MATERNITY II

Sir KB | Unit 2: Abnormal Intranatal Period

UNIT 2: ABNORMAL INTRANATAL PERIOD ➢ Prematurity

➢ Placenta previa
OVERVIEW:
SIGNS AND SYMPTOMS
➢ Pulsating mass upon IE
Premature rupture of membrane (PROM)
➢ Variable deceleration
Prolapsed Umbilical Cord
Supine Hypotension Syndrome
Precipitous Labor and Delivery
Dystocia
Amniotic Fluid Embolism
Fetal Distress
Rupture of Uterus
INTERVENTION
Uterine inversion
➢ Reduce pressure on the cord.
Abnormal Presentations and Positions o Positioning (LLP, knee chest, T-position)
Operative Obstetrics ➢ Never re-place or push back the cord (may result to
cord kinking)
PREMATURE RUPTURE OF MEMBRANE (PROM) ➢ Push presenting part upward
✓ Spontaneous rupture of amniotic membranes before ➢ Cover cord with gauze soaked in saline (to avoid
onset of labor. exposure to air that will dry the cord)
✓ RISK: infection (ascending infection) ➢ Deliver the baby ASAP.
✓ Should deliver the baby within 24 hours. ➢ Anticipate CS
➢ Don’t leave the patient.
SIGNS AND SYMPTOMS ➢ O2 (8-10 L/m) via face mask
➢ Fluid pulling in the vaginal vault. ➢ Monitor for fetal hypoxia.
➢ (+) Nitracin paper test
➢ (+) Fern test
SUPINE HYPOTENSION SYNDROME
INTERVENTION Occlusion of abdominal blood vessels or vena cava
➢ Assess the following: ↓
o Amount Low veinous return (preload)
o Color ↓
o Consistency Low cardiac output
o Odor ↓
➢ Assess or monitor the following: Hypotension
o VS (FMWB)
o Temperature (mother) Preload and Afterload:
o FHT (tachycardia)
➢ NO frequent IE Preload Afterload
➢ Rx: Administer antibiotics.
➢ Deliver the baby within 24 hours. Pp
Veins arteries

PROLAPSED UMBILICAL CORD

SIGNS AND SYMPTOMS
✓ “nauna lumabas ang umbilical cord”
➢ Faintness/dizziness/breathlessness
✓ Umbilical cord lies in front of the presenting part and
➢ Tachycardia
the membranes are ruptured.
➢ Hypotension
➢ Sweating (cool and clamp)
CAUSES
➢ Fetal distress
➢ Polyhydramnios
➢ Long cord
INTERVENTION
➢ Malposition or Malpresentation (fetal)

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MATERNITY II
Sir KB | Unit 2: Abnormal Intranatal Period

➢ Positioning (LLP, placing a pillow/wedge under hip or ➢ Hemorrhage

side of the mother) ➢ Infant mortality
➢ Monitor FMWB SIGNS AND SYMPTOMS
➢ Excessive abdominal pain
➢ Abnormal contraction pattern
PRECIPITOUS LABOR AND DELIVERY ➢ Fetal distress
✓ < 3 hours of labor ➢ Tachycardia (mother and baby)
➢ Lack of progess of labor.
Normal duration of labor:
• Multi = 6 – 8 hours ABNORMAL LABOR INDICATORS
• Primi = 10 – 12 hours
INDICATION PRIMI MULTI
CAUSES Prolonged latent > 20 hours > 14 hours
➢ Very small passenger phase
➢ Very large passage Prolonged second > 2 hours or > 1 hour
➢ Multiparity stage > 3 hours > 2 hours
Protracted dilation < 1.2 cm/hour < 1.5 cm/hour
➢ Excessive oxytocin stimulation
Protracted descent < 1 cm/hour < 2 cm/hour
Arrest of dilation > 2 hours > 2 hours
INTERVENTION Arrest of descent > 2 hours > 1 hour
➢ Precipitous delivery tray Prolonged third > 30 minutes > 30 minutes
➢ Always stay with the client. stage
➢ Deliver the baby.
➢ Pant between contractions INTERVENTION
➢ DO NOT try to prevent the fetus from being delivered. ➢ Monitor the following:
o FMWB
o Uterine contractions
DYSTOCIA o Color of amniotic fluid
✓ Prolonged and difficult labor o I & O monitoring (maintain hydration)
➢ Assess the following:
CAUSES o Prolapsed cord after rupture of membrane
➢ Problems with the 3P’s o Client’s fatigue
o Passenger - Ix: sedative, pain meds
o Passage - Rest and comfort (back rubs),
o Power position changes
➢ Assist in ultrasound.
PASSENGER PASSAGE POWER o Rule out CPD.
- w/o CPD – administer oxytocin.
Large infant Abnormal shape, Abnormal uterine - w/ CPD – CS
(CPD, FPD) size, adequacy of contractility
➢ Administer prophylactic antibiotics as prescribed.
pelvis.
Abnormal fetal o to prevent infection
presentation ➢ Administer IV fluids as prescribed.
➢ Instruct client on:
UTERINE CONTRACTION o Breathing exercises
HYPOTONIC HYPERTONIC o Relaxation techniques
Weak Strong
Note:
Infrequent Frequent • NO local anesthesia before 4 cm (latent)
• Local anesthesia lengthens the 2nd stage by 25
Painless Ineffective uterine minutes
contraction

