Wesleyan University –Philippines

Cabanatuan City
College of Nursing

NCM 109- Care of Mother and Child at Risk or with Problems

(Acute and Chronic)-LECTURE
PRELIM PERIOD
WEEK 5
Nursing Care of a Family Experiencing a
Complication of labor or Birth

I.COMPLICATION WITH THE POWER( THE FORCE OF LABOR)

Uterine contractions are the basic force that
moves the fetus through the birth canal
> They occur due to the roles of :
• major electrolytes: calcium, sodium, and potassium
• specific contractile proteins: actin and myosin
• Hormones: epinephrine, norepinephrine, oxytocin, estrogen,
progesterone, and prostaglandin
Nursing Care of a Family Experiencing a
Complication of labor or Birth
 Inertia is a time-honored to denote sluggishness of contractions,
or that the force of labor is less than usual.
 Dysfunctional labor is the current term
 Risk: postpartum infection, hemorrhage, infant mortality
 Several factors on prolonged labor are fetus is large or the
contractions are hypotonic, hypertonic or uncoordinated.
 INEFFECTIVE UTERINE CONTRACTION
1. HYPOTONIC CONTRACTION
-the number of contractions is usually infrequent
-it occurs during the active phase of labor and tend to occur
after administration of analgesia
CAUSES:
1.1.Inappropriate use of analgesia-An epidural block
(sometimes referred to as “an epidural”) is the
most common type of pain relief used for childbirth
in the United States.
 For labor and vaginal delivery, a combination of analgesics and
anesthetics may be used.
 many physicians induce analgesia as soon as the diagnosis of active
labor has been established and the patient has requested pain relief.
 Complication: hypotension and headache (epidural analgesia)
> An epidural anesthesia injection works by injecting an
anesthetic into the epidural space around the spine so that it
can stop pain signals from traveling from the spine to the
brain.
2. Poor fetal position-is the relationship of the
presenting part to a specific quadrant and side
of a woman’s pelvis.
➢Review: The maternal pelvis is divided into four quadrants
1.Right anterior 2.Left anterior
3.Right posterior 4.Left posterior
A fetus is born fastest from an ROA
(Right Occiput Anterior) or LOA (Left Occiput Anterior)
Labor would be extended if the position is posterior ;
ROP or LOP and may be more painful for a woman
because the rotation of the fetal head puts
pressure on sacral nerves
3. Extension rather than flexion of the fetal head
4.Overdistention of the uterus
5.Cervical rigidity (unripe)
6. Presence of a full rectum or urinary
bladder- full bladder can hinder the uterus
from contracting efficiently.
An empty bladder leaves more space for
the baby to pass through.
7. Woman becoming exhausted from labor
Management During Labor:
Dependent Nursing Intervention:
1. 1.Amniotomy – artificial rupture of the membranes
2. 2. IVF insertion for Pitocin administration
Advantages of doing Amniotomy before the introduction of Pitocin:
 a. Contractions are more similar to those of spontaneous labor
 b. Usually no risk of rupture of the uterus
 c. Does not require as close surveillance
Management After the Administration of Pitocin
Independent Nursing Intervention
 1.Assess contractions – are they increasing but not titanic
 2.Assess dilatation and effacement
 3.Monitor vital signs and FHT/POL
 4.Refer immediately to the attending physician if with signs of Fetal Distress
 5.Administer Oxygen inhalation to the mother
 4.C/S – if fetal descent does not occur (dependent intervention)
