• fetus
• pelvic bones & other pelvic structures
• uterine contractions
• client's psychological state

• prolonged labor
• potential for operative delivery
• extension of episiotomy
• 3rd or 4th degree laceration of perineum

• intense back pain in labor
• dysfunctional labor pattern
• prolonged active phase
• secondary arrest of dilatation
• arrest of descent 

• occurs because of ineffective contractions or flattened bony pelvis 
• results in fetal head being in horizontal or transverse position
• vaginal delivery can be accomplished by stimulating contractions with Pitocin and use of forceps if pelvic structure is inadequate

• fetal ecchymosis or edema of face
• transient facial paralysis
• maternal lacerations
• episiotomy extensions

• newborn cephalohematoma
• retinal hemorrhage
• intracranial hemorrhage

• vertex
• brow
• face
• sincipital (military attitude)
• breech
• shoulder

• increased risk of prolonged labor and operative delivery
• anticipate vaginal delivery if mother's pelvis is adequate and infant's chin (mentum) is in anterior position
• Anticipate cesarean delivery if mentum is posterior or signs of fetal distress occur
• Fetal monitor electrode should NOT be placed on presenting part
• edema and bruising of face, eyes, and lips are common 

• "military attitude"
• larger diameter of fetal head is presented
• labor progress is slowed with slower descent of fetal head

1. Frank Breech
2. Incomplete (footling) breech
3. Complete breech

• prolonged labor (decreased pressure exerted by breech on cervix)
• PROM (risk of infection)
• cesarean or forceps delivery
• trauma to birth canal during delivery (manipulation and forceps)
• intrapartum or postpartum hemorrhage

• compressed or prolapsed umbilical cord
• entrapment of fetal head in incompletely dilated cervix
• aspiration and asphyxia at birth
• birth trauma from manipulation and forceps to free fetal head

• fetal body may pass through an incompletely dilated cervix, entrapping larger fetal head
• head must be delivered quickly to avoid hypoxia
• piper forceps (long handle) may be applied to after-coming fetal head

• acromium process is presenting part
• transverse lie
• vaginal delivery not considered possible
• possible use of external cephalic version

• place on external fetal monitor
• start IV fluids
• administer terbutaline (Brethine) via IVPB to relax uterine muscle
• closely monitor FHR
• discontinue version if undue maternal or fetal distress occurs

• more than one part of fetus presents
• most common type is hand or arm prolapsing behind head
• Risk of cord compression and prolapse

• Leopold's maneuvers for detection
• observe for abnormal labor patterns
• monitor FHR and contractions continuously
• Provide client and family teaching
• provide client support
• anticipate forceps-assisted birth
• anticipate cesarean birth for incomplete breech or shoulder presentations
• prepare for neonatal emergencies 

• reposition mother on left side
• administer O2 by face mask at 8-10 L/min
• increase IV fluids
• discontinue oxytocin infusion
• notify provider immediately

• reposition mother on either side
• if not corrected, reposition on other side
• administer O2 by face mask at 8-10L/min
• Trendelenburg or knee-chest position
• vaginal exam and apply upward digital pressure on presenting part to relieve pressure on umbilical cord

• varies <2-5 bpm, appears flat
• indicates depression of ANS; controls HR
• affected by fetal sleep, sedation, and hypoxia

• FHR slows following peak of contraction and slowly returns to baseline rate during resting phase
• indicates fetal response to hypoxia form uteroplacental insufficiency
• considered omnious pattern regardless of depth of deceleration of FHR and requires immediate intervention

• FHR repeatedly decelerates below 90 bpm for > 60 sec before returning to baseline
• indicates interference of fetal blood flow from cord compression
• leads to fetal hypoxia and low APGAR scores unless corrective steps are taken

• ROM before engagement 
• small fetus
• breech presentation
• multifetal pregnancy
• transverse lie (shoulder presentation)

• place mother in knee-chest or trendelenburg position
• perform sterile vaginal exam pushing fetal presenting part upward with fingers to relieve pressure on cord
• administer O2 by face make at 8-10 L/min
• maintain continuous fetal monitoring
• Prepare for rapid delivery via vaginally or cesarean 

