Gynecoid

Anthropoid
Android
Sonogram
Acceleration
Deceleration
Tocolytic Agent
Rickets
-the occiput is directed diagonally
and posteriorly
- In the process of internal rotation, the
fetal head must rotate not through a
90-degree arc, which is necessary for
the anterior position, but through an
arc approx. 135-degree arc
- Can be delivered spontaneously but
with increase molding and caput
Risk Factors:
Women with android, anthropoid or
contracted pelvis
> Pressure and pain in the
mother’s lower back
* interventions:
> Counter pressure on the sacrum ( Back rub, apply
fist or heel of hand to sacral area)
> Heat or cold applications in the sacral area– which
ever feels best
> lying on the side opposite the fetal back
> Double hip squeeze – ex: knee-chest position
- partner, nurse or doula places hands over gluteal
muscles and presses with palms of hands up and
inward toward the center of the pelvis
> knee press
Measure to facilitate the rotation of the fetal head
 Lateral abdominal stroking: stroke the abdomen in
direction that the fetal head should rotate
 Hands and knees position: kneeling while leaning
forward over a birth ball, padded chair seat,bed or
over-the-bed table
 Squatting
 Pelvic rocking
 Stair climbing
 Lateral position: towards the fetus should turn
Caesarean if:
Recommended practice to auscultate FHR
according to AAP/ACOG and AWHONN
With no risk:
* First stage (active phase) – every 30 minutes
* Second stage – every 15 minutes
With risk:
* First stage (active phase) – every 15 mintues
* Second stage – every 5 mintues
What controls the FHR?
1. Intrinsic rhythmicity of fetal heart rate
2. CNS
3. Fetal ANS

Baseline FHR – average rate during a 10-minute

segment that excludes periodic or episodic changes
Variability of FHR – irregular fluctations in the
baseline FHR of two cycles per minute or greater
_ one of the most realiable indicators of fetal
well-being
Four ranges of variability
1. Absent or undetected variability
2. Minimal variability – greater than
undetected but no more than 5 beats/min
3. Moderate variability – 6-25 beats/min
4. Marked variability – greater than 25
beats/min
If no variability is present, it indicates that the
natural pacemaker activity of the fetal heart
(effects of the sympathetic and
parasympathetic NS) has been affected.
 e.g.
Administration of narcotics or
barbiturates
Acceleration
- visually apparent abrupt increase in FHR
above the baseline rate
- the increase is 15 beats/min or greater and
last 15 seconds or more with return to
baseline less than 2 minutes from the
beggining of the acceleration.
- preterm (peak of 10 beats/min or more
above baseline for atleast 10 seconds
Deceleration
- abrupt decrease in FHR
1.Early deceleration – periodic decreases in FHR
resulting from pressure on the fetal head during
contractions
- parasympathetic stimulation in response to
vagal nerve compression brings about a
slowing of FHR
- rate rarely falls below 100 bpm, and it
returns quickly to between 120-160 bpm
- mirror of the contraction
Fetal Malpresentation
1. Brow presentation -
– rarest of the presentation
- occipitomental diameter presents
- fetus in partial extension
- infants will have extreme
ecchymotic bruising in the face
Risk Factors:
Multipara, woman with relaxed
abdominal muscles
2. Face Presentation
- rare; chin or mentum presentation
- the head diameter the fetus presents is
often too large for birth to proceed
- it is a warning signal because something is
abnormal causing the presentation
- instead of flexing the head as labor
proceeds, may extend the head resulting to
this presentation
- long first stage of labor

- attitude is poor
contracted pelvis or placenta previa,
relaxed uterus for a multipara,
prematurity, hydramnios, fetal
malformation, CPD

Sonogram
Vaginal Examination
- the nose, mouth or chin can be felt
as the presenting part
Effects to the baby and its
interventions:
> facial edema and may be purple from
ecchymotic bruising
*observe the infant closely for a patent airway
> lip edema is so severe that the infant is unable
to suck for a day or two
* gavage feedings may be necessary to allow the
infant to obtain enough fluid until he or she can
suck effectively
* the infant maybe transferred to an ICU nursery
for 24H
* reassure the parents that the edema is
transient and will disappear in a few days
3. Sinciput – military attitude
4. Transverse lie or Shoulder
Presentation
Risk Factors:
Women with pendulous abdomen
uterine masses (e.g. Fibroid tumors)
 contraction of the pelvic brim
 congenital anomalies of the uterus (placenta
previa)
 hydramnios
Infants with hydrocephalus or another
abnormality that prevents the head from
engaging
May occur in prematurity
Multiple gestation
Short umbilical cord
Grand multiparity
Leopold’s Maneuvers
Sonogram
Breech Presentation- most
common malpresentation
Three Types

