COLLEGE OF NURSING

Silliman University
Dumaguete City
C O M P L I C ATI O N S O F L AB O R & D E L I V E R Y
Main Topic: Complications of Labor & Delivery
Placement: Second Semester, Level III
Topic Description: This topic deals with common complications of labor and delivery; definition of terms and contributing factors.
Central Objectives: At the end of the 2 hours lecture & discussion, the learners will gain sufficient knowledge, develop beginning skills, and manifest positive
attitude towards determining the different complications of labor and delivery.
SPECIFIC
OBJECTIVES

CONTENT

TA

At the end of 1
hour lecture and
discussion, the
learners shall:
I.

Prayer
Almighty father, creator of all, you are the king of kings; we believe and trust in
you throughout eternity. Father god, we thank you for all experiences, lessons
we learned and the blessings you have given to us. We give thanks to the
gifts of life. We ask for forgiveness of our sins weve done against you, to my
brothers and sisters and to all. We dont desire to have a lighter burden but to
strengthen our body to carry the heave loads of life. All these we pray and ask
to you father God. Amen.

II. Introduction
Labor may start too early (before the 37th week of pregnancy) or may start
late (after the 41st to 42nd week of pregnancy). As a result, the health or life of the
fetus may be endangered. Labor may start too early or late when the woman or
fetus has a medical problem or the fetus is in an abnormal position.
No more than 10% of women deliver on their specified due date (usually
estimated to be about 40 weeks of pregnancy). About 50% of women deliver within
1 week (before or after), and almost 90% deliver within 2 weeks of the due date.

2
min.

T-L
ACTIVITIES

REFERENCES

EVALUATION

III. Nursing Process Overview

a. Define correctly
the terms
related to Labor
and Delivery at
75% level of
competency.
b. Determine
accurately the
different
complications
of Labor and
Delivery at 75%
level of
competency.
b.1. Identify
precisely the
complications
or problems
that are
related to
power/uterine
contraction at
75% level of
competency.

i. Assessment
You need do fetal and uterine monitoring in order to detect deviations
from normal in labor. Working with such apparatus involves explaining its
importance to parents, winning their cooperation, and using judgment in
reading the various patterns.
ii. Nursing diagnosis
Common nursing diagnosis specific to a woman experiencing a
complication during labor or birth refer to specific problems. Some
examples include:
fear related to uncertainty of pregnancy outcome
anxiety related to medical procedures and apparatus
necessary to ensure health of mother and fetus
fatigue related to loss of glucose stores through work
and duration of labor
risk for ineffective tissue perfusion related to excessive
loss of blood with complication of labor
risk for injury (maternal or fetal) related to effect on
mother and fetus of a labor complication and treatment
acquired
risk for injury (maternal or fetal) related to labor
involving a multiple-gestation pregnancy
anticipatory grieving related to nonviable monitoring
pattern of fetus
iii. Outcome identification and Planning
If a complication of labor occurs, identification of expected outcomes can
be difficult because the outcome that may occur is not what the woman
desires. Encouraging the couple to clarify their priorities is helpful.
Reminding the woman that her primary goal is really to have a healthy
baby may help her accept the change, including whatever interventions
are necessary to achieve her ultimate objectives.
iv. Implementation

5
min.

Interventions must be planned and performed efficiently and effectively,

based on the individual circumstances. Be certain to provide
psychological reassurance to accompany actions to fully safeguard both
the woman and her fetus.
v. Outcome Evaluation
Evaluation of client might reveal unhappiness, because not every woman
who experiences a deviation from the normal labor and birth will be able
to give birth to a healthy child. Some deviations will be too great. Some
interventions will not be maximally effective because of individual
circumstances. Some infants will die; a few women may be left unable to
bear future children. Evaluation may lead to a new analysis that the
couples chief need at that point is to grieve for the child or for a lifestyle
that can no longer be theirs. If the outcome is positive, evaluate the
couple for signs that they are able to begin interaction with the child after
their harrowing experience. Example of outcome achievement: Client
voices confidence that she can cope with the fear she feels about her
fetus welfare.
IV. Common complications of Labor and Delivery
3.1. Power
3.1.1 Ineffective Uterine Contraction
Uterine contractions are the basic force moving the fetus through the birth
canal. It happens because of the interplay of contractile hormones (adenosine
triphosphate, estrogen, and progesterone) and the influence of major electrolytes
such as calcium, sodium, and potassium, specific contractile protein (actin and
myosin), epinephrine and norepinephrine, oxytocin, and prostaglandins.
Abnormal contractions may occur which includes hypotonic contractions,
hypertonic contractions and uncoordinated contractions. These are ineffective
contraction which also results to ineffective labor.
There are methods in evaluating the uterine activity such as Electronic Uterine
Monitoring and Montevideo units. These will monitor the duration, strength, and
interval between contractions.

