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2M Intrapartal Complications Written Report 109
2M Intrapartal Complications Written Report 109
College of Nursing
Mandaue City, Cebu, Philippines
ANTEPARTUM COMPLICATIONS
Group A – 3:
Balbuena, Katya
Gabun, Johncen Brian L.
Hamoy, Heaven Khrys
Igot, Marvie Raymon
Jayson, Ellen Rose
Joe, Rinoah Airish
Lear, Niekkah Mae P.
Limboy, Roanna Therese G.
Locsin, Aaliyah Bjorn B.
Locsin, Ninna Cherizze M.
Magan, April Pai A.
Oliver, Diamae S.
Osnan, Jasper G.
Pangilinan, Carlin Gyandev P.
Rosal, Cromwell Ernest
II. Etiology/Cause
Premature rupture of the membranes, which occurs when a mother's water breaks prior
to labor and her baby's head has started to "engage," (settle into the delivery canal), is the most
prevalent cause of cord prolapse. Aside from the rupture of the membranes, it also includes:
● Fetal presentation other than cephalic
● Placenta previa
● Intrauterine tumors prevent the presenting part from engaging
● Small fetus
● CPD (Cephalopelvic disproportion) preventing firm engagement
● Polyhydramnios
● Multiple gestations
Source:
Doenges, M. D.
E., Moorhouse, M.
M. R. M. F., &
Murr, A. M. C.
(2019). Nursing
Care Plans:
Guidelines for
Individualizing
Client Care
Across the Life
Span (Tenth ed.)
[E-book]. F.A.
Davis Company.
5. Demonstrate 5. Showing
knee-to-chest the mother
position how to
(Trendelenbur properly
g position) to position
the mother in can
relieving decrease
pressure on further
the umbilical compressi
cord. on on the
umbilical
cord and
helps
reduce the
possibility
of a
prolapsed
cord while
waiting for
the
delivery.
Source:
TeachMe ObGyn.
(2017). Umbilical
Cord Prolapse -
Risk Factors -
Management -
TeachMeObGyn.
Retrieved
February 12,
2022, from
TeachMeObGyn
website:
https://teachmeob
gyn.com/labour/e
mergencies/cord-
prolapse/
6. Instruct 6. Breathing
mother about exercises
breathing promote
exercises as a more
regime and effective
preparation breathing
for childbirth and airway
managem
ent to the
mother
and for the
benefit of
the baby
especially
when
contractio
ns are
occurring
as an
indication
of labor.
Source:
Doenges, M. D.
E., Moorhouse, M.
M. R. M. F., &
Murr, A. M. C.
(2019). Nursing
Care Plans:
Guidelines for
Individualizing
Client Care
Across the Life
Span (Tenth ed.)
[E-book]. F.A.
Davis Company.
Dependent: 7. Funic
7. Assist the decompre
mother in ssion is
preparing for a the most
vaginal frequent
examination means of
or funic relieving
decompressio cord
n to alleviate compressi
the pressure on, and it
of the is also the
presenting maneuver
part on the doctors
cord as favor. The
ordered by the examiner's
physician. hand is put
in the
vagina
and used
to lift the
fetal head
off the
cord while
preparing
for an
emergenc
y
cesarean
birth.
Source:
StatPearls. (2021,
May 20). Umbilical
Cord Prolapse.
Retrieved
February 12,
2022, from
StatPearls
website:
https://www.statp
earls.com/ArticleL
ibrary/viewarticle/
30751
Source:
Cleveland Clinic
medical
professional.
(2020). Umbilical
Cord Prolapse:
Causes,
Diagnosis &
Management.
Retrieved
February 12,
2022, from
Cleveland Clinic
website:
https://my.clevela
ndclinic.org/health
/diseases/12345-
umbilical-cord-
prolapse#manage
ment-and-
treatment
Interdependent:
9. Collaborate 9. Dieticians
with a provide
dietician for informatio
the mother's n and
diet meal plan guidance
and lifestyle in
modifications determinin
g
individual
nutritional
needs
incorporati
ng one's
pregnancy
. Also, it
aids in
discussion
s about
necessary
lifestyle
changes
that aim at
realistic
goals for
the
patient,
especially
for a case
of
prolapsed
cord.
Source:
Doenges, M. D.
E., Moorhouse, M.
M. R. M. F., &
Murr, A. M. C.
(2019). Nursing
Care Plans:
Guidelines for
Individualizing
Client Care
Across the Life
Span (Tenth ed.)
[E-book]. F.A.
Davis Company.
Source:
Doenges, M. D.
E., Moorhouse, M.
M. R. M. F., &
Murr, A. M. C.
(2019). Nursing
Care Plans:
Guidelines for
Individualizing
Client Care
Across the Life
Span (Tenth ed.)
[E-book]. F.A.
Davis Company.
