COMPLICATIONS OF LABOR occipitoposterior position, no
rotation -- C/S
PASSENGER
Occipitoposterior Position Nursing care:
a. Occiput is directed diagonally & emotional support to prevent panic
posteriorly e.g. ROP or LOP fear , things are not going “by the book”
b. Common in women with frequent reassurance that labor is w/in
android, anthropoid or safe, controlled limits
contracted pelvis forceps may be used - - lacerations,
hemorrhage & infection pp
BREECH PRESENTATION
Fetal life assumes breech pres but by
38th wk rotate to cephalic
Complete breech take up more space
97% of fetuses rotate so buttocks
are in the fundus
Meconium may be present but not a
sign of fetal distress - but may lead to
meconium aspiration if infant inhales
amniotic fluid
Hazards of Breech Pres:
anoxia from prolapsed cord
intracranial hemorrhage
fracture or paralysis of the arm or spine
dysfunctional labor
early PROM due to CPD
Assess Breech Pres:
PASSENGER 1. FHT
Dysfunctional labor pattern e.g 2. Leopolds Manuever
prolonged active phase 3. Vaginal exam
> cord prolapsed since head does not fit 4. Sonography
snugly the cervix
Intense pressure & pain in lower back Nursing Care
due to sacral nerve compression. Monitor FHR & uterine contraction – det
fetal distress due to cord prolapse
Nursing Care Vital signs
sacral counterpressure e.g. Back rub, Watch for Signs of infections
change position Birth technique
heat or cold application o push only after full dilatation
side lying opposite fetal back o support w/ sterile towel as
maintain hands & knees position – help breech spontaneously emerge
fetus rotate
voids q 2 hours – full bladder impedes Breech Presentation
fetal descent deliver gradually & spontaneously to
may need IVF glucose sol to replace prevent intracranial injury & hypoxia
glucose stores for energy Aid delivery of head w/ the fetal trunk
Maternal exhaustion -Ineffective straddled over the physician’s right
uterine contractions - uterine forearm, two fingers at infants mouth.
dysfunction - transverse arrest of Head my be aided by piper forceps to
fetal head -- persistent control flexion & rate of descent.
inform parents of progress
frank breech, infants legs extended at occipitomental dm presents C/S for
level of face from 2-3 days, footling safe delivery
breech may tend to keep legs extended
in footling position in few days.
FACE PRESENTATION
Infant have extreme ecchymotic bruises
on the face
Reassure parents
TRANSVERSE LIE
Asynclitism – when fetal head presents at
different angle than expected.
Face & brow presentation are rare but if
it occurs, fetal head dm is too large for
the pelvis
Fetal back is concave – FHT is forward
thrust where feet & arms are palpated
Face pres is confirmed by vaginal exam,
may occur due to:
o CPD
o placenta previa
o multipara due to relaxed uterus
o fetal compl e.g. prematurity,
hydramnious, fetal malformation Causes:
Any abnormal conditions Common in women w/ pendulous
If chin is posterior w/ prolong posterior to abdomen
anterior rotation - uterine dysfunction Uterine masses e.g. fibroid tumors
or transverse arrest C/S obstruct lower uterine segment
Contracted pelvic brim
Nursing Care:
Cong uterine abnormality
babies born - facial edema purple from
Hydramnios
ecchymotic bruising
Hydrocephalic Infant – prevents head
observe for patent airway
from engaging
severe lip edema unable to suck
Prematurity has room for free
gavage feedings
movement
ICU care for 24 hrs
Multiple gestation in 2nd twin
reassure parents that edema is transient
Short umbilical cord
BROW PRESENTATION Assess:
Rarest presentation 1. Inspection
Common in multipara due to relaxed 2. Leopolds Manuever
abdl muscles obstructed labor, 3. Sonogram
head is jammed in pelvic brim as
May deliver vaginally but if w/ PROM , no firm widen pelvic outlet & deliver anterior
pres part cord prolapsed & shoulder may shoulder
obstruct cervix - C/S apply suprapubic pressure - help
shoulder escape from beneath the
OVERSIZED FETUS symphysis pubis & be delivered.
