PROBLEMS WITH PASSENGER

A successful labor depends on four integrated concepts, often referred to as the

four P’s, which are: passage, powers, psyche, and passenger. The passage refers to
the route a fetus must travel from the uterus to the cervix and vagina to the external
perineum. The power or the powers of labor is the force supplied by the fundus of the
uterus and implemented by uterine contractions, which causes cervical dilatation and
then expulsion of fetus from the uterus. Psyche or the woman’s psychological outlook,
refers to the psychological state or feelings a woman brings into labor. And lastly,
passenger refers to the fetus. Problems due to passenger are usually due to
inappropriate size of the fetus and in a disadvantageous position and presentation.

The body part of the fetus that has the widest diameter is the head, so this is the
part least likely to be able to pass through the pelvic ring. Whether a fetal skull can pass
depends on both its structure (bones, fontanelles, and suture lines) and its alignment
with the pelvis. Some of the most common encountered problems with regards to
passenger is cephalopelvic disproportion (CPD) and shoulder dystocia.

 Cephalopelvic Disproportion (CPD)

Cephalopelvic disproportion (CPD) is a pregnancy complication in which there is a size

mismatch between the mother’s pelvis and the fetus’ head. The baby’s head is
proportionally too large or the mother’s pelvis is too small to easily allow the baby to fit
through the pelvic opening. This can make vaginal delivery dangerous or impossible.

Risk factors and causes of cephalopelvic disproportion:

 Infertility treatment (a measurement of the mother’s

 Maternal obesity pelvis) (4)
 Previous cesarean delivery  The mother has a history of
 Polyhydramnios (1) childhood calcium deficiency or
 Gestational diabetes rickets (5)
 Postmaturity or gestational age  A variety of problems with the
over 41 weeks pelvis or birth canal
 Multiparity (mother has previously  Contracted pelvis
been pregnant) (2)  Large sized baby
 Age 35 or over (advanced
maternal age)
 Short stature (3)
 Transverse diagonal
measurement < 9.5 cm

Signs and symptoms of cephalopelvic disproportion (CPD):

The presence of certain conditions during labor and delivery indicate that there may
be a case of cephalopelvic disproportion. If the fetus maintains a high station, even after
a significant amount of contractions, this indicates that fetal descent through the birth
canal may be difficult. Although it is not the only potential explanation, CPD should be
evaluated as a possible cause of failure to descend. Prolonged and arrested labor can
result in oxygen deprivation, so medical professionals should also watch for signs of
fetal distress.

Treatment for cephalopelvic disproportion (CPD):

Treatment for CPD varies based on severity and when it is diagnosed. If it is
severe and diagnosed early, a planned C-section is indicated. In other cases, CPD may
be treated with a symphysiotomy (the surgical division of pubic cartilage) or an
emergency C-section after a trial of labor. When CPD is present, continued attempts to
deliver the baby vaginally can cause undue trauma and permanent injury to the baby.

 Shoulder Dystocia

Shoulder dystocia occurs when one shoulder of the fetus lodges against the
woman’s pubic bone, and the baby is therefore caught in the birth canal.

The fetus is positioned normally (head first) for delivery, but the fetus’s shoulder
becomes lodged against the woman’s pubic bone as the fetus’s head comes out.
Consequently, the head is pulled back tightly against the vaginal opening. The baby
cannot breathe because the chest and umbilical cord are compressed by the birth
canal. As a result, oxygen levels in the baby’s blood decrease.

Shoulder dystocia is not common, but it is more common when any of the following is
present:

 A large fetus is present.

 Labor is difficult, long, or rapid.
 A vacuum extractor or forceps is used because the fetus’s head has not fully
moved down (descended) in the pelvis.
 Women are obese.
 Women have diabetes.
 Women have had a previous baby with shoulder dystocia.

