NUR 146

SESSION 1. PROLAPSE OF THE UMBILICAL CORD

DESCRIPTION

 Prolapse may occur at any time after the membranes rupture if the presenting fetal part is
not fitted firmly into the cervix.

It tends to occur most often with:

 Premature rupture of membranes

 Fetal presentation other than cephalic

 Placenta previa

 Intrauterine tumors preventing the presenting part from engaging

 A small fetus

 CPD preventing firm engagement

 Polyhydramnios

 Multiple gestation

The incidence is about 0.5% of cephalic births but can rise as high as 10% or higher with breech
or transverse lies.

EMERGENCY MANAGEMENT FOR PROLAPSE OF UMBILICAL CORD

PROCEDURE

1. Gather all items you will need for the internal examination and prepare for double set-up.

For internal examination

Clean gloves

lubricant

For Vaginal delivery (depends on institutional set-up)

2 sterile gloves

1 straight forceps

1 mayo scissors

1 urinary catheter

1 placental basin

1 needle holder

Sterile OS

1 syringe with needles

1 chromic 2/0 (optional)

2% Lidocaine (optional)

Cotton balls with betadine

SCRIPT FOR RETURN DEMONSTRATION

Good morning/good afternoon! I will demonstrate the

emergency management for prolapse of the umbilical

cord.

First, I will gather all items that I will need on this

procedure.

RATIONALE:
For easy accessibility for the inspection of the external genitalia, vagina and cervix.

2. Identify the client, introduce yourself and explain the procedure Good
morning/afternoon/evening ma’am. I am

(mention your name) and I will be your nurse for the day. I will do internal examination to assess
the progress of your labor

RATIONALE:

To obtain client’s cooperation and work simultaneously.

3. Position the client on the examination table.

*Three positions are employed for internal

examination:

 Dorsal Recumbent

 Sim’s Position

 Knee-chest Position

(Ma’am you will be positioned on the examination

table to check for the progress of your labor)

RATIONALE:

The aforementioned positions are made best so as to expose the gynecologic area to be
examined. Position depends on client’s capability and examiner’s preferred position.

4. Drape the client. Expose only the gynecological area. Ma’am I will put the drape on you and
will expose the part that I only need to assess.

RATIONALE:

Always respect the client’s modesty and to provide privacy.

5. Wash hands- and put-on examination gloves. I will do handwashing then I will put on
examination gloves for the internal examination and I will change into sterile gloves after I
assess your progress of labor

RATIONALE:
To protect the health care provider from contracting gynecological diseases caused by highly
infective organisms.

6. Assess the well-being of the pregnant woman if the cord is visible outside of the vagina or can
be felt in the vagina below the presenting part. Handle the cord carefully. DO NOT PINCH THE
CORD

Ma’am while I insert my 2 fingers kindly take a deep breath while I do the internal examination.
If I see a cord protruding on the vagina I will handle it carefully.

RATIONALE:

On inspection, the cord may be visible at the vulva and to assess the cord for pulsations After
performing internal examination:

7. Assess the well-being of the fetus:

Fetal Heart Rate

I will now be assessing the Heart Rate of your baby by putting the stethoscope on your
abdomen.

RATIONALE:

Cord prolapse is first discovered only after the membranes have ruptured, when the FHR is
discovered to be unusually slow or a variable deceleration FHR pattern suddenly becomes
apparent on a fetal monitor. To rule out cord prolapse, always assess fetal heart sounds
immediately after rupture of the membranes, whether this occurs spontaneously or by
amniotomy.

*IF YOU ARE IN A CEMONC FACILITY REPORT THE FINDINGS TO THE OBSTETRICIAN FOR
EMERGENCY CESAREAN SECTION.

*IF YOU ARE IN A BEMONC FACILITY THE FOLLOWING PROCEDURES BELOW ARE THE
EMERGENCY MANAGEMENT FOR PROLAPSE OF THE UMBILICAL CORD

8. Assist the mother to do knee-chest, head tilt, left lateral position and instruct the mother to
take deep breath and control the urge to bear down Ma’am I will assist you in a knee-chest
position, take a deep breath and do not bear down if you have the urge to do so.

RATIONALE:

Knee-chest position and uses gravity to shift the fetus out of the pelvis. (as shown below) (Put
on sterile gloves before doing the procedure below)
9. Elevate the presenting part by filling the urinary bladder by inserting a catheter. Instruct the
client not to bear down. (as shown below) Ma’am I will be inserting a catheter that will inflate
your bladder by a sterile fluid to help in reducing the compression on the prolapse cord.

RATIONALE:

• If the decision-to-delivery interval is likely to be prolonged, particularly if it involves

ambulance transfer, elevation through bladder filling may be more practical.

• Bladder filling can be achieved quickly by inserting the cut end of an intravenous giving set
into a Foley’s catheter.

• The catheter should be clamped once 500-750 ml have been instilled.

• It is essential to empty the bladder again just before any delivery attempt, be it vaginal or
caesarean section.

10. Elevate the presenting part by inserting your fingers into the vagina and push the head of
the fetus upward (DO NOT REMOVE your fingers until you arrived at the operating room or by
instruction of the obstetrician) (as seen below)Ma’am I will put my gloved hands into your
vagina to push the head of your baby upward and take a deep breath when you have the urge
to bear down

RATIONALE:

Elevation of the presenting part is thought to relieve pressure on the umbilical cord and prevent
mechanical vascular occlusion.

• Manual elevation is performed by inserting a gloved hand or two fingers in the vagina and
pushing the presenting part upwards.

• Excessive displacement may encourage more cord to prolapse. To prevent vasospasm, there
should be minimal handling of loops of cord lying outside the vagina.

11. Call out the time of birth and gender of the baby. I will call out the time of birth and gender
of the newborn. If the newborn is with good cry I will proceed with EINC if its not crying I will
cut the cord and resuscitate the infant if needed.

RATIONALE:

To safeguard mother and baby against infection. To facilitate spontaneous breathing of the
infant.

12. Remove gloves and wash hands. After the procedure I will remove my gloves and wash my
hands.

RATIONALE: For infection control

13. Document the date, time and the procedures that was done to the patient. After the
procedure I will document the date, time and the procedure.

RATIONALE:

To provide accurate data in the care of the client.

MULTIPLE CHOICE (10 points)

Answer the following questions

1. Cord Prolapse occurs more with the following conditions. SELECT ALL THAT APPLY

A. Premature rupture of membranes

B. Fetal presentation other than cephalic

C. Placenta previa

D. A small fetus

E. CPD preventing firm engagement

2. Dayanara, a pregnant client is admitted to the Emergency Room Department and was transfer
to your area. She told you that her membranes ruptured on the way to the hospital and there is
something on her vagina that feels like rope. Upon initial assessment it is umbilical cord
prolapse. Which of the following is the nurse’s initial action when umbilical cord prolapse
occurs?

B. Place the client in a knee-chest position in bed

3. When assessing Dayanara, the nurse will check the progress of her labor. The nurse should
position her: SELECT ALL THAT APPLY
A. Dorsal Recumbent

B. Sim’s Position

C. Knee-chest Position

4. When assessing Dayanara, the nurse finds a prolapsed cord. The nurse should:

C. Elevate the client’s hips

5. You are caring for Dayanara who was diagnosed with cord prolapse and was ordered by the
Obstetrician to do Knee-Chest position. She asked you why she needs to be positioned that way,
you answered:

C. Knee-chest position uses gravity to shift the fetus out of the pelvis and will lessen cord
compression.

6. You are on duty in CEmONC Facility while assessing a pregnant client you found out the
presentation is breech and with prolapse cord. What will you do?

A. Remove my gloves and report it to the Obstetrician.

7. Karen a pregnant woman's amniotic membranes rupture. Prolapsed umbilical cord is

suspected. What intervention would be the less priority?

A. Placing the woman in the knee-chest position

8. TRUE or FALSE: Elevating the presenting part by filling the urinary bladder by inserting a
catheter and instruct the client not to bear down.

A. True
9. What is the rationale of Elevating the presenting part by filling the urinary bladder by
inserting a catheter and instruct the client not to bear down. SELECT ALL THAT APPLY

A. If the decision-to-delivery interval is likely to be prolonged, particularly if it involves

ambulance transfer, elevation through bladder filling may be more practical.

B. Bladder filling can be achieved quickly by inserting the cut end of an intravenous giving set
into a Foley’s catheter.

C. Elevation of the presenting part is thought to relieve pressure on the umbilical cord and
prevent mechanical vascular occlusion.

D. Manual elevation is performed by inserting a gloved hand or two fingers in the vagina and
pushing the presenting part upwards.

10. TRUE or FALSE: Elevating the presenting part by inserting your fingers into the vagina and
push the head of the fetus upward.

A. True

II. DYSTOCIA Although labor often proceeds without any deviation from the normal, many
potential complications can occur. A difficult labor—dystocia—can arise from any of the four
main components of the labor process: (a) the power, or the force that propels the fetus
(uterine contractions); (b) the passenger (the fetus); (c) the passageway (the birth canal); or (d)
the psyche (the woman’s and family’s perception of the event).

session 2

FORCEPS ASSISTED BIRTH/DELIVERY (p. 1363)

DESCRIPTION

 Obstetrical forceps are steel instruments constructed of two blades that slide together at
their shaft to form a handle.

Although no longer used routinely, forceps may be necessary with any of the following
conditions:
 A woman is unable to push with contractions in the pelvic division of labor such as might
happen with

-a woman who received regional anesthesia or who has a spinal cord injury.

-Cessation of descent in the second stage of labor occurs.

fetus is in an abnormal position.

- a fetus is in distress from a complication such as a prolapsed cord.

 Before forceps are applied:

Membranes must be ruptured

CPD must not be present.

The cervix must be fully dilated.

The woman’s bladder must be empty.

KINDS OF FORCEPS

 Fenestrated or Pseudofenestrated Blades have an opening within or a depression along the

blade surface respectively. (can be seen on Figure 2.1 and 2.2 below)

 True Fenestration reduces the degree of head slippage during forceps rotation.

 Disadvantageously, it can increase friction between the blade and vaginal wall.

 Pseudofenestration, the forceps blade is smooth on the outer maternal side but indented on
the inner fetal surface.

 The goal is to reduce head slipping yet improve the ease and safety of application and
removal of forceps compared with pure fenestrated blades.

PREREQUISITES FOR FORCEPS APPLICATION

1. Anesthesia: general, epidural, spinal or pudendal block

2. Adequate pelvic outlet

3. Aseptic technique
4. Contraction of the uterus should be present

5. Fully dilated cervix

6. Engaged head

7. Ruptured membranes

8. Favourable position and presentation

 Occipito-anterior

 Occipito-posterior

 Face presentation

 After-coming head in breech

TYPES OF FORCEPS APPLICATION

1. CEPHALIC APPLICATION-the forceps is applied on the sides of the fetal head in the mento-
vertical diameter so the injury of the fetal face, eyes and facial nerves are avoided.

2. PELVIC APPLICATION- The forceps is applied along the maternal pelvic wall irrespective to the
position of the head. It is easier for application but carries a great risk of fetal injuries.

3. CEPHALO-PELVIC APPLICATION-

it is the ideal application and possible when the occiput is directly anterior or posterior or in
direct mento-anterior position.

FORCEPS APPLICATION

1. Assemble the forceps before application. Ensure that the parts fit together and lock well.

2. Lubricate the blades of the forceps.

3. Wearing sterile gloves, insert two fingers of the right hand into the vagina on the side of the
fetal head. Slide the left blade gently between the head and fingers to rest on the side of the
head. (as shown below)

4. Repeat the same maneuver on the other side, using the left hand and the right blade of the
forceps. (as shown below)

5. Depress the handles and lock the forceps.

Difficulty in locking usually indicates that the application is incorrect. In this case, remove the
blades and recheck the position of the head. Reapply only if rotation is confirmed.

6. After locking, apply steady traction inferiorly and posteriorly with each contraction.

7. Between contractions check:

- fetal heart rate, and

- application of forceps.

8. Lift the head slowly out of the vagina between contractions.

FORCEPS FAILURE

Forceps failed if:

- Fetal head does not advance with each pull.

- Fetus is undelivered after three pulls with no descent or after 30 minutes (WHO)

Every application should be considered a trial of forceps. Do not persist if there is no descent
with every pull.

If forceps delivery fails, perform a cesarean section.

COMPLICATIONS

Fetal complications

 Injury to facial nerves requires observation.

This injury is usually self-limiting.

 Lacerations of the face and scalp may occur.

Clean and examine lacerations to determine if sutures are necessary.

 Fractures of the face and skull require observation.

Maternal complications

 Tears of the genital tract may occur.

 Examine the woman carefully and repair any tears to the cervix or vagina, or repair the
episiotomy.

 Uterine rupture may occur and requires immediate treatment.

Classification

 The classification of operative vaginal deliveries is based on the station of the head within the
pelvis as defined by American College of Obstetricians and Gynecologists’ Committee in
Obstetrics, Maternal, and Fetal Medicine.

Outlet Forceps

 Scalp visible at the introitus without separating the labia

 Fetal skull has reached the pelvic floor

The sagittal suture is in:

- anteroposterior diameter

- right or left occiput anterior or posterior position (i.e. rotation 45 degrees)

 Fetal head is at or on the perineum

Low Forceps

 Head is at Spines +2 cm or lower

Two sub-divisions:

- rotation of 45 degrees

- rotation of 45 degrees

Mid-Forceps
 Head is engaged at Spines 0 + 1

 Leading position of the skull is above station +2

***FORCEPS SHOULD NEVER BE APPLIED THROUGH A CERVIX THAT IS NOT FULLY DILATED
NOR WITH AN UNENGAGED PRESENTING PART.

SESSION 3. VACUUM ASSSISTED DELIVERY/VACUUM EXTRACTION (p.1364)

DESCRIPTION

 Suction is created within a cup placed on the fetal scalp such that traction on the cup aids
fetal expulsion.

 Vacuum extraction has advantages over forceps birth in that little anesthesia is necessary,
thus leaving the fetus with less respiratory depression at birth.

INDICATIONS

 Vacuum extraction is reserved for fetuses who have attained a gestational age of 34 weeks.

 Maternal exhaustion

 Drug induced analgesia

 Soft tissue resistance with failure to descend

 Predisposing maternal illness

 Hemorrhage

 Relative Cephalopelvic disproportion

 Malposition

 Malpresentation

 Non reassuring fetal heart rate

CONTRAINDICATIONS
 Operator inexperience

 Inability to assess fetal position

 High station (above 0 station)

 Suspicion of cephalopelvic disproportion

 Other presentations than vertex.

 Premature fetus (<34 weeks).

 Intact membranes

PRE-REQUISITES OF THE PROCEDURE

 Procedure should be explained to the patient

and consent should be taken

 Emotional support and encouragement

 Lithotomy position.

 Bladder should be emptied.

 Antiseptic measures for the vagina, vulva and perineum.

 Vaginal examination to check pelvic capacity, cervical dilatation, presentation, position,

station and degree of flexion of the head and that the membranes are ruptured.

ADVANTAGES

 Regional Anesthesia is not required so it is preferred in cardiac and pulmonary patient.

 The ventouse is not occupying a space beside the head as forceps.

 Less compression force (0.77 kg/cm2) compared to forceps (1.3 kg/cm2) so injuries to the
head is less common.

 Less genital tract lacerations.

 Can be applied before full cervical dilatation.

 It can be applied on non-engaged head.

DISADVANTAGES
 Over natural birth is that more perineal lacerations may occur.

 It causes a marked caput on the newborn head that may be noticeable as long as 7 days after
birth.

 Vacuum extraction should not be used as a method of birth if fetal scalp blood sampling was
used because the suction pressure can cause severe bleeding at the sampling site.

 Vacuum extraction is not advantageous for preterm infants because of the softness of the
preterm skull.

COMPLICATIONS

Maternal

 Perineal, vaginal, labial, periurethral and cervical lacerations.

 Cervical incompetence and future prolapse if used with incompletely dilated cervix.

 Tears of the genital tract may occur. Examine the woman carefully and repair any tears to the
cervix or vagina, or repair the episiotomy.

Fetal

 Cephalohematoma.

 Scalp lacerations and bruising

 Subgaleal hematomas-also known as a subgaleal hemorrhage, is a serious

complication that occurs when blood accumulates outside of the baby's skull (extracranially)

 Intracranial hemorrhage.

 Neonatal jaundice

 Subconjunctival hemorrhage

 Injury of sixth and seventh cranial nerves

 Retinal hemorrhage

 Fetal death

MANAGEMENT
PROCEDURE RATIONALE

1. Explain the procedure and ask for consent. Explaining the procedure to the client’s
cooperation and will lessen the apprehension.

2. Bladder should be emptied or need to be catheterized. Bladder emptying helps in dislodging

the shoulders.

3. Examine the woman, cervix must be fully dilated. When the cervix is not fully dilated, there's
a significant chance of injuring or tearing the cervix. Cervical injury requires surgical repair and
may lead to problems in future pregnancies.

4. Determine the position of the fetal head. The anterior fontanelle is larger and forms a cross
The posterior fontanelle is smaller and forms a Y

*REMEMBER: Molding of the head makes assessment difficult Think about dystocia if the fetus
will fit through the pelvis

5. Equipment and vacuum needs to be ready Provides efficiency of the procedure and ensures
thatno defective materials are used.

6. Application of the cup over the sagittal suture 3cm in front of the posterior fontanelle. The
cup is applied by compressing it in an anteroposterior diameter and then introducing it into the
posterior fourchette while protecting the maternal tissues and making space with the opposite
hand. (as shown below)

Flexion point: Proper application of the cup results in

flexion of the fetal head when traction is applied

Identification of the flexion point: (as shown below)

-It is situated 3 cm in front of the posterior fontanelle.

-Centre of the cup should be overlying the flexion point. This placement promotes flexion,
descent and autorotation. If traction is directed from this point the fetal head is flexed to the
narrowest sub-occipitobregmatic diameter(9.5 cm).

