Getting through labor is one of the most anticipated events during a woman’s pregnancy. To avoid complications during labor, thorough assessment should be conducted by the health care providers early during the woman’s pregnancy.
- Uterine rupture is a rare but serious complication.
- Uterine rupture is a condition wherein the uterus cannot sustain the strain that it underwent.
- Factors that contribute to uterine rupture are abnormal presentation, prolonged labor, multiple gestation, improper use of oxytocin, and traumatic effects of forceps use or traction.
- Fetal death can be avoided in uterine rupture if immediate cesarean birth can be performed.
- Symptoms that a woman may feel preceding rupture are a sudden, severe pain during a labor contraction or a tearing sensation.
- Rupture can be complete or incomplete.
- With complete uterine rupture, the rupture goes through the endometrium, myometrium, and peritoneum, and then the contractions would immediately stop.
- With incomplete uterine rupture, the rupture only goes through the endometrium and the myometrium only, with the peritoneum still intact.
- Symptoms of complete uterine rupture include hemorrhage, shock, fading fetal heart sounds, distinct swellings of the retracted uterus and extrauterine fetus.
- For incomplete rupture, there is localized tenderness, persistent aching pain in the lower uterine segment, and lack of contractions and fetal heart sounds.
- Confirmatory diagnosis of uterine rupture can be revealed through ultrasound.
- Administration of emergency fluid replacement as ordered should be anticipated as well as IV oxytocin.
- Laparotomy would be performed to control the bleeding and repair the rupture.
- Cesarean hysterectomy or tubal ligation can also be performed with consent from the patient to remove the damaged uterus and remove the childbearing activity of the woman.
- Fetal outcome, the woman’s safety, and the extent of the surgery must be revealed to the patient and allow time for them to express their emotions.
- The woman would be advised not to conceive again after a rupture of the uterus unless the rupture is in the inactive lower segment.
- The viability of the fetus and the woman’s prognosis depends on the extent of the rupture.
Inversion of the Uterus
- Uterine inversion occurs when the uterus turns inside out due to the delivery of the fetus or the placenta.
- Factors that contribute to inversion are application of traction to the umbilical cord to remove the placenta, if pressure is applied to the uterine fundus when the uterus is not contracting, or if the placenta is attached to the fundus so during birth the fundus pulls it down.
- Signs of inversion include sudden gush of a large amount of blood from the vagina, a non-palpable fundus, signs of blood loss such as hypotension, dizziness, and paleness, and if bleeding continues, exsanguinations.
- The inversion should never be replaced and the placenta, if still attached, should never be removed.
- Administration of oxytoxic drugs could only worsen the inversion and make the uterus tense so that it is difficult to replace.
- To manage uterine inversion, an IV line with a large-gauge needle should be established to restore fluid volume, oxygen administration should be started, assessment of vital signs, and cardiopulmonary resuscitation if the woman undergoes arrest.
- Nitroglycerin or a tocolytic drug would be given intravenously to relax the uterus, and the physician would replace the fundus manually.
- Oxytocin would be given after manual replacement to help the uterus contract and remain in its natural place.
- Antibiotics would be prescribed because the endometrium was exposed to prevent infection.
- Inform the woman that a future pregnancy would need to be delivered via cesarean section because there is a possibility that the inversion would re-occur.
Amniotic Fluid Embolism
- Amniotic fluid embolism occurs when the amniotic fluid is forced into an open maternal uterine blood sinus or after membrane rupture or partial premature separation of the placenta.
- The most likely cause of the embolism is anaphylactoid or humoral response.
- Amniotic fluid embolism cannot be prevented because it cannot be predicted.
- Risk factors include abruption placenta, hydramnios, and oxytocin administration.
- The woman experiences sharp chest pain, inability to breathe, pallor, and lack of blood flow.
- Emergency measures include oxygen administration and CPR.
- The woman’s prognosis would depend on the speed of the detection of the condition, the skill and speed of the emergency interventions, and the size of the embolism.
- Endotracheal intubation and fibrinogen therapy would be needed because the risk for DIC is high.
- The prognosis for the fetus is uncertain because reduced placental perfusion happens from a severe drop in maternal blood pressure.
