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PROLAPSED UMBILICAL CORD – a loop of the umbilical cord slips down in front of the presenting

 Prolapse may occur at any time after the membranes rupture and if the presenting part is not fitted
firmly into the cervix.
 Prolapsed cord tends to occur with premature rupture of the membranes, fetal position other than
cephalic presentations, placenta previa, intrauterine tumors or cephalopelvic disproportion that
prevents firm engagement of the fetus, a small fetus, polyhydramnios, and multiple gestation.
 Cord prolapse automatically leads to cord compression because the fetal presenting part presses
against the cord at the pelvic brim.
 The incidence of prolapsed cord is 1 in 200 pregnancies.
 Management is aimed at relieving pressure on the cord and thereby relieving the compression and the
resulting fetal anoxia.
 If the cervix is fully dilated at the time of prolapse, the physician may choose to deliver the infant
rapidly, possibly with forceps delivery, to prevent a lengthy period of anoxia.
 If dilation is incomplete, the birth method of choice is upward pressure on the presenting part by a
practitioner’s hand in the woman’s vagina until cesarean birth is complete.

Assessment Findings:
 Cord felt as presenting part
 Presence of cord in vagina after rupture of membranes
 Variable deceleration pattern on fetal monitor

Nursing Implications:
 Monitor fetal heart rate and observe for variable deceleration pattern.
 Monitor and record fetal heart rate immediately following rupture of membranes.
 Place the client in Trendelenberg or knee-chest position, which causes the fetal head to fall back from
the cord if cord prolapse is discovered.
 Prepare the client for relief of cord compression; a hand is placed in the vagina (insert two fingers
into the vagina to the cervix) and the fetal head is manually elevated off the cord.
 Administer oxygen at 10 L/min by face mask to prevent fetal anoxia.
 Be prepared to administer a tocolytic to reduce uterine activity.
 Cover any exposed portion of the cord with a sterile saline compress to prevent drying.
 Do not attempt to push any exposed cord back into the vagina because it may cause additional
compression by kinking or knotting.

MULTIPLE GESTATION (PREGNANCY) – occurs when more than one fetus is growing in the uterus.

 Multiple gestation is a complication of pregnancy because a woman’s body must adjust to the effects
of more than one fetus.
 Single-ovum (monozygotic, identical) twins usually have one placenta, one chorion, two amnions,
and two umbilical cords and are of the same sex.
 Double-ova (dizygotic, nonidentical) twins have two placentas, two chorions, two amnions, and two
umbilical cords and may be of the same or different sex.
 Multiple gestations of three, four, five or six children maybe singe-ovum conceptions, multiple ova
conceptions, or a combination of both.
 Multiple gestations often occur as a result of ovulation stimulation by clomiphene citrate (Clomid);
with in vitro fertilization, several fertilized ova are introduced into the uterus, resulting in a high
possibility of multiple births.
 Women with multiple gestations are more susceptible to complications such as pregnancy-induced
hypertension, hydramnios, placenta previa, postpartal hemorrhage and anemia.
 There is also a higher incidence of velamentious cord insertion (the cord inserted into the fetal
 Monozygotic twins can share the same vascular communication, which can lead to an overgrowth of
one fetus and an undergrowth of the second (twin-to-twin transfusion).

Assessment Findings:
 Uterine size greater than expected for dates
 Elevated alpha-fetoprotein levels
 Ultrasonography positive for multiple pregnancy
 More than one set of fetal heart sounds

Nursing Implications:
 Obtain a thorough antepartal history and physical examination to establish a baseline.
 Ensure adequate nutrition by instructing the client to eat six small meals a day rather than three large
ones since the growing uterus will compress her stomach and reduce her appetite.
 Review with the client her need for extra rest periods and “shoes off” times during the day to increase
tissue perfusion.
 Advise the client to refrain from coitus during the last 2 to 3 months of pregnancy.
 Advise the client to return to the health care facility every month for ultrasound examination or
weekly nonstress tests to document normal fetal growth beginning with the 28 th week of pregnancy.
 Encourage the client to adhere to her prescribed bed rest routine during the last 2 or 3 months of her
 Monitor fetal heart rate and fundic height as well as maternal vital signs per facility’s protocol.
 Prepare the client emotionally and physically for labor and delivery of multiple fetuses.
 Twins may be born by cesarean birth to decrease the risk that the second fetus will experience anoxia;
this is also often the situation in multiple gestations of three of more, because of the increased
incidence of cord entanglement and premature separation of the placenta.


