COMPLICATIONS WITH THE PASSAGE

CEPHALOPELVIC DISPROPORTION
- A narrowing, or contractions, of the birth canal, which
can occur at the inlets, midpelvis, or outlet, causes a
disproportion between the size of the fetal head and
the pelvic diameters, or cephalopelvic disproportion
(CPD). CPD results in failure of labor to progress

PRIMARY PROBLEMS
Malpositioning can occur because the fetuss
head isnt engaged in the pelvis.
Malpositioning can lead to further
complications. For example, if membranes
rupture, the risk for cord prolapse increases
significantly.

CAUSES
Small pelvis is major contributing factor in CPD. It may
result in rickets in the early life of the mother, or a
pelvis that isnt fully matured in a young adolescent.
The fetal head may be too large to fit or the overall fetal
size may be prohibitively large (known as macrosomia).

 Abnormal poritions of the fetus canal so cause

CPD.
Fetal anomalies such as hydrocephalus,
hydrops fetalis and tumors of the fetal head
can also result in CPD.

DETECTION
A previous vaginal birth without any problem
is substantial proof that the birth canal is
considered adequate.

Pelvic measurement should be taken and

recorded before week24.

MANAGEMENT
A trial labor may be allowed to continue of descent of the
presenting part and dilatationof the cervix are occurring.
The following nursing measures areimportant in trial labor:
Monitor fetal heart sounds anduterine contractions continuously.
Make sure that the womans urinarybladder is kept empty to allow
thefetal head to use all space, makingdelivery possible.

Labor & Delivery

1. Passage
a. Gynecoid
- normal female pelvis
- ideal for childbirth
- round shape pelvic inlet
b. Android
- male pelvis
- heart shaped pelvic inlet
c. Anthropoid
- ape like pelvis
- oval shaped pelvic inlet
d. Platypeloid
- flattened pelvis
- reverse oval shaped

CEPHALOPELVIC DISPROPORTION

PROBLEMS WITH POWERS

Hypotonic Uterus
- contraction is weak; dilatation and effacement does
not progress.

-oxytocin stimulation will be beneficial.

-occur during the active phase of labor

Induction or Stimulation of Labor

Elective Induction:
1. Pharmacologic means:
- Vaginal insertion of Prostaglandin E2, cervix softens and
effaces
- 8-12hrs after prostaglandin E2, oxytocin infusion

2. Mechanical means:
- amniotomy
-laminaria insertion
-nipple stimulation

 Augmentation of Labor:
-assisting client when labor process is not
progressing normally ( prolonged labor) by
pharmacologic or mechanical means

Nursing Care of Clients During Induction of Labor:

Assessment
-Obstetric history
- Maternal status:
- Uterine contractions
-Status of cervix, membranes
-ultrasound findings
- Level of anxiety
- Fetal status:
- Gestational age
- (-) CPD
- fetal monitor results

Nursing Diagnoses:

1. Anxiety r/t uncertainty of labor and birth process

2. Risk for infection r/t ruptured membranes
3. Pain r/t use of oxytocics
4. Risk for trauma r/t possibility of sustained
contractions from oxytocin or fetal cord prolapse
following amniotomy

Planning/Implementation
1. Prepare mother and labor coach for induction
- explain all procedures
- obtain informed consent
2. Remain with the patient at all times
3. Obtain and record baseline v/s, FHR, contractions
4. Monitor pitocin administration
- gradual increase drip rate till contractions occur every 23mins
- slow rate if (+) hypotension or tachycardia

- D/C pitocindrip if:

sustained uterine contractions occur
fetal accelerations
decelerations persist
urinary flow decreases to 30 ml/hr
signs of abruptio placenta appear
5. Monitor effect of prostaglandin
6. Assist with amniotomy
maintain asepsis
monitor FHR immediately after rupture
Note time, color, amount of AF

7. Maintain hydration
Prepare for E CS if necessary
Evaluation/Outcome
1. Labor begins or increases and progresses to birth
2. Pitocin causes no adverse effects
3. Anxiety is decreased
4. Client shows no signs of infection

Hypertonic Uterus - contractions are painfully strong and

frequent but ineffective in producing effacement and
dilatation.
-Reposition patient and administer analgesic.
-Tocolytic drugs (ritodrine) maybe effective.
-occur in the latent phase of labor.