15
min.

Socialized
discussion
with the
use of
pictures.

Mosbys
Pocket
Dictionary of
Medicine,
Nursing &
Allied Helath ,
4th Ed.
Philippines:
2002
Potter, P. &
Perry
Fundamentals
of Nursing, 5th
Ed. Mosby: St.
Louis, 2001

Define or
discuss terms
at 75% level of
competency
included in a
10 item quiz.
State and
briefly define
or describe at
least 2 labor
and delivery
complications
on the
following, at
75% level of
competency
included in a
10 item quiz:
1. Power

3.1.1.1 Hypotonic Contractions

With hypotonic uterine contraction, the number of contraction is usually low or
infrequent (not increasing beyond two or three in a 10-minute period). The resting
tone of the uterus remains below 10mmHg, and the strength of contractions does
not rise above 25mmHg. Hypotonic contractions are most apt to occur during the
active phase of labor. They may occur when analgesia has been administered too
early (before cervical dilatation of 3 to 4 cm) or when bowel or bladder distention
prevents descent or firm engagement. They may occur in a uterus overstretched
by a multiple gestation, a larger-than-usual single fetus, or hydramnios, or in a
uterus lax from grand multiparity. Such contractions are not exceedingly painful,
because of the lack of intensity.
Hypotonic contractions increase the length of labor, because more of them are
necessary to achieve cervical dilatation. During the postpartal period, the uterus
can be exhausted from a long labor and may not continue to contract as
effectively, thus increasing the womans chance for postpartal hemorrhage. With
the cervix dilated for a long period, both the uterus and the fetus are at greater risk
for infection.
For these reason, after ultrasonic confirmation rules out cephalopelvic
disproportion, an oxytocin infusion to augment labor usually is started to
strengthen contractions and increase their effectiveness. Membranes may be
artificially ruptured (amniotomy) to further speed labor.
3.1.1.2 Hypertonic Contractions
Hypertonic uterine contractions are marked by an increase in resting one to
more than 15mmHg. However, the intensity of the contraction may be no stronger
than that associated with hypotonic contractions. Hypertonic contractions tend to
occur frequently; they are most commonly seen in the latent phase of labor.
Hypertonic contractions occur because the muscle fibers of the myometrium do
not repolarize after a contractions, thereby wiping it clean to accept a new
pacemaker stimulus. They are believed to occur because more than one
pacemaker is stimulating the contractions. Hypertonic contractions tend to be
painful, because the myometrium becomes tender from constant lack of relaxation
and resultant anoxia to uterine cells. The woman may become frustrated or

Cabbe, Niebyl
and Simpson.
Obstetrics
Normal &
Problem
Pregnancies,
3rd Ed.
Churchill
Livingstone
Inc.: USA,
1996
Norak, J.C. &
Broom, B.C.
Maternal &
Child Health,
5th Ed. Mosby:
USA, 1996

