receiving certain tocolytic
medicines to prevent uterine contractions.
Cord coil
Unexplained third trimester bleeding (placenta
previa )
The bag of waters (amniotic sac) has ruptured.
A cesarean delivery is needed, such as when the
placenta partially or completely covers the cervix
(placenta previa) or has separated from the wall of
the uterus (placenta abruptio).
Fetal monitoring shows that the fetus may not be
doing well.
The fetus has a hyperextended head. This means
that the neck is straight, rather than bending the
head forward with the chin tucked into the chest.
The fetus is known or suspected to have a birth
defect.
The mother's uterus does not have a normal shape.
External cephalic version has an average success rate
of 58%. Version is most likely to succeed when:
The mother has already had at least one pregnancy
and childbirth.
The fetus, or a foot or leg, has not dropped down
into the pelvis (has not engaged).
The fetus is surrounded by a normal amount of
amniotic fluid.
The procedure is performed near term (34 or more
completed weeks of pregnancy), before labor starts.
Version is least likely to succeed when:
The fetus is engaged down in the mother's pelvis.
The doctor cannot grasp the fetal head.
The uterus is hard or tense to the touch.
About 4% of fetuses return to a breech position after
a successful version.
Compared to the first attempt, repeat version
attempts are less likely to be successful.
 Risks
With frequent monitoring, the risks of external cephalic version
to the mother and fetus are low.
Potential risks of version, for which the fetus and mother are
closely monitored, include:
Twisting or squeezing of the umbilical cord, reducing blood
flow and oxygen to the fetus.
The beginning of labor, which can be caused by rupture of the
amniotic sac around the fetus (premature rupture of the
membranes, or PROM).
Placenta abruptio, rupture of the uterus, or damage to the
umbilical cord. The potential exists for such complications, but
they are very rare.
On the rare occasion that labor begins or the fetus or mother
develops a serious problem during version, an emergency
cesarean section (C-section) may be done to deliver the fetus.
Shoulder Presentation
Tranverse lie – acromium process is the presenting part
a. Vaginal delivery is not considered possible in term infant
b. CS is preferred method of delivery
Causes
Prematurity
Placenta Previa
Abnormal uterus
Contracted pelvis or relaxed abdominal wall
Polyhydramnios
Shoulder presentation
SHOULDER PRESENTATION WITH PROLAPSED ARM
FETAL DISTRESS
- Insufficient oxygen supply to meet the demands of
the fetus
Causes
a. Compression of the umbilical cord
b. Uteroplacental insufficiency caused by placental
abnormalities or maternal condition
Signs and Sypmtoms
a. Meconium-stained amniotic fluid (excluding
breech presentation
b. Changes in fetal heart rate baseline
1) Tachycardia (above 160): early sign of distress
2) Bradycardia (below 110): late sign of distress
c. Decreased or absence of variability of heart rate
1) Heart rate varies less than 2 to 5 beats per
minute causing a flattened appearance to the
heart rate
2) Indicates depression of the autonomic
nervous system that controls heart rate
3) Fetal sleep, sedation, and hypoxia may affect
variability
 Late deceleration
1. Fetal heart rate slows following the peak of a
contraction and slowly returns to baseline rate during
the resting phase
2. Indicates fetal response to hypoxia from uteroplacental
insufficiency
3. Considered an omnious pattern regardless of the depth
of the deceleration of the FHR and requires immediate
intervention
 Nursing management
(uteroplacental insufficiency)
Reposition the mother on her left side
Administer oxygen via face-mask at 8-10
lpm
Increase IV fluids
Discontinue oxytocin infusion, if labor is
being induced
Notify the doctor
 Severe variable deceleration
1. Fetal heart rate repeatedly decelerates
below 90 beats/min. for over 60 secs.
before returning to baseline
2. Indicates interference of fetal blood
flow from cord compression
3. Leads to fetal hypoxia and low APGAR
scores unless steps are taken to correct
it
Nursing management
(cord compression)
Reposition the mother on her side
If not corrected, reposition to opposite side
Administer oxygen by face-mask at 8-10 lpm
Trendelenburg or knee-chest position, if not
corrected
Perform vaginal examination and apply
upward digital pressure on the presenting
part to relieve pressure on the cord.
AMNIOINFUSION
Amniotic fluid may be replaced
with warmed saline through an
intrauterine catheter when signs
of cord compression are present
during labor after PROM.
Infusion is continued until signs
of cord compression disappear.
SEVERE VARIABLE DECELERATION
TABLE 3
Indications and Contraindications for Use of Transcervical
Amnioinfusion

