CARE OF MOTHER AND CHILD SEM 02 | 01

LECTURE / AT RISK OR WITH ACUTE/CHRONIC PROBLEMS AUF-CON

MODULE 05.1 – HIGH-RISK LABOR AND DELIVERY [OBSTRUCTED LABOR AND

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PROBLEMS OF THE PASSENGER]
5. This is the measurement between the anterior
OUTLINE surface of the sacral prominence and the posterior
I Obstructed Labor surface of the inferior margin of the symphysis pubis.
II Problems of the Passenger a. Diagonal Conjugate
A Fetal Distress
B Prolapsed Umbilical Cord b. Interspinous Diameter
C Multiple Gestation c. Conjugate Vera
D Fetal Malposition and Malpresentation d. Ischial Tuberosity
i Occipitoposterior Position
ii Breech, Face, Brow Presentation
iii Transverse Lie 6. The pelvic inlet is rated as adequate for childbirth if
E Macrosomia the diameter is more than:
F Fetal Anomalies
a. 10.5 cm
b. 11.5 cm
INTRODUCTION c. 12.0 cm
d. 12.5 cm
PRETEST
7. A loop of the umbilical cord slips down in front of the
1. A type of obstructed labor when true labor lasts for presenting fetal part that occurs anytime after the
more than about 8 hours without entering the active rupture of membrane:
first stage: a. Meconium Staining
a. Prolonged Active Phase b. Placenta Previa
b. Prolonged Second Stage c. Prolapse Umbilical Cord
c. Prolonged Latent Phase d. Hydramnios
d. Hypotonic Contractions
8. The optimal position of the baby for vaginal birth is:
2. It determines whether vaginal route of delivery will be a. Right Occiput Anterior
safe for both the infant and the mother: b. Right Occiput Transverse
a. Amniocentesis c. Right mentum Anterior
b. Pelvic Measurements d. Left Sacrum Posterior
c. MRI
d. All of the Above 9. This refers to the route the fetus must travel from the
uterus through the cervix and vagina to the external
3. The inlet of this type is well rounded forward and perineum; because these organs are contained inside
backward, and the pubic arch is wide. This pelvic type the pelvis, the fetus must also pass between the pelvic
is ideal for childbirth. ring.
a. Anthropoid a. Passageway
b. Gynecoid b. Passenger
c. Platypelloid c. Power
d. Android d. Psyche

4. This is the distance between the anterior surface of 10. This refers to good emotional state of the mother
the sacral prominence and the anterior surface of the which helps her cope with the pain effectively; helps
inferior margin of the symphysis pubis. It is the most her tune in to her body and helps guide her to her
useful measurement for estimation of pelvic size: baby’s needs:
a. Diagonal Conjugate a. Passageway
b. True Conjugate b. Passenger
c. Conjugate Vera c. Power
d. Ischial Tuberosity d. Psyche

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 MODULE 05.1 – HIGH-RISK LABOR AND DELIVERY [OBSTRUCTED LABOR AND PROBLEMS OF THE PASSENGER]
11. This is supplied by the fundus of the uterus and
implemented by uterine contractions, a process that
causes cervical dilatation and the expulsion of the
fetus from the uterus.
a. Passageway
b. Passenger
c. Power
d. Psyche
12. This refers to the fetus' appropriate size and in an
advantageous position and presentation.
a. Passageway
b. Passenger
c. Power
d. Psyche
13. A type of contraction problem where the number of
contractions is infrequent (not more two or three
contractions in a 10-minute period); the resting tone of
the uterus remains less than 10mmHg, and strength of
contraction does not rise above 25 mmHg:
a. Hypertonic Uterine Contraction
b. Hypotonic Uterine Contraction
c. Uncoordinated contraction
d. Prolonged Contraction
14. A type of dysfunctional contraction where in more
than one pacemaker may be initiating contractions
with uncoordinated contractions, or receptor points in
the myometrium may be acting independently of the
pacemaker:
a. Hypertonic Uterine Contraction
b. Hypotonic Uterine Contraction
c. Uncoordinated contraction
d. Prolonged Contraction
15. A type of contractions are marked by an increase in
resting tone to more than 15 mmHg, single contractions
lasting 2 minutes or more, or five more contractions in
a 10 minute period.
a. Hypertonic Uterine Contraction
b. Hypotonic Uterine Contraction
c. Uncoordinated contraction
d. Prolonged Contraction
MODULE PROPER
OBSTRUCTED LABOR
A. OBSTRUCTED LABOR
● Primarily defined as the failure of the fetus to
descend through the birth canal
○ CAUSE: Presence of impassable barrier
(obstruction) that prevents its descent despite
strong uterine contractions
○ LOCATION: Usually occurs at the pelvic brim,
but occasionally it may occur in the pelvic
cavity or at the outlet of the pelvis
○ RISK: When labor is prolonged because of
failure to progress, there is a high risk that the
descent of the fetus will become obstructed
CAUSES OF OBSTRUCTED LABOR
POWER (CONTRACTIONS)
● Either the uterine contractions are not strong
enough to efface and dilate the cervix in the first
stage of labor, or the muscular effort of the uterus
is insufficient to push the baby down the birth
canal during the second stage.
● Major cause of prolonged labor
PASSENGER (FETUS)
● Prolonged labor may occur if the fetal head is too
large to pass through the mother’s pelvis, or the
fetal presentation is abnormal
PASSAGE (BIRTH CANAL)
● The mother’s pelvis is too small for the baby to
pass through
● The pelvis has an abnormal shape
● There is a tumor or other physical obstruction in
the pelvis
PSYCHE (PERCEPTION)
● Problems may arise such as inability to bear down
properly, fear and anxiety.
B. PROLONGED LABOR
● No single definition of prolonged labor because
what counts as ‘too long’ varies with the stage of
labor
● PROLONGED LATENT PHASE OF LABOR
○ True labor lasts for more than about 8 hours
without entering into the active first stage
● PROLONGED ACTIVE PHASE OF LABOR
○ True labor takes more than about 12- 14 hours
without entering into the second stage.
● PROLONGED SECOND STAGE OF LABOR
○ Multigravida mother: when it lasts for more
than 1 hour
○ Primigravida mother: when it lasts for more
than 2 hours
○ Although labor can be classed as ‘prolonged’ at
any stage, note that obstructed labor most
commonly develops after the labor has
entered the second stage
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PROBLEMS OF THE PASSENGER ○ Blood flow is distributed to the two babies;