7. Gentle traction should be applied at right angles to the plane of the cup. (as shown below)To
ensure that no maternal tissue is between the fetal head and the vacuum cup. This should be
reconfirmed before each pull on the vacuum and following any re-application or suggestion of
loss of contact during traction

8. Traction is usually applied at settings between 500 and 600 mm Hg (0.6–0.8 kg/cm2 ). The
vacuum pressure may or may not be released between contractions, to resting pressure settings
of between 100 and 200 mm Hg (0.1– 0.3 kg/cm2), depending on the type of vacuum used.

9. No rotational force should be applied; the fetal head may rotate on its own with descent.
Traction should always be in the direction of the pelvic curve—initially downward and finally
upward. A common error is to attempt to extend the head prematurely, thereby increasing the
diameter that must pass over the perineum and increasing the likelihood of perineal trauma.

10. Apply traction with contractions and with maternal expulsive efforts. After every vacuum
delivery, the newborn should be observed to ensure that the expected swelling on the head
does not enlarge significantly and that there is no evidence of developing hypovolemia, which
might occur with a subgaleal hemorrhage.

Vacuum failure

 Before undertaking any attempt at operative vaginal delivery, consider the risk of failure for
vaginal delivery and the potential for other complications, such as shoulder dystocia and
postpartum hemorrhage.

 Ensure adequate assistance is present if such complications should occur.

 Consider the fetal status before making your attempt to deliver the baby and the time
necessary to initiate a cesarean section if the procedure fails.

 Under circumstances in which fetal well-being is suspect and/or the potential for success of
an operative vaginal delivery is in doubt, proceed directly to cesarean section, if available. If
times permits, consider transfer to the next level of care.

 Whenever operative delivery is considered, a health care provider skilled in newborn

resuscitation should be present at the birth. This person’s sole responsibility must be the care of
the newborn.

 The vacuum procedure has failed when descent or delivery has not been accomplished.

 The procedure should be abandoned at this point, and an alternate method of delivery
should be selected.

When to halt—beware

 3 pulls over 3 contractions, no progress abandon procedure

 3 pop-offs: after 1, reassess carefully before reapplying

 After 20 minutes of application with no progress reassess

 The above recommendations should be considered the maximal limits.

 The incidence of scalp trauma is increased when the cup application is greater than 10
minutes compared to less than 10 minutes.

 It is imperative that some descent is observed with each pull.

 If these limits are approached, progress does not occur or there is evidence of scalp trauma,
the procedure should be abandoned.

MULTIPLE CHOICE (20 points)

1. Although no longer used routinely, forceps may be necessary with any of the following
conditions: SELECT ALL THAT APPLY

A. A woman is unable to push with contractions in the pelvic division of labor such as might
happen with a woman who received regional anesthesia or who has a spinal cord injury.

B. Cessation of descent in the second stage of labor occurs.

C. A fetus is in an abnormal position.

D. A fetus is in distress from a complication such as a prolapsed cord.

2. All but one is true regarding Fenestrated Blades.

B. It reduces the degree of head slippage during forceps rotation.

3. All but one is true regarding Pseudofenestrated Blades.

D. the forceps blade is smooth on the outer maternal side but indented on the inner fetal
surface.

4. All but one is true regarding Fenestrated or Pseudofenestrated Blades.

A. It has an opening within or a depression along the blade surface

5. The following are favourable position and presentation for Forceps Assisted Delivery, EXCEPT:

C. Shoulder presentation

6. The following are prerequisite for Forceps Application, SELECT ALL THAT APPLY:

A. Contraction of the uterus should be present

B. Fully dilated cervix

C. Engaged head

D. Ruptured membranes

7. The following are fetal complications of Forceps Application, EXCEPT:

D. Uterine rupture

8. A type of Forceps Application wherein the forceps is applied on the sides of the fetal head in
the mento-vertical diameter so the injury of the fetal face, eyes and facial nerves are avoided.

B. Cephalic Application

9. A type of Forceps Application wherein the forceps is applied along the maternal pelvic wall
irrespective to the position of the head. It is easier for application but carries a great risk of fetal
injuries.

A. Pelvic Application

10. A type of Forceps Application wherein it is the ideal application and possible when the
occiput is directly anterior or posterior or in direct mento-anterior position.

C. Cephalo-Pelvic Application

11. The following are indications of Vacuum Assisted Delivery, EXCEPT:

D. Premature fetus

12. The following are advantages of Vacuum Assisted Delivery, EXCEPT:

C. Should be applied only at full cervical dilatation

13. The following are disadvantages of Vacuum Assisted Delivery, EXCEPT:

A. The ventouse is not occupying a space beside the head as forceps

14. The following are maternal complications of Vacuum Assisted Delivery, EXCEPT:

D. Injury of sixth and seventh cranial nerves

15. Application of the cup over the sagittal suture ____ in front of the posterior fontanelle.

B. 3 cm

16. Gentle traction should be applied at _____ angles to the plane of the cup.

B. Right

17. Traction is usually applied at settings between __________.

C. 500 and 600 mmHg

18. The following are indication of a Vacuum Failure, EXCEPT:

E. It is imperative that some descent is observed with each pull.

19. Assuming fetopelvic disproportion and malpresentation have been ruled out, vacuum
extraction delivery may be appropriate when:
B. Fetal head is rotated 45° from the midline

20. The following are signs that Vacuum Assisted Delivery should be stop, EXCEPT:

A. The vacuum procedure has failed when descent or delivery has not been accomplished

SESSION 4. SHOULDER DYSTOCIA (p.1359)

DESCRIPTION

 Shoulder dystocia is a birth problem that is increasing in incidence because the weight and
therefore the size of newborns is increasing.

 Shoulder dystocia is most apt to occur in women with diabetes, in multiparas, and in
postdate pregnancies.

 The condition may be suspected earlier if the second stage of labor is prolonged, if there is
arrest of descent, or if, when the head appears on the perineum (crowning), it retracts instead
of protruding with each contraction (a turtle sign).

DIAGNOSIS

Immediate recognition of shoulder dystocia is essential. Signs include: Head recoils against
perineum, the “turtle” sign Spontaneous restitution does not occur Failure to deliver with
expulsive effort and usual maneuvers

Management Protocol Avoid the 4 P's. DO NOT!

1. Pull

2. Push

3. Panic

4. Pivot (i.e. severely angulating the head, using the coccyx as a fulcrum)

MANAGEMENT
Management

 No consensus on best treatment/maneuver or order of their application.

HELPERR mnemonic - all maneuvers able to be performed by Emergency Physician, generally

from least to most invasive

H call for help

E Evaluate for possible Episiotomy to increase the anteroposterior diameter of passage

L Legs flex (McRoberts maneuver) - best first option - hyperflexion of legs with mild abduction
and external rotation

P Pressure (suprapubic pressure, aka Rubin I maneuver) - apply pressure just proximal to pubic
symphysis, either continuously or in rocking motion

E Entry maneuvers - Wood’s corkscrew maneuver by applying pressure to anterior aspect of

posterior shoulder causing movement of shoulder into more oblique position in pelvis or Rubin
II maneuver - applying pressure to posterior aspect of most accessible shoulder (anterior or
posterior)

R Remove posterior arm by sweeping it across the chest and bring fetal hand to the chin, grasp
and pull out of the birth canal and across the face

R Roll on all fours (Gaskin position)

ALARMER mnemonic is an alternative to the HELPERR mnemonic and provides a slightly

altered sequence of interventions:

A Ask for help

L Legs to chest (McRoberts maneuver)

A Anterior shoulder disimpaction by suprapubic pressure

R Release posterior shoulder (attempt made to deliver posterior shoulder prior to anterior
shoulder)

M Maneuver of Wood

E Episiotomy
R Roll on all fours (Gaskin’s Maneuver)

PROCEDURE

Set up unique systems for calling for help in obstetric emergencies to assure that appropriate
equipment and personnel are available consistent with local circumstances.

RATIONALE:Establish and practice a management protocol that includes all available health care
providers. Post the protocol in the labor area so it is available to refer to during an emergency.

1. Gather all items you will need for the internal

examination.

SCRIPT FOR RETURN DEMONSTRATION

First, I will gather all items needed for the procedure for easy accessibility.

RATIONALE: For easy accessibility for the inspection of the external genitalia, vagina and cervix.

2. Identify the client, introduce yourself and explain the procedure (internal examination). Good
morning/afternoon/evening ma’am. I am Kisha and I will be your nurse for the day. I will do
internal examination by inserting my gloved fingers to assess the progress of your labor

RATIONALE: To obtain client’s cooperation and work simultaneously.

3. Position the client on the examination table.

*Three positions are employed for internal

examination:

 Dorsal Recumbent

 Sim’s Position

 Knee-chest Position

Ma’am you will be positioned on the examination table to assess the progress of your labor

RATIONALE: The aforementioned positions are made best so as to expose the gynecologic area
to be examined. Position depends on client’s capability and examiner’s preferred position.
4. Drape the client. Expose only the gynecological area.Ma’am I will put the drape on you for
your privacy and I will just expose the part that I only need to assess.

RATIONALE: Always respect the client’s modesty and to provide privacy.

5. Wash hands- and put-on examination gloves. I will do handwashing and put on examination
gloves to do assess the client’s progress of labor.

RATIONALE: To protect the health care provider from contracting gynecological diseases caused
by highly infective organisms.

DURING THE EMERGENCY DELIVERY

6. Notify assistant or backup to enlist other appropriate health care providers, including those
health care providers skilled in neonatal resuscitation.

I will notify other health care providers to assist or back me up during the emergency delivery
and neonatal resuscitation.

RATIONALE: When shoulder dystocia is suspected, the nurse can be prepared to assist staying
calm and calling for added assistance with health care providers.

7. Perform McRobert’s Maneuver by helping the client to move to a lithotomy position (supine
with buttocks at edge of the bed) in bed. Lower head of bed if elevated. Hyperflex both legs
(McRobert's maneuver, shown below). McRobert’s Maneuver is done by grasping the mother’s
posterior thighs and flexing them against her abdomen. I will instruct the mother to grasp her
posterior thigh and flex them against her abdomen.

RATIONALE: McRobert’s Maneuver straightens sacrum and decreases angle of incline symphysis
pubis and dislodges the impacted shoulder. Shoulder dystocia is often resolved by this
maneuver alone. The picture below demonstrates the changes in the pelvic dimensions when
the legs are flexed against the abdomen.

Anterior disimpaction

8. Mazzanti Maneuver is done by applying suprapubic pressure applied with the heel of
clasped hands from the posterior aspect of the anterior shoulder to dislodge it (Mazzanti
maneuver, figure

4). (this is done by another health care practitioner.) Apply a steady pressure first and, if
unsuccessful, apply a rocking pressure. Do NOT use fundal pressure. Mazzanti Maneuver is done
by applying pressure on the suprapubic region is done to dislodge anterior shoulder and
simultaneously instructing the client to bear down while I apply suprapubic pressure downward
with palm or fist 30 seconds of continuous pressure

RATIONALE: In combination with the McRoberts maneuver, this will deliver the baby in 91% of
cases. It is useful to understand the lay of the baby, so as to apply pressure from the correct side
and be most effective. It is also useful to have a stool in delivery area to facilitate this maneuver.
It is important to be above the woman when performing suprapubic pressure Fundal pressure
alone is to be avoided because of the potential neurological complications.

9. Vaginal approach

Rubin’s Maneuver/Reverse Woodscrew Maneuver is done by adduction of the anterior

shoulder by pressure applied to the posterior aspect of the shoulder. (shown at figure 5A)

The shoulder is pushed towards the chest, or pressure is applied to the scapula of the anterior
shoulder (shown at figure 5B)

SCRIPT FOR RETURN DEMONSTRATION

Rubin Maneuver/Reverse Woodscrew Maneuver is done with inserting my fingers behind the
posterior aspect of the anterior shoulder and rotate the shoulder toward fetal chest. I will insert
my fingers behind the posterior aspect of the armpit of the fetus then I will rotate the shoulder
towards the fetal chest.

RATIONALE:

This maneuver attempt to position the shoulders to utilize the smallest possible diameter of the
fetus through the largest diameter of the woman.

10. Rotation of the posterior shoulder Woodscrew Maneuver is done by applying

pressure to the anterior aspect of the posterior shoulder, and an attempt is made to rotate the
posterior shoulder to the anterior position. Woodscrew maneuver is done by inserting two
fingers on anterior aspect of posterior shoulder while pressure is applied to the anterior aspect
of the posterior shoulder, and an attempt is made to rotate the posterior shoulder to the
anterior position.

RATIONALE: Woods maneuver is a screw-like maneuver. Success of this maneuver allows easy
delivery of that shoulder once past the symphysis pubis. In practice, the anterior disimpaction
maneuver and Woods‟ maneuver may be done simultaneously and repetitively to achieve
disimpaction of the anterior shoulder

11. Manual removal of the posterior arm

The arm is usually flexed at the elbow. If it is not, pressure in the antecubital fossa can assist
with flexion. The hand is grasped, swept across the chest and delivered (as shown in Figure 9
below).

SCRIPT FOR RETURN DEMONSTRATION

Delivering the posterior arm is done by applying pressure intravaginally at the antecubital fossa
which causes fetal arm to flex and I will grasp it and swept across the chest and towards the
opposite side of the fetal face.

RATIONALE: This may lead to humeral fracture if its not done properly, which does not cause
permanent neurological damage.

12. Episiotomy (this procedure should be done by the obstetrician as seen below)

May be delayed until after pressure and McRoberts

Effect:

-Increases room to work for rotational maneuvers Nurses cannot perform episiotomy and
should be done by the obstetrician.

13. Roll over to “all fours” position:

Gaskin Maneuver is done by assisting the client to roll onto hands and knees and applying
downward traction to deliver posterior shoulder and may be repeated if needed until the
shoulder is delivered. Gaskin maneuver is done by assisting the client to roll onto hands and
knees and I will apply downward traction (pull downward) to deliver the posterior shoulder that
can be repeated until the shoulder of the fetus is delivered

RATIONALE:

Gaskin maneuver Moving the woman to "all fours" appears to increase the effective pelvic
dimensions, allowing the fetal position to shift; this may disimpact the shoulders. With gentle
downward pressure on the posterior shoulder, the anterior shoulder may become more
impacted (with gravity), but will facilitate the freeing up of the posterior shoulder. Also, this
position may allow easier access to the posterior shoulder for rotational maneuvers or removal
of the posterior arm Prior experience with delivery in this position is an asset (this maneuver, as
shown in Figure 10) This is believed to increase pelvic size and make use of the force of gravity.
14. Call out the time of birth and gender of the baby.

I will call out the time of birth and gender of the newborn and if the baby is crying I will
proceed with EINC if the baby is not crying I will cut the cord and resuscitate the infant.

RATIONALE:

To safeguard mother and baby against infection. To facilitate spontaneous breathing of the
infant.

15. After the delivery Assess the baby’s Moro reflex Check for a fractured clavicle or humerus

After the delivery I will assess the baby’s Moro reflex and check for fractured clavicle or
humerus for possible injury

RATIONALE:

A complete symmetric Moro response usually indicates no brachial plexus injury, which is the
most common serious resulting in injury. If an injury occurred, be prepared to discuss the
possible outcomes with the parents after the pediatrician has spoken with them, 80% of these
injuries resolve and cause no permanent damage with appropriate treatment.

16. Assess for postpartum hemorrhage. After delivery of the placenta I will check for its
cotyledons if it is complete, I will assess the

RATIONALE: perineum and the vagina for lacerations. This is the greatest risk to the mother
from a shoulder dystocia. The hemorrhage is usually related to uterine atony or vaginal or
cervical lacerations.

17. Remove gloves and wash your hands. I will remove my gloves after I clean the instruments
and will wash my hands after. RATIONALE: To limit the transfer of microorganism

18. Document the procedure.

I will document the procedure and record.

RATIONALE:

To provide accurate data in the care of client.

Other Maneuvers:

***If nothing has worked to this point and all the procedures have been tried again.

***The following maneuvers is performed by an obstetrician

PROCEDURE

1. Deliberate fracture of the clavicle. Pull clavicles outward and Fracture one or both Risk of
underlying vascular or lung injury

2. Symphysiotomy

The cartilage of the symphysis pubis (where the pubic bones come together) may be surgically
divided to increase the size of the pelvic outlet.

Symphysiotomy results in a temporary increase in pelvic diameter (up to 2 cm) by surgically

dividing the ligaments of the symphysis under local anesthesia. This procedure should be
carried out only in combination with vacuum extraction. Symphysiotomy in combination with
vacuum extraction is a life-saving procedure in areas where cesarean section is not feasible or
immediately available. Symphysiotomy leaves no uterine scar and the risk of ruptured uterus in
future labors is not increased.

3. Zavenelli maneuver: cephalic replacement

This maneuver involves reversing the cardinal movements of labor. The head is rotated to
occiput anterior (as shown in Figure 12.) Flex, push up, rotate to transverse, disengage, and
perform a cesarean section.

Cesarean Section with cephalic replacement One provider performs emergency cesarean
Second provider replaces head Rotate fetal head into direct Occiput Anterior position Fetal neck
is flexed with chin pressing into perineum Head pushed back into vagina (gently) Provider
provides continuous pressure on head to hold the fetus within the uterus Uterine relaxation
with IV Nitroglycerin or inhalational Anesthetic may be needed

MULTIPLE CHOICE (10 points)

Answer the questions carefully

1. This maneuver straightens sacrum and decreases angle of incline symphysis pubis and
dislodges the impacted shoulder. Shoulder dystocia is often resolved by this maneuver alone.