Complications of shoulder dystocia:

Shoulder dystocia can increase risks for both you and baby. Most mothers and
babies with shoulder dystocia don’t experience any significant or long-term
complications. However, it’s possible that complications, while rare, can occur. These
include:
 excessive bleeding in the mother
 injuries to a baby’s shoulders, arms, or hands
 loss of oxygen to the baby’s brain, which can cause brain damage
 tearing of a mother’s tissues, such as the cervix, rectum, uterus, or vagina

Your doctor can treat and minimize most of these complications to ensure they won’t
be long-term concerns. Less than 10 percent of babies with injuries after shoulder
dystocia have permanent complications.

Treatment of shoulder dystocia:

Doctors use a mnemonic “HELPERR” as a guide for treating shoulder dystocia:

 “H” stands for help. Your doctor should ask for extra help, such as assistance
from nurses or other doctors.
 “E” stands for evaluate for episiotomy. An episiotomy is an incision or cut in the
perineum between your anus and the opening of your vagina. This doesn’t
usually solve the entire concern for shoulder dystocia because you baby still has
to fit through your pelvis.
 “L” stands for legs. Your doctor may ask you to pull your legs toward your
stomach. This is also known as the McRoberts maneuver. It helps to flatten and
rotate your pelvis, which may help your baby pass through more easily.
  “P” stands for suprapubic pressure. Your doctor will place pressure on a certain
area of your pelvis to encourage your baby’s shoulder to rotate.
 “E” stands for enter maneuvers. This means helping to rotate your baby’s
shoulders to where they can pass through more easily. Another term for this is
internal rotation.
 “R” stands for remove the posterior arm from the birth canal. If your doctor can
free one of the baby’s arms from the birth canal, this makes it easier for your
baby’s shoulders to pass through the birth canal.
 “R” stands for roll the patient. This means asking you to get on your hands and
knees. This movement can help your baby to pass more easily through the birth
canal.

These don’t have to be performed in the order listed to be effective. Also, there are
other maneuvers a doctor can perform for either mom or baby to help the baby deliver.
The techniques will likely depend on you and your baby’s position and your doctor’s
experience. Sometimes when these techniques are tried, the nerves to the baby’s arm
are damaged or the baby’s arm bone or collarbone may be broken. An episiotomy (an
incision that widens the opening of the vagina) may be done to help with delivery. If
these techniques are unsuccessful, the baby may be pushed back into the vagina and
delivered by cesarean. If all of these techniques are unsuccessful, the baby may die.

Other factors that play a part in whether a fetus is properly aligned in the pelvis
and in the best position to be born are fetal attitude, fetal lie, fetal presentation, and fetal
position.

 Fetal Attitude

Attitude describes the degree of flexion of a fetus assumes during labor or the
relation of the fetal parts to each other. A fetus in good attitude is in complete flexion:
the spinal column is bowed forward, the head is flexed forward so much that the chin
touches the sternum, the arms are flexed and folded on the chest, the thighs are flexed
and folded on the chest, the thighs are flexed onto the abdomen, and the calves are
pressed against the posterior aspect of the thighs. This usual “fetal position” is
advantageous for birth because it helps the fetus present the smallest anteroposterior
diameter of the skull to the pelvis and also because it puts the whole body in an ovoid
shape, occupying the smallest space possible.

 Fetal Lie

Lie is the relationship between the long (cephalocaudal) axis of the fetal body and
the long (cephalocaudal) axis of a woman’s body, in other words, whether the fetus is
lying in a horizontal (transverse) or a vertical (longitudinal) position. Approximately 99%
of foetuses assume a longitudinal lie (with their long axis parallel to the long axis of the
woman) (Coad & Dunstall, 2011). Longitudinal lies are further classified as cephalic,
which means the fetal head will be the first part to contact the cervix, or breech with a
foot or the buttocks as the first portion to contact the cervix.

