DYSTOCIA

characterized by slow, abnormal labor progression resulting from abnormalities of uterine contractions or maternal expulsive forces. Dystocia is the leading indication for augmentation and is the leading indication for primary cesarean delivery. Pathophysiology and Etiology Inadequate contractions result in poor labor progression and slow fetal descent. Common causes include: increased uterine tone,

1.

2. hypotonic labor (prolonged latent phase, 3. protracted or arrested active phase, or prolonged second stage of labor), 4. abnormal contraction pressure.

Problems with the force of labor result in ineffective contractions or bearing down efforts (pushing) during the second stage of labor. Etiology of abnormalities in the force of labor include: Early or excessive use of analgesia Overdistention of the uterus Excessive cervical rigidity Grand multiparity (> 6) Mild pelvic contraction

Diagnostic Evaluation Inadequate progress of cervical effacement, dilation, or descent of the presenting part as determined by vaginal examination. Comparison of serial evaluations of labor progress using Friedman's curve criteria A prolonged latent phase in the primigravida is more than 20 hours and in the multigravida, more than 14 hours. During the active phase, the cervix of a primigravida will normally dilate at a rate of 1.2 cm/hour, and the multigravida 1.5 cm/hour.

In addition, the fetus should be descending through the birth canal; typically the rate of descent in a primigravida is equal to 1 cm/hour, and 2 cm/hour for the multigravida

Management

1. use of oxytocin 2. If the problem is related to the inlet or midpelvis, a cesarean delivery is indicated. 3. If the size of the outlet is the problem, a forceps or vacuum extraction may be performed. Complication of Dystocia Maternal exhaustion Infection Postpartum hemorrhage Fetal intolerance Fetal or maternal trauma from operative vaginal delivery Nursing Assessment Perform Leopold's maneuvers, and evaluate fetal presentation, position, and size. Using Friedman's labor curve, periodically evaluate progress of labor. Monitor FHR and contraction status periodically and per facility policy. Nursing Diagnoses Acute Pain related to physical and psychological factors of difficult labor Anxiety related to threat of possible operative delivery Nursing Interventions

1. Promoting Comfort 2. Decreasing Anxiety AMNIOTIC FLUID EMBOLISM known as anaphylactic syndrome of pregnancy, occurs once amniotic fluid filled with fetal cells and debris enter the maternal circulation.

Deposit of fluid or debris into the pulmonary arterioles, resulting in rapid onset of respiratory distress, shock, and the possible development of DIC, occurs with this condition. The mortality for this condition is 60% to 90%. Incidence is 1 per 8,000-20,000 births in the United States Risk factors Intrapartum period (70%) Multiparous (75%) Abruptio placenta History of allergy (41%) Male fetal gender (controversial) Multiple gestations Genetic influences

Clinical Manifestations Sudden dyspnea and chest pain Cyanosis, tachycardia Pulmonary edema Seizures Increasing restlessness and anxiety Coughing with frothy, pink sputum DIC Cardiac dysrhythmias Cardiopulmonary collapse

Diagnostic Evaluation Clinical picture of sudden onset of respiratory collapse, shock, and ultimately unresponsiveness. DIC confirmed by coagulation studies (prolonged thrombin time, PT, and PPT, decreased factor V, VIII, X; decreased platelets; increased fibrin split products). Pulmonary aspirate evaluation for fetal cells.

Autopsy evaluation to confirm fetal cells and debris intravascularly and located in the lung tissue

Management 1. Respiratory support with oxygen therapy and intubation as necessary. 2. Administration of I.V. crystalloid fluids. 3. Administration of blood products to combat hemorrhage, shock, and DIC. 4. Establishment of a pulmonary artery catheter if appropriate. 5. Cardiopulmonary resuscitation in a wedge position or abdominal displacement. 6. Perimortem cesarean delivery within 5 minutes of cardiopulmonary collapse Nursing Assessment and Interventions 1. Be alert and suspicious to signs and symptoms of potential AFE and patients at risk (see above risk factors). 2. Monitor maternal vital signs to assess for signs of shock. 3. Monitor FHR for signs of intolerance. 4. Administer oxygen to assist respiratory status. 5. Alert medical staff immediately, and assist with emergency procedures, such as delivery and cardiopulmonary resuscitation, as needed. 6. Provide information and comfort to the family or support persons. Umbilical Cord Prolapse If the umbilical cord precedes the presenting part of the fetus or lies adjacent to the primary presenting part, prolapse has occurred. Types of cord prolapse include: Completethe cord completely and significantly precedes the primary fetal presenting part; may be in the vagina or visible outside the introitus. Occultthe cord is beside or just in front of the presenting part of the fetus. Funicthe cord can be felt on vaginal examination through intact membranes preceding the fetal presenting part. Umbilical Cord Prolapse

