2 Female external genitals First we will review the anatomy.The vulva is the area from the mons pubis to the fourchette.The perineal area is between the fourchette and the anusFemale external genitals
3 L&D- the P’s of Labor Power uterine contractions maternal pushing Passage bony boundaries of pelvis softening of cartilage linking pelvic bonesPassenger lie attitude presentation occiput brow, face shoulder sacrum position – LOA,ROPPsych
4 POWER Uterine muscle layers. Muscle fiber placement. The layers of the myometrium show the three types of smooth muscle fiber. The outer layer is longitudinal fibers – mostly found in the fundus, the middle layer has figure 8 fibers and the inner layer has circular fibers these are mostly found where the fallopian tubes enter the uterus and surround the cervical os controlling entry.Uterine contractions and maternal pushingUterine muscle layers. Muscle fiber placement.
5 Pelvic types: gynecoid, android, anthropoid, platypelloid PASSAGEThere are basically four shapes to the pelvic bone. – most women do not have a true pelvic shape but a combination of these four.Gynecoid 50% - round cylindrical shape throughout. Good for vag birth. This pelvic shape has wide diameters and gentle curves throughout Most favorable for vaginal birth all the diameters are adequate.Android – 30% heart or triangular-shaped inlet. Narrow diameters throughout. Narrow public arch – poor for vaginal birth.Anthropoid 25% white and 50% non-white – The shape is long, narrow oval. Anteroposterior diameter is longer than transverse diameter. Narrow pubic arch. Favorable.Platypelloid – 3% flattened, wide, short, oval in shape Transverse diameter wide, but anteroposterior diameter short. Wide public arch. Poor prognosis for vaginal birth.Pelvic types: gynecoid, android, anthropoid, platypelloid
6 PASSENGER Typical anteroposterior diameters of the fetal skull. Typical anteroposterior diameters of the fetal skull. When the vertex of the fetus presents and the fetal head is flexed with the chin on the chest, the smallest anteroposterior diameter (suboccipitobregmatic) enters the birth canal.Typical anteroposterior diameters of the fetal skull.
7 LIEThe relationship of the long axis of the fetus to the long axis of the woman99% the lie is longitudinal and parallelTransverse lie – fetus is at right angle to motherTransverse lie - uncommon
8 Fetal attitude is the relationship of fetal body parts to itself. Flexion is normalflexedextensionFetal attitude is the relationship of fetal body parts to itself.
9 PRESENTATION The fetal part that first enters the pelvis Cephalic Vertex presentation.p.268Vertex – most common or occiput presentation.Military head is in neutral positionBrow – head partly extendedFace = head is extendedBreech presentationBreech presentation.
11 Breech presentations Full Breech Frank Breech Footling Breech Complete breech in left sacral anterior (LSA) position.Breech presentation. Frank breech.Incomplete (footling) breechFootling Breech
12 PositionFetal position describes the location of a fixed reference point on the presenting part in relation to the four quadrants of the maternal pelvisAbbreviations of presenting part is “cuddled” between maternal pelvisLOA, LOP, ROA, ROP, RSA, LMPOcciput, Sacrum, Mentum (chin), Anterior, Posterior
15 PSYCHE Preparation and information Anxiety and fear decrease coping Culture affects viewsBoth physical and emotional experienceDo not “nurse the machines”
16 L&D nursing responsibilities History Antepartal weight gain fetal gest & growth risk factors present statusObstetricalMedical surgicalintervalAssessment maternal vital signs uterine activity bladder status I&O bloody show response to labor maternal discomfort fetal heart rate Amniotic fluid
17 L&D Leopold’s maneuvers Palpate upper abdomenPalpate opposite side in circular motion for fetal extremitiesPalpate for engagement of presenting partPalpate to identify cephalic prominence
18 What fetal part is in fundus Figure 16–5a Leopold’s maneuvers for determining fetal position and presentation. First maneuver: Facing the woman, palpate the upper abdomen with both hands. Note the shape, consistency, and mobility of the palpated part. The fetal head is firm and round and moves independently of the trunk. The buttock feels softer, and it moves with the trunk.What fetal part is in fundus
19 Figure 16–5b Second maneuver: Moving the hands on the pelvis, palpate the abdomen with gentle but deep pressure. The fetal back, on one side of the abdomen, feels smooth, and the fetal extremities on the other side feel knobby.Palpate for back
20 Palpate for engagement of presenting part Figure 16–5c Third maneuver: Place one hand just above the symphysis. Note whether the part palpated feels like the fetal head or the breech and whether it is engaged.Palpate for engagement of presenting part
21 Palpate position of head – determine descent & flexion Figure 16–5d Fourth maneuver: Facing the woman’s feet, place both hands on the lower abdomen and move hands gently down the sides of the uterus toward the pubis. Note the cephalic prominence or brow.Palpate position of head –determine descent & flexion
