RN Notes

Abruptio Placenta
Description

Abruptio placenta is premature separation of a normally

implanted placenta after the 20th week of pregnancy, typically with
severe hemorrhage.

1.
2.

Etiology
The cause of abruptio placenta is unknown.
Risk factors include:
Uterine anomalies
Multiparity
Preeclampsia
Previous cesarean delivery
Renal or vascular disease

Trauma to the abdomen

Previous third trimester bleeding
Abnormally large placenta
Short umbilical cord

Pathophysiology

The placenta detaches in whole or in par from the implantation

site. This occurs in the area of the deciduas basalis.
Assessment Findings
1.
Associated findings. Severe abruption placentae may produce
such complications as:
a.
Renal failure
b.
Disseminated intravascular coagulation
c.
Maternal and fetal death
2.
Common clinical manifestation include:
a.
Intense, localized uterine pain, with or without vaginal
bleeding.
b.
Concealed or external dark red bleeding
c.
Uterus firm to boardlike, with severe continuous pain
d.
Uterine contractions
e.
Uterine outline possibly enlarged or changing shape
f.
FHR present or absent.
g.
Fetal presenting part may be engaged.
3.
Laboratory and diagnostic study findings.
a.
Ultrasound may be able to identify the extent of abruption.
However, the absence of an ultrasound finding does not rule out the
presence of abruption.
1.

2.

Nursing Management
Continuously evaluate maternal and fetal physiologic
status, particularly:
Vital signs
Bleeding
Electronic fetal and maternal monitoring tracings
Signs of shock-rapid pulse, pallor, cold and most skin,
decrease in blood pressure
Decreasing urine output
Never perform a vaginal or rectal examination or take any
action that would stimulate uterine activity.
Assess the need for immediate delivery. If the client is in
active labor and bleeding cannot be stopped with bed rest, emergency
cesarean delivery may be indicated.

3.

4.
5.

Provide appropriate management.

On admission, place the woman on bed rest in a lateral
position to prevent pressure on the vena cava.
Insert a large gauge intravenous catheter into a large vein
for fluid replacement. Obtain a blood sample for fibrinogen level.
Monitor the FHR externally and measure maternal vital
signs every 5 to 15 minutes. Administer oxygen to the mother by
mask.
Prepare for cesarean section, which is the method of choice
for the birth.
Provide client and family teaching.
Address emotional and psychosocial needs. Outcome for the
mother and fetus depends on the extent of the separation, amount of
fetal hypoxia, and amount of bleeding.

Anemia in Pregnancy
Description

1.

Hemoglobin value of less than 11 mg/dL or hematocrit value less

than 33% during the second and third trimesters
2.
Mild anemia (hemoglobin value of 11 mg/dL) poses no threat but
is an indication of a less than optimal nutritional state.
3.
Iron deficiency anemia is the most common anemia of pregnancy,
affecting 15% to 50% of pregnant women. It is identified as physiologic
anemia of pregnancy.
Etiology

Causes of anemia include:

Nutritional deficiency (e.g., iron deficiency or megaloblastic
anemia, which includes folic acid deficiency and B12 deficiency).
2.
Acute and chronic blood loss
3.
Hemolysis (e.g., sickle cell anemia, thalassemia, or glucose-6phosphate dehydrogenase [G-6-PD])
1.

Pathophysiology

1.

The hemoglobin level for nonpregnant women is usually 3.5 g/dL.

However, the hemoglobin level during the second trimester of
pregnancy averages 11.6 g/dL as a result of the dilution of the
mothers blood from increased plasma volume. This is called
physiologic anemia and is normal during pregnancy.
2.
Iron cannot be adequately supplied in the daily diet during
pregnancy. Substances in the diet, such as milk, tea, and coffee,
decrease absorption of iron. During pregnancy, additional iron is
required for the increase in maternal RBCs and for transfer to the fetus
for storage and production of RBCs. The fetus must store enough iron
to last 4 to 6 months after birth.
3.
During the third trimester, if the womans intake of iron is not
sufficient, her hemoglobin will not rise to a value of 12.5 g/dL and
nutritional anemia may occur. This will result in decreased transfer of
iron to the fetus.
4.
Hemoglobinopathies, such as thalassemia, sickle cell disease,
and G-6-PD, lead to anemia by causing hemolysis or increased
destruction of RBCs.

