Abnormal labor_085807.ppt Obstetrics and Gynaecology
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Mar 02, 2025
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About This Presentation
Abnormal labour, introduction, causes, risk factors, management of abnormal labour, obstetrics and gynecology.
Slide Content
BY:
PAUL NYONGESA
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 1
PAUL NYONGESA
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 1
Broad objective
By the end of the lesson, the
learners will be able to manage a
mothers in abnormal labor
Sunday, March 2, 2025 2ABNORMAL LABOR: BY PAUL NYONGESA
By the end of the lesson, the
learners will be able to manage a
mothers in abnormal labor
Sunday, March 2, 2025 2ABNORMAL LABOR: BY PAUL NYONGESA
Specific objectives
1.To describe obstructed labor
2.Prolonged labour
3.To describe occipitoposterior
position
4.To describe mal-presentations
Sunday, March 2, 2025 3ABNORMAL LABOR: BY PAUL NYONGESA
1.To describe obstructed labor
2.Prolonged labour
3.To describe occipitoposterior
position
4.To describe mal-presentations
Sunday, March 2, 2025 3ABNORMAL LABOR: BY PAUL NYONGESA
Factors influencing good
prognosis of labour
Strength of the uterine contractions
Flexion of the head
Degree of moulding of the foetal head, that is,
reduced engaging diameters
The giving of pelvic joints. In pregnancy, the
joints of the pelvis are relaxed and separate
by half to one centimetre
Maternal courage
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 4
prognosis of labour
Strength of the uterine contractions
Flexion of the head
Degree of moulding of the foetal head, that is,
reduced engaging diameters
The giving of pelvic joints. In pregnancy, the
joints of the pelvis are relaxed and separate
by half to one centimetre
Maternal courage
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 4
Factors influencing poor
prognosis
Early rupture of membrane which may be
accompanied by prolapsed cord
Poor moulding of the head
Maternal or foetal distress which will
necessitate intervention on trial of vaginal
delivery
Remember: Do not hesitate to terminate
the trial of labour when there is foetal or
maternal distress.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 5
prognosis
Early rupture of membrane which may be
accompanied by prolapsed cord
Poor moulding of the head
Maternal or foetal distress which will
necessitate intervention on trial of vaginal
delivery
Remember: Do not hesitate to terminate
the trial of labour when there is foetal or
maternal distress.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 5
Maternal Injuries
Most maternal injuries occur during the
second stage of labour but the diagnosis is made
in the third stage after the delivery of the baby.
The most common ones are described below.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 6
Most maternal injuries occur during the
second stage of labour but the diagnosis is made
in the third stage after the delivery of the baby.
The most common ones are described below.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 6
Perineal Tears
The perineum is the region between the vaginal opening
and the anus.
The perineum may get injured when there is overstretching
or rapid stretching during the delivery of the baby.
An inelastic perineum due to the presence of a scar can also
lead to a perineal tear.
causes of overstretching of the perineum leading to
perineal tear are:
A big baby - usually babies more than 4000 grams or 9
ounces are considered big.
Malpresentation of the baby like occipitoposterior position
or face presentation.
Average sized baby with a narrow maternal vaginal outlet
Forceps delivery or other instrumental deliveries
Shoulder Dystocia
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 7
The perineum is the region between the vaginal opening
and the anus.
The perineum may get injured when there is overstretching
or rapid stretching during the delivery of the baby.
An inelastic perineum due to the presence of a scar can also
lead to a perineal tear.
causes of overstretching of the perineum leading to
perineal tear are:
A big baby - usually babies more than 4000 grams or 9
ounces are considered big.
Malpresentation of the baby like occipitoposterior position
or face presentation.
Average sized baby with a narrow maternal vaginal outlet
Forceps delivery or other instrumental deliveries
Shoulder Dystocia
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 7
Degrees of Perineal Tears
There are three degrees of perineal tear.
First Degree perineal tear: This is only a mild degree
of laceration or tear of the skin at the edge of the
vaginal opening. The lower part of the vagina as well
as the perineal skin may be torn but the major
muscles of this region are not affected.
Second degree perineal tear: This involves rupture
of the muscles of the perineum with deep tears in the
vaginal wall. The tear may extend right up to the anus,
but does not involve the anal sphincter.
Third degree perineal tear: In a complete perineal
tear, the tear extends from the vaginal opening
through the posterior vaginal wall and the perineal
muscles up to the anus with injuries to the external
anal sphincter. The anal or the rectal canal may or
may not be involved.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 8
There are three degrees of perineal tear.
First Degree perineal tear: This is only a mild degree
of laceration or tear of the skin at the edge of the
vaginal opening. The lower part of the vagina as well
as the perineal skin may be torn but the major
muscles of this region are not affected.
Second degree perineal tear: This involves rupture
of the muscles of the perineum with deep tears in the
vaginal wall. The tear may extend right up to the anus,
but does not involve the anal sphincter.
Third degree perineal tear: In a complete perineal
tear, the tear extends from the vaginal opening
through the posterior vaginal wall and the perineal
muscles up to the anus with injuries to the external
anal sphincter. The anal or the rectal canal may or
may not be involved.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 8
Management of Perineal Tears
Prevention is the best management. The
second stage of labour should be properly conducted. An
episiotomy should be performed wherever deemed
necessary to prevent tear of the perineum.
Immediate Repair: A first degree or second degree tear
should be immediately repaired, preferably within the
first 24 hours.
Delayed Repair: If the tear is diagnosed after 24 hours,
then the woman is given antibiotics and the wound
dressed so that infection , if any, is controlled. Then the
tear is repaired.
Third Degree tear: A third degree tear is always
repaired after immediately after the delivery of the baby
to allow the tissues to regain the pre-pregnant state.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 9
Prevention is the best management. The
second stage of labour should be properly conducted. An
episiotomy should be performed wherever deemed
necessary to prevent tear of the perineum.
Immediate Repair: A first degree or second degree tear
should be immediately repaired, preferably within the
first 24 hours.
Delayed Repair: If the tear is diagnosed after 24 hours,
then the woman is given antibiotics and the wound
dressed so that infection , if any, is controlled. Then the
tear is repaired.
Third Degree tear: A third degree tear is always
repaired after immediately after the delivery of the baby
to allow the tissues to regain the pre-pregnant state.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 9
Vaginal Tears
Vaginal Tears can occur at any part of the vaginal wall,
but are seen mostly at the junction between the lateral
and posterior walls. These tears may be superficial with
only minor lacerations of the vaginal mucosa. But,
sometimes the tears may be deep enough to expose the
inner muscles.
Vaginal tears can also occur at the region around the
urethra - the opening through which urine comes out.
These are then called ' Paraurethral tears'. The
problem with these type of tears is that there may be
profuse bleeding from even a small tear since the region
has a large blood supply.
Treatment / Management of vaginal Tears
The vagina should always be examined under proper
light immediately after the delivery of the baby for any
such tears. All tears should be repaired immediately.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 10
Vaginal Tears can occur at any part of the vaginal wall,
but are seen mostly at the junction between the lateral
and posterior walls. These tears may be superficial with
only minor lacerations of the vaginal mucosa. But,
sometimes the tears may be deep enough to expose the
inner muscles.
Vaginal tears can also occur at the region around the
urethra - the opening through which urine comes out.
These are then called ' Paraurethral tears'. The
problem with these type of tears is that there may be
profuse bleeding from even a small tear since the region
has a large blood supply.
Treatment / Management of vaginal Tears
The vagina should always be examined under proper
light immediately after the delivery of the baby for any
such tears. All tears should be repaired immediately.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 10
Cervical Tears
Minor tears of the cervix are very common
during delivery, especially in a woman who
is delivering her first child.
But sometimes, major lacerations which can
cause severe bleeding
Cervical tears are the commonest form of
traumatic post partum hemorrhage.
Cervical tears are commonest at the lateral
angle, between the anterior and posterior lips
of the cervix.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 11
Minor tears of the cervix are very common
during delivery, especially in a woman who
is delivering her first child.
But sometimes, major lacerations which can
cause severe bleeding
Cervical tears are the commonest form of
traumatic post partum hemorrhage.
Cervical tears are commonest at the lateral
angle, between the anterior and posterior lips
of the cervix.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 11
Causes of Cervical Tears
Delivery through an undilated cervix
whether spontaneously, or by forceps.
Precipitate labour.
Rigid cervix due to previous operations like
the LEEP procedure, conisation, or cervical
amputation.
Very vascular cervix as can occur in low level
placenta previa
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 12
Delivery through an undilated cervix
whether spontaneously, or by forceps.
Precipitate labour.
Rigid cervix due to previous operations like
the LEEP procedure, conisation, or cervical
amputation.
Very vascular cervix as can occur in low level
placenta previa
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 12
Management
The aim of treatment is to control bleeding as
early as possible by repairing the tear.
Minor lacerations without active bleeding
does not require to be repaired - they heal
spontaneously with no ill effects.
Major cervical lacerations or tears need to be
repaired in the Operating theater under
anesthesia, good light and proper exposure of
the tear.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 13
The aim of treatment is to control bleeding as
early as possible by repairing the tear.
Minor lacerations without active bleeding
does not require to be repaired - they heal
spontaneously with no ill effects.
Major cervical lacerations or tears need to be
repaired in the Operating theater under
anesthesia, good light and proper exposure of
the tear.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 13
Vulval Hematoma
Collection of blood anywhere in the vulval
region is called vulval hematoma.