Predisposing factors include:

1. Rupture of membranes, before the presenting part is engaged in the pelvis 2. More common in abnormal fetal positions, such as shoulder and foot presentations 3. Prematurity 4. Polyhydramnios 5. Multifetal gestation 6. CPD 7. Abnormally long umbilical cord 8. Result of interventions or maneuvers (ie, ECV or amniotomy) Umbilical Cord Prolapse Clinical Manifestations

1. Cord may be seen protruding from vagina or palpated in the vagina or through the cervix. 2. Compression of the cord may cause variable decelerations with contractions or between contractions; prolonged decelerations or bradycardia may develop over time. Complications

Maternal Infection Risk for hemorrhage Risk for increased perineal trauma from emergency operative delivery Uterine atony related to anesthesia effects Fetal Prematurity Hypoxia Meconium aspiration Fetal death if delayed or undiagnosed ASSESSMENT NURSING MANAGEMENT

UTERINE INVERSION Uterine inversion is a potentially life-threatening complication in which the uterus turns inside out during the third stage of delivery. Uterine inversions may be classified as: Completefundus inverts and passes through the cervical os into the vagina and may prolapse through the introitus. Partialfundus of uterus partially inverts but not beyond the cervical os.

Pathophysiology and Etiology Excessive traction on the cord while the placenta is still attached Fundal pressure Lax or thin uterine wall Spontaneous inversion Abnormally short umbilical cord Uterine atony Uterine anomalies Fundal placentation Abnormally adherent placental tissue (placenta accreta or increta) Fetal macrosomia Clinical Manifestations 1. Primary sign is hemorrhage and sudden, severe pelvic pain (anesthesia may dull pain sensation). 2. Maternal bleeding and shock, with symptoms seeming out of proportion for the blood loss. 3. A complete inversion may appear protruding from vagina. 4. Inability to palpate fundus in association with clinical manifestations. 5. Confirmed with bimanual examination. Management 1. Prevention is the most effective therapy. Proper management of the third stage of labor can help to prevent most uterine inversions. 2. Goal is to manually restore the uterus to its normal position.

3. Typically, anesthesia is necessary to complete manual manipulation and for proper pain control. 4. Tocolytic therapy (terbutaline or MgSO4) is recommended if manipulation is difficult or lengthy 5. Monitor maternal vital signs for signs of shock. 6. After the uterus has been restored, oxytocin is given to contract the uterus. 7. Abdominal or vaginal surgery may be necessary if manual replacement fails. 8. Post procedure, a broad-spectrum antibiotic is ordered. Complications Infection Anemia Hysterectomy Hemorrhagic shock Death Nursing Assessment and Interventions Before Correction of the Inversion Check maternal vital signs and evaluate for blood loss. Assist practitioner, as needed, for manual replacement. Administer oxygen as warranted. Maintain primary I.V. line and establish a second line with a 16G or 18G catheter for administration of fluids, blood products, and medications. Apply a pulse oximeter to determine oxygen saturation. If replacement of the uterus is unsuccessful, prepare the woman and her support persons for emergency surgery After Correction of the Inversion Check maternal vital signs, and monitor CBC for signs of bleeding, infection. Administer oxytocin and other uterine tonics, as ordered. Measure and record accurate intake and output.

Evaluate uterine fundus carefully for position and firmness. Evaluate lochia for amount of blood loss. Evaluate for transfusion reactions (ie, itching, wheezing, anaphylaxis). Administer antibiotics, as ordered, to minimize risk of infection. Provide support to the woman, and encourage her to express her feelings Rupture of Uterus Rupture of uterus from stress of labor from uncontrolled titanic and hypertonic contractions, prolonged labor, prior uterine surgey, fetal abnormalities and faulty use of forceps. Clinical manifestation: sudden onset of sharp, stabbing abdominal pain during labor, shock syndrome, cessation of uterine contraction with rigidity of abdomen. Main Nursing diagnosis: Altered tissue perfusion and Pain. Nursing care involves Close monitoring of labor and fetal and maternal vital signs ; preparation to emergency surgery Pathophysiology and Etiology Risk factors: Previous uterine surgery, previous termination of pregnancy High doses of oxytocin, prostaglandin preparations (ie, misoprostol, dinoprostone) Prolonged tachysystole, or hypertonus Grand multiparity (more than 6 pregnancies to term) Blunt or penetrating abdominal trauma Midforceps rotation, maneuvers within the uterus Obstructed labor, abnormal fetal lie Vigorous pressure on the uterus at birth (ie, fundal pressure Signs and Symptoms (May be absent or present individually or collectively)

