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PROBLEMS WITH THE PASSENGER

PROLAPSED UMBILICAL CORD – a loop of the umbilical cord slips down in front of the presenting
part.

Description:
 Prolapse may occur at any time after the membranes rupture and if the presenting part is not fitted
firmly into the cervix.
 Prolapsed cord tends to occur with premature rupture of the membranes, fetal position other than
cephalic presentations, placenta previa, intrauterine tumors or cephalopelvic disproportion that
prevents firm engagement of the fetus, a small fetus, polyhydramnios, and multiple gestation.
 Cord prolapse automatically leads to cord compression because the fetal presenting part presses
against the cord at the pelvic brim.
 The incidence of prolapsed cord is 1 in 200 pregnancies.
 Management is aimed at relieving pressure on the cord and thereby relieving the compression and the
resulting fetal anoxia.
 If the cervix is fully dilated at the time of prolapse, the physician may choose to deliver the infant
rapidly, possibly with forceps delivery, to prevent a lengthy period of anoxia.
 If dilation is incomplete, the birth method of choice is upward pressure on the presenting part by a
practitioner’s hand in the woman’s vagina until cesarean birth is complete.

Assessment Findings:
 Cord felt as presenting part
 Presence of cord in vagina after rupture of membranes
 Variable deceleration pattern on fetal monitor

Nursing Implications:
 Monitor fetal heart rate and observe for variable deceleration pattern.
 Monitor and record fetal heart rate immediately following rupture of membranes.
 Place the client in Trendelenberg or knee-chest position, which causes the fetal head to fall back from
the cord if cord prolapse is discovered.
 Prepare the client for relief of cord compression; a hand is placed in the vagina (insert two fingers
into the vagina to the cervix) and the fetal head is manually elevated off the cord.
 Administer oxygen at 10 L/min by face mask to prevent fetal anoxia.
 Be prepared to administer a tocolytic to reduce uterine activity.
 Cover any exposed portion of the cord with a sterile saline compress to prevent drying.
 Do not attempt to push any exposed cord back into the vagina because it may cause additional
compression by kinking or knotting.

MULTIPLE GESTATION (PREGNANCY) – occurs when more than one fetus is growing in the uterus.

Description:
 Multiple gestation is a complication of pregnancy because a woman’s body must adjust to the effects
of more than one fetus.
 Single-ovum (monozygotic, identical) twins usually have one placenta, one chorion, two amnions,
and two umbilical cords and are of the same sex.
 Double-ova (dizygotic, nonidentical) twins have two placentas, two chorions, two amnions, and two
umbilical cords and may be of the same or different sex.
 Multiple gestations of three, four, five or six children maybe singe-ovum conceptions, multiple ova
conceptions, or a combination of both.
 Multiple gestations often occur as a result of ovulation stimulation by clomiphene citrate (Clomid);
with in vitro fertilization, several fertilized ova are introduced into the uterus, resulting in a high
possibility of multiple births.
 Women with multiple gestations are more susceptible to complications such as pregnancy-induced
hypertension, hydramnios, placenta previa, postpartal hemorrhage and anemia.
 There is also a higher incidence of velamentious cord insertion (the cord inserted into the fetal
membrane).
 Monozygotic twins can share the same vascular communication, which can lead to an overgrowth of
one fetus and an undergrowth of the second (twin-to-twin transfusion).

Assessment Findings:
 Uterine size greater than expected for dates
 Elevated alpha-fetoprotein levels
 Ultrasonography positive for multiple pregnancy
 More than one set of fetal heart sounds