22 Location of FHR in relation to the more commonly seen fetal positions.
23 Location of FHR in relation to the commonly seen fetal position
24 Electronic fetal monitoring by external technique Electronic fetal monitoring by external technique. The tocodynamometer (“toco”) is placed over the uterine fundus. The toco provides information that can be used to monitor uterine contractions. The ultrasound device is placed over the area of the fetal back. This device transmits information about the fetal heart rate. Information from both the toco and the ultrasound device is transmitted to the electronic fetal monitor. The fetal heart rate is displayed in a digital display (as a blinking light), on the special monitor paper, and audibly (by adjusting a button on the monitor). The uterine contractions are displayed on the special monitor paper as well.Electronic fetal monitoring by external technique. The tocodynamometer (“toco”) is placed over the uterine fundus. The ultrasound device is placed over the area of the fetal back.
28 Normal fetal heart rate pattern obtained by internal monitoring. Note normal FHR, 140 to 158 beats/min, presence of long- and short-term variability, and absence of deceleration with adequate contractions. Arrows on bottom of tracing indicate beginnings of uterine contractions.Normal fetal heart rate pattern obtained by internal monitoring.
29 Fetal Heart Rate Patterns Tachycardia – greater than 160 for 10 minBradycardia – less than 110 for 10 minAbsent or minimal beat-to-beat variabilityEarly decelerations – head compressionLate decelerations – uterine placenta insufficiencyVariable decelerations – cord compression
30 ABFigure 19–1 a & b Comparison of labor patterns. A, Normal uterine contraction pattern. In this example contraction frequency is every 3 minutes; duration is 60 seconds. The baseline resting tone is below 10 mm Hg. B, Hypotonic uterine contraction pattern. In this example the contraction frequency is every 7 minutes (with some uterine activity between contractions), duration is 50 seconds, and intensity increases approximately 25 mm Hg during contractions.Power – contraction not effectiveComparison of labor patterns. A) Normal uterine contraction pattern. B) Hypotonic uterine contraction pattern..
31 Types and characteristics of early, late, and variable decelerations.
32 Nursing Interventions for Decelerations Early Continue to observeLate Stop oxytocin Replace fluids Change mother’s position Check B/P and Pulse Administer oxygen Notify physicianVariable Stop oxytocin Replace IV fluids Change mothers position Check for prolapsed cord Check B/P and Pulse Administer oxygen Notify the physician Prepare to assist with fetal scalp blood sample
33 Conditions Associated with Fetal Compromise FHR below 100 or above 160Amniotic fluid Meconium-stained (greenish) Cloudy, yellowish, or foul-smellingContractions lasting longer than 90 seconds occurring less than 2 minutes apartMaternal hypotension, hypertension, feverFHR below 100 or above 160Amniotic fluid Meconium-stained (greenish) - fetal distress or post matureCloudy, yellowish, or foul-smelling – suggests infectionContractions lasting longer than 90 seconds - reduces placenta blood flow.occurring less than 2 minutes apart – may not give placental blood flow time to resume during intervalIncomplete uterine relaxation and intervals shorter than 60 seconds between contractions – reduces placental blood flow.Maternal hypotension, hypertension, feverHypotension – may divert blood flow away from the placenta to ensure adequate perfusion of the maternal brain and heatHypertension – may be associated with vasospasm in spiral arteries, which supply the intervillous spaces of the placentaFever (100.4 or higher
34 Actions to increase oxygen to fetus If receiving Pitocin stop or slow rateReposition motherIncrease non-additive IV fluidsAdminister 100% oxygen thru snug face mask to mother at rate of 8-10 liters/minKeep mothers bladder emptyChange under-pads regularlyp. 353
35 L & D true vs false labor True labor contractions: Start in back & move wavelike toward abdomenBecome more intense with walkingResult in ripening of cervix, dilation & effacementFalse labor contractions: Noticed primarily in abdomen Begin & remain consistent Disappear with walking No change in cervical dilation or effacement
36 Before labor begins, the cervix is long (approximately 2 Before labor begins, the cervix is long (approximately 2.5 cm), the sides feel thick, and the cervical canal is closed, so an examining finger cannot be inserted. During labor, the cervix begins to dilate, and the size of the opening progresses from 1 cm to 10 cm in diameter.To gauge cervical dilatation, the nurse place the index and middle fingers against the cervix and determines the size of the opening.
