University of San Agustin

General Luna St., Iloilo City 5000, Philippines

[Link]
COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

CARE OF MOTHER AND CHILD

AT RISK OR WITH PROBLEMS
(ACUTE OR CHRONIC)

Prepared by:

Sharon Maquiran, RN
 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

MODULE 3: NURSING CARE OF THE CLIENT DURING LABOR AND DELIVERY

Overview
Welcome to Module 1!
In this module, we will discuss principles illnesses and other events that can
complicate pregnancy when they occur prior to or during pregnancy.
At the end of the module, you will submit a :
1. Reflective Journal
2. Synthesis Paper
3. Journal Updates
4. CHEMATIC DIAGRAM

Consultation hours
Phone / messenger:
Virtual time:

Learning Objectives
By the end of the module, students will be able to:

➢ Assess a woman with an illness during pregnancy for changes occurring in the illness
because of the pregnancy or in pregnancy because of the illness.
➢ Formulate nursing diagnoses related to the effect of a preexisting or newly acquired
illness or pregnancy.
➢ Implement nursing care for a woman when illness complicates pregnancy.
➢ Evaluate expected outcomes for achievement and effectiveness of care.
 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

Module Content:

A. High Risk Factors that influence the progress of labor :

1. Fetal malposition and malpresentation
2. Prolapse umbilical cord
3. Abnormal size or shape of the pelvis
4. Cephalo-pelvic disproportion
5. Shoulder dystocia
6. Dystocia or difficult labor
7. Pathologic retraction rings
8. Premature labor
9. Precipitate labor and birth
10. Uterine prolapse
11. Uterine rupture
12. Placental problems
i. Placenta accrete
ii. Placenta succenturiata
iii. Placenta circumvallata
iv. Battledore placenta
v. Velamentous insertion of the cord
vi. Vasa Previa
B. Nursing care of the postpartum:
1. Post-partal hemorrhage
A. Early post-partal hemorrhage
b. Late post-partal hemorrhage
2. Postpartal puerperal infection
a. Endometritis
b. Wound infection
c. UTI
3. Thromboembolic disorders
4. Postpartal psychiatric disorder
D. Nursing care of Male and Female Clients with General and specific problems in
Reproduction and sexuality
a. Causes of infertility in males & females
b. Diagnostic tests/procedures
c. Nursing interventions
 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

MALPOSITION AND MALPRESENTATIONS

SCHEMATIC DIAGRAM

Malpositions are abnormal positions of the vertex of the fetal head (with the
occiput as the reference point) relative to the maternal pelvis.
Malpresentations are all presentations of the fetus other than vertex.

Risk factors/etiology/cause:

➢ More than 1 pregnancy (Multipara, Grand

multipara)
➢ More than 1 fetus (e.g. twins)
➢ Too much or too little amniotic fluid
(polyhydramnios, oligohydramnios)
➢ Abnormal uterine shape or abnormal growth
(e.g Fibroid)
➢ Placenta previa
➢ The baby is preterm
➢ Laxity (slackness) of muscular layer in the walls
of the uterus

MANAGEMENT

➢ Early detection
➢ referral of a woman in any of these situations can save her life and that of her baby.
 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

Malpresentation: are all presentations of the fetus other than vertex.

CEPHALIC (Normal) BREECH

OBLIQUE TRANSVERSE

Malposition: are abnormal positions of the vertex of the fetal head (with the occiput as the
reference point) relative to the maternal pelvis

NORMAL
 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

ABNORMAL

BREECH PRESENTATION

the fetus lies with its buttocks in the lower part of the uterus, and its buttocks and/or the feet
are the presenting parts during delivery.

