Problems with the POWER  Use of drugs like magnesium sulfate

(Uterine Inversion, (given to halt preterm labor)

Uterine Rupture, Amniotic Fluid Embolism)  Placenta accreta (the placenta has
grown too deeply into the uterine
Inversion of the Uterus wall)

Uterine inversion refers to the uterus turning  CAUSES

inside out with either birth of the fetus or The cause of uterine inversion is the
delivery of the placenta. It is a rare incomplete separation of the placenta from
phenomenon, occurring in about 1 in 20,000 the uterine wall. As a result, the placenta
births(Poggi, 2007). It may occur if traction is pulls the uterus with it when it emerges from
applied to the umbilical cord to remove the the birth canal. The uterus is also more likely
placenta or if pressure is applied to the uterine to invert if it’s overly relaxed, or if the
fundus when the uterus is not contracted. umbilical cord is pulled too hard during
delivery.
 FOUR DEGREES OF UTERINE INVERSION
 1st degree (also called incomplete) – The The most common cause is the
fundus is within the endometrial cavity mismanagement of 3rd stage of labor, such
 2nd degree (also called complete) – The as:
fundus protrudes through the cervical os  Fundal pressure
 3rd degree (also called prolapsed) – The  Excess cord traction during the 3rd stage
fundus protrudes to or beyond the of labor
introitus Other natural causes can be:
 4th degree (also called total) – Both the  Uterine weakness, congenital or not
uterus and vagina are inverted  Precipitate delivery
 Short umbilical cord
TIME OF OCCURRENCE:
 Acute – Within 24 hours of delivery  SIGNS AND SYMPTOMS
 Subacute – More than 24 hours but less
than four weeks postpartum  Vaginal bleeding that may be mild or
 Chronic – ≥1 month postpartum severe.
 Vaginal bleeding that may be mild or
RISK FACTOR severe.
 Macrosomia, or a very large baby  Feeling dizzy, light-headed, weak,
 A uterine inversion during a previous confused, tired or drowsy.
delivery  Rapid heartbeat and shallow breathing.
 An extended labor of more than 24 hours  Cold and clammy skin.
 Several previous vaginal deliveries  Muscle cramps.
 Severe preeclampsia  Thirst
  give uterine relaxants such as;
 COMPLICATIONS  Nitroglycerin (glyceryl trinitrate)
Complications associated with uterine inversion  Terbutaline
can be due to the condition (primary) or its  Inhalational anesthetic agents,
management (secondary). such as sevoflurane, desflurane,
and isoflurane.
The condition's complications primarily revolve Preferred secondary interventions — If the
around hemorrhage and its associated risks, above measures to replace the uterus fail,
including multi-organ damage, shock, Sheehan then the patient should be taken promptly to
syndrome, hysterectomy). Without treatment, the operating room to attempt surgical
the condition can result in significant, persistent correction of the inversion.
blood loss and tissue necrosis. Complications  Huntington procedure
accompanying treatment relate to general  Haultain procedure
anesthesia and blood transfusions.
 NURSING MANAGEMENT
 LABORATORY TEST/ DIAGNOSIS Promptly identify and assist with the
 Severe atony of the uterus resolution of uterine inversion.
 Uterovaginal prolapse  Recognize signs of impending
 Fibroid polyp inversion, and immediately notify
 Neurogenic collapse the physician and call for assistance.
 Postpartum collapse  Immediate manual replacement of
 Retained placenta without inversion the uterus at the time of inversion
 Coagulopathy will prevent cervical entrapment of
the uterus
 MEDICAL MANAGEMENT  Take steps in order to prevent or
Initial interventions — Interventions for the limit hypovolemic shock.
management of acute uterine inversion should  Insert a large gauge
begin promptly and simultaneously. A delay in intravenous catheter for fluid
diagnosis or in prompt initiation of treatment replacement.
increases the risk of maternal morbidity and  Measure and record
mortality. maternal vital signs every 5
 Discontinue uterotonic drugs to 15 minutes to establish a
 Call for immediate assistance baseline and document
 Establish adequate intravenous access and change.
aggressive fluid/blood product  Open an established
resuscitation. intravenous line for optimal
 Do not remove the placenta fluid replacement.
 Immediately attempt to manually replace
the inverted uterus
  A fibrinogen level should be  RISK FACTORS
drawn to determine the risk for  History of uterine surgery.
formation of a blood clot.  Previous uterine rupture.
 Prepare for anesthesia as  Uterine trauma.
needed.  Congenital uterine anomalies such as
 Prepare to administer CPR, if septate uterus or bicornuate uterus.
required.  Your uterus is stretched, such as when
 If manual reinversion is not successful, you’re pregnant with multiples or
prepare the client and family for have too much amniotic fluid.
possible general anesthesia and  Your baby is breech and requires manual
surgery. turning before delivery (external
cephalic version).
 PROGNOSIS  Prolonged labor
Acute cases can lead to hemorrhagic shock, but
prompt management usually mitigates long-term  CAUSES
sequelae. It is unknown whether the condition During labor, pressure builds as the baby
affects future pregnancy prospects, but case moves through the mother’s birth canal. This
reports exist of uncomplicated pregnancies. pressure can cause the mother’s uterus to
tear. Often, it tears along the site of a
Uterine Rupture previous cesarean delivery scar. When a
Rupture of the uterus during labor, although uterine rupture occurs, the uterus’s contents
rare, is always a possibility (Scearce & Uzelac, including the baby may spill into the mother’s