Caution on Pitocin
> Use only if CPD is not present
> Give 20 units /1000ml of fluid and hang as a secondary infusion never as primary
 Goal : to achieve contractions every 2-3 minutes of good intensity with relaxation between
Independent Nursing Intervention During Labor:
1.Ambulation – getting up and walking will increase contractions
2.Nipple Stimulation – causes release of endogenous Pitocin which can stimulate contractions
3.Assisting the woman every 2 hours to empty her bladder.
Nursing management:
First hour after birth:
1. palpate the uterine fundus
2.check the woman’s BP
3. assess the amount of lochia every 15 mins for the
1st hour
4.check for post partum complication
Rationale: to make sure the postpartal contractions
are not also hypotonic
2. HYPERTONIC CONTRACTION
- FREQUENCY OF CONTRACTION: Adequate uterine contractions are
1 in 3 minutes lasting for 45 seconds with good relaxation in between
- marked by increased of resting tone
- The contraction occurs frequently
-the intensity is high, and more painful
-danger of hypertonic is that the lack of relaxation
between contractions may not allow optimal uterine artery
filling that may lead to fetal anoxia, which is the major risk
- Commonly seen during the latent phase of labor
- The intensity may be stronger and tend to occur frequently and uncoordinated.
 * There is no pain free period. Patient is exhausted and express concern about loss
of control because of intense pain
 * Contractions are ineffective, erratic, uncoordinated and involved only a portion of the
uterus
 * increased frequency of contractions, but intensity is decreased, do not bring about
dilatation and effacement of the cervix.
> decelerations in the FHT means lack of pushing and need C/S birth.
Fetal Heart Rate Patterns
1. Accelerations
> Normal increases in FHR caused by fetal movement, a change in maternal position or
administration of an analgesic.
2. Early Deceleration
> Normal decreases in FHR resulting from pressure on the fetal
head during contractions
> a transient decrease in heart rate that coincides with the onset
of a uterine contraction, resulting in vagal stimulation and
slowing of the heart rate
3.Late Decelerations
➢Decelerations that are delayed after the onset of
contractions
that suggest decreased blood flow to the uterus
➢gradual decrease in the fetal heart rate typically following
the
uterine contraction
Causes:
a. uteroplacental insuffiency ( not enough oxygen to the
baby),
b. amniotic fluid infection which can occur due to excessively
long labor after the water has been broken
c. low maternal blood pressure
Variable Decelerations
➢Decelerations that occur at unpredictable times in relation to
contractions that indicate compression of the umbilical cord
Risk:
 Prolonged latent phase – stay at 2-3 minutes
 > Fetal distress occurs – decreasing placental perfusion
Management:
Dependent Intervention:
1.applying a uterine and a fetal external monitor to any woman whose pain seems
out of proportion to the quality of her contractions- to identify that the resting
phase between contraction is adequate.
2.Sedation
3.Hydration/IVF
4.Tocolytics – no oxytocin
5.Oxygen administration
6.Monitor POL(Progress of Labor: frequency, intensity, duration)
Independent Intervention
1.Bed Rest
2. Provide comfort measure
• Explain to the woman and her partner that although the contractions are
very strong, they are ineffective and are not achieving cervical dilatation.