CAUSES:
➢ Premature labour, beginning before the baby
undergoes spontanous inversion from breech to In abdominal palpation the fetal head is
vertex presentation
found above the mother’s umbilicus as a
➢ Multiple pregnancy, preventing the normal
inversion of one or both babies hard, smooth, rounded mass, which
➢ Polyhydramnios: excessive amount of amniotic gently ‘ballots’ (can be rocked) between
fluid, which makes it more difficult for the fetal your hands.
head to ‘engage’ with the mother’s cervix
➢ Hydrocephaly (‘water on the brain’) i.e. an
abnormally large fetal head due to excessive
accumulation of fluid around the brain
➢ Placenta praevia
➢ Breech delivery in the previous pregnancy
➢ Abnormal formation of the uterus.
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General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

Regardless of the type of breech presentation, there are significant associated risks to the baby. They
include:

• The fetal head gets stuck (arrested) before delivery

• Labour becomes obstructed when the fetus is disproportionately large for the size of the
maternal pelvis
• Cord prolapse may occur, i.e. the umbilical cord is pushed out ahead of the baby and may
get compressed against the wall of the cervix or vagina
• Premature separation of the placenta (placental abruption)
• Birth injury to the baby, e.g. fracture of the arms or legs, nerve damage, trauma to the
internal organs, spinal cord damage

ASSESSMENT (DIAGNOSIS) COMPLICATIONS:

➢ Leopold’s maneuver ➢ Anoxia
➢ Vaginal examination ➢ Traumatic head injury
➢ UTZ/Sonography ➢ Fracture of the arm and spine
➢ Dysfunctional labor
➢ EROM/PROM
➢ Meconium Aspiration

MANAGEMENT

➢ Refer all cases of breech presentation to the nearest higher-level health

facility.
➢ If the woman is in early labor and the membranes are intact, attempt
External Cephalic Version.
➢ If ECV is successful, proceed with normal childbirth. If ECV fails or is not
advisable, deliver by caesarean section.
➢ Tocolytics, such as Terbutaline 0.25 mg IM, can be used before ECV to
help relax the uterus.
➢ Monitor FHR
➢ Monitor Uterine contraction
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General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

External cephalic version (ECV) is a process by which a breech baby can sometimes be turned from
buttocks or foot first to head first. It is a manual procedure that is recommended by national guidelines
for breech presentation of a pregnancy with a single baby, in order to enable vaginal delivery.

Criteria for external version:

• Breech presentation is present at or after 37 weeks (before 37 weeks, a successful version is
more likely spontaneously revert back to breech presentation)
• Vaginal delivery is possible
• Membranes are intact and amniotic fluid is adequate;
• There are no complications (e.g. fetal growth restriction, uterine bleeding, previous caesarean
delivery, fetal abnormalities, twin pregnancy, HPN, fetal death).

[Link]

FACE PRESENTATION
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

occurs when the baby’s neck is so completely extended (bent backwards) that the
occiput at the back of the fetal skull touches the baby’s own spine

CAUSES: DIAGNOSIS:
• Laxity (slackness) of the uterus after • Abdominal palpation
many previous full-term
pregnancies
• Multiple pregnancy
• Polyhydramnios (excessive amniotic
fluid) COMPLICATIONS:
• Congenital abnormality of the fetus
• Obstructed labour and
(e.g. anencephaly, which means no
ruptured uterus
or incomplete skull bones)
• Cord prolapse
• Abnormal shape of the mother’s • Facial bruising
pelvis. • Cerebral haemorrhage
(bleeding inside the
fetal skull).

MANAGEMENT:

Anterior:
If the cervix is fully dilated:
➢ Allow to proceed with normal childbirth;
➢ If there is slow progress and no sign of obstruction, augment labor with
oxytocin;
➢ If descent is unsatisfactory, deliver by forceps.
If the cervix is not fully dilated and there are no signs of obstruction:
➢ augment labor with oxytocin.
Posterior:
If the cervix is fully dilated:

➢ Deliver by caesarean section.

If the cervix is not fully dilated

➢ Monitor descent, rotation and progress. If there are signs of obstruction,

deliver by caesarean section.

