CARE OF MOTHER AND CHILD SEM 02 | 01

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

NCM 0109 MODULE 05.2 – HIGH-RISK LABOR AND DELIVERY [PROBLEMS OF THE PASSAGE]
I. ASSESSMENT
OUTLINE
I Problems of the Passage A. NORMAL PELVIC MEASUREMENTS
A Abnormal Size/Shape of the Pelvis
B Cephalopelvic Disproportion DIAGONAL CONJUGATE
C Shoulder Dystocia ● It suggests AP diameter of the pelvic inlet
● ANTERIOR-ANTERIOR: distance between the
anterior surface of the sacral prominence and the
PROBLEMS OF THE PASSAGE
anterior surface of the inferior margin of the
A. ABNORMAL SIZE AND SHAPE OF THE PELVIS symphysis pubis
● Adequate/ideal for childbirth or vaginal delivery if
● CONTRACTION OR NARROWING OF THE the diameter is more than 12.5 cm
PASSAGEWAY ● Most useful measurement for estimation of pelvic
○ Causes narrowing as the diameter of the pelvis size
is reduced to normal, therefore reducing pelvic TRUE CONJUGATE OR CONJUGATE VERA
capacity = cephalopelvic disproportion (hindi
● Cannot be directly measured but it can be
nagpo-progress ‘yung labor)
estimated
● Either reduces the capacity of the pelvic
● ANTERIOR-POSTERIOR: Measurement between the
inlet, midpelvis, or the pelvic outlet
anterior surface of the sacral prominence and the
○ This results in dystocia, which refers to difficult
posterior surface of the inferior margin of the
or painful labor
symphysis pubis.
● NOTE: Labor that lasts for two days is okay
as long as the vital signs and FHT remain Diagonal conjugate measurement minus 1.5–2 cm
normal (depth of symphysis pubis) = 10.5–11 cm (actual
diameter of pelvic inlet through which the fetal head
CAUSES must pass)
Android and platypelloid pelvis
Congenital Pelvic have narrower shape which
Abnormalities make labor difficult, leading to
pelvic dystocia
Result in inadequate growth of
Maternal
the pelvic bones, leading to a
Malnutrition
smaller and narrower pelvis
Condition that affects bone
development in children; causes
Rickets bone pain, poor growth and soft, Straight line shows diagonal conjugate; dotted line
and weak bone because of lack shows true conjugate
of calcium in the diet ISCHIAL TUBEROSITY
Neoplasm or Prevents the descent of fetal ● External measurement of the
Tumors head distance between the ischial
Scoliosis or kyphosis can lead to tuberosity or the transverse
Lower Spinal
pelvic deformities that can cause diameter of the outlet
Disorders
difficulties during childbirth ● Measured at the level of the
Cause physical changes to the anus
pelvic structure, such as a ● Diameter of 11 cm is considered
Pelvic Fractures to be adequate for childbirth
narrower or misaligned pelvis,
or Trauma ● HOW TO MEASURE?
that can impede the baby's
passage ○ Pelvimeter
○ Ruler or comparison with clenched-fist
measurements

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○ Pelvimetry (x-ray) ○ Voiding every 2 hours to allow fetal head to use

