5. Disorders affecting fluid-gas transport: maternal
1. Uterine rupture
   1. Pathophysiology - stress on uterine muscle exceeds its ability to stretch.
   2. Etiology:
      1. Overdistention - due to large baby, multifetal gestation.
      2. Old scars - due to previous cesarean births or uterine surgery.
      3. Contractions against CPD, fetal malpresentation, pathological retraction ring (Bandl’s).
      4. Injudicious obstetrics - malapplication of forceps (or application without full effacement/dilation).
      5. Tetanic contraction - due to hypersensitivity to oxytocin (or excessive dosage) during induction/augmentation of labor.
   3. Assessment:
      1. Identify predisposing factors early.
      2. Complete rupture
         1. Pain: sudden, sharp, abdominal; followed by cessation of contractions; tender abdomen.
         2. Signs of shock; vaginal bleeding.
         3. Fetal heart tones - absent.
         4. Presenting part - not palpable on vaginal examination.
      3. Incomplete rupture
         1. Contractions: continue, accompanied by abdominal pain and failure to dilate; may become dystonic.
         2. Signs of shock.
         3. May demonstrate vaginal bleeding.
         4. Fetal heart tones - absent/bradycardia.
   4. Prognosis
      1. Maternal - guarded.
      2. Fetal - grave.
   5. Analysis/nursing diagnosis:
      1. Pain related to rupture of uterine muscle.
      2. Fluid volume deficit related to massive blood loss secondary to uterine rupture.
      3. Anxiety/fear related to concern for self, fetus.
      4. Altered tissue perfusion related to blood loss secondary to uterine rupture.
      5. Altered urinary elimination related to necessary conservation of intravascular fluid secondary to blood loss.
      6. Anticipatory grieving related to expected loss of fetus; inability to have more children.
   6. Nursing care plan/implementation:
      1. Medical management:
         1. Surgical - laparotomy, hysterectomy.
         2. Replace blood loss - transfusion, packed cells.
         3. Reduce possibility of infection - antibiotics.
      2. Nursing management:
         1. Goal: safeguard status.
            1. Report immediately; mobilize staff.
            2. Prepare for immediate laparotomy.
            3. Oxygen per mask - to increase circulating oxygen level.
            4. Order stat type and crossmatch for blood - to replace blood loss.
            5. Establish IV line - to infuse fluids, blood, medications.
            6. Insert indwelling catheter - to deflate bladder.
            7. Abdominal prep - to remove hair, bacteria.
            8. Surgical permit (informed consent) for hysterectomy.
         2. Goal: emotional support - to allay anxiety (woman and family).
            1. Encourage verbalization of fears, anxiety, concerns.
            2. Explain all procedures.
            3. Keep family informed of progress.
   7. Evaluation/outcome criteria:
   1. Experiences successful termination of emergency; minimal blood loss.
   2. Postoperative status stable.
2. Amniotic fluid embolus (Anaphylactoid Syndrome)
1. Pathophysiology: acute cor pulmonale - due to embolus blocking vessels in pulmonary circulation; massive hemorrhage - due to DIC resulting from entrance of thromboplastin-like material into bloodstream.
2. Etiology - amniotic fluid (with any meconium, lanugo, or vernix) enters maternal circulation through open venous sinuses at placental site; travels to pulmonary arterioles. Triggers cardiogenic shock and anaphylactoid reaction.
   1. Rare.
   2. Associated with: tumultuous labor, abruptio placentae, AROM, placement of intrauterine catheter.
3. Prognosis - poor; often fatal to mother.
4. Assessment:
   1. May occur during labor, at time of rupture of membranes, or immediately postpartum.
   2. Sudden dyspnea and cyanosis.
   3. Chest pain.
   4. Hypotension, tachycardia.
   5. Frothy sputum.
   6. Signs of DIC:
      1. Purpura - local hemorrhage.
      2. Increased vaginal bleeding - massive.
      3. Rapid onset of shock.
5. Analysis/nursing diagnosis:
   1. Impaired gas exchange related to pulmonary edema.
   2. Risk for fluid volume deficit related to DIC.
   3. Anxiety/fear for self and fetus related to severity of symptoms, perception of jeopardy.
6. Nursing care plan/implementation:
   1. Medical management:
      1. IV heparin, whole blood.
      2. Birth: immediate, by forceps, if possible; or cesarean birth.
      3. Digitalize, as necessary.
   2. Nursing management:
      1. Goal: assist ventilation.
         1. Position: semi-Fowler’s.
         2. Oxygen under positive pressure.
         3. Suction prn.
      2. Goal: facilitate/expedite administration of fluids, medications, blood.
         1. Establish intravenous line with large-bore needle.
         2. Administer heparin, fluids, as ordered.
      3. Goal: restore cardiopulmonary functions, if needed. Cardiopulmonary resuscitation techniques.
      4. Goal: emotional support of woman, family.
      5. Allay anxiety, as possible.
      6. Explain all procedures.
      7. Keep informed of status.
7. Evaluation/outcome criteria:
   1. Dyspnea relieved.
   2. Bleeding controlled.
   3. Successful birth of viable infant.
   4. Uneventful postpartum course.