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• Dystocia


  Delay or arrest in the progress of labor
• Causes of dystocia

  • Problems with the 4 P's: Powers (expulsive forces), Passenger (presentation, potion, and fetal development), Passage (the bony pelvis or birth canal), and Psyche (client's psychological status)
• Shoulder Dystocia


  Obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has been delivered
• Risks for birthing client with shoulder dystocia

  • Injury
  • Postpartum hemorrhage (secondary to uterine atony, vaginal lacerations, anal tears, and uterine rupture)
• Risks for fetus with shoulder dystocia

  • Transient Erb or Duchenne brachial plexus palsy
  • Clavicular or humeral fractures
• Risk factors for shoulder dystocia

  • Maternal obesity
  • Macrosomic infant
  • LGA
  • Mother with diabetes
  • Turtle sign
• Interventions for shoulder dystocia

  1. Ask for help

  2. Hyperflexion of legs

  3. Anterior shoulder disimpaction

  4. Rotate posterior shoulder

  5. Manual removal of posterior arm

  6. Episiotomy

  7. Roll over onto all fours
• Cord Prolapse


  Rare obstetrical emergency that occurs when the cord precedes the fetal presenting part
• Causes of cord prolapse

  • Polyhydramnios
  • Long cord
  • Malpresentation (breech, transverse)
  • PROM
  • Amniotomy (before engaged vertex)
• Always check FHR after ROM-hold presenting part off cord, prepare for C/S
• Vaginal Birth After Caesarian (VBAC)

  A client who gives birth vaginally after having at least one previous caesarian birth
• Contraindications for VBAC


  • Prior classic uterine incision
  • Prior transfundal uterine surgery
  • Uterine scar other than low-transverse
  • Contracted pelvis
  • Previous uterine rupture
  • Placenta previa
  • Malpresentation
• Oxytocin induction increases the risk for uterine rupture, but augmentation is not contraindicated
• Must obtain consent, documentation, surveillance, readiness for emergency for VBAC
• Early Losses


  • Ectopic Pregnancy
  • Miscarriage/abortion
  • Medical interruption
  • Infertility
  • Stillbirth
• Loss of a healthy baby/uncertain prognosis

  • Premature infant
  • Special needs
  • Compromised
  • Anomalies
• Disenfranchised Grief


  Occurs when the loss does not receive normal social support, is not openly acknowledged, or cannot be mourned publicly
• 4 tasks of Mourning

  • Accept the reality
  • Work through the pain and grief
  • Adjust to a world without the deceased
  • Find an enduring connection while moving forward
• Yearly incidence of violence in pregnancy is 6-8%, increases to 7-11% during pregnancy
• More than 35% of women report exposure to some form of violence in their lifetime
• 51% of women >16 reported at least 1 incident of physical/sexual assault
• 25% of women had been abused by their intimate partners
• 63,300 women reported being victimized by a partner while they were pregnant
• 40% of Canadian women reported violence that began during pregnancy
• Indigenous women have 4-5x the odds of being a victim of IPV
• Impact of Domestic Violence

  • Delayed prenatal care
  • Increased substance use/abuse
  • Increased physical and sexual health complaints
• Fetal Impact of Domestic Violence

  • Direct physical trauma causing injury
  • Preterm labor
  • LBW
• Principles of trauma and violence informed care

  • Trauma awareness
  • Emphasis of safety and trust
  • Opportunities for choice collaboration
  • Focus on strengths
• Dystocia


  Delay or arrest in the progress of labor
• Causes of Dystocia


  • Problems with the 4 P's: Powers (expulsive forces – hypertonic uterine dysfunction, hypotonic uterine dysfunction, precipitate labor), Passenger (presentation, position, and fetal development – breech/shoulder dystocia, cord prolapse, macrosomia), Passage (the bony pelvis or birth canal – pelvic contraction, obstructions in maternal birth canal), and Psyche (client's psychological status)
• Shoulder Dystocia


  Obstruction of fetal descent and birth by the axis of the fetal shoulders after the fetal head has been delivered
• Risks for birthing client with Shoulder Dystocia

  • Injury
  • Postpartum hemorrhage (secondary to uterine atony)
  • Vaginal lacerations
  • Anal tears
  • Uterine rupture
• Risks for fetus with Shoulder Dystocia

  • Transient Erb or Duchenne brachial plexus palsies
  • Clavicular humeral fractures
• Risk factors for Shoulder Dystocia

  • Maternal obesity
  • Macrosomic infant
  • LGA
  • Mother with diabetes
  • Turtle sign
• Interventions for Shoulder Dystocia

  • Ask for help
  • Life/hyperflex legs
  • Anterior shoulder disimpaction
  • Rotate posterior shoulder
  • Manual removal of posterior arm
  • Episiotomy
  • Roll over onto all fours
• Cord Prolapse


  Rare obstetrical emergency that occurs when the cord precedes the fetal presenting part. The protrusion of the umbilical cord alongside or ahead of the presenting part.
• Causes of Cord Prolapse

  • Polyhydramnios
  • Long cord
  • Malpresentation (breech, transverse)
  • PROM
  • Amniotomy (before engaged vertex)
• Always check FHR after ROM - hold presenting part off cord, prepare for C/S
• Vaginal Birth After Caesarian (VBAC)

  A client who gives birth vaginally after having at least one previous caesarian birth
• Contraindications for VBAC


  • Prior classic uterine incision
  • Prior transfundal uterine surgery
  • Uterine scar other than low-transverse
  • Contracted pelvis
  • Previous uterine rupture
  • Placenta previa
  • Malpresentation