 3. UNCOORDINATED CONTRACTION
• Uterine contraction- the tightening and shortening of
the uterine muscles.
• During labor, contractions accomplish two things:
1 they cause the cervix to thin (efface) and dilate (open); and
2.they help the baby to descend into the birth canal.
> Once the contraction started, it sweeps down over the organs,
encircling it; repolarization occurs, relaxation or a low resting tone
is achieved and another pacemaker-activated contraction begins.
All contractions are initiated at one pacemaker point high in the
uterus
 * Under normal circumstances, all contractions are initiated at
one pacemaker point high in the uterus.
 Uterine contractions generally begin at the top of
the uterine fundus and spread down toward the cervix.
 Uterine contractions during the final trimester increase the
strength of the uterine muscle called Braxton-
Hicks contractions, these are slow, rhythmic contractions of
the uterine myometrium.
  With uncoordinated uterine contractions, more than one pacemaker may be
initiating contractions
 Occur so closely together that they can interfere with the blood supply to the
placenta
 It is difficult for the woman to rest between contraction or to breathe effectively with
contractions because the contractions appear erratically

CRITERIA HYPERTONIC HYPOTONIC

Most common phase of latent active
occurrence
Symptoms painful Limited pain
Medication used
oxytocin Unfavorable reaction Favorable reaction
sedation helpful Little value
Management:
Dependent Intervention:
• A fetal and uterine external monitor must be attached to the woman to
assess the rate, pattern, resting tone, and fetal response to contractions
for at least 15 minutes.
• Oxytocin administration can also be done to stimulate a more effective
and consistent pattern of contractions with a better, lower resting tone.
DYSFUNCTION AT THE FIRST STAGE OF LABOR
 1. PROLONGED LATENT PHASE
-contraction is ineffective during this 1st stage
-latent phase that last longer than 20 hours in nullipara or 14 hours
multipara
CAUSES:
-happened if the cervix is not ripe at the beginning of labor
-uterus tends to be hypertonic state, relaxation between contraction is
inadequate and the contraction is mild that’s why it is ineffective.
-Excessive use of analgesic early in labor
 Management: If caused by hypertonic contractions
Independent:
1.helping the uterus to rest
2.providing adequate fluid for hydration
3.darkening the room,
4.decreasing noise and changing linen and gowns
Dependent:
1. Providing adequate fluid for hydration
2.Administer pain reliever (morphine sulfate)
3. Administer oxytocin infusion to assist the labor
4.amniotomy-artificial rupturing of the membrane
5.Cesarean birth-if all measures are not effective
2. PROTRACTED ACTIVE PHASE
Caused by:
1.fetal malformation or CPD or Cephalo Pelvic Disproportion
-diameter of fetal head is too
large for the mothers pelvic diameter
2. Ineffective myometrial activity
 this phase is prolonged if cervical dilatation
does not occur at a rate of at least 1.2 cm/hr in a nullipara
or 1.5 cm/hr in a multipara
If the active phase lasts longer than 12 Hrs in a primigravida or 6 Hrs in a
multigravida
Management:
Dependent Intervention:
1.If the cause is fetal malposition or CPD- C/S
2.If UTZ is done and the result is not CPD- oxytocin may be prescribed to
augment labor

3.PROLONGED DECELERATION PHASE

When it extends beyond 3 Hours in a nullipara or 1 HR in a multipara
Due to abnormal fetal head position
Management:
Dependent Intervention: Cesarean birth
4. SECONDARY ARREST OF DILATATION
 if there is no progress in cervical dilatation for longer than 2 hours
Management: Dependent Intervention: Cesarean birth

SUMMARY:
DYSFUNCTION AT THE FIRST STAGE OF LABOR
1. PROLONGED LATENT PHASE
2. PROTRACTED ACTIVE PHASE
3. PROLONGED DECELERATION PHASE
4. SECONDARY ARREST OF DILATATION
DYSFUNCTION AT THE SECOND STAGE OF LABOR
1.PROLONGED DESCENT
- The downward movement of the biparietal diameter of the fetal head within the
pelvic inlet
> Rate of descent -nullipara-less than 1.0cm per hour
-multi para 2.0cm per hour
 Contractions become infrequent and of poor quality, dilatation also stops
Management:
> If contraction are of good quality and duration, effacement and beginning
dilatation have occurred, but contractions become infrequent and of poor quality
and dilatation stops and CPD and poor fetal presentation have been ruled out by
UTZ, the following can be done:
Independent Intervention:
1. Rest and fluid intake
2. Semi fowler’s position, squatting, kneeling or more effective pushing may
speed descent
Dependent Intervention:
1.If membranes have not ruptured-amniotomy may be helpful.
2.Intravenous oxytocin may be used to induce the uterus to contract
2. ARREST OF DESCENT
 Happened after 2 hours of no descent for nulli para/ 1 hour multi para
 No engagement at all or failure of descent occurs when expected descent of the fetus does not
begin or engagement or movement beyond 0 station does not occur
 Causes 2nd stage on CPD( CS is needed)
Management:
Dependent Intervention:
1.If no contraindication to vaginal birth- Oxytocin may be used
2.Cesarean birth is necessary

SUMMARY:
DYSFUNCTION AT THE SECOND STAGE OF LABOR
1.PROLONGED DESCENT
2. ARREST OF DESCENT
I.a.PRECIPITATE LABOR
 A cervical dilatation that occurs at a rate of 5cm or more per hour in
primipara or 10cm or more per hour in a multipara.
 Occurs when uterine contractions are so strong a parent gives birth with
only a few, rapidly occurring contractions, often defined as a labor that is
completed in fewer than 3 hours
 High Risk: Grand multiparity women at 28weeks
Effects:
1.Can lead to premature separation of the placenta placing the woman at
2.Lacerations of the perineum risk for hemorrhage
Risks to the Fetus:
> Subdural hemorrhage due to the rapid release of pressure on the head
Management
1.Advice women at 28th week of gestation with history of precipitate labor to
arrange for adequate transportation to the hospital or alternative birthing center.
2. A birthing room must be converted to birth readiness before full dilatation is
obtained.

