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.
6. Disorders affecting fluid-gas transport: fetal
   1. Fetus in jeopardy - general aspects:
      1. Pathophysiology - maternal hypoxemia, anemia, ketoacidosis, Rh isoimmunization, or decreased uteroplacental perfusion.
      2. Etiology - maternal:
         1. Preeclampsia/eclampsia.
         2. Heart disease.
         3. Diabetes.
         4. Rh or ABO incompatibility.
         5. Insufficient uteroplacental/cord circulation due to:
            1. Maternal hypotension/hypertension.
            2. Cord compression:
               1. Prolapsed.
               2. Knotted.
               3. Nuchal.
            3. Hemorrhage; anemia.
            4. Placental problem:
               1. Malformation of the placenta/ cord.
               2. Premature “aging” of placenta.
               3. Placental infarcts.
               4. Abruptio placentae.
               5. Placenta previa.
            5. Postterm gestation.
            6. Maternal infection.
            7. Hydramnios.
            8. Hypertonic uterine contractions.
         6. Premature rupture of membranes (PROM) with chorioamnionitis.
         7. Dystocia (e.g., from CPD).
      3. Assessment - intrapartal:
         1. Amniotic fluid examination - at or after rupture of membranes. Signs of fetal distress: meconium stained, vertex presentation - due to relaxation of fetal anal sphincter secondary to hypoxia/anoxia. Note: Fetus “gasps” in utero - may aspirate meconium and amniotic fluid.
         2. Fetal activity:
            1. Hyperactivity - due to hypoxemia, elevated CO₂.
            2. Cessation - possible fetal death.
         3. Methods of monitoring FHR:
            1. Fetoscope.
            2. Phonocardiography with microphone application.
            3. Internal fetal electrode - attached directly to fetus through dilated cervix after membranes ruptured.
            4. Doppler probe using ultrasound flow.
            5. Cardiotocograph - transducer on maternal abdomen transmits sound.
         4. Abnormal FHR patterns.
            1. Persistent arrhythmia.
            2. Persistent tachycardia of 160 or more beats/min.
            3. Persistent bradycardia of 100 or fewer beats/min.
            4. Early deceleration - due to vagal response to head compression.
            5. Late deceleration - due to uteroplacental insufficiency.
            6. Variable deceleration - due to cord compression.
            7. Decreased or loss of variability in FHR pattern.
         5. Medical evaluation - procedures: fetal blood gases, pH.
            1. Purpose - to identify fetal acid-base status.
            2. Requirements for:
               1. Ruptured membranes.
               2. Cervical dilation.
               3. Engaged head.
            3. Procedure - under sterile condition, sample of fetal scalp blood obtained for analysis.
            4. Signs of fetal distress:
               1. pH <7.20 (normal range is 7.3 - 7.4).
               2. Increased CO₂.
               3. Decreased PO₂
      4. Analysis/nursing diagnosis:
         1. Impaired gas exchange, fetal, related to decreased placental perfusion/insufficient cord circulation.
         2. Altered tissue perfusion related to hemolytic anemia.
         3. High risk for fetal injury related to hypoxia.
   2. Prolapsed umbilical cord
      1. Pathophysiology - cord descent in advance of presenting part; compression interrupts blood flow, exchange of fetal/maternal gases —> fetal hypoxia, anoxia, death (if unrelieved).
      2. Etiology:
         1. Spontaneous or artificial rupture of membranes before presenting part is engaged.
         2. Excessive force of escaping fluid, as in hydramnios.
         3. Malposition - breech, compound presentation, transverse He.
         4. Preterm or SGA fetus - allows space for cord descent.
      3. Assessment:
         1. Visualization of cord outside (or inside) vagina.
         2. Palpation of pulsating mass on vaginal examination.
         3. Fetal distress - variable deceleration and persistent bradycardia.
      4. Analysis/nursing diagnosis:
         1. Impaired gas exchange, fetal, related to interruption of blood flow from placenta/ fetus.
         2. Anxiety/fear, maternal, related to knowledge of fetal jeopardy.
      5. Nursing care plan/implementation:
         1. Goal: reduce pressure on cord.
            1. Position: knee to chest; lateral modified Sims’ with hips elevated; modified Trendelenburg.
            2. With gloved hand, support fetal presenting part.
         2. Goal: increase maternal/fetal oxygenation: oxygen per mask (8-10 L/minute).
         3. Goal: protect exposed cord: continuous pressure on the presenting part to keep pressure off cord.
         4. Goal: identify fetal response to above measures, reduce threat to fetal survival: monitor FHR continuously.
         5. Goal: expedite termination of threat to fetus: prepare for immediate cesarean birth.
         6. Goal: support mother and significant other by staying with them and explaining.
      6. Evaluation/outcome criteria:
         1. FHR returns to normal rate and pattern.
         2. Uncomplicated birth of viable infant.
7. Summary of danger signs during labor
   1. Contractions - strong, every 2 minutes or less, lasting 90 seconds or more; poor relaxation between contractions.
   2. Sudden sharp abdominal pain followed by boardlike abdomen and shock - abruptio placentae or uterine rupture.
   3. Marked vaginal bleeding.
   4. FHR periodic pattern decelerations - late; variable; absent.
   5. Baseline.
      1. Bradycardia (<100 beats/minute).
      2. Tachycardia (>160 beats/minute).
   6. Amniotic fluid.
      1. Amount: excessive; diminished
      2. Odor.
      3. Color: meconium stained; port-wine; yellow.
      4. 24 hours or more since rupture of membranes.
   7. Maternal hypotension, or hypertension.