Nursing Care of A Family Experiencing A Complication of Labor or Birth

Nursing Care of a Family Experiencing a Complication of Labor or Birth OB LECTURE
Ma’am Anne Maris L. Rellama, RN, MAN
Classified as:
ASSESSMENT
● Primary - occurring at the onset of labor
● Conscientious assessment of labor progress (fetal and uterine
● Secondary - occurring later in labor
monitor)
○ Closely monitor the fetal heart rate and uterine
RISKS OF PROLONGED LABOR
contractions
● Maternal postpartum infection
○ Limits the woman’s ability to ambulate or move
● Hemorrhage
freely
● Increase infant mortality
○ If you have to hook the woman to the monitor,
explain the importance of the procedure to gain
FACTORS THAT CAUSES PROLONGED LABOR
their cooperation ● Large Fetus or macrosomic (more than 10 lbs.)
● Providing emotional support to woman & family is essential ● Hypotonic
especially if complication occurs in any point in labor ● Hypertonic
INTRAPARTUM COMPLICATIONS ● Uncoordinated uterine contractions
Dystocia
● Difficult labor Uterine Contractions
● Aka Dysfunctional labor ● Basic force that moves the fetus through the birth canal
● Abnormally slow progress of labor ● Occurs through interplay of
● There is failure of labor to progress ○ Adenosine triphosphate
○ Calcium, sodium, potassium
COMMON CAUSES OF DYSFUNCTIONAL LABOR ○ Actin & myosin
● Primigravida status ○ Epinephrine & norepinephrine
● Pelvic bone contraction ○ Oxytocin
● Posterior rather than anterior fetal position (fetal malposition) ○ Estrogen, progesterone, prostaglandin
● Failure of the uterine muscles to contract properly
● Overdistention of the uterus Ineffective Uterine Force
○ Eg. macrosomia, multiple pregnancy, multiple ● In 95% of labor, contractions follow a predictable, efficient
pregnancy, polyhydramnios course
● Non-ripe cervix ● Dysfunctional labor - less strength than usual; rapid but
○ Closed and firm cervix ineffective
● Presence of a full rectum or urinary bladder
○ Interferes with the descent of the baby
Dysfunctions Associated with Ineffective Uterine Force
● Exhaustion of the woman from labor
Hypotonic Contractions
● Inappropriate use of analgesia
● Happens during the active phase of labor
○ Given after the pregnant woman reaches 3cm
● Number of contractions is unusually infrequent (occur less
cervical dilatation or higher
frequently)
● Number of contractions
CAN ARISE FROM ANY OF FOUR MAIN COMPONENTS OF LABOR
PROCESS (4Ps) ○ Not more than 2
1. Passageway - maternal pelvis or 3 occurring in
2. Passenger - fetus a 10-minute
3. Power period
a. Primary power - strength of uterine contraction ○ Normally, 4 - 5
b. Secondary power - woman’s strength to push or to contractions in a
bear down 10-minute period
4. Psyche - the woman's views and experience with labor and ● Resting tone of uterus
delivery ○ Remains less than 10 mmHg
○ Normal: 10-15 mmHg
Strengths of contractions
COMPLICATIONS WITH THE POWER ●
○ Does not rise above 25 mmHg
COMPLICATIONS WITH THE POWER
○ Normally, uterine contractions are about 40 - 70
● Sluggishness of contractions
mmHg in active phase especially during the peak
● Force of labor is less than usual
of contractions (acme)
● Used to be called Inertia
● Uterine contractions are less effective, less tense and they
● Most recent term is Dysfunctional labor
occur infrequently
1 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

● Also increase the length of the labor because uterine COMPLICATIONS SECONDARY TO HYPERTONIC CONTRACTIONS
contractions are necessary to achieve normal cervical ● Fetal anoxia - early in the latent phase of labor
dilatation
● If the uterus become exhausted during the labor, this can MANAGEMENT
also result to the uterus being ineffectively contracting during ● Apply uterine and fetal external monitor
the postpartum period ○ Fetal tachycardia as a manifestation of fetal
● If the uterus becomes boggy → ineffective contractions → anoxia → conservative management: left-lying
risk for postpartum hemorrhage position and additional oxygen for the woman
● Cesarean birth
CAUSES OF HYPOTONIC CONTRACTIONS ○ FHR deceleration
● After administration of analgesia (3-4 cm dilated) ○ Abnormally long 1st stage of labor
○ Not yet reached 3 cm dilatation (too early in labor) ○ Lack of progress with pushing (2nd stage arrest)
● Bowel or bladder distention (descent / firm engagement)
● Overstretched uterus COMPARISON OF HYPO- & HYPERTONIC CONTRACTIONS
○ Macrosomia, multiple pregnancy, polyhydramnios
● Grand multiparity (lax uterus)
○ Secondary to grand multiparity or delivery of 5 or
more babies
NURSING RESPONSIBILITIES
● Assessment of the uterine fundus (1st hour postpartum)
○ The uterus may be exhausted due to the
prolonged labor → risks of poor contraction after
delivery → risk of bleeding after birth
● Monitor the woman’s blood pressure
○ Blood pressure that is consistently decreasing may
indicate bleeding or hemorrhage ● Illustration A: normal pattern of uterine contractions
● Assess lochia every 15 min (1st hr postpartum) ○ During acme, tone increases but as it reaches
○ To further assess early signs of hemorrhage decrement, the tone during resting phase / interval
is only 10 mmHg or lower
Hypertonic Contractions ● Illustration B: Hypotonic contractions
● Happens during latent phase of labor ○ Few occurrence of contractions (2-3 in 10 mins)
● Number of contractions occur more frequently ○ Tone during interval reached zero (complete
○ Greater than 5 contractions per 10 mins (ex. in relaxation of uterus)
graph, 5 contractions in only 7 mins) ● Illustration C: Hypertonic contractions
● Resting tone of uterus more than 15 mmHg ○ Contractions occur more frequently
● Occur because more than one uterine pacemaker is ○ Tone during interval is still about 35-40 mmHg (way
stimulating contractions above normal resting tone of 10-15 mmHg)
● Muscle fibers of the myometrium do not re-polarize or relax

after a contraction Criteria Hypertonic Hypotonic
○ Maintains its tone above 15mmHg Most common phase Latent Active
● UC tend to be more painful than usual of occurrence
○ Because there is no relaxation in the uterine Symptoms Painful Limited pain
muscles
Medication used:
Oxytocin Unfavorable reaction Favorable reaction
Sedation Helpful Little value
● Sedation - helpful in hypertonic because it can alleviate pain

and decrease hyperactivity or lessen intensity of uterine
muscles since it can relax muscles in the body
Normal Contractions
● All contractions are initiated at one pacemaker point high in
the uterus (fundus)

Uncoordinated Contractions (abnormal uterine contractions) ● Occurs if the cervix is not ripe at the beginning of labor
● Any deviation from the normal pattern of uterine contraction ● Excessive use of analgesic
affecting the normal course of labor early in labor
● More than one pacemaker may be initiating contractions, or ● Uterus tends to be in a
receptor points in the myometrium may be acting hypertonic stage
independently of the pacemaker
● Occur so closely together/erratically
○ Interfere with the blood supply to the placenta
○ Difficult for woman to rest between contractions or
to breathe effectively with contraction MANAGEMENT
● Rest the uterus
MANAGEMENT
○ Prevent stimulation of the uterus
● Apply uterine and fetal external monitor (rate, pattern, resting
○ Uterine massage should not be done so as not to
tone, fetal response to contractions for 15 mins)
stimulate the uterus
○ Can be done longer if it is necessary especially in
● Adequate fluid for hydration
early labor
○ Either per orem or per IV administration
○ May reveal the abnormal pattern of contractions
● Relieve pain (morphine sulfate)
● Oxytocin administration
○ Administered by anesthesiologist, not by nurses
○ To stimulate a more effective and consistent
○ Drug that is used to manage pain that can be
pattern of contractions with better resting tone
administered by nurses is Nalbuphine Hydrochloride
→ decreases blood pressure → can cause
DYSFUNCTIONAL LABOR AND ASSOCIATED STAGES OF LABOR respiratory depression on the fetus
● Change the bed linen and woman’s gown
EFFECTS OF DYSFUNCTIONAL LABOR
○ To provide comfort especially if it is stained with
● Anxiety
vaginal discharge
● Fear
● Dim lights
● Discouragement
○ Provides comfort and will allow the woman to rest
NOTE: Regardless of the phase of labor these dysfunctions occur, the
well
effects to the woman or her support system will always be the same
○ The environment will be conducive for rest and
NOTE: As nurses, we have to explain to the woman & her support
sleep
system what is causing the prolonged labor & update them on the
● Decrease noise and stimulation
progress of labor
If all the mentioned measures are ineffective, the ff are done:

DYSFUNCTIONS AT THE FIRST STAGE OF LABOR
● Cesarean birth
Involves:
● Amniotomy and oxytocin infusion
● Prolonged latent phase
○ To assist labor if the fetal position/presentation is
● Protracted active phase
favorable for a vaginal delivery
● Prolonged deceleration
● Secondary arrest dilatation
Protracted Active Phase
● Usually associated with fetal malposition or cephalopelvic
Dysfunctions at the First Stage of Labor
disproportion
Prolonged Latent Phase
● May reflect ineffective myometrial activity
● Develop when uterine contractions become ineffective
● Active phase is prolonged if cervical dilatation does not
during the 1st stage of labor (lower strength)
occur at a rate of at least 1.2 cm/hr (nullipara) or 1.5 cm/hr
● Affected by administration of anesthesia (Epidural
(Multipara)
Anesthesia) too early in labor
○ Active phase longer than 12 hrs (Primigravida)
○ Timing of the administration can help in the normal
○ Active phase longer than 6 hours (Multigravida)
process of labor
○ Should be done after the woman has reached
Cephalopelvic disproportion
3cm cervical dilatation or (ideally) when the
woman reaches the 6 cm cervical dilatation so as
not to cause prolonged labor
● Defined as a latent phase that lasts longer than 20 hours
nullipara or longer than 14 hours in a multipara