Complete
Frank
Footling- knee extends below
the buttocks
- Foot extends below the
buttocks
1. Complete
2. Frank Breech
- attitude is moderate because the hips are
flexed but the knees are extended to rest on
the chest
- the buttocks alone present to the cervix

- infant may tend to keep the legs extended

and at the level of the face for the first 2-3

days of life
3. Footling
- Neither the thighs nor lower legs are
flexed
- if one foot presents, it is a single-footling

breech; if both presents, it is a double-

footling breech
- may tend to keep the legs extended in a
footling position for the first few days
* Inform the parents of the possible posture of
the infant so that they do not misinterpret the
unusual posture of their infant
Diagnosis is made by abdominal
palpation and vaginal examination

Confirmed by ultrasound scan

Risk Factors:
Preterm birth
Abnormality in a fetus such as anencephaly,
hydrocephalus, or meningocele
Hydramnios or oligohydramnios
Congenital anomalies of the uterus (e.g.
Midseptum)
Any space-occupying mass in the pelvis (e.g.
Fibriod mass, placenta previa)
Pendulous abdomen
Multifetal gestation
Unknown factors
Complications
• Anoxia from a prolapsed cord
• Traumatic injury to the aftercoming head
(possibility of intracranial hemorrhage or
anoxia)
• Fracture of the spine or arm
• Dysfunctional labor
• Early rupture of the membranes because
of the poor fit of the presenting part
• Aftercoming head can be trapped by an
incompletely dilated cervix
 Possible
meconium staining because of the
inevitable contraction of the fetal
buttocks from cervical pressure. This is
not due to fetal anoxia as a sign of fetal
distress but this is expected because of
the pressure in the buttocks. This can
be aspirated however if the infant
inhales amniotic fluid.
Assessment
* Fetal heart sounds are best heard
at or above the umbilicus
* Leopold’s maneuvers
* Vaginal Examination
* Ultrasound examination
* Radiographic pelvimetry – to
determine which patients are suitable
for trial of labor
Interventions
* Assess fetal heart rate and pattern to
determine the cause of passage of
meconium
* if vaginal delivery is preferred, the
woman is allowed to push after full
dilatation is achieved
-Vaginal birth is accomplished by
mechanisms of labor that manipulate the
buttocks and lower extremities as they
emerge from the birth canal
* Piper forceps sometimes are used to
deliver the head
External Cephalic Version
- is used to attempt to turn the
fetus from a breech or shoulder
presentation to a vertex
presentation for birth
- usual time is 37-38 weeks but it

