Complications Complications with the with the

PASSENGERPASSENGERPROBLEMS WITH

POSITION,PRESENTATION, OR SIZE

• Problems can occur with the fetus’s presentation or position during labor and delivery.

• Although most fetuses move into the proper birthing position, alternative positions and presentations can occur, making vaginal delivery difficult, and, in some situations, impossible.

OCCIPITOPOSTERIOR OCCIPITOPOSTERIOR POSITIONPOSITION

– The fetal position is posterior rather than the traditional anterior presentation.

– When this occurs, the occiput is directed diagonally and posteriorly, right occipitoposterior or left.

OCCIPITOPOSTERIOR OCCIPITOPOSTERIOR POSITIONPOSITION

• Causes:• Android, anthropoid, or contracted pelvic structures

OCCIPITOPOSTERIOR OCCIPITOPOSTERIOR POSITIONPOSITION

• Assessment:• A posteriorly presenting head will be found to not fit

the cervix as one occurring in an anterior position.• Prolonged active phase• Arrested descent• FHR heard best at the lateral sides of the abdomen• Position of the fetus is confirmed on vaginal

examination or by sonogram.

OCCIPITOPOSTERIOR OCCIPITOPOSTERIOR POSITIONPOSITION

• Management:• Place pressure on the sacrum, such as with a back rub, or suggest

a position change to relieve some of the pain.• Apply heat or cold, depending on which is more successful in

obtaining relief.• Ask the woman to lie on side opposite the fetal back or maintain a

hands-and-knees position to help the fetus rotate.• Encourage to void approximately every 2 hrs to keep the bladder

empty to avoid impeding the descent of the fetus and additional discomfort.

• IV glucose solutions to replace glucose stores used for energy.

BREECH PRESENTATIONBREECH PRESENTATION

• The baby enters the birth canal with the buttocks or feet first as opposed to the normal head first presentation.

BREECH PRESENTATIONBREECH PRESENTATION• Categories:

There are either three or four main categories of breech births, depending upon the source:

• Frank breech - the baby's bottom comes first, and his or her legs are flexed at the hip and extended at the knees (with feet near the ears). 65-70% of breech babies are in the frank breech position.

• Complete breech - the baby's hips and knees are flexed so that the baby is sitting crosslegged, with feet beside the bottom.

• Footling breech - one or both feet come first, with the bottom at a higher position. This is rare at term but relatively common with premature fetuses.

• Kneeling breech - the baby is in a kneeling position, with one or both legs extended at the hips and flexed at the knees. This is extremely rare, and is excluded from many classifications.

BREECH PRESENTATIONBREECH PRESENTATION

BREECH PRESENTATIONBREECH PRESENTATION• Causes:

• Gestational age younger than 40 weeks• multiple (or multifetal) pregnancy (twins, triplets or

more)• abnormal volume of amniotic fluid:

both polyhydramnios and oligohydramnios• fetal anomalies: hydrocephaly, anencephaly and

other congenital abnormalities• uterine abnormalities• prior Cesarean section

BREECH PRESENTATIONBREECH PRESENTATION• Assessment:

• FHS are commonly heard high in the abdomen• Leopold’s maneuver identify the fetal head in the

uterine fundus• Ultrasound reveals position of the fetus

BREECH PRESENTATIONBREECH PRESENTATION• Extraction of Breech

FACE PRESENTATIONFACE PRESENTATION– The chin or mentum is

the presenting part.– When this occurs, birth

usually can’t proceed because the diameter of the presenting part is too large for the maternal pelvis.

FACE PRESENTATIONFACE PRESENTATION• Cause:

• A woman with contracted pelvis• Placenta previa• Relaxed uterus of a multipara• Prematurity• Hydramnios• Fetal malformation

FACE PRESENTATIONFACE PRESENTATION• Assessment:

• Fetus’s head that feels more prominent than normal with no engagement apparent during Leopold’s maneuver

• Difficulty outlining fetus’s back.• Vaginal examination that reveals the

nose, mouth, or chin as the presenting part

• Management:• There may be a long first stage of

labor beause the face doesn’t mold well to make a snugly engaging part.