sometimes happen only in 1 infant
A. FETAL DISTRESS
B. FETAL DANGER SIGNS OF LABOR
● A condition in which the fetus develops a problem
during the mother’s labor: fetus is not well and
● ↑ or ↓ fetal heart rate
excessively fatigued → fetal hypoxia
● FETAL HYPOXIA NORMAL TACHYCARDIA BRADYCARDIA
○ Problems with oxygenation and circulation 110–160 bpm >160 bpm <110 bpm
○ Can lead to acidosis (compromises blood flow
to the organs), causing learning disabilities, ○ Tachycardia: compensatory mechanism for
mental retardation, and seizures later in life decreased oxygenation and poor tissue
○ NURSING RESPONSIBILITIES perfusion
● Careful monitoring of labor on vital signs, ○ NURSING RESPONSIBILITY: MONITORING
FHR and uterine contractions ● Done by fetoscope, Doppler, or a monitor
● Checking late decelerations and fetal ● WOF late/variable decelerations as these
movements (hyperactivity indicates that indicate uteroplacental insufficiency or
the baby is struggling for oxygen; or cord compression
decreased fetal movements)

I. ASSESSMENT

A. CAUSES

● Strong contractions
○ Intense contractions, induced by oxytocin,
compress umbilical cord and tighten muscles
which decrease placental flow and vena cava
compression
○ NR: Careful administration of oxytocin via IV
● Infection (amnionitis)
○ Infections during pregnancy can cause fetal ● Meconium staining
distress by damaging the placenta ○ NOTE: This is not always a sign of fetal distress
● Reduces the placenta's ability to function but is highly correlated with its occurrence
properly and lead to a decrease in oxygen ○ Presents as green color in amniotic fluid
and nutrient supply to the fetus ● CAUSE: Fetus has had a loss of rectal
● Abruptio placenta and cord prolapse sphincter control, allowing meconium to
○ Decreases blood flow to the fetus pass into the amniotic fluid
○ In AP, placental blood flow is disrupted, ○ Stimulation of the vagal reflex because
consequently affecting fetal supplementation of hypoxia
● Oxytocin ○ This leads to increased bowel motility =
○ Promotes uterine contraction which decreases losing control of rectal sphincter
blood flow; vasoconstrictor
● Hypotension Nakain ni baby and nag-lodge sa bronchioles →
○ Decreased BF to placenta and to the fetus from narrowed airways → hypoxia → stimulate vagal
reflex → increased bowel motility
epidural anesthesia
○ For painless labor: wait for 5 cm dilatation and
○ Although this may be usual in a breech
active phase before administering
presentation because pressure on the buttocks
○ Best position: left-lateral to remove pressure on
causes meconium loss, it should always be
vena cava (supine hypotension syndrome)
reported immediately even with breech
● Shoulder dystocia
presentations so its cause can be investigated
○ Fetus is huge enough to prolong labor
● Hyperactivity
(horizontal lie: acromion/shoulder as the
○ Ordinarily, a fetus remains quiet and barely
presenting part)
moves during labor
● Multiple births