● Left: cephalopelvic disproportion ○ It is possible that the dilation would stop due to
○ Diameter of maternal pelvis can’t accommodate infrequency
the passage of fetal head ● Suspected if the 2nd stage lasts over 2 hours (multipara)
○ Disproportion of fetal head in relation to ○ 2nd stage of labor starts when the cervix has
size/diameter of maternal pelvis already reached the 10cm dilation
● Right: fetal malposition
○ Ideally, fetal head should be positioned anteriorly MANAGEMENT
● Rest
MANAGEMENT ○ The women may feel weak
● Cesarean birth ○ To regain her strength → more effective pushing
○ if the cause of the delay in dilatation is fetal ○ Advise to push alternately (rest for this contraction
malposition or CPD and push for the next one)
● Oxytocin ● Fluid intake
○ to augment labor ○ May help the woman relieve her exhaustion and
○ Administration through IV incorporation feeling of body weakness
● Amniotomy
Prolonged Deceleration Phase ○ If spontaneous rupture of the bag of water has not
● When it extends beyond 3 hours (nullipara) occurred, artificial rupture of membranes may be
● When it extends beyond 1 hour (multipara) necessary
● Most often results from abnormal fetal head position ● Oxytocin via IV infusion
(brow/face presentation) ● Semi-Fowler's position
● The progress usually slows after the 8cm dilatation ○ Force of gravity in upright position may help in
● Uterine contraction and dilation may have started normally descent of fetus
but the progress has slowed down or the intensity is ● Squatting
dysfunctional ○ May also help in further descent of the baby
● Cervix becomes edematous & thick → making dilation more ● Kneeling
difficult ○ May also help in further descent of the baby
● More effective pushing
MANAGEMENT ○ Teach the woman the correct technique in
● Cesarean Birth bearing down
Secondary Arrest of Dilatation Arrest of Descent

● Occurs if there is no progress in cervical dilatation for longer ● Results when no descent occurred for 2 hour (nullipara) or 1
than 2 hours hour (multipara)
● Usually occurs in the later phase of labor ● Occurs when the expected descent of the fetus does not
● Hemorrhage may occur if vaginal delivery is forced without begin or engagement or movement beyond station 0 does
cervical dilatation not occur
● Some obstetricians have to wait 1 to 2 hours after the cervix ○ Normally, the baby is expected to descend further
stopped dilating until the fetal head becomes visible in the vulva
● Buscopan per IV may be administered ● Most likely cause for arrest of descent during the second
○ An antispasmodic medication that causes muscle stage is CPD (Cephalopelvic Disproportion)
relaxation ○ Which can be secondary to a macrosomic baby
○ This may also result or help in the effacement and
further dilatation of the cervix MANAGEMENT
● If despite the administration of buscopan and there is still no ● Cesarean Birth
progress → emergency CS ● Oxytocin
○ May also be used to assist labor when there is no
MANAGEMENT contraindication to vaginal birth (eg. when the
● Cesarean birth baby is in a longitudinal lie or the diameter of the
woman’s pelvis is adequate enough to facilitate
Dysfunctions at the Second Stage of Labor the passage of the fetus)
Prolonged Descent ○ Facilitates NSD if it is not contraindicated (helps in
● Occurs if the rate of descent is less than 1.0 cm/hr (nullipara) further descent of the baby)
or less than 2.0 cm/hr (multipara)

○ An increase in the uterine contraction may INDUCTION & AUGMENTATION OF LABOR

increase the Ferguson reflex
○ In the second stage of labor the woman may feel INDUCTION OF LABOR AUGMENTATION OF LABOR
Ferguson reflex (the uncontrollable urge to push) →
There is no initiation or There is the presence of
if they push during this stage, the pressure of the
occurrence yet of uterine spontaneous uterine
presenting part of the fetus and the presenting part
contraction contractions but has become
of the maternal pelvis may also facilitate further ineffective
descent of the baby
Labor is started artificially Assisting labor that has started
spontaneously but is not
PRECIPITATE LABOR
effective
● Precipitate dilatation is cervical dilatation that occurs at a
rate of: Oxytocin - Administered to To further augment or increase
○ 5cm or more per hour in primi (1cm/12mins) facilitate and stimulate the intensity of the uterine
○ 10cm per hour in multi (1cm/6mins) occurrence of uterine contractions:
● Precipitate birth occurs when uterine contractions are so contractions a. Oxytocin/IV
b. Amniotomy - artificial
strong a woman gives birth only a few, rapidly occurring
rupture of BOW
contractions
● Often defined as a labor that is completed in fewer than 3
hours or less than 2 hours CONDITIONS THAT MIGHT MAKE INDUCTION NECESSARY (before
39th week of gestation)
● Most likely to occur with grand multiparity
If a woman has one or more of these presented conditions, induction
○ This means that the woman has already given birth
of labor or immediate delivery of the baby may be necessary as to
to 5 or more babies
prevent worsening of the disease condition or complication:
● May occur after indication of labor by oxytocin
1. Preeclampsia
2. Eclampsia
RISKS
3. Severe hypertension
● Premature separation of placenta (Forceful UC)
4. Diabetes mellitus
○ Associated or secondary to forceful uterine
5. RH sensitization
contractions
6. Prolonged rupture of the membranes
● Laceration of the perineum
7. Intrauterine growth restriction
● Hemorrhage
8. Post maturity (Pregnancy beyond 42 weeks gestation)
● Subdural hemorrhage (fetus)
● In this case, the placenta may not be working well as
○ May result from the rapid release of pressure on the
expected because normally the placenta functions
fetal head
well to provide the necessary oxygenation and
NOTE: With the short duration of labor, in this case the woman and her
nutrients to the fetus only until the 40th week of
support person can feel overwhelmed by the speed of the labor
gestation
NURSING RESPONSIBILITIES ● If pregnancy goes beyond the 42nd week, the fetus
● Caution a multiparous woman by week 28 of pregnancy with inside the uterus may be compromised because the
Hx of brief labor to plan for adequate transportation to the placenta may not be able to provide anymore the
hospital or alternative birthing center needed nutrients and oxygen by the fetus
● Have the birthing room converted to birth readiness before ● A post-mature baby needs to be delivered
full dilatation is obtained immediately → induction of labor may be necessary
○ So that even if a sudden birth occurs, it can be

RISKS OF INDUCTION OR AUGMENTATION OF LABOR
accomplished in a controlled environment
● Uterine rupture
● Predicting precipitate labor
● Premature separation of placenta
○ This can be predicted by a labor graph if it is used
during the active phase of the dilatation
○ Nullipara: Greater than 5cm/hr (1cm/12min) NOTE: Although Oxytocin is an effective uterine stimulant, there is a
○ Multipara: 10cm/hr (1cm/6min) thin line between adequate stimulation and hyperstimulation.
Nurses have to be careful in observing and monitoring the woman
who is receiving oxytocin either to induce or augment labor. Close
monitoring should be done throughout the entire procedure.

INDUCTION OR AUGMENTATION OF LABOR WITH OXYTOCIN

MUST BE USED CAUTIOUSLY IN WOMEN WITH:
● Multiple gestation
● Polyhydramnios
○ Presence of uterine scar → risk for uterine rupture
● Grand multiparity BISHOP’S CRITERIA FOR SCORING THE CERVIX
● Older than 40 y/o Used to make sure if the cervix is ready for birth and will be able to
○ High risk population for heart problems respond to the induction of labor or to ensure that the induction of
○ Oxytocin may further increase HR labor will be beneficial or result to the dilatation of the cervix
● With previous uterine scars
○ There is a weak point of ano raw cjdnvojwnve→
Score Dilation Position of Effacement Station Cervical
risk for uterine rupture
(cm) Cervix (%) (-3 to +3) Consistency
NOTE: Administration of oxytocin to women having one of these cases
0 Closed Posterior 0-30 -3 Firm
would pose risks or possible complications
1 1-2 Mid 40-50 -2 Medium
CONDITIONS BEFORE INDUCTION position
● Fetus is in longitudinal lie 2 3-4 Anterior 60-70 -1, 0 Soft
○ The long axis of the fetus should be parallel to the 3 5-6 - 80 (and +1, +2 -
long axis of the mother (vertical) above)
○ Ideally, the baby should be in a cephalic
presentation. Interpretation of Results:
● 8 or greater than 8 = cervix is ready for birth and will be able
to respond to induction
NOTE: We have to ensure that the cervix is ripe before we induce labor
if it is necessary
● Cervix is ripe
○ Cervix should be soft and thin to facilitate Methods to Help Ripen the Cervix
effacement 1. Stripping the membranes
● Presenting part is the fetal head