• If the chin is posterior, caesarean delivery is the optimal method of birth.

BROW PRESENTATIONBROW PRESENTATION– In a brow presentation, the

fetal head is midway between full flexion (vertex) and hyperextension (face) along a longitudinal axis.

– The presenting portion of the fetal head is between the orbital ridge and the anterior fontanel. The face and chin are not included.

BROW PRESENTATIONBROW PRESENTATION– The frontal bones are the point of

designation and can present (as with the occiput during a vertex delivery) in any position relative to the maternal pelvis.

– When the sagittal suture is transverse to the pelvic axis and the anterior fontanel is on the right maternal side, the fetus would be in the right frontotransverse position (RFT).

TRANSVERSE LIETRANSVERSE LIE– Occurs when the fetus

lays horizontal to the uterus

– Because there’s no firm presenting part, a vaginal delivery isn’t possible

TRANSVERSE LIETRANSVERSE LIE• Causes:

• A woman with pendulous abdomen• A uterine mass that obstructs the lower uterine

segment• Contraction of the pelvic brim• Hydramnios• Prematurity• Multiple gestation• Short umbilical cord• Fetal abnormalities

TRANSVERSE LIETRANSVERSE LIE• Assessment:

• Obvious on inspection when the ovoid of the uterus is found to be more horizontal than vertical

• Leopold’s maneuver• Sonogram

• Management:• Cesarean Birth is mandatory in this instance.

OVERSIZED FETUS OVERSIZED FETUS (MACROSOMIA)(MACROSOMIA)

– The size of the fetus may be an indication of a difficult delivery.

– A fetus who weighs more than 4,500 kg (9.9 lb) may lead to a difficult delivery.

– An abnormally large fetal size may pose a problem at birth because it can cause fetal pelvic disproportion or uterine rupture from obstruction.

OVERSIZED FETUS OVERSIZED FETUS (MACROSOMIA)(MACROSOMIA)

• Causes:• Common in diabetic pregnant women• Multiparity because each neonate born to a woman

tends to be slightly heavier and larger than the one born just before.

OVERSIZED FETUS OVERSIZED FETUS (MACROSOMIA)(MACROSOMIA)

• Assessment:• Detected in pelvimetry or sonography

• Management:• If the fetus is too large that the child can’t be delivered

vaginally, caesarean delivery becomes the method of choice.

Shoulder DystociaShoulder Dystocia

• Shoulder dystocia is a specific case of dystocia whereby after the delivery of the head, the anterior shoulder of the infant cannot pass below the pubic symphysis, or requires significant manipulation to pass below the pubic symphysis.

• It is diagnosed when the shoulders fail to deliver shortly after the fetal head

In shoulder dystocia, it is the chin that presses against the walls of the perineum. Shoulder dystocia is an obstetrical emergency, with fetal demise occurring within about 5 minutes if the infant is not delivered, due to compression of the umbilical cord within the birth canal.

Risk factorsRisk factors• Although the definition is imprecise, it occurs in

approximately 1% of vaginal births. There are well-recognised risk factors, such as diabetes, fetal macrosomia, and maternal obesity, but it is often difficult to predict.

• Despite appropriate obstetric management, fetal injury (such as brachial plexus injury) or even fetal death can be a complication of this obstetric emergency.

Signs• One often described feature is the turtle

sign, which involves the appearance and retraction of the fetal head (analogous to a turtle withdrawing into its shell), and the erythematous, red puffy face indicative of facial flushing. This occurs when the baby's shoulder is obstructed by the maternal pelvis.

