INTRAPARTAL COMPLICATIONS Complications:

 maternal (exhaustion, excessive pain, uterine rupture); fetal

*Dystocia = broad term for abnormal/difficult labor and delivery
(fetal distress)
I. Problems with the Force of Labor/Power Treatment:
A. Ineffective uterine force  sedation and rest

 presence of abnormalities in the basic force that moves the Nursing Management
fetus through the birth canal or abnormal uterine  assist client with relaxation
contractions
 evaluate client’s complaint of pain in relation to the quality
* uterine inertia = sluggishness of contractions of her contractions via uterine and external electronic fetal
monitor for at least 15 minutes interval
Causes
 encourage client rest
 in appropriate use of analgesics, pelvic bone contraction,  administer analgesics and sedatives as prescribed
poor fetal position, over distention (due to multiparity,  provide comfort measures (dim lights and decrease noise
multiple pregnancy, polyhydramnios, excessively large and stimulation)
babies)  anticipate CS birth if there is deceleration of FHR,
abnormally long first stage of labor and lack of progress
2 TYPES with pushing.
1. Primary uterine dysfunction (Hypertonic contractions)  provide support with client and partner.

- Frequent, strong, painful contractions occurring 2-3 minutes apart,

lasting 60 seconds or more
2. Secondary Uterine Dysfunction (Hypotonic contractions)
- Occur more frequently in latent phase of labor
- Slow, infrequent, weak contractions occurring more than 3 minutes
Causes: apart and lasting less than 40 seconds

 Cephalopelvic disproportion or abnormal fetal position - Most apt to occur during active phase of labor, when analgesia has
been administered too early (before 3-4cm dilation), or bowl/bladder
Tetanic contractions: distention which prevents descent
 Uterus stays contracted for more than 90 seconds; often due Causes:
to misuse of oxytocin or mechanical obstruction.
 uterine overdistention due to large fetus/twins, polyhydramnios
and grand multiparit.
Complications:
  maternal (intrauterine infection, postpartum hemorrhage,  dilation rate > 5 cm/hr (nullipara),
fatigue, exhaustion, and dehydration), fetal (fetal distress, dilation rate > 10cm/hr (multipara)`
infection)
Nursing management:
Treatment:
 monitor uterine contractions and FHR using electronic fetal
 stimulation of labor by oxytocin administration or amniotomy monitoring
 administration of tocolytic agents as prescribed
Nursing management:
 use a labor graph to chart progress especially during active
 anticipate ultrasound to rule out cephalopelvic disproportion phase of dilation
(CPD  inform multiparous client at 28th week AOG that her labor
 prepare client for infusion of oxytocin for labor induction and might be shorter than previous one
augmentation.  prepare DR for rapid delivery of grand multipara or client with
 assist with artificial rupture of membranes (amniotomy) to history of precipitate labor
speed labor
 after delivery – palpate uterus after every 15 minutes and
assess lochia to ensure uterine contractility. C. Uterine Rupture
- a tearing or splitting of the uterine wall during labor
B. Precipitate Labor
- a result of thinned or weakened area that cannot withstand the starin
- a very rapid, intense labor of 2-4 hours duration and force of uterine contractions
- labor and delivery that is completed in less than 3 hours after the - occurs in about 1 in 1500th
onset of true labor pains
causes / risk factors:
Causes
 multiparity, unwise use of oxytocins, large fetus, weakened/old
- multiparity, following oxytocin administration or amniotomy.
CS section scar, overdistention, faulty presentation, prolonged
Complications: labor, trauma due to forceps delivery or traction, multiple
gestation
 maternal (hemorrhage due to sudden release of intraabdominal
pressure leading to shock/abruption placenta, trauma to soft Types:
tissues of the cervix or vagina or perineum leading to lacerations,
 complete rupture (going through endometrium, myometrium,
loss of self-control), fetal (fetal hypoxia, subdural hemorrhage due
peritoneum), incomplete rupture (leaving peritoneum intact)
to sudden release of pressure on head)
Signs and Symptoms:
Assessment findings
 patholic retraction ring (an indentation across the abdomen
over the uterus; sign of impending rupture)
  sudden severe pain during a strong contraction D: Uterine Inversion
 complaints of a “tearing sensation”
 Fundus is forced through cervix so that the uterus is turned
 stoppage of uterine contractions (incomplete rupture)
inside out
 falling FHR
 change in abdominal contour with 2 visibly distinct swellings  May occur after birth (if there is a traction to umbilical cord or
(the retracted uterus and extrauterine fetus) if there is pressure to uterine fundus when relaxed)
 shock (rapid weak pulse, falling BP, cold clammy skin,  Occurs in various degrees, inverted fundus may lie within the
dilation of nostrils from air hunger) uterine cavity or protrude from the vagina in total inversion
 fetal and maternal distress
Causes:
Treatment:
 short umbilical cord, insertion of placenta at the fundus (as
 hysteroctomy rapid expulsion of fetus causes pulling down of fundus),
Nursing Management: pulling out of umbilical cord, strong fundal push, attempt to
deliver placenta prior to signs of placental separation,
 perform electronic fetal monitoring. trying to express placenta when uterus is relaxed
 administer fluid replacement (IV, BT) and IV oxytocin as
prescribed. Treatment:
 prepare for immediate laparotomy.  hysterectomy due to severe hemorrhage
 obtain preoperative laboratory studies (CBC, blood typing)
 administer prophylactic antibiotics as ordered. Nursing Management
 offer support to client and support persons and inform  never attempt to replace the inversion
immediately about fetal outcome or extent of surgery and  never attempt to remove placenta if there are no signs of
woman’s safety. placental separation
 allow woman and significant others time to grieve about  start IV line as prescribed
possible loss of baby and fertility.  administer oxygen mask as ordered
 assess vital signs
 administer general anesthetic; tocolytic drugs IV
 monitor client during manual replacement of fundus by MD
 administer oxytocin after manual fundal replacement as
ordered
 administer prophylactic antibiotic as prescribed
E: Uterine Prolapse > Feeling of heaviness or pulling in the pelvis