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 MODULE 05.1 – HIGH-RISK LABOR AND DELIVERY [OBSTRUCTED LABOR AND PROBLEMS OF THE PASSENGER]
○ May be a subtle sign that hypoxia is occurring
because frantic motion is a common reaction
to the need for oxygen
● Low oxygen saturation
○ Normal: 40–70%
○ Assessed by inserting a catheter next to the
cheek (<40% = further assessment)
● Fetal acidosis
NORMAL >7.25 during labor
(+) ACIDOSIS <7.2
○ Scalp puncture: manner by which the fetal
blood is obtained for pH level assessment
○ WHY IS THIS A CONCERN?
● If the fetal cells are acidotic, this means
that oxygen cannot be used = hypoxia
II. MANAGEMENT
● CESAREAN DELIVERY
○ To urgently deliver the baby when
manifestations arise
○ NSD AS MODE OF DELIVERY: done if mother is on
her 9–10 cm dilation and +2-3 station when the
fetus experiences hypoxia
● LABOR INDUCTION
○ Labor is started artificially
○ Assessment: check for cervical dilatation and
appropriateness of maternal pelvis as these aid
in acceleration of childbirth process
○ Oxytocin: administered to promote uterine
contractions
○ Primrose oil and cerviprime: administered to
soften the cervix
● EPISIOTOMY
○ To hasten the delivery and to avoid lacerations
○ Repaired using episiorrhaphy
● FORCEPS DELIVERY
○ Done if there are decreased fetal movements,
(-) contractions, and maternal inability to bear
down
B. PROLAPSED UMBILICAL CORD
● Loop of the umbilical cord slips down in front of the
presenting fetal part
○ May occur at any time after the membranes
rupture if the fetal presenting part is not fitted
firmly into the cervix
● Happens in 0.5% of cephalic births and
15–20% of breech/transverse births
● ❗ ALWAYS AN EMERGENCY
○ Causes cord compression as the fetal part
presses against the pelvic brim → fetal distress
and may further lead to fetal anoxia
PROLAPSE OF THE UMBILICAL CORD
A. The cord is prolapsed but still within the uterus
B. The cord is visible at the vulva
In both instances, the fetal nutrient supply is being
compromised, although only a cord such as that
shown in image B would be visible. Both prolapses
could be detected by fetal monitoring
I. ASSESSMENT
A. CAUSES
● Polyhydramnios
○ Excessive amount of free fetal movements
leading to rapid descent of the presenting part
and increasing the risk of the cord slipping past
the baby's head
● Intrauterine tumors
○ Leaves no space, preventing the presenting
part from engaging
● Malposition and malpresentation
○ Causes fetus to move erratically during labor,
leading to cord prolapse as the presenting part
may not be well applied to the cervix
● Prematurity
○ Fetus may be small and have a weakly
developed cord, increasing the risk of prolapse
during delivery
● Placenta previa
○ Low implantation of the placenta prevents firm
engagement of fetal head/presenting part
● Multiple gestation
○ Cord can become compressed between the
fetuses or as one fetus descends, the cord of
the other twin can slip past the presenting part
and prolapse
● Premature rupture of membranes
○ The increased pressure inside the uterus and
amniotic fluid that is released can cause the
umbilical cord to slip past the presenting part
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 MODULE 05.1 – HIGH-RISK LABOR AND DELIVERY [OBSTRUCTED LABOR AND PROBLEMS OF THE PASSENGER]
● Small fetus
○ Presenting part does not fit; cord slipping past
the baby's head
● Cephalopelvic disproportion
○ Prevents firm engagement, especially if the
head does not fit
B. GENERAL ASSESSMENT
● Cord as the presenting part: discovered on an
initial vaginal examination during labor or through
visualization on ultrasound if one of these is taken
during labor
○ Happens only on rare occasions
● ROM and abnormal FHR: these signs may lead to
the discovery of a prolapsed cord; the cord is visible
at the vulva upon inspection
● RULING OUT CORD PROLAPSE
○ Immediately assess fetal heart sounds after the
rupture of membranes
○ 📌 REMEMBER: ROM is one of the causes of cord
prolapse d/t exertion of pressure
C. SIGNS AND SYMPTOMS
● Cord protrudes from the vagina
● Palpation of the cord in cervix during internal exam
● Fetal distress (variable decelerations in FHR; there
should be no decelerations in a relaxed state)
II. THERAPEUTIC MANAGEMENT
A. NURSING MANAGEMENT
GOAL OF MANAGEMENT: relief of pressure on the cord
→ relieved compression and (-) fetal anoxia
● BED REST: after rupture of membranes followed by
assessment of FHR
○ Trendelenburg/knee-chest position: causes
the fetal head to fall back from the cord
● UPWARD PRESSURE ON THE PRESENTING PART
○ Using a gloved hand, manually elevate the fetal
presenting part off the cord
● Put on sterile gloves and insert two fingers
into the vagina, then push presenting part
upward
○ Done until the baby can be born via CS (usually,
cervical dilatation is still incomplete at this
point)
● DELIVERING THE BABY
○ (+) cervix fully dilated + (-) fetal
distress = NSD
○ (-) cervix not completely dilated + (+)
fetal distress = CS
● OXYGENATION: administered at 10 L/min via face
mask to improve fetal oxygenation, especially with
the cord being compromised
● TOCOLYTIC AGENTS: reduces uterine activity and
pressure on the fetus
EXPOSED UMBILICAL CORD: causes drying, leading to
constriction and atrophy of vessels
● DO NOT PUSH THE CORD BACK
○ Further contributes to the compression
because of knotting or kinking
● STERILE SALINE COMPRESS
○ Covering the exposed portion prevents drying
B. MEDICAL MANAGEMENT
AMNIOINFUSION: addition of sterile fluid into the
uterus to supplement the amniotic fluid
● Another way to relieve pressure (compression) on
the cord
○ Used for only a short time until the cervix is fully
dilated or a cesarean birth can be arranged
● Can also be performed daily for women with
oligohydramnios (kulang ‘yung amniotic fluid)
● STERILE DOUBLE-LUMEN CATHETER
○ Introduced through the cervix and into the
uterus
○ Warm NSS or
Lactated Ringer’s
solution: rapidly
infused upon
insertion of the
catheter into an IV
tubing
● Initially,
approximately 500 mL of warm solution is
infused, and then the rate is adjusted to
infuse the least amount necessary to
maintain an FHR monitor pattern without
variable decelerations
● 💡 PREVENTS CHILLING: this is the reason
why the solution should be warmed to body
temperature
● LATERAL RECUMBENT POSITION: position of the
mother throughout the procedure to prevent supine
hypotension syndrome
● NURSING RESPONSIBILITIES
○ Aseptic technique: maintained during the
catheter insertion and while it remains in place
○ Continuous monitoring
● FHR and uterine contractions
○ Late/variable decelerations indicate
fetal distress
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● Maternal temperature to detect infection PROCEDURES IN FETAL BLOOD SAMPLING

○ Amnioinfusion is invasive
VISUALIZING THE FETAL HEAD
○ Since the amniotic sac (protects the
baby from microorganisms) has After cervical dilatation of 3–4 cm and rupture of
already ruptured, the mother and baby the membranes, the fetal head is visualized by the
are at higher risk for infections use of an amnioscope, a small, cone-shaped
instrument with a light source at the far end. This
○ Warm solution: prevents chilling of the woman 1
and fetus is followed by cleaning the scalp with
povidone-iodine and spraying it with silicon.
● Place the bag of fluid on a radiant heat
warmer or by using a blood/fluid warmer
before administration Why silicon?: It causes blood to form in beads,
which are caught by a capillary tube
○ Frequent changing of bedsheets: (+)
continuous flow of the infusing solution out of INCISION USING A SCALPEL
the woman’s vagina A small scalpel is introduced vaginally into the
○ (+) constant drainage: if leakage stops, it
2 cervix, and the fetal scalp is nicked. The incision is
usually means the fetal head is firmly engaged then compressed until the bleeding has stopped.
and all fluid being infused is being held in the OBSERVATION/MONITORING
uterus After the procedure, the woman must be
● Leads to hydramnios (presence of observed after two or three contractions to be
excessive amniotic fluid) and possibly certain that no new fetal scalp bleeding occurs
uterine rupture
After birth, the small incision on the infant scalp
FETAL BLOOD SAMPLING: obtaining fetal SpO2 and pH
3 needs to be observed to be certain it is healing
and infection is not present
● OTHER WAYS TO OBTAIN
FETAL SpO2 and BLOOD pH
NOTE: Infants who have had internal scalp blood
○ Fetal oximeter is
samples taken should not have a vacuum applied
inserted into the uterus
to facilitate birth, because this procedure can
to rest next to the fetal
lead to renewed bleeding at the puncture site
cheek
○ Scalp stimulation is
C. MULTIPLE GESTATION
done; the HCP aims to
get a positive response Pregnancies with two or more fetuses
●
● CAPILLARY BLOOD FROM FETAL SCALP: taken to RISE OF IN-VITRO FERTILIZATION
●
assess the oxygen saturation, partial pressure of
○ This procedure often produces a multiple
oxygen (PO2) and carbon dioxide (PCO2), pH, pregnancy
bicarbonate excess, and hematocrit levels
○ The rising popularity of IVF contributes to the
○ (-) pain but (+) discomfort substantial increase in multiple gestations over
● Discomfort is caused by pressure from the last 10 years
examining hand in the vagina PREFERRED MODE OF DELIVERY: CESAREAN SECTION
●
○ Decreases the risk that the second fetus will
NORMAL >7.25 during labor
experience anoxia
REMEASURED
7.21–7.25 ○ This is also the situation in multiple gestations
AFTER 30 MIN.
of three or more because of the increased
(+) ACIDOSIS <7.20 incidence of cord entanglement and
PURPOSE premature separation of the placenta
✅
●
Verify that an ominous heart rate pattern on a ● HEIGHTENED RISK OF ANEMIA AND GESTATIONAL
monitor truly reflects anoxia HYPERTENSION
✅ No acidosis is occurring, even if a monitor rate ○ Be certain to assess the woman’s hematocrit
level and blood pressure closely during labor or
is showing decreased variability
while waiting for cesarean arrangements

