1 A WOMAN WHO DEVELOPS COMPLICATION DURING LABOR AND BIRTH

Dystocia
Inertia

A difficult labor
is a time-honored term to denote that sluggishness of contractions, or the force
of labor, has occurred.
dysfunctional labor
can occur at any point in labor, but it is generally classified as primary
(occurring at the onset of labor) or secondary (occurring later in labor).
Uterine contractions
are the basic force moving the fetus through the birth canal.
HYPOTONIC CONTRACTIONS
hypotonic uterine
the number contractions is unusually low or infrequent (not more two
contractions
or three occurring in a 10-minute period).
* The resting tone of the uterus remains less than 10 mm Hg, and the strength
of
contractions does not rise above 25 mm Hg
Hypotonic contractions are most apt to occur during
ACTIVE PHASE
Analgesia, 3 to 4
They may occur after the administration Of_, especially if the cervix is not
dilatated to _cm or if bowel or bladder distention prevents descent or firm
engagement.
They may occur in a uterus that_.
Multiple gestation
Larger-than-usual single
fetus
Hydramnios
A uterus that is lax from
grand multiparity.
not exceedingly painful
Such contractions are_, because Of their lack of intensity.
length of labor
Hypotonic contractions increase the_, because
more of them are necessary to achieve cervical dilatation.
HYPERTONIC CONTRACTIONS
Hypertonic uterine
_marked by an increase in resting tone to more than 15 mm Hg (see Fig.
contractions
23.1C).
However, the intensity of the contraction may be no stronger than that
associated with hypotonic contractions.
Hypertonic uterine
This type of contraction occurs because the muscle
contractions
fibers of the myometrium do not repolarize or relax after a contraction,
thereby wiping it clean to accept a new pacemaker stimulus.
more painful than usual
They tend to be_ because the myometrium becomes tender from constant
lack of relaxation and the anoxia of uterine cells that results.
to fetal anoxia
A danger of hypertonic contractions is that the lack of relaxation between
contractions may not allow optimal uterine artery filling; this could lead _early in
the
latent phase of labor.
cesarean birth
If deceleration in the fetal heart rate (FHR) or an abnormally long first stage of
labor or lack of progress with pushing (second-stage arrest) occurs, _may be
necessary.
UNCOORDINATED CONTRACTIONS
one pacemaker
With uncoordinated contractions, more than _may be initiating contractions, or
receptor points in the myometrium may be acting independently of the
pacemaker.
good cotyledon filling.
Uncoordinated contractions
may occur so closely together that they do not allow_.
breathing exercises with
it may be difficult for a woman to rest between contractions or to use_.
contractions.
Oxytocin administration
_may be helpful in uncoordinated labor to stimulate more effective and

2 A WOMAN WHO DEVELOPS COMPLICATION DURING LABOR AND BIRTH

consistent pattern of contractions with a better, lower resting tone.
DYSFUNCTION AT THE FIRST STAGE OF LABOR
PROLONGED LATENT PHASE
prolonged latent phase
When contractions become ineffective during the first stage of labor, a _ can
develop.
20 hours, 14 hours
A prolonged latent phase, as defined by Friedman (1978), is a latent phase that
is longer than
_in a nullipara or _in a multipara
not ripe
This may occur if the cervix is _at the beginning of labor and time must be
spent getting truly ready for labor.
analgesic
It may occur if there is excessive use of an _early in labor.
a hypertonic state.
With a prolonged latent phase, the uterus tends to be in _
inadequate

Relaxation between contractions is_, and the contractions are only mild (less
than 15 mm Hg on a monitorprintout) and therefore ineffective.
Management of a prolonged latent phase in labor that has been caused by
hypertonic contractions involves _.

