LECTURE NOTES ON NCM 102 PREPARED BY: MS. ROSE ANNE R. RIOTOC, R.

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INTRAPARTUM CARE 1. The intrapartum period extends from the beginning of contractions that cause cervical dilation to the first 1 to 4 hours after delivery of the newborn and placenta. 2. Intrapartum care refers to the medical and nursing care given to a pregnant woman and her family during labor and delivery. GOALS OF INTRAPARTUM CARE 1. To promote physical and emotional well-being in the mother and fetus. 2. To incorporate family-centered care concepts into the labor and delivery experience. NATIONAL HEALTH GOALS Labor and birth are both high-risk periods for mother and the fetus. Several national health goals speak to this risk. They are: 1. To reduce the number of fatal deaths to 3.3 / 100,000 live births from a baseline of 7.1/100,000. 2. To reduce number of fatal deaths at 20 or more weeks gestation to 4.1 / 1,000 live births from a base line of 6.8 / 1,000. 3. To reduce fatal and infant deaths during the prenatal period (28 weeks gestation to 7 days after birth) to 4.5 / 1,000 live births from a baseline of 7.5 / 1,000 live births (Department of Health and Human Services, 2000) FACTORS AFFECTING THE INTRAPARTUM EXPERIENCE 1. 2. 3. 4. 5. 6. 7. 8. 9. Previous experience with pregnancy Cultural and personal expectations Pre-pregnant health and biophysical preparedness for childbearing Motivation for childbearing Socioeconomic readiness Age of mother Partnered versus unpartnered status Extend of parental care Extend of childbirth education

INTRAPARTUM CARE: PHENOMENA AND PROCESS OF LABOR AND DELIVERY A. ONSET OF LABOR 1. Labor is the process by which the fetus and products of conception are expelled as the result of regular, progressive, frequent, strong uterine contractions. 2. Theoretically labor is thought to result from: a. Progesterone deprivation b.Oxytocin stimulation c. Fatal endocrine control d.Uterine deciduas activation (release of a complex cascade of bioactive chemical agents into amniotic fluid) B. FACTORS AFFECTING LABOR 1. PASSAGEWAY. This refers to the adequacy of the pelvis and birth canal in allowing fetal descent; factors include: a. Type of pelvis (for example, gynecoid, android, anthropoid, or platypelloid) b.Structure of pelvis (for example, true versus false pelvis) c. Pelvic inlet diameters d.Pelvic outlet diameters e. Ability of the uterine segment to distend the cervix to dilate, and the virginal canal and introitus to distend. 2. PASSENGER. This refers to the fetus and its ability to move through the passage way, which is based on the following: a. Size of the fetal head and capability of the head to mold the passageway. b.Fetal presentation the part of the fetus enters to maternal pelvis first (for example, cephalic [vertex, face, brow]: breech [frank, single or double footing complete]; or shoulder [transverse, lie]) c. Fetal attitude the relationship of fetal parts to one another. d.Fetal position the relationship of a particular reference points of the presenting part and the maternal pelvis, described with a series of three letters (side of maternal pelvis [L, left; R, right; T, transverse], presenting [O, occiput; S, sacrum; Sc, scapula; M, mentum], and the part of the maternal pelvis (A, anterior; P, posterior]. 3. POWER. This refers to the frequency duration and strength of uterine contraction to cause complete cervical effacement and dilation. 4. PLACENTAL FACTORS refers to the site of placental insertion. 5. PSYCHE refers to the clients psychological state, available support systems, preparation.

C. SIGNS AND SYMBOLS OF IMPENDING LABOR (premonitory signs) 1. Lightning is the descent of the fetus and uterus into the pelvic cavity 2 to 3 weeks before the onset of labor. 2. Braxton hicks contractions are irregular, intermittent contractions that have occurred throughout the pregnancy; become uncomfortable, and produce a drawing pain in the abdomen and groin. 3. Cervical changes include softening ripening and effacement of the cervix that will cause explosion of the mucus plug (bloody show) and increased vaginal discharge. 4. Rupture of amniotic membranes may occur before the onset of labor if the woman suspects that her membranes have ruptured, she should contact her health care provider and go to the labor suite immediately so that she may be examined for prolapsed cord a life-threatening condition for the fetus. 5. Burst of energy or increased tension and fatigue may occur before the onset of labor. 6. Weight loss of about 1 to 3 pounds may occur 2 to 3 days before the offset of labor. 7. Urinary frequency returns. 8. Backache D. CHARACTERISTICS OF TRUE LABOR 1. Contractions occur at regular intervals (Client and Family Teaching 9-1) 2. Contractions start in the black and sweep around to the abdomen, increase in intensity and durations and gradually have shortened intervals. 3. Walking intensifies contractions. 4. Bloody show (pink-tinged mucus released from the cervical canal as labor starts) is usually present. 5. Cervix becomes effaced and dilated. 6. Sedation does not stop contractions. E. CHARACTERISTICS OF FALSE LABOR 1. Contractions occur at regular intervals (Client and Family Teaching 9-1) 2. Contractions starts in the back and sweep around to the abdomen, intensify remains the same or is variable, and the intervals remain long. 3. Walking does not intensify contractions and often relief. 4. Blood show usually is not present, if present, it is usually brownish rather than right red and may be due to a recent pelvic examination or intercourse. 5. There are no cervical changes. 6. Sedation tends to decrease the number of contractions. F. STAGES OF LABOR 1. The FIRST STAGE of labor begins with the onset of regular contractions which cause progressive cervical dilation and effacement. It ends when the cervix is completely effaced and dilated. It is composed of a latent, an active, and a transition phase. a. Latent phase. This phase begins with the onset of regular contractions and effacement and dilation of the cervix 3 to 4 cm. It lasts an average of 6.4 hours for multiparas. Contractions become increasingly stronger and more frequent. b.Active phase. Dilation continues from 3 to 4 cm to 7 cm. Contractions become stronger, more frequent, longer, and more painful. c. Transition phase. The culmination of the first stage is the transition phase during which the cervix dilates from 8 to 10 cm. The intensity, frequency, and durations of contractions peak and there is an irresistible urge to push. 2. SECOND STAGE (expulsive stage) a. The second stage begins with complete dilation of the cervix and ends with delivery of the newborn. Durations may differ among primiparas (longer) and multiparas (shorter), but this stage should be completed within 1 hour after complete dilation. b.Contractions are severe at 2 to 3 minute intervals, with a duration of 50 to 90 seconds. c. The newborns exists the birth canal with help from the following cardinal movements or mechanisms of labor i. Engagement ii. Descent iii. Flexion iv. Internal Rotation v. Extension vi. External Rotation (restitution) vii. Expulsion d.Crowning occurs when the newborns head or presenting part appears at the vagina; opening e. Episiotomy (surgical incision in perineum) may be done to facilitate delivery and avoid laceration of the perineum. 3. THIRD STAGE (placental stage) a. This stage begins with delivery of the newborn and ends with delivery of the placenta. It occurs in two phases placental separation and placental expulsion. b.Signs of placental separation include the uterus becoming globular, the fundus rising in the abdomen, lengthening of the cord, and increased bleeding (trickle or gush) c. Contraction of the uterus controls uterine bleeding and aids placental separation and explanation. d.Generally, oxytocic drugs are administered to help the uterus contract. 4. FOURTH STAGE (recovery and bonding) a. This stage lasts from 1 to 4 hours after birth. b.The mother and newborn recover from the physical process of birth. c. The maternal organs undergo initial readjustment to the nonpregnant state. d.The newborn body systems begin in the midline of the abdomen with the fundus midway between the umbilicus and symphysis pubis.