📌REMEMBER: What goes in, goes out
Kapag may lightening na nag-occur, it means na
all available space (hindi harang-harang ‘yung
bladder)
‘yung fetal head nag-move na siya below the inlet. ● DISCONTINUATION OF TRIAL LABOR
Referring to the reminder above, since nagkasya siya ○ Done if there is no adequate progress
sa inlet, makakapag-pass through rin siya sa documented after 6–12 hours OR the fetus is in
midpelvis and outlet. distress already
● PRIMIGRAVIDAS: (-) engagement means ○ Cesarean birth: preferred mode of delivery
fetal/pelvic abnormality ● Assure the woman and her support person
● MULTIGRAVIDAS: previous vaginal birth = pelvic that this is just an alternative, not an
adequacy inferior, method of birth for them
● Because labor is not progressing, it is the
B. ABNORMAL PELVIC MEASUREMENTS method of choice to allow them to achieve
their goal of a healthy mother and healthy
INLET CONTRACTION
child
ANTERIOPOSTERIOR Narrowed to <11 cm ● EMOTIONAL SUPPORT
TRANSVERSE Narrowed to <12 cm ○ Difficult to undertake: they know they may not
be able to complete
DIAGONAL CONJUGATE <11.5 cm
● They become hesitant because the effort
● Caused by rickets (lack of Vitamin D or calcium) in required subjects them needlessly to pain
early life or an inherited small pelvis ● NR: Emphasize, but do not overstress, that it
● Weak uterine contractions is a sign is best for their baby to be born vaginally
○ Discouragement: since they may feel as if they
OUTLET CONTRACTION
themselves are on trial, they begin to feel
discouraged and inadequate when dilatation
TRANSVERSE
(distance between the does not occur
Narrowed to <11 cm ● A woman may not be aware of how much
ischial tuberosities at the
outlet) she wanted the trial labor to work until she
is told it is not working.
MIDPELVIS
(internal ischial <8 cm ● The support person may be as frightened
diameter) and feel as helpless as she does and so
momentarily stops being a support person
● Characterized by long and narrow pubic arch
● Seen in android pelvises B. CEPHALOPELVIC DISPROPORTION

● Presenting part of the fetus is too large

II. MANAGEMENT: TRIAL LABOR (macrosomia) to pass through the woman’s pelvis
○ Infant’s head is too big to fit through mother’s
● Encouraged to determine whether labor will pelvis (hydrocephalus; built of baby d/t genetic
progress normally factors)
○ Continues as long as descent of the presenting ● Biparietal diameter is closer to 10 cm
part and dilatation of the cervix continue to
○ Ideal for NSD: 9cm
occur
PATIENTS THAT CAN UNDERGO TRIAL LABOR
✅
● I. ASSESSMENT
Borderline (just adequate) inlet
measurements A. CAUSES OR RISK FACTORS
✅ Good fetal lie and position
✅ Suspected CPD ● Large fetal head
○ Macrosomic babies (GDM) with more than
NURSING RESPONSIBILITIES 4000 grams of weight causes CPD wherein the
fetal head is too large to pass through the
● MONITORING mother's pelvis
○ Fetal heart sounds and uterine contractions ● Multiparity

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○ Repeated childbirths can lead to changes in B. CESAREAN BIRTH

the mother's pelvis, such as a decrease in the
pelvic opening or an increase in pelvic rigidity ● Ideal birth method for cephalopelvic disproportion
● Genetics (CPD)
○ CPD may also be caused by genetic factors ○ Helps avoid potential complications that may
that affect the size and shape of the mother's arise during a vaginal delivery, such as fetal
pelvis, the fetal head, or both distress or birth trauma to the baby's head and
○ One or both parents are of large body built neck
● Small or abnormal pelvis ○ Reduces the risk of pelvic injury and
○ A narrow or deformed pelvis can create a postpartum hemorrhage for the mother
physical barrier to the passage of the fetal
head (android, platypoid) C. EXTERNAL CEPHALIC VERSION
● Abnormal fetal positions
○ If the fetus is in an abnormal position, such as
breech, occipitoposterior, brow, face or
transverse, it may not be able to align properly
with the mother's pelvis during delivery
● Adolescents
○ The pelvis of an adolescent mother may not
have fully developed or contracted/narrow
pelvises
○ Immature reproductive organs