• determine presence of pulsation
• wrap cord loosely with warm sterile saline soaked towel or dressing to prevent drying
• do not allow dressing or towel to cool, which could cause spasms of cord vessels and decrease fetal oxygen

• anterior-posterior diameter < 10 cm
• transverse diameter <12 cm
• makes engagement difficult
• influences fetal position and presentation

• interspinous diameter < 9.5 cm
• hampers internal rotation of fetal head
• secondary arrest of dilatation or arrest of descent of fetal head occurs 

• interischial tuberous diameter < 8 cm

• physician may allow labor to continue or may even stimulate labor with oxytocin when pelvic measurements are borderline to see if fetal head will descend, making vaginal delivery possible 
• if progressive changes in dilatation and station do not occur, a cesarean delivery is performed 

• fetal head is too large to pass through bony pelvis
• cesarean necessary

• prolonged labor
• exhaustion
• hemorrhage
• infection

• lacerations and tears of birth canal
• postpartum hemorrhage

• hypoxia
• fractures of clavicle
• injury to neck and head
• death

• obesity
• increased fundal height
• hx of macrosomia
• maternal diabetes or gestational diabetes
• prolonged 2nd stage of labor

• Epinephrine secreted in response to stress
• Vascular changes divert blood from uterus to skeletal muscles 
• Oxygen and glucose supplies decrease accumulation of lactic acid in uterine muscle
• higher perception of pain
• decrease in available energy supply to support effective contractions
• labor progress is slowed

• dystocia
• CPD
• fetal distress
• breech presentation
• previous cesarean birth

• aspiration or pulmonary embolism
• hemorrhage or infection
• injury to bowel or bladder
• thrombophlebitis

• prematurity
• injury at birth
• respiratory problems caused by delayed absorption of fetal lung fluid

• vertical 
• Pfannenstiel's: transverse lower abdominal incision

• Classical: through upper uterine segment
• low cervical transverse: low uterine segment
• Lower uterine segment vertical 

• assess NPO status
• explain procedure to client and family
• obtain consent
• perform abdominal prep
• insert foley cath to prevent bladder trauma
• start IV fluids using large bore catheter
• administer antacid IV or PO to decrease risk of lung damage form aspirating acidic gastric contents during surgery
• administer antibiotics as ordered
• assist with positioning & administration of regional anesthesia if used

• provide heated crib and supplies for NB
• provide immediate care to NB 
• provide assistance to surgical team and immediate care for mother

• v/s, pulse oximetry, & cardiac monitoring q15min for first hour and until stable
• begin postanesthesia assessments
• assess fundus for firmness and location
• assess vaginal bleeding
• assess catheter and urine output
• turn, cough, deep breath hourly
• assess for return of sensation 
• admin medication for pain PRN
• promote maternal-infant contact and bonding

labor and vaginal birth after previous cesarean is considered safe option if indication for cesarean delivery is not likely to be repeated

• previous classical incision into the uterus
• large infant (over 4000g)
• malpresentatioin
• pelvic measurements inadequate
• any fetal or placental problem that may require cesarean section
• delivery in alternative birth setting

• uterine rupture and hemorrhoage (1%)
• failure of trial of labor, requiring repeat cesarean

• ability to experience vaginal L&D (70% success rate)
• vaginal delivery is less costly with fast, easier recovery period and less risk complications
• does not preclude induction or augmentation of labor

• shock or hemorrhage
• report of "ripping or tearing" sensation or sharp uterine pain
• abrupt cessation of contractions
• abrupt onset of fetal distress
• more easily palpated fetus (lying outside of uterus)

• induction of labor
• dystocia or difficult labor
• premature labor
• precipitate labor and birth
• uterine prolapse
• uterine rupture

• cervical ripening with prostaglandins or laminaria
• amniotomy
• misoprostol (cytotec)
• Oxytocin (Pitocin)

• placenta previa
• transverse lie and other fetal malpresentations
• prior classic uterine incision
• pelvic structure abnormality
• prolapsed umbilical cord
• active genital herpes
• invasive cervical cancer 

• prolonged labor
• nonprogressive labor
• pain
• fatigue

sedation aimed at stopping contractions, promoting rest, and allowing normal labor pattern to develop