C. McRoberts
2. Shoulder dystocia is an obstetrical emergency, therefore:

B. The obstetrician must begin a cesarean section immediately

3. What type of pressure should be avoided during a shoulder dystocia delivery?

A. Fundal

4. Suprapubic pressure should be applied for no longer than:

B. 30 seconds

5. The main purpose of Rubin’s maneuver is to:

D. Deliver the anterior arm

6. This maneuver is done by applying suprapubic pressure applied with the heel of clasped
hands from the posterior aspect of the anterior shoulder to dislodge it:

C. Mazzanti Maneuver

7. This maneuver is done by applying pressure to the anterior aspect of the posterior shoulder,
and an attempt is made to rotate the posterior shoulder to the anterior position.

B. Woodscrew Maneuver

8. This maneuver is done by assisting the client to roll onto hands and knees and applying
downward traction to deliver posterior shoulder and may be repeated if needed until the
shoulder is delivered.

D. Gaskin Maneuver

9. This maneuver attempts to position the shoulders to utilize the smallest possible diameter of
the fetus through the largest diameter of the woman.
A. Rubin’s Maneuver

10. This maneuver involves reversing the cardinal movements of labor. The head is rotated to
occiput anterior, flex, push up, rotate to transverse, disengage, and perform a cesarean section.

B. Zavanelli Maneuver

SESSION 5. BREECH EXTRACTION (p.1355)

DEFINITION

 the fetal head is the widest single diameter,

the buttocks (breech) plus the legs of the

fetus actually take up more space.

 As the fundus is the largest part of the uterus,

this places the bulkiest parts of the fetus in

the fundus.

 There are several types of breech

presentations: complete, frank, and footling.

Overall, a breech presentation is more hazardous to

a fetus than a cephalic presentation because there is

a higher risk of the following:

• Developing dysplasia of the hip

• Anoxia from a prolapsed cord

• Traumatic injury to the after-coming head

(possibility of intracranial hemorrhage or anoxia)

• Fracture of the spine or arm

• Dysfunctional labor

• Early rupture of the membranes because of the

poor fit of the presenting part

• Meconium staining

RISK FACTORS

 Abnormal amnionic fluid volume

 High parity with uterine relaxation

 Prior breech delivery

 Hydrocephaly

 Anencephaly

 Pelvic tumors

 Uterine anomalies

 Multifetal gestation

 Early gestational age

 Placenta previa

 Fundal placental implantation

Three types of vaginal breech deliveries are

described:

1. Spontaneous breech delivery: No traction or manipulation of the infant by the clinician is

done. The fetus delivers spontaneously on its own. This occurs predominantly in very preterm
deliveries.

2. Assisted breech delivery: This is the most common mode of vaginal breech delivery. In this
method a “no-touch technique” is adopted in which the infant is allowed to spontaneously
deliver up to the umbilicus, and then certain maneuvers are initiated by the clinician to aid in
the delivery of the remainder of the body, arms, and head.

3. Total breech extraction: In this method, the fetal feet are grasped, and the entire fetus is
extracted by the clinician. Total breech extraction should be used only for a noncephalic second
twin; it should not be used for singleton fetuses because the cervix may not be adequately
dilated to allow passage of the fetal head.

INDICATIONS

Certain indications for breech vaginal delivery are:

• Frank or complete breech (not footling)

• Estimated fetal weight between 1.5 kg and 3.5 kg

• Gestational age (36–42 weeks)

• Well-flexed fetal head (no evidence of hyperextension of the fetal head)

• Adequate pelvis (no fetopelvic disproportion)

• Normal progress of labor on partogram

• Uncomplicated pregnancy (No contraindications to vaginal birth, e.g. placenta previa, severe
IUGR, etc.

• Multiparas

• No obstetric indication for cesarean section, e.g. placenta previa, etc.

• An experienced clinician

• Presence of severe fetal anomaly or fetal death

• Mother’s preference for vaginal birth

• Delivery is imminent in case of breech presentation.

MANAGEMENT

PROCEDURE

1. Gather all items you will need for the internal

examination.
For easy accessibility for the inspection of the

external genitalia, vagina and cervix.

2. Identify the client, introduce yourself and explain

the procedure (internal examination).

To obtain client’s cooperation and work

simultaneously.

3. Position the client on the examination table.

*Three positions are employed for internal

examination:

 Dorsal Recumbent

 Sim’s Position

 Knee-chest Position

The aforementioned positions are made best so as to expose the gynecologic area to be
examined. Position depends on client’s capability and examiner’s preferred position.

4. Drape the client. Expose only the gynecological area.

Always respect the client’s modesty and to provide privacy.

5. Wash hands- and put-on sterile gloves. To protect the health care provider from contracting
gynecological diseases caused by highly infective organisms.

6. Explain the necessity of effective pushing in the second stage of labor. Spontaneous descent
and expulsion to the umbilicus should occur with maternal pushing only DO NOT PULL ON THE
BREECH! Rotation of the sacrum anterior position is desired and maybe facilitated.

DELIVERY OF THE BABY’S LEGS

7. GROIN TRACTION

In single groin traction, Hook the index finger of

ONE hand in the groin fold and traction is exerted towards the fetal trunk rather than towards
the fetal femur, in accordance with the uterine contractions. (as shown below) In double groin
traction, Hook the BOTH fingers of the hand are in the groin folds and then traction is applied.
(as seen below)

This procedure is done if the buttocks and hips are not delivered by themselves. The Health
Care Provider can make use of these two procedures: Groin traction and Pinard Maneuver.

8. If the legs do not deliver spontaneously, perform the Pinard maneuver.

Do not attempt to extract the legs until the popliteal fossae are visible. (as seen on figure 6)

This procedure involves manipulation within the birth canal to convert the frank breech into a
footling breech. It aids in bringing the fetal feet within reach of the operator. This causes
spontaneous flexion of the knee and delivery of the foot. Pinard’s Maneuver is used as well in
frank breech extraction

DELIVERY OF THE ANTERIOR SHOULDER

9. Lovset’s Maneuver

This maneuver is based on the principle that due to the curved shape of the birth canal, when
the anterior shoulder is above the pubis symphysis, the posterior shoulder would be below the
level of pubic symphysis.

The maneuver should be initiated only when the fetal scapula becomes visible underneath the
pubic arch

Step 1 The baby is grasped using both hands by femoropelvic grip keeping the thumbs parallel
to the vertebral column.(as seen below)

Holding the baby by the flank or abdomen, may cause kidney or liver damage.

Do not pull on the breech or compress the woman’s abdomen.

Maintain flexion of the fetal head by keeping the body below the horizontal.

Step 2 The baby is lifted up slightly to cause lateral flexion. (as seen below)

This will bring posterior arm to emerge under the pubic arch which is then hooked out.

The appearance of one axilla indicates that its time to deliver the shoulders.
There’s no difference which shoulder is delivered

first.

The trunk is rotate through 180 degrees keeping the

back anterior and maintaining downward traction. (as

seen below)

The body of the fetus is rotated 180 degrees in the

reverse direction to deliver the other shoulder and

arm.

Step 3 The trunk is then rotate in the reverse

direction keeping the back anterior to deliver the

anterior shoulder under the symphysis pubis.

Rotating on the reverse direction keeping the back

anterior will help to deliver the anterior shoulder

under the symphysis pubis.

DELIVERY OF THE POSTERIOR SHOULDER

***If the clinician is unable to turn the baby’s body to deliver the arm that is anterior first,
through Lovset’s maneuver, then the clinician can deliver the shoulder that is posterior first.

10. Step 1 Feet are grasped in one hand and drawn

upward over the inner thigh of the mother, toward

which the ventral surface of the fetus is directed. (as

seen below)

This maneuvers are done when the anterior shoulder

cannot be delivered through Lovset’s.

Step 2 By rotating the fetus through a half circle in

such a direction that the friction exerted by the birth

canal will serve to draw the elbow toward the face.

(as seen below)

By depressing the body of the fetus, the anterior

shoulder emerges beneath the pubic arch, the arm

and hand usually follow spontaneously.

Step 3 Nuchal Arm

Push the fetus upward in an attempt to release it (as shown below)and hook a finger(s) over it
and force the arm over the shoulder, and down the ventral surface. Nuchal arm delivery is done
when the arm and hand does not follow on with the rotation of the fetal body by the health
care provider thus lessening the risk for clavicular and humeral fracture.

10. Modified Prague Maneuver Two fingers of one hand will grasp the shoulders of the back-
down fetus from below while the other hand draws the feet up and over the maternal
abdomen. (as seen below)

Rarely, the back of the fetus fails to rotate to the

anterior.

Rotation of the back to the anterior may be achieved

using stronger traction on the fetal legs or bony

pelvis.

If the above-mentioned maneuvers are still

unsuccessful Modified Prague Maneuver is another

way to deliver the shoulders.

DELIVERY OF THE AFTER-COMING HEAD

11. BURNS-MARSHALL MANEUVER

Step 1: Baby’s trunk is allowed to hang by its own

for a while (never for more than 1 minute).

Burns-Marshall Maneuver is a method of breech

delivery when the head is flexed involving traction to

prevent the neck from bending backwards and being

fractured.

Step 2: When the nape of the neck is visible under

the pubic arch, baby’s trunk is gradually lifted up.

With the help of gravity the head of the baby will be

delivered with safely.

Step 3: Put the left hand on the perineum and while

grasping the feet of the baby swing it upward

gradually towards mother’s abdomen by holding

baby’s legs above the ankles, thus head is delivered.

To lessen the risk for perineal laceration with the

delivery of the head.

2. MAURICEAU-SMELLIE-VEIT MANEUVER

Step 1: Maintain the head in flexion by placing the

finger over the chin and malar eminences.

(as shown below)

This is another commonly used maneuver for the

delivery of after-coming fetal head and is named

after the three

clinicians who had described the method of using

this grip.
The fingers that are placed over the chin and malar

eminence can be placed as well on the mouth. (jaw

thrust)

Step 2: The ring and little fingers of the pronated

right hand are placed on the baby’s right shoulder,

the index finger is placed on the left shoulder and the

middle finger is placed on the sub-occipital region.

(as shown with the hand placement on the picture

below)

The handling of the baby provides adequate support

when pulling the baby outward.

Step 3: Traction is now given in downward and

backward direction till the nape of neck is visible

under the pubic arch. The assistance gives supra

pubic pressure during the period to maintain flexion.

(as shown in the picture with arrows)

Step 4: The baby is carried in upward and forward

direction towards the mother’s abdomen releasing

the face, brow and lastly, the trunk is depressed to

release the occiput and vertex.(as shown below)

With the bearing down effort of the mother and the

suprapubic pressure applied by the assistant the

head of the baby will be delivered and as well as

minimizing the lacerations on perineal and vaginal

area.

12. Call out the time of birth and gender of the baby.

To safeguard mother and baby against infection.

To facilitate spontaneous breathing of the infant.

13. Assess for postpartum hemorrhage. This is the greatest risk to the mother from a

shoulder dystocia. The hemorrhage is usually related

to uterine atony or vaginal or cervical lacerations.

14. Remove gloves and wash your hands. To limit the transfer of microorganism

15. Document the procedure. To provide accurate data in the care of client.

MULTIPLE CHOICE (10points)

Answer the following questions carefully

1. The following are risk factors of breech delivery. SELECT ALL THAT APPLY

A. Abnormal amnionic fluid volume

B. High parity with uterine relaxation

C. Prior breech delivery

D. Hydrocephaly

E. Anencephaly

2. This type of vaginal breech delivery wherein there is no traction or manipulation of the infant
by the clinician is done. The fetus delivers spontaneously on its own.

A. Spontaneous breech delivery

3. In this method of vaginal breech delivery, a “no-touch technique” is adopted in which the
infant is allowed to spontaneously deliver up to the umbilicus. This is the most common mode
of vaginal breech delivery.

B. Assisted breech delivery

3. In this method, the fetal feet are grasped, and the entire fetus is extracted by the clinician.

D. Total breech extraction

4. In this type of groin traction, the health care provider hook the index finger of his one hand in
the groin fold and traction is exerted towards the fetal trunk rather than towards the fetal
femur, in accordance with the uterine contractions.

A. Single Groin Traction

5. In this type of groin traction, the health care provider Hook both fingers of the hand are in
the groin folds and then traction is applied.

C. Double Groin Traction

6. This maneuver is based on the principle that due to the curved shape of the birth canal, when
the anterior shoulder is above the pubis symphysis, the posterior shoulder would be below the
level of pubic symphysis.

B. Lovset’s Maneuver

7. A method of breech delivery when the head is flexed involving traction to prevent the neck
from bending backwards and being fractured.

D. Burns Marshall Maneuver

8. This procedure involves manipulation within the birth canal to convert the frank breech into a
footling breech. It aids in bringing the fetal feet within reach of the health care provider.
C. Pinard’s Maneuver

9. This is another commonly used maneuver for the delivery of after-coming fetal head and is
named after the three clinicians who had described the method of using this grip.

A. Mauriceu-Smellie Vei Maneuver

10. This maneuver is done by rotating the back to the anterior that may be achieved by using
stronger traction on the fetal legs or bony pelvis.

E. Modified Prague Maneuver

SESSION 6. VERSIONS
 Fetal presentation is altered by physically substituting one pole of a longitudinal presentation
for the other, or converting an oblique or transverse lie into a longitudinal presentation.

1. EXTERNAL CEPHALIC VERSION (as seen on figure 6.30 A to D)

 Manipulations performed through the abdominal wall that yield a cephalic presentation.

 External cephalic version (ECV) reduces the rate of non-cephalic presentation at birth
(Hofmeyr,

2015b).

INDICATIONS

 Breech presentation

 Transverse lie

CONTRAINDICATIONS

 early labor,

 oligohydramnios or rupture of membranes

 nuchal cord,

 structural uterine abnormalities

 fetal-growth restriction, and prior

 abruption or its risks (Rosman, 2013).

 Prior Cesarean Section

COMPLICATIONS

 risks for placental abruption

 preterm labor

 fetal compromise

 uterine rupture

 feto-maternal hemorrhage

 alloimmunization

 amnionic fluid embolism

 death may also complicate attempts at external version

 dystocia

 malpresentation

 non-reassuring fetal heart patterns

2. INTERNAL PODALIC VERSION

 A fetus is turned to a breech presentation using the hand placed into the uterus (Fig. 45-26).

 The obstetrician grasps the fetal feet to then effect delivery by breech extraction.

INDICATION

 the only indication is when the fetus in transverse lie in case of second baby in twin
gestation.

Technique for Internal Podalic Version

Prerequisites for Internal Podalic Version

Before undertaking the procedure of internal podalic version, the obstetrician must make sure
that the
following conditions are fulfilled:

• Cervix must be completely dilated.

• Liquor/amniotic fluid must be adequate for intrauterine manipulation.

• Fetal lie, presentation and FHR must be assessed by an experienced obstetrician before
undertaking the procedure.

Actual Procedure

The procedure must be ideally performed under general anesthesia with the uterus sufficiently
relaxed.

• Under all aseptic precautions, the clinician introduces one of his/her hands into the uterine
cavity in a cone-shaped manner.(b)

• The hand is passed along the breech to ultimately grasp the fetal foot, which is identified by
palpation of its heel. While the foot is gradually brought down, clinician’s other hand present
externally over the abdomen helps in gradually pushing the cephalic pole upwards.(c)

• Rest of the delivery is completed by breech extraction.

Complications due to internal podalic version Maternal Fetal

• Placental abruption

• Asphyxia

• Rupture uterus

• Cord prolapse

• Increased maternal mortality and morbidity

• Intracranial hemorrhage

SESSION 7. CESAREAN SECTION

 Cesarean section is a surgical procedure commonly used in the obstetric practice.

 the fetal delivery is attained through an incision made over the abdomen and uterus, after 28
weeks

of pregnancy.

If the removal of fetus is done before 28 weeks of pregnancy, the procedure is known as
hysterotomy.

 The use of cesarean delivery helps in avoiding difficult cases of vaginal delivery, which may be

associated with considerable maternal and fetal mortality and morbidity.

INDICATIONS

 Cephalopelvic disproportion

 Placenta previa

 Estimated fetal weight >4 kg

 Hyperextension of fetal head

 Footling breech (danger of entrapment of head in an incompletely dilated cervix)

 Severe Intrauterine Growth Restriction (IUGR)

 Clinician not competent with the technique of breech vaginal delivery

COMPLICATIONS

 Abdominal pain

 Injury to bladder, ureters, etc.

 Increased risk of rupture uterus and maternal death

 Neonatal respiratory morbidity

 Requirement for hysterectomy

 Thromboembolic disease

 Increased duration of hospital stay

 Antepartum or intrapartum intrauterine deaths in future pregnancies

 Patients with a previous history of cesarean delivery are prone to develop complications, like

placenta previa and adherent placenta during future pregnancies

PROCEDURE

Preoperative Preparation

The following steps should be taken for preoperative preparation:

1. Empty stomach: The patient should be NPO for at least 12 hours before undertaking a
cesarean section. In case the patient is full stomach, she should be administered H2 receptor
blocker (ranitidine 150 mg) and an antiemetic (metoclopramide 10 mg) at least 2 hours prior to
the surgery.

To prevent the risk of aspiration at the time of administration of anesthesia

2. Patient position: The patient is placed with 15° lateral tilt on the operating table.

To reduce the chances of hypotension.

3. Anesthesia: While cesarean section can be performed both under general or regional
anesthesia, nowadays regional anesthesia is favored.

Spinal and epidural anesthesia have become the most commonly used forms of regional
anesthesia in the recent years.

4. Clinical examination: Before cleaning and

draping the patient, it is a good practice to check the fetal lie, presentation, position and fetal
heart sounds once again. Foley’s or plain rubber catheter must be inserted, following which the
cleaning and draping of the abdomen is done.

To monitor the fetal heart tone of the fetus.

5. Preparation of the skin: The area around the proposed incision site must be washed with
antiseptic soap solution (e.g. savlon and/or betadine solution).

 The antiseptic solution must be applied at least three times over the incision site, using a
high-level disinfected sponge-holding forceps and cotton or gauze swab.