Although vulval haematomas can also occur
after an injury due to any cause, it is
commonly seen after the vaginal delivery of a
baby.
A Vulval hematoma can occur either
spontaneously or after improper repair of an
episiotomy wound.
Blood from a rupture of the deep veins of this
region collects in a closed space with no
opening for it to drain out.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 14
Collection of blood anywhere in the vulval
region is called vulval hematoma.
Although vulval haematomas can also occur
after an injury due to any cause, it is
commonly seen after the vaginal delivery of a
baby.
A Vulval hematoma can occur either
spontaneously or after improper repair of an
episiotomy wound.
Blood from a rupture of the deep veins of this
region collects in a closed space with no
opening for it to drain out.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 14
Signs and Symptoms
A steadily increasing swelling to one side of
the vagina.
The swelling is tense and tender to the touch.
The woman complains of severe pain, more
so on sitting down.
There may be difficulty in passing urine if the
swelling presses on the urethra.
The bleeding can be severe enough to cause
the patient to go into shock.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 15
A steadily increasing swelling to one side of
the vagina.
The swelling is tense and tender to the touch.
The woman complains of severe pain, more
so on sitting down.
There may be difficulty in passing urine if the
swelling presses on the urethra.
The bleeding can be severe enough to cause
the patient to go into shock.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 15
Management
The aim of treatment is to ligate the bleeding
blood vessels as early as possible and support
the patient with IV drips and medicines so
that she does not go into shock.
An incision is made at the most distended
point of the hematoma.
The incision is then deepened and the blood
clots scooped out.
The bleeding vessels are identified and tied
up.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 16
The aim of treatment is to ligate the bleeding
blood vessels as early as possible and support
the patient with IV drips and medicines so
that she does not go into shock.
An incision is made at the most distended
point of the hematoma.
The incision is then deepened and the blood
clots scooped out.
The bleeding vessels are identified and tied
up.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 16
Management cont..
The incision is closed by applying different
layers of stitches.
A drain may be put in the wound for 24 hours
to allow any oozing blood to flow out.
Proper antibiotics are prescribed and the
patient kept under close observation.
Blood transfusion is given if necessary.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 17
The incision is closed by applying different
layers of stitches.
A drain may be put in the wound for 24 hours
to allow any oozing blood to flow out.
Proper antibiotics are prescribed and the
patient kept under close observation.
Blood transfusion is given if necessary.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 17
PROLONGED LABOUR
Labor is said to be prolonged when the combined
duration of both the first stage and second stages
of labor is more than 18 hours.
It is more common in a first pregnancy and in
women over the age of 35 years
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 18
Labor is said to be prolonged when the combined
duration of both the first stage and second stages
of labor is more than 18 hours.
It is more common in a first pregnancy and in
women over the age of 35 years
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 18
Complications of labor cont.
Abnormal labor arises as result of
factors causing obstructed and
prolonged labor
i. Obstructed labour
There is no advancement of the
presenting part despite strong
uterine contractions
Sunday, March 2, 2025 19ABNORMAL LABOR: BY PAUL NYONGESA
Abnormal labor arises as result of
factors causing obstructed and
prolonged labor
i. Obstructed labour
There is no advancement of the
presenting part despite strong
uterine contractions
Sunday, March 2, 2025 19ABNORMAL LABOR: BY PAUL NYONGESA
Complications of labour cont.
Obstructed labour occurs mainly at
the pelvic brim
There may be abnormality of the
passage and the passenger
ii. Prolonged labour
In prolonged labour “power” is the
main cause
Sunday, March 2, 2025 20ABNORMAL LABOR: BY PAUL NYONGESA
Obstructed labour occurs mainly at
the pelvic brim
There may be abnormality of the
passage and the passenger
ii. Prolonged labour
In prolonged labour “power” is the
main cause
Sunday, March 2, 2025 20ABNORMAL LABOR: BY PAUL NYONGESA
Causes
Causes of Prolonged First Stage of Labour
Poor uterine contractions, leading to the cervix dilating slowly
or not at all
Pelvic abnormalities (passage), where contracted pelvis and
tumours of the pelvis cause poor progress in labour
The foetus (passenger) is big foetus (macrosomia)
Malposition
Malpresentation
Psychological causes, for instance; tension and fear of the
unknown tend to prolong labour, most commonly in women
who are primigravidae
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 21
Causes of Prolonged First Stage of Labour
Poor uterine contractions, leading to the cervix dilating slowly
or not at all
Pelvic abnormalities (passage), where contracted pelvis and
tumours of the pelvis cause poor progress in labour
The foetus (passenger) is big foetus (macrosomia)
Malposition
Malpresentation
Psychological causes, for instance; tension and fear of the
unknown tend to prolong labour, most commonly in women
who are primigravidae
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 21
Causes
Causes of Prolonged Second Stage of Labour
Secondary hypotonic contractions
Poor maternal effort, which could be due to fear, exhaustion or
lack of sensation due to epidural block, which may inhibit the
woman’s ability to bear down
A rigid perineum
Reduced pelvic outlet, as in the android pelvis,
Macrosomia
Malposition
Malpresentation, leading to a large presenting diameter,
accounting for the delay
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 22
Causes of Prolonged Second Stage of Labour
Secondary hypotonic contractions
Poor maternal effort, which could be due to fear, exhaustion or
lack of sensation due to epidural block, which may inhibit the
woman’s ability to bear down
A rigid perineum
Reduced pelvic outlet, as in the android pelvis,
Macrosomia
Malposition
Malpresentation, leading to a large presenting diameter,
accounting for the delay
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 22
Causes of Prolonged Labor
Problems with Uterine Contraction: The
uterine muscle may fail to contract properly
when it is grossly distended as in twin
pregnancy and polyhydramnios . Presence of
tumors like fibroids in the uterine
musculature can also affect uterine
contraction.
Use of Sedatives and Anesthesia: Excessive
use of painkillers or anesthesia can cause
inefficient uterine action.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 23
Problems with Uterine Contraction: The
uterine muscle may fail to contract properly
when it is grossly distended as in twin
pregnancy and polyhydramnios . Presence of
tumors like fibroids in the uterine
musculature can also affect uterine
contraction.
Use of Sedatives and Anesthesia: Excessive
use of painkillers or anesthesia can cause
inefficient uterine action.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 23
Causes of Prolonged Labor
They can also decrease the pain of normal labour
and prevent voluntary effort by the mother to deliver
the baby during the second stage of labor.
Cervical dystocia or stenosis: The term cervical
dystocia is used when the cervix fails to dilate
properly and remains at the same position for more
than 2 hours. The cervix may fail to dilate when it is
fibrosed due to previous operations like cone biopsy
or due to the presence of tumors like cervical polyps
and fibroids.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 24
They can also decrease the pain of normal labour
and prevent voluntary effort by the mother to deliver
the baby during the second stage of labor.
Cervical dystocia or stenosis: The term cervical
dystocia is used when the cervix fails to dilate
properly and remains at the same position for more
than 2 hours. The cervix may fail to dilate when it is
fibrosed due to previous operations like cone biopsy
or due to the presence of tumors like cervical polyps
and fibroids.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 24
Signs and Symptoms of
Prolonged Labour
Labor extends for more than 18 hours.
Patient looks exhausted and distressed. Dehydration may be
present. Mouth may be dry due to prolonged mouth breathing.
Pain may be more on the back radiating to the thighs rather
than inside the abdomen. This is due to pressure over the
muscles and ligaments.
Labor pains may initially be severe, frequent and prolonged but
later decrease and become very mild as the muscles become
fatigued.
Pulse rate is often high.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 25
Prolonged Labour
Labor extends for more than 18 hours.
Patient looks exhausted and distressed. Dehydration may be
present. Mouth may be dry due to prolonged mouth breathing.
Pain may be more on the back radiating to the thighs rather
than inside the abdomen. This is due to pressure over the
muscles and ligaments.
Labor pains may initially be severe, frequent and prolonged but
later decrease and become very mild as the muscles become
fatigued.
Pulse rate is often high.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 25
Signs and Symptoms of
Prolonged Labour
The large intestines are dilated and can be palpated along both
sides of the uterus as large, thick structures filled with air. They
give off the hollow sound of drums on tapping.
The uterus is tender on palpation and does not relax fully
between contractions.
Ketosis may develop due to prolonged starvation.
Fetal distress may develop.
Membranes may or may not rupture early. In early rupture,
there is a risk of infection of the uterine contents if proper
antibiotics are not prescribed.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 26
Prolonged Labour
The large intestines are dilated and can be palpated along both
sides of the uterus as large, thick structures filled with air. They
give off the hollow sound of drums on tapping.
The uterus is tender on palpation and does not relax fully
between contractions.
Ketosis may develop due to prolonged starvation.
Fetal distress may develop.
