Maternal Midterm

Chapter 21
Nursing Care of a Family

Experiencing a Sudden Pregnancy
Complication
2
Objectives:
1. Describe sudden complications of pregnancy that
place a pregnant woman and her fetus at high
risk.
2. Assess a woman who is experiencing a
complication of pregnancy.
3. Formulate nursing diagnoses that address the
needs of a woman and her family experiencing a
complication of pregnancy.
4. Identify expected outcomes to minimize the risks
to a pregnant woman and her fetus when a
sudden complication of pregnancy occurs.
5. Using the nursing process, plan nursing care.
3
Objectives:
6. Implement nursing care specific to a woman
who has developed a sudden complication of
pregnancy,
7. Evaluate expected outcomes for effectiveness
and achievement of care.
8. Integrate knowledge of complications of
pregnancy with the interplay of nursing process.
4
BLEEDING DURING
PREGNANCY
5
Nursing Diagnoses and Related

Interventions
• Nursing Diagnosis:
• Risk for deficient fluid volume related to bleeding during
pregnancy
• Outcome Evaluation:
1. Patient’s blood pressure is maintained at above 100/60
mmHg; pulse rate is below 100 beats/min;
2. only minimal bleeding is apparent;
3. fetal heart rate (FHR) is maintained at 120 to 160
beats/min with adequate short- and long-term variability;
4. maternal urine output is greater than 30 ml/hr.
6

Interventions
Goals of Therapy for hypovolemic shock
1. restoring blood volume
2. halting the source of hemorrhage as quickly as
possible.
7

Interventions
• If the blood deficit continues so blood cannot
reach other major organs, multi-organ failure can
result.
1. Obtaining hemoglobin and hematocrit levels
and securing a blood sample for typing or
cross-matching
2. A woman suspected of having serious bleeding
will need intravenous fluid replacement, such as
Ringer’s lactate, as an early intervention.
8

Interventions
• If the blood deficit continues so blood cannot reach other
major organs, multi-organ failure can result.
3. Use a large-gauge Angiocath (16 or 18) for rapid fluid
expansion as this will also allow a blood transfusion to
be administered through the same site as soon as blood
is available.
4. If respirations are rapid, administer oxygen by mask
5. monitor oxygen saturation levels by pulse oximetry.
9

Interventions
6. Assessments of vital signs and continuous fetal
monitoring;
7. Urge the woman to rest in a side-lying position
(left lateral is preferred)
❖If this is not possible, position her on her back, with a
wedge under one hip to minimize uterine pressure on
the vena cava and prevent blood from being trapped in
the lower extremities (supine hypotension syndrome).
8. Continue to provide information about care and
emotional support to her and her family
members.
10

Interventions
10. A woman may have a central venous pressure catheter
(measures the right atrial pressure or the pressure of
blood within the vena cava) or a pulmonary capillary
wedge catheter (measures the pressure in the left
atrium or the filling pressure in the left ventricle) inserted
after bleeding is halted.
Common Causes of Bleeding
According to Trimester
First Trimester Second Trimester Third Trimester
• Spontaneous • Gestational • Placenta previa
miscarriage trophoblastic • Abruptio placentae
• Threatened disease • Preterm labor
(hydatidiform mole)
• Imminent
• Premature cervical
• Complete
dilatation
• Missed • Disseminated
• Incomplete intravascular
• Ectopic pregnancy coagulation (DIC)
• Abdominal
pregnancy
12
1st Trimester Bleeding

❖Spontaneous Miscarriage
• Abortion
−A medical term for any interruption of a
pregnancy before a fetus is viable (20-24
wks. AOG or at least 500 g).
• Miscarriage
−Interruption of pregnancy occurs
spontaneously.
13

❖Causes of Spontaneous Miscarriage
1. Abnormal fetal development
−Teratogenic factors
−Chromosomal aberration
2. Implantation abnormalities
3. Corpus luteum in the ovary fails to produce
enough progesterone to maintain the desidua
basalis
4. Systemic infection
−Rubella, syphilis, poliomyelitis, cytomegalovirus,
toxoplasmosis,UTI
5. Ingestion of teratogenic drug
−E.g. isotretinoin (Accutane)
6. Alcohol ingestion
14

❖Assessment of Spontaneous Miscarriage
1. Confirmation of pregnancy
2. Pregnancy length
3. Duration of bleeding
4. Intensity/amount of blood loss
5. Description
6. Frequency
7. Associated symptom
8. Action
9. Blood type of the woman
15
Threatened Miscarriage
• Symptoms:
1. Vaginal bleeding
➢Initially scant, bright red
2. Slight cramping
3. No cervical dilation
• Diagnostic tests:
1. Ultrasound
2. Blood test for hCG and is repeated in 48 hrs.
➢↑hCG means placenta is still intact.
16
Threatened Miscarriage
• Interventions:
1. Avoid strenuous activity for 24 – 48 hrs.
2. Restrict coitus for 2 wks.
17
Imminent/ (Inevitable) Miscarriage

• Symptoms:
1. Uterine contractions
2. Cervical dilation
1. Check for FHT
2. Ultrasound
• Interventions:
1. D & E (dilation & evacuation)
2. After discharge following D & E, assess for
bleeding by recording no. of pads used.
18
Complete Miscarriage
➢Entire products of conception

(fetus, membranes, and placenta)
are expelled spontaneously without any
assistance.
➢Bleeding usually slows within 2 hrs. and then

stops after a few days after passage of the
products of conception.
19
Incomplete Miscarriage
• Part of the conceptus (usually the fetus) is
expelled, but the membrane or placenta is
retained in the uterus.
• Intervention:
1. D & C
2. Suction curettage
20
Missed Miscarriage
• Fetus dies in utero but is not expelled.
• Symptoms:
1. No increase in fundal height
2. FHS cannot be heard
3. May have had symptoms of
threatened miscarriage
• Interventions:
1. D & E
2. If pregnancy is ↑14 wks. Labor may
be induced by:
• Prostaglandin suppository or
misoprostol to dilate the cervix
• Oxytocin is administered
to stimulate uterine contraction
21
Complications of Miscarriage
1. Hemorrhage
➢Therapeutic Management:
1) Monitor V/S
2) Position the woman flat and massage the
uterine fundus to aid in contraction if
there is excessive bleeding.
3) D & C may be needed to
empty the uterus.
4) Blood transfusion may be
necessary to replace blood
loss.
22
2. Infection (endometritis)
• Signs:
1) Fever
2) Abdominal pain or tenderness
3) Foul vaginal discharge
• Causative organism:
➢Escherichia coli (spread from the rectum
into the vagina).
23
2. Infection (endometritis)
• Therapeutic management:
1) Antibiotic (Clindamycin)
2) Oxytocic agent (methylergonovine)
➢To encourage uterine contraction
3) Analgesic for abdominal discomfort.
4) Sitting in a Fowler’s position or walking
➢Encourages lochia drainage by gravity.
5) Wear gloves when helping the woman
change her perineal pads.
6) Use good handwashing techniques before &
after handling the contaminated pads.
24
3. Septic Abortion
➢Abortion that is complicated by infection.
➢Occurs in women who tried self-abortion or
were aborted illegally using a non-sterile
instrument.
➢Therapeutic management:
1) Monitor urine output/hr. to assess kidney
function.
2) IVF is started to restore fluid volume
3) Broad spectrum antibiotic is started
• Penicillin (gm+), gentamicin (gm- aerobic),
Clindamycin (gm- anerobic)
4) TT and TIG is ordered for prophylaxis of tetanus
5) D & C will be performed.
25
Ectopic Pregnancy
• Implantation occurs outside
the uterine cavity.
• Sites of implantation:
1. Fallopian tube (most common)
2. Surface of ovary
3. Cervix
• Predisposing factors:
1. Smokers
2. Use of IUDs
3. Following in vitro fertilization
4. Who had 1 ectopic pregnancy
26
Ectopic Pregnancy
1. Ultrasound
2. MRI (magnetic resonance imaging)
• Signs & Symptoms:
1. Sharp, stabbing pain in one of her lower
abdominal quadrants at the time of rupture
(6 – 12 wks. AOG).
2. Scant vaginal spotting
3. If internal bleeding progresses to acute
hemorrhage, a woman may experience:
➢Lightheadedness
➢Rapid pulse
➢Signs of shock
27
Ectopic Pregnancy
• Assessment findings:
1. Falling hCG or serum progesterone level
2. Rigid abdomen from peritoneal irritation
3. Umbilicus may develop a bluish tinge
(Cullen’s sign)
4. Movement of cervix on pelvic exam may
cause excruciating pain.
5. Pain in the shoulders from blood in the
peritoneal cavity causing
irritation to the phrenic nerve.
6. Tender mass palpable in
Douglas’ cul-de-sac on
vaginal exam.
28
Ectopic Pregnancy
• Therapeutic Management:
1. For unruptured ectopic pregnancy:
1) Methotrexate
➢Attacks and destroy fast-growing cells.
➢Treatment is continued until hCG titer is
negative.
2) Mifepristone
➢Cause sloughing of the tubal implantation
site.
29
Ectopic Pregnancy
2. For ruptured ectopic pregnancy:
1) IVF with large-gauge catheter to restore
intravascular volume (19 gauge needle)
2) Blood transfusion can be started after
cross-matching
3) Laparoscopy
➢To ligate the bleeding vessels
➢To remove or repair the damaged fallopian tube.
4) Women with Rh-negative blood should receive
Rh (D) immune globulin (RhIG) after ectopic
pregnancy for isoimmunization protection in
future childbearing.
30
2nd Trimester Bleeding