*Do not perform vacuum extraction for face presentation.

 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

BROW PRESENTATION

In brow presentation, the baby’s

head is only partially extended at the
neck (compare this with face
presentation), so its brow (forehead)
is the presenting part

DIAGNOSIS:

• Brow presentation is not usually detected before the onset of labour, except by very
experienced birth attendants.
• On abdominal examination, the head is high in the mother’s abdomen, appears unduly large
and does not descend into the pelvis, despite good uterine contractions.
• On vaginal examination, the presenting part is high and may be difficult to reach. You may be
able to feel the root of the nose, eyes, but not the mouth, tip of the nose or chin. You may
also feel the anterior fontanel, but a large caput (swelling) towards the front of the fetal skull
may mask this landmark if the woman has been in labour for some hours.

MANAGEMENT

• If the fetus is alive or dead, deliver by caesarean section.

*Do not deliver brow presentation by vacuum extraction, outlet forceps or

symphysiotomy.
 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

PROLAPSE UMBILICAL CORD

• The loop of the umbilical cord slips down in front of the fetal presenting part.
• May occur anytime after the membranes rupture if the presenting part is not fitted
firmly into the cervix

Occurs most often with the following conditions:

• PROM (Premature rupture of membranes)

• Fetal presentation other than cephalic
• Placenta previa
• Intrauterine tumors preventing the presenting part from engaging
• A small fetus
• CPD preventing firm engagement
• Hydramnios
• Multiple gestation

Assessment:

• Visualization of the cord

• Palpation of pulsating mass on vaginal exam
• Fetal distress (variable deceleration)
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General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

MANAGEMENT:

• Position on knee-chest; lateral modified Sim’s position with hips elevated; modified
Trendelenburg
• With gloved hand, support fetal presenting part
• Cover prolapsed cord with a sterile saline-soaked gauze
• Oxygen at 8 to 10L
• Monitor FHR and evaluate for signs of variable deceleration patterns
• Caesarean birth is necessary before rupture of membranes occurs.

ABNORMAL SHAPE AND SIZE OF THE PELVIS

➢ Narrow transverse and wide AP does not conform to the head of the baby.

➢ Shallow AP diameter may not allow the fetal head to rotate.

CONTRACTED PELVIS

➢ There is an alteration in the size and shape of the pelvis of sufficient degree so as to
alter the normal mechanism of labor in an average size baby.
 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

Diagnosis:

➢ Abdominal examination:
o Non-engagement of the head
o Pendulous abdomen
o Malpresentations: are common
➢ Pelvimetry
➢ UTZ

Management: (depends on the degree of disproportion)

➢ Minor disproportion: Vaginal delivery

➢ Major disproportion: Cesarean section delivery
 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

CEPHALOPELVIC DISPROPORTION (CPD)

• A contracture or narrow diameter in birth passage especially if fetus is larger than the
maternal pelvic diameters.

• Implications: Maternal: prolonged labor, arrest of descent, uterine rupture, forceps-

assisted birth with trauma

• Implications: Fetal: cord prolapse, excessive molding of head, birth trauma to skull and
CNS

CAUSES:

✓ increased fetal weight

✓ fetal position
✓ problems with the pelvis
✓ problems with the genital tract

SIGNS AND SYMPTOMS: DIAGNOSIS:

• the delivery of the baby is obstructed • Estimation of the size of the pelvis:

• The labor is prolonged Clinical pelvimetry – assessment of the size

of the pelvis is made manually by examining
the pelvis and palpating the pelvic bones by
vaginal examination

COMPLICATIONS: Radiologic pelvimetry – xrays or CT scans are

taken of the pelvis in different angles and
• Premature rupture of membranes views and the pelvic diameter measured.
• Dystocia
• Extreme molding of the head UTZ
• Umbilical cord prolapse
• Fetal distress
• Damage to the mom's perineum
• Injury to the baby’s head
• Uterine rupture
 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

MANAGEMENT:

➢ CESAREAN SECTION
➢ NURSING PLAN:
o Assess cervical change and fetal descent frequently
o Continuously monitor FHT
o Be alert for signs of fetal stress
o Assist with optimal positioning during labor such as squatting, hands and knees

SCHEMATIC DIAGRAM

Fetus does not engage but remains floating

Premature rupture
Trial labor malposition
of membranes

Prolonged labor

Uterine cord prolapse

Delayed second stage

Fetal distress!!
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General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

DYSTOCIA

➢ Difficult or obstructed labor.

