Problems With Passenger

1. Problems with position, presentation, or size

A. Fetal Malposition
 Persistent occiput posterior- is directed diagonally and posteriorly, right, ROP or LOP
 Tend to occur in women with:
 Android pelvis- “male” pelvis
 Anthropiod pelvis- “ape-like”
 Contracted pelvis
 Posteriorly presenting head does not fit the cervix as snugly as one in anterior position

B. Fetal Malpresentation
 Fetal head presenting at a different angle than expected is termed Asynclitism

a. Vertex Presentation
1. Face presentation(Chin or Mentum) - the head is extended, and the fetal occiput is
near the fetal spine(full extension).
2. Brow presentation(the rarest type) - fetal head is partly extended (poor
flexion-extension)
3. Sincipito presentation - “military position”
- occipitofrontal diameter(2nd widest anteroposterior)
 Babies born after face presentation will have:
 Facial edema- ecchymotic bruising
 Lip edema- infant unable to suck
 Reassure parents that edema is transient will disappear in few days

b. Breech Presentation
Note:
Majority of fetuses are in breech presentation early in pregnancy by week 38 AOG
fetuses normally turn to cephalic presentation and “retain most comfortable position”
Head is widest in single diameter; buttocks plus legs= take up more space

 Uterus
Fundus- largest part of uterus, 97% of all pregnancies, fetuses turns so that the
buttocks and lower extremities are in the fundus those who failed to turn are
breech
 Prevention:
 Woman to assume 15 minutes knee-chest position for 3x a day during pregnancy
so breech presentation will be less likely to occur

Types of Breech Presentation:

1. Complete Breech- feet and legs are flexed on thigh, thighs flexed on abdomen and buttocks;
feet are presenting parts
2. Frank- legs are extended and lie against abdomen and chest; feet at levels of shoulder;
buttocks are the presenting parts
3. Footling
a. Double footling- legs are unflexed and extended; presenting part- feet
 b. Single footling- one leg is unflexed & extended; presenting part- one of the feet
4. Kneeling- thighs are extended but the knees are flexed, bringing the knees down to present at
the brim.
Risk of breech presentation:
 Anoxia from a prolapsed cord
 Traumatic injury to the after coming head
--> intracranial hemorrhage or anoxia
 Fracture of the spine or arms
 Dysfunctional labor
 Presenting part does not fit cervix
 Early rupture of BOW
 Risk of infection
--> meconium aspiration although mecoinum leakage is not a sign of fetal distress
but expected from buttocks pressure

Causesof breech presentation:

 Age of Gestation under 40 weeks
 Abnormality in the fetus- anencephaly, hydrocephalus, meningocele
 Hydramnios- free fetal movement
 Pendulous abdomen- lax abdominal muscle
 Any space-occupying mass in uterus
e.g. Midseptum- traps fetus in position
 Multiple gestation- ca’t turn to vertex position

Assessment:
 FHT- heard high in the abdomen
 Leopold’s maneuver and vaginal examination- reveal breech presentation
 Ultrasound- to confirm

Hazards/Risks part of breech birth:

 Cord compression- because the umbilicus precedes the head, a loop of cord passes down
alongside the head and pressure of the head compress the loop cord
 Intracranial hemorrhage- because of pressure changes
 Tentorial tears- causes gross motor and mental incapacity or lethal damage to the
fetus
(Tentorium an extension of one of the membranes covering thecerebrum which, with the
transverse fissure, separates the cerebrumfrom the cerebellum.)
 Abruption placenta
 Erb-Duchene paralysis (Erb’s palsy)- injury to the brachial plexus
S/S:Loss of sensation at arm and paralysis
Atrophy of deltoid and biceps and brachial muscles

Management for Breech Presentation:

I. Maneuvers
a. Internal Podalic Version- direct manipulation of the baby inside the uterine cavity to the
breech position
b. External Podalic Version- external cephalic version (ECV) refers to a procedure by
which an obstetrician or midwife turns the baby from the breech
to the cephalic position by manipulating the baby through the
maternal abdomen.
II. Forceps Delivery
 OB forceps- steel or metal instruments (2 blades left and right with lock), used if the
fetal head reaches the perineum
 Maybe high forceps(non-engaged head) or midforceps(level of ischial spines)
 Maybe used with pudendal block