1. Abdominal pain and tenderness (may be dulled by anesthesia or analgesia) 2. Uterine contractions will usually continue but may diminish in intensity and tone 3. Vaginal or abdominal bleeding into the peritoneal cavity

4. Vomiting 5. Syncope 6. Tachycardia 7. Pallor Signs and Symtoms 8. Significant change in FHR characteristics: sudden onset of severe variable decelerations or bradycardia 9.Fetal parts may possibly be palpated in the abdominal cavity 10. Radiating shoulder pain (sign of intra-abdominal bleeding) 11. Signs of shockrapid, weak pulse; cold, clammy skin; pale color 12. Chest pain from diaphragmatic irritation due to bleeding into the abdomen Management Immediate stabilization of maternal hemodynamics followed by immediate cesarean delivery. Fetus is extracted as soon as possible, and the uterus is repaired, if possible. A hysterectomy may be done if bleeding cannot be controlled. Adequate blood and fluid replacement is maintained. Antibiotic therapy Complications Maternal

1. Bladder and ureteral injury 2. Hysterectomy 3. Concurrent complete or partial abruptio placentae; hemorrhage 4. Hypovolemic shock 5. Anemia, with possibility of transfusion 6. Bowel laceration, with possibility of peritonitis 7. Infection

8. Death Fetal

1. Hypoxia leading to perinatal asphyxia (perinatal asphyxia can occur as early as 10 to 18 minutes after onset) 2. Hypoxic-ischemic encephalopathy; neonatal brain injury 3. Death Nursing Assessment 1. Continuously evaluate maternal vital signs; note an increase in the rate and depth of respirations, an increase in pulse, or a drop in BP indicating status change. 2. Observe for signs and symptoms of impending rupture periodically during labor progression; particularly with a patient experiencing a VBAC delivery or a history of uterine surgery 3. Assess fetal status by continuous monitoring. 4. Speak with family, and evaluate their understanding of the situation. Nursing Diagnoses 1. Deficient Fluid Volume related to active fluid loss secondary to hemorrhage 2. Ineffective Tissue and Vital Organ Perfusion: Maternal and Fetal, related to hypovolemia 3. Fear related to outcome for fetus and mother Nursing Interventions

1. Maintaining Fluid Volume 2. Maintaining Maternal and Fetal Tissue Perfusion 3. Reducing Fear Evaluation: Expected Outcomes 1. Vital signs stable; no evidence of shock 2. Hemoglobin and hematocrit stable 3. Verbalizes concerns about self and her fetus Uterine Inversion

Uterine inversion is a potentially life-threatening complication in which the uterus turns inside out during the third stage of delivery. Uterine inversions may be classified as: Completefundus inverts and passes through the cervical os into the vagina and may prolapse through the introitus. Partialfundus of uterus partially inverts but not beyond the cervical os. Pathophysiology and Etiology of Uterine inversion Excessive traction on the cord while the placenta is still attached Fundal pressure Lax or thin uterine wall Spontaneous inversion Abnormally short umbilical cord Uterine atony Uterine anomalies Fundal placentation Abnormally adherent placental tissue (placenta accreta or increta) Fetal macrosomia Clinical Manifestations of Uterine Inversion Primary sign is hemorrhage and sudden, severe pelvic pain (anesthesia may dull pain sensation). Maternal bleeding and shock, with symptoms seeming out of proportion for the blood loss. A complete inversion may appear protruding from vagina. Inability to palpate fundus in association with clinical manifestations. Confirmed with bimanual examination.

Management of Uterine Inversion Prevention is the most effective therapy. Proper management of the third stage of labor can help to prevent most uterine inversions. Goal is to manually restore the uterus to its normal position. Typically, anesthesia is necessary to complete manual manipulation and for proper pain control.