Prolapse of the Umbilical Cord
- In prolapsed of the umbilical cord, a loop of umbilical cord slips down in front of the presenting fetal part.
- Factors that occur with prolapse are a small fetus, placenta previa, CPD, premature rupture of membranes, hydramnios, and multiple gestation.
- During assessment of the presenting fetal part through vaginal examination, the cord might be felt.
- Diagnosis of prolapsed of the membrane can be made through ultrasound.
- Cesarean section should be performed before rupture of the membrane or the cord would slide down the vagina.
- However, cord prolapsed is mostly discovered after rupture of the membranes, when the fetal heart rate has a variable deceleration.
- Assessment of fetal heart sounds is necessary after rupture of membranes to rule out cord prolapse.
- The goal in therapeutic management is to relieve cord compression to avoid fetal anoxia that can be achieved through manually lifting the head of the fetal head off the cord through the vagina or placing the woman in a Trendelenburg position.
- Oxygen administration is also necessary to improve the fetal oxygenation.
- Uterine activity and pressure of the fetus should also be reduced through a tocolytic agent.
- Once the cord has prolapsed and is exposed to air, drying of the umbilical cord and atrophy of the umbilical vessels would begin.
- Cover any exposed portion of the cord with a sterile saline compress to avoid drying.
- If there is already complete dilatation, the physician can deliver the baby to prevent fetal anoxia.
- If the cervical dilatation is not yet complete, cesarean birth would be performed as an emergency procedure because of the reduced blood flow that can harm the fetus.
- Amnioinfusion, which is the addition of a sterile fluid into the uterus to supplement the amniotic fluid, can be performed just to prevent additional cord compression.
- During the infusion, monitor the fetal heart rate and uterine contractions internally and record maternal temperature hourly to detect infection.
- When a woman has multiple gestation, additional personnel are needed for the birth and there is excitement inside the birthing room.
- Be aware of the needs of the woman during a multiple birth because she may be more frightened than excited of the delivery.
- Multiple gestations often result in fetal anoxia on the part of the second fetus, so cesarean birth is more preferable than normal delivery.
- Anemia and pregnancy-induced hypertension mostly occur in women with multiple gestations, so assessment of the blood pressure and hematocrit is necessary.
- If the woman plans to give birth vaginally, she should be advised to come to the hospital early in labor.
- Instruct the woman breathing techniques to minimize the use of analgesia or anesthesia, thereby decreasing the possibility of respiratory difficulties that the infants might experience because of lung immaturity.
- There may not be firm head engagement for multiple gestations because the babies are small.
- Common conditions that occur with multiple gestations are abnormal fetal presentation, an overstretched uterus, premature separation of placenta, and uterine dysfunction due to a long labor.
- Twin pregnancies usually have vertex presentations, but in gestations with three or more fetuses, the presentations are varied.
- Oxytocin is administered after the birth of the last fetus unlike in singleton pregnancies to avoid compromising the remaining fetuses.
- If the next fetus does not have a vertex presentation, external version might be attempted to make it vertex or cesarean birth can be performed.
- To shorten the time span between births, an oxytocin infusion can be started.
- To relax the uterus, nitroglycerin may be administered.
- The first infant’s placenta separates before the birth of the second fetus which causes a sudden, profuse bleeding at the vagina, creating a great risk for the woman.
- If the separation of the first placenta causes loosening of the other placentas or there is a common placenta, the fetal heart rate of the other fetuses would signal distress.
- Most multiple gestations today which are not in vertex presentation are born through cesarean section because they need to be born all at once so they can survive.
- Parents should be given an opportunity to view and inspect their fetuses to dispel the fears that they have that their infants are less than perfect.
- Assess the woman thoroughly and immediately after birth because an overly distended uterus might have difficulty in contracting, placing her at risk for hemorrhage due to uterine atony.
- Infants also need careful assessment to determine their gestational age and if any unusual conditions have occurred.
Practice Quiz: Labor Complication Nursing Care
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1. A woman experiences uterine inversion with the placenta still attached. What would be your best action?