REFERENCES:
Boyd, T. K., Parast, M. M., Horii, M., & Tantbírójn, P. (2018). Placental Correlates of Unanticipated
Fetal Death. Diagnostic Gynecologic and Obstetric Pathology, 1182–1218.
https://doi.org/10.1016/b978-0-323-44732-4.00032-7
Brennan, D. (2021, March 9). What Is Umbilical Cord Prolapse? Retrieved February 10, 2022,
from WebMD website: https://www.webmd.com/parenting/what-is-umbilical-cord-
prolapse
De Bellefonds, C. (2020, November 16). Cord Prolapse During Pregnancy. Retrieved February
10, 2022, from What to Expect website:
https://www.whattoexpect.com/pregnancy/pregnancy-health/complications/cord-
prolapse.aspx
Rashid, H. (2019). Umbilical Cord Prolapse, Presented By Mohammed Haroon Rashid. Retrieved
February 11, 2022, from Slideshare.net website:
https://www.slideshare.net/HaroonRashid110/umbilical-cord-prolapse-presented-by-
mohammed-haroon-rashid
Multiple Gestation
I. Definition/Description of the Disease or Complication
II. Etiology/Cause
Multiple Gestation can happen randomly. During a cycle, if a woman ovulates two
eggs, then each egg will have the capability to be fertilized by the sperm. In the event that
two different sperm fertilize two different eggs, the woman will then be pregnant with non-
identical (fraternal) twins. A fertilized egg will also randomly divide itself into multiple,
genetically identical embryos. Identical twins will likely develop if the egg divides into two.
Fraternal twins
- In the uterus, two separate eggs will be fertilized and implanted. The fetuses are
siblings who share the same uterus – might look alike or different, and could be of
the same gender (two girls or two boys) or of two different genders.
- This type of twins has its own placenta and amniotic sac, making this pregnancy
the lowest risk of all multiple pregnancies.
- Fraternal twins are frequently referred to as 'dizygotic' twins since they have two
zygotes (fertilized eggs).
Identical twins
- When a single fertilized egg is split in half, identical twins are produced. The
fetuses will share the same DNA because each half (embryo) is genetically
identical, meaning they will share many characteristics.
- Identical twins can look quite different from each other since their appearance is
influenced by both their environment and their DNA.
- This type of twins can share the same placenta and amniotic sac, or have their
own placenta and amniotic sac.
- Identical twins are frequently referred to as 'monozygotic' since they have one
zygote (fertilized egg).
Signs Symptoms
https://youtu.be/nVhEkRG8-ws
VII. One (1) priority Nursing Care Plan for each complication
Martin, P. B.
(2019b, June 1). 4
Dysfunctional
Labor (Dystocia)
Nursing Care
Plans.
Nurseslabs.
https://nurseslabs
.com/4-
dysfunctional-
labor-dystocia-
nursing-care-
plans/#risk_for_fe
tal_injury
Miyazaki, C.
(2016, January
14). Tocolysis for
inhibiting preterm
birth in extremely
preterm birth,
multiple
gestations and in
growth-restricted
fetuses: a
systematic review
and meta-analysis
- Reproductive
Health. BioMed
Central.
https://reproductiv
e-health-
journal.biomedce
ntral.com/articles/
10.1186/s12978-
015-0115-7
Dependent
Tanigaki, S.,
Takemori, S.,
Osaka, M., &
Watanabe, M.
(2020). Cesarean
Section of
Multifetal
Pregnancy. US
National Library of
Medicine.
https://www.ncbi.
nlm.nih.gov/pmc/
articles/PMC7396
478/
9. Collaborate 9. Mothers
with a nutritionist carrying two or
and/or a dietician more fetuses
to create a proper need more
and suitable meal calories, protein,
plan for the and other
Multifetal nutrients,
pregnant mother. including iron.
Partner Support
During
Pregnancy.
(2020).
MyHealthAlberta.
https://myhealth.a
lberta.ca/Health/p
ages/conditions.a
spx?hwid=abp735
2#:~:text=When%
20both%20partne
rs%20support%2
0each,feel%20ha
ppier%20and%20
less%20stressed.
REFERENCES:
SheCares Editorial Team. (2021, December 26). Multiple Gestation: Twin Pregnancy and More.
SheCares. https://www.shecares.com/pregnancy/multiple-gestation-twin-pregnancy-and-
more
II. Etiology/Cause
Amniotic fluid is a clear, slightly yellowish liquid that surrounds the unborn baby (fetus)
during pregnancy. It is contained in the amniotic sac. The amount of fluid increases until the
36th week of pregnancy. After that, it slowly decreases. If the fetus makes too much urine or
does not swallow enough, amniotic fluid builds up. This causes hydramnios. It may be caused
by diabetes in the mother.
Signs Symptoms
https://youtu.be/AH9d89iRGFw
VII. One (1) priority Nursing Care Plan for each complication
Nursing Nursing Scientific Basis Objectives of Nursing Actions Rationale
Assessment Diagnosis Care
I. Physio
Nursing Polyhydramnios General Independent:
logic
Diagnosis: is a disorder that Objectives:
Risk for affects a pregnant 1.) Place the 1.) Mild
Risk for Fetal After ____ of mother on close polyhydramniosis
Maternal and woman's uterus.