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 MODULE 05.1 – HIGH-RISK LABOR AND DELIVERY [OBSTRUCTED LABOR AND PROBLEMS OF THE PASSENGER]
● FETAL PRESENTATION
I. THERAPEUTIC MANAGEMENT
A. PREPARATORY MANAGEMENT
● FLURRY OF EXCITEMENT: additional personnel are
needed for the birth, including as many nurses to
attend to possibly immature infants as there are
infants, plus additional persons skilled in newborn
resuscitation
○ RESPONSIBILITY: Since it is easy to forget a
woman having a multiple birth may be more
frightened than excited, be certain to focus on
her needs as well as those of her babies so she
is not neglected
● EARLIER ARRIVAL TO THE HOSPITAL: instructed to
mothers who will deliver their fetuses vaginally
○ The first stage of labor does not differ greatly
from that of a woman with a single gestation
pregnancy
○ RESPONSIBILITY: Urge the woman to spend the
early hours of labor engaged in an activity such
as playing cards or reading to make the time
pass more quickly (para hindi nila ma-feel na
ang bagal ng oras or ang tagal ng labor)
● PRACTICE FOR BREATHING EXERCISES: use early
hours of labor to help the mother practice her
breathing
○ Since multiple pregnancies end before full term,
the woman may not yet have practiced
breathing exercises
○ Inform them that this minimizes the need for
analgesia or anesthesia and any respiratory
difficulties the infants may have at birth
because of their immaturity
B. FETAL MONITORING
● HEARING TWO SEPARATE HEART BEATS
○ Be certain that, when taking FHRs by Doppler or
a fetal monitor, you are definitely hearing two
separate beats as proof each infant is doing
well
● RISK FOR FETAL ABNORMALITIES
○ Malpresentation d/t multiple fetuses
● Most twin pregnancies present with both
twins vertex
● This is followed in frequency by vertex and
breech, breech and vertex, and then breech
and breech
○ (-) Firm engagement d/t small fetal size
● WOF cord prolapse after rupture of
membranes
● DETERMINING LIE OF THE SECOND FETUS
○ Done by external abdominal palpation or
ultrasound after delivering the first child
○ Breech delivery as the safest mode of delivery
● Often an internal podalic version, where the
feet are grasped by the delivering provider,
is completed to accomplish a breech
delivery of the second twin
○ NOTE: Sublingual nitroglycerin may be
prescribed to relax the uterus and
make an external version possible
○ 📌 REMEMBER: The time allowed for this
inspection depends on the infants’ weights and
conditions because, if preterm, cold
hypothermia is a concern
C. LABOR AND POSTPARTUM CARE
● CORD CARE: after the first infant is born, both ends
of the baby’s cord are tied or clamped
permanently, rather than with cord clamps, which
could slip
○ Prevents hemorrhage through an open cord
end if additional infants have shared the
placenta
● (-) OXYTOCIN ADMINISTRATION AFTER DELIVERY
○ This avoids compromising the circulation of the
infants not yet born
● COMPLICATIONS AFTER DELIVERY OF THE FIRST
CHILD
○ Uterine dysfunction from a long labor, an
overstretched uterus, unusual presentation, and
premature separation of the placenta
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 MODULE 05.1 – HIGH-RISK LABOR AND DELIVERY [OBSTRUCTED LABOR AND PROBLEMS OF THE PASSENGER]

● Risk for hemorrhage (r/t uterine atony) ● LOA is the most common and favorable fetal
● Risk for infection d/t prolonged labor or position followed by ROA (born and delivered the
birth fastest)
○ RESPONSIBILITY: Assess the woman carefully in ○ Kapag hindi LOA or ROA, mas matagal ang
the immediate postpartum period because a pag-ikot ng occiput papunta sa vaginal canal
uterus that was overly distended may have and mas matagal ang delivery
more difficulty contracting than usual ● NURSING RESPONSIBILITY: lay the mother in
a side-lying position or bring the knees and
D. NEWBORN CARE hands towards the abdominal chest to
compress the abdomen and help with fetal
● IDENTIFICATION positioning
○ The first infant is identified as A, and newborn
care is begun
● CAREFUL ASSESSMENT OF THE INFANTS
○ Determine true gestational age and assess for
certain phenomena such as twin-to-twin
transfusion that could have occurred
● RESPONSIBILITIES FOR THE PARENTS
○ Difficulty believing: They may feel a need to
recount over and over their surprise and to view
their infants together to prove to themselves it
is true
○ Parental inspection: This is done to dispel any
fears they had throughout pregnancy the
babies would be born less than perfect
● If the babies have complications such as
LBW and danger of chilling, make sure that
the parents are able to inspect their
children as soon as possible
○ Concerns about identification: They may worry
about improper identification (mismatch),
which is why it is best to review with them the NORMAL ANGLES
measures used, such as arm-bands, to ensure
this will not happen ● SUBOCCIPITOBREGMATIC: NORMAL FLEXION
(OCCIPUT)
D. FETAL MALPOSITION AND MALPRESENTATION ○ Narrowest diameter is from the inferior aspect
NORMAL PASSENGER POSITION of the occiput to the center of the anterior
fontanelle (approximately 9.5 cm)
● Positions are indicated by an abbreviation of three ● Fits in the anteroposterior and transverse
letters diameter of minimum of 10 cm
○ FIRST LETTER: whether the landmark is pointing ● OCCIPITOFRONTAL: MILITARY POSITION (SINCIPUT)
to the mother’s right or left ○ Measured from the bridge of the nose to the
● Right (R) or Left (L) side of the maternal occipital prominence (approximately 12 cm)
pelvis ● Expect longer labor, the fetus will not
○ MIDDLE LETTER: fetal landmark (O, M, Sa, A) engage, greater effort of the fetus to rotate
● Occiput, Mentum, Sacrum, Acromion internally during delivery
Process ● OCCIPITOMENTAL: FACE PRESENTATION
○ LAST LETTER: whether the landmark points A, P, ○ Widest AP diameter measured from the chin to
or T the posterior fontanelle (approximately 13.5
● Depending on whether the landmark is in cm)
front (anterior), back (posterior), or side
(transverse) of the pelvis

