LABOR AND DELIVERY

INTRA PARTAL PERIOD

Whd is Labor?
It is the uterine contractions that lead to progressive effacement
and dilatation of the cervix and to expulsion of the fetus and placenta
from the uterus
The hormone OXYTOCIN initiates uterine contractions that begin
when the labor process.
THl~RIES OF ONSET OF LABOR

J. Uterine stretch theory

J. Oxytocin stimulation Theory
-1- Progesterone deprivation
J_ Prostaglandin theory
-l- Theory of Aging Placenta

TYPES OF LABOR

f FALSE LABOR TRUE LABOR

Begin irregularly but become

Begin and remain irregular regular and predictable
Ir-
Felt first abdominally and Felt first in lower back and
1
remained confined to the sweep around to the abdomen in
I a wave

L
abdomen and groin

t
.e n disappear with ambulation Continue no matter what the
and sleep woman's level of activity

)o not increase in duration, Increase in duration, frequency,

frequency, or intensity and intensity

Do not achieve cervical Achieve cervical dilatation

dilatation
 SIGNS OF LABOR

PIU:LIMINARY SIGNS OF LABOR

Before labor, the woman often experience subtle sign that can signal the
onset the labor. All pregnant women should be taught how to recognize
the~;e.

Lightening of the fet.a1 presenting part into the pelvis

f'
Increase in level of activity
Braxton hick's Contraction
Ripening of the cervix

SIGNS OF TRUE LABOR

Signs of true labor involve uterine and ceroical changes

•:• Uterine Contractions

Show
Rupture of the membrane

* Two risks associated with ruptu.res membrane

·•· Intra uterine infection

•· Pro lapse of the umbilical cord

COJYIPONENTS OF LABOR
t'

PASSAGE
J.. The woman's pelvis is of adequate size and contour
i Route thee fetus must travel from the uterus through the cervix
and vagina to the external perineum

PABSENGER
l- Is of appropriate size and in an advantageous position and
presentation
i Compose of the fetus and placenta, the body part of a fetus that
has the widest diameter is the head, so this is the part least likely
to be able to pass through the pelvic ring

'l'
 PO\ITERS

t Of labor are adequate

4- Is also compose of the contractions, the hypotonic, hypertonic and
uncoordinated, supplied by the fundus and uterus

PSYCHE

.,- The woman's psyche is preserved so afterward labor can be viewed

as a positive experience
Psychological sites or feeling's that woman bring into labor with
them

FETAL PRESENTATION ARD POSITION

AT1'ITUDE
J_ Describes the degree of flexion the fetus assumes during labor or
the relation of the fetal parts to each other

.!,. Vertex ( good attitude)

-.J._ Sinciput ( Moderate Flexlon)
·-i- Brow ( partial extension)
.L Poor flexion

ENOAGEMENT
i.. Refers to the settling of the presenting part of the "fetus far enough
into the pelvis to be at the level of the ischial spines, a midpoint of
the pelvis
1'

i. Floating- if the presenting part is not yet engaged

J,. Dipping- one that is descending but has not reached the iliac
spines

FE'lrAL LIE
4- The relationship of the long axis of the fetal body and the long axis
of the woman 1s body

l- Horizontal or Transverse- fetus long axis lies parallel with

4- Vertical or Longitudinal- the long axis of a woman

FE'tAL PRESENTATION
i Determ.ined by fetal lie and the degree of flex.ion

., .!. Cephalic prenntatlon

.i. Breech preaentatlon
 !- Shoulder presentation

POSITION
!- Is the relationship of the presenting part to a specific quadrant of
the woman's pelvis
1~111 I !- This is important because it influences the process and efficiency
of labor

l- LOA and ROA- fetus delivers fastest in this kind of position

!- LOP and ROP- labor is considerably extended in this position

STAGES OF LABOR

Labor is traditionally divided into four stages

FIRST STAGE (Dtlatational Stage)

·J_ The begging with true labor contractions and ending when the
cervix is fully dilated

SECOND STAGE (Expulsive Stage)

-J.. From the time of full dilatation until the infant is born

THJRD STAGE (Placental Stage)

.f.. From the time the infant is born until the delivery of the placenta

FOURTH STAGE (Recovery Period)

J. The first 1 to 4 hours after birth of the placenta. Because close
observation is needed at this time.
r
PHASES OF LABOR