Fetus weighs more than 4,000 to 4,500
gms FETAL ANOMALIES
Common in DM, multiparity may lead fetal presenting part does not engage
to: well as in hydrocephalus or
o uterine dysfunction anencephaly
o overstretching of endometrium
o fetal pelvic disproportion due PROBLEMS WITH PASSAGE
wide shoulder
Dystocia due to contracted or narrowing
Uterine rupture due to obstruction of passageway at inlet, midpelvis or
C/S to prevent: outlet CPD failure to progress in
o fetal cervical nerve palsy labor
o diaphragmatic nerve injury
o fractured clavicle due to
INLET CONTRACTION
shoulder dystocia
pp maternal risk of bleeding due Narrowing of the anteroposterior dm to
overdistended uterus less than 11 cm or transverse dm to less
than 12cm
Cause by rickets in early life
SHOULDER DYSTOCIA
If no engagement in primi suspect:
common in DM, multipara & post date o fetal abnormality – larger than
pregnancy usual head or
occurs with increasing ave weight of NB o pelvic abnormality – smaller
suspected in prolonged 2nd stage of than usual pelvis
labor o w/ CPD fetus does not engage
o arrest of descent but remains “floating”
o head is crowning but retracts malposition occurs
instead of protruding with each o if w/ PROM cord prolapse
contraction turtle sign increases
OUTLET CONTRACTION
narrowing of the transverse dm at the
outlet < than 11 cm, distance bet ischial
tuberosities
prenatal visit to anticipate narrow dm
before labor begins.
TRIAL LABOR
2nd stage of labor , fetal head is born but trial labor may be done if woman has
shoulders are too broad to enter pelvic borderline or adequate inlet
brim mat risk of vaginal or cervical measurement and fetal lie or position
tears, fetal risk cord compression bet are good
fetal body & pelvis
Forced birth fetal fractured clavicle or Nursing Care:
brachial plexus palsy monitor FHT
void q 2hrs
Nursing care: o assess if engage, station,
McRobert’s Maneuver - ask mother to PROM, prolapsed cord
flex thighs sharply on her abdomen to
o if no progress of labor 12hrs o < fetal blood supply due to poor
C/S placental perfusion
o reassure woman, support o Abruptio placenta
system Used cautiously in women w/ multiple
o manage fear & pain gestation, hydramnios, grand parity
previous uterine tears, age > 40
EXTERNAL CEPHALIC VERSION
Cervical ripening
It is the turning of the fetus from breech 1st step in early labor - change in the
to cephalic position before birth. cervical consistency from firm to soft
o Done at 34 to 35 wks
o Record FHR w/ U/S Methods to ripen the cervix:
o Tocolytic agent may be adm to a. “stripping the membranes” or separating
help relax the uterus the membranes from the lower uterine
o Fetal breech & vertex grasped segment manually using a gloved finger
transabdominally on the in the cervix – easy proc done during
woman’s abdomen clinic visit.
o Gentle pressure exerted to
rotate the fetus in forward Complications include:
direction to a cephalic lie Bleeding from undetected low lying
o May help decrease C/S birth placenta
o C.I. – multiple gest, severe Inadvertent rupture of membranes
oligohydramnios, cord wraps Infections
around the neck, unexplained
3rd trim bleeding b. hygroscopic suppositories – seaweed
Note: that swell on contact w/ cervical
Women who are Rh negative should secretions.
receive Rh immunoglobulin p proc if
minimal bleeding occurs. Procedure:
inserted gradually & gently urge
INDUCTION & AUGMENTATION OF dilatation of the cervix
LABOR held in place w/ OS saturated w/ PVP
or antifungal cream
Induction of Labor – labor started artificially, document number of OS inserted so
necessary because the fetus is in danger, none remains
primary reasons include:
Preeclampsia, eclampsia c. Prostaglandin gel
DM e.g. misoprostol 2-3 doses– commonly
RH sensitization, prolonged PROM used to speed cervical ripening, inserted
IUGR to the interior surface of the cervix by
Postmaturity catheter or suppository or external
Induction may be done w/ ff conditions: surface by applying it to a diaphragm
fetus is longitudinal lie against the cervix
cx is ripe
Pres part engage Nursing care:
no CPD bed rest on side lying position – prevent
full term as shown in U/S, L/SW ratio leakage of medication
monitor FHR cont 30 min after each
application (2hrs p vagl insertion)
AUGMENTATION OF LABOR
observe for side effects – vomiting,
refers to assisting labor that ahs started fever, diarrhea, & HPN
spontaneously to be more effective, Oxytocin induction may be started 6-12
necessary for hypotonic uterus. Carries hrs after the last prostaglandin dose
risk of:
o uterine rupture
Prostaglandin must be used w/ caution AUGMENTATION BY OXYTOCIN
in women w/ asthma, renal or
cardiovascular ds. Required if labor contractions begin
spontaneously but then become them
hypotonic that assistance is needed to
INDUCTION OF LABOR BY strengthen them.