Induction and Augmentation of Labor

When labor contractions are ineffective, several interventions, such as induction
and augmentation of labor with oxytocin or amniotomy may be initiated
1. Induction of labor
Means labor is started artificially
2.Augmentation of labor
> refers to assisting labor that has started spontaneously but is not effective
Reasons:
Pre eclampsia
Eclampsia
Severe Hypertension
Diabetes
Rh sensitization
Prolonged Rupture of the Membranes
Intrauterine growth restriction
Fetus is in danger
Term baby but no spontaneous uterine contraction
Procedure:
1. Cervical Ripening
A change in cervical consistency from firm to soft
To determine whether a cervix is ripe or ready for dilatation,
establish criteria for scoring the cervix
If the score is 8 or greater, the cervix is ready for birth
method for Ripening the cervix :
a.stripping the membranes or separating the membranes from the
lower uterine segment manually using a gloved finger in the cervix
Possible complication: bleeding from an undetected low-lying
placenta and possibility of infection
b.Laminaria technique - Hygroscopic suppositories of seaweed that
swell on contact with cervical secretions that will urge dilatation
Procedure:
held in place by gauze sponges saturated with povidone-iodine or
antifungal cream
If sponges are used, proper documentation is needed to ensure that
none remained inside.
c. Insertion of prostaglandin suppositories (dinoprostone) into the
posterior fornix of the vagina, by the cervix
Procedure:
Remain in place in the evening, cervical ripening will begin by morning
Oxytocin induction can be started 12 HRs after the prostaglandin dose
to prevent overstimulation of the uterus
Management after the insertion:
Advice the woman to lie in a side lying position-to prevent loss or
leakage of the medication
Monitor the FHR after each application and other side effects: vomiting,
fever, diarrhea, and hypertension in the mother
Precaution:
Women with the ff. health condition should not use prostaglandin:
• Asthma
• Renal or cardiovascular disease
• Glaucoma
• History of C/S births
Reasons: danger of side effects and hyperstimulation

2. Induction of Labor by Oxytocin

Mixed 10 international units in 1,0000 ml of Ringer’s lactate
Ten International Units of oxytocin is the same as 10,0000 milliunits
Alternative dilution: 15 International Units of oxytocin to 260 ml of IV
solution=60milliunits per 1 ml
Side Effects:
1.Causes peripheral vessel dilation- hypotension
Management before administering:
a.Check the woman’s PR and BP every hour
b.Monitor uterine contraction and FHR
2.Can cause decreased urine output-water intoxication: siezures, coma
and death because of the large shift in the interstitial tissue fluid
S&S
Headache
Vomiting
Management:
>stop the infusion and report immediately to the attending physician
Management for water intoxication
>keep a record of the I & O
>test and record urine specific gravity to detect fluid retention
Induction and Augmentation of Labor
Consideration to perform Induction and Augmentation of Labor
 The fetus is in longitudinal llie
 The cervix is ripe, or ready for birth
 A presenting part is engaged
 There is no CPD
 The fetus is estimated to be mature by date
I.b.Uterine Rupture
 Rupture of the uterine during labor , although rare is always a possibility
- Occurs when a uterus undergoes more strain than it is capable of sustaining
- Strong contraction without cervical dilatation
 Most often to previous CS women
 FACTORS ARE (prolonged labor, abnormal presentation, multiple gestation, unwise use of
oxytocin, obstructed labor and traumatic maneuvers of forceps or traction
 Fetal death will follow unless immediate CS
s/sx
 1. severe pain
 2.hemorrhage
 3.signs of hypotensive shock
 4. no FHT
MANAGEMENT
 1. FLUID THERAPY 4. Advised patient not to conceived again
I.c.INVERSION OF THE UTERUS
 -refers to the uterus turning inside out with either birth of the fetus or delivery of the
placenta.
 Rare phenomenon 1:20000 births
 Excessive traction of the uterine fundus
 When it happened a large sudden gush of blood expel from the vagina
 s/sx
 1. fundus is no longer palpable
 2. signs of blood loss(hypotension,, dizziness, paleness, diaphoresis)
 No oxytocin-can cause uterus more tense
 Management:
 Oxygen administration
 CPR
 TOCOLYTIC DRUGS-to relax the uterus
 Antibiotic-infection
 CS and possible hysterectomy
 I.d.AMNIOTIC FLUID EMBOLISM
 Occurs when amniotic fluid is forced into an open uterine blood sinus after a
membrane rupture or partial; separation of the placenta
 Come from meconium particles or shed fetal skin
 Cause a humoral- anaphylactoid response to amniotic fluid in the blood stream
during labor or post partum period
 Rate 1:20000 births not preventable
 s/sx:
 1.chest pain 2. hypoxia 3. pale to bluish gray color
4.unconsciousness
 Mngt:
 1.oxygen administration
 2.endotracheal intubation(ICU)
 3.IMMEDIATE CS to save the fetus
II. COMPLICATION WITH THE PASSENGER