LATENT PHASE

.j,. Stage of dilatation

.I,. Preparatory phase
.j.. Be&fns at the onset of reaularly perceived uterine contraction
and ends when rapid cervical dilatation begins
.I,.. Contraction• are mild and short lasting to 20-40 seconds
.J.. Cervical effacement occurs
-1- 0-3 cervical dilatation
.L. Nullipara- 6 houra
.I- Multlpara- 4 .5 hours
I.. Woman can continue to walk about and make preparations for
birth

ill
 J_ Woman in this stage is excited with some degree of
apprehension but still with the ability to communicate

ACTIVE PHASE

•- Cervical dilatation occurs more rapidly

•'- Contractions grow stronger 40-60 seconds occurs every 3-5
minutes
·- 4-7 cm cervical dilatation
,.. Increase vaginal secretions
,;- Bloody show and spontaneous rupture membranes may occur
+ Nullipara - 3hours
,b- Multipara- 2 hours
f'
,I- Woman feels of losing herself

TRANSITION PHASE

.l- Contractions reach their peak

-1-- Every 2-3 minutes
.l- Interval 2-3 minutes
1- Duration: 60-90 seconds
.I,.Dilatation: 8-10 cm
I- At 9 cm there is slight showing of dilatation
J. If membranes have not yet previously ruptured, they will
rupture at full dilatation as- a rule
-!.. At 10 cm new sensation occurs
i.. The mood of the woman suddenly changes and the nature oi
contractions intensity

HYPOTONIC UTERINE CONTRACTION

i low or frequent number of contractions ( not increasing beyond 2

or 3 in a 10 minute period)
i the resting tone of the uterus remains less then l OmmHg and
strength does not rise above 25mmHg.
i occurs during active phase of labor, and after administer of
analgesia if when the cervix is not dilated to 3-4cm or if with
bladder or bowel prevents descent or firm engagement.
t- in multiple gestation with overstretch uterus, with larger than
usual single fetus, or hydramnios, or a ground multi.parity with low
uterus causing increase in the length of labor leading to
exhaustion and chance for postpartal hemorrhage and infection.
 MAJJAGEMENT
-~ Oxytocin to augment labor by strengthening contractions- and
increasing the effectivity.
.l.. Amniotomy to speed the labor .
.l.. After birth, assess lochia every 15 minutes for 2 hours for possible
bleeding.

~I HYPERTONIC UTERINE CONTRACTIONS

o Frequent and increase in resting tone to more than 15mm.Hg
common on the latent phase of labor.
o The myometrium becomes tender from constant lack of relaxation
r and anoxia and uterine cells leading to fetal anoxia.
MAJIAGEMENT
-l- Involves rest and pain relief with morphine sulfate.
-1- Change the patients' gown& linen, decrease noise and stimulation.
-1- If with deceleration, long 1st stage of labor, or lack of progress with
pushing (2nd- stage arrest) occurs, cesarean birth is needed.
COl4PARISION
Criteria H ertonic H otonic
- of
Phase - labor
- - - -- -+~~-------+-~--
Latent Active - - - - - -
Symptoms Painful Painless

Mec.s:
Oxytocin Unfavorable reaction Favorable reaction
Sed!ition Hel ful Little Value

PRECIPITATE LABOR
l'

o Precipitate labor and birth occur when contraction are so

strong that the woman gives birth only a few, rapidly
occurring contraction lasting up to 3hrs only.
o Happens during active phase of dilatation, the rate is greater
than Scm/ hr (1cm q 12mins) in nullipara or l0cm/hr (1cm
q 6mins) in a multipara
o Occurs with grand multiparity, or it may occur after
induction of labor by oxytocin or amniotomy.
o Can lead to premature separation of placenta

~I
 /

RISJK for MATERNAL & FETAL HEMORRHAGE

o Sudden release of pressure on the head of the fetus can lead
to subdural hemorrhage.
o Forceful birth may cause lacerations.

MAUAGEMENT
o Tocolytic may be administered to reduce the force and
frequency of lacerations.
,Uff\1 1 o Viability of the fetus depends on the extent of the rupture
l ,,, ,
and the time elapsed between rupture and abdominal
I

extraction.
> A woman's prognosis depends on the extent of the rupture
and the blood loss.

UTERINE RUPTURE (UR)

o Occurs when a uterus undergoes more strain than its

capable of sustaining can cause fetal death, ECS.
o Occurs 1: 1,500 births, 5% of all maternal deaths.
o Common with vertical scan from previous cesarean birth or
hysterotomy repair tears.
o Contributing factors include prolonged labor, abnormal
presentation, multiple gestation, and unwise use of oxytocin,
obstructed labor and traumatic maneuvers of forceps or
traction.