Membranes may or may not rupture early. In early rupture,
there is a risk of infection of the uterine contents if proper
antibiotics are not prescribed.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 26
Diagnosis of Prolonged Labour
Proper history of labour including type, duration and frequency
of uterine contractions
Examination of the mother, checking for general appearance,
whether distressed or exhausted
Check the temperature and pulse as an increase of either of
them would be significant
Urinalysis, where concentrated urine suggests fluid imbalance
and dehydration. Check for ketones in the urine, the presence
of this must be corrected at once
It is important to identify the cause in order to decide the
course of action.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 27
Proper history of labour including type, duration and frequency
of uterine contractions
Examination of the mother, checking for general appearance,
whether distressed or exhausted
Check the temperature and pulse as an increase of either of
them would be significant
Urinalysis, where concentrated urine suggests fluid imbalance
and dehydration. Check for ketones in the urine, the presence
of this must be corrected at once
It is important to identify the cause in order to decide the
course of action.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 27
Diagnosis of Prolonged Labour
Proper history of labour including type, duration and frequency
of uterine contractions
Examination of the mother, checking for general appearance,
whether distressed or exhausted
Check the temperature and pulse as an increase of either of
them would be significant
Urinalysis, where concentrated urine suggests fluid imbalance
and dehydration. Check for ketones in the urine, the presence
of this must be corrected at once
It is important to identify the cause in order to decide the
course of action.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 28
Proper history of labour including type, duration and frequency
of uterine contractions
Examination of the mother, checking for general appearance,
whether distressed or exhausted
Check the temperature and pulse as an increase of either of
them would be significant
Urinalysis, where concentrated urine suggests fluid imbalance
and dehydration. Check for ketones in the urine, the presence
of this must be corrected at once
It is important to identify the cause in order to decide the
course of action.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 28
Risks of Prolonged Labour
Fetal Risks:
Fetal Distress due to decreased oxygen reaching the fetus.
Intracranial hemorrhage or bleeding inside the fetal head.
Increased chances of operative delivery like Cesarian sections.
Longterm risks of the baby developing cerebral palsy.
Maternal Risks:
Intrauterine infections
Trauma and injuries in the maternal birth passage (See Maternal
Injuries.)
Postpartum hemorrhage.
Postpartum infection.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 29
Fetal Risks:
Fetal Distress due to decreased oxygen reaching the fetus.
Intracranial hemorrhage or bleeding inside the fetal head.
Increased chances of operative delivery like Cesarian sections.
Longterm risks of the baby developing cerebral palsy.
Maternal Risks:
Intrauterine infections
Trauma and injuries in the maternal birth passage (See Maternal
Injuries.)
Postpartum hemorrhage.
Postpartum infection.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 29
Management / Treatment of
Prolonged Labour
With the discovery of various drugs capable of
accelerating labour, prolonged labour is a rare
nowadays.
After 3cms of dilation, the cervix should dilate at the
rate of 1cm per hour. If there is lack of dilation for a
reasonable period of time, then an oxytocin drip is
started.
Drugs like buscopan causes softening of tissues in the
cervix.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 30
Prolonged Labour
With the discovery of various drugs capable of
accelerating labour, prolonged labour is a rare
nowadays.
After 3cms of dilation, the cervix should dilate at the
rate of 1cm per hour. If there is lack of dilation for a
reasonable period of time, then an oxytocin drip is
started.
Drugs like buscopan causes softening of tissues in the
cervix.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 30
Management / Treatment of
Prolonged Labour
If the cervix fails to dilate in spite of adequate uterine
contraction, epidosin or buscopan can be safely given to cause
softening of the cervix.
Intensive clinical monitoring should be done, recording the
pulse, BP, fetal heart sound (FHS) and dilation of the cervix at
intervals of two hours. FHS should be checked even more
frequently if necessary.
If, in spite of the above procedures, labour fails to get
accelerated or if foetal distress develops, Cesarian Section
should be done.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 31
Prolonged Labour
If the cervix fails to dilate in spite of adequate uterine
contraction, epidosin or buscopan can be safely given to cause
softening of the cervix.
Intensive clinical monitoring should be done, recording the
pulse, BP, fetal heart sound (FHS) and dilation of the cervix at
intervals of two hours. FHS should be checked even more
frequently if necessary.
If, in spite of the above procedures, labour fails to get
accelerated or if foetal distress develops, Cesarian Section
should be done.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 31
OBSTRUCTED LABOUR
There is no advancement of the presenting
part despite strong uterine contractions
Causes of obstructed labour
Cephalopelvic disproportion
Mal-positions
Mal-presentation
Fibroids in the lower uterine segment
Tumours in the lower uterine segment
Sunday, March 2, 2025 32ABNORMAL LABOR: BY PAUL NYONGESA
There is no advancement of the presenting
part despite strong uterine contractions
Causes of obstructed labour
Cephalopelvic disproportion
Mal-positions
Mal-presentation
Fibroids in the lower uterine segment
Tumours in the lower uterine segment
Sunday, March 2, 2025 32ABNORMAL LABOR: BY PAUL NYONGESA
Cervical or vaginal stenosis
Cervical dystocia
Gross foetal abnormalities
Deep transverse arrest
Shoulder dystocia
Disordered uterine action
Sunday, March 2, 2025 33ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
Cervical dystocia
Gross foetal abnormalities
Deep transverse arrest
Shoulder dystocia
Disordered uterine action
Sunday, March 2, 2025 33ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
OBSTRUCTED LABOUR
i. Early signs of obstruction
The presenting part does not enter the
pelvic brim despite good uterine
contraction
The cervix dilates slowly and hangs
loosely like an empty sleeve due to
poor application of the presenting
part
Sunday, March 2, 2025 34ABNORMAL LABOR: BY PAUL NYONGESA
i. Early signs of obstruction
The presenting part does not enter the
pelvic brim despite good uterine
contraction
The cervix dilates slowly and hangs
loosely like an empty sleeve due to
poor application of the presenting
part
Sunday, March 2, 2025 34ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
•The membranes tend to rupture early
ii. Later signs
Concurrent foetal and maternal distress
Hypertonic contractions and the
mother does not relax in between them
Moulded uterus around the foetus
Maternal pyrexia and tachycardia
Sunday, March 2, 2025 35ABNORMAL LABOR: BY PAUL NYONGESA
•The membranes tend to rupture early
ii. Later signs
Concurrent foetal and maternal distress
Hypertonic contractions and the
mother does not relax in between them
Moulded uterus around the foetus
Maternal pyrexia and tachycardia
Sunday, March 2, 2025 35ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
On vaginal examination;
Severely moulded head
Large caput succedaneum
Hot and dry vagina
Oedematous cervix
Oedematous vulva e.g. shoulder
dystocia
Sunday, March 2, 2025 36ABNORMAL LABOR: BY PAUL NYONGESA
On vaginal examination;
Severely moulded head
Large caput succedaneum
Hot and dry vagina
Oedematous cervix
Oedematous vulva e.g. shoulder
dystocia
Sunday, March 2, 2025 36ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
Wedged and immovable
presenting part in cephalic
presentation
Difficulty in passing urine
Bloodstained urine if catheterized
due to the bruised urethra
Poor urinary output
Sunday, March 2, 2025 37ABNORMAL LABOR: BY PAUL NYONGESA
Wedged and immovable
presenting part in cephalic
presentation
Difficulty in passing urine
Bloodstained urine if catheterized
due to the bruised urethra
Poor urinary output
Sunday, March 2, 2025 37ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
Uterine exhaustion
Uterine contractions cease for a
while, commencing with renewed
vigour, especially in primigravida
Foul smelling meconium stained
liquor
Already drained amniotic fluid
Sunday, March 2, 2025 38ABNORMAL LABOR: BY PAUL NYONGESA
Uterine exhaustion
Uterine contractions cease for a
while, commencing with renewed
vigour, especially in primigravida
Foul smelling meconium stained
liquor
Already drained amniotic fluid
Sunday, March 2, 2025 38ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
A Bandle’s ring
The lower uterine segment
progressively enlarges and thins
out, and
The upper uterine segment
becomes shorter and thick
Sunday, March 2, 2025 39ABNORMAL LABOR: BY PAUL NYONGESA
A Bandle’s ring
The lower uterine segment
progressively enlarges and thins
out, and
The upper uterine segment
becomes shorter and thick
Sunday, March 2, 2025 39ABNORMAL LABOR: BY PAUL NYONGESA
Prevention of obstructed labour
Good pre-natal care
History taking to include previous
obstructed/prolonged labour, fresh
still births and neonatal asphyxia
All pregnant women should attend
antenatal clinic promptly
Sunday, March 2, 2025 40ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
Good pre-natal care
History taking to include previous
obstructed/prolonged labour, fresh
still births and neonatal asphyxia
All pregnant women should attend
antenatal clinic promptly
Sunday, March 2, 2025 40ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
OBSTRUCTED LABOUR
Hospital delivery of all mothers
with previous caesarean section
Discourage home deliveries,
especially of primigravida and
grand multiparous
Advise the community against too
early or too late pregnancies
Sunday, March 2, 2025 41ABNORMAL LABOR: BY PAUL NYONGESA
Hospital delivery of all mothers
with previous caesarean section
Discourage home deliveries,
especially of primigravida and
grand multiparous
Advise the community against too
early or too late pregnancies
Sunday, March 2, 2025 41ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
Rule out possible obstruction of
labour through;
Vaginal examination in late
pregnancy rule out CPD
Abdominal palpation to rule out
big baby, mal-presentations
Sunday, March 2, 2025 42ABNORMAL LABOR: BY PAUL NYONGESA
Rule out possible obstruction of
labour through;
Vaginal examination in late