A. Remove the placenta manually so that the uterus contracts.
B. Give an emergency bolus of oxytocin.
C. Increase the woman’s intravenous fluid to help restore blood loss.
D. Attempt to replace the uterus so that it becomes compressed.
2. Which of the following would lead the nurse to suspect that a pregnant woman has developed amniotic fluid embolism?
A. Rapid cervical dilatation of 5 cm/hour.
B. Report of sudden severe chest pain and dyspnea.
C. Evidence of hypotonic contractions and poor force of labor.
D. Report of back pain when ambulating or lying in bed.
3. Conditions that may place the patient at high risk for uterine rupture during birthing process include which of the following?
A. Premature labor
B. Abnormal presentation
D. Previous episiotomy scar
4. The nurse recognizes that the pregnant woman is experiencing uterine inversion when she notes the following symptoms:
A. Sudden gush of a large amount of blood.
B. Sharp chest pain.
C. Two distinct swellings in the uterus.
D. Unusually low or infrequent uterine contractions.
5. How can a nurse confirm the diagnosis of uterine rupture?
A. Through laparotomy
B. Through ultrasound
C. Through CT scan
D. Through MRI
6. One of the factors that occur with prolapse of the umbilical cord is:
D. Uterine rupture
7. This intervention refers to the addition of sterile fluid into the uterus to supplement the amniotic fluid.
A. Fetal blood sampling
8. What is the most common complication of multiple gestation?
A. Fetal death
B. Fetal anoxia
D. Severe drop in the maternal blood pressure
9. What would the nurse tell a multipara who has a term fetus which has still not engaged?
A. The fetus will not engage because the woman’s urinary bladder is empty.
B. Engagement would occur if the woman ambulates.
C. No firm engagement will occur for multiple gestations because the babies are small.
D. Engagement is firm among multiple gestations because every fetal head is of normal size.
10. Administration of oxytocin in multiple gestation occurs when?
A. After the birth of the last fetus
B. After the birth of the first fetus
C. Before the birth of the second fetus
D. Before the birth of the first fetus
11. Labor may be induced in which of the following women?
A. Presenting part engaged.
B. A premature fetus.
C. A fetus in transverse lie.
D. Cephalopelvic disproportion.
12. A woman is to undergo labor induction. Which of the following assessment findings should be present?
A. A breech presentation.
B. A cephalopelvic disproportion.
C. A premature fetus.
D. A ripe cervix.
13. Which of the following is a method in cervical ripening?
B. Use of hygroscopic suppositories
14. When is it appropriate to artificially rupture the amniotic membranes?
A. After full cervical dilation.
B. When the dilation reaches 4cm.
C. Before dilation starts.
D. After cervical ripening.
15. Which is false about augmentation of labor?
A. Oxytocin must be increased in large amounts to speed up the labor process.
B. Augmentation is required if labor contractions are weak and ineffective.
C. The uterus responds effectively to oxytocin used as administration.
D. Precautions for oxytocin administration are the same with primary induction of labor.
Answers and Rationale
1. Answer: C. Increase the woman’s intravenous fluid to help restore blood loss.
- C: Blood needs to be replaced because of the bleeding in uterine inversion.
- A: Removal of the placenta creates a larger surface area for bleeding.
- B: Oxytocin makes the uterus tense and difficult to replace.
- D: Handling of the uterus can increase the bleeding.
2. Answer: B. Report of sudden severe chest pain and dyspnea.
- B: The woman experiences sharp chest pain and inability to breathe.
- A: Rapid cervical dilatation does not occur in amniotic fluid embolism.
- C: Contractions and force of labor are normal in this condition.
- D: Pain is reported to occur at the chest.
3. Answer: B. Abnormal presentation
- B: Abnormal presentation may place the woman at high risk for uterine rupture.
- A: Prolonged labor predisposes the woman to uterine rupture.
- C: Multiparas are more at risk for uterine rupture than primiparas.
- D: A previous episiotomy scar could not lead the woman to a risk of uterine rupture.
4. Answer: A. Sudden gush of a large amount of blood.
- A: When a large amount of blood gushes from the vagina, suspect that the woman might have experienced uterine inversion.
