Complications on

o Uterine contractions are the basic force

moving the fetus through the birth canal.

Labor and Delivery o They occur because of the interplay of the

contractile enzyme adenosine triphosphate
DYSTOCIA and the influence of major electrolytes such
as calcium, sodium, and potassium, specific
o A difficult labor that can arise from any of contractile proteins (actin and myosin),
the four main components of the labor epinephrine and norepinephrine, oxytocin (a
process: posterior pituitary hormone), estrogen,
a. the power, or the force that propels progesterone, and prostaglandins.
the fetus (uterine contractions)
b. passenger (the fetus) A. Hypotonic Contractions
c. the passageway (the birth canal), or
d. the psyche (the woman’s and o The number of contractions is unusually low
family’s perception of the event). or infrequent (not more two or three occurring
in a 10-minute period).
COMPLICATIONS WITH THE POWER o The resting tone of the uterus remains less
than 10 mm Hg, and the strength of
(THE FORCE OF LABOR) contractions does not rise above 25 mm Hg .
o These are most apt to occur during the active
INERTIA
phase of labor.
o a time-honored term to denote that
sluggishness of contractions or the force of CAUSES
labor that has occurred.
o administration of analgesia, especially if the
o A more current term used is dysfunctional
cervix is not dilatated to 3 to 4 cm
labor
o bowel or bladder distention
TWO GENERAL CLASSIFICATION: o uterus that is overstretched by a multiple
gestation, a larger-than-usual single fetus,
Primary: occurring at the onset of labor hydramnios, or in a uterus that is lax from
Secondary: occurring later in labor grand multiparity.

Associated risks: maternal postpartal infection, MANAGEMENT

hemorrhage, and high infant mortality
o In the first hour after birth following a labor of
COMMON CAUSES OF DYSFUNCTIONAL hypotonic contractions, palpate the uterus
LABOR o Assess lochia every 15 minutes to ensure that
postpartal contractions are not also hypotonic
o Inappropriate use of analgesia (excessive or and therefore inadequate to halt bleeding.
too early administration)
o Pelvic bone contraction B. Hypertonic Contractions
o Poor fetal position (posterior rather than
anterior position) o are marked by an increase in resting tone to
o Extension rather than flexion of the fetal head more than 15 mm Hg (see Fig. 23.1C).
o Overdistention of the uterus, as with multiple o tend to occur frequently and are most
pregnancy, hydramnios, or an excessively commonly seen in the latent phase of labor
over- sized fetus o more painful than usual, because the
o Cervical rigidity (unripe) myometrium becomes tender from constant
o Presence of a full rectum or urinary bladder lack of relaxation and the anoxia of uterine
o Woman becoming exhausted from labor cells that results.
o Primigravida status
CAUSES:
INEFFECTIVE UTERINE FORCE o muscle fibers of the myometrium do not
repolarize or relax after a contraction.
 o Help the uterus to rest
 Danger of hypertonic contractions: o Provide adequate fluid for hydration
o Pain relief with a drug such as morphine
o lack of relaxation between contractions may sulfate.
not allow optimal uterine artery filling; this o Change the linen and the woman’s gown
could lead to fetal anoxia early in the latent o Darken room lights
phase of labor. o Decrease noise and stimulation
o If labor is not effective and does not begin to
MANAGEMENT: progress: cesarean birth or amniotomy
(artificial rupture of membranes) and oxytocin
o Uterine and fetal external monitor should be infusion
applied for at least 15 minutes to ensure that
the resting phase of the contractions is B. Protracted Active Phase
adequate and that the fetal pattern is not
showing late deceleration. o is usually associated with cephalopelvic
o Cesarean birth may be necessary if disproportion (CPD) or fetal malposition
deceleration in the fetal heart rate (FHR) or an o This phase is prolonged if cervical dilatation
abnormally long first stage of labor or lack of does not occur at a rate of at least 1.2 cm/hr in
progress with pushing (“second-stage arrest”) a nullipara or 1.5 cm/hr in a multipara
occurs. o This phase is also prolonged if the active
phase lasts longer than 12 hours in a
C. Uncoordinated Contractions primigravida or 6 hours in a multigravida

o Normally, all contractions are initiated at one MANAGEMENT

pacemaker point high in the uterus.
o With uncoordinated contractions, more than o If the cause of the delay in dilatation is fetal
one pacemaker may be initiating contractions, malposition or CPD, cesarean birth may be
or receptor points in the myometrium may be necessary.
acting independently of the pacemaker.
C. Prolonged Deceleration Phase
MANAGEMENT o A deceleration phase has become prolonged
o Apply a fetal and a uterine external monitor when it extends beyond 3 hours in a nullipara
o Assess the rate, pattern, resting tone, and fetal or 1 hour in a multipara.
response to contractions for at least 15 o Prolonged deceleration phase most often
minutes (or longer if necessary in early labor) results from abnormal fetal head position.
reveals the abnormal pattern.
o Oxytocin administration may be helpful in MANAGEMENT
uncoordinated labor to stimulate a more o A cesarean birth is frequently required.
effective and consistent pattern of contractions
with a better, lower resting tone. D. Secondary Arrest of Dilatation
Dysfunction at the FIRST Stage of Labor o Occurs if there is no progress in cervical
dilatation for longer than 2 hours.
A. Prolonged Latent Phase
o A latent phase that is longer than 20 hours in a MANAGEMENT
nullipara or 14 hours in a multipara. o cesarean birth maybe necessary.
CAUSES:
Dysfunction at the SECOND Stage of Labor
o if the cervix is not “ripe” at the beginning of
A. Prolonged Descent
labor and time must be spent getting truly
ready for labor. o occurs if the rate of descent is less than 1.0
o Excessive use of an analgesic early in labor. cm/hr in a nullipara or 2.0 cm/hr in a
o Management multipara.
o It can be suspected if the second stage lasts o uncoordinated contractions, obstetric
over 3 hours in a multipara manipulation or by the administration of
oxytocin

MANAGEMENT
CAUSES
o Administration of IV morphine sulfate
o CPD and poor fetal presentation o Inhalation of amyl nitrite may relieve a
retraction ring.
MANAGEMENT o A tocolytic can also be administered to halt
o Rest and fluid intake contractions.
o If the membranes have not ruptured, rupturing o Manual removal of the placenta under general
them at this point may be helpful. anesthesia may be required if the retraction
o Intravenous (IV) oxytocin may be used to ring does not allow the placenta to be
induce the uterus to contract effectively delivered.
o Semi-Fowler’s position, squatting, kneeling,
or more effective pushing may speed descent. COMPLICATIONS
B. Arrest of Descent o uterine rupture
o Neurologic damage to the fetus
o results when no descent has occurred for 1 o In the placental stage, massive maternal
hour in a multipara or 2 hours in a nullipara. hemorrhage because the placenta is loosened
o when expected descent of the fetus does not but then cannot deliver, preventing the uterus
begin or engagement or movement beyond 0 from contracting.
station has not occurred.
PRECIPITATE LABOR
CAUSE: CPD.
o occurs when uterine contractions are so strong
MANAGEMENT that a woman gives birth with only a few,
o Cesarean birth usually is necessary. rapidly occurring contractions.
o If there is no contraindication to vaginal birth, o It is often defined as a labor that is completed
oxytocin may be used to assist labor. in fewer than 3 hours.
o Precipitate dilatation is cervical dilatation that
CONTRACTION RING occurs at a rate of 5 cm or more per hour in a
primipara or 10 cm or more per hour in a
o It is a hard band that forms across the multipara.
uterus at the junction of the upper and lower
uterine segments and interferes with fetal AS PREDICTED FROM LABOR GRAPH
descent.
o The most frequent type seen is termed o during the active phase of dilatation, the rate is
a pathologic retraction ring (Bandl’s greater than 5 cm/hr (1 cm every 12 minutes)
ring). in a nullipara or 10 cm/hr (1 cm every 6
o The ring usually appears during the second minutes) in a multipara.
stage of labor and can be palpated as a
horizontal indentation across the abdomen CAUSES
o It is a warning sign that severe dysfunctional o grand multiparity
labor is occurring as it is formed by excessive o after induction of labor by oxytocin or
retraction of the upper uterine segment amniotomy.
o Contraction rings often can be identified by
ultrasound. COMPLICATIONS
CAUSES o Hemorrhage: premature separation of the
placenta, placing the woman at risk for
hemorrhage.
o Fetal subdural hemorrhage
o lacerations of the birth canal from the forceful Dosage: Initially 1 to 2 mU/min by intravenous
birth. (IV) infusion, increased at a rate no more than 1 to
2 U/min at 15- to 30-minute intervals until a
INDUCTION AND AUGMENTATION OF contraction pattern similar to normal labor is
LABOR achieved
Induction of labor Possible Adverse Effects: Nausea, vomiting,
o labor is started artificially. cardiac arrhythmias, uterine hypertonicity, tetanic
o The primary reasons for inducing labor contractions, uterine rupture (with excessive
include the presence of pre- eclampsia; dosages), severe water intoxication, and fetal
eclampsia; severe hypertension; diabetes; Rh bradycardia.
sensitization; prolonged rupture of the NURSING CONSIDERATIONS
membranes; intrauterine growth restriction;
and postmaturity (a pregnancy lasting beyond o Always administered intravenously, so that, if
42 weeks)—all situations that increase the hyperstimulation should occur, it can be
risk for a fetus to remain in utero. quickly discontinued.
o Prepare IV solution by adding 1 mL (10 IU) to
1000 mL of designated intravenous fluid
Augmentation of labor (resulting solution contains 10 mU/mL).
o An alternative dilution method is to add 15 IU
o refers to assisting labor that has started
of oxytocin to 250 mL of an IV solution; this
spontaneously but is not effective.
yields a concentration of 60 mU/1 mL.
o Use an infusion pump to ensure accurate
PURPOSE: to make uterine contractions stronger
control of infusion rate.
if the contractions are hypotonic or too weak or
o Infusions are usually begun at a rate of 0.5 to 1
infrequent to be effective.
mU/min.
CAUTION: women with a multiple gestation, o If there is no response, the infusion is
hydramnios, grand parity, maternal age older gradually increased every 15 to 60 minutes by
than 40 years, or previous uterine scars. small increments of 1 to 2 mU/min until
contractions begin.
RATIONALE: possibility of uterine rupture
COMMON SIDE EFFECTS: extreme
Before induction of labor is begun, the following
hypotension, decreased urine flow, headache and
conditions should be present:
vomiting.
o The fetus is in a longitudinal lie.
o To ensure safe induction, take the woman’s
o The cervix is ripe, or ready for birth.
pulse and blood pressure every 15 minutes.
o A presenting part is engaged. o Monitor uterine contractions and FHR
o There is no CPD. conscientiously.
o The fetus is estimated to be mature by date, o Monitor uterine contractions and FHR
demonstrated by a lecithin– sphingomyelin conscientiously.
ratio or ultrasound biparietal diameter to rule o Contractions should occur no more often than
out preterm birth. every 2 minutes, should not be stronger than
50 mm Hg pressure, and should last no longer
Induction of Labor by Oxytocin (REVIEW) than 70 seconds.
o initiates contractions in a uterus at pregnancy. o If contractions become more frequent or
longer in duration than these safe limits, or if
Classification: Oxytocin is a synthetic form of the signs of fetal distress occur, stop the IV
naturally occurring posterior pituitary hormone. infusion and seek help immediately.
o Monitor frequency, duration, and strength of
Action: Used to initiate uterine contractions in a contractions.
term pregnancy o Assess maternal pulse and blood pressure, and
watch for possible hypertension. If
 hypertension occurs, discontinue drug and o Never attempt to remove the placenta if it is
notify physician. still attached
o Continuously monitor fetal heart rate for signs o Don’t Administer an oxytocic drug : only
of fetal distress. compounds the inversion or makes the uterus
o Anticipate the need for oxygen administration. more tense and difficult to replace.
o Excessive stimulation of the uterus by o An IV fluid line needs to be started and use a
oxytocin may lead to tonic uterine large-gauge needle
contractions with fetal death or rupture o Administer oxygen by mask, and assess vital
of the uterus. signs.
o If stopping the oxytocin infusion does not stop o Be prepared to perform cardiopulmonary
the hyperstimulation, terbutaline sulfate resuscitation (CPR)
(Brethine) or magnesium sulfate may be o The woman will immediately be given
prescribed to decrease myometrial activity. general anesthesia or possibly
o Keep an accurate intake and output record, nitroglycerin or a tocolytic drug
and test and record urine specific gravity intravenously to relax the uterus.
throughout oxytocin administration to detect o The physician or nurse-midwife then replaces
fluid retention. the fundus manually.
o Limit the amount of IV fluid being given to o She needs to be informed that cesarean birth
150 mL/hr by ensuring that the main IV fluid will probably be necessary in any future
line is infusing at a rate not greater than 2.5 pregnancy, to prevent the possibility of repeat
mL/min. inversion.

