- labor includes occiput posterior and occiput

MATERNAL AND CHILD HEALTH transverse positions

NRS 2211-7
TOPIC: Nursing Care of the client during Labor and Fetal Malpresentation
Delivery - when the part of the fetus which is closest to the
LECTURER:l
pelvic inlet is not the vertex of the fetal head.
COLOR GUIDE
TOPIC : NURSING CARE OF THE CLIENT DURING Occipito-Posterior Position
LABOR AND DELIVERY
● Problems of the Passenger ● LOA (Left Occipito-Anterior) - most ideal and
● Problems with the Passageway common
● Problems with the Power ● LOP (Left Occipito-Posterior) - located on the
left and posterior quadrant pelvis
● ROP (Right Occipito-Posterior) - located at the
TOPIC OUTLINE
right and the posterior quadrant pelvis.
● Problems of the Passenger
- fetal head must rotate through an arc
o Fetal Malposition approximately 35 degrees.

o Fetal Malpresentation A posterior position is suggest by:

o Fetal distress - a dysfunctional labor pattern such as a

prolonged active phase, arrested descent, or
o Prolapsed umbilical cord fetal heart sounds heard best at the lateral sides
● Problems with the Passageway of the abdomen.

o Abnormal size or shape of the pelvis Signs and Symptoms

o Cephalopelvic Disproportion (CPD) ● Intense lower back pain (lumbosacral pain) - due
to compression of sacral nerves during rotation
o Shoulder dystocia ● shooting leg pains

● Problems with the Power Nursing Management

o Dystocia or difficult labor ● provide back rubs

● change of position (squatting position) - may
o Premature labor help fetus to rotate
o Precipitate labor and birth ● encourage voiding every 2 hours to keep
bladder empty
o Uterine prolapse ● apply hot/cold compress
● delivered via CS
o Uterine rupture

o Bandl’s Ring
I. Face presentation
● chin/mentum
TOPIC: NURSING CARE OF THE CLIENT DURING ● rare but when it does not occur, the head
LABOR AND DELIVERY diameter the fetus presents to the pelvis is often
A. Problems of the Passenger too large for birth to proceed.
● Fetal Malposition
Signs
● Fetal malpresentation
- head that feels more prominent than normal
● Fetal distress - head and back are both felt on the same side of
the uterus with Leopold’s maneuvers.
● Prolapsed umbilical cord - FHT heard on the side of the fetus where feet
Fetal Malposition and arms can be palpated
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- confirmed by vaginal examination when the Signs and Assessment

nose, mouth, or chin can be felt as the
presenting part. - Fetal tachycardia
- Fetal bradycardia
Management - Hyperactivity
- Acidosis
- ultrasound to confirm - Late deceleration
- observe infants closely for a patent airway.
Complication of Fetal Distress

II. Brow presentation
- rarest of the presentations
- occurs in a multipara or a woman with relaxed
abdominal muscles.
- leaves extreme ecchymotic bruising on the face
of infant Intervention
- parents might need additional assurance that
the child is well after birth.
III. Transverse Lie
- occurs in women w pendulous abdomens
- with contraction of the pelvic brim
- with congenital abnormalities of the uterus, or
with hydramnios. Prolapsed umbilical cord
- a mature fetus cannot be delivered vaginally
from this presentation
- the cord or arm may prolapse, or the shoulder
may obstruct the cervix.
- Mental Retardation
- Seizure
- Cerebral palsy
- Intrauterine Fetal Demise
- CS/ Forceps Delivery
- Position the patient in lateral position
- Discontinue oxytocin if using STAT
- Administer O2
- Monitor FHT and maternal status
- Prepare for CS, I.C.E
- U.C is displaced between the presenting part
and the amnion or protruding through the cervix,
causing compression of the cord and
compromising fetal circulation.