pregnancy rule out CPD
Abdominal palpation to rule out
big baby, mal-presentations
Sunday, March 2, 2025 42ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
Clinical and radiological
investigations for pelvic adequacy
Arrange for elective caesarean
section
Emphasize on well-balanced diet to
all girls, adolescent children and
pregnant women
Sunday, March 2, 2025 43ABNORMAL LABOR: BY PAUL NYONGESA
Clinical and radiological
investigations for pelvic adequacy
Arrange for elective caesarean
section
Emphasize on well-balanced diet to
all girls, adolescent children and
pregnant women
Sunday, March 2, 2025 43ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
Management of obstructed labour
Careful assessment of the progress
throughout labour
Immediately alert an obstetrician when
obstructed labour is suspected
Commence an intravenous infusion e.g
normal saline
Take blood for GXM
Sunday, March 2, 2025 44ABNORMAL LABOR: BY PAUL NYONGESA
Management of obstructed labour
Careful assessment of the progress
throughout labour
Immediately alert an obstetrician when
obstructed labour is suspected
Commence an intravenous infusion e.g
normal saline
Take blood for GXM
Sunday, March 2, 2025 44ABNORMAL LABOR: BY PAUL NYONGESA
Keep at least two units of blood in
case transfusion is needed
Catheterise to empty the urinary
bladder
Maintain aseptic techniques
Administer prophylactic antibiotics in
case of early rupture of membranes
Sunday, March 2, 2025 45ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
case transfusion is needed
Catheterise to empty the urinary
bladder
Maintain aseptic techniques
Administer prophylactic antibiotics in
case of early rupture of membranes
Sunday, March 2, 2025 45ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
OBSTRUCTED LABOUR
Administer Pethidine 100mg IM
stat as ordered
In 1
st
stage of labour;
Prepare her for emergency
caesarean section
Maintain fluid in take output chart
Monitor urine output
Sunday, March 2, 2025 46ABNORMAL LABOR: BY PAUL NYONGESA
Administer Pethidine 100mg IM
stat as ordered
In 1
st
stage of labour;
Prepare her for emergency
caesarean section
Maintain fluid in take output chart
Monitor urine output
Sunday, March 2, 2025 46ABNORMAL LABOR: BY PAUL NYONGESA
In the second stage of labour;
Failure to progress in labour
Perform an emergency caesarean
section if rotation and assisted
birth fail
Inform newborn unit to prepare
for asphyxiated baby
Sunday, March 2, 2025 47ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
Failure to progress in labour
Perform an emergency caesarean
section if rotation and assisted
birth fail
Inform newborn unit to prepare
for asphyxiated baby
Sunday, March 2, 2025 47ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
Keep a resuscitation equipment
ready
Paediatrician should be present at
birth
Caesarean section is done even if
the foetus is dead as vaginal birth
cannot be achieved
Sunday, March 2, 2025 48ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
ready
Paediatrician should be present at
birth
Caesarean section is done even if
the foetus is dead as vaginal birth
cannot be achieved
Sunday, March 2, 2025 48ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
OBSTRUCTED LABOUR
Maternal complications
Chronic pelvic pain
Rupture of the uterus
Traumatised bladder
Vesico-vaginal fistula
Recto-vaginal fistula
Urinary incontinence
Sunday, March 2, 2025 49ABNORMAL LABOR: BY PAUL NYONGESA
Maternal complications
Chronic pelvic pain
Rupture of the uterus
Traumatised bladder
Vesico-vaginal fistula
Recto-vaginal fistula
Urinary incontinence
Sunday, March 2, 2025 49ABNORMAL LABOR: BY PAUL NYONGESA
Intra uterine infection due to
prolonged rupture of the membranes
Maternal death
Peripheral nerve injuries (foot drop)
Sheehan’s syndrome due to pituitary
ischemia
Sunday, March 2, 2025 50ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
prolonged rupture of the membranes
Maternal death
Peripheral nerve injuries (foot drop)
Sheehan’s syndrome due to pituitary
ischemia
Sunday, March 2, 2025 50ABNORMAL LABOR: BY PAUL NYONGESA
OBSTRUCTED LABOUR
OBSTRUCTED LABOUR
Foetal complications
Intra uterine asphyxia
Intra-cranial haemorrhage
Neonatal pneumonia
Neonatal death
Sunday, March 2, 2025 51ABNORMAL LABOR: BY PAUL NYONGESA
Foetal complications
Intra uterine asphyxia
Intra-cranial haemorrhage
Neonatal pneumonia
Neonatal death
Sunday, March 2, 2025 51ABNORMAL LABOR: BY PAUL NYONGESA
ABNORMAL UTERINE ACTION
Abnormal uterine action is a dysfunction of uterine
muscles due to neuromuscular disharmony. Some
types of abnormal uterine action include:
Hypotonic uterine action
In-co-ordinate uterine action, including hypertonic
lower uterine segment, constriction ring dystocia,
colicky uterus and spurious labour
Cervical dystocia
Precipitate labour
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 52
Abnormal uterine action is a dysfunction of uterine
muscles due to neuromuscular disharmony. Some
types of abnormal uterine action include:
Hypotonic uterine action
In-co-ordinate uterine action, including hypertonic
lower uterine segment, constriction ring dystocia,
colicky uterus and spurious labour
Cervical dystocia
Precipitate labour
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 52
Hypotonic Uterine Action
This is poor tone in the uterine muscle fibres
which results from weak/short contractions.
The contractions are infrequent and cause less
pain.
The uterus may be indented at the height of a
contraction. Both mother and baby are affected
by the contractions.
The effects of weak contractions bring about
very slow or no cervical dilatation. This results
in prolonged labour.
There are two types of hypotonia; primary and
secondary uterine inertia also respectively
known as primary and secondary hypotonia.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 53
This is poor tone in the uterine muscle fibres
which results from weak/short contractions.
The contractions are infrequent and cause less
pain.
The uterus may be indented at the height of a
contraction. Both mother and baby are affected
by the contractions.
The effects of weak contractions bring about
very slow or no cervical dilatation. This results
in prolonged labour.
There are two types of hypotonia; primary and
secondary uterine inertia also respectively
known as primary and secondary hypotonia.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 53
Types of Hypotonia
Primary hypotonia starts at the onset of
labour. The cause is unknown and it is
common in primigravida.
Secondary hypotonia occurs when labour
has already been established. The uterus is
exhausted and contractions slow down, due
to:
Retained second twin
Cephalopelvic disproportion
Malpresentation or malposition
Effect after epidural anaesthesia
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 54
Primary hypotonia starts at the onset of
labour. The cause is unknown and it is
common in primigravida.
Secondary hypotonia occurs when labour
has already been established. The uterus is
exhausted and contractions slow down, due
to:
Retained second twin
Cephalopelvic disproportion
Malpresentation or malposition
Effect after epidural anaesthesia
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 54
Incoordinate Uterine Action
In cases of incoordinate uterine action, there
is alteration in the polarity of the uterus with
an increase in the resting tone.
The uterus is very irritable. The contractions
are strong, painful and erratic but in spite of
strong contractions, the cervix dilates slowly.
Clinically, the patient experiences a lot of
pain both before and after contraction.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 55
In cases of incoordinate uterine action, there
is alteration in the polarity of the uterus with
an increase in the resting tone.
The uterus is very irritable. The contractions
are strong, painful and erratic but in spite of
strong contractions, the cervix dilates slowly.
Clinically, the patient experiences a lot of
pain both before and after contraction.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 55
Incoordinate Uterine Action
She is exhausted and bears down early due to
severe backache. This may lead to retention
of urine.
Foetal hypoxia occurs due to the hypertonic
state of uterus, which interferes with the
placental circulation.
On Vaginal Examination (VE) the cervix is
noted to dilate slowly despite frequent painful
contractions.
The cervix is tight, unyielding and
oedematous since the mother bears down
with each contraction.
There are four varieties of Incoordinate
uterine action, which will be explored:
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 56
She is exhausted and bears down early due to
severe backache. This may lead to retention
of urine.
Foetal hypoxia occurs due to the hypertonic
state of uterus, which interferes with the
placental circulation.
On Vaginal Examination (VE) the cervix is
noted to dilate slowly despite frequent painful
contractions.
The cervix is tight, unyielding and
oedematous since the mother bears down
with each contraction.
There are four varieties of Incoordinate
uterine action, which will be explored:
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 56
Incoordinate Uterine Action
There are four types of incoordinate uterine action
Hypertonic Lower Uterine Segment
Colicky Uterus
Constriction Ring Dystocia
Spurious Labour
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 57
There are four types of incoordinate uterine action
Hypertonic Lower Uterine Segment
Colicky Uterus
Constriction Ring Dystocia
Spurious Labour
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 57
Hypertonic Lower Uterine
Segment
In this case, the lower uterine segment is
hypertonic.
There is loss of polarity and intermittent
abdominal pains.
The pains occur before and persist long after a
uterine contraction.
The cervix fails to dilate.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 58
Segment
In this case, the lower uterine segment is
hypertonic.
There is loss of polarity and intermittent
abdominal pains.
The pains occur before and persist long after a
uterine contraction.
The cervix fails to dilate.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 58
Colicky Uterus
The upper uterine segment contracts strongly and
spasmodically.
As a result of the different parts of the uterus
contracting differently the cervical dilatation is
ineffective.
There may be reduced placental blood flow leading
to foetal distress.
There is intense crump-like pain, contractions are
not effective and the uterus is tender.
The mother may not experience severe backache.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 59
The upper uterine segment contracts strongly and
spasmodically.
As a result of the different parts of the uterus
contracting differently the cervical dilatation is
ineffective.
There may be reduced placental blood flow leading
to foetal distress.
