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Chapter-23 - Lecture notes 23

Nursing (Capitol Technology University)

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CHAPTER 23

NURSING CARE OF A FAMILY

EXPERIENCING A COMPLICATION OF COMMON TYPES OF DEVIATIONS THAT
LABOR OR BIRTH CAN CAUSE COMPLICATIONS DURING
COMMON TYPES OF DEVIATIONS THAT LABOR OR BIRTH: THE THREE P’S
CAN CAUSE COMPLICATIONS DURING
LABOR OR BIRTH: THE THREE P’S
• Dystocia- is difficult labor or abnormally
• Dystocia- is difficult labor or abnormally slow progression of labor
slow progression of labor Four main components of the labor process:

Four main components of the labor

1. the power, or the force that
propels the fetus (uterine
process:
contractions)
1. the power, or the force that 2. the passenger (the fetus)
propels the fetus (uterine
contractions) 3. the passageway (the birth canal)

2. the passenger (the fetus)

4. the psyche (the woman’s and
family’s perception of the event)
3. the passageway (the birth
Notes:
canal) Although labor often proceeds without any
deviation from the normal, many potential
4. the psyche (the woman’s and complications can occur.
family’s perception of the
event)
A difficult labor—dystocia—Dystocia is
difficult labor or abnormally slow
progression of labor, can arise from any of
the four main components of the labor
process: (a) the power, or the force that
propels the fetus (uterine contractions); (b)
the passenger (the fetus); (c) the
passageway (the birth canal); or (d) the
psyche (the woman’s and family’s
perception of the event)

Because complications can occur at any

point in labor, a continuous assessment of a
laboring woman and her fetus as well as
providing emotional support for her and her
family are essential. The hours of labor are
stressful even when everything is
proceeding normally. Be certain to reassure
all women in labor that everything is going
smoothly and both she and her fetus appear
to be doing well. If a complication arises and

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assurances cannot be given as freely, it is Inertia is a time-honored term to denote

doubly important that a woman has sluggishness of contractions, or that the
someone who is both knowledgeable about force of labor, is less than usual.
the deviation and what measures need to
be taken as well as able to feel empathetic
to her sense of helplessness and the A more current term is dysfunctional
necessary change in her birth plan labor Dysfunction can occur at any point in
(Zielinski, Brody, & Low, 2016). Nurses are labor, but it is generally classified as primary
able to play a key role in providing this type (i.e., occurring at the onset of labor) or
of care because they are skilled secondary (i.e., occurring later in labor). The
practitioners of both physical and emotional risk of maternal postpartal infection,
care. hemorrhage, and infant mortality is higher in
women who have a prolonged labor than in
those who do not. Therefore, it is vital to
recognize and prevent dysfunctional labor to
Problems With the POWER the extent possible (Hunt & Menticoglou,
2015).
• Ineffective uterine force Prolonged labor appears to result from
several factors but is most likely to occur if a
• Inertia is a time-honored
fetus is large or if the contractions are
term to denote hypotonic, hypertonic, or uncoordinated
sluggishness of contractions occur
contractions, or that the
force of labor, is less than
INEFFECTIVE UTERINE FORCE
usual.
Uterine contractions are the basic force that
• Dysfunctional labor and moves the fetus through the birth canal.
associated stages of labor - A They occur because of the interplay of the
more current term contractile enzyme adenosine triphosphate
and the influence of major electrolytes such
is dysfunctional labor- The risk of
as calcium, sodium, and potassium, specific
maternal postpartal infection, contractile proteins (actin and myosin),
hemorrhage, and infant mortality epinephrine and
is higher in women norepinephrine, oxytocin (a posterior
pituitary hormone), estrogen, progesterone,
• Hypotonic Contractions - The and prostaglandins.
number of contractions is usually In about 95% of labors, contractions follow a
low or infrequent predictable, efficient course. When they
• Hypertonic Contractions – have less strength than usual or are rapid
but ineffective, dysfunctional labor occurs.
increased in resting tone
• Uncoordinated contractions can Hypotonic Contractions
occur so closely together that Hypotonic Uterine Contraction The number
they can interfere with the blood of contractions is usually low or infrequent
supply to the placenta May occur after the administration of
analgesia especially if the cervix is not
Notes: dilated to 3 or 4 cm or if bowel and bladder
Complications With the Power (The distension prevents descent or from
Force of Labor) engagement.

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Management: Rest and pain relief with a

Hypotonic contractions occur during the drug such as morphine sulfate. Darkening
active phase of labor and tend to occur after room lights. Decrease noise and stimulation
the administration of analgesia, especially if Cesarean birth maybe necessary.
the cervix is not dilated to 3 to 4 cm or if
bowel or bladder distention is preventing Uncoordinated Contractions
descent or firm engagement. They also may
occur in a uterus that is overstretched by a Normally, all contractions are initiated at one
multiple gestation, a larger than usual single pacemaker point high in the uterus. A
fetus, polyhydramnios, or in a uterus that is contraction sweeps down over the organ,
lax from grand multiparity. encircling it; repolarization occurs;
relaxation or a low resting tone is achieved;
and another pacemaker-activated
Hypotonic contractions will increase the contraction begins. With uncoordinated
length of labor because more of them are contractions, more than one pacemaker
necessary to achieve cervical dilatation. If may be initiating contractions, or receptor
the uterus becomes exhausted, this can points in the myometrium may be acting
cause it to not contract as effectively during independently of the pacemaker.
the postpartal period, thus increasing a
woman’s chance for postpartal hemorrhage.
Uncoordinated contractions can occur so
closely together that they can interfere with
Management: Start oxytocin infusion the blood supply to the placenta. Because
Amniotomy, to further speed labor In the they occur so erratically, such as one on top
first hour after birth palpate the uterus and of another and then a long period without
assess lochia every 5 minutes. any, it may be difficult for a woman to rest
between contractions or to breathe
effectively with contractions.
Hypertonic Contractions- Hypertonic
Contractions Are marked by an increased in
Problems With the POWER
resting tone. However, the intensity of the
contraction may be no stronger than that DYSFUNCTIONAL LABOR AND
associated with hypotonic contractions. In ASSOCIATED STAGES OF LABOR
contrast to hypotonic contractions, these
occur frequently and are most commonly • Dysfunction at the First Stage of
seen in the latent phase of labor. Labor - involves a prolonged latent
phase, protracted active phase,
prolonged deceleration phase, and
A danger of hypertonic contractions is that
secondary arrest of dilatation.
the lack of relaxation between contractions
may not allow optimal uterine artery filling;
this can lead to fetal anoxia early in the
• Prolonged Latent Phase -a
latent phase of labor. latent phase that lasts longer
than 20 hours in a nullipara or 14
hours in a multipara.
“Fetal anoxia may occur from inadequate
oxygenation of the mother, low maternal • Protracted Active Phase -
blood pressure, or abnormalities in the usually associated with fetal
uterus, placenta, or umbilical cord that malposition or cephalopelvic
result in inadequate blood flow to the fetus” disproportion, if the active phase
lasts longer than 12 hours in a
primigravida or 6 hours in a