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 MODULE 05.1 – HIGH-RISK LABOR AND DELIVERY [OBSTRUCTED LABOR AND PROBLEMS OF THE PASSENGER]
NORMAL PASSENGER PRESENTATION
● VERTEX POSITION: baby's head is positioned to
emerge first from the birth canal during childbirth;
most common and safest for mother and child
● ASYNCLITISM: a fetal head presenting at a different
angle than expected
○ Military
● Fetal head is neither flexed or extended
(straight)
● The occipitofrontal diameter presents to
the maternal pelvis
● The sinciput is the presenting part
○ Brow:
● The fetal head is partially extended
● The occipitomental diameter, the largest
anteroposterior diameter, is presented to
the maternal pelvis
● Rarest
○ Face: hyperextended head; occipitomental
● The fetal head is hyperextended (complete
extension)
● The face is the presenting part
○ Often too large for birth to proceed
(12–13.5 cm)
OCCIPITOPOSTERIOR POSITION
● POSTERIOR FETAL POSITION
○ Occurs in 1/10 of labors
○ The occiput (assuming the presentation is
vertex) is directed diagonally and posteriorly,
either to the right (ROP) or to the left (LOP)
● In these positions, during internal rotation,
the fetal head must rotate not through a
90° arc, but through an arc of
approximately 135°
○ Tend to occur in women with android,
anthropoid, or contracted pelvis
● Contracted: narrowed or small size
compared to normal
● Android and anthropoid: narrowed
transverse diameter
○ Dysfunctional labor patterns are seen such as
prolonged active phase, arrested descent, or
fetal heart sounds heard best at the lateral
sides of the abdomen
○ Increased risk for cord prolapse occurs
● A posteriorly presenting head does not fit
the cervix as snugly as one in an anterior
position
● HOW DOES THE FETUS ROTATE IN THIS POSITION?
○ Needs to rotate through a 135°-arc
○ Aided by having the woman assume a
hands-and-knees position, squatting, or lying
on her side (on her left side if the fetus is right
occiput posterior, or on her right side if the fetus
is left occiput posterior)
● Shifting the weight from right to left or
“lunging” or swinging her body right to left
while elevating her left foot on a chair
widens the pelvic path and makes fetal
rotation easier
○ Not evidence-based and is tiring for mothers in
labor
The majority of fetuses presenting in posterior
positions—if they are of average size, in good flexion,
and aided by forceful uterine contractions—rotate
through the large arc, arrive at a good birth position
for the pelvic outlet, and are born satisfactorily with
only increased molding and caput formation.
LEFT OCCIPITOPOSTERIOR POSITION
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 MODULE 05.1 – HIGH-RISK LABOR AND DELIVERY [OBSTRUCTED LABOR AND PROBLEMS OF THE PASSENGER]
● A. Fetus in a cephalic presentation, LOP position.
View is from the outlet.
● B. Descent and flexion
● C. Internal rotation beginning. Because of the
posterior position, the head will rotate in a longer
arc than if it were in an anterior position.
● D. Internal rotation.
LEFT OCCIPITOANTERIOR POSITION
● A. A fetus in a cephalic presentation, LOA position.
View is from the outlet. The fetus rotates 90 degrees
from this position
● B. Descent and flexion
● C. Internal rotation complete
● D. Extension; the face and chin are born
I. ASSESSMENT
● Pressure and pain in the lower back d/t sacral
nerve compression
○ Caused by rotation of the fetus against the
sacrum
○ These sensations may be so intense she asks
for medication for relief, not for her contractions
but for the intense back pressure and pain
II. DIAGNOSIS
● Vaginal examination or by sonogram
○ NURSING RESPONSIBILITY
● Still monitor labor patterns and auscultate
FHT even if not internal examination
III. MANAGEMENT
BIRTH TECHNIQUES
A. NATURAL SPONTANEOUS DELIVERY
● Fetus is of average size, has (+) ability to rotate, and
good flexion
● (+) forceful and effective uterine contractions
● Sunny side up: baby is then born looking at the
ceiling
○ Some patients are able to pass a persistent
occipitoposterior position through their pelvis
● COMPLICATIONS
○ Increased molding: overlapping of cranial
bones
○ Increased caput: in-and-out motion of fetal
head, disappears after a few days
○ Arrest of descent = no engagement
● Pelvic inlet does not properly seal →
presenting part does not engage in cervix
→ umbilical cord prolapse
B. FORCEPS DELIVERY
● PROCEDURE
○ Place forceps on fetal head
○ After clasping, instruct mother to push (bear
down)
○ While we pull fetal head, the body will follow
(with minimal/slow elevation to pull head and
the rest of the baby)
● COMPLICATIONS
○ Forceps mark: disappears within a few days
○ Facial nerve damage (if wrong placement), or
eye damage: fetus will manifest as red spots
and asymmetrical facial grimace but tell
mother that it will be resolved
○ Cerebral hemorrhage for the baby
○ Cervical lacerations: causes infections in the
postpartum period
C. CESAREAN DELIVERY
● Done if the baby is large for gestational age, unable
to rotate, and has maintained posterior position
(persistent occipitoposterior position)
● Presentation is military, brow, face
● Hypotonic uterine contractions (mahina)
NURSING INTERVENTIONS
● DEEP BREATHING: to maximize therapeutic effect of
back rub
● COMFORT MEASURES: changing linens, partial
darken room and music, changing position, and
applying warm/cold compresses
○ POSITIONING THE MOTHER
● Counteract mother and baby’s position to
make baby’s body swing, relieving
compression on sacral nerve
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 MODULE 05.1 – HIGH-RISK LABOR AND DELIVERY [OBSTRUCTED LABOR AND PROBLEMS OF THE PASSENGER]
○ ROP: position mother on left side or
squatting
○ LOP: position on right side
● Maintaining a hands-and-knees position or
leaning forward over a birthing ball may
help the fetus rotate
● Squatting, left-side lying if ROP; right side
lying if LOP
● COUNTERPRESSURE ON SACRUM
○ Place fist or heel of hand at the sacral area
● ROBEZO METHOD
○ Jiggling and massaging the uterus may be
helpful when assisting the fetus to rotate into a
better position
● VOIDING EVERY 2 HOURS
○ To keep bladder empty as a full bladder can
impede descent of fetus
○ HOW WILL THE MOTHER URINATE?
DILATATION METHOD
1–4 cm Going to the bathroom
Urinal/bed pan or diaper is
>8 cm
placed under buttocks
Placing a straight catheter is the last resort.
● ORAL SPORTS DRINK/IV GLUCOSE SOL’N
○ Provides energy for prolonged labor
○ Replaces glucose stores being used to keep
active in labor
● PROVISION OF EMOTIONAL SUPPORT
○ They may be worried about the length of labor
or that things are not going “by the book”
○ Provide frequent reassurance that although
their pattern of labor is not “textbook,” it is within
safe, controlled limits
BREECH PRESENTATION
● Buttocks or feet are the presenting parts
○ Fetal head is the last part to be delivered
● BREECH PRESENTATION THROUGHOUT PREGNANCY
○ Most fetuses are in a breech presentation early
in pregnancy
○ By week 38, however, in approximately 97% of
all pregnancies, a fetus would rotate and turns
to a cephalic presentation (i.e., head down)
● This probably happens because, although
the fetal head is the widest single diameter,
the buttocks (breech) plus the legs of the
fetus actually take up more space →
napupunta sa largest part ng uterus
(fundus)
● WHAT TO EXPECT:
○ Expect longer labor hours and firm
engagement
○ CS is the ideal delivery but NSD is possible
● POSSIBLE COMPLICATIONS
○ Developing dysplasia of the hip
○ Anoxia (absence of oxygen) from a prolapsed