Tocolytic therapy (terbutaline or MgSO4) is recommended if manipulation is difficult or lengthy. Monitor maternal vital signs for signs of shock. After the uterus has been restored, oxytocin is given to contract the uterus. Abdominal or vaginal surgery may be necessary if manual replacement fails. Postprocedure, a broad-spectrum antibiotic is ordered

Complications of Uterine Inversion Infection Anemia Hysterectomy Hemorrhagic shock Death

Nursing Assessment and Interventions Before Correction of the Uterine Inversion

1. Check maternal vital signs and evaluate for blood loss. 2. Assist practitioner, as needed, for manual replacement. 3. Administer oxygen as warranted. 4. Maintain primary I.V. line and establish a second line with a 16G or 18G catheter for administration of fluids, blood products, and medications. 5. Apply a pulse oximeter to determine oxygen saturation. 6. If replacement of the uterus is unsuccessful, prepare the woman and her support persons for emergency surgery. After Correction of the Uterine Inversion Check maternal vital signs, and monitor CBC for signs of bleeding, infection. Administer oxytocin and other uterine tonics, as ordered. Measure and record accurate intake and output. Evaluate uterine fundus carefully for position and firmness.

Evaluate lochia for amount of blood loss. Evaluate for transfusion reactions (ie, itching, wheezing, anaphylaxis). Administer antibiotics, as ordered, to minimize risk of infection. Provide support to the woman, and encourage her to express her feelings. OPERATIVE OBSTETRICS On Maternal complications Lacerations Occurs when tissues are unable to stretch further and tear under pressure Can occur in the following sites:

1. Cervix 2. Vagina 3. perineum Category of lacerations

First degree tissue connecting the posterior end of the labia Second degree involves perineal skin ,vaginal mucous membrane ,underlying fascia & muscles of perineum Third degree extends from the perineum & involves the anal sphincter .May extend up to the anterior wall of the rectum Fourth degree like third degree but extends through the rectal wall into the lumen of the rectum. EPISIOTOMY surgical incision of the peritoneum used to increase the vaginal opening for delivery of the fetus. An episiotomy is one of the most common obstetric procedures performed in the United States. Approximately 33% of women experiencing vaginal birth also experience an episiotomy. It was once believed that by performing an episiotomy, the practitioner reduced the risk of a jagged tear in the perineum. Episiotomies are only recommended for such maternal or fetal indications as avoiding severe maternal lacerations or facilitating or expediting difficult deliveries.

Photos of episiotomy

Median (Midline) 1. Incision is made midline down the perineum directed toward the rectum. 2. This method is believed to heal with few complications, is more comfortable for the woman during healing, is easy to repair, and is associated with minimal blood loss. 3. Increases risk of third- and fourth-degree lacerations. 4. Decreased postpartum dyspareunia. Mediolateral 1. Incision 45 degrees or more from the midline. 2. This method avoids the anal sphincter if an extension is needed. 3. Women find it extremely uncomfortable during healing. 4. Difficult to repair. 5. Associated with increased blood loss. 6. Necessitates longer wound healing time. Management Pain relief The stretching of the perineum and pressure from the fetal head may provide a natural numbing effect. Local perineal infiltration with lidocaine provides anesthesia for performing and repairing the episiotomy. A pudendal block provides anesthesia to the lower two-thirds of the perineum and vagina using lidocaine injection into the vaginal walls. Epidural anesthesia provides anesthesia from the level of the umbilicus to the midthigh area.

The episiotomy is performed when the fetal head is about 3 to 4 cm visible with a contraction. The repair of the episiotomy usually begins after the delivery of the placenta. Complications

Infection Bleeding Third- and fourth-degree lacerations Pain Hematoma Dyspareunia (painful intercourse)

Nursing Assessment During the recovery period, the episiotomy should be evaluated periodically after delivery. Describe and document the degree of healing. Assess for infection -may be indicated by edema, redness, purulent drainage at the site, increased temperature. Notify health care provider of signs of infection or bleeding at site, other than slight oozing. Monitor for hematoma formation. Apply ice packs periodically to limit edema and pain. Episiotomy

Nursing Diagnoses 1. Acute Pain related to surgical procedure 2. Risk for Infection related to traumatized tissue Nursing Interventions Preventing Infection 1. Instruct & assist to clean from the front to the back. 2. Provide instructions & Assist on techniques used for perineal care. 3. Instruct to squirt the water gently on her perineum after voiding. 4. Instruct & assist to change the perineal pad each time after urination and defecation; dispose of in proper receptacle.

