Placenta Previa

Placenta previa is a condition in which the placenta implanted improperly in the lower uterine segment near or over the internal cervical os.

Types of Placenta Previa:

1. Total: the internal os is covered entirely by the placenta when the cervix is dilated fully
2. Partial: the internal os is covered incompletely
3. Marginal: only an edge of the placenta extends to the internal os
4. Low-lying placenta: the placenta is implanted in the lower uterine segment but does not reach the internal os

Signs and Symptoms:

• Painless red vaginal bleeding occur in the last half of pregnancy
• Uterus is soft, relaxed, and non-tender
• Fundal height may be greater than expected for gestational age

Nursing Interventions:

• Interventions depend on the classification of the previa and gestational age of the fetus
• Monitor maternal vital signs, fetal heart rate, and fetal activity
• Prepare for ultrasound
• Avoid vaginal examination
• Bed rest in a left leteral position
• Monitor amount of bleeding (shock)
• Administer IV fluids, blood products, or tocolytic medication as prescribed
• Cesarean section may be performed if bleeding is heavy
• Administer Rh immune globulin if the mother is Rh-negative and has not been given the injection at 28 weeks of gestation

Rupture of Uterus

Rupture of uterus is a separation of the uterine tissue, complete or incomplete. It is a result of a tear in the wall of the uterus from the stress of labor.

Signs and Symptoms - Rupture of Uterus:

• Chest pain
• Abdominal pain or tenderness
• Contraction may stop or fail to progress
• Rigid abdomen
• Signs of maternal shock
• Absent fetal heart rate
• Fetus palpated outside the uterus (complete rupture)

Nursing Interventions - Rupture of Uterus:

• Monitor and treat signs of shock (oxygen, IV fluids, blood products)
• Prepare patient for cesarean section or hysterectomy
• Provide emotional support for both of patient and partner

Preterm Labor

Preterm labor means the labor that occurs after the 20th week but before 37th week. It may be associated with infection. The contractions occur more frequent than every 10 minutes and last 30 seconds or longer and persist.

Signs and Symptoms:

• Abdominal cramping
• Uterine contractions
• Low back pain
• Pelvic pressure or heaviness
• Discharge may be thicker or thinner, bloody, brown or colorless and may be odorous
• Amniotic membranes are ruptured

Nursing Interventions:

• The interventions are focused on stopping the labor: treat infection, restrict activity, and hydration
• Monitor fetal status
• Bed rest and lateral position
• Administer medications as prescribed: Ritodrin (Yutopar), Magnesium sulfate, Terbutaline (Brethine), Nifedipine (Procardia), Indomethacin (Indocin).

Precipitous Labor and Delivery

Precipitous labor means the labor that lasting less than three hours.

Nursing Interventions:

• Provide emotional support to calm mother
• Stay with the mother
• Encourage the mother to pant between contractions
• Prepare for rupturing membranes when the head crowns
• Do not try to keep fetus from being delivered

Interventions if Delivery is Necessary:

• Apply gentle pressure to fetal head upward toward the vagina to prevent damage to the fetal head and vaginal lacerations
• Support infant's body during delivery
• Deliver the infant between contractions and check for the cord around the neck
• Use restitution to deliver the posterior shoulder
• Use gentle downward pressure to move the anterior shoulder under the pubic symphysis
• Clear the infant's mouth
• Dry and cover the infant to keep the body warm
• Let the placenta separate naturally
• Place the infant on the mother's abdomen or breast to induce uterine contractions

Propalse Cord

Prolapse cord is displacement of umbilical cord between the presenting part and the amnion or protruding through the cervix. It causes compression of the cord and compromise fetal circulation.