INTRAPARTUM CARE: FIRST AND SECOND STAGES OF LABOR A. Maternal Assessment 1. A complete health history should include. a. Name b.Age c. Physician d.Weight e. Allergies f. Blood type and Rh factor g.Previous medical conditions h.Prenatal problems i. Gravida and para status j. Estimated date of delivery k. Prenatal education l. Method of newborn feeding 2. Screening to risk factors is essential and should include: a. Bleeding b.Premature of membranes (if ruptured, determine time of the note color and odor, if any) c. Hydramnios d.Abnormal presentations e. Multiple gestations f. Prolapsed cord g.Preparations labor h.Meconium, stained amniotic fluid i. Fetal heart irregularities 3. Physical Assessment a. Material vital signs, weight, and cardiac and respiratory status are monitored. The frequency of maternal vital signs and respiratory status assessment is as follows. i. First stage latent: Blood pressure (BP), pulse, and respirations are assessed every hour (if the BP is greater than 140/90 or if the pulse is greater than 10, contact the primary care provider). Temperature is assessed every 4 hours (every 2 hours if the membranes are ruptured) ii. First stage active: BP, pulse, and respirations are assessed every hour. iii. First stage transition: BP and respirations are assessed every 30 minutes. iv. Second stage: BP, and pulse are assessed every 5 to 15 minutes. b.Fundal height is measured. c. Status of labor (that is, contractions [onset, frequency, duration, and intensify], membranes, bleeding, cervical dilation, and fetal descent) is determined. d.The clients need for comfort, analgesia, or anesthesia is assessed continuously (see section III and IV). 4. Psychosocial assessment should include anxiety, childbirth educations, support systems, and clients response to labor. 5. Labor progress assessment should include: a. Palpation or electronic monitoring (external with tocodynamometer and internal with intrauterine pressure catheter) is performed to assess the duration, frequency, and intensify of contractions. The frequency of contraction assessment is as follows. i. First latent every 30 minutes ii. First stage active every 15 to 30 minutes iii. First stage transition every 15 minutes iv. Second stage each contraction b.Sterile vaginal examination is performed to assess cervical (opening of external or from closed to 10 cm) and cervical effacement (thinning and shortening of the cervix, as measured from 0% [thick] to 100% [paper thin] effaced). c. Station is determined (that is, the relationship of the presenting part to the pelvic ischial spines). B. FETAL ASSESSMENT 1. Inspect the maternal abdomen to determine fetal lie the relationship of the long axis (spine) of the fetus to the long axis of the mother. Fetal lie can longitudinal or transverse. a. Longitudinal lie is when the long axis of the fetus is parallel to the long axis of the mother. b.Transverse lie is when the long axis of the fetus is perpendicular to the long axis of the mother. 2. Palpate the abdomen using the four Leopold Manuevers to determine fetal position and possible size. 3. Montior fetal status a. Auscultate the FHR every 30 minutes during the first stage latent; every 15 minutes during first stage active and stage transition; every 5 to 15 seconds. b.Assess changes in FHR to identify the following. i. Early deceleration slowing of the FHR early on the contraction. It is considered benign, minor the contraction and has a characteristics V or U pattern. ii. Late deceleration an indication of fetal hypoxia due to uteroplacental insufficiency. It usually begins at the peak of the contraction and ends after the contraction ends. iii. Variable deceleration a transient decrease in FHR before, during or after the contraction. It indicates cord compression and has a characteristics V or U pattern. iv. Bradycardia an FHR less than 100 beats per minutes or a drop of 20 beats per minutes below baseline. In indicates cord compression or placental separations.

Tachycardia an FHR greater than 160 beats per minute. It indicates fetal distress if it persists for more than 1 hour is accompanied by late deceleration. vi. Loss of beat-to-beat variability indicates fetal reaction to maternal drugs, fetal sleep, or fetal demise. c. Assess fetal acid-base status with fetal blood sampling or fetal scalps stimulations. 4. Continually assess the fetal response to the pain-relief methods used. C. NURSING DIAGNOSIS 1. Health-Seeking behaviors 2. Anxiety 3. Ineffective Individual Coping 4. Pain 5. Risk for Injury 6. Risk for Ineffective airway clearance (newborn) 7. Risk for Hypoxia D. PLANNING AND OUTCOME IDENTIFICATION 1. The woman will be property admitted to the labor and delivery unit. 2. The woman will be partner will understand normal labor process and progress. 3. The woman and the partner will implement good coaching, breathing and other 4. The woman will receive physical, emotional, and pharmacologic support as needed. 5. The woman will experience maximum safety. 6. The woman will be prepared for the birth of her child. 7. The newborn will receive essential immediate care. 8. The newborn and parents will experience early contact. E. IMPLEMENTATION 1. Perform admission procedures. a. Collect urine specimen and other samples for laboratory testing as prescribed (such as hemoglobin, hematocrit, serologic tests for syphilis, and type and cross-match if indicated) b.Perform perineal preparation and enema, if indicated. c. Notify attending physician or midwife, and report status. d.Obtain informed consent from the client. 2. Provided client and family teaching throughout the first and second stages. a. Explain how activity toileting and hydration needs will be met during labor. b.Explain equipment that will be used to monitor vital signs, labor and fetal status. c. Explain the normal process and progress of labor and delivery to the woman and her support person. d.Explain to the woman, that as the fetus descends in the birth canal, she will feel increased rectal pressure or the urge to push. e. Coach the woman regarding effective pushing effort. Explain the importance of assuming a position that facilitates exclusive efforts, maintains placental perfusion and prevents or alleviates cord compression. 3. Reinforce coaching, breathing, and other relaxation measures. 4. Provide physical, emotional, and pharmacologic support as needed throughout the first and second stages. a. Provide pleasant, comfortable, surroundings b.Collaborative with the client and birth attendant to determine the most effective method of pain relief during each stage of the intrapartum period. c. Provide pharmacologic support as prescribed (see Drug Chart 9-1, page 134) d.Provide support during contractions by coaching breathing, giving back rubs and offering cool cloths. e. Assist the client with pushing as indicated. 5. Promote safety during the first and second stages of labor. a. If the clients membranes are ruptured and the fetal head is not engaged, position the mother prevent cord prolapse. b.Assess hydration status to avoid dehydration. c. Offer the client an opportunity to avoid every 1 to 2 hours to prevent trauma to the bladder during pushing and birth of the newborn. d.Interpret changes in the electronic fetal and maternal monitor strip, and take appropriate action. 6. Prepare for the birth of the newborn. a. Prepare for delivery when the perineal area is bulging in a primipara and when the cervix is dilated 7 to 8 cm in a multipara. b.Prepare the delivery area with equipment and supplies. c. Place the client in the birthing position. d.Assist the attending physician or nurse, midwife with the birth; help the support person to be supportive, and check all vital signs and FHR. 7. Implement immediate newborn care. a. Establish and maintain a patent airway; suction with a bulb syringe or a De Lee mucus trap, and place the newborn on his side. b.Compensate for poor newborn thermoregulation. i. Dry the newborn immediately with a warm blanket ii. Place the newborn under a radiant warmer iii. Wrap the newborn in a warmed, dry blanket, a/or place the newborn on the mothers skin. c. Determine the Apgar score at 1 and 5 minutes after delivery. d.Inspect the umbilical cord for two arteries and one vein. e. Weigh and measure the newborn as his condition stabilizes.