Indications:
 To shorten 2nd stage of labor- when woman is unable to push with contractions in pelvic
division of labor
  After regional anesthesia
 Cessation of progress of labor
 Failure of fetal head to rotate
 Fetal distress
 Prolapsed cord
 FHT 100 bpm or 160 bpm
 Meconium stain in cephalic presentation

5 Common Types of OB Forceps

1. Kielland’s- with short handles and a marked cephalic curve use like Baxton
2. Piper- used to deliver the head in breech presentation
3. Simpson’s- used as outlet forcep
4. Baxton- with hinge in the right blade used to rotate fetal head to a more favorable position
such as ROP/ROA
5. Tarnier’s- axis traction forceps

Kielland’s Piper Simpson’s Tarnier’s

Pre-requisities:
 Pelvis should be adequate- no CPD
 Fetal head must be deeply engaged (+3 - +4 station)
 Cervix must be completely dilated and effaced
 Accurate diagnosis position and station must be made- vertex presentation
 Membranes (BOW) must be ruptured
 Some form of anesthesia must be used
e.g. Pudendal block- to achieve pelvic relaxation and reduce pain
 Rectum and bladder must be empty

Types of Forceps Application:

I. Low-forceps operation
Easy delivery; forceps are applied after the head has rendered the perineal floor with
sagittal suture in anterior-posterior of the outlet- vertex at introitus
II. Mid forceps operation
Forceps are applied before the criteria for low forceps are met but after engagement has
taken place- vertex at ischial spine
III. High forceps operation
Forceps are applied before engagement has taken place (only used in modern OB- rarely
done)- biparietal diameter above ischial spine)

Complications:

MATERNAL: FETUS:

 Lacerations- vagina, cervix-->  Cephalhematoma

hemmorhage & infection  Brain damage
 Rupture of uterus  Skull fracture
 Injury to bladder and rectum  Facial paralysis
 Cord compression
 Facial marks- temporary 24-48
hours only

Nursing Management:
 Prepare patient
 Explain the procedure
 Explain outcome ASAP especially on outcome of procedure e.g. marks, bruising
 III. Vacuum Extraction
 Used in place of forceps (duration- 30 minutes)
 Delivery of a fetus in vertex presentation with the use of a cap suction device that is
applied to fetal scalp for traction e.g. Ventouse vacuum extration

Complications:
 Scalp ecchymoses- expected- posterior fontanelle
 Cephalhematoma- prolonged used >30 minutes- damaged to scalp

Advantages over forceps:

 Use off little anesthesia (fetus less depressed at birth)
 Fewer laceration (non-invasive)

Disadvantage:
 Marked caput- >7 days after birth- assure mother
 Tentorial fear- from extremities pressure

Contraindicated if:
 Scalp blood sampling was done- bleeds
 Preterm- soft skull

IV. Cesarean Delivery

 Surgical extraction of the fetus via the uterine incision through the abdomen- trans-
abdominal incision of the uterus

Scheduled Cesarean Birth Emergency Cesarean Birth

Indications: Done for reasons such as:

 Transverse lie  Placenta previa
 Genital herpes  Abruptio placenta
 CPD  Fetal distress
 Avoidance of post procedure stress  Failure to progress in labor
incontinence
Risks:
Benefits:  The woman may not be a candidat
 Reduces transfer of HIV, hepatitis for anesthesia
C, herpes 2 from mother to NB  Psychologically unprepared fluid and
 “once a cesarean always a electrolyte imbalance
cesarean” mo longer applies  Emotionally and physically
exhausted from labor

Other indications:
 Uterine inertia
 Previous C/S
 Severe toxemia
 Placental accident(eclampsia)
 DM
 Old primi
 Prolapsed cord
 Post-term pregnancy
 Failed forceps delivery

c. Compound and Shoulder Presentation

1. Shoulder Presentation(Transverse Lie)
 Long axis of the fetus is perpendicular to the long axis of the mother
 Shoulder presents over the pelvic inlet