ProceduresProcedures A number of obstetrical maneuvers are sequentially performed in attempt to facilitate delivery at this point, including :•McRoberts maneuver

– Exaggerated hyper flexion of the thighs upon the abdomen

– suprapubic pressure on fetal face

ProceduresProcedures• Rubin II or posterior pressure on the anterior

shoulder, which would bring the fetus in an oblique position with head somewhat towards the vagina

• Woods' screw maneuver – which leads to turning the anterior shoulder to the

posterior and vice versa (somewhat the opposite of Rubin II maneuver)

• Jacquemier's maneuver (also called Barnum's maneuver), – or delivery of the posterior shoulder first, in which the

forearm and hand are identified in the birth canal, and gently pulled.

.

7-Delivery of the posterior arm :

By inserting a hand into the posterior

vagina and ventrally rotating the arm at

the shoulder

delivery over the perineum

• Gaskin maneuver, – named after Certified Professional Midwife, Ina May

Gaskin, involves moving the mother to an all fours position with the back arched, widening the pelvic outlet.

More drastic maneuvers include:

• Zavanelli's maneuver – which involves pushing the fetal head back in with

performing a cesarean section. or internal cephalic replacement followed by Cesarean section

1. The head first manually rotated to the occipito anterior

(Pre-restitution) position

2.Flexion of the head, Returning it to the vagina with upward constant firm pressure, followed by CS

• maternal symphysiotomy, which makes the opening of the birth canal laxer by breaking the connective tissue between the two pubes bones facilitating the passage of the shoulders.

• abdominal rescue, described by O'Shaughnessy, where a hysterotomy facilitates vaginal delivery of the impacted shoulder

Management• Ask for help. This involves requesting the help of an

obstetrician, anesthesia and pediatrics for subsequent resuscitation of the infant.

• Leg hyperflexion (McRoberts' maneuver)• Anterior shoulder disimpaction (suprapubic pressure)• Rubin maneuver• Manual delivery of posterior arm• Episiotomy• Roll over on all fours

ComplicationsComplications

• Klumpke paralysis• Erb's Palsy• Fetal hypoxia

– Fetal death– Cerebral palsy

• Maternal post partum haemorrhage

Fetal Complications of Sh DFetal Complications of Sh D

Complications Complications with the with the

PASSagePASSage

CEPHALOPELVIC CEPHALOPELVIC DISPROPORTIONDISPROPORTION

• A narrowing, or contractions, of the birth canal, which can occur at the inlets, midpelvis, or outlet, causes a disproportion between the size of the fetal head and the pelvic diameters, or cephalopelvic disproportion (CPD). CPD results in failure of labor to progress.

PRIMARY PROBLEMSPRIMARY PROBLEMS• Malpositioning can occur

because the fetus’s head isn’t engaged in the pelvis. Malpositioning can lead to further complications. For example, if membranes rupture, the risk for cord prolapse increases significantly.

CAUSESCAUSES• Small pelvis is major contributing factor in

CPD. It may result in rickets in the early life of the mother, or a pelvis that isn’t fully matured in a young adolescent.

• The fetal head may be too large to fit or the overall fetal size may be prohibitively large (known as macrosomia).

• Abnormal poritions of the fetus can also cause CPD.

• Fetal anomalies such as hydrocephalus, hydrops fetalis and tumors of the fetal head can also result in CPD.

DETECTIONDETECTION• A previous vaginal birth

without any problem is substantial proof that the birth canal is considered adequate.

• Pelvic measurement should be taken and recorded before week 24.

MANAGEMENTMANAGEMENT• A trial labor may be allowed to continue of

descent of the presenting part and dilatation of the cervix are occurring.

• The following nursing measures are important in trial labor:– Monitor fetal heart sounds and

uterine contractions continuously.– Make sure that the woman’s

urinary bladder is kept empty to allow the fetal head to use all space, making delivery possible.

– After rupture of the membranes, assess fetal heart rate carefully. If the fetal head is till high, alterations in FHR may indicate an increased danger of prolapsed cord and fetal anoxia.

– Monitor progress of labor.– Emphasize that its best for the baby to be born

vaginally, if possible, and not that she’s been subjected to pain.

– If for cesarean, explain why the procedure is necessary.