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whichever feels best.  Posterior positions tend to occur in women with android.  Advise the client to return to the health care facility every month for ultrasound examination or weekly nonstress tests to document normal fetal growth beginning with the 28 th week of pregnancy. A posterior position is suggested by a dysfunctional labor pattern such as a prolonged active phase.  Lying on the side opposite the fetal back or maintaining a hands-and-knees position may help the fetus rotate.  If the fetus is of average size and in good flexion and aided by forceful uterine contractions. the fetal head must rotate. during internal rotation. Applying heat or cold. Breech Presentation Description:  Fetal presentation in which either the buttocks or feet are the first body parts to contact the cervix.  Monitor fetal heart rate and fundic height as well as maternal vital signs per facility’s protocol. In these instances. either to the right (ROP) or to the left (LOP). Leopold’s maneuvers. a woman may experience pressure and pain in her lower back due to sacral nerve compression. Nursing Implications:  As the fetal head rotates against the sacrum. PROBLEMS WITH PRESENTATION.  During a long labor. because of the increased incidence of cord entanglement and premature separation of the placenta. she may need an IV glucose solution to replace glucose stores used for energy. the diameter that the fetus presents to the pelvis is often too large for birth to proceed.  The inevitable contraction of the fetal buttocks from cervical pressure often causes meconium to be extruded into the amniotic fluid before birth. arrested descent or fetal heart sounds heard best at the lateral sides of the abdomen. arrive at a good birth position for the pelvic outlet. but when it does occur. fetal heart sounds usually are heard high in the abdomen.  Ensure adequate nutrition by instructing the client to eat six small meals a day rather than three large ones since the growing uterus will compress her stomach and reduce her appetite. this is also often the situation in multiple gestations of three of more. 2 .  Counterpressure on the sacrum such as backrub or change of position may be helpful in relieving a portion of the pain.  The fetal head may arrest in the transverse position (transverse arrest).  In these positions.  This presentation is rare.  With breech presentation. a vaginal examination or ultrasound examination reveals the presentation.  Encourage the client to adhere to her prescribed bed rest routine during the last 2 or 3 months of her pregnancy.  Prepare the client emotionally and physically for labor and delivery of multiple fetuses. Risk of Breech Presentation  anoxia from a prolapsed cord  Traumatic injury to the aftercoming head  Fracture of the spine or arm  Dysfunctional labor  Early rupture of the membranes because of the poor fit of the presenting part Causes of Breech Presentation  Gestational age less than 40 weeks  Abnormality in a fetus  Hydramnios  Any space-occupying mass in the pelvis  Pendulous abdomen  Multiple gestation  Unknown factors Face Presentation Description:  Fetal presentation in which either the chin or mentum is the first body parts to contact the cervix. or rotation may not occur at all (persistent occipitoposterior position). the fetus must be born by cesarean birth. POSITION AND SIZE Occipitoposterior Position Description:  The occiput is directed diagonally and posteriorly.  A posteriorly presenting head does not fir the cervix snugly thus increases the risk of umbilical cord prolapse. anthropoid or contracted pelvis. not through a 90-degree arc but through an arc of approximately 135 degrees. and are born satisfactorily with only increased molding and caput formation.  Twins may be born by cesarean birth to decrease the risk that the second fetus will experience anoxia. rotate through the large arc. Such meconium excretion can lead to meconium aspiration if the infant inhales amniotic fluid.  Review with the client her need for extra rest periods and “shoes off” times during the day to increase tissue perfusion. also may help.  Advise the client to refrain from coitus during the last 2 to 3 months of pregnancy. Nursing Implications:  Obtain a thorough antepartal history and physical examination to establish a baseline.