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multigravida This may occur if the cervix is not “ripe” at

the beginning of labor. It may occur if there
• Prolonged Deceleration is excessive use of an analgesic early in
Phase- when it extends beyond labor.
3 hours in a nullipara or 1 hour in
a multipara
With a prolonged latent phase, the uterus
tends to be in a hypertonic state.
• Secondary Arrest of Dilatation-
no progress in cervical dilatation
for longer than 2 hours. Relaxation between contractions is
inadequate, and the contractions are only
mild (less than 15 mmHg on a monitor
printout) and, therefore, ineffective. One
Notes: segment of the uterus may be contracting
DYSFUNCTIONAL LABOR AND with more force than another segment.
ASSOCIATED STAGES OF LABOR
Regardless of when dysfunctional labor Management of a prolonged latent phase in
occurs, the effect on a woman and her labor that has been caused by hypertonic
support person will be the same: anxiety, contractions involves helping the uterus to
fear, or discouragement. A woman needs rest, providing adequate fluid for hydration,
good explanations of what is happening: and pain relief with a drug such as morphine
“We’re going to take an ultrasound to check sulfate.
the baby’s position.” “This is a drug to make
your contractions stronger.” “I know resting
is the last thing you feel like doing, but that Changing the linen and the woman’s gown,
is what I want you to try to do.” darkening room lights, and decreasing noise
and stimulation can also be helpful. These
Dysfunction at the First Stage of Labor measures usually combine to allow labor to
Dysfunction that occurs with the first stage become effective and begin to progress. If it
of labor involves a prolonged latent phase, does not, a cesarean birth or amniotomy
protracted active phase, prolonged (i.e., artificial rupture of membranes) and
deceleration phase, and secondary arrest of oxytocin infusion to assist labor may be
dilatation. necessary.

Prolonged Latent Phase Protracted Active Phase

When contractions become ineffective A protracted active phase is usually
during the first stage of labor, a prolonged associated with fetal malposition or
latent phase can develop. How long the cephalopelvic disproportion (CPD) (the
stages of labor take is affected by individual diameter of the fetal head is larger than the
circumstances and whether a woman has woman’s pelvic diameters), although it may
received analgesia or an epidural reflect ineffective myometrial activity.
anesthesia
This phase is prolonged if cervical dilatation
A prolonged latent phase, as defined by does not occur at a rate of at least 1.2 cm/hr
Friedman (1978), is a latent phase that lasts in a nullipara or 1.5 cm/hr in a multipara, or
longer than 20 hours in a nullipara or 14
hours in a multipara.
if the active phase lasts longer than 12
hours in a primigravida or 6 hours in a

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multigravida . assisting labor that has started

spontaneously but is not
effective.
If the cause of the delay in dilatation is fetal
malposition or CPD, cesarean birth may be
necessary. Dysfunctional labor during the
• inductions should be avoided
until 39 weeks unless medically
dilatational division of labor tends to be
indicated
hypotonic in contrast to the hypertonic
action at the beginning of labor. After an
ultrasound to show CPD is not present, Notes:
oxytocin may be prescribed to augment Precipitate dilatation is cervical dilatation
labor (see later discussion on augmentation that occurs at a rate of 5 cm or more per
by oxytocin). hour in a primipara or 10 cm or more per
Prolonged Deceleration Phase hour in a multipara. Precipitate
A deceleration phase has become birth occurs when uterine contractions are
prolonged when it extends beyond 3 hours so strong a woman gives birth with only a
in a nullipara or 1 hour in a multipara. A few, rapidly occurring contractions, often
prolonged deceleration phase most often defined as a labor that is completed in fewer
results from abnormal fetal head position. A than 3 hours. Such rapid labor is likely to
cesarean birth is frequently required. occur with grand multiparity, or it may occur
after induction of labor by oxytocin.
Secondary Arrest of Dilatation Contractions can be so forceful they lead to
Arrest of Descent premature separation of the placenta or
Arrest of descent results when no descent lacerations of the perineum, placing the
has occurred for 2 hours in a nullipara or 1 woman at risk for hemorrhage. Rapid labor
hour in a multipara. Failure of descent also poses a risk to the fetus because
occurs when expected descent of the fetus subdural hemorrhage may result from the
does not begin or engagement or rapid release of pressure on the head. The
movement beyond 0 station does not occur. woman and her support person can feel
The most likely cause for arrest of descent overwhelmed by the speed of labor.
during the second stage is CPD. Cesarean A precipitate labor can be predicted from a
birth usually is necessary. If there is no labor graph if, during the active phase of
contraindication to vaginal birth, oxytocin dilatation, the rate is greater than 5 cm/hr (1
may be used to assist labor cm every 12 minutes) in a nullipara or 10
cm/hr (1 cm every 6 minutes) in a multipara.
Problems With the POWER
DYSFUNCTIONAL LABOR AND “Precipitate delivery refers
ASSOCIATED STAGES OF LABOR to childbirth after an unusually rapid labor
(combined 1st stage and second stage
• PRECIPITATE LABOR duration is under two hours) and culminates
in the rapid, spontaneous expulsion of the
• INDUCTION AND AUGMENTATION OF infant. Delivery often occurs without the
benefit of asepsis”
LABOR

• Induction of labor means labor Caution a multiparous woman by week 28

is started artificially (oxytocin or of pregnancy that because a past labor was
amniotomy ) so brief, her labor this time also may be
brief so that she has time to plan for
• Augmentation of labor refers to adequate transportation to the hospital or

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alternative birthing center. Both grand
multiparas and women with histories of
precipitate labor should have the birthing
room converted to birth readiness before full
dilatation is obtained. Then, even if a
sudden birth should occur, it can be
accomplished in a controlled surrounding.
INDUCTION AND AUGMENTATION OF
LABOR
When labor contractions are ineffective,
several interventions, such as induction
and augmentation of labor with oxytocin or
amniotomy (artificial rupture of the
membranes), may be initiated to strengthen
them (Gilstrop & Sciscione, 2015).
Induction of labor means labor is started
artificially.
parity, who are older than 40 years, or have
previous uterine scars (Norman, 2012).
Oxytocin is an effective uterine stimulant,
but there is a thin line between adequate
stimulation and hyperstimulation, so careful
observation during the entire infusion time is
an important nursing responsibility (Bor,
Ledertoug, Boie, et al., 2016). Before
induction of labor is begun in term and
postterm pregnancies, the following
conditions should be present:
• The fetus is in a longitudinal lie.
• The cervix is ripe, or ready for birth.
• The presenting part is the fetal head
(vertex) and is engaged.
• There is no CPD.
• The fetus is estimated to be mature
by date (over 39 weeks).

Augmentation of labor refers to assisting

labor that has started spontaneously but is
not effective. Although induction may be Problems With the POWER
necessary to initiate labor before the time DYSFUNCTIONAL LABOR AND
when it would have occurred spontaneously ASSOCIATED STAGES OF LABOR
because a fetus is in danger, it is not used
as an elective procedure until the fetus is at
term (over 39 weeks).
• Cervical Ripening

Due to fetal lung maturity should not be

used and inductions should be avoided until
39 weeks unless medically indicated.
Conditions that might make induction
necessary before that time include
preeclampsia, eclampsia, severe
hypertension, diabetes, Rh sensitization,
prolonged rupture of the membranes, and
intrauterine growth restriction. Postmaturity
(a pregnancy lasting beyond 42 weeks) is
yet another situation that makes it more
potentially dangerous for a fetus to remain
in utero than to be born.
Because either augmentation or initiation of
labor carries a risk of uterine rupture or
premature separation of the placenta, it
must be used cautiously in women with
multiple gestation, polyhydramnios, grand

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antifungal cream. If sponges are used,

documentation of how many were placed is
important so it can be documented
afterward that none remain.