5. Explain the importance of proper hand washing before and after perineal care. 6. Explain that perineal care should be performed after urination and defecation and periodically throughout the day. 7. Encourage a diet that is high in protein and vitamin C and encourage hydration. Forceps delivery are designed for rotating or extracting the fetus. Most forceps are placed on each side of the fetal vertex and others are utilized for special considerations (breech extraction)

Forceps consist of Metal spoon-shaped blades attached to handle that lock together Forceps consist of two pieces: 1. 2. a right blade, which is slipped into the right side of the mother's pelvis, a left blade, which is slipped into the left side.

Forceps increase the diameter of the presenting part, which may hinder delivery. 1. Outlet Forceps Scalp is visible at the introitus without separating labia. Fetal skull has reached pelvic floor. Sagittal suture in anteroposterior diameter or right or left occiput anterior or posterior position. Fetal head is at or on perineum. Rotation does not exceed 45 degrees. Types of Forceps Deliveries

2. Low Forceps Leading point of fetal skull is at station +2 cm or above and not on the pelvic floor. Rotation is less than 45 degrees (left or right occiput anterior to occiput anterior or left or right occiput posterior to occiput posterior). Rotation is greater than 45 degrees.

3. Mid Forceps

Station is above +2 cm but head is engaged.

Indications for Forceps Delivery No indication is absolute. The fetal head must be engaged and the cervix fully dilated. Prolonged second stage labor Nulliparous women: lack of continuing progress for 3 hours with regional anesthesia or 2 hours without regional anesthesia Multiparous women: lack of continuing progress for 2 hours with regional anesthesia or 1 hour without regional anesthesia Suspicion of immediate or potential fetal compromise Shortening of the second stage for maternal benefit

Contraindications of Forceps Delivery 1. Confirmed CPD 2. Face or brow presentation 3. Incomplete dilation of the cervix 4. Unengaged fetal head 5. Preterm infant Complications of forceps delivery Maternal 1. Lacerations of the vulva, cervix, vagina, and rectum 2. Fracture of coccyx 3. Extensions of an episiotomy that may extend to the rectum 4. Bladder trauma, uterine rupture 5. Postpartum infection, postpartum hemorrhage secondary to uterine atony 6. Anemia secondary to uterine atony/hemorrhage Complications of forceps delivery Fetal

1. Bruising 2. Cephalohematoma 3. Facial paralysis 4. Brachial palsy 5. Skull fracture 6. Ocular trauma 7. Intracranial hemorrhage 8. Brain damage 9. Cord compression Nursing Assessment After application of the forceps, the FHR should be evaluated continuously or at least every 5 minutes until delivery. Evaluate maternal sensation. Evaluate bladder fullnessbladder should be empty before the application of the forceps. Ensure that sterile technique is maintained.

Nursing Diagnoses Anxiety related to fetal outcome Acute Pain related to procedures Nursing Interventions Decreasing Anxiety Explain how the forceps are applied. Explain that a sensation of pressure will be felt. Answer any questions. Stay with the woman, and provide guidance during the delivery process. Promoting Comfort Encourage use of breathing and relaxation techniques.

Make sure bladder is completely empty. Encourage relaxation between contractions and use of abdominal muscles and pushing with the contractions. Use blankets and pillow supports when positioning the woman for delivery. VACUUM EXTRACTION Vacuum extraction applies suction to the fetal vertex to assist in delivery without increasing the diameter of the presenting part.

Advantages : 1. 2. ease of application and ability; therefore, the procedure is gaining favor in the United States. It is also associated with less maternal trauma and less need for general or regional anesthesia. Indications Same as forceps.

Contraindications 1. CPD 2. Face or brow presentation 3. Breech presentation 4. Unengaged fetal head 5. Premature infant 6. Incomplete dilation of the cervix Management 1. Fetus is in vertex presentation. 2. The woman is in the lithotomy position. 3. The bladder is usually catheterized. 4. Evaluate progress with suction. 5. Anesthesia may be indicated. 6. Unsuccessful extraction is followed by a cesarean delivery.