COMPLICATIONS
AMNIOTIC FLUID EMBOLISM
➢ Infection
✓ Escape of amniotic fluid into the maternal circulation
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MATERNITY II
Sir KB | Unit 2: Abnormal Intranatal Period

➢ Excessive oxytocin
CAUSES ➢ Overdistention of uterus
➢ Unknown ➢ Placenta accreta
➢ Dystocia or precipitate labor
RISK FACTORS
➢ Placental abnormalities (previa/abruptio) SIGNS AND SYMPTOMS
➢ C-section ➢ Bandl’s ring
➢ Instrumental delivery ➢ Sudden, sharp pain at the peak of contraction.
➢ Advanced maternal age
➢ Grand multi’s (> 5) 2 TYPES OF UTERINE RUPTURE

SIGNS AND SYMPTOMS COMPLETE INCOMPLETE

➢ Respiratory distress (chest pain, cyanosis, difficulty Pain at peak of contractions Persistent pain
breathing) but stops when UC stops.
➢ Fetal distress
Bleeding Bleeding
RISK
➢ DIC Uterine cavity has direct Uterine cavity and peritoneal
communication with cavity has no direct
peritoneal cavity communication.
INTERVENTION
➢ EMERGENCY SITUATION
INTERVENTION
o O2: 8-10 LPM (face mask/resuscitation bag)
➢ IVF
o Prepare for intubation and mechanical
➢ BT
ventilation.
➢ E-CS
o Position mother on her side
➢ Emotional Support
o Rx: IV fluids, blood products, medication
(DIC)
o FMWB monitoring
UTERINE INVERSION
o E-delivery
✓ Uterus was turned inside out.
o Emotional support
CAUSES
Anything that causes PRESSURE on UNCONTRACTED
FETAL DISTRESS
UTERUS
✓ FHT
➢ Pulling of cord when the uterus is uncontracted.
o Acceleration (> 160 bpm)
➢ Fundal push
o Deceleration (< 120 bpm)
➢ Placenta accreta
✓ Fetal hyperactivity/hypoactivity
➢ Sudden expiratory reflex
✓ Meconium-stained amniotic fluid.
SIGNS AND SYMPTOMS
INTERVENTION
➢ Fundus is not palpable.
➢ Discontinue oxytocin (if infusing)
➢ Gush of blood
➢ Position client in side-lying (LLP)
➢ Uterus appears in vulva.
➢ Oxygen: 8-12 LPM (face mask)
➢ Shock
➢ Administer IV fluids (bolus)
➢ FMWB Monitoring
INTERVENTION
➢ ! Prepare mother for emergency CS.
➢ Control hemorrhage and shock
➢ Re-place back the uterus
o The part that comes back last goes first.
RUPTURE OF UTERUS
o Lower uterine segment first and fundus last
✓ Tearing of uterine muscles
o If unsuccessful: uterine replacement guided
by laparotomy.
CAUSES
➢ Stimulates uterine contraction.
➢ Previous CS (most common)
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MATERNITY II
Sir KB | Unit 2: Abnormal Intranatal Period