Injury nursing monitoring. in pregnant
Fetal Injury In this disease, intervention, the women
Objective related to the uterus fills patient will deliver They might not
Cues: polyhydramni with too much the fetuses with no necessitate
os amniotic fluid (the complications. active
liquid that management.
● Shortn surrounds the Specific
The majority of
Objectives:
ess of baby in the
After _ hours of
the time, they will
breath womb). When this holistic nursing resolve
or the happens, the care, the client will themselves.
inabilit uterus expands be able to: They will, instead
y to beyond its typical Any indicators of
1. deterioration
breath size.
To willingly should be
e continuously
The amniotic fluid Participate in the
● Swelli medical and watched.
plays an
ng in nonpharmacologic and their
important function
the al therapy manifestations
in the
lower regimens
development of prescribed by the
extrem
the fetus. doctors. 2.) Prepare the 2.) An ultrasound
ities
Amniotic fluid is patient for examination
and
normally ingested 2. Ensure that the biophysical called a
abdom fetal heart rate is profile and
by the infant in the biophysical
inal normal. non-stress test.
womb and profile is used to
wall 3. Demonstrate determine the
subsequently
● Uterin behavior and health of a
urinated out. The mannerisms that
e person.
amount of fluid in reduce the danger
disco to determine the
the uterus is
of fetal damage,
mfort
especially when
amount of
stabilized as a
or the mother is amniotic fluid in
result of this. the uterus
contra carrying two
ctions This problem fetuses. as well as the
● Fetal tone, movement,
might appear as
and breathing
malpo early as 16 weeks
Non-stress exam
sition, into the on the baby - to
such pregnancy. see if the
as However, as the the baby's heart
breech pregnancy rate when he or
presen advances into the she is
tation latter weeks, it is Moves.
more likely to
manifest.
3.) Prepare the 3.) To allow the
Subjective patient for healthcare team
Cues: admission if to monitor the
there is pregnant mother
any evidence of and her baby,
● “Magli worsening and to provide
sud maternal and/or prescribed
man fetal health due treatments as
kug to deemed
Cr” polyhydramnios. necessary.
● “Lisud
man
kug 4.) Treat the 4.) Efficient
ginha underlying maternal or
wa” conditions paternal care
● “Mura related to It's possible that
man polyhydramnios, gestational
such as diabetes will aid
kug
gestational/ in the resolution
nangh
maternal of the problem.
upong diabetes and polyhydramnios.
” rhesus disease. Anti-D
● “Nang medication is
hagi given.
man infusion of
akua immunoglobulin
pus.on into a pregnant
” woman
Rh D negative
women can avoid
getting pregnant.
Rhesus disease
is a contagious
disease that can
lead to death.
polyhydramnios.
Dependent:
SOURCE:
Polyhydram
nios
nursing
care plans
diagnosis
and
intervention
s.
NurseStudy
.Net. (2021,
September
2).
Retrieved
February
13, 2022,
from
https://nurs
estudy.net/
polyhydram
nios-nclex-
nursing-
review/
.
REFERENCES:
- In the occiput-posterior position, the baby is facing the mother’s front with its head
down, meaning the occiput (assuming the presentation is vertex) is directed
diagonally and posteriorly, either to the right (right occipito-posterior [ROP]) or to
the left (occipito-posterior [LOP]). But, ROP is more common than LOP.
- The occipito-posterior position is known to be the most common abnormality
regarding fetal positioning. It tends to occur in women with android, anthropoid, or
contracted pelvises.
- Studies suggest that this is associated and may lead to many complications in
labor that consequently lead to adverse maternal and natal conditions such as
operative vaginal delivery (forceps or vacuum delivery), cesarean delivery, and
postpartum hemorrhage.
- The fetal head rotates against the sacrum, a woman may experience pressure and
pain in her lower back because of sacral nerve compressions.
I. Etiology / Cause
● Shape of the pelvic inlet: associated with either an anthropoid (oval-shaped) or
android (heart shaped) pelvis
● Maternal Kyphosis: or hunchback (excessive curvature of the spinal cord) can
make the fetal back fit into the curve.
● Other causes:
○ Multiple pregnancies
○ Placenta Previa
○ Pelvic tumors
○ Polyhydramnios
● Palpation
○ Fetal limbs are felt more easily
near midline on either side
○ Fetal back is felt far away from
midline on flank
○ Head is not engaged
● Auscultation
○ FHS can be heard on the
lower part of the belly.
● Vaginal examination
○ Sagittal suture occupies any of
the oblique diameter of pelvis
○ Posterior fontanelle is felt near
the sacro-iliac joint
○ Anterior fontanelle is felt more
easily.
● Ultrasonography or lateral view x-ray
IV. Management
● Nursing, Medical, Pharmacologic, Surgical
Nursing Management Medical Management Pharmacologic Surgical Management
Management
https://www.youtube.com/watch?v=YLSZJxdkKik
VI. One (1) priority Nursing Care Plan for each complication
Nursing Nursing Scientific Basis Objectives of Nursing Actions Rationale
Assessment Diagnosis Care
4. Continue to 4. An increased
monitor the body temperature
patient's may indicate the
temperature, presence of
check redness, infection.
swelling and pain Redness, swelling
or any abnormal and pain are also
drainage on the associated.
lacerated site.