 is the downward displacement of the uterus into the vaginal > Vaginal bleeding
canal or a gradually descends of the uterus in the axis of the > Increased vaginal discharge
vagina taking the vaginal wall with it
Usually prolapse is rated by degress;
First-degree Prolapse – the cervix rest in the lowest part of the vagina Treatment

Second-degree Prolapse – the cervix is at vaginal opening Surgery

Third-degree prolapse – the uterus protrudes through the introitus.  use to treat genital genital prolapse.
Vaginal pessary
Etiology  This device fits inside in vagina to hold and uterus in place.
> Stretching of muscles and fibrous tissue.
Eg. Pregnancy and childbirth Collaborative Care
> Increased intra-abdominal pressure as a result of chronic coughing, Preventive measures:
lifting of heavy objects and obesity, place pressure on the pelvic floor.
 *Early visits to HC provider = early detection
> A constitutional predisposition to stretching of the ligaments as a
response presumably to years in the erect position  *Teach Kegel’s exercises during PP period
> Menopause and ageing increase the risk of prolapse Preoperative nursing care:
(the female hormone estrogen plays an important role in maintaining  *Thorough explanation of procedure, expectation and effect on
the strength of the pelvic floor) future sexual f(x)
 *Laxative and cleansing edema (rectocele) – independently, at
Clinical Manifestation home a day prior to procedure
> Feeling like you are sitting on a small ball  *Perineal shave prescribed also
> Difficult or painful sexual intercourse  *Lithotomy position for surgery
> Frequent urination or a sudden urge to empty the bladder Postop nursing care:
> Low backache  *Pt. is to void few hours after surgery; catheter if unable (after 6
> Uterus and cervix that stick out through the vaginal opening hours)

> Repeated bladder infections

F. Premature Labor: - Pain Medications/Analgesics are given in minimum dosage to
prevent respiratory depression in infants
> uterine contractions occurring prior to 37 weeks’ gestation
- Steroids (Bethamethasone/Celestone) are given to help in fetal lung
Risk Factor maturity by hastening production of surfactants
 : multiple gestations polyhydramnios, hypertension, 3rd Contraindications:
trimester bleeding, premature rupture of membranes,
incompetent cervix  maternal DM, infection, hypertension, AOG>34th week

Clinical Manifestations Caudal, spinal or infiltration anesthesia is preferred because it does not
compromise fetal respiration
 contractions occurring in increasing frequency and intensity,
premature rupture of membranes Nursing Care:

Management: 1. Provide emotional support

+ Administration of tocolytic agents (one which suppresses labor) 2. Assist in delivery if there is presence of maternal complication
(ex. DM, preeclampsia, hemorrhage)
Examples of Tocolytic Agents:
3. Minimize fetal complications (position client left lateral
A) Ritodrine (Yutopar) po – muscle relaxant position)
Side effects: hypotension, tachycardia, altered FHR  
Nursing Responsibility: Notify MD if maternal PR>120 or
FHR>180bpm
B) Isoxsuprine (Vasodilan) IV – a vasodilator
Side effects: hypotension, tachycardia
C) Terbuline (Bricanyl) – bronchodilator
Side effects: tachycardia, nervousness and tremors
 Tocolytic Agents are given if NO bleeding and cervical dilation
is present
 If premature uterine contractions are accompanied by
progressive fetal descent and cervical dilation, premature
delivery is inevitable
D) Ethyl alcohol (Ethanol) IV – blocks release of oxytocin
Side Effects: nausea and vomiting, mental confusion
 POSTPARTAL COMPLICATIONS  history of uterine atony, grand multiparity (more than 4),
closed spaced pregnancies, uterine overdistention (from
I. POSTPARTUM HEMORRHAGE multiple gestation, macrosomic infant of polyhydramnios), CS,
prolong and difficult labor, precipitate labor and delivery,
 Blood loss greater than 500 ml after delivery (occurs up to 28th placental accidents (abruption placenta/placenta previa), PIH
day postpartum) with Magnesium sulfate infusion, general anesthesia
 Leading cause of maternal mortality rate during the administration, retained placental fragments, full bladder
postpartum, hemorrhage Nursing management
 Hemorrhage is considered severe if one or more of the  careful assessing of uterine contractility and lochia
following occurs: blood loss exceeds 1L, systolic or diastolic  gently and firmly massage the fundus (initial nursing action)
BP decreases by 30 mmHg, Hemoglobin concentration is  ice compression application
reduced by 3g.
 oxytocic administration as ordered
Risk factors  empty the client’s bladder
 a manual compression of retained placental fragments
 precipitate labor, dystocia, abruption placenta, placenta previa,
 prepare the client for possible hysterectomy (last resort)
forceps delivery, multiple pregnancy, large fetus,
polyhydramnios 2. Lacerations
Causes > Jagged / irregular cut or tears
 uterine atony, perineal/vaginal/cervical lacerations, retained > Perineal, vaginal, or cervical lacerations are often the result of
placenta and placental fragments, hematoma, subinvolution and trauma to maternal tissues during delivery
coagulation disorder (DIC)
* Excessive bleeding may develop because of a previously undetected
Classification laceration of a defective suture or repair of laceration
A. Early Postpartum Hemorrhage Treatment
– occurs within 24 hours of delivery
 nursing (inspect perineal area after delivery, watch for oozing
of blood from vagina); surgical (suturing/resuturing of bleeding
edges)
1. Uterine atony
3. Disseminated intravascular coagulation (DIC)
> uterus that fails to contract adequately or relaxation of the uterine
muscle > A result of an imbalance between clot formation and clot breakdown
systems that results in serious hemorrhaging.
> Accounts for 80-90% of early postpartum hemorrhage; most
frequent cause > An abnormal form of rapid coagulation in which clotting factors are
consumed and depleted (hypofibrinogenemia), resulting in generalized
Risk Factors: bleeding.
Treatment Nursing management
: medical – fluid replacement (IV, BT) • inspect placenta at time of delivery for intactness
• never force the expulsion of placenta
: nursing – administration of cryoprecipitate or fresh frozen plasma • wait for signs of placental separation before attempting to
(FFP) and platelet transfusion as ordered, administration of deliver placenta
anticoagulants as ordered, monitor vital signs, monitor for signs of
shock
2. Hematoma
B. Late postpartum hemorrhage
> Tumor composed of blood cells, resulting from tissue injury or blood
 Occurs more than 24 hours after delivery vessels injury during delivery
Incidence:
1. Retained placenta/retained placental fragments
• commonly seen in precipitate delivery and those with perineal
> Placenta is not delivered spontaneously within 30 minutes or some varicosities
parts of placenta are left inside the uterus
Treatment:
Causes
• surgery – incision of site and ligation of bleeding vessel
• partial separation of placenta, mismanagement of 3rd stage of
labor, abnormal adherence of entire placenta or portion of Nursing management:
placenta to the uterine wall :watch for complaints of pain in perineum : inspect perineum for
Degrees of abnormal adherence of placenta: discoloration and tenderness

• placenta accreta or placenta vera (slight penetration of : apply ice compress during the 1st 24 hours : administer analgesics
myometrium by placenta) as ordered : monitor vital signs
• placenta increta (deep penetration by placenta in the
myometrium)
• placenta percreta or placenta destruans (perforation of uterus 3. Subinvolution
by placenta or complete penetration through the myometrium)
> An abnormal, incomplete return of the uterus to its prepregnant state
• Impairs the ability of the uterus to fully contract
after childbirth
Treatment:
> Causes: malposition, myomas, retained products of conception,
• dilatation and curettage (retained placental fragments), infection
hysterectomy (abnormal adhesions)
> Management: medical - If no bleeding = oxytocin administration,
antibiotic therapy, warm acetic douches
- If with bleeding = dilatation and curettage (D&C), oxytocics and
antibiotics administration
Nursing management II. PUERFERAL INFECTIONS
• assess for discomforts (pelvic discomfort, backache vaginal >“Childbirth fever”; any infection of the reproductive tract during the
bleeding for boggy uterus), administer oxytocic’s and postpartum period
antibiotics as ordered (* Sheehan’s syndrome / Postpartum
anterior pituitary necrosis) Predisposing factors:
• May occur after sever hemorrhage or shock, loss of pituitary • antepartal infections, premature rupture of membranes
function leads to deficient thyroid, ovarian and adrenocortical (PROM), prolonged labor, laceration, anemia, postpartum
function. hemorrhage, poor aseptic technique
Signs and symptoms Sources:
• increased breast size, loss of pubic and axillary hair, genital • endogeneous / primary sources – bacteria in the normal flora
atrophy, amenorrhea become virulent when tissues are traumatized and general
Treatment resistance is lowered
• exogeneous / secondary sources – pathogens introduced from
• thyroid, cortisone, and estrogen hormone replacement external sources (most common source: hospital personnel due
to breakage in aseptic technique like faulty handwashing or
Complications use of unsterile instruments/supplies)
• infertility, decreased resistance to infections, proneness to • Etiologic agents: anaerobic streptococci; staphylococcus
shock, premature aging aureus
• General symptoms: T-38 degrees C (taken at least 4x on any 2
of the first ten postpartum days with exception of first 24hours
postpartum), malaise, anorexia, chills, headaches, tachycardia,
General Nursing Interventions for Postpartum
profuse and foul smelling discharge
Hemorrhage: • Areas involved
1. Type and crossmatch blood for women at high risk to develop • uterus (endometritis – most often affected)
postpartal hemorrhage • localized infection via lymphatics into pelvic organs (resulting
in thrombophlebitis, salphingitis, oophoritis, peritonitis,
2. Anticipate replacement of IV fluids and blood septicemia)
3. Monitor hemoglobin and hematocrit values • urinary system (pyelitis, cystitis)

