3.

FORELYING

: cord can be felt on VE, but cannot be seen,

usually contained within intact membranes,
PROBLEMS WITH THE 5 P'S OF PREGNANCY the cord lies in the presenting part.

S/Sx:

PROBLEM WITH THE PASSENGER 1. cord is protruding from vagina

2. cord can be palpated in the vagina or cervix
I. UMBILICAL CORD PROLAPSE (UCP)
3. fetal distress/anoxia/bradycardia
: is a well-known obstetric emergency in which
MANAGEMENT:
the umbilical cord passes through the cervix
at the same time as or in advance of the fetal 1. knee chest or T-position
presenting part.

CAUSES:

1. breech presentation
2. transverse lie
3. unengaged presenting part
4. hydramnios
2. 02 – prevent fetal hypoxia
5. small fetus
3. push presenting part upward
TYPES: 4. apply moistened sterile towel
5. delivery ASAP Prepare for emergency
1. COMPLETE
delivery.
: the cord can be felt on vaginal examination  full dilated cervix = deliver the infant
and can be seen in the vaginal canal quickly (possibly with forceps)
membranes are ruptured. Changes in the FHT  incomplete dilation = CS
are evident.

2. OCCULT
II. PROBLEMS WITH PRESENTATION &POSITION OR
: Cord cannot be felt on VE between the SIZE FETAL PRESENTATION
presenting part and the maternal pelvis.
1. FETAL PRESENTATION - relationship of
Membranes can be intact or ruptured
presenting part to the mother’s cervix

A. CEPHALIC – most ideal presentation

TYPES: 2. SIZE

 VERTEX A. MACROSOMIA
» most common
: newborn with an excessive birth weight
» fetal head fully flexed
: A diagnosis of fetal macrosomia can be made
» sub-occipitobregmatic diameter is the
only by measuring birth weight after delivery
presenting part.
*the condition is confirmed only
 Military
retrospectively = after delivery of the
» fetal head is in neutral position
neonate
occipitofrontal diameter is presenting
 Brow Factors associated with fetal macrosomia:
» fetal head is partly extended
 genetics
 Face
 duration of gestation
» poor flexion
 presence of gestational diabetes
» complete extension of all body parts
 class A, B, and C diabetes mellitus.
B. BREECH  racial and ethnic
 gender – male typically weigh more
DISADVANTAGES:

 less effective in dilating cervix

 fetal head is the last part to come out 3. FETAL ANOMALIES / CONGENITAL ANOMALIES

VARIATIONS: : Fetal malformation or abnormal development

: caused by problems during the fetus's
 incomplete
development before birth
 complete
 frank CONDITIONS DURING PREGNANCY THAT AFFECT
 footling THE BABY
» single footling
a. Certain illnesses during pregnancy,
» double footling
particularly during the first nine weeks
c. SHOULDER PRESENTATION - shoulders is in
» cytomegalovirus, chicken pox or rubella
transverse lie
b. Chronic maternal condition

» diabetes, hypertension, autoimmune d.

c. Alcohol consumption

» fetal alcohol spectrum disorders

d. Eating raw or uncooked foods during : safest type of delivery for mother and baby is
pregnancy foods. a caesarean

e. Certain medications CAUSES:

1. Large baby due to:

» Hereditary factors
III. FETAL DISTRESS
» Diabetes
: refers to the presence of signs in 2. Post maturity (still pregnant after due date
a pregnant woman before or during childbirth has passed)
that suggest that the fetus may not be well 3. Multiparity (not the first pregnancy)
4. Abnormal fetal positions
CAUSES:
5. Small Pelvis
1. Breathing problems 6. Abnormally shaped pelvis
2. Abnormal position and presentation of the
MANAGEMENT:
fetus
3. Multiple births 1. evaluate pelvic diameters
4. Shoulder dystocia 2. continue labor with careful monitoring
5. Umbilical cord prolapse 3. perform assisted vaginal or caesarean birth
6. Nuchal cord
7. Placental abruption
8. Premature closure of the fetal ductus II. DYSTOCIA
arteriosus
: difficult labor or abnormally slow progress
9. Uterine rupture
of labor
10. Intrahepatic cholestasis of pregnancy
: OTHER TERMS = “dysfunctional labor” /
=a liver disorder during pregnancy
“failure to progress” / CPD