● There is NO CPD
○ No cephalopelvic disproportion ● Simplest method
● The fetus is estimated to be mature by date (39 weeks) ● There is a separation of the membranes from the lower
○ “Term pregnancy” uterine segment manually with the help of the health
○ At least 38 weeks of gestation or beyond professional’s gloved hand
● Can induce ripening of the cervix or softening of the cervix
the first by the simplest method (the sweeping of the
CERVICAL RIPENING
membranes)
● To facilitate effacement, the cervix must be ripe
● One or two fingers will be inserted on the cervix and a gentle
● Refers to the softening of the cervix that typically begins prior
rotation will be done by the health professional to separate
to the onset of labor contractions and is necessary for
the amniotic membrane from the uterine walls
cervical dilation and the passage of the fetus
● This method stimulate the release of prostaglandin and this
○ When the cervix is not ripe, it is said that the cervix is
prostaglandin will trigger uterine contractions
long, thick, and firm
● In some cases the doctor may also gently stretch or massage
○ Cervix is ripe → soft & thin
the cervix to help start it to soften and dilate
■ Facilitates cervical dilatation
● Stripping or sweeping of the membranes may be
recommended by the health professional or by the
obstetrician

○ If the woman is already at term pregnancy or is ● Each slab of Dinoprostone contains about 10 mg in a
already near her term pregnancy hydrogel insert
○ If baby is necessary to be delivered even when the ● It also has the retrieval system which is a long tape designed
woman is not yet at term because of other to aid the retrieval or the removal of the of Dinoprostone at
underlying medical conditions the end of the dosing or if it is needed to be earlier, it can be
POSSIBLE COMPLICATIONS removed easily with this long designed tape which is said to
● Bleeding be the retrieval system of the dinoprostone
○ When the woman has an undetected low-lying ● How to administer:
placenta, the fingers of the examiner are inserted 1. Prepare - pick up the insert between 2
in the cervix → facilitates separation of placenta fingers and lightly coat with
from the uterus → bleeding may occur water-miscible lubricant
● Inadvertent rupture of membranes ○ The healthcare professional
○ Accidental rupture of membrane should wear gloves and
● Infection lubricate at least two of their
○ If the membranes rupture fingers to facilitate insertion of
their fingers and prevent friction
2. Insertion of Hypogrospic Suppository that can cause discomfort on
the patient
○ It is recommended to use a
water-soluble lubricant when
lubricating a gloved hand
whenever necessary
2. Insert - gently place your fingers with the insert into
the vagina. Position the insert transversely in the
posterior vaginal fornix. Take care not to dislodge the
● Suppositories are hydrogel based suppositories insert when removing fingers. Slightly tuck the retrieval
○ Made of seaweeds that swell on contact with tape into the vagina.
cervical secretions ○ The suppository or slab is held by the gloved
● They gradually and gently urge cervical dilatation similar to hand particularly with the two lubricated
the effect of laminaria fingers. The plug is inserted into the vagina by
● Held in place by either a gauze or sponges saturated by the lubricated fingers. The plug is positioned
povidone iodine or any antifungal cream transversely in the posterior vaginl fornix.
● If sponges are used, documentation of the number of ○ Be careful not to dislodge the suppository
sponges used is important when removing the fingers.
○ How many sponges were placed? - very important ○ We can slightly tuck the retrieval tape inside
so we can document afterwards that none remain the vagina to prevent accidental pulling of
inside retrieval system (this is used when we have to
○ Because if sponges are inside the cervix for longer remove the suppository later on)
periods of hours → may cause infection 3. Retrieve - To retrieve, locate the retrieval tape and
● When the suppository absorbed cervical secretions it would pull it gently until the product is fully removed
swell thereby facilitating cervical dilatation ○ Upon removal of Cervidil, it is essential to
ensure that the slab has been removed, as it
3. Insertion of Dinoprostone (Prepidil, Cervidil) will continue delivering the active agent
NURSING RESPONSIBILITIES
1. Remind the patient to assume side-lying position
● To prevent the loss/leakage of the medication
2. Monitor FHR
● To ensure fetal wellbeing
3. Monitor SE: vomiting, fever, diarrhea and HTN
4. Use with caution in women with asthma, renal or
cardiovascular disease, glaucoma, Hx of CS
● These are flat polymeric plug with regular or rectangular ● Because of the danger of hyperstimulation
shape, they contain pouch of knitted polyester retrieval
system

REMEMBER: Used to promote cervical ripening and dilatation. After

administration of dinoprostone, if the cervix is already ripe, oxytocin Oxytocin/IV incorporation
induction can be started 12 hrs after the prostaglandin dose or after
insertion of dinoprostone.
● If we induce labor in less than 12 hours after the insertion of
dinoprostone, there may be a hyperstimulation of the uterus.
● Hyperstimulation of the uterus may affect the baby.
● In clinical practice, dinoprostone is not commonly
seen/available. What we often see is misoprostol or cytotec
(tablet) → not approved by FDA for obstetric use but is still
used to assist in cervical ripening **Label it properly and regulate it as ordered
○ Tablet that is inserted vaginally that assists in
cervical ripening, as effective as dinoprostone and Use of infusion pump
requires the same precautions (FHR & maternal VS) ● If the equipment is available and to be able to administer
○ Cheaper than dinoprostone oxytocin accurately to the patient, an infusion pump is used
● May cause additional charges to the patient
INDUCTION OF LABOR BY OXYTOCIN ● But it delivers the medication and IV fluid accurately
● Should only be done if the cervix is ripe ● Connect IV tubing to the machine then set on the desired
ordered rate or dose per hour
CONDITIONS BEFORE INDUCTION
● Pregnancy is at term RISK OF OXYTOCIN ADMINISTRATION
● Presenting part is the 1. Uterine Hyperstimulation
fetal head ○ 5 or more UC in 10 min. period
● There is no CPD ○ UC lasting more than 2 min in duration
■ Normal: not more than 90 sec
○ UC occurring within 60 sec of each other (interval is
NOTE: Assessment of fetal head size by ultrasound or manual less than 1 minute)
examination should be done first before administering oxytocin ○ Interfere with placenta filling and fetal oxygenation
(fetal hypoxia)
Oxytocin ○ Interventions for Uterine Hyperstimulation
● It is a synthetic pituitary hormone ■ Discontinue the oxytocin infusion
● Used to induce labor contractions (if the cervix is already ■ Turn the woman onto her left side - to
ripe) improve blood flow
● Always administered intravenously (piggyback or side bottle) ■ Administer IV fluid volume - to dilute level
○ So that if hyperstimulation of the uterus occurs, it of oxytocin in the bloodstream
can be quickly discontinued and the plain IV fluid ■ Administer oxygen/mask (8-10L) - to
will be infused prevent fetal hypoxia
○ One IV fluid does not contain any incorporated ○ Terbutaline - to relax uterus
medication; the other one contains the oxytocin ○ If during labor hyperstimulation occurs, observe the
● Half-life is approximately 3 minutes baby closely after birth for hyperbilirubinemia or
○ The decrease in the serum level and the effect of jaundice because these are associated with
oxytocin will be observed almost immediately after oxytocin administration
the discontinuation (a decrease in the intensity of ○ Remember
uterine contractions) Uterine contractions:
○ Vice versa, if we start administering oxytocin, we ■ Should occur no more often than every 2
will already see the results after 3-5 minutes min (intervals should be more than 2 min)
● Dose/regulation is prescribed by the primary care provider ■ Should not be stronger than 50 mmHg
○ We never administer this w/o the doctor’s order ■ Should last no longer than 70 sec
● Dose: ■ Resting pressure should not exceed 15
○ 10 “iu”/1000 mL of Ringer’s Lactate mmHg (normal: 10-15 mmHg)
○ 10 “iu” = 10,000 milliunits 2. Extreme hypotension
** Depending on the doctor’s order and case of the patient. If the ○ From peripheral vessel dilation
patient is diabetic, plain NSS IV will be given, not an IV containing ○ Intervention
glucose. Not diabetic: D5NR or D5NM. ■ Take the woman’s PR and BP every hour

■ Monitor the UC and FHR continuously ● Spontaneous tearing of the uterus that may result in the fetus
3. Water Intoxication being expelled into the peritoneal activity
○ From decreased uterine flow ● Rare but always a possibility
○ In its most severe form may lead to seizure, coma, ● An immediate emergency
and death ● Woman experiences sudden severe pain during a strong
○ Manifestations labor contraction (tearing sensation)
■ Headache ● May result to fetal death - baby may die due to hypoxia
■ Vomiting secondary to maternal hemorrhage
○ Management ● Confirmed by ultrasound
■ Accurate intake and output
■ Test and record urine specific gravity - RISK FACTOR
throughout the oxytocin administration to ● Previous cesarean scar
detect water retention
■ Limit amount of IVF (150/hr) - maintain IV CONTRIBUTING FACTORS
fluid infused, rate should not be greater ● Prolonged labor
than 2.5 ml/min or approximately 37-38 ● Abnormal presentation - like transverse presentation
drops/min to prevent water retention and ● Multiple gestation - due to overstretching of uterus
water intoxication ● Unwise use of oxytocin - which may result in hyperstimulation
● Obstructed labor
Augmentation by Oxytocin ● Traumatic maneuvers of forceps or traction
● Used if labor contraction begin spontaneously but then
become weak, irregular, or ineffective COMPLETE UTERINE RUPTURE
○ In augmentation of labor, uterine contractions ● Division of all three layers of the uterus
started normally. During the process, these uterine ● The tear goes through the endometrium, myometrium, and
contractions became weak, irregular or ineffective peritoneum
(hypotonic uterine contractions)
● Precautions are the same as for primary oxytocin induction of MANIFESTATIONS
labor ● UC will immediately stop
○ When administering oxytocin or infusing IV fluid with ● Two distinct swellings will be visible on the woman’s
oxytocin incorporation we have to increase the abdomen - retracted uterus and fetus inside the peritoneal
regulation gradually. (small increment only) cavity
○ Fetal heart rate must be monitored during the ● Vaginal bleeding - due to rupture (hemorrhage secondary to
entire administration of oxytocin torn uterine artery that floods into the abdominal cavity)
● Signs of hypotensive shock - rapid and weak PR, falling BP,
cold clammy skin, dilatation of nostrils, fading of fetal heart
Uterine Rupture
rate → absence of FHR later on
INCOMPLETE UTERINE RUPTURE