SIGNS & SYMPTOMS

o Presence of pathologic retraction ring or presence of strong
· uterine contraction without cervical dilatation needs an
immediate CS.
o Sudden, severe pain, "tearing", sensation during strong labor
contraction.

1' Complete UR Incomplete UR

Endometrium Endometrium &
Myometrium Myometrium
-Peritoneum
With 2 distinct swellings will be Localized tenderness & a persistent
visible aching pain over the area of the
An woman's abdominal lower uterine segment fetal &
1. retracted uterus maternal.
2. <:·x trauterine fetus

. I''
 * Hem<;>rrhage to abdominal cavity to vagina.
,\ sign of shock begins
Followed by fetal death.
* Di stress U FH sound, lack of contraction & changes in the woman VS)
MA~AGEMENT
o 'E ' fluid replacement therapy
o IV oxytocin to contract the uterus and minimize bleeding.
o Prepare for 'E' laparotomy- repair the uterus and control the
bleeding.
o 'E ' cesarean hysterectomy ( removal of damaged uterus)
o Most women are advised not to conceive again after a
rupture or the uterus, unless the rupture occurred in the
inactive lower segment provide EMOTIONAL, SPIRITUAL,
PSYCHOWGICAL SUPPORT.

INVERSION OF THE UTERUS

;..- turning of fetus inside out with either birth of the fetus or delivery
of the placenta
occurs 1:15,000 births
;;. Occurs if traction is applied to the umbilical cord to remove the
placenta or if pressure is applied to the uterine fundus when the
uterus is not contracted. Attachments of placenta at the fundus,
and passage of the fetus pulls the fundus down.
;,,. Inversion occurs in various degrees. The inverted fundus may lie
within the uterine cavity or the vagina, or, in total inversion, it may
protrude from the vagina.

SIGNS
Large amount of blood suddenly gushes from the vagina.
fi.mdus is not paipable in the abdomen
hemorrhage
hypotension
dizziness
paleness
diaphoresis

MANAGEMENT
,, DO's
,, Administer oxygen
,/ IV line, assess VS
,/ She will be given general anesthesia or possibly nitroglycerine or a
tocolytic drug per IV, to relax the uterus.

.,
 ,/
The physician or nu 'd •
v' Ad • .st rse-nu Wife replaces the fundus manually.
1 mim er of oxytocin to help the uterus to contract and remain in
pace
v' Antibiotic therapy
v' CS for future pregnancy

DO!PT's

•"••·
~ever attempt to replace an inversion, handling the uterus may
mcrease the bleeding.
i~,1 Never attempt to remove the placenta if it is still attached, it would
create larger area for bleeding.
•:~
Never administer oxytocin while the uterus is inversion, making
the uterus more tense and difficult to replace.

II. PROBLEMS WITH THE PASSENGERS

A. l~rolapsed of the Umbilical Cords
o A loop of the umbilical cord slips down in front of the presenting
part.
o May occur at any time after the membranes ruptures.
o If the presenting part is not fitted firmly into the cervix.

It tends to occurs most often with the following:

1. Premature rupture of membrane
2. Fetal presentation other than cephalic
3. Placenta previa
4. Intrauterine tumors preventing the presenting part from engaging
5. Small fetus
6. Cephalopelvic disproportion preventing from engagement
7. Hydramnios
8. Multiple gestation

AS8ESSMENT
r ;, Cord may felt as the presenting part on an initial vaginal exam ( CS
necessary)
When a variable deceleration FHR pattern suddenly becomes
apparent.
;, Cord may then be visible at vulva.
Immediately after PROM, occurring either spontaneous or by 3.

amniotomy.

MANAGEMENT
,/ cord prolapse automatically leads to cord compression

1m11
 ,/ m~8:gement aim toward relieving pressure on the c~rd, hereby
relieving the compression and resulting to fetal anoxia

DONE BY: j

,/ Placing glove hand in vagina and manually elevating the fetal

heads off the cord or .
'/ Placing in KNEE- CHEST or TRENDELENBURG POSITION which
causes the fetal head to fall back from the cord.
,/ Administer Oxygen at 1O L/ minute by face mask to improve
oxygenation.
,/ Tocolytic agent to reduce uterine activity and pressure on fetus.
,/ Cord is exposed in room air- dry- atrophy of umbilical vessels.
,/ Do not attempt to push any exposed cord back into vagina may
add to compression by causing knotting /kinking.
,r Instead cover any exposed portion with a sterile saJine compress to
prevent drying. . ,
,r: If fully dilated deliver by use of forceps to prevent 'fetal ano?°a ·
,r If incomplete birth methods is upward pressure on presenting part.