Etiology:
  Pendulous abdomen
 Uterine masses that obstruct lower uterine segment
 Contraction of the pelvic brim
 Congenital abnormalities of the uterus
 Hydrocephalus
 Polyhdramnios
 Prematurity
 Multiple gestation
 Short umbilical cord

Nursing Care of Client with Malpresentation

 Screen for abnormal fetal presentation
 Perform abdominal plapation on all patients in labor
 Palpate presenting part when performing vaginal exams
 Report abnormal findings to the physician
 Assist with diagnostic procedures
 Avoid rupturing membranes
 Ecnourage to empty bladder q2h
 Be prepared for CS, forceps delivery, neonatal resuscitation or postpartum hemorrhage

2. Compound Presentation
 A fetal hand is coming out with fetal head
 Prolapsed or concurrent presentation of an extremity with the presenting part
 This is a problem because:
--> the amount of baby that must come through the birth canal at one time is
increased.
---> there is increased risk of mechanical injury to the arm and shouldr, including
fractures, nerve injuries and soft tissue injury
Etiology:
 No specific cause
 Factor that predispose to a loose-fitting presenting part:
--> small premature babies

Management:
 A compound presentation may be resolved if the fetus can be encouraged to withdraw the
hand.
 If the fetus and arm are relatively small in comparison to the maternal pelvis, vaginal delivery
may still be possible but with some risk of injury to the arm.
 If the fetus and arm are relatively large in comparison to the maternal pelvis, obstructed labor
will occur and a cesarean will be needed.

C. Fetal Size
 Oversized fetus (Macrosomia)
 Weighs >4000 to 4500g (9-10 lbs)
 Large babies associated with: DM, multiparity
 Oversized infant may cause uterine dysfunction during labor or at birth because to the
overstretching of the fiber of the myometrium.

2. Fetal Anomalies

A. Congenital Anomalies
1. Hydrocephalus- accumulation of CSF in brain ventricles
2. Anencephalus- absence of the cranium or top portion of the head, lack of firm cervical
dilation
3. Condition causing abdominal(fetal) distention; overgrowth of liver(hepatomegaly), ascetic
cysts, cystic fibrosis(exocrine glands produce excessive viscous glands secretions causing
problems in respiratory and gastrointestinal functions), erythroblastosis fetalis(large immature
RBCs compensating for anemia producing edema in peritoneum and pleural spaces)

B. Fetal Distress
 Compromise of the fetus during the antepartum or intrapartum period
 Commonly used to describe fetal hypoxia

Causes:
 Breathing problems
 Abnormal position and presentation of the fetus
 Multiple births
 Shoulder dystocia
 Umbilical cord prolapse
 Nuchal cord
 Placental abruption
 Premature closure of the fetal ductus arteriosus

Signs & Symptoms:

a. Antepartum Period
 “Kick count” less than 10
 Cramps with bleeding
b. Intrapartum Period
 Tachycardia & Bradycardia- especially during conractions
 Decreased variability in fetal heart rate
 Meconium in the amniotic fluid
 Fetal acidosis- fetal scalp pH <7.2
 Lactic acidosis- elevated fetal blood lactate levels

Nursing Interventions:
 Place patient in a lateral position, elevate legs
 Administer oxygen at 8-10 L/min via face mask
 Discontinue oxytocin(Pitocin) if infusing
 Monitor maternal and fetal status
 Prepare for induction of labor or emergency cesarean section

3. Prolapse of the Umbilical Cord

 A loop of the umbilical cord slips downward infront of the presenting fetal part after the
membranes rupture.
 Interferes blood flow and fetal oxygenation because of compression.