The umbilical cord enters the placenta at the usual midpoint. It occurs with a multipara or with relaxed abdominal muscles. 5. This occurs in a woman with the following conditions:  Contracted pelvis  In the presence of Placenta Previa  Relaxed Uterus of a Multipara  With Prematurity  With Hydramnios  With Fetal Malformation Brow Presentation  Fetal presentation in which the brow is the first body parts to contact the cervix. the cord or an arm may prolapse. multiparas. Cesarean birth is necessary. Battledore Placenta – the cord inserted marginally rather than centrally.500 grams (10 lbs. uterine masses such as fibroid tumors that obstruct the lower uterine segment 3. 2. women with pendulous abdomens 2. Placenta Circumvalata – ordinarily the chorion membrane begins at the edge of the placenta and spreads to envelop the fetus.  Is the rarest of the presentations.  Applying suprapubic pressure may help the shoulder escape from beneath the symphysis pubis (Wood’s Maneuver) PROBLEMS WITH THE PASSAGEWAY  Inlet contraction is defined as a narrowing of the anteroposterior diameter of the pelvis to less than 11 cm. or fractured clavicle because of shoulder dystocia. Transverse Lie  Fetal presentation in which the shoulder is the first body parts to contact the cervix. or the shoulder may obstruct the cervix. 3. when there is short umbilical cord Macrosomia (Oversized Fetus)  Size may become a problem in a fetus who weighs more than 4. may occur in prematurity when the infant has room for free movement 8. no chorion covers the fetal side of the placenta. the infant may be delivered without difficulty. The large infant born vaginally has a higher-than-normal risk of cervical nerve palsy.  Hazardous to the fetus because the cord is compresses between the fetal body and the bony pelvis.).  The condition may be suspected earlier if the second stage of labor is prolonged.  Outlet contraction is defined as the narrowing of the transverse diameter to less than 11 cm. the fetal side of the placenta is covered to some extent with chorion. infants with hydrocephalus or other gross abnormalities that prevent head from engaging 7. In placenta circumvallata. unless the presentation spontaneously corrects.the fold of chorion reaches just to the edge of the placenta. Causes: 1. Placenta Marginata. congenital abnormalities of the uterus 5.  Often. Brow presentations also leave the infant with extreme ecchymotic bruising on the face. separates into small vessels that reach the placenta by spreading across a fold of amnion.  If the infant is so oversized that he or she cannot be delivered vaginally. or if when the head appears on the perineum (crowning) it retracts instead of protruding with contraction ( A TURTLE SIGN )  Asking a woman to flex her thighs sharply on her abdomen (McRobert’s Maneuver) widens the pelvic outlet and may let the anterior shoulder deliver. contraction of the pelvic brim 4. 3 .  If the chin is anterior and the pelvic diameters are within normal limits. instead of entering the placenta directly. if there in arrest of descent.  Hazardous to the mother because it can result in vaginal and cervical tears. Because there is no firm presenting part.  The abnormal presentation can be confirmed by Leopold’s maneuvers.  If the chin is posterior. the membranes rupture at the beginning of labor. cesarean birth will be the choice of birth. Shoulder Dystocia The problem occurs at the second stage of labor when the head is born but the shoulders are too broad to enter and be delivered through the pelvic outlet. diaphragmatic nerve injury. 4.  Causes are the same as those of face presentation. cesarean birth becomes the birth method of choice. Velamentous Insertion of the Cord – is a situation in which the cord. women with hydramnios 6. It results in obstructed labor. Placenta Succenturiata – has one or more accessory lobes connected to the main placenta by blood vessels. multiple gestation 9. and in post-date pregnancies. possibly resulting in fractured clavicle or a brachial plexus palsy. ANOMALIES OF THE PLACENTA 1.  Most apt to occur in women with diabetes. cesarean birth will be necessary to deliver the infant safely. and large vessels spread out from there.