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f. Footprint the newborns and fingerprint the mother. g.Record the newborns first voiding and stool passage. h.Assess the newborns gestational age. i. Administer prophylactic eye medication to protect the conjunctiva from infection. j. Administer vitamin K (phytonadione [AquaMEPHYTON], if prescribed. k. Encourage initial parent-newborn bonding by placing the newborn in the mothers arms with skinto-skin contact. F. OUTCOME EVALUATION 1. The woman is properly admitted to the labor and delivery unit. 2. The woman and her partner use their knowledge of normal labor process and progress. 3. The woman and her partner implement food coaching breathing and other relaxation measures. 4. The mother receives physical, emotional, and pharmacologic support as needed and verbalizes increases comfort. 5. The woman experiences maximum safety, and there are no complications. 6. The woman is prepared for the birth of her child. 7. The newborn receives essential immediate care. 8. Parents hold and explore their infant. INTRAPARTUM CARE: THIRD AND FOURTH STAGES OF LABOR A. Assessment during the third and fourth stages on the following: 1. Maternal physiologic adjustment, including vital signs, bladder uterine firmness uterine fundus, perineum, and amount and color of lochia. 2. Maternal emotional adjustment. 3. Newborn physiological adjustment, including respiratory effort and maintenance of body temperature. 4. Signs of parents-newborn attachment. 5. Mothers and newborns breast-feeding attempts, if the mother is breast-feeding. B. Nursing diagnosis 1. Risk for Injury (Mother) 2. Ineffective Thermoregulation (newborn) 3. Risk for infection 4. Pain 5. Ineffective Breast-feeding 6. Altered Family Coping C. Planning and Outcome Identification 1. Physiologic adaptation will be achieved by the new mothers 2. Physiologic adaptation will be achieved by the newborns. 3. Potential complications will be detected. 4. Comfort measures will be provided as needed. 5. An opportunity to breast-feed will be provided. 6. A parent-newborn relationship and family integration will be established. 7. Accurate documentation of intrapartum care will be maintained. D. IMPLEMENTATION 1. Promote maternal physiologic adaptation a. Initiate fundal massage gently, with adequate support to the lower uterine segment. b.Evaluate vaginal bleeding and vital signs. 2. Promote newborn physiologic adaptation. a. Suctions secretions from the newborns nose and mouth as necessary to maintain respirations b.Maintain the newborns temperature by placing him in skin-to-skin contact with mother covering him with warm blankets, or using a radiant warmer. INTRAPARTUM COMPLICATIONS: ESSENTIAL CONCEPTS y Problems that can be anticipated because of maternal and fetal conditions or that can be stabilized and corrected without emergency intervention are increasingly managed in facilities designed to accommodate high-risk maternal and fetal clients. When the expectant mother is the best incubator for the high risk newborn, she may be transported to a tertiary care facility before the onset of the labor and the actual birth. C. Because intrapartun emergencies commonly develop rapidly, on-the-spot nursing assessment and intervention are crucial. D. Principles of nursing care during normal labor apply to complicated labor as well.

A. ASSESSMENT 1. Health History a. Elicit a description of symptoms, including onset, duration, location and precipitating factors or events. Cardinal signs and symptoms may include: i. A sudden gush of fluid from the vagina ii. Any copious vaginal bleeding iii. Presence of uterine contractions with or without abdominal pain iv. Decreased fetal movement b.Explore maternal and family history for risk factors fro intrapartum complication. i. Age younger than 18 ii. History of preterm labors iii. Poor obstetric history

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iv. Multiple pregnancy v. Hydramnios vi. Smoking vii. Poor hygiene viii. Poor nutrition ix. Employment Family risk factors may include: a. History of diabetes b.History of complications of birth in other family members. c. Assess the familys responses to high-risk pregnancy, labor, and a potential crisis situation. d.Assess maternal, paternal, and family bonding, and the potential for perinatal loss and grief. 2. Physical Examinations a. Vital signs i. Measure maternal blood pressure, pulse and respirations in the presence of vaginal fluid leakage, or bleeding to assess for infection. ii. Measure maternal vital signs to identify presence of shock. iii. Monitor fetal heart rate (FHR) to determine fetal status. b.Inspection i. Inspect the perineum for characteristics of vaginal discharge. Observe for color, odor, consistency, and amount ii. Observe size and shape of the uterus iii. At delivery, visually inspect the placenta for abnormal characteristics. c. Palpation i. Monitor uterine activity to determine progress of labor. ii. Evaluate the cervix for readiness for, or progress in, labor. Do not perform a vaginal examination if bleeding is present. 3. Laboratory and diagnostic studies a. Ultrasound is used to determine fetal status, localize the placenta, and determine amniotic fluid volume. b.Kleihauer-Betke or fetal cell blood test is used to determine whether the blood cells are maternal or fetal. Maternal cells remain colorless when stained. Fetal cells become purple-pink when stained. c. Nitrazine test tape and presence of ferning are used to determine if there is rupture of the amniotic sac. Nitrazine paper turns green-blue in the presence of amniotic fluid. On microscopic examination of a sample of fluid, a ferning pattern, similar to frost on window, appears on the dried slide. This is characteristic of a high-estrogen fluid. d.Electronic urine monitoring will demonstrate the presence of uterine contractions. e. Complete blood count will document the presence of anemia infection. NURSING DIAGNOSIS - In addition to complication-specific diagnosis, the following nurses diagnoses are common to care of the at-risk intrapartum client. 1. Anxiety 2. Fear 3. Ineffective Compromised Family Coping 4. Anticipatory Grieving 5. Self-Esteem Disturbance 6. Spiritual Distress 7. Knowledge Deficit 8. Pain 9. Risk for Injury PLANNING AND OUTCOME IDENTIFICATION 1. Threats to optimal physical and emotional pregnancy outcome will be determined. 2. The client will be physically comfortable, and the client and family will have a healthy response to their high-risk pregnancy status and potential complications. 3. The client and family will understand their pregnancy complication and the necessary treatment. IMPLEMENTATION 1. Assess maternal and fetal physiologic status to detect early maternal and fetal changes requiring early intervention. a. Perform ongoing assessment during the intrapartum period. b.Expect the unexpected, and be prepared to provide critical care nursing if needed. c. Accurately document the assessed problem and subsequent nursing interventions and their effectiveness. 2. Provide physical emotional support a. Observe the client and family for emotional response and ability to cope with discomfort and pain. b.Provide comfort measures. c. Coordinate physical care for client with emotional needs of the client and family. d.Assess and support the clients and familys psychosocial and emotional needs, particularly in relation to potential loss and grief. e. Encourage and support coping mechanisms, including aspects of loss and grief. OUTCOME EVALUATION 1. The client and fetus maintain normal physiological status; any deviations that arise are identified and corrected early. 2. The couple demonstrates greater comfort, decreased fear and anxiety, increased used of coping techniques.

