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Complicated Labor and Delivery

High risk factors may develop at

anytime during the course of
labor in client who has been
otherwise healthy throughout
her pregnancy.

Clients Response to the onset of High-
risk factors

1. Stress, fear and anxiety brought about by
unexpected complications during labor may
have profound effects on maternal and fetal
2. Maternal anxiety can increase tension,
produce higher pain perception and may
make labor contractions less effective.
3. Cathecholamines released during stress
produce vasoconstriction that may negatively
affect uterine blood flow.
Problems with the Passenger
A. Types of Malposition
1. Occiput Posterior Position
- R or L Occiput Posterior occurs in about 25%
of all term pregnancies but usually rotates to
O.A. as labor progress
- Failure to rotate is termed persistent occiput
- Maternal risks include prolonged labor,
potential for operative delivery extension of
the episiotomy, or 3
and 4
laceration of the perineum
Maternal Symptoms
Intense back pain in labor
Dysfunctional labor pattern
Prolonged active phase
Secondary arrest dilatation
Arrest of descent.

2. Occiput Transverse Position (O.T)
- Incomplete rotation of O.P to O.A results in the
fetal head being in a horizontal or transverse
- Persistent O.T position occurs as a result of
ineffective contractions or flattened bony pelvis.
- In the absence of abnormal pelvic structure,
vaginal delivery can be accomplished by
stimulating contractions with Oxytocin (Pitocin)
and application of Forceps for delivery.
Nursing Care
Nursing Diagnosis: Pain, Ineffective coping
- Encourage mother to lie on her side opposite
from the fetal back, which may help with
- Knee-chest position may facilitate rotation
- Pelvic rocking may help with rotation
- Apply sacral-counter pressure with heel of the
hand to relieve back pain
Medical Management
1. Forceps : metal instruments applied to the
fetal head to facilitate delivery
- Provides traction or a means of rotating fetal
- Risks are fetal ecchymosis or edema of the
face, transient facial paralysis, maternal
lacerations or episiotomy extensions.

2. Vacuum extraction : a suction cup applied to
the fetal head to facilitate delivery
- Provides traction to shorten the second stage
of labor
- Risks are newborn cephalhematoma, retinal
hemorrhage and intracranial hemorrhage.

- Refers to fetal presenting part other than
vertex and includes breech, transverse, face,
brow and sinciput.
- Malpresentations may be identified late in
pregnancy or may not be discovered until the
initial assessment during labor.
Related Factors:
- The woman has had more than one pregnancy
- There is more than one fetus in the uterus

- The uterus has too much or too little amniotic
- The uterus is not normal in shape or has
abnormal growths such as fibroids
- Placenta previa
- The baby is preterm

A. Vertex Malpresentation
a. Brow presentation
- Fetal forehead is the presenting part
- 50% convert to vertex or face presentation
b. Face Presentation
- The presenting part is the face
- Palpation of the nose, mouth and eyes and
chin through vaginal examination
- Increased risk of prolonged labor and
operative delivery
- Anticipate vaginal delivery if the pelvis is
adequate and the chin is in the anterior
- Anticipate cesarian delivery if chin is
posterior or signs of fetal distress occurs.

c. Sincipital presentation
- The sinciput presentation occurs when the
larger diameter of the fetal head is presented
- Labor progress is slowed with lower descent
of the fetal head
B. Breech Presentation
a. Complete
- The babys hip and knees are flexed so that
the baby is sitting cross-legged with feet
beside the bottom
b. Frank
- The babys bottom comes first, and the legs
are flexed at the hip and extended at the
knees with feet near the ears.
- 65-70% of breech babies are in frank position
c. Incomplete
- One or both feet comes first with the
bottom, at a higher position. This is rare at
term but relatively common with premature
- Risk for umbilical cord prolapse

d. Kneeling Breech
- The baby is in kneeling position, with one or
both legs extended at the hips and flexed at
the knees. This is extremely rare.
Maternal Risks
- Prolonged labor due to dec. pressure exerted
by the breech on the cervix
- Premature rupture of membranes may expose
clients to infection
- Cesarean forceps delivery
- Trauma to birth canal during delivery from
manipulation and forceps to free the fetal head
- Intrapartum or postpartum hemorrhage
Fetal Risks:
- Umbilical cord prolapse
- Entrapment of fetal head in incompletely dilated
- Aspiration and asphyxia at birth
- Birth Trauma from manipulation and forceps to
free the fetal head

Nursing Interventions:
- Vaginal delivery of breech
- Cesarean section
- External cephalic version

C. Transverse Lie (Shoulder lie)
- The acromium process is the presenting part.
- Vaginal delivery is not considered.
- Cesarian methos is the preferred method of
Risk factors
- Low birth weight
- Multiple gestation
- Polyhydramnios
- Large pelvis
- Rupture of membranes
- External cephalic version
- Compound presentation may be noted on an
antepartum obstetrical ultrasound examination
or palpated during cervical examination,
typically during early labor.
- Examiner will feel an irregular shape beside or
in advance of the vertex or breech.
Nursing care of clients with malpresentations
- Assessment: Leopolds Maneuver
- Nursing Diagnosis:
Risk for injury
Deficient knowledge
Ineffective individual/family coping

Planning and Implementation
- Observe closely for abnormal labor patterns
- Monitor fetal heart rate and contractions
- Provide client/family teaching
- Provide client support and encouragement
- Anticipate forceps-assisted delivery
- Anticipate CS for incomplete breech or
shoulder presentation.

