I.

SPECIFIC PROBLEMS OF THE PASSANGER

A. FETAL MALPOSITION
1. OCCIPITO POSTERIOR POSITION
• occiput posterior position
• One of the most common causes of prolonged labor. A malposition of the vertex presentation.
• The labor is prolonged because the fetus rotate a longer distance to reach the symphisis pubis with the mother
experiencing much back pain due to the pressure exerted by the fetal head as it moves against the sacrum
• During internal rotation the fetal head must rotate 135 degrees.
• Can be aided by having the woman assume
• Hands and knees position
• Squatting
• Lying on her side
a. Left side if the fetus in the right occiput posterior
b. Right side if the fetus is in left occiput posterior
• Lunging
• Swinging her body from right to left
• Occur in women with an android, anthropoid or contracted pelvis.
• Suggest a dysfunctional labor such as:
• Prolonged active phase
• Arrested descent
• Fetal heart sounds heard best at the lateral sides of the abdomen.
• Posterior presenting head does not fit the cervix
• Increases the risk of cord prolapsed
• Position of the fetus is confirmed by vaginal exam or by UTZ
• If with average size rotate through the large arc= labor isprolonged
• In good flexionarrive at a good birth position for the pelvic outlet
With forceful uterine contraction-Born satisfactorily with increased molding and caput formation
• Labor is prolonged because of the arc of rotation
• Experience pressure and pain in her left lower back == sacral nerve compression

Nursing care management

1. Applying counter pressure on the sacrum by a back rub may be helpful in relieving a portion of the pain
2. Applying heat or cold
3. Lying on her side opposite the fetal back
4. Maintain a hand and knees position may help rotate the fetus
5. Voids every 2 hrs = bec a full bladder could impede descent of the fetus
6. Be aware of how long the woman last ate
• During labor, she may need an oral sports drink or IV glucose to replace glucose stores used for energy.
7. Advise mother to change position frequently to relieve pain
8. Back rub
9. Apply sacral pressure during contractions
• If contraction is ineffective of the fetus is larges than the average or not in good flexion
• Rotation through the 135 degrees may not be possible.
• Uterine dysfunction may result from maternal exhaustion
• Fetal head may arrest in transverse position (transverse arrest) or rotation may not occur (
persistent occipitoposterior position)
• Fetus must be born via CS.

2. OVERSIZED FETUS (MACROSOMIA)

Wt >4000-4500g (9-10 lbs) –born with diabetic mother
• Associated with multiparity ---- slightly heavier and larger than the one born just before
• May cause uterine dysfunction === leading to overstretching of the fiber of the myometrium
• Wide shoulders — cause fetal pelvic disproportion or uterine rupture from obstruction
• CS- birth method

B. FETAL MALPRESENTATION

1. VERTEX MALPRESENTATION
a. Brow presentation
• Rrarest/most uncommon of all presentations.
• Brow presentation is commonly unstable, it usually converts to face or vertex extreme facial edema, tell
parents that their babies unsightly appearance will disappear in a few days.
• Occur in multipara/women with relaxed abdominal muscles.
• Results in
• Obstructed labor because the head becomes jammed in the brim of the pelvis as the occipitomental
diameter presents.
b. Face presentation
• Occurs when the head is hyper extended and the chin( mentum) is the presenting part.
 • ASYNCLITISM – fetal head presenting at the different angle expected.
• Face and brow= common
• Chin= rare
• The back is difficult to outline === concave
• If the fetal back is extremely concave === FHT be herd on the side of the fetus where the feet and arms
be palpated.
• Confirmed in vaginal exam
• A fetus in a posterior position instead of flexing the head as labor proceeds may extend the head resulting
in CHIN presentation usually with contracted pelvis/placenta previa.
• Also occur in a relaxed uterus of multipara, hydramnios, fetal malformation.
• If chin is anterior and the pelvic diameter are within the normal limit, the infant may be delivered without
difficulty but with long stage of labor because the face does not mold well to make a snugly engaging
part.
• If the chin posterior – CS maybe the choice of birth
• Results of chin /face presentation:
• Facial edema
• Ecchymosis
• Lip edema
c. Transverse Lie
• Occurs in women with:
• pendulous abdomen
• uterine masses such as fibroid the obstruct the lower segment
• contraction of the pelvic brim
• congenital abnormalities of the uterus
• hydramnios
• May occur with infant who hydrocephalus/gross abnormalities that prevents the head from engaging.
• May occur in prematurity == when the infant has room for free movement, multiple gestation (particularly
the 2 twin), short umbilical cord
nd

