This document discusses problems that can occur with fetal position, presentation, or size during labor and delivery. It describes issues like occipitoposterior position where the baby's head is facing the wrong way, breech presentation where the baby is feet or butt first, face or brow presentations which are types of abnormal head position, and transverse lie where the baby is laying horizontally across the womb. It provides information on assessment of these problems, contributing risk factors, potential complications, and therapeutic management approaches including manual maneuvers, positions, and when cesarean delivery may be recommended.

1. Problems with the
Passenger

2. PROLAPSE OF THE UMBILICAL
CORD/UMBILICAL CORD PROLAPSED
Main Problem:
* A loop of the umbilical cord slips down
in front of the presenting fetal part.
* Occurs at any time after the
membranes rupture if the presenting
part is not fitted firmly into the cervix.
* Incidence is 0.4% 0f births

3. PROLAPSE OF THE UMBILICAL CORD
A. The cord is prolapsed
but still within the
uterus.
B. The cord is visible at the
vulva.

4. PROLAPSE OF THE UMBILICAL
CORD/UMBILICAL CORD PROLAPSED
 CONTRIBUTING FACTORS:
1. Premature rupture of membranes
2. Fetal presentation other than cephalic
3. Placenta previa
4. Intrauterine tumors preventing the presenting part
from engaging.
5. Small fetus
6. CPD preventing firm engagement
7. Hydramnios
8. Multiple gestation.

5. ASSESSMENT
1. Cord may be felt as presenting part on initial
vaginal exam.
- Inspect the perineum to confirm prolapse of the
cord before providing immediate intervention.
- Assess if the fetus is preterm or small for gestational
age; if the presenting part is not engaged, and it the
membranes are ruptured.
2. Cord may be visible at the vulva.
- If cord prolapse is identified, notify the physician
and prepare for emergency cesarean birth.
3. Sonogram
4. Variable deceleration FHR pattern
- Fetal bradycardia with deceleration during contraction
- Evaluation of FHR must be done periodically in 5-10
minutes, especially if the membranes are ruptured.

6. THERAPEUTIC MANAGEMENT
 Complication: Fetal Distress or Fetal Hypoxia
/Anoxia d/t cord compression
Goal #1 : Relieve umbilical cord compression by relieving
pressure on the cord.
1. Place a gloved hand in the vagina and manually
elevating the fetal head off the cord.
2. Place the woman in a knee-chest or Trendelenburg
position.
3. Administer tocolytic agent as prescribed.
- To reduce uterine activity & pressure on the fetus.

7. THERAPEUTIC MANAGEMENT
Goal # 2: Improve oxygenation to the fetus
1. Administer oxygen at 10 L/min by face mask to the
mother.
Goal # 3: Prevent atrophy of the umbilical vessels.
(in case the umbilical cord prolapsed is
exposed to room air)
1. Cover the exposed portion of the cord with a sterile
saline compress to prevent drying.
2. Do not attempt to push any exposed cord back into
the vagina
- Pushing may add to the compression by causing
knotting or kinking.

8. THERAPEUTIC MANAGEMENT
Goal # 4: If cervix is fully dilated, prevent
fetal anoxia.
1. The physician may choose to deliver the infant
quickly (by forceps)
Goal # 5: If dilatation is incomplete, prevent
cord compression.
1. The birth method is upward pressure on the
presenting part in the woman’s vagina, to keep
pressure off the cord, and baby can be born by
C/S.

9. CRITICAL THINKING EXERCISE
NURSING MANAGEMENT OF THE CLIENT WITH A
PROLAPSED UMBILICAL CORD
Situation: A woman in labor room tells the nurse, “My water just
broke, and it felt like something fell out.”
1. Prioritize the following interventions for this client. Explain your
reasoning.
____ Place the woman in Trendelenburg position
____ Use a gloved hand to push the fetal presenting part upward
____ Administer oxygen
____ Call the primary care provider
____Press the call light for assistance
____ Inspect the perineum to see if the cord is visible
____ Assess the fetal heart rate

10. Explanations:
1. ______________________________________________
2. ______________________________________________
3. ______________________________________________
4. ______________________________________________
5. ______________________________________________
6. ______________________________________________
7. ______________________________________________

11. PROBLEMS WITH
POSITION,PRESENTATION,
OR SIZE

12. OCCIPITOPOSTERIOR POSITION
(ROP/LOP)
 The fetal position is posterior rather than anterior,
the occiput is directed diagonally and posteriorly,
either to the right (ROP) or to the left (LOP).
Occiput
(LOP)
 In these positions (LOP or ROP), during internal rotation, the fetal
head must rotate through an arc of 135°