UTERINE INVERSION
Amniotic Fluid Embolism
o refers to the uterus turning inside out with
either birth of the fetus or delivery of the o occurs when amniotic fluid is forced into an
placenta. open maternal uterine blood sinus through
some defect in the membranes or after
CAUSES membrane rupture or partial premature
separation of the placenta
o if traction is applied to the umbilical cord to o This condition may occur during labor or in
remove the placenta or if pressure is applied the postpartal period.
to the uterine fundus when the uterus is not o The incidence is about 1 in 20,000 births;
contracted. o It is not preventable because it cannot be
o if the placenta is attached at the fundus so that predicted
during birth, the passage of the fetus pulls the
fundus down. CAUSE: humoral or anaphylactoid response

CLINICAL MANIFESTATIONS RISK FACTORS: oxytocin administration,

abruptio placentae, and hydramnios.
o a large amount of blood suddenly gushes from
the vagina.
o The fundus is not palpable in the abdomen.
CLINICAL MANIFESTATIONS
Signs of blood loss: hypotension, dizziness, o sits up suddenly and grasps her chest because
paleness, or diaphoresis. of sharp pain
o inability to breathe
Because the uterus is not contracted in this
o pallor
position, bleeding continues, and exsanguination
o typical bluish gray skin
could occur within a period as short as 10
minutes.
MANAGEMENT
MANAGEMENT
o Oxygen administration by face mask or
o Never attempt to replace an inversion cannula.
o Within minutes, she will need CPR.
 o is a term used to describe a pregnancy with
PROBLEMS WITH PASSENGER more than one fetus.
o It includes twins, triplets, quadruplets, or
Prolapse Of The Umbilical Cord
more.
o A loop of the umbilical cord slips down in o The most common type of multiple-gestation
front of the presenting fetal part pregnancy is a twin pregnancy.
o It tends to occur most often with: o Twins may be born by cesarean birth to
o Premature rupture of membranes decrease the risk that the second fetus will
o Fetal presentation other than cephalic experience anoxia
o Placenta previa
o Intrauterine tumors preventing the presenting COMPLICATIONS/RISKS:
part from engaging o Anemia and pregnancy-induced hypertension
o A small fetus o To detect these, be certain to assess the
o Cephalopelvic disproportion preventing firm woman’s hematocrit level and blood pressure
engagement closely during labor or while waiting for
o Hydramnios cesarean surgery.
o Multiple gestation o Risk for cord prolapse after rupture of the
membranes
o Abnormal fetal presentation may occur.
o Uterine dysfunction from a long labor, an
ASSESSMENT overstretched uterus, unusual presentation,
o the cord may be felt as the presenting part on and premature separation of the placenta after
the birth of the first child.
an initial vaginal examination during labor.
o A variable deceleration FHR pattern suddenly
MANAGEMENT
becomes apparent.
o The cord may be visible at the vulva. o If a woman with a multiple gestation will be
o It may also be identified in this position on an giving birth vaginally, she is usually
ultrasound. instructed to come to the hospital early in
labor.
MANAGEMENT o Urge the woman to spend the early hours of
labor engaged in an activity such as playing
o Assess fetal heart sounds immediately after
cards or reading, to make the time pass more
rupture of the membranes whether this occurs quickly.
spontaneously or by amniotomy. o During labor, support the woman’s breathing
o Relieving pressure on the cord, thereby
exercises to minimize the need for analgesia
relieving cord compression and the resulting or anesthesia;
fetal anoxia. o Monitor each FHR by a separate fetal monitor
o Placing a gloved hand in the vagina and
during labor.
manually elevating the fetal head off the cord, o After the first infant is born, both ends of the
o Place the woman in a knee–chest or
baby’s cord are tied or clamped permanently,
Trendelenburg position, rather than with cord clamps, which could slip.
o Administer oxygen at 10 L/min by face mask o Oxytocin usually is not be given, to avoid
o A tocolytic agent may be prescribed to reduce compromising the circulation of the infants
uterine activity and pressure on the fetus. not yet born.
o Do not attempt to push any exposed cord back o Assess the woman carefully in the immediate
into the vagina. This may add to the postpartal period, because the uterus that has
compression by causing knotting or kinking. been overly distended owing to the multiple
o Instead, cover any exposed portion with a gestation may have more difficulty contracting
sterile saline compress to prevent drying. than usual, placing her at risk for hemorrhage
from uterine atony (lacking normal tone).
Multiple Gestation o The risk for uterine infection increases if labor
or birth was prolonged.
o The infants need careful assessment to o Early rupture of the membranes because of the
determine their true gestational age poor fit of the presenting part

Occipitoposterior Position ASSESSMENT

o The fetal position is posterior rather than o Fetal heart sounds usually are heard high in
anterior. That is, the occiput is directed the abdomen.
diagonally and posteriorly, either to the right o Leopold’s maneuvers and a vaginal
(ROP) or to the left (LOP). examination usually reveal the presentation.
o Posterior positions tend to occur in women o If the presentation is unclear, ultrasound
with android, anthropoid, or contracted pelvis. clearly confirms a breech presentation.
o A posterior position is suggested by a
dysfunctional labor pattern such as a CAUSES OF BREECH PRESENTATION
prolonged active phase, arrested descent, or
fetal heart sounds heard best at the lateral o Gestational age less than 40 weeks
sides of the abdomen. o Abnormality in a fetus, such as anencephaly,
hydrocephalus, or meningocele
MANAGEMENT o Hydramnios
o Congenital anomaly of the uterus that traps the
o Because the fetal head rotates against the fetus in a breech position, s
sacrum, a woman may experience pressure o Any space-occupying mass in the pelvis, such
and pain in her lower back owing to sacral as a fibroid tumor of the uterus or a placenta
nerve compression. These sensations may be previa,
so intense that she asks for medication for o Multiple gestation.
relief, not for her contractions but for the o Unknown factors
intense back pressure and pain.
o Applying counterpressure on the sacrum by a
back rub may be helpful in relieving a portion MANAGEMENT
of the pain
o Applying heat or cold, whichever feels best, o Always monitor FHR and uterine contractions
also may help. continuously, if possible, during this time.
o Lying on the side opposite the fetal back or This allows early detection of fetal distress
maintaining a hands-and-knees position may from a complication such as prolapsed cord
help the fetus rotate and allows for prompt intervention.
o During a long labor of this type, be certain a
woman voids approximately every 2 hours to Face Presentation
keep her bladder empty, because a full bladder
o A fetal head presenting at a different angle
could further impede descent of the fetus.
o During a long labor, she may need an an oral than expected is termed asynclitism.
o In a Face (chin, or mentum) presentation, the
sports drink or IV glucose solution to replace
glucose stores used for energy. head diameter the fetus which presents to the
pelvis is often too large for birth to proceed.
Breech Presentation o When a face presentation is suspected, an
ultrasound is done to confirm it;
Types of breech presentation: complete, frank, o Effects on babies: facial edema and lip edema,
and footling may be purple from ecchymotic bruising.
Breech presentation is hazardous to a fetus MANAGEMENT AFTER BIRTH
because there is a higher risk of:
o Observe the infant closely for a patent airway.
o Anoxia from a prolapsed cord o In some infants, lip edema is so severe that
o Traumatic injury to the after coming head they are unable to suck for a day or two.
(possibility of intracranial hemorrhage or Gavage feedings may be necessary
anoxia) o They may be transferred to a NICU for 24
o Fracture of the spine or arm hours.
o Dysfunctional labor
o Reassure the parents that the edema is o Size may become a problem in a fetus who
transient and will disappear in a few days, weighs more than 4000 to 4500 g
with no aftermath. (approximately 9 to 10 lb).
o are most frequently born to women with
Brow Presentation diabetes or develop gestational diabetes
o Also associated with multiparity
o A brow presentation is the rarest of the
presentations. RISKS
o It occurs in a multipara or a woman with
relaxed abdominal muscles. o uterine dysfunction during labor or at birth
o It almost invariably results in obstructed labor, because of overstretching of the fibers of the
because the head becomes jammed in the myometrium.
brim of the pelvis as the occipitomental o fetal pelvic disproportion or even uterine
diameter presents. rupture from obstruction/ The wide shoulders
o EFFECTS ON THE BABY: extreme of the baby
ecchymotic bruising on the face, bruisng over o higher- than-normal risk of cervical nerve
the same area as the anterior fontanelle, or palsy, diaphragmatic nerve injury, or
“soft spot,” fractured clavicle because of shoulder
o Unless the presentation spontaneously dystocia.
corrects, cesarean birth will be necessary to o woman has an increased risk of hemorrhage,
birth the infant safely. because the overdistended uterus may not
contract as readily as usual.
Transverse Lie o uterine dysfunction during labor or at birth
because of overstretching of the fibers of the
o the ovoid of the uterus is found to be more
myometrium.
horizontal than vertical. o fetal pelvic disproportion or even uterine
o The abnormal presentation can be confirmed
rupture from obstruction/ The wide shoulders
by Leopold’s maneuvers. of the baby
o An ultrasound may be taken to further confirm
the abnormal lie and to provide information
on pelvic size.
MANAGEMENT
CAUSES o If the infant is so oversized that he or she
o women with uterine fibroid tumors that cannot be born vaginally, cesarean birth
obstruct the lower uterine segment, with becomes the birth method of choice.
contraction of the pelvic brim, with congenital
abnormalities of the uterus, or with Shoulder Dystocia
hydramnios, in infants with hydrocephalus or o The problem occurs at the second stage of
another abnormality that prevents the head labor, when the fetal head is born but the
from engaging. shoulders are too broad to enter and be born
o It may also occur in prematurity if the infant, through the pelvic outlet.
in multiple gestation (particularly in a second
twin), or if there is a short umbilical cord. RISKS:
MANAGEMENT o it can result in vaginal or cervical tears.
o the cord can be compressed between the fetal
o A mature fetus cannot be delivered vaginally
body and the bony pelvis.
from this presentation. o The force of birth can result in a fractured
o Cesarean birth is necessary.
clavicle or a brachial plexus injury for the
fetus.
Oversized Fetus (Macrosomia)
CAUSES
o women with diabetes, in multiparas, and in o The normal placenta weighs approximately
post-date pregnancies. 500 g and is 15 to 20 cm in diameter and 1.5
to 3.0 cm thick.
ASSESSMENT o Its weight is approximately one sixth that of
the fetus.
o The condition may be suspected earlier if the o A placenta may be unusually enlarged in
second stage of labor is prolonged, if there is women with diabetes.
arrest of descent, o In certain diseases, such as syphilis or
o or if, when the head appears on the perineum
erythroblastosis, the placenta may be so large
(crowning), it retracts instead of protruding that it weighs half as much as the fetus.
with each contraction (a turtle sign).
Placenta Succenturiata
MANAGEMENT
o a placenta that has one or more accessory
o asking a woman to flex her thighs sharply on
lobes connected to the main placenta by blood
her abdomen (McRobert’s maneuver) may vessels.
widen the pelvic outlet and allow the anterior o The small lobes may be retained in the uterus
shoulder to be born.
after birth, leading to severe maternal
o Applying suprapubic pressure may also help
hemorrhage.
the shoulder escape from beneath the o On inspection, the placenta appears torn at the
symphysis pubis and be born
edge, or torn blood vessels extend beyond the
edge of the placenta.

PROBLEMS WITH THE PASSAGE MANAGEMENT

Inlet Contraction o The remaining lobes are removed from the

uterus manually to prevent maternal
o The narrowing of the anteroposterior diameter hemorrhage from poor uterine contraction.
to less than 11 cm, or of the transverse
diameter to 12 cm or less. Placenta Circumvallata
 It usually is caused by rickets in
early life or by an inherited small o Ordinarily, the chorion membrane begins at
pelvis. the edge of the placenta and spreads to
o In primigravidas, the fetal head normally envelop the fetus; no chorion covers the fetal
engages between weeks 36 to 38 of side of the placenta.
pregnancy. o In placenta circumvallata, the fetal side of the
o Suspected If engagement does not occur in a placenta is covered to some extent with
primigravida chorion
o Should the membranes rupture, possibility of o Placenta marginata The fold of chorion
cord prolapse. reaches just to the edge of the placenta.
o Every primigravida should have pelvic
measurements taken and recorded before Velamentous Insertion of the Cord
week 24 of pregnancy. o a situation in which the cord, instead of
entering the placenta directly, separates into
Outlet Contraction
small vessels that reach the placenta by
o It is the narrowing of the transverse diameter spreading across a fold of amnion
at the outlet to less than 11 cm. o This form of cord insertion is most frequently
found with multiple gestation.
o This is the distance between the ischial o Because it may be associated with fetal
tuberosities anomalies, an infant born with this type of
placenta should be examined carefully.
o It is also easily reassessed during labor

ANOMALIES OF THE PLACENTA Vasa Previa

The Placenta
o the umbilical vessels of a velamentous cord
insertion cross the cervical os and therefore Unusual Cord Length
deliver before the fetus
o The vessels may tear with cervical dilatation, o An unusually short umbilical cord can result in
just as a placenta previa may tear. premature separation of the placenta or an
o If sudden, painless bleeding occurs with the abnormal fetal lie.
o An unusually long cord may be easily
beginning of cervical dilatation, either
placenta previa or vasa previa is suspected. compromised because of its tendency to twist
o It can be confirmed by ultrasound. or knot.