Helping the uterus to rest

Providing adequate fluid
for hydration, and pain
Relief with a drug such as
morphine sulfate.
_can also be helpful.
Changing the linen and
the womans gown
Darkening room lights
decreasing noise and
stimulation
a cesarean birth or
If it does not progress, _ to assist labor may be necessary.
amniotomy (artificial
rupture of membranes)
and oxytocin infusion
PROTRACTED ACTIVE PHASE
with cephalopelvic
A protracted active phase is usually
disproportion (CPD) or
Associated_ although it may reflect ineffective myometrial activity.
fetal malposition
1.2 cm/hr, 1.5
This phase is prolonged if cervical dilatation does not occur at a rate of at least
_in a nullipara _ in a multipara.
cm/hr
12 hours, 6 hours
if the active phase lasts longer than _in a primigravida or _in a multigravida.
cesarean birth
If the cause of the delay in dilatation is fetal malposition or CPD_ may be
necessary.
hypotonic
during the dilatational division of labor tends to be_.
oxytocin
After an ultrasound to show that CPD is not present,_may be prescribed to
augment labor.
PROLONGED DECELERATION PHASE
beyond 3 hours, 1 hour
A deceleration phase has become prolonged when it extends _hrs in a
nullipara or_in a multipara.
abnormal fetal head
Prolonged deceleration phase most often results from_.
position
Cesarean birth
A_ is frequently required.
SECONDARY ARREST OF DILATATION
No, 2 hours
A secondary arrest of dilatation has occurred if there is _progress in cervical
dilatation for longer than_. Again, cesarean birth may be necessary.
DYSFUNCTION AT THE SECOND STAGE OF LABOR

3 A WOMAN WHO DEVELOPS COMPLICATION DURING LABOR AND BIRTH

PROLONGED DESCENT
1.0 cm/hr, 2.0
cm/hr
3 hours
Intravenous (IV) oxytocin
semi-Fowlers
ARREST OF DESCENT
1 hour, 2 hours
engagement or
movement beyond 0
station
CPD
Cesarean,oxytocin
CONTRACTION RINGS
contraction ring
Pathologic Retraction
Ring (Bandls ring)
upper uterine segment

uncoordinated
contractions
obstetric manipulation or
by the administration of
oxytocin.
Administration of IV
morphine sulfate, of amyl
nitrite
tocolytic
massive maternal
hemorrhage
cesarean birth

PRECIPITATE LABOR
Precipitate labor and
birth
Precipitate labor
Precipitate dilatation,
5 cm, 10 cm
grand multiparity,
oxytocin or amniotomy
hemorrhage

12 minutes, 6 minutes

Prolonged descent of the fetus occurs if the rate of descent is less than _in a
nullipara or _in a multipara.
It can be suspected if the second stage lasts over _in a multipara.
_may be used to induce the effect to contract effectively.
A _position, squatting, kneeling, or more effective pushing may speed descent.
Arrest of descent results when no descent has occurred for _in a multipara or
_in a nullipara.
Failure of descent has occurred when expected descent of the fetus does not
begin or_ has not occurred.
The most likely cause for arrest of descent during the second stage is_.
_usually is necessary. If there is no contraindication to vaginal birth,_may be
used to assist labor.
A _is a hard band that forms across the uterusat the junction of the upper and
lower uterine segments and interferes with fetal descent.
The most frequent type seen is termed a_. The ring usually appears during the
second stage of labor and can be palpated as a horizontal indentation across
the abdomen.
It is a warning sign that severe dysfunctional labor is occurring as it is formed
by excessive retraction of the_; the uterine myometrium is muchthicker above
than below the ring.
When a pathologic retraction ring occurs in early labor, it is usually caused by_.
In the pelvic division of labor, it is usually caused by_

_or the inhalation _may relieve a retraction ring.

A _can also be administered to halt contractions.

In the placental stage, _may result, because the placenta is loosened but then
cannot deliver, preventing the uterus from contracting.
Most likely, a _will be necessary to ensure safe birth of the fetus.
Manual removal of the placenta undergeneral anesthesia may be required if
the retraction ring does not allow the placenta to be delivered.
_occur when uterine contractions are so strong that a woman gives birth with
only a few, rapidly
occurring contractions.
It is often defined as a labor that is completed in fewer than 3 hours
_is cervical dilatation that occurs at a rate of _or more per hour in a primipara
or _or more per hour in a multipara.
Such rapid labor is likely to occur with _, or it may occur after induction of labor
by_.
Contractions can be so forceful that they lead to premature separation of the
placenta, placing
the woman at risk for_.
A precipitate labor can be predicted from a labor graph if, during the active