37 Measuring the station of the fetal head while it is descending
39 A, Engagement and decent B, Flexion. C, Internal rotation. D, Extension. E, External rotation. Mechanisms of labor.
40 Stages of LaborStage I cervical dilation to 10 cm & effacement to 100% early/latent active transitionStage II crowning to birth of babyStage III birth of baby to delivery of placentaStage IV 1-4 hours after delivery of placenta stabilization recovery
41 Phases of Stage I of Labor Early/latent - dilates cm contractions q 5 min X secActive - dilates – cm contractions q 2-5 min X secTransition- dilates – 8-10 cm contractions q 2-3 min apart X secp. 275Early/latent - dilates cm contractions q 5 min X 30 secPrimip 8-9 hours Multip 5-6 hrsContractions mild and may start in back. Many describe as if menstrual cramps. Woman is usually social, excited and cooperativeActive - dilates – cm contractions q 2-5 min X secPrimip 4-5 hours multip 2-3 hoursContractions are moderate to strong in intensityBehavior changes becomes anxious and feels helpless. Sociability is gone and replaced by serious inward focus. If will take pain medication – now is the time to do it.Transition- dilates – 8-10 cm contractions q 2-3 min apart X secPrimip – 3-4 hours for primip multip – times variesContractions are very strong. – Leg tremors, nausea, and vomiting are common.Behavior – irritable and lose control. Partner becomes confused because actions that were helpful just a short time ago now bother her.
42 Effacement of the cervix in the primigravida. Beginning of labor Effacement of the cervix in the primigravida. Beginning of labor. There is no cervical effacement or dilatation. The fetal head is cushioned by amniotic fluid.
43 Beginning cervical effacement Beginning cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head.
44 Cervix about one-half effaced and slightly dilated Cervix about one-half effaced and slightly dilated. The increasing amount of amniotic fluid exerts hydrostatic pressure.
45 Complete effacement and dilatation. End of Stage 1
46 Friedman Curve Predicable progression of labor for Nulliparous and MultiparousPrimip = 1 cm per hourMultip is usually from 8-10 hoursPrimip is usually from hours
47 Responsibilities during First Stage of Labor Promote Comfort positioning, lighting temperature, cleanliness bladder, mouth careRelieve pain breathing techniques nonpharmacologic massage, touch, pressure hydrotherapy imagery or focal pointp. 310Promote Comfort positioning - assume any position she finds comfortable other than supine and change positions frequentlylighting - soft indirect lightingtemperature - cool, damp washcloths on woman's face and neck promote comfortcleanliness bloody show and amniotic fluid leak and should change the sheets and gown frequentlybladder - a full bladder intensifies the discomfort and can delay fetal descent. Empty bladder at least every two hours. mouth care – ice chips, hard candy on a stick, frozen fruit bars.Relieve pain breathing techniques – pNonpharmacologicRelaxation – comfortable environment, general comfort measures, reduce anxiety, Self-massage, massage by others – body powder. Sacral pressure helps with back pain, two tennis balls in a sock. Touch, stroking, warmth to backHydrotherapyMental stimulation – imagery and focal point.
48 Stage 2 From 10cm 100% to birth of Baby Assist mother with pushingPreparation of sterile delivery tablePerineal cleansingSutures for episiotomy or lacerationInitial care and assessment of newbornAPGAR
49 Effects of labor on the fetal head. Caput succedaneum formation. Figure 19–2a Effects of labor on the fetal head. Caput succedaneum formation. The presenting portion of the scalp area is encircled by the cervix during labor, causing swelling of the soft tissue.Effects of labor on the fetal head. Caput succedaneum formation.