3. The client and partner express understanding of their pregnancy complication and the necessary procedures to be performed. INTRAPARTUM COMPLICATIONS: PREMATURE RAPTURE OF MEMBRANES (PROM) A. DESCRIPTION. PROM is rupture of chorion and amnion before the onset of labor. The gestational age of the fetus and estimates of viability affect management. B. ETIOLOGY. The precise cause and specific predisposing factors are unknown. C. PATHOPHYSIOLOGY. 1. PROM is associated with malpresentation, possible weak areas in the amnion and chorion, subclinical infection, and possibly incompetent cervix. 2. Basic and effective defense against the fetus contracting an infection is lost the risk of ascending intrauterine infection, known as chorioamnionitis, is increased. 3. The leading cause associated with PROM is infection. 4. When the latent period (time between rupture of membranes and onset of labor) is less than 24 hours, the risk of infection is low. D. ASSESSMENT FINDINGS 1. Clinical manifestations a. PROM is marked by amniotic fluid gushing from the vagina. The fluid may trickle or leak from the vagina in the absence of contractions. b.Pooling of amniotic fluid in the vagina will be visualized during a speculum examination. c. Maternal fever, fetal tachycardia, and malodorous discharge may indicate infection. 2. Laboratory and diagnostic study findings. Rupture of the membranes is confirmed by the following. a. Ferning is evident. b.Nitrazine test tape turns blue-green E. NURSING MANAGEMENT 1. Prevent infection and other potential complications. a. Make an early and accurate evaluation of membrane status, using sterile speculum examination and determination of ferning. Thereafter, keep vaginal examinations to a minimum to prevent infection. b.Obtain smear specimens from vagina and rectum as prescribed to test for betahemolytic streptococci, organisms that risk to the fetus. c. Determine maternal and fetal status, including estimated gestational age. Continually assess for signs of infection. d.Maintain the client on bed rest if the fetal head is not engaged. This method may prevent cord prolapsed if additional rupture and loss of fluid occur. Once the fetal head is engaged, ambulation can be encouraged. 2. Provide client and family education. a. Inform the client, if the fetus is at term, that the chances of spontaneous labor beginning are excellent; encourage the client partner to prepare themselves for labor and birth. b.If labor does not begin or the fetus is judged to be preterm or at risk for infection, explain treatments that are likely to be needed. INTRAPARTUM COMPLICATIONS: PRETERM LABOR A. DESCRIPTION. Preterm labor is labor that begins after 20 weeks gestation and before 37 weeks gestation. B. ETIOLOGY. Among the many causes of preterm labor are: 1. PROM 2. Preeclampsia 3. Hydramnios 4. Placenta previa 5. Abruptio placentae 6. Incompetent cervix 7. Trauma 8. Uterine structural anomalies 9. Multiple gestation 10. Intrauterine infection (chorioamniotics) 11. Congenital adrenal hyperplasia 12. Fetal death 13. Maternal factors, such as stress (physical and emotional), urinary tract infection, and dehydration C. PATHOPHYSIOLOGY. T he uterine begins the process of contraction prior to term gestational age. D. ASSESSMENT FINDINGS. Clinical manifestations of preterm labor are basically the signs of true labor that occur when the gestational age of the fetus is greater than 20 and less than 37 weeks. 1. Low back pain 2. Suprapubic pressure 3. Vaginal pressure 4. Rhythmic uterine contractions 5. Cervical dilation and effacement 6. Possible rupture of membranes 7. Expulsion of the cervical mucus plug 8. Bloody show E. NURSING MANAGEMENT 1. Assess the mothers condition and evaluate signs of labor. a. Obtain a thorough obstetric history. b.Obtain specimen for complete blood count and urinalysis.