There is intense crump-like pain, contractions are
not effective and the uterus is tender.
The mother may not experience severe backache.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 59
Spurious Labour
Spurious labour is a condition where
contractions occur before the onset of labour,
which are painful and are accompanied by
backache.
Giving pethidine or morphine 1ml to relax the
uterine contractions can abolish them.
This differentiates it with true labour.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 60
Spurious labour is a condition where
contractions occur before the onset of labour,
which are painful and are accompanied by
backache.
Giving pethidine or morphine 1ml to relax the
uterine contractions can abolish them.
This differentiates it with true labour.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 60
Precipitate Labour
Def:
strong and frequent contractions from the
onset of labour, resulting in an abnormally
rapid progress of labour and delivery may
occur within an hour from the onset of
labour. There are several types of
complications which can occur.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 61
Def:
strong and frequent contractions from the
onset of labour, resulting in an abnormally
rapid progress of labour and delivery may
occur within an hour from the onset of
labour. There are several types of
complications which can occur.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 61
Precipitate Labour
Over-Stimulation of the Uterus
This may occur as a result of excessive use of
syntocinon or prostaglandin, which may cause
tetanic contractions with inadequate periods of
relaxation.
Complications of over-stimulation of the uterus
include
foetal hypoxia.
If uterine spasms that reduce the transfer from the
placenta of foetal oxygen are not treated, foetal death
may occur.
precipitate labour and
rupture of uterus in cases of disproportion.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 62
Over-Stimulation of the Uterus
This may occur as a result of excessive use of
syntocinon or prostaglandin, which may cause
tetanic contractions with inadequate periods of
relaxation.
Complications of over-stimulation of the uterus
include
foetal hypoxia.
If uterine spasms that reduce the transfer from the
placenta of foetal oxygen are not treated, foetal death
may occur.
precipitate labour and
rupture of uterus in cases of disproportion.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 62
Precipitate Labour
Methods of management should include the
following:
Stop the administration of syntocinon or
prostaglandin
at once
In case of tonic contractions, the patient should be
given
two puffs of ventolin inhaler
If there is foetal distress, give I.V normal saline and
oxygen by mask
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 63
Methods of management should include the
following:
Stop the administration of syntocinon or
prostaglandin
at once
In case of tonic contractions, the patient should be
given
two puffs of ventolin inhaler
If there is foetal distress, give I.V normal saline and
oxygen by mask
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 63
Precipitate Labour
Tonic Contractions
This is where the contractions are excessively longer, stronger
and more frequent. This results in almost continuous
contractions with short periods of relaxation.
Tonic contractions are caused by cephalopelvic disproportion.
The uterus attempts to overcome the obstruction and so it
increases its strength and frequency.
The condition is common in primigravida.
Possible complications of tonic contractions include
rupture of the uterus and
foetal death due to hypoxia
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 64
Tonic Contractions
This is where the contractions are excessively longer, stronger
and more frequent. This results in almost continuous
contractions with short periods of relaxation.
Tonic contractions are caused by cephalopelvic disproportion.
The uterus attempts to overcome the obstruction and so it
increases its strength and frequency.
The condition is common in primigravida.
Possible complications of tonic contractions include
rupture of the uterus and
foetal death due to hypoxia
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 64
Precipitate Labour
Management of Tonic contractions
If the patient is on syntocinon drip, it should be
discontinued and the doctor informed.
The vital signs, including observations of pulse &
blood pressure, should be monitored carefully.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 65
Management of Tonic contractions
If the patient is on syntocinon drip, it should be
discontinued and the doctor informed.
The vital signs, including observations of pulse &
blood pressure, should be monitored carefully.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 65
Precipitate Labour
There are several factors, which predispose to
abnormal uterine action, these include:
elderly primigravida
Primigravida
Cephalopelvic disproportion
Malpresentation
Post maturity
Multiple pregnancy
Early rupture of membranes
Emotional tension of the patient
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 66
There are several factors, which predispose to
abnormal uterine action, these include:
elderly primigravida
Primigravida
Cephalopelvic disproportion
Malpresentation
Post maturity
Multiple pregnancy
Early rupture of membranes
Emotional tension of the patient
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 66
Precipitate Labour
Maternal complications include
cervical and perennial lacerations.
The uterus may fail to contract during the
third stage of labour, leading to a retained
placenta.
Post partum haemorrhage
Acute uterine inversion
Shock and collapse may occur due to sudden
relief of pressure.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 67
Maternal complications include
cervical and perennial lacerations.
The uterus may fail to contract during the
third stage of labour, leading to a retained
placenta.
Post partum haemorrhage
Acute uterine inversion
Shock and collapse may occur due to sudden
relief of pressure.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 67
Precipitate Labour
Foetal complications include
foetal hypoxia, which may occur as a result of
frequent and strong contractions.
Rapid moulding may result in intracranial
pressure and, during delivery, this may lead
to intracranial haemorrhage.
Asphyxia may occur due to rapid expulsion
of the baby’s unmoulded head.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 68
Foetal complications include
foetal hypoxia, which may occur as a result of
frequent and strong contractions.
Rapid moulding may result in intracranial
pressure and, during delivery, this may lead
to intracranial haemorrhage.
Asphyxia may occur due to rapid expulsion
of the baby’s unmoulded head.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 68
Precipitate Labour
Remember: Precipitate labour tends to recur.
Therefore, with future pregnancies the
mother needs to be admitted early
into hospital for safe delivery.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 69
Remember: Precipitate labour tends to recur.
Therefore, with future pregnancies the
mother needs to be admitted early
into hospital for safe delivery.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 69
Cervical Dystocia
Cervical dystocia can be divided into
two classes; primary and secondary.
Primary cervical dystocia
Secondary cervical dystocia
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 70
Cervical dystocia can be divided into
two classes; primary and secondary.
Primary cervical dystocia
Secondary cervical dystocia
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 70
Primary Cervical Dystocia
Primary Cervical Dystocia: the uterine
contractions are normal and the presenting
part is low down in the pelvis but the cervix
fails to dilate.
The delay is due to the formation of a
cartilaginous ring round the cervix.
This condition occurs mainly in primigravida
whereby the first stage is prolonged and
there is severe and persistent backache.
On vaginal examination the cervix feels thin,
tight and unyielding.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 71
Primary Cervical Dystocia: the uterine
contractions are normal and the presenting
part is low down in the pelvis but the cervix
fails to dilate.
The delay is due to the formation of a
cartilaginous ring round the cervix.
This condition occurs mainly in primigravida
whereby the first stage is prolonged and
there is severe and persistent backache.
On vaginal examination the cervix feels thin,
tight and unyielding.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 71
Secondary Cervical Dystocia
This occurs due to previous trauma to the cervix, for
example, tears which were repaired, scarring or
from infection.
The cervix fails to dilate dispite of good uterine
contractions.
The management of cervical dystocia is by
encouraging the mother to lie on her back, elevation
of the bed foot to ease pressure on the cervix and
care must be taken to avoid lacerations.
Caesarean section should be done to hasten delivery
of the baby.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 72
This occurs due to previous trauma to the cervix, for
example, tears which were repaired, scarring or
from infection.
The cervix fails to dilate dispite of good uterine
contractions.
The management of cervical dystocia is by
encouraging the mother to lie on her back, elevation
of the bed foot to ease pressure on the cervix and
care must be taken to avoid lacerations.
Caesarean section should be done to hasten delivery
of the baby.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 72
Cervical Dystocia
Cervical dystocia can be further divided into one of three types,
any of which can occur as primary or secondary cervical
dystocia.
Rigid cervix
Annular detachment of the cervix
Oedematous anterior lip of cervix
Rigid cervix: is a rare condition in which the cervix fails to
dilate despite normal uterine contractions.
It is characterised by severe persistent backache.
On vaginal examination the cervix feels thin, tight and
unyielding.
Annular detachment of the cervix: there is total circular
separation of the anterior or posterior lip of the internal OS
during or immediately after delivery.
Sometimes both lips are separated resulting in cervical
amputation
Rarely occurs
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 73
Cervical dystocia can be further divided into one of three types,
any of which can occur as primary or secondary cervical
dystocia.
Rigid cervix
Annular detachment of the cervix
Oedematous anterior lip of cervix
Rigid cervix: is a rare condition in which the cervix fails to
dilate despite normal uterine contractions.
It is characterised by severe persistent backache.
On vaginal examination the cervix feels thin, tight and
unyielding.
Annular detachment of the cervix: there is total circular
separation of the anterior or posterior lip of the internal OS
during or immediately after delivery.
Sometimes both lips are separated resulting in cervical
amputation
Rarely occurs
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 73
Trial of Labour
Trial of labour is a test of labour conducted
where there is a minor or moderate degree of
Cephalopelvic Disproportion (CPD) in which it is
difficult to decide whether delivery per vagina is
possible.
Common with borderline pelvis
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 74
Trial of labour is a test of labour conducted
where there is a minor or moderate degree of
Cephalopelvic Disproportion (CPD) in which it is
difficult to decide whether delivery per vagina is
possible.
