Misamis University Graduate School

Master in Nursing/Master of Arts in Nursing

213-INTENSIVE PRACTICUM 2
Second Semester, S.Y. 2022-2023

A CASE STUDY OF FETAL MALPRESENTATION

(Transverse Fetal Lie)

STUDENT:
PROFESSOR:

PATIENT’S DEMOGRAPHIC DATA

 PATIENTS INITIAL:
 AGE:
 ADDRESS:

 OCCUPATION:
 DATE OF ADMISSION:

BRIEF HISTORY OF PRESENT ILLNESS/ OB HISTORY

CHIEF COMPLAINT’S 1 day PTA onset of labor pain.
MEDICAL DIAGNOSIS
 ADMITTING DIAGNOSIS - G5P4 (4004) PU 39 2/7 weeks aog by lmp: t/c
MALPRESENTATION

 FINAL DIAGNOSIS - G5P5 (5005) Pregnancy uterine delivery via primary

low transverse caesarean section, extracted a live term
transverse baby boy, Apgar score8-9 bw:2540lbs
appropriate I gestational age.

OBSTETRIC HISTORY Gravida-4, Parity-4, Living-4

LMP: 7/18/2022 EDD:4/25/2023
Pregnancy uterine 39 2/7 weeks aog

PHYSICAL EXAMINATION GENERAL SURVEY: Alert, Awake

VITAL SIGNS: BP:120/80mmHg; HR:84bpm;
RR:20cpm; Temperature: 36 °C
ABDOMEN: Gravid FH 30cm, FHT: 127 RLQ Cephalic

GU/IE: IE: Blood-stained exam finger, Cervical

 dilatation:10cm, (+) intact bow
CHEST AND LUNGS: Clear breath sounds

LABORATORY:
HEMATOLOGY
WBC 9.87
RBC 3.99
HEMOGLOBIN 12.7
HEMATOCRIT 37.2
PLATELET 200

PELVIC UTRASOUND

IMPRESSION:

SINGLE ALIVE INTRAUTERINE PREGNANCY IN SHOULDER PRESENTATION IN

GOOD CARDIAC AND SOMATIC ACTIVITIES, 39 WEEKS AND 2 DAYS BY
COMPOSITE AGING PLACENTA POSTERIOFUNDAL HIGHLYING GRADE II- III
ADEQUATE AMNIOTIC FLUID.
 FETAL MALPRESENTATION
Presentation’ describes how your baby is facing down the birth canal. The ‘presenting
part’ is the part of your baby’s body that is against the cervix. The ideal presentation is head-
first, with the crown (top) of the baby’s head against the cervix, with the chin tucked into the
baby’s chest. This is called ‘vertex presentation’.

If your baby is in any other position, it’s called ‘malpresentation’. Malpresentation can
mean your baby’s face, brow, buttocks, foot, back, shoulder, arms or legs or the umbilical cord
are against the cervix.

It’s safest for your baby’s head to come out first. If any other body part goes down the birth canal
first, the risks to you and your baby may be higher. Malpresentation increases the chance that
you will have a more complex vaginal birth or a caesarean.

There are different types of malpresentation

 Breech presentation
 Face presentation
 Transverse lie
 Oblique lie
 Unstable lie
 Cord presentation

1.) Breech presentation Types of breach presentation

This is when your baby is lying with their

bottom or feet facing down. Sometimes one
foot may enter the birth canal first (called a
‘footling presentation’).Breech
presentation is the most common type of
malpresentation.
2.) Face presentation
This is when your baby is head-first but
stretching their neck, with their face against
the cervix.

3.) Transverse lie

This is when your baby is lying sideways.
Their back, shoulders, arms or legs may be
the first to enter the birth canal.

4.) Oblique lie

This is when your baby is lying diagonally.
No particular part of their body is against the
cervix.
5.) Unstable lie
This is when your baby continually changes
their position after 36 weeks of pregnancy.

6.) Cord presentation

This is when the umbilical cord is against
the cervix, between your baby and the birth
canal. It can happen in any situation where
your baby’s presenting part is not sitting
snugly in your pelvis. It can become an
emergency if it leads to cord prolapse (when
the cord is born before your baby,
potentially reducing placental blood flow to
your baby).

