This document discusses various complications that can occur with the passage of the baby during birth due to issues with the mother's pelvis or birth canal. It describes how narrowing or contractions of the inlet, midpelvis, or outlet can cause cephalopelvic disproportion. It also discusses other potential issues like anomalies of the placenta such as placenta succenturiata which could lead to hemorrhage if lobes are retained, and vasa previa which involves blood vessels crossing the cervix and can cause bleeding with dilation. External cephalic version and trial of labor are mentioned as potential approaches to addressing some of these complications.

1. NCM 109- Care of Mother
and Child at Risk or with
Problems
(Acute and Chronic)-LECTURE
Wesleyan University –Philippines
Cabanatuan City
CONAMS
Jhonee Balmeo
Instructor

2. II. COMPLICATIONS WITH THE PASSAGE
ANATOMY OF THE PELVIS

3. II. COMPLICATIONS WITH THE PASSAGE
ANATOMY OF THE PELVIS

4. II. COMPLICATIONS WITH THE PASSAGE
ANATOMY OF THE PELVIS

5. II. COMPLICATIONS WITH THE PASSAGE
 The reason why dystocia can occur is a contraction or narrowing of the
passageway or birth canal.
 This can happen at the: INLET, at the MIDPELVIS, or at the OUTLET
 The narrowing causes CPD, or a disproportion between the size of the fetal head
and the pelvic diameters, that results in failure to progress in labor.

6. II. COMPLICATIONS WITH THE PASSAGE
 The reason why dystocia can occur is a contraction or narrowing of the
passageway or birth canal.
 This can happen at the: INLET, at the MIDPELVIS, or at the OUTLET
 The narrowing causes CPD, or a disproportion between the size of the fetal head
and the pelvic diameters, that results in failure to progress in labor.

7. a. Inlet Contraction
Is narrowing of the anteroposterior diameter of the pelvis to less than 11 cm
or of the transverse diameter to 12 cm or less.

8. Usually caused by rickets in early life or by an inherited small pelvis
Rickets- caused by lack of calcium
Primigravidas – fetal head engages between weeks 36 and 38 of pregnancy
• If occurs anytime before labor begins, the pelvis is of adequate size
• Literally means, the fetal head sunk below the inlet

9. • “Whatever goes in, comes
out”- a head that engages into
the pelvic brim will be able to
pass through
• Rule: engagement does not
occur in multigravidas until
labor begins, vaginal birth of a
full term infant only proves
that their birth canal is
adequate

10. • Every primigravida should have pelvic
measurements taken and recorder before
week 24 of pregnancy.
• If CPD occurs, fetus may not engage but
remains “floating”, consider the possibility of
cord prolapse

11. b. Outlet contraction
Is a narrowing of the transverse diameter, the distance between ischial
tuberosities at the outlet, to less than 11cm
is rare, but should be readily diagnosed at the routine assessment of
the pelvis during the prenatal period.
When in doubt, accurate measurements of the bony outlet by X-ray
pelvimetry are mandatory.

12. Management:
1.Can be delivered by NSD
2.Cesarean Section
*TRIAL LABOR
If with borderline (just adequate) inlet measurement
May be done if with descent of the presenting part and dilatation of the
cervix

13. Management During the Trial Labor:
Independent:
1.Monitor FHR and uterine contractions frequently
2.Urge the woman to void every 2 hours
3.Explain why C/S is scheduled or explain that it is an alternative method of
delivery
Dependent:
C/S if after 6-12Hrs
If no adequate progress is noted

14. • EXTERNAL CEPHALIC VERSION
Is the turning of a fetus from a breech to a cephalic positions before birth
Done 34-45 weeks of gestation

15. EXTERNAL CEPHALIC VERSION

16. Indications:
Breech presentation
Transverse lie
Procedure:
Independent: Monitoring and recording of FHR and UTZ result
Dependent: Tocolytic- to help relax the uterus
Although not always successful, but can decrease the number of C/S

17. Contraindications:
Multiple gestation
Severe oligohydramnios
Small pelvic diameters
Nuchal cord
Unexpected third trimester bleeding

18. Contraindications:
Multiple gestation
Severe oligohydramnios
Small pelvic diameters
Nuchal cord
Unexpected third trimester bleeding

19. It is a condition where the baby’s head or body is
too large to fit through the mother’s pelvis.
• A. CPD
• B. Nuchal Cord
• C. Outlet contraction
• D. Inversion

20. A pregnant woman who’s having her trial labor has
already exceeded more than 6 hours can now be a
candidate for CS?
•Yesh
•Nooh!