Assessment Findings

1.

Associated findings. In clients with a hemoglobin level of 10.5

g/dL, expect complaints of excessive fatigue, headache, and
tachycardia.
2.
Clinical manifestations:

Signs of iron deficiency anemia (hemoglobin level below 10.5

g/dL) include brittle fingernails, cheilosis (severely chapped lips), or a
smooth, red, shiny tongue.

Women with sickle cell anemia experience painful crisis episodes.

Nursing Management

1.
2.
3.

Provide client and family teaching. Discuss using iron

supplements and increasing dietary sources of iron as indicated.
Prepare for blood-typing and crossmatching, and for
administering packed PBCs during labor if the client has severe
anemia.
Provide support and management for clients with
hemoglobinopathies.
In a client who has thalassemia or who carries the trait,
provide support, especially if the woman has just learned that she is a
carrier. Also assess for signs of infection throughout the pregnancy.
In a pregnant client with sickle cell disease, assess iron and
folate stores, and reticulocyte counts; complete screening for
hemolysis; provide dietary counseling and folic acid supplements; and
observe for signs of infection.
In a pregnant client with G-6-PD, provide iron and folic acid
supplementation and nutrition counseling, and explain the need to
avoid oxidizing drugs.

APGAR Scoring System

The APGAR Scoring System was developed by Dr. Virginia APGAR as a method
of assessing the newborns adjustment to extrauterine life. It is taken at one
minute and five minutes after birth. With depressed infants, repeat scoring every
five minutes as needed. The one minute score indicates the necessity for
resuscitation. The five minute score is more reliable in predicting mortality and
neurologic deficits. The most important is the heart rate, then the respiratory rate,
the muscle tone, reflex irritability and color follows in decreasing order. A heart
rate below 100 signifies an asphyxiated baby and a heart rate above 160

signifies distress.

Assess

HEART RATE

Absent

Below 100

Above 100

RESPIRATION

Absent

Slow

Good crying

MUSCLE TONE

Flaccid

Some flexion

Active motion

REFLEX IRRITABILITY

No Response

Grimace

Vigorous cry

COLOR

Blue all over

Body pink,

Pink all over

extremities blue
SCORE:

7-10 Good adjustment, vigorous

Moderately depressed infant, needs airway clearance
Severely depressed infant, in need of resuscitation

Birth Asphyxia
Description

Birth asphyxia is characterized by hypoxemia (decreased PaCO2),

hypercarbia (increased PaCO2), and acidosis (lowered pH).
Etiology

1.
2.
3.
4.
5.

Maternal causes include amnionitis, anemia, diabetes, pregnancyinduced hypertension, drugs, and infection.
Uterine causes include prolonged labor and abnormal fetal
presentations.
Placental causes include placenta previa, abruption placental,
and placental insufficiency.
Umbilical causes include cord prolapsed and cord entanglement.
Fetal causes include cephalopelvic disproportion, congenital
anomalies, and difficult delivery.
Pathophysiology

1.

Unless vigorous resuscitation begins promptly, irreversible multiorgan tissue changes will occur, possibly leading to permanent damage
or death.
2.
During the 24 hours after successful resuscitation, the newborn is
vulnerable to post-asphyxial syndrome.

Assessment Findings

1.
2.
3.
4.
5.
6.
7.
8.