• GESTATIONAL TROPHOBLASTIC
DISEASE (Hydatidiform Mole)
➢Abnormal proliferation and degeneration of the
trophoblastic villi
cells degenerate
become filled with fluid and appear
as fluid-filled, grape-sized vesicles
embryo fails to develop
31

• Risk factors:
1. Low protein intake
2. Older than 35 y.o.
3. Asian heritage
32

• Types:
1. Complete Mole
➢All trophoblastic villi swell and become
cystic
➢If an embryo forms, it dies early at only 1
– 2 mm in size
➢No fetal blood formed in the villi
33

• Types:
2. Partial Mole
➢Some of the villi form normally.
➢Macerated embryo of approximately 9 wks.
Gestation may be present
➢Fetal blood present in the villi
➢Has 69 chromosomes (a triploid formation
in which there are 3 chromosomes instead
of 2 for every pair.
34
GESTATIONAL TROPHOBLASTIC
1. Rapid increase of uterine size
2. No FHT is heard
3. Level of hCG continue to be strongly (+)
after day 100 of pregnancy (1 – 2 milli-IU)
4. Marked nausea & vomiting due to high hCG.
5. Symptoms of PIH:
1) Hypertension
2) Edema
3) Proteinuria
6. Vaginal spotting of dark brown blood
accompanied with clear fluid-filled vesicles.
35
GESTATIONAL TROPHOBLASTIC
1. Suction & curettage
2. Pelvic exam, chest X-ray, and a serum test for
hCG
3. Level of hCG is analyzed every 2 wks. until
normal; reassessed every 4 wks. For 6 – 12
months thereafter.
4. Health care providers usually will continue to test
hCG levels after a pregnancy loss to ensure they
return back to <5.0.
5. A contraceptive method is used for 12 months.
6. Methotrexate may be prescribed for
prophylaxis.
36
hCG levels in weeks from LMP (gestational

age)
• 3 weeks LMP - - - - - - 5 – 50 mIU/ml
• 4 weeks LMP - - - - - - 5 – 426 mIU/ml
• 5 weeks LMP - - - - - - 18 – 7,340 mIU/ml
• 6 weeks LMP - - - - - - 1,080 – 56,500 mIU/ml
• 7 – 8 weeks LMP - - - 7, 650 – 229,000 mIU/ml
• 9 – 12 weeks LMP - - 25,700 – 288,000 mIU/ml
• 13 – 16 weeks LMP - - 13,300 – 254,000 mIU/ml
• 17 – 24 weeks LMP - - 4,060 – 165,400 mIU/ml
• 25 – 40 weeks LMP - - 3,640 – 117,000 mIU/ml
37
Premature Cervical Dilatation

• Incompetent cervix
➢Cervix dilates prematurely and therefore
cannot hold a fetus until term.
➢Cervical dilatation is painless, no uterine
contractions
➢Commonly occurs at the week 20 of
pregnancy.
• Risk factors:
1. Increased maternal age
2. Congenital structural defects (short cervix)
3. Trauma to the cervix (e.g. repeated D & C)
38

• Risk factors:
4. History of traumatic birth
5. Client’s mother treated with
diethylstilbestrol (DES) when pregnant
with the client
• Diethylstilbestrol is a synthetic nonsteroidal estrogen that
was used to prevent miscarriage and other pregnancy
complications.
• Women who were exposed to diethylstilbestrol in utero
may have structural reproductive tract anomalies, an
increased infertility rate, and poor pregnancy outcomes.
6. Uterine anomalies
39

• Pathophysiology
➢Connective tissue structure of the cervix
is not strong enough to maintain closure
of the cervical os during pregnancy.
40

1. Pink-stained vaginal discharge (show);
first symptom
2. Rupture of the membranes
3. Discharge of the amniotic fluid
4. Uterine contractions begin.
41

• Medical Management:
1. Cervical Cerclage
➢Performed at approx. week 12 – 14 of the next
pregnancy.
➢Purse-string sutures are placed in the cervix
by vaginal route under regional anesthesia.
➢Strengthens the cervix and prevents it from
dilating.
➢McDonald or Shirodkar procedure
➢Sutures removed at week 37 – 38 of
pregnancy.
42

• The McDonald procedure
➢is done with a 5 mm band of
permanent suture is placed
high on the cervix.
➢This is indicated when there
is significant effacement of the
lower portion of the cervix.
➢It is generally removed at 37 weeks, unless
there is a reason to remove it earlier, like
infection, preterm labor, premature rupture of
the membranes, etc.
43

• The Shirodkar
➢is also frequently used
technique.
➢this was previously a
permanent purse string
suture that would remain
intact for life.
➢When this type of cerclage
is done, a cesarean section
will always be performed.
➢There are physicians performing modified
techniques, where the delivery does not necessarily
have to be by cesarean, nor the suture left intact.
44

• Nursing Management
1. Provide client and family teaching.
➢Describe problems that must be reported immediately
(ie,pink-tinged vaginal discharge, increased pelvic
pressure, and rupture of the membranes).
2. Maintain an environment to preserve the
integrity of the pregnancy.
➢Prepare for cervical cerclage, if appropriate.
➢Maintain activity restrictions as prescribed.
➢Discuss the need for vaginal rest (ie, no intercourse or
orgasm)
3. Prepare for the birth if membranes are
ruptured.
4. Address emotional and psychosocial
needs.
45
3rd Trimester Bleeding

• Placenta Previa
➢Low implantation of the placenta
➢Occurs in 4 degrees:
1. Low-lying placenta
• Implantation in the lower rather than in the
upper portion of the uterus.
2. Marginal implantation
• Placenta edge approaches that of the cervical os.
46

• Placenta Previa
➢Low implantation of the placenta
➢Occurs in 4 degrees:
3. Partial placenta previa
• Implantation that occludes a portion of the
cervical os.
4. Total placenta previa
• Implantation that totally obstructs the
cervical os.
47

• Placenta Previa
➢Risk factors:
1. Increased parity
2. Advanced maternal age
3. Past cesarean births
4. Past uterine curettage
5. Multiple gestation
6. Male fetus.
48

• Pathophysiology of Placenta Previa
➢Bleeding occurs when the lower uterine
segment begins to differentiate from the
upper segment late in pregnancy (wk. 30) and
cervix begins to dilate.
➢Bleeding results from placenta’s inability to
stretch to accommodate the differing shape of
the lower uterine segment or the cervix.
➢Signs & Symptoms:
1. Abrupt
2. Painless
3. Bright red bleeding
49
Placenta Previa
• Immediate Care Measures:
1. Place woman immediately on bed rest on a
side-lying position.
2. Assess for the following:
➢Duration of pregnancy
➢Time the bleeding began
➢Woman’s estimation of the amount of blood
➢Accompanying pain if any
➢Color of the blood
50
Placenta Previa
1. Place woman immediately on bed rest on a
side-lying position.
2. Assess for the following (continued…)
➢Woman’s actions to halt bleeding, if any.
➢Any prior episodes of bleeding during the
pregnancy.
➢Prior cervical surgery for premature cervical
dilatation
3. Inspect the perineum for bleeding.
51
Placenta Previa
4. Determine vaginal blood loss by weighing
perineal pads before and after use.
5. Identify the origin of the blood (maternal or
fetal) through Apt or Kleihauer-Betke test
(test strip procedures)
• is a blood test used to measure the amount of fetal
hemoglobin transferred from a fetus to a
mother's bloodstream.
• It is usually performed on Rh-negative mothers to
determine the required dose of Rho(D) immune globulin
(RhIg) to inhibit formation of Rh antibodies in the mother
and prevent Rh disease in future Rh-positive children.
52
Placenta Previa
• Rho(D) immune globulin (RhIg)
• Administer 1 syringe (1,500 units) at
approximately 26 to 28 weeks' gestation,
followed by another full dose, preferably within
72 h following delivery, if the infant is Rh
positive.
53
Placenta Previa
6. Obtain baseline V/S.