2. Passenger
3. Passage
4. Placental
Anomalies
5. Cord
Anomalies

disappointed with the breathing exercises for childbirth, because they are
ineffective in achieving pain relief.
The lack of relaxation between contractions does not allow optimal uterine
artery filling, which may lead to fetal anoxia early in the latent phase of labor. Any
woman whose pain seems out of proportion to the quality of her contractions
should have both a uterine and fetal external monitor applied for at least 15-minute
interval to ensure the resting phase of the contractions is adequate and the fetal
pattern is not showing late deceleration. Both the woman and her support person
need to understand that, although the contractions are strong, they are, in reality,
ineffective and are not achieving cervical dilatation.
3.1.1.3 Uncoordinated Contractions
Normally, all contractions are initiated at one pacemaker point in the uterus. A
contraction sweeps down over the uterus, encircling it; repolarization occurs, a low
resting tone is achieved, and another pacemaker-activated contraction begins.
With uncoordinated contractions, more than one pacemaker may be initiating
contractions, or receptor points in the myometrium are acting independently of the
pacemaker. Uncoordinated contractions may occur so closely together that they
do not allow good cotyledon filling. Because they occur so erratically (one on top
of another and then a long period without any), it may be difficult for the woman to
rest or use breathing exercises between contractions.
Applying a fetal and uterine external monitor and assessing the rate, pattern,
resting tone, and fetal response to contractions for at least a 15-minute interval (a
longer time may be necessary to show the disorganized pattern in early labor)
reveals the abnormal pattern. Oxytocin administration maybe helpful in
uncoordinated labor to stimulate a more effective and consistent patter of
contractions with a better, lower resting tone.
3.1.2 Dysfunctional Labor
As stated previously, dysfunctional or ineffective labor can occur at any point
in labor. Regardless of when dysfunctional labor occurs, the effect on the woman
and her support person will be the same: anxiety, fear, or discouragement.
3.1.2.1. Dysfunction at the First Stage of Labor.

The major dysfunction that can occur in the first stage of labor is a prolonged
latent phase. A prolonged latent phase, as defined by Friedman, is a latent phase
that is longer than 20 hours in a nullipara and 14 hours in a multipara. This may
occur if the cervix is not ripe at the beginning of labor and time has to be spent
getting truly ready for labor. It may occur if there is excessive use of an analgesic
early in labor. With a prolonged latent phase, the uterus tends to be in a
hypertonic state. Relaxation between contractions is inadequate, and the
contractions are only mild (less than 15mmHg on a monitor printout) and
therefore ineffective. One segment of the uterus may contract with more fore than
another segment.
A protracted active phase is usually associated with cephalopelvic
disproportion (CPD) or fetal malposition, although it may reflect ineffective
myometrial activity. This phase is prolonged if cervical dilatation does not occur at
a rate of 1.2cm/h or more in a nullipara or 1.5cm/h or more in a multipara or if the
active phase lasts over 12 hours in a primigravida, 6 hours in multigravida. If the
cause of the delay in dilatation is fetal malposition or CPD, cesarean birth may be
necessary.
A deceleration phase has become prolonged when it extends beyond 3 hours
in a nullipara and 1 hour in a multipara. Prolonged deceleration phase most often
results from abnormal fetal head position. A cesarean birth is frequently required.
A secondary arrest of dilatation has occurred when there is no progress in
cervical dilatation for more than 2 hours.
3.1.2.2 Dysfuncional at the Second Stage of Labor.
Prolonged Descent. Prolonged descent of the fetus occurs if the rate of
descent is less than 1.0cm/h in a nullipara or less than 2.0cm/h in a multipara.
With both a prolonged active phase of dilatation and prolonged descent,
contractions have been of good quality and proper duration, and effacement and
beginning dilatation have occurred. But then, the contractions become infrequent
and of poor quality, and dilatation stops. If everything except the suddenly faulty
contractions is normal (CPD or poor fetal presentation has been ruled out by
sonogram), then rest and fluid intake, as advocated for hypertonic contractions,
also apply. If membranes have not ruptured, rupturing them at this point may be
helpful. Intravenous oxytocin may be used to induce the uterus to contract