50 Care of Infant Maintaining cardiopulmonary function – APGAR Supporting thermoregulationIdentifying infantExamining for obvious anomalies and birth injuriesMedication administrationp. 323Assess APGARPlace infant on a prewarmed warmer with head turned to one side to allow drainage of secretions. Suction secretions from the infants mouth and nose with a bulb syringe as needed.Thermoregulation = hypothermia raises the infants metabolic rate and oxygen consumption worsening any respiratory problems. Apply towels to reduce evaporative heart loss. The head should be dried well. 0 it is about ¼ of body's surface area. The stimulus of drying the skin promotes vigorous crying and lung expansion in most healthy infant. Stockinet cap reduces heat loss. Not to wear cap in warmer because it slows transfer of heat to baby.Band with matching imprinted numbers and identifying information are the primary means to ensure the right mother goes with the right infant. Apply two bands for infant and mother and support person wears the fourth.
51 Clamp is positioned 1/2 to 1 in from the abdomen and then secured.
52 APGAR Heart rate – above 100 Respiratory Effort – spontaneous with cry Muscle tone – flexed with movementReflex response – active, prompt cryColor – pink or acrocyanosis0-3 infant needs resuscitation4-7 Gentle stimulation – Narcan8-10 – no action neededp. 324
53 Cut cord. The one vein and two arteries can be seen.
54 Placenta Separation Stage 3 Uterus changes shapeUterus rises upward in the abdomenCord begins to move out of the vaginaGush of blood noted from vaginap. 279Stage 111 = shortest stage lasting about 30 min with an average of 5-10 minutes.When the infant is born, the uterine cavity becomes much smaller. The reduced size decreases the size of the placenta site, causing it to separate form the uterine wall. Fours signs suggest placenta separation.The uterus has a spheric shapeThe uterus rises upward in the abdomen as the placenta descends into the vagina and pushes the fundus upward.The cord descends further from the vagina.A gush of blood appears as blood trapped behind the placenta is released.
55 Stage IIIPlacental separation and expulsion.Schultze mechanism.
56 Stage 4 of Labor First 1-4 hours after delivery of placenta Palpate fundusAssess vital signsAssess lochiaIce pack to perineumCare of infant and Care of motherIdentificationPromoting bonding
57 Stage 4Physical recovery of mother and baby lasts 1-4 hours.Uterus at or below umbilicusMany women complain of chills lasting about 20 min care – warm blanket, hot drink or soup may help.Ice packs to perineum helpIdeal time for bonding because the interest of both the parents and the newborn is high. May initiate breastfeeding if no problems.Baby is alter and seeks eye contact with the new parents..The left hand is placed just above the symphysis pubis, and gentle downward pressure is exerted. The right hand is cupped around the uterine fundus.Suggested method of palpating the fundus of the uterus during the fourth stage.
58 Common Intrapartum Procedures AmniotomyStimulation of labor induction augmentationAssisted delivery episiotomy forceps vacuum extractorCesarean delivery
59 Amniotomy Artificial rupture of fetal membranes Advantages decrease some labor assessment of fluid for meconium permits internal monitoringRisks cord prolapse infectionp. 396Assess baseline FHT prior. At least minAssess for complicationscheck FHT for one full minute after check for quality, color, and odor of amniotic fluid.Vernix may mean preterm Greenish may be post term or placental insufficiency.HydramniosCheck woman temp q 2-4 hours report if above or FHR above 160
60 Assessment of Fluid Quality, Color, and Odor Greenish, meconium stainedLarge amount of vernixStrong order, cloudy or yellowHydramniosOligohydramniosFluid should be clear often with bits of vernix and have a mild odor.Greenish, meconium stained - post term or placental insufficiencyLarge amount of vernix – suggests fetus may be pretermStrong order, cloudy or yellow suggests chorioamnionitisHydramnios is associated with some fetal abnormalitiesOligohydramnios – lack may be associated with placental insufficiency or fetal urinary tract abnormalities
62 Induction & Augmentation of Labor During Stage 1 DefinitionsCriteria – Bishop’s scoring, 39 weeks gest.Methods surgical – amniotomy drugs Oxytocin (Pitocin) – IV stimulate contractions Cervical ripening agents prostaglandin Misoprostol (Cytotec)- tab dinoprostone (Prostin E2) Cervidil/Prepidil - vaginal/cervical gelInduction – any attempt to initiate uterine contractions before their spontaneous onset to facilitate a vaginal deliveryNot having contractionsAugmentation – any attempt to stimulate uterine contractions during the course of labor to facilitate a vaginal delivery having contractionsBishops scoring – 13 is highest p. 399 needs be 7 or higher for primip and 5 or higher for multip Rating 0,1,2,35 factors –four are of cervix of motherDilation 0, 1-2, 3-4, 5-6, effacement 0-30%, 40-59%, 60-70%, 80% and more, cervical consistency firm, med, soft, cervical position posterior, middle, anteriorand one of fetus – station 3, 2, 1 or 0, +1 or +2
