Assignment on ncm 109 a

Submitted by:
Vivienne marie louise g. opina
Bsn – 2d

Submitted to:
Mrs. Teresita d. ong, rn, mn
ABO Incompatibility
ABO incompatibility is a complication which can occur during pregnancy.
Essentially, it is an immune response which occurs when babies have a different blood
type to their mother and are then affected by the antibodies she has produced. This is
never under a mother's control; blood groups are just part of an individual's makeup.
Babies with an ABO incompatibility needs to be monitored closely, though with effective
treatment they respond very well and experience no long-term health effects.
In ABO hemolytic disease of the newborn (also known as ABO HDN) maternal IgG
antibodies with specificity for the ABO blood group system pass through the placenta to
the fetal circulation where they can cause hemolysis of fetal red blood cells which can
lead to fetal anemia and HDN. In contrast to Rh disease, about half of the cases of ABO
HDN occur in a firstborn baby and ABO HDN does not become more severe after
further pregnancies.
In most instances of ABO Incompatibility, the maternal blood type O and the fetal
blood is either A or B type blood. This causes jaundice to a newborn.
Causes
 Environmental exposure
Anti-A and anti-B antibodies are usually IgM and do not pass through the placenta, but
some mothers "naturally" have IgG anti-A or IgG anti-B antibodies, which can pass
through the placenta. Exposure to A-antigens and B-antigens, which are both
widespread in nature, usually leads to the production of IgM anti-A and IgM anti-B
antibodies but occasionally IgG antibodies are produced.
 Fetal-maternal transfusion
Some mothers may be sensitized by fetal-maternal transfusion of ABO incompatible red
blood and produce immune IgG antibodies against the antigen they do not have and
their baby does. For example, when a mother of genotype OO (blood group O) carries a
fetus of genotype AO (blood group A) she may produce IgG anti-A antibodies. The
father will either have blood group A, with genotype AA or AO or, more rarely, have
blood group AB, with genotype AB.
 Blood transfusion
It would be very rare for ABO sensitization to be due to therapeutic blood transfusion as
a great deal of effort and checking is done to ensure that blood is ABO compatible
between the recipient and the donor.
Diagnosis
 Coombs - after birth baby will have a direct coombs test run to confirm
antibodies attached to the infant's red blood cells. This test is run from cord
blood. In some cases, the direct coombs will be negative but severe, even fatal
HDN can occur. An indirect coombs needs to be run in cases of anti-C, anti-c and
anti-M. Anti-M also recommends antigen testing to rule out the presence of
HDN.
  Hgb - the infant's hemoglobin should be tested from cord blood.
 Reticulocyte count - Reticulocytes are elevated when the infant is producing
more blood to combat anemia. A rise in the retic count can mean that an infant
may not need additional transfusions. Low retic is observed in infants treated with
IUT and in those with HDN from anti-Kell
 Neutrophils - as Neutropenia is one of the complications of HDN, the neutrophil
count should be checked.
 Thrombocytes - as thrombocytopenia is one of the complications of HDN, the
thrombocyte count should be checked.
 Bilirubin should be tested from cord blood.
 Ferritin - because most infants affected by HDN have iron overload, a ferritin
must be run before giving the infant any additional iron.
 Newborn Screening Tests - Transfusion with donor blood during pregnancy or
shortly after birth can affect the results of the Newborn Screening Tests. It is
recommended to wait and retest 10–12 months after last transfusion. In some
cases, DNA testing from saliva can be used to rule out certain conditions.
Treatment
 Phototherapy - Phototherapy is used for cord bilirubin of 3 or higher. Some
doctors use it at lower levels while awaiting lab results.
 IVIG - Intravenous Immunoglobulin therapy (IVIG) has been used to successfully
treat many cases of HDN. It has been used not only on anti-D, but on anti-E as
well. IVIG can be used to reduce the need for exchange transfusion and to
shorten the length of phototherapy. The AAP recommends "In isoimmune
hemolytic disease, administration of intravenous γ-globulin (0.5-1 g/kg over 2
hours) is recommended if the TSB is rising despite intensive phototherapy or the
TSB level is within 2 to 3 mg/dL (34-51 μmol/L) of the exchange level. If
necessary, this dose can be repeated in 12 hours (evidence quality B: benefits
exceed harms). Intravenous γ-globulin has been shown to reduce the need for
exchange transfusions in Rh and ABO hemolytic disease.
 Exchange transfusion - Exchange transfusion is used when bilirubin reaches either
the high or medium risk lines on the normogram. Cord bilirubin >4 is also
indicative of the need for exchange transfusion.