effectively. A semi-Fowlers position, squatting, kneeling, or more effective

pushing may speed descent.
Arrest of descent results when no descent has occurred for 1 hour in a
multipara, or 2 hours in a nullipara. Failure of descent has occurred when
expected descent of the fetus does not begin (engagement or movement beyond
0 station has not occurred).
3.1.3 Contraction Rings
Two types of contraction rings can occur in a dysfunctional labor. A simple type
is a constriction ring, which can occur at any point in the myometrium and at any
time during labor. The most common is a pathologic retraction ring (Bandls ring)
that occurs at the juncture of the upper and lower uterine segments. This is a
warning sign that severe dysfunctional labor is occurring. The ring usually
appears during the second stage of labor as a horizontal indentation across the
abdomen. It is formed by excessive retraction of the upper uterine segment; the
uterine myometrium is much thicker above than below the ring.
When a pathologic retraction ring occurs in early labor, it is usually from
uncoordinated contractions. In the pelvic division of labor, it is usually caused by
obstetric manipulation or the result of the administration of oxytocin. The fetus is
gripped by the retraction ring and cannot advance beyond point. The undelivered
placenta will also be held at that point.
Most likely, a cesarean birth will be necessary to ensure safe birth of the fetus.
Manual removal of the placenta under general anesthesia may be required if the
retraction ring does not allow the placenta to be delivered.
3.1.4 Precipitate Labor
Precipitate and birth occur when uterine contractions are so strong that the
woman gives birth with only few rapidly occurring contractions. It is often defined
as a labor that is completed in fewer than 3 hours. Such rapid labor is likely to
occur with multiparity or may follow induction of labor by oxytocin or amniotomy.
Contractions may be so forceful they lead to premature separation of the
placenta, placing the mother and fetus at risk for hemorrhage. Rapid labor also
poses a risk to the fetus because subdural hemorrhage may result from the
sudden release of pressure on the head. The woman may sustain lacerations of

the birth canal from the forceful birth. She also can feel overwhelmed by the
speed of labor.
A precipitate labor can be predicted from a labor graph if, during the active
phase of dilatation, the rate is greater than 5cm/h (1cm every12 minutes) in a
nullipara and more than 10cm/h (1 cm every 6 minutes) in a multipara. If this is
occurring, a tocolytic may be administered to reduce the force and frequency of
contractions.
3.1.5 Uterine Rupture
Rupture of the uterus during labor, although rare (occurring only in about1 in
1500 births), is always a possibility. A uterus ruptures when it undergoes more
strain than it is capable of sustaining. Rupture occurs most commonly when a
vertical scar from a previous cesarean birth or hysterectomy repair tears.
Contributing factors may include prolonged labor, faulty presentation, multiple
gestation, unwise use of oxytocin, obstructed labor, and traumatic maneuvers
using forceps or traction. Uterine rupture accounts for as many as 5% of all
maternal deaths. When it occurs, fetal death will occur unless immediate
cesarean birth can be accomplished. In these instances, fetal outcome can be
optimal.
Impending rupture is preceded by a pathologic retraction ring (an indention is
apparent across the abdomen over the uterus) and strong uterine contractions
without any cervical dilatation. To prevent rupture when these symptoms are
present, anticipate the need for an immediate cesarean birth. If a uterus should
rupture, the woman experiences a sudden, severe pain during a strong labor
contraction. She may report a tearing sensation. Rupture can be complete,
going through endometrium, myometrium, and peritoneum, or incomplete, leaving
the peritoneum intact. With a complete rupture, uterine contractions will stop.
There is hemorrhage from the torn uterus into the abdominal cavity and possibly
into the vagina. Signs of shock begin, including rapid, weak pulse, falling blood
pressure, cold and clammy skin, and dilatation of the nostrils from air hunger. The
womans abdomen will change in contour. Two distinct swellings will be visible:
the retracted uterus and the extrauterine fetus. Fetal heart sounds become
absent. If the rupture is incomplete, the signs are less evident than in complete
rupture. With an incomplete rupture, the woman may experience only a localized
tenderness and a persistent aching pain over the area of the lower segment. Fetal

heart sounds, a lack of contractions. And the womans vital signs will gradually
reveal fetal and maternal distress.
It is inadvisable for a woman to conceive again after a rupture of the uterus
unless it occurred in the inactive lower segment. Therefore, the physician, with
consent, may perform a hysterectomy (removal of the damaged uterus) or tubal
ligation at the time of the laparostomy. Both procedures result in loss of
childbearing ability.
3.1.6 Uterine Inversion

b.2. Discuss
correctly the
common fetal
causes of the
LRDR
complications
at 75% level of
competency.