MULTIPLE GESTATION
) - Usually causes a flurry of excitement in a birthing room.
;.,, Twins may be born by cesarean birth to decrease the risk that the
2 nd fetus will experience ANOXIA.
If vaginally come to hospital early in labor.
;, analgesia administration should be conservative so it will not
compound any respiratory difficulties
o Because of immaturity
o Support the woman's breathing exercise
;, Monitor each HER babies are usually small risk for cord prolapse
frrm head .e ngagement may not occur.
;, Uterine dysfunction long labor.
:, Overstretched uterus.
Premature separation of the placenta
COMMON
Abnormal fetal presentation
-~ Anemia & HPN of pregnancy occur at higher than usual incidence
, >PRESENTATION
1s t fetus usually present vertex
Breech & vertex
Breech & breech
>if born vaginally-oxytocin infusion
:;; Nitroglycerin may be administered to relax the uterus.
:;; Occasionally, placenta of the first infant separates before the 2nd
fetus is born. ·
 }~ If the separation f th
additional 1 ° e_ 1st placenta caused loosening of the
heart P acenta or if common placenta is involved, the fetal
;~ If all ~u;1-ds of the other fetus will register, "DISTRESS".
e ietuses are not vertex CS.
MAl~PREsENTATION
J. . Occipitoposterior position
c, fetal position is posterior rather than anterior
c, The _occ~put is directed diagonally and posteriorly rather than WP.
c, Dunng internal rotation the fetal head must rotate through an arc
of approximately 135.
c, occurs un android
o anthropoid
o contracted pelvis
> su.g gested dysfunctional labor such as:
Prolonged Active Phase
Arrested Descent
* FH sound heard best at lateral side of abdominal
* Arc of rotation is greater- prolonged labor.
* (+} pain in lower back
fetal head rotates against the sacrum
Sacral netve compression
* Management in Sacral
> back rub
\ > change of position
> heat/ cold compress
> lying on the side
> opposite the fetal back
> hands and lmees position
* voids approximately 92 hrs to keep the bladder
empty
* needs to glucose solution to replace glucose store
used for energy.
* uterine dysfunction result to maternal exhaustion.
* transverse arrest- fetal head arrest in transverse
position
*(-)rotation- persistent ocdpitoposterfor position.
* may be rotated with the use for birth, woman is at
risk for reproductive tract lacerations, hemorrhage and
infection in the post-partum period.

BREECH PRESENTATION
o 38th week of gestation1 fetal normally turns to cephalic
presentation.
o head widest dm.
o fund us- largest part of the uterus.
 CAl[TSES· G ta·
* Abn~ es ~onal age under 40 weeks.
rmally In fetus (anencephaly' hydrocephalus, meningocele)
* Hydramnous
Congenital anomaly of fetus .
*
: Space occupying mass in pelvis (fibroid, tumors, placenta previa)
Pendulous abdomen
* Multiple gestation

HIGH RISK
; Anoxia from a prolonged cord
Traumatic of spine or ann
J"" dysfunctional labor
>• Contraction of the fetal buttocks form cervical pressure often
causes meconium to be extruded into the amniotic fluid before
birth .
}• lead to meconium aspiration if the infant inhales amniotic fluid
AS~iESSMENT
~,. Leopold's Maneuver
~" Vaginal exam
,,- Ultra sound
,,- Sonography- confirms in breech birth, the same stage in vertex
birth.

BIRTH TECHNIQUE

As the breech spontaneously emerges from the birth canal, it is

striated and support by a sterile to held against the infant's inferior
surface.
Head is most hazardous
A loop of cord passes down a long side the head
Intracranial hemorrhage
2nd danger of breech birth
Tentoria tears

Causes gross motor and mental in capacity or lethal damage to the

fen.:.s
* Delivery suddenly - intracranial hemorrhage
* Delivery gradually - hypoxia
* Pressure·is applied to the occiput to the flex head fully
* may also delivered by aid of piper forceps to control flexion and
rate descent.