Antiseptic skin cleansing before surgery is thought to reduce the risk of postoperative wound
infections

Steps of Surgery

6. A vertical or transverse incision can be given over

the skin (Fig. 7.3). The vertical skin incision can be either given in the midline or paramedian
location, extending just above the pubic symphysis to just below the umbilicus.

Previously, vertical skin incision at the time of cesarean section was favored, as it was supposed
to provide far more superior access to the surgical field in comparison to the transverse incision.
Also, the vertical incision showed potential for extension at the time of surgery. However, it was
associated with poorcosmetic results and an increased risk of wound dehiscence and hernia
formation. Therefore, nowadays, transverse incision is mainly favored due to better cosmetic
effect, reduced postoperative pain and improved patient recovery.

Two types of transverse incisions are mainly used, while performing cesarean section:

(1) the sharp (Pfannenstiel) type and

(2) the blunt (Joel Cohen) type.

Sharp Pfannenstiel transverse incision: While giving this type of incision, a slightly curved,
transverse skin incision is made at the level of pubic hairline, about an inch above the pubic
symphysis and is extended somewhat beyond the lateral borders of rectus abdominis muscle.

 The subsequent tissue layers, until the level of anterior rectus sheath are opened by using a
sharp scalpel.

7. Dissecting the Rectus Sheath

After dissecting through the skin, subcutaneous fat and fascia, as the anterior rectus sheath is
reached, sharp dissection may be required. A scalpel can be used to incise the rectus sheath
throughout the length of the incision. The cut edges of the incised rectus sheath are held with
the help of allis forceps and then carefully separated out from the underlying rectus muscle and
pyramidalis.

These muscles are then separated with the help of blunt and sharp dissection to expose
transversalis fascia and peritoneum.

8. Opening the Peritoneum

The transversalis fascia and peritoneal fat are dissected carefully to reach the underlying
parietal peritoneum. After placing two hemostats about 2 cm apart to hold the peritoneum, it is
carefully opened.

The layers of parietal peritoneum are carefully examined to be sure that omentum, bowel or
bladder is not lying adjacent to it.
9. Insertion of the Doyen’s Retractor

Following the identification of lower uterine segment, some surgeons prefer to put a moistened
laparotomy pack in each of the paracolic gutters. The loose fold of the uterovesical peritoneum
over the lower uterine segment is then grasped with the help of forceps and incised
transversely with the help of scissors. The lower flap of the peritoneum is held with artery
forceps and the loose areolar tissue pushed down. The underlying bladder is then separated by
blunt dissection. Finally, the lower flap of peritoneum and the areolar tissue is retracted by the
Doyen’s retractor to clear the lower uterine segment. The upper flap of the peritoneum is
pushed up to leave about 2 cm wide strip on the uterine surface, which is not covered with
visceral peritoneum.

Doyen Retractor is used in abdominal OB/GYN, retracting bladder, and cesarean section
procedure. The retractor has a round concave blade, the palm grip handle has a little hook at
the end and a thumb rest, the handle is designed to provide grip and comfort. It is used by
surgeons to either actively separate the edges of a surgical incision or wound, or can hold back
underlying organs and tissues, so that body parts under the incision may be accessed.

10. Giving a uterine incision: An incision is made

on the lower uterine segment about 1 cm below the upper margin of peritoneal reflection and
about 2–3 cm above the bladder base. While making an incision in the uterus, a curvilinear
mark of about 10 cm length is made by the scalpel, cutting partially through the myometrium.
Following this, a small cut (about 3 cm in size) is

made, using the scalpel in the middle of this incision

mark, reaching up to, but not through the membranes. The rest of the incision can be
completed either by

The uterine incision must be gently given, taking care to avoid any injury to the underlying fetus.
stretching the incision, using the tips of two index fingers along both the sides of the incision
mark (Fig. 7.4A) or using bandage scissors, to extend the incision on two sides (Fig. 7.4B).The
metzenbaum scissors are introduced into the uterus over the two fingers, in order to protect
the fetus.

The uterine incision must be large enough so as to

allow the delivery of the head and trunk without the

risk of extension of the incision laterally into the

uterine vessels. As the fetal membranes bulge out

through the uterine incision, they are ruptured.

The amniotic fluid, which is released following the

rupture of membranes, is sucked with the help of a

suction machine.

The use of metzenbaum scissors may be especially

required in cases, where the lower uterine segment

is thickened andthe uterine incision cannot be

extended using the fingers. If the lower uterine

segment is very thin, injury to the fetus can be

avoided, by using the handle of the scalpel or a

hemostat (an artery forceps) to open the uterus.

Location of the uterine incision: The incision in the uterus is commonly given over the lower
uterine

segment.

The classical incision has been found to be associated with high risk of scar rupture during
future

pregnancies. As a result, lower segment transverse scars are nowadays preferred.

The lower segment uterine scar is considered to be stronger than the upper segment scar due
to the

reasons mentioned in Table 7.3.

11. Delivery of the Infant

In case of cephalic presentation, once the fetal

presenting

part becomes visible through the uterine incision, the

surgeon places his/her right hand below the fetal

presenting part and grasps it.

In case of cephalic presentation the fetal head is

then elevated gently, using the palms and fingers of

Delivery of the fetal head should be in the same way

as during the normal vaginal delivery.

Fundal massage, following the delivery of the baby,

helps in reducing bleeding and hastens the delivery

of placenta. the hand.

The Doyen’s retractor is removed, once the fetal

presenting part has been grasped.

In order to facilitate delivery, fundal pressure is

applied by

the assistant. Delivery is completed in the manner

similar

to normal vaginal delivery.

Once the baby’s shoulders have delivered, an IV

infusion containing 20 IU of oxytocin per liter of

crystalloids is infused at a rate of 10 mL/minute, until

effective uterine contractions are obtained.

Following the delivery of the baby, the doctor will call

out the time of delivery and the sex of the baby.

The cord is clamped and cut and the baby handed

over to the clinician.

12. Placental Removal

Following the delivery of the placenta, the remnant

bits of membranes and decidua are removed using a

sponge-holding forceps. The cut edges of the uterine

incision are then identified and grasped with the help

of Green Armytage clamps.(as seen below)

The uterine angles are usually grasped with allies

forceps.

At the time of cesarean, the placenta should be

removed,

using controlled cord traction (Fig. 7.5) and not

manual

removal as this reduces the risk of endometritis.

13. Closing the Uterine Incision

The main controversy related to the closure of the

uterine incision is whether the closure should be in

the form of a single-layered or a double-layered

closure.

Both single-layered and double-layered closure of

uterine

incision are being currently practiced.

If tubal sterilization has to be performed, it is done

following the closure of uterine incision.

Following the uterine closure, swab and instrument

count is done.

Once the count is found to be correct, the abdominal

incision is closed in layers.

Though single- layered closure is associated with

reduced operative time and reduced blood loss in the

short term, the risk of the uterine rupture during

subsequent pregnancies is increased. The current

recommendation is to close the uterus in two layers,

as the safety and efficacy of closing uterus in a

single layer is presently uncertain. Individual

bleeding sites can be approximated with the help of

figureof-eight sutures.

14. Peritoneal Closure

The current recommendation by (Royal College of

Obstetrician and Gynecologist)RCOG is that neither

the visceral nor the parietal peritoneum should be

sutured at the time of cesarean section.

This reduces the operative time and the requirement

for the postoperative analgesia.

15. Closure of the Rectus Sheath

Rectus sheath closure is performed after identifying

the angles and holding them with allies forceps.

The angles must be secured using 1-0 vicryl sutures.

The rectus layer is closed with the help of continuous

locked sutures placed no more than 1 cm apart.

Hemostasis must be checked at all levels.

16. Closure of Subcutaneous Space

There is no need for the routine closure of the

subcutaneous tissue space, unless there is more

than 2 cm of subcutaneous fat.

To reduce the incidence of the wound infection.

17. Skin Closure

Clinicians should be aware that presently the

differences

between the use of different suture materials and

methods of skin closure at the time of cesarean

section are not certain.

Skin closure can be either performed, using

subcutaneous, continuous repair absorbable or

nonabsorbable stitches or using interrupted stitches

with nonabsorbable sutures or staples.

Following the skin closure, the vagina is swabbed

dried and dressing applied to the wound.

POSTOPERATIVE CARE

1. After surgery is completed, the woman needs to

be

monitored in a recovery area.

When the effects of anesthesia have worn off, about

4–8 hours after surgery, the woman may be

transferred to the postpartum room.

Monitoring of routine vital signs (blood pressure,

temperature, breathing), urine output, vaginal

bleeding

and uterine tonicity (to check, if the uterus remains

adequately contracted), needs to be done at hourly

intervals for the first 4 hours. Thereafter, the

monitoring

needs to be done at every four hourly intervals for

the first

postoperative day at least. Adequate analgesia

needs to

be provided, initially through the IV line and later with

oral medications.

2. Fluids and oral food after cesarean section: As

a general rule, about 3 liters of fluids must be

replaced by IV infusion during the first postoperative

day, provided that the woman’s urine output remains

greater than 30 mL/hour.

If the urine output falls below 30 mL/hour, the woman

needs to be reassessed to evaluate the cause of

oliguria.
In uncomplicated cases, the urinary catheter can be

removed by 12 hours postoperatively. Intravenous

fluids may need to be continued, until she starts

taking liquids orally.

The clinician needs to remember that prolonged

infusion of IV fluids can alter electrolyte balance. If

the woman receives IV fluids for more than 48 hours,

her electrolyte levels need to be monitored every 48

hours.

Balanced electrolyte solution (e.g. potassium

chloride 1.5 g in 1 L IV fluids) may be administered.

3. Ambulation after cesarean section: The women

must be encouraged to ambulate as soon as 6–8

hours following the surgery.

Walking also improves blood flow and speeds wound

healing. Failure to walk may cause increased

constipation and gas pain and weakness, and puts

the patient at a higher risk for infections, blood clots

and lung problems such as pneumonia.

4. Dressing and wound care: The dressing must be

kept on the wound for the first 2–3 days after

surgery, so as to provide a protective barrier against

infection. Thereafter, dressing is usually not required.

If blood or fluid is observed to be leaking through the

initial dressing, the dressing must not be changed.

The amount of blood/fluid lost must be monitored.

If bleeding increases or the bloodstain covers half

the dressing or more, the dressing must be removed

and replaced with another sterile dressing.

The dressing must be changed while using a sterile

technique.

The surgical wound also needs to be carefully

inspected.

5. Length of hospital stay: Length of hospital stay

is likely to be longer after a cesarean section (an

average of 3–4 days) in comparison to that after a

vaginal birth (average 1–2 days).

Women who are recovering well and have not

developed complications following cesarean may be

offered early discharge.

Multiple Choice:

Answer the following questions carefully.

1. Raya is pregnant and was told by her OB doctor that her baby is on face presentation. In face
presentation, when is cesarean birth necessary?

A. If the chin is anterior.

2. What is a contraindication to external cephalic version?

A. Hydramnios
3. Julanne a client who delivered by cesarean section 24 hours ago is using a patient-controlled
analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She
is now complaining of nausea and bloating, and states that because she had nothing to eat, she
is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority?

C. Impaired bowel motility related to pain medication and immobility

4. Karina is performing an assessment of a client who is scheduled for a cesarean delivery.

Which assessment finding would indicate a need to contact the physician?

A. Fetal heart rate of 180 beats per minute

5. Which of the following fetal positions is most favorable for cesarean birth?

A. Vertex presentation

6. Carly a client is admitted to the L & D suite at 36 weeks’ gestation. She has a history of C-
section and complains of severe abdominal pain that started less than 1 hour earlier. When the
nurse palpates tetanic contractions, the client again complains of severe pain. After the client
vomits, she states that the pain is better and then passes out. Which is the probable cause of
her signs and symptoms?

C. Uterine rupture

7. Manipulations performed through the abdominal wall that yield a cephalic presentation.

A. External Cephalic Version

8. A fetus is turned to a breech presentation using the hand placed into the uterus.

B. Internal Podalic Version

9. Which of the following are complications of Cesarean Section, SELECT ALL THAT APPLY:

A. Injury to bladder and ureters

B. Increased risk of rupture uterus and maternal death

C. Neonatal respiratory morbidity

D. Requirement for hysterectomy

10.Which of the following are indications for Cesarean Section, SELECT ALL THAT APPLY:

A. Cephalopelvic disproportion

B. Placenta previa

C. Estimated fetal weight >4 kg

D. Hyperextension of fetal head

11. Astra had a cesarean section and is 2 days post-op. What is an important measure to reduce
the size of the bladder and keep it away from the surgical field during cesarean birth?

C. Insert a urinary catheter to drain the bladder and decrease its size.

12. Carrie is to administer ranitidine (Zantac) as ordered prior to a planned cesarean birth to:

B. Decrease gastric secretions.

13. Carrie instructs Astra on deep breathing exercises as part of the preoperative teaching plan.
The rationale for this exercise is to:

A. Stimulate the diaphragm to contract.

B. Promote involution on a traumatized uterus.

C. Prevent stasis of mucus in the lungs.

D. Prevent pulmonary edema.

14. You are asked by your instructor regarding Cesarean Section. What is the most important
responsibility of the healthcare team before the surgery starts?

D. Securing an informed consent and ensuring that it is obtained.

15. The nurse administers Ringer’s solution intravenously for what purpose?

B. To ensure that the woman is fully hydrated.

16. Dr. Callum a surgeon plans to perform a low segment incision rather than a classic incision.
This type of incision is more advantageous because:

D. The likelihood of a postpartal uterine infection is decreased.

17. Katrine was asked by her instructor that if oxytocin is ordered postoperatively for the client
who has had a cesarean birth, the most important nursing intervention would be to:

A. Monitor the woman’s blood pressure.

18. Charie was asked which of the following interventions would be most helpful to assist a
woman to void after a cesarean birth?

C. Running water from the tap within woman’s hearing distance.

19. Ramina has undergone a cesarean birth is to be discharged. You would instruct the woman
to notify her health care provider if she develops which of the following?

A. Drainage at her incision line.

20. Which of the following is a complication of pain that occurs postoperatively?

B. Pneumonia
SESSION 8. UTERINE ATONY
Nursing Care of a Family Experiencing a Postpartum Complication

UTERINE ATONY

Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartum
hemorrhage; it tends to

occur most often in Asian, Hispanic, and Black woman (Grobman, Bailit, Rice, et al., 2015).

Factors that predispose a woman to poor uterine tone or the inability of her uterus to maintain
a contracted

state are summarized in Box 25.3. When caring for a woman in whom any of these conditions
are present, be

especially conscientious in your observations and be on guard for signs of uterine bleeding.

Nursing Diagnoses and Related Interventions

Nursing Diagnosis:

Deficient fluid volume related to excessive blood loss after birth.

Outcome Evaluation:

Patient’s blood pressure and heart rate remains within usual defined limits; lochia flow is less
than one

saturated perineal pad per hour.

 If the uterus suddenly relaxes, there will be an abrupt gush of blood vaginally from the
placental site.

This can occur immediately after birth but is more likely to occur gradually, over the first
postpartum

hour, as the uterus slowly loses its tone.

 If the loss of blood is extremely copious, a woman will quickly begin to exhibit symptoms of

hypovolemic shock such as a falling blood pressure; a rapid, weak, or thready pulse; increased
and

shallow respirations; pale, clammy skin; and increasing anxiety.

 If the blood loss is unnoticed seepage, there is little change in pulse and blood pressure at
first

because of circulatory compensation. Suddenly, however, the system is able to compensate no

more,

and the pulse rate rises rapidly and becomes weak.

 Blood pressure then drops abruptly. With slow bleeding, a woman develops these
symptoms over a

period of hours; the end result of continued seepage, however, can be as life threatening as a
sudden

profuse loss of blood (Andrighetti, 2013).

It is difficult to estimate the amount of blood a postpartal woman is losing because it is difficult
to estimate the

amount of blood

 It takes to saturate a perineal pad (between 25 and 50 ml). By counting the number of
perineal pads

saturated in given lengths of time, such as half-hour intervals, a rough estimate of the amount
of blood

loss can be formed.

 Five pads saturated in half an hour is obviously a different situation from five pads saturated
in 8 hours.

 A woman will have lost approximately 250 ml of blood, and if either scenario is allowed to
continue

unattended, she will be in grave danger of hypovolemia.

 Be certain that when you are counting perineal pads, you differentiate between saturated
and used.

Weighing perineal pads before and after use and then subtracting the difference is an accurate
technique to

measure vaginal discharge:

 1 g of weight is comparable to 1 ml of blood volume,

 if a pad weights 50 g more after use, the woman has lost 50 ml of blood.

Note:

1. Always be sure to turn a woman on her side when inspecting for blood loss to be certain a
large

amount of blood is not pooling undetected beneath her.

2. The best safeguard against uterine atony is to palpate a woman’s fundus at frequent intervals
to be

assured her uterus is remaining contracted. Under usual circumstances, a well-contracted

uterus feels

firm and is easily recognized because it feels like no other abdominal organ. If you are unsure
whether

you have located a woman’s fundus on palpation, it means the uterus is probably in a state of

relaxation.

3. Frequent assessments of lochia (to be certain the amount of the flow is under a saturated
pad per hour

and that any clots are small), as well as vital signs, particularly pulse and blood pressure, are
equally

important determinations.

Therapeutic Management

In the event of uterine atony, the first step in controlling hemorrhage is to attempt fundal
massage to

encourage contraction. Unless the uterus is extremely lacking in tone, this procedure is usually
effective in

causing contraction, and, after a few seconds, the uterus assumes its healthy, grapefruit-like feel
(World Health

Organization [WHO], 2015).

FUNDAL MASSAGE

PROCEDURE

1. Explain the necessity for the procedure and

provide privacy.

Nurse: Good day Ma’am, I am nurse (state your

name), I will be your nurse for the day. I will render a

fundal massage to control vaginal bleeding and

encourage uterine contraction.

RATIONALE:

Help to decrease anxiety, and providing privacy

enhances self-esteem.

