Problems with Passengers

• Cephalic

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

  • 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 skull
• Fetal Presentation


  The position of the fetus as it enters the birth canal

  
• 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 of the Occiput

  • 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 Malposition of the Occiput(ECPPIM)

  • Early rupture of the membranes
  • Cord prolapses
  • Prolonged labor
  • Premature expulsive effort
  • Infection
  • Maternal exhaustion
• Interventions for Malposition of the Occiput (COG AA-E-AAA)

  • 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


  Any presentation other than vertex
• Types of Malpresentations

  • Breech
  • Face
  • Brow
  • Shoulder
• Breech Presentation


  Fetal buttocks lie lowermost in the maternal uterus and the fetal head occupies the fundus
• Types of Breech Presentation

  • Flexed or complete breech
  • Extended or frank breech
  • Footling presentation
• Causes of Breech Presentation (PUOPUCFHMMGPP)

  • 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
• Nursing Diagnoses for Face Presentation

  • Fear related to unknown outcome of the labor and appearance of the baby
  • Risk for Injury to the newborn's face related to edema secondary to the birth process
• Expected Outcomes for Face Presentation

  • The woman and her partner understand the implications and problems of face presentation
  • The mother and her baby have a safe labor and birth
  • The woman and her baby initiate the bonding process
• Brow Presentation


  The head is midway between flexion and extension
• Nursing Implementation for Brow Presentation

  • Explain the position of the fetus to the laboring couple
  • Stay close at hand to reassure the couple, inform them of any changes, and assist them with labor-coping techniques
  • Reassure the couple that the facial edema and excessive molding are only temporary and will subside in a few days
• Expected Outcomes for Brow Presentation

  • The woman and her partner understand the implications and associated problems of brow presentation
  • The mother and her baby have a safe labor and birth
  • The woman and her baby initiate the bonding process
• 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 (FREE-CPD)

  • Full dilatation of the cervix
  • Ruptured bag of water
  • Engaged head
  • Empty bowel and bladder
  • No CPD
• Complications/Prognosis of Forceps Delivery M(LHUUCR) F(FIHBSTC)

  • 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 for 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(LHUUCR)

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

  • 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