Uterine inversion is a rare phenomenon, occurring in about 1 in 15,000 births,

in which the uterus turns inside out. It may occur after the birth of the infant if
traction is applied to the umbilical cord to remove the placenta or if pressure is
applied to the uterine fundus when the uterus is not contracted. It may also occur
when the placenta attaches at the fundus, so that during birth, the passage of the
fetus pulls the fundus down.
Inversion occurs in various degrees. The inverted fundus may lie within the
uterine cavity or the vagina or, as in total inversion, protrude from the vagina.
When an inversion occurs, a large amount of blood suddenly gushes from the
vagina. The fundus is not palpable in the abdomen. If the loss of blood continues
unchecked for more than a few minutes, the woman will immediately show signs
of blood loss: hypotension, dizziness, paleness, or diaphoresis. Since the uterus
is not contracted in this position, bleeding continues. A woman could
exsanguinate within a period as short as 10 minutes.
Never attempt to replace the inversion because handling may increase the
bleeding. Never attempt to remove the placenta if it is still attached, because this
will only create a larger surface area for bleeding. In addition, administering an
oxytocic drug only compounds the inversion. An intravenous fluid line needs to be
started, if one is not already present (if doing this, use a large-gauge needle
because blood will need to be replaced).
3.1.7 Amniotic Fluid Embolism
Amniotic fluid embolism occurs when amniotic fluid is forced into an open
maternal uterine blood sinus through some defect in the membranes or after
membrane rupture or partial premature separation of the placenta. Previously, it

was thought that particles such as meconium or shed fetal skin cells in the
amniotic fluid entered the maternal circulation and reached the lungs as small
emboli. Now, it is recognized that a humoral or anaphylactoid response is the
more likely cause. This condition may occur during labor or in the postpartal
period. The incidence is no more than 1 in 8000 births; it is not preventable
because it cannot be predicted. Possible risk factors include oxytocin
administration, abruption placentae, and hydramnios.
The clinical picture is dramatic. The woman, in strong labor, sits up suddenly
and grasps her chest because of sharp pain and inability to breathe (secondary to
pulmonary artery constriction). She become pale and then turns the typical bluish
gray associated with pulmonary embolism and lack of blood flow to the lungs. The
immediate management is oxygen administration by facemask or cannula. Within
minutes, the woman will need CPR. CPR may be ineffective, because these
procedures (inflating the lungs massaging the heart) do not relieve the pulmonary
constriction. Therefore, blood still cannot circulate to the lungs. Death may occur
in minutes.
The womans prognosis depends on the size of the embolism and the skill and
speed of emergency interventions. Even if she survives the initial insult, the risk
for disseminated intravascular coagulation (DIC) developing is high, further
compounding her condition. In this event, she will need continued management
that includes endotracheal intubation to maintain pulmonary function and therapy
with fibrinogen to counteract DIC. The woman most likely will be transferred to an
ICU. The prognosis for the fetus is guarded, because reduced placental perfusion
results from the severe drop in maternal blood pressure. Labor often begins or the
fetus is delivered immediately by cesarean birth.
15
min.
3.2 Passenger
3.2.1 Umbilical Prolapse
A complication wherein the umbilical cord of the fetus slips down in front of the
presenting part. This condition happens when the presenting part is not well fitted
into the cervix after the bag of water ruptures. In addition, this condition often
happens when the fetus is in breech presentation wherein the cervix is not well
blocked by the presenting part.

Socialized
discussion

Lowdermilk,
Perry, &
Bobak.
Maternal
Nursing, 5th
Ed. Mosby
Inc.: USA,
1999

The conditions that most often results to Umbilical Cord Prolapse are the
following:
1. PROM or Premature Rupture Of Membrane
This condition is characterized by the spontaneous rupture of amniotic
sac before the onset of labor.
2. Fetal presentation other than cephalic such as breech presentation.
In Breech presentation (Frank and Footling), the presenting part does
not fit tightly in the cervix thus leaving a space for the umbilical cord to
slip down.
3. Placenta previa
In this condition, the placenta is abnormally implanted in the uterus thus
covering the internal os of the uterine cervix.
Complete previa this refers to a placenta that has grown and
completely covers the internal cervical os.
Low-lying placenta refers to a placenta that is just within the lower
uterine segment.
Partial or Marginal previa refers to a placenta that partially covers
the internal os.
4. Intrauterine tumors
The location of intrauterine tumors is important. If the tumor is located in
such a way that it prevents the presenting part to fit tightly in the cervix ,
then cord prolapse is most likely to happen.
5. Relatively small fetus
Even if the pregnant mother has an average birth canal, if her baby is
small, then there will be enough room for the cord to slip down the cervix
and eventually will be visible in the vaginal.
6. CPD or Cephalopelvic Disproportion
In this condition, the babys head is too large or the mothers birth canal
is too small to permit normal labor or birth.
Relative CPD the size of the babys head is within normal limits but
larger than average or the size of the mothers birth
canal is within normal limits but smaller than the
average.

