CARE OF MOTHER AND CHILD A-RISK OR WITH PROBLEMS (ACUTE & CHRONIC) FINALS
CAUSES
INTRAPARTUM EMERGENCIES
➢ Uterine rupture is associated with previous uterine surgery
UTERINE RUPTURE
such as cesarean
• Rupture of the uterus
➢ birth or surgery to remove fibroids.
during labor, although
➢ The risk for rupture is greater in women with a classic
rare, is always a
incision (vertical into the upper uterine segment) than in
possibility.
women with a low transverse incision.
• It occurs most often in ➢ Rupture of the unscarred uterus is more likely for women
women who have a of high parity with a thin uterine wall, women sustaining
previous cesarean scar blunt abdominal
• When uterine rupture ➢ trauma, and women having intense contractions, especially
occurs, fetal death will if fetopelvic disproportion is present.
follow unless immediate ➢ Excessively strong contractions (hypertonic) may cause the
cesarean birth can be intrauterine pressure to exceed the tensile strength of the
accomplished. uterine wall.
• Rupture can be complete, For this reason, vaginal birth after cesarean (VBAC) is not
going through the endometrium, myometrium, and recommended for women who have had a previous birth
peritoneum layers, or incomplete, leaving the peritoneum through a classic cesarean incision.
intact. ➢ Uterine rupture is associated with previous uterine surgery
• such as cesarean birth or surgery to remove fibroids.
• Rupture can be complete, going through the endometrium, ➢ The risk for rupture is greater in women with a classic
myometrium, and peritoneum layers, or incomplete, incision (vertical into the upper uterine segment) than in
leaving the peritoneum intact. women with a low transverse incision.
DIAGNOSIS
• The rupture can be confirmed by ultrasound
THERAPEUTIC MANAGEMENT
• Initial management is to stabilize the woman and the fetus
for a cesarean birth.
• Fluid replacement therapy as prescribed.
• Anticipate the use of IV oxytocin to attempt to contract the
uterus and minimize bleeding.
• If the rupture is small and the woman wants other children,
it may be repaired.
• A woman with a large uterine rupture requires
• COMPLETE RUPTURE hysterectomy.
▪ uterine contractions will immediately stop. • Blood Transfusion
▪ Two distinct swellings will be visible on the • The viability of the fetus depends on the extent of the
▪ woman’s abdomen: the retracted uterus and the rupture and the time elapsed between rupture and
extrauterine fetus. abdominal extraction.
▪ Hemorrhage from the torn uterine arteries floods • A woman’s prognosis depends on the extent of the rupture
into the abdominal cavity and possibly into the and the blood loss.
vagina.
▪ Signs of hypotensive shock begin, including a INVERSION OF THE UTERUS
rapid, weak pulse; falling blood pressure; cold and UTERINE INVERSION
clammy skin; and dilatation of ▪ refers to the uterus turning inside out with either birth of
▪ the nostrils from air starvation. the fetus or delivery of the placenta.
▪ Fetal heart sounds fade and then are absent ▪ It is a rare phenomenon, occurring in about 1 in 20,000 birth
• INCOMPLETE RUPTURE
▪ the signs of rupture are less evident.
▪ With an incomplete rupture, a woman may
experience only a localized tenderness and a
persistent aching pain over the area of the lower
uterine segment.
▪ Fetal heart sounds, a lack of contractions and the
changes in the woman’s vital signs will gradually
reveal fetal and maternal distress.
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CARE OF MOTHER AND CHILD A-RISK OR WITH PROBLEMS (ACUTE & CHRONIC) FINALS
CAUSES ➢ The woman will immediately be given general anesthesia or
• It may occur if traction is applied to the umbilical cord to possibly nitroglycerin or a tocolytic drug by IV to relax the
remove the placenta or if pressure is applied to the uterine uterus.
fundus when the uterus is not contracted. ➢ The primary care provider then replaces the fundus
• It may also occur if the placenta is attached at the fundus so manually.
that, during birth, the passage of the fetus pulls the fundus ➢ Administration of oxytocin after manual replacement helps
downward (Purcell & Bienstock, 2012) the uterus to contract and remain in its natural place.
• Because inversion occurs in various degrees, the inverted ➢ Uterine endometrium was exposed, a woman will need
fundus may lie within the uterine cavity or the vagina, or in antibiotic therapy to prevent infection.
total inversion, it may protrude from the vagina. ➢ She needs to be informed that cesarean birth will probably
be necessary in any future pregnancy to prevent the
possibility of repeat inversion.
UTERINE RUPTURE
NURSING MANAGEMENT
• Assess the uterine fundus for firmness, height, and
deviation from the midline.