Will I have a malpresentation in my future pregnancies?

If you had a malpresentation in one pregnancy, you have a higher chance of it happening again,
but it won’t necessarily happen in future pregnancies. If you’re worried, it may help to talk to
your doctor or midwife so they can explain what happened.

How to diagnose?

 Palpation
-Fetal back is found in the other side or maybe difficult to identified?
- the fetal head is posterolateral and will be free above bim.
 Auscultation
 - The fetal heart best heard in the flank but descend to just above the pubis as
the head rotates and descends.

PATHOPHYSIOLOGY

TRANSVERSE PRESENTATION
(SHOULDER PRESENTATION)

NON-PROGRESSIVE PROGRESSIVE

PERSISTENT SHOULDER DEEP TRANSVERSE

PRESENTATION ARREST

CONSIDER OXYTOCIN VAGINAL CEASAREAN

AUGMENTATION DELIVERY SECTION

CEASAREAN DELIVER AS
SECTION SHOULDER
PRESENTATION
ETHIOLOGY
REFERRENCE PATIENT
 Increase fetal movement in the uterus
Risk factors affecting malpresentation  Multi gravida
include:
 A low-lying placenta.
 Too much or too little amniotic fluid
 An abnormally shaped uterus or
problems with the uterus, such as large
fibroids
 (Multigravida) Many previous
pregnancies, making the muscles of
the uterus less stable
 Carrying twins or more

MANAGEMENT:
 SURGICAL MANAGEMENT: EMERGENCY CEASARIAN SECTION

NURSING RESPONSIBILITIES
DURING LABOR
 Monitored maternal and fetal status.
 Encouraged patient for deep breathing exercises to minimize labor pain.
 Checked for any signs cord prolapse.
AFTER BIRTH
 Monitored for any signs of profuse vaginal bleeding
 Carried out doctor’s order for stat cs
 Maintained uterine contractions after birth
  Checked maternal and fetal status for any signs of birth defect
 Updated attending physician for any additional management.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: “Ma Through the nursing Independent Goals are met

feel jud nako nga Risk for intervention and -Obtained and then review application of
sa kilid mo sipa maternal and monitoring, the risk for the history, duration and proper nursing
ang akoang anak fetal injury injury both maternal onset of patient’s labor. management for
Maam” as related to the and fetal will be the diagnosis of
verbalized by the activity of the deceased. Dependent transverse lie
patient. fetus via -Assessed uterine presentation were
contractions pattern effectively applied.
transverse
Objective: through palpations or with
presentation.
Ultrasound external and internal
result- fetus is in monitor.
transverse lie
presentation Collaborative
-With preparation for C-
section as indicated, e.g.;
Malpresentation
DRUGS STUDY:
GENERIC NAME OXYTOCIN
CLASSIFICATION UTEROTONIC
DOSSAGE 10 “IU/ML”
ROUTE IVTT, IM, IV infusion
FREQUENCY 10 “U” IM single dose after delivery

MECHANISM OF ACTION Synthetic oxytocin elicits the same pharmacological

response produced by endogenous oxytocin, with cervical
dilation, parity, and gestational age as predictors of the
dose response to oxytocin administration for labor
stimulation. Oxytocin increases the sodium permeability
of uterine myofibrils, indirectly stimulating contraction of
the uterine smooth muscle. The uterus responds to
oxytocin more readily in the presence of high estrogen
concentrations and with the increased duration of
pregnancy.

INDICATIONS To induce parturition in cases of uterine inertia during

3rd stage of labor. As therapy and prophylaxis in cases of
placental hemorrhage and uterine atony.

CONTRAINDICATIONS Hypertonic uterine contractions, fetal distress when

delivery is not eminent. Placenta previa, abruptio
placentae. History of major uterine surgery.
CNS: Headache, Nausea, Dizziness
SIDE EFFECT
CV: Cardiac arrhythmias, Hypotension

SKIN: Rash
1.) Discontinue oxytocin infusion immediately in the
NURSING event of uterine hyperactivity or fetal distress.
RESPONSIBILITIES
2.) Monitor fetal heart rate, resting uterine tone and
 frequency, duration and force of contractions.