Clinical manifestations include:

Poor response to resuscitative efforts
Hypoxia
Hypercarbia
Metabolic and or respiratory acidosis
Minimal or absent respiratory effort
Seizures
Altered cardiac function
Multi-organ system failure
Nursing Management
1. Observe the newborn that has been successfully resuscitated for the
following constellation of signs.

Absence of spontaneous respirations

Seizure activity in the first 12 hours after birth
Decreased or increased urine output (which may indicate acute
tubular necrosis or syndrome of inappropriate antidiuretic hormone)

Metabolic alterations (e.g., hypoglycemia and hypocalcemia)

Increased intracranial pressure marked by decreased or absent

reflexes or hypertension.

2. Decrease noxious environmental stimuli.

3. Monitor the infants level of responsiveness, activity, muscle tone, and
posture.
4. Administer prescribed medications, which may include anticonvulsants
(e.g., Phenobarbital) as prescribed.
5. Provide respiratory support.
6. Monitor for complications.

Measure and record intake and output to evaluate renal function.

Check every voiding for blood, protein, and specific gravity, which
suggests renal injury.

Check every stool for blood, suggesting necrotizing enterocolitis

(NEC). NEC is a condition in which the bowel develops necrotic patches
that interfere with digestion and possibly cause paralytic ileus,
perforation, and peritonitis.

Take serial blood glucose determinations to detect hypoglycemia,

and monitor serum electrolytes, as ordered.

7. Administer and maintain intravenous fluids to maintain hydration and fluid

and electrolyte balance.
8. Provide education and emotional support.

Cesarean Delivery
Description

1.

In this surgical procedure, the newborn is delivered through the

abdomen from an incision made through the maternal abdomen and
the uterine myometrium.
2.
The surgery may be preplanned (elective) or arise from an
unanticipated problem.
3.
Two incisions are made: one in the abdominal wall (skin incision)
and the other in the uterine wall. Either of two skin incisions is used: a
midline vertical incision between the umbilicus and the symphysis or a
Pfannenstiel incision just above the symphysis (Fig. 1). Three types of
uterine incisions are possible (Fig. 2): (1) low transverse; (2) low
vertical; and (3) classic, a vertical incision into the upper uterus. The
low transverse uterine incision is preferred unless a very large fetus or
placenta previa in the lower uterus prevents its use. The uterine
incision does not always match the skin incision. For example, a

woman may have a vertical skin incision and a low transverse uterine
incision, particularly if she is very obese.
4.
In subsequent pregnancies and delivery, a trial of labor and
vaginal birth is increasingly regarded as safe and appropriate as long
as cephalopelvic disproportion does not exist and the previous incision
was low transverse.
5.
Elective, repeat cesarean may be performed in the absence of a
specific indication for operative delivery when either the physician or
the client is unwilling to attempt vaginal delivery.
6.
Anesthesia may be general, spinal, or epidural; preoperative and
postoperative care will vary accordingly.

Skin (abdominal wall) incisions for cesarean birth.

Uterine incisions for cesarean birth. The abdominal and uterine incisions do not
always match. VBAC, Vaginal birth after cesarean
Positioning

Supine, with a small roll under the right hip (to reduce vena cava
compression); arms extended on armboards.
Incision sites

Classic approach, vertical (low midline).

Packs/drapes

Extra drape sheet

Towels
Receiving pack for baby
Instrumentation

C-section tray
Delivery forceps
Cord clamp
Supplies/ Equipment

Basin set
Blades
Suction
Neonatal receiving unit
Self-contained oxygen
I.D bands
Bulb syringe
Solutions
Sutures
Procedure

1.

2.
3.
4.

5.
6.