- B: Sharp chest pain is felt by a woman with amniotic fluid embolism.
- C: Two distinct swellings of the uterus is indicative of impending uterine rupture.
- D: Infrequent contractions are present in hypotonic contractions.
5. Answer: B. Through ultrasound
- B: Ultrasound can confirm the uterine rupture.
- A: Laparotomy is performed to control the bleeding.
- C: CT scan can confirm uterine rupture but is not necessary.
- D: MRI can confirm uterine rupture but is not the confirmatory test recommended.
6. Answer: A. Hydramnios
- A: Hydramnios occurs with prolapse of the umbilical cord.
- B: Hydramnios occurs with prolapse of the umbilical cord instead of oligohydramnios.
- C: Multiparity occurs with prolapse of the umbilical cord instead of primiparity.
- D: Uterine rupture does not predispose the woman to prolapsed of the umbilical cord.
7. Answer: B. Amnioinfusion
- B: Amnioinfusion is the addition of sterile fluid into the uterus to supplement the amniotic fluid.
- A: Fetal blood sampling determines whether the fetus is becoming acidotic, and it also determines the oxygen saturation, partial pressures of oxygen and carbon dioxide, pH, bicarbonate excess, and hematocrit.
- C: Amniocentesis is the aspiration of amniotic fluid from the amniotic sac.
- D: Augmentation refers to assisting labor that has started spontaneously but is not effective.
8. Answer: B. Fetal anoxia
- B: Multiple gestations usually result in fetal anoxia on the part of the second fetus.
- A: Fetal death occurs in women with uterine rupture.
- C: Shock occurs in inversion of the uterus.
- D: A severe drop in the maternal blood pressure occurs with amniotic fluid embolism.
9. Answer: C. No firm engagement will occur for multiple gestations because the babies are small.
- C: There is no firm engagement in multiple gestation because the babies’ heads are small.
- A: Engagement would not occur if the woman’s bladder is full.
- B: Ambulation speeds up descent and not the engagement.
- D: There is no firm engagement in multiple gestation and the sizes of the fetal heads are small.
10. Answer: A. After the birth of the last fetus
- A: Oxytocin administration occurs after the birth of the last fetus, unlike in singleton pregnancies to avoid compromising the remaining fetuses.
11. Answer: A. Presenting part engaged.
- A: Before induction of labor, a presenting part must be engaged first.
- B: The fetus must reach full term before it can be induced.
- C: A fetus must be in longitudinal lie before it can be induced.
- D: CPD or transverse lie is contraindicated in induction of labor.
12. Answer: D. A ripe cervix.
- D: The cervix must be ripe before the physician would consider induction of labor.
- A: Breech presentation is not allowed for normal vaginal delivery and contraindicated for induction of labor.
- B: The fetus must be in longitudinal lie before considering induction of labor.
- C: The fetus must reach its full term before induction of labor is allowed.
13. Answer: B. Use of hygroscopic suppositories
- B: Hygroscopic suppositories or seaweed suppositories swell upon contact with cervical secretions and gently urge dilatation.
- A: Amnioinfusion is an intervention for prolapse of the umbilical cord wherein it prevents additional cord compression.
- C: Augmentation is assisting labor that has started spontaneously yet is not effective.
- D: Induction of labor refers to a labor that has started artificially.
14. Answer: B. When the dilation reaches 4cm.
- B: Artificial rupture of membranes may be done once cervical dilatation reaches 4 cm to further induce labor.
- A: The membranes should be ruptured before full cervical dilation to allow the fetus to descend.
- C: Artificial rupture of membranes should not occur before dilatation but when it reaches 4 cm.
- D: Cervical ripening would occur with dilatation, and rupture of membranes must occur when the cervix has dilated to at least 4 cm.
15. Answer: A. Oxytocin must be increased in large amounts to speed up the labor process.
- A: Oxytocin must be increased in small increments only.
- B: Augmentation of labor is required when labor contractions start spontaneously but become weak, ineffective, and irregular.
- C: Oxytocin administration is effective in augmenting labor.
- D: There are the same precautions for oxytocin administration and primary induction of labor.