7. Neonatal staff is in attendance at delivery. Complications of Vacuum Extraction Complications are usually less frequent and less severe with vacuum extraction than with forceps. Maternal Lacerations of the cervix or vagina Fetal Cephalohematoma Caput succedaneum (swelling of the scalp) from the vacuum Intracranial hemorrhage Retinal hemorrhage Abrasions Subgaleal hemorrhage Nursing Assessment After application of the vacuum extractor, the FHR should be evaluated at least every 5 minutes or continuously until delivery. Evaluate maternal sensation. Evaluate bladder fullnessbladder should be empty before the application of the vacuum extractor. Make sure sterile technique is maintained. Monitor the vacuum pressure of the equipment according to your facility's protocol. Monitor pop-offs (vacuum extractor cup pops off the fetal head); if three pop-offs have occurred, other options (forceps, cesarean) should be considered. Cesarean Delivery The birth through an abdominal incision into the uterus.

Indications of Caesarian Section 1. severe PIH

2.

genital herpes or papilloma

3. previous C/S History 4. 5. placenta previa, abruption placenta tranvers fetal li

6. breech presentation 7. extreme low birth weight 8. fetal distress 9. large fetus Types of Cesarean Delivery (Uterine incisions ) Uterine Incisions Incision choice is based on the clinical scenario and future fertility and uterine health.

1.Low transversetransverse incision made across the lower uterine segment. Incision is made across the thickest section and away from uterine activity (fundus); minimizes blood loss and improves the integrity of the scar, decreasing risk of future dehiscence or rupture. Postoperative convalescence is more comfortable. Incidence of postoperative adhesions and danger of intestinal obstruction are reduced. First-line choice of incision in most clinical case scenarios.

Types of Cesarean Delivery

2.Classicvertical incision from the fundus down the body of the uterus to the lower uterine segment; may be utilized for emergent or preterm deliveries. Useful when bladder and lower segment are involved in extensive adhesions. Surgery of choice with a diagnosed anterior placenta previa, which inhibits the use of the low transverse incision. Increased blood loss versus low transverse. Increased risk of uterine rupture in subsequent deliveries.

3.T-extension (low transverse with midline vertical incision extending upward from the middle of the horizontal incision). Utilized to enlarge incision to complete the delivery. Commonly used with preterm deliveries.

Abdominal Incisions 1.Pfannenstiela horizontal incision across the suprapubic area Cosmetic advantage; incision is hidden by clothing and often pubic hair Decreased chance of dehiscence or hernia formation Most commonly utilized

2. Verticala midline vertical incision from below the umbilicus to the symphysis pubis Quicker to perform Provides better uterine visualization Cosmetically less appealing Greater chance of wound dehiscence and hernia formation

TYPES OF CESAREAN incisions TYPES OF CESAREAN DELIVERY TYPES OF CESAREAN DELIVERY NURSING INTERVENTIONS NURSING INTERVENTIONS PLANNING HOMECARE for the MOTHER AND NEWBORN after CESAREAN DELIVERY Postpartum Complications

POSTPARTUM INFECTION Postpartum (puerperal) infection should be suspected if the patient's temperature exceeds 100o F (37.8o C) on two occasions at least 6 hours apart during the first 10 days postpartum. Postpartum endometritis occurs in 1% to 3% of postpartum women. The infection may remain localized or extend to various parts of the body such as connective tissue by lymphatic dissemination (parametritis).

The broad ligament is the main pathway for systemic infection. Types of infection include: 1. Endometritis: inflammation of the endometrium 2. Endomyometritis: inflammation of the endometrium and myometrium 3. Parametritis: inflammation of the endometrium and parametrial tissue 2. Other infections include: 1. Wound or UTIs 2. Pneumonia 3. Mastitis 4. Pelvic thrombophlebitis 5. Necrotizing fascitis Risk factors: Operative birth Prolonged labor or rupture of membranes Use of invasive procedures (ie, internal monitoring, amnio infusion , fetal scalp sampling) Multiple pelvic examinations Excessive blood loss Pyelonephritis or diabetes Socioeconomic and nutritional factors compromising host defense mechanisms Anemia and systemic illness Smoking

POSTPARTUM HEMORRHAGE - reflects a blood loss in excess of 500 mL following a vaginal birth or 1,000 mL or greater following a cesarean birth. Severe bleeding is the single most significant cause of maternal death worldwide.

