PROBLEMS WITH THE

PASSENGER

Clinical Practicum 102-A

1. Prolapse of the Umbilical Cord

Cord Proplased

– A complication when the

umbilical cord falls or is
washed through the
cervix into the vagina.
– A loop of the umbilical
cord slips down infront
of the presenting part.
• Prolapse may occur at anytime after the membranes
rupture if the presenting fetal part is not fitted firmly into
the cervix.
• Incidence
0.5% of cephalic births
15% to 20% with breech or transverse lies
• 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
– A small fetus
CPD preventing firm engagement
Hydramnios
Multiple gestation

Assessment
1. the cord may be felt as a presenting part on the
initial vaginal examination during labor
– 2. more often, cord prolapse is first discovered only
after the membranes have ruptured
– 3. the cord may be visible at the vulva

– To rule out cord prolapse, always assess FHSounds

immediately after rupture of the membranes
Therapeutic Management

1. relieve pressure on the

cord by placing the
woman on
Trendelenburg position
or knee-chest position
which causes the fetal
head to fall back from the
cord.
2. administration of oxygen 10L/min by face mask to the
woman to improve oxygenation of the fetus.

3. A tocolytic agent may be prescribed to reduce uterine

activity and pressure on the fetus.
4. Amnioinfusion is yet
another way to relieve
pressure on the cord.
Amnioinfusion is the
addition of sterile fluid into
the uterus to supplement
the amniotic fluid.
warm saline solution or
lactated Ringer’s solution;
initial 500ml
– 5. If the cord is exposed
to room air, dying will
begin leading to athropy
of umbilical vessels.
Cover the exposed
portion with a sterile
saline compress to
prevent drying.
• 6. observe for fetal distress
• 7. provide emotional support
• 8. prepare for CS

• Prolapsed cord is always an emergency situation

because the reduced blood flow to the fetus can quickly
caused fetal harm.
2. Multiple Pregnancy

Definition : a pregnancy in which more than one fetus is

present. The fetuses may arise from one or more zygotes
and are usually separate, but may be conjoined.
• Types
– A. Dizygotic (fraternal) multiple
pregnancy
• Involves two or more ova fertilized
by separate sperm.
• Fetuses have separate placentas,
amnions and chorions (although
the placenta may fuse to resemble
a single one)
• May be the same or different sexes
B. Monozygotic (Identical)
multiple pregnancy
Develops from a single
fertilized ovum.
Fetuses share a common
placenta and chorion but have
separate amnions.
They have the same sex
• Anemia and PIH occur at higher than usual
incidences during multiple gestations.
• If a woman with multiple gestation will be giving birth
vaginally, she is usually instructed to come to the hospital
early in labor.
• Multiple pregnancies often end before full term.
• If possible, monitor each FHR by a separate fetal monitor
during labor.
• Because the babies are usually small, firm head
engagement may not occur, increasing the risk for cord
prolapse after rupture of the membranes.
• Abnormal fetal presentation may occur

• Premature separation of the placenta after the birth of the

first child may be more common.
• Most twin pregnancies present with
both twins vertex
vertex and breech
breech and vertex
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 are
tied or clamped permanently rather than with cord
clamps, which could slip.
• This prevents hemorrhage through an open cord end if
additional infants have shared the placenta.
• The first infant is identified as A and newborn care is
started
• In singleton pregnancies, oxytocin is usually given
immediately to contract the uterus and minimize bleeding
after an infant is born; with this woman, however, it will not
be given, to avoid compromising the circulation of the
infant 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.
• If this is not successful, a decision for breech birth or
caesarian birth must be made.
• If the infant will be born vaginally, an oxytocin infusion
may be begun at this point to assist uterine contractions
thereby shortening the time span between births.
• If uterine relaxation is needed, nitroglycerin, an 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.
• If uterine relaxation is needed, nitroglycerin, an 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.
• 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 caesarian birth.
• Assess the woman carefully in the immediate postpartal
period for bleeding and infection
• The infant need careful assessment to determine their
true gestational age
4. Abnormal Presentation
A. Breech Presentation
Most fetuses are in 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.
• Types of Breech Presentation
– Complete - The buttocks are in place to come out first during delivery. The legs are straight up in front
of the body, with the feet near the head. This is the most common type of breech position.