- The client and fetus have a safe labor and
- The client verbalizes understanding of the
implications of the malpresentation

- Insufficient oxygen supply to meet the
demands of the fetus.
- Compression of the umbilical cord
- Uteroplacental insufficiency caused by
placental abnormalities or maternal condition
- Multiple births
- Shoulder dystocia
- Umbilical cord prolapse
- Nuchal cord
- Abruptio placenta
- Premature closure of the fetal ductus
- Meconium-stained amniotic fluid

Changes in Fetal heart rate baseline
1. Tachycardia
2. Bradycardia

Decreased or absence of variability of heart rate
3. A heart rate of less than 2-5 beats per minute
causing a flattened appearance to heart rate
4. Indicates depression of the autonomic nervous
system that controls the fetal sleep. Sedation,
and hypoxia may affect variability

Late Decelaration pattern
- FHR slows following the peak of a contraction
and slowly returns to baseline rate during the
resting phase.
- Indicates fetal response to hypoxia from
uteroplacental insufficiency
- Considered omnious pattern regardless of the
depth of the deceleration of the fetal heart
rate and requires immediate intervention

Variable Deceleration pattern
- FHR repeatedly decelerates below 90 bpm for
over 60 seconds before returning to baseline
- Indicates interference of fetal blood flow from
cord compression
- Leads to fetal hypoxia and low apgar scores
unless steps are taken to correct it.
1. Assess FHR baseline, variability, and pattern
periodic changes

2. Assess contraction pattern and maternal
response to labor
1. Decreased cardiac output (fetal)
2. Impaired gas exchange
3. Anxiety
Planning and Implementation
Late Deceleration
- To improve maternal blood flow to the
a. Reposition the mother on her left side
b. Administer O2 by face mask at 8-10pm
c. Increase IV fluids
d. Discontinue oxytocin infusion, if labor is being
e. Notify the health care provider immediately.

Variable deceleration
- To relieve pressure on the umbilical cord
a. Reposition the mother on either side
b. If not corrected, reposition to the opposite
c. Administer O2 by face mask at 8-10lpm
d. Trendelenburg or knee-chest position, if not
e. Perform vaginal examination and apply
upward digital pressure on the presenting
part to relieve pressure on the umbilical cord

- Fetal heart rate remains in normal range with
adequate variability and absence of ominous
periodic changes.
- The client verbalizes that anxiety is decreased.
- Family coping strategies are strengthened.

A. Amnioinfusion
- FHR monitoring is required
- Intrauterine catheter is inserted
- Warmed sterile saline is delivered via the
catheter using an infusion pump.
- Infusion is continued until signs of cord
compression disappear.
B. Intrauterine Resuscitation
- Administration of Terbutaline (Brethine), a
tocolytic agent to stop uterine contractions
and provide an opportunity for uteroplacental
circulation to improve when fetal distress is
present during the first stage of labor.

C. Prevention of Meconium Aspiration
- If meconium is present during labor steps to
prevent aspiration should be taken.
- The nasopharynx of the infant is suctioned
prior to delivery of the chest and abdomen.
- Visualization of the larynx and vocal chords
with deep suction is performed immediately
after delivery and before first breath is taken.
4. Cord Prolapse
What is an umbilical cord?
- Is a flexible, tube-like structure that, during
pregnancy, connects the fetus to the mother.
- The umbilical cord is the babys lifeline to the
- It transports nutrients to the baby and also
carries away the babys waste products.
- It is made up of three blood vessels
Cord Prolapse
- Also called an umbilical cord prolapse
- A very rare obstetrical emergency which can
result in a birth injury or worse.
- It is when the babys umbilical cord descends
alongside or descends before his head.
- Can be life-threatening to the baby since
blood flow-and therefore oxygen- through his
umbilical cord is usually compromised due to
cord compression
Contributing factors
- Premature rupture of the amniotic sac
- Polyhydramnios
- Long umbilical cord
- Fetal malpresentation
- Multiparity
- Multiple gestation

Monitor FHR to measure the babys heart rate
(if the baby has prolapsed, may have
The physician may conduct a pelvic
examination and may see the prolapsed cord,
or palpate the cord with his or her fingers.
Priority Nursing Diagnoses
Risk for impaired gas exchange
Risk for injury

ACTION: To relieve pressure on the cord and
restore fetal oxygenation
A. Place mothers hip higher than her head
1. Knee-chest position
2. Trendelenburg position
B. Perform sterile vaginal exam pushing fetal
presenting part upward with fingers to
relieve pressure on the cord
1. Administer O2 by face mask at 8-10 lpm
2. Maintain continuous electrical fetal
3. Prepare for rapid delivery vaginally, or by
cesarean section
4. If cord protrudes through the vagina,
determine that pulsation is present and apply
sterile saline soaked dressing to prevent
1. The fetal heart rate remains within normal
range and without ominous sign
2. The fetus is safely delivered
3. The client and family verbalize understanding
of the implications of prolapsed cord and the
need for emergency maganement

The Pelvis
- Problems of the bony pelvis that can influence
the progress of labor include:
a. Contracted pelvis due to Avitaminos D or
Ricketts in childhood

Malpositioning can occur because the fetus head
isnt engaged in the pelvis.
- Small pelvis may be a result of rickets in the early
life, a genetic predisposition, Pelvis isnt fully
mature in young adolescent
- Macrosomia
> Inlet contraction occurs when narrowing of the
anteroposterior diameter is less than 11 cm, or a
maximum transverse diameter is 12cm or less.
Outlet contraction, the transverse diameter
narrows to at the outlet to less than 11cm
Abnormal positions of the fetus can also cause
Fetal anomalies such as hydrocephalus,
hydrops fetalis and tumors of the fetal head.
How it is detected?
1. Pelvic measurements
- Every primigravida should have before week
- Methods of performing clinical pelvimetry
range from very simple to very complex.
Simple digital examination of the pelvis
allows the examiner to categorize it as
probably adequate for an average sized baby,
borderline, or contracted. Other methods
include the following:

Measuring the diagonal conjugate. Insert 2
fingers into the vagina until they reach the
sacral promontory. The distance from sacral
promontory to the exterior portion of the
symphysis is the diagonal conjugate and should
be greater than 11.5cm
Measure the bony outlet by pressuring your
closed fist against the perineum. Compare the
previously measured diameter of your fist to the
palpable distance between the ischial
tuberosities. Greater than 8cm bituberous is
considered normal.
Feel the ischial spines for their relative
prominence or flatness. Spinal prominence
narrows the transverse diameter of the pelvis.
Feel the pelvic sidewalls to determine
whether they are parallel (OK), diverging or
(even better), or converging (bad). True outlet
obstruction is fortunately rare.

2. Presence of large caput succedaneum
A. Trial Labor
- If the pelvic measurements are borderline or
just adequate
- - may be allowed to continue if descent of the
presenting part and dilatation of the cervix are
- Nsg. Measures:
- - Monitor FHR and uterine contractions
-- Make sure that the urinary bladder is kept empty.
-- After rupture of membranes, assess FHT carefully.
-- Monitor progress of labor.
-- Emphasize that its best for the baby to be born
vaginally if possible.
-- If the trial labor fails and CS is scheduled, explain
why procedure is necessary.
-- A woman having a trial labor may feel shes on
trial herself. She may feel being misjudged and
may be self-conscious if labor doesnt go well as
-- When dilatation doesnt occur, the woman
may feel discouraged and inadequate, as if
shes somehow at fault.
-- Remember to support the support person.
-- Assure the parents that CS isnt an inferior
method of birth. Remind them its an
alternative method.

