PROBLEMS OF THE PASSENGER

FETAL MALPRESENTATION
FETAL MALPOSITIONS
 PRE TEST
1-4. What are the components of labor?
5. What does passenger refers to?
6. Which body part of a fetus has the widest
diameter?
7.What is the narrowest diameter of the skull in an
anterior posterior position?
8. It is the relationship of the presenting part to a
specific quadrant of the woman’s pelvis.
9. It is the relationship between the long axis of the
fetal body and the long axis of the woman’s body.
10. It denotes the body part of the fetus that will first
contact the cervix or deliver first.
1. BREECH PRESENTATION
 It means that either the buttocks or the feet are the
first body parts that will contact the cervix.
 most common malpresentation.
 occurs in approximately 3% of the births
 More common in premature labor
 Breech presentations can be difficult births,
with the presenting point influencing the degree
of difficulty.
 Approx 1/3 are diagnosed during labor.
 PROBLEMS OF THE PASSENGER

 Fetal Malpresentation
 All presentation other than vertex.

 Fetal Malposition
 Abnormal positions of the vertex of the fetal
head relative to the maternal pelvis.
 Positions other than an occipitoanterior position.
 Fetal Malpresentation
• Types:
1. Breech presentation
2. Shoulder presentation
3. Cephalic presentation (Asynclitism)
4. Face presentation
5. Brow presentation
6. Sinciput presentation
 Types of Breech Presentation
1. Complete (Flexed)Breech Presentation
The baby's hips and knees are flexed so that the
baby is sitting crosslegged, with feet beside the
bottom.
2. Footling Breech Presentation
One or both feet come first, with the bottom
at a higher position.
This is rare at term but relatively common
with premature fetuses.
3. Frank (Extended) Breech Presentation
The baby's bottom comes first, and the legs
are flexed at the hip and extended at the
knees (with feet near the ears).
 65-70% of breech babies are in the frank
breech position.
4. Kneeling Breech Presentation
The baby is in a kneeling position, with
one or both legs extended at the hips
and flexed at the knees.
This is extremely rare.
Causes of Breech Presentation:
 AOG <40 weeks
 Abnormal fetus
 hydrocephalus
 Hydramnios
 Congenital anomaly of the uterus
 Midseptum uterus
 Fibroid uterus
 Placenta previa
 Pendulous abdomen
 Multiple gestation
Maternal Risks :
1. Prolonged labor r/t decreased pressure exerted by the breech on
the cervix.
2. PROM may expose client to infection.
3. Cesarean or forceps delivery.
4. Trauma to birth canal during delivery from
manipulation and forceps to free the fetal head.
5. Intrapartum or postpartum hemorrhage.
Fetal Risks:
1. Compression or prolapse of umbilical cord.
2. Entrapment of fetal head in incompletely dilated cervix.
3. Aspiration and asphyxia at birth.
4. Birth trauma from manipulation and forceps to free the fetal
head.
Management :
• Attempt external cephalic version if:
• Breech presentation is present at or after 37 weeks
Vaginal delivery is possible
• Membranes are intact and amniotic fluid is adequate;
• There are no complications (e.g. fetal growth restriction,
uterine bleeding, previous caesarean delivery, fetal
abnormalities, twin pregnancy, HPN, fetal death)
• Then:
• Tocolytics, such as Terbutaline 0.25 mg IM, can be used
before ECV to help relax the uterus.
• If ECV is successful, proceed with normal childbirth.
• If ECV fails or is not advisable, deliver by caesarean
section
ECV (External Cepahalic Version)
 Isthe turning of fetus from a breech to cephalic
position before birth.
 The breech and vertex of fetus are located and
grasped transabdominally by the examiner’s hand
on the womans abdomen.
 Done 37-38 weeks of pregnancy
 Contraindications:multiple gestation, severe
oligohydramnios, cord coil, placenta previa
VAGINAL BREECH DELIVERY. A vaginal breech delivery
by a skilled health care provider is safe and feasible
under the following conditions:
  -complete or frank breech
 -adequate clinical pelvimetry
- fetus is not too large
- no previous caesarean section for cephalopelvic
disproportion
- flexed head
Birth technique:
 Allowed only to push after full dilatation.
 Allow cardinal stages to poceed.
 As the leg is born, held a sterile tower against the
infant’s inferior surface
 The arm of the posterior shoulder is drawn down by
passing two fingers over the infants shoulder and
down the arm to elbow
 Then sweeping the flexed arm across the infant’s
face and chest and out.
 Other arm is delivered the same way.
 External rotation is allowed to occur for the head
 Birth technique:
-For the delivery of head, trunk of infant is
straddled over the physicians left forearm
Two fingers of physicians left hand are placed
in
the infant’s mouth.
-The right hand is slid into the mother’s vagina,
palm down along the infant’s back
-Pressure is applied to the occiput to flex the
head fully
-Gentle traction( upward and outward) to
deliver the head.
-Or in an aftercoming head, Piper forceps may
aid for the delivery.
CESAREAN SECTION
recommended in cases of:
 Double footling breech
 Small or malformed pelvis
 Very large fetus
 Previous cesarean section for cephalopelvic
disproportion
 Hyperextended or deflexed head.
 2. TRANSVERSE LIE PRESENTATION
a fetus lies horizontally in the pelvis so that the
longest fetal axis is perpendicular to that of the
mother.
 Thepresenting part is usually one of the shoulders
(acromion process), an iliac crest, a hand, or an
elbow.
Related factors:
 Pendulous abdomen
 Uterine masses
 Contraction of the pelvic brim
 Congenital abnormalities of the uterus
 Hydramnios
 Multiple gestation
 Short umbilical cord
Signs:
 uterus is more horizontal
 Determine Ovoid through leopold’s
maneuver
 Since no presenting part, cord or arm may
prolapse.
Management:
 Ifan infant is preterm and smaller than usual, an
attempt to turn the fetus to a horizontal lie may be
made.
 Most infants in transverse lie must be born by
cesarean birth (transverse uterine incision)
 Internal podalic version is no longer attempted.
3. COMPOUND PRESENTATION
 Prolapse of the limb of a the fetus alongside
the head (cephalic presentation) or of one or
both arms in breech presentation.
 4. FACE PRESENTATION
 The face presentation is caused by hyper-extension of the fetal head so that
neither the occiput nor the sinciput is palpable on vaginal examination.
 Occurs in 1 in 300 deliveries
 Asynclitism- refers to a fetal head presenting at different angle than expected.
Related factors:
 Contracted pelvis
 Placenta previa
 Relax uterus of multiparous mother
 Prematurity
 Hydarmnios
 Fetal malformation
Management :
Chin-anterior position
• prolonged labor is common.
• Descent and delivery of the head by flexion may occur
• If the cervix is fully dilated: Allow to proceed with normal childbirth;
• If there is slow progress and no sign of obstruction, augment labor with oxytocin;
• If descent is unsatisfactory, deliver by forceps.
• If the cervix is not fully dilated and there are no signs of obstruction: augment labor
with oxytocin.