Using the appropriate incisions, consistent with the estimated

size of the fetus, the abdomen is opened, the rectus muscle are
separated, and the peritoneum incised (similar to an abdominal
hysterectomy), exposing the distended uterus.
Large vessels are clamped or cauterized, but usually no attempt
to control hemostasis is made since it may delay delivery time ( 3-5
minutes after initial incision is ideal).
The scrub person must be ready with suction, dry laps, and a bulb
syringe.
The bladder is retracted downward with the bladder blade of the
balfour retractor and a small incision is made with the second knife and
extended with a bandage scissors (blunt tip prevents injury to the
babys head).
The amniotic sac is entered and immediately aspirated the fluid.
The bladder blade is removed, and the assistant will push on the
patients upper abdomen while the surgeon simultaneously delivers
the infants head in an upward position.

7.

The babys airways are suctioned with the bulb syringe, and the
baby is completely delivered and placed upon the mothers abdomen.
8.
The umbilical cord is double clamped and cut.
9.
The baby is wrapped in a sterile receiving blanket and transferred
to the warming unit for immediate assessment and care.
10.
Once the bay has been safely delivered, the emergent phase of
the procedure has been ended.
11.
Using a nonecrushing clamp, the uterine wall is grasped for
traction during closure.
12.
The closure is performed in two layers with a heavy absorbable
suture, using a continuous stitch, the second overlapping the first.
13.
Following closure of the uterus, the bladder flap is
reperitonealized with a running suture, and the uterus is pushed back
inside the pelvic cavity.
14.
The cavity is irrigated with warm saline, and closed in layers.
15.
Skin is closed with the surgeons preference. If a tubal ligation is
to be performed, it is done prior to the abdominal closure sequence.
Perioperative Nursing Considerations
1.

A C-section requires an additional uterine count of sponges,

sharps, and instruments prior to its closure.
2.
Oxytocin should be available for the anesthesiologist to
administer I.V.
3.
Once the uterus is opened, immediate suctioning is necessary.
4.
A warm, portable isolette should be available to transport the
infant to the newborn nursery.
Reasons For Performing A Cesarean Delivery
1. Maternal factors
a.
b.
c.
d.

Cephalopelvic disproportion (CPD)

Active genital herpes or papilloma
Previous cesarean birth by classic incision
Presence of severe disabling hypertension or heart disease
2. Placental factors

a.
b.

Placenta previa
Abruptio placental

3. Fetal factors
a.
b.
c.
d.

Transverse fetal lie

Extreme low birth weight
Fetal distress
Compound conditions, such as macrosomia and transverse lie.
Nursing Management
1. Perform a complete maternal and fetal assessment.

Obtain a complete obstetric history.

If he client presents with labor determine frequency, duration,
and intensity of contractions.

Determine the condition of the fetus through fetal heart tones,

fetal monitoring strips, fetal scalp blood sample, fetal activity changes,
and presence of meconium in amniotic fluid.

2. Prepare the client for cesarean delivery in the same way whether the
surgery is elective or emergency. Depending on hospital policy:

Shave or clip pubic hair.

Insert a retention catheter to empty the bladder continuously.
As prescribed, insert intravenous lines, collect specimens for
laboratory analysis, and administer preoperative medications.
Also as prescribed, provide an antacid (to prevent vomiting and
possible aspiration of gastric secretions) and prophylactic antibiotics
(to prevent endometritis).
Assist the client to remove jewelry, dentures, and nail polish, as
appropriate.
As needed, reinforce the obstetricians explanation of the
surgery, the expected outcome, and the anesthesiologists explanation
of the kind of anesthetics to be used (depending on the clients
cardiopulmonary status).
Make sure the clients signed informed consent is on file.
Continue assessing maternal and fetal vital signs in
accordance with hospital policy until the client is transported
to the operating room.
Notify other health care team members of the pending delivery.
Modify preoperative teaching to meet the needs of
planned versus emergency cesarean birth; depth and breadth

of instruction will depend on the circumstances and time

available.

If there is time, begin explaining what the client can expect

postoperatively. Discuss pain relief, turning, coughing, deep breathing,
and ambulation.