4. Treat for shock General treatment:

5. Monitor vital signs and amount and Lochia • medical – antibiotics, antipyretics, oxytocics
• dietary – high protein, high calorie, high vitamins, increase
6. Promote good nutrition fluid intake (3-4L/24hours)
7. Teach client how to palate uterus firmness and to massage
uterus if relaxed
General Nursing Management • nursing – administer meds as prescribed, place client in semi
Fowler’s position to drain out lochia or prevent pooling of
: maintain meticulous aseptic technique during labor and delivery infected discharges
: encourage ambulation balance with rest
: encourage good nutrition 3. Mastitis
: encourage to increase fluid intake > Inflammation of breasts due to invasion of the breast tissue by
: administer medications(analgesics, antipyretics, antibiotics) as pathogenic organisms
prescribed: monitor vital signs Causative agent:
• staphylococcus aureus which transmitted via nasopharynx of
Types of Puerperal Infections: nursing infant
Occurrence:
• during 1st 2months postpartum, often in the 2nd or 3rd week
1. Infection of the perineum
Predisposing factors:
Specific symptoms:
• fissured nipples, erosion of areola
• pain, heat and feeling of pressure in the perineum, inflamed
suture line (with 1-2 stitches sloughed off), with or without Signs and symptoms:
elevated temperature
• localized pain, swelling and redness in breast tissues; lump in
Specific management: the breasts; milk becomes scanty; with or without fever (fever
= 39.4 to 40 degrees C, chills and tachycardia)
• surgical – removal of sutures to drain area and resuturing
• nursing care – apply warm compress, do not sitz baths Treatment:
• antibacterial (Penicillin), antipyretic, analgesic
2. Endometritis
Nursing care:
> Inflammation/infection of the lining of the uterus
: teach mother how to cleanse breasts and nipples
Specific symptoms:
: explain importance of wearing support bra
• abdominal tenderness, uterus not contracted and painful to
touch, dark brown foul smelling lochia : apply ice to breasts (to decrease pain)

Specific management: : discard milk from infected breast while temperature is elevated

• medical – oxytocins and antibiotics administration : encourage good nutrition and adequate rest
: administer medications as ordered
4. Urinary tract infections (UTI) – 6. Thromboembolic disorders
5. Wound infection Major causes:
> Common type of postpartum infection • venous stasis, hypercoagulation, blood vessel injury
* CS surgical incision: most common site Predisposing factors:
Causative agent: • age (>35 y/o), varicose veins, history of thrombophlebitis,
prolonged bed rest, inactivity, multigravidas (>3 pregnancies),
• staphylococcus aureus (25-30% of wound infection) use of oral contraceptives, smoking
Signs and symptoms: a. Superficial venous thrombosis
• edema, warmth, redness, tenderness and pain, with • generally involves the saphenous venous system and is
seropurulent discharge when edges of wound is pull apart confined to the lower leg; associated with varicose veins and
Therapeutic management: limited to calf area

• incision and drainage, administration of medications (broad Signs and symptoms:

spectrum antibiotics, analgesics) warm compresses, sitz baths • swelling of involved extremity, redness, tenderness and
Nursing responsibilities: warmth, presence of pain when walking, palpation of
enlarged/hardened cordlike vein
• providing reassurance and supportive care to patients
• giving comfort measures (sitz baths, warm compresses, and Therapeutic management:
frequent perineal care) • rest, analgesics, elastic support, elevation of affected extremity,
• emphasizing good handwashing techniques warm packs application, avoidance of standing for long
• advising client on adequate fluid intake and diet. periods, gradual ambulation if symptoms disappear
• modification of activities (depending on site, severity,
treatment of wound infection) b. Deep vein thrombosis/thrombophlebitis
• teaching patient to perform daily wound care
Signs and symptoms are caused by inflammatory process and
• anticipatory guidance (teaching side effects of medications,
obstruction of venous return
signs of worsening condition, self-care measures)
Signs and symptoms:
• positive Homan’s sign, swelling of leg (2> cm larger than the
opposite leg), erythema, heat, tenderness and pedal edema, pain
on ambulation, chills, general malaise and stiffness of affected
leg
Diagnostics: C. Pulmonary Embolism
: ultrasound with vein compression and Doppler flow analysis > Serious complication of deep vein thrombosis of and a leading cause
of maternal mortality; occurs when fragments of a blood clot
: venography – most accurate diagnostics; may cause pain, dislodge/amniotic fluid and its debris are carried to the lungs (the
anaphylaxis/allergic reaction, and radiation exposure embolus occludes a vessel and partially/completely obstruct blood
flow into the lungs)

