MATERNAL AND CHILD CHAPTER 23

2ND SEMESTER FINALS S.Y. 2023-2024 Autonomic Nervous

PROFESSOR: SystemGOOPIO
MS. CZARLYNN

⋆ The uterus tends to be in a hypertonic state.

CHAPTER 23: NURSING CARE OF A FAMILY
EXPERIENCING A COMPLICATION OF LABOR Management
OR BIRTH ⋆ Providing adequate fluid for hydration,
COMPLICATIONS WITH THE POWER ⋆ Pain relief with a drug such as morphine sulfate
(THE FORCE OF LABOR) ⋆ Changing the linen and the woman’s gown,
Inertia is a time-honored term to denote darkening room lights
sluggishness of contractions, or that the force of
labor is less than usual. A more current term is PROTRACTED ACTIVE PHASE
dysfunctional labor. ⋆ is usually associated with fetal malposition or
cephalopelvic disproportion (CPD) (the diameter
Dysfunction can occur at any point in labor, but of the fetal head is larger than the woman’s pelvic
it is generally classified as: diameters)
Primary - occurring at the onset of labor ⋆ This phase is prolonged if cervical dilatation
Secondary - occurring later in labor does not occur at a rate of at least 1.2 cm/hr in a
nullipara or 1.5 cm/hr in a multipara, or if the
CAUSES OF DYSFUNCTIONAL LABOR active phase lasts longer than 12 hours in a
COMMON primigravida or 6 hours in a multigravida
⋆ Primigravida status
⋆ CPD PROLONGED DECELERATION
⋆ Posterior rather than anterior fetal position or PHASE
extension rather than flexion of the fetal head ⋆ A deceleration phase has become prolonged
⋆ Failure of the uterine muscle to contract when it extends beyond 3 hours in a nullipara or
properly or overdistention of the uterus 1 hour in a multipara.
⋆ A nonripe cervix ⋆ A prolonged deceleration phase most often
⋆ Presence of a full rectum or urinary bladder that results from abnormal fetal head position. A
impedes fetal descent cesarean birth
⋆ A woman becoming exhausted from labor is frequently required.
⋆ Inappropriate use of analgesia (excessive or too
early administration) SECONDARY ARREST OF
DILATATION
⋆ A secondary arrest of dilatation has occurred if
there is no progress in cervical dilatation for
longer than 2 hours. Again, cesarean birth may be
necessary

DYSFUNCTION AT THE
SECOND STAGE OF LABOR
PROLONGED DESCENT
⋆ Occurs if the rate of descent is less than 1.0
cm/hr in a nullipara or 2.0 cm/hr in a multipara.
⋆ It can be suspected if the second stage lasts over
2 hours in a multipara
DYSFUNCTION AT THE
FIRST STAGE OF LABOR ARREST OF DESCENT
PROLONGED LATENT PHASE ⋆ Arrest of descent results when no descent has
⋆ This may occur if the cervix is not “ripe” at the occurred for 2 hours in a nullipara or 1 hour in a
beginning of labor. multipara. Failure of descent occurs when the
⋆ It may occur if there is excessive use of an expected descent of the fetus does not begin or
analgesic early in labor.
engagement or movement beyond 0 station does • The fetus is in a longitudinal lie.
not occur. • The cervix is ripe, or ready for birth.
• The presenting part is the fetal head (vertex) and
PRECIPITATE LABOR is engaged.
PRECIPITATE DILATATION • There is no CPD.
⋆ is cervical dilatation that occurs at a rate of 5 • The fetus is estimated to be mature by date
cm or more per hour in a primipara or 10 cm or (over 39 weeks).
more per hour in a multipara.
CERVICAL RIPENING
PRECIPITATE BIRTH the first change of the uterus in early labor
⋆ occurs when uterine contractions are so strong because, until this has happened, dilatation and
a woman gives birth with only a few, rapidly coordination of uterine contractions will not
occurring contractions, often defined as a labor occur.
that is completed in fewer than 3 hours
INDUCTION AND TO HELP A CERVIX “RIPEN,” A NUMBER OF
AUGMENTATION OF LABOR METHODS CAN BE INSTITUTED.
AUGMENTATION OF LABOR Stripping the membrane - separating the
⋆ artificial rupture of the membranes (with membranes from the lower uterine segment
oxytocin or amniotomy) manually,
⋆ refers to assisting labor that has started
spontaneously but is not effective. Use of hygroscopic suppositories- suppositories
of seaweed that swell on contact with cervical
INDUCTION OF LABOR secretions
⋆ labor is started artificially.
⋆ induction could be completed if a fetus was Insertion of a prostaglandin - dinoprostone
proven to have adequate lung surfactant by (Prepidil, Cervidil) into the posterior fornix of
amniocentesis at term but less than 39 weeks. the vagina, by the cervix