Pelvic Dystocia - abnormalities in any of the 3

planes of the pelvis, inlet contraction, midplane
and outlet contraction.
-Contraction is low
-Cervical dilatation and effacement does not
progress
-Fetus fails to descent in the pelvic planes.

ABNORMAL PROGRESS IN LABOR

LENGTHS OF PHASES & STAGES OF

NORMAL LABOR IN HOURS
Nullipara

Multipara

PHASE

PHASE
AVERAGE

UPPER
NORMAL

AVERAGE

UPPER
NORMAL

LATENT

8.6

20

5.3

14

ACTIVE

5.8

12

2.5

2ND STAGE

1.5

0.25

Labor Curves

PATHOLOGIC RETRACTION RING

PROLONGED LABOR
PELVIC DYSTOCIA

PATHOLOGIC RETRACTION RING

CESAREAN DELIVERY

CS delivery Indications:
1.CPD
2.malposition
3.Malpresentation
4previous CS
5.complete or partial placenta previa
6.abruptio placenta
7.prolapsed umbilical cord
8.fetal distress

Obstetric Intervention
Types:
1. Low Segment
incision done on lower uterine segment
blood loss is minimal
possibility of later uterine rupture is lessened
2.Classic
incision is made on the wall of the body of the uterus
done for anterior placenta previa
done for transverse lie

PFANNENSTIEL ( BIKINI) INCISION

PFANNENSTIEL

VERTICAL ABDOMINAL INCISION

Indications of Cesarean Section

Obstetric Interventions:
Nursing Care:
a. monitor vital signs closely
b. check dressing site
c. inspect perineal pad
d. check uterine fundus for firmness
e. breathing exercises
f. out of bed 1st post-op day
g. have the woman hold the baby ASAP

Other Complications:
A. PREMATURE LABOR & BIRTH Contributing
Factors:
a. multiple gestation
b. Polyhydramnios
c. PROM
d. incompetent cervix
E .placenta previa / abruptio placenta
f. previous preterm labor
g. infection

Management :
1. Prevention of Premature Delivery
- if woman is currently in preterm labor, she is admitted to the hospital

Bedrest
monitoring of contractions
IE
Tocolytic drugs ( Ritodrine, Terbutaline SO4)

Patient Teaching:
- teach woman symptoms of preterm labor

uterine contractions irregular pattern for more than 1 hour while at rest
intermittent or constant uterine cramps
low, dull backache & abdominal cramping
rupture of membrane

Nursing Care of Clients with Preterm Labor with Tocolytic

Therapy:
A. Assessment
1. Number of weeks of gestation
2. Presence of live and viable fetus
3. Presence of labor:
2 contractions lasting 30 seconds in a 15 minute period
cervical dilatation less than 4 cms
effacement of 50% or less
4. No signs of hemorrhage or infection
5. Presence of severe PIH
6. Prolonged rupture of membranes
7. Emotional impact on mother

Analysis/Nursing Diagnoses:
1.
2.

3.
4.
5.
6.
7.

Anxiety r/t uncertainty of labor and birth process

Ineffective family coping r/t need for specialized care and
continued hospitalization of the newborn
Fear r/t acute status of baby and potential for death
Knowledge deficit r/t cause and treatment for preterm labor
Altered parenting r/t the physical condition of the baby
Situational low self -esteem r/t failure to carry pregnancy to full
term
Risk of trauma r/t use of medications

Interventions:
1. Monitor VS, FHR, contractions and progression of labor
2. Maintain bed rest
3. Inform client about the medication; obtain consent
4. Provide emotional support; reduce anxiety and prepare for possible
loss of baby
5. Provide special care related to the administration of tocolytic drugs
6. Prepare for use of glucocorticoid therapy for the fetus
7. Prepare for premature birth if labor continues
8. Provide home instructions for halting preterm labor