4 A WOMAN WHO DEVELOPS COMPLICATION DURING LABOR AND BIRTH

phase of dilatation, the rate is greater than 5 cm/hr (1 cm every_) in a nullipara

or 10 cm/hr (1 cm every_) in a multipara.
tocolytic
In such instances, a _may be administered to reduce the force and frequency
of contractions.
week 28
Caution a multiparous woman by _of pregnancy that, because a past labor was
so brief, her labor this time also may be brief.
INDUCTION AND AUGMENTATION OF LABOR
Induction of labor
_means that labor is started artificially.
Augmentation of labor _refers to assisting labor that has started spontaneously but is not effective.
labor
Induction may be necessary to initiate _before the time when it would have
occurred spontaneously.
The primary reasons for inducing labor include the presence of _.
Pre-eclampsia
Eclampsia
Severe hypertension
diabetes
Rh sensitization
Prolonged rupture of the
membranes
Intrauterine growth
restriction
Postmaturity (a
pregnancy lasting
beyond 42 weeks)
hypotonic
Augmentation of labor or assistance to make uterine contractions stronger may
be necessary if the contractions are _or too weak or infrequent to be effective.
Because augmentation or initiation of labor carries a risk
Decrease in the fetal
of uterine rupture, _.
blood supply from poor
cotyledon filling
premature separation
of the placenta
A multiple gestation
Hydramnios
Grand parity
Maternal age older than
40 years
Previous uterine scars.
Before induction of labor is begun, the following conditions
The fetus is in a
should be present:
longitudinal lie.
The cervix is ripe, or
ready for birth.
A presenting part is
engaged.
There is no CPD
The fetus is estimated to
be mature by date
CERVICAL RIPENING
Cervical ripening
_, or a change in the cervical consistency from firm to soft, is the first step the
uterus must complete in early labor.
scoring the cervix
To determine whether a cervix is ripe, or ready for dilatation, Bishop (1964)
established criteria for _

5 A WOMAN WHO DEVELOPS COMPLICATION DURING LABOR AND BIRTH

8 or greater
stripping the membranes

Bleeding from an
Undetected low-lying
placenta
Inadvertent rupture of
membranes
The possibility of
infection if membranes
should rupture.
hygroscopic suppositories

laminaria technique

prostaglandin gel,
misoprostol

6 hours, Two or three

side-lying, FHR

Using this scale, if a womans total score is _the cervix is considered ready for
birth and should respond to induction.
One of the method used to ripen the cervix known as _, or separating the
membranes from the lower uterine segment manually, using a gloved finger in
the cervix.
Possible complications of this mechanical method include _

The use of _(suppositories of seaweed that swell on contact with cervical

secretions) is also a
time-honored method.
These suppositories can be inserted to gradually and gently urge dilatation (_).
They are held in place by gauze sponges saturated with povidone-iodine or an
antifungal cream.
A more commonly used method of speeding cervical ripening is the application
of a_, such as _, to the interior surface of the cervix by acatheter or
suppository, or to the external surface by applying it to a diaphragm and then
placing the diaphragm against the cervix.
Additional doses of misoprostol may be applied every_. _doses are usually
adequate to cause ripening.
Women should remain in bed in a _position to prevent leakage of the
medication,
and the_ should be monitored continuously for at least 30 minutes after each
application.
Side effects are_ so these should also be monitored.

Vomiting,
Fever
Diarrhea
Hypertension
6 to 12 hours
Oxytocin induction may be started _after the last prostaglandin dose.
INDUCTION OF LABOR BY OXYTOCIN
oxytocin
Administration of _ (synthetic form of naturally occurring pituitary hormone)
initiates contractions in a uterus at pregnancy term.
Intravenously
Oxytocin is always administered_.
3 minutes

10 IU in 1000 mL
10,000 milliunits
(mU)
water intoxication
headache and vomiting
seizures, coma, and
death

Because the half-life of oxytocin is approximately_, the falling serum level and
effects are apparent almost immediately after discontinuation of IV
administration.
Usually a form of oxytocin, such as Pitocin, is mixed in the proportion of _of
Ringers lactate.
Ten international units of oxytocin is the same as_, so each milliliter of this
solution contains 10 mU of oxytocin.
Oxytocin has an antidiuretic side effect that can result in decreased urine flow,
possibly leading to_.
Water intoxication is first manifested by _.
Water intoxication in its most severe form can lead to _because of the large
shift in interstitial tissue fluid.