cord
● Cord prolapse d/t incomplete seal of
presenting parts
● Baby is highly dependent on umbilical cord
and it becomes compressed by the fetal
head
○ Traumatic injury to the after-coming head
(possibility of intracranial hemorrhage or
anoxia)
○ Fracture of the spine or arm
● Due to extreme pressure from NSD
○ Dysfunctional labor
● Buttocks, legs, and feet exert less pressure
on cervix → less dilation
○ Early rupture of the membranes because of the
poor fit of the presenting part
○ Meconium staining
● Occurs because of inevitable contraction
every time there is a cervical pressure on
the fetal buttocks and rectum
● May lead to meconium aspiration if the
infant inhales amniotic fluid
○ Hypoxia
● Stimulates the vagal response of the fetus
→ increases the bowel motility → lower
sphincter area control would be lost →
release of meconium in the AF → the baby
may drink the AF and the meconium stain
→ difficulty in stimulating them to cry
TYPES OF BREECH PRESENTATION
COMPLETE BREECH
● Thighs tightly flexed on the
abdomen
● Buttocks + feet = tightly flexed to
the cervix
● Longitudinal lie
● Good attitude (chin is touching
the chest)
● Presenting part: buttocks/feet
(not enough to cause cervical
dilatation)
● FHT: left upper quadrant
FRANK BREECH
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● Thighs are extended to rest on
chest
● Buttocks alone present to cervix
● Longitudinal lie
● Moderate attitude (chin is
touching chest, legs are
extended to the rest of body)
● Presenting part: buttocks
○ Not enough to cause
cervical dilatation
○ Prolonged labor
○ Pelvic inlet and cervix is not
completely sealed
○ If BOW ruptured, umbilical
cord can go out (umbilical
cord prolapse)
● FHT: left upper quadrant
SINGLE/DOUBLE FOOTLING BREECH
● SINGLE FOOTLING: one foot is
present
● DOUBLE FOOTLING: both feet
present
● Longitudinal lie
● Moderate attitude: head is
flexed, extremities are extended
● FHT: Left upper abdomen
I. ASSESSMENT
A. CAUSES
● Unknown
● <40 weeks AOG
● Fetal abnormalities
○ Anencephaly, hydrocephalus, or meningocele
● In a fetus with hydrocephalus, the widest
fetal diameter is the head, so it retains the
most “comfortable” position
● Polyhydramnios
○ Allows for free fetal movement, so the fetus fits
within the uterus in any position
● Congenital anomaly of the uterus (septate uterus)
○ Traps fetus in breech position d/t presence of
abnormal septum in the middle of the uterine
cavity and the fetus cannot fully rotate
Any space-occupying mass in the pelvis (e.g.,
●
fibroid tumor or placenta previa)
○ Obstruction/tumor prevent head to be
presented or reach the maternal pelvis
Pendulous abdomen
●
○ If the abdominal muscles are lax, the uterus
may fall so far forward that the fetal head
comes to lie outside the pelvic brim, causing a
breech presentation
● Multiple gestation
○ DIfficulty of the fetuses to rotate in the uterine
cavity
B. GENERAL ASSESSMENT
● FETAL HEART SOUNDS
○ With a breech presentation, fetal heart sounds
usually are heard high in the abdomen
○ Always monitor FHR and uterine contractions
during delivery frequently because this allows
for early detection of fetal distress from a
complication such as prolapsed cord or arrest
of descent (the descent is not progressing)
II. DIAGNOSIS
● LEOPOLD MANEUVER AND VAGINAL EXAMINATION
○ Usually reveal if breech presentation
○ If the breech is complete and firmly engaged,
the tightly-stretched gluteal muscles of the
fetus may be mistaken on vaginal examination
for a head and the cleft between the buttocks
may be mistaken for the sagittal suture line
● ULTRASOUND
○ If the presentation is unclear, ultrasound clearly
confirms a breech presentation
○ Also gives information on pelvic diameters, fetal
skull diameters, and evidence of possible
placenta previa causing the breech
presentation
III. MANAGEMENT
● INITIAL PHYSICAL ASSESSMENT
○ Done to determine a possible reason for the
breech presentation
● UNUSUAL POSTURE AFTER BIRTH (NOT ABNORMAL)
○ Explain to the parents that this is normal and is
related with the infant’s breech presentation
intrauterine; would return to normal eventually
○ Frank: keep legs extended at level of face for
the first 2-3 days of life
○ Footling: legs extended in footling position for
the first few days
● EXTERNAL CEPHALIC
VERSION
○ Manual turning of
the fetal
presentation from
breech to cephalic
(180-degree turn)
○ Nurses are not
allowed to perform
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 MODULE 05.1 – HIGH-RISK LABOR AND DELIVERY [OBSTRUCTED LABOR AND PROBLEMS OF THE PASSENGER]
this unless they are licensed
○ Consider FHT, uterine size, fetal size, placenta
○ There is still a high chance to return to breech
BIRTH TECHNIQUES
A. VAGINAL BIRTH
LEFT SACROPOSTERIOR is the position before labor
✅
●
● PUSHING AFTER (+) FULL DILATATION
○ The breech, trunk, and shoulders are born
● As the breech spontaneously emerges from
the birth canal, it is steadied and supported
by a sterile towel held against the infant’s
inferior surface
● SHOULDERS PRESENTING TO THE OUTLET
○ The widest diameter anteroposterior is seen
○ DELIVERING THE SHOULDER
● If they are not born readily, the arm of the
posterior shoulder may be drawn
downward
○ Pass two fingers over the infant’s
shoulder and down the arm to the
elbow
○ Sweep the flexed arm across the
infant’s face and chest and out
○ Do the same for the other arm
● DELIVERING THE HEAD
○ External rotation is then allowed to occur to
bring the head into the best outlet diameter
○ Most hazardous part of breech birth
○ The trunk of the infant is usually straddled over
the primary care provider’s right forearm
● Two fingers of the right hand are then
placed in the infant’s maxilla
● The left hand is slid into the woman’s
vagina, palm down, along the infant’s back
and pressure is applied to the occiput to
flex the head fully
● Gentle traction applied to the shoulders
(upward and outward) delivers the head
● An aftercoming head may also be
delivered with the aid of Piper forceps to
control flexion and the rate of descent
(forceps delivery)
DANGERS OF BREECH BIRTH (NSD)
● UMBILICAL CORD COMPRESSION
○ Because the umbilicus precedes the head, a
loop of cord passes down alongside the head
○ The pressure of the head against the pelvic
brim automatically causes compression on this
loop of cord
● INTRACRANIAL HEMORRHAGE
○ With a cephalic presentation, molding to the
confines of the birth canal occurs over hours
○ With a breech birth, pressure changes occur
instantaneously, a situation that can result in
tentorial tears leading to gross motor and
mental incapacity or lethal damage to the
fetus
○ Experienced by babies who are born suddenly
to reduce the duration of cord compression
● HYPOXIA
○ Danger to the infant who is born gradually to
reduce the possibility of intracranial injury
● TENTORIAL TEARS ON THE FETAL BRAIN
○ Due to fast changes in pressure and extreme
molding of the head to fit in the vaginal canal
○ Leads to gross motor and mental incapacity or
lethal damage to the fetus
B. FORCEPS DELIVERY
● Generally considered
safe for both mother
and baby when
performed by a skilled
medical professional
● Not always successful
and may result in
complications, such as bruising, cuts, or even
fractures of the baby's skull or facial bones, which is
why it is typically only used in emergency situations
when other delivery methods are not possible
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 MODULE 05.1 – HIGH-RISK LABOR AND DELIVERY [OBSTRUCTED LABOR AND PROBLEMS OF THE PASSENGER]