Early postpartum hemorrhage occurs in the first 24 hours and may be considered late after 24 hours up until 12 weeks after birth. The greatest risk is during the first hour after birth. Hemorrhage may also be defined as a decrease in hematocrit of at least 10%, but determinations of hemoglobin and hematocrit concentrations may not reflect current hematologic status.

Primary: Early Postpartum Hemorrhage (First Hour after Birth) Main cause: uterine atony (80%)relaxation of the uterus secondary to: Overdistention of uterus secondary to multiple pregnancy, polyhydramnios, or macrosomia. High parity (more than six pregnancies). Prolonged labor with maternal exhaustion. Medicationsoxytocin, MgSO4, tocolytics, anesthetics (halothane). Fibroidsprevents uterus from contracting. Retained placental fragments

Secondary: Late Postpartum Hemorrhage (Birth to 12 weeks Postpartum) Main cause is retained placental fragments Infection Subinvolution (delayed healing) of placental site Clinical Manifestations Early Postpartum Hemorrhage With uterine atony, uterus is soft or boggy, usually difficult to palpate, and will not remain contracted; excessive vaginal bleeding occurs. Lacerations of the vagina, cervix, or perineum care cause bright red, continuous bleeding even when the fundus is firm. Hypotension, dizziness, pallor, and decreased urine output occur late, after loss of 10% total blood volume. Late Postpartum Hemorrhage

Uterus is soft or boggy. Slow, reddish oozing or heavy bleeding (first 6 weeks postdelivery). Low persistent backache. Abdominal pain or tenderness. Fatigue. Loss of appetite. NURSING ALERT In cases of postpartum hemorrhage, remember the acronym ORDER: Oxygen Restore circulation Drugs to alleviate bleeding Evaluate interventions Remedy underlying cause Mastitis

Specific Risk factors: 1. infrequent breast-feeding, 2. 3. incomplete breast emptying, plugged milk duct,

4. cracked or bleeding nipples (may be secondary to improper latch-on and removal) Clinical Manifestations Endometritis Postpartum 1. Fever occurring around third day postpartum is the most important finding. 2. Uterus usually larger than expected for postdelivery day and tender. 3. Lochia may be profuse, bloody, and foul-smelling. 4. Chills, malaise, and fever occur if lochial discharge is obstructed by clots.

5. WBC greater than 20,000/mm3 with increased neutrophils. 6. Infection may spread to myometrium (endomyometritis), parametrium, fallopian tubes, peritoneum, and blood. Parametritis (Pelvic Cellulitis) 1. Chills, fever (102 to 104 F [38.9 to 40 C]), tachycardia. 2. Severe unilateral or bilateral pain in lower abdomen. 3. Enlarged and tender uterus. 4. Uterine position may become fixed as it is displaced by the exudate along the broad ligament. 5. Commonly the result of an infected wound in the cervix, vagina, perineum, or lower uterine segment. 6. Diagnostic Evaluation and Management 7. Obtain urinalysis and urine culture to rule out UTI. 8. Obtain blood sample for CBC and report results; assess for leukocytosis more than 20,000/mm3. 9. Antibiotic therapy: obtain cultures to identify causative agent. Broad-spectrum antibiotics are the treatment of choice including penicillins, cephalosporins (cefoxitin [Mefoxin], cefazolin), clindamycin (Cleocin), and aminoglycosides (gentamicin [Garamycin], tobramycin). Antibiotics are given until the woman is afebrile for 48 hours (maternal response usually occurs within 48 to 72 hours) and may include home therapy. Increase daily fluid intake.

Diagnostic Evaluation and Management Encourage intake of 1,800 to 2,000 calories if lactating; diet should include a variety of foods, usually high in protein and vitamin C (promotes wound healing). Ensure adequate urine output (30 mL/hour). Supportive therapy is used to control pain and to maintain hydration and nutritional status. Drainage is indicated for abscess development.

Instruct woman to discontinue breast-feeding, yet continue to pump (and dump) milk until infection clears.

Complications Thrombophlebitis may result from postpartum infection spread along the veins. Femoral thrombophlebitisappears 10 to 20 days after delivery as pain in calf, positive Homans' sign (pain with foot flexion), fever, edema; affected leg circumference is 2 cm greater than unaffected leg. Pelvic thrombophlebitisinfection of the veins of uterine wall and broad ligament usually caused by anaerobic streptococci; presents 14 days after delivery with severe chills and wide range of temperature changes. Treatment includes strict bed rest, anticoagulants, and antibiotics.

