Complications of labor - PASSENGER AND PASSAGE

• Umbilical cord prolapse - loop of the umbilical cord slips down in front of the presenting part
• Assessment of prolapsed cord;

  1. Assess fetal heart sound
• Management of prolapsed cord;

  1. Manually elevating the head of the cord
  2. Trendelenburg / knee-chest position
  3. Oxygen administration
  4. Tocolytic administration
• If umbilical cord is exposed to room air, cover with sterile saline compress to prevent drying
• Fetal intolerance to labor - FHR change indicate abnormal adjustment to labor; cord compression occur
• Management to Fetal intolerance to labor;

  1. Amnioinfusion
  2. Oxygen administration
  3. Stop oxytocin
  4. administer tocolytic
• Amnioinfusion - addition of sterile fluid into the uterus to supplement the amniotic fluid to reduce compression; initially 200 ml is infused
• Problems w/ Fetal position, presentation, or size

  1. occipitoposterior position
  2. Breech presentation
  3. Face presentation
  4. Transverse lie
  5. Macrosomia
• Occipitoposterior (ROP/LOP) - in these positions, during internal rotation, the fetal head must rotate through an arc of 135 degrees
• Occipitoposterior occurs in patient with;

  1. Android pelvis
  2. Anthropoid pelvis
  3. Contracted pelvis
• Management for Occipitoposterior;

  1. Back rub - to reduce pain during rotation
• If contractions are not effective and fetus is transverse arrest, cesarean birth is advise
• Breech presentation is when the baby is feet first and the head is posterior to the buttocks
• 3 types of Breech presentation;

  1. Complete
  2. Frank
  3. Footling
• Assessment for Breech presentation;

  1. FHR heard high in the abdomen
  2. Leopolds maneuver and vaginal examination to determine the position
• Stages of birth;

  1. Flexion
  2. descent
  3. Internal rotation
  4. expulsion
  5. external rotation
• Face presentation when the fetus' head is extended
• Asynchtism - fetal head presenting at different angle
• Assessment for face presentation;

  1. contracted pelvis
  2. placenta previa
  3. relaxed uterus of a multipara
  4. prematurity, hydramnios, or fetal malformation
• Management for face presentation

  1. observe fetal patent airway
  2. Gavage feeding - lip edema is so sever that infant unable to suck for a day or 2
  3. Delivered by cesarean
• Transverse lie;

  Management;

  1. Cesarean birth
• Oversized fetus (macrosomia) - fetus weighs more than 4,000-4,500 g (9-10 lbs)
• Risk factors for Macrosomia;

  1. Diabetic/gestational diabetes
  2. Multiparity
• Complication of Macrosomia;

  1. uterine dysfunction during labor
  2. overstretching of the fibers of the myometrium
• Problems with the Passage;

  1. Inlet contraction
  2. Outlet contraction
  3. trial labor
  4. External cephalic version
  5. Forceps birth
  6. Vacuum extraction
• inlet contractions - narrowing of the anterioposterior diameter of the pelvis to less than 11 cm; transverse 12 cm
• Inlet contractions caused by Rickets (lack of vitamin D)
• If it engages before labor begin, proof that the inlet is adequate. If not; fetal abnormality (Large head), pelvic abnormality (small pelvis)
• Outlet contractions - narrowing of the transverse diameter; ischial tuberosities at the outlet by less than 11 cm
• Trial Lobor - If CPD is suspected, trial labor is conducted; to determine whether labor progress normally
• Management for trial labor - Void every 2 hours
• If no adequate progress and fetal distress occurs, cesarean birth is advise
• External Cephalic version - turning the fetus from a breech position to a cephalic position before birth; done as early as 34 - 35 wks
• Assessment for External cephalic version;

  1. assess FHR
  2. Ultrasound - check for cord coil
• Contraindications for External Cephalic Version;

  1. Multiple gestation
  2. sever oligohydramnios
  3. small pelvic diameter
  4. cord coil
  5. bleeding (placenta previa)
• Management for External Cephalic vERSION;

  1. epidural given
  2. Rhogam
• Forceps birth - performed if umbilical cord prolapsed

  rarely used; can cause rectal sphincter tear; could lead to dyspareunia and incontinence
• Used if patients is;

  1. Unable to push w/ contractions (under anesthesia, spinal cord injury)
  2. Cessation of descent in second stage of labor
  3. Fetus abnormal position
  4. Fetus is distress but low in pelvis
• Assessment for Forceps birth;

  1. FHR
  2. Assess cervix
  3. record voiding time
• Before forceps are applied;

  1. membranes ruptured
  2. no CPD
  3. Cervix fully dilated
  4. Bladder empty