The American College of Obstetricians and Although not approved for obstetric use by the
Gynecologists (ACOG) has issued a statement U.S. Food and Drug Administration (FDA),
(ACOG, 2013) indicating that fetal lung maturity misoprostol is a drug you may often see used off
should not be used and inductions should be label to assist in cervical ripening.
avoided until 39 weeks unless medically
indicated. INDUCTION OF LABOR BY
OXYTOCIN
CONDITIONS Oxytocin is always administered intravenously,
⋆ Preeclampsia, Eclampsia, Severe hypertension so that, if uterine hyperstimulation should occur,
⋆ Diabetes it can be quickly discontinued.
⋆ Rh Sensitization
⋆ Post maturity - a pregnancy lasting beyond 42 UTERINE RUPTURE
weeks Rupture of the uterus during labor.

Oxytocin is an effective uterine stimulant, but CONTRIBUTING FACTORS

there is a thin line between adequate stimulation ⋆Prolonged labor
and hyperstimulation, so careful observation ⋆Abnormal presentation
during the entire infusion time is an important ⋆Multiple gestation
nursing responsibility. ⋆Unwise use of oxytocin
⋆Obstructed labor
Before induction of labor is begun in term and ⋆Traumatic maneuvers of forceps or traction
post term pregnancies, the following conditions
should be present:
 IMMEDIATE MANAGEMENT:
ASSESSING THE PREGNANT WOMAN ⋆Oxygen administration by face mask or cannula.
WITH COMPLETE UTERINE RUPTURE ⋆Cardiopulmonary resuscitation (CPR)
SIGNS OF HYPOTENSIVE SHOCK:
⋆Rapid, weak pulse PROLAPSE OF THE UMBILICAL CORD
⋆Falling blood pressure UMBILICAL CORD PROLAPSE
⋆Cold and clammy skin a loop of the umbilical cord slips down in front of
⋆Dilation of the nostrils from air starvation the presenting fetal part.
⋆Fetal heart sounds fade and then are absent
IT TENDS TO OCCUR MOST OFTEN WITH:
MANAGEMENT ⋆ Premature rupture of membranes
⋆ Fetal presentation other than cephalic
⋆Administer emergency fluid replacement ⋆ Placenta Previa
therapy as prescribed. ⋆ Intrauterine tumors preventing the presenting
⋆Anticipate the use of IV Oxytocin. part from engaging
⋆Prepare the woman for a possible laparotomy as ⋆ A small fetus
an emergency measure. ⋆ CPD preventing firm engagement
⋆Cesarean Hysterectomy - removal of damaged ⋆ Polyhydramnios
uterus. ⋆ Multiple gestation

INVERSION OF THE UTERUS ASSESSMENT:

UTERINE INVERSION ⋆ Can be visualized through ultrasound.
the uterus turning inside out with either birth of ⋆ When the FHR is discovered to be unusually
the fetusor delivery of the placenta. slow or a variable deceleration FHR pattern
suddenly becomes apparent on a fetal monitor.
SIGNS OF UTERINE INVERSION ⋆ Cord may be visible in the vulva.
⋆Blood Loss
⋆Hypotension THERAPEUTIC MANAGEMENT:
⋆Dizziness ⋆Placing a gloved hand in the vagina and
⋆Paleness manually elevating
⋆Diaphoresis the fetal head off the cord,
⋆Position the woman in knee-chest or
INVERSION OF THE UTERUS trendelenburg position.
MANAGEMENT OF UTERUS INVERSION ⋆ Administer oxygen by face mask.
⋆ Never attempt to replace the inversion of the ⋆ Amnioinfusion
uterus ⋆ If the cord prolapsed has been exposed to room
⋆ Never attempt to remove the placenta air, cover any exposed portion with a sterile saline
⋆ Discontinue Oxytocin compress.
⋆ Insert IV fluid
⋆ Administer oxygen by mask AMNIOINFUSION
⋆ Monitor vital signs the addition of a sterile fluid into the uterus to
⋆ Be prepared to perform cardiopulmonary supplement the amniotic fluid and reduce
resuscitation (CPR) compression on the cord.