Common with borderline pelvis
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 74
Contraindications for trial of
labour
Grossly contracted pelvis
Medical or obstetrical complications
Mal-presentations, for example, breech
Elderly primigravida
Cases where trial of labour failed before
Cases of two previous caesarean sections
Remember: Your encouragement and friendly
attitude will boost the mother’s morale.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 75
labour
Grossly contracted pelvis
Medical or obstetrical complications
Mal-presentations, for example, breech
Elderly primigravida
Cases where trial of labour failed before
Cases of two previous caesarean sections
Remember: Your encouragement and friendly
attitude will boost the mother’s morale.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 75
Management of Trial of Labour
Explain the situation to the mother and
prepare her for possible operative
intervention.
Assess patient carefully on admission to
ascertain the following:
Whether the mother is in established labour
Presentation of foetus
Check for flexion of the head
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 76
Explain the situation to the mother and
prepare her for possible operative
intervention.
Assess patient carefully on admission to
ascertain the following:
Whether the mother is in established labour
Presentation of foetus
Check for flexion of the head
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 76
Management of Trial of Labour
State of foetal heart, that is, rate, rhythm and volume
General condition of mother physically and
emotionally
Confine the mother to bed to prevent early rupture of
membranes
Close observations of temperature and blood
pressure every four hours
Observe foetal heart rate and maternal pulse
quarterly to half hourly
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 77
State of foetal heart, that is, rate, rhythm and volume
General condition of mother physically and
emotionally
Confine the mother to bed to prevent early rupture of
membranes
Close observations of temperature and blood
pressure every four hours
Observe foetal heart rate and maternal pulse
quarterly to half hourly
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 77
Management of Trial of Labour
Observe for signs of foetal and maternal distress.
Accurately observe and record for onset, strength,
frequency and duration of the contractions.
Closely observe the descent of the head every one to
two hours per abdominal palpation by the same
midwife if possible.
Encourage the mother to pass urine every two hours
and test for acetone to exclude acidosis.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 78
Observe for signs of foetal and maternal distress.
Accurately observe and record for onset, strength,
frequency and duration of the contractions.
Closely observe the descent of the head every one to
two hours per abdominal palpation by the same
midwife if possible.
Encourage the mother to pass urine every two hours
and test for acetone to exclude acidosis.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 78
Management of Trial of Labour
Do vaginal examination every four hours to assess
the level of the presenting part, the degree moulding
and flexion, the dilation of the cervix (whether
progressive or not), the consistency of the cervix and
the presence or absence of caput.
Check whether the membranes are intact or
ruptured.
Encourage adequate hydration by giving intravenous
normal saline
Sedate the mother with pethidine in early labour to
promote rest, and reduce anxiety.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 79
Do vaginal examination every four hours to assess
the level of the presenting part, the degree moulding
and flexion, the dilation of the cervix (whether
progressive or not), the consistency of the cervix and
the presence or absence of caput.
Check whether the membranes are intact or
ruptured.
Encourage adequate hydration by giving intravenous
normal saline
Sedate the mother with pethidine in early labour to
promote rest, and reduce anxiety.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 79
Trial of Scar
Trial of scar is a test of labour for a woman with a
previous caesarean section scar, where no recurrent
indication is present.
Studies have shown that some 60 – 65% of previous
caesarean section mothers deliver per vagina,
involving same or fewer risks than a repeated
section.
The trial should be in a facility where, where a
caesarean section, this can be performed
immediately.
The midwife should be vigilant in making the
necessary observations.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 80
Trial of scar is a test of labour for a woman with a
previous caesarean section scar, where no recurrent
indication is present.
Studies have shown that some 60 – 65% of previous
caesarean section mothers deliver per vagina,
involving same or fewer risks than a repeated
section.
The trial should be in a facility where, where a
caesarean section, this can be performed
immediately.
The midwife should be vigilant in making the
necessary observations.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 80
Management
Palpate abdomen gently
Check for any tenderness over the scar
Observe for any signs of impending rupture of the
uterus
Report any constant pain in abdomen
Educating the Patient on Avoiding Unnecessary
Caesarean Birth
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 81
Palpate abdomen gently
Check for any tenderness over the scar
Observe for any signs of impending rupture of the
uterus
Report any constant pain in abdomen
Educating the Patient on Avoiding Unnecessary
Caesarean Birth
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 81
Contraindications
CPD
Classical type of C/S
Malpresentation
Two previous scars, regardless of the causes
Previous scar wound did not heal with the first intension
Pregnancy occurs within 6months of a C/S
Over-distension due to multiple pregnancy or p0lyhydromnious
Multiparity
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 82
CPD
Classical type of C/S
Malpresentation
Two previous scars, regardless of the causes
Previous scar wound did not heal with the first intension
Pregnancy occurs within 6months of a C/S
Over-distension due to multiple pregnancy or p0lyhydromnious
Multiparity
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 82
Maternal
Distress
Is a serious and life threatening condition, which
should not occur in this era.
Happens when the metabolism and the electrolyte
balance of the woman in labour is disturbed and this
can result into keto-acidosis hypotonic uterine
inertia.
Maternal and foetal distresses usually occur together
after prolonged labour.
Often maternal and foetal distress present together
in women who have been in labour for a long time at
home and are brought to a health centre or hospital
in poor condition.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 83
Distress
Is a serious and life threatening condition, which
should not occur in this era.
Happens when the metabolism and the electrolyte
balance of the woman in labour is disturbed and this
can result into keto-acidosis hypotonic uterine
inertia.
Maternal and foetal distresses usually occur together
after prolonged labour.
Often maternal and foetal distress present together
in women who have been in labour for a long time at
home and are brought to a health centre or hospital
in poor condition.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 83
Signs and Symptoms
Maternal exhaustion due to severe
abdominal pain and lack of sleep because of
the prolonged and obstructed labour.
Signs of anxiety
Dry and furred tongue
Pulse rate of over 120 b/min
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 84
Maternal exhaustion due to severe
abdominal pain and lack of sleep because of
the prolonged and obstructed labour.
Signs of anxiety
Dry and furred tongue
Pulse rate of over 120 b/min
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 84
Signs and Symptoms
Rapid and deep respiration because of acidosis
Hot, dry and inelastic skin
Abdominal distension
Oliguria of highly concentrated urine
Temperature of 38°C
Purulent discharge from an intrauterine infection
due to early rupture of the membranes
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 85
Rapid and deep respiration because of acidosis
Hot, dry and inelastic skin
Abdominal distension
Oliguria of highly concentrated urine
Temperature of 38°C
Purulent discharge from an intrauterine infection
due to early rupture of the membranes
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 85
Management
The main investigation is testing for the
presence of acetone in the urine.
The management of Maternal Distress
involves giving an infusion of normal saline
to correct dehydration.
A caesarean section is performed when in the
first stage of labour.
In the second stage, an episiotomy is given
and delivery is assisted with vacuum
extraction.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 86
The main investigation is testing for the
presence of acetone in the urine.
The management of Maternal Distress
involves giving an infusion of normal saline
to correct dehydration.
A caesarean section is performed when in the
first stage of labour.
In the second stage, an episiotomy is given
and delivery is assisted with vacuum
extraction.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 86
Foetal Distress
Foetal distress occurs when the foetus is deprived of
oxygen and, as a result, develops hypoxia.
The baby may be born as a still birth or develop
asphyxia and suffer brain damage.
Foetal tachycardia of more than 160 per minute is an
early sign while foetal bradycardia or pulse less than
110 beats per minute is a late sign of foetal distress.
Foetal heart acceleration related with uterine
contraction is a sign of foetal distress.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 87
Foetal distress occurs when the foetus is deprived of
oxygen and, as a result, develops hypoxia.
The baby may be born as a still birth or develop
asphyxia and suffer brain damage.
Foetal tachycardia of more than 160 per minute is an
early sign while foetal bradycardia or pulse less than
110 beats per minute is a late sign of foetal distress.
Foetal heart acceleration related with uterine
contraction is a sign of foetal distress.