at least a pudendal block .  The primary reasons for including labor are the presence of preeclampsia. and premature separation of the placenta.  Be aware that oxytoxin should be administered intravenously so that its effect can be quickly discontinued to prevent hyperstimulation. such as headache and vomiting.  Assess for signs of water intoxication. prolonged rupture of membranes.  Some anesthesia. eclampsia.  Monitor fetal heart rate and uterine contraction by electronic monitoring.  Labor induction is a procedure that should be used cautiously with multiple gestation. the following conditions must be present: *The fetus is in a longitudinal lie and at a point of extrauterine viability. 7. this is a midforceps birth (although rarely seen today). Placenta Accreta – is an unusually deep attachment of the placenta to the uterine myometrium. or if the fetus is in an abnormal fetal position. Rh sensitization. no CPD  Fetal head is deeply engaged  Cervix is completely dilated and effaced  Membranes have ruptured  Vertical presentation has been established  The rectum and bladder are empty  Anesthesia is given Nursing Implications 4 .  Labor induction or augmentation may be accomplished by the administration of oxytocin or by amniotomy.  Before induction of labor is begun. they are basically normal uterine contractions. 6.  A fetus in distress from a complication such as prolapsed cord can be delivered more quickly by the use of forceps.  Forceps are designed to prevent pressure from being exerted on the fetal head and also may be used to reduce pressure and avoid subdural hemorrhage in the fetus as the fetal head reaches the perineum. severe hypertension or diabetes. Vasa Previa – the situation in which the umbilical vessels of the velamentious cord insertion cross the cervical os so they would deliver before the fetus. The vessels may tear with cervical dilatation the same as vasa previa may tear. a decrease in the fetal blood supply from cotyledon filling.  Piggyback the oxytocin solution with a maintenance intravenous solution so that if the oxytocin needs to be shut off abruptly. Types:  Low forceps birth – fetal head is at +2 station or more  Mid forceps birth . is necessary for forceps application to achieve pelvic relaxation and reduce pain. *There is no cephalopelvic disproportion (CPD). and presence of uterine scars because it carries a risk of uterine rupture. Nursing Implications:  Assist with obtaining ultrasonography or a lecithin-sphingomyelin ratio to assess fetal maturity. *The presenting part is engaged. *The cervix is ripe or ready for birth.  Assess and document maternal vital signs every 15 minutes.  Assure the client that once contractions start by these methods. hydramnios. such as after regional anesthesia.< +2 station Prerequisites:  Pelvis should be adequate. the shafts are brought together in the midline to form the handle.  Forceps are applied first by on blade being slipped into a woman’s vagina next to the fetal head and then the other side being slipped into place. and postmaturity.  Know that the half-life of oxytoxin is about 3 minutes so that with intravenous administration the functioning level ends this quickly. augmentation refers to assisting a labor that has started spontaneously to be more affective. Forceps Delivery Description  A forceps delivery refers to a method of delivery involving steel instruments constructed of two blades that slide together at their shaft to form a handle. since oxytocin has an antidiuretic effect. intraurine growth retardation. maternal age older than 35 years. the intravenous line will not be lost. grand parity. if progress ceases in the second stage of labor. Induction and Augmentation of Labor Description  Induction of labor means that labor is artificially started.  Forceps may be necessary to deliver the baby if a woman is unable to push with contractions in the pelvic division of labor. or situations in which it seems risky for the fetus to remain in utero.  A low forceps birth may be used to indicate the fetal head is at a +2 station.  Augmentation of labor or assistance to make uterine contractions stronger may be necessary when uterine contractions are too weak or infrequent to be effective. if the fetal head is still at the level of the ischial spines (0 station).

which must be present before forceps are applied. the blood loss is increased because large blood vessels of the myometrium are involved.  Record the time and amount of the client’s first voiding to rule out bladder injury. because a danger of forceps use is that the cord could be compressed between the blade and the head.  It may be planned (elective) or arise from an unanticipated problem (emergency).  Assist the client to empty her bladder before using forceps. there is also a greater possibility of rupture of the scar in subsequent pregnancies because the uterine musculature is weakened. the incision is easy to repair with less chance of rupture of the uterine scar during future deliveries.  Assess the client’s cervix after a forceps birth to be certain that no laceration has occurred.  Prepare the client physically and emotionally for forceps application. and the uterine incision is horizontal in the lower uterine segment. it is done when the fetus is in transverse lie and when adhesions from previous cesarean deliveries are present and with an anteriorly implanted placenta.  Monitor the fetal heart rate before applying forceps and immediately after applying them. possible complications of a forceps birth.  In a low segment cesarean delivery. blood loss is minimal with fewer postdelivery complications.  Be aware that no caphalopelvic disproportion can be present before forceps are applied.  Assess the client for complete cervical dilation before using forceps. typically. CESAREAN BIRTH Description:  Cesarean birth refers to a surgical procedure in which the neonate is delivered through an incision made in the maternal abdomen. the skin incision is made low (“bikini” or Pfanenstiel incision). Clinical Indications: Maternal Factors  Cephalopelvic Disproportion  Active genital Herpes or HPV  Previous CS by classic incision Placental Factors  Placenta Previa  Abruptio Placenta Fetal Factors  Transverse fetal lie  Extreme low birth weight  Fetal distress 5 . a vertical midline incision is made in the skin and the body of the uterus. allow the client and partner to verbalize feelings and concerns.  Inform the client and partner that the neonate may have a transient erythematous mark on the cheek. and thus indicated in emergency situations. assure them that this will fade in 1 to 2 days.  Assess the neonate for facial palsy or subdural hematoma.  Anticipate an episiotomy to prevent perineal tearing owing to pressure on the perineum.  Provide emotional support and guidance throughout the procedure to alleviate anxieties and fears. allowing easier access to the fetus.  Assess the client’s membranes for rupture. it is not useful in emergencies.  In a classic cesarean delivery. the most common type. the procedure takes longer to perform then the classic incision and therefore.  It was previously termed C-section.