Signs and Symptoms:

• Umbilical cord is visible or palpable
• Mother has feeling that something is coming through the vagina
• Fetal heart rate is irregular and slow
• Variable deceleration or bradycardia after rupture of the membranes
• Violent fetal activity may occur and then cease if fetal hypoxia is severe

Nursing Interventions:

• Relieve umbilical cord immediately
• Reposition mother: turn her side to side or elevate her hips to shift the fetal presenting part toward her diaphragm
• Apply finger pressure with a sterile glove hand to elevate fetal presenting part that is lying on the cord
• Do not attempt to push the cord into the uterus
• Assess fetus for hypoxia
• Prepare for emergency cesarean birth
• Administer oxygen by face mask to the mother as prescribed

Distocia

Dystocia means prolonged or more painful labor. It can caused by uterine contractions, the fetus, or the bones and tissue of the maternal pelvis, large fetus, malpositioned, or abnormal presentation.

The contraction may be hypertonic or hypotonic. Dystocia can cause maternal dehydration, infection, and fetal injury or death.

Sign and Symptoms:

• Contraction pattern is abnormal
• Abdominal pain
• Fetal distress
• Lack of progress in labor
• Maternal or fetal tachycardia

Nursing Intervention:

• Assess and monitor fetal heart rate and fetal distress
• Monitor maternal temperature and heart rate
• Monitor uterine contraction
• Assist with pelvic examination, measurement, ultrasound or other procedures
• Administer antibiotic and IV fluid as prescribed
• Monitor intake and output
• Assess for dehydration
• Monitor color of amniotic fluid
• Teach mother in breathing and relaxing techniques
• Provide good rest and comforts
• Assess for prolapse of the cord

Fetal Heart Rate Monitoring

Fetal monitoring is the way to displays the fetal heart rate (FHR). Fetal heart rate is monitored in relation to maternal contraction. The baseline FHR is measured between contraction and the normal FHR at term is 120-160 beats per minute. The device that monitors uterine activity can assess frequency, duration and intensity of contractions.

There are two types of fetal monitoring: external fetal monitoring and external fetal monitoring.

External Fetal Monitoring
It is noninvasive procedure and is performed using a tocotransducer or Doppler ultrasonic tranducer. The ultrasound transducer is placed over the area in which the fetal back is located and fasten with a belt. The tocotransducer is placed over the fundus of uterus where contractions feel stronger and fasten with a belt. This external fetal monitoring will allow the client to get position comfortably.


Internal Fetal Monitoring It is invasive procedure and requires rupturing of the membranes and the electrode is attached to the presenting part of the fetus. For being available of internal fetal monitoring, the mother must be dilated 2-3 cm.

FETAL HEART RATE PATTERN

Fetal Bradycardia:
The FHR is less than 120 beats per minute for 10 minutes of more

Fetal Tachycardia:
The FHR is greater than 160 beats per minute for 10 minutes or more.

Acceleration
Accelerations are temporary increases of FHR at least 15 beats greater than the baseline and lasting at least 15 seconds, reflect a responsive nonacidotic fetus. Acceleration may occur with fetal movement, uterine contraction, vaginal examinations, or when the fetus is in a breech presentation.

Early Decelerations
In early decelerations, the fetal heart rate is below baseline and return to the baseline by the end of the contraction. It usually occurs during contractions and not associated with fetal compromise and requires no interventions. A uniform shape and mirror image of uterine contraction are showed.

Late Decelerations
In late decelerations, the fetal heart rate looks similar to early deceleration but begin well after the contraction begins and return to baseline after the contraction ends. Late decelerations reflect impaired placental exchange or uteroplacental insufficiency. The intervention includes improving placental blood flow and fetal oxygenation by placing patient on side, administer oxygen by tight face mask, discontinue oxytocin (if any), hydration, and correct hypertension (if any).

Variable Deceleration
In variable decelerations, the fetal heart rate does not have the uniform appearance. Shape, duration and degree of FHR fall below baseline are variable. Variable decelerations are significant when the FHR repeatedly decreases to less than 7- beats per minutes and persists at the level for at least 60 seconds before returning to the baseline. The cause of variable decelerations is the conditions that restrict flow through the umbilical cord (compressed umbilical cord). Interventions include change position (trendelenburg may be helpful), discontinue oxytocin (if any), check for cord prolapsed or imminent delivery by vaginal exam, consider amnioinfusion, and administer 100% oxygen by tight face mask.