Indications Repeated severe variable fetal heart rate

decelerations not responsive to conventional therapy
Thick/particulate meconium staining of the amniotic fluid

Contraindications
Amnionitis
Polyhydramnios
Uterine hypertonus
Multiple gestation
Known fetal anomaly
Known uterine anomaly
Severe fetal distress
Nonvertex presentation
Fetal scalp pH <7.20
Placental abruption or placenta previa
The two most common applications of transcervical
amnioinfusion are treatment of severe variable
decelerations and dilution of thick meconium fluid
during labor.

The greatest attractions of amnioinfusion have been

that it is easy to perform, inexpensive and safe.

After an initial bolus of 250 mL, normal saline is

infused at a rate of 10 to 20 mL per hour.
AMNIOINFUSION PROCEDURE
 TECHNIQUE
Amnioinfusion can per performed via a transcervical or
transabdominal route. The transcervical route is preferred
because it is does not require ultrasound guidance and easily
allows for repeated fluid instillation.
Transcervical approach — A lactated Ringers or normal saline
(without dextrose) solution is infused into the amniotic cavity
through an intrauterine pressure catheter. Normal saline
solution may cause derangement of neonatal electrolytes, thus
lactated ringers is preferable. Most protocols call for a bolus
infusion of 250 to 1,000 mL of fluid at a rate of 10 to 15
mL/minute, followed by a continuous infusion of 100 to 200
mL/hour via pump infusion or gravity. Alternatively, repeat
boluses may be administered, as needed.
There is no evidence that the fluid needs to
be warmed above ambient room temperature
prior to administration. A blood warmer
should be used if warming to body
temperature is desired. In cases of prolonged
amnioinfusion, sonographic assessment of the
amniotic fluid volume is suggested to avoid
iatrogenic polyhydramnios.
INTRAUTERINE RESUCITATION
Administration of terbutaline
(tocolytics), to stop uterine
contractions and provide an
opportunity for uteroplacental
circulation to improve when
fetal distress is present during
the first stage of labor.
PREVENTION OF MECONIUM ASPIRATION
1. If meconium is present during labor (green-
tinged amniotic fluid), steps to prevent
aspiration at the time of delivery should be
taken
2. The nasopharynx of the infant is suctioned prior
to delivery of the chest and abdomen
3. Visualization of the larynx and vocal cords with
deep suction is performed immediately after
delivery and before the first breath is taken
 PROLAPSED UMBILICAL CORD
Cause: fetus is not firmly engaged, allowing room for
the cord to move beyond (overt prolased) or
alongside the presenting part (occult prolapse)
Contributing factors
a. rupture of membranes before engagement of the
presenting part
b. small fetus
c. Breech presentation
d. multifetal pregnancy
e. Tranverse lie
•Overt prolapse, which is the most common, refers to
protrusion of the cord in advance of the fetal
presenting part, often through the cervical os and into
or beyond the vagina. The fetal membranes are
invariably ruptured in these cases and the cord is
visible or palpable on examination.
•Occult prolapse occurs when the cord descends
alongside, but not past, the presenting part. It can
occur with intact or ruptured membranes. The
diagnosis should be considered in the setting of a
sudden, prolonged fetal heart rate deceleration. An
occult prolapse often cannot be diagnosed with
certainty, but is suggested by clinical features (eg, fetal
bradycardia) and findings at cesarean delivery.
Managing UCP
 Managing UCP
Goal of care: actions to relieve pressure on the cord and
restore fetal oxygenation
a. Place the mother’s hip higher than her head
 Knee-chest position
 Trendelenburg position

