Problems during Labor and Delivery: Passenger

Question 1

Lie

Answer 1

The relationship between the long axis of the fetus and the mother.

Question 2

Position

Answer 2

The position of the fetal head as it exits the birth canal.

Question 3

Presentation

Answer 3

The fetal part that first enters the maternal pelvis.

Question 4

Fetal Malposition

Answer 4

• involves the fetus lying longitudinally and the vertex is presenting, however, it is not in an occipitoanterior position
• fetal head must rotate through an arc of approximately 135 degrees during internal rotation
• head in posterior position does not fit the cervix like a head in anterior position does.
• confirmed through vaginal examination or through ultrasound
• occur in women with android, anthropoid, and contracted pelvis.
• happen in dysfunctional labor patterns such as prolonged active phase, arrested descent, or fetal heart sounds heard best at lateral sides of the abdomen.

Question 5

Gynecoid

Answer 5

Inlet
- Shape: Round
- Anterior and Posterior Segment: equal and spacious
- Sacrum: Sacral angle (SA) more than 90°; Inclined backwards; Well curved from above down and side to side

Cavity
- Sacrosciatic notch: Wide and shallow
- Sidewalls: Straight or slightly divergent
- Ischial spines: Not prominent

Outlet
- Pubic arch: Curved
- Subpubic angle: Wide (85°)
- Bi-ischiadic diameter: Normal

Question 6

Anthropoid

Answer 6

Inlet
- Shape: Anteroposteriorly oval
- Anterior and Posterior Segment: Both increased with slight anterior narrowing
- Sacrum: SA more than 90°; Inclined posteriorly; Long and narrow; Usual curve

Cavity
- Sacrosciatic notch: Wider and shallower
- Sidewalls: Straight or divergent
- Ischial spines: Not prominent

Outlet
- Pubic arch: Long and Curved
- Subpubic angle: Slightly Narrow
- Bi-ischiadic diameter: Normal or short

Question 7

Android

Answer 7

Inlet
- Shape: Triangular
- Anterior and Posterior Segment: Posterior segment short and anterior segment narrow
- Sacrum: Sacral angle less than 90°; Inclined forwards and straight

Cavity
- Sacrosciatic notch: Narrow and deep
- Sidewalls: Convergent
- Ischial spines: Prominent

Outlet
- Pubic arch: Long and straight
- Subpubic angle: Narrow
- Bi-ischiadic diameter: Short

Question 8

Platypelloid

Answer 8

Inlet
- Shape: Transversely oval
- Anterior and Posterior Segment: Both reduced-flat
- Sacrum: SA more than 90°; Inclined posteriorly; Short and straight

Cavity
- Sacrosciatic notch: Slightly narrow and small
- Sidewalls: Divergent
- Ischial spines: Not prominent

Outlet
- Pubic arch: Short and curved
- Subpubic angle: Very wide (more than 90°)
- Bi-ischiadic diameter: Wide

Question 9

Fetal Malposition MGT.

Answer 9

• applying counterpressure on the sacrum by a back rub may be done, and heat or cold application can also help relieve a portion of the pain in lower back
• assume a hands-and-knees position, squatting or lying on her side to aid rotations from posterior positions
• void every 2 hours to keep her bladder empty and avoid impeding the descent of the fetus.
• cesarean birth necessary since fetal head might arrest in the transverse position or there might be no rotation at all
• Provide reassurances

Question 10

Fetal Malpresentation

Answer 10

1. Breech Presentation
2. Face Presentation
3. Brow Presentation

Question 11

Breech Presentation

Answer 11

• Most fetuses are in a breech presentation early in pregnancy; however, by week 38, it turns into a cephalic presentation.
• increases the fetal risk for anoxia, traumatic injury to the head, fracture of the spine or arm, dysfunctional labor, and early rupture of membranes
• Fetal heart sounds are heard high in the abdomen
• Leopold’s maneuver and vaginal examination can determine breech presentation
• head is the most dangerous part because a loop of umbilical cord that has passed down alongside the head may be compressed
• infant born from a frank breech position usually extends his or her legs continuously during the first 2 or 3 days

Question 12

Types of Breech Presentation

Answer 12

1. Frank Breech
2. Complete Breech
3. Footling or Incomplete Breech

Question 13

Frank breech (50-70%)

Answer 13

Hips flexed, knees extended (pike position)

Question 14

Complete breech (5-10%)

Answer 14

Hips flexed, knees flexed (cannonball position)

Question 15

Footling or incomplete (10-30%)

Answer 15

One or both hips extended, foot presenting.

Question 16

Face Presentation

Answer 16

• fetal head presenting at a different angle than expected
• head diameter of the fetus presents to the pelvis is often too large for birth to proceed.
• determined through vaginal examination when the nose, mouth, or chin is felt as the presenting part or through ultrasound.
• occurs in women with contracted pelvis, or placenta previa, in a relaxed uterus of a multipara, with prematurity, hydramnios, or fetal malformation.
• Facial edema and ecchymosis are present in a baby born after a face presentation

Question 17

What if situations for face presentation

Answer 17

• chin is anterior and the pelvic diameters are within normal limits, the infant can be born vaginally.
• chin is posterior, cesarean birth is the birth method of choice

Question 18

Face Presentation MGT.

Answer 18

• Assess the patency of the infant’s airway closely.
• Reassure the parents that the edema is transient and will disappear after a few days.

Question 19

Brow Presentation

Answer 19

• rarest
• occurs in multipara women or in a woman with relaxed abdominal muscles.
• Cesarean birth would be necessary unless the presentation spontaneously corrects itself.
• Extreme ecchymosis on the face is also present
• bruising over the same area as the anterior fontanelle is normal.