a.Prolapse of the Umbilical Cord

 A loop of the umbilical cord slips down in front of the presenting fetal
part.
 If the presenting fetal part is not fitted firmly into the cervix
 Occur after rupture of membrane
 The pressure of the fetal head against the cord at the pelvic brim
leads to cord compression and decreased oxygenation to the fetus
Management:
Goal: relieving pressure on the cord, to relieve pressure the compression
and the resulting fetal anoxia
Procedure:
1.Placing a gloved hand in the vagina and manually elevating the fetal
head off the cord
2.Placing the woman in knee chest or Trendelenburg position
>Knee chest position uses gravity to shift the fetus out of
the pelvis. The woman’s thighs should be at right angles
to the bed and her chest flat on the bed
3. Administer Oxygen by mask 10L/min by face mask to the
woman- helpful to improve oxygenation to the fetus.
4. Do not attempt to push any exposed cord back into vagina-
this can cause more compression by knotting or kinking
5.Cover any exposed portion with a sterile saline compress to
prevent drying.
6. Cesarean Birth-if no cervical dilatation
b. Multiple Gestation
>More than one fetus in the utero
Management:
1.If NSD:
Instruct woman to come to the hospital early in labor
First stage may be long
Urge woman to spend the early hours in an activity to make time pass
more quickly
Teach woman proper breathing techniques or exercises
During labor- support the woman’s breathing pattern- to minimize the
use of analgesia or anesthesia-minimize any respiratory difficulties
among infants
Expect to hear two separate beats as proof each infant is doing well
Expect for abnormal presentation may occur-vertex and breech
Expect head engagement may not occur because the babies are usually
small-cord prolapse after rupture of membrane
Expect uterine dysfunction, overstretched uterus, unusual presentation
and premature separation of the placenta after birth of the first child
The first infant is identified as A-newborn care is given
Oxytocin is not given yet after the delivery of the first infant-to avoid compromising
the circulation of the infants not yet born
Assess woman for post partum hemorrhage and infection due to prolonged labor
2.If by C/S:
Additional personnel are needed
Focus on the woman’s needs as well as those of her babies
Prepare pre operative management