B. SIGNS AND SYMPTOMS

● Difficulty in labor and delivery (prolonged first stage
of labor)
● Lack of engagement at the beginning of the labor
● Poor fetal descent (even with strong contractions)
II. DIAGNOSIS
● PELVIMETRY: measure pelvic inlet and outlet
● ULTRASOUND: determine fetal size
● INTERNAL EXAMINATION
III. MANAGEMENT
A. NSD USING McROBERTS MANEUVER
● Turning of a fetus from a breech to a cephalic
position before birth
● Done at 34–38 WEEKS AOG
○ Earliest: 34–35 weeks
○ Usual: 37–38 weeks
● Although not always successful, the use of external
versions can decrease the number of cesarean
births necessary from breech presentations
● CONTRAINDICATIONS
○ Multiple gestation, severe oligohydramnios,
small pelvic diameters, a cord that wraps
around the fetal neck, and unexplained
third-trimester bleeding, which might be a
placenta previa

The breech and vertex of the fetus are located

● In a dorsal recumbent
position, lying on back 1 and grasped transabdominally by the examiner’s
hands on the woman’s abdomen
and legs are flexed
○ Flexed legs are Gentle pressure is then exerted to rotate the fetus
2 in a forward direction to a cephalic lie
almost touching
the abdomen
○ Widen pelvic area NURSING INTERVENTIONS
● Suprapubic pressure
○ Fist has a ● MONITORING: FHR and ultrasound
downward pressure ● TOCOLYTIC AGENT: administered to relax the uterus
on the symphysis pubis; help in the adduction ● DISCOMFORT: may be experienced by the mother
of the shoulders due to exertion of pressure
○ Baby’s body will internally rotate for faster ● RHOGAM: must be received by Rh- mothers should
delivery minimal bleeding occur

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D. FORCEPS BIRTH
● BEFORE: used routinely to deliver babies
● NOW: rarely used (4–8% of births) because it can
lead to rectal sphincter tears in the woman, which
can lead to dyspareunia, anal incontinence, or
increased urinary stress incontinence
INDICATIONS FOR FORCEPS DELIVERY
✅
●
A woman is unable to push with contractions
in the pelvic division of labor such as might
happen with a woman who received regional
anesthesia or who has a spinal cord injury
✅ Cessation of descent in the second stage of
labor occurs
✅ A fetus is in an abnormal position
✅ A fetus is in distress from a complication such
as a prolapsed cord
● OBSTETRICAL FORCEPS: steel instruments
constructed of two blades that slide together at
their shaft to form a handle
PROCEDURES
Before forceps are applied:
✅ (+) rupture of membranes
1 ❌ (-) cephalopelvic disproportion
✅ (+) full cervical dilatation and empty bladder
One blade is slipped into the woman’s vagina
2 next to the fetal head and the other is slipped into
place on the other side of the head
Next, the shafts of the instrument are brought
3 together in the midline to form the handle
The primary care provider then applies pressure
on the handle to manually extract the fetus from
the birth canal
Although forceps appear as if they would put
4 ○ Little anesthesia is necessary = less respiratory
forceful pressure on the fetal head, the pressure
registers on the steel blades rather than the head
so they can actually reduce pressure, thus
avoiding a complication such as subdural
hemorrhage
NURSING INTERVENTIONS
● RECORD FHR BEFORE AND AFTER APPLICATION
○ Because there is a danger that the cord could
be compressed between the forceps blade and
the fetal head, assess FHR again immediately
after application
● ASSESS THE CERVIX
○ Needs to be carefully assessed after forceps
birth to be certain no lacerations have occurred
● RULE OUT BLADDER INJURY
○ Record the time and amount of the first voiding
● NEWBORN ASSESSMENT
○ Assess the newborn to be certain no facial
palsy exists from pressure
○ A forceps birth may leave a transient
erythematous mark on the newborn’s cheek
● This mark will fade in 1–2 days with no
long-term effects
E. VACUUM EXTRACTION
● A fetus, if positioned far enough down the birth
canal, may be born by vacuum extraction
With the fetal head at the perineum, a soft,
1 disk-shaped cup is pressed against the fetal
scalp and over the posterior fontanelle
When vacuum pressure is applied, air beneath
2 the cup is suctioned out
Cup adheres so tightly to the fetal scalp that
3 traction on the vacuum cord leading to the cup
extracts the fetus
● ADVANTAGE
depression at birth
DISADVANTAGES
●
○ More perineal lacerations may occur
○ Causes a marked caput on the newborn head
that may be noticeable as long as 7 days after
birth
● A woman may need reassurance that the
caput swelling is harmless for her infant
and will decrease rapidly
○ Tentorial tears from extreme pressure
○ Not advantageous for preterm infants because
of the softness of the preterm skull
● CONTRAINDICATION
○ Fetal scalp blood sampling
● Suction pressure can cause severe
bleeding at the sampling site
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○ Brachial plexus injury (MP): originates from