may be done at 34-35 weeks

- can decrease the number of

cesarean births necessary

Procedure:
Fetal Heart Rate and possibly ultrasound are
recorded continuously to identify potential
problems such as cord entanglement and
placental separation
A tocolytic agent may be administered to help
relax the uterus
The breech and the vertex of the fetus is located
and grasp transabdominally by the examiner’s
hands on the woman’s abdomen
Gentle pressure is then exerted to rotate the
fetus in a forward direction to a cephalic
Contraindications:
1. Multiple gestation
2. Severe oligohydramnios
3. Placenta previa
4. A cord that wraps around the neck
5. Unexplained third-trimester bleeding
6. Uterine anomalies
7. Previous cesarean birth
8. CPD
Interventions
> Before ECV is done, ultarsound scanning is
required to determine the fetal position
> Locate the umbilical cord; rule out placenta
previa
> Evaluate the adequacy of the maternal pelvis
> Assess the amount of amniotic fluid, the fetal
age and the presence of any anomalies
> A non-stress test is performed to confirm fetal
well-being
> Assess fetal heart rate
> Obtained informed consent
> Checks maternal vital signs
> Assess the woman’s level of comfort
because the procedure may cause
discomfort
> Assess for vaginal bleeding
> Women who are Rh-negative should
receive Rh immunglobulin because the
manipulation can cause fetomaternal
bleeding
Fetal Distress
*Fetal Heart Beat less than 120bpm or
greater than 160bpm
* meconium-stained amniotic fluid
* fetal hyperactivity
* progressive decrease in baseline variability
* severe variable deceleration
* late deceleration
Interventions
Monitor fetal heart rate every 15 min
Place the mother in a lateral position; elevate
her legs
Monitor maternal and fetal status
Prepare for emergency cesarean section
Administer oxygen at 8-10 LPM via face mask
as ordered
Discontinue oxytocin if infusing as ordered
Prolapsed Umbilical Cord
- occurs when the cord lies below the
presenting part of the fetus
 - may be occult (hidden, not visible at any time
during labor whether or not membranes are
ruptured
 - it is most common to see frank (visible)
prolapse directly after rupture of membranes.
When gravity washes the cord in front of the
presenting part
 - occurred in 1.9 of 1000 live births in 2002
 - always an emergency situation, because the
reduced blood flow to the fetus can quickly
cause fetal harm
Risk Factors:
Premature rupture of membranes
Amniotomy if the if the presenting part is high
Malpresentation (breech)
Long cord (longer than 100 cm)
Transverse lie
Unengaged presenting part
A small fetus
CPD preventing firm engagement]
Hydramnios
Multiple gestation
 Assessment
Vaginal Examination – they may be felt as the
presenting part
FHB continuous monitoring – fetal bradycardia with variable
deceleration during uterine contraction
If fetal hypoxia is severe, violent fetal activity may occur and cease
Woman reports feeling the cord after the membranes rupture
Cord is seen or felt in or protruding from the vagina
Interventions
> Always assess fetal heart sounds
immediately after rupture of the membranes
occuring either spontaneously or by
amniotomy
Cord prolapsed automatically lead to cord
compression
> Management is aimed toward relieving pressure on
the cord to prevent fetal anoxia
> The examiner put a sterile gloved hand into
the vagina and hold the presenting part off the
cord
> Assist the woman into a position such as a
modified Sim’s, Trendelenburg, or knee-chest
position
The cord has prolapsed to the extent that it is
exposed to room air ―> drying will begin ―>
atrophy of the umbilical veins
>Do not attempt to push any exposed cord
back into the vagina
(this may add to the compression by
causing knotting or kinking)
>Cover any exposed portion with a sterile
saline compress to prevent drying
Cervix is fully dilated at the time of proplapse
> A forceps- or vacuum-assisted birth can
be performed for the fetus in cephalic
presentation; other wise a cesarean birth is
likely to be performed
Dilatation is not complete
> The birth method of choice is upward
pressure on the presenting part applied by the
practitioner’s hand in the vagina
> The baby is delivered by cesarean
Emergency Interventions
Call for assistance
Notify primary health care provider immediately
Glove the examining hand quickly
Place the woman in the appropriate situation
If the cord is protruding from the vagina, wrap
loosely in a sterile towel saturated with warm,
sterile normal saline solution
Administer O2 via facemask at 8-10LPM until
birth is accomplished
Start IV fluids or increase existing drip
Continue to monitor FHR by internal fetal
scalp electrode, if possible
Explain to woman and support person
what is happening and the way it is
managed
Prepare for immediate vaginal birth if
cervix is fully dilated or cesarean birth if it
is not
 Dystocia - long, difficult , or abnormal labor
 - occurs in approximately 8%-11% of women during
the first stage of labor and is the primary cause of cesarean
birth
 It is cause by the folowing:
 1. Dysfunctional labor

 2. Alterations in the pelvic structure

 3. Abnormal position, presentation, and excessive size

of the fetus
 4. Maternal position during labor and birth

 5. Psychological responses of the mother to labor

related to past experiences, preparation, culture and
heritage and support system
 Specific problems with the
Passageway
Pelvis Dystocia – can occur whenever there
are contractures of the pelvic diameters
that reduce the capacity of the bony pelvis,
including inlet, midpelvis, outlet or any
combinations of the these planes
Pelvic contractures may be caused by
congenital abnormalities, maternal
malnutrition, neoplasms, or lower spinal
disorders
Inlet Contraction
- the diagonal conjugate is less than 11.5cm
- incidence of shoulder or face presentation is
increased
-weak uterine contractions may be noted
during the first stage of labor