Therapeutic Management: Signs and symptoms:

• dyspnea, sudden sharp chest pain, tachycardia,
I. Preventing thrombus formation syncope/fainting, tachypnea, pulmonary rales,
hemoptysis/spitting of blood, cyanosis
> Prophylactic heparin/anticoagulants for women at risk (discontinue
during labor and birth and resumed 4-12 hours postpartum) Diagnostics:
> Placing legs on padded stirrups during delivery • :arterial blood gases (ABG) – decreased P02
• : chest X-ray – areas of atelectasis/lung collapse and pleural
> Early ambulation effusion/ accumulation of fluid in the pleural cavity
> If woman unable to ambulate, range of motion and gentle leg • : ventilation-perfusion scan – shows areas of ventilated lungs
exercises (should begin within 8 hours after childbirth ) but not perfused because of the blockage

> Application of antiembolic stockings Therapeutic management:

> Discharge instructions on lifestyle changes (avoid constricting • : oxygen administration : administration of narcotic
clothing, prolonged sitting/standing) analgesics (Demerol)
• : CBR with head of bed elevated : intensive care and
support of ventilation (depend on pulmonary status)
II. Initial treatment • : initiation of pulse oximetry : evaluation of ABGs
> Bed rest with affected leg elevated • : administration of thrombolytic drugs : embolectomy (may
be attempted to allow clot to dissolve)
> Gradual ambulation when symptoms disappear
Nursing responsibilities:
> Anticoagulant therapy
• : monitor for signs : facilitate transfer to ICU
> Analgesics to control pain • : facilitate oxygenation (oxygen via face mask at 8-10L/min,
stay with client, raising head of bed, keep client warm, narcotic
> Antibiotic therapy as necessary to prevent/control infection
analgesics given as ordered)
> Continuous application of moist heat compress • : seek assistance (IV administration of heparin, continuous vital
signs assessment, administration of emergency drugs)
 Therapeutic Management of the Problems or Potential Contraindications:
Problems in Labor and Delivery • CPD, fetal distress, previous uterine surgery (CS),
overdistended uterus (hydramnios, multiple births),
grand multiparty (over 4)
I. Induction of Labor
Nursing Care:
• deliberate stimulation of uterine contractions before the
1. Primary concern is to monitor intensity of contractions
normal occurrence of labor; to bring about labor before
(Remember: if uterine contractions are unduly sustained or
the time when it would have occurred spontaneously or
duration is greater than 70 seconds, uterine rupture may occur)
because it does not occur spontaneously
2. Check rate of flow regularly
Indications
3. Turn of IV if with FHR abnormalities or uterine contractions
• Maternal (slow progress of labor, prolonged ROM,
(Discontinue if contractions are more frequent than every 2
post term pregnancy, presence of preexisting maternal
min, contraction duration exceeds 75-90 sec, uterus does not
disease like HPN or renal disease), Fetal (hemolytic
relax or remains contracted and tetanic)
disease/Rh incompatibility, postmaturity, fetal death,
congenital anomaly like anencephaly) 4. Watch out for complications: hypertension (Monitor BP
because oxytocic is a vasoconstrictor), antidiuresis (decrease
Prerequisites
urine output can cause water intoxication seen as headache and
• NO CPD, fetus is viable (decreased survival if below vomiting lading to convulsion, coma and death therefore,
32 weeks AOG), single fetus in longitudinal lie and is monitor urine output)
engaged, ripe cervix (fully or partially dilated at least
a. Prostaglandin administration (PGE2) - local application of
1-2 cm)
Prostaglandin gel to soften or prime the cervix and induce labor
May be accomplished by:
Procedure:
a. Amniotomy (deliberate rupture of membranes; artificial
• For 30min, FHR and uterine contractions are
rupture of membranes/bag of waters)
monitored via electronic monitor for baseline data. MD
b. Oxytocin Administration (Pitocin/Syntocinon) - IV instills 0.5 mg of PGE2 gel intracevically using a
administration with MD in attendance plastic catheter. The parturient remains in bed for 30
min, then may ambulate. Contractions usually begins a
Procedure: half hour after theadministration. Amniotomy will be
• 10 'u' in 1L D5W/D5LR at slow rate of 8 gtts/min done at 4 cm dilation and internal fetal monitor is
given initially; if no fetal distress is observed in 30 applied. If woman does not deliver within 24 hours,
minutes, infusion rate is increased 16-20 gtts/min. cervix is reassessed; an Induction by oxytocin is done
Amniotomy will be done when cervix is dilated ro if indicated.
about 4 cm. (Check FHR)
Nursing Responsibilities: Types:
• Monitor FHR, BP and PR every 30 min; Monitor 1. Low outlet forceps used when the head is visible at the
uterine contractions perineum)
Nursing Management 2. Mid and high forceps no longer used
 Explain all procedures to client 3. Piper forcep used in breech deliveries
 Prepare appropriate equipment and medications
Complications:
 Frequently check maternal vital signs (BP, PR) and FHR every
15 min  maternal (lacerations to the birth canal and rectum), fetal
 Carefully assess uterine contractions (cephal hematoma, lacerations and bruising to face, facial
 Notify MD fo any untoward reactions paralysis, skull fracture, umbilical cord compression)
4. Vacuum extraction used when head is visible - silastic suction cup
applied to presenting part and gentle traction exerted while mother
II. Assisted Delivery: pushes
 Vacuum or Forceps - use of instruments to extract the fetus
from the birth canal; are applied when the fetal head is at the
perineum (+3 or +4 station) and sagittal suture line is in an Nursing Management:
anteroposterior position in relation to the outlet
 Anticipate request for forceps/vacuum if possible
Prerequisites:  Monitor FHR continuously
 Explain the procedure to client if awake, advise mother/family
 NO CPD, head is engaged, fully dilated cervix, membranes about possible presence of bruising that will go away but may
ruptured, vertex presentation/face presentation (mentum), contribute to jaundice, also risk of perineal or vaginal tearing
empty bladder and bowel, anesthesia is given for sufficient
 Newborn assessment should include careful examination for
perineal relaxation and to minimize pain
bruising and facial nerve damage with forceps and cephal
Indications: hematoma with vacuum
 Ongoing newborn assessment includes careful checking for
 maternal (medical conditions like cardiac or pulmonary or jaundice