b. Perform sterile vaginal exam pushing fetal

presenting part upward with fingers to relieve
pressure on the cord
c. Administer oxygen by face mask at 8-10 lpm
d. Maintain continuous electronic fetal monitoring
 Managing UCP
e. Prepare for rapid delivery either
vaginally or cesarean section

f. If cord protrudes through the vagina,

determine that pulsation is present and
apply sterile saline soaked dressing to
prevent drying
 Abnormal size or shape of pelvis
Contracted pelvic inlet: anterior-posterior diameter less than
11 cm; transverse dm less than 12 cm.
1. Caused by rickets in early life or inherited small pelvis
2. Makes engagement difficult
3. Influences fetal position and presentation
4. Risk of UCP
Contracted mid-pelvic plane: interspinous dm less than 9.5 cm
1. Hampers internal rotation of the fetal head
2. Secondary arrest of dilation or arrest of fetal head occurs
Contracted pelvic outlet: interschial tuberous diameter
less than 11 cm
 TRIAL OF LABOR
 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 dilation and
station do not occur, a cesarean delivery is
performed
Urge woman to void every 2 hours
Assess UCP after membranes ruptured
Emphasize advantage of vaginal delivery
 Cephalopelvic disproportion (CPD)
1. Fetal head is too large to pass through the
bony pelvis
2. Signs & symptoms: fetal head does not
descend even though there are strong
contractions
3. Maternal risks include prolonged labor,
exhaustion, hemorrhage, and infection
4. Fetal risks include hypoxia and birth trauma
5. Cesarean birth is necessary
 Fetal Macrosomia
Weighs more than 4,000 – 4,500g (9-10 lb)
Associated with;
1. Multiparity
2. Diabetes or Gestational diabetes
Maternal Risk
1. Uterine dysfunction during labor or at birth
2. CPD
3. Uterine rupture
4. CS delivery
5. Post partum hemorrhage
 Fetal macrosomia
Neonatal Risk (Vaginal delivery)
1. Cervical nerve palsy
2. Diaphragmatic nerve injury
3. Fracture clavicle
 Shoulder Dystocia
 An obstetric emergency resulting from
difficulty or inability to deliver the shoulders.
Shoulder is too broad to enter and be born
through the pelvic outlet.
Fetal macrosomia increases the risk of shoulder
dystocia. Occurs at the second stage of labor.
Maternal Risk:
1. Lacerations and tears of birth canal (vaginal &
cervical tears)
2. Postpartum hemorrhage
Shoulder Entrapment
Neonatal Risks
1. Hypoxia
2. Fractures of clavicle or brachial plexus
3. Injury to neck and head
Risk Factors
1. Obesity
2. Increased fundal height
3. History of macrosomia
4. Maternal diabetes or gestational diabetes
5. Prolonged second-stage labor/descent arrest
6. Post date pregnancy
7. Multiparity
McRobert's Position
As soon as shoulder dystocia is identified, the mother's
hips are flexed back onto her abdomen. This is called
McRobert's Position, and helps the baby's shoulder slip
under the mother's pubic bone by enlarging the pelvic
outlet. Usually at about the same time, a nurse or other
assistant pushes down on the baby's shoulder, behind
the pubic bone, helping it pass under. More than half
of all shoulder dystocias are relieved just by these two
maneuvers, which usually take less than a minute. It is
important that the pressure be suprapubic in nature to
dislodge the shoulder from beneath the pubic bone
and not fundal, or on the top of the uterus, as this
serves only to further impact the shoulder beneath the
pubic bone.
McRobert’s Maneuver
 Rescue Maneuvers
It is very rare that the baby cannot be delivered
by the maneuvers discussed so far. If the shoulder
dystocia persists, however, other rescue
maneuvers include:
Zavanelli Maneuver. The baby's head and body are
pushed back into the uterus and cesarean delivery
is performed. Although there are some risks to
the mother and baby with this procedure, there
are many reports of it successfully relieving severe
shoulder dystocia. This maneuver would be
considered heroic and is not practiced routinely.
 .
Proctoepisiotomy.
In this maneuver, the normal midline
episiotomy is extended intentionally into
the rectum. Though this requires a
complex repair that can lead to future
rectal dysfunction, it can also serve to
widen the birth canal posteriorly and
allow for disimpaction of the anterior
shoulder.
Corkscrew. The shoulders of the baby are twisted
around and pushed out of the anterior-posterior
(front to back) plane. This may allow the front
shoulder to come out from behind the pubic bone
and be delivered.
Delivery of the further arm. The obstetrician
reaches back into the birth canal alongside the baby
to grasp the baby's further hand or forearm and pull it
out by sweeping it across the baby's chest. Once the
arm is out, the rest of the baby's body is usually
delivered easily. The upper bone of the baby's arm,
called the humerus, may be broken during this
maneuver, but it heals up quite easily.
 Problems with Powers
A. Induction of labor: pharmacologic
and nonpharmacologic measures to
initiate contractions and cervical
change
 Labor is started artificially
1. Methods of induction
a. Cervical Ripening
1) Prostaglandins (PGE2) gel
2) Laminaria (hydrophilic agent)
 Drugs Used for Induction of Labor
Drug Route/Action Side Effects & Potential
Complications