Chin-Posterior Position
• In the chin-posterior position, however, the fully extended head is blocked by the
sacrum.
• This prevents descent and labor is arrested.
• If the cervix is fully dilated: Deliver by caesarean section.
• If the cervix is not fully dilated Monitor descent, rotation and progress. If there are
signs of obstruction, deliver by caesarean section.
• *Do not perform vacuum extraction for face presentation.
Management afterbirth:
 Babies born after face presentation may have facial
edema and ecchymotic bruising.
 Observe the infant closely for a patent airway.
 Lip edema may also severe.
 Gavage feeding
 5. BROW PRESENTATION
 The brow presentation is caused by partial extension
of the fetal head so that the biggest diameter (mento
vertex) presents.
 Occurs in 1 in 500 deliveries.
 Only diagnosed once labour is well established.
 Anteriorfontanelle and super orbital ridges are
palpable on vaginal examination
 Management:
 Ifthe fetus is alive or dead, deliver by
caesarean section.
 ***Do not deliver brow presentation by
vacuum extraction, outlet forceps or
symphysiotomy
 6. SINCIPUT PRESENTATION
• The sinciput presentation occurs when the larger
diameter of the fetal head is presented. Labor
progress is slowed with slower descent of the fetal
head.
 NURSING CARE OF CLIENTS WITH
MALPRESENTATIONS
• Observe closely for abnormal labor patterns.
• Monitor fetal heart beat and contractions
continuously.
• Anticipate forceps-assisted birth. Anticipate cesarean
birth for incomplete breech or shoulder presentation.
• Be prepared for childbirth emergencies such as
cesarean section, forceps-assisted delivery, and
neonatal-resuscitation.
• Position pt. in Trendelenburg or knee-chest position.
• Manually raise the presenting part aseptically
 Nursing Care:
Anxiety
• Provide client and family teaching
• Be available to client for listening and talking
• Provide client support and encouragement
• Encourage client to acknowledge and express feelings.
• Encourage breathing exercises to relieve anxiety.
Fear
• Provide client and family teaching,
• Note for degree of incapacitation.
• Stay with the client or make arrangements to have someone else be
there.
• Provide opportunity for questions and answer honestly.
• Explain procedures within level of client’s ability to understand and
handle.
Risk for Injury
• Observe closely for abnormal labor patterns.
• Monitor fetal heart beat and contractions continuously
• Be prepared for childbirth emergencies such as cesarean
section, forceps-assisted delivery, and neonatal-resuscitation.
• Maintain sterility of equipments
Risk for infection
• Stress proper hand washing techniques of all caregivers.
• Maintain sterile technique.
• Cleanse incision site daily and prn. Change dressings as
needed.
• Encourage early ambulation, deep breathing, coughing, and
position change.
FETAL MALPOSITIONS
Types:
 occipitoposterior positions
 occipitotransverse positions
Factors:
 multipara
 lax abdominal wall
 Occipitoposterior Positions
 The most common malposition.
 The head initially engages normally but then the occiput rotates posteriorly
rather than anteriorly.
 The anterior fontanelle is felt anteriorly while bregma is felt posteriorly.
 During internal rotation, the fetal head rotates through
an arc of approximately 135 degree.
Related factors:
Flat sacrum
Android, anthropoid or
contracted pelvis
Poorly flexed head
Weak uterine contractions
Epidural analgesia
Symptoms:
 Dysfunctional labor pattern
 Prolonged active phase
 Arrested descent
 FHT heard best at lateral sides of the abdomen
 Arrested labor may occur when the head does
not rotate and/or descend.
 Pressure and pain in lower back due to sacral
nerve compression
 Delivery may be complicated by perineal tears
or extension of an episiotomy.
 Nursing management
 Close maternal and fetal monitoring
 Counterpressure on the sacrum
 Applying heat or cold
 Lying on side opposite the fetal back- help fetus
rotate
 Woman should void every after 2 hours.
 Adequate fluid be given to the mother.
 May need IV glucose solution
 The mother may get the urge to push before the full
dilatation, thus instruct not to push.
Occipitotransverse Position