Fetal Malpresentation
Fetal malpresentation refers to fetal presenting part other than vertex and includes
breech, transverse, face, brow, and sinciput. Malpresentations may be identified late in
pregnancy or may not be discovered until the initial assessment during labor.
Related Factors
 The woman has had more than one pregnancy
 There is more than one fetus in the uterus
  The uterus has too much or too little amniotic fluid
 The uterus is not normal in shape or has abnormal growths, such as fibroids
placenta previa
 The baby is preterm

Types of Malpresentation
1. BREECH
 Complete (Flexed) Breech Presentation
 Footling Breech Presentation
 Frank (Extended) Breech Presentation
 Kneeling Breech Presentation
2. VERTEX
 Brow Presentation
 Face Presentation
 Sincipital Presentation
3. TRANSVERSE

Breech
Breech presentation means that either the buttocks or the feet are the first body parts
that will contact the cervix. Breech presentations occurs in approximately 3% of the
births and are affected by fetal attitude. Breech presentations can be difficult births, with
the presenting point influencing the degree of difficulty.
 Frank Breech
- The baby's bottom comes first, and the legs are flexed at the hip and
extended at the knees (with feet near the ears). 65-70% of breech babies are
in the frank breech position.
 Complete Breech
- The baby's hips and knees are flexed so that the baby is sitting cross-legged,
with feet beside the bottom.
 Footling Breech
- One or both feet come first, with the bottom at a higher position. This is rare
at term but relatively common with premature fetuses.
 Kneeling Breech
- The baby is in a kneeling position, with one or both legs extended at the hips
and flexed at the knees. This is extremely rare.
Maternal Risks
 Prolonged labor r/t decreased pressure exerted by the breech on the cervix.
 PROM may expose client to infection.
 Cesarean or forceps delivery.
 Trauma to birth canal during delivery from manipulation and forceps to free the
fetal head.
 Intrapartum or postpartum hemorrhage
Fetal Risks
 Compression or prolapse of umbilical cord.
 Entrapment of fetal head in incompletely dilated cervix.
 Aspiration and asphyxia at birth.
 Birth trauma from manipulation.
Management
 If the woman is in early labor and the membranes are intact, attempt External
Cephalic Version.
 Tocolytics, such as Terbutaline 0.25mg IM, can be used before ECV to help relax
the uterus.
 If ECV is successful, proceed with normal childbirth. If EVC fails or is not advisable,
deliver by caesarean section.
Attempt external version (manually rotating the baby) if:
 Breech presentation is present at or after 37 weeks (before 37 weeks, a successful
version is more likely spontaneously revert back to breech presentation)
- Vaginal delivery is possible
- Membranes are intact and amniotic fluid is adequate;
- There are no complications (e.g. fetal growth restriction, uterine bleeding,
previous caesarean delivery, fetal abnormalities, twin pregnancy, HPN, fetal
death).
 Vaginal Breech Delivery
A vaginal breech delivery by a skilled health care provider is safe and feasible
under the following conditions:
- complete or frank breech
- adequate clinical pelvimetry
 - fetus is not too large
- no previous caesarean section for cephalopelvic disproportion
- flexed head.
 Cesarean Delivery for breech presentation.
A cesarean section is safer than vaginal breech delivery and recommended in
cases of:
- Double footling breech
- Small or malformed pelvis
- Very large fetus
- Previous cesarean section for cephalopelvic disproportion
- Hyperextended or deflexed head.

