Problems in Passenger

• Pregnancy is stressful but a good experience.
• Difficult Labor (DYSTOCIA) can arise from problems occurring from the main components of the LABOR PROCESS (Power, Passenger, Passageway, Psyche)
• What are the four main components of the labor process? (4 P's)

  • Passenger
  • Passageway
  • Power
  • Psyche
• Labor or Birth Complications

  • Problems of Passenger
  • Problems with the Passageway
  • Problems with Powers
  • Problems with Psyche factor
  • Placental problems
• ASSESSMENT. Fetal and uterine monitors are tools to detect deviations
• What are the four stages of labor?

  • Cervical dilatation
  • Delivery of the fetus (stage of expulsion)
  • Delivery of the placenta (placental stage)
  • Postpartum (maternal homeostatic stabilization stage)
• Review of fetal skull:

  A) sagittal suture

  B) coronal suture

  C) frontal suture

  D) lambdoid suture

  E) anterior fontanel

  
• Diameters of fetal skull:

  A) submentobregmatic = 9.5 cm

  B) verticomental = 13.5 cm

  C) suboccipitobregmatic dimension = 9.5 cm

  D) suboccipitofrontal = 10.5

  E) occipitomental dimension = 12.5 cm

  F) occipitofrontal dimension = 11.5 cm

  
• What part of the head is presented in submentobregmatic?

  face (face presentation)
• What part of the head is presented in verticomental?

  brows (brow presentation)
• What part of the head is presented in suboccipitobregmatic dimension?

  vertex (vertex presentation)
• What part of the head is presented in occipitofrontal dimension?

  vertex (vertex presentation of the deflexed head)
• maternal pelvic diameters:

  A) transverse of inlet = 13.5 cm

  B) interspinous = 10 cm

  C) obstetrical conjugate = 10.5 cm

  
• Types of pelvis:

  A) gynecoid

  B) platypelloid

  C) android

  D) anthropoid

  
• It is a fetal malposition that causes back pain to the mother.

  occipitoposterior position
• Occipitoposterior position occurs more in women with what type of pelvis?

  • android
  • anthropoid
  • contracted pelvis
• Fetal malposition is suggested through:

  • prolonged active phase
  • arrested descent
  • fetal heart sounds heard best at the lateral sides of the abdomen
• TRUE or FALSE. Mother may experience INTENSE pressure and pain in the lower back (fetal head rotates against the sacrum) - sacral nerve compression.

  TRUE
• Fetal malpositions:

  A) occipitoposterior (OP)

  B) right occipitoposterior (ROP)

  C) right occipitotransverse (ROT)

  D) left occipitoposterior (LOP)

  E) right occiput anterior (ROa)

  F) transverse lie

  G) occiput anterior (Oa)

  H) left occiput anterior (LOa)

  I) left occipitotransverse (LOT)

  
• Fetal malposition is confirmed by vaginal examination and ultrasound
• TRUE or FALSE. Posteriorly presenting head fits the cervix as snugly as one in anterior position.

  FALSE.

  Posteriorly presenting head does not fit the cervix as snugly as one in anterior position.
• Successful vaginal delivery with fetal malposition is only possible if:

  • fetus is of average size
  • good flexion
  • forceful uterine contraction
  • rotate through a large arc
  • arrive at good birth position for the pelvic outlet
  • results only to increased molding and caput formation
• Not evidence-based and tiring management of fetal malposition to the mother:

  • Assume hands and knees position, squatting or lying on her side
  • Shifting from right to left or lunging or swinging body right to left while elevating her left foot on a chair
• TRUE or FALSE. Most women don't choose epidurals.

  FALSE

  
  

  Most women choose epidurals.
• TRUE or FALSE. Peanut ball between the woman’s legs has been found to open the cervix and reduce total labor time according to Roth et.al. 2016

  TRUE
• MANAGEMENT OF FETAL MALPOSITION:

  • Apply counter pressure on the sacrum by a back rub
  • Rebozo method (Cohen & Thomas, 2015) – jiggling and massaging the uterus maybe helpful when assisting the fetus to rotate to a better position
  • Void every 2 hours (full bladder impedes descent)
  • IV or oral glucose (to replace used glucose stores to keep active in labor)
  • CS delivery if resulted to uterine dysfunction (maternal exhaustion)
  • If born vaginally, the baby is born looking at the ceiling or “sunny side up)
• MANAGEMENT OF FETAL MALPOSITION. Forceps are used to aid for internal rotation.
• Low forceps or outlet forceps are usually applied after crowning.
• Using forceps as management to fetal malpresentation might result to: (CHI)

  • cervical lacerations
  • hemorrhage
  • infection
• A disk shaped cup placed over the vertex of the head and vacuum applied. Used as a management to fetal malposition.

  Vacuum Extraction
• Surgical incision to allow more room.

  Episiotomy
• Variations in Presentation;

  A) normal

  B) shoulder/transverse

  C) face/brow

  D) complete breech

  E) breech (footling)

  F) breech (frank)

  
• Presenting part is buttocks.

  breech presentation
• Most of the fetuses are in breech presentation early in pregnancy and by 38th week, 97% turns cephalic presentation.
• What are the 3 breech presentations? (CBB)

  • complete breech
  • breech (footling)
  • breech (frank)
• Risks of breech presentation: (DATEDFM)

  • Developing dysplasia of the hip
  • Anoxia from prolapsed cord
  • Traumatic injury aftercoming head
  • Early rupture of membrane because of poor fit of the presenting part
  • Dysfunctional labor
  • Fracture of spine/arm
  • Meconium staining
• Why is meconium staining expected in breech presentation?

  due to the inevitable contraction of fetal buttocks from cervical pressure
• Can lead to meconium aspiration if the infant inhales the amniotic fluid.

  Meconium excretion
• Causes of breech presentation:

  • gestational age < 40 weeks
  • fetal anomaly
  • hydramnios (amniotic fluid disorder/polyhydramnios---too much amniotic fluid builds up during pregnancy)
  • uterine anomaly
  • space-occupying mass in the pelvis
  • pendulous abdomen
  • multiple gestation
  • unknown factors
• ASSESSMENT OF BREECH PRESENTATION:

  • FHB heard high in the abdomen
  • Leopold’s maneuver and vaginal examination
  • Complete breech may be mistaken into head (fully engaged)
  • Ultrasound may confirm presentation
  • It will still follow the same mechanisms of labor (flexion, descent, internal rotation, expulsion and external rotation)