1. SHOULDER DYSTOCIA

PROBLEMS WITH THE PASSAGE (PELVIC : is a specific case of dystocia whereby after
STRUCTURE) the delivery of the head, the
I. CEPHALOPELVIC DISPROPORTION (CPD) anterior shoulder of the infant cannot pass
below, or requires significant manipulation to
: occurs when a baby’s head or body is too
pass below the pubic symphysis
large to fit through the mother’s pelvis
: diagnosed when the shoulders fail to deliver
: rare, but many cases of “failure to progress”
shortly after the fetal head
during labor are given a diagnosis of CPD
: an obstetric emergency = fetal demise can Characteristics: uterine contractions that are
occur if the infant is not delivered inadequate
=compression of the umbilical cord within
CAUSES:
the birth canal
a. early analgesia
b. bladder or bladder distention
PROBLEMS WITH THE POWERS (UTERINE c. multiple gestation

CONTRACTIONS) d. large fetus

e. hydramnios
CONTRACTION
f. grandmultiparity
: OBSTETRICS = motion of the uterus as part of
TREATMENT
the process of childbirth
: IN GENERAL = one condition that releases the a. oxytocin & amniotomy
hormone oxytocin into the body b. CS
: become longer as labor intensifies

II. CONTRACTION'S RING-TONIC / BANDL’S RING

I. INEFFECTIVE UTERINE FORCE
: due to obstructed labor
1. HYPERTONIC CONTRACTIONS
PATHOLOGIC ANATOMY OF THE UTERUS
OCCURRENCE: Latent Phase
1. There is a gradual increase in intensity,
CHARACTERISTICS: duration and frequency of uterine
contraction
a. contractions that are frequent, strong but
2. The relaxation phase becomes less and less
uncoordinated
3. ultimately a state of tonic contraction
b. contractions that are ineffective in
develops
accomplishing cervical effacement &
4. Retraction, however continues
dilatation
5. The lower segment already thinned by
TREATMENT: circumferential dilatation in the first stage,
elongates and becomes progressively thinner
a. rest & sedation
to accommodate the fetus driven from the
b. fetal monitoring
upper segment
2. HYPOTONIC CONTRACTIONS

Occurrence: Active Phase

III. PRECIPITATE LABOR AND BIRTH EPIDEMIOLOGY:

: refers to a delivery which results after an  risk = 1 per 625 women who chose repeat
unusually rapid labor (less than three hours) cesarean without labor
and culminates in the rapid, spontaneous  1 per 192 women who went into labor and
expulsion of the infant tried for VBAC
: Delivery often occurs without the benefit of  1 per 129 for those who had their labor
asepsis induced without prostaglandins
 1 per 41 when prostaglandin medications
PREDISPOSING FACTORS OF PRECIPITATE
were used for induction
DELIVERY:
 When uterus ruptured = 1 in 18 babies died,
1. Multiparity and 1 in 23 of the women required a
2. history of rapid labor hysterectomy
3. premature or small fetus
CAUSES AND FACTORS:
4. large bony pelvis
1. previous surgery on the uterus
RISKS:
2. Prior classical cesareans, where the incision
1. perineal lacerations is near the top of the uterus
2. haemorrhage 3. prior removal of fibroid tumors
3. cerebral trauma 4. any other uterine surgery that went through
the full depth of the muscular portion of the
MANAGEMENT:
uterus,
4. fetal monitoring 5. multiple (three or more) prior low
5. analgesia transverse cesareans
6. assess for birth injury 6. having had more than five full-term
7. assess for cervical, vaginal, perineal pregnancies
lacerations 7. having an overdistended uterus (as with
twins or other multiples),
8. abnormal positions of the baby such as
IV. UTERINE RUPTURE transverse lie
9. the use of Pitocin and other labor-inducing
: is one of the most feared complications of
medications like prostaglandins
pregnancy
: the fetus, placenta, and a lot of blood
extruding into the mother's abdomen
: from a weak spot in the uterine wall or
uterus scar
CLINICAL PRESENTATION: 4. should be scheduled for cesarean usually
between 36 and 39 weeks' gestation
1. Most uterine ruptures occur without
symptoms and do not cause problems for the
mother or fetus
v. INVERSION OF THE UTERUS
2. this mild type is only noticed when surgery is
required for other reasons. INCIDENCE: 1 out of 2000
3. In the most severe form the laceration is
CAUSES:
large or cuts across the uterine blood vessels
4. The mother may hemorrhage and require a 1. Mismanagement of 3rd stage
blood transfusion 2. Placenta accreta
5. The uterus may not be repairable and must be 3. Congenital predisposition
surgically removed (hysterectomy) 4. Fundal implantation of placenta
6. Many women will be advised not to get
pregnant again, due to the risk of repeated
rupture : In complete inversions once the fundus
7. The baby may not survive passes through the cervix, the cervical
8. The mother's life cannot be saved tissues function as a constricting band and
edema rapidly forms. The prolapsed mass
SIGNS OF UTERINE RUPTURE:
then progressively enlarges and increasingly
1. severe, localized pain obstructs venous and finally arterial flow,
2. abnormalities of the fetal heart rate contributing to the edema.
3. vaginal bleeding : Potentianlly life threatening complication of
4. the vaginal examination may show that the childbirth
baby is not as low in the birth canal as he had : Almost all cases occur after delivery/
been earlier. CSection

