Nursing Care of a Family Experiencing a Labor or Birth Complication PDF

NURSING CARE OF A FAMILY EXPERIENCING A COMPLICATION OF LABOR OR BIRTH Dystocia, difficult labor, can arise from any of May occur in overstretched uterus (multiple the four components of the labor process: gestation, larger fetus, hydramnios, grand...

NURSING CARE OF A FAMILY EXPERIENCING A COMPLICATION OF LABOR OR BIRTH Dystocia, difficult labor, can arise from any of May occur in overstretched uterus (multiple the four components of the labor process: gestation, larger fetus, hydramnios, grand a. the power, or the force that propels the multiparity). fetus (uterine contractions) Can cause ineffective contractions postpartum, b. the passenger (fetus) increasing risk for hemorrhage. c. the passageway (birth canal) In the first hour post-birth, assess uterus and d. the psyche (woman’s and family’s lochia every 15 minutes. perception of the event) Complications can occur at any point in labor Hypertonic Contractions thus, continuous monitoring of a laboring woman Resting tone > 15 mmHg; frequent, often in the and fetus and providing emotional support for latent phase. her and her family are essential. Muscle fibers do not repolarize after contraction. More painful; breathing exercises ineffective. Lack of relaxation may lead to fetal anoxia. Strong but ineffective contractions; may require cesarean if FHR deceleration or prolonged labor occurs. Uncoordinated Contractions More than one pacemaker may initiate contractions. Contractions too close together prevent good cotyledon filling. Oxytocin may help establish effective contraction patterns. Dysfunctional Labor Stages First Stage: ○ Prolonged Latent Phase: > 20 hours in Uterine Inertia nullipara, > 14 hours in multipara; Time-honored term for sluggish contractions; also called occurs if cervix not “ripe” or with dysfunctional labor. excessive analgesic use. Primary inertia: Occurs at the onset of labor. Management: rest, hydration, Secondary inertia: Occurs later in labor. pain relief; may need cesarean Risks: Higher risk of maternal postpartal infection, or amniotomy and oxytocin. hemorrhage, and infant mortality in prolonged labor. ○ Protracted Active Phase: Cervical Prolonged labor: Most likely with a large fetus dilatation < 1.2 cm/hr (nullipara) or < 1.5 (macrosomia). cm/hr (multipara); > 12 hours in Ineffective Uterine Force (Uterine Inertia): Uterine primigravida, > 6 hours in multigravida. contractions move the fetus through the birth canal. Possible cesarean for fetal malposition or CPD; oxytocin Hypotonic Contractions may augment labor if CPD not Unusually low or infrequent contractions (not present. more than 2 or 3 in 10 minutes). ○ Prolonged Deceleration Phase: > 3 Resting tone of uterus < 10 mmHg; strength of hours (nullipara) or > 1 hour (multipara); contractions < 25 mmHg. often results from fetal head position; Most likely during the active phase of labor. cesarean often needed. May occur after analgesia if cervix not dilated to ○ Secondary Arrest of Dilatation: No 3-4 cm or if bowel/bladder distended. progress in dilatation for > 3 hours; cesarean may be necessary.  Second Stage: Cervical Ripening: ○ Prolonged Descent: Descent < 1 cm/hr (nullipara) or < 2 cm/hr (multipara); Change from firm to soft; first step in early labor. suspected if second stage > 3 hours in Ripe cervix: woman’s score of 8 or greater. multipara. Methods: ○ Arrest of Descent: No descent for 1 hour ○ Stripping the membranes manually. (multipara) or 2 hours (nullipara); no ○ Hygroscopic suppositories to urge expected movement beyond 0 station; dilatation. most likely due to CPD. ○ Prostaglandin gel (misoprostol); contraindicated for past cesarean births. PRECIPITATE LABOR occurs when uterine contractions are so strong Induction of Labor by Oxytocin: that a woman gives birth only a few, rapidly occurring contractions defined as labor Initiates contractions; always given IV for rapid completed in fewer than 3 hours discontinuation if needed. Precipitate dilatation: cervical dilatation that Half-life: approximately 3 minutes. occurs at a rate of 5 cm or more per hour in a Mixed as 10 IU in 1000 mL of Ringer’s Lactate; primipara or 10 cm or more per hour in multipara may be administered piggyback. likely to occur with grand multiparity or after Infusion pump recommended for regulation; do induction of labor by oxytocin or amniotomy not increase rate without instructions. Contractions are so forceful that may lead to Artificial rupture of membranes may occur at 4 premature separation of placenta, inreasing risk cm dilation. for hemorrhage. Poses risk to fetus: subdural hemorrhage may Monitoring During Oxytocin Administration: result from rapid release of pressure on the Assess pulse and blood pressure every 15 head. minutes. The woman may sustain lacerations of the birth Monitor contractions (should not occur more canal. If precipitate labor is predicted from the often than every 2 minutes, last longer than 70 labor graph, a tocolytic may be administered to seconds, or stronger than 50 mmHg). reduce force and frequency of contractions. Stop IV infusion if contractions exceed safe limits or fetal distress occurs. Induction and Augmentation of Labor Complications of Oxytocin: Induction: Labor started artificially. Augmentation: Assisting labor that has begun Hyperstimulation may cause uterine rupture or but is ineffective. fetal death. Beta-adrenergic drugs or magnesium sulfate Reasons for Induction: may be prescribed to reduce myometrial activity. Risk of water intoxication due to oxytocin's Fetus in danger or labor not starting at full term. antidiuretic effect; monitor intake and output. Primary reasons: preeclampsia, eclampsia, Symptoms: headache, vomiting; severe cases severe hypertension, diabetes, Rh sensitization, may lead to seizures, coma, death. prolonged rupture of membranes, intrauterine growth restriction, postmaturity. Induced Labor Outcomes: Conditions for Induction: Induced labor generally has a shorter first stage than unassisted labor. Fetus in longitudinal lie. Newborns may have hyperbilirubinemia and Cervix is ripe and ready for birth. jaundice; monitor closely. Presenting part is engaged. No CPD (cephalopelvic disproportion). Fetus estimated to be mature (lecithin-sphingomyelin ratio or ultrasound). Augmentation by Oxytocin: Cesarean hysterectomy or tubal ligation can also be performed with consent from the patient Required if contractions become weak or to remove