MANAGEMENT
o Before inserting any instrument such as an
Cesarean Birth
internal fetal monitor, be certain to identify
o birth accomplished through an abdominal
structures to prevent accidental tearing of a
vasa previa as tearing would result in sudden incision into the uterus
fetal blood loss. o The word “cesarean” is derived from the
o the infant needs to be born by cesarean birth. Latin word caedore, which means “to
cut.”
o USES: prophylactic measure to alleviate
Placenta Accreta problems of birth such as cephalopelvic
disproportion, breech or multiple fetus
o an unusually deep attachment of the placenta
births, or failure to progress in labor
to the uterine myometrium so deeply the
placenta will not loosen and deliver. TWO TYPES OF CESAREAN BIRTH

MANAGEMENT Scheduled Cesarean Birth

o Do not attempt to remove it manually : may o There is time for thorough preparation for
lead to extreme hemorrhage because of the the experience throughout the antepartal
deep attachment. period.
o Hysterectomy or treatment with methotrexate: o Some women may take a childbirth
to destroy the still-attached tissue may be preparation class specifically for cesarean
necessary. birth
o Mandatory when there is a physical
Anomalies of the Cord indication such as a transverse
presentation, genital herpes, CPD
Two-Vessel Cord o May reduce the transfer of the human
o A normal cord contains one vein and two immunodeficiency virus (HIV), hepatitis
arteries. C, or herpes type 2 from mother to
o The absence of one of the umbilical newborn,
arteries is associated with congenital o It can reduce mortality among infants
heart and kidney anomalies presenting breech.
o It may be advantageous for a preterm
MANAGEMENT birth--- to avoid pressure on the fetal
o Inspection of the cord as to how many vessels head or to avoid post-procedure stress
are present must be made immediately after incontinence
birth, before the cord begins to dry, because Emergent Cesarean Births
drying distorts the appearance of the vessels.
o Document the number of vessels present o are done for reasons such as placenta
conscientiously. previa, premature separation of the
o An infant with only two vessels needs to be placenta, fetal distress, or failure to
observed carefully for other anomalies during progress in labor.
the newborn period.
 o Preparation must be done much more o It also leads to peripheral
rapidly fully informing a woman and her vasoconstriction---- forces blood to the
support person central circulation and increases blood
 what circumstances created the pressure.
need for a cesarean birth
INTERFERENCE WITH CIRCULATORY
 how the birth will proceed
FUNCTION
INDICATIONS FOR CESAREAN BIRTH
The Skin
Maternal Factors
o serves as the primary line of defense
o Active genital herpes or perhaps human against bacterial invasion.
papillomavirus o When skin is incised for a surgical
o AIDS or HIV-positive status procedure, this important line of defense is
o Cephalopelvic disproportion lost.
o Cervical cerclage o Strict adherence to aseptic technique
o Disabling conditions, such as severe during surgery and in the days following
hypertension of pregnancy, that prevent the procedure are necessary: to
pushing to accomplish the pelvic division compensate for this impaired defense.
of labor o Many women receive prophylactic
antibiotics, such a
Placenta Factors
INTERFERENCE WITH CIRCULATORY
o Placenta previa FUNCTION
o Premature separation of the placenta
o Umbilical cord prolapse o Extensive blood loss can lead to
hypovolemia and lowered blood pressure.
Fetal Factors --------lead to ineffective perfusion of all
o Compound conditions such as macrosomic body tissues
fetus o The amount of blood lost in cesarean birth
o in a breech lie is comparatively high-----. because pelvic
o Extreme low birth weight vessels are congested with blood TO
supply the placenta
o Fetal distress
o During a vaginal birth, a woman loses 300
o Major fetal anomalies, such as
to 500 mL of blood.
hydrocephalus
o During a caesarian birth, a woman loses
o Multigestation or conjoined twins
500 to 1000 mL
o Transverse fetal lie

EFFECTS OF SURGERY ON A WOMAN

Stress Response INTERFERENCE WITH BODY ORGAN
FUNCTION
o The body responds with measures to
preserve the function of major body Uterus
systems. o may not contract well afterward----can
o This results in release of epinephrine and
lead to postpartum hemorrhage.
norepinephrine from the adrenal medulla.
Bladder
Epinephrine
o must be displaced anteriorly for or a
o causes an increased heart rate, bronchial
surgeon to reach the uterus
dilatation, and elevation of the blood
glucose level. Intestine
 o paralytic ileus or halting of intestinal o Encourage her to do as much as possible
function may occur for herself preoperatively, to help her feel
in control and diminish her fear
Lower Extremities
o Include support person in all explanations
o Thrombopheblitis is possible from and admission routines, to keep his or her
impaired lower extremity blood flow anxiety under control as well
o When any body organ is handled, cut, or
QUESTIONS TO DISCOVER:
repaired in surgery, it may respond with a
temporary disruption in function. o The woman’s knowledge about the
o Pressure from edema or inflammation: as procedure
fluid moves into the injured area o The length of hospitalization anticipated
further impairs function of the primary o If she knows about any postsurgical
organ involved, as well as that of equipment to be used such as an
surrounding organs. indwelling catheter or intravenous fluid
o Blood vessels become compressed and line
distant organs may be deprived of blood o Any special precautions that will be
flow: a result of edema, leading to necessary for her infant
reduced function in those organs
POOR NUTRITIONAL STATUS
INTERFERENCE WITH SELF-IMAGE OR
SELF-ESTEEM Obesity

Incisional Scar o Interferes with wound healing.

o Tissue that contains an abundance of fatty
o Its appearance may cause a woman to feel cells is difficult to suture---- so the
self-conscious later. incision may take longer to heal.
Loss of Self-Esteem o A prolonged healing period increases the
risk for infection and rupture of the
o if she believes CS makes her less of a incision (dehiscence).
woman than others because she was o The woman’s heart may also have an
unable to give vaginal birth increased workload.
o often has more difficulty turning and
ambulating postoperatively than does a
NURSING CARE OF A WOMAN woman of normal weight: therefore has
ANTICIPATING FOR CESARIAN BIRTH an increased risk for development of
respiratory or circulatory
Pre-Op Interview
complications such as pneumonia or
o Nursing assessment is essential. thrombophlebitis
o Obtain a health history and make an
Protein or Vitamin Deficiency
assessment and decision for safe use of
anesthesia– can be done by the physician o At risk for poorer healing: because
and the anesthesiologist or nurse- protein and vitamins C and D are
anesthetist necessary for new cell formation at the
o Any past surgeries, secondary illnesses, incision site.
allergies to foods or drugs, reactions to o Vitamin K is necessary after surgery : for
anesthesia, bleeding problems, and current blood clotting
medications: to help establish surgical
Age
risk
o After the woman is admitted to the health o Young adult age group are excellent
care facility, allow her time to talk about candidates for surgery.
any fears she has.
 o A woman older than 40 ----slightly higher (considering that she may have had
risk nothing to eat or drink for almost 24
hours)
o Aggravating Factors: recent vomiting,
Altered General Health diarrhea, or a chronic poor fluid intake
o IVF replacement usually is initiated
o Asking about any secondary illnesses is an
preoperatively and continued
essential component of a preoperative postoperatively: to prevent fluid and
nursing history (secondary illness such as electrolyte imbalances
cardiac disease, diabetes mellitus,
anemia, or kidney or liver disease)
o A general medication history also is
FEAR
important: some drugs increase surgical
risk by interfering with the effect of an o Women need a very detailed explanation
anesthetic or with healing of tissue. of the procedure before they can enter
surgery
DRUGS THAT MAY RESULT IN
o Most cesarean births currently are
COMPLICATIONS OF SURGERY
performed under epidural anesthesia: less
Antibiotics frightening than when general
anesthesia was used.
o Specific antibiotics may predispose to
o Woman who is frightened is at a greater
renal insufficiency or increase
risk for cardiac arrest during anesthesia
neuromuscular blockage; can lead to
administration than a woman who is calm
opportunistic infections Anticoagulants
and relaxed.
o May cause hemorrhage due to lack of
o Help a woman acknowledge that her fear
hemostasis during surgery
of surgery is normal and expected ------
Anticonvulsants helps to enhance her self-esteem and
lower anxiety
o May increase liver action and metabolism
of anesthetic OPERATIVE RISK TO THE NEWBORN