FRANK MANEUVER (Infants)

., Tends to keep his or her extend and at the level of the face for the
first 2 or 3 days of life.
/r -
FACE PREsENTATION
,L Asynclitism. fetal presenting at a different angle than expected.
E~ample: Face & brow presentation, face, chin or mentum- fhe
diameter that the fetus presents to the pelvis is often too large for
birth to proceed.
l Head that feels more prominent than normal
> no engagement on Leopold's maneuver .
1 When the ·head and back are both felt on the same side of the
uterus with leopold's maneuver.
·-1- Concave back ( extremely )
-1- Fit may be transmitted to the forward-thrust chest and heard on
side of the fetus, where feet and arms can be palpated.
l sonography
o confirmation
.l- occurs in :
," contracted pelvis
,/ placenta previa
,,, relax uterus of multipara
,,, prematurity
,r hydramnios
,r fetal malformation
,r chin is anterior
,,, Cesarean Birth

CHIN PRESENTATION
* fecal edema
* purple from ecchymosis, bruising
* lip edema- severe
* unable to suck for a day/ hero.
4- need gauge feeding
0
obtaining enough fluid until he/she can suck effectively
i. observed closely for patent airway.
l- assume that edema in transient
o . disappear.in few days with no after math
BR.OW PRESENTATION
i- rarest
l Occurs in : multipara, relax abdominal mm. obstructed labor CS-
to deliver safely.
l Brow presentation- leave the infant with extreme ecchymotic
bruising on face.
!.. upon seeing, this bruising over the same area as the anterior
fontanel or" soft spot"
 TRiLNSVERSE LIE
,, ·"- Occurs in • d
I- . . . pen ulous abdomens
.I- uterine_ masses ( fibroid tumors)
· congenital abnormaliti f
·'- hydramnois es o uterus
·'- hydrocephaI · f:
us m ant> other gross abnormalies that prevent the
h ead from engaging.
·'- prematurity
.I,. multiple gestation ( 2nd hun)
'- short Umbilical cord
·'- avoid of the uterus is found to be more horizontal than vertical
-1- abnormal presentation detected by:
-1- Leopold's maneuver
-1- sonogram- confirm
.I,. a mature fetus cannot be delivered vaginally from this
presentation. Often membranes rupture at the beginning of labor,
because there is no finn presenting part, the cord or an arm may
prolapse, or the shoulder obstructs the cervix.
·.I,. CS- necessary.

OVJ~RSIZED FETUS ( Macrosomia)

o weight more than 4000-4500 g (9-10 lbs}
o common with diabetic mother
o association with multiparity
o cause uterine dysfunction
o wide shoulder- cause fetal pelvic disposition and uterine rupture
from obstruction.
o CS- birth of choice
o pelvimetry- sonography
o used to compare the fetal size with the woman's pelvic capacity.
HIGH RISK
:..- cervical nerve palsy
;;.. diaphragmatic nerve injury
_.,,. fractured clavicle- because of shoulder dystocia
_.,. hemorrhage because of over distended, uterus may not contract as
readily

SHOULDER DYSTOCIA
A delivery problem that is increasing in incidence along with the
I' increasing average weight of infants.
J.. occurs at: 2 nd stage of labor
L Fetal head is born but the shoulder are too broad to enter and be
delivered through the pelvic outlet.
L Hazardous to mother= result in vaginal or cervical tears.

'',. , ...
 Hazardous to fetus- cord is compresses but the fetal bod~, ~d th e
bony pelvis(+)·result: fractures.clavicle? brachia! plexus mJury.
·,1
Most to occur in:
* diabetic
* multipara
* post date pregnancies
suspected earlier if the 2nd stage of labor is prolonged: .
if there is arrest of descent on when the head appears on the
perineum.

TURTLE SIGN
>• retracts instead of protruding with each contraction

MC ROBERT's MANEUVER
woman flex her thigh sharply on her abdomen. .
widens the pelvic outlet, and let the anterior shoulder deliver

· APPLYING Suprapubic Pressure

> keep the shoulder escape from beneath the symphysis pubis.

