NSG 109 LEC

Problems with Passengers

• Birth complications may arise due to:

  • Immaturity or preterm maternal pelvis

  • Undersized pelvis (especially in early adolescence)

  • Smaller pelvic diameters compared to fetal skull sizes

  • Umbilical cord prolapse

  • Presence of multiple fetuses

  • Malposition or excessive size of a fetus for the birth canal.

Prolapse of the Umbilical Cord

• Defined as a situation where a loop of the umbilical cord slips down in front of the presenting fetal part.

• Timing: Can occur any time after membranes rupture if the fetal part isn't firmly engaged in the cervix.

• Common Causes:

  • Premature rupture of membranes

  • Non-cephalic fetal presentations

  • Placenta previa

  • Intrauterine tumors that prevent engagement

  • Small fetus or cephalopelvic disproportion

  • Hydramnios and multiple gestations.

Assessment of Prolapse

• May be detected during initial vaginal exam by feeling the cord as the presenting part.

• Identified through ultrasound (CS may be required before membrane rupture).

• After membranes rupture, cord may slide down into the vagina due to pressure from amniotic fluid, possibly leading to decelerations in the fetal heart rate (FHR).

• Assess FHSs immediately after membrane rupture to rule out cord prolapse.

Therapeutic Management of Cord Prolapse

• Objective: Relieve pressure on the cord to avoid fetal anoxia.

• Methods:

  • Manually elevating fetal head off the cord with a gloved hand.

  • Positioning mother in knee-chest or Trendelenburg position.

  • Administering oxygen at 10 L/min via face mask.

  • Possibly using tocolytic agents to reduce uterine activity.

  • Important: Avoid pushing any exposed cord back into the vagina to prevent added compression, instead cover exposed areas with a sterile saline compress.

  • For fully dilated cervix during prolapse, forceps delivery may be necessary. If incomplete dilatation, apply upward pressure via the vagina until CS can be performed.

  • Amnioinfusion to add sterile saline into the uterus may be used to supplement amniotic fluid and alleviate cord compression.

Fetal Distress

• Defined as fetal condition resulting from hypoxia.

• Risk Factors include:

  • Dystocia

  • Cord entanglement/compression

  • Improper use of oxytocin, anesthesia, or analgesia

  • Maternal conditions like diabetes mellitus (DM) and cardiac disease.

  • Bleeding complications in the third trimester, hypertension, and supine hypotensive syndrome.

• Assessment Findings:

  • Abnormal FHT (>160 or <120/min)

  • Meconium-stained amniotic fluid in non-breech presentations

  • Fetal hypermobility/hyperactivity.

Fetal Distress Interventions

• Reposition the mother to left lateral recumbent to relieve vena cava pressure, improving perfusion.

• Stop oxytocin drip if infusing.

• Administer oxygen at 6-7 L/min.

• Correct hypotension by elevating legs, increasing IV hydration (with plain IVF, no oxytocin), or repositioning.

• Continuous monitoring of FHTs and promptly notify physician.

Problems with Fetal Position and Presentation

• Breech Presentation:

  • Most fetuses start in breech but usually convert to cephalic by week 38.

  • Breech types:

  • Complete: Thighs flexed on the abdomen with both buttocks and feet presenting.

  • Frank: Hips flexed, knees extended; buttocks alone present.

  • Footling: Thighs and lower legs not flexed; single/double-footling breech.

• Higher risks for breech presentation include:

  • Anoxia from cord prolapse

  • Injuries to head (intracranial hemorrhage), spine or arms

  • Dysfunctional labor, early rupture of membranes.

Assessment of Breech Presentation

• FHTs heard high in the abdomen.

• Confirmed through Leopold's maneuvers & ultrasound (UTZ).

Birth Technique for Breech

• If vaginal delivery is intended, mother may push after full dilatation, and infant supported with a sterile towel against the inferior surface.

Multiple Gestations

• Requires additional personnel for birth and has a higher incidence of complications like cord entanglement.

• Risks include anemia, pregnancy-induced hypertension, and premature separation of placenta or previa.

  • Continuous monitoring of each FHR during labor.

Occipitoposterior Position

• Occurs when fetal position is posterior instead of anterior (approximately 10% of labors).

• May cause prolonged labor, increased molding, and sacral pressure pain.

  • Therapeutic management includes counter pressure on sacrum, heat/cold application, and maternal positioning to aid fetal rotation.

  • Cesarean birth indicated if ineffective contractions continue or if the fetus is disproportionately large or improperly positioned.

Asynclitism and Face Presentation

• Face presentations result from extension rather than flexion of the head, confirmed through vaginal examination or ultrasound. Vaginal birth is possible if chin is anterior; CS if posterior.

• Risks include facial edema; monitor for baby's airway and consider NICU transfer for severe cases.

Other Complicated Presentations

• Brow Presentation: Rare and typically requires cesarean.

• Transverse Lie: Will not allow for vaginal delivery; confirmed by inspection and Leopold maneuvers, CS is needed.

• Oversized Fetus (Macrosomia): Larger than 4000-4500 g. May complicate delivery and increase risks for the mother post-delivery.

• Shoulder Dystocia: Occurs when shoulders are too broad, leading to potential fetal injuries or tears in the mother.

Problems with Powers

• Dysfunctional Labor: Characterized by ineffective contractions leading to increased maternal and infant risks.

  • Hypotonic Contractions: Low-frequency or weak contractions during active labor, often due to distention or ineffective settings.

  • Hypertonic Contractions: High resting tone with frequent contractions, can lead to maternal and fetal distress.

Comparison of Contractions

• Hypotonic: Active phase, limited pain, effective response to medications.

• Hypertonic: Latent phase, painful, may require intervention for ineffective labor.