• Can be detected by LM and confirm by UTZ

• A mature fetus can’t be delivered vaginally from this presentation
• Rupture membranes beginning labor because there is no firm presenting part
• The cord , arm may prolapsed
• Shoulders may obstruct the cervix
• CS

2. BREECH PRESENTATION
• Common in early pregnancy
• 38 weeks , the fetus normally turns to a cephalic presentation:

Causes
1. Gestational age less than 40 weeks
2. Abnormally in a fetus such as:
• Anencephaly
• Hydrocephalus
• Meningocele
3. Hydramnios = allows free fetal movt, allowing the fetus to fit within the uterus in any position
4. Congenital anomaly of the uterus such as midseptum that trap the fetus in a breech position
5. Any space occupying mass in the pelvis that does not allow the fetal head to present like:
• Fibroid tumor of the uterus
• Placenta previa
• Pendulous abdomen == abdominal muscle are lax allowing the uterus to fall forward that the fetal head
comes to lie outside the pelvic brim
• Multiple gestation = the presenting part cannot turn to a vertex position
• Unknown factors

Assessment
1. FHT are heard high in the abdomen
2. Leopold’s and vaginal exam may reveal the presentation
• Breech is complete == gluteal muscles of the fetus may be mistaken as the head during vaginal exam
• The cleft between the buttocks may be mistaken as the sagittal suture line
• If presentation is unclear --- UTZ to confirm
• Always monitor FHR and uterine contractions = allows detection of fetal distress from a complication such
as prolapsed umbilical cord.

Types of breech presentation

1. Complete
2. Frank
3. Footling
• Hazardous to a fetus than a cephalic presentation because there is higher risk of:
• Anoxia from a prolapsed cord
• Traumatic injury to the after coming head (possibility of intracranial hemorrhage or anoxia)
 • Fracture of the spine or arm
• Dysfunctional labor
• Early rupture of the membranes because of the poor fit of the presenting part
• The inevitable contraction of the fetal buttocks from cervical pressure causes meconium to be extruded in the
amniotic fluid before birth == may lead to meconium aspiration if the infant inhales the amniotic fluid.

• BIRTH TECHNIQUE
• If the infant will be born vaginally when full dilatation = the woman is allowed to push and the breech, trunk
and shoulders are born.
• Breech spontaneously emerges= supported by the sterile towel held against the infant’s inferior surface.
• Birth of the head is the most hazardous part of a breech birth because the umbilicus precedes the head
leading to cord prolapsed.
• Intracranial hemorrhage == 2 danger nd

• With a cephalic presentation= molding to the confines of the birth canal occurs over hours.
• With a breech birth = pressure changes occur instantaneously.
• Tentorial tears which can cause gross motor and mental incapacity or lethal damage to the fetus may result.
• Infant who is delivered suddenly to reduce the amount of time = cord compressed = suffer an intracranial
hemorrhage.
• Infant who is delivered gradually to reduce the possibility of intracranial injury may suffer hypoxia.
• An infant who was delivered in a frank breech position may tend to keep his/her legs extended and at the
level of the face for the 1 2 or 3 day of life.
st nd rd

• Infant who was a footling breech may tend to keep the legs extended in a footling position for the 1 few days
st

3. PODALIC VERSION
• Turning of the fetus in the uterus from an unfavorable position. It is an alternative method to cesarean section

Types of Version
A. External Cephalic Version
• The purpose of this type of version is to convert an unfavorable position. (breech presentation,shoulder
presentation) to vertex by external manipulation of the fetus through the abdominal wall.
• Performed at 34 -35 wks gestation although the usualtime 37 to 38 weeks of pregnancy. Version is most likely to
be successful if the woman is not obese, there is enough amniotic fluid and the presenting part has not yet
descended into the pelvis.
• Gentle pressure is exerted to rotate the fetus in a forward direction to a cephalic lie.
• Can decrease the number of cesarean births
• Can be uncomfortable because of the feeling of pressure