Prostaglandins Intravaginally close to Abdominal cramping, nausea,

(Cervidil; cervix; vomiting, diarrhea
Prepidil) Causes softening &
effacement or cervical
ripening
Misoprostol Synthetic prostaglandin Sudden onset of hypertonic
(Cytotec) administered orally or contractions & elevated resting
intravaginally to produce tone of the uterus w/c may
contractions lead to fetal distress
Oxytocin Synthetic oxytocin Uterine tetany & fetal distress
(Pitocin) administered IV in small are major concerns; can lead to
amts. & titrated to water intoxication,
produce contraction that hyponatremia &
mimic normal labor hypochloremia
 Amniotomy
 Artificial rupture of membranes (AROM)
1) Auscultate FHR prior to and immediately after
AROM to detect prolapse of the umbilical cord or
fetal distress
2) Take maternal temperature q 1 to 2 hrs following
AROM to detect signs of infection
Misoprostol (Cytotec) administration
1) administered orally/vaginally at doses of 25 to 50
mg
2) Continuous monitoring of the FHR, uterine
activity, & maternal v/s is essential
Oxytocin administration
1) Bishop score may be used to asses maternal
readiness for induction
2) Prior to induction, begin external fetal monitoring
3) Assess & record maternal v/s, I&O, & contraction
frequency & intensity
4) Begin primary intravenous infusion
5) Mix oxytocin in 500 to 1000cc of IV balanced-saline
fluids such as lactated Ringer’s & piggyback into
primary IV at a site as close to the client as possible
6) Control & titrate the oxytocin solution using IV
pump
7) Begin at 0.5 to 2mU/min, increasing at
increments of 1 to 2mU q 15 to 60 min. up to a
maximum of 40mU according to hospital
protocol & until contractions occur regularly
8) Continue monitor contractions & FHR
closely & stop infusion immediately if
contractions are closer than 2 min, last longer
than 90 sec, or if there is any indication of
fetal distress
 Contraindication of Induction
a. Placenta previa
b. Tranverse lie & other fetal lajpresentations
c. Prior classic uterine incision
d. Pelvic structure abnormality
e. UCP
f. Active genital herpes
g. Invasive cervical cancer
Precipitate labor & birth
Rapid labor (<3 hours) resulting in precipitous birth
Maternal Risk
a. Cervical, vaginal, or rectal lacerations
b. Hemorrhage due to rapid passage through the birth
canal
c. Injury at birth
Interventions
a. Tocolytics
b. Do not leave the client; send someone or call for help
c. Don sterile gloves, if time allows
d. Instruct the client to pant or blow to decrease urge to push
d. Support the perineum w/ sterile towel as
crowning occurs
e. Apply gentle pressure on the fetal head to prevent
rapid delivery
1) lacerations of perineum can occur
2) Subdural or dural tears may occur w/ sudden
expulsion of the infant’s head
f. After delivery of the head, suction the infant’s
mouth then nose with bulb syringe
g. Check around the infant’s neck for possible tight
umbilical cord; if present, cord must be clamped &
cut before delivery
h. Place hands on each side of the infant’s head &
instruct client to push
i. Gentle down ward pressure facilitates birth of the
anterior shoulder
j. Gentle upward traction facilitates birth of the
anterior shoulder
k. Support the infants body w/ a towel as it is expelled
from the birth canal
l. suction & dry the infant
m. Place infant on mother’s abdomen asap
n. Clamp & cut U.C
o. Observe for placental separation
p. Gently pull the cord while massaging
the fundus to deliver the placenta
q. Continue to massage the fundus to
prevent hemorrhage or put the infant to
breast
r. Inspect the perineum for lacerations or
tears
Uterine prolapse
1. Vigorous massage of the fundus and pulling on the
umbilical cord to speed placental separation may cause
prolapse of the cervix and lower uterine segment through
the introitus.