Absolute CPD the babys head is abnormally enlarged or the

mothers birth canal is abnormally contracted.
7. Hydramnios
This is a condition wherein the amniotic sac contains excess or extra
volume of amniotic fluid.
8. Multiple gestation
Multiple fetuses increases the risk of cord prolapse after the rupture of
membranes and abnormal fetal presentations may also occur.
Cord prolapse in this situation usually occurs after the first baby is
delivered.
3.2.2 Multiple Gestation
The possibilities of cord entanglement, premature separation of the placenta,
abnormal fetal presentation, uterine dysfunction, and overstretched uterus are
increased during multiple gestations since there are more than two fetuses in the
womb unless they are Dichorionic Diamniotic (separate placentae). Cesarean
sectioning is a primary option because of the risk that the second fetus will
experience anoxia.
3.2.3 Presentation, Position, or Size
1. Occipitoposterior position
A presenting head, posteriorly positioned, does not fit tightly
compared to a presenting head which is anteriorly positioned. This
position increases the risk of umbilical cord prolapse. Mothers delivering
their babies with this position experience pressure and pain in their
lower back due to sacral nerve compression.
2. Breech presentation
The fetus buttocks along with the legs take up more space
compared to the fetal head which has the widest single diameter.
Meconium staining in the amniotic fluid while the fetus is still inside the
uterus occurs due to the unavoidable contraction of the fetal buttocks
into the cervix. Compared to cephalic presentation, breech presentation

allows the following complications to occur:

b.3. Efficiently
identify most of
the
passage/pelvic
complications
at 75% level of
competency.

a. Anoxia a result of cord prolapse.

b. Traumatic injury to the aftercoming head such as intracranial
hemorrhage.
c. Fracture spine or arm of the fetus.
d. Dysfuctional labor or ineffective labor
e. Early rupture of membranes because the presenting part is
poorly fitted to the cervix.
3. Face presentation (chin or mentum)
In this type of presentation, the head diameter of the fetus presenting
to the pelvis is often too large for birth to proceed. Babies born after a
face presentation have a great deal of facial edema and may be purple
from ecchymotic bruising.
4. Brow presentation
The rarest of all presentations. This presentation almost always
results in obstructed labor because the head comes jammed in the brim
of the pelvis as the occipitomental diameter presents. This type of
presentation, like face presentation, also leaves the infant with extreme
ecchymotic bruising on the face.
5. Transverse Lie
In this position, the membranes rupture at the beginning of labor. The
umbilical cord and arm may prolapse and the shoulder may obstruct the
cervix since there is no firm presenting part. The mature fetus cannot be
delivered vaginally thus; mothers opt to undergo cesarean section.
6. Oversized fetus / Macrosomia
An oversized fetus may cause uterine dysfunction during labor or at
birth because of overstretching of the myometrium, fetal pelvic
disproportion, or even uterine rupture from obstruction. Mothers
delivering oversized fetuses have increased risk of hemorrhage due to
overly distended uterus which may not contract easily and readily.