2. Ask the patient to void (unless bleeding is

extensive and more rapid actions seems necessary).

Ask her to lie supine with knees flexed.

Nurse: Before we begin the procedure Ma’am, I

would to assist you to void/urinate to lessen the

pressure and avoid discomfort. (optional, unless

bleeding is extensive).

After the patient have voided.

Nurse: Ma’am, may I assist you to lie on the bed with

RATIONALE:

An empty bladder prevents displacement of the

uterus and ensures accurate assessment of uterine

tone.

Proper positioning enhances visualization and

effectiveness of procedure. your knees flex.

3. Put on gloves. Place one hand on the abdomen

just above the symphysis pubis. Place the other

hand around the top of the fundus. (as shown below)

Nurse: Ma’am, I am going to start to massage your

fundus by placing may one hand on your abdomen

just above your symphysis pubis while my other

hand is around the top of your fundus

RATIONALE:

This anchors the lower uterine segment and allows

you to locate and assess the fundus.

4. Rotate the upper hand to massage the uterus

until it is firm, being careful not to overmassage. (as

seen below)

Nurse: Ma’am, I am now rotating my upper hand to

carefully massage your uterus in order to encourage

uterine contraction.

RATIONALE:

Massage should be done only when the uterus is not

firm and aggressive massage may lead to a partial or

complete uterine prolapse.

5. When the uterus is firm, press the fundus between

the hands using the slight downward pressure

against the lower hand.

Nurse: I can now feel that the uterus is firm, I will

now press your fundus between my hands with slight

downward pressure against my lower hand.

RATIONALE:

Gently squeezing with downward pressure helps to

expel blood or clots collected in the uterine cavity.

6. Remove and observe the woman’s perineum for

the passage of clots and the amount of bleeding.

Nurse: Ma’am, please allow me to check your

perineum, in order to remove the passage of clots

RATIONALE: and estimate the amount of your vaginal bleeding.

This helps to assess the degree of bleeding.

7. Massage the uterus one more time to be certain it

remains firm, cleanse the perineum and apply a

clean perineal pad. Discard gloves and soiled pads

according to agency policy.

Nurse: Ma’am, we are almost done, I will do a fundal

massage one more time just to make sure that your

uterus is firm.

Nurse: (After the fundal massage) Ma’am, I am now

done with the procedure. I am now cleaning your

perineum and afterwards I will apply a clean perineal

pad.

RATIONALE:

This helps to promote comfort and hygiene while

reducing the risk for infection.

8. Document the result of the procedure. Continue to

assess the fundus and lochia according to agency

policy, Notify the primary care provider if the fundus

does not remain firm or if bleeding continues.

After the procedure I will document the result of the

procedure and I will continue to assess the fundus

and lochia and I will notify the primary care provider

if the fundus does not remain firm or if the bleeding

RATIONALE:

Documentation provides a means for evaluation.

Continued assessment allows for early identification

and prompt intervention with additional measures

such as oxytocin to prevent hemorrhage.

continues.

With uterine atony, even if the uterus responds well to massage, the problem may not be
completely resolved

because, as soon as you remove your hand from the fundus, the uterus may relax and the lethal
seepage will

begin again.

1. To prevent this, remain with a woman after massaging her fundus and assess to be certain
her
uterus is not relaxing again. Continue to assess carefully for the next 4 hours.

2. If a woman’s uterus does not remain contracted, contact her primary care provider so
interventions to

increase contraction such as administering:

o a bolus or a dilute intravenous infusion of oxytocin (Pitocin) can be prescribed to help the

uterus maintain tone (Lang, Zhao, & Robertson, 2015).

3. Be aware, however, that oxytocin has a short duration of action:

o approximately 1 hour, so symptoms of uterine atony can recur quickly if it is administered only

as a single dose.

o If oxytocin is not effective at maintaining tone,

1. Carboprost tromethamine (Hemabate), a prostaglandin F2a derivative, or

methylergonovine maleate (Methergine), an ergot compound, both given

intramuscularly, are second possibilities.

2. Misoprostol (Cytotec), a prostaglandin E1 analogue, may also be administered

rectally to decrease postpartum hemorrhage.

 Carboprost tromethamine may be repeated every 15 to 90 minutes up to 8 doses;

 Methylergonovine maleate may be repeated every 2 to 4 hours up to 5 doses.

 A second dose of misoprostol should not be administered unless a minimum of 2 hours has

elapsed.

4. Check that all of these drugs are readily available for use on a hospital unit in the event of
postpartum

hemorrhage. Because prostaglandins tend to cause diarrhea and nausea as a side effect, assess
for this

after administration; some women will need to be administered antiemetic to limit these side
effects

(Bateman, Tsen, Liu, et al., 2014).

5. Be aware that all of these medications can increase blood pressure and so must be used
cautiously

in women with hypertension. Assess blood pressure prior to administration and about 15
minutes afterward to

detect this potentially dangerous side effect.

Additional measures that can be helpful to combat uterine atony include:

 Elevate the woman’s lower extremities to improve circulation to essential organs.

 Offer a bedpan or assist the woman to the bathroom at least every 4 hours to be certain her

bladder is emptying because a full bladder predisposes a woman to uterine atony. To reduce

the possibility of bladder pressure, insertion of a urinary catheter may be prescribed.

 Administer oxygen by face mask at a rate of about 10 to 12 L/min if the woman is

experiencing

respiratory distress from decreasing blood volume. Position her supine (flat) to allow adequate

blood flow to her brain and kidneys.

 Obtain vital signs frequently and assess them for trends such as a continually decreasing
blood

pressure with a continuously rising pulse rate.

When planning continuing care after sudden blood loss

 Remember that a woman may be so exhausted from labor and the effect of the blood loss
that she

resents frequent uterine and blood pressure assessments.

 Explain that you realize these measures are disturbing, but that they are important for her
welfare.

 Obtain measurements as quickly and gently as possible to cause a minimum of discomfort

and

disruption, allowing the woman time to rest.

Bimanual Compression
If fundal massage and administration of uterotonics (drugs to contract the

uterus) are not effective at stopping uterine bleeding, a sonogram may be done

to detect possible retained placental fragments. The woman’s primary care

provider may attempt bimanual compression (Weeks & Mallaiah, 2016).

 The primary care provider inserts one hand into a woman’s vagina

while pushing against the fundus through the abdominal wall with the

other hand.

 If this is ineffective, the woman may be returned to the birthing room, so

that her uterine cavity can be explored manually.

 Under sonogram visualization, a balloon catheter may be introduced

vaginally and inflated with sterile water until it puts pressure against the

bleeding site.

 Vaginal packing is inserted during this procedure to stabilize the placement of the balloon.

 Be certain to document the presence of the packing so it can be removed before agency
discharge

because retained packing serves as a growth medium for microorganisms that could lead to
postpartal

infection (Vintejoux, Ulrich, Mousty, et al., 2015).

Multiple Choice (10 points)

Answer the following questions carefully.

1. The mother had delivery an hour ago, the nurse must identify that the patient exhibits
hypovolemic shock when:

B. Low blood pressure, weak pulse, cold clammy skin

2. The nurse is caring for a mother who has undergone post-operative delivery. To be able to
prevent complication, the nurse must know how to estimate the amount of blood a postpartal
woman after delivery, EXCEPT:

D. Assuming that the mother will consume five pads the whole shift.

3. During the assessment, the nurse noticed that the mother had uncontrolled blood loss, the
nurse should position the mother in:

D. Prone Position

4. These are conditions that leave the uterus of the woman unable to contract readily, EXCEPT:

A. Well-contracted uterus

5. The nurse noticed that the mother in the delivery room is having hypovolemic shock after
giving birth. The nursing diagnosis would be:

A. Risk for excess fluid volume

6. The patient was brought to OB ward after delivery with a history of multiple gestation. The
nurseknows that this is one of the risk factors of uterine atony. What is the initial nurse action?

A. Check for body temperature

7. The nurse assesses that the mother’s uterus is not relaxing despite continuously massaging
her fundus for 4 hours. The nurse notifies her physician and learn that the nurse should prepare
for administering:

A. Oxytocin (Pitocin) incorporated to current intravenous fluid as ordered.

8. Nurse Digna is aware that the oxytocin (Pitocin) has a short duration of action and notices
that it is not working on contracting the mother’s uterus. What should the nurse prepare to
administer after referring the situation to her physician?

C. Prepare to administer methylergonovine maleate (Methergine) intramuscularly as ordered

9.The nurse administered methylergonovine maleate intramuscular to patients with uterine

atony. What are the nurse precautions in giving this medication?

C. Assess for patient’s blood pressure

10. The nurse administered carboprost tromethamine to the mother with uterine atony, the
physician ordered to repeat the dose every 30 minutes interval. The nurse knows that
carboprost tromethamine can be administered repeatedly for:

D. Up to 8 doses

11. This drug is administered rectally to decrease postpartum hemorrhage.

B. Misoprostol (Cytotec)

12. During the patient’s combat to uterine atony, the nurse responsibilities are, EXCEPT:

D. Check vital signs every 4 hours

13. The patient had completed the dose for the administration of uterotonics, however her
body doesn’t respond to the treatment provided. Her physician would likely attempt bimanual
compression. The nurse knows this procedure is done:

B. By inserting one hand into the woman’s vagina while pushing against the fundus

14. The physician referred the patient from the birthing room to be examined and admitted in
the tertiary hospital for further evaluation. The patient’s uterus is not responding to bimanual
compression done by the primary care provider. The nurse knows that the next procedure that
the gynecologist would be:
D. Using sonogram for visualization, a balloon catheter may be introduced vaginally and
inflated with sterile water until it puts pressure against the bleeding site.

15. After the bimanual compression using a balloon catheter, the physician facilitated vaginal
packing that is inserted to stabilize the placement. The nurse responsibility is to:

B. Document the presence of vaginal packing

SESSION 7. CESAREAN SECTION

 Cesarean section is a surgical procedure commonly used in the obstetric
practice.

 the fetal delivery is attained through an incision made over the abdomen and
uterus, after 28 weeks

of pregnancy.

If the removal of fetus is done before 28 weeks of pregnancy, the procedure is

known as hysterotomy.

 The use of cesarean delivery helps in avoiding difficult cases of vaginal delivery,
which may be

associated with considerable maternal and fetal mortality and morbidity.

INDICATIONS

 Cephalopelvic disproportion

 Placenta previa

 Estimated fetal weight >4 kg

 Hyperextension of fetal head

 Footling breech (danger of entrapment of head in an incompletely dilated

cervix)
 Severe Intrauterine Growth Restriction (IUGR)

 Clinician not competent with the technique of breech vaginal delivery

COMPLICATIONS

 Abdominal pain

 Injury to bladder, ureters, etc.

 Increased risk of rupture uterus and maternal death

 Neonatal respiratory morbidity

 Requirement for hysterectomy

 Thromboembolic disease

 Increased duration of hospital stay

 Antepartum or intrapartum intrauterine deaths in future pregnancies

 Patients with a previous history of cesarean delivery are prone to develop

complications, like

placenta previa and adherent placenta during future pregnancies

PROCEDURE

Preoperative Preparation

The following steps should be taken for preoperative preparation:

1. Empty stomach: The patient should be NPO for at

least 12 hours before undertaking a cesarean section.

In case the patient is full stomach, she should be

administered H2 receptor blocker (ranitidine 150 mg)

and an antiemetic (metoclopramide 10 mg) at least 2

hours prior to the surgery.

RATIONALE

To prevent the risk of aspiration at the time of administration of anesthesia

2. Patient position: The patient is placed with 15° lateral tilt on the operating
table.

RATIONALE

To reduce the chances of hypotension.

3. Anesthesia: While cesarean section can be

performed both under general or regional anesthesia,

nowadays regional anesthesia is favored.

RATIONALE

Spinal and epidural anesthesia have become the most commonly used forms of
regional anesthesia in the recent years.

4. Clinical examination: Before cleaning and draping the patient, it is a good

practice to check the fetal lie, presentation, position and fetal heart sounds once
again. Foley’s or plain rubber catheter must be inserted, following which the
cleaning and draping of the abdomen is done.

RATIONALE

To monitor the fetal heart tone of the fetus.

5. Preparation of the skin: The area around the proposed incision site must be
washed with antiseptic soap solution (e.g. savlon and/or betadine solution).

 The antiseptic solution must be applied at least three times over the incision
site, using a high-level disinfected sponge-holding forceps and cotton or gauze
swab.

RATIONALE

Antiseptic skin cleansing before surgery is thought to reduce the risk of

postoperative wound infections

Steps of Surgery

6. A vertical or transverse incision can be given over the skin (Fig. 7.3). The vertical
skin incision can be either given in the midline or paramedian location, extending
just above the pubic symphysis to just below the umbilicus.

RATIONALE

Previously, vertical skin incision at the time of cesarean section was favored, as it
was supposed to provide far more superior access to the surgical field in
comparison to the transverse incision. Also, the vertical incision showed potential
for extension at the time of surgery. However, it was associated with poor
cosmetic results and an increased risk of wound dehiscence and hernia formation.
Therefore, nowadays, transverse incision is mainly favored due to better cosmetic
effect, reduced postoperative pain and improved patient recovery.

Two types of transverse incisions are mainly used, while performing cesarean
section:

(1) the sharp (Pfannenstiel) type and

(2) the blunt (Joel Cohen) type.

Sharp Pfannenstiel transverse incision: While giving this type of incision, a slightly
curved, transverse skin incision is made at the level of pubic hairline, about an
inch above the pubic symphysis and is extended somewhat beyond the lateral
borders of rectus abdominis muscle.
 The subsequent tissue layers, until the level of anterior rectus sheath are
opened by using a sharp scalpel.

7. Dissecting the Rectus Sheath

After dissecting through the skin, subcutaneous fat and fascia, as the anterior
rectus sheath is reached, sharp dissection may be required. A scalpel can be used
to incise the rectus sheath throughout the length of the incision. The cut edges of
the incised rectus sheath are held with the help of allis forceps and then carefully
separated out from the underlying rectus muscle and pyramidalis.

RATIONALE

These muscles are then separated with the help of blunt and sharp dissection to
expose transversalis fascia and peritoneum.

8. Opening the Peritoneum

The transversalis fascia and peritoneal fat are dissected carefully to reach the
underlying parietal peritoneum. After placing two hemostats about 2 cm apart to
hold the peritoneum, it is carefully opened.

RATIONALE

The layers of parietal peritoneum are carefully examined to be sure that

omentum, bowel or bladder is not lying adjacent to it.

9. Insertion of the Doyen’s Retractor

Following the identification of lower uterine segment, some surgeons prefer to

put a moistened laparotomy pack in each of the paracolic gutters. The loose fold
of the uterovesical peritoneum over the lower uterine segment is then grasped
with the help of forceps and incised transversely with the help of scissors. The
lower flap of the peritoneum is held with artery forceps and the loose areolar
tissue pushed down. The underlying bladder is then separated by blunt dissection.
Finally, the lower flap of peritoneum and the areolar tissue is retracted by the
Doyen’s retractor to clear the lower uterine segment. The upper flap of the
peritoneum is pushed up to leave about 2 cm wide strip on the uterine surface,
which is not covered with visceral peritoneum.

RATIONALE

Doyen Retractor is used in abdominal OB/GYN,

retracting bladder, and cesarean section procedure. The retractor has a round
concave blade, the palm grip handle has a little hook at the end and a thumb rest,
the handle is designed to provide grip and comfort. It is used by surgeons to either
actively separate the edges of a surgical incision or wound, or can hold back
underlying organs and tissues, so that body parts under the incision may be
accessed.

10. Giving a uterine incision: An incision is made on the lower uterine segment
about 1 cm below the upper margin of peritoneal reflection and about 2–3 cm
above the bladder base. While making an incision in the uterus, a curvilinear mark
of about 10 cm length is made by the scalpel, cutting partially through the
myometrium. Following this, a small cut (about 3 cm in size) is made, using the
scalpel in the middle of this incision mark, reaching up to, but not through the
membranes. The rest of the incision can be completed either by stretching the
incision, using the tips of two index fingers along both the sides of the incision
mark (Fig. 7.4A) or using bandage scissors, to extend the incision on two sides (Fig.
7.4B).

RATIONALE

The uterine incision must be gently given, taking care to avoid any injury to the
underlying fetus.

The metzenbaum scissors are introduced into the uterus over the two fingers, in
order to protect the fetus. The uterine incision must be large enough so as to
allow the delivery of the head and trunk without the risk of extension of the
incision laterally into the uterine vessels. As the fetal membranes bulge out
through the uterine incision, they are ruptured. The amniotic fluid, which is
released following the rupture of membranes, is sucked with the help of a suction
machine.

RATIONALE

The use of metzenbaum scissors may be especially required in cases, where the
lower uterine segment is thickened andthe uterine incision cannot be extended
using the fingers. If the lower uterine segment is very thin, injury to the fetus can
be avoided, by using the handle of the scalpel or a hemostat (an artery forceps) to
open the uterus.

Location of the uterine incision: The incision in the uterus is commonly given
over the lower uterine segment.

The classical incision has been found to be associated with high risk of scar
rupture during future

pregnancies. As a result, lower segment transverse scars are nowadays preferred.

The lower segment uterine scar is considered to be stronger than the upper
segment scar due to the reasons mentioned in Table 7.3.

11. Delivery of the Infant

In case of cephalic presentation, once the fetal presenting part becomes visible
through the uterine incision, the surgeon places his/her right hand below the fetal
presenting part and grasps it. In case of cephalic presentation the fetal head is
then elevated gently, using the palms and fingers of the hand. The Doyen’s
retractor is removed, once the fetalpresenting part has been grasped. In order to
facilitate delivery, fundal pressure is applied by the assistant. Delivery is
completed in the manner similar to normal vaginal delivery. Once the baby’s
shoulders have delivered, an IV infusion containing 20 IU of oxytocin per liter of
crystalloids is infused at a rate of 10 mL/minute, until effective uterine
contractions are obtained. Following the delivery of the baby, the doctor will call
out the time of delivery and the sex of the baby. The cord is clamped and cut and
the baby handed over to the clinician.
RATIONALE

Delivery of the fetal head should be in the same way as during the normal vaginal
delivery. Fundal massage, following the delivery of the baby, helps in reducing
bleeding and hastens the delivery of placenta.