SOURCE:
Taylor, M. (2021).
Postpartum
Infections:How To
Spot The Signs.
What to Expect.
Retrieved from
Postpartum
Infections: Signs
of a Puerperal
Infection After
Birth
(whattoexpect.co
m)
5. Encourage 5. Appropriate
frequent perineal self-care of the
care and peripad perineum in
changes. Also postpartum and
should be changing peripad,
reinforced. including hand
hygiene, reduces
the risk of
pathogenic
microorganism
invasion.
Information also
should be
reiterated in order
to retain
information and
promote practice.
SOURCE:
Postpartum
Perineal Care.
Drugs.com. Know
More. Be Sure.
(2022). Retrieved
from Postpartum
Perineal Care
(Aftercare
Instructions) -
What You Need to
Know (drugs.com)
SOURCE:
Ramar, C. &
Grimes, W.R.
(2021). Perineal
Lacerations.
NCBI. Retrieved
from Perineal
Lacerations -
StatPearls - NCBI
Bookshelf
(nih.gov)
SOURCE:
Will Stress
Catapult You Into
Premature Labor?
(2021, June 14).
Verywell Family.
https://www.veryw
ellfamily.com/can-
stress-cause-
premature-labor-
2748464#:%7E:te
xt=Although%20st
ress%20can%20b
e%20more,also%
20known%20as%
20preterm%20lab
or).
Dependent
1. Administration 1. Ergometrine is
of ergometrine as administered to
prevention for prevent
postpartum postpartum
hemorrhage hemorrhage
(PPH) which may lead to
complications. It
does this by
narrowing smooth
muscle tissues in
the blood vessels,
thereby, reducing
blood flow.
SOURCE:
Ergometrine
Injection BP
0.05% w/v -
Summary of
Product
Characteristics
(SmPC) - (emc).
(2020, June 26).
Medicines.Org.
Retrieved
February 12,
2022, from
https://www.medi
cines.org.uk/emc/
product/6265/smp
c#gref
Collaborative
1. Refer the
patient to a
dietician and/or
nutritionist for an
appropriate diet
that may quicken
recovery.
Belleza, M. (2021). Problems with Fetal Position, Presentation, Size and Passage. Nurselabs.
Retrieved from Problems with Fetal Position, Presentation, Size, & Passage - Nurseslabs
Cafasso, J. (2018). What Your Baby’s Position in the Womb Means. Healthline. Retrieved from
Baby Positions in Womb: What They Mean (healthline.com)
Kay, C., M.D. (2020). Signs That Your Baby Ha sTurned Into a Head-Down Position. Healthline.
Retrieved from https://www.healthline.com/health/pregnancy/symptoms-of-baby-turning-
head-down
Malposition and Malpresentation. Geneva Foundation for Medical Education and Research.
(2021). Retrieved from Malpresentations and Malpositions ,OP position - D. El-Mowafi
(gfmer.ch)
Occiput Posterior Effect On Labor and Ways to Manage It. Parenting Healthy Babies. (2019).
Retrieved from Occiput Posterior Effect On Labor and How to Manage It
(parentinghealthybabies.com)
Pillai, S. (2021). Occiput Posterior: Does It Affect Labor And How To Manage It? Mom Junction.
Retrieved from
https://www.momjunction.com/articles/ways-to-avoid-having-an-occiput-posterior-
position_0082926/
Vaginal Tears During Childbirth. Cleveland Clinic. (2022) Retrieved from Vaginal Tears (Perineal
Lacerations) (clevelandclinic.org)
Face, breech, brow presentation
I. Definition/Description of the Disease or Complication
Face Presentation
Face presentation which is also referred to as “chin or mentum” is under the examples of
asynclitism which is when the fetal head is presenting at a different angle than expected. It
happens infrequently, however when it does, the diameter of the fetus’ head that presents to the
pelvis is often too large for birth to take action. During Leopold’s maneuver, a face presentation
is said to be when the head is more prominent than normal with no perceptible engagement, as
well as when the head and the back are felt on the same side of the uterus upon palpation. It can
be verified by vaginal examination when the nose, mouth, or chin are felt as the presenting part.
Breech Presentation
The fetal head mostly turns to a cephalic presentation (head down) from a breech presentation
by 38 weeks. If it does not turn, the fetus’ buttocks, feet, or both will be the ones to come out first
during birth. This is called the breech presentation which is when the fetus is in a longitudinal lie
with the buttocks or feet nearest to the cervix. It can be confirmed by Leopold’s maneuver and
vaginal examination. Breech presentation occurs very rarely in about 3-4% of all deliveries and is
more dangerous to the fetus compared to cephalic presentation as it poses higher fetal risks such
as:
● Developing dysplasia,
● Anoxia from prolapsed cord,
● Traumatic injury to the after-coming head (with possibility of intracranial hemorrhage or
anoxia),
● Fracture of the spine or arm,
● Dysfunctional labor.
● Early rupture of the membranes because of the poor fit of the presenting part, and
● Meconium staining.