Risk Factors:
* Rickets in early life
*Inhereted small or flat pelvis
Engagement in primigravida
>occurs 36-38th week of pregnancy
>if engagement does not occur, then
either a fetal abnormality (larger-than-
usual head) or a pelvic abnormality
( smaller-than-usual pelvis) should be
suspected
Engagement in multigravida
> occurs when the labor begins
Interventions
 Every primigravida should have
pelvic measurements taken and
recorded before week 24 of
pregnancy
Based on these measurements

and the assumption the fetus will

be of average size, birth decision
can be made.
Outlet Contraction
- interischial diameter is 8cm or less
- woman with this problem have a long,
narrow pubich arch and an android pelvis
(causes fetal descent to be arrested)
- easy to assess during prenatal visit and
reassessed during labor
transverse diameter – is the distance
between the ischial tuberosities
Assessment of Pelvic
Adequacy
Evaluation of pelvic adequacy using internal
conjugate and ischial tuberosity diameters is
generally done during pregnancy, so that, by
weeks 32 to 36 of pregnancy, the nurse-
midwife or physician is alerted that a
cephalopelvic disproportion could occur
> woman with this potential problem are
cautioned not to attempt a home birth or use
a birthing center without nearby hospital
facilities available
Suprapubic angle
* place the fingers vaginally and press up
against the pubic arch.
If the angle is too steep, the fetal head can lock
behind it and perineal tissue may tear during
birth as the fetal head is pushed posteriorly
If the fingers cannot be separated in this
position, the angle is unusually steep (>90
degrees)
Cephalopelvic Disproportion
- also called fetopelvic disproportion
- is often related to excessive fetal
size (i.e., 4000g or more)
- the fetus cannot fit in through the
maternal pelvis to be born vaginally
- occurred at a rate of 15.8 % per
1000 live births in 2002
Excessive fetal size, or macrosomia can
be associated with maternal DM, obesity,
multiparity, or the large size of one or
both parents

 If the maternal pelvis is too small,

abnormally shaped, or deformed, CPD
may be of maternal origin
Shoulder Dystocia
- fetal head is born but the anterior
shoulder cannot pass under the pubic
arch
- .24%-2.0% of all vaginal births are
complicated by this problem
- it occurs in the second stage of labor
- hazardous to the mother because it
can result in vaginal or cervical tears
- it is often not identified until the head has already
been born and the wide anterior shoulder locks
beneath the symphysis pubis
- hazardous to the fetus if the cord is compresses
between the fetal body and the bony pelvis
- the force of birth can result in a fractured clavicle or
humerus or a brachial plexus damage for the fetus
- the mother’s primary risk stems from excessive blood
loss as a result of uterine atony or rupture, lacerations,
extension of the episiotomy,or endometritis
Risk Factors:
Woman with diabetes
Multiparas
Post-date pregnancies
Fetopelvic disproportion due excessive
fetal size (>4000g)
Maternal pelvic abnormalities
Interventions
Ask the woman to flex her thighs sharply on
her abdomen - McRobert’s Maneuver – this causes
the sacrum to straighten, and the symphisis pubis
rotates toward the mother’s head; the angle of pelvic
inclination is decreased, freeing the shoulder
Apply suprapubic pressure to the anterior
shoulder using the Mazzanti or Rubin
maneuver in an attempt to push the shoulder
under the symphysis pubis
Squatting position or lateral recumbent
position
Mazzanti technique – pressure is applied
directly, posteriorly and laterally above
the symphysis pubis

Rubin technique – pressure is applied obliquely

posteriorly against the anterior shoulder
> When shoulder dystocia is diagnosed, the nurse
helps the woman assume the position(s) that may
facilitate birth of the shoulders
> Assist the primary health care provider with
these maneuvers
> Provide encouragement and support to reduce
anxiety and fear
> Examine newborn for fracture of the clavicle or
humerus, as well as brachial plexus injuries
> Maternal assessment should focus on early
detection of hemorrhage and trauma to the soft
tissue of the birth canal
Dysfunctional labor
- an abnormal uterine contractions
that prevent the normal progress of
cervical dilation, effacement,or
descent
Risk factors:
Body build (e.g., 30 pounds or more overweight;
short stature
Uterine abnormalities (e.g. Congenital
malformations; overdistention, as with multiple
gestation or hydramnios)
Malpresentation and positions of fetus
CPD
Overstimulation of oxytocin
Maternal fatigue, dehydration and electrolyte
imbalance, and fear
Inappropriate timing of analgesic or anesthetic
administration
1.Hypertonic Uterine Dysfunction
- the muscle fibers of the myometrium do
not repolarize or relax after the
contraction, to accept a new
pacemaker stimulus
- tend to be more painful and frequent
contractions but do not cause cervical
dilatation or effacement
- marked by an increase in resting tone to
more than 15 mmhg
- occur in the latent stage and are usually
uncoordinated
- the force of the contraction may be in the
midsection of the uterus rather than in the
fundus, and teh uterus is therefore unable to
apply downward pressure to push the
presenting part against the cervix
- the uterus may not relax completely
between contractions
Fetal Anoxia – danger of hypertonic
uterine contraction
- results if there is lack of relaxation between
contractions which may not allow optimal
uterine artery filling
Interventions:
 Monitor maternal and fetal status