CLASSIFICATION

Abnormalities of the Abnormalities with Abnormalities of the passenger:

Power/Uterine passageway:
Dysfunction • Fetal Malposition
• Pelvic dystocia o Transverse lie
• Hypotonic UD • Soft tissue o Face or brow
• Hypertonic UD dystocia o Breech
• Inadequate o Persistent POP
secondary forces o CPD
during the second • Fetal anomalies
stage of o Hydrocephalus
labor(inability of o Conjoined twins
the mother to o Meningomyelocele
push effectively) • Fetal size
o Macrosomia

ASSESSMENT:

• Progress of labor is slower than expected; rate of dilatation, effacement, descent for
specific client.
• Length of labor prolonged; prolonged latent phase (>20 hrs in nullipara pt. or >4 h in a
multipara pt), protracted active phase dilatation np. <1-2cm, mp <1.5cm; protracted
descent <1 cm per hr change in station in the nullipara pt. or <2 cm per hour in the mp pt.
• Maternal exhaustion/ distress
• Fetal distress
• Arrest of descent: no progress in fetal station greater than 1 hour
 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

SCHEMATIC DIAGRAM

(PATHOPHYSIOLOGY)

• Precipitating
• Predisposing
Genetic Malpresentation and malposition of the
Overweight fetus
Multiple gestation Congenital malformation of the uterus
Hydramnios Over stimulation with oxytocin
Maternal fatigue CPD
Pelvic malformation Fetal anomalies such as neural tube
Inappropriate timing of analgesic and defects, large tumor, and gross ascites
anaesthetic administration
Gestational DM
STDs
Other diseases

Medical Management:
1. Treatment for contraction abnormalities involves stimulation of labor through the use of
oxytocin. An intrauterine pressure catheter may be used.
2. Management for maternal passageway or fetal passage problems involves delivery in the
safest manner for the mother and fetus.
• If the problem is related to the inlet or midpelvis, a CS delivery is indicated.
• If the size of the outlet is the problem, a forceps or vacuum extraction maybe
perform.
Surgical Management:
1. Caesarean in necessary for delivery of the fetus

Nursing intervention:
✓ Individual as to cause
✓ Provide comfort measures for client
✓ Provide client, supportive descriptions of all actions taken
✓ Administer analgesia if ordered
✓ Monitor mother/ fetus continuously
 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

is a specific case of dystocia whereby after the delivery of the head, the anterior shoulder of
the infant cannot pass below the pubic symphysis, or requires significant manipulation to pass
below the pubic symphysis

SIGNS:

turtle sign (appearance and retraction of the baby's head

(analogous to a turtle withdrawing into its shell),

erythematous ,red puffy face indicative of facial flushing

RISK FACTORS:

 Maternal diabetes
 Fetal macrosomia
 Maternal obesity
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

 McRoberts maneuver

-is employed in case of shoulder dystocia during childbirth and involves hyperflexing the
mother's legs tightly to her abdomen. This widens the pelvis, and flattens the spine in the
lower back (lumbar spine). If this maneuver does not succeed, an assistant applies pressure on
the lower abdomen (suprapubic pressure), and the delivered head is also gently pulled.
 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

 Gaskin maneuver, named after

Certified Professional Midwife, Ina
May Gaskin, involves moving the
mother to an all fours position with
the back arched, widening the
pelvic outlet