3.) Maintained and accurate rate of infusion flow.

GENERIC NAME CEFUROXIME

CLASSIFICATION ANTIBIOTIC
DOSSAGE 750mg
ROUTE IVTT
FREQUENCY EVERY 8 HOURS
MECHANISM OF ACTION Bind to bacterial cell wall membrane causing cell death

INDICATIONS for surgical prophylaxis, reducing or eliminating

infection, treatment for gynecologic infections, lower
respiratory tract infections, skin and soft tissue, urinary
tract infections.

CONTRAINDICATIONS Hypersensitivity to cephalosporin and related antibiotics;

category B, lactation.

SIDE EFFECT GI: diarrhea, nausea, unpleasant taste of the mouth.

SKIN: rash, pruritus, urticarial
EENT: Stuffy nose
CNS: Seizures

NURSING 1.) Asses patient for signs and symptoms of infection

RESPONSIBILITIES prior to and throughout therapy.

2.) Before initiating therapy, obtain a history to

determine previous use of and reactions to
penicillin. Persons with a negative sensitivity may
still have an allergic response.

3.) Observe patient for signs and symptoms of

anaphylaxis (rash, pruritus, laryngeal edema,
wheezing). Discontinue the drug an notify
physician.
 4.) Instruct patient to report signs of hypersensitivity

GENERIC NAME KETOROLAC TROMETHAMINE

CLASSIFICATION ANTI-PYRETIC

DOSSAGE 30mg
ROUTE IVTT
FREQUENCY EVERY 6 HOURS IF NECCESSARY

MECHANISM OF ACTION Anti- inflammatory analgesic activity, inhibits

prostaglandins and leukotriene synthesis.

INDICATIONS Short term management of pain (up to 5 days)

CONTRAINDICATIONS Contraindicated with significant renal impairment, aspirin

allergy, recent GI bleed or perforation. Use cautiously with
impaired hearing, allergies and hepatic condition.

SIDE EFFECT CNS: Headache, dizziness, somnolence, insomnia, fatigue

and ophthalmologic effects.

NURSING 1. be aware that patient may be at risk for CV events, GI

RESPONSIBILITIES bleeding, renal toxicity, monitor accordingly.
2. Keep emergency equipment readily available at time of
initial dose, in case of severe hypersensitivity reaction.

3. Protect drug from light.

4. Administer every 6 hours to maintain serum levels and

control pain.
GENERIC NAME RANITIDINE
CLASSIFICATION ANTI-ULCER
HISTAMINEH2ANTAGONIST
DOSSAGE 50mg
ROUTE IVTT
FREQUENCY EVERY 8 HOURS

MECHANISM OF ACTION Inhibits action of histamine at the H2 receptor site located

primarily in gastric parietal cells, resulting in inhibition of
gastric acid and secretion.

Has some anti-bacterial action against H. pyloric.

INDICATIONS This drug is used alone or with concomitant antacids for the
following conditions: short-term treatment of active
duodenal ulcer, treating gastric acid hypersecretion due to
Zollinger-Ellison syndrome, and other conditions that may
pathologically raise gastric acid levels. It also used in the
short-term treatment of active benign gastric ulcers and
maintenance therapy of gastric ulcers at a reduced dose.

CONTRAINDICATIONS Hypersensitivity, cross- sensitivity may occur some oral

liquid contain alcohol and should be avoided in patients
with known intolerance.

ADVERSE EFFECT GI: Nausea, Abdominal Pain, Diarrhea, Constipation

SKIN: Rash

CNS: Drowsiness, Dizziness, Headache, Insomnia

CV: Bradycardia
NURSING 1.) Instruct patient not to take new medication without
RESPONSIBILITIES consulting physician.
2.) Allow 1 hour between any other antacid and ranitidine.

3.(Monitor creatinine clearance if renal dysfunction is

present.

4.) Be alert for early signs of hepatoxicity.

DISCHARGE PLANNING

HEALTH TEACHING
 Encouraged to avoid lifting heavy objects at home.
 Educated patient for a higher chance of a malpresentation in her future pregnancy.
TREATMENT
 Educated woman the importance of medication compliance.