– Remember to support the support person.– Assure the parents that a cesarean birth isn’t an

inferior method but an alternative method.

THERAPEUTIC THERAPEUTIC MANAGEMENT OF MANAGEMENT OF

PROBLEMS OR PROBLEMS OR POTENTIAL POTENTIAL

PROBLEMS IN PROBLEMS IN LABOR AND LABOR AND

BIRTHBIRTH

INDUCTION OF LABORINDUCTION OF LABOR– Means that labor is started artificially– May be necessary to initiate labor before the time

when it would have occurred spontaneously because the fetus is in danger or because labor does not occur spontaneously and the fetus appears to be at term.

– Induction is begun by the dilute administration of an IV form of oxytocin.

INDUCTION OF LABORINDUCTION OF LABOR– Before induction of labor is begun, the

following conditions should be present:• The fetus is in a longitudinal lie• The cervix is ripe, or ready for birth.• A presenting part is engaged• There is no CPD.• The fetus is estimated to be mature by date.

INDUCTION OF LABORINDUCTION OF LABOR• Indications:

– Preeclampsia & Eclampsia– Severe HTN– DM– Rh sensitization– Prolonged rupture of membranes– Intrauterine growth restriction– Postmaturity

INDUCTION OF LABORINDUCTION OF LABOR• Nursing Responsibilities:

– Monitor maternal and fetal vital signs before and during induction.

– Monitor labor progress, closely observe for signs of abnormal labor progress

– Avoid uterine hyperstimulation by infusing oxytocin to achieve adequate contraction, frequency, duration, and relaxation.

– Monitor for signs of uteroplacental insufficiency during the process of induction.

AUGMENTATION OF LABORAUGMENTATION OF LABOR• Refers to assisting labor that has started

spontaneously to be more effective.• Promotes stronger uterine contractions.• May be necessary if the contractions are hypotonic

or too weak or infrequent to be effective.• This can shorten labor and avoid the necessity of

caesarean birth.• Precautions regarding oxytocin administration are

the same as for primary induction of labor.

Cesarean Delivery

INSTRUMENTAL VAGINAL INSTRUMENTAL VAGINAL DELIVERYDELIVERY

• Instrumental vaginal delivery refers to the use of specially designed instruments, namely the obstetric forceps and the vacuum extractor, to facilitate delivery of the fetal head.

INSTRUMENTAL VAGINAL INSTRUMENTAL VAGINAL DELIVERYDELIVERY

• Their use is usually restricted to certain difficult deliveries in order to shorten the second stage of labour whenever fetal or maternal distress is already present, or strongly anticipated.

• The decision to choose between the obstetric forceps or the vacuum extractor is individualized according to each case and is largely dependant on the clinician's state of experience.

INSTRUMENTAL VAGINAL INSTRUMENTAL VAGINAL DELIVERYDELIVERY

• THE OBSTETRIC FORCEPS– The obstetric forceps is an instrument designed for

traction or combined traction and rotation of the fetal head.

– It consists of two blades, each having two curves: Cephalic curve to fit on each side of the fetal skull. Pelvic curve to obtain a central grip on the head and to

promote flexion.

INSTRUMENTAL VAGINAL INSTRUMENTAL VAGINAL DELIVERYDELIVERY

INSTRUMENTAL VAGINAL INSTRUMENTAL VAGINAL DELIVERYDELIVERY

• INDICATIONS FOR THE USE OF FORCEPS– Prolonged second stage of labour.– To shorten second stage of labor.– Inadequate maternal expulsive forces. – Fetal distress if the cervix is fully dilated. – Prolapsed pulsating cord with fully dilated

cervix.– Some Malpositions & malpresentations: - O.P. after failure of spontaneous rotation. - After coming head in breech.