Contraindications
1. Previous CS
2. Multiple Pregnancy
3. Hydrocephalus and other congenital malformations
4. Rh incompatibility
5. Hypertension of Pregnancy
6. Intrauterine fetal death
7. Severe Oligohydramnios
8. Contraindications to vaginal birth
9. Cord loop
10. Unexplained third trimester bleeding like placenta previa

Complications
1. Abruptio placenta
2. Uterine rupture
3. Isoimmunization
4. Fetal distress
5. Preterm Labor
6. Maternal and fetal death

Nursing care management

1. Explain purpose of procedure to the woman
a. Place the woman in supine position, apply talcum powder over the abdomen
2. A tocolytic drug may be administered to the woman to promote uterine relaxation
3. Take FHT before ,during and after the procedure
4. Leopold’s Maneuver or Ultarasound
5. Best to perform version in DR so that delivery of the fetus can be affected quickly if fetal distress or other grave
complication occur
6. After the procedure fetal presentation is assessed weekly of version is used

B. Internal Podalic Version

• This type of version is used to change any fetal presentation to breech
 • This is performed to during labor with the cervix dilated.
• The patient is placed under anesthesia and the obstetrician inserts her whole hand into the uterine cavity grasping
the feet of the fetus and moving them towards the direction of the birth canal. The external hand guides the fetal
head and body upwards. Because of the increased risk associated with internal version. It is seldom performed
nowadays.

4. SHOULDER PRESENTATION
• Occurs when the fetus assumes a transverse or oblique lie.
• Shoulder presentation is suspected when upon palpation.
• The fetal head occupies one side of the uterus and the buttocks, the other side. It can also be observed that the
shape of the uterus is more horizontal than vertical.
• Occurs in women with
• pendulous abdomen
• uterine masses such as fibroid the obstruct the lower segment
• contraction of the pelvic brim
• congenital abnormalities of the uterus
• hydramnios
• May occur with infant who hydrocephalus/gross abnormalities that prevents the head from engaging.
• May occur in prematurity == when the infant has room for free movement, multiple gestation (particularly the
2 twin), short umbilical cord
nd

• Can be detected by LM and confirm by UTZ

• A mature fetus can’t be delivered vaginally from this presentation
• Rupture membranes beginning labor because there is no firm presenting part
• The cord , arm may prolapsed
• Shoulders may obstruct the cervix
• CS

Causes
1. Lax uterine and abdominal muscles due to multiparity is most common cause
2. Contacted pelvis
3. Fibroids and congenital abnormality of the uterus
4. Preterm fetus, hydrocephalus
5. Placenta previa
6. Multiple pregnancy

Management
1. External version before labor begins can be performed to rotate fetus in a deliverable position
2. If version fails, the preferred method is CS. Sometimes vaginal delivery is possible if the pelvic canal is large.

5. FETAL DISTRESS
• Labor does not proceed normally
• Refers to signs before and during childbirth indicating that the fetus is not well.
• Occurs when the fetus has not been receiving enough oxygen.
• Fetal distress may occur when the pregnancy lasts too long (postmaturity) or when complications of pregnancy or
labor occur.

Assessment
1. Increased FHT
2. Fetal trashing
3. Meconium stained amniotic fluid
• Abnormality in the heart rate
• Giving the woman oxygen
• Increasing the amount of fluids given intravenously to the woman
• Turning the woman on her left side
• If these measures are not effective, the baby is delivered as quickly as possible by a vacuum extractor,
forceps, or cesarean delivery.