c. Determine frequency, duration and intensity uterine contractions. d.Determine cervical dilation and effacement. e. Assess status of membranes and bloody show. 2. Evaluate fetus from distress, size and maturity (sonography and lecithin-sphingomyelin ratio). 3. Perform measures to manage or stop preterm labor. a. Place client on bed rest in the side-lying position. b.Prepare for possible ultrasonography, amniocentesis, tocolytic drug therapy, steroid therapy. c. Administer tocolytic (contraction-inhibiting) medication as prescribed. d.Assess for side effects of tocolytic therapy (such as decreased maternal blood pressure, dyspnea, chest pain and FHR exceeding 180 beats/minute) e. Provide physical and emotional support. Provide adequate hydration. INTRAPARTUM COMPLICATIONS: VASA PREVIA A. DESCRIPTION. Vasa previa is a rare development disorder made up of two separate disorders. 1. Velamentous insertion of the umbilical cord, in which the umbilical blood vessels course through amnion and chorion and meet to form the umbilical cord a distance from the placental surface. This places the fragile umbilical vessels at risk for tearing and hemorrhage. 2. The fragile unprotected umbilical vessels cross the internal os and are in front of the presenting fetal head, thus creating a vasa previa. B. ETIOLOGY. Uncertain. However, it may be due to uneven growth of the placenta or abnormal implantation of the blastocyte. C. PATHOPHYSIOLOGY. The fetal vessels rupture or are compressed, leading to fetal hypoxia. D. ASSESSMENT FINDINGS 1. Associated findings a. Vasa previa is of no danger to the mother. b.Once the umbilical vessel rupture, fetal demise is virtually certain. 2. Clinical manifestations a. Vessels are occasionally palpated during a vaginal examination. b.Minimal bright red vaginal bleeding is evident. c. Fetal bradycardia occurs. 3. Laboratory and diagnostic findings a. Ultrasound may reveal vasa previa b.Kleihauer-Betke or fetal cell blood test will confirm the presence of fetal blood cells. MEDICATIONS USED FOR INTRAPARTUM COMPLICATIONS CLASSIFICATIONS Tocolytics Ritodrine HCl (Yutopar) Terbutaline sulfate (Brethine) USED FOR * Terminates preterm labor * Acts on beta-2 receptor sites SELECTED INTERVENTIONS *Assess maternal and fetal heart rates continuously during infusion *Always use an infusion control mechanism to maintain a specified flow rate. *Always administer as a piggy back IV *Measure I&O every hour. Output should be 30 ml/hr or more. *Assess maternal BP continuously during infusion of this drugs. *Monitor for the following side effect hypotension, increased heart rate, hypokalemia, pulmonary edema, nausea vomiting, headache, and increase serum glucose Calcium channel blocker Nifedioine (Procardia) *Measure I&O every hour. Output should be 30ml/hr or more. *Assess maternal BP continuously during administration of these drugs. *Monitor for the following side effects: headache,jitteriness, shakiness, palpitations, chest pain, and tachycardia. Non-steroidal antiinflammatory drugs (NSAID) Indomethacin (Indocin) *Prostaglandin antagonist that can be used to inhibit uterine contractions. *Assess and maternal and fetal heart rates continuously during administration. *Measure I&O every hour. Output should be 30 ml/hr or *Inhibits contraction of smooth muscle *Assess maternal and fetal heart rate continuously during administration.

more. *Assess maternal BP continuously during administration of these drugs. *Monitor for the following side effects: headache, nausea, vomiting, prolonged bleeding time, blurred vision, and syncope. Anticonvulsant Magnesium Sulfate (MgSO4) * A CNS depressant that halts uterine contractions * Muscle relaxant; prevent seizures *Assess maternal and fetal heart rates continuously during infusion. *Always use an infusion control mechanism to maintain a specified flow rate. *Always administer as a piggy back IV *Measure I&O every hour. Output should be 30ml/hr or more. *Assess maternal BP continuously during infusion of this drugs. *Assess deep-tendon reflexes every 2 to 4 hours during continuous infusion of MgSO4. *Discontinue MgSO4 if tendon reflexes are absent or if respirations fall below 14/minute. *Monitor the following side effects, including flushing thirst, respiratory depression, decreased urinary output, respiratory arrest, and cardiac arrest. Electrolyte Calcium gluconate (10% solution) *Used as an antidote for effects of magnesium sulfate electrolyte. *Maintains nervous and muscle cell permeability. *Acts as an activator in the transmission of nerve impulses and contraction of cardiac, skeletal, and smooth muscle. *Assess maternal and fetal heart rates continuously infusion. *Always use an infusion control mechanism to maintain a specified flow rate. *Always administer as a piggy back IV * Measure I&O every hours. Output should be 30ml/hr or more. *Assess maternal BP continuously during infusion of these drugs. *Monitor for the following side effects: Bradycardia, syncope, nausea, vomiting, phlebitis at IV site, and cardiac arrest. Prostaglandin Dinoprostone (Prepidil, Prostin E2 [suppository or gel]) * Stimulates uterine smooth muscle to contract *Initiates softening, effacement, and dilation of the cervix *Suppository (prostaglandin) is inserted ever 2 hrs times 3. *Keep the suppository cold and bring it to room temperature before insertion. After insertion, have the client remain dorsal recumbent for 15-30 minutes. *The gel inserted into the cervical os by catheter two times; 6 hours apart. * Monitor for the following side effects: headache, nausea, vomiting, hypotension, dyspnea, and uterine hyperstimulation. Oxytoncic Oxytocin (Pitocin, Syntocinon [IV drip]) *Used for induction of labor. *Oxytocin is infused at a rate of 1-2 mU/minute and increased by 1-2 mU/minutes every 15-30 minutes until a contraction pattern is established. *Monitor vital signs and fetal heart rate closely. *Assess the contractile pattern. *Limit IV fluids to 150 ml/hours * Mix 10 IU oxytocin in 1000 ml Ringers lactate and

hang as a piggy back solution. * Always use the infusion port closest to the client. * Monitor for water intoxication Corticosteroid-inflammatory immunosuppressant (Betamethasone, Celestone) *Hastening fetal lung maturity * Preventing respiratory distress syndrome in the newborn *Give to mother 12-24 hours before deliver *Administer initial dose IM *May repeat in 24 hours and again in 2 weeks *Assist with measures to halt preterm labor *Observe for burning, itching, and irritation at the injection site *Adverse effects include swelling, tachycardia, sodium and fluid retention, increased risk of infection with long term use. *Initial dose is 12.5mg IM E. NURSING MANAGEMENT 1. Identify and assist with treatment of the disorder a. Monitor FHR and status during labor b.Assist with diagnosis of the condition c. Anticipate and assist with emergency cesarean birth 2. Provide physical and emotional support 3. Provide client and family education. Explain emergency procedures to the client and family. INTRAPARTUM COMPLICATIONS: UMBILICAL CORD PROLAPSE A. DESCRIPTION 1. Cord is descent of the umbilical cord into the vagina ahead of the fetal presenting part with resulting compression of the cord between the presenting part and the maternal pelvis. 2. Cord prolapsed is an emergency situation; immediate delivery will be attempted to save the fetus. 3. It occurs in 1 of 200 pregnancies B. ETIOLOGY 1. This problem occurs most frequently in prematurity, rupture of membranes with fetal presenting part unengaged, and shoulder or footling breech presentations. 2. It may allow rupture of the amniotic membranes because the fluid rush may carry the cord along toward the birth canal. C. PATHOPHYSIOLOGY. Compression of the cord results in the compromise or cessation of fetoplacental perfusion. D. ASSESSMENT FINDINGS 1. Associated findings a. Cord prolapsed may be occult and occur any time in the labor process, even when the amniotic membranes are intact. b.Client reports feeling the cord within the vagina 2. Clinical manifestations a. Fetal bradycardia with deceleration during contraction b.The umbilical cord seen or felt during a vaginal examination E. NURSING MANAGEMENT 1. Identify prolapsed of the cord and provide immediate intervention a. Assess a laboring client often if the fetus is preterm or small for gestational age, if the fetal presenting part is not engaged, and if the membranes are ruptured. b.Periodically evaluate FHR, especially after rupture of membranes (spontaneous or surgical), and again in 5 to 10 minutes. c. If cord prolapsed is identified, notify the physician and prepare for emergency cesarean birth. d.If the client is fully dilated, the most emergent delivery route may be vaginal. In this case, encourage the client to push and assist with the delivery as follows. i. Lower the head of the bed and elevate the clients hips on a pillow, or place the kneechest position to minimize pressure on the cord. ii. Apply oxygen at 10 to 12 L/minutes iii. Apply firm upward manual pressure to the presenting part of the fetus and relieve pressure from the cord. iv. Assess cord pulsations constantly v. Gently wrap gauze soaked in sterile normal saline solution around the prolapsed cord. 2. Provide physical and emotional support. 3. Provide client and family education. INTRAPARTUM COMPLICATIONS: PROLONGED PREGNANCY A. DESCRIPTION 1. A prolonged or postdate pregnancy is a pregnancy that extends beyond 42 weeks gestation.