Inform the client that intraoperative and postpartum care will be

performed by the surgical and obstetric team, and that the newborn
will receive care by the pediatrician and a nurse skilled in neonatal
care procedures (ie, resuscitation).
3. Facilitate a family- centered cesarean birth by including , when possible,
such activities as:
Preparing the partner for participation in the delivery.
Reuniting the family as soon as possible following delivery.
Providing for family time alone in the critical first hours after the
mother and newborn are stabilized.

Including the father and siblings (as possible) when

demonstrating care of the newborn.

Encouraging the mothers support person to remain with her as

much as possible. In some cases, this person may accompany the
client to the surgical suite and stay with her throughout the birth.

4. Provide physical and emotional support.

Anticipate parental feelings of failure related to cesarean rather
than normal birth. In such a situation, provide time for them to relive
and talk through the experience. Offer reassurance and support.

Assist the family in planning for care of mother and newborn at

home (Client and Family Teaching- Table 1)

Table 1
Client and Family Teaching
Explain to the mother, her partner, and other family members that recovery
from a surgical cesarean delivery is slower, and often more painful, when
compared with recovery from a normal vaginal delivery. The following
considerations must be taken into account:

Need for increased rest (influenced by type of anesthesia, length of labor,

and the type of abdominal or uterine incision)

Need for increased pain medication and other pain-relieving techniques

Inability to climb the stairs
Inability to drive a car
Difficulty with breast feeding the newborn in certain positions (e.g., cradle
hold).teach the mother the best positions to use and how to use pillows to
cushion the incision site.

Difficulty with normal ADLs (e.g., dressing, bathing, toileting, and so on).
Difficulty with providing normal newborn care (e.g., lifting, carrying, bathing,
and dressing the newborn) and the need for assistance in caring for the
newborn.

Circumcision
Definition
The excision of the foreskin (prepuce).
Circumcisions are commonly performed on the male infant at
birth or shortly thereafter. However, the uncircumcised adult may
experience difficulty in retracting the prepuce from the glans of the
penis because of a stricture (phimosis), which requires surgical
intervention, or circumcision may be performed to treat recurrent
balanitis or as a religious rite.

If performed on an infant, the procedure may take place in a

separate part of the newborn nursery, aseptically suited for the
procedure.

Positioning

Supine, with legs slightly apart, or lithotomy.

Children and infants may be placed in a frog-leg position or on a
specially designed board.
Incision Site

Circumferentially around the glans penis.

Packs/ Drapes

Child: Pediatric Lap sheet

Adult: Laparotomy pack
Infant: Pediatric Lap sheet or folded towels
Instrumentation

Infants and children: Pediatric Lap tray

Circumcision lamp
Adults: Minor/ very fine tray, Probe and groove director.
Supplies/ Equipments

Basin set
Blades
Needle counter
Catheter
Gauze roll and impregnated gauze strips

Solutions
Procedure

1.
2.
3.
4.
5.
6.
7.

If phimosis is present, a dorsal slit is made. Adhesions are lysed.

A circumferential incision is made at the reflection of the foreskin,
which is then excised.
Hemostasis is achieved, and the wound edges are approximated
using absorbable suture.
For a very young infant, the skin edges are usually not
approximated.
A strip of nonadherent gauze is placed around the incision and is
covered with a gauze roll dressing.
A piece of umbilical tape may hold the gauze roll in place.
No other dressing is usually necessary.
Perioperative Nursing Considerations

1.

Consider the special needs of the Jewish patient for a ritual

circumcision. All female team members may be asked to leave the
room during the procedure.
2.
Instruct the patient the proper way of cleansing the wound.

Cord Prolapse
Description

1.

Cord prolapse is descent of the umbilical cord into the vagina

ahead of the fetal presenting part with resulting compression of the
cord between the presenting part and the maternal pelvis.
2.
Cord prolapse is an emergency situation; immediate delivery will
be attempted to save the fetus.
3.
It occurs in 1 of 200 pregnancies.

Etiology

1.