Fetal Distress High Risk Factors

- refers to the lack of fetal reserves of the - Shoulder and breech presentation
presence of fetal hypoxia, acidosis, or asphyxia - PROM
- when the fetal supply of the oxygen is not - Rupture of the BOW when the presenting part
enough to meet the fetus physiological needs had not yet engaged\
and demands = oxygen deprivation and hypoxia - Polyhydramnios
Causes Assessment
- Asphyxiating effect - Feeling of something coming through the vagina
- Hypovolemic effect - U.C. is visible/palpable
- Vasoconstricting - Irreg/Slow FHR
- Hypoxic effect - Bradycardia after the rupture of membranes.
- Hypertensive effect

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Intervention
- elevate the fetal presenting part that is lying on
the cord by applying finger pressure
- place the client into extreme trendelenburg or
modified Sim’s/Knee chest position.
- Monitor FHR and assess the fetus for hypoxia
- Do NOT reposition the cord back into the vagina
- Prep to start IV
- Prep for immediate birth
- Document
B. Problems with the Passageway
● Abnormal size or shape of the pelvis
● Cephalopelvic Disproportion (CPD)
● Shoulder dystocia
Shoulder Dystosia
● The problem occurs at the second stage of
labor, when the fetal head is born but the
shoulders are too broad to enter and be born
through the pelvic outlet. This occurs in women
with diabetes, nine multiparas, and in post-date
pregnancies.
Management
● Asking a woman to flex her thighs sharply on
her abdomen (McRoberts maneuver)
○ It may widen the pelvic outlet and
allow the anterior shoulder to be born.
● Apply suprapubic pressure
○ It may also help the shoulder escape
from beneath the symphysis pubis and
be born.
C. Problems with the Power
● Dystocia or difficult labor
● Premature labor
● Precipitate labor and birth
● Uterine prolapse
● Uterine rupture
● Bandl’s ring
Dystocia
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● Dystocia is a difficult labor that is prolonged or
more painful
● Occurs because of problems caused by uterine
contractions, the fetus, or the bones and tissues
of the maternal pelvis
● Contraction may be hypotonic or hypertonic
Causes
● Hypotonic contraction
○ short, irregular and weak, amniotomy
○ treatment measures: oxytocin infusion
● Hypertonic contractions
○ painful, occur frequently and are
uncoordinated
● Can result in maternal dehydration, infection,
fetal injury or death
Mechanical Factors Associated by Dystocia
● Power
○ Problem with the expulsive forces
● Passenger
○ Problem with the presentation, position
or development of the fetus
● Passageway
○ Problem with the maternal bony pelvis
● Problem with the dilatation of the cervix
Hypertonic Uterine Contraction
● intensity of the contractions may not stronger or
very active and frequent contractions but
ineffective
● occurs more frequently and commonly seen in
latent phase of labor
● muscle fibers of the uterus (myometrium) do not
repolarize
Assessment
● Excessive abdominal pain
● Abnormal contraction pattern
● Fetal distress
● Maternal or fetal tachycardia
● Lack of progress in labor
Management
● Assess FHR, and monitor for fetal distress
● Monitor uterine contraction
● Monitor maternal temperature and heart rate
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● Assist with pelvic examination, measurements, ● Change in character and Amount of usual
ultrasound and other procedure discharge
● Rupture of amniotic membranes
Contraindication ● Presence of fetal fibronectin in cervical canal
● Administer prophylactic antibiotics as prescribed
● Shortening of cervical length
○ to prevent infection
● Administer IV fluids as Rx Intervention
● Monitor intake and output ● Focus on stopping the labor
● Maintain hydration ● Identify and treat infection (if any)
● Instruct the client in breathing techniques and ● Restrict Activity
relaxation exercises ● Ensure hydration
● Monitor color of amniotic fluids ● Maintain bed rest and a lateral position
● Perform fetal monitoring if oxytocin is Rx for ● Monitor fetal status
hypotonic uterine contractions (not Rx to ● Administer fluids
hypertonic) ● Use of 17 alpha-hydroxyprogesterone injection
● Provide rest and comfort as with a normal to decrease risk of preterm delivery
delivery ● Administer medications:
○ back rubs and position changes ○ Tocolysis
● Assess client fatigue and pain medications as ■ Short term benefit for premature
Rx. labor
● Assess for prolapse of the cord after. ■ (+) for bleeding and 2-3 cm
● Membrane ruptures cervical dilation and FHT is
good
■ May stop premature contraction
Premature Labor ■ 15 weeks is the lowest
gestational age for tocolysis
● Usually happens after 20 weeks of gestation but administration
before 36-37 weeks of gestation ■ Contraindicated to intrauterine
● Premature contraction fetal demise, fetal anomaly,
● Effacement of 60- 80% maternal hemorrhage, severe
● Dilatation is 2-3 cm preeclampsia or eclampsia
○ Ritodrine HCL (Yutopar)
Risk Factors
■ Beta sympathomimetic drugs
● History of medical condition
that stimulates beta 2 receptors
● Past and present OB problems
in the smooth muscles
● Infection
■ Frequency and intensity
● Social and environmental factors
decreases as the muscle
● Substance abuse
relaxes
● Multifetal pregnancy
■ Dosing: D5W 500cc + 150mg to
● Age
be infuse at 10-20 ml/hr
Assessment (PALPCARPS) ■ Maternal side effects may
● Painful and painless uterine contractions include tachycardia, systolic rise
● Abdominal cramping (may be accompanied by and diastolic decrease, chest
diarrhea) pain
● Low back pain ■ Fetal side effects may include
● Pelvic pressure fetal tachycardia, hyperglycemia