21. The following are possible causes of
cephalopelvic disproportion (CPD), but one:
A. Fetal positions
B. Small pelvis
C. Abnormally shaped pelvis
D. Diabetes
E. Eclampsia

22. II.A. Anomalies of the Placenta and Cord
Might occur during the third stage of labor (delivery of the placenta) can also
result in complications
1.Anomalies of the Placenta
> Should be carefully examined after birth
• Normal weight: 500 g ; 1/6 of the fetal weight
• Diameter: 15-20 cm
• Thickness: 1.5-3.0 cm

23. a. Placenta Succenturiata
A placenta that have one or more accessory lobes connected to the main
placenta by blood vessels
an accessory lobe of the placenta may be found outside of the main disc.
appears torn at the edge, or torn blood vessels extend beyond the edge of the
placenta

24. a. Placenta Succenturiata
A placenta that have one or more accessory lobes connected to the main
placenta by blood vessels
an accessory lobe of the placenta may be found outside of the main disc.
appears torn at the edge, or torn blood vessels extend beyond the edge of the
placenta

25. a. Placenta Succenturiata
Should be carefully recognized, the small lobes may be retained in the uterus
after birth and can cause hemorrhage

26. b. Placenta Circumvallata
Normally , 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
The fetal side of the placenta is covered to some extent with chorion

27. b. Placenta Circumvallata
Placenta circumvallate refers to a placental abnormality in which the
membranous chorion transitions to a villous chorion in from the placental
edges.

28. c. Placenta accreta
Placenta accreta is a serious pregnancy condition that occurs when the
placenta grows too deeply into the uterine wall.
Typically, the placenta detaches from the uterine wall after childbirth. With
placenta accreta, part or all of the placenta remains attached. This can cause
severe blood loss after delivery.

29. c. Placenta accreta
Unusual deep attachment of the placenta to the uterine myometrium
So deep that the placenta will not loosen and deliver
Attempts to remove it manually may lead to extreme hemorrhage because of
the deep attachment
Management
Hysterectomy Dependent Intervention
Administration of Methotrexate

30. c. Placenta accreta
Unusual deep attachment of the placenta to the uterine myometrium
So deep that the placenta will not loosen and deliver
Attempts to remove it manually may lead to extreme hemorrhage because of
the deep attachment
Management
Hysterectomy Dependent Intervention
Administration of Methotrexate

31. c. Placenta accreta
Unusual deep attachment of the placenta to the uterine myometrium
So deep that the placenta will not loosen and deliver
Attempts to remove it manually may lead to extreme hemorrhage because of
the deep attachment
Management
Hysterectomy Dependent Intervention
Administration of Methotrexate

32. d. Battledore Placenta
The cord is inserted marginally rather than centrally
Rare and has no known significance either

33. d. Battledore Placenta
The cord is inserted marginally rather than centrally
Rare and has no known significance either

34. e. Velamentous Insertion of the Cord
The cord, instead of entering the placenta directly, separates into small vessels
that reach the placenta by spreading across a fold of amnion
Usually found with multiple gestation
Infant born with this anomalies should be examined carefully after birth

35. e. Velamentous Insertion of the Cord
Velamentous cord insertion (VCI) is an umbilical cord attachment to the
membranes surrounding the placenta instead of the central mass.

36. f. Vasa Previa
Vasa previa is a complication that can occur during pregnancy. Some of the
blood vessels that connect the umbilical cord to the placenta lie over or near
the entrance to the birth canal.

37. f. 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

38. Before inserting any instrument such as an internal fetal monitor, be certain to
identify structures to prevent accidental tearing of a vasa previa – sudden fetal
blood loss
Diagnosis: UTZ
If positive for vasa previa, C/S may be needed

39. 2.Anomalies of the Cord
1.two-vessel cord
The umbilical cord is responsible for transporting oxygen-rich blood to a baby
and taking away oxygen-poor blood and waste products from a baby.

40. 2.Anomalies of the Cord
1.two-vessel cord
Normal cord: one vein and two arteries
Absence of one artery suggests congenital heart and kidney anomalies because
the insult that caused the loss of the vessel may have also affected other
mesoderm germ layer structures

41. Management:
Independent:
1.Perform physical assessment among newborn: inspection of the presence of
one vein and two arteries
2.Document the findings
3.Referral to attending physician in case of anomalies

42. 2.Unusual Cord length
Unusual short cord – premature separation of the placenta or an abnormal
fetal lie
Unusual long cord- tendency to twist or knot/nuchal cord

43. 2.Unusual Cord length
Unusual short cord – premature separation of the placenta or an abnormal
fetal lie
Unusual long cord- tendency to twist or knot/nuchal cord

44. As a nurse in the NICU, you just observed that
a newborn has only one umbilical artery. What
condition do you think is associated with this
condition?
A. Battledore Placenta
B. Congenital Heart Disease.
C. Rheumatic Heart Disease
D. Liver Disease

45. During “araw ng mga buntis” you noticed the
UTZ of your client that the umbilical cord of
the baby seems short. This condition may lead
to?
A. Cephalopelvic disproportion
B. Preterm Labor
C. Premature separation of placentA
D. Macrosomia

46. You were assigned in the post delivery setting,
you found out that there are/is mall lobes that
were retained in the uterus after birth in
placenta succenturiata, this may lead to:
A. Severe dehydration
B. Coma
C. Hypotension
D. Severe hemorrhage

47. Pssst… ano ang mga senyales ng vasa previa?
Huh?
A. A single umbilical artery
B. Sudden painless bleeding.
C. A short umbilical cord
D. The fetal side of the placenta is covered by chorion

48. Chill na dude, ala na sasagutan. That concludes
the discussion for today. May natutunan ka
ba?
A. Yes po!
B. Uhm, opo!
C. Yeiz, meron!
D. Naman!

49. End of morning
session
prepare for your
quiz/assignment!