This problem occurs most frequently in prematurity, rupture of

membranes with the fetal presenting part unengaged, and shoulder or
footling breech presentations.
2.
It may follow rupture of the amniotic membranes because the
fluid rush may carry the cord along toward the birth canal.
Pathophysiology

Compression of the cord results in the compromise or cessation

of fetoplacental perfusion.
Assessment Findings
1. Associated findings

Cord prolapse may be occult or occur at any time in the labor

process, even when the amniotic membranes are intact.

Client reports feeling the cord within the vagina.

2. Clinical manifestations

Fetal bradycardia with deceleration during contraction.

The umbilical cord can be seen or felt during a vaginal
examination.

Nursing Management
1. Identify prolapse cord and provide immediate intervention.

Assess a laboring client often if the fetus is preterm or small for

gestational age, if the fetal presenting part is not engaged, and if the
membranes are ruptured.
Periodically evaluate FHR, especially right after rupture of
membranes (spontaneous or surgical), and again in 5 to 10 minutes.
If prolapse cord is identified, notify the physician and prepare for
emergency cesarean birth.
If the client is fully dilated, the most emergent delivery route may
be vaginal. In this case, encourage the client to push and assist with
the delivery as follows.
Lower the head of the bed and elevate the clients hips on a
pillow, or place the client in the knee-chest position to minimize
pressure from the cord.
Assess cord pulsations constantly.
Gently wrap gauze soaked in sterile normal saline solution
around the prolapsed cord.
2. Provide physical and emotional support.
3. Provide client and family education.

Measures that may be used to relieve pressure on a prolapsed umbilical cord

until delivery can take place.

Dilation And Curettage (D&C)

Definition

The gradual enlargement of the cervical os and the curetting

(scraping) of endometrial or endocervical tissue for histologic study.
Discussion

The procedure is usually performed to:

1.
2.
3.
4.
5.

To diagnosed cervical or uterine malignancy.

To control dysfunctional uterine bleeding.
To complete an incomplete abortion.
To aid in evaluating infertility.
To relieve dysmenorrheal.
Fractional D&C procedures can assist in differentiating between
endocervical and endometrial lesions.

Positioning

Lithotomy; arms may be extended on armboards.

Packs/ Drapes

Gynecologic pack
Instrumentation

D&C tray
Supplies/ Equipment

Padded stirrups
Telfa
Perineal pad
Suction

Lubricant
Procedure Overview

1.
2.
3.
4.
5.
6.

7.
8.

A weightened speculum is placed in the vaginal vault.

The cervix is grasped with a tenaculum.
A graduated sound is passed through the cervical canal into the
uterine cavity to determine its depth and angulation.
Using Hegar or Hank dilators, the surgeon begins to dilate the
cervical opening, increasing the size of each dilator.
A Telfa sponge is placed over the bill of the weighted speculum,
and the uterus is gently curetted, allowing the tissue specimen to
collect on the Telfa sponge.
The small serrated curette is used to scrape the uterine walls
again or when the D&C is performed to remove retained placental
tissue, while the large, blunt curette and forceps are used to remove
the tissue.
If a fractional D&C is performed, endocervical curettings are
obtained before the uterus is sounded, to avoid bringing endometrial
cells into the cervical os.
The weighted speculum is removed, and the perineum is dressed
with a perineal pad.
Perioperative Nursing Considerations

1.

Stirrups should be padded, and a coccygeal support placed on

the table to protect the lower sacral area.
2.
Raise and lower the legs together and slowly to prevent
disturbances caused by rapid alterations in venous return and/ or injury
to the rotator hip joint.
3.
Instruments are set up on the black table in order of usage, a
scrub person may not be necessary during the procedure.
4.
If a fractional D&C is performed, multiple specimens may be
obtained. They should be placed in separate containers, and labeled
accordingly.

Dysfunctional Labor
Description

Dysfunctional labor is difficult, painful, prolonged labor due to

mechanical factors.
Etiology

1.