Contributing factors:
  Premature rupture of membrane(PROM)
a. Rupture of Fetal Membranes
b. Subsequent Condition
 Fetal precentation other than cephalis (Breech presentation)
 Placenta Previa
 Transverse Lie
 Multiple Gestation
 Hydramnios
 Small fetus
 CPD & intrauterine tumors--> preventingfirm engagement

Factors that increases a woman’s risk for a Prolapsed Umbilical Cord:

 Rupture membranes
 The fetal presenting part at a high station
 A fetus that poorly fits the pelvic inlet because of small size or abnormal presentation
 Excessive volume of amniotic fluid

Assessment:
 Vaginal exam- cord may be felt as the presenting part
 After rupture of membranes occurs- changes of FHR patterns suddenly becomes apparent
and variable decceleration noted
 To rule out cord prolapse, always assess fetal heart sounds immediately after rupture
of the membranes(SROM or ARM)

Management:
 When cord prolapse occurs, priority is to relieve pressure on the cord
 Cord prolapse leads to cord compression because the fetal presentating part presses
against the cord at the pelvic brim
 Aim: Relieving pressure on the cord by---> to improve blood flow
 Placing a gloved hand in the vagina and manually pushes the fetal head upwards and
off the cord.
 Aim: Relieving pressure on the cord by:
 T-position or knee-chest- causes the head to fall back from the cord
 The woman’s thighs should be at right angles to the bed and her chest flat on the
bed
 Hips elevated with two pillows, with side-lying position maintained, often combined with
Trendelenburg(head down) position
 Administer oxygen at 10 L/m by facemask--> help improve oxygenation
 Tocolytic agent (terbutaline)--> reduce uterine activity and pressure on the fetus
 Cover any exposed portion with warm, sterile saline-moistened towels to prevent drying--
> lead to atrophy of the umbilical cord vessels
 Never attempt to push any exposed cord back into the vagina--> add to compression by
causing knotting or kinking
 Fully dilated at the time of prolapsed--> physician may choose to deliver the infant
quickly--> prevent fetal anoxia
 If not fully dilated--> the physician may apply upward pressure on the presenting part in
the woman’s vagina to keep pressure off the cord until the baby can be delivered by
cesarean birth

4. Multiple Gestation

Also known as multifetal pregnancy

 Results when two or more fetuses are present in the uterus at the same time
 Considered as a condition complicating pregnancy because the mother’s body must adjust
 to the effect of more than one fetus

Types of Twining:
Monozygotic Dizygotic
1 ova 2 ovas
1 spermatozoa 2 spermatozoa
1 placenta 2 placentas
1 chorion 2 chorion
2 amnions 2 amnions
2 umbilical cords 2 umbilical cords
Always of the same sex Same or different sexes
Familial maternal pattern

Incidence:
 Frequent in non-whites
 Increase in woman’s:
- parity
- age
- hereditary
 Dizygote twins has a familial maternal pattern

Assessment:
 Uterus- increase in size; rate faster than usual
 Sonogram- reveals multiple gestation sacs
 AFP levels- elevated
 Quickening- flurries of actions at different portion of the abdomen rather than one
persistent portion
 2 distinct & separated FHB may occur
 Discovered at delivery when uterus not empty

Effects:
Mother Fetus
 Susceptible to:  Prematurity
a. Abruptio placenta
b. PIH
c. Hydramnios
d. Placenta previa
e. Anemia
 Umbilical cord accidents:
- entwinement
- cord prolapse

Management:
 Nutrition counseling
- increase caloric & protein intake
- vitamin supplements
 Fetal evaluation- follow-up serial sonogram during pregnancy to evaluate:
- growth & development
- to detect IUGR
- biophysical profile
- amniocentesis
 Evaluate S/S of PIH
 Preterm labor preventation
- explain client the need for hospitalization if S/S of PTL noted
- bed rest an hydration
- fetal monitoring & tocolytic if ordered
 Explain to the client mode of delivery depends on:
- presentation of twins
 - maternal & fetal status
- gestational age
- multiple than twins is done by C/S
* twins can be present in any combination of presentations and positions
 Intrapartum management:
1. IV access and prepare for emergency birth & complication
2. Monitoring for each fetus
3. Double set is recommended
4. Induction may required to secondary hypotonic
 Provide emotional support
 Bring pregnancy to term