2.Uterine inversion: turning inside out of the uterus

a. Complete inversion.
 1.)Inverted uterus is visible outside the introitus.
 2.) Life-threatening because of severe hemorrhage and

shock .
 3.) Uterus must be immediately replaced manually to

stop blood loss.

b. Partial inversion
1.) Is not visible but can be palpated.
2.)Uterine fundus is partially inverted hampering contraction
and control of hemerrhage.
Nursing Management:
-Maintain IV line-optimal flow to restore fluid vol.
-Anticipate blood transfusion
-O2 by facemask
-Asses v/s and hypovolemic shock
-Anticipate CPR
-Woman will be placed on gen. anesthesia, tocolytics given to relax
uterus
-Oxytocin is administered after manual replacement for uterus to
contract and remain in place
-Future pregnancy will be delivered via CS
-Antibiotic therapy endometrium was exposed
3.) Corrected by the physician using a bimanual technique
Uterine rupture: tearing open or
separation of uterine wall
1.Rare but serious complication, occuring in 1 in 1,500 to
2,000 births.
2.Most common causes
a. Separation of scar from previous classical cesarean
b. Uterine trauma
c. Intense uterine contractions
d. Overstimulation of labor with oxytocin
e. Difficult forceps-assisted birth
f. External cephalic or internal version
g. Prolonged labor
3. Risk factors for uterine rupture
a. Multiparity
b. Overdistension of the uterus (multifetal pregnancy)
c. Malpresentation
d. Previous uterine surgery
4. Types
a. Complete extends through the uterine wall into the
peritoneal cavity
b. Incomplete extends into the peritoneum but not into the
peritoneal cavity
1.) Partial separation of cesarean scar
2.) May go unnoticed until repeat cesarean is performed
5. Medical management depends on type of rupture
a. Complete rupture requires management of shock,
replacement of blood, and hysterectomy
b. Incomplete rupture may require laparotomy, repair, and
blood transfusion
6. Nursing assessment: signs and symptoms may be silent
or dramatic.
a. Sudden, sharp, lower abdominal pain
b. Tearing sensation
c. Signs of shock
d. Cessation of contractions
e. FHR ceases
f. Blood loss is often concealed
g. Fetal parts may be easily palpated through abdominal wall
7. Priority nursing diagnosis; Risk for injury; Impaired gas
exchange; Deficient fluid volume
8. Planning and implementation
a. Prevention is best
1.) Identify clients at risk
2.) Avoid hyperstimulation of the uterus during induction

Amniotic Fluid Embolism

- amniotic fluid is forced into an open maternal uterine
blood sinus due to membrane defects or after partial
premature separation of the placenta
- anaphylactoid response
- lung embolism – previously thought
Risk factors:
-oxytocin administration
-abruptio placentae
-hydramnios