COMPLICATIONS

• Brachial plexus injury

✓ Klumpke paralysis
✓ Erb's Palsy
• Fetal hypoxia
• Fetal death
• Cerebral palsy
• Maternal post partum hemorrhage
• Fractured clavicle
• Fractured humerus

TREATMENT

✓ Physical Therapy
✓ Surgical Therapy
 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

PATHOLOGIC RETRACTION RING

(BANDL’S RING)

• During labor the uterus differentiate into 2 parts: the upper contracting portion that becomes
thicker and shorter as labor progresses and the lower passive portion that distends gradually to
accommodate the descending fetus.
• The division or boundary of these two uterine segment is called PHYSIOLOGIC RETRACTION
RING.
• When labor is obstructed (occurs in contracted pelvis, malposition, hydrocephalus), the fetus
cannot descend into the birth canal. Because of this, uterine contractions becomes stronger and
more frequent in an effort to overcome the obstruction until it reaches a state of tonic
contraction when the uterus no longer relaxes. It is in this stage that Bandl’s ring of pathologic
retraction ring develops.
• The continuous retraction of the upper segment result in the division of the two uterine
segment, to become very prominent.
• Bandl’s ring is seen as a horizontal indention running across the abdomen.

MANAGEMENT:

• Morphine sulfate to relax the uterus

• Cesarean section for immediate delivery of the fetus and prevent uterine rupture, if morphine
sulfate is ineffective
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

• If Bandl’s ring develop during the placental stage, woman is placed under anesthesia and the
placenta is removed manually.

UTERINE DYSFUNCTION

• A labor characterize by lack of progress in the 1st and 2nd stage of labor that results in fetal
death, infection, maternal exhaustion and physiological trauma to the parturient.
• It is caused by any or a combination of the following conditions:
o Pelvic contraction
o Fetal malposition
o Oversidtention
o Excessive rigidity of the cervix

HYPOTONIC UTERINE DYSFUNCTION HYPERTONIC UTERINE DYSFUNCTION

• Weak, infrequent contractions which • Usually in Latent phase

are insufficient to dilate the cervix • Contractions that are too frequent
• Usually occurs during the active phase but uncoordinated, the uterus
does not relax completely in
between contractions and
contraction are more painful but
ineffective and out of proportion
to their intensity.

Etiology:
Etiology:
• Premature or excessive analgesia
• CPD • Unknown (theory: ectopic initiation
• Overdistention of uncoordinated uterine
• Fetal malposition/malpresentation contractions)
• Maternal anxiety

ASSESSMENT: ASSESSMENT:

• Onset – may occur in latent phase; most • Early onset of labor

common in active phase • Continuous fundal tension with
• Contractions: previously normal but shows incomplete relaxation
decreased frequency, shorter duration, • Very painful but ineffective
diminished intensity and less contractions
uncomfortable.
• Cervical changes slow or cease
• Signs of fetal distress: rare
• Maternal vital signs may indicate infection
 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

MANAGEMENT: MANAGEMENT:

• Re-evaluate the size of the pelvis to rule • Therapeutic rest: the woman is
of CPD given analgesic (morphine) and
• Amniotomy if membranes are not yet sedatives (barbiturates) to
ruptured promote rest. (The woman usually
• Augmentation of labor by oxytocin awakens with normal labor
• If with CPD, caesarean section is patterns)
performed • IV fluids to restore hydration and
fluid electrolytes balance
• If with CPD, do CS
• Keep bladder empty to provide
more space for the passage of the
fetus
• Encourage side lying position to
maximize blood flow to the
placenta and fetus.
COMPLICATIONS: • Watch for danger signals: fetal
distress, passage of meconium
• Maternal and fetal infections
stained amniotic fluid.
• Postpartum hemorrhage because of
prolonged labor
• Fetal distress and desth
• Maternal exhaustion