2007). It is always serious, because it accounts for abdomen.
as many is a serious complication where your
uterus tears or breaks open. It’s most common in  SIGNS/ SYMPTOMS
people who’ve had a previous C-section delivery  excessive vaginal bleeding
and then try for a vaginal delivery, or vaginal birth  sudden pain between contractions
after cesarean (VBAC).  contractions that become slower or less
intense
A uterine rupture can be complete or incomplete:  abnormal abdominal pain or soreness
 recession of the baby’s head into the
 Complete uterine rupture: The tear goes birth canal
through all three layers of your uterine  bulging under the pubic bone
wall. This is very serious and requires  sudden pain at the site of a previous
immediate treatment. uterine scar
 Incomplete uterine rupture: The tear  loss of uterine muscle tone
doesn’t go through all three layers of your  rapid heart rate, low blood pressure, and
uterine wall. shock in the mother
 abnormal heart rate in the baby
  failure of labor to progress naturally the repeat rupture rate may be higher when
the initial rupture occurs in the uterine
 COMPLICATIONS fundus. Due to the maternal and fetal risk of
Complications for the fetus: repeat rupture, most obstetricians
 Suffocation. recommend repeat cesarean delivery
 Brain damage due to lack of oxygen. between 36 and 37 weeks—before labor is
allowed to begin.
Complications for the pregnant woman:
 Excessive blood loss (hemorrhage). Amniotic Fluid Embolism
 Losing the ability to get pregnant due to Amniotic fluid embolism occurs when
hysterectomy. amniotic fluid is forced into an open maternal
 Stillbirth. uterine blood sinus through some defect in
the membranes or after membrane rupture
 LABORATORY TEST/ DIAGNOSIS or partial premature separation of the
 laparotomy placenta (Schoening, 2007). Previously, it was
thought that particles such as meconium or
 MEDICAL MANAGEMENT shed fetal skin cells in the amniotic fluid
 Cesarean section entered the maternal circulation and reached
the lungs as small emboli.
 NURSING MANAGEMENT
 Monitor for the possibility of uterine  RISK FACTORS
rupture.  Advanced maternal age (being older
 Assist with rapid intervention. than 35 during pregnancy).
 Prevent and manage complications.  Expecting multiples (twins, triplets or
 Provide physical and emotional support. more).
 Fetal distress (changes to the fetal heart
 PROGNOSIS rate).
With quick surgical intervention and  Issues with the placenta like placental
resuscitation, most women survive a uterine abruption.
rupture. The maternal mortality rate associated  Preeclampsia or eclampsia.
with the rupture of an unscarred uterus is higher  Polyhydramnios (too much amniotic
(10%) than the mortality rate associated with the fluid).
rupture of a scarred uterus (0.1%). The neonatal  Cervical tears.
mortality rate after uterine rupture is 6% to 25%.  Labor induction medications or
The risk of recurrent rupture after the uterine procedures.
repair is not well described. This is because the  Having a C-section delivery.
incidence of rupture is low, and many women  Operative assisted deliveries (forceps
with a significant uterine rupture require a delivery or vacuum extraction).
hysterectomy. There is low-level evidence that
 CAUSES  Cephalad spread of spinal anesthetic
There isn’t a known cause of AFE. The placenta
breaking down during labor or delivery may  MEDICAL MNANGEMENT
trigger an immune response in some people,  Electrocardiogram (EKG) to look at your
leading to AFE. It’s not clear why this happens in heart's rhythm.
some people and not others.  Pulse oximeter to check blood oxygen
levels.
 SIGNS AND SYMPTOMS  Chest X-ray to look for fluid around your
 Shortness of breath or difficulty breathing. heart.
 Sudden drop in blood pressure.  Echocardiogram to look at how your
 Pulmonary edema (fluid in your lungs). heart functions.
 Abnormal heart rate.
 Bleeding from your uterus, C-section incision  NURSING MANAGEMENT
or IV (intravenous) sites.  Give immediate and vigorous
 Fetal distress. treatment.
 Agitation, confusion or sudden anxiety.  Give oxygen by face mask.
 Chills.  Maintain normal blood volume through
administration of plasma and
 COMPLICATIONS intravenous fluids.
 Heart and lung failure.  Prevent development of disseminated
 Losing consciousness. intravascular coagulation (DIC).
 Seizures. Serious complications can occur.
 Excessive bleeding.  Administer whole blood and fibrinogen.
 Disseminated intravascular coagulation  Monitor the patient’s vital signs.
(DIC), a type of blood clotting issue.  Deliver the fetus as soon as possible.
 Stroke.
 Cardiac arrest (when your heart stops  PROGNOSIS
beating).  A woman’s prognosis depends on the
 Brain damage. size of the embolism, the speed with
 Death. which the emergency condition was
detected, and the skill and speed of
 LABORATORY TEST/DIAGNOSIS emergency interventions. Even if the
 Pulmonary embolism (PE) woman survives the initial insult, the risk
 Peripartum cardiomyopathy for disseminated intravascular
 Septic shock coagulation (DIC) is high, further
 Myocardial infarction compounding her condition. In this
 Venous air embolism event, she will need continued
 Eclampsia management that includes endotracheal
 Anaphylaxis intubation to maintain pulmonary
 function and therapy with fibrinogen to
counteract DIC. Most likely, she will be
transferred to an ICU.
 The prognosis for the fetus is guarded,
because reduced placental perfusion results
from the severe drop in maternal blood
pressure. Labor often begins or the fetus is
born immediately by cesarean birth.