6 A WOMAN WHO DEVELOPS COMPLICATION DURING LABOR AND BIRTH

AUGMENTATION BY OXYTOCIN
weak, irregular, or
Augmentation of labor is required if labor contractions begin spontaneously but
ineffective
then become so _(hypotonic) that assistance is needed to strengthen them.
ACTIVE MANAGEMENT OF LABOR
12 hours
It includes the aggressive administration of oxytocin to shorten labor
to_, which presumably reduces the incidence of cesarean birth and
postpartal infection.
36 to 40 mU/min
The maximum dosage of oxytocin used may be as high as_.
UTERINE RUPTURE
Uterine rupture
_occurs when a uterus undergoes more strain than it is capable of sustaining.
Assessing the pregnant woman with complete uterine rupture includes:
Rapid, weakpulse
Falling bloodpressure
Possible vaginal bleeding
Rupture occurs most commonly when a_.
Vertical scar from a
previous cesarean birth
Hysterotomy repair tears
Contributing factors may include_
Prolonged labor
.
Abnormal presentation
Multiple gestation
Unwise use of oxytocin
Obstructed labor
Traumatic maneuvers of
forceps
Traction
fetal death
When uterine rupture occurs, _ will follow unless immediate cesarean birth can
be accomplished.
complete
Rupture can be _, going through the endometrium, myometrium, and
peritoneum layers, or incomplete, leaving the peritoneum intact.
swellings
Two distinct _will be visible on the womans abdomen: the retracted uterus and
the extrauterine fetus.
Signs of shock begin_.
Rapid weak pulse
Falling blood pressure
Cold and clammy
Skin dilatation of the
Nostrils from air hunger
Less evident
If the rupture is incomplete, the signs of rupture are_.
lower uterine segment
With an incomplete rupture, a woman may experience only a localized
tenderness and a persistent aching pain over the area of the_.
ultrasound
Uterine rupture can be confirmed by_.
IV oxytocin
Anticipate use of _to attempt to contract the uterus and minimize bleeding.
INVERSION OF THE UTERUS
Uterine inversion
_refers to the uterus turning inside out with either birth of the fetus or delivery
of the placenta.
Uterine inversion
It may occur if traction is applied to the umbilical cord to remove the placenta or
if pressure is applied to the uterine fundus when the uterus is not contracted.
placenta
It may also occur if the _is attached at the fundus so that,
during birth, the passage of the fetus pulls the fundus down.
inverted
The _fundus may lie within the uterine cavity or the vagina, or, in total
inversion,
it may protrude from the vagina.

7 A WOMAN WHO DEVELOPS COMPLICATION DURING LABOR AND BIRTH

Hypotension
Dizziness
Paleness
Diaphoresis
bleeding
eneral anesthesia or
possibly nitroglycerin or a
tocolytic
antibiotic therapy

If the loss of blood continues unchecked for longer than a few minutes,
the woman will show signs of blood loss_.

Never attempt to replace an inversion, because handling of the uterus may

increase the_.
The woman will immediately be given _ drug intravenously, to relax the uterus.

Because the uterine endometrium was exposed, a woman will need _to
prevent infection.
AMNIOTIC FLUID EMBOLISM
Amniotic fluid
_occurs when amniotic fluid is forced into an open maternal uterine blood sinus
through some defect in the membranes or after membrane rupture or partial
embolism
premature separation of the placenta.
humoral or anaphylactoid it is recognized that a _is the more likely cause.
response
labor or in the postpartal
This condition may occur during_.
period
experiences pulmonary
A woman, in strong labor, sits up suddenly and grasps her chest because of
sharp
artery constriction
pain and inability to breathe as she_
bluish gray
She becomes pale and then turns the typical_associated with pulmonary
embolism and
lack of blood flow to the lungs.
oxygen administration by The immediate management is _.
face mask or cannula.
Disseminated
Even if the woman survives the initial insult, the risk for _ is high, further
intravascular coagulation compounding her condition.
(DIC)
PROBLEMS WITH THE PASSENGER
PROLAPSE OF THE UMBILICAL CORD
umbilical cord
In_, a loop of the umbilical cord slips down in front of the presenting fetal part
prolapse
membranes rupture
Prolapse may occur at any time after the _ if the presenting fetal part is not
fitted firmly into the cervix.
Premature rupture of
It tends to occur most often with:
membranes
Fetal presentation other
than cephalic
Placenta previa
Intrauterine tumors
preventing the
presenting part from
engaging
A small fetus
Cephalopelvic
disproportion preventing
firm engagement
Hydramnios

8 A WOMAN WHO DEVELOPS COMPLICATION DURING LABOR AND BIRTH

Multiple gestation
Amnioinfusion

MULTIPLE GESTATION
Anoxia, cord
entanglement and
premature separation of
the placenta
Anemia and pregnancyinduced hypertension
analgesia or
anesthesia

_is the addition of a sterile fluid into the uterus to supplement the amniotic fluid
. The technique neithershortens nor prolongs labor; it just prevents additional
cord
compression.
Twins may be born by cesarean birth to decrease the risk that the second
fetus will experience_; this also is often the situation in multiple gestations of
three or more, because of the increased incidence of _.
_occur at higher-than-usual incidences during multiple gestations.
During labor, support the womans breathing exercises to minimize the need
for_; this helps to minimize any respiratory difficultiesthe infants may have at
birth because of their immaturity.
Uterine dysfunction from a long labor, an_of the first child may also be more
common.

