NCM 102 Complications of Labor and Delivery PROBLEMS WITH THE PASSENGER Fetal Size Macrosomia Infant weighs

more than 4000g Maternal implications : CPD Lacerations Dysfunctional labor Post partum hemmorrhage Neonatal implication: Shoulder dystocia FETAL MALPOSITION where the fetus is lying longitudinally and the vertex is presenting, but it is not in the OA position OT (LOT, ROT) OP the ideal fetal position is flexed with occiput in the right or left anterior quadrant of the maternal pelvis 1. Types of malpositions a. Occiput posterior (OP) position 1) Right or left OP position occurs in about 25% of all term pregnancies but usually rotates to occiput anterior (OA) as labor progresses 2) Failure to rotate is termed persistent occiput posterior 3) Maternal risk include prolonged labor, potential for operative delivery, extension of the episiotomy, 3rd- or 4th- degree of laceration of the perineum 4) Maternal symptoms include intense back pain in labor, dysfunctional labor pattern, prolonged active phase, secondary arrest of dilation, and/or arrest of descent

Possible Problem Prolonged active phase Arrest of descent

Risk Factors Android pelvis Antrhopoid pelvis

b. Occiput tranverse (OT) position 1) Incomplete rotation of OP position to OA results in the fetal head being in a horizontal or tranverse position (OT) 2) Persistent occiput tranverse position occurs as a result of ineffective contractions or a flattened bony pelvis 3) In the absence of abnormal pelvic structure, vaginal delivery can be accomplished by stimulating contractions with oxytocin (Pitocin) and application of forceps for delivery Synclitism - the position of the fetal head in relation to the anteroposterior diameter of the maternal pelvis. Refers specifically to the position of the fetal head when the sagittal suture is halfway between the sacral promontory and symphysis pubis. If synclitism exists, the planes of the pelvis and the fetal skull are parallel with the same space all around the fetal head. Asynclitism. Either posterior or anterior. Posterior - position of the fetal head when the sagittal suture is closer to the sacral promontory. Anterior - position of the fetal head when the sagittal suture is closer to the symphysis pubis.

2. Nursing care a. Encourage the mother to lie on her side opposite from the fetal back, which may help with rotation b. Knee-chest position may facilitate rotation c. Pelvic rocking may help with rotation d. Apply sacral counter-pressure with heel of the hand to relieve back pain e. Continue support and encouragement 1) Keep client and family informed of progress 2) Encourage relaxation with contractions 3) Praise clients efforts to maintain control f. Anticipate forceps/manual rotation and forceps- assisted birth

MEDICAL MANAGEMENT a. Forceps: metal instruments applied to the fetal head to facilitate delivery 1) Provides traction or means of rotating the fetal head 2) Risk are fetal ecchymosis or edema of the face, transient facial paralysis, maternal lacerations, or episiotomy extensions

b. Vacuum extraction: a suction cup applied to the fetal head to facilitate delivery 1) Provides traction to shorten the second stage of labor 2) Risk are newborn cephalhematoma, retinal hemorrhage, and intracranial hemorrhage

Abnormal lie where the long axis of the fetus is not lying along the long axis of the mother LONGITUDINAL (MAY BE EITHER CEPHALIC OR BREECH) TRANSVERSE OBLIQUE FETAL MALPRESENTATION The term malpresentation encompasses any fetal presentation other than vertex, including breech, face, brow, shoulder, and compound presentations. Both fetal and maternal factors contribute to the occurrence of malpresentation. The most common malpresentation is breech. BREECH MALPRESENTATION Breech presentation occurs when the fetal buttocks or lower extremities present into the maternal pelvis. Prior to 28 weeks, approximately 25% of fetuses are in a breech presentation position. As the fetus grows and occupies more of the uterus, it tends, to assume a vertex presentation to accommodate best to the confines and shape of the uterus. By 34 weeks gestation, most fetuses have assumed the vertex presentation position. Breech presentation Etiology: prematurity. Approximately 20% to 30% of all singleton breeches are of low birth weight (<2500g). However, fetal structural anomalies (e.g., hydrocephalus) may restrict the ability of the fetus to present as a vertex. In breech presentations, the incidence of structural anomalies is greater than 6%, or two to three times that of a vertex.

Other etiologic factors include: uterine anomalies multiple gestation, placenta previa, hydramnios, contracted maternal pelvis, and pelvic tumors that obstruct the birth canal.

Classifications There are three types of breech presentation: frank, complete, and incomplete or footling.

Frank breech occurs when both fetal thighs are flexed and both lower extremities are extended at the knees. A complete breech has both thighs flexed and one or both knees flexed (sitting in a squat position). An incomplete (or footling) breech has one or both thighs extended and one or both knees or feet lying below the buttocks. Diagnosis Leopolds maneuver

Pregnancy management Exclude fetal and uterine anomalies. If breech presentation is suspected after 34 weeks, the prenatal records and any prior ultrasonic examinations should be reviewed for the presence of uterine myomata, mullerian anomaly or fetal structural abnormality. If suspicious, a thorough ultrasonic examination should be ordered.