Antihypertensives With Vaginal Birth

o May result in hypotension after anesthesia o When a fetus is pushed through the birth
canal, pressure on the chest helps to rid
Corticosteroids the newborn’s lungs of fluid.
o May block body’s response to shock and o This makes respirations more likely to be
lead to lack of adrenal function adequate at birth than if a fetus had not
been subjected to this pressure.
Insulin
With Cesarian Birth
o May lead to hypoglycemia during labor or
hyperglycemia if a dextrose solution is o A fetus develops some degree of
administered respiratory difficulty for a day or two after
birth than those born vaginally which is
Antianxiety often referred to as transient tachypnea
o May cause hypotension after agents of the newborn.
anesthesia
FLUID AND ELECTROLYTE IMBALANCE
o LOW BLOOD VOLUME: the effect of
surgical blood loss is greater than a woman
who has a normal blood volume.
PREOPERATIVE DIAGNOSTIC that she understands the information
PROCEDURES and can do this well.
o Explain preoperative measures:
Assessments of circulatory and renal function
 surgical skin preparation
and fetal heart rate including:
 eating nothing before the time of
o Vital sign determination surgery,
o Urinalysis  premedication (if this will be used)
o Complete blood count  method of transport to surgery.
o Coagulation profile (prothrombin time  Necessity for an indwelling
[PT], partial thromboplastin time [PTT]) catheter
o Serum electrolytes and pH  Intravenous fluid administration
o Blood typing and cross-matching  placement of an epidural catheter
(if used for post procedural pain
o Ultrasound: to determine fetal
relief)
presentation and maturity
 advantage of early ambulation
NOTE: During pregnancy, a woman, and afterward
particularly one who was in prolonged labor, may
HEALTH TEACHINGS TO PREVENT
have an elevated leukocyte count (up to
COMPLICATIONS
20,000/mm3): not an indication for the presence
of infection Exercises
o Maintain good respiratory and circulatory
function postoperatively and cause fewer
PREOPERATIVE TEACHING
postoperative respiratory and circulatory
o Fear of the unknown----- is one of the complications
hardest fears to conquer. o These preventive exercises are best taught
o Goal of Preoperative teaching: to during the preoperative period: the woman
acquaint a woman with cesarean procedure is free of pain and can concentrate on
and any special equipment to be used: to learning.
make her as informed as possible.
Deep Breathing ADVANTAGES
o Included in Preoperative teaching-----
Activities that help maintain respiratory o Periodic deep breathing exercises fully
and skeletal muscle function to prevent aerate the lungs
post- surgical complications o Helps to prevent the stasis of lung mucus
o Throughout teaching, use visual aids as from the prolonged time spent in the
necessary. Draw pictures or show supine position during surgery.
illustrations of anatomy, if necessary. o Prevents lung infection such as
o Before beginning teaching, assess how pneumonia.
much a woman already knows about the o A typical exercise is to take 5 to 10 deep
surgery. breaths every hour.
o Answer all specific questions, and fill in o Procedure for Deep Breathing
gaps in knowledge. 1. Inhale as deeply as possible
o Ensure that all information offered is 2. Hold her breath for a second or two,
accurate. and
o Be certain not to use hospital jargon such 3. Exhale as deeply as possible.
as “NPO.”: People under stress do not o Be certain she inhales and exhales
process new information well. They fully-----might experience lightheadedness
cannot process information at all if they from hyperventilation
do not understand the terminology.
Incentive Spirometry.
o Ask a woman to return-demonstrate
activities, such as deep breathing: to show o A common device used postoperatively
 o These devices cause a small ping-pong- Ambulation
like ball to rise in a narrow tube or cause
o The most effective way to stimulate lower-
lights to flash
extremity circulation after a cesarean birth
o Main purpose----- to encourage deep
o Woman must be out of bed and walking by
breathing and fully aerate lung spaces
4 hours after surgery (as soon as the effect
General protocol: of the epidural anesthesia has worn off).
o Help her to understand that ambulation is
1. Sit up on the edge of your bed or chair.
extremely important after cesarean birth:
2. Hold the incentive spirometer in an upright
because the edema of the low pelvic
position.
surgery compresses circulation to the
3. Breathe out normally.
lower extremities, increasing the risk for
4. Place the spirometer mouthpiece in your
lower-extremity circulatory stasis.
mouth and close your lips tightly around it.
o Antiembolic stockings (TEDS) may be
5. Breathe in through your mouth as slowly
prescribed for some women in addition to
and deeply as you can, causing the piston
ambulation: to support and encourage
or ball to rise toward the top of the
venous return
chamber.
6. Hold your breath for 3–5 seconds or as IMMEDIATE PREOPERATIVE CARE
long as possible. -----If the spirometer has MEASURE
a goal indicator, use this to guide your
breathing. If the indicator goes above the Informed Consent
marked areas, remove the mouthpiece o Obtaining operative consent is the
from your mouth. surgeon’s responsibility,
7. Breathe out normally. The piston or ball o Seeing that it is obtained is everyone’s
will return to the bottom of the chamber. responsibility.
8. Rest for a few seconds, then repeat the o You may be asked to witness a woman’s
steps 10 or more times.
signature on such a form.
 Go slowly. Take some normal
o Before signing as a witness, be certain that
breaths between deep breaths to
the risks and benefits of the procedure
prevent light-headedness.
were explained in terms the woman could
 Do this every 1–2 hours when
easily understand
you’re awake.
9. After each set of 10 deep breaths, cough a Overall Hygiene
few times to clear your lungs
o For women having a planned cesarean
NOTE: After each set of 10 breaths, cough to birth and admitted to the facility on the
cleanse your lungs of any mucus buildup. morning of surgery-------have showered or
bathed at home.
o You can also clear your lungs throughout
o On admission, provide a clean hospital
the day with relaxed breathing exercises :
gown.
1. Relax your face, shoulders, and neck, and
o If a woman’s hair is long, encourage her to
put one hand on your stomach.
2. Exhale as slowly as possible through your braid it or put it into a ponytail so that it
mouth. will more easily fit under the surgical cap
3. Breathe in slowly and deeply while she will wear: Hair contained by a cap is
keeping your shoulders relaxed. less likely to spread microorganisms
4. Repeat four or five times per day during surgery
o Follow institutional procedure about
Turning removing nailpolish, jewelry, contact
o Turning postoperatively is important: to lenses, piercings, or hair ornaments before
surgery.
prevent both respiratory and
circulatory stasis.
 o Woman’s toenails are free of polish: possible introduction of microorganisms
toenails can be used to assess capillary into the bladder.
refill o If catheterization is difficult before
surgery, avoid repeated attempts:
traumatizes the urethra
o Catheterization can be done in the birthing
or delivery room after the anesthetic agent
GASTROINTESTINAL TRACT
is given.
PREPARATION
o If there is a delay between the catheter
Metoclopramide (Reglan) insertion time and surgery, mark the
drainage bag just before surgery with the
o A gastric emptying agent such as to speed
amount in the bag, or empty it-----so that
stomach emptying pre-surgery urine output can be
Ranitidine (Zantac) differentiated from post-surgery urine
output.
o A histamine blocker to decrease stomach
secretions may be prescribed prior to
surgery. Hydration
Sodium Citrate (Bicitra) o Most women have an IV line begun before
o an oral antacid which acts to neutralize surgery with a fluid such as lactated
acid stomach secretions. Ringer’s solution.----to ensure that a
woman is fully hydrated and will not
BASELINE INTAKE AND OUTPUT experience hypotension from epidural
DETERMINATIONS anesthesia administration, temporary
Indwelling Urinary Catheter use of a supine position, or blood loss at
birth.
o prescribed before transport for surgery or o Be certain that this line is started in the
after arrival in the surgical suite: To woman’s non-dominant hand------so that
reduce bladder size and keep the she can hold her newborn after surgery
bladder away from the surgical field without interference.
o Catheterizing a pregnant woman is more o Use a large-size catheter or needle (18 or
difficult than catheterizing a non-pregnant 20 gauge)----so that blood replacement
woman---the pressure of the fetal head therapy can be administered, if needed,
puts pressure on the urethra and by the same line
distorts anatomic landmarks.
o The vulva may be swollen and PREOPERATIVE MEDICATION
distorted----- vulval varicosities or •A minimum of preoperative medication is used
edema. -------to prevent compromising the fetal blood
o Use good lighting----to clearly reveal the supply and to ensure that the newborn is wide
perineum awake at birth and can initiate respirations
o Save a sample for culture----- to rule out a spontaneously.
urinary tract infection.
PATIENT CHART AND PRE-SURGERY
o After catheter insertion, be certain that
CHECKLIST
urine is draining freely----- fetal pressure
on the urethra may reduce the flow of o Documentation of nursing care ----------
urine considerably. must be completed up until a woman
o During transport, keep the drainage bag leaves the labor room for the OR.
below the level of the woman’s bladder----
PREOPERATIVE CHECKLIST
to prevent urine backflow and the
 o Used as a reminder of all necessary o The anesthesiologist may ask the woman
measures to be taken. to curve her back------ to separate the
o Checking and signing such a form vertebrae and facilitate entry of the
indicates that the specific measures were spinal needle
completed. o It is difficult for a woman having uterine
contractions to remain in this position for
TRANSPORT TO SURGERY
long.
o A woman may be transferred to surgery in o Talking to her while gently restraining her
her bed, or she may be helped to move to a and letting her lean against you-------the
stretcher. most effective means of helping her
o Urge her to lie on her left side during maintain this position
transport-----to prevent supine Epidural Anesthesia
hypotension syndrome.
o Raise the side rails on the bed or o is usually administered with the woman
stretcher---ensures additional safety lying on her side
o Cover her with a blanket or sheet---- to
Duramorph
avoid her feeling chilled.
o Check that her identification is secure o a form of morphine commonly used in
before she leaves the patient unit. epidurals.
o Make sure that her chart with the surgical o Its effect lasts up to 24 hours
checklist accompanies her o Continuous pulse oximetry must be used
for 24 hours postsurgery---------it can
NURSING CARE DURING AN EMERGENT
cause late occurring respiratory
CESARIAN BIRTH
depression
o Obtain baseline history and physical
SKIN PREPARATION
examination information at the beginning
of labor.---determines surgical risks in o Reduces possibility of bacteria entering the
an emergent situation incision at the time of surgery.
o Preoperative preparation measures: vital o Shave away abdominal hair, if indicated
signs, urinalysis, and blood work. o Wash the skin area over the incision site
o Immediate preparation concerns --- with soap and water
informed consent, application of elastic o Some hospitals require extensive skin
stockings (if appropriate), preparation from above the umbilicus to
gastrointestinal tract preparation, below the pubic hair
bladder catheterization, and
establishment of an intravenous line. Surgical Incision
o Most cesarean births are completed within o After anesthetic administration, a woman
30 minutes is positioned with a towel under her right
INTRAOPERATIVE NURSING CARE hip -------to move abdominal contents
away from the surgical field and to lift
o During transport or in surgery, encourage her uterus off the vena cava.
the woman to remain on her side, or insert o A screen may be placed at her shoulder
a pillow under her right hip---- to keep level and covered with a sterile drape ------
her body slightly tilted to the side, to to block the flow of bacteria from her
prevent supine hypotension syndrome. respiratory tract to the incision site.
o The incision area on the woman’s
Administration Of Anesthesia
abdomen is then scrubbed with an
o Position in administering an spinal antiseptic such as iodine
anesthetic (which may be used in an
emergency)---- Sitting up.
 o Appropriate drapes are placed around the o Takes longer to perform-----possibly
area of incision--- -so that only a small making it impractical for an emergent
area of skin is left exposed. cesarean birth.
TYPES OF CESAREAN INCISION BIRTH OF THE INFANT (CS PROCEDURE)
Classic Cesarean Incision 1. Once the surgical incision is complete,
retractors (long, curved, metal
o the incision is made vertically through
instruments) are slipped into the incision.
both the abdominal skin and the uterus. 2. Gentle traction on the handles applied by
o It is made high on the uterus so that it can an assistant and keeps the incision spread
be used with a placenta previa---to avoid apart------allows for good visualization of
cutting the placenta. the uterus and the internal incision.
3. Sterile towels may be placed in the
DISADVANTAGE OF THIS TYPE OF incision----- to separate the uterus from
INCISION other organs.
4. The uterus is then cut, and the child’s head
o it leaves a wide skin scar and also runs is born manually or by the application of
through the active contractile portion of forceps
the uterus. 5. The mouth and nose of the baby are
o A Woman will not be able to have a suctioned by a bulb syringe, the same as in
subsequent vaginal birth----- Because this a vaginal birth, before the remainder of the
type of scar could rupture during labor child is born.
6. Oxytocin is administered intravenously by
LOW SEGMENT INCISION
the anesthesiologist as the child or
o commonly referred to as a low transverse placenta is delivered---------to increase
incision uterine contraction and reduce blood
o is one made horizontally across the loss.
abdomen just over the symphysis pubis 7. In many instances, a woman’s partner may
and also horizontally across the uterus just be allowed to cut the umbilical cord.
over the cervix. 8. After full birth, the uterus is pulled
o This is the most common type of cesarean forward onto the abdomen and covered
incision. with moist gauze.
o It is also referred to as a Pfannenstiel 9. The internal cavity of the uterus is then
incision or a “bikini” incision, ----- inspected, and the mem- branes and
because even a low-cut bathing suit will placenta are manually removed.
cover the scar.  If the woman wishes to have a tubal
ligation, it can be done at this time.
ADVANTAGES 10. The uterus, subcutaneous tissues, and skin
o This type of incision is through the non- incisions are then closed.
active portion of the uterus (the part that 11. Metal staples are usually used on the
contracts minimally with labor)---- it is exterior skin---- because they leave the
less likely to rupture in subsequent least amount of scarring
labors, making it possible for a woman INTRODUCTION OF THE NEWBORN
to have a vaginal birth with a future
pregnancy o Once it is determined that the newborn is
o It also results in less blood loss, is easier to breathing spontaneously, he or she is
suture, decreases post-partal uterine shown to the mother and support person,
infections few postpartum gastrointestinal just as is done after a vaginal birth.
complications o The support person may hold the baby
immediately.
MAJOR DISADVANTAGE
 o Women are able to breastfeed after o Check for abdominal distention------which
cesarean births the same as after vaginal suggests the pain may be caused by
births intestinal gas rather than incision pain.
o Initial breastfeeding is usually delayed o If so, ambulation is often the most
until the woman has been moved to a effective method----- to relieve this type
recovery room------- because of pain.
breastfeeding initiates uterine o DO NOT use acetylsalicylic acid
contractions and that may interfere (aspirin)------ because this can interfere
with suture placement with blood clotting and healing.
o Placing a pillow over her lap while she
NURSING DIAGNOSES AND RELATED
feeds------ can deflect the weight of the
INTERVENTIONS DURING THE IMMEDIATE
infant from her suture line and lessen
POSTPARTAL PERIOD
pain.
o Immediately after surgery, a woman is o Encourage the football hold for
transferred by stretcher from the operating breastfeeding as another way----- to keep
room table to the postanesthesia care unit the infant’s weight off the mother’s
(PACU) or postpartal room. incision.
o If spinal anesthesia was used, remember
that her legs are fully anesthetized and she
will not be able to help move them PATIENT-CONTROLLED ANALGESIA
PAIN RELATED TO SURGICAL INCISION o a method of pain control in which women
administer doses of intravenous narcotic
o Pain may be so intense from the uterine or
analgesia such as morphine to themselves
abdominal incision that it interferes with a
as needed.
woman’s ability to move and deep
o Although the technique may be used
breath------leads to surgical
during labor, it is most frequently used to
complications such as pneumonia or
control postsurgical pain
thrombophlebitis.
o It also impaired a woman’s ability to bond PROCEDURE
with her newborn, ----because holding
her infant may be so painful. o With a solution such as Ringer’s lactate
o Women who had a long-action morphine infusing intravenously, a PCA pump
epidural for labor- ---- have good pain containing a locked syringe of narcotic
relief up to 24 hours. (meperidine or morphine) is attached to
o Woman without analgesia or received a the intravenous line at a port close to the
woman.
shorter acting drug for birth, need
o To receive a dose of analgesia, the woman
analgesia----for comfort.
o Patient-controlled analgesia (PCA) or pushes a button similar to a call bell. ---
This alerts the automatic pump to
continued epidural injections----- give
deliver a set amount of narcotic into the
maximum pain relief.
intravenous line.
o Supplement with other comfort measures
o The pump has a “lock-out” setting that
such as change of position or straightening
prevents a woman from administering a
of bed linen.
larger dose or doses more frequently than
o Always ask a woman what type of pain
would be safe such as every 8 minutes
she is experiencing before administering a
new dose of analgesia---- to be certain EPIDURAL ANALGESIA
that she is describing incisional or
o morphine (Duramorph) or fentanyl is
uterine pain and not pain in a leg or
some other body part that would added to the epidural catheter immediately
suggest a complication of surgery. after surgery, a technique -----keeps them
pain free for the next 24 hours
 o Common side effects: intense itching and  every 30 minutes for the next 2
nausea and vomiting hours,
o Diphenhydramine (Benadryl)  every hour for the next 4 hours,
 An antihistamine given to reduce or as specifically ordered
pruritus; SIGNS INDICATIVE OF POSSIBLE
o Metoclopramide (Reglan) HEMORRHAGE
 An antiemetic may be administered to
counteract nausea. o Falling blood pressure (more than 20 mm
o The use of fentanyl reduces the risk for Hg),
these side effects. o A systolic blood pressure less than 80 mm
o Patient-controlled epidural anesthesia Hg
(PCEA) o A drop of 5 to 10 mm Hg over several
 an effective means of relieving pain readings
o A change in pulse rate (greater than 110
beats per minute or less than 60 beats per
TRANSCUTANEOUS ELECTRICAL NERVE minute)
STIMULATION o Rapid respirations
o Restlessness
o the transmission of an electrical current
o A sense of thirst
across the skin.
o Small electrodes are attached to the
woman’s skin near her incision; MANAGEMENT:
o When she feels pain, she pushes a
o Inspect the dressing over the surgical
transformer button.
incision for blood staining each time vital
PRINCIPLE: Irritation or stimulation of large signs are assessed.
afferent nerve fibers by the electrical stimulation o Observe the perineal pad for lochia flow,
block the ability of the smaller, pain-carrying and palpate the fundal height each time as
nerve fibers to transmit impulses (as predicted by well.
gating control theory). o Lochial discharge may be decreased in a
o The use of TENS can provide important woman after a cesarean birth: because the
uterus was cleaned during surgery,
pain relief after a cesarean birth because it
o Lochial discharge follows a typical rubra,
gives a woman a sense of control over
her situation serosa, alba pattern.
o Be certain to help a woman turn so you
Nursing Diagnosis: Risk for deficient fluid can look under her body for bleeding.
volume related to blood loss during surgery Blood oozing from a surgical wound or
Outcome vaginally can pool considerably under a
woman before it is visible.
Evaluation:
o Oxytocin may be ordered to be added to
o Patient’s blood pressure is 100/60 mm Hg the first 1 or 2 L of intravenous fluid after
or higher; surgery----- to ensure firm uterine
o Pulse remains between 60 and 100 beats contraction.
per minute; o It may be safer to allow the rate of fluid
o Scant to no bleeding on surgical dressing administration to remain behind for a
is apparent. time,.---Oxytocin can elevate blood
o Monitor blood pressure, pulse, and pressure by causing vasoconstriction.
respiratory rate to detect the earliest signs o Be aware that a woman is very prone to
of bleeding hemorrhage at the point the oxytocin is
 every 15 minutes for the first discontinued---- because this is the first
hour after surgery,
 time her uterus is being asked to maintain o fluid intake equals 2 to 3 L/day.
contraction on its own.
o Notify physician of any changes in vital MANAGEMENT:
signs that might indicate hemorrhage------
o Adequate fluid intake is important after
so that prompt action can be taken.
surgery-- ---- to replace blood loss from
o Remember that a minimal but continued
surgery and to maintain blood pressure
change in vital signs (pulse steadily
and renal function.
increasing, blood pressure steadily
o Because the intestine is handled during
declining) is as ominous a sign of
surgery, it takes approximately 24 to 48
hemorrhage as is a sudden alteration in
hours before full peristaltic function is
these measurements.
restored and oral intake is possible.
o A woman who has had either spinal or
o IV fluids must be infused during this time,
epidural anesthesia usually will not
at a rate that is not too rapid (which could
experience pain on uterine palpation until
lead to cardiac overload) or too slow
the anesthesia has worn off, approximately
(which could lead to inadequate
4 to 24 hours.
circulatory compensation).
o Palpate gently once the effect of the
o Keep an accurate intake and output record
anesthesia or analgesia has decreased to
for at least the first 24 hour-------- to be
determine uterine consistency
certain an adequate fluid balance has
o Assess a woman’s uterus for firmness
been achieved.
o Assess the remainder of her abdomen for
o She must turn frequently when in bed and
softness.
ambulate early in the postpartal period----
 Hard, “guarded” abdomen - one
to reduce Her risk for thrombophlebitis
of the first signs of peritonitis
o Women are kept NPO for a time after
(peritoneal infection), a
surgery---- to avoid paralytic ileum that
complication that may occur with
occurs from bowel handling during
any abdominal surgical procedure
surgery.
NURSING DIAGNOSES AND RELATED o Assess a woman’s abdomen at least once
INTERVENTIONS DURING EXTENDED every 8 hours for bowel sounds--- To
POSTPARTAL PERIOD establish that bowel function has
returned,
o The average woman whose child is born
o small “pinging” sounds heard on
by cesarean birth remains in the hospital
auscultation at a rate of 5 to 10 per
from 48 hours to 4 days
minute----which demonstrate that air
o During this period and until she returns to
and fluid are moving through the
have her sutures or staples removed,
intestines.
several interventions are necessary:
o Passage of flatus -----another indication
 To promote healing
that intestinal function is again active.
 To prevent postoperative
o As soon as these signs are present,
complications
intravenous fluid therapy is usually
 To help the woman and her
discontinued and the woman is allowed
family establish bonding with the
sips of fluid.
new child.
o After she begins oral intake, wait 1 hour
Nursing Diagnosis: Risk for deficient fluid before removing the intravenous line.
volume related to postsurgical fluid restriction Doing so ensures that a woman is not
experiencing nausea and vomiting, which
Outcome Evaluation:
might require restarting intravenous
o Patient’s urine specific gravity remains therapy.
between 1.003 and 1.030; o Introduce oral fluid slowly—for example,
o weight loss is not more than 5 to 10 lb; ice chips for the first hour, then sips of
 clear fluid such as ginger ale, Jello, tea, or o Bladder tone or ability to sense filling may
flavored frozen ice. be inadequate to initiate voiding-----
o Gradually advance her diet to a soft and Because the bladder was handled and
then a regular diet as prescribed. displaced during surgery,
o Teach women to continue to drink large
INDWELLING CATHETER
quantities of fluid after they return home
(at least six glasses daily)-----so that they o placed before surgery is usually left in
have adequate body fluid to make place for 4 to 24 hours -----to ensure good
breastfeeding successful urine drainage.
o Assess that the catheter is draining (a
postpartal woman has a urine output of
Nursing Diagnosis: Constipation related to 3000 to 5000 mL per 24 hours). Bladder
effects of abdominal surgery and anesthesia distention will occur rapidly if the catheter
becomes blocked.
Outcome Evaluation: Woman voices she has a
o Before catheter removal, a urine culture
bowel movement every 2 to 3 days or her usual
may be ordered----- to check for the
pattern
possibility of a urinary tract infection.
MANAGEMENT: o After removal of the catheter, the average
woman voids in 4 to 8 hours.
o Note carefully the time of a woman’s first
o Assess for bladder filling at the end of this
bowel movement after surgery.
time by palpation, pressing lightly over the
o A stool softener, a suppository, or an
symphysis pubis---- to assess fullness.
enema– may be ordered by the physician if
o On percussion
there has been no bowel movement to
 an empty bladder------ sounds
facilitate stool evacuation.
dull;
o Reassure a woman who is not receiving
 a full bladder-----resonant;
much food yet that it is normal not to have
 An extended bladder--
bowel movements for 3 or 4 days
hyperresonant
postoperatively, especially if an enema
was administered before surgery. RETENTION WITH OVERFLOW
o Teach women to eat a diet high in
 Occurs when the bladder has filled to
roughage and fluid and to attempt to move
capacity but cannot empty properly
their bowels at least every other day
 Voiding 30 to 60 mL of urine every 15 to
o Stool softener can be prescribed: incisional
20 minutes.
pain interferes with their ability to use
 This voiding pattern is potentially
their abdominal muscles effectively.
dangerous----- because it means that the
o Avoid straining during defecation: this
woman’s bladder is held continuously
puts pressure on their incision. under tension. This can result in
o Keep their water pitcher full to remind permanent bladder damage
them to drink fluids  The constantly full bladder may prevent
Nursing Diagnosis: Risk for impaired urinary the uterus from contracting---increasing
elimination related to surgical procedure the risk of postpartal hemorrhage.