6. PROLAPSED UMBILICAL CORD

• Loop of the umbilical cord slips down in front of the presenting fetal part.
• Occurs anytime after the PROM
• Occurs if the fetal part is not fitted firmly to the cervix.
• Occur most often
• PROM
• Fetal presentation other than cephalic
• Placenta previa
• Intrauterine tumors preventing the presenting part from engaging
• A small fetus
• CPD
• Hydramnios
• Multiple gestation
 Assessment
1. Presence of cord on palpation on vaginal examination during labor or ultrasound
2. Cord is visible at the vulva
3. Assess FHT immediately after rupture

Nursing care management

1. Relieve pressure on the cord
2. Cord prolapsed leads to cord compression == because the presenting part presses against the cord at the pelvic brim.
3. A gloved hand on the vagina and manually elevating the fetal head off the cord.
4. Place the client in trendelenburg position/knee chest position === to cause the fetal head to fall back from the cord.
5. Administer Oxygen at 10L/min facial mask == to prevent hypoxia to the part of the fetus.
6. Tocolytic agent == to reduce uterine activity
7. Amnioinfusion == to relieve pressure on the cord
• Infuse iinitial amount of 500ml/IV (LR) inserted to the cervix to supplement the amount of amniotic fluid
• Side lying position == to prevent supine hypotension syndrome
• Solution should be warm
• Practice aseptic technique to prevent infection
• Continuously monitor FHT, Temp of the woman
• Change the linens frequently
• If vaginal leakage stops == fetal head is firmly engaged but it is dangerous === it may lead to hydramnios ===
uterine rupture
• forcep delivery == if the cervix is fully dilated and , to prevent hypoxia
• if the cervical dilatation is incomplete === apply an upward pressure on he presenting part to the vagina === to
keep pressure of the cord until CS is done.

7. MULTIPLE GESTATION
• CS==to decrease the risk of of the 2 baby to experience anoxia
nd

• After the 1 infant is born == both ends of the baby’s cord are tied or clamped permanently rather than with cord
st

clamps which could slip.

• Oxytocin is given after birth with a single pregnancy == to contract the uterus to minimize bleeding BUT if with
multiple ==== OXYTOCIN is not being given coz it can compromise the circulation of the infant not yet born.
• If the presentation of the 2 infant is not in vertex ==== EXTERNAL CEPHALIC VERSION is done.
nd

• If ECV is not effective ==== CS

• If infant will be born vaginally == Oxytocin infusion is given to shorten the time, assisting uterine contraction
• If relaxation is needed === give NITROGLYCERIN(uterine relaxant)
• Placenta of the 1 baby separates before the second fetus is born === expect a sudden profuse bleeding at
st

the vagina. ==== the uterus cannot contract coz it is full the 2 twin.
nd

• If there is separation of the 1 placenta is involved == the fetal heart sounds will register distress immediately.
st

• Multiple gestation may have difficulty contracting as usual placing them at risk of hemorrhage from uterine
atony and uterine infection.

II. PROBLEMS WITH THE PASSAGEWAY

1. ABNORMAL SIZE OR SHAPE OF THE PELVIS

• Narrowing of the passageway/birth canal
• Happen in the inlet, outlet and midpelvis
• Types of pelvis
• Gynecoid
• Anthropoid- oval inlet, ape
• Android – male pelvis, hear shaped
• Platypelloid- compressed front-back, oval
• The narrowing causes: CPD and failure to progress in labor.

2. CEPHALOPELVIC DISPROPORTION/ CPD

• Is suggested by lack of engagement at the beginning of labor, prolonged first stage and finally poor fetal descent.
• A disproportion between the size of the fetal head and the pelvic diameters. This result in failure to progress labor.
• INLET CONTRACTION- Narrowing of the anteroposterior diameter to less than 11 cmor of the transverse
diameter to 12 cmor less

Causes
• Rickets in early life
• Small pelvis
• OUTLET CONTRACTION- Narrowing of the transverse diameter at the outlet to less than 11 cm. This is the
distance between the ischial tuberosities, a measurement that is easy to make during a prenatal visit.
3. SHOULDER DYSTOCIA
• Occurs at the 2 stage of labor when the infant head is born but the shoulders are too btoad to enter and be
nd

delivered thru the pelvic outlet.

• Hazardous to the mother- can result in vaginal cervical tear
• Hazardous to the fetus == cord compression
• Occur with women with diabetetis, multipara, post dated pregnancies

Risk Factors
1. Brachial plexus injury
2. Brain injury- due to lacj of o2 r/t cord compression of umbilical cord
3. Chest compression leading to the uncoordinated breathing

Management
1. Mc Robert’s Manuever- mother is sharlply flexing her thighs on her abdomen
2. Suprapubic pressure