Evaluation/Outcome:
1. Labor ceases
2. FHT satisfactory
3. No adverse effects from tocolytic drugs
4. Anxiety decreases
5.Client and partner able to state recurring signs
of preterm labor

Other Complications:
PRECIPITATE DELIVERY - characterized by very strong contractions &
delivery that occurs less than 3 hours of labor
Predisposing Factors:
multiparity
history of rapid labor
premature or small fetus
large bony pelvis Risks:
perineal lacerations
hemorrhage
cerebral trauma

Management:

fetal monitoring- fht..

analgesia - nubain (nalbuphine); demerol
assess for birth injury
assess for cervical, vaginal & perineal
lacerations

Nursing Care of Clients During Precipitate Labor:

A. Assessment
1. Rapid cervical dilatation
2. Accelerated fetal descent
3. History of rapid labor
4. Frequent uterine contractions with decreased relaxation
B. Analysis/Nursing Diagnoses
1. Risk for maternal injury r/t rapid expulsion of fetus resulting
in lacerations and hemorrhage
2. Risk for fetal trauma r/t cranial battering during rapid birth

Planning/Implementation:
1. Remain with mother and monitor closely
2. Keep emergency birth pack at bedside
3. Keep mother and partner informed throughout process of
labor and birth
Evaluation/Outcomes:
1. Mother is safe throughout labor and birth
*babys are nose breathers
2.Neonate remains injury free during birth

UTERINE INVERSION
*baby out. Placenta next.. Delivered w/in 30mins.
Check for placental separation
*gushing of blood
*involution of uterus
*rising of fundus
*lenghtening of the cord
*BRANT ANDREWS MANUEVER-movement: updown, right-left placenta

UTERINE INVERSION CORRECTION

UTERINE PROLAPSE/inversion
- can happen to old women; multigravida.. ; who didnt give birth
& h-mole

UTERINE RUPTURE
*prolonged labor due to cephalopelvic
disproportion
*previous CS
*primigravida with prolonged cpd

PLACENTAL PROBLEMS
PLACENTA PREVIA
ABRUPTIO PLACENTA

Abnormally Adherent Placenta:

Accreta - attachment of the placental villi to the
myometrium.
Increta - invasion of the placental villi into the
myometrium.
Percreta -penetration of the placental villi through the
myometrium to the serosa

PLACENTA ACCRETA

PROBLEMS WITH THE PSYCHE

FACTORS:

1.First Trimester
- ambivalence; focuses more on self
- fear
-possible decrease in sex drive
TASK:
Accepting the pregnancy, I am pregnant
2.Second Trimester
- increased awareness and interest in fetus
-acceptance of reality of pregnancy
- feeling of well-being
-preoccupation with self
TASK:
Accepting the baby, A baby is growing inside
me

3. Third Trimester
- anticipation of labor and delivery
- fears ( impending labor ) and fantasies
( motherhood) about pregnancy
- heightened introversion
- view infant as reality vs fantasy
- spurt of energy during the last month
TASK:
Preparing for parenthood, I am a mother
COUVADE SYNDROME - group of physiological & behavioral
manifestation experienced by the husban- are often the results of stress, anxiety & empathy for the pregnant
women

Onset:3-5 days after birth

Symptoms: sadness, fears
Incidence:75% of all births
Etiology :probable hormonal changes, life
changes
Therapy :support, empathy
Nursing Role: offer compassion&
understanding
*taking in centered on mothers feelings
*taking hold -return demo
*letting go: holding the baby

Onset: 1-6 months after birth

Symptoms: anxiety , feeling of loss,
sadness
Incidence: 10% of all births
Etiology : history of poor parental
relationship ,hormonal response

Therapy : counseling
Nursing Role: refer for counseling

Onset: within 1st month after birth

Symptoms: delusions, hallucinations
Incidence: 2% of all birth
Etiology : possible activation
of previous mental illness, hormonal
changes

