NCM 109: Care for Mother and Child with Problems (Maternal)

• Cephalic


  Head first, also known as Vertex or the crown
• Landmarks of fetal position

  • Right occiput Posterior (ROP)
  • Left occiput Posterior (LOP)
  • Right occiput Transverse
  • Left occiput Transverse
  • Right occiput anterior
  • Left occiput anterior
• Fetal Lie


  The orientation of the fetus in the uterus

  
• Fetal Skull


  The structure of the fetal head
• Fetal Presentation


  The part of the fetus that enters the birth canal first

  
• Malpresentations


  • Brow
  • Face
  • Shoulder
  • Breech
• Malposition of the Occiput


  When the fetal occiput lies adjacent to the sacroiliac joint and occupies either the left or right posterior quadrants of the mother's pelvis with the brow directed anteriorly

  
• Causes of malposition of the Occiput

  • Modern lifestyle and poor posture
  • Decrease nutrition and lifestyle of the mother affects the fetus
  • Use of epidural anesthesia
  • Decrease the tone of the pelvic floor muscle which results in failure of the vertex to rotate = OPP
  • Android Pelvis
  • Heart shaped pelvis same with the male pelvis which has a narrow floor pelvis which forces the fetus to take OPP
• Assessment of malposition

  • On inspection: abdomen appears flattened, or slightly depressed, below the umbilicus
  • On palpation: fetal head is high, the occiput and brow may be felt at the same level at the pelvic inlet, while the fetal back can be palpated out in the flank
  • On Auscultation: The fetal heart sounds can be heard in the midline just below the umbilicus

  
• Complications of OPP

  • Early rupture of the membranes
  • Cord prolapses
  • Prolonged labor
  • Premature expulsive effort
  • Infection
  • Maternal exhaustion
• Interventions for OPP

  • Communication and support
  • One-to-one care
  • General comfort and pain relief
  • Ambulation and position
  • Assessment of progress
  • Effective assessment of maternal and fetal wellbeing
  • Appropriate and decisive clinical decisions
  • Appropriate referral when necessary
  • Accurate and detailed record-keeping
• Malpresentations of the Fetus


  Refers to the orientation of the fetus and may be diagnosed during pregnancy or in labour. Any presentation other than vertex is termed a malpresentation.
• Types of Malpresentations


  • Breech
  • Face
  • Brow
  • Shoulder
• Breech presentation


  Fetal buttocks lie lowermost in the maternal uterus and the fetal head occupies the fundus. Longitudinal lie, common before 37th weeks.

  
• Types of Breech presentation

  • Flexed or complete breech - the fetus sits with the thighs and knees flexed with the feet close to the buttocks
  • Extended or frank breech - the fetal thighs are flexed, the legs are extended at the knees and lie alongside the trunk, with the feet near the fetal head
  • Footling presentation - one or both feet present below the fetal buttocks, with hips and knees extended

  
• Causes of Breech presentation


  • Primigravida
  • Uterine anomalies
  • Oligohydramnios
  • Placental location
  • Uterine fibroids
  • Contracted pelvis
  • Fetal anomalies
  • Hydrocephalus
  • Multiple pregnancy
  • Maternal alcohol or drug abuse
  • Grand multiparty
  • Polyhydramnios
  • Prematurity
• Face presentation


  Occurs when the head and neck are hyperextended but the limbs flexed, so that the fetus lies in the uterus in a curious S-shaped attitude with the occiput against its shoulder blades and the face directly presenting
• Nursing Assessment of Face presentation

  • The back of the fetus is difficult to outline, and a deep furrow can be palpated between the hard occiput and the fetal back
  • Fetal heart tones can be heard on the side where the fetal feet are palpated
• Brow presentation


  The head is midway between flexion and extension
• Shoulder presentation


  Shoulder presentation occurs as a result of a transverse or an oblique lie

  
• Nursing Assessment of Shoulder presentation

  • Identify a transverse lie by: inspection and palpation of the abdomen, auscultation of FHTs in the midline of the abdomen, vaginal examination
  • On palpation, no fetal part is felt in the fundal portion of the uterus or above the symphysis pubis
  • The head may be palpated on one side and the breech on the other
  • FHTs are usually auscultated just below the midline of the umbilicus
  • On vaginal examination, if a presenting part is palpated, it is the ridged thorax or possibly an arm that is compressed against the chest
  • Women with a transverse lie may report less shortness of breath, pelvic pressure, and urinary frequency than other women because pressure is not exerted on the diaphragm and the bladder