13. FETAL POSITIONS

14. CONTRIBUTING FACTOR:
- A woman with android, or anthropoid, or
contracted pelvis.

15. ASSESSMENT
1. Dysfunctional labor pattern AEB a prolonged active
phase, arrested descent.
2. Fetal heart sounds heard best at the lateral sides of
the abdomen.
3. The fetal presenting head does not snugly fit the
cervix.
4. The position of the fetus is confirmed by sonogram
5. Prolonged labor because the arc of rotation is
greater.
6. Woman experience intense lower back
pressure & pain due to sacral nerve
compression.

16. THERAPEUTIC MANAGEMENT:
1. Counterpressure on the sacrum (e.g. back rub)
 Relieve a portion of pain
2. Applying heat or cold
3. Assist woman on side-lying
position opposite the fetal back or maintaining a hands-and-
knees position.
4. Let woman void every 2 hrs. to keep bladder empty
 Full bladder could further impede descent of the fetus
5.During long labor, IV glucose solution to replace glucose stores
used for energy.

17. THERAPEUTIC MANAGEMENT:
6. Fetus may be born by C/S if:
 Contractions are ineffective
 Fetus larger than average
 Fetus not in good flexion
 Fetal head may arrest in the transverse
position.
 Persistent occipitoposterior position
7. Provide emotional support.

18. BREECH PRESENTATION
- Either the buttocks or the feet are the first body
parts that will contact the cervix.
- 3% of births are breech presentations; can be
difficult births with the presenting point influencing
the degree of difficulty.
- 3 Types:
1. Complete
2. Frank
3. Footling

19. BREECH PRESENTATION
1. Frank breech presentation
Lie: Longitudinal
Attitude: Moderate
1
• Attitude is moderate because the hips are flexed but the knees are
extended to rest on the chest. The buttocks alone present to the
cervix.

20. BREECH PRESENTATION
2. Complete breech presentation
Lie: Longitudinal
Attitude: Good (fulLflexion)
2
• The fetus has thighs tightly flexed on the abdomen; both the
buttocks and the tightly flexed feet present to the cervix.

21. BREECH PRESENTATION
3. Footling breech presentation
Lie: Longitudinal
Attitude: Poor
3
• Neither the thighs nor lower legs are flexed. If one foot presents, it
is a single-footling breech; if both present, it is a double-footling
breech.

22. BREECH PRESENTATION
Complications:
1. Anoxia from prolapsed cord
2. Traumatic injury to the after-coming head
(possibility of intracranial haemorrhage or
anoxia)
3. Fracture of the spine or arm
4. Dysfunctional labor
5. Early rupture of the membranes because of
the poor fit of the presenting part.
6. Meconium aspiration

23. BREECH PRESENTATION
Assessment:
1. FHT heard high in the abdomen
2. Leopold’s, vaginal exam, or ultrasound exam
reveals the presentation.
- Ultrasound clearly confirms the presentation including
additional information on pelvic diameters, fetal skull
diameter, and evidence of possible placenta previa causing
the breech presentation.
3. Monitor FHR and uterine contractions
continuously
- to detect early signs of fetal distress from a complication like
prolapsed cord.

24. BREECH PRESENTATION
- Birth technique:
1. Vaginal delivery
 Birth of head is the most hazardous because
umbilicus precedes the head.
 Head compresses the cord
 2nd danger is intracranial hemorrhage
2. Planned C/S – usual method

25. BREECH PRESENTATION
BIRTH TECHNIQUE: VAGINAL DELIVERY
 As the breech spontaneously
emerges from the birth canal, it
is steadied and supported by a
sterile towel against the infant’s
inferior surface.
 To aid in delivery of the head, the
trunk of the infant is usually
straddled over the physician’s right
forearm .
 Two fingers of the physician’s left
hand are placed in the infant’s
mouth

26. Vertex Malpresentation
 Asynclitism
- Fetal head presenting at different angle.
- Examples: Face and brow presentations
FACE BROW
FACE BROW

27. Vertex Malpresentation
 Face presentation (chin, or mentum)
o Fetus is in poor flexion
o Back is arched
o Neck extended
o Complete extension
o Presenting the occipitomental diameter (13.5 cm)
FACE

28. VERTEX MALPRESENTATION:
FACE PRESENTATION
ASSESSMENT
 CONTRIBUTING FACTORS:
1. Woman with contracted pelvis
2. Placenta previa
3. Relaxed uterus of a multipara
4. Prematurity, hydramnios, or fetal malformation
 A sonogram is done to confirm
- If the chin is anterior and the pelvic diameters are within
normal limits, a successful vaginal birth is possible.
- If the chin is posterior, cesarean birth may be the method of
choice to avoid uterine dysfunction or a transverse arrest.