7. Assess Bp every 5 – 15 min.
8. Monitor urine output every hour.
9. Never attempt a pelvic or rectal exam with
painless bleeding late in pregnancy.
54
Placenta Previa
10. Begin IVF therapy
11. Attach an external fetal monitor and begin
recording FHT and uterine contractions.
12. Blood test for:
• Hemoglobin
• Hematocrit
• Prothrombin time, partial thromboplastin time,
fibrinogen, platelet count
• Blood type and cross-matching
• Antibody screen
55
Placenta Previa
13. Determine the placental location for
possible vaginal delivery through
ultrasound.
14. Vaginal exam is done in an operating
room.
15. Have O2 equipment available.
56
Placenta Previa
• Continuing Care Measures:
16. If labor has begun, bleeding is continuing,
or the fetus is being compromised, birth
must be accomplished regardless of
gestational age.
17. Woman remains in the hospital on bed
rest for close observation for 48 hrs.
18. Betamethasone may be prescribed for the
mother to encourage the maturity of fetal
lungs if the fetus is less than 34 wks.
PREMATURE SEPARATION OF THE
PLACENTA
(ABRUPTIO PLACENTA)
• Premature separation of the placenta (abruptio
placentae)
• placenta appears to have been implanted correctly.
Suddenly, however, it begins to separate and bleeding
results.
• is the most frequent cause of perinatal death (Ananth,
Lavery, Vintzileos, et al., 2016).
• The separation generally occurs late in pregnancy; even
as late as during the first or second stage of labor.
PLACENTA (ABRUPTIO PLACENTAE)
• Always be alert to both the amount and kind of
pain and vaginal bleeding a woman is having in
labor.
• The primary cause:
• Unknown
1. high parity
2. advanced maternal age
3. short umbilical cord
4. chronic hypertensive disease
5. hypertension of pregnancy
6. direct trauma (as from an automobile accident or
intimate partner violence)
7. vasoconstriction from cocaine or cigarette use
8. thrombophilic conditions that lead to thrombosis
formation (Boisramé, Sananès, Fritz, et al., 2014)
9. chorioamnionitis or infection of the fetal membranes
and fluid (Hackney, Kuo, Petersen, et al., 2016).
10. rapid decrease in uterine volume, such as occurs
with sudden release of amniotic fluid as can happen
with polyhydramnios.
o Usually, the fetal head is low enough in the pelvis that when
membranes rupture, this prevents loss of the total volume of
the amniotic fluid at one time, so normally a rapid reduction
in amniotic fluid does not occur.
Assessment
1. sharp, stabbing pain high in the uterine fundus as
the initial separation occurs.
2. If labor begins with the separation, each
contraction will be accompanied by pain over and
above the pain of the contraction.
3. Tenderness can be felt on uterine palpation.
4. Heavy bleeding usually accompanies premature
separation of the placenta, although it may not be
readily apparent.
• External bleeding will only be evident if the
placenta separates first at the edges.
Assessment
5. If the center of the placenta separates first, blood
can pool under the placenta, and although
bleeding is just as intense, it will be hidden from
view.
• Whether blood is evident or not, signs of hypovolemic
shock usually follow quickly.
6. The uterus becomes tense and feels rigid to the
touch.
7. If blood infiltrates the uterine musculature,
Couvelaire uterus or uteroplacental apoplexy,
forming a hard, boardlike uterus occurs.
Assessment
8. As bleeding progresses, a woman’s reserve of
blood fibrinogen becomes diminished as her body
attempts to accomplish effective clot formation,
and DIC syndrome can occur.
▪ s/sx of Disseminated Intravascular Coagulation
✓ bleeding, bruising, low blood pressure, shortness of
breath, or confusion.
✓ blood clots may reduce blood flow and block blood
from reaching bodily organs resulting to multiple
organ failure.
Assessment
• If a woman is being admitted to the hospital after
experiencing symptoms at home, assess:
1. when the time the bleeding began
2. whether pain accompanied it
3. the amount and kind of bleeding,
4. if trauma could have led to the placental separation.
Assessment
• Initial blood work should include:
1. hemoglobin level
✓ Normal adult female = 12 – 16 gm/dl
2. typing and cross-matching
3. fibrinogen level and fibrin breakdown products to detect
DIC.
✓ normal level of fibrinogen in the blood = 1.5 to 3.0 grams per
liter
✓ D-Dimer is a fibrin degradation product. It is named as such
because it contains two cross-linked D fragments of the fibrin
protein.
Assessment
• D-dimer Range
• In Conventional Units: ≤ 250 ng/mL D-dimer units (DDU)
• In SI Units: ≤ 0.50 mcg/mL fibrinogen equivalent units
(FEU)
• Increased levels imply increased fibrinolysis and can be
seen in DIC and thrombotic states.
Types of Placental Separation
Grading of Placental Separation
Therapeutic Management
• Because of the threat to both the woman and the fetus,
separation of the placenta is immediately an emergency
situation (Heavey & Dahl Maher, 2015).
1. A woman needs a large-gauge intravenous catheter
inserted for fluid replacement.
2. oxygen by mask to limit fetal anoxia.
3. Monitor fetal heart sounds externally
4. record maternal vital signs every 5 to 15 minutes to
establish baselines and observe progress.
5. The baseline fibrinogen determination will be followed
by additional determinations up to the time of birth.
6. Keep a woman in a lateral, not supine, position to
prevent pressure on the vena cava and additional
interference with fetal circulation.
7. Do not perform any abdominal, vaginal, or pelvic
examination on a woman with a diagnosed or
suspected placental separation.
• It is important not to disturb the injured placenta any further.
8. Unless the separation is minimal (grades 0 and 1), the
pregnancy must be ended because the fetus cannot
obtain adequate oxygen and nutrients.
9. If vaginal birth does not seem imminent, cesarean birth
is the birth method of choice.
10. Intravenous administration of fibrinogen or
cryoprecipitate (which contains fibrinogen) can be used
to elevate a woman’s fibrinogen level prior to and
concurrently with surgery.
• If DIC has developed, cesarean birth may pose a grave risk
because of the possibility of hemorrhage during the surgery
and later from the surgical incision.
Fresh frozen plasma
a lifelong bleeding disorder in which

your blood doesn't clot well
11. With the worst outcome, a hysterectomy might be
necessary to prevent exsanguination (loss of blood to a
degree sufficient to cause death).
• Prognosis:
• Fetal
• depends on the extent of the placental separation and the degree of fetal
hypoxia.
• Maternal
• depends on how promptly treatment can be instituted.
• Death can occur from massive hemorrhage leading to
shock and circulatory collapse or renal failure from
circulatory collapse.
• Any woman who has had bleeding before birth is more
prone to infection after birth than the average woman.
• A woman with a history of premature separation of the
placenta, therefore, needs to be observed closely for the
development of infection in the postpartum period.
76
Chapter 21

Experiencing a Sudden Pregnancy
Complication
Preterm Labor
❖Occurs before the end of week 37 of
gestation.
❖Because of this, it is responsible for almost
two thirds of all infant deaths in the neonatal
period (American College of Obstetricians
and Gynecologists [ACOG], 2016a).
❖A woman is documented as being in actual
labor rather than having false labor
contractions if contractions have caused
cervical effacement over 80% or dilation
over 1 cm.
Copyright © 2018 Wolters Kluwer · All Rights Reserved
Preterm Labor
❖Maintaining general health during pregnancy
is the best preventive measure to avoid
preterm birth
❖Educate woman about the signs of labor
o Knowing the signs of labor can help women
identify if preterm birth is beginning because
some women wait before they seek help for
preterm labor because they diagnose back pain
or contractions as nothing more than extremely
hard Braxton Hicks contractions.

Preterm Labor
❖It is associated with:
o Dehydration
o urinary tract infection
o periodontal disease
o Chorioamnionitis
o large fetal size.
o Women who continue to work at strenuous jobs
during pregnancy or perform shift work that
leads to extreme fatigue.

Preterm Labor
❖It is associated with:

o Intimate partner violence and the trauma this
causes may be yet another cause (Alhusen, Ray,
Sharps, et al., 2015).
❖Common symptoms of early preterm

labor:
1. persistent, dull, and low backache
2. vaginal spotting
3. a feeling of pelvic pressure or abdominal
tightening.
Preterm Labor
❖Common symptoms of early preterm

labor:
4. menstrual-like cramping
5. increased vaginal discharge
6. uterine contractions
7. intestinal cramping.

THERAPEUTIC MANAGEMENT
1. A woman who is in preterm labor is usually

first admitted to the hospital and placed on
bed rest to relieve the pressure of the fetus
on the cervix.
2. External fetal and uterine contraction
monitors are attached to monitor FHR and
the intensity of contractions.
3. Intravenous fluid therapy to keep her well
hydrated is begun because although not
well documented, hydration may help stop
contractions.
THERAPEUTIC MANAGEMENT
o This is thought to be effective because if a

woman is dehydrated, the pituitary gland will be
activated to secrete antidiuretic hormone, which
might cause the pituitary gland to release
oxytocin as well, strengthening uterine
contractions.
4. Vaginal and cervical cultures and a clean-

catch urine sample are prescribed to rule
out infection.
o If a urinary tract infection is present, the
woman will be prescribed an antibiotic that is
especially effective for group B streptococcus
as this infection can be fatal in a newborn.
DRUG ADMINISTRATION
1. Terbutaline
o is a drug approved to prevent and treat
bronchospasm but may be used as a tocolytic
agent (i.e., an agent to halt labor).
o should not be used for over 48 to 72 hours of
therapy because of a potential for serious
maternal heart problems and death.
o It should not be used in an outpatient or home
setting because its administration requires
constant professional assessment (Roman,
2013).

DRUG ADMINISTRATION
2. Magnesium sulfate,
o For fetal neuroprotection is used prior to 32
weeks to help prevent cerebral palsy in
premature infants (Nijman, van Vliet, Koullali,
et al., 2016).
3. Corticosteroid (betamethasone)
o the formation of lung surfactant appears to
accelerate, thus reducing the possibility of
respiratory distress syndrome or
bronchopulmonary dysplasia (Msan, Usta,
Mirza, et al., 2015).

DRUG ADMINISTRATION
3. Corticosteroid (betamethasone)
o If the pregnancy is under 34 weeks, a woman
may be given
▪ two doses of 12 mg betamethasone I.M. 24 hours
apart, or
▪ four doses of 6 mg dexamethasone I.M. 12 hours
apart.