   It is the incomplete rotation of OP to OA results in the

fetal head being in a horizontal or transverse position
(OT).
  
 Management
 Ifthe second stage is reached, the head must be
manually rotated with Keillands forcep or
delivered using vacuum extraction.
 Immediate CS if failure to deliver through forceps.
 Fetal malpositions
• Abdominal examination – the lower part of the abdomen is flattened, fetal limbs
are palpable anteriorly and the fetal flank.
• Vaginal examination – the posterior fontanelle is toward the sacrum and the
anterior fontanelle may be easily felt if the head is deflexed
• Maternal risks: prolonged labor potential for operative delivery extension of
episiotomy, 3rd or 4th degree laceration of the perineum.
• Maternal symptoms:
– Intense back pain in labor
– Dysfunctional labor pattern
– prolonged active phase
– secondary arrest of dilatation
– arrest of descent
Nursing Management
• Encourage the mother to lie on her side from
the fetal back, which may help with rotation.
• Pelvic – rocking Knee – chest position may
help and facilitate with rotation.
• Apply sacral counter – pressure with heel of
hand to relieve back pain.
• Continue support and encouragement: Keep
client and family informed progress.
• Praise client’s efforts to maintain control.
 Monitor FHB appropriately
 Be prepared for childbirth emergencies such as C-
section, forceps-assisted delivery, and neonatal-
resuscitation.
 Encourage relaxation with contractions.
 Apply sacral counter–pressure with heel of hand to
relieve back pain.
 Provide comfortable environment.
 Teach breathing exercises for use during early labor
until client receives pharmacologic relief.
 Monitor physical response for example,
palpitations/rapid pulse
• If there are signs of obstruction or the
fetal heart rate is abnormal at any
stage, deliver by caesarean section.
• If the cervix is not fully dilated and
there are no signs of obstruction,
augment labor with oxytocin.
• If the cervix is fully dilated but there is
no descent in the expulsive phase,
assess for signs of obstruction.
• If the cervix is fully dilated and if: the
leading bony edge of the head is above -2
station, perform caesarean section;
• the leading bony edge of the head is
between 0 station and -2 station, Delivery
by Vacuum Extraction and Symphysiotomy
• If the operator is not proficient in
symphysiotomy, perform caesarean section;
• If the bony edge of the fetal head is at 0
station, deliver by vacuum extraction or
forceps.
 SYMPHYSIOTOMY