7. Shoulder Dystocia
This condition is hazardous to both the mother and fetus because it
can possibly result to cervical or vaginal tearing and cord compression
which is fatal respectively. The force of birth or contraction can result to
fractured clavicle or brachial plexus injury for the fetus.
8. Fetal anomalies
There are a couple of fetal anomalies which can complicate the
birthing process since the presenting part does not engage well in the
cervix. Among these fetal anomalies are the hydrocephalus and
anencephaly.
3.3 Passage
3.3.1 Inlet Contraction
Inlet contraction is the narrowing of the anteroposterior diameter to less than
11 cm, or of the transverse diameter to 12 cm or less. Inlet contraction is usually
caused by rickets in early life or by an inherited small pelvis. Rickets is rare in
developed countries but can occur among immigrants who were raised in an
underdeveloped country where milk supplies were not plentiful. In primigravidas,
the fetal head normally engages between weeks 36 to 38 of pregnancy. If this
occurs before labor begins, it is a proof that the pelvic inlet is adequate. Following
the general rule that what goes in, comes out, a head that engages or proves it
fits into the pelvic brim will probably also be able to pass through the midpelvic
and through the outlet.
In primigravidas, if engagement does not occur, then either a fetal abnormality
(larger-than-usual head) or a pelvic abnormality (smaller-than-the-usual) should
be suspected. On the other hand, engagement does not occur in multigravidas
until labor begins because previous birth of a full term infant is a proof that their
birth canals are adequate. Every primigravidas should have pelvic measurements
taken and recorded before week 24 of pregnancy so that birth decision can be
made with the assumption that the fetus will be of average size.
The treatment goal is to allow the natural forces of labor to push the biparietal
diameter of the fetal head beyond the potential interspinous obstruction. Although

10
min.

Lecture
discussion

Elizabeth Jean
Dickason, etal.
MaternalInfant Nursing
Care, 3rd Ed.
Mosby:
London, 1998

forceps may be used, they cause difficulty because pulling on the head destroys
flexion, and the space is further diminished. A bulging perineum and crowning
indicate that the obstruction has been passed.
b.4. Proficiently
determine the
different
placental
anomalies at
75% level of
competency.

3.3.2 Outlet Contraction

The interischial tuberous diameter of less than 8 cm constitutes an outlet
contracture. Outlet and midpelvic contractures frequently occur simultaneously.
Whether vaginal birth can occur depends on the womans interischial tuberous
diameter and the fetal posteriosagittal diameter. This measurement is easy to
make during prenatal visit, so the narrow diameter can be anticipated before labor
begins. It is also easily reassessed during labor since you already have the
baseline data during the prenatal visits.
3.3.3 Trial Labor
If a woman has a borderline or just adequate inlet measurement and the
fetal lie and position is good, her physician may allow her a trial labor to
determine whether the labor can progress normally. A trial labor continues as long
as descent of the presenting part and dilatation of the cervix are occurring.
Our nursing responsibilities include the monitoring of fetal heart sounds and
uterine contractions continuously, if possible, during this time. Urge the woman to
void every 2 hours so that her urinary bladder is as empty as possible, allowing
the fetal head to use all the space available. After rupture of the membranes,
assess FHR carefully; if the fetal head is still high, there is an increased danger of
prolapsed cord and anoxia in the fetus. If after a definite period (6 to 12 hours)
adequate progress in labor cannot be documented, or if at any time fetal distress
occurs, the woman will be scheduled for a cesarean birth.
Reassure the woman and her support person that a cesarean birth is an
alternative, not an inferior, method of birth. In this instance, because labor is not
progressing, it is the method of choice, because it will allow them to achieve their
goal of a healthy mother and healthy child.
3.3.4 External Cephalic Version
External cephalic version is the turning of the fetus from a breech to a cephalic

position before birth. It may be done as early as 34 to 35 weeks, although the

usual time is 37 to 38 weeks of pregnancy. For the procedure, FHR and possibly
ultrasound are recorded continuously. A tocolytic agent may be administered to
help relax the uterus. The breech and vertex of the fetus are located and grasped
transabdominally by the examiners hands on the womans abdomen. Gentle
pressure is then exerted to rotate the fetus in a forward direction to a cephalic lie.
The use of external version can decrease the number of cesarean births
necessary from breech presentations. Contraindication to the procedure include
multiple gestation, severe oligohydramnios, contraindications to vaginal birth, a
cord that wraps around the neck, and unexplained third-trimester bleeding, which
might be placenta previa. External version can be uncomfortable for the woman
because of the feeling of pressure. Women who are Rh negative should receive
Rh immunoglobulin after the procedure in case minimal bleeding occurs.
3.4 Placental Anomalies
3.4.1 Placenta Succenturiata

b.5. accurately
explain the two
cord anomalies
at 75% level of
competency.