infection, exhaustion, ineffective pushing due to anesthesia),
fetal (fetal distress, cord prolapse)
Purposes:
 to shorten 2nd stage of Labor if with maternal or fetal
indications, to prevent excessive pounding of fetal head against
the perineum, to deliver babies against poor uterine
contractions or rigid perinem
III. Cesarean Birth/Cesarean Section Delivery - 2. Classical cesarean section
 delivery of the baby through an incision into the abdominal  vertical incision is made into both abdomen and uterus (upper
and uterine walls uterine segment)
Basic Purpose: Indications: bladder or lower uterine segment is involved in extensive
adhesions resulting from previous operations, transverse lie/shoulder
 to preserve life or health of the mother and her fetus presentation, anterior placenta previa
Indications:
 maternal (uterine dystocia, preexisting maternal diseases like Nursing Management:
cardiac disease or DM, STDs like genital herpes or gonorrhea,
severe pre-eclampsia or eclampsia, previous cesarean * Preoperative Care
birth/surgery on the uterus, uterine tumors, postterm
a. Signed consent
pregnancy, placenta previa, abruptio placenta), fetal (fetal
distress, cord prolapse, fetal abnormalities like b. Blood typing and crossmatching and CBC
hydrocephalus), breech or other malpresentattion, CPD,
macrosomia, multiple gestation c. Removal of: any hair pins/application of haircap, cosmetics,
jewelries (taping of wedding ring), glasses and contact lenses,
dentures, nail polish, underwear (brassiere and undies)
Types of Cesarean Birth d. Check vital signs, uterine contractions and FHR
1. Low segment transverse incision e. Maintain on NPO status
 incision is made in the abdomen (above public hairline) and in f. Start IV line as ordered
uterus; incision is made in the lower uterine segment (thinnest and
g. Abdominoperineal preparation - shaving from below nipple
most passive portion during active labor); preferred and most
line, including the entire abdomen from side to side as well as
commonly used method; vaginal birth after this type of cesarean
the perineal area)
birth (VBAC) is a possibility (if no indication of previous CS
delivery) h. Insert indwelling catheter as ordered
Advantages: i. Preoperative medications are given as ordered (Atropine)
 minimal blood loss, incision is easier to repair, low incidence
of postpartum infetion, less incidence of uterine rupture
* Postoperative Care III. POSTPARTAL PSYCHIATRIC DISORDERS
a. Deep breathing and coughing exercises
b. Turning client from side to side if indicated A. Postpartum depression
c. Monitor IV line and vital signs  Intense and pervasive sadness, disordered thinking and severe
d. Encourage ambulation after 12 hours as ordered mood swings with psychotic episode; 9-15% of postpartum
woman experience this disorder
e. Assess level of consciousness or return of sensation  Has a gradual onset, developing slowly over several weeks
 May occur any time during the 1st year postpartum
f. Asess uterine firmness, incision for signs of infection or
bleeding Signs and symptoms:
g. Monitor intake and output  confusion and fear of losing minds, entertain ideas of
committing suicide or of harming their infants
h. Watch for signs of hemorrhage - inspect perineal pad/lochia,
palpate uterus (massage if relaxed after application of Risk factors:
abdominal binder)
 : depression during any trimester of pregnancy (strongest
i. Administer analgesics as ordered predictor)
j. Encourage breastfeeding (can start 24 hours after delivery)  : anxiety during any trimester of pregnancy
 : stressful life events (occupational changes, accidents)
 : lack of social support
Complications:  : marital dissatisfaction
 : history of previous depression before this pregnancy
 hemorrhage, infection, uterine atony  : child care stress (health, feeding and/or sleeping problems)
 : postpartum blues
Common symptoms reported by patients:
 : lack of concentration : loss of customary interests
 : loneliness : insecurity
 : obsessive thinking : lack of position emotions
 : loss of self (fears life will never return to normal) : anxiety
attacks
 : loss of control : guilt over thoughts of harming infant
 : contemplation of death to end the pain : confusion
 : sleep disturbances : headache
 : gastrointestinal disorders : hair loss
 : dysmenorrhea : breastfeeding difficulties
  : disinterest in sex : variable energy levels and mood Management:
 clients may be hospitalized/brought to mental institution,
administration of antidepressants in conjunction with
Nursing interventions: professional psychiatric counseling
 : awareness of symptoms by health care providers
 : discussion with clients about postpartum blues and depression
prior to discharge Infertility
 : teach client the difference between symptoms of postpartum
blues and depression  Inability of a couple to produce a living child as a result of
failure to conceive (after a year of effort) or of failure to carry
 : encourage client to promptly report signs of depression
the conceived baby to a viable state
 : assist in screening during follow up visits with other health
care professionals a. Primary infertility = there have been no previous conceptions
 : referral to support groups/therapists/psychiatrists depending
on a severity of symptoms b. Secondary infertility = there has been a previous viable
pregnancy
Sterility
B. Postpartum psychosis
 A term applied when there is an absolute factor preventing
 Severe distress that results in significant changes in thought reproduction/conception
process, emotions and behaviors; 1 % of postpartum women
experience this disorder Essential Components for Normal Fertility:
 More common in primiparas; with abrupt onset; most often Female partner
occurring between 3 days to 2 months after delivery
 Clients may experience hallucinations or delusions; withdrawn,  Vaginal and cervical mucus must be favorable for survival of
uninterested and suspicious behaviors spermatozoa
 Clients often victims of unreasonable fears and sleep  Clear open passage between the cervix and fallopian tubes
disturbances  Patent fallopian tubes with normal peristaltic movement to
 In severe cases, clients may become dangerous to themselves allow ascent of spermatozoa and descent ovum
and others  Ovaries must produce and release ovum
 With 5% risk of suicide and/or infanticide  No obstruction between the ovaries and the uterus
  Endometrium must be in a normal physiologic state to allow
Triggering mechanism: implantation of the blastocyst and to sustain normal growth