Fetal factors (passenger) include unusually large fetus, fetal

anomaly, malpresentation, and malposition
2.
Uterine factors (powers) include hypotonic labor, hypertonic
labor, precipitous labor, and prolonged labor.
3.
Pelvic factors (passage) include inlet contracture, midpelvis
contracture, and outlet contracture.
4.
Psyche factors include maternal anxiety and fear and lack of
preparation.
Pathophysiology

Uterine contractions are ineffective secondary to muscle fatigue

or overstretching.
Assessment Findings

Clinical manifestations include irregular uterine contractions

and ineffective uterine contractions in terms of contractile strength and
duration.
Nursing Management

1.

Optimize uterine activity. Monitor uterine contractions for

dysfunctional patterns; use palpation and an electronic monitor.
2.
Prevent unnecessary fatigue. Check the clients level of
fatigue and ability to cope with pain.

3.

4.

5.

Prevent complications of labor for the client and infant.

Assess urinary bladder; catheterize as needed.
Assess maternal vital signs, including temperature, pulse,
respiratory rates, and blood pressure.
Check maternal urine for acetone (an indication of
dehydration and exhaustion).
Assess condition of fetus by monitoring FHR, fetal activity,
and color of amniotic fluid.
Provide physical and emotional support.
Promote relaxation through bathing and keeping the client
and bed clean, back rubs, frequent position changes (sidelying),
walking (if indicated), and by keeping the environment quiet.
Coach the client in breathing and relaxation techniques.
Provide client and family education.

Early Postpartum Hemorrhage

Description

1.

Early postpartum hemorrhage is defined as blood loss of 500 mL

or more during the first 24 hours after delivery.
2.
Post partum hemorrhage is the leading cause of maternal death
worldwide and a common cause of excessive blood loss during the
early postpartum period.
3.
Approximately 5% of women experience some type of
postdelivery hemorrhage.

Etiology
1.

Major causes of postpartum hemorrhage are uterine atony

(responsible for at least 80% of all early postpartum hemorrhages);
laceration of cervix, vagina, or perineum; and retained placental
fragments.
2.
Predisposing factors include hypotonic contractions,
overdistended uterus, multiparity, large newborn, forceps delivery, and
cesarean delivery.
Pathophysiology

The uterus is unable to contract effectively and maintain

hemostasis.
Assessment Findings
Clinical manifestations include:

1.
2.
3.

Vaginal bleeding.
Hypotonic uterus.
Excessive blood loss, which may produce hypotension, thread
pulse, pallor, restlessness, dyspnea, and chills.

Nursing Management
1. Assist with appropriate treatment to prevent complications.

Determine the presence of uterine firmness and location and

amount of vaginal bleeding immediately after delivery.
Measure and record serial maternal vital signs after deliveryevery 5 to 15 minutes until stable; increase or decrease the frequency
of assessment relative to baseline and amount of bleeding.
Notify the practitioner of abnormal assessment findings.
Massage the fundus gently, taking care to support the uterus with
the hand just above the symphysis pubis.
Administer medications as prescribed.
Keep an accurate pad count (100 mL per saturated pad).
Assess condition of skin, urine output, and level of consciousness.
2. Provide physical and emotional support.
3. Provide client and family education.

Ectopic Pregnancy
Description

Implantation of products of conception in a site other than the

uterine cavity (e.g., fallopian tube, ovary, cervix, or peritoneal cavity.)
Etiology

Ectopic pregnancy can result from conditions that hinder ovum

passage through the fallopian tube and into the uterine cavity, such as:
1.
Salpingitis
2.
Diverticula
3.
Tumors
4.
Adhesions from previous surgery

5.

Transmission of the ovum from one ovary to the opposite

fallopian tube.

Sites of ectopic pregnancy. Numbers indicate the order of prevalence.