Problems with the Powers
1. Dystocia
- Prolonged difficult labor and or delivery
because of problems with the 4Ps
1. Faults of the passenger
a. Abnormal position
b. Malpresentations
c. Hydrocephaly
d. Large fetus
e. Abnormal lie
f. Multiple pregnancy
2. Faults of the passageway
a. Cervical inertia
b. Contracted pelvis
c. CPD
Non-gynecoid pelvis
d. Cervical scar tissue from previous surgery
3. Faults of the primary power
a. Hypertonic uterine inertia
b. Hypotonic uterine inertia
4. Faults of the person: poor psychosocial
responses which are influenced by theses
a. Education and preparation
b. Previous experiences
c. Readiness
d. Support systems
e. Maternal position
f. Race and culture
g. Environment
h. Socioeconomic status

1. Maternal exhaustion and dehydration
2. Infection
3. Traumatic operative births
4. Fetal distress
5. Birth injuries
6. Perinatal mortality

- Bedrest
- Sedation for hypertonicity
- Stimulation with oxytocin for hypotonicity
- Cesarean section
- Forceps as indicated
- Vaginal exam - Leopolds Man
- Pelvimetry - Ultrasound

- Prepare client for/ assist in various diagnostic
- Promote rest and comfort: quite darken room
- Proper position for comfort: lateral
- Monitor:
a. Labor: uterine contractions and cervix
b. Fetal well-being: FHT, movement, passage of
- Give reassurance and support
Uterine contractions force the moving fetus
through the birth canal.
This process is aided by:
- Hormones: estrogen and progesterone E and
NE, oxytocin
- Electrolytes: calcium, sodium and potassium
- Proteins: actin and myosin
- Prostaglandin

2 types of ineffective labor
a. Primary (at the beginning of labor)
b. Secondary (later in labor)

- Hypertonic contractions
- Hypotonic contractions
- Uncoordinated contractions
Are marked by an increase resting tone to
more than 15mmHg
Intensity of the contractions may be no
stronger than with hypotonic contractions
Tend to occur frequently
Most commonly seen in the latent phase of
May result in precipitous labor
- Occurs because the muscle fibers of the
myometrium dont repolarize after a
- Oxytocin administration can also cause
hypertonic uterine contraction
- Determined by the presence of painful uterine
contractions that are either palpated or

- On the electronic monitoring the uterine
contractions show a high resting tone, and a lack
of relaxation between contractions is also
- Fetal monitoring may reveal bradycardia and
fetal distress in the form of late decelerations
because the absence of uterine relaxation
doesnt allow the best possible uterine filling
- The woman wont be able to relax between
contractions and may find it difficult to breathe
with her contractions
- Contractions are painful
- Uterine and fetal extrenal monitor applied for
at least 15 min
- Promote rest
- Provide analgesia with a drug as morphine
- Possibly sedation so the woman can rest.
- Such as changing the linen and the patients
gown, darkening room lights and decreasing
noise and stimulation.

- Cesarean birth is necessary if decelerating FHR

The number of frequency of contractions is
Strength of contractions does not rise above
25 mmHg.
Usually occur during the active phase of labor.
Tend to increase the length of labor because
so many of theses contractions are necessary
to achieve cervical dilatation.
Can result in exhaustion

- Exhaustion can lead to:
Ineffective contractions of the uterus, in
creasing the womans chance for postpartum
Risk of infection of the uterus and the fetus
because of the extended period of cervical


- Analgesia has been administered too early
(before cervical dilatation of 3-4cm)
- Bowel or bladder distenton is present,
preventing descent or engagement.
- The uterus is overstretched due to multiple
gestation, larger than normal single fetus,
hydramnios, or grandmultiparity.
How its detected
The contractions arent normally painful
because they arent intense.
Lack of labor progression and cervical
Contractions are sufficient to dilate the cervix
and wont register as intense on an electronic
uterine contraction monitoring strip.

1. If hypotonicity is the only abnormal factors
(including ruling out CPD or poor fetal
presentation by sonogram), then rest and
fluid intake should be encouraged.
2. If the membranes havent ruptured
spontaneously, rupturing them at this point
may be helpful.
3. Oxytocin may be administered IV to augment
labor causing the uterus to contract more
4. If hypertension occurs, discontinue oxytocin
and notify practitioner.
Uncoordinated contractions
Occur erratically, such as one on top of
another followed by a long period without
May occur so closely that they dont allow
good filling time.
The lack of regular pattern of contractions
makes it more difficult for the woman to rest
or to use breathing exercises between

With uncoordinated contractions, more than
one pacemaker may initiate contractions.
Receptor points in the myometrium act
independently of the pacemaker.

How it is detected
Application of a fetal external monitor.
Allows assessment of the rate, pattern, resting
tone and fetal response to contractions,
revealing an abnormal pattern. Usually
detected within 15 minutes. (Longer time
span may be necessary to show disorganized
pattern of early labor.)
Oxytocin administration may be helpful to
stimulate a more and effective and consistent
pattern of contractions with better, lower
resting tone.
If hypertension occurs, discontinue oxytocin
and notify physician.
Postpartal Hemorrhage
Postpartal hemorrhage is the loss of blood
totaling 500ml or more within a 24 hour
Can be late already after 24 hours until 6
weeks puerperium
- Uterine atony - Retained placental frag.
- Lacerations - DIC
A. Uterine atony.
- Relaxation of the uterus
- Typical cause of postpartal hemorrhage
- Overdistended uterus
- Fatigue uterus (tocolytics such as Mg and
Calcium channel blocker)
- Obstructed uterus: Accreta and Inccreta
Nursing Interventions:
- Palpate the womans fundus and frequent intervals
- Frequently assess the lochia and vital signs
Therapeutic Mgt:
- Attempt uterine massage to encourage contraction
- Infusion of oxytocin to help the uterus remain in
- Offer oxygenation without the doctors order 2l/min
- Position her in supine position
B. Lacerations
- Tears of birth canal are common and maybe
considered normal consequence of normal
- Vaginal trauma most common with surgical or
assisted vaginal deliveries.
3 types of Lacerations:
a. Vaginal arterial bleeding (bright red)
b. Cervical occur when the women bear down
in no time.
c. Perinial
Risk Factors:
- Delivery of large infants
- Intrumentations or intrauterine manipulation
- Episiotomy
- Precipitate birth