PRECIPITATE LABOR AND DELIVERY

• Also called Rapid labor

• Labor that occurs within 3 hour from the onset of contraction to delivery of
baby.
• Precipitate delivery – delivery that occurs without warning

Symptoms of rapid labor can vary, but can include:

• The sudden pattern of strong contractions that are very close to one
another and don’t let you rest or recover between each one
• Pain that feels like one long contraction
• A sudden feeling of having to push down like a bowel movement; this can
also feel like strong pressure in the pelvis
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

Predisposing factors: COMPLICATIONS:

• Multiparity Maternal:
• Large pelvis
• Laceration of birth canal
• Lax unresistant maternal tissue
• Uterine rupture
• Small baby in good position
• Postpartum hemorrhage
• Induction of labor: amniotomy and oxytocin
• Amniotic fluid embolism
administration
• Absence of painful sensation and thus a lack Fetal:
of awareness of vigorous labor
• Hypoxia
• Intracranial hemorrhage due to sudden
change of pressure
• Erb-Duchenne palsy
• Premature separation of placenta
• Injuries (falling to the floor in unattended
birth)

MANAGEMENT:

• Inform multiparous woman that succeeding labors are usually shorter than the previous one’s
so she can make appropriate plans for rapid transportation to the hospital when labor occurs.
• Warn woman with history of precipitate labor that rapid labor and delivery may happen again.
• If accelerated labor pattern occurs during oxytocin administration, STOP INFUSION right away
and turn woman on her side.
• Never hold the baby back if rapid labor occurs by making the woman lock her thighs together, as
it can result to fetal brain damage.
• Ask woman to pant rather than push to prevent rapid expulsion.
• If supplies are not available (forceps, cord clamp), do not cut cord with ordinary scissors, blade
or knife, or tie it with sewing thread. Transport mother and baby to the nearest health care
facility.
• If baby does not cry spontaneously, rub the sole of the feet.
• Place baby on mother’s abdomen to stimulate contraction of the uterus, while waiting for the
birth of the placenta.
• Show baby to mother, initiate breastfeeding if possible to stimulate uterine contractions.
• Check baby for injury after birth.
• Examine woman for laceration.
 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

UTERINE PROLAPSE

Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken and no longer
provide enough support for the uterus. As a result, the uterus slips down into or protrudes out of the
vagina.

Symptoms
Mild uterine prolapse generally doesn't cause signs or symptoms. Signs and symptoms of
moderate to severe uterine prolapse include:

• Sensation of heaviness or pulling in your pelvis

• Tissue protruding from your vagina
• Urinary problems, such as urine leakage (incontinence) or urine retention
• Trouble having a bowel movement
• Feeling as if you're sitting on a small ball or as if something is falling out of your vagina
• Sexual concerns, such as a sensation of looseness in the tone of your vaginal tissue
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

Causes COMPLICATIONS:

Uterine prolapse results from the weakening

• Anterior prolapse
of pelvic muscles and supportive tissues.
(cystocele). Weakness of
Causes of weakened pelvic muscles and
connective tissue separating the
tissues include: bladder and vagina may cause the
bladder to bulge into the vagina.
• Pregnancy
Anterior prolapse is also called
• Difficult labor and delivery or trauma
prolapsed bladder.
during childbirth
• Delivery of a large baby • Posterior vaginal prolapse
• Being overweight or obese (rectocele). Weakness of
• Lower estrogen level after connective tissue separating the
menopause rectum and vagina may cause the
• Chronic constipation or straining rectum to bulge into the vagina.
with bowel movements You might have difficulty having
• Chronic cough or bronchitis bowel movements.
• Repeated heavy lifting

PREVENTION:

• Perform Kegel exercises regularly. These exercises can strengthen your pelvic floor muscles —
especially important after you have a baby.
• Treat and prevent constipation. Drink plenty of fluids and eat high-fiber foods, such as fruits,
vegetables, beans and whole-grain cereals.
• Avoid heavy lifting and lift correctly. When lifting, use your legs instead of your waist or back.
• Control coughing. Get treatment for a chronic cough or bronchitis, and don't smoke.
• Avoid weight gain. Talk with your doctor to determine your ideal weight and get advice on weight-
loss strategies, if you need them.
 University of San Agustin
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

DIAGNOSIS:

• PELVIC EXAM

TREATMENT:

Treatment depends on the severity of uterine prolapse. Your doctor might recommend:

• Self-care measures. If your uterine prolapse causes few or no symptoms, simple self-
care measures may provide relief or help prevent worsening prolapse. Self-care
measures include performing Kegel exercises to strengthen your pelvic muscles, losing
weight and treating constipation.

• Pessary. A vaginal pessary is a plastic or rubber ring inserted into your vagina to
support the bulging tissues. A pessary must be removed regularly for cleaning.

• Removal of your uterus (hysterectomy). Hysterectomy might be recommended for

uterine prolapse in certain instances. A hysterectomy is generally very safe, but with
any surgery comes the risk of complications.

•
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

UTERINE RUPTURE

• Tearing of the muscles of the uterus, occurs when the uterus can no longer withstand
the strain placed upon it.
• It is a serious complication of labor than can lead to maternal and fetal death.

ETIOLOGY:

• Overdistention – due to large baby

• Old scars – due to previous CS or uterine surgery
• Contractions against CPD, fetal malpresentation, Pathologic retraction ring
• Injudicious obstetrics – malapplication of forceps
• Tetanic contractions

SIGNS AND SYMPTOMS:

• Impending uterine rupture is often manifested by a pathologic retraction ring.

• During the peak of a contraction, the woman suddenly complains of a sharp tearing
pain after which, relief will be felt as the uterus will no longer contract.
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

ASSESSMENT:

• Identify predisposing factors

• Complete rupture:
o Sudden, sharp, abdominal pain followed by cessation of contractions, very tender
abdomen
o Signs of shock
o Absent fetal heart tones
o Presenting part not palpable on vaginal exam
• Incomplete rupture:
o Continued contractions accompanied by abdominal pain; failure to dilate; becomes
dystonic
o Signs of shock
o May demonstrate vaginal bleeding
o Fetal heart tone may be absent or bradycardic

MANAGEMENT:

• Blood transfusion and administration of IVF to correct shock.

• Administer mask oxygen to the woman
• Emergency Laparotomy to deliver the baby
• Reduce possibility of infection
• Surgical hysterectomy
o Post – op care:
▪ Explain need to avoid driving 3-6 weeks
▪ Explain need to avoid jogging, sexual intercourse, dancing, and lifting heavy
objects for 6-8 weeks.
• Provide emotional support. Inform woman of what is happening, the procedures being done,
answer questions as honestly as possible, do not give false reassurance.

PLACENTAL PROBLEMS

PLACENTA PLACENTA
VELAMENTOUS
ACCRETA CIRCUMVALLATA
INSERTION OF THE
CORD

VASA
PLACENTA BATTLEDORE
PREVIA
SUCCENTURIATA PLACENTA
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

PLACENTA ACCRETA:

 Is a serious pregnancy condition that occurs when the placenta grows too deeply into the
uterine wall.

 Typically, the placenta detaches from the uterine wall after childbirth. With placenta accreta,
part or all of the placenta remains attached. This can cause severe blood loss after delivery.

 Placenta accreta is considered a high-risk pregnancy complication. If the condition is diagnosed

during pregnancy, you'll likely need an early C-section delivery followed by the surgical removal
of your uterus (hysterectomy).

SYMPTOMS:

 Placenta accreta often causes no signs or symptoms during pregnancy — although vaginal
bleeding during the third trimester might occur.

 Occasionally, placenta accreta is detected during a routine ultrasound.