 crisis of parenthood; with history of previous emotional

instability or illness
Male Partner  = use of nicotine, alcohol or drugs = premature ejaculation
 = impotence = coital positioning
 Testes must produce spermatozoa of normal quality and  = too frequent intercourse
quantity
 Male genital tract must not be obstructed
 Secretions from genital tract be normal Female infertility factors:
 Ejaculated sperm must be deposited in the female genital tract
in such a manner that they reach the cervix a. Anovulation – causes: pituitary or thyroid disturbances, immaturity
or disease of ovaries (endometriosis), chronic exposure Xrays or
radioactive substances
Male Infertility Factors: b. Structural abnormalities
a. Coital difficulties  = unusual size of uterus (infantile uterus)
 timing and frequency of coitus, chordee (erection curves  = lack of ovaries
downward), or obesity  = imperforate hymen
 = absence or stenosis of vagina
b. Semen factors
 = fallopian tube blockage/strictures
 sperm abnormalities: small ejaculatory volume (2<ml), low
c. Coital factors
sperm count (<20 million/ml, normal minimal number is 40-50
million/ml), poor motility of sperm  use of lubricants or douching which change the pH or may
 obstruction to sperm motility due to adhesions, occlusions, or cause infection
congenital structures of spermatic duct= changes in seminal
fluid due to infection/chronic disease with persistent fever (ex. d. Emotional problems
Parotitis/mumps)  severe psychoses or psychoneuroses
c. Testicular abnormalities e. Chronic infections
 = undescended, atrophic or absent testes =  pelvic inflammatory disease (PID) caused by gonorrhea
cryptorchidism leading to salphingitis, previous use of intrauterine device
 = any trauma, irradiation or increased temperature for (IUD), other vaginal infections
prolonged periods (ex. Orchitis after mumps, gonorrhea or TB)
f. Immunologic reaction to sperm
d. Structural abnormalities
g. Social/emotional problems – use of nicotine, alcohol drugs
 = hypospadias/epispadias = urethral strictures
 = varicocele
e. Severe nutritional deficiency (low vitamin intake)
f. Social/emotional factors
 Fertility Assessment
A. Male fertility studies 4. Cervical mucosal tests