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■Contraindicated to antepartal ○ Gravidity (high) and length of previous

hemorrhage and intrauterine labor (short)
fetal death ○ Strong and frequently contractions or
○ Terbutaline Sulfate (Bricanyl) tetanic contractions
■ Beta 2-adrenergic receptor ○ Rapid labor and delivery
agonist. Decreases intracellular ○ Severe maternal anxiety, intense
calcium behavior and bearing down
■ Maternal side effects include ● Signs and Symptoms of Impending Labor
tachycardia, palpitations, ○ Strong contractions
lowered BP, shortness of breath, ○ Ruptured membranes
tremors ○ Heavy bloody show
■ Contraindicated to pt with ○ Bulging rectum
cardiac disease ○ Strong desires to push
■ Dosing:
● Continuous IV infusion:
2.5 to 5 ugtts/min Complications
titration every 20-30 ● Maternal Complication
mins until to the ○ Soft tissue lacerations
maximum of 25 ugtts ○ Hemorrhage
until contraction is ○ Infection
abated ○ Uterine rupture if birth canal is not
● Subcutaneously: readily distensible
0.25mg every 20-30 ○ Hypotonic post-delivery hemorrhage
mins ● Fetal/Neonatal Complications
■ Antedote: Inderal or propanolol ○ Hypoxia, anoxia from rapid delivery
Precipitate Labor and Birth ○ Sepsis
○ Soft tissue injuries
Definition ○ Intracranial hemorrhage
● The extremely rapid labor and delivery occurring
less than 3 hrs after the onset of uterine activity. Intervention (Nursing Management)
It may happen in a hospital setting or outside of ● Never leave the client, offer vigilant attendance
a health facility. ● Provide continuous assessment and
reassessment (uterine contraction, FHT q15,
Risk Factors signs of fetal hypoxia, bulging perineum, rupture
● Multiparity – the most common important factor of BOW)
● Large pelvis and pelvic relaxation ● Provide emotional support
● Lax vaginal soft tissues ● Encourage the client to pant bet contraction
● Small fetus, prematurity, SGA ● Do not try the fetus from being delivered
● Labor induction by oxytocin and rupture of ● If delivery is necessary before the arrival of the
membranes health care provider, do the following:
● Trauma a. Apply gentle pressure to the fetal heart
● Severe emotional stress upward towards the vagina lacerations,
● History of rapid labors supporting the perineal area. Both
actions constitute the Ritgen maneuver.
b. Support the infant’s body during delivery
Assessment c. Deliver the infant between contractions
● Assessment Findings checking for the cord around the neck
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d. Use restitution to deliver the posterior
shoulder
e. Use gentle downward pressure to move
the anterior shoulder under the pubic
symphysis
f. Bulb suction the infant’s mouth first and
then suction each naris.
g. Dry and cover the infant to keep the
body warm.
h. Allow the placenta to separate naturally
i. Place the infant on the mother’s
abdomen or breast to induce uterine
contraction
Uterine Inversion
Definition
● A rare phenomenon, have an incident rate of 1
in 15,000 births, in which the uterus completely
or partly turns inside out. It may occur during
delivery or after delivery of the placenta
● Occurs in various degrees:
○ 1st degree inversion- uterus is straight
instead of forward
○ 2nd degree inversion- uterus is at the
back
○ 3rd degree inversion- top of the uterus is
below its neck and is located back and
is folded over itself
○ 4th degree inversion- uterus protrude
from the vagina
Risk Factors
● Fundal implantation of the placenta
● Manual extraction of the placenta
● Short umbilical cord
● Uterine atony
● Leiomyomas
● Abdominal adherent placental tissue
Assessment
● Fundus is not palpable
● Depression in the fundal area of the uterus
noted
● The interior of the uterus may be seen through
cervix or protruding through the vagina
● Client experiences severe pain
● Hemorrhage is evident
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● Signs of shock
Intervention
● Monitor for hemorrhage and signs of shock and
treat shock
● Recognize signs of impending inversion and
immediately notify the physician
● Never attempt to replace the inversion because
handling may increase the bleeding
● Never attempt to remove the placenta if it still
attached
● Take steps to prevent or limit hypovolemic shock
○ use large gauge IV catheter for fluid
replacement
○ Measure and record maternal VS every
5 to 15 minutes to establish baseline
changes
● Administer oxygen by mask
● Be prepared to perform CPR if the heart fails
due to sudden blood loss
● The mother will be given general anesthesia or
nitroglycerin or a tocolytic drug IV to immediately
relax the uterus
● The physician/nurse midwife replaces the
fundus manually (pushing the uterus back
inside); if unsuccessful laparotomy with
replacement to the correction is done
Uterine Rupture
Definition
● The complete or incomplete separation of the
uterine tissue as a result of a tear in the wall of
the uterus from the stress of labor
● Complete: Direct communication between the
uterine and peritoneal cavities
● Incomplete: Rupture into the peritoneum
covering the uterus, but not into the peritoneal
cavity
● Manifestations vary with the degree of rupture
Risk Factors
● Labor after previous CS
● Overdistended uterus after CS
● Faulty presentation
● Multiple gestation
● Hydramnios
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● Abdominal trauma ● Bandl’s ring is seen as horizontal indenion