• Assess vital signs every 15 minutes or more frequently
• until stable, and then according to recovery room routine.
Observe for tachycardia and a falling blood pressure, which
are associated with shock.
• Remember that the fall in blood pressure is often a late sign
of hemorrhagic shock.
CLINICAL MANIFESTATIONS • A cardiac monitor identifies dysrhythmias, which
• When an inversion occurs, a large amount of blood • may occur with shock, while a pulse oximeter indicates the
suddenly gushes from the vagina. woman’s pulse rate and oxygen saturation
• The fundus is no longer palpable in the abdomen. • An indwelling catheter usually is inserted to observe fluid
• The woman begins to show signs of blood loss: balance and keep the bladder empty so that the uterus can
hypotension, dizziness, paleness, or diaphoresis contract well.
• Assess the catheter for patency, and record intake and
THERAPEUTIC MANAGEMENT output.
➢ Never attempt to replace an inversion, because handling of • Urine output should be at least 30 mL per hour. A fall in
the uterus could increase the bleeding. urine output may indicate hypovolemia or an obstructed
➢ Never attempt to remove the placenta if it is still attached, catheter
because this would create a larger surface area for • The woman is allowed nothing by mouth until her condition
bleeding. is stable.
• She usually can receive fluids and progress to solid foods
quickly because uterine inversion does not usually recur in
the current postpartum period.
• It may recur in a future pregnancy if conditions favor its
development
➢ Oxytocin, if being used, should be discontinued because it
makes the uterus more tense and difficult to replace.
➢ An IV fluid line should be inserted if one is not already
present (use a large-gauge needle, because blood will need
to be replaced).
➢ Administer oxygen by mask,
➢ Monitor vital signs.
➢ Be prepared to perform cardiopulmonary resuscitation
(CPR) if the woman’s heart should fail from the sudden
blood loss.
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CARE OF MOTHER AND CHILD A-RISK OR WITH PROBLEMS (ACUTE & CHRONIC) FINALS
AMNIOTIC FLUID EMBOLISM (AFE) ➢ A woman’s prognosis depends on the size of the embolism,
the speed with which the emergency condition was
detected, and the skill and speed of emergency
interventions.
➢ Even if the woman survives the initial insult, the risk for
disseminated intravascular coagulation (DIC) is high, further
compounding her condition.
➢ In this event, she will need continued management, which
includes endotracheal intubation to maintain
➢ pulmonary function and therapy with fibrinogen to
counteract DIC.
RAPID THERAPEUTIC MANAGEMENT
➢ Cardiopulmonary resuscitation and support
➢ Oxygen with mechanical ventilation
➢ Correction of hypotension
➢ Blood component therapy (e.g., fibrinogen, packed red
blood cells, platelets, fresh-frozen plasma) to correct
➢ Amniotic fluid embolism occurs when amniotic fluid is
coagulation defects
forced into an open maternal uterine blood sinus after a
o If the pregnant mother is in cardiac arrest, immediate
membrane rupture or partial premature separation of the
cesarean birth is likely to improve survival odds for
placenta (Sahni, 2012).
the baby
➢ Previously, it was thought particles such as meconium or
shed fetal skin cells in the amniotic fluid entered the
maternal circulation and reached the lungs as small emboli.
➢ A more likely cause of symptoms is a humoral or
anaphylactoid response to amniotic fluid in the maternal
circulation.
➢ This condition may occur during labor or in the postpartal
period.
➢ The incidence is about 1 in 20,000 births, and it accounts for
at least 10% of maternal deaths in the United States (Knight,
Tuffnell, Brocklehurst, et al., 2010).
➢ Although it is associated with induction of labor, multiple
pregnancy, and perhaps hydramnios (i.e., excess amniotic
fluid), it is not preventable
➢ because it cannot be predicted
➢ The clinical picture is dramatic:
▪ A woman, usually in the active phase of labor, sits
up suddenly and grasps her chest because of
sharp pain and inability to breathe as pulmonary
artery constriction occurs.
▪ She becomes pale and then turns the typical
bluish gray associated with a pulmonary
embolism and lack of blood flow to the lungs.
▪ Within minutes, she could be unconscious, and
her fetus is put in danger as placenta blood
circulation halts. The immediate management is
oxygen
▪ The immediate management is oxygen
▪ Administration by face mask or cannula. Within
minutes, she will need CPR; however, CPR may be
ineffective because these procedures (inflating
the lungs and massaging the heart) do not relieve
the pulmonary constriction.
▪ Blood still cannot circulate to the lungs. Death
may occur within minutes.