2. The incidence of prolonged pregnancy is approximately 10%. B. ETIOLOGY. The actual physiologic cause of prolonged pregnancy is unknown. A suggested etiology is estrogen deficiency. C. PATHOPHYSIOLOGY. Pathophysiology includes excessively large infant with resultant birth trauma or small-forgestational-age infant who are deprived of hydration and nutrition because of placental aging and dysfunction and decreased amniotic fluid. D. ASSESSMENT FINDINGS 1. Clinical manifestations a. Weight loss and decrease uterine size (when the infant is suffering from p placental dysfunction) b.Excessively large uterus c. Meconium-stained fluid. d.Non-reassuring FHR pattern 2. Laboratory and diagnostic study findings. Ultrasound examination maybe use to assist in determination of fetal size. E. NURSING MANAGEMENT 1. Carefully assess the fetus to identify risk. a. Perform a careful risk assessment upon admission. b.Closely monitor fetal status. 2. Prevent birth complications. a. Assist the induction of labor. b.Prepare for a difficult delivery. c. Notify the pediatric staff of the potential for a birth-injured baby. 3. Provide physical and emotional support. 4. Provide client and family education. INTRAPARTUM COMPLICATIONS: DYSFUNCTIONAL LABOR A. DESCRIPTION. Dysfunctional labor is difficult, painful, prolonged labor due to mechanical factors. B. ETIOLOGY 1. Fetal factors (passenger) include unusually large fetus, fetal anomaly, malpresentation, and malposition. 2. Uterine factors (powers) include hypotonic labor, precipitious labor, and prolonged labor. 3. Pelvic factors (passage) include inlet contracture, midpelvis contracture, and outlet contracture. 4. Psyche factors include maternal anxiety are ineffective secondary to muscle fatigue or overstretching. C. PATHOPHYSIOLOGY. Uterine contractions are ineffective secondary to muscle fatigue or overstretching. D. ASSESSMENT FINDINGS. Clinical manifestations include irregular uterine contractions and ineffective uterine contractions in terms of contractile strength and duration. E. NURSING MANAGEMENT 1. Optimize uterine activity. Monitor uterine contractions for dysfunctional patterns; use palpation and an electronic monitor. 2. Prevent unnecessary fatigue. Check the clients level of fatigue and ability to cope with pain. 3. Prevent complications of labor for the client and infant. a. Assess urinary bladder; catheterize as needed. b.Assess maternal vital signs, including temperature, pulse, respiratory rate, and blood pressure. c. Check maternal urine for acetone (an indication of dehydration and exhaustion) d.Assess condition of fetus by monitoring FHR, fetal activity, and color of amniotic fluid. 4. Provide physical and emotional support. a. Promote relaxation through bathing and keeping the client and bed clean, back rubs, frequent position changes (side-lying), walking (if indicated), by keeping the environment quiet. b.Coach the client in breathing and relaxation techniques. 5. Provide client and family education. INTRAPARTUM COMPLICATIONS: SHOULDER DYSTOCIA A. DESCRIPTION. In shoulder dystocia, the anterior shoulder of the baby is unable to pass under the maternal pubic arch. B. ETIOLOGY. Shoulder dystocia is associated with advance maternal age, diabetes, maternal obesity, large baby (macrosomia), postdate pregnancy, and multiparity. C. PATHOPHYSIOLOGY. The plane of the fetal shoulders aligns perpendicular to the pubis instead of an angle. This causes the shoulder to become wedged under the pubic arch. D. ASSESSMENT FINDINGS 1. Associated findings. The birth process may seem unnecessarily prolonged. 2. Clinical manifestations. a. The fetal head retracts against the mothers perineum as soon as the head is delivered. This known as the turtle sign. b.External rotation does not occur. E. NURSING MANAGEMENT. Identify shoulder dystocia and assist with management. 1. Place the client in the McRoberts position (thighs pulled up against the abdomen with hips abducted). 2. Apply suprapubic pressure. INTRAPARTUM COMPLICATIONS: INDUCTION OF LABOR A. DESCRIPTION 1. The deliberate initiation of labor before spontaneous contractions begin may be either mechanical (amniotomy [rupture of amniotic membranes]), physiologic (ambulation and nipple stimulation), or chemical (prostaglandins and oxytocin).