Brow Presentation
Brow presentation is said to be the rarest of all types of presentations. A fetus in a brow
presentation is when the chin is situated to be untucked and the neck is to some degree extended
backwards. From the word itself “brow”, the forehead is the presenting part or the first to go
through the cervix. The diameter of the presenting part may be too large to fit through the pelvis,
thus a normal spontaneous vaginal delivery can be hard or impossible. It also leaves the infant
with intense ecchymotic bruising on the face. Parents may need supplementary reassurance that
the child is in a well condition after birth when the bruising is over the same area as the anterior
fontanelle.
II. Etiology/Cause
Face Presentation
If a fetus is in a posterior position instead of flexing the head as labor takes action, then the head
may extend causing a face presentation. The causative factors that are linked with face
presentation are also alike to those causing general malpresentation and those that prevent head
flexion. This habitually occurs in a woman with a contracted pelvis or placenta previa, relaxed
uterus of a multipara or with prematurity, polyhydramnios, or fetal malformations. Generally,
something abnormal usually causes face presentation.
Breech Presentation
It is said that the reason why the baby is in a breech presentation is not always known. However,
there are factors that may contribute to it and these are:
● Multiple gestation (as it is harder for each baby to get into the favored position),
● Hydramnios (too much amniotic fluid causes for space for the fetus to move),
● Placenta previa,
● Pre-term (baby may not have turned into a cephalic prevention),
● Uterus is abnormal in shape or has abnormal growth, and
● Birth defect that causes the fetus not to turn the head down.
Brow Presentation
The causes of brow presentation are generally the same to those resulting to a face presentation
and these include the following:
● Cephalopelvic disproportion,
● Increasing parity,
● Prematurity,
● Multigravida, or/and
● A woman with relaxed abdominal muscles.
3. Frank Breech
- It is when the legs of the baby are folded flat up against the head and the bottom is the
nearest to the birth canal.
IV. Signs and Symptoms
Signs Symptoms
V. Management
● Nursing, Medical, Pharmacologic, Surgical
Nursing Management Medical Management Pharmacologic Surgical Management
Management
https://youtu.be/O6jddbdeFUo
https://youtu.be/-C5RXHUzQhg
VII. One (1) priority Nursing Care Plan for each complication
Nursing Nursing Scientific Basis Objectives of Nursing Actions Rationale
Assessment Diagnosi Care
s
3. Monitor 3. The
the client’s woman's
labor labor
status. status is
determine
d by
assessing
her
contractio
n pattern,
performing
vaginal
examinati
on if there
are no
contractio
ns, and
determinin
g whether
her
membrane
s have
ruptured.
Source: Abraham,
Kylene (2018).
"Nursing
Management
During Labor and
Delivery."
Lippincott Manual
of Nursing
Practice 11th
Edition, 990-1014.
4. Provide 4. Active
informatio participati
n about on of the
birthing client/coup
alternative le is
s, if important
available in the
and decision-
appropriat making
e. process.
Source: 36 Labor
Stages, Induced
and Augmented
Labor Nursing
Care Plans.
(2017, May 3).
Nurseslabs.
https://nurseslabs.
com/labor-stages-
labor-induced-
nursing-care-
plan/#a1
5. Assess if 5. Most
the client women
is a who are 37
candidate weeks
for pregnant
external with a
cephalic baby in the
version breech
(ECV). position
are
candidate
s for an
ECV. The
procedure
has been
found to
be
successful
in turning
these
babies into
a head-
down
position in
around 50
percent of
cases.
Source:
Young, B.
(2018,
April 12).
What Is
External
Cephalic
Version
and Is It
Safe?
Healthline;
Healthline
Media.
https://ww
w.healthlin
e.com/hea
lth/pregna
ncy/extern
al-
cephalic-
version
6. Obtain 6. When
informed procedure
consent s involve
for the client's
procedure body, it is
s, e.g., critical that
external the client
cephalic has
version. adequate
Explain informatio
the n to make
procedure informed
s and the decisions.
possible Source: 36 Labor
risks Stages, Induced
associate and Augmented
d with Labor Nursing
labor and
Care Plans.
delivery.
(2017, May 3).
Nurseslabs.
https://nurseslabs.
com/labor-stages-
labor-induced-
nursing-care-
plan/#a1
7. Encourag 7. This
e use of reduces
relaxation anxiety,
technique promotes
s, relaxation,
including and gives
patterned the client a
breathing. sense of
control,
allowing
them to
cope
positively
with the
situation.
Source: Martin, P.
(2019, June 2). 4
Dysfunctional
Labor (Dystocia)
Nursing Care
Plans. Nurseslabs.
https://nurseslabs.
com/4-
dysfunctional-
labor-dystocia-
nursing-care-
plans/
Dependent 8. External
8. Assist the cephalic
physician version
in (ECV) is
performin an attempt
g external to turn the
cephalic fetus so
version. that he or
she is
head
down.
ECV can
improve
the
chance of
having a
vaginal
birth.
Source: If Your
Baby Is Breech.