63 Episiotomy Most common operation primip – 70% multip – 30% Types midline – most common problem with 3-4th degree lacerationmediolateral increased PP pain, more scaringMain risk – infectionComplication of infection – prolonged dyspareniaPrevention – perineal massage & stretching beginning at 34 weeks.Midline p. 409AdvantagesMinimal blood loss Neat healing with little scarring less postpartum pain than mediolateralDisadvantages an added laceration may extend into the anal sphincter limited enlargement of the vaginal sphincterProlonged dysparenia is painful intercourseMediolateralMore enlargement of the vaginal openingLittle risk that the episiotomy will extend into the anusDisadvantagesMore blood lossIncreased postpartum painMore scarring and irregularity in the healed scarPainful intercourse
65 LacerationsFirst degree - limited to fourchette, perineal skin, vaginal membraneSecond degree - underlying fascia and muscle of the perineal bodyThird degree – involves the anal sphincterFourth degree – extends thru the rectal mucosa to lumen of rectumCould be extension of episiotomy
66 Interventions During Stage 2 Forceps & Vacuum ExtractionAssist with decent and rotation of fetal headRisk- trauma to maternal and fetal tissueCriteria scalp is visible at vaginal opening normal scalp ph is above 7.25 Low forceps - station is +2 or lower Mid forceps - station 0 to +2Normal scalp ph is above 7.25 or infant is hypoxic with acidosis and in distress if lower
67 Forceps With correct placement of the blades, the handles lock easily. During uterine contractions traction is applied to the forceps in a downward and outward direction to follow the birth canal.With correct placement of the blades, the handles lock easily.
68 The cup is placed on the fetal occiput and suction is created The cup is placed on the fetal occiput and suction is created. Traction is applied in a downward and outward direction.Vacuum extractor
69 Risks to Mother and Infant Mother laceration hematoma of the vaginaInfant ecchymoses facial and scalp lacerations and abrasions cephalhematoma intracranial hemorrhageChignon –scalp edema from vacuum extractorp
70 Cesarean Birth About 22% of all births Indications – dystocia, CPD, PIH, DM, genital herpes, prolapsed cord, fetal malpresentations, placenta previa or abruptio placentaeMaternal risk same as any abdominal ORInfant’s greatest risk is lung immaturityMaternal mortality is higher for C/S than for vaginal birth but is still relatively low
71 Preparation for C/S NPO, get operative permit signed Pre-op teaching Lab work – CBC, clotting series, type and cross match one or more unitsSingle IV dose of antibioticsFamotidine (Pepcid) and citrate (Bicitra)Shave abdomenInsert foley catheterPerform abdominal scrub
72 Incisions for C/SAbdominal incision vertical – umbilicus to symphysis transverse or bikini – above symphysisUterine incisions low transverse low vertical classicAbdominal and uterine incisions do not always match
73 Low transverse incision Uterine incisions for a cesarean birth. This transverse incision in the lower uterine segment is called a Kerr incision. preferredLow transverse incision
74 classic uterine incision Figure 20–5c This view illustrates the classic uterine incision that is done in the body (corpus) of the uterus. The classic incision was commonly used in the past but is associated with increased risk of uterine rupture in subsequent pregnancies and labor.Used for placenta previaclassic uterine incision
75 Nursing Considerations C/S Routine assessments q 15 min X 1 hr, q 30 min X 1 hr then hourly VS fundus for firmness, height, deviation lochia urine output abdominal dressingAssess need for pain medicationTCDB – support incision with pillow
76 Intrauterine Infection Signs Fetal tachycardia – FHT greater than 169 Maternal fever – greater than Foul or strong-smelling amniotic fluid Cloud or yellow appearance to amniotic fluid
77 Nursing Care for Infection Prevention wash hands limit vaginal examinations keep under pads dryAssess VS q 4 hours if ROM than q 2 hrsCollect culture specimens
79 Dystocia Abnormal progress of labor Contributing factors sedation, anxiety, anesthesia, unripe cervix, supine position, cephlopelvic disproportion - CPDManagement depends on causeDysfunctional labor – problem with powers of laborHypotonic contractions or Hypertonic contractionsIneffective maternal pushingCephlopelvic Disproportion Fetal head size too big for maternal pelvis
80 Complications of Pregnancy Hemorrhage – late in pregnancyPlacenta PreviaAbruptio Placentaep.671After 20 weeks the major causes of hemorrhage are placenta previa and abruptio placentae
81 Placenta previa Placenta located over/near cervical opening S&S: painless bleeding in 3rd trimester, hemorrhage, fetal distressRisk factor: multiparity in older womenTX: Hospitalization, bedrest, ultrasoundCare: Do not perform vag exam Monitor mother and fetus Prepare for delivery / no oxytocinThe three classifications of placenta previa depend on how much of the internal cervical os is covered by the placenta. This is determined by ultrasoundIncidence 1 in 200 births higher in women with previous previa, older women, multipara, cigarette smokingSigns and symptomsSudden onset of painless uterine bleedingNo manual examinations and no administration of oxytocin to prevent strong contractions that could result in sudden placental separation and rapid hemorrhage
82 Placenta previa. Low placental implantation. Marginal (low-lying)Placenta is implanted in lower uterus but its lower border is >3 cm from the internal cervical osThese are common in early ultrasound examinations and often appear to move upward and away form the internal cervical os as the fetus grows. Only about 10% of placenta a previa diagnosed in the second trimester will remain a previa at termDelivery occasionally by CSPlacenta previa. Low placental implantation.