● FETAL HEART TONES

DANGERS OF FORCEPS DELIVERY ○ May be transmitted to the forward-thrust
chest and heard on the side of the fetus where
● HEAD ENTRAPMENT feet and arms can be palpated if the back is
○ Occur when the forceps are not properly extremely concave
positioned, which can cause the baby's head to
become stuck in the birth canal, leading to II. DIAGNOSIS
oxygen deprivation and potential brain
damage ● LEOPOLD’S MANEUVER
● SKULL FRACTURES ○ Head that feels more prominent than normal
○ Occur if the forceps are applied with too much ○ (-) engagement because the AP diameter does
force or if they are not positioned correctly, not fit
which can cause fractures to the baby's skull, ○ Head and back are both felt on the same side
resulting in bleeding and potential brain injury of the uterus
● BRAIN INJURY ● The back is difficult to outline in this
○ Occur as a result of oxygen deprivation during presentation because it is concave
a difficult forceps delivery, which can lead to ● IE OR VAGINAL EXAMINATION
long-term neurological damage, such as ○ Pelvic diameters (diagonal conjugate, true
cerebral palsy or cognitive impairments conjugate, and transverse diameter of pelvis)
are measured to check if vaginal birth is
C. ELECTIVE CESAREAN BIRTH possible
● Note that there will be a long first stage of
● Preferred method of birth because of the difficulties labor because the face does not mold well
with the birth of the head to make a firm engaging part
● SONOGRAM
FACE PRESENTATION ○ Nose, mouth, or chin can be felt as the
presenting part
CHARACTERISTICS ○ Done to confirm face presentation
LIE Longitudinal
Poor (complete extension); III. MANAGEMENT
ATTITUDE
hyperextension
PRESENTING PART Chin/mentum BIRTH TECHNIQUES