ABNORMAL PRESENTATIONS AND POSITIONS o McRobert’s Maneuver (thighs are pressed

against the abdomen)
1.1. BREECH PRESENTATION o Gaskin Maneuver (mother is positioned on
✓ Most common fetal malpresentation all fours)
➢ Apply suprapubic pressure.
CAUSES
➢ Lax uterus (multis) COMPLICATIONS
➢ Hydramnios ➢ Erb’s palsy – paralysis or weakness of shoulder or
➢ Oligohydramnios arm of the baby
➢ Multiple pregnancy ➢ Fracture – clavicle, humerus
➢ Prematurity ➢ Abnormal reflexes – asymmetrical

INTERVENTION
➢ External version OPERATIVE OBSTETRICS
➢ CS
➢ Vaginal delivery FORCEPS DELIVERY
o No CPD
o Fetus is not large (< 3600g) TYPES OF DELIVERY FORCEPS
o There are skilled professional. ➢ Simpsons – occiput – posterior position
➢ Tucker McLane – to rotate and deliver the head from
1.2. FACE PRESENTATION posterior to anterior.
✓ Head is hyperextended. ➢ Kielland Barton – from transverse to anterior
✓ Denominator (mentum) ➢ Piper – used to deliver the head after coming from
✓ Mechanism of labor breech.

METHODS OF DELIVERY TYPES OF FORCEPS DELIVERY

➢ Anterior position (LMA, RMA) – vaginal delivery ➢ High forceps – applied before the head engages.
➢ Posterior position (LMP, RMP) – CS and NO vaginal ➢ Mid forceps – applied when the head is already
delivery engaged.
➢ Outlet forceps – applied when the head is already
1.3. BROM PRESENTATION crowning.
✓ Most uncommon ➢ Low forceps – applied when the head is already at
✓ Usually converts to vertex/face. station +2

1.4. SHOULDER PRESENTATION COMPLICATIONS

✓ Transverse lie MOTHER
➢ Laceration
2.1. OCCIPUT POSTERIOR POSITION ➢ Rupture (uterine)
✓ Severe back pain (sacral pain) FETUS
➢ Cephal hematoma
INTERVENTION ➢ Facial palsy
➢ Position change frequently ➢ Intracranial hemorrhage
➢ Back rub ➢ Skull fracture
➢ Apply sacral pressure.
INTERVENTION
➢ FMWB monitoring
SHOULDER DYSTOCIA ➢ Reassurance (mother)
✓ After the delivery of the head, the anterior shoulders ➢ Assist in the repair of lacerations.
are trapped and arrested behind the symphysis pubis. ➢ Check the neonate for possible injuries.

INTERVENTION VACUUM EXTRACTION

➢ Positioning ✓ Use suction to assist delivery.

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MATERNITY II
Sir KB | Unit 2: Abnormal Intranatal Period

INTERVENTION
➢ Traction is applied during uterine contraction.
➢ Suction should not be kept in place longer than 25
minutes.
➢ FHT monitoring (early deceleration)
➢ Assess for signs of cerebral trauma.
➢ Monitor for cephal hematoma.
➢ Monitor for caput succedaneum.

EPISIOTOMY
✓ Surgical incision of the perineum to enlarge the
vaginal introitus.
✓ Done when the head is crowning.

PURPOSE
➢ Prevent laceration.
➢ Shorten the 2nd stage.
➢ Enlarge the outlet.

INTERVENTION
➢ Ice packs (1st 24 hours)
➢ Sitz bath (after 24 hours) (warm compress)
➢ Analgesic spray/ointment (Rx)
➢ Perineal care (clean technique)
➢ Drying of perineum (NO blotting and wiping)
➢ Bath: shower
➢ Perineal pad (DON’T touch inside the surface of the
pad)
➢ Report bleeding or discharge

EXTERNAL VERSION
✓ Turning of fetus from unfavorable to favorable
presentation or position.
✓ Alternative CS

INTERVENTION
➢ Done: after 34th weak AOG
➢ Rh negative: RhoGAM (28th week AOG)
➢ Non stress test
➢ IV Fluids/tocolytic therapy
➢ UTZ guided by ultrasound.
➢ Monitor SHS
➢ After external version:
o Non-stress test
o Monitoring of maternal VS, Uterine act.,
bleeding
o Coomb’s test

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