 Uterine and fetal external monitor applied for

15 minutes
 Therapeutic rest – warm bath or shower

 Administer analgesics such as morphine,

meperidine, or nalbuphine – inhibit uterine

contractions, reduce pain and encourage sleep
 After a 4- to 6- hour rest,
theses women are likely to
awaken in active labor with a
normal uterine contraction
pattern
> Decrease noise and stimulation
> Change the linen and client’s gown
> Darken the room lights
Cesarean if:
2. Hypotonic Uterine Contraction
- more common type; also called secondary uterine
inertia
- the woman initially makes normal progress into the
active stage of labor; then the contractions become
weak and inefficient or stop together
- uterus is easily indented, even at the peak of
contractions
- intrauterine pressure during the contraction (usually <
25mmhg) is insufficient for progress of cervical
effacement and dilatation
- occur during the active phase of labor
- not exceedingly painful
Risk factors:
 Administration of analgesia especially if the cervix is
not dilatated 3-4 cm or if the bladder is distended that
prevents the descent of the fetus
 Multiple gestation – the uterus is overstretched

 A larger-than-usual fetus

 Hydramnios

 Uterus that is lax from grand multiparity

 CPD

 Malpositions
Complications:
Increase length of labor −> uterus is
exhausted −> not contract as
effectively during the post partal period
−> post partal hemorrhage

Cervix is dilated for a long period of time

– risk for infection
Interventions
> Perform ultrasound or an x-ray examination to rule out
CPD
> Assess FHR and pattern, characteristics of amniotic
fluid if membranes are ruptured, and maternal well-being
> If findings are normal, ambulation,
hydrotherapy,enema, striping or rupture of membranes,
nipple stimulation, and oxytocin infusion can be used to
augment labor
> Infusion of oxytocin to augment labor by strengthening
contractions and increasing the effectiveness
> Amniotomy may be done to further speed labor
> In the first hour after birth, palpate the uterus and
assess lochia Q15 minutes to ensure that post partal
contractions are not also hypotonic
Interventions
Monitor and assess the rate, pattern,
resting tone, and fetal response to
contractions for atleast 15 mins (or
longer if necessary for early labor)
Oxygen therapy as ordered
Administer oxytocin to stimulate a more
effective and consistent pattern of
contractions
Uncoordinated Contractions
- more than one pacemaker may be
initiating contractions, or receptor points
in the myometrium may be acting
independently of the pacemaker.
- do not allow good cotelydon filling

- occur so eratically (difficult for a woman

to rest between contraction or breathing
technique with contractions)
DYSFUNCTIONAL LABOR AND
ASSOCIATED STAGES OF LABOR

1. DYSFUNCTION WITH THE FIRST STAGE

OF LABOR

Prolonged Latent Phase

- major dysfunction that can occur in the
first stage of labor
- a latent phase that is longer than 20
hours in a nullipara or 14 hours in a
multipara
Risk Factors: The cervix is not
“ripe”at the beginning of labor,
excessive use of analgesic early in
labor
Interventions
> Administer morphine sulfate as ordered to relax
hypertonicity

> Administer IVF as ordered or encourage fluid intake to

prevent dehydration

> Amniotomy

> Oxytocin infusion

> Cesarean delivery if NSVD is not possible

Protracted Active Phase
- usually associated with CPD or fetal
malposition
Cervical dilatation does not occur at a
rate of atleast 1.2cm/h in a nullipara or
1.5cm/h in a multipara
- active phae last longer than 12h in a
primigravida or 6h in multigravida.
- contraction is hypotonic
- Cesarean birth if fetal malposition and
CPD is present
- If CPD is not present, oxytocin may be
administered to augment labor
Secondary Arrest of Dilatation
- There is no progress in cervical dilatation for more than 2
hours

DYSFUNCTION AT THE SECOND STAGE OF LABOR

Prolonged Descent
- occurs if the rate of descent is less than 1cm/h in a
nullipara or 2cm/h in a multipara
Interventions
> Encourage rest and fluid intake
> Rupturing of the membrane may be
helpful
> IV oxytocin administration for effective
contraction
> Place client in semi-Fowler’s position,
squatting, kneeling
> Encourage more effective pushing
( if no CPD or Fetal Malpresentation )
Arrest of Descent
-no descent has occured for 1 hour in
multipara and 2 hours in nullipara