Occipitoposterior Position
 The occiput 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
but through an arc of approximately 135 degrees.
 Posterior positions tend to occur in women with android, anthropoid or contracted pelvis. A
posterior position is suggested by a dysfunctional labor pattern such as a prolonged active phase, arrested
descent or fetal heart sounds heard best at the lateral sides of the abdomen.
 A posteriorly presenting head does not fir the cervix snugly thus increases the risk of umbilical
cord prolapse.
 If the fetus is of average size and in good flexion and aided by forceful uterine contractions, rotate
through the large arc, arrive at a good birth position for the pelvic outlet, and are born satisfactorily with
only increased molding and caput formation.
Nursing Implications:
 As the fetal head rotates against the sacrum, a woman may experience pressure and pain in her lower back
due to sacral nerve compression.
 Counterpressure on the sacrum such as backrub or change of position may be helpful in relieving a portion
of the pain. Applying heat or cold, whichever feels best, also may help.
 Lying on the side opposite the fetal back or maintaining a hands-and-knees position may help the fetus
 During a long labor, she may need an IV glucose solution to replace glucose stores used for energy.
 The fetal head may arrest in the transverse position (transverse arrest), or rotation may not occur at all
(persistent occipitoposterior position). In these instances, the fetus must be born by cesarean birth.
Breech Presentation
 Fetal presentation in which either the buttocks or feet are the first body parts to contact the cervix.
 The inevitable contraction of the fetal buttocks from cervical pressure often causes meconium to be
extruded into the amniotic fluid before birth. Such meconium excretion can lead to meconium aspiration if
the infant inhales amniotic fluid.
 With breech presentation, fetal heart sounds usually are heard high in the abdomen. Leopold’s maneuvers,
a vaginal examination or ultrasound examination reveals the presentation.
Risk of Breech Presentation
 anoxia from a prolapsed cord
 Traumatic injury to the aftercoming head
 Fracture of the spine or arm
 Dysfunctional labor
 Early rupture of the membranes because of the poor fit of the presenting part
Causes of Breech Presentation
 Gestational age less than 40 weeks
 Abnormality in a fetus
 Hydramnios
 Any space-occupying mass in the pelvis
 Pendulous abdomen
 Multiple gestation
 Unknown factors
Face Presentation
 Fetal presentation in which either the chin or mentum is the first body parts to contact the cervix.
 This presentation is rare, but when it does occur, the diameter that the fetus presents to the pelvis is often
too large for birth to proceed.