29. VERTEX MALPRESENTATION:
FACE PRESENTATION
 Therapeutic management:
1. Observe infant for patent airway
 May have a great deal of facial edema and
may be purple from ecchymotic bruising.
2. Gavage feeding
 Lip edema is so severe that the infant is
unable to suck for a day or 2.
3. Observe infant for 24 hours in ICU nursery.

30. VERTEX MALPRESENTATION:
BROW PRESENTATION
 It is the rarest of the presentations. BROW
 CONTRIBUTING FACTOR:
1. Multipara or a woman with relaxed abdominal muscles.
 ASSESSMENT:
1. Obstructed labor
 BIRTH TECHNIQUE:
1. Cesarean birth

31. VERTEX MALPRESENTATION:
BROW PRESENTATION
 Therapeutic management:
1. Observe infant for patent airway
- May have extreme ecchymotic bruising on the face, over the
same area as the anterior fontanelle or “soft spot”.
2. Infant must be observe for eye injury.

32. TRANSVERSE LIE
Description:
- A fetus lies horizontally in the pelvis, longest fetal
axis is perpendicular to that of the mother.
- The presenting part is one of the shoulders
(acromion process), an iliac crest, a hand, or an
elbow

33. TRANSVERSE LIE
Occurs in women with:
1. Women with pendulous abdomen
2. Uterine masses that obstructs the lower uterine
segment
3. Contracted pelvic brim
4. Congenital abnormalities of the uterus
5. Hydramnios
6. Infants with hydrocephalus
7. Prematurity
8. Multiple gestation

34. TRANSVERSE LIE
Assessment:
1. Uterus is more horizontal than vertical
2. Confirmed by Leopold’s maneuver
3. Ultrasound
Complications:
1. Early rupture of membranes usually at the beginning of
labor.
2. Cord or arm prolapse or shoulder may obstruct the cervix
Therapeutic management:
1. C/S is the birth method of choice

35. OVERSIZED FETUS
(MACROSOMIA)
 Fetus who weighs more than 4,000 – 4,500 g
(9 – 10 lbs.)
 Risk factors:
1. Diabetic or develop gestational diabetes
2. Multiparity

36. OVERSIZED FETUS
(MACROSOMIA)
 Complications:
1. Uterine dysfunction during labor/birth
• Overstretching of the fibers of the myometrium
2. Wide shoulders cause fetal pelvic disproportion
3. Uterine rupture from obstruction
4. Fractured clavicle of the baby because of
shoulder dystocia
5. Woman has an increased risk of hemorrhage
• Overdistended uterus may not contract
 Cesarean birth becomes the birth method of choice

37. FETAL DISTRESS
 DESCRIPTION:
A fetal condition resulting from fetal hypoxia.
 RISK FACTORS:
1. Shoulder dystocia
2. Cord coil, cord compression
3. Improper use of oxytocin, analgesia/anesthesia
4. Diabetes mellitus, cardiac disease, and other co
existing conditions in the mother
5. Bleeding complications in the third trimester like
placenta previa and abruptio placenta
6. Pregnancy induced hypertension (PIH)
7. Supine hypotensive syndrome

38. FETAL DISTRESS
 ASSESSMENT FINDINGS TRIAD SYMPTOMS
1. FHT above 160 or below 120 per minute
2. Meconium-stained amniotic fluid in a non-breech
presentation
3. Fetal hypermobility/hyperactivity

39. FETAL DISTRESS
 NURSING IMPLEMENTATION
1. Reposition mother to left lateral recumbent (LLR).
- To relieve pressure on the inferior vena cava (IVC) , thereby increasing
venous return resulting in increased perfusion of placenta and fetus.
2. Stop the oxytocin drip if being infused.
3. Administer oxygen per mask at 6-7 liters per minute.
4. Correct hypotension.
a. Elevate legs
b. Increase IV rate (increase hydration) provided the IV fluid is plain and
with no oxytocin.
c. Turn mother to her left if it is a case of vena caval syndrome.
5. Monitor FHT continuously.
6. Notify the physician.
7. Prepare for emergency CS if indicated