Problems with fetal position, presentation, or size

1.Face presentation
A fetal head presenting at a different angle than expected in termed
asynclitism
Example: face and brow presentations
*face (chin or mentum) is rare, but when it does occur, the head diameter the
fetus presents on the pelvis is often too large for birth to proceed.
Signs and Symptoms:
Head feels more prominent than normal
No engagement apparent on LM
Present with contracted uterus or placenta previa, polyhydramnios, or
fetal malformation
Diagnosis: assessment thru:
Palpation: vaginal examination – when nose, mouth or chin can be felt
UTZ
What to expect from an Infant:
Facial edema
Purple from ecchymotic bruising
Observe infant for patent airway
b. Brow presentation
The rarest of the presentation
Occurs in multipara or with woman with relaxed abdominal muscles
Can results to obstructed labor due to head becomes jammed in the brim of the
pelvis
Management: C/S
c. Transverse Lie
Occurs in women with pendulous abdomen, uterine fibroid tumors
Contractions of the pelvic brim, with congenital anomalies of the
uterus, or with polyhydramnios
Occur in infants with hydrocephalus or any abnormality that
prevents the head from engaging
May occur in prematurity if the infant has room for free movement
If with short umbilical cord.
Diagnosis thru assessment: method: inspection: the ovoid of the uterus is found to be more
horizontal than vertical
 Can be confirmed by LM
 UTZ for final confirmation
Management: a mature infant cannot be born normally: membranes rupture prematurely, cord or
arm can prolapse, or shoulder may obstruct the cervix
> C/S
d. Macrosomia
 Weighs more than 4,000 to 4,500 g (9-10 lbs)
 High incidence: women with diabetes or who
developed gestational diabetes
 Risk:
• uterine dysfunction due to overstretching of the uterus
• Fetal pelvic disproportion – due to the wide shoulders of the infant
• Perineal lacerations
Management: C/S
Fetal Risks:
 > Brachial plexus injury due to improper or excessive traction
applied to the fetal head
Brachial plexus injuries during childbirth include:
– Erb-Duchenne Palsy
– > It involves injury to the 5th, 6th and sometimes the 7th
cervical nerve roots. It results in paralysis of the deltoid
and infraspinatus muscles as well as the flexor muscles
of the forearm.
– > The affected extremity is held straight and
– internally rotated with the elbow extended and
– the wrist and fingers flexed.
– > Moro, biceps and radial reflexes are
– absent on the affected extremity however,
– grasp reflex remains intact.
e. Shoulder Dystocia
Problem occurs at 2nd stage of labor- fetal head is born but the
shoulders are too broad to enter and be born through the pelvic outlet
Danger:
a. hazardous to the woman- can cause vaginal or cervical tears
b. Hazardous to the infant-if cord is compressed between the body and
the bony pelvis
Common in:
> Women with diabetes, multiparas, postdate pregnancies
Diagnosis: if 2nd stage is prolonged: arrest of descent,
head appears in the perineum (crowning)
Breech Presentation
> when the fetus presents buttocks or feet first (rather than head
first – a cephalic presentation).
Complication to be anticipated:
> Perinatal morbidity and mortality from difficult delivery
>LBW from prematurity, growth retardation
>Prolapsed cord
>Placenta previa
>Multiple fetuses
Sub- Classification

1. a.Frank breech – lower extremities are

flxed at the hips and extended at the
knee
b. Complete breech – one or both knees
are flexed
c.. Footling breech – one or both feet is at
the lowermost in the birth canal
Diagnosis:

1. Abdominal exam – leopold’s maneuver

LM1 – hard, round, readily ballotable fetal head is found to
occupy the fundus
LM 2 – indicates the back to be on one side of the abdomen and
the small parts on the other
LM3 – breech is movable above the pelvic inlet
LM4 – firm breech to be beneath the symphysis

• FHB is in the lower quadrant and/or in the umbilicus

2. Vaginal exam – both ischial, sacrum and the anus are palpable

3. x-ray and ultrasound

III. Complications with the Psyche

> It is another word for the emotional state during birth.

> A good emotional state helps woman cope with the pain
effectively; helps her tune in to her body; helps guide her to her
baby’s needs and allows the other 3 P’s to sync up effectively

If woman is afraid, tense, stressed out, angry, feels unsafe

or unsupported, she will not likely do well during birth.
For some, the fear is intense enough to schedule
a c-section and to avoid a vaginal birth all together.
For others, it may prevent cervical dilation,
fetal decent, or prevent mom from pushing effectively.
IV. COMPLICATIONS WITH THE PASSAGE
 The reason why dystocia can occur is a contraction or narrowing of the
passageway or birth canal.
 This can happen at the: INLET, at the MIDPELVIS, or at the OUTLET
 The narrowing causes CPD, or a disproportion between the size of the
fetal head and the pelvic diameters, that results in failure to progress in
labor.