The most common method used to promote

Notes:
Cervical Ripening
Cervical ripening, or a change in the
cervical consistency from firm to soft, is the
first change of the uterus in early labor
because, until this has happened, dilatation
and coordination of uterine contractions will
not occur. To determine whether a cervix is
“ripe,” or ready for dilatation, Bishop (1964)
established criteria for scoring the cervix
sing this scale, if a woman’s total score is 8
or greater, the cervix is ready for birth and
should respond to induction.
To help a cervix “ripen,” a number of
methods can be instituted.
The simplest method is known as
“stripping the membranes,” or separating
the membranes from the lower uterine
segment manually, using a gloved finger in
the cervix.
cervical ripening, however, is the insertion of
a prostaglandin such as dinoprostone
(Prepidil, Cervidil) into the posterior fornix of
the vagina, by the cervix (Kunzier, Park,
Cioffi, et al., 2016). If the prostaglandin is
put in place in the evening, cervical ripening
will usually have begun by morning. It’s best
if women remain in bed in a side-lying
position to prevent loss or leakage of the
medication.
Monitor the FHR after each application and
for side effects such as vomiting, fever,
diarrhea, and hypertension in the mother.
Oxytocin induction can be started 12 hours
after the prostaglandin dose; beginning it
sooner might lead to hyperstimulation of the
uterus. Even with these side effects,
prostaglandins are well accepted by most
women as a way to aid cervical ripening
(Kunzier et al., 2016). They should be used
with caution in women with asthma, renal or
cardiovascular disease, glaucoma, or in
those who have had past cesarean births
because of the danger of side effects and
hyperstimulation
Problems With the POWER
DYSFUNCTIONAL LABOR AND
ASSOCIATED STAGES OF LABOR
• Induction of Labor by Oxytocin

For a second method, the use of

• After a cervix is “ripe,” administration of
hygroscopic suppositories oxytocin, can be used to initiate labor
(suppositories of seaweed that swell on contractions if a pregnancy is at term.
contact with cervical secretions), which
gradually and gently urge dilatation
(laminaria technique), can be inserted. They
• Augmentation by Oxytocin
can be held in place by gauze sponges
saturated with povidone-iodine or an

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usually defined as five or more contractions

in a 10-minute period or contractions lasting
more than 2 minutes in duration or occurring
within 60 seconds of each other, situations
that have the potential to interfere with
placenta filling and fetal oxygenation.

If uterine hyperstimulation should occur,

several interventions such as asking the
woman to turn onto her left side to improve
blood flow to the uterus, administering an IV
fluid bolus to dilute the level of oxytocin in
Notes: the maternal blood stream, and
TRIVIA: Oxytocin is a hormone and a administering oxygen by mask at 8 to 10 L
neurotransmitter that is involved in childbirth are all helpful. In addition, a primary care
and breast-feeding. It is also associated provider may prescribe terbutaline to relax
with empathy, trust, sexual activity, and the uterus. The surest method to relieve
relationship-building. It is sometimes tachysystole, however, is to immediately
referred to as the “love hormone,” because discontinue the oxytocin infusion. If in doubt,
levels of oxytocin increase during hugging err on the side of stopping the infusion when
and orgasm. the action isn’t needed (it can easily be
restarted) rather than delaying stopping it so
that fetal or maternal harm results.
For administration, oxytocin (Pitocin) is
commonly mixed in the proportion of 10
Induction of Labor by Oxytocin International Units in 1,000 ml of Ringer’s
After a cervix is “ripe,” administration of lactate.
oxytocin (a synthetic form of naturally
occurring pituitary hormone) can be used to
A side effect of oxytocin is that it causes
initiate labor contractions if a pregnancy is
peripheral vessel dilation, and peripheral
at term (Zheng, 2012).
dilation can lead to extreme hypotension. To
ensure safe induction, therefore, take the
Oxytocin is always administered woman’s pulse and blood pressure every
intravenously, Prepare oxytocin as hour. Monitor uterine contractions and FHR
prescribed using a piggyback intravenous conscientiously.
setup. so that, if uterine hyperstimulation
should occur, it can be quickly discontinued.
A second side effect of oxytocin is that it
can result in decreased urine flow, possibly
Because the half-life of oxytocin is leading to water intoxication. This is first
approximately 3 minutes, the falling serum manifested by headache and vomiting. If
level and effects are apparent almost you observe these danger signs in a woman
immediately after discontinuation of IV during induction of labor, report them
administration. immediately and halt the infusion. Water
intoxication in its most severe form can lead
The danger of hyperstimulation is that a
to seizures, coma, and death because of
fetus needs 60 to 90 seconds between
the large shift in interstitial tissue fluid.
contractions in order to receive adequate
oxygenation from placenta blood vessels.
Hyperstimulation (i.e., tachysystole) is Women may worry that induced labor will be

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more painful or “so different” from normal

labor that breathing exercises will be
worthless, or that labor will progress so fast
it will be harmful to the fetus. Induced labors
do tend to have a slightly shorter first stage
than the average unassisted labor; however,
this can be an advantage not a
disadvantage. Once contractions begin by
this method, they are basically the same as
unassisted contractions. Assure the woman
of this so that she does not fight the
contractions or become unnecessarily
tense, which could prevent her from using
her breathing techniques effectively.

Augmentation by Oxytocin
Notes:
Augmentation of labor may be used if labor
UTERINE RUPTURE
contractions begin spontaneously but then
become weak, irregular, or ineffective (i.e., Rupture of the uterus during labor, although
hypotonic) et al., 2016). rare, is always a possibility.
Precautions regarding oxytocin
augmentation are the same as for primary It occurs most often in women who have a
oxytocin induction of labor. Be certain the previous cesarean scar .
drug is increased in small increments only
Contributing factors may include prolonged
and that fetal heart sounds are well
labor, abnormal presentation, multiple
monitored during the procedure
gestation, unwise use of oxytocin,
obstructed labor, and traumatic maneuvers
Problems With the POWER of forceps or traction.
DYSFUNCTIONAL LABOR AND
When uterine rupture occurs, fetal death will
ASSOCIATED STAGES OF LABOR
follow unless immediate cesarean birth can
be accomplished.
• UTERINE RUPT URE - It occurs most
often in women who have a previous
If a uterus should rupture, the woman
cesarean scar. experiences a sudden, severe pain during a
strong labor contraction, which she may
• sudden, severe pain during a strong report as a “tearing” sensation.
labor contraction, which she may report
as a “tearing” sensation. Rupture can be complete, going through
the endometrium, myometrium, and
peritoneum layers, or incomplete, leaving
the peritoneum intact. With a complete
rupture, uterine contractions will
immediately stop.

Two distinct swellings will be visible on the

woman’s abdomen: the retracted uterus and
the extrauterine fetus. Hemorrhage from the

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torn uterine arteries floods into the

abdominal cavity and possibly into the
vagina.

Signs of hypotensive shock begin, including

a rapid, weak pulse; falling blood pressure;
cold and clammy skin; and dilation of the
nostrils from air starvation. Fetal heart
sounds fade and then are absent.