83 Total placenta previaTotal: Placenta completely covers internal cervical osWith frank bleeding delivery always by C/S
84 Abruptio Placentae Premature separation of placenta S&S: Concealed or apparent hemorrhage in 3rd trimester, uterine tenderness, abd Pain, Board like abdomen, shock, fetal distressRisk factors: PIH, multiparty, DMTX: Replacement of blood loss, IV fluids, deliveryCare: Explain procedures, monitor mother and fetal condition, prepare for deliveryAlso known as placenta abruption, hemorrhage many be apparent or concealed. The severity depends on how much bleeding.Classic four symptoms are above can also have pack pain, signs of hypovolemic shock, fetal distress, or fetal deathDangerous conditionMajor danger is hemorrhage, Hypovolemic shock and clotting abnormalities
85 Marginal abruption with external hemorrhage. Abruptio placentae.Bleeding with abdominal pain that is constantMarginal abruption with external hemorrhage.
86 Abruptio placentaeComplete separation with concealed bleeding.
87 Shoulder DystociaRisk factors diabetes; macrosomic infant obesity prolonged second stage previous shoulder dystociaMorbidityManagementIncidence – 1 out of ever 300 deliveriesRisk factors diabetes; macrosomic infant obesity - poor muscle controlprolonged second stage previous shoulder dystociaMorbidity –Fractured clavicle or humerusBrachial plexus injury – no use of arm - $11 million settlementAsphyxia and fetal/neonatal deathManagementGenerous episiotomyMcRoberts maneuver. Hyperflex the mothers hips against her abdomen thus rotating the pelvis
89 Prolapsed CordCause – increase risk - high station, AROM, poor fit, hydramnios, breechSigns of prolapse – visible, suspectManagement – Emergency - Call Light Reduce cord compression Position hip higher than head Hold fetal part upward Give oxygen 8-10 liters/minPrompt delivery is the prioritypCauses – when the fetal presenting part has a poor fit in the pelvis fetus at high station, very small fetus, breech presentation, Transverse lie , HydramniosSigns – visible cord or changes in FHT such as bradycardia or variable decelerations
90 Other Complications Precipitous delivery Retained placenta Uterine inversionUterine ruptureUmbilical cord problemsMultiple birthsPrecipitous delivery – delivery within 1 hour after onset of laborRetained placenta - placenta has not delivered spontaneously within 30 minutes of delivery, Management – gentle traction on cord and notify anesthesia and prepare for manual removalUterine inversion – ER partial or complete – attempt to replace may need anesthesia so can relax enough to replace, follow with PitocinUterine rupture – May occur with scarred uterus, trauma, over use of Pitocin, over-distended uterusPresents with fetal distress, pain, bleeding, change in uterus contour, stopping of contractionsUmbilical cord problems1) True knots – occur in about 1% of deliveries, Caused by fetal tumbling inside uterusPerinatal mortality 6%2 nuchal cord longer cord ) normal about inches, Loops of cord around fetal neck20-25% of all deliveries, Causes variable decelerations3) Abnormal insertion sites of cord to placenta ,Battledore – insertion of margin- no clinical significance4) single umbilical artery, 1% of all – may indicate GU abnormalities5) Cord prolapse