 If the chin is anterior and the pelvic diameters are within normal limits, the infant may be delivered
without difficulty.
 If the chin is posterior, cesarean birth will be the choice of birth.
This occurs in a woman with the following conditions:
 Contracted pelvis
 In the presence of Placenta Previa
 Relaxed Uterus of a Multipara
 With Prematurity
 With Hydramnios
 With Fetal Malformation
Brow Presentation
 Fetal presentation in which the brow is the first body parts to contact the cervix.
 Is the rarest of the presentations. It occurs with a multipara or with relaxed abdominal muscles. It results in
obstructed labor, unless the presentation spontaneously corrects, cesarean birth will be necessary to deliver
the infant safely. Brow presentations also leave the infant with extreme ecchymotic bruising on the face.
 Causes are the same as those of face presentation.
Transverse Lie
 Fetal presentation in which the shoulder is the first body parts to contact the cervix.
 The abnormal presentation can be confirmed by Leopold’s maneuvers.
 Often, the membranes rupture at the beginning of labor. Because there is no firm presenting part, the cord
or an arm may prolapse, or the shoulder may obstruct the cervix. Cesarean birth is necessary.
1. women with pendulous abdomens
2. uterine masses such as fibroid tumors that obstruct the lower uterine segment
3. contraction of the pelvic brim
4. congenital abnormalities of the uterus
5. women with hydramnios
6. infants with hydrocephalus or other gross abnormalities that prevent head from engaging
7. may occur in prematurity when the infant has room for free movement
8. multiple gestation
9. when there is short umbilical cord
Macrosomia (Oversized Fetus)
 Size may become a problem in a fetus who weighs more than 4,500 grams (10 lbs.). The large infant born
vaginally has a higher-than-normal risk of cervical nerve palsy, diaphragmatic nerve injury, or fractured
clavicle because of shoulder dystocia.
 If the infant is so oversized that he or she cannot be delivered vaginally, cesarean birth becomes the birth
method of choice.
Shoulder Dystocia
The problem occurs at the second stage of labor when the head is born but the shoulders are too broad to
enter and be delivered through the pelvic outlet.
 Hazardous to the mother because it can result in vaginal and cervical tears.
 Hazardous to the fetus because the cord is compresses between the fetal body and the bony pelvis,
possibly resulting in fractured clavicle or a brachial plexus palsy.
 Most apt to occur in women with diabetes, multiparas, and in post-date pregnancies.
 The condition may be suspected earlier if the second stage of labor is prolonged, if there in arrest of
descent, or if when the head appears on the perineum (crowning) it retracts instead of protruding with
contraction ( A TURTLE SIGN )
 Asking a woman to flex her thighs sharply on her abdomen (McRobert’s Maneuver) widens the pelvic
outlet and may let the anterior shoulder deliver.
 Applying suprapubic pressure may help the shoulder escape from beneath the symphysis pubis (Wood’s
 Inlet contraction is defined as a narrowing of the anteroposterior diameter of the pelvis to less than 11
 Outlet contraction is defined as the narrowing of the transverse diameter to less than 11 cm.


1. Placenta Succenturiata – has one or more accessory lobes connected to the main placenta by blood vessels.
2. Placenta Circumvalata – ordinarily the chorion membrane begins at the edge of the placenta and spreads to
envelop the fetus; no chorion covers the fetal side of the placenta. In placenta circumvallata, the fetal side
of the placenta is covered to some extent with chorion. The umbilical cord enters the placenta at the usual
midpoint, and large vessels spread out from there.
3. Placenta Marginata- the fold of chorion reaches just to the edge of the placenta.
4. Battledore Placenta – the cord inserted marginally rather than centrally.
5. Velamentous Insertion of the Cord – is a situation in which the cord, instead of entering the placenta
directly, separates into small vessels that reach the placenta by spreading across a fold of amnion.

6. Vasa Previa – the situation in which the umbilical vessels of the velamentious cord insertion cross the
cervical os so they would deliver before the fetus. The vessels may tear with cervical dilatation the same
as vasa previa may tear.
7. Placenta Accreta – is an unusually deep attachment of the placenta to the uterine myometrium.
Induction and Augmentation of Labor
 Induction of labor means that labor is artificially started; augmentation refers to assisting a labor that has
started spontaneously to be more affective.
 The primary reasons for including labor are the presence of preeclampsia, eclampsia, severe hypertension
or diabetes, Rh sensitization, prolonged rupture of membranes, intraurine growth retardation, and
postmaturity, or situations in which it seems risky for the fetus to remain in utero.
 Augmentation of labor or assistance to make uterine contractions stronger may be necessary when uterine
contractions are too weak or infrequent to be effective.
 Before induction of labor is begun, the following conditions must be present:
*The fetus is in a longitudinal lie and at a point of extrauterine viability.
*The cervix is ripe or ready for birth.
*The presenting part is engaged.
*There is no cephalopelvic disproportion (CPD).
 Labor induction is a procedure that should be used cautiously with multiple gestation, hydramnios, grand
parity, maternal age older than 35 years, and presence of uterine scars because it carries a risk of uterine
rupture, a decrease in the fetal blood supply from cotyledon filling, and premature separation of the
 Labor induction or augmentation may be accomplished by the administration of oxytocin or by
Nursing Implications:
 Assist with obtaining ultrasonography or a lecithin-sphingomyelin ratio to assess fetal maturity.
 Be aware that oxytoxin should be administered intravenously so that its effect can be quickly
discontinued to prevent hyperstimulation.
 Know that the half-life of oxytoxin is about 3 minutes so that with intravenous administration the
functioning level ends this quickly.
 Piggyback the oxytocin solution with a maintenance intravenous solution so that if the oxytocin needs to
be shut off abruptly, the intravenous line will not be lost.
 Monitor fetal heart rate and uterine contraction by electronic monitoring.
 Assess and document maternal vital signs every 15 minutes.
 Assess for signs of water intoxication, such as headache and vomiting, since oxytocin has an antidiuretic
 Assure the client that once contractions start by these methods, they are basically normal uterine
Forceps Delivery
 A forceps delivery refers to a method of delivery involving steel instruments constructed of two blades
that slide together at their shaft to form a handle.
 Forceps are applied first by on blade being slipped into a woman’s vagina next to the fetal head and then
the other side being slipped into place; the shafts are brought together in the midline to form the handle.
 Forceps may be necessary to deliver the baby if a woman is unable to push with contractions in the pelvic
division of labor, such as after regional anesthesia; if progress ceases in the second stage of labor; or if
the fetus is in an abnormal fetal position.
 A fetus in distress from a complication such as prolapsed cord can be delivered more quickly by the use of
 Forceps are designed to prevent pressure from being exerted on the fetal head and also may be used to
reduce pressure and avoid subdural hemorrhage in the fetus as the fetal head reaches the perineum.
 A low forceps birth may be used to indicate the fetal head is at a +2 station; if the fetal head is still at the
level of the ischial spines (0 station), this is a midforceps birth (although rarely seen today).
 Some anesthesia, at least a pudendal block , is necessary for forceps application to achieve pelvic
relaxation and reduce pain.
 Low forceps birth – fetal head is at +2 station or more
 Mid forceps birth - < +2 station
 Pelvis should be adequate; no CPD
 Fetal head is deeply engaged
 Cervix is completely dilated and effaced
 Membranes have ruptured
 Vertical presentation has been established
 The rectum and bladder are empty
 Anesthesia is given
Nursing Implications