If the rupture is incomplete, the signs of

rupture are less evident. With an incomplete
rupture, a woman may experience only a
localized tenderness and a persistent
aching pain over the area of the lower
uterine segment. However, fetal heart
sounds, a lack of contractions, and the
changes in the woman’s vital signs will
gradually reveal fetal and maternal distress. Notes:
The rupture can be confirmed by INVERSION OF THE UTERUS
ultrasound. Uterine inversion refers to the uterus
turning inside out with either birth of the
fetus or delivery of the placenta. It is a rare
Most women are advised not to conceive
phenomenon, occurring in about 1 in 20,000
again after a rupture of the uterus, unless
births. It may occur if traction is applied to
the rupture occurred in the inactive lower
the umbilical cord to remove the placenta or
segment. At the time of the rupture, the
if pressure is applied to the uterine fundus
primary care provider, with consent, may
when the uterus is not contracted. It may
perform a cesarean hysterectomy (i.e.,
also occur if the placenta is attached at the
removal of the damaged uterus) or tubal
fundus so that, during birth, the passage of
ligation, both of which will result in loss of
the fetus pulls the fundus downward
childbearing ability.
(Choubey & Werner, 2015).
Because inversion occurs in various
Problems With the POWER degrees, the inverted fundus may lie within
DYSFUNCTIONAL LABOR AND the uterine cavity or the vagina, or in total
ASSOCIATED STAGES OF LABOR inversion, it may protrude from the vagina.

• INVERSION OF THE UTERUS- refers

When an inversion occurs, a large amount
to the uterus turning inside out with of blood suddenly gushes from the vagina.
either birth of the fetus or delivery of the The fundus is no longer palpable in the
placenta abdomen. The woman begins to show signs
of blood loss: hypotension, dizziness,
paleness, or diaphoresis. Because the
uterus is not able to contract in this position,
bleeding cannot be halted or will continue to
such an extent exsanguination could occur
within 10 minutes.

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Never attempt to replace an inversion

because handling of the uterus could
increase the bleeding. Never attempt to
remove the placenta if it is still attached
because this would create a larger surface
area for bleeding. Oxytocin, if being used,
should be discontinued because it makes
the uterus more tense and difficult to
replace.

An IV fluid line should be inserted if one is

not already present (use a large-gauge
needle because blood will need to be
replaced). If a line is already in place, open
it to achieve optimal flow of fluid to restore
fluid volume. Administer oxygen by mask,
and assess vital signs. Be prepared to
perform cardiopulmonary resuscitation Notes:
(CPR) if the woman’s heart should fail from
the sudden blood loss. The woman will AMNIOTIC FLUID EMBOLISM
immediately be given general anesthesia or Amniotic fluid embolism (a.k.a: AFE or
possibly nitroglycerin or a tocolytic drug by Anaphylactic Syndrome of Pregnancy) is
IV to relax the uterus. The primary care a condition that occurs during labor or
provider then replaces the fundus manually. immediate postpartum period. Though rare,
Administration of oxytocin after manual it is the common cause of maternal death
replacement helps the uterus to contract during childbirth.
and remain in its natural place. Because the
uterine endometrium was exposed, a
woman will need antibiotic therapy to What Causes Amniotic Fluid Embolism?
prevent infection. She needs to be informed Amniotic fluid embolism occurs when
that cesarean birth will probably be amniotic fluid enters the maternal circulation
necessary in any future pregnancy to through rupture of uterine veins or a tear in
prevent the possibility of repeat inversion. placental membranes. Blood vessels
throughout the body along with the ones
supplying to the lung and heart undergo
rapid constriction. This condition leads to
decrease in contraction of heart muscles
Problems With the POWER leading to heart failure. The blood’s ability to
DYSFUNCTIONAL LABOR AND clot is also affected leading to clotting
ASSOCIATED STAGES OF LABOR issues and bleeding.

• Amniotic fluid embolism (a.k.a: AFE or

Anaphylactic Syndrome of A more likely cause of symptoms is a
Pregnancy) is a condition that occurs humoral or anaphylactoid response to
during labor or immediate postpartum amniotic fluid in the maternal circulation.
period. Though rare, it is the common
cause of maternal death during Although it is associated with induction of
childbirth. labor, multiple pregnancy, and perhaps

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polyhydramnios (i.e., excess amniotic fluid), Problems With the Passenger

it is not preventable because it cannot be Although the fetus is basically passive
predicted. during birth, complications may arise if an
The clinical picture is dramatic. A woman, infant is immature or preterm or if the
usually in the active phase of labor, sits up maternal pelvis is so undersized that its
suddenly and grasps her chest because of diameters are smaller than the fetal skull,
sharp pain and inability to breathe as such as occurs in early adolescence or in
pulmonary artery constriction occurs. She women with altered bone growth from a
becomes pale and then turns the typical disease such as rickets. It also can occur if
bluish gray associated with a pulmonary the umbilical cord prolapses, if more than
embolism and lack of blood flow to the one fetus is present, or if a fetus is
lungs. malpositioned or too large for the birth
canal.
A woman’s prognosis depends on the size
of the embolism, the speed with which the PROLAPSE OF THE UMBILICAL CORD
emergency condition was detected, and the In umbilical cord prolapse, a loop of the
skill and speed of emergency interventions. umbilical cord slips down in front of the
presenting fetal part .

Problems With the Passenger
Umbilical cord prolapse- Occurs when the
umbilical cord comes out of the uterus with
or before the presenting part of the fetus
Prolapse may occur at any time after the
membranes rupture if the presenting fetal
part is not fitted firmly into the cervix. It
tends to occur most often with:

• Premature rupture of membranes

Amnioinfusion- a sterile fluid into the
• Fetal presentation other than
uterus to supplement the amniotic fluid and
cephalic
reduce compression on the cord
• Placenta previa
• Intrauterine tumors preventing the
presenting part from engaging
• A small fetus
• CPD preventing firm engagement
• Polyhydramnios
• Multiple gestation
The incidence is about 0.5% of cephalic
births but can rise as high as 10% or higher
with breech or transverse lies

Therapeutic Management
A prolapsed cord is always an emergency
situation because the pressure of the fetal
Notes: head against the cord at the pelvic brim

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leads to cord compression and decreased infant is immature or preterm or if the

oxygenation to the fetus. Management is
aimed, therefore, at relieving pressure on
the cord, thereby relieving the compression
and the resulting fetal anoxia. This may be
done by placing a gloved hand in the vagina
and manually elevating the fetal head off the
cord, or by placing the woman in a knee–
chest or Trendelenburg position, to cause
the fetal head to fall back from the cord.
maternal pelvis is so undersized that its
diameters are smaller than the fetal skull,
such as occurs in early adolescence or in
women with altered bone growth from a
disease such as rickets. It also can occur if
the umbilical cord prolapses, if more than
one fetus is present, or if a fetus is
malpositioned or too large for the birth
canal.

If the cord has prolapsed to the extent it is Problems With the Passenger
exposed to room air, drying will begin, Multiple gestation is pregnancy
leading to constriction and atrophy of the pregnancies with two or more fetuses) with
umbilical vessels. Do not attempt to push more than one baby at a time.
any exposed cord back into the vagina
because this could add to the compression It is a type of high-risk pregnancy,
by causing knotting or kinking. Instead, requires extra care.
cover any exposed portion with a sterile
saline compress to prevent drying.