• A surgical procedure in which the

cartilage of the symphysis pubis is divided
to widen the pelvis allowing childbirth
when there is a mechanical problem.
• Currently the procedure is rarely
performed in developed countries, but is
still routine in developing countries where
cesarean section is not always an option.
 Forceps DELIVERY

provides traction or a
means of rotating the fetal
head.
Risks: fetal ecchymosis or
edema of the face,
transient facial paralysis,
maternal lacerations, or
episiotomy extensions.
 Vacuum extraction

Provides traction to
shorten the second stage
of labor.
Risks: newborn
cephalhematoma, retinal
hemorrhage and
intracranial hemorrhage.
THE
END
PREPARE
FOR POST-
TEST
1. A type of fetal malpresentation by
which either the buttocks or the feet
are the first body parts that will
contact the cervix.
2. The most common breech presentation.
3. It is the turning of fetus from a breech
to cephalic position before birth by
grasping the woman’s abdomen
transabdominally.
4-6. Give three causative factors for
breech presentation.
7. What is the medical management for brow
presentation?
8. How is the fetus being delivered, having
face presentation with a chin posterior
position ,if the mother’s cervix is fully
dilated?
9. It is a surgical procedure in which the
cartilage of the symphysis pubis is divided
to widen the pelvis allowing childbirth.
10. What is the most common fetal
malposition?
 OUTLINE

 Occiput Posterior (10%)- Vaginal delivery

 Face presentation (<0.2%)
 Mentum anterior- vaginal delivery
 Mentum posterior – cesarean section
 Brow presentation (0.02%)-cs
 Compound Presentation (<0.5%)- vaginal delivery
 Transverse presentation (0.3%)- cesarean
1.Passenger
2. Passage
3. Power
4. Psyche
5. Fetus
6. Head
7. Suboccipitobregmatic diameter
8. Position
9. Lie
10. Presentation
PROLAPSE UMBILICAL CORD
 An emergency situation
A loop of umbilical cord that slips down
in front of the presenting part.
 Itoccurs after ROM and the presenting
part is not fitted firmly into the cervix.
 Can lead to cord compression since the
fetal presenting part presses against
the cord at the pelvic brim
CONDITION AFFECTING UCP

 PROM
 Fetal Pres other than cephalic
 Placenta Previa
 Intrauterine tumors
 CPD
 Hydramnios
 Multiple Gestation
Assessment
 On initial vaginal exam, cord may be felt
as with the presenting part
 It may be seen in the sonogram
 Always assess the FHT
immediately after ROM in order
to rule out UCP since the
nutrient and blood supply could
be compromised toward the
fetus.
 MANAGEMENT
 Aimis to relieve compression on the cord that may
result to fetal anoxia.
 APPLICABLE
ONCE CORD IS NOT TOO MUCH EXPOSED
TO ROOM TEMP
 Place a gloved hand in the vagina and manually elevate the
fetal head off the cord
 Place the woman in knee-chest/ trendelenberg
 Administer O2 @ 10LPM by face mask to the mother
 Administer tocolytic agent per prescription
 To reduce uterine activity and pressure of fetus
 MANAGEMENT
 APPLICABLE
IF CORD IS EXTENTLY EXPOSED
TO ROOM TEMP
 Do not attempt to push any exposed cord back to
vagina
 Coverany exposed portion with sterile saline
compress
 Ifcervix is full dilated , deliver infant quickly
(forcep delivery)
  If incomplete dilatation:
Apply an upward pressure on the
presenting part
Do CS birth
 Ifdetected at sonogram before
ROM:
 CS birth is necessary