● Dehiscence
● The myometrium is disrupted but the serosa is intact
MANIFESTATIONS
● Localized tenderness
● Persistent aching over the area of the lower uterine segment
● Fetal and maternal distress
○ Closely monitor FHR, uterine contractions and any
● In this case, there can be a tear/scar from a previous changes in the woman’s VS
cesarean section
○ The tear can just follow the previous scar from a UTERINE RUPTURE (both complete and incomplete)
previous uterine procedure MANAGEMENT
○ May also extend inferiorly along the side of the ● Emergency fluid replacement therapy
uterus ● IV Oxytocin - to contract uterus → lessen bleeding
○ May extend into the vagina ● Laparotomy - to repair or remove the uterus

○ Tubal ligation may also be done after the repair of ● Second degree - the inverted fundus extends through the
uterus to prevent future pregnancy cervix but remains within the vagina (fundus
○ Damaged uterus may be removed which will result is not yet visible outside the vaginal opening)
in the loss of the childbearing ability of the woman ● Third degree - the inverted fundus extends outside the
● REMEMBER: Woman who experienced uterine rupture will be vagina (now visible when woman is in dorsal recumbent or
advised not to conceive again because rupture may also lithotomy position)
occur on her succeeding deliveries unless the rupture occurs ● Total inversion - the vagina and uterus are inverted (fundus
on the lower inactive segment of the uterus. has protruded way beyond the vaginal opening)
● We have to be prepared to offer information to the family
members or relatives of the woman to inform them of the MANIFESTATIONS
outcome of pregnancy, the extent of the surgery to be done ● Sudden gush of large amount of blood from the vagina
and the safety of the woman. ● Fundus is no longer in the abdomen
● Allow them to express their emotions and anxiety without ● Signs of blood loss (hypotension, dizziness, paleness, or
being threatened. diaphoresis)
● Exsanguination occurs in 10 min - draining of blood from the
PROGNOSIS body
● Fetus
○ Viability depends on the extent of the rupture MANAGEMENT
○ Time elapsed between rupture and abdominal 1. Never attempt to replace the inversion
extraction ● Putting back the uterus to its normal position may
● Woman cause increase in bleeding
○ Depends on the extent of the rupture and the 2. Never attempt to remove the placenta if it is still attached
blood loss ● EINC: wait for about 5-10 mins for sign of placental
○ Course of the problem depends on the extent of separation to occur before applying gentle
rupture and extent of blood loss. More amount of retraction to the umbilical cord to deliver the
blood loss → more severe → lesser chance for the placenta
woman’s recovery ● Never pull unless there is a sign of placental
separation from the uterus
Inversion of the Uterus 3. Discontinue oxytocin
● Refers to the uterus turning inside out with either birth of the ● This will further increase the uterine tone and would
fetus or delivery of the placenta make it difficult to replace or put back the uterus
● Rare 4. Insert an IVF line
● Occurs if traction is applied to the umbilical cord to remove ● To restore fluid volume
the placenta or if pressure is applied to the uterine fundus ● With large-gauge needle because blood will need
when the uterus is not contracted to be restored (there is a possibility that blood
● Also occurs if the placenta is attached to the fundus, so that transfusion will be done to restore normal blood
during birth the passage of the fetus pulls the fundus volume)
downward 5. Administer oxygen by mask
● To provide additional oxygen for the baby
6. Assess vital signs
● To assess early signs of hypotension and
hypovolemic shock
7. CPR - if the woman’s heart should fall from the sudden blood
loss (nurses are trained for CPR)
8. General anesthesia/Nitroglycerin/tocolytic drug by IV - to
relax uterus → it would be easier to replace or put back the
● Fundus comes out with the inner lining of the uterus exposed. inverted uterus
Like a pouch being inverted. 9. Manual replacement of the uterus
10. Administer oxytocin - (via IV incorporation or IM) to promote
Degree of Uterine Inversion contractions of uterus for it to remain in its natural
● First degree - the inverted place/position after manual replacement of uterus
fundus extends to, but not 11. Antibiotic therapy - since the endometrial layer of uterus has
through, the cervix been exposed to the environment, antibiotic is necessary to
prevent infection

12. CS birth will probably be necessary in any future pregnancy - ● Endotracheal intubation
to prevent possible repeat of uterus inversion ○ To maintain pulmonary functioning
● Therapy with fibrinogen
Manual replacement of the uterus ○ A woman with amniotic fluid embolism is at risk of
- Putting the uterus back to its normal placement developing DIC and may be prone to bleeding →
- Nurses don’t do this but during emergency situations when fibrinogen is given to prevent
no one else can do this to the patient, we have to do it ● ICU
○ The woman has to be monitored closely and
endorsed to ICU for more critical management
PROGNOSIS
● Woman
○ Depends on the size of the embolism
■ The bigger the emboli is, the more fatal it
can be
● First pic: the protruding fundus is grasped by using a gloved ○ The speed with which the emergency condition
hand was detected
● Fundus is pushed back towards the posterior fornix. The ○ Skill and speed of emergency interventions
gloved hand will further grasp the fundus and push it through ■ The earlier the interventions are done, the
the pelvis and into the abdomen. Steady pressure towards better for the woman to recover and has
the umbilicus is applied. increased survival rate
● Usually, to maintain the uterus in its normal placement, the ● Fetus
gloved hand stays inside the utero (fist) for a few minutes until ○ Guarded unless the fetus is born immediately by CS
it is firm and stabilized in that particular position. birth
● This technique is also called the Johnson’s Method ○ No guarantee of well-being unless delivered
Johnson’s Method immediately via CS birth (whether term or not) to
● (A) The protruding fundus is grasped with fingers directed prevent further complications
towards the posterior fornix
● (B, C) The uterus is returned to position by pushing it through COMPLICATIONS WITH THE PASSENGER
the pelvis and into the abdomen with steady pressure DYSFUNCTIONAL LABOR (DYSTOCIA)
towards the umbilicus ● Refers to dysfunctional labor described to be difficult, painful,
● Acute inversion of uterus reduced manually or O’Sullivan prolonged due to mechanical factors
(hydrostatic pressure) or surgery ● Difficult labor
● Can arise from any of the four main component of labor
Amniotic Fluid Embolism process
● Occurs when the amniotic fluid is forced into an open ○ Passageway
maternal uterine blood sinus after a membrane rupture or ■ Pelvic factors or abnormalities
partial premature separation of the placenta ○ Power
■ Uterine dysfunction
RISK FACTORS ○ Passenger
● Induction of labor - by oxytocin administration ■ E.g. fetal malpresentation
● Multiple pregnancy ○ Psyche
● Polyhydramnios ■ Mother’s anxiety and fear
■ E.g. lack of preparation
MANIFESTATIONS Passenger
● Sharp pain on the chest - (grasps her chest) ● Refers to the fetus
● Inability to breathe - a s pulmonary constriction occurs ● The size, presentation and position of the fetus are important
● Pale → bluish gray (cyanosis due to pulmonary embolism and in the conduct of labor
lack of blood flow to the lungs) Fetal lie
● Unconscious → fetus will be put in danger as placental blood ● Relationship of the long axis of the fetus to the long axis of the
circulation stops maternal abdomen
MANAGEMENT ● Refers to the position of the spinal column of the fetus in
● Oxygen administration/face mask or cannula relation to the spinal column of the mother; should be
● CPR - unconscious parallel to each other

● Has great impact on labor and birth ● Fixed reference point would be
the mentum
● Can be the left mentum
anterior or the right mentum
posterior
Fetal presentation
● Position of the body of the fetus that is foremost within the
birth canal or in closest proximity to it
● Cephalic, breech, shoulder, compound
● Refers to the part of the baby that will appear first from the
birth canal ** Towards the end of pregnancy, the fetus moves into a position
● Weeks before the woman’s due date, the fetus usually drops favorable for delivery. Normally, the position of the baby if facing
lower in the uterus rearward or the back of the mother, with the face and the body
● Ideally, the fetus should be positioned head down, facing the angled to one side, neck is flexed, and head first
mother’s back, with its chin tucked to its chest and the back
of the head ready to enter the pelvis → the smallest part of Attitude
the baby's head leads the way into the cervix and into the ● Relationship of the fetal body parts; the head and the body
birth canal → vertex presentation (cephalic presentation) to one another
● The posture of the fetus or the fetal habitus
● The normal (universal) fetal attitude is flexion
○ The head may be extended presenting the face
first
Fetal position
● Presentation and position are two DIFFERENT terms
● Describes the location of the fixed reference point on the
presenting part in relation to the four quadrants of the
maternal pelvis
● Best position for the fetus to pass is with the head down, Diameters of the fetal head
vertex presentation, and the body should be facing towards ● The Suboccipitobregmatic - diameter of the fetal head from
the mother’s back the lowest posterior point of the occipital bone to the center
○ Occiput-anterior position - best position favorable of the anterior fontanel
for vaginal birth ○ This is the smallest diameter and is the one that
● Three notations used to describe the fetal position presents optimally in labor
○ Right or left of the maternal pelvis ○ Measures 9.5 cm
○ Landmark of the fetal presenting part ● If it is face presentation, the fetus can also be delivered
■ E.g. if it’s vertex, the fixed reference point vaginally since it is also the smallest fetal diameter head
would be the occiput ● The brow presentation has the largest dimension
○ Anterior, posterior or transverse ○ Measures 13.5cm
■ Depends on whether the landmark is in ○ Constitutes an absolute fetopelvic disproportion
font, back, or side of the pelvis ○ Vaginal delivery may be impossible
■ Can be left occiput-anterior or right

occiput-anterior
■ Depends on the case references point
● Where is it facing?
■ What if the baby will present face first?
● It can be the face or chin