Question 20

Macrosomia

Answer 20

• fetus weighs more than 4000 to 4500g
• usually born to women with diabetes or develop gestational diabetes, and multiparas.
• result from uterine dysfunction
• Cesarean birth is necessary if the fetus is so oversized
• pelvimetry or ultrasound can be performed
• high risks for cervical nerve palsy, diaphragmatic injury, or fractured clavicle due to shoulder dystocia if baby born vaginally
• woman is at risk for over because of the overdistended uterus and uterine atony.

Question 21

Shoulder Dystocia

Answer 21

• occurs during the second stage of labor when the fetal head is born but the shoulders are too broad to enter and be born through the pelvic outlet.
• risk for vaginal and cervical tears, while the fetus is at risk for cord compression between the fetal body and the bony pelvis.
• occurs in women who have diabetes, in multiparas, and in post-date pregnancies
• If birth is forced through the vaginal opening, the fetus would sustain a fractured clavicle or a brachial plexus injury.

Question 22

Conditions that may suggest shoulder dystocia

Answer 22

• prolonged second stage of labor
• arrest of descent
• head starts to crown, it retracts instead of protruding with each contraction.

Question 23

Shoulder Dystocia MGT.

Answer 23

• Instruct the woman to flex her thighs sharply on her abdomen (McRobert’s Maneuver) to widen the pelvic outlet
• Applying suprapubic pressure can also help the shoulder out from beneath the symphysis pubis

Question 24

Multiple Gestation

Answer 24

• often result in fetal anoxia on the part of the second fetus, so cesarean birth is more preferable than normal delivery.
• Anemia and pregnancy-induced hypertension mostly occur so assessment of the blood pressure and hematocrit is necessary
• if woman plans to give birth vaginally, she should be advised to come to the hospital early in labor
• There may not be firm head engagement for multiple gestations because the babies are small
• Twin pregnancies usually have vertex presentations
• three or more fetuses, the presentations are varied.

Question 25

Common Conditions that occur with multiple gestations

Answer 25

- abnormal fetal presentation - overstretched uterus - premature separation of placenta - uterine dysfunction due to a long labor

Question 26

Types of Presentation during multiple gestations

Answer 26

- Vertex and Vertex (45%): Both twins are head-down (vertex presentation). This is the most common presentation. - Vertex and Breech (37%): One twin is head-down (vertex), and the other is breech (butt or feet first). This is the second most common presentation. - Breech and Breech (10%): Both twins are breech. This is less common than vertex presentations. - Vertex and Transverse (5%): One twin is head-down (vertex), and the other is lying transversely (across the uterus). - Breech and Transverse (2%): One twin is breech, and the other is transverse. This is a less frequent presentation. - Transverse and Transverse (0.5%): Both twins are lying transversely. This is the least common presentation.

Question 27

Risks of Multiple Gestations

Answer 27

- The first infant’s placenta separates before the birth of the second fetus which causes a sudden, profuse bleeding at the vagina, creating a great risk for the woman. - If the separation of the first placenta causes loosening of the other placentas or there is a common placenta, the fetal heart rate of the other fetus would signal distress.

Question 28

Complications of Multiple Gestations

Answer 28

- Anemia: Iron deficiency and megaloblastic anemia due to increased fetal demands. - Placenta Previa: Due to a large placental site. - Pre-Eclampsia and Eclampsia: Cause unknown. - Premature Labor: Due to the bulk of the pregnancy and polyhydramnios. - Growth Restriction or Intra-uterine Death: Due to placental insufficiency or 'transfusion syndrome'. - Post-partum Hemorrhage: Due to a large placental site.

Question 29

Multiple Gestation MGT.

Answer 29

- cesarean section is done because they need to be born all at once so they can survive - Parents should be given an opportunity to view and inspect their fetuses to dispel the fears - Assess the woman thoroughly and immediately after birth - Infants also need careful assessment to determine their gestational age and if any unusual conditions have occurred.

Question 30

Cord Prolapse

Answer 30

- a loop of umbilical cord slips down in front of the presenting fetal part - During assessment of the presenting fetal part through vaginal examination, the cord might be felt. - Diagnosis made through ultrasound. - mostly discovered after rupture of the membranes, when the fetal heart rate has a variable deceleration. - Assessment of fetal heart sounds is necessary after rupture of membranes to rule out cord prolapse

Question 31

Cord Prolapse MGT.

Answer 31

- goal in therapeutic management is to relieve cord compression to avoid fetal anoxia which can be achieved by manually lifting the head of the fetal head off the cord through the vagina or placing the woman in a Trendelenburg position. - Oxygen administration is also necessary to improve the fetal oxygenation - use tocolytic agent to reduce uterine activity and pressure of the fetus - Cover any exposed portion of the cord with a sterile saline compress to avoid drying - If there is already complete dilatation, the physician can deliver the baby to prevent fetal anoxia - If the cervical dilatation is not yet complete, cesarean birth would be performed as an emergency procedure because of the reduced blood flow that can harm the fetus. - Amnioinfusion, which is the addition of a sterile fluid into the uterus to supplement the amniotic fluid, can be performed just to prevent additional cord compression.

Question 32

Fetal Distress

Answer 32

- emergency pregnancy, labor, and delivery complication in which a baby experiences oxygen deprivation (birth asphyxia).

Question 33

Fetal Distress S/sx

Answer 33

- Decreased fetal movement in the womb - Abnormal fetal heart rate - Abnormal amniotic fluid level - Vaginal bleeding - Cramping - Insufficient or excessive maternal weight gain

Question 34

Fetal Distress MGT.

Answer 34

administration of oxygen, fluids, and medication to the mother, or a change in the mother’s position. Often, an emergency C-section is required in order to remove the baby from the conditions causing the fetal distress,