(2019). Acog.org.
https://www.acog.
org/womens-
health/faqs/if-
your-baby-is-
breech#:~:text=In
%20the%20last%
20weeks%20of,c
ome%20out%20fi
rst%20during%20
birth.
9. Assist in 9. When
preparing ECV is
for a done
vaginal successful
birth or a ly, it is
planned possible to
cesarean try for a
delivery. vaginal
birth.
However,
for those
who are
not
candidate
s or
decline
ECV, a
planned
cesarean
section is
recommen
ded for
delivery
sometime
after 39
weeks.
Source: Gray, C.
J., & Shanahan,
M. M. (2021,
August 11).
Breech
Presentation.
Nih.gov;
StatPearls
Publishing.
https://www.ncbi.
nlm.nih.gov/books
/NBK448063/#:~:t
ext=Diagnosis%2
0of%20a%20bree
ch%20presentatio
n,should%20be%
20visualized%20a
nd%20documente
d.
Interdependent:
10. Collaborat 10. An
e with an obstetrician is a
obstetricia doctor who
n for the specializes in
appropriat childbirth and
e method providing medical
of birth care to women
and during pregnancy
postnatal and after
care. childbirth.
Obstetricians are
trained to manage
complex or high-
risk pregnancies
and births, as well
as to perform
interventions and
cesarean
sections.
Source: What
does an
obstetrician do?
(2021, January).
Pregnancybirthba
by.org.au;
Healthdirect
Australia.
https://www.preg
nancybirthbaby.or
g.au/the-role-of-
your-
obstetrician#:~:te
xt=An%20obstetri
cian%20is%20a%
20doctor,can%20
perform%20interv
entions%20and%
20caesareans.
REFERENCES:
36 Labor Stages, Induced and Augmented Labor Nursing Care Plans. (2017, May 3). Nurseslabs.
https://nurseslabs.com/labor-stages-labor-induced-nursing-care-plan/#a1
Breech presentation: diagnosis and management | Better Safer Care. (2020). Vic.gov.au.
https://www.bettersafercare.vic.gov.au/clinical-guidance/maternity/breech-presentation-
diagnosis-and-management#goto-management
Gray, C. J., & Shanahan, M. M. (2021, August 11). Breech Presentation. Nih.gov; StatPearls
Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK448063/#:~:text=Diagnosis%20of%20a%20bree
ch%20presentation,should%20be%20visualized%20and%20documented.
Meera, K. (2018, August 1). SASGOG Pearls of Exxcellence | the Society for Academic
Specialists in General Obstetrics & Gynecology. https://exxcellence.org/list-of-
pearls/management-of-brow-face-and-compound-malpresentations/
Moldenhauer, J. S. (2021, July 6). Fetal Dystocia. MSD Manual Professional Edition; MSD
Manuals. https://www.msdmanuals.com/professional/gynecology-and-
obstetrics/abnormalities-and-complications-of-labor-and-delivery/fetal-dystocia
Wayne, G. (2022, January 28). 11 Cesarean Birth (C-Section) Nursing Care Plans. Nurseslabs.
https://nurseslabs.com/cesarean-birth-nursing-care-plans/
Transverse Lie
I. Definition/Description of the Disease or Complication
Also called as lying sideways, transverse lie happens when the fetus inside the womb of
a woman is in horizontal position across the uterus, and not vertically. In this case, the back of
the baby may be positioned:
a. Down (back is facing toward the birth canal)
b. With one shoulder directing toward the birth canal
c. Up (hands and feet are facing toward the birth canal)
II.Etiology/Cause
There is no definite reason as to why some babies are positioned in transverse lie.
However, there are certain factors that are believed to cause this to happen, such as:
a. Body structure - The pelvis structure of the mother does not allow the head of the baby to
engage in later pregnancy.
b. Uterine structure - This also prevents the head of the baby from engaging in later
pregnancy, including fibroids and/or cysts that can be found in the uterus.
c. Polyhydramnios - The amount of amniotic fluid is too many, making the room of the baby
move as they begin to engage the pelvis. This situation, however, only happens to around
1 to 2 percent of pregnancies.
d. Multiples - Once there are two or more babies inside, one or more may be breech or
transverse as they compete for space inside the uterus during the pregnancy.
e. Placental issues - The event where the cervical opening is covered by the placenta during
the latter part of the pregnancy, or placenta previa, is likewise linked to breech or
transverse presentation.
4. Promote 4. Finding
avoidance out about
of the
unnecess challenges
ary stress of having a
to the baby who
patient by is in
giving transverse
physical lie can be
and very
emotional stressful
support; a for the
support mother
person and
can also through
be of great continuou
help. s support,
other risks
will be
prevented
such as
the
occurrenc
e of mental
condition,
and also
for the
mother to
still feel
confident
to follow
the
necessary
measures.
Source:
Mental wellbeing
during pregnancy.
(2019,
November).Pregn
ancy, Birth and
Baby.
https://www.pregn
ancybirthbaby.org
.au/mental-
wellbeing-during-
pregnancy
Dependent:
1. Administer 1. The
antibiotics medicatio
(such as ns
Penicillins, indicated
vancomyci are
n, antibiotics
nitrofurant safe for
oin, pregnacy
metronida that
zole, prevent/tre
clindamyci at
n, and ascending
fosfomyci infections
n) to the while also
client as protecting
indicated the fetus.