the damaged uterus and remove the ineffective after spontaneous onset. childbearing activity of the woman. Precautions similar to induction; monitor fetal Fetal outcome, the woman’s safety, and the heart sounds. extent of the surgery must be revealed to the patient and allow time for them to express their Active Management of Labor: emotions. The woman would be advised not to conceive Aggressive oxytocin administration to shorten again after a rupture of the uterus unless the labor to 12 hours. rupture is in the inactive lower segment. Maximum dosage may reach 36 to 40 units; The viability of the fetus and the woman’s potential to reduce postpartal infection and prognosis depends on the extent of the rupture. cesarean births. INVERSION OF THE UTERUS UTERINE RUPTURE Uterine rupture is a rare but serious Uterine inversion occurs when the uterus turns complication. inside out due to the delivery of the fetus or the Uterine rupture is a condition wherein the uterus placenta. cannot sustain the strain that it underwent. Factors that contribute to inversion are Factors that contribute to uterine rupture are application of traction to the umbilical cord to abnormal presentation, prolonged labor, multiple remove the placenta, if pressure is applied to the gestation, improper use of oxytocin, and uterine fundus when the uterus is not traumatic effects of forceps use or traction. contracting, or if the placenta is attached to the Fetal death can be avoided in uterine rupture if fundus so during birth the fundus pulls it down. immediate cesarean birth can be performed. Signs of inversion include sudden gush of a Symptoms that a woman may feel preceding large amount of blood from the vagina, a rupture are a sudden, severe pain during a labor non-palpable fundus, signs of blood loss such as contraction or a tearing sensation. hypotension, dizziness, and paleness, and if Rupture can be complete or incomplete. bleeding continues, exsanguinations. With complete uterine rupture, the rupture goes The inversion should never be replaced and the through the endometrium, myometrium, and placenta, if still attached, should never be peritoneum, and then the contractions would removed. immediately stop. Administration of oxytoxic drugs could only With incomplete uterine rupture, the rupture only worsen the inversion and make the uterus tense goes through the endometrium and the so that it is difficult to replace. myometrium only, with the peritoneum still intact. To manage uterine inversion, an IV line with a Symptoms of complete uterine rupture include large-gauge needle should be established to hemorrhage, shock, fading fetal heart sounds, restore fluid volume, oxygen administration distinct swellings of the retracted uterus and should be started, assessment of vital signs, and extrauterine fetus. cardiopulmonary resuscitation if the woman For incomplete rupture, there is localized undergoes arrest. tenderness, persistent aching pain in the lower Nitroglycerin or a tocolytic drug would be given uterine segment, and lack of contractions and intravenously to relax the uterus, and the fetal heart sounds. physician would replace the fundus manually. Confirmatory diagnosis of uterine rupture can be Oxytocin would be given after manual revealed through ultrasound. replacement to help the uterus contract and Administration of emergency fluid replacement remain in its natural place. as ordered should be anticipated as well as IV Antibiotics would be prescribed because the oxytocin. endometrium was exposed to prevent infection. Laparotomy would be performed to control the bleeding and repair the rupture.  Inform the woman that a future pregnancy would Assessment of fetal heart sounds is necessary need to be delivered via cesarean section after rupture of membranes to rule out cord because there is a possibility that the inversion prolapse. would re-occur. The goal in therapeutic management is to relieve cord compression to avoid fetal anoxia AMNIOTIC FLUID EMBOLISM that can be achieved through manually lifting the head of the fetal head off the cord through the Amniotic fluid embolism occurs when the vagina or placing the woman in a Trendelenburg amniotic fluid is forced into an open maternal position. uterine blood sinus or after membrane rupture or Oxygen administration is also necessary to partial premature separation of the placenta. improve the fetal oxygenation. The most likely cause of the embolism is Uterine activity and pressure of the fetus should anaphylactoid or humoral response. also be reduced through a tocolytic agent. Amniotic fluid embolism cannot be prevented Once the cord has prolapsed and is exposed to because it cannot be predicted. air, drying of the umbilical cord and atrophy of Risk factors include abruption placenta, the umbilical vessels would begin. hydramnios, and oxytocin administration. Cover any exposed portion of the cord with a The woman experiences sharp chest pain, sterile saline compress to avoid drying. inability to breathe, pallor, and lack of blood flow. If there is already complete dilatation, the Emergency measures include oxygen physician can deliver the baby to prevent fetal administration and CPR. anoxia. The woman’s prognosis would depend on the If the cervical dilatation is not yet complete, speed of the detection of the condition, the skill cesarean birth would be performed as an and speed of the emergency interventions, and emergency procedure because of the reduced the size of the embolism. blood flow that can harm the fetus. Endotracheal intubation and fibrinogen therapy Amnioinfusion, which is the addition of a sterile would be needed because the risk for DIC is fluid into the uterus to supplement the amniotic high. fluid, can be performed just to prevent additional The prognosis for the fetus is uncertain because cord compression. reduced placental perfusion happens from a During the infusion, monitor the fetal heart rate severe drop in maternal blood pressure. and uterine contractions internally and record maternal temperature hourly to detect infection. PROLAPSE OF THE UMBILICAL CORD Fetal blood sampling is a procedure used to In the prolapse of the umbilical cord, a loop of diagnose, treat or monitor various fetal umbilical cord slips down in front of the problems. A sample of capillary blood is taken presenting fetal part. from fetal scalp as it presents at the dilated Factors that occur with prolapse are a small cervix. fetus, placenta previa, CPD, premature