- Primigravida
Cervix is not stretched
Dont know what to do
- Use of lithotomy position
Increased tension on the perineum

Therapeutic Mgt:
A. Cervical lacerations:
- Very difficult to repair because of severe

- Maybe necessary for the women to be given by
anesthetic to relax the uterine muscle and
prevent pain.
B. Vaginal Lacerations
- Are hard to repair because they vaginal tissues
are friable
- Rare, easier to assess than cervical lacerations
because they viewed.
- Packing that is left too long leads to stasis and
* Packing - putting up cervical OS to stop the
oozing of blood.
- Diet high in fluid and stool softener maybe
administered for the first week.
* Enema diagnostics of the LGI tract

Know the degrees of lacerations and the types
of lacerations and the types of nursing

C. Retained placental fragments
- Occurs when the placenta does not deliver
- Keeps from the uterus from contraction that
causes severe bleeding. (Deliver the placenta
do controlled contraction, place your palm in
the fundus so that thee uterus would not
invert that will cause bleeding.)
- If an undetected retained fragment is present,
bleeding will be apparent in immediate
postpartal period
Risk Factors:
- Uterine surgery
- Premature surgery
- Prolonged placental delivery

Therapeutic Mgt:
- D and C
- Methotrexate maybe prescribe
- Observe the color of the lochia discharge

D. Disseminated Intravascular Coagulation
- Deficiency in clotting ability caused by
vascular injury
- Fibrinogen protein that helps blood
- DIC causes more clots in the circulation
Risk factors:
- Multipara - Episiotomy
- Prolonged labor - Macrosomia
- Multiple gestation - Abruptio placenta
- Uncontrolled bleeding
- Decreased blood pressure
- Increased heart rate
- Decreased RBC count
- Swelling and pain in tissues in the vaginal and
perinial area

- Inspect the vagina and cervix fro bleeding
- Estimation of blood loss
- Pulse rate and BP measurement
- Clotting factors of the blood should be
examined. ( D-dimer)
- Medication (Oxytocin, Methergine)
- Manual massage of the uterus to stimulate
- Removal of placental pieces
- Examination of the uterus
- Hysterectomy
- Replace loss of blood and fluids
Puerperal Infection
Refers to a bacterial infection following
Maybe referred to as puerperal or postpartum
Genital tract, particularly the uterus is the
most commonly infected site.
In some cases infection can spread to other
points in the body-fatal.
1. Endometritis
- The primary cause of postpartum infection.
- E. coli, K. pneumoniae and Proteus are the
most frequently identified organisms.
- Endometritis occurring on postpartum day 1
or 2 most frequently caused by group A
- If infection develops on day 3 or 4 it is most
commonly caused by enteric bacteris
- If infection develops more than 7 days after
delivery it is most frequently caused by
Chlamydia trachomatis.
- Infection following C/S is most frequently
caused by Bacteriodes species.
- C/S
- Young age
- Low socioeconomic status
- Prolonged labor
- Prolonged rupture of membranes
- Multiple vaginal exam
- Placement of intrauterine catheter
- Preexisting infection
- Twin delivery
- Manual removal of the placenta
A benign temperature elevation may occur on
the first postpartal day, particularly if the
woman is not drinking fluid.
Fever may manifest on the 3
and 4

postpartal day
Assess vital signs.
Fundal tenderness
- Mucopurulent vaginal discharge

Differential Diagnosis:
- Acute pyelonephritis
- Lower genital tract infection
- Wound infection
- Atelectasis
- Pneumonia
- Thrombophlebitis
- Mastitis
- appendicitis
Laboratory tests:
- CBC count
- Urinalysis
- Urine culture
- Blood cultures
- Chest radiography
IV antibiotics: Clindamycin and Gentamycin
Reg. diet

Urinary Tract Infection
Bacterial inflammation of the bladder or urethra
- C/S
- Forceps delivery - Vacuum delivery
- Induction of labor - Cathetherization
- PIH - Length of hos. stay
- Epidural anesthesia - Prev. uti during preg
Bladder infections:
- Frequent urination
- Nocturia
- Urethritis
- Dysuria
- Pain at the midline suprapubic region(sharp)
- Pyuria
- Hematuria
- Pyrexia
- Cloudy-foul smelling urine

- Urinary incontinence
- Maybe asymptomatic
Kidney Infection
- Emesis
- Back, side or groin pain
- Abdominal pain or pressure
- Shaking chills and high spiking fever
- Night sweats
- Extreme fatigue
- Excessive thirst

Diagnostic tests
Obtain a clean catch urine
Urine culture

Therapeutic management
Encourage to drink large amount of fluids
Oral analgesic for pain
Treatment with antibiotic is 3-7 days
Wound infection
Include infection of the perineum developing
at the site of an episiotomy or laceration, as
well as the abdominal incision after a c/s
Diagnosed on the basis of: erythema, warmth,
tenderness, induration and purulent
discharges from the incision site with or
without fever.

- May become apparent on the 3
and 4
- Infected lochia
- Fecal contamination of the wound
- Poor hygiene
RISK FACTORS: (Abdominal)
- S. aureus from the skin - Obese
- DM - Tx w/cortecosteroids
- Hypertension - Chorioamnionitis
- Prolonged labor, prolonged rupture, prolonged OR
time, abdominal twin delivery, excessive blood loss

- Erythema and edema accompanied with purulent
- Inordinate amount of pain
- Hematoma
Abdominal: (develop around postoperative day 4)
- Erythema, warm, tender and indurated
- Purulent drainage may or may not be obvious
may release a serosanguineous or purulent fluid
- Sitz bath
- Broad spectrum antibiotic
- Incision and drainage
- Antibiotics
Inflammation of the mammary gland

- Milk stasis and cracked nipples contribute to
the influx of skin flora
- Incomplete emptying of the breast
- Improper nursing technique
Breast tenderness
Therapeutic management
Continue with breastfeeding
Apply cold or ice compress
Use a supportive bra
For milk stasis:
- Moist heat - proper positioning of the infant
- Massage - manual expression of milk
- Fluids rest - analgesics

Thromboembolic Disorder
A group of disorders that caused by blood clots in
the blood vessels.
May travel through the bloodstream and block an
3 types:
1. Superficial Thrombophlebitis
- inflammation of the wall of the vein located
close to the skin surface (superficial). It may be
accompanied by blood clot formation and may
be uncomfortable, but not dangerous.