Source:
Martin, P. B.
(2019, June 1). 4
Dysfunctional
Labor (Dystocia)
Nursing Care
Plans.
Nurseslabs.
https://nurseslabs
.com/4-
dysfunctional-
labor-dystocia-
nursing-care-
plans/
2. Monitor 2. This is to
the fetal detect
heart rate abnormalit
noting the ies such
variability, as
periodic exaggerat
changes ed
and variability,
baseline bradycardi
rate as a, and
ordered by tachycardi
the a, which
attending can be
physician. caused by
stress,
hypoxia,or
acidosis.
Source:
Martin, P. B.
(2019, June 1). 4
Dysfunctional
Labor (Dystocia)
Nursing Care
Plans.
Nurseslabs.
https://nurseslabs
.com/4-
dysfunctional-
labor-dystocia-
nursing-care-
plans/
Souce:
Bonvissuto, D.
(2018, February
21). External
Cephalic Version
(ECV). WebMD.
https://www.web
md.com/baby/ext
ernal-cephalic-
version-
overview#:%7E:te
xt=guide%20the%
20process.-
,Does%20ECV%
20Hurt%3F,an%2
0ECV%20without
%20any%20paink
illers.
Interdependent:
1. Collaborat 1. Many
e with the collaborati
client’s ons and
OB-GYN, cooperatio
Midwife or n between
doula different
healthcare
workers
with
varying
levels of
education
and
profession
al
certificatio
ns are
required in
the
delivery of
health
care. In a
dynamic
and
complicate
d care
setting,
effective
collaborati
on of
nurses
and
midwives
with
physicians
help to
improve
patient
well-being,
quality of
treatment,
and
provider
satisfactio
n.
Source:
Melkamu, E.
(2020, April 26).
Inter-professional
collaboration of
nurses and
midwives with
physicians and
associated factors
in Jimma
University
specialized
teaching hospital,
Jimma, south
West Ethiopia,
2019: cross
sectional study -
BMC Nursing.
BioMed Central.
https://bmcnurs.bi
omedcentral.com/
articles/10.1186/s
12912-020-
00426-w
REFERENCES:
Cheriyedath, S. (2019, February 26). What is a Transverse Baby? News-Medical.Net. https://
www.news-medical.net/health/What-is-a-Transverse-Baby.aspx#:~:text=Diagnosis%20of
%20Transverse%20Presentation&text=Vaginal%20examination%E2%80%94%20A%20
shoulder%20may,confirms%20the%20transverse%20lie%20position.
Crider, C. (2020, October 16). Where Do You Feel Baby Kicks During Pregnancy? Healthline.
https://www.healthline.com/health/pregnancy/where-do-you-feel-baby-kicks#how-soon
Fetal presentation before birth. (2020, August 11). Mayo Clinic. https://www.mayoclinic.org/healt
hy-lifestyle/pregnancy-week-by-week/multimedia/fetal-positions/sls-20076615?s=6#:~:te
xt=This%20baby%20is%20in%20a,back%20facing%20the%20birth%20canal
Johnson, S. (2021, September 7). Placenta Previa. Healthline. https://www.healthline.com/healt
h/placenta-previa
Marcin, A. (2020, February 28). Can You Turn a Transverse Baby? Healthline. https://www.healt
hline.com/health/pregnancy/transverse-baby
Martin, P. (2019, June 2). Dysfunctional Labor (Dystocia) Nursing Care Plans. Nurseslabs.
https://nurseslabs.com/4-dysfunctional-labor-dystocia-nursing-care-plans/
Macrosomia
I. Definition/Description of the Disease or Complication
Macrosomia is an oversized infant who weighs more than 4,000g to 5,000g
(approximately 9lbs to 10lbs).
II. Etiology/Cause
This condition is most frequently born to women who enter pregnancy with
diabetes or who develop gestational diabetes. Higher amounts of sugar in the mother’s
system pass through the placenta and convert into fat, leading to a larger baby. Other
than diabetes, other causes of fetal macrosomia are:
● Having a family history of fetal macrosomia
● Excessive weight gain during pregnancy
● Obesity during pregnancy
● Multiple pregnancies
● A pregnancy lasting more than 40 weeks
● A mother with an above-average height and weight
● Having a male child
IV. Management
● Nursing, Medical, Pharmacologic, Surgical
Nursing Management Medical Management Pharmacologic Surgical Management
Management
https://www.youtube.com/watch?v=dYIYL_rNwoc
VI. One (1) priority Nursing Care Plan for each complication
Nursing Nursing Scientific Basis Objectives of Nursing Actions Rationale
Assessment Diagnosis Care
3. Determine 3. to identify
individual family necessary
stressors, referrals. Impact
economic of pregnancy on
situation/ family with
financial needs, limited resources
and can create added
availability/use of stress and result
resources in
limited prenatal
care and
preparation for
newborn.