rupture If fetus is hypoxic, pH is aciotic. A scalp blood of membranes, hydramnios, and multiple greater than 7.25 is normal; 7.21 to 7.25 should gestation. be remeasured in 30 mins. During assessment of the presenting fetal part Infants who have had internal scalp blood through vaginal examination, the cord might be samples taken should not be born by vacuum felt. extraction because it could lead to severe Diagnosis of prolapsed of the membrane can be bleeding. made through ultrasound. Cesarean section should be performed before Problems With Fetal Position, Presentation or Size rupture of the membrane or the cord would slide Occipitoposterior Position down the vagina. The usual fetal position is posterior rather than However, cord prolapsed is mostly discovered anterior. after rupture of the membranes, when the fetal Assuming that the presentation is vertex, the heart rate has a variable deceleration. occiput is directed diagonally and posteriorly, either to the left or to the right.  During internal rotation in these positions, the The fetal head may be the widest single fetal head must rotate through an arc of diameter but the fetus’ buttocks and legs take up approximately 135 degrees. more space. Rotations from a posterior position can be aided The fetus turns into a cephalic position mostly by having the woman assume a hands-and-knee because the fundus is the largest part of the position, squatting or lying on her side; however, uterus, so the buttocks and the lower extremities this is tiring for women in labor. are in the fundus. Posterior positions usually occur in women with Types of breech presentation include complete, android, anthropoid, and contracted pelvis. frank, and footling. Posterior positions happen in dysfunctional labor Breech presentation increases the fetal risk for patterns such as prolonged active phase, anoxia, traumatic injury to the head, fracture of arrested descent, or fetal heart sounds heard the spine or arm, dysfunctional labor, and early best at the lateral sides of the abdomen. rupture of membranes. A head in the posterior position does not fit the Meconium present in the amniotic fluid is a sign cervix like a head in the anterior position does. of buttock pressure, and this can lead to This can be confirmed through vaginal meconium aspiration once the infant inhales examination or through ultrasound because it amniotic fluid. might cause umbilical cord prolapse. Fetal heart sounds are heard high in the Labor is prolonged because the arc of rotation is abdomen in breech presentation. greater. Leopold’s maneuver and vaginal examination Pressure and pain would be experienced by the can determine breech presentation. woman in her lower back owing to sacral nerve Be certain to monitor the FHR and uterine compression when the fetal head rotates against contractions continuously to detect fetal distress the sacrum. early and provide prompt intervention. To relieve a portion of the pain, applying In a breech birth, the birth of the head is the counterpressure on the sacrum by a back rub most dangerous part because a loop of the may be done, and heat or cold application can umbilical cord that has passed down alongside also help. the head may be compressed. To help the fetus rotate, the woman may lie on Intracranial hemorrhage is another danger of the side opposite the fetal back or assume a breech birth because of the pressure changes hands-and-knees position. that have occurred spontaneously. The woman should void every 2 hours to keep An infant born from a frank breech position her bladder empty and avoid impeding the usually extends his or her legs continuously descent of the fetus. during the first 2 or 3 days of life, so be sure to The woman may also need an oral sports drink point out to the parents that this is normal. or IV glucose solution to replace glucose stores used for energy. Face Presentation Maternal exhaustion can cause uterine Face and brow presentations are called dysfunction, so a rotation of 135 degrees may asynclitism or a fetal head presenting at a not be possible if the contractions are ineffective different angle than expected. or if the fetus is larger than average. In face presentation, the head diameter the fetus The fetal head might arrest in the transverse presents to the pelvis is often too large for birth position or there might be no rotation at all, so to proceed. cesarean birth would be necessary. The back would be difficult to outline because it Provide reassurances to the woman that even is concave. though her labor is not “by the book” it is still Face presentation can be determined through within safe and controlled limits. vaginal examination when the nose, mouth, or chin is felt as the presenting part or through Breech Presentation ultrasound. Most fetuses are in a breech presentation early Face presentation usually occurs in women with in pregnancy; however, by week 38, it turns into contracted pelvis, or placenta previa, in a a cephalic presentation. relaxed uterus of a multipara, with prematurity, hydramnios, or fetal malformation.  If the chin is anterior and the pelvic diameters Uterine dysfunction might result from an are within normal limits, the infant can be born oversized fetus because of the overstretching of vaginally. the fibers of the myometrium. If the chin is posterior, cesarean birth is the birth The wide shoulders pose a problem at birth method of choice. because it can cause fetal-pelvic disproportion Facial edema and ecchymosis are present in a or uterine rupture from obstruction. baby born after a face presentation. Cesarean birth is necessary if the fetus is so Assess the patency of the infant’s airway closely. oversized to be born vaginally. Reassure the parents that the edema is To compare the size of the fetus with the transient and will disappear after a few days. woman’s pelvic capacity, pelvimetry or ultrasound can be performed. Brow Presentation If a macrosomic baby is born vaginally, there are The rarest among the presentations is the brow high risks for cervical nerve palsy, diaphragmatic presentation. injury, or fractured clavicle due to shoulder This presentation usually occurs in multipara dystocia. women or in a woman with relaxed abdominal The woman is at risk for over because of the muscles. overdistended uterus and uterine atony. Obstructed labor occurs because the head becomes jammed in the brim of the pelvis as the SHOULDER DYSTOCIA occipitomental diameter presents. Shoulder dystocia