CAUSES:

 Placenta accreta is thought to be related to abnormalities in the lining of the uterus, typically
due to scarring after a C-section or other uterine surgery. Sometimes, however, placenta accreta
occurs without a history of uterine surgery.

RISK FACTORS:

 Previous uterine surgery. The risk of placenta accreta increases with the number of C-sections
or other uterine surgeries.

 Placenta position. If the placenta partially or totally covers your cervix (placenta previa) or sits
in the lower portion of your uterus.

 Maternal age. Placenta accreta is more common in women older than 35.

 Previous childbirth. The risk of placenta accreta increases as your number of pregnancies
increases.

COMPLICATIONS:

 Heavy vaginal bleeding. Placenta accreta poses a major risk of severe vaginal bleeding
(hemorrhage) after delivery. The bleeding can cause a life-threatening condition that prevents
your blood from clotting normally (disseminated intravascular coagulopathy), as well as lung
failure (adult respiratory distress syndrome) and kidney failure. A blood transfusion will likely
be necessary.

 Premature birth. Placenta accreta might cause labor to begin early. If placenta accreta causes
bleeding during pregnancy, need to deliver your baby early.

DIAGNOSIS:

 If you have risk factors for placenta accreta during pregnancy — such as the placenta partially or
totally covering the cervix (placenta previa) or a previous uterine surgery — your health care
provider will carefully examine the implantation of your baby's placenta.

 Through an ultrasound or MRI, your health care provider can evaluate how deeply the placenta
is implanted in your uterine wall.
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

 Removing manually may lead to extreme hemorrhage, because of the deep attachment.

 Hysterectomy or treatment with methotrexate to destroy the still-attached tissue may be

necessary.

PLACENTA SUCCENTURIATA:

 An extra placenta separate from the main placenta. In anatomy "succenturiate" means
accessory to an organ. In this case, a succenturiate placenta is an accessory placenta.

 It has one or more accessory lobes connected to the main placenta by blood vessels.

 No fetal abnormality is associated with this type, however it is important that it should be
recognized, because the smaller lobes may be retained in the uterus after birth.
 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

MANAGEMENT:

 The remaining lobes must be removed from the uterus manually to prevent maternal
hemorrhage

PLACENTA CIRCUMVALLATA

 The fetal side of the placenta is covered to some extent with chorion.
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

BATTLEDORE PLACENTA:

 The cord is inserted marginally rather than centrally.

 This anomaly is rare and has no known significance

VELAMENTOUS INSERTION OF THE CORD:

 The cord, instead of entering the placenta directly, separates into small vessels that reach the
placenta by spreading across a fold of amnion.

 Most commonly found with multiple gestation.

 Maybe associated with fetal anomalies, the newborn should be examined carefully
 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
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COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

VASA PREVIA

 The umbilical vessels of a velamentous cord insertion cross the cervical os and therefore deliver
before the fetus.

 The vessel may tear with cervical dilatation (just as a placenta previa may tear.)

 Tearing would result to sudden sudden fetal blood loss.

 If sudden, painless bleeding occurs with the beginning of cervical dilation, vasa previa should be
suspected.

 Can be confirmed by sonography.

 If with vasa previa, CS is recommended.

PREMATURE RUPTURE OF MEMBRNES (PROM)

Rupture of chorion and amnion 1 hour or more before the onset of

labor.

ETIOLOGY: MANAGEMENT:

• Malpresentation • Assess discharge with Nitrazine paper

• Subclinical infection • Obtain specimen for culture and sensitivity
• Incompetent cervix • Assess for early signs of infection
• Increase uterine size • Bedrest
• Uterine and fetal anomalies • Adequate hydration
 University of San Agustin
General Luna St., Iloilo City 5000, Philippines
[Link]
COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING

CONGRATULATIONS!!! You have finished part of Module 3

This Module is intended for the use of the BSN 2 students only of the University
of San Agustin. Reproduction for any purposes is not allowed without
permission from the author.