Outcome Evaluation: MANAGEMENT

o Urinary output is more than 30 mL/h;  To help a woman void, suggest she take
o Patient reports no pain, frequency, her prescribed analgesic ---to help relax
burning, or hesitancy on voiding abdominal musculature.
 Provide privacy for voiding
VOIDING AFTER SURGERY  Assist the woman to walk to the bathroom
at least every 2 hours.
  Pouring warm water over her vulva to a standing position-----to prevent
(measure the amount of water used, so that orthostatic hypotension (sudden low
it can be differentiated from urine) blood pressure that occurs with sudden
 Running water from a tap within hearing position changes).
distance. o Assess blood pressure before a woman
 Drink adequate fluid (at least five to six gets out of bed for the first time is an
glasses daily) : to ensure an adequate fluid additional safeguard.
output and help prevent urinary tract o Before ambulation, also assess the lower
infection after they return home. extremities
 Teach about symptoms of urinary tract  for pain in the calf on
infection: pain or frequency with voiding dorsiflexion of the foot (Homans’
or blood in urine. sign)
 for pain, edema, warmth, or
Nursing Diagnosis: Risk for ineffective
redness in the calf, to detect the
peripheral tissue perfusion related to immobility
possibility of a thrombus.
during and after surgery
NOTE: It is dangerous for a woman to ambulate
Outcome Evaluation:
if signs of a thrombus are present. A thrombus
o Capillary refill is less than 5 seconds; could shift, becoming an embolus, a potentially
o there is absence of calf pain, redness, lethal situation.
edema, or areas of warmth on lower
o Encourage her to use adequate analgesia
extremities
---to enable her to move and ambulate with
MANAGEMENT: the least amount of pain.
o Reinforce the need for continued activity
o Pain while sitting or standing, an
balanced with rest after discharge
uncomfortable feeling often described as
“everything falling out.”--- Because a
woman’s abdominal muscles are lax
Nursing Diagnosis: Fatigue related to effects of
from the stretching that occurred
surgery
during pregnancy, abdominal contents
tend to shift forward and put pressure Outcome Evaluation:
on the suture line
o Patient states she is pleased with level of
o A woman may feel more comfortable
self-care;
turning and sitting up if she supports her
o ambulates well by 24 hours
abdomen with one hand or splints the
incision with a pillow. o sleeps restfully at night.
o Leg exercises such as flexing and MANAGEMENT:
extending her knees and early
ambulation------ prevents lower o Encourage adequate rest. Extreme fatigue
extremity circulatory problems interferes with healing and possibly
increases the risk for infection. It also can
THROMBOHEMOLYTIC /ANTIEMBOLIC eventually interfere with bonding.
STOCKINGS o Help a woman plan a day that includes
o may be prescribed ----to help promote care of her new child as well as periods of
venous return and prevent venous rest for herself.
stasis. o Be certain she has adequate analgesic
o Instruct to apply these before arising, medication at bedtime-- to allow her to be
while she is supine and venous distention pain free for the night.
is minimal. o Provide a time in the middle of the
o Always allow her to sit on the edge of the morning and again in the afternoon for
bed for a few minutes before helping her uninterrupted rest.
 o Rest is often best accomplished if it is o Discuss restrictions on exercise or activity:
scheduled for every time her newborn DO NOT lift any object heavier than 10 lb
sleeps. or walk upstairs more than once a day for
o Inadequate rest leads to increased uterine the first 2 weeks
bleeding----has the potential to lead to o Also teach her to recognize signs of
excessive loss of fluid and iron stores possible complications directly related to
the surgery, such as:
Nursing Diagnosis: Impaired skin integrity  Redness or drainage at the incision
related to surgical incision line
 Lochia heavier than a normal
Outcome Evaluation:
menstrual period
o Incision line is clean, dry, and intact  Abdominal pain (other than suture
without erythema; line or afterpain discomfort)
o oral temperature is less than 38° C  Temperature greater than 38° C
(100.4° F)
MANAGEMENT:  Frequency or burning on urination
o Assess the surgical incision once during o Resumption of sexual activity: as soon as
each nursing shift while a woman is the act is comfortable for her, possibly as
hospitalized----- to ensure that the early as 1 week after discharge.
wound edges are approximated and o Return Clinic visit: usually in 2 weeks for
there are no signs of infection, such as both herself and her newborn.
erythema. o Unless the reason for the cesarean birth
o As soon as she can walk steadily, a woman was cephalopelvic disproportion, a woman
can take a warm shower (after first can probably have her next child vaginally
removing the dressing)---- warm, clean
water on the incision is soothing.
o After this point, she can make a decision
about whether to continue to wear a Dilatation and
dressing. Lack of a dressing prevents
moisture accumulation at the incision site Curettage
and decreases the possibility of infection.
o Teach women to continue to observe their o "Dilation" refers to the opening of the
incision daily at home. cervix.
o Instruct to watch out for signs and o "Curettage" refers to the aspiration or
symptoms of possible infection: redness or removal of tissue within the uterus with an
instrument called a curette.
the presence of a discharge
o Is used when the gestational age of a
o Instruct to report any of these signs to their
pregnancy is still less than 13 weeks. This
physician. is done in an ambulatory setting using a
o With a cesarean birth, healing will be paracervical anesthetic block that does not
adequate enough by day 3 that skin sutures eliminate all pain but limits what the
or clamps can be removed, although many woman experiences to cramping and
are left in place until the woman returns feeling of pressure.
for a follow-up appointment in 2 weeks o The cervix is dilated and the uterus is
scraped clean with a curette , removing
zygote and trophoblast cells with the
DISCHARGE PLANNING uterine lining.