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 87
Causes of Fetal Distress
Severe Congenital malformation
Problems with the cord e.g. prolapse, true knot,
twisted round the neck
Obstetric complications
Preeclampsia/eclampsia
Severe anaemia, APH
Prolonged labour
Malpresentation
Malposition
Shoulder dystocia
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 88
Severe Congenital malformation
Problems with the cord e.g. prolapse, true knot,
twisted round the neck
Obstetric complications
Preeclampsia/eclampsia
Severe anaemia, APH
Prolonged labour
Malpresentation
Malposition
Shoulder dystocia
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 88
Management
Inform the obstetrician immediately fetal distress is
diagnosed
When fetal distress is anticipated, a blood sample is
taken for pH testing, the normal pH being 7.35
If pH falls to 7.2, labour has to be terminated
Below pH of 7, the brain cells perish
If the mother is on an oxytocin drip, stop it
immediately
Change the mother’s position and give oxygen by
facemask
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 89
Inform the obstetrician immediately fetal distress is
diagnosed
When fetal distress is anticipated, a blood sample is
taken for pH testing, the normal pH being 7.35
If pH falls to 7.2, labour has to be terminated
Below pH of 7, the brain cells perish
If the mother is on an oxytocin drip, stop it
immediately
Change the mother’s position and give oxygen by
facemask
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 89
Management
If the mother is in the 1
st
stage of labour, a c/s
should be performed
If she is in the 2
nd
stage, an episiotomy should be
given
Use Forceps or vacuum to hasten the birth
A pediatrician should always be present, if
possible for resuscitation of baby
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 90
If the mother is in the 1
st
stage of labour, a c/s
should be performed
If she is in the 2
nd
stage, an episiotomy should be
given
Use Forceps or vacuum to hasten the birth
A pediatrician should always be present, if
possible for resuscitation of baby
Sunday, March 2, 2025 ABNORMAL LABOR: BY PAUL NYONGESA 90
OCCIPITO POSTERIOR
POSITION (OPP)
The vertex occupies the posterior
position instead of the anterior
It can be left or right occipito-
posterior position
The cause is associated with pelvic
abnormalities
Sunday, March 2, 2025 91ABNORMAL LABOR: BY PAUL NYONGESA
POSITION (OPP)
The vertex occupies the posterior
position instead of the anterior
It can be left or right occipito-
posterior position
The cause is associated with pelvic
abnormalities
Sunday, March 2, 2025 91ABNORMAL LABOR: BY PAUL NYONGESA
OCCIPITO POSTERIOR POSITION
(OPP)
Diagnosis of Occipito Posterior
Position
On inspection of the lower abdomen:
The unengaged head is observed as a
full bladder while at the level of the
umbilicus, it will be saucer-shaped
Sunday, March 2, 2025 92ABNORMAL LABOR: BY PAUL NYONGESA
(OPP)
Diagnosis of Occipito Posterior
Position
On inspection of the lower abdomen:
The unengaged head is observed as a
full bladder while at the level of the
umbilicus, it will be saucer-shaped
Sunday, March 2, 2025 92ABNORMAL LABOR: BY PAUL NYONGESA
OCCIPITO POSTERIOR
POSITION (OPP)
On palpation;
The head is high, as the engaged diameter of
11.5cm cannot enter the brim till flexion
takes place
The head feels large and the occiput and
sinciput are on the same level
The fetal back is difficult to palpate
Limbs are felt on both sides of the abdomen
Sunday, March 2, 2025Limbs
are felt on both sides of the
abdomen
93ABNORMAL LABOR: BY PAUL NYONGESA
POSITION (OPP)
On palpation;
The head is high, as the engaged diameter of
11.5cm cannot enter the brim till flexion
takes place
The head feels large and the occiput and
sinciput are on the same level
The fetal back is difficult to palpate
Limbs are felt on both sides of the abdomen
Sunday, March 2, 2025Limbs
are felt on both sides of the
abdomen
93ABNORMAL LABOR: BY PAUL NYONGESA
OPP
On auscultation;
The foetal heart is heard on the
right flank, it can also be heard
at;
The umbilicus, either at the
middle line or slightly to the left
Sunday, March 2, 2025 94ABNORMAL LABOR: BY PAUL NYONGESA
On auscultation;
The foetal heart is heard on the
right flank, it can also be heard
at;
The umbilicus, either at the
middle line or slightly to the left
Sunday, March 2, 2025 94ABNORMAL LABOR: BY PAUL NYONGESA
OPP
During labour the mother may
complain of severe backache
Slow descent of the presenting
part
Early rupture of membrane may
occur
Sunday, March 2, 2025 95ABNORMAL LABOR: BY PAUL NYONGESA
During labour the mother may
complain of severe backache
Slow descent of the presenting
part
Early rupture of membrane may
occur
Sunday, March 2, 2025 95ABNORMAL LABOR: BY PAUL NYONGESA
OPP
On vaginal examination;
Anterior fontanelle is felt to the left
anterior in right occipito- position
(ROP).
The Sagittal sutures are felt in the
right oblique of the pelvis, but the
findings will depend on the degree
of flexion of the head
Sunday, March 2, 2025 96ABNORMAL LABOR: BY PAUL NYONGESA
On vaginal examination;
Anterior fontanelle is felt to the left
anterior in right occipito- position
(ROP).
The Sagittal sutures are felt in the
right oblique of the pelvis, but the
findings will depend on the degree
of flexion of the head
Sunday, March 2, 2025 96ABNORMAL LABOR: BY PAUL NYONGESA
OPP
In 1
st
stage of Labour
Back massage
Encourage the mother to be on all
fours to aid the rotation of the foetal
head
Give intravenous fluid
Regulate uterine action by syntocinon
Sunday, March 2, 2025 97ABNORMAL LABOR: BY PAUL NYONGESA
In 1
st
stage of Labour
Back massage
Encourage the mother to be on all
fours to aid the rotation of the foetal
head
Give intravenous fluid
Regulate uterine action by syntocinon
Sunday, March 2, 2025 97ABNORMAL LABOR: BY PAUL NYONGESA
OPP
•Observe foetal heart 1/2hourly
•Observe uterine contractions 4 hourly,
Observe blood pressure 4 hourly
Maintain a strict intake and output chart
Discourage early pushing
Encourage her to change positions
Breathing techniques to control the urge
of early pushing
Sunday, March 2, 2025 98ABNORMAL LABOR: BY PAUL NYONGESA
•Observe foetal heart 1/2hourly
•Observe uterine contractions 4 hourly,
Observe blood pressure 4 hourly
Maintain a strict intake and output chart
Discourage early pushing
Encourage her to change positions
Breathing techniques to control the urge
of early pushing
Sunday, March 2, 2025 98ABNORMAL LABOR: BY PAUL NYONGESA
OPP
In 2
nd
stage of labour
Caput may be seen at the vulva with the
anterior lip of the cervix
During labour, one of the following may
occur:
Long internal rotation
Short internal rotation
Deep transverse arrest
Sunday, March 2, 2025 99ABNORMAL LABOR: BY PAUL NYONGESA
In 2
nd
stage of labour
Caput may be seen at the vulva with the
anterior lip of the cervix
During labour, one of the following may
occur:
Long internal rotation
Short internal rotation
Deep transverse arrest
Sunday, March 2, 2025 99ABNORMAL LABOR: BY PAUL NYONGESA
OPP
Long Internal Rotation: The head
turns 3/8 of a circle in 90% of cases
The baby is born as in occiput
anterior
Short Rotation: It persists with the
same position
The baby is born face to pubis
Sunday, March 2, 2025 100ABNORMAL LABOR: BY PAUL NYONGESA
Long Internal Rotation: The head
turns 3/8 of a circle in 90% of cases
The baby is born as in occiput
anterior
Short Rotation: It persists with the
same position
The baby is born face to pubis
Sunday, March 2, 2025 100ABNORMAL LABOR: BY PAUL NYONGESA
OPP
Deep Transverse Arrest
The occiput fails to rotate forward
forcing the sinciput to reach the pelvic
floor first and rotate forwards
Administer analgesics
Operative delivery is necessary
(forceps delivery, vacuum extraction)
Sunday, March 2, 2025 101ABNORMAL LABOR: BY PAUL NYONGESA
Deep Transverse Arrest
The occiput fails to rotate forward
forcing the sinciput to reach the pelvic
floor first and rotate forwards
Administer analgesics
Operative delivery is necessary
(forceps delivery, vacuum extraction)
Sunday, March 2, 2025 101ABNORMAL LABOR: BY PAUL NYONGESA
FACE PRESENTATION
The head is in complete extension
The occiput is in contact with its spine
Primary face presentation occurs
before labour
Secondary face presentation occurs
during labour
Sunday, March 2, 2025 102ABNORMAL LABOR: BY PAUL NYONGESA
The head is in complete extension
The occiput is in contact with its spine
Primary face presentation occurs
before labour
Secondary face presentation occurs
during labour
Sunday, March 2, 2025 102ABNORMAL LABOR: BY PAUL NYONGESA
FACE PRESENTATION
The denominator is the mentum/chin
The face presentation positions;
Right mento posterior, left mento
posterior, right mento lateral, left
mento-lateral, right mento anterior,
and left mento anterior
Sunday, March 2, 2025 103ABNORMAL LABOR: BY PAUL NYONGESA
The denominator is the mentum/chin
The face presentation positions;
Right mento posterior, left mento
posterior, right mento lateral, left
mento-lateral, right mento anterior,
and left mento anterior
Sunday, March 2, 2025 103ABNORMAL LABOR: BY PAUL NYONGESA
FACE PRESENTATION
The presenting diameters are;
The submento bregmatic
(9.5cm) ,and
The bi-temporal (8.2cm)
Causes of face presentation
Anterior obliquity of the Uterus
Contracted Pelvis
Sunday, March 2, 2025 104ABNORMAL LABOR: BY PAUL NYONGESA
The presenting diameters are;
The submento bregmatic
(9.5cm) ,and
The bi-temporal (8.2cm)
Causes of face presentation
Anterior obliquity of the Uterus
Contracted Pelvis
Sunday, March 2, 2025 104ABNORMAL LABOR: BY PAUL NYONGESA
FACE PRESENTATION
Polyhydramnios
Congenital Abnormality
Determining face presentation;
On abdominal examination;
S-shaped foetal spine
The round occiput is prominent
Sunday, March 2, 2025 105ABNORMAL LABOR: BY PAUL NYONGESA
Polyhydramnios
Congenital Abnormality
Determining face presentation;