FETAL ANOMALIES
).. hydrocephalus
).. fluid filled ventricles
;.. anencephaly
;.. absence of cranium

PROBLEM WITH THE PASSAGE

c can cause dystocia due to contraction or narrowing of the

passageway or birth canal.
o can happen at the inlet, midpelvis, outlet
o narrowing cause CPD or disproportion between the size of the
normal fetal head and the pelvic diameter
o result: failure to progress

A. Inlet Contraction
,) Narrowing
• of the anteroposterior
. diameter to less than 11 cmor
maximum transverse diameter of 12cm or less.
,) may be due to ricketsia
. . inherited small pelvis
) pnm1grav1da: fetal head normally engage at 36-38 k f
pregnancy wee s o
·) general rule : " what goes in comes out" t

r
 c the head that
probably al beenga; e s or proves its
. fits into the pelvic brim will
the outlet. 50 a le to pass through the midpelvis and through

c, if engagement does not occur in primigravida

c, -fet3:1 abnormally(. larger than usually head)
c, pe~vi~ abnormally ( smaller than usual pelvis )
c, pnrmgravida should have pelvic measurement taken and recorded
before 24 weeks of pregnancy.
° CPD- fe_t';ls does not engagement but remains floating -
malpos1tion may occur.

B. Outlet Contraction
c, Narrowing of the transverse diameter at the outlet to less than 11
cm.
ci Distance between the ischial tuberosities.

C. 1'rlal Labor
ci if there is: adequate borderline
ci good fetal lie
.o good position
o monitor fetal heart sound and uterine contraction
o empty the bladder- void every 2hrs
o after ROM- assess FHR carefully
r o because if the fetal head is still high there is an increased danger
of prolapsed cord and anoxia.
o if: definite period ( 6- l 2hrs)
o adequate progress not documented
o CS-method of choice

D. lt.xtrenal Cephalic Version

turning of a fetus from a breech to a cephalic position before birth
0
tocolytic agent- may be administered to help the uterus relax.
()
gentle pressure is then exerted to rotate the fetus in forward
0
direction to cephalic lie.
gentle version- decreased the number of CS from breech
0
presentation
1ijli: I () CI: multiple pregnancy
() severe oligohydramnios
() Vaginal birth
() Nu chal cord
<)
Unexplained 3rd trimester bleeding
()
Rh(-) should receive an imrnunoglobulin in case minimal bleeding
!' occurs

I':_;;
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 PUJ~RPERAL COMPLICATION:
H~r.lORRHAGE- occurs on the fiIrSt ~2 hours post partum, 12-24 hours after
d e livery is the period when th
e second highest number of haemorrhages occurs.

Nursing management:
• Monitor vital sign
• Measure the amount of blood loss
• Guard the patient after 24 hours of delivery

The usual blood loss during delivery amounts to about 150- 200 cc. a
postpartum haemorrhage is 500 cc or more.

Sym.ptoms:
•
Excessive Vaginal Discharge
•
Paleness
•
Dizziness
•
Uncomfortable
Uterine Atony - the most important cause of postpartum haemorrhage. Due to
prolonged labor, the muscle are fatigue and fail to contract.

Predisposing factor:
• Grand multiparas - because uterine muscle have been stretched many
times and have lost their tone.
• Overdistention of the uterus from a multiple pregnancy
• Large baby
• Hydramnios
• Premature separation of the placenta- blood may have been forced into
the muscle fibers of the uterus rendering them incapable of contracting

Signs and symptoms

• Uterus is boggy and large
• Shock
• Pallor
• Weak rapid pulse
• Cold perspiration
• Air hunger}
• Restlessness
• AnXiety
• Drop in blood pressure

N urs~ manacement
• Massage the uterus until it become firmer and contracted in a few
minu tes
• Press down in the fundus in the direction of the birth canal to express
any clots.
• Monitor patien ts vital sign and massage the fundus
• Administer oxytocin
,, •
•
Start in infusion with pitocin
Catherization is done if patient has,distended bladder and is unable to
void
 •
.Put the patient m
. t-positio ·
Ret· • d n m case of shock.
,une placental- tiaaue-
As long
the
mo~t common cause of late postpartum bleeding
Fibers as any tissue:.. remains inside the uterus the muscle
cannot contract properly to occlude the blood vessels.
s·igns -u,id aymptoma
• Hemorrhage
• No contractions
• Hypotension
• Symptoms of shock

Treatment and nursing care

• Give ergotrate by mouth to help expel the retained placental fragments
• If bleeding is severe, IV fluids with pitocin are added.
• Inspect for the passing of any tissue or parts of the membranes.
• If bleeding continues despite the administration of o~ocin, a dilation
and curettage 0D4CD may be necessary.