PREGNANCY-INDUCED
HYPERTENSION

PREGNANCY-INDUCED
HYPERTENSION
➢ A condition in which vasospasm occurs during

pregnancy in both small and large arteries.
➢ With gestational hypertension, this reduced

responsiveness to blood pressure changes
appears to be lost because of the prostaglandin
release.
 Vasoconstriction occurs
 blood pressure increases dramatically.
PREGNANCY-INDUCED
HYPERTENSION
➢ Beginning about the 20th week of pregnancy,

almost all body systems begin to be affected.
➢ The cardiac system, for example, can easily
become overwhelmed because the heart is
forced to pump against rising peripheral
resistance.
➢ causes a reduced blood supply to organs, most
markedly the kidney, pancreas, liver, brain, and
placenta.
➢ Poor placental perfusion reduces the fetal nutrient and
oxygen supply.
PREGNANCY-INDUCED
HYPERTENSION
➢Ischemia in the pancreas

▪ can result in epigastric pain and an elevated
amylase–creatinine ratio.
➢If spasm occurs in the arteries of the retina,
▪ vision changes can occur.
➢If retinal hemorrhage occurs

▪ blindness can result.
PREGNANCY-INDUCED
HYPERTENSION
➢Vasospasm in the kidney

 increased blood flow resistance leads to
degenerative changes of the kidney glomeruli
because of back pressure.
▪ This leads to increased permeability of the
glomerular membrane
 allowing the serum proteins albumin and globulin to
escape into the urine (i.e., proteinuria).
▪ Decreased glomerular filtration
✓ lowered urine output and clearance of creatinine.
PREGNANCY-INDUCED
HYPERTENSION
➢ If increased kidney tubular reabsorption occurs,

retention of sodium begins.
✓ sodium retains fluid, edema results.
✓ Edema is further increased because, as more protein
is lost, the osmotic pressure of the circulating blood
falls and fluid diffuses from the circulatory system into
the denser interstitial spaces to equalize the pressure.
➢ Extreme edema
✓ can lead to maternal cerebral and pulmonary edema
and seizures (eclampsia).
PREGNANCY-INDUCED
HYPERTENSION
➢Thrombocytopenia or a lowered platelet

count
✓ occurs as platelets cluster at the sites of
endothelial damage.
PATHOPHYSIOLOGY OF PIH
Vasospasm
Vascular effects Kidney effects Interstitial effects
Decreased
Vasoconstriction Diffusion of fluid
glomeruli filtration
rate, increased from blood
permeability of stream into
glomeruli interstitial tissue
membranes
PATHOPHYSIOLOGY OF PIH (cont’d…)
Increased serum
Poor organ perfusion
blood, urea, Edema
nitrogen, Uric acid,
creatinine
Increased Bp Decreased urine

output &
proteinuria
PREGNANCY-INDUCED HYPERTENSION
RISK FACTORS:
1. Multiple pregnancy
2. Primiparas younger than 20 y.o. or older
than 40 y.o.
3. Women who have polyhydramnios
4. Low socioeconomic background
RISK FACTORS:
5. Women with underlying disease
• Heart disease
• Diabetes
• Essential hypertension
SIGNS & SYMPTOMS:
1. Hypertension
2. Edema
3. proteinuria
 Gestational Hypertension
 Bp 140/90 mmHg, or
 Systolic Bp >30 mmHg; Diastolic > 15 mmHg
above pregnancy level
 No proteinuria nor edema
 Bp returns to normal after birth.

 Mild Preeclampsia
 Bp 140/90 mmHg
 Systolic Bp >30 mmHg; Diastolic > 15 mmHg
above pregnancy level
 Proteinuria +1 to +2
 Weight gain 2 lbs/wk. in 2nd trimester; 1 lb./wk

in 3rd trimester.
 Mild edema in upper extremities or face.
 Severe Preeclampsia
 Bp 160/110 mmHg
 Proteinuria: 3+ to 4+ on a random sample
 Oliguria: 500 ml or less in 24 hrs.
 Pulmonary involvement: shortness of breath
 Hepatic dysfunction
 Epigastric pain due to ischemia in the pancreas

and liver
 cerebral edema
visual disturbances such as blurred vision or
seeing spots before the eyes may be reported.
severe headache
marked hyperreflexia
ankle clonus (i.e., a pulsed motion of the foot after
flexion).
 Rating the ankle clonus:
• Mild = 2 movements; Moderate = 3–5 movements
Severe = Over 6 movements
 Extreme edema
is most readily palpated over bony surfaces, such
as over the tibia on the anterior leg, the ulnar
surface of the forearm, and the cheekbones, where
the sponginess of fluid-filled tissue can be palpated
against bone.
If there is swelling or puffiness at these points to a
palpating finger but the swelling cannot be
indented with finger pressure, the edema is
described as nonpitting.
 Extreme edema
1+ = If the tissue can be indented slightly, this is
pitting edema;
2+ = moderate indentation;
3+ = deep indentation;
4+ = indentation so deep it remains after removal
of the finger is pitting edema.
 This accumulating edema will reduce a woman’s
urine output to approximately 400 to 600 ml per
24 hours.
 Eclampsia
 Seizure or coma occurs.
 Signs & symptoms of preeclampsia
Nursing Diagnosis:
1. Ineffective tissue perfusion r/t
vasoconstriction of blood vessels
2. Deficient fluid volume r/t fluid loss to
subcutaneous tissue
Nursing Diagnosis:
3. Risk for fetal injury r/t reduced placental
perfusion 2° to vasospasm
4. Social isolation r/t prescribed bed rest
Nursing Intervention:
1. Mild preeclampsia
1) Monitor Antiplatelet Therapy
❖ Because of the increased tendency for platelets to
cluster along arterial walls, a mild antiplatelet agent,
such as low-dose aspirin, may prevent or delay the
development of preeclampsia (Leaf & Connors,
2015).
1) Monitor Antiplatelet Therapy
❖ Be certain they purchase low-dose aspirin (81 mg, sold
as baby aspirin) as excessive salicylic levels can cause
maternal bleeding at the time of birth.
2) Promote Bed Rest
❖ When the body is in a recumbent position, sodium
tends to be excreted at a faster rate than during
activity.
❖ Bed rest, therefore, is the best method of aiding
increased evacuation of sodium and encouraging
diuresis of edema fluid.
2) Promote Bed Rest
❖ Be certain women know to rest in a lateral
recumbent position to avoid uterine pressure on
the vena cava and prevent supine hypotension
syndrome.
3) Promote Good Nutrition
❖ Assess if a woman has someone to help her
prepare food, or either bed rest or nutrition
may be compromised.
4) Provide emotional support
2. Severe Preeclampsia
1) Support bed rest.
• Needs hospitalization so
bed rest can be enforced
and woman can be
observed closely.
• Restrict visitors to
support people (e.g.
husband)
• Raise side rails (padded)
to prevent injury
• Room needs to be dimly
lit.
2) Monitor maternal well-being
 Monitor Bp
 Obtain blood studies as ordered.
o Obtain daily hematocrit levels as ordered
• this level will rise (>40%) if increased fluid is
leaving the bloodstream for interstitial tissue
[edema].
 Assess weight: same time, daily
 Indwelling catheter may be inserted.
3) Monitor fetal well-being
 External fetal monitor is attached
 O2 adm. may be necessary to maintain adequate
fetal oxygenation
4) Support a nutritious diet
 Moderate to high protein diet
 Moderate sodium in the diet
 IVF line should be initiated and maintained to serve
as an emergency route for drug adm.
5) Administer medications to prevent eclampsia
a) Hydralazine (Apresoline) to reduce
hypertension (5 – 10 mg/IV)
 Lowers Bp by peripheral dilatation
 Can cause tachycardia
• Assess pulse & Bp before & after adm.
• Diastolic should not be lowered below 80 –
90 mmHg or inadequate placental perfusion
could occur.
b) Magnesium Sulfate (Loading dose 4–6 g
Maintenance dose 1–2 g/hr IV)
 Muscle relaxant
 Prevent seizures
• Has CNS depressant action by blocking peripheral
neuromuscular transmission
 Reduces edema by causing a shift in fluid from
extracellular spaces into the intestine
b) Magnesium Sulfate
 Symptoms of overdose:
1) Decreased urine output
2) Depressed RR
3) Reduced consciousness
4) Decreased tendon reflexes
I.V. Infusion Pump
The patellar reflex is scored as:

0 = No response; hypoactive; abnormal
1+ = Somewhat diminished response but not
abnormal
2+ = Average response
3+ = Brisker than average but not abnormal
4+ = Hyperactive; very brisk; abnormal
c) Diazepam (Valium)
o Halt seizures
o 5–10 mg IV, administer slowly.
✓ Dose may be repeated q 5–10 minutes (up to 30
mg/hr).
o Observe for respiratory depression or hypotension
in mother and respiratory depression and hypotonia
(decreased muscle tone) in infant at birth.
d) Calcium gluconate
 Antidote for MgSO4 intoxication.
 10 ml of a 10% calcium gluconate (1 g I.V.) must
be prepared at bedside when administering MgSO4.
 Administer at 5 ml/min.
2. Eclampsia
 Preliminary signs before seizure:
1. Bp rises suddenly from additional spasm.
2. Temperature rises (39.4 - 40°C) from increased
cerebral pressure
3. Blurring of vision or severe headache from
increased cerebral edema
4. Hyperactive reflexes
5. Epigastric pain & nausea from vascular
congestion of the liver or pancreas
2. Eclampsia
 Tonic-Clonic seizures
A. Tonic seizures:
 Back arches
 Arms & legs stiffen
 Jaw closes abruptly
 Respirations stop
 Lasts for approx. 20 sec.
 Maintain patent airway