o Emphasize the need for adequate help with

DILATATION AND VACUUM
her newborn and other responsibilities at
EXTRACTION
home, before discharge.
 o Is used with termination between 12 and
16 age of gestation. They are done in an
inpatient or ambulatory setting Contact your doctor if you have any of the
o A narrow suction tip is introduced into the following symptoms after a D&C:
cervix. A suction pump or vacuum 1. Heavy or prolonged bleeding or blood
container gently evacuates the uterine clots
contents over a 15 minute period. The 2. Fever
woman may feel pain as the cervical 3. Pain
dilatation is performed and some pressure 4. Abdominal tenderness
and cramping similar to menstrual cramps. 5. Foul-smelling discharge from the vagina
o During the suction, it is not markedly
painful procedure

REASONS FOR A D&C

Urinary
1. Remove tissue in the uterus during or after Catheterization
a miscarriage or abortion or to remove
small pieces of placenta after childbirth. o It is the introduction of a catheter into the
This helps prevent infection or heavy urinary bladder. The catheter is used as a
bleeding. conduit to drain urine from the bladder
2. Diagnose or treat abnormal uterine into an attached bag or container.
bleeding. A D&C may help diagnose or o It is a hollow, partially flexible tube that
treat growths such as fibroids, polyps, collects urine from the bladder and leads to
hormonal imbalances, or uterine cancer. A
a drainage bag.
sample of uterine tissue is viewed under a
microscope to check for abnormal cells. o Catheters are commonly made of rubber or
plastics although they may be made from
latex, silicone, or polyvinyl chloride
PROCEDURE (PVC).
1. An auvard speculum is placed to open the o They are sized by the diameter of the
posterior wall of the vagina lumen using the French (Fr) scale: the
2. A Heaney right angle retractor is placed to larger the number, the larger the lumen.
elevate the anterior wall of the vagina Either straight catheters, inserted to drain
3. A Schroeder tenaculum is placed on the the bladder and then immediately
cervix to stabilize the uterus. removed, or retention catheters, which
4. A sims uterine sound is inserted to remain in the bladder to drain urine, may
determine the depth of the uterus be used.
5. Hegar dilators are inserted to dilate the o Urinary catheterization may be short term
cervix ( from smallest to largest)
(2 weeks or less) or long term (more than 1
6. A sims uterine curette is inserted to scrape
tissue from the uterus month) (Parkeret al., 2009). The steps for
7. A Thomas dull curette is used to remove inserting an indwelling and a single-use
any remaining tissue. straight/intermittent catheter are the same.
The difference lies in the inflation of a
balloon to keep the indwelling catheter in
AFTER A D&C, THERE ARE POSSIBLE place and the presence of a closed drainage
SIDE EFFECTS AND RISKS system.
COMMON SIDE EFFECTS INCLUDE: TYPES OF URINARY CATHETERS
1. Cramping 1. Straight Catheter
2. Spotting or light bleeding o is a single-lumen tube with a small eye or
3. Complications such as a damaged cervix
and perforated uterus or bladder and blood opening about 1.25 cm (0.5 in.) from the
vessels are rare. insertion tip.
2. Retention or Foley Catheter
 o is a double-lumen catheter. and thus it can be better controlled during
o The outside end of this two-way retention insertion, and passage is often less
catheter is bifurcated; that is, it has two traumatic.
openings, one to drain the urine, the other 4. Three-Way Foley Catheter
to inflate the balloon. o This is used for clients who require
o The larger lumen drains urine from the continuous or intermittent bladder
bladder and the second smaller lumen is irrigation.
used to inflate the balloon near the tip of o The three-way catheter has a third lumen
the catheter to hold the catheter in place through which sterile irrigating fluid can
within the bladder. flow into the bladder.
o Retention catheters are usually connected o The fluid then exits the bladder through
to: the drainage lumen, along with the urine.
a. CLOSED GRAVITY
GUIDELINES IN THE SELECTION OF A
DRAINAGE SYSTEM
URINARY CATHETER
 This system consists of the
catheter, drainage tubing, 1. Determine the appropriate catheter length by
and a collecting bag for the the client’s gender.
urine. o Adult female clients: use a 22-cm catheter
 A closed system cannot be o Adult male clients: use a 40-cm catheter.
opened anywhere along 2. Determine appropriate catheter size by the size
the system, from catheter of the urethral canal.
to collecting bag. o Use sizes such as #8 or #10 for children,
b. OPEN SYSTEM #14 or #16 for adults.
 consists of separate o Men frequently require a larger size than
packages for the catheter women, for example, #18.
and the drainage tubing o The lumen of a silicone catheter is slightly
and collecting bag. larger than that of a same-sized latex
 The open system requires catheter
the nurse to be especially 3. Select the appropriate balloon size.
vigilant to ensure sterile o The size of the retention catheter balloon is
technique is maintained
indicated on the catheter along with the
when connecting the
diameter, for example, “#16 Fr—5 mL
catheter and drainage
balloon.”
tubing.
o The purpose of the catheter balloon is to
 The closed system is
secure the catheter in the bladder.
preferred because it
o For adults, use a 5-mL balloon to facilitate
reduces the risk of
optimal urine drainage.
microorganisms entering
o The smaller balloons allow more complete
the system and infecting
the urinary tract. Urinary bladder emptying because the catheter tip
drainage systems typically is closer to the urethral opening in the
depend on the force of bladder.
gravity to drain urine from o However, a 30-mL balloon is commonly
the bladder to the used to achieve hemostasis of the prostatic
collecting bag. area following a prostatectomy.
3. Coudé (Elbowed) Catheter o Use 3-mL balloons for children
o It is a variation of the indwelling catheter
which has a curved tip.
o This is sometimes used for men who have PERFORMING URINARY
a hypertrophied prostate, because its tip is CATHETERIZATION
somewhat stiffer than a regular catheter Purposes:
 o To relieve discomfort due to bladder o Allow adequate time to perform the
distention or to provide gradual catheterization. Although the entire
decompression of a distended bladder procedure can require as little as 15
o To assess the amount of residual urine if minutes, several sources of difficulty could
the bladder empties incompletely result in a much longer period of time. If
o To obtain a sterile urine specimen possible, it should not be performed just
o To empty the bladder completely prior to prior to or after a meal.
surgery o Some clients may feel uncomfortable
o To facilitate accurate measurement of being catheterized by nurses of the
urinary output for critically ill clients opposite gender. If this is the case, obtain
whose output needs to be monitored the client’s permission. Also consider
hourly whether agency policy requires or
o To provide for intermittent or continuous encourages having a person of the client’s
bladder drainage and/ or irrigation same gender present for the procedure.
o To prevent urine from contacting an Equipments
incision after perineal surgery
o Sterile catheter of appropriate size (An
extra catheter should also be at hand.)
ASSESSMENT o Catheterization kit or individual sterile
items: o Sterile gloves o Waterproof
o Determine the most appropriate method of drape(s) o Antiseptic solution o Cleansing
catheterization based on the purpose and balls o Forceps o Water-soluble lubricant o
any criteria specified in the order such as Urine receptacle o Specimen container
total amount of urine to be removed or size o For an indwelling catheter: o
of catheter to be used.  Syringe prefilled with sterile water
o Use a straight catheter if only a one-time in amount specified by catheter
urine specimen is needed, if amount of manufacturer
residual urine is being measured, or if  Collection bag and tubing
temporary decompression/emptying of the o 5–10 mL 2% Xylocaine gel or water-
bladder is required. soluble lubricant for male urethral
o Use an indwelling/retention catheter if the injection (if agency permits)
bladder must remain empty, intermittent o Clean gloves
catheterization is contraindicated, or o Supplies for performing perineal cleansing
continuous urine measurement/collection o Bath blanket or sheet for draping the client
is needed. o Adequate lighting (Obtain a flashlight or
o Assess the client’s overall condition.
lamp if necessary.
Determine if the client is able to
participate and hold still during the
procedure and if the client can be
positioned supine with head relatively flat.
For female clients, determine if she can
have knees bent and hips externally
rotated. Implementation
o Determine when the client last voided or
A. Preparation
was last catheterized. If catheterization is
 If using a catheterization kit, read
being performed because the client has
the label carefully to ensure that all
been unable to void, when possible,
necessary items are included.
complete a bladder scan to assess the
 Apply clean gloves and perform
amount of urine present in the bladder.
routine perineal care to cleanse
Planning gross contamination. For women,
 use this time to locate the urinary Note: The lubricant causes the urethra to distend
meatus relative to surrounding slightly and facilitates passage of the catheter
structures. without traumatizing the lining of the urethra
 Remove and discard gloves.
8. Open the catheterization kit. Place a
 Perform hand hygiene.
waterproof drape under the buttocks
(female) or penis (male) without
contaminating the center of the drape
B. Performance
with your hands.
1. Prior to performing the procedure,
9. Apply sterile gloves.
introduce self and verify the client’s
10. Organize the remaining supplies:
identity using agency protocol.
 Saturate the cleansing balls
Explain to the client what you are
with the antiseptic solution.
going to do, why it is necessary, and
 Open the lubricant package.
how he or she can participate.
 Remove the specimen
2. Perform hand hygiene and observe
container and place it nearby
other appropriate infection prevention
with the lid loosely on top.
procedures.
11. Attach the prefilled syringe to the
3. Provide for client privacy.
indwelling catheter inflation hub.
Note: Adjust the bed to a comfortable working Apply agency policy and/or
height, usually elbow height of the caregiver manufacturer recommendation
regarding pretesting of the balloon.
4. Place the client in the appropriate
position and drape all areas except the Rationale: There is little research regarding
perineum. pretesting of the balloon; however, some balloons
 Female: supine with knees (e.g., silicone) may form a cuff on deflation that
flexed, feet about 2 feet apart, can irritate the urethra on insertion.
and hips slightly externally
12. Lubricate the catheter 2.5 to 5 cm (1
rotated, if possible.
to 2 in.) for females, 15 to 17.5 cm (6
 Male: supine, thighs slightly
to 7 in.) for males, and place it with
abducted or apart
the drainage end inside the collection
5. Establish adequate lighting. Stand on
container.
the client’s right if you are right-
13. If desired, place the fenestrated drape
handed, on the client’s left if you are
over the perineum, exposing the
left-handed.
urinary meatus.
6. If using a collecting bag and it is not
14. Cleanse the meatus.
contained within the catheterization
kit, open the drainage package and Note: The non-dominant hand is considered
place the end of the tubing within contaminated once it touches the client’s skin.
reach.
FEMALES: Use your non-dominant hand to
Rationale: Because one hand is needed to hold spread the labia so that the meatus is visible.
the catheter once it is in place, open the package Establish firm but gentle pressure on the labia.
while two hands are still available The antiseptic may make the tissues slippery but
the labia must not be allowed to return over the
7. If agency policy permits, apply clean
cleaned meatus.
gloves and inject 10 to 15 mL
Xylocaine gel into the urethra of the Note: Location of the urethral meatus is best
male client. Wipe the underside of the identified during the cleansing process
penile shaft to distribute the gel up the
 Pick up a cleansing ball with the
urethra. Wait at least 5 minutes for the
forceps in your dominant hand
gel to take effect before inserting the
and wipe one side of the labia
catheter.
 majora in an anteroposterior Rationale: This is to be sure it is fully in the
direction. Use great care that bladder, will not easily fall out, and the balloon is
wiping the client does not in the bladder completely.
contaminate this sterile hand.
o For male clients, some experts recommend
 Use a new ball for the opposite
side. advancing the catheter to the “Y”
 Repeat for the labia minora. bifurcation of the catheter. Check your
 Use the last ball to cleanse agency’s policy.
directly over the meatus o If the catheter accidentally contacts the
labia or slips into the vagina, it is
MALES: Use your non- dominant hand to grasp considered contaminated and a new, sterile
the penis just below the glans. If necessary, retract catheter must be used. The contaminated
the foreskin. Hold the penis firmly upright, with catheter may be left in the vagina until the
slight tension. new catheter is inserted to help avoid
mistaking the vaginal opening for the
Rationale: Lifting the penis in this manner helps
urethral meatus
straighten the urethra.
 Pick up a cleansing ball with 16. Hold the catheter with the non-
the forceps in your dominant dominant hand.
hand and wipe from the 17. For an indwelling catheter, inflate the
center of the meatus in a retention balloon with the designated
circular motion around the volume.
glans. Use great care that  Without releasing the catheter
wiping the client does not (and, for females, without
contaminate the sterile hand. releasing the labia), hold the
 Use a new ball and repeat inflation valve between two
three more times. The fingers of your non-dominant
antiseptic may make the hand while you attach the
tissues slippery but the syringe (if not left attached
foreskin must not be allowed earlier) and inflate with your
to return over the cleaned dominant hand. If the client
meatus nor the penis be complains of discomfort,
dropped immediately withdraw the
instilled fluid, advance the
15. Insert the catheter. catheter farther, and attempt to
 Grasp the catheter firmly 5 to inflate the balloon again.
7.5 cm (2 to 3 in.) from the tip.  Pull gently on the catheter
Ask the client to take a slow until resistance is felt to ensure
deep breath and insert the that the balloon has inflated
catheter as the client exhales. and to place it in the trigone of
Slight resistance is expected as the bladder.
the catheter passes through the
sphincter. If necessary, twist 18. Collect a urine specimen if needed.
the catheter or hold pressure For a straight catheter, allow 20 to 30
on the catheter until the mL to flow into the bottle without
sphincter relaxes. touching the catheter to the bottle. For
 Advance the catheter 5 cm (2 an indwelling catheter pre-attached to
in.) farther after the urine a drainage bag, a specimen may be
begins to flow through it. taken from the bag this initial time
only.
19. Allow the straight catheter to continue
draining into the urine receptacle. If
 necessary (e.g., open system), attach forms or checklists supplemented by
the drainage end of an indwelling narrative notes when appropriate.
catheter to the collecting tubing and
EVALUATION
bag.
20. Examine and measure the urine. In o Perform a detailed follow-up based on
some cases, only 750 to 1,000 mL of findings that deviated from expected or
urine are to be drained from the normal for the client. Relate findings to
bladder at one time. Check agency previous assessment data if available.
policy for further instructions if this o Teach the client how to care for the
should occur indwelling catheter, to drink more fluids,
21. Remove the straight catheter when and provide other appropriate instructions.
urine flow stops.
 For an indwelling catheter, NURSING INTERVENTIONS FOR CLIENTS
secure the catheter tubing to WITH INDWELLING CATHETERS
the inner thigh for female o Nursing care of the client with an
clients or the upper thigh or indwelling catheter and continuous
lower abdomen for male drainage is largely directed toward
clients with enough slack to preventing infection of the urinary tract
allow usual movement. and encouraging urinary flow through the
 Also, secure the collecting drainage system.
tubing to the bed lines, and o It includes encouraging large amounts of
hang the bag below the level
fluid intake, accurately recording the fluid
of the bladder. No tubing
intake and output, changing the retention
should fall below the top of
catheter and tubing, maintaining the
the bag
patency of the drainage system, preventing
 Hang the urine bag below the
contamination of the drainage system
level of the bladder, and it
should not be touching the A. Fluids
floor. o The client with a retention catheter
 Proper attachment prevents
should drink up to 3,000 mL/day if
trauma to the urethra and
permitted.
meatus from tension on the
o Large amounts of fluid ensure a
tubing. Whether to take the
large urine output, which keeps the
drainage tubing over or under
bladder flushed out and decreases
the leg depends on gravity
the likelihood of urinary stasis and
flow, patient’s mobility, and
subsequent infection.
comfort of the patient
o Large volumes of urine also
22. Wipe any remaining antiseptic or minimize the risk of sediment or
lubricant from the perineal area. other particles obstructing the
Replace the foreskin if retracted drainage tubing
earlier. Return the client to a B. Dietary Measures
comfortable position. Instruct the o Acidifying the urine of clients with
client on positioning and moving with a retention catheter may reduce the
the catheter in place. risk of UTI and calculus formation.
23. Discard all used supplies in Foods such as eggs, cheese, meat
appropriate receptacles. and poultry, whole grains,
24. Document the catheterization cranberries, plums and prunes, and
procedure including catheter size tomatoes tend to increase the
Band results in the client record using acidity of urine. Conversely, most
fruits and vegetables, legumes, and
 milk and milk products result in
alkaline urine.
STEPS IN REMOVING A RETENTION
CATHETER
C. Perineal Care 1. Obtain a receptacle for the catheter (e.g., a
o No special cleaning other than disposable basin); a clean, disposable
routine hygienic care is necessary towel; clean gloves; and a sterile syringe to
for clients with retention catheters, deflate the balloon. The syringe should be
nor is special meatal care large enough to withdraw all the solution
recommended. The nurse should in the catheter balloon. The size of the
check agency practice in this balloon is indicated on the label at the end
regard of the catheter.
D. Changing the Catheter and Tubing 2. Ask the client to assume a supine position
o Routine changing of catheter and as for a catheterization.
tubing is not recommended.
Optional: Obtain a sterile specimen before
o Collection of sediment in the
removing the catheter. Check agency protocol.
catheter or tubing and impaired
urine drainage are indicators for 3. Remove the catheter-securing device
changing the catheter and drainage attaching the catheter to the client, apply
system. gloves, and then place the towel between
o When this occurs the catheter and the legs of the female client or over the
drainage system are removed and thighs of the male.
discarded, and a new sterile 4. Insert the syringe into the injection port of
catheter with a closed drainage the catheter, and withdraw the fluid from
system is inserted using aseptic the balloon. After the fluid has been
technique. aspirated, the walls of the balloon do not
E. Removing Indwelling Catheters deflate to their original shape but collapse
o Indwelling catheters are removed into uneven ridges, forming a “cuff ”
after their purpose has been around the catheter. This cuff can cause
achieved, usually on the order of discomfort to the client as the catheter is
the primary care provider. removed. Do not pull the catheter while
o If the catheter has been in place for the balloon is inflated; doing so will injure
a short time (e.g., 48 to 72 hours), the urethra
the client usually has little
All of the sterile water must be removed to
difficulty regaining normal urinary
prevent injury to the patient
elimination patterns. Swelling of
the urethra, however, may initially 5. After all of the fluid is removed from the
interfere with voiding, so the nurse balloon, gently withdraw the catheter and
should regularly assess the client place it in the waste receptacle.
for urinary retention until voiding 6. Dry the perineal area with a towel.
is reestablished. 7. Measure the urine in the drainage bag.
o A few days before removal, the 8. Remove and discard gloves.
catheter may be clamped for 9. Perform hand hygiene.
specified periods of time (e.g., 2 to 10. Record the removal of the catheter.
4 hours), then released to allow the Include in the recording
bladder to empty. This allows the (a) the time the catheter was removed;
bladder to distend and stimulates (b) the amount, color, and clarity of the
its musculature. Check agency urine;
policy regarding bladder training
(c) the intactness of the catheter; and
procedures
(d) instructions given to the client.
 11. Provide the client with either a urinal or large amounts of sediment, use a three-
(men), bedpan, commode, or toilet way system with continuous irrigation.
collection device (“hat”) to be used with o Never disconnect the tubing to obtain
each, subsequent unassisted void. urine samples, to irrigate the catheter or to
12. Following removal of the catheter, ambulate or transport the patient.
determine the time of the first voiding and o Never leave the catheter in pace longer
the amount voided during the first 8 hours. than is necessary.
Compare this output to the client’s intake. o Avoid urine catheter changes. The catheter
13. Observe for dysfunctional voiding is changed only to correct problems such
behaviors (i.e., < 100 mL per void), which as leakage, blockage or encrustations.
might indicate urinary retention. If this o Avoid unnecessary handling or
occurs, perform an assessment of PVR manipulation of the catheter by the patient
using a bladder scanner if availabl or staff.
o Carry out hand hygiene before and after
handling the catheter, tubing or drainage
GUIDELINES FOR PREVENTING bag.
INFECTION IN THE CATHETERIZED o Wash the perineal area with soap and
PATIENT water at least twice a day; avoid to-and-fro
o Use scrupulous aseptic technique during motion of the catheter. Dry the area well,
but avoid applying powder because it may
insertion of the catheter. Use a pre-
irritate the perineum.
assembled sterile closed urinary drainage
o Monitor the patient’s voiding when the
system.
o To prevent contamination of the closed catheter is removed. The patient must void
within 8 hours; if unable to void, the
system, never disconnect the tubing. The
patient may require catheterization with a
drainage bag must never touch the floor.
straight catheter.
The bag and collecting tubing are changed
o Obtain a urine sample for culture at the
if contamination occurs, if urine flow
becomes obstructed, or if tubing junctions first sign of infection
start to leak at the connections.
o If the collection bag must be raised above
the level of the patient’s bladder, clamp HOME CARE CONSIDERATIONS
the drainage tube. This prevents backflow A. For intermittent catheterization,
of contaminated urine into the patient’s instruct the client to:
bladder from the bag. o Follow instructions for clean
o Ensure a free flow of urine to prevent technique.
infection. Improper drainage occurs when o Wash hands well with warm water
the tubing is kinked or twisted, allowing and soap prior to handling
pools of urine to collect in the tubing equipment or performing
loops. catheterization.
o To reduce the risk of bacterial o Monitor for signs and symptoms of
proliferation, empty the collection bag at UTI including burning, urgency,
least every 8 hours through the drainage abdominal pain, and cloudy urine;
spout –more frequently if there is a large in older adults, confusion may be
volume of urine. an early sign.
o Avoid contamination of the drainage o Ensure adequate oral intake of
spout. A receptacle in which to empty the fluids.
bag is provided for each patient. o After each catheterization, assess
o Never irrigate the catheter routinely. If the the urine for color, odor, clarity,
patient is prone to obstruction from clots and the presence of blood.
 o Wash rubber catheters thoroughly CSF total Protein
with soap and water after use, dry,
o 20-60 mg/dL
and store in a clean place
Gamma Globulin
B. For indwelling catheters, instruct the
client to: o 3 to 12% of the total protein
o Never pull on the catheter.
CSF Glucose
o Secure the catheter tubing to your
leg using a catheter-securing o 50 to 80 mg/dL
device.
o Ensure that there are no kinks or CSF cell count
twists in the tubing. o Normal CSF contains no RBC, the WBC
o Keep the urine drainage bag below count is 0-5 WBC per microliter (all
the level of the bladder. A leg bag mononuclear)
may substitute for a hanging bag
for those who are upright. Pleocytosis
o Empty the drainage bag regularly.
o The presence of WBC in cerebrospinal
o Take a shower rather than a tub
fluid
bath. Sitting in a tub allows
o Small number of monocytes can be normal
bacteria easier access to the urinary
tract. o Large number of granulocytes often
o Monitor for signs and symptoms of suggest bacterial meningitis
UTI including burning, urgency, o White cells can indicate central nervous
abdominal pain, cloudy urine; in system hemorrhage, leukemia, recent
older adults, confusion may be an seizure or a metastatic tumor
early sign. o When erythrocytes are detected in the CSF
o Ensure adequate oral intake of sample: suggests causes intracranial
fluids hemorrhage
CSF Chloride

Lumbar Tap o 118 to 130 mEg/L

Gram stain
Review on cerebrospinal fluid- Normal and
Abnormal Findings o No microorganism (bacteria, fundi or
virus) is present
CSF Samples for Analysis with Normal Values
Normal CSF Pressure:
o 70 to 180 mm H20
o CSF is produced mainly by the choroid
plexus ABNORMAL FINDINGS
Appearance: Pressure
o CSF is normally clear and colorless  o Increased intracranial pressure (ICP)
o Sometimes with a difficult lumbar occurs as a result of a tumor, hemorrhage,
puncture, the CSF is initially bloody or trauma induced edema
because of local trauma but then becomes o Decreased intracranial pressure (ICO) may
clearer reveal a spinal subarachnoid obstruction 
 o Signs and symptoms: Altered LOC, NURSING RESPONSIBILITIES WITH
confusion SPECIMEN COLLECTION

Appearance 1. Note relevant information on the

laboratory request slip (name, hospital
o Cloudy appearance indicating: infection
number, receiving nurse)
o Yellow to reddish appearance indicating: 2. Explain the purpose of specimen collection
spinal cord obstruction or intracranial and the procedure for obtaining the
hemorrhage specimen
o Brown to orange appearance indicating: 3. Provide client comfort, privacy and safety
increased protein levels or RBC 4. Use correct procedure for obtaining
breakdown specimen collection
CSF protein 5. Transport the specimen in the laboratory
promptly to have more accurate results
o Increased protein indicating: tumor, 6. Report abnormal result to physician
trauma, Diabetes Mellitus, or blood in CSF
o Decreased protein indicating: rapid CSF LUMBAR PUNCTURE
production o An invasive procedure carried out by
o Hydrocephalus: high CSF inserting a needle into the lumbar
subarachnoid space through the third and
Gamma globulin
fourth and fifth lumbar interface (between
o Increased gamma globulin indicating a the L3-L4, L4-L5) to withdraw CSF
demyelinating disease such as multiple  To prevent paralysis
sclerosis, neurosyphylis, or Guillan-Barre  Spinal cord is until L1
Syndrome o Landmark: iliac crest
CSF Glucose Other names for a lumbar puncture
o Increased glucose: hyperglycemia 1. Spinal tap
o Decreased glucose indicating: 2. Spinal puncture
hypoglycemia, bacterial or fungal 3. Thecal puncture
infection, TB or meningitis 4. Rachiocentesis

CSF Cell Count Lumbar Puncture

o Increased white blood cells in the CSF o The procedure usually takes around 30 to
suggesting: meningitis, tumor, abscess, 45 minutes and can be done on an
acute infection, stroke, or demyelinating outpatient basis at a hospital or clinic.
disease o A successful lumbar punctures requires
o RBC in the CSF indicating: bleeding into that the patient be relaxed; an anxious
the spinal fluid or the result of a traumatic patient is tense, and this may increase the
lumbar puncture pressure reading
o One of the responsibilities of the nurse
CSF chloride
during a lumbar puncture is to provide
o Decreased Chloride indicating infected information and instructions before, during
meninges Gram stain and after the procedure
o Gram positive or gram negative organism o Common position: Fetal position
indicating bacterial meningitis
ADVANTAGES OF A WELL-INFORMED
PATIENT ON THE PROCEDURE
 o It will decrease fear and anxiety among the o Normally, CSF pressure rises rapidly in
patient and their families response to compression of the jugular
o It will also lessen the occurrence of veins and returns quickly to normal when
potential complications of post-lumbar the compression is released.
puncture. o A slow rise and fall in pressure indicates a
partial block due to a lesion compressing
SPECIFIC INDICATIONS FOR LUMBAR the spinal subarachnoid pathways
PUNCTURE
CONTRAINDICATIONS OF LUMBAR
o To obtain CSF for examination PUNCTURE
o To measure and reduce CSF pressure
o Increased intracranial pressure due to a
o To determine the presence or absence of
brain tumor.
blood in the CSF (subarachnoid o Cerebral or cerebellar herniation with
hemorrhage)
severe neurological deterioration may
o To detect spinal subarachnoid block
occur after the withdrawal of CSF fluid
o Assist in the diagnosis of suspected CNS o Skin infection near the puncture site (entry
infections (bacteria or viral meningitis, of microorganism)
meningoencephalitis), intracranial or o The presence of skin infection near the site
subarachnoid hemorrhage and some
of the lumbar puncture increases the risk
malignant disorders
of contamination of infected material into
o Evaluate and diagnose demyelinating or
the CSF
inflammatory CNS process such as o Severe degenerative vertebral joint disease
Multiple sclerosis, Guillan-Barre
(stiff spine). There will be difficulty in
syndrome (GBS), acute disseminated
passing the needle through the degenerated
encephalomyelitis (ADEM)
arthritic interspinal space.
o Infuse medications which include spinal
o Severe coagulopathy. Due to significant
anesthesia before surgery, contrast
risk of epidural hematoma formation
material for diagnostic imaging such as
CT-myelography, and chemotherapy drugs EQUIPMENT FOR LUMBAR TECHNIQUE
directly into the spinal cord
The lumbar puncture kit contains:
o Treat normal pressure hydrocephalus,
cerebrospinal fistulas, and idiopathic o Sterile gloves
intracranial hypertension (IIH) o Sterile drapes and procedure tray
o Placement of a lumbar CSF drainage o Sterile gauze pads
catheter o Aseptic solution: povidone-iodine solution
(Betadine)
Queckenstedt’s Test
o Local anesthetic: Lidocaine 1% solution
Purpose: To test for subarachnoid obstruction o 25G needle
o Also known as lumbar manometric test o 10ml syringe (1)
performed by compressing the jugular o Spinal needle with stylet (size 22G or
veins for 10 seconds on each side (first on 25G)
one side, and then on the other side) of the o CSF tube (2 to 4)
neck during the lumbar puncture. o Stopcock
o The increase in pressure caused by the o Manometer tubing
compression is noted; then the pressure is
NURSING RESPONSIBILITIES BEFORE
released and pressure readings are made.
THE PROCEDURE
 1. Determine whether written consent for the  a lateral decubitis/recumbent
procedure has been obtained. position with the back arched, head
2. Introduce yourself and the rest of the team. and knees flexed to the abdomen
3. Explain the procedure to the patient. and chin tucked against his chest
4. Explain to the patient the purpose of (fetal position) or:
lumbar puncture, how and where it’s done,  sitting while leaning over a bedside
and who will perform the procedure. table. These position widen the
5. Ask about: intervertebral spaces between the
a. Blood-thinning or other spinous processes of the vertebrae,
anticoagulant medications. the easier entry into the
Examples include warfarin subarachnoid space.
(Coumadin), Clopidogrel (Plavix)  The nurse assists the patient to
b. Over-the-counter pain relievers maintain the position to avoid
such as aspirin, ibuprofen (Advil, sudden movement-----which can
Motrin IB, others) or naproxen produce a traumatic (bloody) trap.
sodium (Aleve o Place a small pillow under the patient’s
c. Allergy to any medications, such head to maintain the spine in a horizontal
as numbing medications (local position; a pillow may be placed between
anesthetics). the legs to prevent the upper leg from
6. Provide for client privacy rolling forward. Encourage the patient to
7. Assist physician when positioning patient relax and to breathe normally---because
8. Describe sensations that are likely during hyperventilation may lower an elevated
procedure (i. e, a sensation of cold as the pressure.
site is cleansed with a solution, a needle o Sterilize site of insertion. The skin is site is
prick when local anesthetic is injected) prepared and draped, and a local anesthetic
9. Determine whether the patient has any is injected.
question or misconceptions about the o Insert the spinal needle.
procedure  The spinal needle is inserted in the
10. Reassure the patient that the needle will midline between the spinous
not enter the spinal cord or cause paralysis processes of the vertebrae (usually
11. Instruct the patient to void before the between the third fourth or the
procedure to promote comfort fourth and fifth lumbar vertebrae).
12. Reinforce diet. Advise the patient that o Remove the stylet from the needle.
fasting is not required  The stylet is removed from the
13. Promote comfort. Instruct the patient to needle. CSF will drop out of the
empty the bladder and bowel before the needle if it’s properly positioned. A
procedure stopcock and manometer are
14. Establish a baseline assessment data. Do attached to the needle to measure
vital signs monitoring and neurologic the initial (opening) CSF pressure.
assessment of the legs by assessing the o Collect specimen.
patient’s movement, strength, and  Specimens are collected and placed
sensation in the appropriate containers. A
LUMBAR TAP TECHNIQUE specimen of CSF is usually
collected in three test tubes, labeled
Done by the Physician in order of collection. The tubes of
o Position the patient to fetal position. The CSF are sent to the laboratory
patient is positioned on his side at the edge immediately.
of the bed assuming: o Remove the needle.
  The needle is removed, and a small labeled and sent to the laboratory
sterile dressing is applied immediately for further evaluations.
11. Administer analgesia as ordered.
Headaches after the procedure can last for
NURSING RESPONSIBILITIES AFTER THE a few hours or days and is usually treated
PROCEDURE with analgesics.
12. Monitor the patient for complications of
1. Apply brief pressure to the puncture site.
lumbar puncture; notify physician if
2. Pressure will be applied to avoid bleeding,
complications occur
and the site is covered by a small occlusive
dressing or band-aid.
3. The patient remains prone for 2 hours,
NURSING MANAGEMENT OF LUMBAR
then flat on bed for 4 to 6 hours. He or she
PUNCTURE COMPLICATIONS
may turn from side to side as long as the
head is not elevated: to separate the Post lumbar puncture headaches
alignment of the dural and arachnoid
o The most common complications of LP
needle punctures in the meninges, to
that occurs due to the leakage of CSF from
reduce leakage of CSF and to prevent
the puncture site or into the tissues around
spinal headache.(headache may develop
it.
due to CSF leakage
o This is the most common complication,
4. Monitor vital signs, neurologic status, and
intake and output. Take vital signs, occurring in 15% to 30% of patients.
measure intake and output, and assess o It is a throbbing bifrontal or occipital
neurologic status at least every 4 hours for headache, dull and deep in character.
24 hours to allow further evaluation of the o The headache caused by CSF leakage at
patient’s condition. the puncture site.
5. Check for the puncture site for redness, o The pain is aggravated while sitting,
swelling, and signs of CSF leakage and standing, or coughing and resolves after
drainage of blood and drainage every hour lying down.
for the first 4 hours, and then every 4 o A post-lumbar puncture headache, ranging
hours for the first 24 hours. from mild to severe, may appear a few
6. If CSF pressure is elevated, assess the hours to several days, after the procedure.
patient’s neurologic status every 15
Prevention of post-lumbar or post-spinal
minutes for 4 hours.
headache
7. If he’s stable, assess him every hour for 2
hours and then every 4 hours or according Post-lumbar puncture headache maybe
to the present schedule avoided if:
8. Assess for Signs of CSF leakage:
a. A small-gauge needle is used
positional headaches, nausea and
b. The patient remains prone after the
vomiting, neck stiffness, photophobia
procedure.
(sensitivity to light), sense of imbalance,
tinnitus (ringing in the ear), and Management (post-lumbar or post-spinal
phonophobia (sensitivity to sound). headache)
9. Encourage increased fluid intake. An
1. Instruct to remain prone for 2 hours, then
increased amount of fluid intake (up to
flat on bed for 4 to 6 hours
3,000 ml in 24 hours) will replace CSF
a. Encourage bed rest
removed during the lumbar puncture.
b. Administer analgesics as ordered
10. Label and number the specimen tube
c. Encourage to increase fluid intake
correctly. Ensure all samples are properly
 2. Back pain. A pain or discomfort in the brain tissue that can lead to the
lower back may happen as a result of compression or herniation of the brainstem
trauma to the local soft tissue. (controls breathing and pulse)
Signs and Symptoms
Nursing management (back pain)
 High blood pressure.
1. Back pain is a self- limiting condition and  Irregular or slow pulse.
may resolve after 5 to 7 days.  Severe headache.
2. Apply Hot and cold massage  Weakness.
3. Administer Mild analgesics as ordered like  Wide (dilated) pupils and no
paracetamol and topical NSAIDS> movement in one or both eyes
4. Consult physician of symptom does not  Cardiac arrest (no pulse)
resolve  Seizures
5. Pain or numbness. A feeling of tingling  Loss of consciousness, coma.
sensation and numbness in the legs is felt  Loss of all brainstem reflexes
temporarily. (blinking, gagging, and pupils
reacting to light)
Nursing management (numbness)
 Respiratory arrest (no breathing)
1. Rest. Many of the conditions that cause leg
Management (herniation/ICP)
and foot numbness, such as nerve pressure,
improve with rest. 1. Assess neurologic status at least every 4
2. Ice. Apply cold compresses or wrapped hours for 24 hours
icepacks to numb legs and feet for 15 2. Maintain on high fowler’s position.
minutes at a time several times daily. Promotes lung expansion and improves
3. Hot compress. Heat can sometimes help cerebral tissue perfusion
loosen stiff or tense muscles that can put 3. Elevate HOB 15 to 30 degrees to promote
pressure on nerves and cause numbness. drainage of CSF
4. Massage. Massaging numb legs and feet 4. Adequate oxygenation.
helps improve blood flow and may reduce 5. Raise siderails
symptoms. 6. Encourage bed rest
5. Epsom salt baths. Epsom salts contain 7. Administer antihypertensives, diuretics,
magnesium, a compound known to corticosterioids and anticonvulsants as
increase blood flow and circulation. ordered.
6. Sleep. Numbness may worsen with a lack 8. Avoid factors that increase ICP
of proper sleep. a. Valsava maneuver (UMIRE)
7. Bleeding. Bleeding is usually noted in the b. Enema (Inserting liquid to cleanse
area of the punctured site, or in some rare the colon)
cases into the subarachnoid, subdural or c. Bending and stooping (increase
epidural space. ICP)

Management (bleeding) RECOVERING FROM LUMBAR

PUNCTURE
1. Apply pressure on puncture site.
2. Cover puncture site with small occlusive DO’S
dressing or band-aid.
o Drink plenty of fluids
3. Assess site every 15 minutes.
o Take painkillers as prescribed, such as
4. Notify physician if bleeding does not stop.
5. Brainstem herniation: The increased paracetamol
pressure caused by the removal of CSF o Lie down instead of sitting upright (4
during LP will cause sudden shifting of hours)
 o Try drinks containing caffeine, such as
coffee, tea or cola: helps to relieve the
headache
o Remove the dressing or plaster yourself
the next day
o Recovering from a lumbar puncture

DONTs
o Do not drive or operate machinery for at
least 24 hours
o Do not play sport or do any strenuous
activities for at least a week
CONTACT PHYSICIAN IF
o Headaches are severe or do not go away
o Feeling or being sick
o Very high temperature or feel hot and
shivery
o It's painful to look at bright lights
o The swelling in your back lasts for more
than a few days or keeps getting worse
o You see blood or clear fluid leaking from
your back
CAUSES OF ICP
o Brain tumor
o Increased CFS production
o Stroke/ hemorrhagic stroke