Placenta Succenturiata has one or more accessory lobes connected to the

main placenta by blood. However, it is important that it be recognized, because
the small lobes may be retained in the uterus after birth, leading to severe
maternal hemorrhage. On inspection, the placenta appears torn at the edge of the
placenta. The remaining lobes must be removed from the uterus manually to
prevent maternal hemorrhage from poor uterine contraction.
3.4.2 Placenta Circumvallata
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. They end abruptly at the point where the
chorion folds back onto the surface, however. Although no abnormalities are
associated with this type of placenta, its presence should be noted. There is an
increased risk of repeated, small prenatal hemorrhages resulting in preterm birth.
There also is an increased risk of retained placenta leading to postpartum

5
min.

Socialized
discussion

Pillitteri, Adele.
Maternal &
Child Health
Nursing, 5th
Ed. Lippincot
Williams &
Wilkins:
London, 2007.

hemorrhage.
3.4.3 Battledore Placenta
Battledore placenta is when the cord inserts at the placental margin rather
than in the center of the placenta as with normal insertion. This anomaly is rare
and has no known clinical significance.
3.4.4 Velamentous Insertion of the Cord
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. This form of cord insertion is most
frequently found with multiple gestation. Because it may be associated with fetal
anomalies, the newborn should be examined carefully.
3.4.5 Vasa Previa
In vasa previa, the umbilical vessels of a velamentous cord insertion cross the
cervical os and therefore deliver before the fetus. The vessels may tear with
cervical dilatation, just as a placenta previa may tear. Before inserting any
instrument such as an internal fetal monitor, structures should be identified to
prevent accidental tearing of a vasa previa. Tearing would result in sudden fetal
blood loss. If sudden, painless bleeding occurs with the beginning of cervical
dilatation, vasa previa should be suspected. It can be confirmed by sonography. If
vasa previa is identified, the infant needs to be born by cesarean birth.
3.4.6 Placenta Accreta
Placenta Accreta is an unusually deep attachment of the placenta to the
uterine myometrium. The placenta will not loosen and deliver. Attempts to remove
it manually may lead to extreme hemorrhage because of the deep attachment.
Hysterectomy or treatment with methotrexate to destroy the still-attached tissue
may be necessary. Placenta accrete is the result of partial or total absence of the
deciduas basalis, which allows the placental villi to attach to the myometrium.
3

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Pillitteri, Adele.
Maternal &

3.5 Cord Anomalies

min.

3.5.1 Two-vessel Cord

Fetuses with only two vessels, instead of having three (1 vein and 2 arteries),
needs to be carefully observed for other anomalies during the newborn period
and later in infancy. Having only 2 blood vessels instead of 3 is associated with
congenital heart and kidney anomalies.
3.5.2 Unusual Cord Length
Unusually short umbilical cord length can result to premature separation of the
placenta and abnormal fetal lie.
III. Evaluation

5
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discussion

Child Health
Nursing, 5th
Ed. Lippincot
Williams &
Wilkins:
London, 2007.

SILLIMAN UNIVERSITY
COLLEGE OF NURSING
Dumaguete City

NURSING CARE MANAGEMENT 102

RESOURCE UNIT ON COMPLICATIONS OF LABOR AND DELIVERY

Submitted By:
Student Nurses:
Paul Jasper Sinda
Sheena Torremocha
Submitted To:
Ms. Dove Christian Sumagang R.N.

Clinical Instructor
LRDR Rotation

References:
Cabbe, Niebyl and Simpson. Obstetrics Normal & Problem Pregnancies, 3rd Ed. Churchill Livingstone Inc.: USA, 1996
Elizabeth Jean Dickason, et al. Maternal-Infant Nursing Care, 3rd Ed. Mosby: London, 1998
Lowdermilk, Perry, & Bobak. Maternal Nursing, 5th Ed. Mosby Inc.: USA, 1999
Mosbys Pocket Dictionary of Medicine, Nursing & Allied Health, 4th Ed. Philippines: 2002
Norak, J.C. & Broom, B.C. Maternal & Child Health, 5th Ed. Mosby: USA, 1996
Pillitteri, Adele. Maternal & Child Health Nursing, 5th Ed. Lippincot Williams & Wilkins: London, 2007.
Potter, P. & Perry Fundamentals of Nursing, 5th Ed. Mosby: St. Louis, 2001