Problems With The Passenger

PROBLEMS WITH THE PASSENGER
PROLAPSE OF THE UMBILICAL CORD
- A loop of the umbilical cord slips down in front of the presenting fetal part
- May occur any time after the membranes rupture (assess FHR right after rupture
of membranes)
- May lead to cord compression --> fetal anoxia
Occurs most often with:

a. PROM
b. fetal presentation other than cephalic
c. placenta previa
d. intrauterine tumors
e. small fetus
f. CPD
g. hydramnios
h. multiple gestation
Management:
a. place a gloved hand in the vagina and manually elevate the fetal head off the cord
b. place the woman in a knee-chest or trendelenburg position (causes the fetal head
to fall back from the cord)
c. do not push any exposed cord back into the vagina (may lead to further
compression)
d. cover the exposed portion with a sterile saline compress to prevent drying
e. oxygen administration (for fetal oxygenation)
f. tocolytic (to reduce uterine contraction and pressure on the fetus)
g. if fully dilated: emergency birth
h. if not fully dilated: CS birth
i. Amnioinfusion: addition of a sterile fluid into the uterus to supplement the amniotic
fluid to prevent additional cord compression
- a sterile catheter is inserted through the cervix into the uterus after rupture
of the membranes, attached to intravenous tubing, and a solution of
warmed normal saline or lactated ringer’s solution is rapidly infused
- monitor FHR
- monitor maternal body temperature
MULTIPLE GESTATION
May cause:
a. anoxia to the second fetus (if shared placenta)
b. anemia and PIH
c. uterine dysfunction (from prolonged labor, overstretched uterus, abnormal
presentation)
d. hemorrhage/uterine atony
Management:
a. monitor FHR (because of increase risk of cord prolapse and abnormal
presentation)
b. cesarean delivery if all fetuses are not in vertex position
OCCIPITOPOSTERIOR POSITION (ROP or LOP)

- Occurs more frequently in women with android, anthropoid, or contracted pelves
May cause: Assessmnet:

a. prolonged labor a. confirmed by vaginal examination or
b. cord prolapse ultrasound
Management:
a. lying on the side opposite the fetal back or maintaining a hands-and-knees
position may help the fetus rotate
b. empty bladder every 2 hours (a full bladder impedes descent of the fetus)
c. cesarean birth if normal delivery is not possible
BREECH PRESENTATION
- Fetuses may be in breech presentation early in pregnancy, but turns to cephalic
by week 38
Causes:
a. less than 40 weeks
b. hydrocephalus
c. hydramnios
d. congenital anomaly of the uterus
e. mass/tumor in the uterus/placenta previa
f. pendulous abdomen
g. multiple gestation
May cause:
a. anoxia from prolapsed cord d. dysfunctional labor g. cord compression
b. traumatic injury to the head e. PROM after body has
c. fracture of the spine or arm f. meconium aspiration delivered
Assessment:
a. FHR is heard in the upper abdomen
b. vaginal examination and leopold’s maneuver determine the presentation
c. ultrasound confirms the presentation
Management:
a. closely monitor FHR and uterine contractions (for early detection of distress)
b. normal delivery:
- presenting part is supported by a sterile towel
- head is delivered by forceps
c. cesarean birth
Health education:
a. frank: legs extended at the level of the face for the first 2 – 3 days
b. footling: legs extended in footling position for the first few days
FACE PRESENTATION (CHIN OR MENTUM)
Causes:
a. ROP/LOP d. prematuriy
b. contracted pelvis/placenta previa e. hydramnios
c. relaxed uterus of a multipara f. fetal malformation
Assessment:
a. detected by leopold’s maneuver or vaginal examination
b. confirmed by ultrasonography
May cause:
a. prolonged labor (for posterior chin)
b. facial edema (including lip edema) and may be purple from ecchymotic bruising
- facial edema will disappear in few days
Management:
a. cesarean birth (for posterior chin)
b. gavage feeding until infant can suck effectively
c. NICU for 24 hours
BROW PRESENTATION (rare)
Causes: Management:
a. multipara a. cesarean section
b. relaxed abdominal muscles
c. ecchymotic bruising on the face
TRANSVERSE LIE
Causes:
a. pendulous abdomen
b. uterine tumors that obstruct the lower segment
c. hydramnios
d. congenital abnormalities of the uterus
e. hydrocephalus
f. prematurity
g. multiple gestation (second twin)
h. short umbilical cord
Assessment:
a. detected by leopold’s maneuver
b. confirmed by ultrasound
Management: Cesarean section
MACROSOMIA
- Fetus weighs more than 4000 g
Causes:
a. DM mothers
b. multiparity
May cause:
a. uterine dysfunction (because of overstretching of the myometrium)
b. fetal pelvic disproportion or uterine rupture because of wide shoulders
c. if vaginal delivery: because of shoulder dystocia:
- clavicle injury, brachial plexus injury, cervical nerve palsy, diaphragmatic
nerve injury
- vaginal or cervical tear
d. postpartal hemorrhage because of overstretched uterus

Problems With The Passenger

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Problems With The Passenger

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PROBLEMS WITH THE PASSENGER

PROLAPSE OF THE UMBILICAL CORD

Occurs most often with:

OCCIPITOPOSTERIOR POSITION (ROP or LOP)

May cause: Assessmnet:

FACE PRESENTATION (CHIN OR MENTUM)

BROW PRESENTATION (rare)

Management: Cesarean section

- Fetus weighs more than 4000 g

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