Therapy : psychotherapy , drug

therapy
Nursing Role: refer for
counseling, safeguard mother
from injury to self or newborn

HIGH RISK POSTPARTAL CLIENTS:

BLEEDING
INFECTION
THROMBOEMBOLISM
PSYCHIATRIC DISORDERS

Postpartum Complications : Subinvolution

Description
- Incomplete involution or failure of uterus to return to its norma lsize and
condition
Assessment :
Pelvic pain or heaviness
Backache
Uterus is larger and softer than expected
Prolonged lochial discharge
Irregular or excessive uterine bleeding
Interventions:
Monitor fundal height and lochia
Prepare to administer methylergonovine maleate (Methergine) as
prescribed

Postpartum
Complications:Hemorrhage
Description - Blood loss exceeding 500 ml. after vaginal childbirth or
1000 ml. after cesarean birth
Assessment :
Early
Occurs during 24 hours after delivery
Caused by uterine atony or laceration or inversion of uterus
Late
Occurs after the 24 hours following delivery
Caused by retained fragments of placenta

Signs of Uterine Atony :

Uterine fundus is difficult to locate
Soft or boggy fundus
Uterus becomes firm when massaged but loses tone when massage
is stopped
Uterine fundus located above expected level
Excessive lochia, especially if it is bright red
Expulsion of excessive number of clots

Interventions:

Notify health-care provider if hemorrhage occurs

Assess client for uterine atony
If uterus is not firmly contracted, massage fundus until it is firm
and to express clots that may have accumulated in the uterus (but
do not push on uterus)
Monitor client's vital signs and fundus every 5 to 15 minutes
Prepare to administer intravenous fluids, blood transfusions, and
medications such as oxytocin (Pitocin) to maintain firm contraction
of uterus
If bleeding is due to a laceration, prepare client for repair
of laceration

Postpartum Complications: Infection

Description - Any infection of the reproductive organs
that occurs within 28 days of delivery or abortion
Assessment :
Chills and fever
Anorexia
Pelvic discomfort or pain
Vaginal discharge
Increased white blood cell count

Interventions:
Check client's vital signs and temperature every 2 to 4
hours
Make mother as comfortable as possible; position her for
comfort and to promote vaginal drainage
Keep mother warmed if chilled
Isolate newborn from the mother only if mother is
infectious
Provide a high-calorie, high-protein diet and encourage
fluids to 3000 to4000 ml/day if not contraindicated
Encourage frequent voiding and monitor client's intake and
output
Monitor results of cultures if they were prescribed
Administer antibiotics according to organism, as prescribed

Postpartum
Complications:Endometritis
Description :
Infection of uterine lining after delivery; caused by bacteria
that invade uterus at site of attachment of placenta
Infection may spread, involving entire endometrium and
causing peritonitis, paralytic ileus, or pelvic abscess
Assessment :
Chills and fever
Uterine tenderness and enlargement
Foul odor or purulent lochia; may increase or decrease in
volume
Malaise, fatigue, tachycardia

I nterventions:
Monitor client's vital signs
Obtain cultures of blood and lochia
Assist client into Fowler's position to facilitate
drainage of lochia
Administer antibiotics and pain medication as
prescribed
Instruct client in proper handwashing techniques
Initiate wound(contact) precautions as necessary
Breastfeeding may be restricted during infectious
period; if woman is breastfeeding, she may need
to pump her breasts to establish and maintain
lactation

Postpartum Complications:
Thrombophlebitis
Description:
A condition in which a clot forms in a vessel wall as a
result of inflammation of the wall
Partial obstruction of vessel may occur
Increased levels of clotting factors in postpartum
period place client at risk
Assessment :
Heat, tenderness, and pain in affected leg
Swelling of affected leg
Homans' sign
Chills and fever

Swelling/Homans sign
- pain is felt when the foot is dorsiflexed on the affected area.
Do not massage