Pathophysiology

The uterus is the only organ capable of containing and sustaining

a pregnancy. When the fertilized ovum implants in other locations the
body is unable to maintain the pregnancy.
Assessment Findings
1. Associated findings

Suspect ectopic pregnancy in a client whose history includes a

missed menstrual period, spotting, or bleeding pelvic or shoulder pain,
use of intrauterine device, pelvic infections, tubal surgery, or previous
ectopic pregnancy.

Be aware of grief and lost manifestations in the client and family.

2. Common clinical manifestations. (The client with ectopic pregnancy may

report signs and symptoms of a normal pregnancy or may have no symptoms at
all.)

Dizziness and syncope (faintness)

Sharp abdominal pain and referred shoulder pain
Vaginal bleeding
Adnexal mass and tenderness
A ruptured fallopian tube can produce life threatening
complications, such as hemorrhage, shock, and peritonitis.
3. Laboratory and diagnostic study findings

Blood samples for hemoglobin value, blood type, and group, and
crossmatch.

A pregnancy test reveals elevated serum quantitative beta hCG.

Ultrasound will confirm extrauterine pregnancy.

Nursing Management
1. Ensure that appropriate physical needs are addressed and monitor for
complications. Assess vital signs, bleeding, and pain.
2. Provide client and family teaching to relieve anxiety.
Explain the condition and expected outcome.

Maternal prognosis is good with early diagnosis and prompt

treatment, such as laparotomy, to ligate bleeding vessels and repair
or remove the damaged fallopian tube.

Pharmacologic agents, such as methotrexate followed by

leucovorin, may be given orally when ectopic pregnancy is diagnosed
by routine sonogram before the tube has ruptured. A
hysterosalpingogram usually follows this therapy to confirm tubal
patency.

Rh-negative women must receive RhoGAM to provide

protection from isoimmunization for future pregnancies

b. Describe self-care measures, which depend on the treatment.

3. Address emotional and psychosocial needs.

Fetal Skull
Importance of the fetal skull
1.
2.
3.

Largest part of the fetal body.

Most frequent [resenting part of the fetus.
Least compressible of all fetal parts.
Anatomy of the Fetal Skull
Cranial Bones
The fetal skull is made up of six cranial bones which are the following:

1.
2.
3.
4.
5.
6.

Sphenoid
Ethmoid
Temporal
Frontal
Occipital
Parietal
The frontal, occipital and the parietal cranial bones could either be fetal
presenting part if the presentation is vertex.

Membrane Spaces
During birth, bones move and overlap with each other to allow the fetal head to fit
through the birth canal which is a process termed as molding. Molding is made
possible because of the presence of the suture lines. Without these structures a

fetus head cannot pass through the birth canal. There are different types of
sutures:

Sagittal suture line joins the two parietal bones.

Coronal suture line joins the frontal and the parietal bones.
Lambdoid suture line joins the occiput and the parietal bones.
Fontanelles
Fontanelle is a membrane-covered space at the junction of a main suture line.
Types of Fontanelles:

Anterior fontanelle diamond-shaped fontanelle. This fontanelle

closes at about 12-18 months and is larger than the other.

Posterior fontanelle triangular-shaped fontanelle. This fontanelle

closes between 2-3 months of age and is smaller.

Measurements of the fetal skull

Transverse diameters of the fetal skull

Biparietal 9.25 cm
Bitemporal 8 cm
Bimastoid 7 cm
Anteroposterior (AP) diameter

Suboocipitobregmatic 9.5 cm (the narrowest AP diameter). This

measurement is taken from below the occiput to the anterior
fontanelle.

Occipitofrontal 12 cm (from the occiput to the mid-frontal bone)

Occipitomental 13.5 cm (the widest AP diameter). This

measurement is taken from the occiput to the chin.

Which one of these diameters is presented at the birth canal depends on the
degree of flexion, which is known as the ATTITUDE, the fetal head assumes prior
to delivery.

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