PROBLEM WITH THE PASSENGER

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Birth complications may arise:
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. Infant is immature or preterm.
. Maternal pelvis is so undersized = occurs in early adolescence
. Women with altered bone growth from a disease such as rickets that its diameters are
smaller than the fetal skull diameters.
. Umbilical cord prolapses = if more than one fetus is present, or if a fetus is malpositioned or
too large for the birth canal

[Link] OF THE UMBILICAL CORD

– Loop of the umbilical cord slips down in front of the presenting fetal part
– May occur at any time after the membranes rupture if the presenting fetal part is not fitted
firmly into the cervix

It tends to occur most often with:

● Premature rupture of membranes
● Fetal presentation other than cephalic
● Placenta previa
● Intrauterine tumors preventing the presenting part from engaging
● Small fetus
● Cephalopelvic disproportion preventing firm engagement
● Hydramnios
● Multiple gestation
– Incidence is about 0.5% of cephalic births; this rises as high as 15% to 20% with breech or
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transverse
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Cord prolapse may be subdivided into 3 types
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. Overt cord prolapse = Cord descends through the cervix into the vaginal canal after the
membranes are ruptured.
. Funic presentation = Loop of umbilical cord lies between the fetal presenting part and the
still-intact fetal membranes covering the cervical os.
 . Occult prolapse = occurs when the cord is located alongside the presenting part, but it is not
detectable by the examiner
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ASSESSMENT &THERAPEUTIC MGMENT
. Cord may be felt as the presenting part on an initial vaginal examination during labor.
– May be identified in this position on an ultrasound.
– IF happen: cesarean birth is necessary before rupture of the membranes occurs.
– Otherwise, membrane rupture would cause the cord to slide down into the vagina from the
pressure exerted by the amniotic fluid.
– However, cord prolapse is first discovered only after the membranes have ruptured, when a
variable deceleration FHR pattern suddenly becomes apparent.
– Cord may be visible at the vulva.
– To rule out cord prolapse
– always assess fetal heart sounds immediately after rupture of the membranes whether
this occurs spontaneously or by amniotomy
. Cord prolapse automatically leads = to cord compression, because the fetal presenting part
presses against the cord at the pelvic brim.

Management
– Aimed at relieving pressure on the cord, thereby relieving the compression and the resulting
fetal anoxia.
a. Done by placing a gloved hand in the vagina and manually elevating the fetal head off the cord
b. Placing the woman in a knee–chest or Trendelenburg position,
which causes the fetal head to fall back from the cord
. Administering oxygen at 10 L/min by face mask = to improve oxygenation to the fetus.
. Tocolytic agent may be prescribed to reduce uterine activity and pressure on the fetus.
. Amnioinfusion = Amnioinfusion is the addition of a sterile fluid into the uterus to supplement
the amniotic fluid.
– Prevents additional cord compression.
– Sterile catheter is introduced through the cervix into the uterus after rupture of the
membranes.
– It is attached to intravenous tubing, and a solution of warmed normal saline or lactated
Ringer’s solution is rapidly infused
. Drying will begin = If the cord has prolapsed to the extent that it is exposed to room
air,leading to atrophy of the umbilical vessels.
– Do not attempt to push any exposed cord back into the vagina.
– may add to the compression by causing knotting or kinking.
– Cover any exposed portion with a sterile saline compress to prevent drying.
. If Cervix is fully dilated at the time of the prolapse = the physician may choose to birth the
infant quickly, possibly with forceps, to prevent fetal anoxia
. IF : Dilatation is incomplete
– Birth method of choice = upward pressure on the presenting part, applied by a practitioner’s
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hand in the woman’s vagina, to keep pressure off the cord until the baby can be born by
cesarean birth.
. Fetal Blood Sampling = Although obtaining a fetal oxygen saturation level by inserting a fetal
oximeter into the uterus to rest next to the fetal cheek or obtaining a positive response to
scalp stimulation usually supplies the information as to whether a fetus is becoming acidotic.
– A scalp blood pH lower than 7.20 is acidotic and signifies a level of fetal distress.
– Prolapsed cord is always an emergency situation, because the reduced blood flow to the
fetus can quickly cause fetal harm

2. MULTIPLE GESTATION
– Twins may be born by cesarean birth to decrease the risk that the second fetus will
experience anoxia.
– often the situation in multiple gestations of three or more, because of the increased incidence
of cord entanglement and premature separation of the placenta

Assessment & Therapeutic Management:

. Anemia and pregnancy-induced hypertension = occur at higher-than-usual incidences during
multiple gestations.
– Assess the woman’s hematocrit level and blood pressure closely during labor or while waiting
for cesarean surgery.
. IF Giving birth vaginally, she is usually instructed to come to the hospital early in labor.
– The first stage of labor does not differ greatly from that of a woman with a single-gestation
pregnancy
. Breathing exercises During labor to minimize the need for analgesia or anesthesia;
– Helps to minimize any respiratory difficulties the infants may have at birth because of their
immaturity.
. Monitor each FHR by a separate fetal monitor during labor.
a. Babies are usually small = firm head engagement may not occur, increasing the risk for cord
prolapse after rupture of the membranes.
b. Because of the multiple fetuses, abnormal fetal presentation may occur

More common after birth:

. Uterine dysfunction from a long labor
. Overstretched uterus
. Unusual presentation
. Premature separation of the placenta

– Most twin pregnancies present with both twins vertex.

– This is followed in frequency by vertex and breech, breech and vertex, and then breech and
breech
 – Multiple gestations of three or more fetuses have extremely varied presentations.
. After the first infant is born, both ends of the baby’s cord are tied or clamped permanently,
rather than with cord clamps, which could slip.
– Prevents hemorrhage through an open cord end if additional infants have shared the
placenta.
– First infant is identified as A, and newborn care is started

*In singleton pregnancies, oxytocin usually is given immediately to contract the uterus and
minimize bleeding after an infant is born
– with this woman = it will not be given, to avoid compromising the circulation of the infants
not yet born
– After the birth of the first child, the lie of the second fetus is determined by external
abdominal palpation or ultrasound.
– If the presentation is not vertex, external version may be attempted to make it so.
– If this is not successful, a decision for a breech birth or cesarean birth must be made

IF INFANT BE BORN VAGINALLY:

. Oxytocin infusion may be begun at this point to assist uterine contractions, thereby
shortening the time span between births.
– Nitroglycerin = If uterine relaxation is needed,a uterine relaxant, may be administered.
. Occasionally, the placenta of the first infant separates before the second fetus is born, and
there is sudden, profuse bleeding at the vagina. This creates a risk for the woman.
– The uterus cannot contract as it normally would, because it is still full with the second twin,
so it is difficult to halt the bleeding
– If the separation of the first placenta caused loosening of additional placentas, or if a
common placenta is involved, the fetal heart sounds of the other fetuses will register distress
immediately.
. They need to be born at once if they are to survive.
– For this reason, with most multiple gestations today, if all of the fetuses are not vertex
presentations, they will be born by cesarean birth
. Assess the woman carefully in the immediate postpartal period, because the uterus that has
been overly distended owing to the multiple gestation may have more difficulty contracting
than usual, placing her at risk for hemorrhage from uterine atony (lacking normal tone).
– Risk for uterine infection increases if labor or birth was prolonged.
. Infants need careful assessment to determine their true gestational age and whether a
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phenomenon such as twin-to- twin transfusion could have occurred

3. PROBLEMS WITH: FETAL POSITION, PRESENTATION, OR SIZE

A. OCCIPITOPOSTERIOR POSITION
– In approximately one tenth of all labors, the fetal position is posterior rather than anterior.
– The occiput (assuming the presentation is vertex) is directed diagonally and posteriorly,
either to the right (ROP) or to the left (LOP).
– In these positions, during internal rotation, the fetal head must rotate, not through a 90-
degree arc (Fig. 23.8), but through an arc of approximately 135 degrees

management:
. Rotation from a posterior position can be aided by having the woman assume :
[Link] and knees position,
B. Squatting
C. lying on her side (on her left side = if the fetus is right occiput posterior; on her right side if the
fetus is left occiput posterior).
– Theoretically, shifting the weight from right to left or “lunging” or swinging her body right to
left while elevating her left foot on a chair widens the pelvic path and makes fetal rotation
easier.
– This is unproved, however, and is tiring for women in labor.
. A posteriorly presenting head does not fit the cervix as snugly as one in an anterior position.
– Because this increases the risk of umbilical cord prolapse, the position of the fetus is
. Because the fetal head rotates against the sacrum, a woman may experience pressure and
pain in her lower back owing to sacral nerve compression.
– These sensations may be so intense that she asks for medication for relief, not for her
contractions but for the intense back pressure and pain.
a) Applying counterpressure on the sacrum by a back rub may be helpful in relieving a portion of the
pain
b) Applying heat or cold, whichever feels best, also may
b) Applying heat or cold, whichever feels best, also may
help.
c) Lying on the side opposite the fetal back or maintaining
a hands-and-knees position may help the fetus rotate
. During a long labor of this type, be certain a woman voids approximately every 2 hours to
keep her bladder empty, because a full bladder could further impede descent of the fetus.
. Be aware of how long it has been since the woman last ate. During a long labor, she may need
an oral sports drink or IV glucose solution to replace glucose stores used for energy
. If contractions are ineffective, or if the fetus is larger than average or not in good flexion,
rotation through the 135- degree arc may not be possible.
– Uterine dysfunction may result from maternal exhaustion.
– The fetal head may arrest in the transverse position (transverse arrest), or rotation may not
occur at all (persistent occipitoposterior position)The fetus must be born by cesarean birth.
. If forceps are used to help the fetus rotate, this places a woman at risk for cervical
lacerations, hemorrhage, and infection in the postpartum period