Risk Factor: CPD

> Cesarean birth

> If no contraindication for NSVD, oxytocin
may be administered to assist labor
 Contraction Rings
Two Types

1.Pathologic Retraction Ring

2.Constriction Ring
Pathologic Retraction Ring
- Bandl’s ring
- most common

- occurs at the juncture of the upper and lower

uterine segments that forms as a warning sign
that severe dysfunctional labor is occuring
- usually appears during the second stage of
labor as a horizontal indentation across the
abdomen
- it is formed by excessive retraction of the
upper uterine segment
- the uterine myometrium is much thicker
above than below the ring
Constriction Ring
 - occur at any point in the myometrium
and at any time during labor

When a pathologic ring occurs in early

labor, it is usually caused by
uncoordinated contractions.
In the pelvic division of labor, usually
caused by obstetric manipulation or by the
administration of oxytocin
Complications
Uterine rupture
Death of the fetus

Massive maternal hemorrhage

(placenta is loosened but then
cannot be delivered preventing
the uterus to contract)
Interventions
> Observe abdomen during FHB monitoring
> Administration of IV morphine sulfate or the
inhalation of amyl nitrite
> Administration of tocolytic agent to halt
contractions
> cesarean birth to ensure safety of the fetus

> Manual removal of the placenta under general

anesthesia
> Report promptly any untoward findings
Precipitate Labor and Birth
- a labor that lasts less than 3 hors from the
onset of contractions to the time of birt
 - occur when uterine contrations are so strong
that the woman gives birth with only a few,
rapidly occuring contractions
 - can be predicted from a labor graph (during
active phase, the rate is > 5cm/h or 1cm/12
minutes in a nullipara, 10 cm/h or 1 cm/6
minutes in multipara )
 - occured at the highest rate (21.9) among
women age 35-39 and at the lowest rate (11.7)
among women younger than 20 years
induction of labor by oxytocin or
amniotomy, history of precipitous labor,
hypertonic uterine contractions that ate
tetanic in intensity
Complications:
• Premature separation of the placenta ―>
mother at risk for hemorrhage
• Uterine rupture
• Lacerations of the birth canal
• Amniotic fluid embolism
• Sudden release of the pressure on the head
―> fetus at risk for intracranial hemorrhage
• Fetal hypoxia – caused by decrease periods of
uterine relaxation between contractions
Interventions
> Monitor maternal and fetal status
 > Assess the previous delivery of client
 > Administer a tocolytic agent to reduce the force
and frequency of contraction
 > Caution a multiparous woman by week 28 of
pregnancy that her labor might be shorter than a
previous one
 > Woman with prior precipitate labor should
alerted that they may deliver this way again
 > Both multiparas and woman with histories of
precipitate labor should have the birthing room
converted to birth readiness before full dilatation
Uterine Rupture
- occurs when a uterus undergoes more strain than it
is capable of sustaining
 - accounts for as many as 5% of all maternal deaths
 - impending rupture may be preceded by a pathologic
retraction ring and by strong uterine contractions
without any cervical dilatation
 - can be complete, going through the endometrium,
myometrium, and peritoneum layers, or incomplete,
leaving the peritoneum intact.
 - fetal death will follow unless immediate cesarean
birth can be accomplished
Risk Factors:
* Prolonged labor
* Abnormal presentation
* Multiple gestation
* Unwise use of oxytocin
* Obstructed labor
* Traumatic maneuvers of forceps or
traction
* Vertical scar from previous
cesarean birth or hysterotomy
Signs and symptoms
1. Pathologic ring
2. A sudden, severe pain during a strong
labor contraction ( woman may report a
“tearing” sensation)
3. with a complete rupture, uterine
contractions will immediately stop
4. two distinct swellings is visible in the
woman’s abdomen
• The retracted uterus

• The extrauterine fetus

6. If the rupture is incomplete, a woman
may experience a localized tenderness and
a persistent aching pain over the area of
the lower uterine segment
7. Maternal and Fetal distress
Interventions
> Close monitoring of the fetal heart sound
and uterine contractions
> Administer emergency fluid replacement
therapy as ordered
> Anticipate use of IV oxytocin to attempt to
contract the uterus and minimize the bleeding
> Prepare the woman for a possible
laparotomy as an emergency measure to
control bleeding and achieve a repair
> Advise woman not to conceive again after
a rupture of the uterus, unless the rupture
occurred in the inactive lower segment
> Cesarean hysterectomy ( removal of the
damaged uterus)
> Tubal ligation at the time of laparotomy
> Allow time to the woman and support
person to express emotions without feeling
threatened
Inversion of the Uterus
- refers to the turning inside out of the uterus
either during birth of the fetus or delivery of the
placenta
- occurring in about 1 in 15,000 births