occurs during the second Cesarean birth would be necessary unless the stage of labor when the fetal head is born but presentation spontaneously corrects itself. the shoulders are too broad to enter and be born Extreme ecchymosis on the face is also present through the pelvic outlet. in infants born after a brow presentation. The woman is at risk for vaginal and cervical Reassure the parents that the bruising over the tears, while the fetus is at risk for cord same area as the anterior fontanelle is normal. compression between the fetal body and the bony pelvis. Transverse Lie If birth is forced through the vaginal opening, the Occurs in women with pendulus abdomens, fetus would sustain a fractured clavicle or a uterine fibroid tumors that obstruct the lower brachial plexus injury. uterine segment, contraction of the pelvic brim, Shoulder dystocia usually occurs in women who congenital abnormalities of the uterus, or have diabetes, in multiparas, and in post-date hydramnios. pregnancies. Occurs in infans with hydrocephalus or other Shoulder dystocia is discovered often during the abnormality that prevents the head from birth of the head and the shoulders lock beneath engaging. the symphysis pubis. Occurs in prematurity if the infant has room for Other conditions that may suggest shoulder face movement, in multiple gestation (esp. in the dystocia are prolonged second stage of labor, second twin), or if there is short umbilical cord. arrest of descent, or when the head starts to A mature fetus cannot be delivered vaginally crown, it retracts instead of protruding with each from this position due to no firm presenting part, contraction. cord or an arm may prolapse or the shoulder Instruct the woman to flex her thighs sharply on may obstruct the cervix. her abdomen (McRobert’s maneuver) to widen the pelvic outlet and allow the anterior shoulder Oversized Fetus (Macrosomia) to be born. Macrosomia or an oversized fetus weighs more Applying suprapubic pressure can also help the than 4000 to 4500g, and this size may become a shoulder out from beneath the symphysis pubis. problem. Macrosomic babies are usually born to women with diabetes or develop gestational diabetes, and multiparas. Fetal Anomalies Monitor vital signs, assess uterine tone, and Fetal anomalies of the head such as assess lab values such as hemoglobin and hydrocephalus (fluid-filled ventricles) or hematocrit levels to detect blood loss. anencephaly (absence of the cranium) can also Signs of severe blood loss include shock complicate birth because the fetal presenting (increased, thready, weak pulse), decreased BP, part does not engage the cervix well. pale and clammy skin, and increasing anxiety. Bimanual Massage. Inserting one hand into POSTPARTAL HEMORRHAGE woman’s vagina while pushing against the fundus through the abdominal wall on the other Blood loss from the uterus greater than 500 mL hand. Uterine packing may be inserted during within the 24-hour period. this procedure to halt bleeding. Five main causes are: uterine atony, lacerations, Prostaglandin Administration. Prostaglandins retained placental fragments, uterine inversion, promote strong, sustained, uterine contractions. and dissemenated intravascular coagulation Observe for nausea, diarrhea, tachycardia, and (DIC). hypertension which are the possible adverse effects. UTERINE ATONY Blood Replacement. Blood transfusion to relaxation of the uterus; most frequent cause of replace blood loss. Blood typing and postpartal hemorrhage. cross-matching were done prior to procedure. First step in controlling hemorrhage is to attempt Hysterectomy or Suturing. Sutures or balloon uterine massage to encourage contraction. compression may be used to halt bleeding in the Remain with the woman after massaging her rare instance of extrreme uterine atony. Last fundus to be certain the uterus is not relaxing resort would be hysterectomy. again. Observe carefully, including fundal height and consistency of lochia for the next 4 hours. LACERATIONS If a uterus cannot remain contracted, dilute IV Large lacerations are not normal and can cause infusion of oxytocin to help the uterus remain complications. tone. They occur most often with difficult or precipitate Carboprost tromethamine (Hemabate), a births, primigravida, large infant, use of lithotomy prostaglandin F2a derivative, or position and instruments. methylergonovine maleate (Methergine), an ergot compound are second possibilities, given Cervical Lacerations IM. Usually found on the sides of cervix, near the Rectal misoprostol, a prostaglandin E1 analogue, branches of uterine artery. may be administered rectally. This is arterial bleeding and it is brighter red Hemabate may be repeated every 15 to 90 than the venous blood with uterine atony. minutes up to 8 doses. Bleeding occurs immediately after placenta Assess for diarrhea if prostaglandins are used, delivery. Usual dosage of oxytocin is 10 to 40 units per Repair is difficult because bleeding can be so 1000 mL of a Ringer’s Lactate solution. intense that it obstructs visualization of the area. Oxytocin has a short duration of action, The woman may be given regional anesthesia to approximately 1 hour so uterine atony can recur relax uterine muscle and to prevent pain if quickly after administration of a single dose. cervical laceration is extensive or difficult to Methylergonovine causes increased BP so it is repair. contraindicated with hypertension (>140 mmHg Sutures for therapeutic management. systolic). Empty bladder because a full bladder pushes an Vaginal Lacerations uncontracted uterus into a more uncontracted Easier to assess than cervical lacerations state. because they are easier to view. Administer oxyge by face mask if woman is in Hard to repair because vagianal tissue is friable. respiratory distress, at a rate of 4 L/min; supine position to allow adequate blood flow.  