  
• Forceps delivery


  Forceps are designed to assist the birth of a fetus by providing traction or by providing the means to rotate the fetal head to an occiput-anterior position
• Indicators/Risk Factors for Forceps delivery

  • Fetal Factors: Second stage of labor fetal distress, Abnormal presentation, Preterm labor to protect fetal head from injuries
  • Maternal Factors: To shorten the second stage of labor, Ineffective expulsive effort/poor progress, Exhaustion medical disease like cardiac disease
• Criteria/prerequisites for Forceps delivery

  • Full dilatation of the cervix
  • Ruptured bag of water
  • Engaged head
  • Empty bowel and bladder
  • No CPD
• Complications/Prognosis of Forceps delivery

  • Maternal: Lacerations, Hemorrhage, Uterine rupture, Uterine prolapse, Cystocele, Rectocele
  • Fetal: Facial paralysis (Bell's palsy), Increased perinatal morbidity and mortality, Intracranial hemorrhage, Brain damage, Skull fracture, Tissue trauma, Cord compression
• Nursing Implementation of Forceps delivery

  • Prepare client and family, Provide psychological support to allay/decrease anxiety, Monitor FHT continuously, Assess mother and infant for complications
• Contraindications to Vacuum Extraction

  • CPD, Nonvertex presentations, Maternal or suspected fetal coagulation defects, known or suspected hydrocephalus, Fetal scalp trauma, Fetal macrosomia, High fetal station, Face or breech presentation, Gestation less than 34 weeks, Incompletely dilated cervix

  
• Neonatal complications of Vacuum Extraction

  • Scalp lacerations, Bruising, Subgleal hematomas, Cephalhematomas
• Maternal complications of vacuum extraction

  • Lacerations
  • Hemorrhage
  • Uterine rupture
  • Uterine prolapse
  • Cystocele
  • Rectocele
• Fetal complications of vacuum extraction

  • Facial paralysis (Bell's palsy)
  • Increased perinatal morbidity and mortality
  • Intracranial hemorrhage
  • Brain damage
  • Skull fracture
  • Tissue trauma
  • Cord compression
• Nursing implementation for vacuum extraction

  1. Prepare client and family

  2. Provide psychological support to allay/decrease anxiety

  3. Monitor FHT continuously

  4. Assess mother and infant for complications
• Contraindications to vacuum extraction

  • CPD
  • Nonvertex presentations
  • Maternal or suspected fetal coagulation defects, known or suspected hydrocephalus
  • Fetal scalp trauma
  • Fetal macrosomia
  • High fetal station
  • Face or breech presentation
  • Gestation less than 34 weeks
  • Incompletely dilated cervix

  
• Neonatal complications of vacuum extraction


  • Scalp lacerations
  • Bruising
  • Subgleal hematomas
  • Cephalhematomas
  • Intracranial hemorrhages
  • Subconjunctival hemorrhages
  • Neonatal jaundice
  • Fractured clavicle
  • Erb's palsy - damage to the sixth and seventh cranial nerves
  • Retinal hemorrhage
  • Fetal death
• Maternal complications of vacuum extraction

  • Perineal trauma
  • Edema
  • Third and fourth-degree lacerations
  • Postpartum pain
  • Infection
• Nursing care management for vacuum extraction

  1. Auscultate fetal heart rate (FHR) at least every 5 minutes or assess by continuous electronic fetal monitoring (EFM)

  2. Inform parents that the caput on the baby's head will disappear within 2 to 3 days

  3. Assess the newborn for complications such as bruising, newborn Jaundice, cephalhematomas, intracranial hemorrhage, and retinal hemorrhages
• Macrosomia


  Fetal weight of more than 4000 g
• A woman who is obese is twice as likely to have a macrosomic fetus
• Increased maternal glucose levels have also been shown to increase fetal weight
• Risk factors for macrosomia

  • post-term pregnancy
  • multiparity, grand multiparity
  • previous macrosomic infant
  • previous shoulder dystocia
  • male sex
  • maternal birth weight
• Nursing assessment for macrosomia

  1. Monitor fetal heart rate (FHR) for non-reassuring heart rate patterns

  2. Evaluate the rate of cervical dilatation

  3. Assess fetal descent