*Nursing actions: hydrate, monitor I&O, promote relaxation

• rule out CPD
• initiate augmentation of labor with oxytocin

• more than 20hrs for nulliparous client or more than 14hrs for multiparous client
• may indicate CPD
• may be caused by false labor
• medical treatment is sedation and rest

• dilatation less than 1.2 cm per hour in nulliparous client or less than 1.5cm per hour in multiparous client
• may be caused my malposition
• assess for CPD and fetal presentation and position

• less than 1 cm per hour change in station in nulliparous client or less than 2 cm per hour in multiparous client
• rule out CPD
• assess contraction intensity and duration
• labor may be augmented with oxytocin 

• cessation of dilatation for more than 2 hours in nulliparous client or more than 1 hour in multiparous client
• rule out CPD
• augment labor, if CPD absent

• no progress in fetal station for more than 1 hour
• assess for CPD
• augment labor, if CPD if absent

1. Physiologic retraction ring
2. Bandl's Ring
3. Constriction Ring

• a boundary btw upper & lower uterine segments that normally forms during labor
• upper segment contracts and becomes thicker as muscle fibers shorten
• lower segment distends and becomes thinner

• a pathological retraction ring that forms when labor is obstructed due t CPD or other complications
• upper segment continues to thicken while lower segment continues to distend
• risk of uterine rupture increases if contractions continue, so cesarean is indicated

• retraction ring forms and impedes fetal descent
• relaxation of constriction ring with analgesics, anesthetics, or both allows vaginal delivery

• contractions occurring q10min or less with or without pain
• low abdominal cramping with or without diarrhea
• intermittent sensation of pelvic pressure, urinary frequency
• low backache (constant or intermittent)
• increased vaginal discharge, may be pink-tinged
• leaking amniotic fluid 

• empty bladder
• assume side-lying position, left preferred
• drink 3-4 cups of water
• palpate abdomen for contractions; if 10 min apart or closer, contact provider
• rest for 30 min and slowly resume activity if Sx disappear
• contact provider if Sx don't subside

• bedrest
• monitor FHR and contractions
• administer ordered tocolytic agents 
• administer betamethasone or dexamethasone to stimulate fetal lung maturity

• drugs to stop labor contractions
• ritodrine (Yupopar)
• terbutaline (brethine)
• magnesium sulfate

• inverted uterus is visible outside introitus
• life-threatening bc of severe hemorrhage and shock
• uterus must be immediately replaced manually to stop blood loss

• uterine fundus is partially inverted, impeding contraction and control of hemorrhage
• not visible but can be palpated
• corrected by physician using a bimanual technique

• tearing open or separation of uterine wall
• rare, but serious
• occurs in 1 in 1,500-2,000 births

• separation of scar from previous classical cesarean
• uterine trauma
• intense uterine contractions
• overstimulation of labor with oxytocin
• difficult forceps-assisted birth
• external cephalic or internal version

• mulitparity
• overdistention of uterus with multifetal pregnancy
• malpresentation
• previous uterine surgery

1. complete
2. incomplete

• extends through uterine wall into peritoneal cavity
• requires management of shock, replacement of blood, and hysterectomy 

• extends into peritoneum but not into peritoneal cavity
• often due to partial separation of cesarean scar
• may go unnoticed until repeat cesarean is performed
• may require laparotomy, repair, and blood transfusions

• cervical, vaginal, or rectal lacerations
• hemorrhage

• hypoxia (decreased perfusion to intervillous space)
• intracranial hemorrhage (rapid passing through birth canal)
• injury at birth

• instruct client to blow or pant to decrease urge to push
• support perineum with a sterile towel as crowning occurs
• apply gentle pressure on fetal head to prevent rapid delivery to prevent lacerations and rapid fetal intracranial pressure changes
• suction infant's mouth then nose after delivery of head
• check for umbilical cord around neck: apply 2 clamps and cut cord in btw clamps
• place hands of each side of head and instruct client to push
• gentle downward pressure facilitates birth of anterior shoulder
• gentle upward pressure facilitates birth of posterior shoulder
• observe for signs of placental separation