Source:
Doenges, M. E.,
Moorhouse, M. F.,
Murr, A. C. (2019).
Nurse’s
Pocket
Guide
Diagnoses,
Prioritized
Interventions, and
Rationales. 15th
ed. Philadelphia:
F.A. Davis
Company
Source:
Doenges, M. E.,
Moorhouse, M. F.,
Murr, A. C. (2019).
Nurse’s
Pocket
Guide
Diagnoses,
Prioritized
Interventions, and
Rationales. 15th
ed. Philadelphia:
F.A. Davis
Company
DEPENDENT:
6. Consult with the 6. Most
physician the macrosomia
appropriate cases are usually
delivery during done through
labor. cesarean delivery
or assisted
vaginal delivery
with forceps
INTERDEPENDE
NT:
7. Discuss with 7. Most pregnant
nutritionist the mothers who are
appropriate expecting
dietary changes macrosomia
that the patient babies have
needs to uphold. obesity or
gestational
diabetes. Doing
the appropriate
dietary changes
can help promote
the effectiveness
of childbirth.
Silbert-Flagg, J., Pillitteri, A. (2018). Maternal and Child Health Nursing. Eigth Edition. Wolters
Kluwer.
II. Etiology/Cause
The following factors that may cause shoulder dystocia:
● Fetal Macrosomia - is a newborn who’s much larger than average.
● Fetus is in the wrong position
● The mother’s pelvic opening is too small
● Excessive prenatal weight gain
● The mother has risks such as gestational diabetes
Signs Symptoms
V. Management
● Nursing, Medical, Pharmacologic, Surgical
Nursing Management Medical Management Pharmacologic Surgical Management
Management
● Enter maneuver
(internal rotation)
- The aim of this
maneuver is to
get the fetus to
rotate his or her
anterior shoulder
into an oblique
plane and under
the maternal
symphysis.
● Zavanelli
Maneuver - In
cases of shoulder
dystocia, an
obstetric
procedure that
involves pushing
the delivered
head back into
the birth canal.
VI. Relevant Pictures/Videos
https://www.youtube.com/watch?fbclid=IwAR3iN85_6JvJS4rMmwlbVw-
ODlroFsizPH3HExdne3RXUTv0_mylkRxo4Vw&v=j_bibDLPW98&feature=youtu.be&ab_channel
=TrialExhibits%2CInc.
VII. One (1) priority Nursing Care Plan for each complication
Nursing Nursing Scientific Basis Objectives of Nursing Actions Rationale
Assessment Diagnosis Care
4.) Note 4. A
effacemen contributin
t,fetal g reason
station for
and fetal prolonged
presentati labor
on. could be
identified
using
these
labor
progress
indicators.
Source: Martin, P.
B. (2019, June 1).
4 Dysfunctional
Labor (Dystocia)
Nursing Care
Plans.
Nurseslabs.
Retrieved
February 12,
2022, from
https://nurseslabs
.com/4-
dysfunctional-
labor-dystocia-
nursing-care-
plans/
Dependent
8.) Prepare 8. An
the patient episiotomy
for an is a
emergenc procedure
y surgical in which
procedure an incision
to deliver is
the baby performed
with in the
shoulder perineum,
dystocia the area
as ordered between
by the the vagina
physician. and the
anus. It
prevents
tearing
and
expands
the
delivery
canal,
allowing
the infant
to slide
through
more
easily.
Source: Dystocia
nursing care plans
and diagnosis
interventions.
NurseStudy.Net.
(2020, December
5). Retrieved
February 11,
2022, from
https://nursestudy
.net/dystocia-
nursing-care-
plans/
9.) As 9. It can help
prescribed distinguish
by the the
physician, difference
administer between
a narcotic false and
or true
sedative,s labor.Morp
uch as hine aids
morphine, in the
pentobarbi elimination
tal of
(Nembutal hypertonic
), or contractile
secobarbit patterns
al and
(Seconal), promotes
for sleep. deep
sedation.T
o alleviate
fatigue, a
period of
rest
conserves
energy
and lowers
the use of
glucose.
Source:Martin, P.
B. (2019, June
1). 4
Dysfunctional
Labor (Dystocia)
Nursing Care
Plans.
Nurseslabs.
Retrieved
February 12,
2022, from
https://nurseslab
s.com/4-
dysfunctional-
labor-dystocia-
nursing-care-
plans/
Interdependent
10.) Co 10. Excessive
llaborate prenatal
with a weight
dietitian gain of the
for the mother is
mother to one of the
monitor causes of
her food shoulder
intake. dystocia.
By
assessing
the
mothers
diet, this
will ensure
a healthier
pregnancy
and
postpartu
m period.
Source: CM;, J.
(2021, August 9).
Shoulder
dystocia: Etiology,
common risk
factors, and
management.
Journal of
midwifery &
women's health.
Retrieved
February 12,
2022, from
https://pubmed.nc
bi.nlm.nih.gov/16
260363/
REFERENCES:
Shoulder dystocia. (2019, June). March of Dimes. Retrieved February 12, 2022, from
https://www.marchofdimes.org/complications/shoulder-dystocia.aspx