Vagina may be packed to maintain pressure on In some cases, placenta accreta is so deeply the suture line after repair. attached that it cannot be surgically removed. Foley catheter may be placed because packing Balloon occlusion and embolization of the causes pressure on the urethra and interfere internal iliac arteries may minimize blood loss. with voiding. Methotrexate may be prescribed to detsroy the Remove packing after 24 to 48 hours before retained placental tissue. discharge. Teach patient to observe lochia discharge at Packing that is left too long leads to stasis and home and report tendency for discharge to infection similar to toxic shock syndrome. change from lochia serosa or alba back to rubra. Perineal Lacerations Uterine Inversion Usually occur when the woman is placed in a Prolapse of the fundus of the uterus through the lithotomy position for birth because it increases cervix so that the uterus turn inside out. tension in perineum. Occurs immediately after birth. Sutured and treated as an episiotomy repair. Document degree of laceration. Fourth degree Disseminated Intravascular Coagulation lacerations need extra precautions to avoid A deficiency in clotting ability caused by vascular having repair sutures loosened or infected. injury. Provide diet high in fluid and a stool softener to May occur in postpartpartal period, but is usually prevent constipation which could break sutures. associated with premature separation of the Woman with third or fourth degree lacerations placenta, missed early miscarriage, or fetal should not have enema or a rectal suppository death in utero. prescribed or temperature should not be taken rectally. SUBINVOLUTION Fourth degree lacerations can lead to long term Incomplete return of the uterus to its dyspareunia, rectal incontinence, or sexual prepregnant size and shape. dissatisfaction. With subinvolution, at a 4 to 6 week postpartal period, uterus is still enlarged and soft. May result from a small retained placental RETAINED PLACENTAL FRAGMENTS fragment, a mild endometritis (infection of the When a placenta does not deliver in its entirety, endometrium), or an accompanying problem fragments of it separate and are left behind. such as uterine myoma that is interferin with Because the portion keeps the uterus from complete contraction. contracting fully, bleeding occurs. To improve uterine tone and complete involution, Most likely to happen with placenta oral administration of Methylergonovine, 0.2 mg succenturiata (a placenta with an accessory four times daily is usually prescribed. lobe) and placenta accreta (a placenta that Oral antibiotic is prescribed if uterus is tender to fuses with myometrium because of an abnormal palpation, suggesting endometritis. decidua basalis). Teach patient to recognize the normal process of Retained placental fragments can be detected involution and lochial discharge before hospital by inspection after birth if it is complete, by discharge to identify subinvolution. ultrasound, and by blood serum sample that Chronic blood loss from subinvolution can lead contains HCG (reveals that part of placenta is to infection or anemia and lack of energy. still present). If retained fragment is large, bleeding occurs in PRETERM LABOR the immediate postpartal period. If it is small, Labor before week 37 of gestation. bleeding is detected day 6 to 10 of postpartum. Persistent uterine contractions (4 every 20 Dilatation and curettage (D&C) is performed to minutes) indicate labor; actual labor is remove placental fragment. diagnosed with >80% cervical effacement or >1 cm dilation. Causes and Risk Factors  Common Causes: Unknown reasons; dexamethasone (6 mg IM, four doses 12 hours associated with dehydration, urinary tract apart) due to better outcomes (Feldman et al., infections, periodontal disease, chorioamnionitis. 2007). Additional Risks: Strenuous jobs, extreme Timing: Effects take about 24 hours; lasts fatigue from shift work, intimate partner abuse, approximately 7 days. Re-dosing may be pregnancies with a small mother and overweight controversial due to potential glucose regulation father (Klebanoff, 2008). issues. Prevention: Mild leisure activities like walking may help prevent preterm birth. Tocolytic Agents Corticosteroids: Used to hasten fetal lung Symptoms of Preterm Labor maturity. Persistent dull low backache Calcium Channel Blockers: Nifedipine and Vaginal spotting indomethacin can halt contractions but have Pelvic pressure or abdominal tightening side effects, including oligohydramnios and fetal Menstrual-like cramping pulmonary hypertension (Karch, 2009). Increased vaginal discharge Magnesium Sulfate: Once common, now less Uterine contractions recommended due to side effects (Simhan & Intestinal cramping Caritis, 2007). Importance of recognizing subtle symptoms; Beta-Sympathomimetics: women should be informed about signs. ○ Ritodrine and terbutaline primarily target beta-2 receptors to reduce uterine Therapeutic Management contractions. Predictive Factors: Presence of fetal fibronectin ○ Terbutaline is more commonly used but in vaginal mucus indicates imminent preterm may cause side effects like hypotension, contractions; shortened cervix on ultrasound is tachycardia, and hypokalemia. also predictive (Cootauco & Althaus, 2007). Management Conditions: Medical intervention Administration Guidelines possible if membranes are intact, no fetal Before Administration: Obtain baseline blood distress, minimal cervical dilation (≤4-5 cm), and data and schedule ECG; monitor uterine and ≤50% effacement. fetal activity. Initial Hospital Care: Drug Mixing: Terbutaline should be mixed with ○ Bed rest to relieve cervical pressure. Ringer's lactate to avoid hyperglycemia. ○ Intravenous fluids for hydration to help Monitoring: Regular assessment of vital signs, stop contractions. including pulse and blood pressure; watch for ○ Cultures and urine tests to rule out chest pain and signs of pulmonary edema. infection; antibiotics if infection is Dosing Schedule: Initial infusion for 12-24 hours, present. then switch to oral terbutaline; instruct women ○ Tocolytics (e.g., terbutaline) may be on pulse checks and proper dosing. prescribed to halt labor. Home Care and Pump Use Home Care After Initial Treatment Subcutaneous Pump: Allows continuous Women can be cared for at home if they remain low-dose administration; can delay labor by 8-9 well-hydrated and continue oral tocolytics. weeks. Recommendations: Limit strenuous activities, Patient Education: Teach women to monitor fetal maintain adequate nutrition, and avoid smoking movements and understand when to seek help if to reduce risk of preterm birth (Dew, 2007). movements decrease significantly. Corticosteroid Administration in Preterm Labor Fetal Assessment Purpose: Accelerates fetal lung surfactant Daily Monitoring: Women should perform a formation; particularly given when labor is "count to 10" test for fetal movements; report chemically halted for pregnancies 50% effaced and >3-4 cm Risks and Complications dilated. Fetal Threats: "Point of No Return": Ruptured membranes ○ Loss of protective amniotic fluid increase infection risk, making it difficult to stop increases risk of uterine and fetal labor. infections. ○ Increased pressure on the umbilical Cesarean Birth Considerations cord can impair nutrient supply and lead If the fetus is very immature when labor cannot to cord prolapse, especially if the fetal be halted, a cesarean may be planned to reduce head is not well engaged. pressure on the fetal head, minimizing the risk of ○ Potential development of Potter-like hemorrhage. syndrome (facial distortion and pulmonary hypoplasia) due to pressure Labor Duration Misconceptions effects (Hofmeyr, 2009). First Stage: Duration is similar to term Preterm Labor: May occur following rupture, pregnancies; often the longest stage. potentially ending the pregnancy. Second Stage: May be shorter due to the smaller size of the infant, but the difference is Assessment of PROM typically only 30 minutes to 1 hour. Symptoms: Characterized by a sudden gush of Patient Education: Important to explain these clear fluid, often with continued minimal leakage. dynamics to alleviate concerns about prolonged Differential Diagnosis: Must distinguish from labor. urinary incontinence. Diagnostic Procedures: Management During Preterm Labor ○ Sterile Vaginal Examination: Observes Rupture of Membranes: Delayed until the fetal for vaginal pooling of fluid. head is engaged to reduce cord prolapse risk. ○ Nitrazine Test: Amniotic fluid turns the Analgesic Use: Caution advised; epidurals paper blue (alkaline), while urine preferred over drugs like meperidine to avoid remains yellow (acidic). sedation effects on the immature fetus. ○ Ferning Test: Microscopic examination Monitoring: Continuous monitoring of uterine shows typical patterns in amniotic fluid, contractions and fetal heart sounds to reassure absent in urine. the mother. ○ Alpha-Fetoprotein (AFP) Levels: High levels in vaginal fluid indicate rupture Delivery Considerations (Shahin & Raslan, 2007). Episiotomy Needs: Despite the smaller head, ○ Ultrasound: May assess amniotic fluid the fragility of a preterm infant may necessitate a index if rupture status is unclear. larger episiotomy to prevent injury. Forceps Use: May be employed to reduce Infection Screening pressure on the fetal head during delivery. Cultures for: ○ Neisseria gonorrhoeae Post-Birth Care ○ Group B Streptococcus Cord Clamping: Usually performed immediately ○ Chlamydia rather than waiting for pulsations to stop to Blood Tests: Check white blood cell count and prevent excess bilirubin buildup and circulatory C-reactive protein levels, which increase with overload in the preterm infant. membrane rupture. Management  Avoid Routine Vaginal Examinations: Increases hours), the baby is kept in an isolation infection risk post-rupture. nursery until the infection cause is Induction of Labor: If the fetus is mature enough determined to prevent transmission. and labor does not begin within 24 hours, 2. Closed Infections: oxytocin may be administered to induce labor ○ If fever is related to a closed infection and reduce infection risk. (e.g., thrombophlebitis) with no risk to the baby, the mother may care for her PUERPERAL INFECTION child with bed rest as prescribed. 3. Infections with Drainage: Infection of the reproductive tract, a leading cause of ○ For infections like endometritis or maternal mortality. perineal abscess, newborn visiting may Predisposing Factors: be contraindicated. If rooming-in ○ Rupture of membranes >24 hours continues, the mother must wash her before birth hands before holding the baby and ○ Retained placental fragments avoid placing the infant on contaminated ○ Postpartal hemorrhage sheets. ○ Pre-existing anemia 4. Nursery Protocol: ○ Prolonged/difficult labor (especially with ○ Babies should not return to a central instruments) nursery after visiting an infected room. ○ Internal fetal heart monitoring Hospitals should provide a designated ○ Pre-existing local vaginal infection isolation nursery or use closed Isolttes ○ Uterine exploration after birth for care. Infection Risk: 5. Breastfeeding Considerations: ○ The uterus is sterile until membranes ○ High fever may decrease breast milk rupture; pathogens can invade supply. If the mother is too ill to nurse or post-rupture. on harmful medications, the baby should ○ Risk increases with tissue edema and be fed formula. Manual expression or trauma. pumping of breast milk is encouraged to Prognosis Factors: maintain production. ○ Type of infectious organism 6. Bottle Feeding Assurance: ○ Portal of entry ○ If discontinuing breastfeeding, the ○ Degree of uterine involution during mother should be reassured about microorganism invasion meeting the baby's needs through bottle ○ Presence of lacerations in the feeding. reproductive tract 7. Hospitalization Arrangements: Potential Seriousness: ○ If extended hospitalization is necessary, ○ Starts as a local infection but can the mother should arrange care for her progress to peritonitis or septicemia, baby (e.g., homemaker service or which can be fatal. temporary foster care). She should Management: maintain contact with older children and ○ Focus on appropriate antibiotics after receive updates on her newborn’s culture and sensitivity testing. condition. ○ Commonly cultured organisms: group B streptococci, aerobic gram-negative bacilli (e.g., E. coli). ENDOMETRITIS Importance: Recognizing risk factors and prompt Infection of the endometrium (uterine lining), typically management is crucial for maternal health. occurring after birth, often associated with chorioamnionitis and cesarean delivery. Common Guidelines for Women with Postpartal Infection Assessment: ○ Temperature: 1. Isolation for Baby: Benign fever may occur on the ○ If the mother has a fever first postpartum day; (≥100.4°F/38°C) for two consecutive endometritis usually causes 24-hour periods (excluding the first 24  fever on the third or fourth day INFECTION OF THE PERINEUM postpartum. Infection that can occur at the suture line from an Fever is defined as >100.4°F episiotomy or laceration repair, providing a portal for (38°C) for two consecutive bacterial invasion. 