12. Placental Removal

Following the delivery of the placenta, the remnant bits of membranes and
decidua are removed using a sponge-holding forceps. The cut edges of the uterine
incision are then identified and grasped with the help of Green Armytage clamps.
(as seen below) The uterine angles are usually grasped with allies forceps.

RATIONALE

At the time of cesarean, the placenta should be removed, using controlled cord
traction (Fig. 7.5) and not manual removal as this reduces the risk of endometritis.

13. Closing the Uterine Incision

The main controversy related to the closure of the uterine incision is whether the
closure should be in the form of a single-layered or a double-layered closure. Both
single-layered and double-layered closure of uterine incision are being currently
practiced. If tubal sterilization has to be performed, it is done following the
closure of uterine incision. Following the uterine closure, swab and instrument
count is done. Once the count is found to be correct, the abdominal incision is
closed in layers.

RATIONALE

Though single- layered closure is associated with reduced operative time and
reduced blood loss in the short term, the risk of the uterine rupture during
subsequent pregnancies is increased. The current recommendation is to close the
uterus in two layers, as the safety and efficacy of closing uterus in a single layer is
presently uncertain. Individual bleeding sites can be approximated with the help
of figureof-eight sutures.
14. Peritoneal Closure

The current recommendation by (Royal College of Obstetrician and

Gynecologist)RCOG is that neither the visceral nor the parietal peritoneum should
be sutured at the time of cesarean section.

RATIONALE

This reduces the operative time and the requirement for the postoperative
analgesia.

15. Closure of the Rectus Sheath

Rectus sheath closure is performed after identifying the angles and holding them
with allies forceps. The angles must be secured using 1-0 vicryl sutures. The
rectus layer is closed with the help of continuous locked sutures placed no more
than 1 cm apart. Hemostasis must be checked at all levels.

16. Closure of Subcutaneous Space

There is no need for the routine closure of the subcutaneous tissue space, unless
there is more han 2 cm of subcutaneous fat.

RATIONALE

To reduce the incidence of the wound infection.

17. Skin Closure

Clinicians should be aware that presently the

differences

between the use of different suture materials and

methods of skin closure at the time of cesarean

section are not certain.

Skin closure can be either performed, using

subcutaneous, continuous repair absorbable or

nonabsorbable stitches or using interrupted stitches

with nonabsorbable sutures or staples.

RATIONALE

Following the skin closure, the vagina is swabbed

dried and dressing applied to the wound.

POSTOPERATIVE CARE

1. After surgery is completed, the woman needs to be monitored in a recovery

area. When the effects of anesthesia have worn off, about

4–8 hours after surgery, the woman may be

transferred to the postpartum room.

RATIONALE

Monitoring of routine vital signs (blood pressure, temperature, breathing), urine

output, vaginal bleeding and uterine tonicity (to check, if the uterus remains
adequately contracted), needs to be done at hourly intervals for the first 4 hours.
Thereafter, the monitoring needs to be done at every four hourly intervals for the
first postoperative day at least. Adequate analgesia needs to be provided, initially
through the IV line and later with oral medications.

2. Fluids and oral food after cesarean section: As

a general rule, about 3 liters of fluids must be

replaced by IV infusion during the first postoperative

day, provided that the woman’s urine output remains

greater than 30 mL/hour.

If the urine output falls below 30 mL/hour, the woman

needs to be reassessed to evaluate the cause of

oliguria.

In uncomplicated cases, the urinary catheter can be

removed by 12 hours postoperatively. Intravenous

fluids may need to be continued, until she starts

taking liquids orally.

RATIONALE

The clinician needs to remember that prolonged

infusion of IV fluids can alter electrolyte balance. If

the woman receives IV fluids for more than 48 hours,

her electrolyte levels need to be monitored every 48

hours.

Balanced electrolyte solution (e.g. potassium

chloride 1.5 g in 1 L IV fluids) may be administered.

3. Ambulation after cesarean section: The women

must be encouraged to ambulate as soon as 6–8

hours following the surgery.

RATIONALE

Walking also improves blood flow and speeds wound

healing. Failure to walk may cause increased

constipation and gas pain and weakness, and puts

the patient at a higher risk for infections, blood clots

and lung problems such as pneumonia.

4. Dressing and wound care: The dressing must be

kept on the wound for the first 2–3 days after

surgery, so as to provide a protective barrier against

infection. Thereafter, dressing is usually not required.

If blood or fluid is observed to be leaking through the

initial dressing, the dressing must not be changed.

The amount of blood/fluid lost must be monitored.

If bleeding increases or the bloodstain covers half

the dressing or more, the dressing must be removed

and replaced with another sterile dressing.

RATIONALE

The dressing must be changed while using a sterile technique.

The surgical wound also needs to be carefully inspected.

5. Length of hospital stay: Length of hospital stay

is likely to be longer after a cesarean section (an

average of 3–4 days) in comparison to that after a

vaginal birth (average 1–2 days).

RATIONALE

Women who are recovering well and have not

developed complications following cesarean may be

offered early discharge.

Multiple Choice:

Answer the following questions carefully.

1. Raya is pregnant and was told by her OB doctor that her baby is on face
presentation. In face presentation, when is cesarean birth necessary?

A. If the chin is anterior.

2. What is a contraindication to external cephalic version?

A. Hydramnios

3. Julanne a client who delivered by cesarean section 24 hours ago is using a

patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been
ice chips only since surgery. She is now complaining of nausea and bloating, and
states that because she had nothing to eat, she is too weak to breastfeed her
infant. Which nursing diagnosis has the highest priority?

A. Altered nutrition, less than body requirements for lactation

B. Alteration in comfort related to nausea and abdominal distention

C. Impaired bowel motility related to pain medication and immobility

D. Fatigue related to cesarean delivery and physical care demands of infant

4. Karina is performing an assessment of a client who is scheduled for a cesarean

delivery. Which assessment finding would indicate a need to contact the
physician?

A. Fetal heart rate of 180 beats per minute

B. White blood cell count of 12,000

C. Maternal pulse rate of 85 beats per minute

D. Hemoglobin of 11.0 g/dL

5. Which of the following fetal positions is most favorable for cesarean birth?

A. Vertex presentation

B. Transverse lie

C. Frank breech presentation

D. Posterior position of the fetal head

6. Carly a client is admitted to the L & D suite at 36 weeks’ gestation. She has a
history of C-section and complains of severe abdominal pain that started less than
1 hour earlier. When the nurse palpates tetanic contractions, the client again
complains of severe pain. After the client vomits, she states that the pain is better
and then passes out. Which is the probable cause of her signs and symptoms?

A. Hysteria compounded by the flu

B. Placental abruption

C. Uterine rupture

D. Dysfunctional labor

7. Manipulations performed through the abdominal wall that yield a cephalic

presentation.

A. External Cephalic Version

8. A fetus is turned to a breech presentation using the hand placed into the
uterus.

B. Internal Podalic Version

9. Which of the following are complications of Cesarean Section, SELECT ALL THAT
APPLY:

A. Injury to bladder and ureters

B. Increased risk of rupture uterus and maternal death

C. Neonatal respiratory morbidity

D. Requirement for hysterectomy

10.Which of the following are indications for Cesarean Section, SELECT ALL THAT
APPLY:

A. Cephalopelvic disproportion

B. Placenta previa

C. Estimated fetal weight >4 kg

D. Hyperextension of fetal head

11. Astra had a cesarean section and is 2 days post-op. What is an important
measure to reduce the size of the bladder and keep it away from the surgical field
during cesarean birth?

A. Administer an oxytocic to contract the bladder.

B. Restrict fluids in the woman for 4 hours before surgery.

C. Insert a urinary catheter to drain the bladder and decrease its size.

D. Give a diuretic to reduce the bladder to its smallest size.

12. Carrie is to administer ranitidine (Zantac) as ordered prior to a planned

cesarean birth to:

A. Promote uterine contractions.

B. Decrease gastric secretions.

C. Delay uterine contractions.

D. Neutralize urine acidity.

13. Carrie instructs Astra on deep breathing exercises as part of the preoperative
teaching plan. The rationale for this exercise is to:

A. Stimulate the diaphragm to contract.

B. Promote involution on a traumatized uterus.

C. Prevent stasis of mucus in the lungs.

D. Prevent pulmonary edema.

14. You are asked by your instructor regarding Cesarean Section. What is the most
important responsibility of the healthcare team before the surgery starts?

A. Assessing the woman’s hygiene.

B. Inserting a urinary catheter.

C. Decreasing the stomach secretions.

D. Securing an informed consent and ensuring that it is obtained.

15. The nurse administers Ringer’s solution intravenously for what purpose?

A. To avoid urinary tract infection.

B. To ensure that the woman is fully hydrated.

C. To reduce bladder size.

D. To decrease urine specific gravity.

16. Dr. Callum a surgeon plans to perform a low segment incision rather than a
classic incision. This type of incision is more advantageous because:

A. The procedure is faster with the incision being made simultaneously through
the abdomen and uterus.

B. The procedure is made with a vertical incision to decrease the chances of

reopening.

C. It is made horizontally and high on the woman’s abdomen.

D. The likelihood of a postpartal uterine infection is decreased.

17. Katrine was asked by her instructor that if oxytocin is ordered postoperatively
for the client who has had a cesarean birth, the most important nursing
intervention would be to:

A. Monitor the woman’s blood pressure.

B. Prevent infection at the incision site.

C. Implement measures to promote comfort.

D. Assess for increased lochia discharge.

18. Charie was asked which of the following interventions would be most helpful
to assist a woman to void after a cesarean birth?

A. Withholding prescribed analgesic.

B. Letting the woman void every 4 hours.

C. Running water from the tap within woman’s hearing distance.

D. Pouring cold water over her perineal area.

19. Ramina has undergone a cesarean birth is to be discharged. You would instruct
the woman to notify her health care provider if she develops which of the
following?

A. Drainage at her incision line.

B. No bowel movement for 2 days.

C. Decrease in lochia.

D. Pain on the incision site.

20. Which of the following is a complication of pain that occurs postoperatively?

B. Pneumonia
SESSION 8
Nursing Care of a Family Experiencing a Postpartum Complication

UTERINE ATONY

Uterine atony, or relaxation of the uterus, is the most frequent cause of

postpartum hemorrhage; it tends to

occur most often in Asian, Hispanic, and Black woman (Grobman, Bailit, Rice, et
al., 2015).

Factors that predispose a woman to poor uterine tone or the inability of her
uterus to maintain a contracted

state are summarized in Box 25.3. When caring for a woman in whom any of these
conditions are present, be

especially conscientious in your observations and be on guard for signs of uterine

bleeding.

Nursing Diagnoses and Related Interventions

Nursing Diagnosis:

Deficient fluid volume related to excessive blood loss after birth.

Outcome Evaluation:

Patient’s blood pressure and heart rate remains within usual defined limits; lochia
flow is less than one

saturated perineal pad per hour.

 If the uterus suddenly relaxes, there will be an abrupt gush of blood vaginally
from the placental site.

This can occur immediately after birth but is more likely to occur gradually, over
the first postpartum
hour, as the uterus slowly loses its tone.

 If the loss of blood is extremely copious, a woman will quickly begin to exhibit
symptoms of

hypovolemic shock such as a falling blood pressure; a rapid, weak, or thready

pulse; increased and

shallow respirations; pale, clammy skin; and increasing anxiety.

 If the blood loss is unnoticed seepage, there is little change in pulse and blood
pressure at first

because of circulatory compensation. Suddenly, however, the system is able to

compensate no more,

and the pulse rate rises rapidly and becomes weak.

 Blood pressure then drops abruptly. With slow bleeding, a woman develops
these symptoms over a

period of hours; the end result of continued seepage, however, can be as life
threatening as a sudden

profuse loss of blood (Andrighetti, 2013).

It is difficult to estimate the amount of blood a postpartal woman is losing

because it is difficult to estimate the

amount of blood

 It takes to saturate a perineal pad (between 25 and 50 ml). By counting the

number of perineal pads

saturated in given lengths of time, such as half-hour intervals, a rough estimate of

the amount of blood

loss can be formed.

 Five pads saturated in half an hour is obviously a different situation from five
pads saturated in 8 hours.

 A woman will have lost approximately 250 ml of blood, and if either scenario is
allowed to continue

unattended, she will be in grave danger of hypovolemia.

 Be certain that when you are counting perineal pads, you differentiate between
saturated and used.

Weighing perineal pads before and after use and then subtracting the difference is
an accurate technique to

measure vaginal discharge:

 1 g of weight is comparable to 1 ml of blood volume,

 if a pad weights 50 g more after use, the woman has lost 50 ml of blood.

Note:

1. Always be sure to turn a woman on her side when inspecting for blood loss to
be certain a large

amount of blood is not pooling undetected beneath her.

2. The best safeguard against uterine atony is to palpate a woman’s fundus at

frequent intervals to be

assured her uterus is remaining contracted. Under usual circumstances, a well-

contracted uterus feels

firm and is easily recognized because it feels like no other abdominal organ. If you
are unsure whether

you have located a woman’s fundus on palpation, it means the uterus is probably
in a state of

relaxation.
3. Frequent assessments of lochia (to be certain the amount of the flow is under a
saturated pad per hour

and that any clots are small), as well as vital signs, particularly pulse and blood
pressure, are equally

important determinations.

Therapeutic Management

In the event of uterine atony, the first step in controlling hemorrhage is to attempt
fundal massage to

encourage contraction. Unless the uterus is extremely lacking in tone, this

procedure is usually effective in

causing contraction, and, after a few seconds, the uterus assumes its healthy,
grapefruit-like feel (World Health

Organization [WHO], 2015).

With uterine atony, even if the uterus responds well to massage, the problem may
not be completely resolved

because, as soon as you remove your hand from the fundus, the uterus may relax
and the lethal seepage will

begin again.

1. To prevent this, remain with a woman after massaging her fundus and assess to
be certain her

uterus is not relaxing again. Continue to assess carefully for the next 4 hours.

2. If a woman’s uterus does not remain contracted, contact her primary care
provider so interventions to

increase contraction such as administering:

o a bolus or a dilute intravenous infusion of oxytocin (Pitocin) can be prescribed to

help the

uterus maintain tone (Lang, Zhao, & Robertson, 2015).

3. Be aware, however, that oxytocin has a short duration of action:

o approximately 1 hour, so symptoms of uterine atony can recur quickly if it is

administered only

as a single dose.

o If oxytocin is not effective at maintaining tone,

1. Carboprost tromethamine (Hemabate), a prostaglandin F2a derivative, or

methylergonovine maleate (Methergine), an ergot compound, both given

intramuscularly, are second possibilities.

2. Misoprostol (Cytotec), a prostaglandin E1 analogue, may also be administered

rectally to decrease postpartum hemorrhage.

 Carboprost tromethamine may be repeated every 15 to 90 minutes up to 8

doses;

 Methylergonovine maleate may be repeated every 2 to 4 hours up to 5 doses.

 A second dose of misoprostol should not be administered unless a minimum of

2 hours has

elapsed.

4. Check that all of these drugs are readily available for use on a hospital unit in
the event of postpartum

hemorrhage. Because prostaglandins tend to cause diarrhea and nausea as a side

effect, assess for this

after administration; some women will need to be administered antiemetic to

limit these side effects
(Bateman, Tsen, Liu, et al., 2014).

5. Be aware that all of these medications can increase blood pressure and so must
be used cautiously

in women with hypertension. Assess blood pressure prior to administration and

about 15 minutes afterward to

detect this potentially dangerous side effect.

Additional measures that can be helpful to combat uterine atony include:

 Elevate the woman’s lower extremities to improve circulation to essential

organs.

 Offer a bedpan or assist the woman to the bathroom at least every 4 hours to
be certain her

bladder is emptying because a full bladder predisposes a woman to uterine atony.

To reduce

the possibility of bladder pressure, insertion of a urinary catheter may be

prescribed.

 Administer oxygen by face mask at a rate of about 10 to 12 L/min if the woman

is experiencing

respiratory distress from decreasing blood volume. Position her supine (flat) to
allow adequate

blood flow to her brain and kidneys.

 Obtain vital signs frequently and assess them for trends such as a continually
decreasing blood

pressure with a continuously rising pulse rate.

When planning continuing care after sudden blood loss

 Remember that a woman may be so exhausted from labor and the effect of the
blood loss that she

resents frequent uterine and blood pressure assessments.

 Explain that you realize these measures are disturbing, but that they are
important for her welfare.

 Obtain measurements as quickly and gently as possible to cause a minimum of

discomfort and

disruption, allowing the woman time to rest.

Bimanual Compression

If fundal massage and administration of uterotonics (drugs to contract the

uterus) are not effective at stopping uterine bleeding, a sonogram may be done

to detect possible retained placental fragments. The woman’s primary care

provider may attempt bimanual compression (Weeks & Mallaiah, 2016).

 The primary care provider inserts one hand into a woman’s vagina

while pushing against the fundus through the abdominal wall with the

other hand.

 If this is ineffective, the woman may be returned to the birthing room, so

that her uterine cavity can be explored manually.

 Under sonogram visualization, a balloon catheter may be introduced

vaginally and inflated with sterile water until it puts pressure against the

bleeding site.

 Vaginal packing is inserted during this procedure to stabilize the placement of

the balloon.

 Be certain to document the presence of the packing so it can be removed

before agency discharge

because retained packing serves as a growth medium for microorganisms that

could lead to postpartal

infection (Vintejoux, Ulrich, Mousty, et al., 2015).

Multiple Choice (10 points)

Answer the following questions carefully.

