COMPLICATIONS OF LABOR
rotation -- C/S
PASSENGER
 Occipitoposterior Position
a. Occiput is directed diagonally &
posteriorly e.g. ROP or LOP
b. Common in women with
android, anthropoid or
contracted pelvis
PASSENGER
 Dysfunctional labor pattern e.g
prolonged active phase
 > cord prolapsed since head does not fit
snugly the cervix
 Intense pressure & pain in lower back
due to sacral nerve compression.
Nursing Care
 sacral counterpressure e.g. Back rub,
change position
 heat or cold application
 side lying opposite fetal back
 maintain hands & knees position – help
fetus rotate
 voids q 2 hours – full bladder impedes
fetal descent
 may need IVF glucose sol to replace
glucose stores for energy
 Maternal exhaustion -Ineffective
uterine contractions - uterine
dysfunction - transverse arrest of
fetal head -- persistent
occipitoposterior position, no
Nursing care:
 emotional support to prevent panic
 fear , things are not going “by the book”
 frequent reassurance that labor is w/in
safe, controlled limits
 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:
1. FHT
2. Leopolds Manuever
3. Vaginal exam
4. Sonography
Nursing Care
 Monitor FHR & uterine contraction – det
fetal distress due to cord prolapse
 Vital signs
 Watch for Signs of infections
 Birth technique
o push only after full dilatation
o support w/ sterile towel as
breech spontaneously emerge
Breech Presentation
 deliver gradually & spontaneously to
prevent intracranial injury & hypoxia
 Aid delivery of head w/ the fetal trunk
straddled over the physician’s right
forearm, two fingers at infants mouth.
Head my be aided by piper forceps to
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
pres part  cord prolapsed & shoulder may
obstruct cervix - C/S
OVERSIZED FETUS
 Fetus weighs more than 4,000 to 4,500
gms
 Common in DM, multiparity may lead
to:
o uterine dysfunction
o overstretching of endometrium
o fetal pelvic disproportion due
wide shoulder
 Uterine rupture due to obstruction
 C/S to prevent:
o fetal cervical nerve palsy
o diaphragmatic nerve injury
o fractured clavicle due to
shoulder dystocia
 pp maternal risk of bleeding due
overdistended uterus
SHOULDER DYSTOCIA
 common in DM, multipara & post date
pregnancy
 occurs with increasing ave weight of NB
 suspected in prolonged 2nd stage of
labor
o arrest of descent
o head is crowning but retracts
instead of protruding with each
contraction  turtle sign
 2nd stage of labor , fetal head is born but
shoulders are too broad to enter pelvic
brim  mat risk of vaginal or cervical
tears, fetal risk cord compression bet
fetal body & pelvis
 Forced birth  fetal fractured clavicle or
brachial plexus palsy
Nursing care:
 McRobert’s Maneuver - ask mother to
flex thighs sharply on her abdomen to
widen pelvic outlet & deliver anterior
shoulder
 apply suprapubic pressure - help
shoulder escape from beneath the
symphysis pubis & be delivered.
FETAL ANOMALIES
 fetal presenting part does not engage
well as in hydrocephalus or
anencephaly
PROBLEMS WITH PASSAGE
 Dystocia due to contracted or narrowing
of passageway at inlet, midpelvis or
outlet  CPD  failure to progress in
labor
INLET CONTRACTION
 Narrowing of the anteroposterior dm to
less than 11 cm or transverse dm to less
than 12cm
 Cause by rickets in early life
 If no engagement in primi suspect:
o fetal abnormality – larger than
usual head or
o pelvic abnormality – smaller
than usual pelvis
o w/ CPD fetus does not engage
but remains “floating” 
malposition occurs
o if w/ PROM  cord prolapse
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
 trial labor may be done if woman has
borderline or adequate inlet
measurement and fetal lie or position
are good
Nursing Care:
 monitor FHT
 void q 2hrs
o assess if engage, station,
PROM, prolapsed cord
 o if no progress of labor 12hrs 
C/S
o reassure woman, support
system
o manage fear & pain
EXTERNAL CEPHALIC VERSION
 It is the turning of the fetus from breech
to cephalic position before birth.
o Done at 34 to 35 wks
o Record FHR w/ U/S
o Tocolytic agent may be adm to
help relax the uterus
o Fetal breech & vertex grasped
transabdominally on the
woman’s abdomen
o Gentle pressure exerted to
rotate the fetus in forward
direction to a cephalic lie
o May help decrease C/S birth
o C.I. – multiple gest, severe
oligohydramnios, cord wraps
around the neck, unexplained
3rd trim bleeding
Note:
 Women who are Rh negative should
receive Rh immunoglobulin p proc if
minimal bleeding occurs.
INDUCTION & AUGMENTATION OF
LABOR
Induction of Labor – labor started artificially,
necessary because the fetus is in danger,
primary reasons include:
 Preeclampsia, eclampsia
 DM
 RH sensitization, prolonged PROM
 IUGR
 Postmaturity
Induction may be done w/ ff conditions:
 fetus is longitudinal lie
 cx is ripe
 Pres part engage
 no CPD
 full term as shown in U/S, L/SW ratio
AUGMENTATION OF LABOR
 refers to assisting labor that ahs started
spontaneously to be more effective,
necessary for hypotonic uterus. Carries
risk of:
o uterine rupture
o < fetal blood supply due to poor
placental perfusion
o Abruptio placenta
 Used cautiously in women w/ multiple
gestation, hydramnios, grand parity
previous uterine tears, age > 40
Cervical ripening
 1st step in early labor - change in the
cervical consistency from firm to soft
Methods to ripen the cervix:
a. “stripping the membranes” or separating
the membranes from the lower uterine
segment manually using a gloved finger
in the cervix – easy proc done during
clinic visit.
Complications include:
 Bleeding from undetected low lying
placenta
 Inadvertent rupture of membranes
 Infections
b. hygroscopic suppositories – seaweed
that swell on contact w/ cervical
secretions.
Procedure:
 inserted gradually & gently urge
dilatation of the cervix
 held in place w/ OS saturated w/ PVP
or antifungal cream
 document number of OS inserted so
none remains
c. Prostaglandin gel
e.g. misoprostol 2-3 doses– commonly
used to speed cervical ripening, inserted
to the interior surface of the cervix by
catheter or suppository or external
surface by applying it to a diaphragm
against the cervix
Nursing care:
 bed rest on side lying position – prevent
leakage of medication
 monitor FHR cont 30 min after each
application (2hrs p vagl insertion)
 observe for side effects – vomiting,
fever, diarrhea, & HPN
 Oxytocin induction may be started 6-12
hrs after the last prostaglandin dose
  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 limitsfetal
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.