 Prepare the client physically and emotionally for forceps application.
 Provide emotional support and guidance throughout the procedure to alleviate anxieties and fears; allow
the client and partner to verbalize feelings and concerns.
 Assess the client’s membranes for rupture, which must be present before forceps are applied.
 Be aware that no caphalopelvic disproportion can be present before forceps are applied.
 Assess the client for complete cervical dilation before using forceps.
 Assist the client to empty her bladder before using forceps.
 Monitor the fetal heart rate before applying forceps and immediately after applying them, because a
danger of forceps use is that the cord could be compressed between the blade and the head.
 Anticipate an episiotomy to prevent perineal tearing owing to pressure on the perineum.
 Assess the client’s cervix after a forceps birth to be certain that no laceration has occurred.
 Record the time and amount of the client’s first voiding to rule out bladder injury.
 Assess the neonate for facial palsy or subdural hematoma, possible complications of a forceps birth.
 Inform the client and partner that the neonate may have a transient erythematous mark on the cheek;
assure them that this will fade in 1 to 2 days.

 Cesarean birth refers to a surgical procedure in which the neonate is delivered through an incision made in
the maternal abdomen.
 It may be planned (elective) or arise from an unanticipated problem (emergency).
 It was previously termed C-section.
 In a classic cesarean delivery, a vertical midline incision is made in the skin and the body of the uterus,
allowing easier access to the fetus, and thus indicated in emergency situations; typically, it is done when
the fetus is in transverse lie and when adhesions from previous cesarean deliveries are present and with an
anteriorly implanted placenta; the blood loss is increased because large blood vessels of the myometrium
are involved; there is also a greater possibility of rupture of the scar in subsequent pregnancies because the
uterine musculature is weakened.
 In a low segment cesarean delivery, the most common type, the skin incision is made low (“bikini” or
Pfanenstiel incision), and the uterine incision is horizontal in the lower uterine segment; blood loss is
minimal with fewer postdelivery complications; the incision is easy to repair with less chance of rupture of
the uterine scar during future deliveries, the procedure takes longer to perform then the classic incision and
therefore, it is not useful in emergencies.
Clinical Indications:
Maternal Factors
 Cephalopelvic Disproportion
 Active genital Herpes or HPV
 Previous CS by classic incision
Placental Factors
 Placenta Previa
 Abruptio Placenta
Fetal Factors
 Transverse fetal lie
 Extreme low birth weight
 Fetal distress