2. Deep vein Thrombosis
- involves formation of a blood clot in the
deep veins of calves, legs or pelvis.

3. Phlebothrombosis
- involves blood clot formation without the
vein inflammation.

Virchow's triad: venous thrombosis occurs via
three mechanisms:
1. decreased flow rate of the blood
2. damage to the blood vessel wall
3. increased tendency of the blood to clot

Varicose vein
Injury to the vein such as injection
Age greater than 35 y.o
History of 3 or more pregnancies
Prolonged labor and use of forceps or c/s
Immobility: long trips, bedridden
Use of oral contraceptive
a. Superficial Thrombophlebitis
- is a common inflammatory-thrombotic
process that may occur spontaneously or as a
complication of medical or surgical
- Sterile thrombophlebitis limited to the
superficial veins rarely is life threatening, but
a thorough diagnostic evaluation is
mandatory because many patients with
superficial phlebitis also have occult deep
vein thrombosis (DVT).

Superficial phlebitis with infection, such as
phlebitis originating at an intravenous
catheter site, is referred to as septic
thrombophlebitis. This clinical entity requires
special diagnostic and therapeutic approaches
that are different from those applicable to
sterile phlebitis.
- Develop within the first 3 days postpartum period
- Tender, painful area along a vein in the calf
- Reddened area
- Vein is enlarged and highly visible
- Area is warm and cordlike to touch
- Extremity may be swollen
- Woman reports pain when walking

- Based on the signs and symptoms
b. Deep vein thrombophlebitis
- is the formation of a blood clot ("thrombus") in
a deep vein. Deep vein thrombosis commonly
affects the leg veins (such as the femoral vein or
the popliteal vein) or the deep veins of the pelvis
- Develop signs and symptoms during pregnancy or
at any time during the postpartum period
- Increase calf pain
- Leg swollen visibly
- Thigh and calf circumference is larger than the
other leg

- Pedal edema
- Area is warm, tender and red
- Positive with homans sign
- Arterial spasms
- Chills, low-grade fever, malaise, stiffness of
the affected leg
- Pain on ambulation

The risk of venous thrombosis and pulmonary
embolism in otherwise healthy women is considered
highest during pregnancy and the puerperium.
Indeed, the risk of pulmonary embolism has been
estimated to be as much as four- to sixfold higher
during pregnancy (Christiansen and Collins, 2006;
Marik and Plante, 2008).
The incidence of all thromboembolic events averages
about 1 per 1000 pregnancies, and about an equal
number are identified antepartum and in the
In a recent study from Norway of more than
600,000 pregnancies, Jacobsen and colleagues
(2008) reported that deep-venous thrombosis
alone was more common antepartum whereas
pulmonary embolism was more common in the
first 6 weeks postpartum.
The frequency of venous thromboembolic
disease during the puerperium has decreased
remarkably as early ambulation has become
more widely practiced.

The gold standard is intravenous venography,
which involves injecting a peripheral vein of
the affected limb with a contrast agent and
taking X-rays, to reveal whether
the venous supply has been obstructed.
Because of its invasiveness, this test is rarely
Real-time and color doppler ultrasound
- non-invasive diagnostic method and is
commonly used.
- Plethysmography
- D-Dimer test

Homans sign: Dorsiflexion of foot elicits pain
in posterior calf. Pratt's sign: Squeezing of
posterior calf elicits pain.
Medical management
1. Anticoagulant
- Heparin
- Warfarin
2. Thrombolytic therapy
- Streptokinase
- Urokinase
- Recombinant Tissue plasminogen activator
3. Analgesia for Pain
4. Antibiotic
5. Surgical procedure
- Venous ligation

Nsg. management
1. Woman may continue breastfeeding while
receiving Heparin
2. Discontinue breastfeeding if woman is
receiving coumadin
3. Examine extremity for obvious prominent
4. Check for Homans sign
5. Promote early ambulation
6. Instruct client to avoid rubbing or massaging
the affected extremity
7. Increase fluid intake
8. Bed rest
9. Apply moist heat warm compress to decrease
10. Teach women not wearing constricting

Pulmonary embolism
- is a blockage of the main artery of the lung or
one of its branches by a substance that has
travelled from elsewhere in the body through
the bloodstream (embolism). Usually this is
due to embolism of a thrombus (blood clot)
from the deep veins in the legs, a process
termed venous thromboembolism.
Signs and symptoms
Sudden, sharp chest pain on inspiration
Low blood pressure
Sudden death

Oxygen therapy

Postpartum Psychiatric Disorders
A disorder during postpartum characterized by
disturbance in a mothers thoughts, emotions
and behavior
During postpartum period, about 85% of
women experience some type of mood
Symptoms are mild and short-lived, however
10-15% of women develop more significant
symptoms of depression or anxiety.
Based on multifactorial model
Psychologically, result from the stress of the
peripartum period and the responsibilities of
child rearing
Sudden decrease in the endorphins of labor
Postpartum thryroid dysfunction
Low free serum tryptophan
Risk factors
Undesired pregnancy
Feeling unloved by mate
Age younger than 20 years
Unmarried status
Medical indigence
Low self-esteem
Economic problems with housing or income
Poor relationship with husband or boyfriend
Being part of a family with 6 or more siblings
Limited parental support
Past or present evidence of emotional
Women with a history of PPD and postpartum