 Adm. O2 by mask
2. Eclampsia
 Assess O2 saturation via pulse oxymeter
 Apply an external fetal monitor
 Turn woman on her side to allow secretions to drain
from her mouth
B. Clonic seizure:
 Body muscles contract & relax repeatedly.
 Inhales & exhales irregularly
 Incontinence of urine & feces may occur

2. Eclampsia
B. Clonic seizure:
 Lasts up to 1 min.
 O2 therapy continued
 MgSO4 or diazepam (Valium) may be administered

IV as an emergency measure
2. Eclampsia
C. Postictal state:
o Semi-comatose
o Extremely close observation is necessary because

seizure may cause premature separation of the
placenta (abruption placenta) and labor may begin.
o Painful stimulus of contraction may initiate another
seizure.
2. Eclampsia
C. Postictal state:
o Keep woman on side lying position.
o Keep NPO
o Continue monitoring FHR and uterine

contractions.
o Check for vaginal bleeding every 15 min.
 Birth:
 Labor may be induced as soon as the woman’s
condition stabilizes, usually 12 – 24 hrs. after
seizure.
 Preferred method of delivery for eclamptic
patient is vaginal delivery
 Cesarean birth is always more hazardous for the fetus than vaginal
birth because of the association of retained lung fluid.
 C/S is preferred if fetus is in imminent danger.
 NURSING INTERVENTIONS DURING THE

POSTPARTUM PERIOD
 Postpartum preeclampsia may occur up to 10 to
14 days after birth, although it usually occurs
within 48 hours after birth.
Therefore, monitoring blood pressure in the
postpartum period and at healthcare visits and
being alert for preeclampsia, which can occur as
late as 2 weeks postbirth, are essential to detect
this residual hypertension (Takaoka, Ishii, Taguchi,
et al., 2016).
HELLP Syndrome
 HELLP syndrome is a variation of the gestational

hypertensive process named for the common
symptoms that occur:
 Hemolysis (rapid destruction of RBC) leads to anemia
 Elevated Liver enzymes lead to epigastric pain
 Low Platelets lead to abnormal bleeding/clotting (Pourrat,
Coudroy, & Pierre, 2015)
 results in a maternal mortality rate as high as 24% and an infant
mortality rate as high as 35%.
 It occurs in both primigravidas and multigravidas and is associated
with APS or the presence of antiphospholipid antibodies (Tufano,
Coppola, Maruotti, et al., 2015).
HELLP Syndrome
 Signs & Symptoms:

1. Proteinuria
2. Edema
3. increased blood pressure,
4. Nausea
5. epigastric pain
6. general malaise
7. right upper quadrant tenderness (if liver

inflammation occur).
HELLP Syndrome
 Laboratory studies reveal

 Hemolysis of red blood cells (they appear
fragmented on a peripheral blood smear)
 Thrombocytopenia (a platelet count
<100,000/mm3), and
 Elevated liver enzyme levels (effects of
hemorrhage and necrosis of the liver).
alanine aminotransferase [ALT] or SGPT
 7 to 56 units per liter of serum.
serum aspartate aminotransferase [AST])
 5 to 40 units per liter of serum
HELLP Syndrome
 Because of the low platelet count, women with the

HELLP syndrome need extremely close observation
for bleeding, in addition to the observations
necessary for preeclampsia.
 Complications
1. subcapsular liver hematoma
2. Hyponatremia
3. renal failure
4. hypoglycemia from poor liver function.
HELLP Syndrome
 Maternal Complications
1. cerebral hemorrhages
2. aspiration pneumonia
3. hypoxic encephalopathy
▪ Fetal complications
1. growth restriction
2. preterm birth (Barnhart, 2015)
HELLP Syndrome
 Therapy
1. transfusion of fresh frozen plasma or platelets
▪ to improve the platelet count.
2. intravenous glucose infusion
▪ If hypoglycemia is present
3. The infant is born as soon as feasible by either vaginal or
cesarean birth.
▪ Be alert that maternal hemorrhage may occur at birth because of
poor clotting ability.
▪ Epidural anesthesia may not be possible because of the low
platelet count and the high possibility of bleeding at the epidural
site.
GESTATIONAL CONDITION
2 GESTATIONAL CONDITION
Hyperemesis gravidarum
Extreme, persistent nausea and
vomiting during pregnancy beyond 1st
trimester that may lead to dehydration
and disturbances in nutrition
Causes:
pregnant with twins (or more)
have a hydatidiform mole
Hyperemesis gravidarum
Symptoms
Severe, persistent nausea during pregnancy, often leads to:
1. Weight loss
2. Lightheadedness or fainting
Exams and Tests
1. physical exam
2. Vital signs
❖Decreased Bp, increased PR
3. Ultrasound
Exams and Tests
The following laboratory tests will be done
to check for signs of dehydration:
1) Hematocrit (Normal for female: 36 - 44%)
2) Urine ketones
Ketones build up when the body needs to
break down fats and fatty acids to use as fuel.
This is most likely to occur when the body does
not get enough sugar or carbohydrates.
Treatment
1. Small, frequent meals and eating dry foods
such as crackers
help relieve uncomplicated nausea.
2. Increase fluid intake
Increase fluids during the times of the day
when least nauseated.
Treatment
3. Vitamin B6 (no more than 100 mg daily)
has been shown to decrease the nausea in early
pregnancy.
4. In severe cases, woman may be admitted to the
hospital, where fluids will be given through an IV.
 Isotonic solution
❖ 0.9% NaCl (NSS)
❖ Dextrose 5% in Water (D5W)
❖ Lactated Ringer’s 5% Dextrose in Water ( D5LR)
Possible Complications
1. Dehydration
2. Poor weight gain during pregnancy.
3. Social or psychological problems may
be associated with this disorder of
pregnancy
If such problems exist, they need to be
identified and addressed appropriately.
Chapter 23

Experiencing a Complication of
Labor or Birth
POWER, PASSAGE, PASSENGER

OBJECTIVES
1. Describe the common deviations in the

power (i.e., force of labor), the passage,
or the passenger that can cause
complications during labor or birth.
2. Assess a woman in labor and during birth
for deviations from the usual labor
process.
3. Formulate nursing diagnoses related to
deviations in labor and birth.

OBJECTIVES
4. Identify expected outcomes associated with

deviations from usual labor and birth across
differing healthcare settings.
5. Using the nursing process, plan nursing
care
6. Implement nursing care related to
complications of labor or birth, such as
preparing the family for a cesarean birth.

OBJECTIVES
7. Evaluate expected outcomes for

achievement and effectiveness of care.
8. Integrate knowledge of deviations from
normal labor and birth with the interplay of
nursing process.

INTRODUCTION
❖Dystocia—can arise from any of the four

main components of the labor process:
a) the power, or the force that propels the
fetus (uterine contractions);
b) the passenger (the fetus);
c) the passageway (the birth canal); or
d) the psyche (the woman’s and family’s
perception of the event) (Neal, Ryan,
Lowe, et al., 2015).

FOR A WOMAN WITH A LABOR OR BIRTH
COMPLICATION
❖Nursing Process Overview

❖ASSESSMENT
o conscientious assessment of labor progress and
to detect deviations of the fetal and uterine
changes.

COMPLICATION

❖NURSING DIAGNOSIS
❖Some examples might include:
1. Pain related to induction and labor procedures
2. Fear related to uncertainty of pregnancy
outcome
3. Anxiety related to medical procedures and
apparatus necessary to ensure health of woman
and fetus

COMPLICATION

4. Fatigue related to loss of glucose stores through
work and duration of labor
5. Ineffective coping related to lack of knowledge
or lack of preparation for labor
6. Fatigue related to prolonged labor

COMPLICATION

7. Risk for ineffective tissue perfusion related to
excessive loss of blood with complication of
labor
8. Risk for injury (maternal or fetal) related to
effect on woman and fetus of a labor
complication and treatment required

COMPLICATION

9. Risk for injury (maternal or fetal) related to
labor involving a multiple gestation pregnancy
10.Anticipatory grieving related to nonviable
monitoring pattern of fetus

COMPLICATION
❖OUTCOME IDENTIFICATION AND PLANNING
❖Encouraging a couple to clarify their
priorities when a complication occurs is
helpful.
❖For example,
o If fetal bradycardia occurs
▪ cesarean birth may become necessary.
o primary goal is really to have a healthy baby.

COMPLICATION
❖IMPLEMENTATION
o If a woman develops a complication of labor or
birth, actions to increase the fetal heart rate
(FHR) or to strengthen uterine contractions are
a priority and possibly an emergency.
o Interventions must be planned and performed
efficiently and effectively, based on the
individual circumstances.

COMPLICATION
❖OUTCOME EVALUATION
❖An evaluation of proposed outcomes may
reveal unhappiness because not every
woman who experiences a deviation from
the normal in labor and birth will be able to
give birth to a healthy child.
❖Some deviations will be too great;
❖Some interventions will not be maximally
effective because of individual
circumstances.
COMPLICATION
❖Some infants will die;
❖a few women may be left unable to bear
future children.
❖An evaluation may lead to a new analysis
that the couple’s chief need at that point is
to grieve for the child or for a lifestyle that
can no longer be theirs.

COMPLICATION
❖If the outcome is more positive, evaluate the
couple for signs that they are able to begin
interacting with their child after their
harrowing experience.
❖Examples of outcome achievement might
include:
1. Patient voices confidence she can cope with the
fear she feels about her fetus’s welfare.