1. Complete history and physical examinations  Cervical mucus is thin, clear, profuse, watery, alkaline and
stingy at time of ovulation
2. Laboratory tests: urinalysis, CBC, blood typing, Kahn and
Wasserman (STD test), testicular biopsy, thyroid function tests  Supplemental estrogen therapy 6 days prior to ovulation
enhances development of spinnbarkheit (elasticity of the
3. Complete serum analysis: cervical mucus)
 examination of seminal fluid for number, appearance and 5. Sims-Huhner/Huhner (test for cervical environment)/postcoital
motility test –
* Collection of specimen – avoid ejaculation for 2-3days, collect  conducted at time of ovulation; from 1-12 hours after coitus to
masturbated specimen in a glass of jar, transport to physician’s determine sperm survival and motility along with the
office/laboratory no later than 2 hours after collection (NO warming or characteristics of cervical mucus
chilling of specimen)
6. Tubal patency tests
* Semen collection should be repeated at least 72 hours apart to allow
for new germ cell maturation  Hysterosalphingography – reveals uterine patency and any
distortions of the endometrial cavity; may have therapeutic
* Normal values of semen = volume (2-5ml), pH(7.2-8.9), density of
effect (flushes out debris, breaks adhesions, or starts peristalsis)
sperm (50 million/ml), motility (>75%), morphology of sperm (60%)
with pregnancy after occurring within the 3 menstrual cycles;
4. Psychological assessment scheduled during the proliferative phase (usually 6 days
postmenstrual flow)
 Laparoscopy – direct visualization of pelvic organs via
B. Female fertility studies abdominal incision; may cause shoulder and chest pain via
1. Complete history and physical examination especially carbon dioxide gas in abdomen lasting 24-48hours after
menstrual history procedure; performed 6-8 months after hysterosalphingogram
during proliferative phase
2. Laboratory tests: CBC, urinalysis, serologic tests, thyroid
function tests, sedimentation rate, Xray and Pap smear  Rubin test – usually done on 3rd day following cessation of
menstruation into cervix through uterus and fallopian tube into
3. Recording of BBT (basal body temperature) and pelvic cavity to assess tube patency
characteristics of cervical mucus to document ovulation
 = if > 100 mm Hg of CO2 and with abdominal pain – strictures
 BBT decreases and then sharply increases at time of ovulation; of fallopian tube
recommend coitus every other day in the period of time  = if > 200 mm Hg of CO2, no sound is heard on auscultation or
beginning 3-4 days prior to and continuously for 2-3 days (-) abdominal pain – occlusion of tubes
following expected time of ovulation
7. Endometrial biopsy – sample of endometrium is obtained during the Side Effects:
2-6 before menstruation; assesses the adequacy of endometrium for
implantation, (+) polyps or inflammatory conditions  Vasomotor flushes, visual spots, nausea, vomiting, headache or
hair loss
b. Human menopausal gonadotropin (Pergonal)
Infertility Management:
Potent hormone combination of LH and FSH obtained from
A. Male postmenopausal women’s urine
1. Threat the underlying cause (e.g. chronic disease or infection) Administration:
2. Abstain for 7-10 days at a time for low sperm count  given IM every day for varying periods of time during the first
half of menstrual cycle
3. Artificial insemination/in vitro fertilization for poor quality or
immotile sperm or due to mumps/orchitis  Couple are advised to have coitus on the day of receiving
4. Prostaglandin inhibitor effects of anti inflammatory drugs have HMG and for the next 2 days
been shown to increase sperm count and motility c. Danazol (danocrine)
A. Female Synthetic androgen steroid; used when endometriosis is determined to
1. Sodium bicarbonate douche for very acidic vaginal be cause of infertility; acts by suppressing FSH and LH allowing
environment endometriosis to heal

2. Treat underlying condition (e.g. antibiotics for infection)  Amenorrhea occurs then with return of menstrual cycle
function after discontinue of meds, conception may occur
3. Surgery for tumors; correction of obstruction/strictures Treatment may last 6 mos to a year; administration: qid for 6-
12 months
4. Endocrine therapy for ovulatory disturbance/administration of
fertility medications  Teach client to see MD at once if harshness of voice occurs; to
avoid foods with excessive sodium to decrease fluid retention
 Use of fertility drugs may lead to a multiple birth rate of about
and increase potassium to decrease muscle cramping.
20% with 15% twins
5. In vitro fertilization:
a. Clomiphene citrate (Clomid) – indicated when ovaries are
normal and pituitary gland is intact; increases FSH and LH  multiple ova are stimulated by use of fertility meds; matured
secretion, which stimulates follicle growth follicles are removed by laparoscopy; ova are transferred for
Administration\ tissue culture media; sperm is added to culture media under
controlled laboratory conditions; if fertilization occurs, a 2nd
 take it daily for 5 days beginning day 5 of menstrual cycle tissue transfer allows for division (3-6days); prior to transfer
with supplemental low dose estrogen of blastocyst to the uterus, the woman is maintained on
progesterone therapy
  Procedure has a success rate of up to 20% with a spontaneous 8. Refer to appropriate community agencies (ex. Adoptive parent
abortion of one in three organization)

Nursing Interventions:
1. Provide information regarding normal functioning of the male and
female reproductive system
2. Thoroughly explain specific exams and diagnostic procedures to
decrease anxiety and fear
3. Promote fertility awareness
= discourage douching and artificial lubricants (alter vaginal
pH)
= encourage retention of sperm (man in superior position
during coitus with female remaining recumbent for at least an
hour after intercourse)
= prevent leakage of sperm (woman elevates her hips with
pillow after intercourse and avoid getting up to urinate)
= encourage intercourse at least 1-3x/week (Intervals should be
no more than 48 hours apart)
= promote relaxation and good nutrition to decrease stress and
anxiety
= explore other methods to increase fertility awareness (check
cervical mucus and BBT)
4. Promote expression of feelings related to sexuality, self-esteem and
body image
5. Assess for common reactions of surprises, denial, anger and guilt
6. Facilitate partner communication
7. Explore alternatives such as adoption, artificial insemination or
remaining childless