– Frank - The buttocks are down near the birth canal. The knees are bent, and the feet are near the buttocks.
– Footling - One leg or both legs are stretched out below the buttocks. The leg or legs are in place to come
out first during delivery.
Types of breech presentation
• Breech presentation is more hazardous to a fetus than a
cephalic presentation, because there is higher risk of:
– Anoxia from a prolapsed cord
– Traumatic injury (intracranial hemorrhage or anoxia)
– Fracture of the spine or arm
• Dysfucntional labor
• Early rupture of the membranes because of the poor fit of
the presenting part
• The inevitable contraction of the fetal buttocks from the
cervical pressure often causes meconium to be extruded
to the amniotic fluid before birth.
• This unlike meconium staining that occurs because of
fetal anoxia, it is not a sign of fetal distress but is
expected from the buttock pressure
• Such meconium excretion can, however lead to
meconium aspirationif the infant enhales amniotic fluid.
Assessment
1. Fetal heart sounds usually are heard high in the
abdomen
2. Leopolds maneuver can reveal the presentation
• Causes of Breech Presentation
– Gestational age less than 40 weeks
– Abnormality in a fetus (anencephaly,hydrcephalus,
meningocele)
– Hydramnios that allows for free fetal movement
– Congenital anomaly of the uterus such as mid septum
that traps the fetus in breech presentation
– Any space occupying mass in the pelvis
– Pendulous abdomen
– Multiple gestation
• Birth Technique
– Vaginal delivery
• A woman is allowed to push after full dilatation is
achieved and the breech, trunk and and
shoulders are born.
• External rotation is allowed to occur to bring the
head into the best outlet diameter.
• Birth of the head is the most hazardous part. 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. Tentorial tears, which can cause gross motor
and mental incapacity or lethal damage to the fetus can
result.
• The infant who is born suddenly to reduce the duration of
cord compression may suffer an intracranial hemorrhage
• In contrast, the infant who is born gradually to reduce the
possibility of intracranial injury may suffer hypoxia.
2. Face Presentation
A fetal head presenting at a
different angle than expected is
termed asynclitism.
Ex. Face and brow
presentations
A face presentation is confirmed
by vaginal examination when the
nose, mouth or chin can be felt
as a presenting part.
• If the chin is anterior and the pelvic diameters are within
normal limits it may be possible for the infant to be born
without difficulty.
• If the chin is posterior, CS is the method of choice
• Babies born after a face presentation have a great deal of
facial edema
may be purple from ecchymotic bruising
lip edema is so severe
they may be transferred to the NICU for 24hours.
• Observe the infant closely for for a patent airway
• Gavage feeding may be necessary to allow them to
obtain enough fluid until they can suck effectively.
• 3. Brow Presentation
– rarest type of presentation
– it occurs in a multipara or a woman with relaxed
abdominal muscles
– results in obstructed labor
– Unless the presentation spontaneously corrects,
cesarean birth will be necessary
• Brow presentations also leave an infant with extreme
echymotic bruising on the face
• Transverse Lie
occurs in women with:
pendulous abdomen
uterine fibroid tumors
contraction of the of the pelvic brim
congenital abnormalities-uterus
hydramnios
• It may occur in infants with:
– Hydrocephalus that prevent engagement
– prematurity
– multiple gestation
– short umbilical cord
• Abnormal presentation can be confirmed by:
• Leopold’s maneuver
• Ultrasoud
• Inspection – ovoid of the uterus is horizontal

• Type of delivery - CS
5. Oversized Fetus (Macrosomia)
• It is a problem if the weight is more than 4000 to 4500g
(approx. 9 to 10lbs)
• 10% of all births
• Born to women who enter pregnancy with DM
• Also associated with multiparity bec each infant born to a
woman tends to be slightly heavier and larger than the
one born before.
• Fetal Pelvic disproportion
• Pelvimetry or ultrasound can be used to compare the size
of the fetus with the woman’s pelvic capacity.
• If the infant is so oversized, that cannot be born vaginally,
CS becomes the birth method of choice
• A large infant born vaginally, has a higher than normal risk
of:
– Cervical nerve palsy
– Diaphragmatic nerve injury
– Fractured clavicle due to shoulder dystocia
• A large infant born vaginally, has a higher than normal risk
of:
– Cervical nerve palsy
– Diaphragmatic nerve injury
– Fractured clavicle due to shoulder dystocia
• 6. Shoulder Dystocia
– The problem occurs at 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.
– This is hazardous to the to the woman because it can
result in cervical or vaginal tears
– It is hazardous to the fetus if the cord is compressed
between the fetal body and the pelvis
– The force of birth can result in a fractured clavicle or a
brachial plexus injury for the fetus
– The condition is suspected if the 2nd stage of labor is
prolonged, arrest of descent,
– When the head appears in the perineum (crowning) it
retracts instead of protruding with each contraction (a
turtle sign)
– Most apt to occur in women with diabetes, in
multiparas, and in post date pregnancies.
Thank You!!! :)