3 Categories
1. Postpartum Blues
2. Postpartum Depression
3. Postpartum Psychosis
Postpartum Blues
Onset is from first to fourth days after birth
Symptoms typically peak on the fourth or fifth
day after delivery and may last for a few hours
or a few days, remitting spontaneously within
two weeks of delivery
Sadness and tears are the common symptoms.
While these symptoms are unpredictable and
often unsettling, they do not interfere with a
womans ability to function
- Probable hormonal changes
- Stress of life changes
- No specific treatment is required.
- If symptoms of depression persist for longer
than two weeks, patient should be evaluated
to rule out a more serious mood disorder.
Postpartum Depression
Typically emerges over the first two to three
postpartum months or may even be present
for longer than one year but may occur at any
point after delivery.
Some women actually note the onset of
milder depressive symptoms during pregnancy
Depression or sad mood
Loss of interest in usual activities
Feelings of guilt
Feelings or worthlessness or incompetence
Sleep disturbance
Change in appetite
Poor concentration
Suicidal thoughts
Generalized anxiety is common, some women
develop panic attacks or hypochondriasis
Postpartum OCD has also been reported
- Hx of previous depression
- Hormonal response
- Lack of social support
Risk factors
- Hx. of depression
- Troubled childhood
- Low self-esteem
- Stress in the home or at work
- Lack of effective support people
Drug therapy
Non-pharmacological therapies are useful in
the treatment of postpartum depression.
- Cognitive-Behavioral therapy
- Interpersonal therapy
Conventional antidepressant medications
- Fluoxetine, sertraline, fluvoxamine and

Postpartum Psychosis
Most severe form of Postpartum psychiatric
A rare event that occurs in aapprox. 1-2 per
1000 women after childbirth
Occurs in the first postpartum year and refers
to a group of severe and varied disorders that
elicit psychotic sypmtoms
Earliest signs are restlessness, irritability, and
Women exhibit a rapidly shifting depressed or
elated mood, disorientation or confusion and
erratic or disorganized behavior.
Delusional beliefs are common and often
center on the infant
Auditory hallucinations may also occur
- Possible activation of previous mental illness
- Hormonal changes
- Family history of bipolar disorder
Referring to counseling
Safeguarding the mother from injury to self or
Considered a psychiatric emergency that
typically requires inpatient treatment

Care of Couple with problems of
Infertility the inability to conceive a child or
sustain a pregnancy to birth.
Subfertility said to exist when a pregnancy has
not occurred after at leats 1 year of engaging in
unprotected coitus
a. Primary there have been no previous
b. Secondary there has been a previous viable
pregnancy but the couple is unable to conceive
at present.
Sterility the inability to conceive because of
a known condition, such as the absence of a

Male Subfertility
- Disturbance in spermatogenesis (production
of sperm cells)
- Obstruction in the seminiferous tubules,
ducts, or vessels preventing movement of
- Qualitative or quantitative changes in the
seminal fluid preventing sperm motility
(movement of sperm)
Development of autoimmunity that
immobilizes sperm
Problems in ejaculation or deposition
preventing spermatozoa from being placed
close enough to a womans cervix to allow
ready penetration and fertilization

1. Inadequate sperm count
The sperm count is the number of sperm in a
single ejaculation or in a milliliter of semen.
N 20 million per milliliter of seminal fluid or
50 million per ejaculation
Atleast 50% of sperm motile and 30% should
be normal in shape and form.
Spermatozoa must be produced and
maintained at a temperature to be fully
Any condition that significantly increases body
- Chronic infection e.g tuberculosis or recurrent
- Actions that increase scrotal heat e.g working
at desk jobs or driving a great deal everyday
(salesmen or motorcyclists)
- Frequent use of hot tubs or saunas may also
lower sperm counts appreciably.
- Cryptorchidism
- Varicocele

2. Obstruction or impaired sperm motility
- Obstruction may occur at any point along the
pathway that spermatozoa must travel to reach
the outside: seminiferous tubules, epididymis,
vas deferens, the ejaculatory duct or the urethra.
Mumps orchitis

Tubal infections such as gonorrhea or
ascending urethral infection can result in this
type of obstruction because of adhesions form
and occlude sperm transport.
Congenital stricture of the spermatic duct
Autoimmune reaction
Extreme Obesity

3. Ejaculation Problems
Erectile dysfunction inability to achieve
Primary erectile dysfunction if the man has
never been able to achieve reection and
Secondary erectile dysfunction if the man has
been able to achieve ejaculation in the past
but now has difficulty
Premature ejaculation ejaculation before

Female Subfertility
- Anovulation (faulty or inadequate production
of ova)
- Problems of ova transport through the
fallopian tubes to the uterus
- Tumors or poor endometrial development
- Nutrition, body weight and exercise
1. Anovulation
- Turners syndrome (hypogonadism) no
ovaries to produce ova
- Hormonal imbalance caused by
Hypothyroidism that interferes with
hypothalamus pituitary-ovarian intreaction
- Chronic or excessive exposure to X-rays or
radioactive substances, general ill health,
poor diet and stress
- Nutrition, body weight and exercise influence
the blood glucose/insulin balance

- When glucose or insulin are too high, they can
disrupt the production of FSH and LH
- Nutrition: eating slowly digested carbohydrate
foods such as brown rice, pasta, dark bread,
beans and fiber rich vegetables increase
- Eating protein is important but from plant
sources: beans, tofu, soy beans and nuts
- Exercising 30 minutes a day help regulate
blood glucose levels
- Stress reduces Hypothalamic secretion of
Gonadotropin releasing hormone which then
lowers the LH and FSH
- Women who are excessively lean and anorexic
can reduce pituitary hormones such as FSH
and LH ( termed hypogonadotropic
- Polycystic Ovary syndrome ovaries produce
excess testosterone lowering the FSH and LH

2. Tubal transport problems
- Develops because scarring has developed in
the fallopian tubes (Chronic PID)
- Ruptured appendix or from abdominal surgery
that spread to fallopian tubes and left
- Tubal ligation

3. Uterine problems
- Fibromas(leiomyomas)
- Endometriosis
4. Cervical problems
- Stenotic cervical os
- Inflammation of the cervix
5. Vaginal problems
- Infection of the vagina cause the pH to
become acidotic limiting or destroying the
motility of the sperm

Fertility assessment
1. Health History
2. Physical assessment
3. Fertility testing
a. Semen analysis
- 2-4 days of abstinence the man ejaculates by
masturbation into a clean, dry specimen jar.
Then number of sperm are counted and
examined under the microscope