Amnioinfusion is the addition of a sterile Notes:

fluid into the uterus to supplement the MULTIPLE GESTATION
amniotic fluid and reduce compression on
Multiple gestation is pregnancy with more
the cord. For this, a sterile double-lumen
than one baby at a time. Examples
catheter is introduced through the cervix
include pregnancy with twins, triplets, and
into the uterus. It is then attached to IV
quadruplets. Multiple gestation occurs in
tubing, and a solution of warmed normal
approximately three percent
saline is rapidly infused. Initially,
of pregnancies. It is a type of high-
approximately 500 ml is infused, and then
risk pregnancy. Delivering twins, triplets, or
the rate is adjusted to infuse the least
more requires extra care.
amount necessary to maintain an FHR
monitor pattern without variable
decelerations. Throughout the procedure, Multiple gestations (i.e., pregnancies with
urge a woman to lie in a lateral recumbent two or more fetuses) have increased
position to prevent supine hypotension substantially over the last several decades
syndrome. as in vitro fertilization has become more
popular and often produces a multiple
Problems With the Passenger pregnancy (ACOG, 2014). When a woman
with a multiple gestation is admitted to a
• Multiple gestation birthing room, it usually causes a flurry of
excitement as additional personnel are
• Problems with fetal position, needed for the birth, including as many
presentation, or size nurses to attend to possibly immature
infants as there are infants, plus additional
Notes: persons skilled in newborn resuscitation.
Problems With the Passenger
Although the fetus is basically passive Multiple Pregnancy
during birth, complications may arise if an

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at higher than usual incidences during

❑ When two, three, four, or even five multiple gestations. To detect these, be
fetuses are conceived, grow and certain to assess the woman’s hematocrit
develop in the uterus at the same time level and blood pressure closely during
labor or while waiting for cesarean
arrangements.
❑ also called multifetal pregnancy.
If a woman with a multiple gestation will be
• Twins – 2 fetuses giving birth vaginally, she is usually
instructed to come to the hospital early in
• Triplets – 3 fetuses labor. The first stage of labor does not differ
greatly from that of a woman with a single
• Quadruplets – 4 fetuses gestation pregnancy.

• Quintuplets – 5 fetuses Twin-to-twin transfusion

syndrome (TTTS) is a rare pregnancy
condition affecting identical twins or other
• Sextuplets – 6 fetuses multiples. TTTS occurs in pregnancies
where twins share one placenta (afterbirth)
• Septuplets – 7 fetuses and a network of blood vessels that supply
oxygen and nutrients essential for
development in the womb. ( will be
Types of Twinning: discussed in chapter 26).

1. Monozygotic or Identical Twin Multiple Pregnancy

Types of Twinning:

❑ Develop from one ovum and one

2. Dizygotic or Fraternal Twin
sperm that undergo too rapid cell
division after fertilization resulting in
the formation of two or more fetuses. ❑ Fraternal twins develop from two or
more ova and sperm cells that were
Notes: fertilized at the same time.
❑ Since the fetuses came from the
same sperm cell and egg cell, they ❑ They have different genetic traits;
naturally possess the same genetic
they may or may not be of the same
traits and are always of the same
sex. sex and always have separate
placentas, chorions, and amnions

Notes:
Twins may be born by cesarean birth to Be certain that when taking FHRs by
decrease the risk the second fetus will Doppler or a fetal monitor, you are definitely
experience anoxia; often, this is also the hearing two separate beats as proof each
situation in multiple gestations of three or infant is doing well. Because of the multiple
more because of the increased incidence of fetuses, abnormal fetal presentation may
cord entanglement and premature occur. Also, because the babies are usually
separation of the placenta (ACOG, 2014). small, firm head engagement may not
Anemia and gestational hypertension occur occur, thus increasing the risk for cord

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prolapse after rupture of the membranes. drugs that promotes ovulation and release
Uterine dysfunction from a long labor, an of several ova at the same time.
overstretched uterus, unusual presentation, Higher incidence in tall and large framed
and premature separation of the placenta women
after the birth of the first child may also be
more common.
Multiple Pregnancy
Complications of Multiple Fetuses:
The infants need careful assessment to
determine their true gestational age and
whether a phenomenon such as twin-to-twin ❑ Abortion
transfusion could have occurred.
❑ Preterm labor and birth
Assess the woman carefully in the
immediate postpartal period because a
uterus that was overly distended because of ❑ Pregnancy-induced hypertension
the multiple gestation may have more
difficulty contracting than usual, thus placing
her at risk for hemorrhage from uterine
❑ Anemia
atony (i.e., lacking normal tone). In addition,
the risk for uterine infection increases if ❑ Birth defects
labor or birth was prolonged.

Multiple Pregnancy
Predisposing Factors of Dizygotic Notes:
Twinning: Abortion: A phenomenon called the
vanishing twin syndrome in which
❑ Race more than one fetus is diagnosed,
but one or more of them vanishes
(or is absorbed), often in the first
❑ Heredity trimester, while the other survive
until term. This may or may not be
accompanied by bleeding. The risk
❑ Age and parity of pregnancy loss is increased in
later trimesters as well.
❑ Higher incidence in women taking Multiple Pregnancy
fertility drugs
Complications of Multiple Fetuses:

Notes:
Predisposing Factors of Dizygotic Twinning: ❑ Caesarian delivery
Race: Highest incidence among black
women. ❑ Postpartum hemorrhage
Heredity: More common in women with
family history of twinning
Age and parity: increased incidence in high
❑ Hydramnios
parity and advanced maternal age
Higher incidence in women taking fertility ❑ Low birth weight

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❑ Placenta previa ❑ Calorie requirement: + 300 kcal to

normal pregnancy
❑ Intrauterine growth retardation
❑ Iron: 60-100 mg
❑ Cord entanglement, prolapse and
compression ❑ Vitamin supplements to meet increased
demand

Multiple Pregnancy
Signs and Symptoms:
❑ 6 small meals rather than 3 large meals
to decrease the discomfort of a large
uterus compressing a full stomach
1. Uterus is large for gestational age
Notes:
2. Auscultation of two or more fetal What is the normal Kcal intake of pregnant
heart tone woman?

3. History of twins in the family Last bullet - The American College

of Obstetricians and Gynecologists
recommends women carrying twins
4. Palpation of two or more large fetal gain at least 35 to 45 pounds
parts Management: 1. Prenatal Care

c. Rest and Ambulation

5. Ultrasound reveals two or more
gestational sac ❑ More bed rest during the 3rd trimester

Multiple Pregnancy ❑ Rest in the left lateral position

Management: 1. Prenatal Care

a. Clinic visit is more frequent ❑ Higher-order multiple pregnancies often

than usual: require bed rest beginning in the middle
of the 2nd trimester
❑ First trimester: Every
Notes:
month
Rest and Ambulation
❑ Second trimester: Every More bed rest during the third trimester to
avoid premature labor
2 weeks
Rest in the left lateral position for optimum
❑ Third trimester: Every placental perfusion
week Higher-order multiple pregnancies often
require bed rest beginning in the middle of
Management: 1. Prenatal Care
the second trimester
b. Nutrition

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Breech Presentation- when the fetus

Multiple Pregnancy presents buttocks or feet first (rather than
Management: 2. Labor & Delivery head first – a cephalic presentation)
(NSD) “types of breech presentations:
complete, frank, and footling “
a. If NSD is planned, instruct to come
to the hospital at the 1st sign of
labor.

b. Monitor for possible complications

during labor & delivery:

❑ Possible prolapsed cord

❑ Possible fetal respiratory distress
due to analgesia

❑ Entanglement of fetuses during Notes:

delivery Breech Presentation
Notes: Most fetuses are in a breech presentation
early in pregnancy. By week 38, however, in
❑ Babies of multiple births tend to be approximately 97% of all pregnancies, a
smaller than a single fetus and may fetus turns to a cephalic presentation (i.e.,
not fill the pelvis completely. The head down). This probably happens
cord may drop when the membranes because, although the fetal head is the
rupture widest single diameter, the buttocks
❑ Analgesia is administered very (breech) plus the legs of the fetus actually
conservatively. Small for gestational take up more space. As the fundus is the
age infants, which is common largest part of the uterus, this places the
among twins, have difficulty bulkiest parts of the fetus in the fundus.
metabolizing analgesia from their
systems prior to birth. Withholding it There are several types of breech
avoids respiratory difficulties presentations: complete, frank, and footling
following delivery (see Chapter 15). Examples of why such
❑ Presentation of all fetuses should be presentations occur are shown in Box 23.7.
known prior to delivery. If the first Overall, a breech presentation is more
fetus is not vertex, cesarean section hazardous to a fetus than a cephalic
is normally done. This prevents the presentation because there is a higher risk
first fetus from becoming entangled of the following:
with other fetuses. More than two • Developing dysplasia of the hip
fetuses indicate caesarian section
for control and quick access to the • Anoxia from a prolapsed cord
infants.
• Traumatic injury to the after-coming
head (possibility of intracranial hemorrhage
Problems With the Passenger or anoxia)

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• Fracture of the spine or arm Notes:

Birth Technique
• Dysfunctional labor
• Early rupture of the membranes It is not always possible to turn
because of the poor fit of the presenting part your baby from being breech.
• Meconium staining Some breech babies can be safely
delivered through the vagina , but usually
Meconium staining occurs because of
doctors deliver them by C-section. Risks
cervical pressure on the buttocks and
involved with a C-section include bleeding
rectum, not because of fetal anoxia, and so
and infection . There also can be a longer
is not a sign of fetal distress. Meconium
hospital stay for both the mother and
excretion can, however, lead to meconium
her baby.
aspiration if the infant inhales amniotic fluid.

If the infant will be born vaginally, a woman

A second danger of a breech birth is
is allowed to push after full dilatation is
intracranial hemorrhage. With a cephalic
achieved, and the breech, trunk, and
presentation, molding to the confines of the
shoulders are born (Fig. 23.10A,B). As the
birth canal occurs over hours. With a breech
breech spontaneously emerges from the
birth, pressure changes occur
birth canal, it is steadied and supported by a
instantaneously, a situation that can result in
sterile towel held against the infant’s inferior
tentorial tears leading to gross motor and
surface (Fig. 23.10C). The shoulders
mental incapacity or lethal damage to the
present to the outlet with their widest
fetus. A danger to the infant who is born
diameter anteroposterior. If they are not
gradually to reduce the possibility of
born readily, the arm of the posterior
intracranial injury is hypoxia. In contrast, the
shoulder may be drawn downward by
infant who is born suddenly to reduce the
passing two fingers over the infant’s
duration of cord compression may suffer an
shoulder and down the arm to the elbow,
intracranial hemorrhage.
then sweeping the flexed arm across the
infant’s face and chest and out. The other
Assessment arm is delivered in the same way. External
rotation is then allowed to occur to bring the
With a breech presentation, fetal heart
head into the best outlet diameter.
sounds usually are heard high in the
abdomen. Leopold maneuvers and a Birth of the head is the most hazardous part
vaginal examination usually reveal the of a breech birth. Because the umbilicus
presentation. 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
Problems With the Passenger loop of cord.

Problems With the Passenger

Asynclitism-A fetal head presenting at a
different angle

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uterus with Leopold maneuvers.

A face presentation is confirmed by vaginal

examination when the nose, mouth, or chin
can be felt as the presenting part.

A fetus in a posterior position, instead of

flexing the head as labor proceeds, may
extend the head, resulting in a face
presentation; this usually occurs in a woman
with a contracted pelvis or placenta previa.
It also may occur in the relaxed uterus of a
multipara or with prematurity,
polyhydramnios, or fetal malformation.

It is a warning signal. Something abnormal

is usually causing the face presentation.

Babies born after a face presentation have

Notes:
Face Presentation A fetal head presenting
at a different angle than expected is termed
asynclitism. Face and brow presentations
are examples. Face (chin, or mentum)
presentation is rare, but when it does occur,
the head diameter the fetus presents to the
pelvis is often too large for birth to proceed.
a great deal of facial edema and may be
purple from ecchymotic bruising. Observe
the infant closely for a patent airway. In
some infants, lip edema is so severe that
they are unable to suck for a day or two.
Gavage feedings may be necessary to allow
them to obtain enough fluid until they can
suck effectively. They may be transferred to
a neonatal intensive care unit (NICU) for 24
hours. Reassure the parents that the edema
is transient and will disappear in a few days
with no aftermath.
Problems With the Passenger
A brow presentation is the rarest of the
presentations. It occurs in a multipara or a
woman with relaxed abdominal muscles.

A head that feels more prominent than

normal, with no engagement apparent on
Leopold maneuvers, suggests a face
presentation.

It is also suggested when the head and

back are both felt on the same side of the

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It occurs in a multipara or a woman with
relaxed abdominal muscles. It almost
invariably results in obstructed labor
because the head becomes jammed in the
brim of the pelvis as the occipitomental
diameter presents.
Unless the presentation spontaneously
corrects, cesarean birth will be necessary to
birth the infant safely.
Brow presentations also leave an infant with
extreme ecchymosis bruising on the face.
On seeing this bruising over the same area
as the anterior fontanelle, or “soft spot,”
parents may need additional reassurance
that the child is well after birth.
Transverse lie- is also described as lying
sideways or even shoulder presentation.
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Transverse lie occurs in women with
pendulous abdomens, with uterine fibroid
tumors that obstruct the lower uterine
segment, with contraction of the pelvic brim,
with congenital abnormalities of the uterus,
or with poly hydramnios.
It may occur in infants with hydrocephalus
or another abnormality that prevents the
head from engaging. It may also occur in
prematurity if the infant has room for free
movement, in multiple gestations
(particularly in a second twin), or if there is a
short umbilical cord.
A transverse lie usually is obvious on
inspection because the ovoid of the uterus
is found to be more horizontal than vertical.
The abnormal presentation can be
confirmed by Leopold maneuvers. An
ultrasound may be taken to further confirm
the abnormal lie and to provide information
on pelvic size.
A mature fetus cannot be born vaginally
from this presentation. Often, the
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membranes rupture at the beginning of becomes the birth method of choice. The
labor. Because there is no firm presenting large size of a fetus may be missed in an
part, the cord or an arm may prolapse, or obese woman because the fetal contours
the shoulder may obstruct the cervix. are difficult to palpate and obesity does not
Cesarean birth is necessary. necessarily indicate a larger than usual
Oversized Fetus (Macrosomia)- newborn pelvis. Pelvimetry or ultrasound can be used
baby that is significantly larger than average to compare the size of the fetus with the
infants. weighs more than 4,000 to 4,500 g woman’s pelvic capacity.
(approximately 9 to 10 lb). a large infant born vaginally has a higher
born to women who enter pregnancy with than normal risk of cervical nerve palsy,
diabetes or who develop gestational diaphragmatic nerve injury, or a fractured
diabetes. clavicle because of shoulder dystocia.
Postpartally, the woman has an increased
Large babies are also associated with risk of hemorrhage because the
multiparity overdistended uterus may not contract as
readily as usual.
Fetal Anomalies - often referred to as birth
defects, are structural changes to one or
more parts of the fetus' body
Fetal anomalies of the head such as
hydrocephalus (i.e., fluid-filled ventricles) or
anencephaly (i.e., absence of the cranium)