COMPLICATION
❖Examples of outcome achievement might
include:
2. Patient demonstrates adequate energy during
course of labor to maintain effective breathing
patterns.
3. Patient’s blood pressure does not drop below
90/50 mmHg despite excessive blood loss with
delivery of the placenta.
4. Patient begins positive grieving behaviors in
response to loss of newborn.
COMPLICATIONS WITH
THE POWER
(THE FORCE OF LABOR)
Dysfunctional labor

Dysfunctional Labor
❖Dysfunction can occur at any point in labor,

but it is generally classified as:
1. primary (i.e., occurring at the onset of labor) or
2. secondary (i.e., occurring later in labor).

INEFFECTIVE UTERINE FORCE
❖Uterine contractions are the basic force that
moves the fetus through the birth canal.
❖They occur because of the interplay of the
contractile enzyme adenosine triphosphate
and the influence of major electrolytes such
as calcium, sodium, and potassium, specific
contractile proteins (actin and myosin),
epinephrine and norepinephrine, oxytocin (a
posterior pituitary hormone), estrogen,
progesterone, and prostaglandins.

21
Problems with the Powers

• HYPERTONIC CONTRACTIONS:
• Primary dysfunctional labor
• Hypertonic uterine contractions are marked by an
increase in resting tone to >15 mmHg (normal
resting tone is 5-10 mmHg)
• A resting pressure > 20 mmHg causes decreased
uterine perfusion
• Signs:
1. Painful & frequent contractions
2. Contractions are ineffective in causing cervical
dilation & effacement
3. Contractions occur in latent stage (cervical
dilation < 4 cm)
4. Uncoordinated contractions
22

• HYPERTONIC CONTRACTIONS:
• Primary dysfunctional labor
• Signs (cont’d)
5. Force of contraction may be in the midsection
of the uterus rather than in the fundus.
❖Uterus unable to apply downward pressure to push
the presenting part against the cervix.
6. Uterus may not relax completely between
contractions.
23
24

HYPERTONIC CONTRACTIONS
• Causes:
• More than one uterine pacemaker is stimulating
contractions or because the muscle fibers of the
myometrium do not repolarize or relax after a
contraction, thereby “wiping it clean” to accept a
new pacemaker stimulus.
oThey tend to be more painful than usual because
the myometrium becomes tender from constant
lack of relaxation and the anoxia of uterine cells
that results.
25

• Occurs in the latent phase of labour, with an
increase in the frequency of contractions and a
decrease in their intensity.
• Contractions are extremely painful because of

uterine muscle cell anoxia but are ineffective in
dilating and effacing the cervix, which leads to
maternal exhaustion.
• Contraction may interfere with uteroplacental

exchange and lead to fetal distress and even death.
• Contractions may be uncoordinated and involve

only portions of the uterus.
26

• Effects on woman:
1. Intense pain
2. Loss of control related to the intensity of pain
and lack of progress.
• although contractions are strong, they are
ineffective and are not achieving cervical
dilatation.
3. Exhaustion.
4. Dehydration.
27

• Potential fetal effect:
• Fetal asphyxia with meconium aspiration, and
death.
➢Uncoordinated contractions can occur so closely
together that they can interfere with the blood
supply to the placenta.
28

• Effects on woman:
1. Intense pain
2. Loss of control related to the intensity of pain and
lack of progress.
3. Exhaustion.
4. Dehydration.
• Management:
1. Warm bath or shower
2. Administration of analgesics:
1) Morphine
2) Meperidine (Demerol)
3) Nalbuphine (Nubain)
29

HYPOTONIC UTERINE DYSFUNCTION
• Secondary uterine inertia
• Signs:
1. Woman initially makes normal progress into the
active stage of labor, then
2. Contractions become weak & inefficient, or stop
altogether.
3. Uterus is easily indented, even at the peak of
contraction
4. IUP is insufficient (usually < 25 mmHg; normal
is 25-100 mmHg) for progress of cervical
effacement and dilation.
30

• Common Causes of Dysfunctional Labor
1. Primigravida status
2. Pelvic bone contraction that has narrowed the
pelvic diameter so a fetus cannot pass
(cephalopelvic disproportion [CPD]) such as
could occur in a woman with rickets
3. Posterior rather than anterior fetal position or
extension rather than flexion of the fetal head
4. Failure of the uterine muscle to contract properly
31

• Common Causes of Dysfunctional Labor
5. Overdistention of the uterus, as with a multiple
pregnancy, polyhydramnios, or an excessively
oversized fetus
6. A nonripe cervix
7. Presence of a full rectum or urinary bladder that
impedes fetal descent
8. A woman becoming exhausted from labor
9. Inappropriate use of analgesia (excessive or too
early administration)
32

• Management:
1. Ultrasound
2. Monitor FHR & pattern
3. Assess characteristics of amniotic fluid if
membranes have ruptured
33

• Management (cont’d):
4. Assess maternal well-being
5. If findings are normal:
▪ Encourage ambulation
▪ Hydrotherapy
▪ Enema
▪ Rupture of membrane
▪ Nipple stimulation
▪ Oxytocin infusion
Assessment of a Family Experiencing a
Complication of Labor or Birth #3

35
DYSFUNCTIONAL LABOR AND

ASSOCIATED STAGES OF LABOR
❖Dysfunction at the First Stage of Labor
involves
1. A prolonged latent phase,
2. Protracted active phase
3. Prolonged deceleration phase, and
4. Secondary arrest of dilatation.
36
Prolonged Latent Phase

• When contractions become ineffective
during the first stage of labor, a prolonged
latent phase can develop.
• latent phase that lasts longer than 20
hours in a nullipara or 14 hours in a
multipara.
• This may occur if the cervix is not “ripe” at the
beginning of labor.
• It may occur if there is excessive use of an
analgesic early in labor.
• With a prolonged latent phase, the uterus tends
to be in a hypertonic state.
37

• Relaxation between contractions is inadequate,
and the contractions are only mild (less than 15
mmHg on a monitor printout) and, therefore,
ineffective.
• One segment of the uterus may be contracting
with more force than another segment.
38
TONUS (Resting tone)

• TONUS : intra uterine pressure in between the contractions.
• During Quiescent (inactive) stage- 2-3mm Hg
• During first stage of labour 8-10mmHg.
❖Uterine Tone
• The lowest intrauterine pressure between contractions is
called resting tone
• Normal resting tone is 5-10 mmHg;
• during labor resting tone may rise to 10-15 mmHg
• Pressure during contractions rises to ~25-100 mmHg (varies
with stage)
• A resting pressure above 20 mmHg causes decreased
uterine perfusion
39

• Management of a prolonged latent
phase in labor that has been caused by
hypertonic contractions involves:
1. helping the uterus to rest
2. providing adequate fluid for hydration
3. pain relief with a drug such as morphine
sulfate.
4. Changing the linen and the woman’s
gown
40

• Management of a prolonged latent
phase in labor that has been caused by
hypertonic contractions involves:
5. Darkening room lights
6. decreasing noise and stimulation
• These measures usually combine to allow labor to become
effective and begin to progress. If it does not, …
7. a cesarean birth or amniotomy (i.e., artificial
rupture of membranes) and oxytocin infusion to
assist labor may be necessary.
41
Protracted Active Phase

• A protracted active phase is usually associated
with fetal malposition or cephalopelvic
disproportion (CPD) (the diameter of the fetal
head is larger than the woman’s pelvic diameters),
although it may reflect ineffective myometrial
activity.
• This phase is prolonged if cervical dilatation does
not occur at a rate of at least 1.2 cm/hr in a
nullipara or 1.5 cm/hr in a multipara, or if the
active phase lasts longer than 12 hours in a
primigravida or 6 hours in a multigravida
• If the cause of the delay in dilatation is fetal
malposition or CPD, cesarean birth may be
necessary.
42
Protracted Active Phase

• Dysfunctional labor during the dilatational
division of labor tends to be hypotonic in
contrast to the hypertonic action at the
beginning of labor.
• After an ultrasound to show CPD is not
present, oxytocin may be prescribed to
augment labor.
43
Prolonged Deceleration Phase

• A deceleration phase has become
prolonged when it extends beyond 3 hours
in a nullipara or 1 hour in a multipara.
• A prolonged deceleration phase most often
results from abnormal fetal head position.
• A cesarean birth is frequently required.
44
Secondary Arrest of Dilatation

• A secondary arrest of dilatation has
occurred if there is no progress in cervical
dilatation for longer than 2 hours.
• A cesarean birth may be necessary
45
Dysfunction at the Second Stage

of Labor
• Dysfunction that occurs with the second
stage of labor involves:
1. prolonged descent and
2. arrest of descent.
46
Prolonged Descent
• Prolonged descent of the fetus occurs if the rate
of descent is less than 1.0 cm/hr in a nullipara or
2.0 cm/hr in a multipara.
• It can be suspected if the second stage lasts over
2 hours in a multipara (Zheng, 2012).
• With both a prolonged active phase of dilatation
and prolonged descent, contractions have been
of good quality and duration, effacement and
beginning dilatation have occurred, but then the
contractions become infrequent and of poor
quality, and dilatation stops.
47
Prolonged Descent
• If everything else is within normal limits except for
the suddenly faulty contractions and CPD and
poor fetal presentation have been ruled out by
ultrasound,
• then rest and fluid intake, as advocated for hypertonic
contractions, also applies.
48
Prolonged Descent
• If the membranes have not ruptured,
1. rupturing them at this point may be helpful.
2. Intravenous (IV) oxytocin may be used to induce the
uterus to contract effectively (see later discussion on
induction of labor by oxytocin).
3. A semi-Fowler’s position, squatting, kneeling, or more
effective pushing may speed descent.
49
Arrest of Descent
• Arrest of descent results when no descent
has occurred for 2 hours in a nullipara or 1
hour in a multipara.
• occurs when expected descent of the fetus does
not begin or engagement or movement beyond 0
station does not occur.
• Cause: CPD.
• Management:
1. Cesarean birth usually is necessary.
2. If there is no contraindication to vaginal birth,
oxytocin may be used to assist labor
50