AMNIOTIC FLUID EMBOLISM MULTIPLE GESTATIONS

occurs when amniotic fluid is forced into an open ⋆ Pregnancies with two or more fetuses.
maternal uterine blood sinus after a membrane ⋆Often delivered by cesarean section.
rupture or partial premature separation of the ⋆Anemia and gestational hypertension occur at
placenta. higher than usual.
⋆ If a woman with a multiple gestation will be BROW PRESENTATION
giving birth vaginally, she is usually instructed to Brow presentation is the rarest of the
come to the hospital early in labor. presentation. It occurs in a woman with relaxed
⋆ During labor, support the woman’s breathing abdominal muscle. It also leaves the infant with
exercises. anterior fontanelle or “soft stop”.
⋆ Be certain that when taking fhrs by doppler or a
fetal monitor. TRANSVERSE LIE
A transverse lie usually is obvious on inspection
PROBLEMS WITH FETAL POSITION, because the ovoid of the uterus is found to be
PRESENTATION OR SIZE more horizontal than vertical. The abnormal
OCCIPITO-POSTERIOR POSITION presentation can be confirmed by Leopold
It is the vertex presentation when occiput is maneuver.
placed posteriorly over the sacro-illiac joint or
directly over sacrum. OVERSIZED FETUS (MACROSOMIA)
An oversized fetus. It occurs frequently in women
RESPONSIBLE FACTORS: with diabetes, it can lead trauma during birth and
⋆Shape of the pelvic inlet a greater chance of a cesarean delivery.
⋆Fetal factors
⋆Uterine factors SHOULDER DYSTOCIA
Is a birth problem that is increasing in incidence
COURSE OF LABOR because the weight and therefore the size of the
First stage (engagement, membrane status, newborn is increasing.
uterine contraction)
Second stage (often delayed due to long FETAL ANOMALIES
internal rotation or malrotation) Fetal anomalies of the head such as
Third stage (long anterior rotation of occiput, hydrocephalus (fluid-filled ventricles) or
short posterior rotation, short anterior rotation) anencephaly (absence of the cranium) are a final
category of fetal factors that can complicate birth.
SUNNY SIDE UP
When the baby is born looking at the ceiling. INLET CONTRACTION
Inlet contraction is narrowing of the
BREECH PRESENTATION anteroposterior diameter of the pelvis to less than
It refers to the fetus in the longitudinal lie with the 11cm, or the transverse diameter to 12 cm or less.
buttocks or lower extremity entering the pelvis It usually is caused by rickets in early life or by
first. an inherited small pelvis.

TYPES OF BREECH PRESENTATION OUTLET CONTRACTION

⋆Complete Inlet contraction is narrowing of the transverse
⋆Frank diameter, the distance between the ischial
⋆Footling tuberosities a the outlet, to less than 11 cm.
Measurement is made by sonogram during
CAUSES OF BREECH PRESENTATION pregnancy.
⋆Gestational age less than 40 weeks
⋆Polyhydramnios TRIAL LABOR
⋆Congenital anomaly of the fetus The trial labor is when a woman has a borderline
⋆Multiple gestation inlet measurement and the fetal lie and position
are good, her primary care provide may allow her
FACE PRESENTATION a “trial” labor to determine whether labor will
A fetal head presenting at a different angle than progress normally.
expected is termed asynclitism.
 EXTERNAL CEPHALIC VERSION TWO-VESSEL CORD (SINGLE UMBILICAL
The turning of a fetus from a breech to cephalic ARTERY)
position before birth. It may be done as early as Is a perinatal finding that may be detected in
34-35 weeks. infants with congenital or chromosomal
abnormalities. Its presence has been associated
FORCEP BIRTH with an increased risk of genitourinary defects.
It is a form of assisted delivery that can help
mothers deliver their babies vaginally when labor UNUSUAL CORD LENGTH
is not progressing. The length of the umbilical cord rarely varies,
some abnormal length may occur. An unusual
VACUUM EXTRACTION short umbilical cord can result in premature
A fetus, if positioned far enough down the birth separation of the placenta or an abnormal fetal lie.
canal, may be born by vacuum extraction. A soft,
disk-shaped cup is pressed against the fetal scalp
and over the posterior fontanelle.

ANOMALIES OF THE PLACENTA

PLACENTA SUCCENTURIATA
A placenta that has one or more accessory lobes
connected to the main placenta by blood vessel.
No fetal anomalies is associated with this type.

PLACENTA CIRCUMVALLATA
The fetal side if the placenta is covered to some
extent with chorion.

PLACENTA MARGINATA
The fold of chorion reaches just to the edge of the
placenta.

BATTLEDORE PLACENTA
The cord is inserted marginally rather than
centrally.
This anomaly is rare and has no known clinical
significance either.

VELAMENTOUS INSERTION OF THE CORD

Is a situation in which the cord, instead of
entering the placenta directly, separates into
small vessels that reach the placenta by spreading
across a fold of amnion.

VESA PREVIA
The umbilical vessels of a velamentous cord
insertion across the cervical and therefore deliver
before the fetus.

PLACENTAL ACCRETA
Is an unusually deep attachment of the placenta to
the uterine myometrium, so deep that the placenta
will not loosen and deliver.