Assessment
● Abdominal pain or tenderness
● Chest pain
● Contractions may stop or fail to progress
● Rigid abdomen
● Absent fetal heart rate
● Signs of maternal shock
● Fetus palpated outside the uterus (complete
rupture)
Intervention
● Administer emergency fluid replacement therapy
as ordered.
● Anticipate use of IV oxytocin to attempt to
contract the uterus and minimize bleeding
● Prepare the woman for a possible laparotomy as
an emergency measure to control bleeding and
effect a repair
● Prognosis depend on the extent of the rupture
and blood loss
Bandl’s Ring
Definition
● During labor the uterus differentiate into two
parts:
1. Upper contracting portion- becomes
thicker and shorter as labor progresses.
2. Lower passive portion- distend gradually
to accommodate the descending fetus.
- The division is called Physiologic retraction
ring
running across the abdomen.
Risk Factors
● Prolonged labor
● Multifetal gestations
Assessment
● This can be seen and felt abdominally as a
transverse groove that may rise to or above the
umbilicus
● Upper segment of the uterus and the distended,
tender, and stretched lower segment
● Distended urinary bladder
● FHS shows evidence of the foetal distress or
even absent
Management
● Morphine Sulfate- helps to relax the uterus
● Cesarean Delivery- immediate delivery of the
fetus that helps to prevent uterine rupture
● If develop during placental stage- woman is
placed anesthesia and placenta is removed
manually
●
Intervention
● Monitor for and treat signs of shock (administer
oxygen, IV fluids and blood products)
● Prepare client for CS
● Provide emotional support for the client and
partner
● Post-operative care (After Hysterectomy)
● Explain need to avoid driving for 3-6 weeks
● Explain need to avoid jogging, sexual
intercourse, dancing, and lifting heavy objects
for 6-8 weeks.

● When labor is obstructed, the fetus cannot

descent into the birth canal
● Uterine contractions become stronger and more
frequent in an effort to overcome the obstruction
until it reaches a state of tonic contraction when
the uterus no longer relaxes
● This stage, Bandl’s ring of pathologic retraction
rings develops. The retraction of the upper
segment could result in the division of the two
uterine segment to become very prominent

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