LACERATIONS- tears in the cervix, vagina or perineum which occurs in

• Precipitate birth
• In primigravidas
• ·Birth of large infant
• With the use of lithotomy position and instruments.

Cenical Laceration. - usually found on the sides of the cervix near the branches of the
uterine artery.

Therapeutic Management:
• Repair of the cervical lacerations is difficult beeause bleeding is so
intense that it obstructs visualization of the area.
• Maintain an air of calm
• Reassure her about her baby's condition

vaginal laceration- occurs in the vagina

Easier to assess
Therapeutic Management:
• Pack the vagina to maintain pressure on the suture line.
• Indwelling catheter may be place.
• Packing that left in place too long can lead to stasis and infection similar
to toxic shock syndrome.
Peri~ ~ : : ~ e n the woman place in lithotomy position for birth

Therapeutic Mana~emeat:
• Sutured and treated as an episiotomy repair
• A diet high in fluid and a stool softener may be prescribed for the first
week after birth. ·
• A woman with 3 rd or 4 th degree laceration should not have an enema or
rectal suppository
r flll!(
IIEl!(ATOfdA o
- ~curs near or at th .
-contain sooec of bl d e Site of the episiotomy
·also knowu as a "Br~EDER•
s·
J.gns and SJ'lnptonia
t'
• The Uterus·18 fi
• B . · lt'tn and contracted
rtght red bleeding tin ·
• Patient may go mto . con
shock ues to trickle steadily from the vagma.
Treatnieiit lllld llllrsing care

• Ice JJenneum
the.glov_e or ice bag is covered with a sterile towel and applied directly to
• E,c~e for the Underlying cause of bleeding.
• Repair of the laceration or debridement of the hematoma follows.
• Administer
infection. IV fluids or blood transfusion and antibiotics to prevent

• If the. Patient is to be returned to the delivery room or operating rooJ?,

Oral fluids should be withheld since a general anaesthesia may be given.
• Continuously monitor the vital signs.
Sl.Jl3:1mrotuT1oxs
• Incomplete return of the uterus to its pre-pregnant size and shape.
• At a 4 or six week postparta:J. visit, the uterus is still present.
• It may result from a small retained placental fragment, a mild
endometntis, or an accompanying problem {myoma) that interfering the
contraction.
Management:
• Oral administration of ti'.lethergine 0.2 mg four tittles daily .
• If the uterus
biotic is tender to palpation suggesting endometritis,
prescribed. an oral-anti-
• A chronic loss of blood loss from involution will result in infection or
anemia and lack of energy.
PUERPERAL INFECTIONS

Postpartum infection of the birth canal.

When the oral
01 temperature taken four times daily reaches a level of at
least 100.4
suspected. on any of the first ten postpartum days, then this is

Causes:

• Resulttheofoutside.
from PBthogenic Or&filllsms being introduced into the genital tract
• Alteration in the virulence of the norma1 bacterial inhabitants of the
.vagina.
• Streptococcus- organism most often responsible
• Straphyloeoccus-- re•Pons!ble for the iocaI or su]lel'ficiaJ infections in the
vaginal or perinea! lacerations or incisions.
• Gonococci, e. coli,. c welchii
 Pr.....11-
~lSposing 'I:\
«-actors:

• Anemia
• EXhaustion
• Dehydration
• Prolonged labor .
• Frequent examinations during labour
Signs and symptoms
• Fever
• Large and tender uterus
• Severe and prolonged after birth pains
• Headache
• Insomnia
• Anorexia
• If breastfeeding, milk supply may be suppressed
• Lochia may be increased in amount, appear brownish, and may be
~,li I
1

\
associated with scanty, odorless lochia.
Treatment
• Isolation of the patient
• Place the patient in fowlers position
• Ergotate is given to promote the tone of the uterus
• Antimicrobial drugs are used to combat the infection
r
ENDOMETRITIS- An infection of the endometrium, the line of the uterus
-Bacteria gain access to the uterus through the vagina and enter the uterus at the time
of biith or during the postpartal period.

Assessment:
• Benign temperature elevation occurs usually manifested on the 3nL 4th
postpartal day.
• Increased WBC 20,000-30,000 cells/mm3
• Increase in oral temperature to more than 1OO.4°F(380C) for two
consecutive 24 hours periods.
• Accompanying in either chills, loss of appetite and general malaise.
• Uterus is not well contracted and painful to touch.
• Dark brown lochia w / foul odor.