ASSESSMENT
COMPLICATIONS MAY ARISE IF ● The prolapse is usually only first discovered only after the
● An infant is immature or preterm membranes have ruptured
○ Premature - fetus is born too early; before 37 weeks ● FHR - Unusually slow or variable deceleration pattern
gestation suddenly becomes apparent
● More than one fetus is present ● Umbilical cord can be felt as the presenting part on vaginal
○ Multiple gestation exam
● Fetus is malpositioned ● Cord may be visible at the vulva upon inspection
○ Position of the fetus has a great impact on labor ● Can be visualized on ultrasound to confirm the prolapse of
and birth the umbilical cord
● Fetus is too large
○ The fetus will not fit the undersized maternal pelvis THERAPEUTIC MANAGEMENT
(Cephalopelvic Disproportion) ● Goal: To relieve pressure from the cord
○ Vaginal birth may be impossible 1. Place gloved hand in
● Fetal abnormalities the vagina and
○ Anomalies that can lead to dystocia manually elevating
○ E.g. hydrocephalus and anencephaly the fetal head off the
● Umbilical cord prolapses cord to prevent cord
compression (may
Prolapse of the Umbilical Cord only be done if the
● A loop of the umbilical cord slips down in front of the cord is not exposed to
presenting fetal part room air)
● May occur after membrane rupture if presenting part is not 2. Knee-chest position or
fitted firmly into the cervix Trendelenburg
(gravity is used to shift the fetus out of the maternal pelvis)
RISK FACTORS 3. Oxygen administration - 10 lpm by face mask (to improve
● Premature rupture of membranes (PROM) oxygenation to the fetus)
● Fetal presentation other than cephalic 4. Tocolytic agent (to reduce the uterine activity and pressure
○ The presenting part may not be fitted into the on the fetus)
cervix which could lead to the prolapse of the cord 5. Amnioinfusion
● Placenta previa ○ Another way to
○ The placenta is low lying relieve pressure
● Intra Uterine tumors on the cord
○ Will prevent the presenting part from engaging ○ Since prolapse of
● Small fetus the cord
○ It has a lot of space and won’t let the fetus fully happens usually
engage and may allow the cord to prolapse after the
● CPD membranes
○ Cephalo-pelvic disproportion prevents fetal have ruptured =
engagement ↓ amniotic fluid inside the womb
● Polyhydramnios ○ Addition of sterile fluid into the uterus to
○ Excessive amniotic fluid supplement the amniotic fluid and reduce
● Multiple gestation compression on the cord
○ Initially 500 mL is infused (warmed normal saline
because if cold, it may cause chilling), then rate is

adjusted to infuse the least amount necessary to ● Occiput posterior position is when the baby’s spine is lying
maintain FHR patterns against the spine of the mother and the baby is facing
○ POSITION: Lateral recumbent position to prevent towards the mother’s abdomen
supine hypotension ● A head in a posterior position does not fit the cervix like the
○ Nursing responsibilities head in an anterior position does which leads to
■ May be done until cervix is fully dilated or dysfunctional labor
CS birth can be arranged ● Occurs in women with android, anthropoid, or contracted
■ Continuous monitoring of FHR and uterine pelvis
contractions ○ Contracted pelvis - the diameters of the pelvis are
■ Monitor maternal temperature to check decreased
for signs of infection
■ Assess for constant drainage, if vaginal ASSESSMENT
leak has stopped → fetal head has ● Dysfunctional labor pattern
engaged and all fluid is being held in the ○ Prolonged active phase
uterus → POLYHYDRAMNIOS → UTERINE ○ Arrested descent
RUPTURE ● Fetal heart sounds heard best at the lateral sides of the
6. If cord is exposed to room air, cover any exposed portion abdomen
with a sterile saline compress to prevent drying ● Intense back pressure and pain in the lower back - sacral
NOTE: Never push any exposed cord back into the vagina because this nerve compression
could add to the compression of the cord. It may cause knotting or ○ When the fetal head rotates against the sacrum
kinking and cause oxygen insufficiency → placental insufficiency ○ Also known as back labor
Fetal blood sampling THERAPEUTIC MANAGEMENT

● Obtaining the fetal oxygen saturation level by inserting a ● Allow rotation
fetal oximeter into the uterus to gain access to fetal blood ○ Hands-and-knees position, squatting, lying on her
● Usually done through inserting a fetal oximeter into the uterus side (left side if fetus is ROP, right side if LOP)
to rest next to the fetal cheek or obtaining a positive ● “Lunging: or swinging body right to left while elevating left
response to scalp stimulation foot on chair
● Usually supplies information as to whether the fetus is ● Using peanut ball in between legs
becoming acidotic or to check if there is presence of anoxia ● Applying counterpressure on the sacrum to relieve a portion
of the pain via a back rub or via warm/cold compress
● Ask woman to void every 2 hours to keep the bladder empty
and avoid impeding the descent of the fetus
● IV glucose solution as ordered to restore the energy because
the mother might feel exhausted already due to prolonged
labor
● Maternal exhaustion is expected and can cause uterine
dysfunction so, a rotation of 135° may not be possible if the
contractions are ineffective or if the fetus is larger than
average
Problems with Fetal Position, Presentation or Size
Occiput Posterior Position Rebozo Method
● During internal rotation, ● Method of jiggling and massaging the uterus which may be
the fetal head must helpful in assisting the fetus to rotate to a better position
rotate not through a ● Video link;
90° arc but through an ○ https://www.youtube.com/watch?v=xGFwav5t8uw
arc of approximately 1. Put the scarf (sarong or lava lava ?) around the belly. Make
135° which entails a sure that it is around the whole belly.
prolonged labor 2. Hold each end of the sarong and turn your hands up and
because the arc of down. You’re gently turning the baby but encouraging them
rotation is greater to a really good position which is down to the front of the
● The occiput is directed diagonally and posteriorly, either to mother’s womb.
the right (ROP) or to the left (LOP) 3. This may be done for 10 minutes.

4. After sifting, it is encouraged to let the mother jump on the ○ traps the fetus in a breech presentation
birth ball to engage the baby in a good position. ● Any space occupying mass in the pelvis (placenta previa,
Surgical Management fibroid tumor of the uterus)
● Cesarean birth ○ does not allow the head to present → prevents
○ If the fetal head arrest in transverse position vertex presentation
(transverse arrest) or rotation may not occur at all ● Pendulous abdomen
(persistent occiput posterior position) ○ if the abdominal muscles are lax → there is a
○ Most women may need a great deal of labor tendency of the uterus to fall forward that the fetal
support because of the intense back pain so, you head comes to lie outside the pelvic ring causing
need to offer reassurance that even though her breech presentation
labor is not going smoothly, it is still within safe and ● Multiple gestation
controlled limits ○ presenting infant cannot turn to a vertex position or
● Forceps presentation
○ Help the fetus to rotate
○ Observe woman closely for hemorrhage from ASSESSMENT
cervical lacerations or infection during the ● Fetal heart sounds heard high in the abdomen
postpartum period ● Leopold’s maneuver and vaginal exam will reveal the
presentation
● If breech is complete, may firmly engage and presenting
Breech Presentation
part may be mistaken for a head upon vaginal examination
● Early in
● Ultrasound confirms breech presentation
pregnancy, you
may expect a
POSSIBLE RISKS
breech
● Developing dysplasia of the hip (dislocation)
presentation.
○ if there is faulty maneuver during delivery →
However, by week
dislocation of the hips
38 it will turn into a
● Anoxia from prolapsed cord
cephalic
○ If it is breech → presenting part may not fit or
presentation
engage fully → there is space and after the
● The fetal head may be the widest single diameter but the
membranes has rupture → cord may prolapse →
fetus legs and buttock take up more space. That’s why in
fetal anoxia
some cases there is breech presentation. The fetus turns to
● Traumatic injury (possible intracranial hemorrhage or anoxia)
cephalic presentation because the fundus is the largest part
○ Because of the pressure changes that has
of the uterus. The buttocks and lower extremities should be in
occurred spontaneously
the fundus.
● Fracture of the spine or arm
● Breech presentation is when the fetus presents buttocks or
● Dysfunctional labor
feet first (rather than the head first - a cephalic presentation)
● Early rupture of the membranes
● Types
○ because of poor fit of presenting part
○ Complete - the extremities are all flexed
● Meconium staining
○ Frank - the legs are extended towards the face
○ occurs not because of respiratory distress but
○ Footling - the legs will present first
because of cervical pressure on the buttocks and
the rectum because that is the presenting part
CAUSES
● Gestational age <40 weeks
CLINICAL ASSESSMENT OF BREECH (LEOPOLD’S MANEUVER)
○ the younger the baby is inside the womb, the
● 1st Maneuver: fetal head occupy the fundus
smaller the baby is → there is more room and
● 2nd Maneuver: fetal back on one side of the abdomen
space inside for the baby to rotate
● 3rd Maneuver: if not engaged, breech is movable above the
● Fetal abnormality (anencephaly, hydrocephalus,
pelvic inlet
meningocele)
● 4th Maneuver: if engaged, firm breech beneath the pelvic
○ In hydrocephalus, the widest fetal diameter is the
symphysis
head so it will retain its most comfortable position
● Polyhydramnios
○ allows for free fetal movement → fetus fits in the
uterus in any position
● Congenital anomaly of the uterus (mid septum)

● Angle of the head titled obliquely
NOTE: The diameter of the head of the fetus is presents to the pelvis
that is often too large for birth to proceed
RISK FACTOR
● Woman with contracted pelvis
● Placenta Previa
● Relaxed uterus of a multipara
BIRTH TECHNIQUE ● Prematurity
● if vaginal birth, woman is allowed to push after full dilatation
● Polyhydramnios
● Hazardous part of breech birth:
● Fetal malformation
○ Pressure of head against pelvic brim automatically
causes compression on the loop of cord
○ Intracranial hemorrhage because the pressure NOTE: because of this factors there will be a problem in firm
changes instantly which could result in tentorial engagement or it won’t allow the baby to be in a normal
tears → subdural hemorrhage → gross motor and presentation
mental incapacity or lethal damage to the fetus
ASSESSMENT
● Head that feels prominent
than normal with no
engagement apparent on
Leopold’s maneuver
○ Very hard to assess
the head
How Breech birth is being done: (page 615 for discussion of breech ● Head and back are both felt
birth) on the same side of the uterus
● Back is difficult to outline
● As the breech spontaneously emerges from the birth canal, it ○ because the back is usually concave → difficult to
is supported (once the buttocks emerges on the birth canal) outline , assess or palpate
with a sterile towel (hold and support) which is held against ● FHR may be transmitted to the forward-thrust chest and
the infant’s inferior surface heard on the side of the fetus where feet and arms can be
● For the delivery of the shoulders, the arm of the posterior palpated
shoulder may be drawn toward or downward by passing 2 ○ Need to do a forward-thrust chest → apply
fingers over the infant’s shoulder. Involves sweeping of the pressure on the side because it is concave → to be
shoulders. able to assess Fetal heart sound
● 3rd image - what they usually do, the 2 fingers of the right ● On vaginal examination, nose, mouth, or chin can be felt as
hand of the doctor are placed in the infant’s mouth and the presenting part
then the left hand is slid into the woman’s vagina, palm
down along the infant’s back and pressure is applied to the DIAGNOSIS
occiput to flex the head fully. Apply a gentle traction to
deliver the head ● Ultrasound is done to confirm
MANAGEMENT
Face Presentation
●
● “Asynclitic birth”
● If chin is anterior and pelvic diameters are within normal limits
● Refers to the position of a fetus
→ may be born without difficulty
in the uterus such that the
● If chin is posterior → Cesarean birth is the method of choice
head of the baby is presenting
Fetal Risk
first and is tilted to the shoulder
● Facial edema - purple from ecchymotic
causing the fetal head to no
bruising
longer be in line with the birth
● Lip edema - due to pressure during birth
canal
● Chin or mentum

● Observe closely for patent airway - assess the patency of the ● Associated with GDM
infant’s airway closely ● Size of the fetus (most specially if baby is too large) →
dysfunctional labor
NOTE: When the mother sees her baby in this condition, it may
RISK
cause anxiety to the mother so reassure the parents that the edema
● Uterine dysfunction during labor and birth
is transient and will disappear after a few days
○ Due to oversize fetus → difficult during labor and
delivery
Brow Presentation ● Can cause fetal pelvic disproportion
● Rarest presentation ○ Large baby may not fit to the pelvis → fetal pelvic
● Occurs in multipara or disproportion
woman with relaxed ● Uterine rupture - due to large fetus
abdominal muscles ● Perineal lacerations - due to overstretching of the uterus to
● Results in obstructed labor accommodate the big baby
○ because the head ● Hemorrhage
becomes jammed
or trapped in the
brim of the pelvis as MANAGEMENT
the occipitomental diameter presents → ● Cesarean birth - birth method of choice
dysfunctional labor ○ For the baby to be
● Cesarean birth is necessary to deliver infant safely delivered safely
○ unless the presentation spontaneously corrects itself ○
● Pelvimetry or ultrasound
Fetal risk ○ To confirm CPD of fetal
● Extreme ecchymotic bruising on the face (just like babies pelvic disproportion
born in face presentation; reassure that the bruising will
disappear for a few days) Fetal Risks
● Cervical nerve palsy - damage
Transverse Lie to the cervical nerve
● Occurs in women with ● Diaphragmatic nerve injury
pendulous abdomens, with ● Fractured clavicle
uterine fibroid tumors,
contraction of the pelvic brim,
NOTE: because the uterus is overstretched → is at risk for uterine
congenital abnormalities of
atony → monitor postpartum
the uterus, polyhydramnios
● Occurs in infants with
hydrocephalus, prematurity, Shoulder Dystocia
multiple gestation, short ● Birth injury that happens when one or both of the baby’s
umbilical cord shoulders get stuck inside the mother’s pelvis during labor
● Occurs at 2nd stage of labor, when fetal head is born but the
ASSESSMENT shoulders are too broad to pass through the pelvic outlet
● On inspection, the ovoid of the uterus is found to be more ● “Turtle neck sign or turtle sign”
horizontal - longitudinal should be vertical, but in transverse ○ Fetal head emerges and
lie it is horizontal (obvious) retracts against the perineum
● Abnormal presentation may be confirmed by Leopold’s ● Occurs in women with GDM, in
maneuver multiparas, post-date pregnancies
● Ultrasound to further confirm abnormal lie ● Suspected if prolonged 2nd stage of
● Cesarean birth is necessary if fetus is mature labor, arrest of descent, when fetal head
○ Cannot be born vaginally appears on the perineum (crowning) but retracts instead of
protruding → turtle neck sign
Macrosomia
● Oversized fetus MANAGEMENT
● Fetus weighs more than 4,000 to 4,500 grams (approx. 9-10 ● McRoberts Maneuver
lbs)

○ Widens the pelvic outlet and allow anterior

shoulder to be born
1. Legs (thighs) flexed onto abdomen
causes rotation of the pelvis, alignment of
sacrum, & opening of birth canal
2. Suprapubic pressure applied to fetal
anterior shoulder → help the shoulder out
from beneath the symphysis pubis →
facilitate delivery of the shoulder
○ Usual method used
*NICE TO KNOW*
● Gaskin Maneuver - Hands and knees
○ Woman placed on
hands and knees
○ Delivery is affected by
downward traction on
the posterior shoulder
or upward traction of
the anterior shoulder
○ On 4s
● Wood’s Corkscrew
○ 180 degree shoulder rotation
of posterior shoulder
○ Delivery of posterior shoulder
○ There is a manipulation of the
shoulders
Fetal anomalies
● another factor to consider and can also contribute to
dysfunctional labor
● Hydrocephalus
○ The diameter of the head

is bigger → problem in
vaginal birth
● Anencephaly
○ absence of the cranium
→ difficult for vaginal
delivery

COMPLICATIONS WITH THE PASSAGEWAY ■ Severe complication is the paralysis of

the extremities, especially the lower
Problems with the Passageway
extremities.
■ Upon entrance, you can see the
Dystocia
manifestations through the patient’s gait,
● Difficult labor
or if the patient is limping.
● Can arise from any of the four main components of labor
○ Injury (Pelvic trauma or fracture) - definitely affect
process : passageway, passenger, power, psyche
the anatomy of the pelvis
Pelvis - Maternal Pelvis

● The pelvis is a basin-shaped structure across the base of the
abdomen that:
1. Supports the spinal column
2. Protects the abdominal organs
● The route a fetus must travel from the uterus through the ● In multipara
cervix and vagina to the external perineum → passageway ○ Ask for history of prolonged labor
■ because she might have hx of prior CPD
Functions of the Pelvis or cephalopelvic disproportion and if she
● Protects and supports the pelvic visceral organs has undergone a operative vaginal
● Supports the weight of the body delivery like forceps or vacuum
● Provides muscle attachment extraction
● Aids in walking ○ Difficult Forceps/Vacuum extraction
○ Part of hx taking is to check if there is problem in ■ This could affect the pelvic floor
walking especially if there is trauma or injury in the
● In females, forms a bony passage for the birth canal area.
The pelvis is divided into 2 dimensions:

● False Pelvis
● True Pelvis ○ It starts from the pelvic inlet and then to the
pelvic cavity or the midplane (the distance between the ● Physical Exam
pelvic inlet and the pelvic outlet) and last is the pelvic outlet. ○ Short stature
■ if the woman is short, the thinking or
concept is she will also have a small
pelvis.
○ Small feet
○ Abnormal gait
■ There is
different type
of gait
NURSING ASSESSMENT depending on
● The responsibility of the nurse in interviewing the patient is the
very crucial. She needs to extract the information needed by affectation
the doctor to be able to come up with the proper diagnosis ○ Limb deformity
and proper management ○ Spinal deformity (Kyphosis scoliosis)
■ Affects the pelvis of the patient that
ASSESSMENT OF PELVIS could lead to intrapartum complications
● History of:
○ Rickets ● Obstetric Exam
■ if it happened during childhood, it would ○ Pendulous abdomen
cause softening and weakening of ■ the fetus would
bones. move very far
■ Usually, there is hx of delayed walking from the
and dentition. We have to ask that from maternal body
the patient.
○ Polio

○ Floating head at term in primigravida ● Narrowing of the anteroposterior diameter of the pelvis to less
■ Did not reach the station 0 than 11 cm , or of transverse diameter to 12 cm or less
○ Malpresentation, malpositions Pelvic cavity (Midplane)

■ do not forget Leopold’s Maneuver. Assess ● height, thickness, and inclination of
for the cephalic prominence. Even if the the symphysis.
presenting part is the head, but the head ● Shape and inclination of the
is extended or hyperextended → sacrum (Curvature)
problem during the delivery ○ Caldwell-Moloy
● Clinical examination Classification of Pelvis
○ Pelvimetry ● Side walls
■ Dr. will measure the dimensions of the ● Ischial Spine
pelvis and this is done through internal ● Interspinous diameter
examinations. Very important to ○ very important because it is the narrowest diameter
emphasize prenatal check-up because that the baby has to pass through
there is no way to assess this but through ○ 10 cm and is at station 0.
check-up. ● Sacrosciatic notch.
○ Radiographically (CT scan or MRI)
Pelvic Outlet
● Inferior pelvic aperture
● AP Diameter: 12.5 cm (greatest
diameter)
● Transverse Diameter: 11 cm
○ NOTE: between the two, pelvimetry is usually done
because it is more convenient and less expensive.
Problem: Outlet Contraction
● Narrowing of the
Muller-Kerr’s Method
Transverse Diameter,
● A valuable detection of the degree
the distance between
of disproportion - gloved hand
the ischial tuberosities
● Empty bladder and rectum
at the outlet, to less
● Dorsal recumbent
than 11 cm.
● Left hand pushes the head into the
pelvis
NOTE: any variation in the size, dimension, could pose problem during
● Right hand (thumb over the symphysis
the delivery and birth
pubis) detects disproportion
● 2 fingers are inserted through an internal exam that will
Measurement of the Pubic Arch
detect the disproportion.
● Angle of pubic arch should be at least
90 degrees
Pelvic Divisions and Measurements
● Significance:
Pelvic Inlet
○ Displaces the fetus
● Superior pelvic aperture
posteriorly toward the
● AP diameter - 11 cm
coccyx as it tries to pass under the arch.
● Transverse diameter - 12 cm
○ If the measurement is not adequate, is less than 90
(greatest diameter)
degrees most probably, the fetus will assume an
occiput posterior position that could further
Pelvic Divisions and Measurements
prolong labor and it will be more painful on the
1. True conjugate (AP) - subtract 1.5 cm from the diagonal
part of the mother.
conjugate
2. Obstetric conjugate - 11 cm
Caldwell-Moloy Classification of Pelvis - based on the shape of the
3. Diagonal conjugate - 12
pelvis
cm
● Gynecoid (circle)
4. Transverse diameter - 12
○ Most common and
cm
adequate type for vaginal
delivery.
Problem: Inlet Contraction

○ Good pelvic shape. CAUSES

○ Has wide diameters ● Larger than average Fetus
○ Gentle curves throughout 2. ○ macrosomic babies would pose great risk → came
● Android (heart) from mothers with DM or GDM conditions.
○ Heart or ● Abnormally high level of blood glucose from GDM or DM
triangular-shaped inlet. ○ it will influence the size of the fetus.
○ Narrow diameters ● Postmaturity, Post-term or Prolonged Pregnancy
throughout. ○ These three terms can be used interchangeably.
○ Narrow pubic arch ○ It has exceeded the duration of the pregnancy.
○ Male pelvis ● Size and Shape of the pelvis
● Platypelloid (oval) ○ influenced by race, genes, and injuries to the pelvis
○ The transverse diameter that could affect the anatomical condition of the
is wide but the AP pelvis.
diameter is short. ● Abnormal Fetal Position
○ Oval shaped ○ take note the findings of Leopold's Maneuver.
○ Even if the head is the presenting part, we should
● Arthropod also check for cephalic prominence, because
○ More favorable than ----- sometimes the face or brow is the presentation →
ma’am,,, hng affects the labor and delivery.
● Short women
○ Height is less than 150 cm or if the woman is less
NOTE: variations in the maternal bony pelvis or soft tissue problem that than 5 feet.
inhibit fetal descent → dysfunctional labor
NOTE: any variations in the size, shape, hx of the patient would greatly Symptoms of CPD
influence the labor of the patient ● Prolonged Labor
NOTE: The problem lies in the disproportion or mismatch of the maternal ○ Ang tagal ng labor.
pelvis and the fetal head ○ there is no progression of labor, there is no dilation
of the cervix after several hours.
● Large Fundal Height
MINOR MODERATE MARKED
○ in cases of macrosomic babies.
The anterior surface The anterior surface ● High Volume of Amniotic Fluid
of the head is in line of the head is in line ○ Two concepts to remember: swallowing and
with the posterior with the anterior urination of the fetus → influence the amount or
surface of the surface of the the volume of the amniotic fluid
symphysis symphysis. ○ high volume is an indicative of a large baby →
problem → CPD
During labor, head is
engaged due to
moulding (following DIAGNOSIS
the contour of the ● Pelvimetry
curvature of the ○ The Dr. will measure the different divisions and
pelvis) dimensions of the pelvis.
● Ultrasound
Vaginal delivery can Vaginal delivery Vaginal delivery is
○ can measure the size of the head of the fetus, the
be achieved may or may not be impossible.
BPD or Biparietal Diameter, Occipitofrontal
possible.
Best mode of Diameter, and the circumference of the head of
delivery is through the fetus.
C-section. NOTE: if the diagnosis suggests CPD, evaluate risk factors
● Checking of maternal Blood Glucose
● NST or Non-stress test
Cephalo-Pelvic Disproportion
○ to monitor the well-being of the fetus.
● A condition when the fetal head is too
large to fit through the maternal pelvis.
If CPD has been confirmed
● There is a mismatch in the size
● If vaginal birth is not possible especially if marked CPD →
● CPD is one of the top indications for
C-section delivery
C-section.

● If vaginal birth is possible and if C-section is harmful to the

Does not know how long to
baby → instruct the woman to change her position into
wait.
squatting position. → If changes in the position are performed ● But in the book, if it is
but still have no progress of labor, another technique that already 12 hours and
could be done is the assisted vaginal delivery or the there is still no progress
operative vaginal delivery (which could be forceps assisted in labor, the doctor
delivery or vacuum assisted delivery. will order for c-section.
If it fails, maternal & fetal

NOTE: The usual position during delivery in the Philippines is the mortality is higher.
Lithotomy position. The best position if there is CPD is squatting since
it will increase the pelvic capacity up to 25-30%. depending on the Assessment: LM
facility. Q: : If the doctor suspects breech presentation what can he/she do?
● LM should have a back-up assessment with Ultrasound to
check what is the position of the baby.
Trial Labor A: ECV (external cephalic version)
● Every woman is given a chance to undergo a trial of labor. ● And if through LM and UTS, the doctor found out that the
● There are some problems or conditions that can only be seen baby is in breech position, the doctor can do ECV or external
once the labor starts. Subukan muna mag labor cephalic version
● A clinical test for the factors that cannot be determined
before the start of labor such as: External Cephalic Version
○ Efficiency of uterine contractions - ● The use of external manipulation (turning) on the mother’s
■ we have to wait for the true labor to abdomen to convert a breech to a cephalic presentation
occur before we assess for this. ○ Iikot ang baby
○ Moulding of the head ● May be done as early as 34 to 35 weeks AOG although usual
○ Yielding of the pelvis and the soft tissues time is between 37 to 38 weeks of pregnancy.
Can be done if:
● If the woman has borderline inlet measurement
○ if it is really marked CPD, usually, she will not
undergo labo → for c-section only.
● If fetal lie and position are good It should be offered:
● If the primary care provider will allow her a “trial” labor to ● At term
determine whether labor will progress normally ● By a practitioner skilled and experienced in the procedure
○ It is still under the discretion of the dr if the woman ○ If you do not know how to perform this, do not do it
has to undergo the trial of labor because it will pose more harm to the mother and
the fetus.
○ Usually performed by a skilled obstetrician.
NURSING RESPONSIBILITIES ● Should be undertaken only in a unit where there are facilities
● Monitor FHR for emergency delivery
● Monitor Uterine Contractions ○ Cannot be seen in a lying-in, clinics
○ Usually, if there is fetal distress + no progres of labor Before the procedure
in 6-12 hours (book) → marker for the doctor to ● US scanning is done to:
possibly order for c-section delivery. ○ Determine fetal position
● Encourage the woman to void every 2 hours ○ Locate umbilical cord
○ empty the bladder so that the fetus can use the ○ Rule out placenta previa
space ○ Evaluate adequacy of maternal pelvis
○ Assess amount of amniotic fluid
○ Assess fetal age
Advantages Disadvantages
■ because this is not done if we have a
premature baby
Decreases C-section rate No well defined cut off point.
○ Presence of any anomalies
● It is still subjective and
If it is successful, it practically depends on the
guarantees delivery through the doctor.
vagina.

CLASSIFICATIONS
NOTE: ECV are performed appropriately by trained obstetricians or
● Low Cavity Forceps
midwives should perform the procedure
○ Used when the head has reached the pelvic floor
and is visible at the vulva.
● Tocolytic agents may be administered to help relax the ● Mid Cavity Forceps
uterus (Terbutaline) ○ used when the head is engaged and the leading
● Breech and vertex of the fetus are located and grasped by part is below the level of the ischial spine.
the examiner’s hand (gloved hand) ● High Cavity Forceps
● Gentle pressure is then exerted to rotate the fetus in a ○ considered unsafe
forward direction to a cephalic lie.
NOTE: Among the 3 classifications, the usual forceps delivery done is
CONTRAINDICATION the low cavity forceps delivery.
● Multiple gestation
● Severe oligohydramnios Before forceps are applied (prerequisites)
● Small pelvic diameter ● Membranes must be ruptured
● Cord that wraps around the fetal neck ○ Otherwise → difficulty in pulling the baby; there is
○ Poses more risk for fetus’ strangulation still an amniotic fluid
● Unexplained 3rd trimester bleeding ● CPD must not be present
○ There could be an involvement of the placenta. ○ especially and definitely if it is marked CPD →
impossible for vaginal birth
● Cervix must be fully dilated
NURSING RESPONSIBILITIES ● Bladder must be emptied
● Ask the patient to sign the consent form.
○ Do not forget this before the procedure has been TYPES OF OBSTETRIC FORCEPS
performed ● Wrigley’s Forceps
● Recheck all essential prerequisites prior to the procedure. ○ designed for use when the
○ AOG head is on the perineum.
○ Make sure that there are no anomalies based on ● Neville-Barnes or Barnes-Neville
the US ○ used for low cavity or mid
● Ask the patient to empty the bladder. cavity delivery when the
● Place the patient in a recumbent position sagittal suture is in the AP
○ May also apply wedge under the buttocks of the diameter of the cavity/outlet
patient of the pelvis.
● Prepare material for lubrication of maternal abdomen ● Simpson’s Forceps
○ mineral oil, ultrasound gel, or talcum powder can ○ Most common type that you will see
be used in our institution.
○ It is used for low cavity or mid cavity
Instrumental delivery delivery when the sagittal suture is in
● Two methods are used: Forceps assisted delivery or vacuum the AP diameter of the cavity/outlet
assisted delivery of the pelvis.
Forceps birth (forceps assisted delivery) ● Keilland’s Forceps

○ designed to deliver the fetal
INDICATION head or at above the pelvic
● Woman is unable to push with contractions brim.
○ usually if the woman is given or received regional
anesthesia or has spinal cord injury, and bearing NURSING RESPONSIBILITIES
down or pushing cannot be achieved. ● Monitor and Record FHR
● Cessation of descent in the 2nd stage of labor ● Ask the patient to sign the consent form
○ Trial of labor → no progress → cessation of descent ○ before the procedure
→ forceps birth ○ Check first if the patient as signed the consent form
● Fetus is in abnormal position ● Prepare the materials for the procedure
● Fetus is in distress from a complication ● Prepare the patient for possible episiotomy

○ to facilitate the delivery of the fetus and to prevent ○ not indicated for infants who had fetal scalp blood
perineal lacerations → episiotomy sampling because you will apply the suction in the
● Record time and amount of first void after delivery. head and more trauma or lacerations in the area
could happen
● Full cervical dilatation
NOTE: Before we apply the forceps, the doctor will administer the
● Facilities for neonatal resuscitation
pudendal block (administration of the anesthetic agent through the
○ should be done in the hospital setting.
pudendal nerve.)
● Usually anesthetic agent used is the lidocaine SOME EQUIPMENTS USED FOR VACUUM EXTRACTION
hydrochloride
● MityOne
● Kiwi
COMPLICATIONS
MATERNAL FETAL
Trauma or soft tissue damage Marks on baby’s face which NURSING RESPONSIBILITIES
(perineum, vagina, or cervix) can be caused by the pressure ● Ask the patient to sign the consent form
● If there is no of the forceps ● Prepare the materials for the procedure
episiotomy → more ● Prepare the patient for possible episiotomy
damage on the ○ like what we did in forceps delivery.
perineum.
● Monitor the patient’s VS
Excessive bruising form the ● Monitor FHR

Rectal-sphincter tears
● Dyspareunia - painful forceps
intercourse COMPLICATIONS
● Anal incontinence Facial palsy - pressure from a
● Increased urinary blade compressing a facial
stress incontinence nerve Maternal Fetal
Hemorrhage Perineal laceration Marked caput

Dysuria succedaneum
Painful perineum (cone-shaped)
Postnatal morbidity - most on the head
severe brought about
the pressure of
the vacuum
Vacuum Extraction (Vacuum assisted delivery) that may be noticeable as long
as 7 days after birth.
INDICATION ● Looks like a bump but
● Women are unable to push with contractions. is subsides after the
delivery
● Cessation of descent in the 2nd stage of labor.
Scalp lacerations
● fetal distress
Cephalhematoma
NOTE: results from the maternal exhaustion

Intracranial hemorrhage
ESSENTIAL PREREQUISITES
● Informed consent
NURSING DIAGNOSIS
○ Always make sure that the patient have signed the ● Fear related to uncertainty of pregnancy outcome
informed consent ○ the woman doesn't know what is going to happen.
● Gestational age >36 weeks What we can do is to support the patient and it is
○ not indicated for preterm infants because the more best to inform the patient on the progress of labor.
that you could pose the infant to further harm ● Anxiety related to medical procedures and apparatus
● Engaged fetal head necessary to ensure health of woman and fetus

○ The woman is hooked to tocodynamometer and

fetal monitor and was told about the possibility of
forceps or vacuum assisted delivery → become
more anxious so it is best to inform the patient
about the significance/importance of applying the
apparatus to her; for the monitoring of her
well-being and fetal well-being.
● Ineffective coping related to lack of knowledge or lack of
preparation for labor
○ Especially if the patient is primi, nurses should
provide health teachings on proper breathing
techniques, other comfort measures (best position
during labor) and other techniques like imagery,
thinking of something that would relax the patient,
and be supportive.
● Fatigue related to prolonged labor
○ Sometimes the patient would cry or ask for CS, →
support the patient, proper breathing techniques,
and instruct the patient to rest between
contractions.
● Risk for ineffective tissue perfusion related to excessive blood
loss with complication of labor
○ we expect that there is blood loss may it be normal
or CS delivery → important to monitor the patient
and the VS of the patient.
● Risk for injury (maternal or fetal) related to the effect of labor
complication and treatment required
○ as nurses, we have to prepare all the materials
needed, we do all proper assessment because our
goal is a healthy baby and healthy mother, and
want, as much as possible to have successful labor
and delivery of the fetus
Smile! Be someone’s sunshine today - Matienzo, 2021 :))

Nursing Care of A Family Experiencing A Complication of Labor or Birth

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Nursing Care of A Family Experiencing A Complication of Labor or Birth

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Nursing Care of a Family Experiencing a Complication of Labor or Birth OB LECTURE

Ma’am Anne Maris L. Rellama, RN, MAN

1 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

Hypertonic Contractions ● Illustration B: Hypotonic contractions

○ Greater than 5 contractions per 10 mins (ex. in relaxation of uterus)

graph, 5 contractions in only 7 mins) ● Illustration C: Hypertonic contractions

stimulating contractions above normal resting tone of 10-15 mmHg)

● Muscle fibers of the myometrium do not re-polarize or relax

● Sedation - helpful in hypertonic because it can alleviate pain

2 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

If all the mentioned measures are ineffective, the ff are done:

3 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

Secondary Arrest of Dilatation Arrest of Descent

4 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

○ An increase in the uterine contraction may INDUCTION & AUGMENTATION OF LABOR

○ So that even if a sudden birth occurs, it can be

5 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

INDUCTION OR AUGMENTATION OF LABOR WITH OXYTOCIN

● Presenting part is the fetal head

6 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

7 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

REMEMBER: Used to promote cervical ripening and dilatation. After

8 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

INCOMPLETE UTERINE RUPTURE

9 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

10 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

11 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

○ Occiput-anterior position - best position favorable of the anterior fontanel

○ Right or left of the maternal pelvis ○ Measures 9.5 cm

○ Anterior, posterior or transverse ○ Measures 13.5cm

■ Depends on whether the landmark is in ○ Constitutes an absolute fetopelvic disproportion

font, back, or side of the pelvis ○ Vaginal delivery may be impossible

■ Can be left occiput-anterior or right

12 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

13 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

Fetal blood sampling THERAPEUTIC MANAGEMENT

14 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

15 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

● Angle of the head titled obliquely

16 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

17 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

○ Widens the pelvic outlet and allow anterior

○ The diameter of the head

18 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

COMPLICATIONS WITH THE PASSAGEWAY ■ Severe complication is the paralysis of

Pelvis - Maternal Pelvis

The pelvis is divided into 2 dimensions:

19 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

○ Malpresentation, malpositions Pelvic cavity (Midplane)

20 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

○ Good pelvic shape. CAUSES

21 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

● If vaginal birth is possible and if C-section is harmful to the

If it fails, maternal & fetal

22 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

Forceps birth (forceps assisted delivery) ● Keilland’s Forceps

23 SACRAMENTO | SALUD|SANTOS, C. | SANTOS, Z | SAPALO | SAUL | SERRANO | SUMABAT

Excessive bruising form the ● Monitor FHR

Hemorrhage Perineal laceration Marked caput