● NORMAL SPONTANEOUS DELIVERY

● Head diameter of fetus present to the pelvic inlet is
○ Done if the chin is anterior and the pelvic
often too large for birth to proceed
diameters are within normal limits
○ When a face presentation is suspected, expect
● CESAREAN SECTION
physician to order several tests
○ If the chin is posterior to avoid waiting for a long
● WARNING SIGNAL
posterior-to-anterior rotation to occur
○ A face presentation is usually caused by
● Such rotation could result in uterine
abnormalities
dysfunction or a transverse arrest

I. ASSESSMENT
NURSING MANAGEMENT
A. RISK FACTORS
● OBSERVE THE INFANT
● Woman with contracted pelvis ○ Check for airway patency
● Relaxed uterus of a multipara ○ Note that they may have great deal of facial
● Placenta previa edema and may be purple from ecchymotic
● Fetal malformation bruising
● Prematurity (free movements d/t small size) ● In some infants, lip edema is so severe that
● Hydramnios (increased AF = more movement) they are unable to suck for a day or two
● Reassure the parents that the edema is
B. GENERAL ASSESSMENT transient and will disappear in a few days
with no aftermath
● GAVAGE FEEDINGS

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 MODULE 05.1 – HIGH-RISK LABOR AND DELIVERY [OBSTRUCTED LABOR AND PROBLEMS OF THE PASSENGER]

○ Necessary to allow them to obtain enough fluid

until they can suck effectively
● NEONATAL INTENSIVE CARE UNIT
○ For close monitoring for 24 hours, especially if
the baby may have an underlying condition

BROW PRESENTATION

CHARACTERISTICS
LIE Longitudinal
Poor (arched back and extended
ATTITUDE
neck)
PRESENTING PART Occipitomental I. ASSESSMENT

● Rarest of the presentations
● Invariably results in obstructed labor
○ Head becomes jammed in the brim of the
pelvis as the occipitomental diameter presents
I. ASSESSMENT
A. RISK FACTORS
● Multiparity
● Woman with relaxed abdominal muscles
● Oligohydramnios (causes limited fetal movement)
● Obstructed labor
B. SIGNS AND SYMPTOMS
● Extreme caput and/or ecchymosis/bruising on the
face
○ This will be absorbed by the body after a few
days
● Bruising over the same area as the anterior
fontanelle (“soft spot”)
○ NR: Parents may need reassurance that the
child is well after birth
II. MANAGEMENT
● CESAREAN DELIVERY
○ Unless the presentation spontaneously corrects,
this will be necessary to birth the infant safely
TRANSVERSE LIE
● Less than 1% of fetuses
● PRESENTING PART: Either the shoulders or the
sacrum
A. RISK FACTORS
● Women with pendulous abdomens (less elasticity
and control of the uterine muscles)
● Uterine fibroid tumors that obstruct the lower
uterine segment
● Contraction of the pelvic brim (narrow pelvic inlet
and there is lesser space to rotate)
● Congenital abnormalities of the uterus
● Grand multiparity (causes relaxation of abdominal
walls)
● Multiple gestations (2nd twin; the 1st twin might be
in a cephalic or breech presentation)
● Hydrocephalus/placenta previa (prevents
engagement of fetal head and limit ability to turn)
● Hydramnios and prematurity (too much fluid
increases fetal movement)
● Short umbilical cord
B. SIGNS AND SYMPTOMS
● Contour of abdomen is distorted
● Fuller side at side rather than top/bottom (mas
malapad; ovoid in shape)
● Membranes rupture at the beginning of labor
II. DIAGNOSIS
● INSPECTION
○ Obvious on inspection as ovoid of the uterus is
found to be more horizontal than vertical
● LEOPOLD’S MANEUVER
○ Abnormal presentation can be confirmed
● ULTRASOUND
○ Taken to further confirm the abnormal lie and
to provide information on pelvic size

III. MANAGEMENT

● CESAREAN BIRTH

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 MODULE 05.1 – HIGH-RISK LABOR AND DELIVERY [OBSTRUCTED LABOR AND PROBLEMS OF THE PASSENGER]

○ A mature fetus cannot be born vaginally from F. FETAL ANOMALIES

this presentation d/t cervical obstructions
● No firm presenting part = the cord or an
arm may prolapse, or the shoulder may
obstruct the cervix
E. OVERSIZED FETUS (Macrosomia)
● HYDROCEPHALUS (fluid-filled ventricles) OR
ANENCEPHALY (absence of the cranium)
○ Final category of fetal factors that can
complicate birth because the fetal presenting
part does not engage the cervix well

● Fetus weighs more than 4,000–4,500 g (9–10 lbs) A. HYDROCEPHALUS

○ Complicate up to 10% of all births
● Common disorder of the CSF physiology resulting in
abnormal expansion of the cerebral ventricles
I. ASSESSMENT
● Can occur at birth (congenital) or from an incident
A. RISK FACTORS later in life (acquired)

● Enter pregnancy with diabetes or develops GDM B. ANENCEPHALY

● Multiparity: each infant born to a woman tends to
● Absence of the cerebral hemispheres
be slightly heavier and larger than the one born just
● Occurs when the upper end of the neural tube fails
before
to close in early intrauterine life
B. COMPLICATIONS
Banaag, Cato, Diala, Ingal, Mallari, Malonzo, Navarro,
● Uterine dysfunction Paras | BSN 2025
○ Overstretching of the fibers of the myometrium
● Fetal pelvic disproportion or uterine rupture REFERENCES
Synchronous Lecture: 02 March 2023
○ Wide shoulders cause an obstruction
Module: NCM 0109 Module 05
● Perineal lacerations Book: Maternal and Child Health Nursing
● Increased mortality rate (15% vs 4% [normal])
● Increased risk of cervical nerve palsy,
diaphragmatic nerve injury
● Fractured clavicle
○ Caused by shoulder dystocia
● Increased risk of hemorrhage
○ Overdistended uterus may not contract as
readily as usual

II. DIAGNOSIS

● MAY BE MISSED IN AN OBESE WOMAN

○ Fetal contours are difficult to palpate
○ Obesity does not necessarily indicate a larger
than usual pelvis
● PELVIMETRY/ULTRASOUND
○ Used to compare the size of the fetus with the
woman’s pelvic capacity

III. MANAGEMENT

● CESAREAN BIRTH
○ If the infant is so oversized that he or she
cannot be born vaginally, a cesarean birth
becomes the birth method of choice

NCM 0109|16