S/Sx- in strong contraction of labor the woman sudden

sits up and grasps her chest because of sharp pain and
inability to breath
- becomes pale then cyanotic
- admin oxygen by mask
- anticipate CPR – death may occur
 Problems with the Psyche
A. Factors influencing the psyche of the client in
labor
1. Fear and anxiety
2. Perception of the problem
3. Self-image
4. Preparation for childbirth
5. Support systems
6. Coping ability
B. The effect of fear and anxiety on labor progress
1. Epinephrine secretion in response to stress
2. Vascular changes divert blood from the uterus to skeletal
muscles
3. Decrease in oxygen and glucose supply with accumulation
of lactic acid in uterine muscle
4. Higher perception of pain
5. Decrease in available energy supply to support effective
contractions
6. Labor progress is slowed
C. Nursing assessment
1. Determine client’s past experience with, preparation for,
and expectations of labor and birth
2. Determine client’s current coping behaviors and their
effectiveness with the current situation
E. Planning and implementation
1. Establish a trusting relationship with the client and
family
2. Reamain at the bedside with the client and family
during labor
3. Encourage relaxation
4. Keep the client and family informed about progress
and procedures
5. Encourage positive coping behaviors and
discourage negative behaviors
6. Promote self-image by praising efforts
 Cesarean Section
A. Delivery of the infant by an abdominal incision:
purpose is to facilitate delivery to preserve the health of the
mother and fetus
1. Number of cesarean births has increased dramatically
beginning in the late 1970s and 1980s
2. National goal of Healthy People 2010 is to reduce the
incidence from the current rate of 25% to 30% to 15% of all
deliveries
B. Major indications for cesarean delivery
1. Dystocia or CPD
2. Fetal distress
3. Breech presentation
4. Previous cesarean birth
C. Maternal risks
1. Aspiration
2. Hemorrhage
3. Infections
4. Injury to bowel or bladder
5. Thrombophlebitis
6. Pulmonary embolism
D. Fetal/neonatal risks
1. Prematurity
2. Injury at birth
3. Respiratory problems related to delayed absorption
of fetal lung fluid
E. Surgical techniques
1. Skin incisions
a. Vertical
b. Pfannenstiel’s (transverse lower abdominal incision)
2. Uterine incisions
a. Classical: through the upper uterine segment
b. Low cervical transverse: lower uterine segment
c. Lower uterine segment vertical
F. Nursing assessment
1. Determine the reason for the cesarean delivery
2. Determine the client’s understanding of the indication,
procedure, and implications for recovery from abdominal
delivery
H. Planning and implementation
1. Discuss cesarean birth in childbirth preparation classes
a. Clients and families cope better if they have time to learn about cesarean
birth
b. Emergency cesarean birth increases anxiety and alters the couple’s
expectations about childbirth
2. Preoperative care
a. Assess NPO status (mother should have nothing by mouth, if possible to
prevent aspiration)
b. Explain procedure so that client and family will know what to expect
c. Obtain client signature on consent form
d. Perform abdominal prep
e. Insert Folley catheter to prevent bladder trauma during surgery
f. Start intravenous fluids using a large bore catheter
g. Administer an antacid either IV or PO to decrease risk of lung damage
from aspirating acidic gastric contents during surgery
h. Administer antibiotics, as ordered
i. Assist with positioning and administration of regional anesthesia, if used
3. Intraoperative care
a. Provide heated crib and supplies to receive the newborn
b. Provide immediate care to the newborn or assist nursery personnel as
needed
c. Provide assistance to surgical team and immediate care for the mother
4. Postoperative care
a. Begin postanesthesia (recovery room) monitoring of vital signs,
pulse oximetry, and cardiac monitoring; monitor vital signs q 15
mins. for first hour and until stable
b. Assess fundus for firmness and location (if boggy, massage until
firm)
c. Assess vaginal bleeding
d. Assess abdominal dressing
e. Assess catheter and urine output
f. Turn, cough, and deep breathe hourly
g. Administer medications for pain, as needed
h. Promote maternal-infant contact and bonding