Two of the most common symptoms of fetal

macrosomia are:
1. Fundal Height Is Larger than Average
2. Excessive Amount of Amniotic Fluid
An oversized infant may cause uterine
dysfunction during labor or at birth because
of overstretching of the fibers of the
myometrium. The wide shoulders may pose
a problem at birth because they can cause
fetal pelvic disproportion or even uterine
rupture from obstruction. A woman may be
left with perineal lacerations (Wang, Zhu,
Zhang, et al., 2016).
Problems with the Passage
If the infant is so oversized that he or she
cannot be born vaginally, a cesarean birth • Inlet contraction - Inlet contraction is

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narrowing of the anteroposterior abnormality (larger than usual head)

diameter of the pelvis to less than 11 or a pelvic abnormality (smaller than
cm. It usually is caused by rickets in usual pelvis) should be suspected.
early life or by an inherited small As a rule, engagement does not
pelvis. occur in multigravidas until labor
• Outlet contraction- is a narrowing of begins. For these women, previous
the transverse diameter vaginal birth of a full-term infant
without problems is proof their birth
• INLET CONTRACTION canal is adequate.
- Rickets is caused by a lack of • Every primigravida should have
calcium and is therefore rare in pelvic measurements taken and
developed countries but can occur recorded before week 24 of
among immigrants who were raised pregnancy so, based on these
where milk supplies were not measurements and the assumption
plentiful. the fetus will be of average size, a
• Rickets is a rare disorder that affects birth decision can be made.
the bones, causing them to soften • OUTLET CONTRACTION- the
and break easily. It is most common distance between the ischial
in children. A lack of vitamin D tuberosities at the outlet, to less than
causes most cases of rickets. 11 cm. This measurement is made
Vitamin D helps bones absorb by sonogram during pregnancy but
calcium and phosphorus. If your can also easily be made manually at
child does not get enough vitamin D, a prenatal visit or at the beginning of
their body may not get the nutrients labor.
it needs to make bones strong.
• In primigravidas, the fetal head
normally engages between weeks Trial labor - the conduction of
36 and 38 of pregnancy. spontaneous labor in a moderate degree of
cephalopelvic disproportion, If a woman has
• If this occurs any time before labor a borderline (just adequate) inlet
begins, it is proof the pelvic inlet is measurement and the fetal lie and position
adequate as lightening, by definition, are good.
means the fetal head has sunk
below the inlet. Following the
general rule that “what goes in,
comes out,” a head that engages or
proves it fits into the pelvic brim will
probably also be able to pass
through the midpelvis and through
the outlet.
• If engagement does not occur in a
primigravida, then either a fetal

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TRIAL LABOR
trial of labour is the conduction of
spontaneous labor in a moderate degree of
cephalopelvic disproportion., If a woman
has a borderline (just adequate) inlet
measurement and the fetal lie and position
are good, It is performed under close
observation by an obstetrician in order to
assess a woman's chances of a successful
vaginal birth.
her primary care provider may allow her a
“trial” labor to determine whether labor will
progress normally.
The trial labor continues as long as descent
of the presenting part and dilatation of the
cervix continue to occur.
With a trial labor, monitor fetal heart sounds
and uterine contractions frequently. Urge
the woman to void every 2 hours so her
urinary bladder is as empty as possible,
allowing the fetal head to use all the space
available. If, after a definite period (6 to 12
hours), adequate progress in labor cannot
be documented, or if at any time fetal
distress occurs, the trial labor will be
discontinued and the woman will be
scheduled for a cesarean birth.
It may be difficult for women to undertake
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labor they know they may not be able to
complete because the effort subjects them
needlessly to pain. Emphasize, but do not
overstress, that it is best for their baby to be
born vaginally. If the trial labor fails and
cesarean birth is scheduled, provide an
explanation as to why cesarean birth is
necessary and why it has become the best
route for the birth of their baby
External cephalic version- is the turning
of a fetus from a breech to a cephalic
position before birth. It may be done as
early as 34 to 35 weeks.
For the procedure, FHR and possibly
ultrasound are recorded continuously. A
tocolytic agent may be administered to help
relax the uterus. The breech and vertex of
the fetus are located and grasped
transabdominally by the examiner’s hands
on the woman’s abdomen. Gentle pressure
is then exerted to rotate the fetus in a
forward direction to a cephalic lie (Fig.
23.11).
Although not always successful, the use of
external version can decrease the number
of cesarean births necessary from breech
presentations (Velzel et al., 2015).
Contraindications to the procedure include
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. External version can be
uncomfortable for a woman because of the
feeling of pressure. Women who are Rh
negative should receive Rh immunoglobulin
after the procedure in case minimal
bleeding occurs.
Forceps birth- Obstetrical forceps are steel
instruments constructed of two blades that
slide together at their shaft to form a handle.
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• A forceps birth may leave a transient blade and the fetal head, assess FHR again
erythematous mark on the immediately after application. The woman’s
newborn’s cheek cervix needs to be carefully assessed after
forceps birth to be certain no lacerations
have occurred. To rule out bladder injury,
The primary care provider then applies record the time and amount of the first
pressure on the handle to manually extract voiding. In addition, assess the newborn to
the fetus from the birth canal. be certain no facial palsy exists from
In years past, babies were routinely born pressure.
with forceps. Today, the technique is rarely A forceps birth may leave a transient
used (in only about 4% to 8% of births) erythematous mark on the newborn’s cheek
because it can lead to rectal sphincter tears (see Chapter 18). This mark will fade in 1 to
in the woman, which can lead to 2 days with no long-term effects.
dyspareunia, anal incontinence, or
increased urinary stress incontinence Vacuum extraction
(Halscott, Reddy, Landy, et al., 2015).
Although no longer used routinely, forceps
may be necessary with any of the following
conditions:
• 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 VACUUM EXTRACTION
stage of labor occurs.
A fetus, if positioned far enough down
• A fetus is in an abnormal position. the birth canal, may be born by vacuum
• A fetus is in distress from a extraction .
complication such as a prolapsed With the fetal head at the perineum, a
cord. soft, disk-shaped cup is pressed against
Although forceps appear as if they would the fetal scalp and over the posterior
put forceful pressure on the fetal head, the fontanelle.
pressure registers on the steel blades rather When vacuum pressure is applied, air
than the head so they can actually reduce beneath the cup is suctioned out and the
pressure, thus avoiding a complication such cup then adheres so tightly to the fetal
as subdural hemorrhage scalp that traction on the vacuum cord
Record the FHR before forceps application. leading to the cup extracts the fetus.\
Because there is a danger that the cord Vacuum extraction has advantages over
could be compressed between the forceps forceps birth in that little anesthesia is