- inverted fundus may lie within the uterine

cavity or the vagina
- it may also protrude from the vagina
Risk Factors:
* If traction is applied to the
umbilical cord to remove the
placenta
* If pressure is applied to the
uterine fundus when the uterus is
not contracted
* If the placenta is attached to the
fundus
Signs and Symptoms
Interventions
> Assess vital signs
> Never attempt to replace an inversion
> Never attempt to remove the placenta if it is
still attached
>Start IV fluid line – use a large-gauge needle
> Administer oxygen via facemask
> Be prepared to perform cardiopulmonary
resuscitation (CPR) if the woman’s heart should
fail
> The woman will immediately be given general anesthesia
or possibly nitroglycerin or a tocolytic drug intravenously, to
relax the uterus
> Administer antibiotic therapy if needed
> Inform the woman that cesarean birth will probably be
necessary in any future pregnancy
> Monitor for hemorrhage and signs of shock
> Laparotomy with replacement is done
Preterm Labor
- cervical changes and uterine contractions
occurring between 20 weeks and 37 weeks of
pregnancy
 - may be associated with infection

Preterm birth – any birth that occurs before the

completion of 37 weeks of pregnancy
Preterm labor and preterm birth are the most
serious complications of pregnancy because
they lead to about 90% of neonatal deaths
Preterm birth are 2nd only to congenital
anomalies as a cause of infant death
Important Key Points
Preterm birth and Low birth weight are often used
interchangeably but they have distincly different
meaning
Preterm birth – describes length of gestation regardless
of the weight of the baby
- more dangerous health condition because length of
time in the uterus correlates with immaturity of body
systems
Low birth weight– describes the weight at a time of birth
- far easier to measure than preterm birth that is
why other use this term for preterm birth
Risk Factors for Preterm Labor
Demographic Risks
• Nonwhite race
• Age (<17 yr, >35 yr)
• Low socioeconomic status
• Unmarried
• Less than high school education
Biophysical Risks
Previous preterm labor and birth
Second trimester abortion (More than two spontaneous
or therapeutic); still births
Grand multiparity; short interval between pregnancies
(≤ 1 year since last birth); familty history of preterm
labor and birth
Progesterone deficiency
Uterine anomalies
Cervical incompetence
Exposure to DES or other toxic substance
Medical diseases (DM, HPN, anemia)
Small stature (<119 cm in height; <45.5 kg or
underweight for height)
Current pregnancy risks:
* multifetal pregnancy
* hydramnios
* bleeding
* placental problems
*gestational hypertension
* PROM
* Fetal anomalies
*Inadequate plasma volume expantion; anemia
Behavioral-Psychosocial Risks
* Poor nutrition; weight loss or low weight gain
* Smoking (> 10 cigarettes a day)
* Substance abuse (e.g., alcohol, ellicit drugs,
especially cocaine)
* Inadequate prenatal care
* Commutes more than 1 ½ hours each day
*Excessive physical activity (heavy physical work,
prolonged standing, heavy lifting, young child
care)
*Excessive lifestyle stressors
Assessment
* Infection is thought to be the major etiologic
factor
* Painful or painless uterine contraction
* Abdominal cramping (may be accompanied
by diarrhea)
* Low back pain
* Pelvic pressure or heaviness
* Change in the character and amount of usual
discharge; may be thicker or thinner, bloody,
brown or colorless, and may be odorous
* Rupture of amniotic membranes
Signs and Symptoms of Preterm
Labor
Uterine Activity
1. Uterine contractions more frequent
than every 10 minutes persisting for
1 hour or more
2. Uterine contractions may be
painful or painless
Discomforts
1. Lower abdominal cramping similar to
gas pains; may be accompanied by
diarrhea
2. Dull, intermittent low back pain
(below the waist)
3. Painful menstrual-like cramps
4. Suprapubic pain or pressure
5. Pelvic pressure or heaviness
6. Urinary frequency
Vaginal Discharge
1. Change in character or amount of
usual discharge: thicker(mucoid) or
thinner (watery), bloody or colorless,
increased amount, odor
2. Rupture of amniotic membranes
Interventions
 Focus on stopping the labor
1. Identify and treat infection
2. Bed rest – a form of care of unknown
effectiveness
- with negative effect
 Monitor fetal status