PREVENTION AND TREATMENT CLASSIFICATION:

1. Some uterine ruptures occur before labor 1. 1ST DEGREE – inverted fundus up to the cervix
and are considered unpreventable
2. 2nd degree – body of uterus protrudes
2. Sudden severe abdominal pain in later
through cervix into vagina
pregnancy should be reported
3. Women with risk factors ( prior classical 3. 3rd degree – prolapse of inverted uterus
cesareans, deep fibroid excisions, and other outside vulva
major uterine surgeries ) should not attempt
labor
CLINICAL PRESENTATION: » Fundus hooked up and resutured

1. Abdominal pain PREVENTION:

2. Post-partum haemorrhage
1. Controlled cord traction – avoid excessive
3. Sudden collapse – degree of shock may be
traction
inconsistent with the amount of blood loss
2. Wait signs of placental separation
4. Absence of uterine fundus at depression over
3. No fundal pressure
fundus
5. Fleshy mass at or outside the introitus =dark
red-blue bleeding mass
VI. AMNIOTIC FLUID EMBOLISM
MANAGEMENT:
: is a pregnancy complication that causes life-
1. Prompt recognition and management threatening conditions, such as heart failure
2. Should be suspended if profound shock : happens when amniotic fluid make way into
without obvious explanation your blood circulation
3. Treat vasovagal shock
CAUSE:
4. Placental should not be detached until the
uterus is replaced or contracted 1. can happen in both – NSVD or CS
5. May require tocolytics, anesthesia or both 2. can happen in abortion
6. Replace the uterus immediately 3. can happen during amniocentesis
 MANUAL REPLACEMENT 4. some – unknown
» By pressing first on that part which
SYMTOPMS:
inverted last
» Once replace, keep hand inside the 1. first stage = cardiac arrest and rapid
uterus until ergotmetrine or oxytocin respiratory failure
has produced a firm contraction 2. fetal distress (signs that the baby is unwell
 O’SULLIVAN’S HYDROSTATIC METHOD including changes in the fetal heart rate or
» Tube passed through the posterior decreased movement in the womb)
fornix 3. vomiting
» Assistant close vulva around operator’s 4. nausea
wrist 5. seizures
» Warm saline run until pressure 6. severe anxiety
gradually restores position of uterus 7. skin discoloration
 SURGICAL REPLACEMENT
» Constricting ring stretched
» Posterior of the ring divided
: Women who survive these events, may enter VII. UTERINE PROLAPSE
a second stage called the hemorrhagic phase.
: is a condition in which a woman’s
» This occurs when there is excessive
uterus slips out of its normal position
bleeding either where the placenta was
: it drops part way into the vagina a lump
attached or at the cesarean incision in the
or bulge
case of a cesarean section
: AFE can be fatal, especially during the first GRADING UTERINE PROLAPSE
stage.
GRADE 0: No prolapse
: Most AFE deaths occur due to sudden cardiac
arrest, excessive blood loss, acute GRADE 1: Descent towards vaginal introitus
respiratory distress, or multiple organ (>1cm above hymen)
failure.
GRADE 2: Descent to vaginal introitus
: In roughly 50 percent of AFE cases, death
(hymen +/- 1cm from hymen)
occurs within an hour after symptoms start
: NO PREVENTION GRADE 3: Descent through introitus
(> 1cm below hymen)
TREATMENT:
GRADE 4: Prolapse totally outside the introitus
MOTHER
(uterine grade 4 )
1. managing symptoms and preventing AFE from
leading to coma or death
2. Oxygen therapy or a ventilator can help you
breathe
3. pulmonary artery catheter – heart
monitoring
4. Medications for blood pressure
5. blood, platelet, and plasma transfusions =for
blood loss during hemorrhagic phase