C. SHOULDER DYSTOCIA spinal cord behind
head and neck
● ↑ FETAL WEIGHT AND SIZE: a birth problem that is (cervical nerves V &
increasing in incidence because the weight and VI); also caused by
therefore the size of newborns is increasing force of birth
● Occurs at the second stage of labor (expulsion) ● Erb’s palsy:
○ BROAD SHOULDERS: the fetal head is born, but unhealthy arm
the shoulders are too broad to enter and be from brachial
born through the pelvic outlet plexus injury;
● Turtle sign: head lang ‘yung lumalabas causes muscle
paralysis and weakness of the arms/leg;
I. ASSESSMENT need of daily therapy
○ Death and hypoxia
A. CAUSES OR RISK FACTORS

II. MANAGEMENT
● Mothers with diabetes
○ Causes larger fetal size due to fetal
● Resolving shoulder dystocia quickly is vital to
macrosomia, which can increase the likelihood
improve both the pregnant patient’s and the fetus’
of shoulder dystocia
outcomes
● Multiparity
● MCROBERTS MANEUVER
○ Cause pelvic relaxation and muscle laxity,
○ The patient is asked to or assisted to deeply flex
leading to a decreased pelvic inlet size
(hyperflexion) their thighs back toward their
● Postdate pregnancies
abdomen and then rotate the thighs laterally
○ Can result in a larger fetal size and decreased
to make a wide V
amniotic fluid levels
○ WHAT DOES IT DO? (not evidence-based)
● Widens pelvic outlet, allowing the delivery of
B. SIGNS AND SYMPTOMS
the anterior shoulders
● Flattens the spine in the lower back
● Suspected earlier if the second stage of labor is
● SUPRAPUBIC PRESSURE
prolonged
○ Completed by nursing staff
● (+) arrest of descent
○ The fetal back is identified
● Turtle sign: crowning takes place but the head
and the nurse stands on
retracts instead of protruding with each contraction
the side of the patient that
● Facial flushing (fetus has red, puffy face)
is closest to the fetal back
○ Downward and lateral
C. EFFECTS/COMPLICATIONS
pressure is applied just
above the patient’s pubic bone (lower
● MATERNAL
abdomen)
○ Vaginal or cervical tears (3rd–4th degree
○ WHAT DOES IT DO?
lacerations)
● Dislodge and rotate the fetal shoulder away
● Suture and advise proper perineal care to
from the midline
reduce risk of infection
● Helps the anterior shoulder escape from
● Postpartum hemorrhage may occur as a
beneath the symphysis pubis and be born
complication
○ Rectrovaginal fistula
● Abnormal connection of rectum and Banaag, Cato, Diala, Ingal, Mallari, Malonzo, Navarro,
Paras | BSN 2025
vagina
○ Uterine rupture d/t forceful delivery REFERENCES
● FETAL Synchronous Lecture: 02 March 2023
○ Hazardous if the cord is compressed between Module: NCM 0109 Module 05
Book: Maternal and Child Health Nursing
the fetal body and the bony pelvis d/t lack of
engagement
○ Forceful birth: fractured clavicle/humerus

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