- ave. ejaculation should produce 2.5-5ml of
semen. (Ave. normal sperm count is 50-200
million per milliliter)
- may be repeated after 2-3 months because
spermatogenesis is an ongoing process and 30-
90days is needed for new sperm to reach
b. Sperm penetration assay and antisperm antibody
- Rarely necessary
- Determine whether a mans sperm, once they
reach the ovum can penetrate it effectively

c. Ovulation Monitoring
- BBT record the temp atleast 4 months, take her
temp every morning before getting out of bed or
engaging in any activity
d. Ovulation determine by strip
- Can be used in place of BBT
- A woman dips a test strip into a midmorning
urine specimen and then compares it with the kit
instructions for a color change
- Purchased OTC, easy to use, have the advantage
of marking the point just before ovulation occurs
rather than just after ovulation as in the case of

e. Tubal patency
- Determine the patency of fallopian tubes and
assess the depth and consistency of the
endometrial lining
a. Sonohysterography
b. Hysterosalpingography

4. Advanced surgical Procedures
a. Uterine endometrial biopsy
b. Hysteroscopy
c. Laparoscopy
Subfertility management
1. Correction of underlying problems
a. Increasing sperm count and motility
b. Reducing the presence of infection
c. Hormone therapy
d. Surgery
2. Assisted Reproductive Techniques
a. Therapeutic Insemination

Gestational Age Variaton
1. SGA
- Birth weight of infants falls below the 10

percentile on intrauterine growth curve.
- Maybe be preterm, term and postterm
1. Chromosomal problems
- Down syndrome
- Congenital anomalies

2. Infections
- Rubella
- Toxoplasmosis
3. Maternal factors
- Malnutrition
- Advanced diabetes
- Smoking
- Grand multiparity
- Alcoholism
Physical characteristics
- Reduced subcutaneous fat
- Loose dry skin
- Decreased muscle mass esp. over buttocks
- Sunken abdomen
- Sparse hair growth
- Wide skull sutures

Perinatal asphyxia
Congenital anomalies
Intrauterine infections and increased
susceptibility to infections
Aspiration syndrome
2. LGA
- Birth weight at or above 90
percentile on the
intrauterine growth curve(>4000g or 9lb)
- Maternal diabetes
- Multiparity
- Excessive maternal weight gain
- Genetic predisposition
Physical charateristics:
- Overweight

- Hypoglycemia
- Polycythemia
- Hyperviscosity
- CPD: dystocia, prolonged stressful labor
- Fractures: shoulder
- CNS trauma: nerve damage to cervical and
brachial plexus
3. Preterm
- Infant born on 37
weeks or earlier
- Multiple pregnancy
- Placenta previa
- Polyhydramnios
- Maternal diabetes
- Cardiovascular-renal problems

- Acute infectious problems
- Genital tract abnormalities
Physical characteristics
- Inadequate amount of surfactnt
- Poorly developed sucking and gag reflexes
- Unstable heart regulation
- Low resistance to infection
- Immature CNS, renal and liver system

- Increased capillary fragility
- Excessive lanugo
- Hypothermia and cold stress
- Neonatal NEC
- Feeding difficulties
- Marked insensible water loss
- Infection: low WBC count

- Apnea
- Hypoglycemia
- Jaundice
4. Postterm
- Infant born on the 42
weeks or above
- Uncertain

Physical characteristics
- Can be large, small or appropriate size; usually
in good condition alert, active
- In postmaturity: long and thin in appearance
Dry, cracked and desquamating skin
Nails extending beyond fingertips
Placental insufficiency
Absent vernix and lanugo
Malnourished and dehydrated
Depleted subcutaneous fat old man
wrinkled appearance

Often meconium-stained skin, nails and cord
- Birth trauma
- Expose to hazards of OCT
- Tolerated stress of labor poorly
- Meconium aspiration
- Cold stress
- Hypoglycemia
- Seizures
Immediate Management
Respiratory parameters
1. Observe respiratory rate, rhythm, and depth.
a. Initially, rate increase without a change in
b. Flaring of nares and expiratory grunting are
early signs of RDS
2. Increase in Apical pulse rate.
3. Subcostal and xiphoid retractions progress to
intercostal, substernal and clavicular retractions
4. Color
a. Progresses from pink to circumoral pallor to
circumoral cyanosis to generalized cyanosis
b. Increased intensity of acrocyanosis
5. Progressive respiratory distress
a. Chin tug (chin pulled down and in with
mouth opening wider-auxiliary muscles of
respiration are used).
b. Abdominal seesaw breathing patterns
c. Distinguish between apneic episodes (15
seconds or longer) and irregular breathing
(cessation of breathing for 5-10seconds)
6. Falling body temperature.
7. Progressing anoxia leading to cardiac
decompensation and failure.
8. Increased muscle flaccidity: frog-like position
D. Nutrition
1. Assess readiness and ability to feed:
swallowing, gag reflexes
2. Screen for hypoglycemia
3. Observe for congenital dysfunction and
anomalies related to tracheoesophageal
fistula, anal atresia and metabolic disorders

4. Check amount and frequency of elimination
5. Assess for vomiting or regurgitation; a
preterm infants stomach capacity is small,
and overfeeding can occur.
6. Check mucous membranes, urine output, and
skin turgor to identify fluid and electrolyte
a. Skin turgor over abdomen and inner thighs
b. Sunken fontanel
c. Urinary output of less than 30 ml per day

E. Temperature regulation
1. Assess infants temperature: frequently done
with a skin probe for continuous monitoring
of temperature in infants at high risk for
2. Check coolness or warmth of body
temperature and extremities.
3. Detect early signs of cold stress.
a. Increased physical activity and crying
b. Increased RR

c. Increased acrocyanosis or generalized
cyanosis along with mottling of the skin(cutis
d. Male with descended testes: presence of
cremasteric reflex(testes pulled back up into
the inguinal canal on exposure to cold)
4. Monitor infants temperature
a. Axillary temperature: 36.5C
b. Place a temperature skin probe on infant
while he or she is in the radiant warmer or
Nursing Interventions
Goal: To maintain respiratory functioning.
A. Provide gentle physical stimulation to remind
infant to breathe.
1. Gently rub the infants back
2. Lightly tap the infants feet
B. Ensure patency of respiratory tract
1. Maintain open airway by means of nasal, oral
or pharyngeal suctioning
2. Position to promote oxygenation.
a. Elevate head 10 degrees with neck slightly
extended by placement of a small folded
towel under the shoulders.
b. Flex and abduct infants arms and place at
c. Avoid diapers or adhere them loosely.
d. Do not place in prone position.
C. Assist infants respiratory efforts.