1. The mother had delivery an hour ago, the nurse must identify that the patient
exhibits hypovolemic shock when:

A. High blood pressure, tachycardic, skin warm to touch

B. Low blood pressure, weak pulse, cold clammy skin

C. High blood pressure, tachycardic, shallow respiration

D. Low blood pressure, weak pulse, skin warm to touch

2. The nurse is caring for a mother who has undergone post-operative delivery. To
be able to prevent complication, the nurse must know how to estimate the
amount of blood a postpartal woman after delivery, EXCEPT:

A. Counting the number of perineal pads saturated in given lengths of time, such
as half-hour intervals, a rough

estimate of the amount of blood loss can be formed.

B. Weighing perineal pads before and after use and then subtracting the
difference.

C. A woman will have lost approximately 250 ml of blood, and if either scenario is
allowed to continue
unattended, she will be in grave danger of hypovolemia.

D. Assuming that the mother will consume five pads the whole shift.

3. During the assessment, the nurse noticed that the mother had uncontrolled
blood loss, the nurse should position the mother in:

A. Lithotomy Position

B. Side lying Position

C. Sitting Position

D. Prone Position

4. These are conditions that leave the uterus of the woman unable to contract
readily, EXCEPT:

A. Well-contracted uterus

B. Labor initiated or assisted with an oxytocin agent

C. Prior history of postpartum hemorrhage

D. Secondary maternal illness such as anemia

5. The nurse noticed that the mother in the delivery room is having hypovolemic
shock after giving birth. The nursing diagnosis would be:

A. Risk for excess fluid volume

B. Deficient fluid volume

C. Risk for infection

D. Risk for Pain

6. The patient was brought to OB ward after delivery with a history of multiple
gestation. The nurse knows that this is one of the risk factors of uterine atony.
What is the initial nurse action?

A. Check for body temperature

B. Palpate the fundus

C. Assess for skin integrity

D. Warm compress

7. The nurse assesses that the mother’s uterus is not relaxing despite continuously
massaging her fundus for 4 hours. The nurse notifies her physician and learn that
the nurse should prepare for administering:

A. Oxytocin (Pitocin) incorporated to current intravenous fluid as ordered.

B. Oxygen 4-6 LPM as ordered

C. 2 Packed of RBC as ordered

D. Paracetamol IV as ordered

8. Nurse Digna is aware that the oxytocin (Pitocin) has a short duration of action
and notices that it is not working on contracting the mother’s uterus. What should
the nurse prepare to administer after referring the situation to her physician?

A. Prepare to administer another dose of oxytocin (Pitocin) as ordered

B. Prepare to administer oxygen 6-10 LPM as ordered

C. Prepare to administer methylergonovine maleate (Methergine)

intramuscularly as ordered
D. Prepare to administer hydralazine as ordered

9.The nurse administered methylergonovine maleate intramuscular to patients

with uterine atony. What are the nurse precautions in giving this medication?

A. Assess for patient’s body temperature

B. Assess for patient’s pulse

C. Assess for patient’s blood pressure

D. Assess for patient’s fluid input.

10. The nurse administered carboprost tromethamine to the mother with uterine
atony, the physician ordered to repeat the dose every 30 minutes interval. The
nurse knows that carboprost tromethamine can be administered repeatedly for:

A. Up to 14 doses

B. Up to 12 doses

C. Up to 10 doses

D. Up to 8 doses

11. This drug is administered rectally to decrease postpartum hemorrhage.

A. Carboprost tromethamine (Hemabate)

B. Misoprostol (Cytotec)

C. Methylergonovine maleate (Methergine)

D. Oxytocin (Pitocin)
12. During the patient’s combat to uterine atony, the nurse responsibilities are,
EXCEPT:

A. Administer oxygen via face mask 10-12 LPM

B. Elevation of lower extremities

C. No bathroom privileges, offer bedpan for bladder emptying

D. Check vital signs every 4 hours

13. The patient had completed the dose for the administration of uterotonics,
however her body doesn’t respond to the treatment provided. Her physician
would likely attempt bimanual compression. The nurse knows this procedure is
done:

A. By placing one hand on the abdomen just above the symphysis pubis.

B. By inserting one hand into the woman’s vagina while pushing against the
fundus

C. By removing tissue inside the uterus

D. By removing thin layer of tissue that lines the uterus

14. The physician referred the patient from the birthing room to be examined and
admitted in the tertiary hospital for further evaluation. The patient’s uterus is not
responding to bimanual compression done by the primary care provider. The
nurse knows that the next procedure that the gynecologist would be:

D. Using sonogram for visualization, a balloon catheter may be introduced

vaginally and inflated with sterile water until it puts pressure against the
bleeding site.

15. After the bimanual compression using a balloon catheter, the physician
facilitated vaginal packing that is inserted to stabilize the placement. The nurse
responsibility is to:

B. Document the presence of vaginal packing

SESSION 9. BALLOON TAMPONADE

DESCRIPTION

 A balloon technology that is being use to tamponade the postpartum uterus to

control postpartum

hemorrhage.

 This involves inserting a rubber or silicone balloon into the uterine cavity and
inflating the balloon with

normal saline.

 The open tip permits continuous drainage of blood from the uterus.

 Balloon ruptures when more than 50 mL was instilled into the balloon, thus a
34F Foley with a 60-ml

balloon can be used.

 If bleeding subsides, the catheter is typically removed after 12 to 24 hours.

INDICATION

 Postpartum hemorrhage due to uterine atony, when uterotonics fail to control

bleeding.

 An intrauterine balloon is used to reduce intrauterine bleeding and avoid

hemostasis hysterectomy.
 In a BEmONC facility, an intrauterine balloon can be used to stabilize the
patient before referring her

to a CEmONC facility.

CONTRAINDICATIONS

 Uterine rupture

 Purulent infection of the vagina, cervix or uterus

TYPES OF BALLOON TAMPONADE

1. CONDOM OR GLOVE TAMPONADE (as seen on

the other column)

 This is a balloon made of a rubber glove,

condom, or other device that is attached to a

rubber urinary catheter and is inserted into

the uterus under aseptic conditions.

 This device is attached to a syringe and filled

with sufficient saline solution, usually 300 ml

to 500 Ml, to exert enough counter-pressure

to stop bleeding.

 When the bleeding stops, the care provider

folds and ties the outer end of the catheter to

maintain pressure. An oxytocin infusion is

continued for 24 hours.

 If bleeding persists, add more saline solution.

If bleeding has stopped and the woman is in

constant pain, remove 50 ml to 100 Ml of the

saline solution.

 The balloon is left in place for 24 to 48 hours;

it is gradually deflated over two hours, and

then removed. If bleeding starts again during

the deflating period, re-inflate the balloon

tamponade and wait another 24 to 48 hours

before trying to deflate a second time.

 A balloon tamponade may arrest or stop

bleeding in 77.5% to 88.8% or more cases

without any further need for surgical

treatment.

2. BAKRI POSTPARTUM BALLOON/ BT-CATH (as

seen on the other column)

 This specialized device works as an

intrauterine tamponade.

 It is costly and may not be suitable for lower_resource settings.

 It is inserted and inflated to tamponade the

endometrial cavity and stop bleeding.

Insertion requires two or three team members.

 The first performs abdominal sonography

during the procedure.

 The second places the deflated balloon into

the uterus and stabilizes it.

 The third member instills fluid to inflate the

balloon, rapidly infusing at least 150 Ml

followed by further instillation over a few

minutes for a total of 300 to 500 Ml to arrest

hemorrhage. It is reasonable to remove the

balloon after approximately 12 hours

3. RUSCH UROLOGICAL HYDROSTATIC BALLOON and SENGSTAKEN-BLAKEMORE

ESOPHAGEAL CATHETER (as seen on the other

column)

 The Rusch urologic hydrostatic balloon

catheter and the Sengstaken-Blakemore

esophageal catheter have been used to

control hemorrhage unresponsive to

uterotonics.

 Both work by creating pressure within the

uterus to stop bleeding.

 However, they are both expensive and not

available in many low-resource countries.

AORTIC COMPRESSION (as seen below on figure

9)

 Aortic compression is a life-saving

intervention when there is a heavy bleeding,

whatever the cause. It may be considered at

several different points during management

of PPH.

 Aortic compression does not prevent or delay

any of the other steps to be taken to clarify

the cause of PPH and remedy it.

 While preparing for a necessary intervention,

blood is conserved by cutting off the blood

supply to the pelvis by the compression.

Step-by-step technique

1. Explain the procedure to the woman, if she is

conscious, and reassure her.

2. Stand on the left side of the woman.

3. Place right fist just above and to the left of the

woman‘s umbilicus.

4. Lean over the woman so that your weight

increases the pressure on the aorta. You should be

able to feel the aorta against your knuckles. Do not

use your arm muscles; this is very tiring.

5. Before exerting aortic compression, feel the

femoral artery for a pulse using the index and third

fingers of the left hand.

6. Once the aorta and femoral pulse have been

identified, slowly lean over the woman and increase

the pressure over the aorta to seal it off. To confirm

proper sealing of the aorta, check the femoral pulse.

7. There must be no palpable pulse in the femoral

artery if the compression is effective. Should the

pulse become palpable, adjust the right fist and the

pressure until the pulse is gone again.

8. The fingers should be kept on the femoral artery

as long as the aorta is compressed to make sure that

the compression is efficient at all times.

Note 1: Aortic compression may be used to stop bleeding at any stage. It is a

simple life-saving skill to learn.

Note 2: Ideally, the birth attendant should accompany the woman during transfer

District or referral hospital

1. Display a PPH management protocol poster in the maternity or case room.

2. Apply Active Management of Third Stage of Labor (AMTSL)

3. Remember the ABCs.

4. Perform any of the procedures described above that are applicable.

5. If these procedures have not stopped the bleeding, consider: Use of

intrauterine tamponade for diagnosis

and treatment Apply anti-shock garment, if not already done. Give blood
transfusion, if resources available

(consider asking family members to donate blood). Perform surgical repair of

vaginal and cervical tears.

6. If unable to control the bleeding or if expertise or specialized resources are

unavailable, prepare the

woman for referral and transfer to next level health care facility.

Tertiary care or university hospital

1. Display a PPH management protocol poster in the maternity or case room.

2. Apply AMTSL.

3. Remember the ABCs.

4. Perform any of the procedures described above that are applicable.

5. Replace lost fluid volume with fresh blood or blood products.

6. If these procedures have not stopped the bleeding, consider the following
procedures depending on the

severity of the bleeding and the condition of the woman:

7. Laparotomy to apply compression sutures using B-Lynch or Cho techniques

Systematic pelvic

devascularization : Uterine and utero-ovarian artery ligation, Interventional

radiology: Uterine artery

embolization

8. Selective arterial embolization may be useful in situations where preservation

of fertility is desired. The

procedure requires immediate access to radiological expertise. The time required

to organize and complete

the procedure in an emergency may make it a non-viable option. Rare

complications include blood vessel

perforation, hematoma formation, infection, allergic reactions to contrast dyes

used as part of the procedure,

and uterine necrosis. Hysterectomy (sub-total or total)

Although a last resort, hysterectomy must be considered prior to the progression

of hemorrhage to the point

of cardiovascular collapse. Sub-total hysterectomy may be effective for bleeding

due to uterine atony, and is

associated with less morbidity and mortality. However, it may not be effective in
controlling bleeding from

trauma to the lower segment, cervix, or upper vaginal tract.

MULTIPLE CHOICE (10 points)

Answer the questions carefully.

1. Which of the following management should be performed in the setting of

postpartum hemorrhage following a vaginal delivery? SELECT ALL THAT APPLY

A. Evaluate birth canal for lacerations

B. Evaluate the placenta for possible retained fragments

C. The uterus should be manually explored, and placental fragments removed

D. Ergot alkaloids for patients with hypertension

2. During evaluation of postpartum hemorrhage following a vaginal delivery,

which of the following maneuvers or medications might be used?

A. Bimanual uterine compression

B. Ergot alkaloids for patients with hypertension

C. Carboprost tromethamine in patients with mild asthma

D. Call for help

3. A 34-year-old G3P3 begins having brisk bright red bleeding following

completion of a vaginal delivery in your birthing facility. What should be
immediately considered? SELECT ALL THAT APPLY

A. Call for help

B. Bimanual uterine compression

C. Place large-bore intravenous lines and begin volume resuscitation

D. Fundal Massage

4. The client is experiencing an early postpartum hemorrhage. Which item in the

client’s care plan requires revision for care?

A. Inserting an indwelling urinary catheter

B. Fundal massage
C. Administration of oxytocic drugs

D. Perineal pad count

5. To avoid any complications associated with labor, the nurse must have a keen
eye for assessment.In the fourth stage of labor, the nurse observed that the client
has a full bladder. The nurse knows that this increases the risk of what postpartum
complication?

A. Shock

B. Disseminated Intravascular Coagulation (DIC)

C. Hemorrhage

D. Infection

6. The client is at the end of the first postpartum day. The nurse is assessing the
client’s status. Which finding requires further evaluation at this time?

A. Uterus in the midline position

B. Firm, round uterus

C. Fundus 2 fingerbreadths above the umbilicus

D. Fundus 1 fingerbreadth below the umbilicus

7. Postpartum assessment of the newly delivered client includes checking the

uterine fundus for firmness and position. On the second day postpartum, you
expect the client’s fundus to be:

A. Slightly boggy and below the umbilicus

B. Soft and either deviated to the right or left side of the abdomen
C. Firm and two to three fingerbreadths below the umbilicus

D. Firm and two to three fingerbreadths above the umbilicus

8. Katrina a postpartum nurse is preparing to care for a woman who has just
delivered a healthy newborn infant. In the immediate postpartum period the
nurse plans to take the woman's vital signs:

A. Every 30 minutes during the first hour and then every hour for the next two
hours.

B. Every 15 minutes during the first hour and then every 30 minutes for the next
two hours.

C. Every hour for the first 2 hours and then every 4 hours

D. Every 5 minutes for the first 30 minutes and then every hour for the next 4
hours.

9. Karina a postpartum nurse is taking the vital signs of a woman who delivered a
healthy newborn infant 4 hours ago. The nurse notes that the mother's
temperature is 100.2*F. Which of the following actions would be most
appropriate?

A. Retake the temperature in 15 minutes

B. Notify the physician

C. Document the findings

D. Increase hydration by encouraging oral fluids

10. Maxima is caring for a client during the immediate recovery phase or fourth
stage of labor. Which
action is most important for the nurse to take at this time? SELECT ALL THAT
APPLY

B. Check the uterine fundus

C. Check for the lochia

SESSION 10. INVERSION OF THE UTERUS

DESCRIPTION

 Puerperal inversion of the uterus is one of the classic hemorrhagic disasters

encountered in obstetrics.

Unless promptly recognized and managed appropriately, associated bleeding

often is massive.

 Uterine inversion occurs rarely, approximately 1 in every 25,000 deliveries. It is

often iatrogenic,

meaning it is caused by health care providers, often resulting from overly vigorous
umbilical cord

traction.

 Uterine inversion is more common in grand multiparous women.

Risk factors include alone or in combination:

(1) fundal placental implantation

(2) uterine atony

(3) cord traction applied before placental separation

(4) abnormally adhered placentation such as with the accrete syndromes

TYPES

1. INCOMPLETE INVERSION-when the fundus of the uterus has turned inside out
but the inverted fundus has

descended through the cervix.

2. COMPLETE INVERSION-when the inverted fundus has passed completely

through the cervix within the

vaginal canal.

DEGREES OF INVERSION

1. FIRST DEGREE INVERSION- the uterus is partially turned out

2. SECOND DEGREE INVERSION-the fundus has passed through the cervix but not
outside the vagina

3. THIRD DEGREE INVERSION-the fundus is prolapsed outside the vagina.

4. FOURTH DEGREE INVERSION- the uterus, cervix and vagina are completely
turned inside out and are visible.

PREVENTION

 Do not employ any method to expel the placenta when the uterus is relaxed

 Patient should not be instructed to change her position.

 Pulling the cord simultaneously with fundal pressure should be avoided

 Manual removal of placenta should be done in proper manner.

CLINICAL MANIFESTATIONS

 Excruciating pelvic pain with a sensation of extreme fullness extending into the
vagina.
 Extrusion of the inner uterine lining into the vagina or extending past the
vaginal introitus.

 Vaginal bleeding and signs of hypovolemia.

MANAGEMENT

***Never attempt to replace an inversion because handling of the uterus could

increase the bleeding.

***Never attempt to remove the placenta if it is still attached because this would
create a larger surface area for bleeding.

MULTIPLE CHOICE (10 points)

1. Which of the following techniques during labor and delivery can lead to uterine
inversion?

B. Strongly tugging on the umbilical cord to deliver the placenta and hasten
placental separation.

2. When the Uterus is firm and contracted after delivery but there is vaginal
bleeding, the nurse should suspect?

A. lacerations of the soft tissues of cervix and vagina

B. uterine rupture

C. uterine inversion

D. uterine hypercontractility

3. A 33 y/o woman was rushed to ER , physical examination reveals the presence

of a smooth, round and round and pale mass protruding from the vagina. What
has most likely occurred in this patient?

A. Uterine atony

B. Uterine inversion

C. Voluntary uterine extension

D. Volatile uterine flexion

4. The following are risk factors of uterine involution, EXCEPT:

D. multifetal pregnancy

5. A 30 y/o woman delivers a 9 lb newborn. After placenta is delivered, a firm pale

mass is noted in the lower vagina. There is also moderate vaginal bleeding during
abdominal examination, uterus cannot be palpated. What is the likely diagnosis?

A. Uterine inversion

6. Which of the following techniques during labor and delivery can lead to uterine
inversion?

B. Strongly tugging on the umbilical cord to deliver the placenta and hasten
placental separation

7. A procedure which is usually done by placing one hand in the vagina and
pushing against the body of the uterus while the other hand compresses the
fundus from above through the abdominal wall.

B. Bimanual uterine compression

8. Karylle a nurse educator on the postpartum unit is reviewing risk factors for
postpartum hemorrhage with a group of nurses. Which of the following should be
included in the discussion? SELECT ALL THAT APPLY

A. Precipitous delivery

B. Lacerations

C. Inversion of the uterus

E. Retained placental fragments

9. While assessing a primipara during the immediate postpartum period, the

nurse in charge plans to use both hands to assess the client’s fundus to:

A. Prevent uterine inversion

10. When the Contractions stop, and bleeding is primarily into the abdominal
cavity, the nurse should suspect?

B. uterine rupture

SESSION 11

hysterectomy

- obstetric hysterectomy refers to the removal of the uterus at the time of a

planned or unplanned cesarean section.
It involves either the removal of pregnant uterus with pregnancy in situ or a
recently pregnant uterus due to some complications of delivery. Sometimes
hysterectomy may be required following delivery, either vaginal or cesarean in
order to save mother's life.

- Obstetric hysterectomy can be performed in the antepartum, peripartum or the

postpartum periods.

- When hysterectomy is performed at the time of cesarean delivery, the procedure

is termed as the cesarean hysterectomy.

- If performed within a short time after vaginal delivery, it is termed as postpartum

hysterectomy.

INDICATIONS

Obstetric Emergencies

? Postpartum hemorrhage

• Intractable uterine atony

• Inverted uterus

• Coagulopathy

• Laceration of a pelvic vessel Sepsis

• Chorioamnionitis with sepsis

 • Myometrial abscesses

Cesarean Delivery ? Rupture uterus

• Traumatic

• Spontaneous

• Extending pelvic hematoma

• Lateral extension of the uterine incision with the involvement of

uterine vessels

? Placental implantation in the lower segment (placenta accreta, increta or

percreta)

? Presence of the large or symptomatic leiomyomas which may

preventeffectiveuterinerepair ? Presence of severe cervical dysplasia or carcinoma
in situ

? Uncontrollable postpartum hemorrhage

? Unrepairable rupture uterus

Operable cancer cervix: In stage one (I) cervical cancers with pregnancy, the
treatment is by cesarean delivery followed by a radical hysterectomy ? Couvelaire
uterus

? Severe uterine infection particularly that caused by Clostridium welchii

Nonemergency Situations (Peripartum Hysterectomy)

? Coexisting gynecological disorders

• Leiomyomas

• Stage I cervical carcinoma

• Cervical intraepithelial neoplasia

• Ovarian malignancy
 • ? Previous gynecological disorders

• Endometritis

- Pelvic Inflammatory Disease

• Heavy and irregular menstrualbleeding

• Pelvic adhesions

1. Hematocrit assessment

RATIONALE

Pregnant women should be offered a hemoglobin assessment before cesarean

section to identify those who have anemia.

2. Blood transfusion

Pregnant women having cesarean section for antepartum hemorrhage, abruption,

uterine rupture and placenta previa are at an increased risk of blood loss greater
than 1,000 mL and should have the cesarean section carried out at a maternity
unit with on-site blood transfusion services.

3. Informed Consent
The indications for the procedure and its possible outcomes must be discussed
with the patient and her partner and an informed consent should be obtained
prior to labor and delivery.

4. Prophylactic Antibiotics

Antibiotics (single dose of first-generation cephalosporin or ampicillin) must be

prescribed prior to the procedure.

5. Assessment of the risk for thromboembolic disease

If the patient appears to be at a high risk of thromboembolic disorders, she can be

offered graduated stockings, hydration, early mobilization and low molecular
weight heparin.

6. Preanesthetic preparation

The patient must be kept nothing per mouth at least 12 hours prior to the surgery.
If performed as an emergency procedure, the patient must be given
premedication with an antacid (sodium citrate 0.3%, 30 mL or magnesium
trisilicate, 300 mg), H2 antagonist (Cimetidine) IV and an antiemetic (perinorm), at
least 1 hour prior to the procedure.
In order to reduce the risk of aspiration pneumonia

7. Catheterization

To prevent injury to the urinary bladder at the time of surgery, it is important that
the bladder be catheterized prior to undertaking the surgery

8. Maternal position during cesarean section: All obstetric patients undergoing

cesarean section should be positioned with left lateral tilt. This can be achieved by
tilting the operating table to the left or by placing a pillow under the patient's
right lower back.

To avoid aortocaval compression

9. Anesthesia: The procedure can be performed either under general anesthesia

or regional anesthesia (epidural or spinal block).

Regional anesthesia is regarded as considerably safer than general anesthesia and

is most commonly used in our setup.
10. Preparation of the skin: The area around the proposed incision site must be
washed with soap and water.

The woman's pubic hair must not be shaved as this increases the risk of wound
infection. The hair may be trimmed, if necessary.

11. Cleaning and draping

The skin at the operation site is routinely cleaned with antiseptic solutions before
surgery because this practice is thought to reduce the risk of postoperative wound
infections.

An antiseptic solution

(e.g. betadine) must be applied at least three times at the incision site using a
high-level disinfected ring forceps and cotton or gauze swab.

POSTOPERATIVE CARE

1. Prophylactic Antibiotics

Immediately after the cord is clamped, a single dose of prophylactic antibiotics

must be given intravenously. This could include ampicillin 2 g IV or cefazolin 1 g IV.
No additional benefit has been demonstrated with the use of multiple-dose
regimens. If signs of infection are present or the woman currently has fever,
antibiotics must be continued until the woman is fever-free for at least 48 hours.

2. Monitor vital signs

After surgery is completed, the woman must be monitored in a recovery area for
about 4-8 hours.

The parameters which need to be monitored include the patient's vital signs such
as pulse, blood pressure, temperature, respiratory rate, amount of bleeding per
vaginum, bleeding from the incision site and whether the uterus remains well-
contracted or not.

3. Analgesics

Pain medication is also given, initially through the IV line, and later with oral
medications.

Adequate postoperative pain control is of prime importance.

4. Diet

If the surgical procedure was uncomplicated, the woman can be started on a

liquid diet from the next day onwards.

If there are signs of infection, or if the surgery was performed for obstructed labor
or uterine rupture, the surgeon must wait until bowel sounds are heard before
giving liquids.

Prior to discharge, the surgeon must ensure that the woman is eating a regular
diet. Women who are recovering well and who do not have complications after
hysterectomy can eat and drink when they feel hungry or thirsty.

When the woman begins to pass gas, she can be given solid food. If the woman is
receiving IV fluids, they should be continued until she starts accepting liquids well.

5. Early ambulation

The woman must be encouraged to ambulate as soon as possible, usually within

24 hours in order

6. Dressing over the incision site

ADVANTAGES

The advantage of performing hysterectomy after cesarean section is the ease of

development of the tissue planes in a pregnant uterus.

- Cesarean hysterectomy at times serves as the last resort for saving the pregnant
woman's life.

This procedure may be unwelcome in women desirous of future conceptions.

COMPLICATIONS

1. Hemorrhage

2. Injury to the urinary tract

3. Infections

SURGICAL PROCEDURE FOR CONTROLLING POSTPARTUM HEMORRHAGE

TYPES KD SURGICAL OPTIONS

- Various surgical options that can be used in a patient to control PPH are as
follows:

- Brace sutures of uterus: B lynch sutures.

. Uterine artery or utero-ovarian artery ligation.

- Bilateral ligation of internal iliac (hypogastric arteries) vessels.

- Angiographic embolization.

- Hysterectomy (as a last option if nothing seems to work).

B-Lynch Compression Sutures

Compressionsuturescanbeconsideredasthebest form ofsurgical approach for

controlling atonic PPH as it helps in preserving the anatomical integrity of the
uterus.

• The B-Lynch suture is the uterine bracing suture, which when

tightened and tied helps in compressing the anterior and posterior uterine walls
together.

• This technique is safe, effective and helps in retaining future fertility.

Before using the B-Lynch suture, the following test must be performed to assess
the effectiveness of these sutures:

• The uterus must be bimanually compressed followed by swabbing

the vagina. If the bleeding is controlled temporarily in this fashion, the B-Lynch
sutures are likely to be effective.

the uterine compression sutures have almost completely replaced uterine artery
ligation, hypogastric artery ligation and postpartum hysterectomy for surgical
treatment of atonic uterus.

These brace- like absorbable sutures help in controlling bleeding by causing

hemostatic compression of the uterine fundus and lower uterine segment.
The sutures are secured vertically around the anterior and posterior uterine walls
giving appearance of suspenders.

The sutures are first anchored in the anterior aspect of lower uterine segment,
passed over the uterine fundus, anchored in the posterior aspect of the lower
uterine segment, then again brought back anteriorly passing over the fundus of
the uterus.

These sutures are finally anchored near the entrance point on the anterior aspect
of the lower uterine segment (Fig. 7.😎. Simultaneously, the uterus is also
massaged and manually compressed in order to reduce its size.

Hypogastric artery ligation

This is a highly effective method of controlling PPH , which is indicated in cases of

PPH due to uterine atony, ruptured uterus and placenta accreta

This method also help in preserving fertility of women desiring pregnancy in

future.

UTERINE ARTERY LIGATION

- The blood supply to the uterus is via the uterine artery, ligation of this vessel
through the uterine wall at the level of uterine isthmus above the bladder flap is
likely to control the amount ofbleeding.

? If, despite of bilateral ligation of uterine vessels, bleeding remains

uncontrollable, ligation of uteroovarian anastamosis is done just below the
ovarian ligament (Fig. 7.10).
UTERINE ARTERY EMBOLIZATION

A commonly used alternative to uterine artery or internal iliac artery ligation is

angiographic arterial embolization of the hypogastric vessel with small pledgets of
gelfoam.

Gelfoam acts as a selective occluding agent which dissolves within 2-3 weeks.

This method has been found to be particularly useful in cases of retroperitoneal

hematomas where surgery may be difficult.

Success rate of up to 95% has been reported with this method.

UTERINE PACKING

Packing of the uterine cavity can be considered in women with refractory PPH due
to uterine atony who want to preserve their fertility.

However, it can be associated with complications such as concealed bleeding and

infection.

REPAIR OF GENITAL TRACT TEARS AND

LACERATIONS

Presence of tears and lacerations in the genital tract is an important cause for
continued bleeding following the birth of the baby.

Multiple choice
1. Refers to the removal of the uterus at the time of a planned or unplanned
cesarean section:

A. Obstetrical Hysterectomy

2. A type of hysterectomy that is performed at the time of cesarean delivery:

B. Cesarean Hysterectomy

3. A type of hysterectomy that is performed within a short time after vaginal

delivery:

Postpartum Hysterectomy

4. The following are indications for Obstetrical Hysterectomy, SELECT ALL THAT
APPLY

Intractable uterine atony

JInverted uterus

Coagulopathy

Laceration of a pelvic vessel

Chorioamnionitis with sepsis

5.Various surgical options that can be used in a patient to control PPH are the
following, SELECT ALL THAT APPLY
Blynch sutures

Uterine artery ligation

Bilateral ligation of internal iliac

Angiographic embolization

Hysterectomy

6. The following are complications of Hysterectomy, EXCEPT:

A Uterine Atony

B. Hemorrhage

C. Injury to the urinary tract

D. Infections

7. A commonly used alternative to uterine artery or internal iliac artery ligation is

angiographic arterial embolization of the hypogastric vessel with small pledgets of
gelfoam:

C. Uterine Artery Embolization

8. This is a highly effective method of controlling PPH, which is indicated in cases

of PPH due to uterine atony, ruptured uterus and placenta accreta:

D. Hypogastric Artery Ligation

9. The blood supply to the uterus is via the uterine artery, ligation of this vessel
through the uterine wall at the level of uterine isthmus above the bladder flap is
likely to control the amount of bleeding:

B. Uterine Artery Ligation

10. This method has been found to be particularly useful in cases of

retroperitoneal hematomas where surgery may be difficult:

C. Uterine Artery Embolization

CRP FOR INFANTS

CPR: for infants 0-1 in age

CABD (Circulation, Airway, Breathing, Defibrillate) An infant is found lying on the

ground.

Assess to make sure the scene is safe for you to respond to the down patient.

Assess Unresponsiveness:

Lightly shake or tap the infant's foot and say their name.

• Look at the chest and torso for movement and normal breathing.

f the infant is unresponsive:

• (One provider) If alone and collapse is un-witnessed: First perform 2

minutes of CPR then call the emergency response team and bring an AED to the
patient.

• (One provider) If alone and collapse is witnessed: First call the

emergency response team and bring an AED, then start CPR.
 • (Two providers) Have someone near call the emergency response
team and bring the AED and you start CPR.

Place Datient supine on a hard flat surface.

Circulation

Feel for either the brachial or femoral pulse ( do not check for more than 10
seconds)

Brachial and femoral pulse

If the infant has a pulse:

• Move to the airway and rescue breathing portion of the algorithm.

• Give 12-20 breaths per minute.

• Recheck the pulse every 2 minutes.

• If the infant doesn't have a pulse:

Begin 5 cycles of CPR (lasts approximately 2 minutes).

Start with Chest Compressions:

Provide 100 to 120 compressions per minute. This is 30 compressions every 15 to

18 seconds.

(One provider) Place two fingers on

the sternum of the lower chest. One between the nipple line and the other 1cm
below.

(Two providers) Encircle the infant's torso with both hands with both thumbs
pointing cephalic positioned 1cm below the nipples over the sternum.

Chest Compressions should be at least 1.5 inches or 1/3 the depth of infant's
chest.

Press hard and fast.

Allow for full chest recoil.

Only allow minimal interruptions to the chest compressions.

(One Provider: 1 cycle is 30 chest compressions to 2 rescue breaths)

(TwoProviders: 1 cycle is 15 chest compressions to 2 rescue breaths)

If you have two providers: switch rolls between compressor and rescue breather
every 2 minutes or 5 cycles of CPR.

Breathing

Scan the patient's chest and torso for possible movement during the "assess
unresponsiveness" portion of the algorithm. Watch for abnormal breathing or
gasping.

If the infant has adequate breathing:

Continue to assess and maintain a patent airway and place the infant in the infant
recovery position. (Only use the recovery

position if its unlikely to worsen patient injury)

If the infant is not breathing or is inadequately breathing:

If the infant has a pulse:

commence rescue breaths immediately.

• If the infant doesn't have a pulse:

• begin CPR (go to Circulation portion of the algorithm).

• Use a barrier device if available.

Make a seal using your mouth over the mouth and nose of the patient.

Each rescue breath should be small and last approximately 1 second.

Watch for chest rise.

• Allow time for the air to expel from the patient.

• During normal CPR with an advanced airway:

Provide 12-20 rescue breaths per minute (do not stop chest compressions for
rescue breaths). If the patient has a pulse and no CPR is required:
Provide 12-20 rescue breaths per minute. Recheck pulse every 2 minutes.
position for infants

• Cradle the infant with the infant's head tilted downward and slightly
to the side to avoid choking or aspiration.

Continually check the infants breathing, pulse, and temperature.

Defibrillate

Arrival of AED (Automated External Defibrillator)

Power:
 • Turn AED On NOW! (early defibrillation is the single most important
therapy for survival of cardiac arrest. Begin use on patient as soon as it arrives).
Follow verbal AED prompts.

• Attachment:

• Firmly place appropriate pads (adult/pediatric) to patient's skin to the

indicated locations (pad image). Analyze:

• A short pause in CPR is required to allow the AED to analyze the

rhythm. If the rhythm is not shockable:

• Initiate 5 cycles of CPR.

• Recheck the rhythm at the end of the 5 cycles of CPR.

• If shock is indicated:

• Assure no one is touching the patient or in mutual contact of a good

conductor of electricity by "Clear, I'm Clear, you're Clear!" prior to delivering a
shock.

• Press the shock button when the providers are clear of the patient.

• Resume 5 cycles of CPR.

Manual defibrillators are preferred for infant use. If the manuals defibrillator is
not available the next best option is an AED with a pediatric attenuator. An AED
without a pediatric attenuator can also be used.

ADVANCE CARDIAC LIFE SUPPORT

Advanced airway interventions, such as supraglottic airway (SGA) placement or

endotracheal intubation (ETI), may improve ventilation, reduce the risk of
aspiration, and enable uninterrupted compression delivery.
Airway placement may interrupt the delivery of compressions or result in a
malpositioned device. Advanced airway placement requires specialized
equipment and skilled providers, and it may be difficult for professionals who do
not routinely intubate children.

MULTIPLE CHOICE

1. A 7-month-old appears to be conscious and not breathing. You check for a pulse
at the:

Brachial

2. A machine that converts ventricular fibrillation into a perfuming rhythm and

that allows for early defibrillation by first responders:

D.Automated External Defibrillator

3. The emergency medical service has transported an 8th-month-old and is being

transferred to the emergency stretcher, you note unresponsiveness, cessation of
breathing, and unpalpable pulse.

Which of the following task is appropriate to delegate to the nursing assistant?

C. Doing chest compressions

4. Before responding to a first aid scenario, what is the first question you should
ask at thescene?*

C. Safety of the scene

5. You are first to the scene and you find an unresponsive baby with no pulse that
has thrown up. You feel CPR is not something you are comfortable giving them.
What would be the next best thing for you to do?

B. Compression only CPR

6. What would your next step be after you are performing single-person CPR and
the AED (Automatic External Defibrillator) advises a shock?

B. Resume CPR with chest compressions

7. One of your 2-month-old infant isn't feeling well and lays down for a nap. After
checking on the baby, you notice they are not breathing and are blue in color.
What would be the best step to take?

D. Deliver two minutes of CPR.

8. What do you do if an infant is choking and while trying to assist them they
become unresponsive?

C. Begin CPR.

9. Properly operating an AED include the following steps:

B. Power on the AED, attach electrode pads, analyze the rhythm, and shock the
person
10. While performing CPR on an infant, another rescuer appears on the scene,
what do you do next?

C. Have the second rescuer help with CPR, to minimize fatigue