B. BREECH PRESENTATION
– Most fetuses are in a breech presentation early in pregnancy. However, by week 38, a fetus
normally turns to a cephalic presentation.
– Although the fetal head is the widest single diameter, the fetus’s buttocks (breech), plus the
legs, actually take up more space.
● FACT: fundus is the largest part of the uterus is probably the reason why, in approximately
97% of all pregnancies, the fetus turns so that the buttocks and lower extremities are in the
fundus

Several types of breech presentation:

. complete
. frank
. footling

More hazardous to a fetus than a cephalic presentation, because there is a higher risk of:
 . Anoxia from a prolapsed cord
. Traumatic injury to the after coming head (possibility of intracranial hemorrhage or anoxia)
. Fracture of the spine or arm
. Dysfunctional labor
. Early rupture of the membranes( poor fit of the presenting part)
– Inevitable contraction of the fetal buttocks from cervical pressure often causes meconium to
be extruded into the amniotic fluid before birth.
– This, unlike meconium staining that occurs because of fetal anoxia, is not a sign of fetal
distress but is expected from the buttock pressure.
– Such meconium excretion can, however, lead to meconium aspiration if the infant inhales
amniotic fluid

ASSESSMENT
– fetal heart sounds usually are heard high in the abdomen.
– PRESENTATION Revealed by Leopold’s maneuvers and a vaginal examination
– If breech is complete and firmly engaged, the tightly stretched gluteal muscles of the fetus
may be mistaken on vaginal examination for a head; the cleft between the buttocks may be
mistaken for the sagittal suture line.
– If presentation is unclear, ultrasound clearly confirms a breech presentation

In a breech birth, the same stages

– flexion, descent, internal rotation, expulsion, and external rotation occur as in a vertex birth
– Always monitor FHR and uterine contractions continuously, if possible, during this time.
– Allows early detection of fetal distress from a complication such as prolapsed cord and allows
for prompt intervention

Therapeutic Management
A. Birth Technique.( procedure)
. If the infant will be born vaginally, a woman is allowed to push after full dilatation is achieved,
and the breech, trunk, and shoulders are born

. As the breech spontaneously emerges from the birth canal, it is steadied and supported by a
sterile towel held against the infant’s inferior surface
. The shoulders present to the outlet with their widest diameter anteroposterior. If they are not
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born readily, the arm of the posterior shoulder may be drawn down by passing two fingers
over the infant’s shoulder and down the arm to the elbow, then sweeping the flexed arm
across the infant’s face and chest and out.
– The other arm is delivered in the same wa
. External rotation is allowed to occur, to bring the head into the best outlet diameter.
– Birth of the head is the most hazardous part of a breech birth. Because the umbilicus
precedes the head, a loop of cord passes down alongside the head.
– The pressure of the head against the pelvic brim automatically compresses this loop of cord.
– A second danger of a breech birth is intracranial hemorrhage. With a cephalic presentation,
molding to the confines of the birth canal occurs over hours.
– With a breech birth, pressure changes occur instantaneously
– Tentorial tears = Can cause gross motor and mental incapacity or lethal damage to the fetus,
may result.
– Infant who is born suddenly to reduce the duration of cord compression may suffer an
intracranial hemorrhage.
– Infant who is born gradually to reduce the possibility of intracranial injury may suffer hypoxia

PROCEDURE :BIRTH IN BREECH

. To aid in birth of the head, the trunk of the infant is usually straddled over the physician’s
right forearm
– Two fingers of the physician’s right hand are placed in the infant’s mouth. The left hand is slid
into the woman’s vagina, palm down, along the infant’s back. Pressure is applied to the
occiput to flex the head fully.
. Gentle traction applied to the shoulders (upward and outward) delivers the head.
– An aftercoming head may also be delivered by the aid of Piper forceps to control flexion and
the rate of descent.
– The difficulty with birth of the head is the reason why planned cesarean