External cephalic version. External cephalic version (ECV) is a procedure in which the obstetrician manually converts the breech fetus to a vertex presentation via external uterine manipulation under ultrasonic guidance. ECV may be considered in a breech presentation at term before the onset of labor. ECV is not carried out prior to 36 to 37 weeks. The procedure must be carried out in a hospital that is equipped to perform an emergency cesarean section because of the small risk of placental abruption or cord compression. The patient should have nothing by mouth for 8 hours The fetus is rotated by external pressure to a cephalic lie Contraindication of ECV Evidence of utero-placental insufficiency Hypertension Intrauterine growth restriction Oligohydramnios History of previous uterine surgery Assisted Breech Spontaneous delivery to the umbilicus Up to four minutes from delivery of the umbilicus to complete delivery associated with Apgar scores of > 7 at 5 minutes If legs do not deliver spontaneously can be assisted by Pinard manoeuvre Note: Trapped head Piper forceps - applied to the after coming fetal head Delivery of Breech Presentation by Forceps Vaginal delivery versus cesarean for breech birth? Most health care providers do not believe a vaginal delivery is possible for a breech birth, although some will wait to make that decision until a woman is in labor. However, the following are often necessary in order for a vaginal birth to be attempted: The baby is full-term and in the frank breech presentation The baby does not show signs of distress while its heart rate is closely monitored The process of labor is smooth and steady; the cervix is widening and the baby is moving down The health care provider estimates that the baby is not too big or the mother's pelvis too narrow for the baby to pass safely through the birth canal Anesthesia is available and a cesarean delivery can be performed on short notice

FACE PRESENTATION Face presentation occurs when the fetal head is hyper-extended such that the fetal face, between the chin and orbits, is the presenting part. Etiology The etiology of face presentation is somewhat enigmatic. During normal vertex delivery, the fetal head is markedly flexed, with the fetal occiput as the leading part. Factors that permit the fetus to enter the pelvis with a markedly extended head include extreme prematurity, high maternal parity, and congenital anomalies. Diagnosis The diagnosis of face presentation is usually made at the time of vaginal examination during labor, when the soft tissues of the fetal mouth and nose are noted adjacent to the malar bones and orbital ridges. OTHER PRESENTATIONS 1. Brow presentation. 2. Shoulder presentation. Note the transverse lie of the fetus with the back down, which cannot be delivered vaginally.

Shoulder Presentation Tranverse lie acromion process is the presenting part Vaginal delivery is not considered possible in term infant CS is preferred method of delivery Causes Prematurity Placenta Previa Abnormal uterus Contracted pelvis or relaxed abdominal wall Polyhydramnios SHOULDER PRESENTATION WITH PROLAPSED ARM 3. A compound presentation occurs when a fetal extremity (usually the hand) prolapses alongside the presenting part (the head) and both parts enter the maternal pelvis at the same time.

Prolapse of the Umbilical Cord Definition: Prolapse of the umbilical cord through the cervical canal along side of the presenting part Etiology/ Risk Factor: Occurs anytime the inlet is not occluded. Fetus is not well engaged GOAL: RELIEVE THE PRESSURE ON THE CORD,SUPPORT MOTHER AND THE FAMILY Prolapse of the Cord NURSING CARE / Therapeutic Interventions: #1 Get the Pressure off the Cord place in trendelenberg or knee-chest position elevate part with sterile gloved hand Nursing Care for Prolapse of Umbilical Cord Palpate FHTs, NEVER ATTEMPT TO REPLACE CORD! Give O2 per mask at 10 Liters Cover exposed cord with sterile wet gauze Stay with the patient and offer support

Managing UCP Goal of care: actions to relieve pressure on the cord and restore fetal oxygenation Place the mothers hip higher than her head Knee-chest position Trendelenburg position b. Perform sterile vaginal exam pushing fetal presenting part upward with fingers to relieve pressure on the cord c. Administer oxygen by face mask at 8-10 lpm d. Maintain continuous electronic fetal monitoring Managing UCP e. Prepare for rapid delivery either vaginally or cesarean section f. If cord protrudes through the vagina, determine that pulsation is present and apply sterile saline soaked dressing to prevent drying

Treatments for Complications of the Passenger 1. ECV alteration of fetal position by abdominal or intrauterine manipulation A new technique involves pressure on the fetal head and buttocks so that the fetus completes a backward flip or forward roll. External Version Procedure Criteria Fetus is not engaged A reactive NST 36+ weeks gestation Contraindications A complicated pregnancy Multiple pregnancy Non-reassuring FHR Nursing Care Administer terbutaline prior to start Monitor maternal and fetal vital sign Post assess for contractions and kick-counts

2. Forceps low forceps or outlet forceps usually applied after crowning Used to shorten the second stage of labor and assist the womans pushing efforts Forceps-Assisted Delivery Risks on Fetus Facial edema or lacerations Caput succedaneum or cephalohematoma Maternal Lacerations of birth canal Perineal bleeding, bruising, edema Nursing Care Preventive measures to decrease need for forceps Patient teaching

After assessment of newborn and assessment of womans perineum.

3. Vacuum extraction disk shaped cup placed over vertex of head and vacuum applied. Vacuum Extraction Used to shorten the second stage of labor and facilitate delivery of the fetus Risk Cephalohematoma or caput succedaneum

Nursing Care Keep woman and partner informed during the procedure After assess newborn

4. Episiotomy surgical incision to allow more room Surgical incision of perineal body to enlarge the outlet Episiotomy Factors that predispose: Primigravida Large baby, macrosomia Posterior position of baby Use of forceps or vacuum extractor Preventive Measures Perineal massage Gradual expulsion Nursing Care Provide comfort and patient teaching After delivery- apply ice and assess site 5. Cesarean Delivery OPERATIVE PROCEDURE IN WHICH THE FETUS IS DELIVERED THROUGH AN INCISION IN THE ABDOMEN Mom may feel less than normal, so may need support

VBAC - Vaginal Birth After Cesarean A woman may be considered a candidate for a VBAC if the following guidelines are met: With previous C-section, had low transverse incision Has an adequate pelvis (absence of pelvic dystocia) A woman who had a previous VBAC Hospital must be set up to perform an emergency cesarean within 30 minutes. Cesarean Birth Nursing Care Frequent monitoring of woman and fetus Complication Uterine rupture

May have option of a VBAC the next time