Pulmonary embolus may occurdyspnea and chest pain. Peritonitisspread of infection through lymphatic channels. Subinvolution Retarded involution of puerperal uterus; With enlarge, boggy uterus, profuse and prolonged lochia rubra, backache, pelvic discomfort, and dragging sensation. May be caused by poor uterine tone, retained placenta, endometritis, fibroids and tumors, and displacement of uterus. Main nursing diagnosis: Fluid volume deficit and high risk for infection. Nursing care include: administration of antibiotics and oxytocin; ambulation; and health teachings. Cystitis Infection of bladder from trauma during delivery, catheterization, and temporary loss of bladder tone. Manifested as urinary frequency, urgency and retention; Dysuria, nocturia, hematuria and tenderness, fever. Main nursing diagnosis: Pain and Knowledge deficit. Nursing Care includes observing closely for bladder function; forcing fluids to 3000 mL per day; antibiotics; Perineal care, Infection precautions. Postpartum Hemorrhage

Bleeding of 500 mL or more following delivery; commonly caused by uterine atony. Woman may experience copious amount of vaginal bleeding with or without bright or dark red clots; boggy uterus; maternal shock. Main Nursing Diagnosis: Fluid volume deficit Nursing responsibility includes Monitoring bleeding, hemoglobin and hematocrit, V/S, I&O, fluid replacement and Oxytocin administration; Maintaining asepsis; Iron supplements; follow up care.

Predisposing factors of Postpartum Hemorrhage

1. Uterine Atony loss of muscle tone in the uterus. a. Over distention b. Over massage 2. Laceration of the birth canal a. 1st degree fourchette, perineal skin b. 2nd degree - perineal muscles, vaginal muscles c. 3rd degree involves the anal sphincter, anus d. 4th degree includes the rectum and rectal muscles. MASTITIS MASTITIS ASSESSMENT NURSING MANAGEMENT THROMBOPHLEBITIS and THROMBOSIS THROMBOPHLEBITIS and THROMBOSIS ETIOLOGY ASSESSMENT ASSESSMENT MEDICAL MANAGEMENT

ANTICOAGULANTS ANTICOAGULANTS ANTICOAGULANTS ANTICOAGULANTS NURSING MANAGEMENT Post Partum Psychosis Psychosis occurring within 4 to 6 weeks after delivery. Clinical Manifestations are clouding of consciousness, depression, withdrawal, hostility, fear, paranoia, feeling of emptiness, and hallucinations. Main Nursing Diagnosis: Anxiety and Defensive coping Nursing Responsibility: Effective nurse- client interaction where client freely express herself; Psychotropic drugs as prescribed; Health teachings. POSTPARTUM MOOD DISORDERS ASSESSMENT

Pathophysiology and Etiology Social, cultural, physiologic, psychological factors may contribute to postpartum depression. Stressful life events during pregnancy or the postpartum period Poor interpersonal relationships. Inadequate support. Poor psychological history before or after pregnancy.

History of sexual abuse or domestic violence. High levels of anxiety, neurotic behavior, and depression or emotional distress. Personal or family history of psychopathology, especially depression. Clinical Manifestations Confusion Exaggerated and prolonged periods of irritability, moodiness, hostility, fatigue Ineffective coping Withdrawal and inappropriate response to the infant or family Loss of interest in activities Insomnia or sleep disturbances Headache Constipation or other GI difficulty Hair loss Dysmenorrhea Difficulties with lactation Decreased sexual responsiveness Nursing Interventions and Patient Education Listen to the woman regarding her adjustment to role of mother, and observe for any clinical manifestations suggesting depression. Ask the woman about the infant's behavior. Negative statements about the infant may suggest that the woman is having difficulty coping. Notify the woman's obstetric or primary care provider. Consult or refer woman to health care provider and other resources skilled in postpartum depression as indicated. Provide support, and encourage family and friends to support and assist with the infant and mother. Physical support as well as emotional support may be indicated. Educate the woman that treatment may help alleviate her symptoms and allow her to better care for herself and infant.

Encourage the woman to engage in activities that enhance attachment: rooming-in, breastfeeding, becoming involved in the medical examination of the neonate. Realize that effective attachment behaviors differ from culture to culture and do not necessarily indicate maladaptive parenting behaviors