INSTRUMENTAL VAGINAL INSTRUMENTAL VAGINAL DELIVERYDELIVERY

• PREREQUISITES BEFORE FORCEPS APPLICATION

– The cervix should be fully dilated. – The head should be engaged.– Cephalopelvic disproportion should be excluded.– The membranes (forewaters) should be ruptured. – Presence of adequate uterine contractions– Antisepsis and anaesthesia – The bladder & rectum should be evacuated

INSTRUMENTAL VAGINAL INSTRUMENTAL VAGINAL DELIVERYDELIVERY

• CONTRAINDICATIONS TO FORCEPS OPERATION– Incompletely dilated cervix – Unengaged head – Cephalopelvic disproportion– Intact membranes – Uterine inertia

INSTRUMENTAL VAGINAL INSTRUMENTAL VAGINAL DELIVERYDELIVERY

• COMPLICATIONS OF FORCEPS PROCEDURES

A) Maternal complications: 1. Maternal birth injuries 2. Postpartum hemorrhage (PPH)

B) Fetal complications: 1- Intracranial hemorrhage 2- Head & Skull injuries

THE VACUUM EXTRACTORTHE VACUUM EXTRACTOR

INTRODUCTIONINTRODUCTION• The use of vacuum–cup deliveries to facilitate vaginal

birth dates back to 18th century. • The idea was to apply traction to fetal scalp guiding the

head down out of the birth canal. • In 1954, Malmstrom, (a Swedish obstetrician),

developed the currently used vacuum extractor.

• Original Malmstrom ventouse used a metal cup applied on fetal scalp for traction, and a glass jar and pump to create a negative pressure.

• Current instruments use pliable plastic and polyethylene cups, and electric suction instruments for negative pressure production.

PREREQUISITES FOR THE USE OF PREREQUISITES FOR THE USE OF VACUUM EXTRACTORVACUUM EXTRACTOR

• The cervix should be fully dilated. • The head should be engaged.• Cephalopelvic disproportion should be excluded.• The membranes (forewaters) should be ruptured. • Presence of adequate uterine contractions• Antisepsis and anaesthesia • The bladder & rectum should be evacuated

INDICATIONS FOR USE OF VACUUM INDICATIONS FOR USE OF VACUUM EXTRACTOREXTRACTOR

• Prolonged second stage of labour.• To shorten second stage of labor.• Inadequate maternal expulsive forces. • Fetal distress if the cervix is fully dilated. • Prolapsed pulsating cord with fully dilated cervix.• Some Malpositions & malpresentations:

CONTRAINDICATIONS TO THE USE OF CONTRAINDICATIONS TO THE USE OF THE VACUUM EXTRACTORTHE VACUUM EXTRACTOR

• Incompletely dilated cervix • Unengaged head • Cephaloopelvic disproportion• Intact membranes • Uterine inertia

• Non vertex presentations, as in face and breech presentations.

• Premature infants, to avoid serious complications.• Marked fetal distress, as it needs a longer period of

application than the forceps.

Advantages of the Vacuum Advantages of the Vacuum extractorextractor

• Allows easy and gentle traction on the fetal head, due to limited force.

• Promotes flexion and helps internal rotation of the fetal head in O.P. positions.

• Less encroachment on maternal pelvic space, resulting in less trauma to maternal birth canal, and less serious lacerations

Complications of the vacuum Complications of the vacuum extractorextractor

A) Maternal complications:1. Vaginal and perineal lacerations.2. Cervical lacerations.3. Rarely rupture uterus, (non engaged head, or non

fully dilated cervix).

B) Fetal complications: 1. Cephalhematoma.2. Scalp lacerations, (excessive force and repeated

slipping of the cup).3. Cerebral hemorrhage (tear of vein of Gallen).

Technical ConsiderationsTechnical Considerations • To promote flexion of the fetal head with traction,

the suction cup is placed over the ' median flexing point ‘.

• Low suction (100 mmHg) is applied. After ensuring that no maternal soft tissue is trapped between the cup and fetal head, suction is increased to 500-600 mmHg and sustained downward traction is applied along the pelvic curve in concert with uterine contractions.

• Suction is released between contractions.

• The procedure should be abandoned if the cup detaches three times or if no descent of the head is achieved.