PRECIPITOUS LABOR
▪ Labor lasts < 3 hrs. from the onset of
contractions to the time of birth.
▪ during the active phase of dilatation, the rate
is greater than 5 cm/hr (1 cm every 12
minutes) in a nullipara or 10 cm/hr (1 cm every
6 minutes) in a multipara.
May result from:
▪ Hypertonic uterine contractions that are
tetanic in intensity.
51

PRECIPITOUS LABOR
• Maternal Complications:
1. Uterine rupture
2. Laceration of birth canal
3. Amniotic fluid embolism
4. Postpartum hemorrhage
52

PRECIPITOUS LABOR
• Fetal Complications:
1. Hypoxia
2. Intracranial hemorhage r/t rapid birth
53
Uterine Prolapse
• Uterine prolapse is falling or sliding of the
womb (uterus) from its normal position into
the vaginal area.
• Causes:
• Muscles, ligaments, and other structures hold the
uterus in the pelvis.
❖If these muscles and structures are weak, the uterus
drops into the vaginal canal (This is called prolapse).
• This condition is more common in women who
have had one or more vaginal births.
54
Uterine Prolapse
• Other things that can cause or lead to
uterine prolapse include:
1. Normal aging
2. Lack of estrogen after menopause
3. Anything that puts pressure on the
pelvic muscles, including chronic cough
and obesity
4. Pelvic tumor (rare)
❖Long-term constipation and the pushing
associated with it can make this condition worse.
55
Uterine Prolapse
Symptoms
1. Feeling like you are sitting on a small ball
2. Difficult or painful sexual intercourse
3. Frequent urination or a sudden urge to empty
the bladder
4. Low backache
5. Uterus and cervix that stick out through the
vaginal opening
6. Repeated bladder infections
7. Feeling of heaviness or pulling in the pelvis
8. Vaginal bleeding
9. Increased vaginal discharge
56
Uterine Prolapse
• Exams and Tests
• A pelvic examination is done while client is
bearing down, as if she was trying to push out
a baby.
❖This shows the doctor how far the uterus has
dropped.
• Mild uterine prolapse is when:
❖the cervix drops into the lower part of the vagina.
• Uterine prolapse is moderate when:
❖the cervix drops out of the vaginal opening.
57
Uterine Prolapse
• Mild uterine prolapse :
❖the cervix drops into the lower part of the vagina.
• Moderate uterine prolapse:
❖the cervix drops out of the vaginal opening.
• Complete uterine prolapse:
❖Cervix and the body of the uterus protrude
through the vagina, and the vagina is inverted.
58
UTERINE PROLAPSE
59
Uterine Prolapse
• Exams and Tests
❖The pelvic exam may also show that the bladder
and front wall of the vagina (cystocele), or rectum
and back wall of the vagina (rectocele) are
entering the vagina.
❖The urethra and bladder may also be lower in the

pelvis than usual.
60
Uterine Prolapse
• Treatment
1. LIFESTYLE CHANGES
1) Weight loss is recommended in obese women
with uterine prolapse.
2) Heavy lifting or straining should be avoided,
because they can worsen symptoms.
3) Coughing can also make symptoms worse.
❖If you a chronic cough, ask your doctor how to prevent
or treat it.
❖If you smoke, try to quit. Smoking can cause a chronic
cough.
61
Uterine Prolapse
• Treatment
2. VAGINAL PESSARY
❖This device hold the uterus in place. It may be
temporary or permanent.
❖Vaginal pessaries are fitted for each individual
woman.
❖Some are similar to a diaphragm used for birth
control.
❖Pessaries must be cleaned from time to time,
sometimes by the doctor or nurse.
62
Uterine Prolapse
Treatment
2. VAGINAL PESSARY
• Side effects of pessaries include:
1) Foul smelling discharge from the vagina
2) Irritation of the lining of the vagina
3) Ulcers in the vagina
4) Problems with normal sexual intercourse and
penetration
63
Uterine Prolapse
Treatment
3. SURGERY
• The specific type of surgery depends on:
1) Degree of prolapse
2) Desire for future pregnancies
3) Other medical conditions
4) The women's desire to retain vaginal function
5) The woman's age and general health
64
Uterine Prolapse
Treatment
3. SURGERY
1) sacrospinous fixation
• This procedure involves using nearby ligaments to
support the uterus.
2) vaginal hysterectomy
• is used to correct uterine prolapse.
• Any sagging of the vaginal walls, urethra, bladder, or
rectum can be surgically corrected at the same time.
65
Uterine Prolapse
Prevention
1. Kegel exercises
2. Estrogen therapy, either vaginal or oral, in
postmenopausal women
3. Weight loss
4. Avoid heavy lifting.
PROBLEMS WITH THE
PASSENGER
66
PROLAPSE OF THE UMBILICAL
CORD
• Loop of the umbilical cord slips down

in front of the presenting fetal part.
• Tends to occur with the following
conditions:
1.Premature rupture of membranes
2.Fetal presentation other than cephalic
3.Placenta previa
67
PROLAPSE OF THE UMBILICAL
CORD
• Tends to occur with the following

conditions:
4. Intrauterine tumors preventing the
presenting part from engaging.
5. Small fetus
6. CPD preventing firm engagement
7. Hydramnios
8. Multiple gestation.
68
Prolapse of umbilical cord
69
Assessment:
1.Cord may be felt as presenting part on

initial vaginal exam.
2.Sonogram
3.Cord may be visible at the vulva.
4.Variable deceleration FHR pattern
70
Therapeutic Management:
1. Aimed toward relieving pressure on the cord.

2. Place a gloved hand on the vagina and
manually elevating the fetal head off the cord.
3. Place woman in a knee-chest or Trendelenburg
position
4. Administer O2 at 10 L/min. by face mask.
5. Tocolytic agent is administered
- To reduce uterine activity & pressure on the
fetus.
71
6. Do not attempt to push any exposed cord back
into the vagina.
7. Cover any exposed portion with a sterile saline
compress to prevent drying.
8. If cervix is fully dilated, the physician may
choose to deliver the infant quickly (by forceps) to
prevent fetal anoxia.
9.If dilatation is incomplete, the birth method is
upward pressure on the presenting part in the
woman’s vagina, to keep pressure off the cord, and
baby can be born by C/S. 72
PROBLEMS WITH POSITION,
PRESENTATION, or SIZE
73
Occipitoposterior Position
(ROP or LOP)
- In these positions, during internal

rotation, the fetal head must rotate
through an arc of 135°
74
Assessment:
1.Android, anthropoid, or contracted pelves

2.Prolonged active phase, arrested descent
3.Fetal heart sounds heard best at the lateral
sides of the abdomen.
4.Position confirmed by sonogram
5.Prolonged labor because the arc of rotation is
greater.
6.Woman experience pressure & pain in her
lower back due to sacral nerve compression.
75
1.Counterpressure on the sacrum

(e.g. back rub)
▪ Relieve a portion of pain
2.Applying heat or cold
3.Let woman void every 2 hrs. to keep bladder
empty
▪ Full bladder could further empede descent of the
fetus
4.During long labor, IV glucose solution to
replace glucose stores used for energy.
76
5. Fetus may be born by C/S if:

▪ Contractions are ineffective
▪ Fetus larger than average
▪ Fetus not in good flexion
▪ Fetal head may arrest in the transverse
position.
▪ Persistent occipitoposterior position
77
Breech Presentation
- Types:
1.Complete
2.Frank
3.Footling
- Complications:
1.Anoxia from prolapsed cord
2.Traumatic injury to the after-coming head
(possibility of intracranial haemorrhage or
anoxia)
78
Breech Presentation
- Complications:
3. Fracture of the spine or arm
4. Dysfunctional labor
5. Early rupture of the membranes
because of the poor fit of the presenting
part.
6. Meconium aspiration
79
Breech Presentation
- Assessment:
1.FHT heard high in the abdomen
2.Leopold’s, vaginal exam, or ultrasound
exam reveals the presentation.
3.Monitor FHR and uterine contractions
80
Breech Presentation
- Birth technique:
1.Vaginal delivery
▪ Birth of head is the most hazardous because
umbilicus precedes the head.
▪ Head compresses the cord
▪ 2nd danger is intracranial hemorrhage
2.Planned C/S – usual method
▪ secure consent
▪ NPO
81
82
Face Presentation
• Asynclitism
o Fetal head presenting at different angle.
• Face presentation
o Fetus is in poor flexion
o Back is arched
o Neck extended
o Complete extension
o Presenting the occipitomental diameter (13.5
cm)
83
Face Presentation
• Assessment:
1.Woman with contracted pelvis
2.Placenta previa
3.Relaxed uterus of a multipara
4.Prematurity, hydramnios, or fetal
malformation
5.A sonogram is done to confirm
84
Face Presentation
• Therapeutic management:
1.Observe infant for patent airway
▪ May have a great deal of facial edema
and may be purple from ecchymotic
bruising.
2.Gavage feeding
▪ Lip edema is so severe that the infant
is unable to suck for a day or 2.
3.Delivered by C/S 85
Transverse Lie
- Occurs in women with:

1.Women with pendulous abdomen
2.Uterine masses that obstructs the lower uterine
segment
3.Contracted pelvic brim
4.Congenital abnormalities of the uterus
5.Hydramnios
6.Infants with hydrocephalus
7.Prematurity
8.Multiple gestation
86
Transverse Lie
- Assessment:
1.Uterus is more horizontal than vertical
2.Confirmed by Leopold’s maneuver
3.Ultrasound
- Therapeutic management:
1.C/S
87
Oversized Fetus
(Macrosomia)
 Fetus who weighs more than 4,000 –

4,500 g (9 – 10 lbs.)
 Risk factors:
1. Diabetic or develop gestational
diabetes
2. Multiparity
88
Oversized Fetus
(Macrosomia)
 Complications:
1. Uterine dysfunction during labor/birth
• Overstretching of the fibers of the myometrium
2. Wide shoulders cause fetal pelvic disproportion
3. Uterine rupture from obstruction
4. Fractured clavicle of the baby because of
shoulder dystocia
5. Woman has an increased risk of hemorrhage
• Overdistended uterus may not contract
89
Problems With the Passage
A. INLET CONTRACTION
❖In primigravidas, the fetal head normally
engages between weeks 36 and 38 of
pregnancy.
❖If this occurs any time before labor begins, it
is proof the pelvic inlet is adequate.
o If engagement does not occur in a primigravida,
then either a fetal abnormality (larger than usual
head) or a pelvic abnormality (smaller than
usual pelvis) should be suspected.

Interventions for Complications of Labor
or Birth According to the Passage #1
❖Problems With the Passage

A. INLET CONTRACTION
o If CPD exists, because the fetus may not engage
but instead remains “floating,” the possibility of
cord prolapse can lead to a secondary concern.

❖Problems With the Passage

B. OUTLET CONTRACTION
❖A narrowing of the transverse diameter, the
distance between the ischial tuberosities at
the outlet, to less than 11 cm.
o This measurement is made by sonogram during
pregnancy but can also easily be made manually
at a prenatal visit or at the beginning of labor.

TRIAL LABOR
❖If a woman has a borderline (just adequate)

inlet measurement and the fetal lie and
position are good, her primary care provider
may allow her a “trial” labor to determine
whether labor will progress normally.
❖The trial labor continues as long as descent
of the presenting part and dilatation of the
cervix continue to occur.

TRIAL LABOR
❖Therapeutic Management::
1. Monitor fetal heart sounds and uterine
contractions frequently.
2. Urge the woman to void every 2 hours so her
urinary bladder is as empty as possible, allowing
the fetal head to use all the space available.
❖ If, after a definite period (6 to 12 hours),

adequate progress in labor cannot be
documented, or if at any time fetal distress
occurs, the trial labor will be discontinued
and the woman will be scheduled for a
cesarean birth.
TRIAL LABOR
❖If the trial labor fails, cesarean birth is

scheduled.
o it is the method of choice to allow them to
achieve their goal of a healthy mother and
healthy child.

EXTERNAL CEPHALIC VERSION
❖is the turning of a fetus from a breech to a
cephalic position before birth.
❖It may be done as early as 34 to 35 weeks,
although the usual time is by 37 to 38 weeks
of pregnancy (Velzel, de Hundt, Mulder, et
al., 2015).
❖Procedure:
1. FHR and possibly ultrasound are recorded
continuously.
2. A tocolytic agent may be administered to help
relax the uterus.
❖Procedure:
3. The breech and vertex of the fetus are located
and grasped transabdominally by the examiner’s
hands on the woman’s abdomen.
4. Gentle pressure is then exerted to rotate the
fetus in a forward direction to a cephalic lie.

❖ Contraindications:
1. multiple gestation
2. severe oligohydramnios
3. small pelvic diameters
4. a cord that wraps around the fetal neck
5. unexplained third-trimester bleeding, which
might be a placenta previa.
❖ Women who are Rh negative should

receive Rh immunoglobulin after the
procedure in case minimal bleeding occurs.
FORCEPS BIRTH
❖Obstetrical forceps are steel instruments
constructed of two blades that slide
together at their shaft to form a handle.

FORCEPS BIRTH
❖Obstetrical forceps are steel instruments
constructed of two blades that slide
together at their shaft to form a handle.
❖Procedure:
1. One blade is slipped into the woman’s vagina
next to the fetal head, and the other is slipped
into place on the other side of the head.
2. The shafts of the instrument are brought
together in the midline to form the handle.
3. The primary care provider then applies
pressure on the handle to manually extract the
fetus from the birth canal.
FORCEPS BIRTH
❖ Today, the technique is rarely used (in only
about 4% to 8% of births) because it can
lead to rectal sphincter tears in the woman,
which can lead to dyspareunia, anal
incontinence, or increased urinary stress
incontinence (Halscott, Reddy, Landy, et al.,
2015).

❖Although no longer used routinely, forceps
may be necessary with any of the following
conditions:
1. A woman is unable to push with contractions in
the pelvic division of labor such as might
happen with a woman who received regional
anesthesia or who has a spinal cord injury.
2. Cessation of descent in the second stage of
labor occurs.
3. A fetus is in an abnormal position.
4. A fetus is in distress from a complication such
as a prolapsed cord.
❖Before forceps are applied:
1. Record the FHR before forceps application.
2. Membranes must be ruptured.
3. CPD must not be present.
4. The cervix must be fully dilated.
5. The woman’s bladder must be empty.

❖After forceps are applied:
1. Record the FHR after forceps application.
2. The woman’s cervix needs to be carefully
assessed to be certain no lacerations have
occurred.
3. Record the time and amount of the first voiding
to rule out bladder injury.
4. Assess the newborn to be certain no facial palsy
exists from pressure.
❖ A forceps birth may leave a transient

erythematous mark on the newborn’s cheek
❖ This mark will fade in 1 to 2 days with no
long-term effects.
VACUUM EXTRACTION
❖Procedure:
1. With the fetal head at the perineum, a soft,
disk-shaped cup is pressed against the fetal
scalp and over the posterior fontanelle.
2. When vacuum pressure is applied, air beneath
the cup is suctioned out and the cup then
adheres so tightly to the fetal scalp that traction
on the vacuum cord leading to the cup extracts
the fetus.

VACUUM EXTRACTION
❖Vacuum extraction advantages over

forceps birth:
o in that little anesthesia is necessary, thus
leaving the fetus with less respiratory depression
at birth.
❖One disadvantage over natural birth is

that more perineal lacerations may occur
(Steinhauer, 2015).
❖Its major disadvantage is that it causes a
marked caput on the newborn head that may
be noticeable as long as 7 days after birth.
VACUUM EXTRACTION
❖Tentorial tears from extreme pressure also
have occurred.
❖A woman may need reassurance that the
caput swelling is harmless for her infant and
will decrease rapidly.
❖Vacuum extraction should not be used as a
method of birth if fetal scalp blood sampling
was used because the suction pressure can
cause severe bleeding at the sampling site.
❖Vacuum extraction is not advantageous for
preterm infants because of the softness of
the preterm skull.


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Chapter 21

Nursing Care of a Family

Nursing Diagnoses and Related

Nursing Diagnoses and Related

Nursing Diagnoses and Related

Nursing Diagnoses and Related

Nursing Diagnoses and Related

Nursing Diagnoses and Related

1st Trimester Bleeding

1st Trimester Bleeding

1st Trimester Bleeding

Imminent/ (Inevitable) Miscarriage

➢Entire products of conception

➢Bleeding usually slows within 2 hrs. and then

2nd Trimester Bleeding

2nd Trimester Bleeding

2nd Trimester Bleeding

2nd Trimester Bleeding

hCG levels in weeks from LMP (gestational

Premature Cervical Dilatation

Premature Cervical Dilatation

Premature Cervical Dilatation

Premature Cervical Dilatation

Premature Cervical Dilatation

Premature Cervical Dilatation

Premature Cervical Dilatation

Premature Cervical Dilatation

3rd Trimester Bleeding

3rd Trimester Bleeding

3rd Trimester Bleeding

3rd Trimester Bleeding

6. Obtain baseline V/S.

a lifelong bleeding disorder in which

Nursing Care of a Family

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

❖It is associated with:

❖Common symptoms of early preterm

❖Common symptoms of early preterm

Copyright © 2018 Wolters Kluwer · All Rights Reserved

1. A woman who is in preterm labor is usually

o This is thought to be effective because if a

4. Vaginal and cervical cultures and a clean-

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

➢ A condition in which vasospasm occurs during

➢ With gestational hypertension, this reduced

➢ Beginning about the 20th week of pregnancy,

➢Ischemia in the pancreas

➢If retinal hemorrhage occurs

➢Vasospasm in the kidney

➢ If increased kidney tubular reabsorption occurs,

➢Thrombocytopenia or a lowered platelet

Vascular effects Kidney effects Interstitial effects

Increased Bp Decreased urine

 Bp returns to normal after birth.

 Weight gain 2 lbs/wk. in 2nd trimester; 1 lb./wk

 Oliguria: 500 ml or less in 24 hrs.

 Pulmonary involvement: shortness of breath

 Epigastric pain due to ischemia in the pancreas

The patellar reflex is scored as: