Week 5 Notes

Care of the Client During Labor and Delivery (At-risk)

• Labor often proceeds without any deviation from the normal, many potential
complications can occur.
• Difficult labor 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).
• Because complications can occur at any point in labor, continuous monitoring of a
laboring woman and fetus and providing emotional support for her and her family are
essential.
• The hours of labor are stressful even when everything is proceeding normally.
• Be sure to reassure a woman in labor that everything is going smoothly and that both
she and her fetus appear to be doing well.
• Suppose a complication arises and assurances cannot be given as freely. In that case, a
woman needs someone knowledgeable about the deviation and its treatment and a
person who understands her feelings of helplessness.
• Nurses play a key role in providing this type of skilled physical and emotional care.

Complications With the Power (The Force of Labor)

• Inertia is a time-honored term to denote that sluggishness of contractions or labor force
has occurred.
• A more current time used is dysfunctional labor
• Dysfunction can occur at any point in labor, but it is generally classified as primary
(occurring at the onset of labor) or secondary (occurring later in labor).

Ineffective Uterine Force

• Uterine contractions are the basic force moving the fetus through the birth canal.
• They occur because of the interplay of the contractile enzyme adenosine triphosphate
and the influence of major electrolytes such as calcium, sodium, and potassium, specific
contractile proteins (actin and myosin), epinephrine and norepinephrine, oxytocin (a
posterior pituitary hormone), estrogen, progesterone, and prostaglandins.
• About 95% of labors are completed with contractions that follow a predictable, normal
course.
• When they become abnormal or ineffective, ineffective labor occurs (Pillitteri, 2018).

Hypotonic Contractions
• Hypotonic contractions are most apt to occur during the active phase of labor.
• They may occur after the analgesia administration, especially if the cervix is not dilatated
to 3 to 4 cm or if bowel or bladder distention prevents descent or firm engagement.
• They may occur in a uterus overstretched by multiple gestations, a larger than-usual
single fetus, hydramnios, or a lax from grand multiparity in a uterus. Such contractions
are not exceedingly painful because of their lack of intensity.
• Keep in mind, however, that the strength of a contraction is a subjective symptom.
• Some women may interpret these contractions as very painful (Pillitteri, 2018).
• Hypotonic contractions increase the length of labor because more of them are necessary
to achieve cervical dilatation
• This can cause the uterus to not contract as effectively during the postpartal period
because of exhaustion, increasing women's chance for postpartum hemorrhage.
• In the first hour after birth following labor of hypotonic contractions, palpate the uterus
and assess lochia every 15 minutes to ensure that postpartal contractions are not
hypotonic and therefore inadequate to halt bleeding (Pillitteri, 2018).

Hypertonic Contractions
• Hypertonic uterine contractions are marked by an increase in resting tone to more than
15 mm Hg.
• However, the intensity of the contraction may be no stronger than that associated with
hypotonic contractions.
• In contrast to hypotonic contractions, hypertonic ones frequently occur and are most
commonly seen in labor latent.
 • This type of contraction occurs because the myometrium's muscle fibers do not
repolarize or relax after a contraction, thereby "wiping it clean" to accept a new
pacemaker stimulus.
• They may occur because more than one pacemaker is stimulating contractions.
• They tend to be more painful than usual because the myometrium becomes tender from
a constant lack of relaxation and uterine cells' anoxia.
• A woman may become frustrated or disappointed with her breathing exercises for
childbirth because such techniques are ineffective with this type of contraction
• A danger of hypertonic contractions is that the lack of relaxation between contractions
may not allow optimal uterine artery filling, leading to fetal anoxia early in the latent
phase of labor.
• Any woman whose pain seems out of proportion to the quality of her contractions should
have both a uterine and an external fetal monitor applied for at least 15 minutes to
ensure that the resting phase of the contractions is adequate and that the fetal pattern is
not showing late deceleration (Pillitteri, 2018).

Uncoordinated Contractions
• Normally, all contractions are initiated at one pacemaker point high in the uterus.
• A contraction sweeps down over the organ, encircling it; repolarization occurs; relaxation
or a low resting tone is achieved, and another pacemaker activated contraction begins.
• With uncoordinated contractions, more than one pacemaker may be initiating
contractions, or receptor points in the myometrium may be acting independently of the
pacemaker.
• Uncoordinated contractions may occur so closely that they do not allow good cotyledon
(one of the visible segments on the placenta's maternal surface) filling.
• Because they occur so erratically, such as one on top of another and then a long period
without any, it may be difficult for a woman to rest between contractions or use breathing
exercises with contractions

Precipitate Labor
• Precipitate labor and birth occur when uterine contractions are so strong that a woman
gives birth with only a few rapidly occurring contractions.
• It is often defined as labor that is completed in fewer than 3 hours.
• Precipitate dilatation is cervical dilatation that occurs at a rate of 5 cm or more per hour
in a primipara or 10 cm or more per hour in a multipara
• Such rapid labor is likely to occur with grand multiparity, or it may occur after induction of
labor by oxytocin or amniotomy.
• Contractions can be so forceful that they lead to premature separation of the placenta,
placing the woman at risk for hemorrhage.
• Rapid labor also poses a risk to the fetus because subdural hemorrhage may result from
the rapid release of pressure on the head.
• A woman may sustain lacerations of the birth canal from the forceful birth. She also can
feel overwhelmed by the speed of labor.
• Caution a multiparous woman by week 28 of pregnancy that, because past labor was so
brief, her labor this time also may be brief.
• This allows her to plan for appropriately timed transportation to the hospital or alternative
birthing center.
• Both grand multiparas and women with histories of precipitate labor should have the
birthing room converted to birth readiness before full dilatation is obtained.
• Then, even a sudden birth can be accomplished in a controlled surrounding

Induction and Augmentation of Labor

• When labor contractions are ineffective, several interventions, such as induction and
augmentation of labor with oxytocin or amniotomy (artificial rupture of the membranes),
may be initiated to strengthen them
• Induction of labor means that labor is started artificially.
• Augmentation of labor refers to assisting labor that has started spontaneously but is not
effective.
• Induction may be necessary to initiate labor before it occurred spontaneously because a
fetus is in danger or because labor does not occur spontaneously.
• The fetus appears to be at term.
 • The primary reasons for inducing labor include the presence of pre-eclampsia;
eclampsia; severe hypertension; diabetes; Rh sensitization; prolonged rupture of the
membranes; intrauterine growth restriction; and postmaturity (a pregnancy lasting
beyond 42 weeks)—all situations that increase the risk for a fetus to remain in utero.
• Augmentation of labor or assistance to make uterine contractions stronger may be
necessary if the contractions are hypotonic or too weak, or infrequent to be effective
• Because augmentation or initiation of labor carries a risk of uterine rupture, decrease in
the fetal blood supply from poor cotyledon filling, or premature separation of the
placenta, it is used cautiously with women with multiple gestations, hydramnios, grand
parity, maternal age older than 40 years, or previous uterine scars

Cervical Ripening
• Cervical ripening, or a change in the cervical consistency from firm to soft, is the first
step the uterus must complete in early labor.
• Until this has occurred, dilatation and coordination of uterine contractions will not occur.
• A more commonly used method of speeding cervical ripening is the application of a
prostaglandin gel, such as misoprostol, to the interior surface of the cervix by a catheter
or suppository or to the external surface by applying it to a diaphragm and then placing
the diaphragm against the cervix
• Additional doses may be applied every 6 hours. Two or three doses are usually
adequate to cause ripening.
• Women should remain in bed in a side-lying position to prevent leakage of the
medication.
• The FHR should be monitored continuously for at least 30 minutes after each application
(perhaps up to 2 hours after vaginal insertion).
• Side effects are vomiting, fever, diarrhea, and hypertension, so these should also be
monitored.
• Oxytocin induction may be started 6 to 12 hours after the last prostaglandin dose
(beginning it sooner might lead to hyperstimulation of the uterus

Induction of Labor by Oxytocin

• Administration of oxytocin (a synthetic form of naturally occurring pituitary hormone)
initiates contractions in a uterus at pregnancy term
• Oxytocin is always administered intravenously so that, if hyperstimulation should occur, it
can be quickly discontinued.
• Because the half-life of oxytocin is approximately 3 minutes, the falling serum level and
effects are apparent almost immediately after discontinuation of IV administration
• Usually, a form of oxytocin, such as Pitocin, is mixed in the proportion of 10 IU in 1000
mL of Ringer's lactate.
• Physician's orders for the administration of oxytocin for induction usually designate the
number of milliunits to be administered per minute
• When administering the infusion, "piggyback" the oxytocin solution to a maintenance IV
solution such as Ringer's lactate.
• If the oxytocin needs to be discontinued quickly during the induction, the main IV line can
still be maintained.
• Always attach the oxytocin solution to the infusion port closest to the woman. This way, if
it is stopped, the little solution remains in the tubing to still infuse.
• Use an infusion pump to regulate the infusion rate, not change even if a woman changes
position.
• A physician should be immediately available during the entire procedure to ensure
safety.
• Peripheral vessel dilatation, a side effect of oxytocin, may cause extreme hypotension.
• To ensure safe induction, take the woman’s pulse and blood pressure every 15 minutes.
• Monitor uterine contractions and FHR conscientiously (Pillitteri, 2018).
• If contractions become more frequent or longer in duration than these safe limits, or if
signs of fetal distress occur, stop the IV infusion and seek help immediately.
• Anticipate the need for oxygen administration.
• Excessive stimulation of the uterus by oxytocin may lead to tonic uterine contractions
with fetal death or rupture of the uterus.
 • Oxytocin has an antidiuretic side effect that can decrease urine flow, possibly leading to
water intoxication.
• Water intoxication is first manifested by headache and vomiting. If you observe these
danger signs in a woman during labor induction, report them immediately, and halt the
infusion.
• Water intoxication can lead to seizures, coma, and death in its most severe form
because of the large shift in the interstitial tissue fluid.
• Keep an accurate intake and output record, test, and record urine specific gravity
throughout oxytocin administration to detect fluid retention

Augmentation by Oxytocin
• Augmentation of labor is required if labor contractions begin spontaneously but become
so weak, irregular, or ineffective (hypotonic) that assistance is needed to strengthen
them. Precautions regarding oxytocin augmentation are the same as for primary
induction of labor.
• A uterus may be very responsive or respond very effectively to oxytocin used as
augmentation.
• Be certain that the drug is increased in small increments only and that fetal heart sounds
are well monitored during the procedure

Uterine Rupture
• It is always serious because it accounts for as many as 5% of all maternal deaths.
• Uterine rupture occurs when a uterus undergoes more strain than it is capable of
sustaining.
• Rupture occurs most commonly when a vertical scar from a previous cesarean birth or
hysterotomy repair tears

Uterine Rupture - Contributing Factors

• Prolonged labor
• Abnormal presentation
• Multiple gestations
• Unwise use of oxytocin
• Obstructed labor
• Traumatic maneuvers of forceps or traction.

Inversion of the Uterus

• Uterine inversion refers to the uterus turning inside out with either birth of the fetus or
delivery of the placenta.
• It may occur if traction is applied to the umbilical cord to remove the placenta or if
pressure is applied to the uterine fundus when the uterus is not contracted.
• It may also occur if the placenta is attached to the fundus so that, during birth, the
passage of the fetus pulls the fundus down.

Problems with the Passenger

Prolapse of the Umbilical Cord
• An umbilical cord prolapse, a loop of the umbilical cord slips down in front of the
presenting fetal part.
• 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 are preventing the presenting part from engaging.
• It tends to occur most often with
• A small fetus
• Cephalopelvic disproportion preventing firm engagement
• Hydramnios
• Multiple gestations
Prolapse of the Umbilical Cord – Assessment
• In rare instances, the cord may be felt as presenting an initial vaginal examination during
labor.
• It may also be identified in this position on an ultrasound. When this happens, cesarean
birth is necessary before rupture of the membranes occurs.
• Otherwise, membrane rupture would cause the cord to slide down into the vagina from
the amniotic fluid's pressure.
• More often, however, cord prolapse is first discovered only after the membranes have
ruptured, when a variable deceleration FHR pattern suddenly becomes apparent.
• The cord may be visible at the vulva.
• To rule out cord prolapse, always assess fetal heart sounds immediately after rupture of
the membranes, whether this occurs spontaneously or by amniotomy (Pillitteri, 2018)

Prolapse of the Umbilical Cord – Therapeutic Management

• Involves relieving pressure on the cord through manual techniques like elevating the
fetal head or adjusting the woman's position.
• Oxygen administration, tocolytic agents to reduce uterine activity, and amnioinfusion are
also utilized.
• If the cord is exposed, cover it with a saline compress to prevent drying, avoiding
attempts to push it back into the vagina.
• If cervix dilation is complete, prompt delivery may be necessary, possibly with forceps.
• If incomplete, pressure on the presenting part is applied until a cesarean birth can be
performed.
• Cord prolapse is always considered an emergency due to the risk of fetal harm.

Amnioinfusion
• Amnioinfusion involves adding sterile fluid into the uterus to supplement the amniotic
fluid, which helps prevent additional cord compression.
• A sterile catheter is inserted through the cervix into the uterus after membrane rupture,
and warmed normal saline or lactated Ringer's solution is infused.
• Throughout the procedure, the woman should lie in a lateral recumbent position to
prevent supine hypotension syndrome.
• Strict aseptic technique is essential during insertion and catheter care. Continuous
monitoring of fetal heart rate (FHR) and uterine contractions is necessary, along with
hourly maternal temperature checks to detect infection.
• Warm the solution to body temperature before infusion to prevent chilling.
• Since fluid will continuously flow out of the vagina during the procedure, change the
woman's bed frequently and ensure constant drainage.
• If vaginal leakage stops, it may indicate fetal head engagement, risking hydramnios and
uterine rupture.
• Warm the solution to body temperature before infusion to prevent chilling.
• Since fluid will continuously flow out of the vagina during the procedure, change the
woman's bed frequently and ensure constant drainage.
• If vaginal leakage stops, it may indicate fetal head engagement, risking hydramnios and
uterine rupture.

Problems with Fetal Position, Presentation, or Size

Occipitoposterior Position
• Occipitoposterior position refers to a fetal position where the back of the baby's head
(occiput) is facing the mother's back (posterior).
• This position can lead to prolonged labor and increased discomfort for the mother due to
pressure on her spine.
• Additionally, it may result in difficulties during delivery, such as increased risk of
instrumental delivery or cesarean section.
• To address occipitoposterior position during labor, techniques like changing positions,
pelvic rocking, and hands-and-knees positioning may be recommended to encourage
the baby to rotate into a more favorable position.
• In some cases, medical interventions such as manual rotation by a healthcare provider
or the use of forceps or vacuum extraction may be necessary to facilitate delivery.
 • Early identification and appropriate management of occipitoposterior position can help
optimize labor progress and improve outcomes for both the mother and the baby.

Breech Position
• In pregnancy, most fetuses start in a breech presentation but typically turn to a cephalic
(head-down) presentation by week 38.
• The fundus being the largest part of the uterus plays a role in this turning process.
• Breech presentations, where the baby's buttocks or feet present first, are less common
and pose higher risks during delivery, including potential complications such as:
o Anoxia from cord prolapse
o Traumatic injuries
o Dysfunctional labor
o Early rupture of membranes.

• The pressure of the fetal buttocks often leads to the passage of meconium into the
amniotic fluid, which can lead to meconium aspiration by the newborn.

Assessment involves various techniques such as:

• Fetal heart sound examination
• Leopold's maneuvers, and vaginal examination.
• Ultrasound confirmation may be necessary for unclear presentations.

During breech birth, similar stages of labor progression occur as in vertex (head-first) births, but
continuous monitoring of fetal heart rate and uterine contractions is crucial for early detection of
complications and timely intervention.

Face Presentation
• Face presentation occurs when the fetal head presents at an angle different from the
typical vertex presentation.
• It is rare but recognizable by the feeling of a prominent head during examination or when
the head and back are on the same side of the uterus.
• Fetal heart tones may be heard on the side where feet and arms are palpated.
• Confirmation is done through vaginal examination, feeling for the nose, mouth, or chin.
• Ultrasound may be used for further confirmation and measurement of pelvic diameters.
• If the chin is anterior and pelvic diameters are normal, vaginal birth may be possible,
albeit potentially prolonged.
• If the chin is posterior, cesarean birth is usually recommended due to the risk of
complications from prolonged labor or malposition.
• Infants born after a face presentation may have facial swelling and bruising, requiring
close observation for a patent airway and possibly gavage feedings until they can suck
effectively.

Brow Presentation
• Brow presentation is the rarest fetal presentation, typically occurring in multiparous
women or those with relaxed abdominal muscles.
• It often leads to obstructed labor because the head becomes stuck in the pelvis due to
the presentation of the occipitomental diameter.
• Unless the presentation spontaneously corrects, cesarean birth is usually necessary for
safe delivery.
• Infants born with a brow presentation may have extreme facial bruising, particularly over
the anterior fontanelle, requiring reassurance for parents post-birth.

Transverse Lie Presentation

• Transverse lie occurs due to various factors such as pendulous abdomen, uterine
fibroids, pelvic contraction, congenital uterine abnormalities, or conditions like
hydramnios.
• It may also happen in infants with certain abnormalities like hydrocephalus or in cases of
prematurity, multiple gestation, or a short umbilical cord.
• Diagnosis is typically evident upon inspection, with the uterus appearing more horizontal
than vertical, and confirmed through Leopold's maneuvers and ultrasound.
 • Vaginal delivery is not possible due to the lack of a firm presenting part, increasing the
risk of cord prolapse or shoulder obstruction.
• Cesarean birth is necessary for safe delivery in cases of transverse lie.

Macrosomia
• An oversized fetus, known as macrosomia, typically weighs more than 4000 to 4500
grams (approximately 9 to 10 pounds) and complicates around 10% of births.
• Women with preexisting diabetes or gestational diabetes are at higher risk of delivering
large babies, as are multiparous women.
• Macrosomic infants can lead to uterine dysfunction during labor due to overstretching of
uterine fibers, and their wide shoulders may cause fetal pelvic disproportion or even
uterine rupture.
• If vaginal delivery is not possible due to size, cesarean birth is usually recommended.
• In obese women, assessing fetal size can be challenging, but techniques like pelvimetry
or ultrasound can help compare fetal size with pelvic capacity to guide delivery
decisions.
• In obese women, assessing fetal size can be challenging, but techniques like pelvimetry
or ultrasound can help compare fetal size with pelvic capacity to guide delivery
decisions.

Shoulder Dystocia
• Shoulder dystocia is a birth problem that increases in incidence along with the increasing
average weight of newborns
• The problem occurs at the second stage of labor when the fetal head is born, but the
shoulders are too broad to enter and be born through the pelvic outlet.
• This is hazardous to the woman because it can result in vaginal or cervical tears.
• It is hazardous to the fetus if the cord is compressed between the fetal body and the
bony pelvis. The force of birth can result in a fractured clavicle or a brachial plexus injury
for the fetus.

Problems with the Passage

• Still, another reason that dystocia can occur is a contraction or narrowing of the
passageway or birth canal.
• This can happen at the inlet, at the mid pelvis, or the outlet. The narrowing causes CPD
or a disproportion between the size of the fetal head and the pelvic diameters. This
results in failure to progress in labor

Trial Labor
• Trial labor, also known as a trial of labor (TOL), refers to the attempt to have a vaginal
birth after cesarean (VBAC) following a previous cesarean delivery.
• It's a consideration for women who have had a previous cesarean section but wish to
attempt vaginal delivery for their subsequent pregnancies.
• During a trial of labor, the woman undergoes labor and attempts to deliver vaginally, with
careful monitoring for any signs of uterine rupture, which is the most significant risk
associated with VBAC.
• Factors such as the reason for the previous cesarean, the type of uterine incision, the
number of previous cesarean deliveries, and the presence of any other complications
influence the suitability and safety of a trial of labor.

Forceps Birth
• Forceps birth is a method used to assist vaginal delivery when there are concerns about
the progress of labor.
• Specialized instruments called forceps are gently applied to the baby's head to help
guide it through the birth canal.
• This technique is typically used when delivery needs to be expedited due to issues like
prolonged labor or fetal distress.
• While forceps deliveries carry some risks, they can help avoid the need for a cesarean
section when performed by skilled healthcare providers.
• Before proceeding, the healthcare team carefully assesses the situation and obtains
consent from the mother.
 • Overall, forceps birth is a valuable option for safely assisting vaginal deliveries when
necessary.

Vacuum Extraction
• Vacuum extraction is a method used to assist vaginal delivery when there are concerns
about the progress of labor.
• A vacuum device, which is a soft or rigid cup attached to a suction pump, is applied to
the baby's head to help guide it through the birth canal.
• This technique is typically used when expediting delivery is necessary due to issues like
prolonged labor or fetal distress.
• Vacuum extraction carries some risks, including scalp injuries or bleeding under the
scalp, but it can help avoid the need for a cesarean section when performed by skilled
healthcare providers.
• Before proceeding, the healthcare team carefully assesses the situation and obtains
consent from the mother.
• Overall, vacuum extraction is a valuable option for safely assisting vaginal deliveries
when necessary.

Nursing Care of the Postpartum Clients (At-risk)

POST-PARTAL HEMORRHAGE

Uterine Atony
• Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartal
hemorrhage
• After birth, the uterus must remain in a contracted state to keep the open vessels at the
placental site from bleeding.
• When caring for a woman in whom any of these conditions are present, be especially
cautious in your observations and be on guard for signs of uterine bleeding.
• This is especially important because many postpartal women are discharged within 48
hours after birth.
• With uterine atony, even if the uterus responds well to massage, the problem may not be
completely resolved.
• After you remove your hand from the fundus, the uterus may relax, and the lethal
seepage may begin again.
• Therefore, remain with the woman after massaging her fundus to be certain the uterus is
not relaxing again.
• Observe, including fundal height and consistency, and lochia, for the next 4 hours.
• If a uterus cannot remain contracted, her physician or nurse midwife probably will order
a dilute intravenous infusion of oxytocin (Pitocin) to help the uterus maintain tone.
Additional measures that can be helpful:
• Offer a bedpan or assist the woman in ambulating to the bathroom at least every 4 hours
to be certain her bladder is empty.
• A full bladder pushes an uncontracted uterus into an even more uncontracted state.
• To reduce bladder pressure, insertion of a urinary catheter may be ordered.
• If a woman is experiencing respiratory distress from decreasing blood volume,
administer oxygen by face mask at a rate of about 4 L/min.
• Position her supine to allow adequate blood flow to her brain and kidneys.
• Obtain vital signs frequently and make sure to interpret them accurately, looking for
trends.
• For example, a continuously rising pulse rate is an ominous pattern. If a woman is losing
enough blood to affect her systemic circulation, she will develop signs of shock, such as
an increased, thready, and weak pulse; decreased blood pressure; increased and
shallow respirations; pale, clammy skin; and increasing anxiety

Management of Uterine Atony may be:

• Bimanual Massage.
• Prostaglandin Administration.
• Blood Replacement.
• Hysterectomy or Suturing.
• Lacerations
• Large lacerations, however, can cause complications.

They occur most often:

• With difficult or precipitate births
• In primigravidas
• With the birth of a large infant (>9 lb)
• With the use of a lithotomy position and instruments

Cervical Lacerations
• Lacerations of the cervix are usually found on the sides of the cervix, near the branches
of the uterine artery.
• If the artery is torn, the blood loss may be so great that blood gushes from the vaginal
opening.
• Because this is arterial bleeding, it is brighter red than the venous blood lost with uterine
atony.
• Fortunately, this bleeding ordinarily occurs immediately after delivering the placenta,
when the physician or nurse-midwife is still in attendance.

Vaginal Lacerations - Therapeutic Management

• Because vaginal tissue is friable, vaginal lacerations are also hard to repair.
• Some oozing often occurs after a repair, so the vagina may be packed to maintain
pressure on the suture line.
• An indwelling urinary catheter (Foley catheter) may be placed simultaneously because
the packing causes pressure on the urethra and can interfere with voiding.
• If packing is inserted, document in a woman's nursing care plan when and where it was
placed, so you can be certain it will be removed after 24 to 48 hours or before discharge.
• Packing that is left in place too long leads to stasis and infection, similar to toxic shock
syndrome, a form of septic shock

Perineal Lacerations- Therapeutic Management

• Perineal lacerations are sutured and treated as an episiotomy repair.
• Ensure that the laceration degree is documented because women with fourth-degree
lacerations need extra precautions to avoid having repair sutures loosened or infected.
• Both lacerations and episiotomy incisions tend to heal in the same length of time.
• A diet high in fluid and a stool softener may be prescribed for the first week after birth to
prevent constipation and hard stools, which could break the sutures.
Retained Placental Fragments
• A placenta does not deliver its entirety; fragments of it separate and are left behind.
• Because the portion retained keeps the uterus from contracting fully, uterine bleeding
occurs.
• To detect the complication of retained placenta, every placenta should be inspected
carefully after birth to see that it is complete.
• Retained placental fragments may also be detected by ultrasound.
• A blood serum sample that contains human chorionic gonadotropin hormone (hCG) also
reveals that part of a placenta is still present

Retained Placental Fragments - Assessment

• If an undetected retained fragment is large, bleeding will be apparent in the immediate
postpartal period because the uterus cannot contract with the fragment in place.
• If the fragment is small, bleeding may not be detected until postpartum days 6 to 10,
when the woman notices an abrupt discharge and a large amount of blood.
• On examination, usually, the uterus is not fully contracted

Retained Placental Fragments - Therapeutic Management

• Removal of the retained placental fragment is necessary to stop the bleeding.
• Usually, a dilatation and curettage (D&C) is performed to remove the placental fragment.
• In some instances, placenta accreta is so deeply attached that it cannot be surgically
removed.
• Balloon occlusion and embolization of the internal iliac arteries may minimize blood loss.
• Methotrexate may be prescribed to destroy the retained placental tissue
• Because the bleeding from retained fragments may be delayed until after a woman is at
home, be certain a woman knows to continue to observe the color of lochia discharge
and to report any tendency for the discharge to change from lochia serosa or alba back
to rubra

Uterine Inversion
• Uterine inversion is prolapsed of the fundus of the uterus through the cervix so that the
uterus turns inside out.
• This usually occurs immediately after birth.

Disseminated Intravascular Coagulation

• Disseminated intravascular coagulation (DIC) is a deficiency in clotting ability caused by
vascular injury.
• It may occur in any woman in the post partal period, but it is usually associated with the
premature separation of the placenta, a missed early miscarriage, or fetal death in utero.

Subinvolution
• Subinvolution is the incomplete return of the uterus to its prepregnant size and shape. At
a 4- or 6- week postpartal visit, the uterus is still enlarged and soft with subinvolution.
• Lochial discharge usually is still present.
• Subinvolution may result from a small retained placental fragment, mild endometritis
(infection of the endometrium), or an accompanying problem such as a uterine myoma
that is interfering with complete contraction.

Subinvolution - Therapeutic Management

• Subinvolution may result from a small retained placental fragment, mild endometritis
(infection of the endometrium), or an accompanying problem such as a uterine myoma
that is interfering with complete contraction.
• Oral administration of methylergonovine, 0.2 mg four times daily, usually is prescribed to
improve uterine tone and complete involution.
• If the uterus is tender to palpation, suggesting endometritis, an oral antibiotic also will be
prescribed.
• Being certain that women are able to recognize the normal process of involution and
lochial discharge before hospital discharge helps women to be able to identify
subinvolution and seek early health care if it occurs.
• A chronic loss of blood from subinvolution will result in infection or anemia and lack of
energy, conditions that possibly could interfere with infant bonding.
Perineal Hematomas
• A perineal hematoma is a collection of blood in the subcutaneous layer of tissue of the
perineum.
• The overlying skin, as a rule, is intact with no noticeable trauma.
• Such blood collections can be caused by injury to blood vessels in the perineum during
birth.
• They are most likely to occur after rapid, spontaneous births and in women who have
perineal varicosities.
• They might occur at the site of an episiotomy or laceration repair if a vein was punctured
during the repair.
• Although they can cause a woman acute discomfort and concern, they usually represent
only minor bleeding.

Perineal Hematomas - Assessment

• Perineal sutures almost always give a postpartal woman some discomfort.
• If a woman reports severe pain in the perineal area or a feeling of pressure between her
legs, inspect the perineal area for a hematoma. If one is present, it appears as an area
of purplish discoloration with obvious swelling.
• The area is tender to palpation.
• It may feel fluctuant at first, but as seepage into the area continues and tissue is drawn
taut, it palpates as a firm globe

Perineal Hematomas - Therapeutic Management

• Report the presence of a hematoma, its size, and the degree of the woman’s discomfort
to her primary care provider.
• Assess the size by measuring it in centimeters with each inspection. Describing a
hematoma as “large” or “small” gives little information about the actual size.
• Describing a hematoma as “large” or “small” gives little information about the actual size.
• Describing a lesion as 5 cm across or the size of a quarter or a half dollar is more
meaningful because it establishes a basis for comparison.
• Administer a mild analgesic as ordered for pain relief.
• Applying an ice pack (covered with a towel to prevent thermal injury to the skin) may
prevent further bleeding.
• Usually, the hematoma is absorbed over the next 3 or 4 days.
• Suppose the hematoma is large when discovered or continues to increase in size.
• In that case, the woman may have to be returned to the delivery or birthing room to have
the site incised and the bleeding vessel ligated under local anesthesia.

Conditions That Increase a Woman’s Risk for Postpartal Infection

• Rupture of the membranes more than 24 hours before birth (bacteria may have started
to invade the uterus while the fetus was still in utero)
• Placental fragments retained within the uterus (the tissue necroses and serves as an
excellent bed for bacterial growth)
• Postpartal hemorrhage (the woman’s general condition is weakened)
• Pre-existing anemia (the body’s defense against infection is lowered)
• Prolonged and difficult labor, particularly instrument births (trauma to the tissue may
leave lacerations or fissures for easy portals of entry for infection)
• Internal fetal heart monitoring (contamination may have been introduced with the
placement of the scalp electrode)
• Local vaginal infection was present at the time of birth (direct spread of infection has
occurred)
• The uterus was explored after birth for a retained placenta or abnormal bleeding site
(infection was introduced with exploration)
Emotional and Psychological Complications of The Puerperium

Postpartum Blues
• Postpartum blues, also known as "baby blues," are common feelings of sadness,
anxiety, and mood swings experienced by many new mothers within the first few days
after childbirth.
• These feelings are typically mild and tend to resolve on their own within a week or two.
• Unlike postpartum depression, postpartum blues are transient and do not usually require
medical intervention.

Postpartum Depression
• Postpartum depression is a type of depression that affects some new mothers within the
first few months after giving birth.
• It is characterized by feelings of overwhelming sadness, frequent crying, irritability,
difficulty bonding with the baby, and changes in appetite or sleep patterns

Postpartum Psychosis
• Postpartum psychosis is a severe mental health condition that can occur in new
mothers, usually within the first few weeks after childbirth.
• It involves experiencing hallucinations, delusions, confusion, and extreme mood swings,
which can pose a risk to the safety of both the mother and the baby
• Comparing Postpartal Blues, Depression, and Psychosis

Comparing Postpartal Blues, Depression, and Psychosis