2. Artificial rupture of membranes (AROM) may be adequate stimulation to initiate contractions, or AROM may be done after oxytocin administration establishes effective contractions. 3. Induction and AROM are initiated when the cervix is soft, partially effaced, and slightly dilated, preferably when the fetal presenting part is engaged. 4. Oxytocin-induced labor must be done with careful, ongoing monitoring; oxytocin is a powerful drug. Hyperstimulation of the uterus may result is titanic contractions prolonged to more than 90 seconds, which could cause fetal compromise due to impaired uteroplacental perfusion, abruption placentae, laceration of the cervix, uterine rupture, or neonatal trauma. B. NURSING MANAGEMENT 1. Monitor for a safe labor and delivery process. a. AROM i. Explain the procedure, and inform the client that labor usually follows within 6 to 8 hours of AROM. ii. Monitor fetal heart tones immediately before, during, and after the procedure. iii. Observe and record color, amount, and odor of amniotic fluid; time of procedure; cervical status; and maternal temperature. iv. Take and record the clients temperature every 2 hours to assess for infection. v. Monitor for the onset of labor. b.Medication-induced labor i. Review the hospitals policy relative to the amount, rate, and interval for increasing oxytocin or a prostaglandin-based preparation. ii. Use an infusion pump for precise regulation of the medication. iii. Observe for signs of hypertonicity, such as contractions exceeding 75 mmHg (when using the internal pressure catheter) or 90 seconds, or closer together than 2 minutes. Be prepared to discontinue the medication immediately. iv. Initiate continuous internal or external fetal monitoring, and evaluate FHR for normal range of 110 to 160 beats/minute. If there is loss of variability, late deceleration, or persistent bradycardia (FHR less than 120 beats/minutes), discontinue medication, administer oxygen, notify physician, reposition client to side-lying position, and perform a vaginal examination; fetal distress may result from rapid labor progress, descent of fetus, or cord prolapsed. v. Assess and record vital signs and FHR every 15 to 30 minutes, depending on stage of labor and risk status; assess for signs of impending delivery. 2. Provide physical and emotional support. INTRAPARTUM COMPLICATIONS: UTERINE RUPTURE A. DESCRIPTION 1. Uterine rupture is tearing of the uterus, either complete (rupture extends through entire uterine wall and uterine contents spill into the abdominal cavity) or incomplete (rupture extends through endometrium and myometrium, but the peritoneum surrounding the uterus remains intact). 2. Small tears may be asymptomatic and may heal spontaneously, remaining undetected until the stress and strain or a subsequent labor. B. ETIOLOGY 1. Traumatic uterine rupture may be caused by injury from obstetric instruments, such as uterine sound or curette used in abortion. 2. Rupture also may result from obstetric intervention, such as excessive fundal pressure, forceps delivery, violent bearing-down, tumultuous labor, and fetal shoulder dystocia. 3. Spontaneous uterine rupture is most likely to occur after previous uterine surgery or with grand multiparity combined with the use of oxytocic agents, cephalopelvic disproportion, malpresentation, or hydrocephalus. C. PATHOPHYSIOLOGY 1. The most common pathologic factors is a preexisting scar that results in a weakened or defective myometrium that does not stretch; this is most frequently identified in spontaneous uterine rupture. 2. Some episodes of rupture are due to traumatic disruption of the uterine surface. 3. More severe ruptures pose the risk of irreversible maternal hypovolemic shock of subsequent peritonitis, consequent fetal anoxia, and fetal or neonatal death. D. ASSESSMENT FINDINGS 1. Clinical manifestations vary from mild to severe, depending on the site and extend of the rupture, degree of extrusion of the uterine contents, and intraperitoneal evidence or absence of spilled amniotic fluid and blood. They include: a. Abdominal pain b.Vaginal bleeding (is not always present) c. Nonreassuring FHR pattern d.Palpation of fetal parts under the skin e. Signs of hypovolemic shock (with complete uterine rupture) E. NURSING MANAGEMENT 1. Monitor for the possibility of the uterine rupture a. In the presence of the predisposing factors, monitor maternal labor pattern closely for hypertonicity or signs of weakening uterine muscle. b.Recognizing signs of impending rupture, immediately notify the physician, and call for assistance. 2. Assist with rapid intervention. a. If the client has signs of possible uterine rupture, vaginal delivery is generally not attempted.

b.If symptoms are not sever, emergency laparotomy is performed to attempt immediate delivery of the fetus and then establish homeostasis. c. Implement the following preparations for surgery. i. Monitor maternal blood pressure, pulse, and respiration; also monitor fetal heart tones. ii. If the client has a central venous pressure catheter in place, monitor pressure to evaluate blood loss and effects of fluid and blood replacement. iii. nsert a urinary catheter for precise determinations of fluid balance. iv. Obtain blood for possible acidosis. v. Administer oxygen, and maintain a patent airway. 3. Prevent and manage complications. Take this steps in order to prevent or limit hypovolemic shock. a. Oxygenate by providing 8 to 10 L/minute using a closed mask. b.Restore circulating volume using one or more intravenous lines. c. Evaluate the cause, response to therapy, and fetal condition. d.Remedy the problem by preparing the client for surgery and administering antibiotics. 4. Provide physical and emotional support. a. Provide support for the clients partner and family members once surgery has begun. b.Inform the partner and family how they will receive information about the mother and newborn. INTRAPARTUM COMPLICATIONS: PLACENTA ACCRETA A. DESCRIPTION. Placenta accrete is an uncommon condition in which the chorionic villi adhere to the myometrium. It can be exhibited as: 1. Placenta Accreta the placental chorionic will adhere to the superficial layer of the uterine myometrium. 2. Placenta Increta the placental chorionic will invade deeply into the uterine myometrium. 3. Placenta Pecreta the placental chorionic will go through the uterine myometrium and often adhere to abdominal structures such as the bladder or intestine) B. ETIOLOGY. Predisposing factors are prior uterine surgery and placenta previa. C. PATHOPHYSIOLOGY. Implantation in an area of defective endometrium with no zone separation between the placenta and the myometrium. D. ASSESSMENT FINDINGS. 1. Associated findings. Placenta accrete is usually diagnosed in the immediate postpartum period when the placenta fails to separate. 2. Clinical manifestations a. Placenta fails to separate b. Profuse hemorrhage may result depending on the portion of placenta involved. E. NURSING MANAGEMENT 1. Identify placenta accrete in the client. Be aware of the clients risk status. 2. Assist with rapid treatment and intervention. Be prepared for a dilation and curettage or hysterectomy. 3. Provide physical and emotional support. 4. Provide client and family education. INTRAPARTUM COMPLICATIONS: CESARIAN BIRTH A. DESCRIPTION 1. In this surgical procedure, the newborn is delivered through the abdomen from an incision made through the maternal abdomen and the uterine myometrium. 2. The surgery maybe preplanned (elective) or arise form an unanticipated problem. 3. Types of cesarean birth include the following: a. Classical or vertical. A vertical midline incision is made in the skin and the body of the uterus, permitting easier access to the fetus. This is indicated in emergency situations, where there are abdominal adhesions for previous surgeries, or when the fetus is in transverse lie. Blood loss increased because large vessels of the myometrium are involved. Because the uterine musculature is weakened, there is greater possibility of rupture of the uterine scar subsequent pregnancies. B. REASONS FOR PERFORMING A CESARIAN BIRTH 1. Maternal factors a. Cephalopelvic disproportion b.Active genital herpes or papilloma c. Previous cesarian birth by classic incision d.Presence of severe disabling hypertension or heart disease 2. Placental factors a. Placenta previa b.Abruptio placentae 3. Fetal factors a. Transverse fetal lie b.Extreme low birth weight c. Fetal distress d.Compound conditions, such as macrosomia, transverse lie C. NURSING MANAGEMENT 1. Perform complete maternal and fetal assessment. a. Obtain a complete obstetric history. b.If the client presents with labor, determine frequency, duration and intensity of contractions. c. Determine the condition of the fetus through FHR, fetal scalp blood sample, fetal activity changes, and presence of meconium in amniotic fluid.