INFANT S/Sx:

1. watch for signs of distress 1. with mild cases of uterine prolapse may have
2. delivered as soon as condition is stabilized no obvious symptoms
3. babies end up in the intensive care unit for 2. Pelvic heaviness or pressure
close observation 3. Pelvic pain
4. Sexual dysfunction, including dyspareunia
5. decreased libido
6. Lower back pain PREVENTION:
7. Constipation
1. Not to prolong the time of birth
8. Difficulty walking
2. Non pressure on the uterus after childbirth
9. Difficulty urinating
3. Support after giving birth
10. Urinary frequency
4. Treat constipation
11. Urinary urgency
5. KEGEL EXERCISE
12. Urinary incontinence
13. Nausea
14. Purulent discharge (rare)
15. Bleeding(rare)
16. Ulceration (rare) MANAGEMENT:
17. A protrusion of tissue from the opening of
1. GELLHORN PESSARY
the vagina recurrent bladder infections
18. Unusual or excessive discharge from the
vagina
COMPLICATIONS:
: Symptoms may be worsened by prolonged
standing or walking. This is due to the added 1. If left untreated, uterine prolapse can
pressure placed on the pelvic muscles by interfere with bowel, bladder and sexual
gravity functions.
2. Infection
CAUSES:
3. Prolapse of other pelvic organs-including
1. Loss of muscle tone as the result of aging rectum and bladder
2. Injury during childbirth, especially if the » A prolapsed bladder bulges into the front
woman has had many babies or large babies part of vagina, causing a cystocele that
(more than 9 pounds) can lead to difficulty in urinating and
3. obesity, chronic coughing or straining and increased risk of urinary tract infection.
chronic constipation =added tension to pelvic » A prolapsed rectum causes a rectocele,
muscles which often leads to uncomfortable
constipation and possibly hemorrhoids .
RISK FACTORS:

1. One or more pregnancies and vaginal births

2. Giving birth to a large baby PROBLEMS WITH THE PLACENTA
3. Increasing age
: Already discussed earlier 2.2.3 third
4. Frequent heavy lifting
trimester complications
5. Chronic coughing
6. Frequent straining during bowel movements
PROBLEMS WITH THE PSYCHE
THE PUSHING STAGE

DON’TS:

1. DON'T HOLD YOUR BREATH

2. DON'T LAY ON YOUR BACK
3. DON'T LET SOMEONE HOLD BACK YOUR LEGS
4. DON'T COUNT THE LENGTH OF A PUSH
5. DON'T PUSH WHEN YOU DON'T FEEL THE URGE

USE AN EFFECTIVE BIRTH POSITION

1. SIDELYING - BEST FOR A SLOW, CONTROLLED

BIRTH
2. ALL FOURS - BEST FOR A LARGE
BABY/POSTERIOR PRESENTATION
3. SQUATTING - BEST FOR A QUICK PHASE & A
LARGE BABY