Tli,erapeutic Management:
l~ij\ji I • Antibiotic such as Clindamycin
• ·Methergine - uterine contraction
I ••

• Sitting in fowler's position or walking encourages lochia drainage.

'.
' '

INFiWTION OF THE PERINEUM- A portal of exit for bacterial invasion in her

perir..eum from an epiaiotomy or a laceration repair,
AaseH.m ent:
• Paip.
• Heat
• Feeling of pressure
• Inflammation of the suture line
• Sloughed stitches
 Therapeutic Management:
• Inform ~uze maybe apply
• Systematic or topical antibiotic
• Analgesic to alleviate discomfort d
• th
Sitz ba or warm compresses may be ordered to haSten drainage an
cleanse the area
• Remind the woman to change perineal pad frequently.
• Be certain that woman wide front to back after bowel maveme~ other
• Do not place the infant on the bottom of the bed sheet of t e m ·
Where he or she could contact pathogenic bacteria.

PEF~TONITIS- Infection of the peritoneal cavity f puerperal

-The gravest complication of childbearing and major causes of deatb rom
infectio?. . · the fallopian tubes
-Infection spread through the lymphatic system or directly through
or uterine wall to the peritoneal cavity. .
-Ab~,cess may be form in the cul-de-sac.of Douglas.

Assessment:
• Rigid abdomen
• .Abdominal pain
• High fever
• Rapid pulse
• Vomiting

Therapeutic Management: 'ting and rest bowel.

• Requires insertion of nasogastric tube to prevent vomi .
• JV fluid or total parenteral nutrition
• Analgesic to relief pain
• Antibiotic

MASTITIS - In flammati·on of the breast ' do not usually develop until the 3 rd or 4 th week
after delivery.
Inflammation of the mammacy gland . . .
Infection localizes in one area of the breast w / collection of purulent material
w I c is could the breast abscess.

Sip and Symptoms: . . .

.• Breast becomes hard, red and painful
• Patient has chill, fever and a rise in pulse rate

STAJ?HYLOCOCCUS - The most common cause of mastitis

_ Most frequently gains entry- through cracks or fissures in the nipple.
Mode of T-rauamlHioa:
From the infant himself who may harbour the organism in his nose or throat
while the baby ts nursing, the staphylococcus gains entrance even though
the mother's nipples are intact.
Prevcmtioa
• Prep~ng the breast for breast-feeding is the excellent way to prevent
mast1t1s.
• Avoid nursing the baby too long
 • Cleansing and drying the breast well
• Use nipple cream

Treatment:
• Broad spectrum antibiotics or penicillin
• The mother must stop breast feeding and supportive n_iea~res, such as
restricting fluid, wearing a good supporting bra, applying ice P8;cks and
administrating analgesic, may be helpful while the breast are drymg up,
• If the breast abscess is present, heat may help to localize it
• The physician may prefer to aspirate the pus rather than resort to
incision or drainage
• When incision and drainage is done, the patient is pr«:Par~d for s~·rgery
and general anesthesia in the usual manner. Packing 1s left m the
incision until purulent material is completely evacuated.

THC>MBOPHLEBITIS
Formation of clots or thrombi in the pelvis or lower extremities due to the
slowdown in the circulation.
Common site is the thigh or calf

Symptoms:
• Chill and fever
• Pain in the leg and one leg may feel hot
• Swelling of the leg usually the left
• Red streaks or locally inflamed are as
• The skin may be so tense that it appears white and shiny- milk leg

Treatment:
• Anticoagulants~ Coumadin or heparin to thin- the b!Qod
• Observe for possible effect of anticoagulant
• Prothombin or clotting times are than to safely control the amount of
anticoagulant given
• Elevate the affected leg on pillows to prevent pooling of blood and a bed
cradle may be used to relieve the pressure of bed clotting.
• Apply ice bags intermittently
• Use a heat lamp under the cradle
• Do not massage the leg
• Bed rest
• Ambulate cautiously to prevent emboli
• Elastic stocking or ace bandages to speed the venous circulation back to
the heart and discourage formation of clots.

An individual's or a couple's choice of contraceptive method should be

~de carefully, with complete lmowledge about -the advantages,
disadvantages, an side effects.
>>Lnportant things to consider include the following:

4. PERSONAL VALUES
J.. ABILITY TO USE METHOD
J- HOW THE METHOD WILL AFFECT SEXUAL ENJOYMENT
-4-- FINANCIAL FACTORS