24-hour periods, excluding the Assessment: first day. ○ Symptoms: ○ Symptoms: Localized pain, heat, pressure; Chills, loss of appetite, malaise, may or may not include fever. painful and poorly contracted Inflammation visible upon uterus, strong afterpains. inspection of the suture line; Lochia: Dark brown, foul odor, possible sloughing of stitches or increased or scant depending purulent drainage. on uterine involution and fever. ○ Action: ○ Diagnosis: Notify the physician or Ultrasound may be used to nurse-midwife; culture any check for retained placental discharge using a sterile swab. fragments. Therapeutic Management: Therapeutic Management: ○ Suture Removal: ○ Antibiotics: Physician/nurse-midwife may Administer appropriate remove sutures to allow antibiotics (e.g., clindamycin) drainage and prevent further based on culture from lochia. infection. ○ Uterine Contraction: Packing (e.g., iodoform gauze) Oxytocic agents (e.g., may be placed in the lesion to methylergonovine) may be promote drainage; the patient prescribed. should be informed to avoid ○ Fluid and Pain Management: dislodging it. Increase fluid intake; provide ○ Antibiotics: analgesics for pain relief. Systemic or topical antibiotics ○ Positioning: typically prescribed prior to Fowler's position or walking can culture results. help with lochia drainage. ○ Pain Management: Infection Control: Analgesics may be provided for ○ Early detection is crucial. Educate about discomfort. normal lochia color, quantity, and odor. ○ Hygiene: ○ Emphasize handwashing before and Sitz baths, warm compresses, after pad changes. or Hubbard tank treatments may Follow-Up and Recovery: be recommended to cleanse the ○ Infection typically resolves in 7 to 10 area and promote drainage. days; teaching about signs of infection is Frequent perineal pad changes essential. are crucial to prevent ○ If hospitalized, arrange for the baby's contamination and reinfection. care during an extended stay. Advise wiping front to back after ○ Possible need for future fertility bowel movements to avoid fecal assessment if scarring occurs. contamination. Considerations for Future Fertility: Follow-Up: ○ Endometritis may lead to tubal scarring, ○ Women are often discharged with a which can interfere with future referral for home care; healing occurs by pregnancies. Mild cases generally don’t tertiary intention (delayed closure). impact fertility, but women should be ○ Localized infections are generally informed of potential risks. manageable and do not restrict infant care, provided hand hygiene is practiced.  Encouragement for Recovery: the passage of ova through the fallopian ○ Encourage ambulation despite pain, as tubes. inactivity may exacerbate discomfort. ○ Ensure the infant does not contact THROMBOPHLEBITIS contaminated bedding. Thrombophlebitis is the inflammation of a blood vessel with the formation of blood clots, typically occurring in the postpartal period as an extension of an endometrial PERITONITIS infection. Infection of the peritoneal cavity, often a serious Risk Factors: complication following endometritis; a major cause of Elevated fibrinogen levels from pregnancy. puerperal infection-related mortality. Dilated lower extremity veins due to fetal Pathophysiology: pressure during birth. ○ Infection spreads via the lymphatic Prolonged inactivity or use of stirrups during system or through the fallopian tubes or delivery. uterine wall, potentially leading to Obesity and smoking. abscess formation in the cul-de-sac of Previous history of thrombophlebitis or varicose Douglas. veins. Assessment: Types: ○ Symptoms: Superficial Vein Disease (SVD): Affects Rigid abdomen, abdominal pain, superficial veins. high fever, rapid pulse, vomiting, Deep Vein Thrombosis (DVT): Involves deeper and signs of acute illness. veins, such as femoral or popliteal veins. Check for a well-contracted uterus and a soft abdomen; a Femoral Thrombophlebitis rigid abdomen indicates Assessment: guarding and is an early sign of Symptoms may appear around 10 days peritonitis. postpartum and include: Therapeutic Management: ○ Elevated temperature, chills, leg pain, ○ Nasogastric Tube: and redness. May be needed to manage ○ Swelling in the leg, appearing shiny and paralytic ileus (intestinal white. blockage), preventing vomiting ○ Positive or negative Homans' sign (pain and allowing bowel rest. with foot dorsiflexion). ○ Nutrition: Diagnostic Tools: Intravenous fluids or total Doppler ultrasound or contrast venography. parenteral nutrition may be Therapeutic Management: necessary. Bed rest with leg elevation. ○ Pain Relief: Anticoagulants and moist heat applications. Analgesics provided for pain Avoid massaging the affected area to prevent management. dislodging clots. ○ Antibiotic Therapy: Pain management with analgesics. Large doses of antibiotics are Monitoring for signs of bleeding and adjusting administered to combat the anticoagulant therapy as needed. infection. ○ Hospitalization: Extended hospital stay typically Pelvic Thrombophlebitis required; prognosis is generally Assessment: good with effective treatment. Symptoms arise later in the postpartum period, Future Fertility Concerns: typically around 14-15 days post-birth. ○ Peritonitis can lead to scarring and Sudden severe illness, high fever, chills, and adhesions in the peritoneum, potentially malaise. impacting future fertility by obstructing Therapeutic Management:  Similar to femoral thrombophlebitis: bed rest, Other factors may include urinary stasis due to antibiotics, and anticoagulants. pain while urinating or difficulty in voiding. Monitor for abscess formation, which may require surgical intervention. Assessment Symptoms: Complications Burning sensation during urination. Pulmonary Embolus: Possible hematuria (blood in urine). Occurs when a blood clot obstructs the Frequent urge to void, potentially leading to pulmonary artery, often as a complication of urinary retention due to pain. thrombophlebitis. Low-grade fever and lower abdominal Symptoms include sudden chest pain, discomfort. tachycardia, tachypnea, orthopnea, and Diagnostic Procedure: cyanosis. Obtain a clean-catch urine specimen: Requires immediate oxygen administration and ○ Instruct the woman on proper cleansing possible ICU transfer. to avoid contamination. ○ Provide a sterile cotton ball for MASTITIS placement in the vagina during the collection to prevent lochia Mastitis is an infection of the breast tissue, commonly contamination. occurring postpartum due to cracked nipples. ○ Mark the specimen accordingly to inform Risk Factors: laboratory staff. Improper breastfeeding techniques. Failure to properly clean hands between perineal and breast care. Therapeutic Management Assessment: Antibiotic Treatment: Usually unilateral, symptoms include: Broad-spectrum antibiotics, such as amoxicillin ○ Pain, swelling, redness in the affected or ampicillin, are typically prescribed. breast. Avoid sulfa drugs during breastfeeding due to ○ Fever and reduced milk supply. the risk of neonatal jaundice. Confirm with the physician if the prescribed Therapeutic Management of Mastitis antibiotic is safe for breastfeeding; adjustments may be needed. Antibiotics: Effective against penicillin-resistant Hydration: staphylococci (e.g., dicloxacillin). Encourage the woman to drink large amounts of Breastfeeding: Continue to empty the breast to fluid (e.g., a glass every hour) to help flush the prevent bacterial growth; express milk if too infection. painful. Pain Management: Pain Relief: Use cold compresses, supportive Recommend an oral analgesic (e.g., bras, and warm wet compresses as needed. acetaminophen) to alleviate discomfort Monitor for abscess development, which may associated with urination. require drainage. Medication Adherence: Stress the importance of completing the full URINARY TRACT INFETION (UTI) course of antibiotics (5 to 7 days), even if A urinary tract infection (UTI) is an infection in any part symptoms improve. of the urinary system, commonly occurring in postpartum Suggest creating a chart or reminder system women, especially those who have been catheterized. (e.g., a refrigerator note) to help track medication. Risk Factors Catheterization during childbirth or the Prevention postpartum period can introduce bacteria into Education: the bladder, increasing the risk of infection. Discuss common preventive measures to avoid future UTIs, such as:  ○ Proper hygiene (wiping front to back). Symptoms ○ Staying hydrated. Psychological: Profound sadness and a ○ Urinating regularly. complete detachment from reality. Women may ○ Avoiding irritants like harsh soaps and deny having had a child and could express bubble baths. harmful thoughts, including infanticide or beliefs that the infant is possessed. POSTPARTAL DEPRESSION Postpartal depression is a significant mental health Management condition that affects many women after childbirth. While Immediate Care: Women exhibiting symptoms of most women experience temporary emotional changes psychosis require close monitoring and should known as "baby blues," about 20% may endure more not be left alone or with their infants due to severe symptoms lasting beyond the immediate safety concerns. postpartum period. Referral: Prompt psychiatric evaluation and treatment, including antipsychotic medication, Symptoms are essential for recovery. Emotional: Persistent sadness, extreme fatigue, Supportive Environment: Recognizing that excessive crying, heightened anxiety regarding childbirth can precipitate such severe mental self or infant, feelings of insecurity, and difficulty illness helps caregivers provide appropriate making decisions. support and interventions. Physical: Psychosomatic symptoms like nausea, vomiting, diarrhea, and mood swings. Risk Factors History of depression. Troubled childhood experiences. Low self-esteem and high stress levels at home or work. Lack of effective support systems. Discrepancies in parenting expectations between partners. ECTOPIC PREGNANCY An ectopic pregnancy occurs when a fertilized egg Assessment and Management implants outside the uterine cavity, most commonly in Detection: Early identification is crucial. Nursing the fallopian tube (approximately 95% of cases). Other assessments through observation and sites include the ovary and cervix. The ampullar portion discussion are effective. Various depression of the fallopian tube is the most frequent implantation scales may assist in diagnosis. site. Intervention: Women may need counseling and possibly antidepressant therapy. Addressing Causes these symptoms is vital for fostering a healthy Ectopic pregnancies often arise due to conditions that maternal-infant bond and supporting family obstruct the fallopian tubes, such as: dynamics. Previous infections (e.g., pelvic inflammatory Follow-Up: Regular assessments during disease, chronic salpingitis). postpartal visits can help identify symptoms Scarring from surgeries or congenital early and facilitate timely referrals for care. abnormalities. Intrauterine devices (IUDs) may also contribute POSTPARTAL PSYCHOSIS by slowing the transport of the zygote. Postpartal psychosis is a rare but severe condition Increasing incidence is noted with in vitro affecting approximately 1 in 500 women following fertilization (IVF). childbirth. This mental health crisis often occurs in those with a prior history of mental illness, triggered by the stresses of childbirth. Incidence Surgical options involve laparoscopy to remove Approximately 2% of all pregnancies are ectopic, making or repair the affected fallopian tube, ligating it the second most common cause of bleeding in early bleeding vessels as necessary. pregnancy. Women with a history of ectopic pregnancy If a tube is removed, fertility is theoretically have a 10% to 20% chance of experiencing another. reduced, but it is possible for the remaining ovary to still achieve fertilization. Assessment Follow-Up Care Initial Symptoms Women with Rh-negative blood should receive Many women exhibit no unusual symptoms Rh immune globulin to prevent isoimmunization immediately after implantation. in future pregnancies. Common early signs include nausea, vomiting, Ongoing monitoring and counseling are and a positive pregnancy test. essential to address emotional and physical health following an ectopic pregnancy. Signs of Rupture Sharp, stabbing pain in the lower abdomen. Scant vaginal spotting or bleeding. Symptoms of internal bleeding, such as lightheadedness, rapid pulse, and signs of shock, may occur if the ectopic pregnancy ruptures. Diagnostic Tests Transvaginal ultrasound is typically used to confirm the diagnosis. Blood tests measuring hCG levels can indicate the progression of the pregnancy. In some cases, a laparoscopy may be performed for direct visualization. Therapeutic Management Medical Treatment Some ectopic pregnancies resolve spontaneously without treatment. Unruptured ectopic pregnancies can be treated with methotrexate, a medication that targets rapidly dividing cells, or with mifepristone, which induces sloughing of the implantation site. Regular monitoring is necessary until hCG levels drop to zero. Surgical Treatment A ruptured ectopic pregnancy is a medical emergency. Immediate interventions include stabilizing the patient with IV fluids and possibly blood transfusions.