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Induction and Augmentation of Labor

Description:
 Induction of labor means that labor is artificially started; augmentation refers to assisting a labor that
has started spontaneously to be more effective.
 The primary reasons for inducing labor are the presence of preeclampsia, eclampsia, severe
hypertension or diabetes, Rh sensitization, prolonged rupture of membranes, intrauterine growth
retardation, and postmaturity, or situations in which it seems risky for the fetus to remain in utero.
 Augmentation of labor or assistance to make uterine contractions stronger may be necessary when
uterine contractions are too weak or infrequent to be effective.
 Labor induction is a procedure that should be used cautiously with multiple gestation, hydramnios,
grandparity, maternal age older than 35 years, and presence of uterine scars because it carries a risk
of uterine rupture, a decrease in the fetal blood supply from cotyledon filling, and premature
separation of the placenta.
 Labor induction or augmentation may be accomplished by the administration of oxytocin or by
amniotomy.
 Cervical ripening may be accomplished by “stripping the membranes” or separating the membranes
from the lower uterine segment or by placing suppositories of seaweed that swell on contact with
cervical secretions or prostaglandin gel to urge dilatation gradually and gently.
Nursing Implications:
 Obtain a health history, including information about fetal maturity.
 Assist with obtaining ultrasonography or a lecithin-sphingomyelin ratio to assess fetal maturity.
 Be aware that oxytocin should be administered intravenously (never intramuscularly) so that its
effect can be quickly discontinued to prevent hyperstimulation.
 Know that the half-life of oxytocin is about 3 minutes so that with intravenous administration the
functioning level ends this quickly.
 Prepare the intravenous solution by using a dilute intravenous form of oxytocin, such as Pitocin or
Syntocinon, as prescribed.
 Piggyback the oxytocin solution with a maintenance intravenous solution so that if the oxytocin
needs to be shut off abruptly, the intravenous line will not be lost.
 Use an infusion pump to control the small amount of fluid given and to ensure a uniform infusion
rate even when the client changes position.
 Make sure that a physician is nearby during the entire procedure to ensure safety.
 Monitor fetal heart rate and uterine contraction by electronic monitoring.
 Assess and document maternal vital signs every 15 minutes.
 Assess the client for signs of water intoxication, such as headache and vomiting, since oxytocin has
an antidiuretic effect.
 Record intake and output and test urine specific gravity.
 Assure the client that once contractions start by these methods, they are basically normal uterine
contractions.
Forceps Delivery
Description:
 A forceps delivery refers to a method of delivery involving steel instrumentation constructed of two
blades that slide together at their shaft to form a handle.
 Forceps are applied by one blade being slipped into a woman’s vagina next to the fetal head and then
the other side being slipped into place; the shafts are brought together in the midline to form the
handle.
 Forceps may be necessary to deliver the baby if a woman is unable to push with contractions in the
pelvic division of labor, such as after regional anesthesia; if progress ceases in the second stage of
labor; or if the fetus is in an abnormal fetal position.
 A fetus in distress from a complication such as prolapsed cord can be delivered more quickly by the
use of forceps.
 Forceps are designed to prevent pressure from being exerted on the fetal head and also may be used
to reduce pressure and avoid subdural hemorrhage in the fetus as the fetal head reaches the perineum.
 A forceps birth is an outlet procedure when the forceps are applied after the fetal head reaches the
perineum.
 A low forceps birth is at +2 station; if the fetal head is still at the level of the ischial spines (0 station),
this is a mid-forceps birth.
 Some anesthesia, at least a pudendal block , is necessary for forceps application to achieve pelvic
relaxation and reduce pain.

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Nursing Implications:
 Prepare the client physically and emotionally for forceps application.
 Provide emotional support and guidance throughout the procedure to alleviate anxieties and fears;
allow the client and partner to verbalize feelings and concerns.
 Assess the client’s membranes for rupture, which must be present before forceps are applied.
 Be aware that no cephalopelvic disproportion can be present before forceps are applied.
 Assess the client for complete cervical dilation before using forceps.
 Assist the client to empty her bladder before using forceps.
 Monitor the fetal heart rate applying the forceps and immediately after applying them, because a
danger of forceps use is that the cord could be compressed between the blade and the head.
 Anticipate an episiotomy to prevent perineal tearing owing to pressure on the perineum.
 Assess the client’s cervix after a forceps birth to be certain that no laceration has occurred.
 Record the time and amount of the client’s first voiding to rule out bladder injury.
 Assess the neonate for facial palsy and subdural hematoma, possible complications of a forceps birth.
 Inform the client and partner that the neonate may have a transient erythematous mark on the cheek;
assure them that this will fade in 1 to 2 days.
Cesarean Birth
Description:
 Cesarean birth refers to a surgical procedure in which the neonate is delivered through an incision
made in the maternal abdomen.
 It may be planned (elective) or arise from an unanticipated problem (emergency).
 It was previously termed C-section.
 In a classic cesarean delivery, a vertical midline incision is made in the skin and body of the uterus,
allowing easier access to the fetus, and thus indicated in emergency situations; typically, it is done
when the fetus is in transverse lie and when adhesions from previous cesarean deliveries are present
and with an anteriorly implanted placenta; the blood loss is increased because large blood vessels of
the myometrium are involved; there is also greater possibility of rupture of the scar in subsequent
pregnancies because the uterine musculature is weakened.
 In a low segment cesarean delivery, the most common type, the skin incision is made low (“bikini” or
Pfannestiel incision), and the uterine incision is horizontal in the lower uterine segment; blood loss is
minimal with fewer postdelivery complications; the incision is easy to repair with less chance of
rupture of the uterine scar during future deliveries, the procedure takes longer to perform than the
classic incision, and, therefore, it is not useful in emergencies.
Assessment Findings:
 Cephalopelvic disproportion
 Uterine dysfunction
 Malposition or malpresentation
 Previous uterine surgery
 Complete or partial placenta previa
 Preexisting medical conditions
 Prolapsed umbilical cord
 Fetal distress
Postpartal Complications
A. Postpartal Hemorrhage
Uterine Atony
Description:
 Lack of tone, is the most frequent cause of postpartal hemorrhage.
 The uterus must remain in a contracted state after birth to allow the open vessels at the placental site to
seal.
 The first step in controlling postpartal hemorrhage in the event of uterine atony is to attempt uterine
massage to encourage contraction.
 If the uterus cannot remain contracted, the physician invariably orders an intramuscular injection of
Methergine or a dilute intravenous infusion of oxytocin to help the uterus maintain tone.
 If uterine massage and administration of methergine and oxytoxin are not effective, the physician may
attempt bimanual compression (one hand inserted into the vagina and the other pushing against the fundus
through the abdominal wall).
 It may be necessary to explore the uterine cavity for retained placental fragments.
 Uterine packing may be placed to help halt bleeding.
 If all other therapeutic measures fail in achieving uterine atony, ligation of the uterine arteries or
hysterectomy, although rare, may be performed.
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Predisposing Factors:
A. Conditions that distend the uterus beyond average capacity
• Multiple Gestation
• Hydramnios
• Large baby
• Presence of uterine myomas
B. Conditions that could have caused cervical or uterine tears
• Operative delivery
• Rapid delivery
C. Conditions with varied placental site or attachment
• Placenta previa
• Placenta accreta
• Abruprio placenta
D. Conditions that leave the uterus too exhausted to contract readily
• Deep anesthesia or analgesia
• Labor initiated or assisted with an oxytocin agent
• Maternal age over 30 years
• High parity
• Prolonged and difficult labor
• Secondary maternal illness such as anemia
• Endometritis
• Prolonged use of magnesium sulfate or oxytocin
E. Conditions that lead to inadequate blood coagulation
• Fetal death
• Disseminated intravascular coagulation
Assessment Findings:
 Sudden uterine relaxation
 Vaginal bleeding (abrupt or seeping)
 Symptoms of shock and blood loss
Nursing Implications:
 Palpate the fundus at frequent intervals to ascertain that the uterus is remaining is a state of contraction.
 Assess vital signs and lochia per protocol and observe for signs of blood loss and shock.
 Perform gentle but firm uterine massage while supporting the base of the uterus to encourage uterine
involution.
 Perform a perineal pad count in given lengths of time to assess better blood loss.
 Weigh perineal pads before and after use to measure vaginal discharge more accurately.
 Be prepared to administer an intramuscular injection of methergine or a dilute intravenous infusion of
oxytocin to help the uterus maintain tone.
 Assess the client’s blood pressure before administering oxytocin or methergin because these medications
can cause hypertension and therefore should not be administered if the client’s blood pressure is over
140/90 mmHg.
 Obtain appropriate laboratory specimens such as crossmatching if it is determined that the client’s blood
loss requires her to receive blood replacement.

LACERATIONS – is a ragged cut. It may involve the skin layer or may penetrate to deeper subcutaneous
tissue or tendons. Bleeding should be halted by pressure on the edge of the laceration. After cleaning, the
area is sutured through each layer of tissue involved to approximate edges. Large lacerations are
complications that occur most often:
 With difficult or precipitate deliveries
 In primigravidas
 With the birth of a large infant (over 9 lb)
 With the use of a lithotomy position and instruments
Cervical lacerations – are usually found on the sides of the cervix near the branches of the uterine artery.
Because it is arterial bleeding, the blood seen will be brighter red than the venous blood lost with uterine
atony. Blood may gush from the vaginal opening. If the cervical laceration appears to be extensive or
difficult to repair, it may be necessary for the woman to be given a regional anesthetic for relaxation of the
uterine muscle and to prevent pain.
Vaginal lacerations – although rare, lacerations can also occur in the vagina. These are easier to assess
because they are easier to view. Vagina may be packed to maintain pressure on the suture line. An indwelling
urinary catheter may be placed at the same time, because the packing causes pressure on the urethra and can
interfere with voiding.

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Perineal lacerations – usually occur when the woman is delivered from a lithotomy position, because this
position increases tension on the perineum. Perineal lacerations are sutured and treated as an episiotomy
repair.
Classification of Perineal Lacerations
 First degree – involves the vaginal mucous membrane and the skin of the perineum
 Second degree – involves not only the vaginal mucous membrane, perineal skin but also the muscles.
 Third degree – involves not only the vaginal mucous membrane, perineal skin and muscles, but also
the external sphincter of the rectum
 Fourth degree – involving the mucous membrane of the rectum
Retained Placental Fragments
Description:
 Retained placental fragments occurs when the placenta does not deliver in its entirety but separates
and leaves fragments behind.
 This results in uterine bleeding because the portion retained keeps the uterus from contracting fully.
 It occurs with placental anomalie, most likely with a succenturiate placenta.
 A placenta accreta that remains after birth, may need to be surgically removed or treated with
methotrexate.
Assessment Findings:
 Excessive postpartal bleeding
 Uterus not fully contracted
 Elevated serum HCG
 Placental fragments visible on ultrasonography
Nursing Implications:
 Thoroughly examine the placenta after birth to make sure it is intact.
 Keep in mind that if the undetected retained fragment is large, the bleeding is apparent in the
immediate postpartal period; if the fragment is small, bleeding may not be detected until the 6 th or
10th postpartal day.
 Perform fundal checks after births and assess for height, consistency, and uterine bleeding.
 Assist with dilaattion and curettage to remove the retained placental fragments.
 Instruct the client to observe her lochia discharge at home and report any tendency for the discharge
to change from lochia alba to rubra, or a sudden discharge of a large amount of blood.
Disseminated Intravascular Coagulation (DIC)
Description:
 DIC is an acquired disorder of blood clotting that results from excessive trauma or some similar
underlying stimulus.
 It can develop during pregnancy, placing the client at high risk for problems; it also is a postpartal
complication, one of the major causes of postpartal hemorrhage.
 Situation associated with DIC and childbirth include pregnancy-induced hypertension, amniotic fluid
embolism, placental retention, septic abortion, retention of a dead fetus, and saline abortion.
 DIC occurs when there is extreme bleeding and so many platelets and fibrin from the general
circulation are used that there are not enough left for clotting.
 This situation result in a paradox: At one point in the circulatory system, the person has increased
coagulation; throughout the rest of the system, a bleeding defect exists.
 DIC is an emergency situation. Maternal death can result if hypofibrinogenemia does not reverse; the
fetus is at risk from hypoxia, maternal sepsis, acidosis, and hypotension.
Assessment Findings:
 Vaginal bleeding continues despite usual measures to induce uterine contractions
 Oozing from an intravenous or blood-drawing site
 Thrombocytopenia
 Decreased fibrinogen levels
 Increased prothrombin time (PT)
 Increased partial thromboplastin time (PTT)
Nursing Implications:
 Be aware that DIC is a complication of pregnancy, ending the pregnancy by delivering the fetus helps
to stop the process of DIC.
 Assess the mother and fetus closely for changes; have emergency equipment available.
 Prepare to administer heparin intravenously, to release the coagulation factors in the one part of the
system aiding coagulation throughout the rest of the body.
 Keep in mind that heparin does not cross the placenta.

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 Anticipate administering blood and blood factors after administering heparin to prevent the
consumption of these new blood factors by the coagulation process.
 Assess the fetus for signs of placental insufficiency and fetal danger signs; following birth, assess the
newborn for signs that placental circulation remained sufficient.

Subinvolution – is incomplete return of the uterus to its prepregnant size and shape. With subinvolution, at a
4 or 6 week postpartal visit, the uterus is still enlarged and soft. Subinvolution may result from a small
retained placental fragment, a mild endometritis, or an accompanying problem, such as a myoma that is
interfering with complete contraction.

Nursing Implications:
 Oral administration of methylergonovine generally is prescribed to improve uterine tone and
complete involution.
 If the uterus is tender on palpation, suggesting endometritis, an oral antibiotic also may be
prescribed.
 A chronic loss of blood from subinvolution will result in anemia and lack of energy.
Perineal Hematoma
Description:
 Perineal hematoma is a collection of blood in the subcutaneous layer of tissue of the perineum.
 As a rule, the overlying skin is intact with no noticeable trauma.
 Such collections may be caused by injury to blood vessels in the perineum during birth; they are most
likely to occur following rapid spontaneous deliveries and in women who have perineal varicosities,
 It may occur at an episiotomy or laceration repair site if a vein was pricked during repair.
 They can cause the woman acute discomfort and concern, but, fortunately, they usually represent
only minor bleeding.
Assessment Findings:
 Severe pain in perineal area
 Complaints of pressure between the legs
 Purplish discoloration
 Obvious swelling (2cm to 8 cm in diameter)
 Tender, fluctuant area on palpation
Nursing Implications:
 Inspect the perineal area closely for presence of hematoma.
 Assess its size and degree of discomfort and notify the physician
 Administer a mild analgesic as prescribed for pain relief.
 Apply an ice pack to help prevent further bleeding.
 Be aware that if the hematoma is large when discovered, the client may have to be returned to the
delivery to have the site incised and the bleeding vessel ligated.
 Advise the client that the hematoma should be absorbed over the next 6 weeks.
 If the episiotomy line is open to drain the hematoma, anticipate the line being left open and packed
with gauze; prepare for packing removal in 24 to 48 hours.
B. Puerperal Infections:
Infection of the Perineum
Description:
 Infections of the perineum generally remain localized or manifest the symptoms of any suture line
infection.
 A laceration repair or an episiotomy is a ready portal of entry for bacterial invasion.
Assessment Findings:
 Pain, heat, and feeling of pressure around suture line
 Normal or elevated temperature
 Inflamed suture line
 Open suture line or sloughing away of one or two sutures
 Appearance of pus
Nursing Implications:
 Observe the episiotomy site.
 Monitor vital signs (temperature) for changes indicating an infection.
 Obtain a culture of inflamed and tender suture line.
 Offer analgesia for pain as prescribed.
 Prepare the client for possible perineal suture removal to open the area and allow for drainage.

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 Packing may be inserted after opening the sutures to help keep them open and promote drainage.
 Administer antibiotic as prescribed.
 Provide sitz baths or warm compress as prescribed to hasten drainage and cleanse the area.
 Instruct the client to change perineal pads frequently because they may be contaminated by
discharge; if left in place for a long time, they might cause vaginal contamination.
 Teach the client to wash her hands after handling perineal pads to prevent transmission of infection.
 Instruct the client to wipe from front to back after a bowel movement to prevent bringing feces
forward onto the healing area.
Endometritis
Description:
 An infection of the endometrium, is a postpartal complication, usually occurring 48 to 72 hours after
delivery.
 Bacteria gain access to the uterus through the vagina and enter the uterus either at the time of birth or
during the postpartal period.
 If the infection is limited to the endometrium, the course is about 7 to 10 days.
 Endometritis can lead to tubal scarring and interfere with future fertility.
Assessment Findings:
 Elevated temperature (38ºC) for 2 consecutive 24-hour periods
 Large, tender, poorly contracted uterus
 Severe postpartum cramping
 Brownish, red, foul-smelling lochia
Nursing Implications:
 Inspect the perineum at least twice daily for redness, edema, ecchymosis, and discharge.
 Assess fundal size, consistency, and tenderness for changes indicating poor involution.
 Evaluate for abdominal pain, fever, and malaise.
 Assess lochia for color, quantity, and odor; report any foul-smelling lochia.
 Obtain culture and sensitivity of lochia.
 Adminiter appropriate antibiotic as prescribed.
 Provide additional fluid to combat fever.
 Administer an analgesic as ordered to relieve severe cramping and discomfort.
 Urge the client to use Fowler’s position and ambulation to encourage lochia drainage by gravity and
prevent pooling of infected secretions.
Thrombophlebitis
Description:
 Thrombophlebitis is inflammation of the lining of a blood vessel with the formation of clots.
 When thrombophlebitis occurs in the postpartal period, it is usually an extension of an endometrial
infection.
 Thrombophlebitis is prone to occur in the postpartal period when blood-clotting ability is high
because of increased fibrinogen; dilation of lower extremity veins owing to pressure of fetal head
during pregnancy and birth; and the relative inactivity of the period that leads to pooling, stasis, and
clotting of blood in the lower extremities.
 Women most prone to thrombophlebitis are those with varicose veins, those who are obese, those
who had a previous thrombophlebitis, women over 30 years old with increased parity who were in a
stirrups position for a long time during birth, and those who have high incidence of thrombophlebitis
in their family.
 With femoral thrombophlebitis, it often occurs on the 10 th postpartum day.
 With pelvic thrombophlebitis, it often occurs on the 14 th or 15th day of the puerperium.
 With pelvic thrombophlebitis, an abscess may form (necessitating incision by laparotomy), which
may cause tubal scarring and interfere with future pregnancies.
Assessment Findings:
Femoral Thrombophlebitis
 Elevated temperature and chills
 Stiffness, pain and redness in the affected leg
 Leg edema with shiny skin (milk leg)
 (+) Homans’ sign
Pelvic Thrombophlebitis
 Feeling of sudden, extreme illness
 High fever
 Chills

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 General malaise
 Pelvic abscess
Nursing Implications:
 Provide prevention of endometritis and thrombophlebitis by using good aseptic technique.
 Encourage early ambulation to increase circulation in the lower extremities and decrease the
possibility of clot formation.
 Be certain that client does not remain in a lithotomy and stirrups position for more than an hour, and
be certain to pad the stirrups to prevent any sharp pressure against the calf of the legs in this position.
 Provide support stockings to the postpartum client who has varicose veins to increase venous
circulation and help prevent stasis.
 Encourage bed rest with the affected leg elevated for the client with femoral thrombophlebitis.
 Obtain daily blood coagulation levels before administering any anticoagulants.
 Administer anticoagulants, analgesics, and antibiotics as prescribed.
 Apply heat applications such as heat lamp or moist, warm compress as prescribed.
 Obtain a record of lochia and weigh perineal pads to assess bleeding if the client is on anticoagulant
therapy.
 Assess for other possible bleeding signs, such as bleeding gums, ecchymotic spots on the skin, or
oozing from an episiotomy suture line.
 Reassure the client receiving heparin that she may continue to breast-feed as this medication will not
be present in breast milk.
 Be prepared to administer protamine sulfate as an antagonist for heparin.
 Prepare the client with pelvic thrombophlebitis for surgery.

C. Emotional and Psychological Complications of the Puerperium


Comparing Postpartal Blues, Depression and Psychosis
Postpartal Blues Postpartal Depression Postpartal Psychosis
Onset 3-5 days after birth 1 – 6 months Within first month after birth

Symptoms Sadness, tears Anxiety, feeling of loss, Delusions, hallucinations


sadness
Incidence 75% of all births 10% of all births 2% of all births

Etiology Probable hormonal History of poor parent Possible activation of previous


changes relationship, hormonal mental illness, hormonal changes
response
Therapy Support, empathy Counseling Psychotherapy, drug therapy

Nursing Role Offer compassion Refer to counseling Refer to counseling, safeguard


and understanding mother from injury to self or to
newborn