 Administer fluids

 Administer medications as prescribed ( tocolytic and

antenatal glucocorticoids)
 Education about the signs and symptoms of preterm
labor
> Encourage client to go on prenatal visit to detect
signs of preterm labor
> If symptoms occur when the woman is engaged in
any of activities, the woman should consider what she
was doing when symptoms began, and then consider
stopping those activities until 37 weeks of pregnancy
> Individualized counselling about lifestyle
modification
> There are no specific rules for which activities are
safe for pregnant women and which are not
Factors influencing the impact
of preterm labor treatment:
Stability of the support system
Financial status
Availability of child support and
assistance with household
maintenance
Medications Used in Preterm labor
1.Ritodrine
2.Magnesium sulfate
3.Terbutaline
4.Nifedipine
5.indomethacin
Predicting Preterm Labor
and Birth
Biochemical Markers
Fetal fibronectin
Salivary estriol

Endocervical Length
* up to 94% - negative result
* < 46 % - positive result

Salivary estriol
- a form of estrogen produced by the fetus that is present in
plasma at 9 weeks of gestation
- have been shown to increase before preterm birth
- specimen are collected by the woman in the home
- the testing is done every 2 weeks for about 10 weeks
* 98% - negative predictive value
* 7% to 25% - positive predictive value

Endocervical length
- studies have suggested that a shortened
cervix precedes preterm labor
- can be determined by ultrasound
measurement
- women whose cervical length is 35 mm at
24 to 28weeks of gestation are more likely to
have a preterm birth than women whose
cervical length exceeds 40mm
Fetal fibronectins
- are glycoproteins found in plasma and
produced during fetal life
 - specimen is the cervical mucus
 - appear in cervical canal early in
pregnancy and then again in late
pregnancy
 - appearance between 24 and 34 weeks of
gestation predicts labor
 - done during vaginal examination
 - can predict who will not go into pretem
labor , but not who will
Factors influencing the psyche of the
client in labor and the effect of fear,
anxiety on labor progress

> Hormones and neurotransmitters released

in response to stress can cause dystocia
> Sources of stress vary for each woman,
but pain and absence of support person are
two recognized factors
An idealized perception of labor and birth may be a
source of guilt and and a sense of failure especially
when the pregnancy is unplanned or is a product of
shaky or terminated relationship

Unresolve fears increase a woman’s stress and can

inhibit the process of labor as a result of the inhibiting
effects of catecholamines associated with the stress
response on uterine contractions
> Confinement to bed and restriction of maternal
movement can be a source of stress
> When anxiety is excessive, it can inhibit normal
cervical dilatation and result in prolonged labor and
increased pain perception
> Anxiety causes increased level of stress-related
hormones ―> Increase hormones―> acts on smooth
muscles of the uterus―> reduce uterine
contractility―> dystocia
Interventions
> Answer her questions or find out the
answers
> Provide support for her and her support
person and family
> Serve as a client’s advocate (women
equate emotional support with information
giving)- give empowerment
> Assures the woman that she is not
expected to act in any particular way and that
the process will end in the birth of the baby
> Women with a history of sexual abuse
* Memories can be triggered during labor by intrusive
procedures such as vaginal examinations; loss of control;
being confined to bed and “restrained” by monitors , IV
lines, and epidurals; being watched by students; and
experiencing intense sensations in the uterus and genital
area, especially at the time when the woman must push
the baby out
> Women who are survivors of abuse may
fight the labor process by reacting in panic or
anger toward care providers, may take control
of everyone and everything related to their
childbirth, may surrender by being submissive
and dependent, or may retreat by mentally
dissociating themselves from the sensations
of labor and birth
Interventions
> Encourage the woman to associate the
sensations they are experiencing with the process
of childbirth and not with their past abuse
> Sense of control should be maintained by
explaining all procedures and why they are
needed, validating her needs and paying close
attention to her requests
> Proceeding at the woman’s pace by waiting for
her permission to touch her
> Accept her often extreme reactions to labor
> Protect her privacy – limit the exposure of her
body and number of persons involve in her care

It is recommended that all laboring

woman be cared for in this manner ,
because it is not unusual for a woman
to choose not to reveal a history of
sexual abuse
 What sets us apart from other
species is that we humans are driven
by ambition. Some ambitions are
specific, while others are vague. A life
without ambition is a waste.
“Aim small, miss small.” These aim
quotes remind us to neverr stop
marching towards our goal.
Thank You Very
Much
God Bless