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necessary, thus leaving the fetus with contractions

less respiratory depression at birth. One • Recognition of abnormal
disadvantage over natural birth is that position of fetus or fetal heart
more perineal lacerations may occur sounds
(Steinhauer, 2015). Its major • Accurate assessment of
disadvantage is that it causes a marked pelvic inlet, outlet, and
caput on the newborn head that may be midpelvis
noticeable as long as 7 days after birth.
2020 National Health Goals Related to a
Family Experiencing a Complication of
Labor or Birth #1
• Reduce the number of cesarean
births among low-risk women to no
more than 23.9 per 100 births from a
baseline of 26.5 per 100 births.
• Reduce the number of cesarean
births among women who have had
a previous cesarean birth to no more
than 61.7 per 100 births from a
baseline of 90.8 per 100 births.
• Reduce the maternal mortality rate
to no more than 11.4 per 100,000
live births from a baseline of 12.7
per 100,000 live births.
• Reduce the rate of maternal
complications during hospitalized
Nursing Diagnoses of a Family
labor and birth to no more than 28
Experiencing a Complication of Labor or
per 100 births from a baseline of
Birth
31.1 per 100 births.
• Fatigue related to loss of glucose
Assessment of a Family Experiencing a
stores during prolonged labor
Complication of Labor or Birth #1
• Risk for ineffective tissue perfusion
• Assessment for complications in of woman and/or fetus
labor and birth is based on careful
uterine and fetal monitoring. • Risk for deficient fluid volume related
• Recognition of hypertonic to length of labor
and hypotonic contractions • Risk for maternal and/or fetal injury
• Mapping of lengths of phases related to a labor complication
and stages of normal labor and/or required medical treatment
• Recognition of abnormal fetal • Anxiety related to uncertainty of
response to uterine pregnancy outcome

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•
Anomalies of the placenta

Placenta succenturiate - A leash of vessels

connecting the main to the small lobe
traverses through the membranes
Circumvallate placenta: the fetal surface is
divided into a central depressed zone
surrounded by a thickened white ring which
is usually complete. The ring is situated at
varying distances from the margin of the
placenta and is composed of a double fold
• Placenta Succenturiata - is a
of amnion and chorion with degenerated
placenta that has one or more
decidua (vera) and fibrin in between.
accessory lobes connected to the
Vessels radiate from the cord insertion as
main placenta by blood vessels.
far as the ring and then disappear from
• Placenta Circumvallata - the fetal view.
side of the placenta is covered to
Battledore placenta- Umbilical cord may be
some extent with chorion
attached in the center, off center, on the
• Battledore Placenta - the cord is edge, or in the membranes of the placenta.
inserted marginally rather than Battledore placenta is a placenta in which
centrally the umbilical cord is attached at the
• Velamentous Insertion of the Cord placental margin. The shortest distance
- instead of entering the placenta between the cord insertion and the placental
directly, separates into small vessels edge is within 2 cm. The incidence of the
that reach the placenta by spreading battledore placenta is 7–9% in singleton
across a fold of amnion pregnancies and 24–33% in twin
pregnancies
Velamentous placenta - Cord insertion, the
umbilical cord inserts into the fetal
membranes (chorioamniotic membranes)

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and then travels within the membranes to Placenta accreta is a serious pregnancy
the placenta (between the amnion and the condition that occurs when
chorion). The exposed vessels are not the placenta grows too deeply into the
protected by Wharton's jelly and hence are uterine wall. Typically,
vulnerable to rupture the placenta detaches from the uterine wall
Vasa previa - A condition in which blood after childbirth. With placenta accreta, part
vessels within the placenta or the umbilical or all of the placenta remains attached.
cord are trapped between the fetus and the This can cause severe blood loss after
opening to the birth canal. delivery
• Preparation for cesarean Placenta accreta is an unusually deep
delivery attachment of the placenta to the uterine
myometrium, so deep that the placenta will
not loosen and deliver (Silver, 2015).
Attempts to remove it manually may lead to
extreme hemorrhage because of the deep
attachment.
Hysterectomy to remove the uterus or
treatment with methotrexate to destroy the
still-attached tissue may be necessary.
Methotrexate is in a class of medications
called antimetabolites. Methotrexate treats
cancer by slowing the growth of cancer
cells.

vessels may tear with cervical dilatation, just

as a placenta previa may tear. Before ANOMALIES OF THE CORD
inserting any instrument such as an internal Two-Vessel Cord
fetal monitor, be certain to identify structures A normal cord contains one vein and two
to prevent accidental tearing of a vasa arteries. The absence of one of the
previa because tearing would result in umbilical arteries is associated with
sudden fetal blood loss. If sudden, painless congenital heart and kidney anomalies
bleeding occurs with the beginning of because the insult that caused the loss of
cervical dilatation, either placenta previa or the vessel may have also affected other
vasa previa is suspected. It can be mesoderm germ layer structures.
confirmed by ultrasound. If vasa previa is Inspection of the cord as to how many
identified, the infant needs to be born by vessels are present must be made
cesarean birth. immediately after birth, before the cord
begins to dry, because drying distorts the
Placenta Accreta appearance of the vessels. Document the

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number of vessels conscientiously because • An unusually long cord may be

an infant with only two vessels needs to be easily compromised because of its
observed carefully for other anomalies tendency to twist or knot.
during the newborn period.
Unusual Cord Length
Although the length of the umbilical cord
rarely varies, some abnormal lengths may
occur. An unusually short umbilical cord can
result in premature separation of the
placenta or an abnormal fetal lie. An
unusually long cord may be easily
compromised because of its tendency to
twist or knot. Occasionally, a cord actually
An average umbilical cord is 55cm long.
forms a knot, but the natural pulsations of
The shortest 5% of umbilical cords are
the blood through the vessels and the
shorter than 35cm, and the longest 5% are
muscular vessel walls usually keep the
over 80cm (1). If an umbilical cord is
blood flow adequate. It is not unusual for a
abnormally short or long, it can increase the
cord to wrap once around the fetal neck
likelihood of various pregnancy, labor, and
(nuchal cord) but, again, with no
delivery complications.
interference to fetal circulation
Although the length of the umbilical cord
rarely varies, some abnormal lengths may
occur. An unusually short umbilical cord can
result in premature separation of the
placenta or an abnormal fetal lie. An
unusually long cord may be easily
compromised because of its tendency to
twist or knot. Occasionally, a cord actually
forms a knot, but the natural pulsations of
the blood through the vessels and the
muscular vessel walls usually keep the
blood flow adequate. It is not unusual for a
cord to wrap once around the fetal neck
(nuchal cord) but, again, with no
interference to fetal circulation

Question 1
A pregnant woman who is carrying triplets is
concerned when her obstetrician suggested
Unusual Cord Length that she give birth by cesarean delivery.
• An unusually short umbilical cord What is the most accurate statement that
can result in premature separation of the nurse can make to the woman regarding
the placenta or an abnormal fetal lie. this?

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A. Traditional labor room suites setup.

cannot accommodate the B. Teach the pregnant woman to lie on
personnel needed during the her back as much as possible during
birth of three infants like the labor.
operating room can. C. Make sure that a fetoscope is
B. It is safer to know exactly available in the room for monitoring.
when the delivery will occur D. Assure the pregnant woman that the
so that the healthcare team induction process will assure a
will be available. shorter than usual labor.
C. A cesarean delivery helps
to prevent complications
due to cord prolapse or
premature placental
separation.
D. Labor contractions are so
powerful in a multiple
gestation that a cesarean
delivery is safer for the
infants and mother.

Question 2
You assess that the fetus of a woman is in
an occiput posterior position. You know that
her labor most likely will be different from a
woman whose fetus is in an anterior
position in that the woman
A. Will have a shorter second stage of
labor
B. May experience more pronounced
back pain
C. May need to have an external
cephalic version performed
D. Probably will need to have the
delivery assisted by forceps or
vacuum extraction

Question 3:
You are preparing for an induction of labor.
Which of these would the nurse expect to
do in preparation?
A. Prepare oxytocin as prescribed
using a piggyback intravenous

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