Overstretched uterus
Unusual presentation
Premature separation of
the placenta after the
birth
PROBLEMS WITH FETAL POSITION,PRESENTATION, OR SIZE
OCCIPITOPOSTERIOR POSITION
posterior
In approximately one tenth of all labors, the fetal position is_rather than
anterior.
90-degree arc
In these positions, during internal rotation, the fetal head must rotate,
not through a _but through an arc of approximately 135 degrees
Rotation from a posterior position can be aided by having the woman assume
A hands and knees
a_.
position
Squatting
Lying on her
Side
android, anthropoid, or
Posterior positions tend to occur in women with_.
contracted pelvis.
BREECH PRESENTATION
week 38
Most fetuses are in a breech presentation early in pregnancy. However, by_, a
fetus normally turns to a cephalic presentation.
There are several types of breech presentation:
Complete
Frank
Footling
Anoxia from a
Breech presentation is more hazardous to a fetus than a cephalic presentation,
prolapsed cord
because there is a higher risk of:
Traumatic injury to the
aftercoming head
(possibility of
intracranial hemorrhage
or anoxia)
Fracture of the spine or
arm
Dysfunctional labor
Early rupture of the

9 A WOMAN WHO DEVELOPS COMPLICATION DURING LABOR AND BIRTH

membranes because of
the poor fit of
the presenting part
abdomen
FACE PRESENTATION
asynclitism
fetal heart tones
extend the head

BROW PRESENTATION
a multipara or a woman
with relaxed abdominal
muscles.
TRANSVERSE LIE
pendulous abdomens,
with uterine fibroid
tumors
hydrocephalus

With a breech presentation, fetal heart sounds usually are heard high in the_.
A fetal head presenting at a different angle than expected is termed_.
If the back is extremely concave, _may be transmitted to the forward-thrust
chest and heard on the side of the fetus where feet and arms can be palpated.
A fetus in a posterior position, instead of flexing the head as labor proceeds,
may_, resulting in a face presentation; this usually occurs in a woman with a
contracted pelvis or placenta previa.
A brow presentation is the rarest of the presentations. It occurs in _.

Transverse lie occurs in women with _that obstruct the lower uterine segment.

It may occur in infants with _or another abnormality that prevents the head
from engaging.
OVERSIZED FETUS (MACROSOMIA)
multiparity
Large babies are also associated with_, because each infant born to a woman
tends to be slightly heavier and larger than the one born just before.
SHOULDER DYSTOCIA
Shoulder dystocia
_is a birth problem that is increasing in incidence along with the increasing
average weight of newborns.
vaginal or cervical tears
This is hazardous to the woman because it can result in_.
Shoulder dystocia is most apt to occur in women with _.
Diabetes
Multiparas
Post-date pregnancies
FETAL ANOMALIES
Hydrocephalus,
Fetal anomalies of the head such as _(fluid-filled
anencephaly
ventricles) or _(absence of the cranium)
PROBLEMS WITH THE PASSAGE
INLET CONTRACTION
11 cm, 12 cm
Inlet contraction is narrowing of the anteroposterior diameter to less than_, or
of the transverse diameter to _ or less.
rickets
It usually is caused by _in early life or by an inherited small pelvis.
Weeks 36 to 38
In primigravidas, the fetal head normally engages between _of pregnancy.
OUTLET CONTRACTION
11 cm
Outlet contraction is narrowing of the transverse diameter at the outlet to less
than_.
TRIAL LABOR
inlet measurement
If a woman has a borderline (just adequate) _are good.
and the fetal lie and
position
2 hours
Urge the woman to void every _so that her urinary bladder is as empty as
possible, allowing the fetal head to use all the space available.
prolapsed cord and
After rupture of the membranes, assess FHR carefully; if the fetal head is still

10 A WOMAN WHO DEVELOPS COMPLICATION DURING LABOR AND BIRTH

anoxia
(6 to 12 hours)

high, there is an increased danger of _to the fetus.

If after a definite period _ adequate progress in labor cannot be documented,
or if at any time fetal distress occurs, the woman will be scheduled for a
cesarean birth.
EXTERNAL CEPHALIC VERSION
External cephalic
_is the turning of a fetus from a breech to a cephalic position before birth.
version
34 to 35 weeks
It may be done as early as _.
tocolytic
A _ agent may be administered to help relax the uterus.
pressure
Gentle _is then exerted to rotate the fetus in a forward direction to a cephalic
lie
Contraindications to the procedure include_.
Multiple gestation
Severe oligohydramnios
Contraindications to
vaginal birth
A cord that wraps around
the fetal neck
And unexplained thirdtrimester bleeding,
placenta previa
FORCEPS BIRTH
Obstetrical forceps
_are steel instruments constructed of two blades that slide together at their
shaft to form a handle.
A woman is unable to
Forceps may be necessary, however, if any of the following conditions occur:
push with contractions in
the pelvic
division of labor such as
might happen with a
woman who
receives regional
anesthesia or has a
spinal cord injury.
Cessation of descent in
the second stage of labor
occurs.
A fetus is in an
abnormal position or is
immature.
A fetus is in distress
from a complication such
as a prolapsed
cord.
forceps birth
A _is a forceps outlet procedure in which the forceps are applied after the fetal
head reaches the perineum.
low forceps birth
The term _may be used to indicate that the fetal head is at a +2 station or
more.
midforceps birth
If the fetal head is engaged but at less than +2 station, the procedure
is called a _.
Membranes must be
Before forceps are applied:
ruptured.

11 A WOMAN WHO DEVELOPS COMPLICATION DURING LABOR AND BIRTH

CPD must not be
present.
The cervix must be fully
dilated.
The womans bladder
must be empty.
FHR

1 to 2

Record _before forceps application. Because there is a danger that the cord
could be compressed between the forceps blade and the fetal head, assess it
again immediately after application.
forceps birth may leave a transient erythematous mark on the newborns
cheek. This mark will fade in _ days with no long-term effects.

VACUUM EXTRACTION
vacuum extraction
A fetus, if positioned far enough down the birth canal, may be born by _
disk-shaped cup
With the fetal head at the perineum, a _is pressed
against the fetal scalp, over the posterior fontanelle.
little anesthesia
Vacuum extraction has advantages over forceps birth in that _is necessary
(leaving the fetus with less respiratory depression at birth) and fewer
lacerations of the birth canal occur.
ANOMALIES OF THE PLACENTA AND CORD
ANOMALIES OF THE PLACENTA
500 g, 15 to 20 cm
The normal placenta weighs approximately and is _in diameter_thick.
PLACENTA SUCCENTURIATA
placenta succenturiata A _ is a placenta that has one or more accessory lobes connected to the main
placenta
by blood vessels.
fetal abnormality
No _is associated with this type.
torn
On inspection, the placenta appears _at the edge, or torn blood vessels extend
beyond the edge of the placenta.
PLACENTA CIRCUMVALLATA
edge
Ordinarily, the chorion membrane begins at the _of the placenta and spreads to
envelop the fetus; no chorion covers the fetal side of the placenta.
placenta circumvallata In_, the fetal side of the placenta is covered to some extent with Chorion.The
umbilical cord enters the placenta at the usual midpoint, and large vessels
spread out from there.
placenta marginata
In_, the fold of chorion reaches just to the edge of the placenta.
no abnormalities
_ are associated with this type of placenta, its presence should be noted.
BATTLEDORE PLACENTA
battledore placenta
In a_, the cord is inserted marginally rather than centrally.
VELAMENTOUS INSERTION OF THE CORD
Velamentous insertion _is a situation in which the cord, instead of entering the placenta directly,
separates into
of the cord
small vessels that reach the placenta by spreading across a fold of amnion.
multiple gestation
This form of cord insertion is most frequently found with_.
fetal anomalies
Because it may be associated with_, an infant born with this type of placenta
should be examined carefully.
VASA PREVIA
vasa previa
In_, the umbilical vessels of a velamentous cord insertion cross the cervical os
and therefore deliver before the fetus.
PLACENTA ACCRETA
Placenta accreta
_is an unusually deep attachment of the placenta to the uterine myometrium so

12 A WOMAN WHO DEVELOPS COMPLICATION DURING LABOR AND BIRTH

deeply the placenta will not loosen and deliver.
Attempts to remove it manually may lead to extreme _because of the deep
attachment.
ANOMALIES OF THE CORD
one vein and two arteries A normal cord contains_.
Congenital heart and
The absence of one of the umbilical arteries is associated with _.
kidney anomalies
UNUSUAL CORD LENGTH
premature separation of
An unusually short umbilical cord can result _
the placenta or an
abnormal fetal lie.
hemorrhage