ANATOMY OF THE PELVIS

ANATOMY OF THE PELVIS
 The reason why dystocia can occur is a contraction or narrowing of the
passageway or birth canal.
 This can happen at the: INLET, at the MIDPELVIS, or at the OUTLET
 The narrowing causes CPD, or a disproportion between the size of the
fetal head and the pelvic diameters, that results in failure to progress in
labor.
a. Inlet Contraction
Is narrowing of the anteroposterior diameter of the pelvis to less
than 11 cm or of the transverse diameter to 12 cm or less.
Usually caused by rickets in early life or by an inherited small pelvis
Rickets- caused by lack of calcium
Primigravidas – fetal head engages between weeks 36 and 38 of pregnancy
• If occurs anytime before labor begins, the pelvis is of adequate size
• Literally means, the fetal head sunk below the inlet
• “Whatever goes in, comes out”- a head that engages into the pelvic brim will
be able to pass through
• Rule: engagement does not occur in multigravidas until labor begins, vaginal
birth of a full term infant only proves that their birth canal is adequate
• Every primigravida should have pelvic measurements taken and recorder before
week 24 of pregnancy
• If CPD occurs, fetus may not engage but remains “floating”, consider the
possibility of cord prolapse
Outlet contraction
Is a narrowing of the transverse diameter, the distance between
ischial tuberosities at the outlet, to less than 11cm
is rare, but should be readily diagnosed at the routine
assessment of the pelvis during the prenatal period. When in
doubt, accurate measurements of the bony outlet by X-ray
pelvimetry are mandatory.
Management:
1.Can be delivered by NSD
2.Cesarean Section
*TRIAL LABOR
If with borderline (just adequate) inlet measurement
May be done if with descent of the presenting part and dilatation
of the cervix
Management During the Trial Labor:
Independent:
1.Monitor FHR and uterine contractions frequently
2.Urge the woman to void every 2 hours
3.Explain why C/S is scheduled or explain that it is an
alternative method of delivery
Dependent:
C/S if after 6-12Hrs no adequate progress is noted
• EXTERNAL CEPHALIC VERSION
Is the turning of a fetus from a breech to a cephalic positions
before birth
Done 34-45 weeks of gestation
EXTERNAL CEPHALIC VERSION
Indications:
Breech presentation
Transverse lie
Procedure:
Independent: Monitoring and recording of FHR and UTZ result
Dependent: Tocolytic- to help relax the uterus
Although not always successful, but can decrease the number of C/S
Contraindications:
Multiple gestation
Severe oligohydramnios
Small pelvic diameters
Nuchal cord
Unexpected third trimester bleeding
V. Anomalies of the Placenta and Cord
Might occur during the third stage of labor (delivery of the
placenta) can also result in complications

1.Anomalies of the Placenta

> Should be carefully examined after birth
• Normal weight: 500 g ; 1/6 of the fetal weight
• Diameter: 15-20 cm
• Thickness: 1.5-3.0 cm
b. Placenta Circumvallata
Normally , the chorion membrane begins at the edge of the
placenta and spreads to envelop the fetus, no chorion covers the
fetal side of the placenta
The fetal side of the placenta is covered to some extent with
chorion
c. placenta accreta
Unusual deep attachment of the placenta to the uterine
myometrium
So deep that the placenta will not loosen and deliver
Attempts to remove it manually may lead to extreme hemorrhage
because of the deep attachment

Management
Hysterectomy Dependent Intervention
Administration of Methotrexate
d. Battledore Placenta
The cord is inserted marginally rather than centrally
Rare and has no known significance either
e.Velamentous Insertion of the Cord
The cord, instead of entering the placenta directly, separates into small
vessels that reach the placenta by spreading across a fold of amnion
Usually found with multiple gestation
Infant born with this anomalies should be examined carefully after birth
f.Vasa Previa
The umbilical vessels of a velamentous cord insertion cross the cervical
os and therefore deliver before the fetus
The vessels may tear with cervical dilatation
Before inserting any instrument such as an internal fetal monitor, be
certain to identify structures to prevent accidental tearing of a vasa
previa – sudden fetal blood loss
Diagnosis: UTZ
If positive for vasa previa, C/S may be needed

2.Anomalies of the Cord

1.two-vessel cord
Normal cord: one vein and two arteries
Absence of one artery suggests congenital heart and kidney anomalies
because the insult that caused the loss of the vessel may have also
affected other mesoderm germ layer structures
Management:
Independent:
1.Perform physical assessment among newborn: inspection
of the presence of one vein and two arteries
2.Document the findings
3.Referral to attending physician in case of anomalies

2.Unusual Cord length

Unusual short cord – premature separation of the placenta
or an abnormal fetal lie
Unusual long cord- tendency to twist or knot/nuchal cord
Thank you for listening!