Maternal Chap 23

• Complications with the power:

  • Higher risk for: Postpartal Infection, Hemorrhage, Infant Mortality
  • Contraction rings: a hard band that forms across the uterus at the junction of the upper and lower uterine segments and interferes with fetal descent
  • Precipitate labor: uterine contractions are so strong that a woman gives birth with only a few, rapidly occurring contractions
• Problems with the passenger:

  • Dysfunctional or prolonged labor refers to prolongation in the duration of labor, typically in the first stage of labor
  • Common causes of dysfunctional labor: most likely to occur if a fetus is large, ineffective uterine force (hypotonic, hypertonic, and uncoordinated contractions)
• Problems with the passage:

  • Dysfunction at the first stage of labor: prolonged latent phase, protracted active phase, prolonged deceleration phase, secondary arrest of dilatation
  • Dysfunction at the second stage of labor: prolonged descent, arrest of descent
• Anomalies of the placenta and cord:

  • Uterine rupture: occurs when a uterus undergoes more strain than it is capable of sustaining, causes include prolonged labor, abnormal presentation, multiple gestation, unwise use of oxytocin, obstructed labor, traumatic maneuvers
  • Signs/symptoms of uterine rupture: sudden, severe pain during uterine contraction, sign of shock
  • Management of uterine rupture: cesarean section, fluid replacement therapy, oxytocin administration, possible laparotomy or hysterectomy, advise not to conceive again
• Uterine rupture:

  • Priority is limiting hypovolemic shock
• Uterine Inversion:

  • Refers to the uterus turning inside out with birth of the fetus or delivery of the placenta
  • Occurs when traction is applied to the umbilical cord to remove the placenta
  • Occurs when pressure is applied to uterine fundus when the uterus is not contracted
  • Management:
  • Never attempt to replace inversion
  • Never attempt to remove the placenta
  • Start an IV line
  • Administer oxygen by mask
  • Perform CPR if CP arrest
  • Antibiotic Therapy
  • Cesarean Section for future pregnancy
• Amniotic Fluid Embolism:

  • Occurs when amniotic fluid is forced into an open maternal uterine blood sinus through some defect in the membranes or after membrane rupture or partial premature separation of the placenta
  • Not preventable because it cannot be predicted
  • Signs/Symptoms:
  • Sharp pain in the chest
  • Inability to breathe
  • Pale then turn to bluish gray
  • Management:
  • Administration of oxygen by cannula or mask
  • Perform CPR
  • Nursing priority: Give immediate and vigorous treatment
• Complications with the Passenger:

  • Prolapse of the Umbilical Cord:
  • A loop of the umbilical cord slips down in front of the presenting fetal part
  • Management:
  • Goal: relieving pressure on the cord
  • Procedure:
  • Placing a gloved hand in the vagina and manually elevating the fetal head off the cord
  • Placing the woman in knee chest or Trendelenburg position
  • Administer Oxygen by mask
  • Do not attempt to push any exposed cord back into vagina
  • Cover any exposed portion with a sterile saline compress
  • Cesarean Birth if no cervical dilatation
• • Multiple Gestation:
  • More than one fetus in the uterus
  • Management:
  • Instruct woman to come to the hospital early in labor
  • Teach proper breathing techniques or exercises
  • Support the woman’s breathing pattern to minimize the use of analgesia
  • Expect abnormal presentation may occur
  • Expect uterine dysfunction, overstretched uterus, unusual presentation, and premature separation of the placenta after birth of the first child
• • Weighs more than 4,000 to 4,500 g
  • Risk: uterine dysfunction due to overstretching of the uterus
  • Management: C/S
• Problems with fetal position, presentation, or size:

  • Face presentation:
  • Head feels more prominent than normal
  • No engagement apparent on Leopold’s maneuvers
  • Diagnosis: assessment thru palpation
  • Brow presentation:
  • The rarest of the presentation
  • Occurs in multipara or with woman with relaxed abdominal muscles
  • Can result to obstructed labor due to head becomes jammed in the brim of the pelvis
  • Management: C/S
  • Transverse Lie:
  • Occurs in women with pendulous abdomen, uterine fibroid tumors
  • Diagnosis: inspection
  • Management: C/S
  • Macrosomia:
• Fetal Risks:

  • Brachial plexus injury:
  • Injury to the nerves that sends signals from the spinal cord to the shoulder, arm, and hand
  • Brachial plexus injuries during childbirth include Erb-Duchenne Palsy
  • Shoulder Dystocia:
  • Problem occurs at 2nd stage of labor
  • Common in women with diabetes, multiparas, postdate pregnancies
  • Breech Presentation:
  • When the fetus presents buttocks or feet first
  • Complications to be anticipated:
  • Perinatal morbidity and mortality from difficult delivery
  • LBW from prematurity, growth retardation
  • Prolapsed cord
• • Placenta previa
  • Multiple fetuses
• Complications with the Psyche:

  • A good emotional state during birth helps mom cope with pain effectively, tune in to her body, and guide her to her baby's needs
  • If mom is afraid, tense, stressed, angry, feels unsafe or unsupported, she may not do well during birth
  • Intense fear may lead to scheduling a c-section or avoiding a vaginal birth altogether
  • Fear can prevent cervical dilation, fetal descent, or effective pushing
• Complications with the Passage Anatomy of the Pelvis:

  • Dystocia can occur due to a contraction or narrowing of the passageway or birth canal
  • Contraction can happen at the inlet, midpelvis, or outlet
  • Contraction can cause cephalopelvic disproportion (CPD), resulting in failure to progress in labor
  • Inlet Contraction:
  • Narrowing of the anteroposterior or transverse diameter of the pelvis
  • Usually caused by rickets or an inherited small pelvis
  • Primigravidas may experience engagement of the fetal head between weeks 36 and 38 of pregnancy
  • Outlet Contraction:
• • Narrowing of the transverse diameter at the outlet to less than 11cm
  • Rare but should be diagnosed during routine assessment
  • Management options include NSD, Cesarean Section, and Trial Labor
• • Velamentous Insertion of the Cord:
  • Cord separates into small vessels reaching the placenta by spreading across a fold of amnion
  • Usually found with multiple gestation, infants should be examined carefully after birth
  • Vasa Previa:
  • Blood vessels connecting the umbilical cord to the placenta lie over or near the birth canal entrance
• Anomalies of the Placenta and Cord:

  • Placenta Succenturiata:
  • A placenta with one or more accessory lobes connected to the main placenta
  • Small lobes may be retained in the uterus after birth, causing hemorrhage
  • Placenta Circumvallata:
  • Chorion membrane transitions to a villous chorion at the placental edges
  • Placenta accreta:
  • Unusual deep attachment of the placenta to the uterine myometrium
  • Management includes hysterectomy and administration of Methotrexate
  • Battledore Placenta:
  • Cord inserted marginally rather than centrally, rare with no known significance
• Anomalies of the Cord:

  • Two-vessel cord:
  • Normal cord has one vein and two arteries, absence of one artery suggests congenital heart and kidney anomalies
  • Unusual Cord length:
  • Short cord may result from premature placental separation or abnormal fetal lie
  • Long cord may lead to twisting, knotting, or nuchal cord
• Fetal blood flows from umbilical vein to ductus venosus, then to left portal vein, and finally to liver.
• Placental circulation involves maternal blood flowing through spiral arteries into intervillous spaces where it comes into contact with fetal capillaries.
• Complications with the power:

  • Higher risk for postpartal infection, hemorrhage, infant mortality
  • Contraction strength needs to be strong enough to dilate the cervix and aid the baby in descent
  • Inertia or dysfunctional labor can occur, especially if the fetus is large
  • Ineffective uterine force can be caused by hypotonic, hypertonic, and uncoordinated contractions
  • Desired frequency of uterine contractions in normal labor is one contraction every two to three minutes or less than five contractions in a 10-minute period
• Dysfunction at the First Stage of Labor:

  • Prolonged latent phase may require management such as changing linen, decreasing noise, amniotomy, oxytocin administration, or cesarean section
  • Protracted active phase may be associated with cephalopelvic disproportion or fetal malposition, requiring oxytocin administration or cesarean section
  • Prolonged deceleration phase may result from abnormal fetal head position, requiring cesarean section
  • Secondary arrest of dilatation may require cesarean section or hysteroscopic dilation
• Dysfunction at the Second Stage of Labor:

  • Prolonged descent may require rupture of the amniotic sac, oxytocin administration, and specific positioning
  • Arrest of descent may require cesarean section or vaginal delivery with oxytocin administration
• Contraction Rings:

  • Pathologic retraction ring (Bandl's Ring) can interfere with fetal descent and may require administration of morphine IV, tocolytic, cesarean section, or manual evacuation of placenta
• Precipitate Labor:

  • Labor completed in fewer than 3 hours with strong contractions
  • May result in premature separation of placenta or perineal lacerations
  • Tocolytic agents like magnesium sulfate, indomethacin, and nifedipine can be used for treatment
• Induction and Augmentation of Labor:

  • Induction started artificially, augmentation assists labor that has started spontaneously but is not effective
  • Reasons for induction include fetal danger, term baby with no spontaneous contractions, PIH, diabetes, Rh sensitization, prolonged rupture of membranes, and post maturity
  • Considerations for induction include longitudinal lie of fetus, ripe cervix, engaged presenting part, absence of CPD, and estimated mature fetus
  • Procedures include cervical ripening with prostaglandin gel like misoprostol and administration of oxytocin
• Uterine Rupture:

  • Occurs when the uterus undergoes more strain than it can sustain, leading to strong contractions without cervical dilatation
  • Causes include prolonged labor, abnormal presentation, multiple gestation, unwise use of oxytocin, obstructed labor, and traumatic maneuvers
  • Signs/symptoms include sudden severe pain during contractions and signs of shock
  • Management may involve cesarean section, fluid replacement therapy, oxytocin administration, possible laparotomy or hysterectomy, and advising against future pregnancies
• Uterine rupture:

  • Priority is limiting hypovolemic shock
• Uterine Inversion:

  • Refers to the uterus turning inside out with birth of the fetus or delivery of the placenta
  • Occurs when traction is applied to the umbilical cord to remove the placenta
  • Occurs when pressure is applied to uterine fundus when the uterus is not contracted
  • Management:
  • Never attempt to replace inversion
  • Never attempt to remove the placenta
  • Start an IV line
  • Administer oxygen by mask
  • Perform CPR if CP arrest
  • Antibiotic Therapy
  • Cesarean Section for future pregnancy
• Amniotic Fluid Embolism:

  • Occurs when amniotic fluid is forced into an open maternal uterine blood sinus through some defect in the membranes or after membrane rupture or partial premature separation of the placenta
  • Not preventable because it cannot be predicted
  • Signs/Symptoms:
  • Sharp pain in the chest
  • Inability to breathe
  • Pale then turn to bluish gray
  • Management:
  • Administration of oxygen by cannula or mask
  • Perform CPR
  • Nursing priority: Give immediate and vigorous treatment
• Complications with the Passenger:

  • Prolapse of the Umbilical Cord:
  • A loop of the umbilical cord slips down in front of the presenting fetal part
  • Management:
  • Goal: relieving pressure on the cord
  • Procedure:
  • Placing a gloved hand in the vagina and manually elevating the fetal head off the cord
  • Placing the woman in knee chest or Trendelenburg position
  • Administer Oxygen by mask
  • Do not attempt to push any exposed cord back into vagina
  • Cover any exposed portion with a sterile saline compress
  • Cesarean Birth if no cervical dilatation
• • Multiple Gestation:
  • More than one fetus in the uterus
  • Management:
  • Instruct woman to come to the hospital early in labor
  • Teach proper breathing techniques or exercises
  • Support the woman’s breathing pattern to minimize the use of analgesia
  • Expect abnormal presentation may occur
  • Expect uterine dysfunction, overstretched uterus, unusual presentation, and premature separation of the placenta after birth of the first child
• Problems with fetal position, presentation, or size:

  • Face presentation:
  • Asynclitism is defined as the "oblique malpresentation of the fetal head in labor"
  • Signs/Symptoms:
  • Head feels more prominent than normal
  • No engagement apparent on Leopold’s maneuvers
  • Diagnosis:
  • Palpation: vaginal examination
  • What to expect from an Infant:
  • Facial edema
  • Purple from ecchymotic bruising
  • Brow presentation:
  • The rarest of the presentation
  • Occurs in multipara or with woman with relaxed abdominal muscles
• • Uterine dysfunction due to overstretching of the uterus
  • Fetal pelvic disproportion
  • Perineal lacerations
  • Management: C/S
• • Can result to obstructed labor due to head becomes jammed in the brim of the pelvis
  • Management: C/S
  • Transverse Lie:
  • Occurs in women with pendulous abdomen, uterine fibroid tumors
  • Diagnosis thru assessment:
  • Inspection: the ovoid of the uterus is found to be more horizontal than vertical
  • Management:
  • A mature infant cannot be born normally: membranes rupture prematurely, cord or arm can prolapse, or shoulder may obstruct the cervix
  • Macrosomia:
  • Weighs more than 4,000 to 4,500 g (9 - 10 lbs)
  • Risk:
• Fetal Risks:

  • Brachial plexus injury:
  • The brachial plexus is the network of nerves that sends signals from your spinal cord to your shoulder, arm and hand
  • Brachial plexus injuries during childbirth include Erb-Duchenne Palsy
  • Shoulder Dystocia:
  • Problem occurs at 2nd stage of labor - fetal head is born but the shoulders are too broad to enter and be born through the pelvic outlet
  • Common in women with diabetes, multiparas, postdate pregnancies
  • Breech Presentation:
  • When the fetus presents buttocks or feet first
  • Sub-Classification:
  • Frank breech
• • Complete breech
  • Footling breech
  • Diagnosis:
  • Abdominal exam - Leopold’s maneuver
  • Vaginal exam
  • X-ray and ultrasound
• Complications with the Psyche:

  • A good emotional state during birth helps mom cope with pain effectively
  • Helps mom tune in to her body
  • Helps guide her to her baby's needs and allows the other 3 P's to sync up effectively
  • If mom is afraid, tense, stressed out, angry, feels unsafe or unsupported, she will not likely do well during birth
  • Fear can lead to scheduling a c-section or avoiding a vaginal birth
  • Fear may prevent cervical dilation, fetal descent, or prevent mom from pushing effectively
• Complications with the Passage Anatomy of the Pelvis:

  • Dystocia can occur due to a contraction or narrowing of the passageway or birth canal
  • Contraction can happen at the inlet, midpelvis, or outlet
  • Narrowing causes CPD, a disproportion between the size of the fetal head and the pelvic diameters, resulting in failure to progress in labor
  • Inlet Contraction:
  • Narrowing of the anteroposterior diameter of the pelvis to less than 11 cm or of the transverse diameter to 12 cm or less
  • Usually caused by rickets or an inherited small pelvis