Vertex
In the last weeks of pregnancy, a fetus usually moves so his or her head is positioned to
come out of the vagina first during birth. This is called a vertex presentation.
 Brow Presentation
- The brow presentation is caused by partial extension of the fetal head so that
the occiput is higher than the sinciput.
 Sinciput
- The sinciput presentation occurs when the larger diameter of the fetal head is
presented. Labor progress is slowed with slower descent of the fetal head.
 Face
- The face presentation is caused by hyper-extension of the fetal head so that
neither the occiput nor the sinciput is palpable on vaginal examination.
- In the chin-anterior position prolonged labor is common. Descent and
delivery of the head by flexion may occur.
- In the chin-posterior position, however, the fully extended head is blocked
by the sacrum. This prevents descent and labor is arrested.
Management
 Chin-Anterior Position
If the cervix is fully dilated:
- Allow to proceed with normal childbirth;
- If there is slow progress and no sign of obstruction, augment labor with
oxytocin;
- If descent is unsatisfactory, deliver by forceps.
- If the cervix is not fully dilated and there are no signs of obstruction:
- augment labor with oxytocin
 Chin-Posterior Position
If the cervix is fully dilated:
- Deliver by caesarean section.
If the cervix is not fully dilated:
- Monitor descent, rotation and progress. If there are signs of obstruction,
deliver by caesarean section.
- Do not perform vacuum extraction for face presentation.
 For brow presentation, If the fetus is alive or dead, deliver by caesarean section.
Do not deliver brow presentation by vacuum extraction, outlet forceps or
symphysiotomy.

Nursing Management
 Observe closely for abnormal labor patterns.
 Monitor fetal heart beat and contractions continuously.
 Anticipate forceps-assisted birth.
 Anticipate cesarean birth for incomplete breech or shoulder presentation.
 Be prepared for childbirth emergencies such as cesarean section, forceps-assisted
delivery, and neonatal-resuscitation.
 Position pt. in Trendelenburg or knee-chest position.
 Manually raise the presenting part aseptically.

Fetal Malposition
Refers to positions other than an occipitoanterior position. Malpositions include
occipitoposterior and occipitotransverse positions of fetal head in relation to maternal
pelvis. It is usually seen in multipara or those with lax abdominal wall. Fetal malpositions
are assessed during labor.
 Occipitoposterior
- It is the vertex position where the occiput is placed posteriorly over the
sacro-ilical joint or directly over the sacrum
- Occipito-posterior position is an abnormal position of the vertex rather
than an abnormal presentation.
 - Occurs in approximately 10% of labours.
- A persistent occipito-posterior
position results from a failure of
internal rotation prior to birth.
- Occurs in 5% of the births.
- ROP is five times more common
than LOP
 Ocipitotransverse
- It is the incomplete rotation of
OP to OA results in the fetal
head being in a horizontal or
transverse position (OT).
- May be end result of incomplete
anterior rotation of the oblique
OPP, or it may be due to non-
rotation of the commonly primary occipitotransverse position of normal
mechanism of labor
Maternal symptoms
 Intense back pain in labor
 Dysfunctional labor pattern
 prolonged active phase
 secondary arrest of dilatation
 arrest of descent
Maternal risks
 prolonged labor
 potential for operative delivery
 extension of episiotomy
 3rd or 4th degree laceration of the perineum.
Diagnosis
 Abdominal examination – the lower part of the abdomen is flattened; fetal limbs
are palpable anteriorly and the fetal flank.
 Vaginal examination – the posterior fontanelle is toward the sacrum and the
anterior fontanelle may be easily felt if the head is deflexed
 Ultrasound
Nursing Management
 Encourage the mother to lie on her side from the fetal back, which may help with
rotation.
 Pelvic – rocking may Knee – chest position help with rotation. may facilitate
rotation.
 Apply sacral counter – pressure with heel of hand to relieve back pain.
 Continue support and encouragement:
 Keep client and family informed progress.
 Praise client’s efforts to maintain control.
References

ABO incompatibility. (n.d.). Retrieved from

https://www.huggies.com.au/pregnancy/complications/abo-incompatibility

Hemolytic disease of the newborn (ABO). (2020, January 17). Retrieved February 20,
2020, from
https://en.wikipedia.org/wiki/Hemolytic_disease_of_the_newborn_(ABO)

Silbert-Flagg, J. A., & Pillitteri, A. (2018). Maternal and Child Health Nursing: Care of the
Childbearing &
Childbearing Family (8th ed., Vol. 1). Philadelphia: Wolters Kluwer.

Areola, J. J. O., Boglosa, U. E., & Sedillo, J. D. (2013). FETAL MALPRESENTATION and
MALPOSITION.
Retrieved from file:///C:/Users/Louise Opina/Desktop/malpresentation-
110220081149-
phpapp01.pdf