2. Prepare the client for cesarean birth in the same way whether the surgery is elective or emergency. Depending on hospital policy: a. Shave or clip pubic hair. b.Insert a retention catheter to empty the bladder continuously. c. As prescribed, insert intravenous lines, collect specimens for laboratory analysis, and administer preoperative medications. d.Also as prescribed, provide an antacid (to prevent vomiting and possible aspiration of gastric secretions) and prophylactic antibiotics (to prevent endometritis) e. Assist the client to remove jewelry, dentures, and nail polish, as appropriate. f. As needed, reinforce the obstetricians explanation of the surgery, the expected outcome, and the anesthesiologists explanation of the kind of anesthetics to be used (depending on the clients cardiopulmonary status). g.Make sure the clients signed the informed const is on file. h.Continue assessing maternal and fetal vital signs in accordance with the hospital policy until the client is transported to the operating room. i. Notify other health care team members of the pending delivery. j. Modify preoperative teaching to meet the needs of planned versus emergency cesarean birth; depth and breadth of instruction will depend on the circumstances and time available. k. If there is time, begin explaining what the client can expect postoperatively. Discuss pain relief, turning, coughing, deep breathing and ambulation. l. Inform the client that intraoperative and immediate postpartum care will be performed by the surgical and obstetric team, and the newborn will receive care by the pediatrician and a nurse skilled in neonatal care procedures (resuscitation). 3. Facilitate a family-centered cesarean birth by including, when possible, such activities as: a. Preparing the partner for participation in the delivery. b.Reuniting the family as soon as possible following delivery. c. Providing for family time alone in the critical first hours after the mother and the newborn stabilized. d.Including the father and siblings (as possible) when demonstrating care of the newborn. e. Encouraging the mothers support person to remain with her as much as possible. In some cases, this person may accompany the client to the surgical suit and stay with her throughout the birth. 4. Provide physical and emotional support. a. Anticipate parental feelings of failure related to cesarean rather than normal birth. In such a situation, provide time for the client to relieve and talk through the experience. Offer reassurance and support. b.Assist the family in planning for care of mother and newborn at home. D. PLANNING FOR CARE OF THE MOTHER AND NEWBORN AT HOME AFTER CESAREAN BIRTH 1. Explain to the mother, her partner, and other family members that recovery from a surgical cesarean birth is slower and often more painful, when compared with recovery from a normal vaginal birth. The following considerations must be taken into account: a. Need for increased rest (influenced by the type of anesthesia, length of labor, and the type of abdominal or uterine incision) b.Need for increased pain medication and other pain relieving techniques c. Inability to climb the stairs d.nability to drive a car e. Difficulty with breast-feeding the newborn in certain positions (for example, cradle hold). Teach the mother the best positions to use and how to use pillows for cushion the incision site. f. Difficulty with normal activities of daily living (such as dressing, bathing, and toileting). Difficulty with providing normal newborn care (such as lifting, carrying, bathing, and dressing the newborn) and the need for assistance in caring for the newborn. INTRAPARTUM COMPLICATIONS: UTERINE INVERTION A. DESCRIPTION. The uterus turns completely or partially inside out; it occurs immediately following delivery of the placenta or in the immediate postpartum period. B. ETIOLOGY 1. Forced inversion is caused by excessive pulling of the cord or vigorous manual expression of the placenta or clots from an atonic uterus. 2. Spontaneous inversion is due to increased abdominal pressure from bearing down, coughing, or sudden abdominal muscle contraction. Predisposing factors include straining after delivery of the placenta, vigorous kneading of the fundus to expel the placenta, manual separation, and extraction of the placenta, rapid delivery with multiple gestation, or rapid release of excessive amniotic fluid. C. PATHOPHYSIOLOGY 1. The inverted uterus is unable to restore normal position or contract appropriately. 2. The woman is placed at increased risk for bleeding and infection. D. ASSESSMENT FINDINGS. Clinical manifestations include: 1. Excruciating pelvic pain with a sensation of extreme fullness extending into the vagina. 2. Extrusion of the inner uterine lining into the vagina or extending past the vaginal introitus. 3. Vaginal bleeding and signs of hypovolemia. E. NURSING MANAGEMENT. Promptly identify & assist with the resolution of uterine inversion. 1. Recognize signs of impending inversion, and immediately notify the physician and call for assistance.

2. Immediate manual replacement of the uterus at the time of inversion will prevent cervical entrapment of the uterus; if reinversion is not performed immediately, rapid and extreme blood loss ma occur, resulting in hypovolemic shock. 3. Take steps to prevent or limit hypovolemic shock. a. Insert a large gauge intravenous catheter for fluid replacement. b.Measure and record maternal vital signs every 5 to 15 minutes to established a baseline and document change. c. Open an established intravenous line for optimal fluid replacement. d.A fibrinogen level should be drawn to determine the risk of blood clot formation. e. Prepare for anesthesia as needed. f. Prepare to administer a cardiopulmonary resuscitation, if required. 4. If manual reinversion is not successful, prepare the client and family for possible general anesthesia and surgery. INTRAPARTUM COMPLICATIONS: EARLY POSTPARTUM HEMORRHAGE A. DESCRIPTION 1. Early postpartum hemorrhage is defined as blood loss of 500ml or more during the first 24 hours after delivery. 2. Postpartum hemorrhage is the leading cause of maternal death worldwide and common cause of excessive blood loss during the early postpartum period. 3. Approximately 5% of women experience some type of postdelivery hemorrhage. B. ETIOLOGY 1. Major causes of postpartum hemorrhage are uterine atony (responsible for at least 80% of all early hemorrhages); laceration of cervix, vagina, or perineum; and retained placental fragments. 2. Predisposing factors include hypotonic contractions, overdistended uterus, multiparity, large newborn, forceps delivery, and cesarean birth. C. PATHOPHYSIOLOGY. T he uterus is unable to contract effectively and maintain homeostasis. D. ASSESSMENT FINDINGS. Clinical manifestations include: 1. Vaginal bleeding 2. Hypotonic uterus 3. Excessive blood loss, which may produce hypotension, thread pulse, pallor, restlessness, dyspnea, can chills. E. NURSING MANAGEMENT 1. Assist with appropriate treatment to prevent complications. a. Determine the presence of uterine atony through frequent periodic assessment of uterine firmness and location and amount of vaginal bleeding immediately after delivery. b.Measure and record serial maternal vital signs after delivery every 5 to 15 minutes until stable, increase or decrease the frequency of assessment relative to baseline and amount of bleeding. c. Notify the physician of abnormal assessment findings. d.Massage the fundus gently, taking care to support the uterus with one hand place just the above the symphysis pubis. e. Administer medications as prescribed. f. Keep an accurate pad count (100 ml per saturated pad) g.Assess condition of skin, urine output, and level of consciousness. 2. Provide physical and emotional support. 3. Provide client and family education. .