 Fetal Presentation

Fetal presentation denoted the body part that will first contact the cervix or be born first
and is determined by the combination of fetal lie and the degree of fetal flexion
(attitude). The most common and safest combination consists of the following:

 Head first (called vertex or cephalic presentation)

 Facing rearward
 Face and body angled toward the right or left
  Neck bent forward
 Chin tucked in
 Arms folded across the chest

If the fetus is in a different position or presentation, labor may be more difficult, and
delivery through the vagina may not be possible. These are fetal presentations that
cause problems during labor and delicery:

 Occiput or cephalic posterior position: Sometimes the baby is positioned

head down as it should be, but other times it is facing the mother's abdomen.
With the head in this position, the baby is looking at the ceiling. You may hear
this position nicknamed sunny-side-up. This increases the chance of a painful
and prolonged delivery.
 Frank breech: In a frank breech, the baby's buttocks lead the way into the birth
canal. The hips are flexed, the knees extended (in front of the abdomen). This
position increases the chance of forming an umbilical cord loop that could
precede the head through the cervix and cause the baby to be injured during a
vaginal delivery.
 Complete breech: In this position, the baby is positioned with the buttocks first
and both the hips and the knees are flexed (folded under themselves). Like other
breech presentations, this position increases the risk of forming an umbilical cord
loop that could precede the head through the cervix and injure the baby if
delivered vaginally.
 Transverse lie: The baby lies crosswise in the uterus, making it likely that the
shoulder will enter the pelvis first. Most babies in this position are delivered by
cesarean (C-section). Sometimes called as shoulder presentation, since in
transverse lie, the presenting part is usally one of the shoulders, an iliac crest, a
hand, or an elbow.
 Footling breech: Sometimes, one or both of the baby's feet are pointed down
toward the birth canal. This increases the chances of the umbilical cord slithering
down into the mouth of the womb, cutting off blood supply to the baby.

 Fetal Position

Fetal position is the relationship of the presenting part to a specific quadrant and
side of a woman’s pelvis. For convenience, the maternal pelvis is divided into four
quadrants according to the mother’s right and left: (a) right anterior, (b) left anterior, (c)
right posterior, and (d) left posterior. Four parts of a fetus are typically chosen as
landmarks to describe the relationship of the presenting part to one of the pelvic
quadrants.

 In a vertex position, the occiout (O) is the chosen point.

 In a face presentation, it is the chin (mentum [M]).
 In breech presentation, it is the sacrum (Sc)
 In a shoulder presentation, it is the scapula or the acromion process (A)

Position is indicated by an abbreviation of three letters. The middle letter denotes the
fetal landmark ( O for occiput, M for mentum, Sc for sacrum, and A for acromion
process). The first letter defines whether the landmark is pointing to the mother’s right
(R) or left (L). The last letter defines whether the landmark points anteriorly (A),
posteriorly (P), or transversely (T).

Left occipitoanterior (LOA) position is the most common fetal position, and right
occipitoanterior (ROA) is the second most frequent. Position is important because it can
influence both the process and efficiency of labor. Typically, a fetus is born fastes from
a ROA or LOA position. Labor can be considerably extended if the position is posterior
(ROP or LOP) and may be more painful because the rotation of the head puts pressure
on sacral nerves. Encouraging a woman to rest in a Sims position on the same side as
the fetal spine or use a hands and knees position may encourage rotation from an
occipitoposterior to an occipitoanterior position prior to and during labor (Simkin, 2010).

REFERENCES:

Pillitteri, A. (2014). Maternal and Child Health Nursing Care of the Childbearing & Childbearing
Family Seventh Edition Volume 1 (pp. 351-357)

https://www.healthline.com/health/pregnancy/delivery-shoulder-dystocia#risk-factors

https://www.glowm.com/section_view/heading/abnormal-labor-diagnosis-and-
management/item/132

https://my.clevelandclinic.org/health/articles/9677-fetal-positions-for-birth

https://www.msdmanuals.com/home/women-s-health-issues/complications-of-labor-and-
delivery/abnormal-position-and-presentation-of-the-fetus