OXYTOCIN Precautions & nursing care is same with
e.g. Pitocin – adm IV initiates contraction of the oxytocin adm
uterus at term, stop if hyperstimulation occurs.
Adm “piggyback” to IV sol of D5W 3 Active Management of Labor
Use infusion pump to regulate IV so A technique used in western countries
drops won’t change een w/ position w/c include aggressive adm of oxytocin (
changes 6mU/min max of 36 to 40mU/min rather
Do not increase rate to more than 20 than 1 or 2mU/min) to shorten labor to
mU/min w/out instructions cause 12 hrs w/c presumably reduces C/S birth
excessive stimulation tetanic & PP infection
contractions or tonic UC w/ fetal death Controversial due to birth tradition
or rarely uterine rupture
Antidote if stopping pit drip does not FORCEPS BIRTH
stop hyperstimulation give B
adrenergic receptor drug such as Mgso4
or terbutaline sulfate (Brethine)
decrease myometrial activity.
Cx dilated to 4cm, amniotomy is done to
induce labor, disc pitocin drip
Nursing care to ensure safe induction:
o VS esp PR, BP q 15 min
monitor UC, should occur not more than
q 2min & not stronger than 50mmHg
pressure & should last no longer than 70
sec. the resting pressure bet UC should
not exceed 15mmHg by monitor.
UC freq & longer than safe limitsfetal
distress stop infusion
seek help & adm O2 prn
oxytocin has antidiuretic effect
decrease urine flow water
intoxication, s/s headache & vomiting
report immediately
Adv eff of H2O intoxication seizures,
coma & death due to large shift in
interstitial tissue fluid accurate I&O,
test sp gravity of urine to detect fluid
retention
reg IVF to 150ml/hr w/ rate not greater
than 2.5ml/min.
Reassure woman that induction of labor
may be adv. Not resist UC & breathing
techniques
Induction of labor by oxytocin may
predispose NB to hyperbilirubinemia &
jaundice observe closely in 1st few
days of life.
OB forceps are steel instruments w/ two
blades slipped into the vagina & fetal
head, shafts of forceps brought together
to form a handle then physician applies
pressure & manually pulls the fetus out
of birth canal
Low forceps – used if fetal head is +2
station or more
Mid-forceps – used if fetal head is
engaged but less than +2 station
rarely justified assoc w/ birth trauma
both mother & fetus
Pudendal block – to relax the pelvis &
reduce pain
Indications of forceps birth
o unable to push w/ contractions
o cessation of descent
o abnormal position or immature
fetus
o fetal distress
Pre forceps application
o membranes must be ruptured
o CPD must be present
o cervix fully dilated
o bladder is empty
o record FHR
Post forceps del Adv. – less anesthesia is used less
o assess cervix for lacerations fetal RDS at birth
o observe & record time & amount o fewer lacerations at birth canal
of voiding to assess bladder Disadv. Causes marked caput on the
injury NB up to 7 days, presence of tentorial
o assess NB for facial palsy, tears
subdural hematoma Reassure mother of transient caput &
o explain to parents’ transient swelling
erythematous marks on NB Vacuum extraction must not be used as
cheek a method of birth if fetal scalp blood
sampling was done because suction
pressure can cause severe bleeding at
VACUUM EXTRACTION
the sampling site
Done if fetus is positioned far enough Adv to premies due to soft skull
down the birth canal
A disk-shaped cup is pressed against
the fetal scalp over posterior fontanelle,
then pressure applied & sucked the fetal
scalp & delivers the fetus.