1. Monitor oxygen pressure.
a. Anywhere 21%-100% oxygen is administered
to maintain the PO2 around 50 to 80mmHg.
b. Avoid high concentrations of oxygen for
prolonged periods: leads to complications of
retrolental fibroplasia and
bronchopulmonary dysplasia.
2. Positive end-expiratory pressure helps keep
alveoli open at the end of expiration by
providing positive pressure.
3. Continuous positive airway pressure (CPAP)
counteracts the tendency of the alveoli to
collapse by providing continuous distending
airway pressure.
D. Monitor oxygen therapy.
1. Pulse oximeter

Goal: To provide adequate nutrition
A. Detect hypoglycemia and treat immediately:
administer 5% dextrose in water IV if infant is
unable to tolerate oral feeding.
B. Oral feeding: initial feeding
1. Use sterile water: 1-2ml for a small infant
2. Use preemie nipple
3. Feedings are small amount and increased in

C. Detect complications that arise with feeding
the preterm infant as a result of:
1. Weak or absent sucking and swallowing
2. Poor gag reflex leading to aspiration
3. Incompetent cardiac sphincter
4. Increased incidence of vomiting and
development of abdominal distention
5. Inability to absorb essential nutrients.
6. Excessive water loss through evaporation
from the skin and respiratory tract

Respiratory Distress
- Formerly termed Hyaline membrane disease.
1. Low level or absence of surfactant
- Surfactant is a phospholipid that normally
lines the alveoli and resists surface tension
on expiration to keep alveoli from collapsing
on expiration.

Risk factors:
- Preterm birth
- Meconium aspiration
- Infection
- Anesthesia

- High pressure is required to fill the lungs with
air for the first time and overcome the
pressure of lung fluid.

At birth

Decrease surfactant

Areas of hypoinflation

Increase pulmonary resistance

Lungs poorly perfused

Poor gas exchange

Hypoxia Inc CO2 level

Release lactic acid Formation of the
hyaline membrane
on alveolar surface

Further prevents the exchange of O2 and CO2
at the alveolar capillary membrane

Leads to severe acidosis


Dec. pulmonary perfusion

Further limits surfactant production
(this vicious cycle continues until the O2-CO2
exchange in the alveoli is no longer adequate
to sustain life
Tachypnea (more than 60 cpm)
Nasal flaring
Sternal and subcostal retractions
Seesaw breathing
Apneic spells
Abnormal breath sounds:rales and rhonchi
Chin tug
Expiratory grunting

- An ominous sign and indicates impending
need for respiratory assistance
- Grunting sound occurs as a result of air
pushing past a partially closed glottis.
- Accompanied by whining or moaning sound

Chest x-ray
Blood culture
Lumbar puncture (R/O CNS problems)
Determine Lecithin/Sphingomyelin ratio
Surfactant Resplacement
- Synthetic surfactant is sprayed into the lungs
by a syringe through an endotracheal tube at
Oxygen administration with ventilator
Additional therapy
- Pancuronium (Pavulon)

Meconium aspiration syndrome
Meconium is present as early as 10 weeks
Infant with hypoxia in utero has a vagal reflex
relaxation of the rectal sphincter which
releases meconium into the amniotic fluid
Babies in breech position may expel
meconium because from the pressure on the
Mecoinum can cause severe Respiratory
distress in 3 ways:
1. Can bring about inflammation of bronchioles
because it is foreign substance
2. It can block small bronchioles by mechanical
3. It can cause decrease surfactant production
through lung cell trauma
Apgar score is low
Chest retractions
Barrel chest
Coarse bronchial sound

Therapeutic Management
Suction the infant with bulb syringe while at
the perineum
Tracheal suction
Oxygen administration with ventilation
Chest physiotherapy with clapping and

Neonatal Sepsis
Refers to the presence of bacteria in the
Risk factors:
1. Prematurity
2. Invasive procedure
3. Immature immunological system
4. Maternal antepartal infection
5. Intrapartal maternal infection

Lethargy, poor temperature control
Poor feeding
Abdominal distention
Irregular respirations: Apnea
Blood culture and sensitivity
Chest x-ray
Viral studies
Lumbar puncture
1. Antibiotics
2. Antiviral
3. Antifungal
Supportive treatment:
1. Oxygen
2. IV therapy
3. Regulation of fluids and electrolytes
Is a condition in which there is too much
bilirubin in the blood.
When RBC break down, a substance called
bilirubin is formed.
Babies are not easily able to get rid of the
bilirubin and it can build up in the blood and
other tissues and fluids of the babys body.
Because bilirubin has a pigment or coloring, it
causes a yellowing of the babys skin and
tissues. This is called jaundice.
- Hemolytic disease of the newborn
- Rh Incompatibility
- ABO incompatibility

Signs and Symptoms
- Yellow sclerae
- Yellow skin
- Anemia
- Enlarged spleen
- Normal colored stools

- Fatigue
- Light colored stools
- Dark urine
- Lethargy
- Poor feeding
- Mental retardation
- Less mature
- Rigidity
- Tremors
- ataxia
Risk Factors:
- Prematurity
- Asian ancestry
- Maternal diabetes
- Kernicterus
Diagnostic tests:
- Coombs test
Direct coombs test
Indirect coombs test
- Measurement of levels of specific types of
- Reticulocyte count
- Jaundice and elevated levels of serum
bilirubin confirm the diagnosis of
- Inspection of the neonate is a well-lit room
(without yellow or gold lighting) reveals
yellowish skin coloration particularly in the

- Phototherapy
- Initiation of early feeding
- Exchange transfusion
- Albumin transfusion
- Drug therapy
- Jaundice - Serious brain damage
- Kernicterus - Severe anemia
Nursing Management
- Isotonic IV fluids
- Supplemental oxygen
- Cardiac monitoring
- Nasogastric suction
- Bladder catheterization
- ERCP papillotomy
- Interferon: Cortecosteroids
Medical management
- Penicillamine
- Phenobarbital

Sudden Infant death syndrome
Is the sudden unexplained death in infant
Tends to occur at a higher than usual rate in
the infants of:
- Adolescent mothers
- Highly closely spaced pregnancy
- Underweight
- Preterm
- Bronchopulmonary dysplasia
- Infants of narcotic independent mothers

Possible contributing factors:
- Viral respiratory or botulism infection
- Distorted familial breathing pattern
- Possible lack of surfactant in alveoli
- Sleeping prone

Peak ages of incidence are between 2 weeks
and 1 year of age.