On abdominal examination;
S-shaped foetal spine
The round occiput is prominent
Sunday, March 2, 2025 105ABNORMAL LABOR: BY PAUL NYONGESA
FACE PRESENTATION
The round occiput may be
ballottable in mento-posterior
A deep groove can be felt between
round occiput and and the back
On vaginal examination;
High, soft, and irregular
presenting part
Sunday, March 2, 2025 106ABNORMAL LABOR: BY PAUL NYONGESA
The round occiput may be
ballottable in mento-posterior
A deep groove can be felt between
round occiput and and the back
On vaginal examination;
High, soft, and irregular
presenting part
Sunday, March 2, 2025 106ABNORMAL LABOR: BY PAUL NYONGESA
FACE PRESENTATION
Orbital ridges, eyes, nose and mouth
may be felt
The mouth may be open with hard
gums
Foetus may suck the examining finger
Oedematous face indistinguishable
from a breech presentation
Sunday, March 2, 2025 107ABNORMAL LABOR: BY PAUL NYONGESA
Orbital ridges, eyes, nose and mouth
may be felt
The mouth may be open with hard
gums
Foetus may suck the examining finger
Oedematous face indistinguishable
from a breech presentation
Sunday, March 2, 2025 107ABNORMAL LABOR: BY PAUL NYONGESA
Management of face
presentation
First stage of labour;
Inform the obstetrician
Observe BP and temperature 2 hourly
Observe maternal pulse, foetal heart
rate and contraction 1/2 hourly
Empty urinary bladder 2 hourly
Sunday, March 2, 2025 108ABNORMAL LABOR: BY PAUL NYONGESA
presentation
First stage of labour;
Inform the obstetrician
Observe BP and temperature 2 hourly
Observe maternal pulse, foetal heart
rate and contraction 1/2 hourly
Empty urinary bladder 2 hourly
Sunday, March 2, 2025 108ABNORMAL LABOR: BY PAUL NYONGESA
Management of face
presentation
Vaginal examination 4 hourly to
determine cervical dilation and
descent of the head
Take care not to injure the eyes
Note whether the mentum is lower
than the sinciput since rotation and
descent depends on this
Sunday, March 2, 2025 109ABNORMAL LABOR: BY PAUL NYONGESA
presentation
Vaginal examination 4 hourly to
determine cervical dilation and
descent of the head
Take care not to injure the eyes
Note whether the mentum is lower
than the sinciput since rotation and
descent depends on this
Sunday, March 2, 2025 109ABNORMAL LABOR: BY PAUL NYONGESA
Management of face
presentation
Vaginal delivery; give an episiotomy
when the face extends to the
perineum
•Maintain extension when the face
appears at the vulva by holding the
sinciput until the chin is delivered
Allow the occiput to sweep the
perineum when the chin is delivered
Sunday, March 2, 2025 110ABNORMAL LABOR: BY PAUL NYONGESA
presentation
Vaginal delivery; give an episiotomy
when the face extends to the
perineum
•Maintain extension when the face
appears at the vulva by holding the
sinciput until the chin is delivered
Allow the occiput to sweep the
perineum when the chin is delivered
Sunday, March 2, 2025 110ABNORMAL LABOR: BY PAUL NYONGESA
Management of face
presentation
•Allow the occiput to ride over the
perineum
The head is flexed completely and
it is delivered
Inform the doctor if the head does
not descend in the second stage
Sunday, March 2, 2025 111ABNORMAL LABOR: BY PAUL NYONGESA
presentation
•Allow the occiput to ride over the
perineum
The head is flexed completely and
it is delivered
Inform the doctor if the head does
not descend in the second stage
Sunday, March 2, 2025 111ABNORMAL LABOR: BY PAUL NYONGESA
Management of face
presentation
Forceps delivery; is done in a
mento-anterior position
Caesarean section; prepared for
caesarean section if the head
remains high despite good uterine
contractions (in impacted head or
suspicious pelvic disproportion)
Sunday, March 2, 2025 112ABNORMAL LABOR: BY PAUL NYONGESA
presentation
Forceps delivery; is done in a
mento-anterior position
Caesarean section; prepared for
caesarean section if the head
remains high despite good uterine
contractions (in impacted head or
suspicious pelvic disproportion)
Sunday, March 2, 2025 112ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
The foetus lies with the buttocks in the
lower pole of the uterus after 34 weeks
of pregnancy
Maternal causes
Contracted pelvis
Polyhydramnios, and
Multiple pregnancy
Sunday, March 2, 2025 113ABNORMAL LABOR: BY PAUL NYONGESA
The foetus lies with the buttocks in the
lower pole of the uterus after 34 weeks
of pregnancy
Maternal causes
Contracted pelvis
Polyhydramnios, and
Multiple pregnancy
Sunday, March 2, 2025 113ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
Foetal causes
Pre-term labour
Hydrocephalus
Extended legs
Sunday, March 2, 2025 114ABNORMAL LABOR: BY PAUL NYONGESA
Foetal causes
Pre-term labour
Hydrocephalus
Extended legs
Sunday, March 2, 2025 114ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
Types of breech presentation
Complete breech presentation
Incomplete breech presentation
Frank breech (breech with
extended legs
Footling breech
Knee presentation
Sunday, March 2, 2025 115ABNORMAL LABOR: BY PAUL NYONGESA
Types of breech presentation
Complete breech presentation
Incomplete breech presentation
Frank breech (breech with
extended legs
Footling breech
Knee presentation
Sunday, March 2, 2025 115ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
Antenatal diagnosis
History of breech, though not
conclusive
Abdominal palpation
A round, hard, ballot able mass
on palpation at the fundus
Sunday, March 2, 2025 116ABNORMAL LABOR: BY PAUL NYONGESA
Antenatal diagnosis
History of breech, though not
conclusive
Abdominal palpation
A round, hard, ballot able mass
on palpation at the fundus
Sunday, March 2, 2025 116ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
Auscultation
Foetal heart is heard above the
level of the umbilicus on
auscultation
Ultrasound examination
Sunday, March 2, 2025 117ABNORMAL LABOR: BY PAUL NYONGESA
Auscultation
Foetal heart is heard above the
level of the umbilicus on
auscultation
Ultrasound examination
Sunday, March 2, 2025 117ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
Diagnosis during labor
On vaginal examination;
A soft mass is felt
Genital parts may be felt, and
The examining finger may be
grasped by the foetus’ rectum
Sunday, March 2, 2025 118ABNORMAL LABOR: BY PAUL NYONGESA
Diagnosis during labor
On vaginal examination;
A soft mass is felt
Genital parts may be felt, and
The examining finger may be
grasped by the foetus’ rectum
Sunday, March 2, 2025 118ABNORMAL LABOR: BY PAUL NYONGESA
On abdominal palpation
Position is expressed as Left
Sacro Anterior or (LSA) or Right
sacro anterior, (RSA)
Antenatal management
Refer to a doctor at 36 weeks
gestation
Sunday, March 2, 2025 119ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
Position is expressed as Left
Sacro Anterior or (LSA) or Right
sacro anterior, (RSA)
Antenatal management
Refer to a doctor at 36 weeks
gestation
Sunday, March 2, 2025 119ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
•Confirm breech by ultrasound scan
Perform an external cephalic version
Contra-indications of external
cephalic version; multiple
pregnancy , previous c/s, Rh –ve, high
blood pressure, oligohydramnious,
ruptured membranes, HIV +
Sunday, March 2, 2025 120ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
Perform an external cephalic version
Contra-indications of external
cephalic version; multiple
pregnancy , previous c/s, Rh –ve, high
blood pressure, oligohydramnious,
ruptured membranes, HIV +
Sunday, March 2, 2025 120ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
BREECH PRESENTATION
Complications of external
cephalic version;
knotting of the umbilical cord
separation of the placenta
rupture of the membranes
Sunday, March 2, 2025 121ABNORMAL LABOR: BY PAUL NYONGESA
Complications of external
cephalic version;
knotting of the umbilical cord
separation of the placenta
rupture of the membranes
Sunday, March 2, 2025 121ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
Mechanism of breech delivery
Descent /compaction: This takes
place with increasing compaction
due to increased flexion of limbs
Sunday, March 2, 2025 122ABNORMAL LABOR: BY PAUL NYONGESA
Mechanism of breech delivery
Descent /compaction: This takes
place with increasing compaction
due to increased flexion of limbs
Sunday, March 2, 2025 122ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
Internal Rotation of the Buttocks: The
anterior buttock reaches the pelvic brim
first and rotates one eighth of a circle
forwards along the right side of pelvis
The bi-trochanteric diameter becomes the
antero-posterior diameter of the outlet
Lateral Flexion of the Body: The anterior
buttock escapes under the symphysis pubis
Sunday, March 2, 2025 123ABNORMAL LABOR: BY PAUL NYONGESA
Internal Rotation of the Buttocks: The
anterior buttock reaches the pelvic brim
first and rotates one eighth of a circle
forwards along the right side of pelvis
The bi-trochanteric diameter becomes the
antero-posterior diameter of the outlet
Lateral Flexion of the Body: The anterior
buttock escapes under the symphysis pubis
Sunday, March 2, 2025 123ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
The posterior buttock sweeps the
perineum and the buttocks are
born by a movement of lateral
flexion
Restitution of the Buttock; The
anterior buttock turns slightly to
the patient’s right side
Sunday, March 2, 2025 124ABNORMAL LABOR: BY PAUL NYONGESA
The posterior buttock sweeps the
perineum and the buttocks are
born by a movement of lateral
flexion
Restitution of the Buttock; The
anterior buttock turns slightly to
the patient’s right side
Sunday, March 2, 2025 124ABNORMAL LABOR: BY PAUL NYONGESA
Internal Rotation of the
Shoulders; The shoulders enter in
the same oblique diameter of the
brim as the buttocks
The anterior shoulder rotates
forwards one eighth of a circle along
the right side of the pelvis and
escapes under the symphysis pubis
Sunday, March 2, 2025 125ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
Shoulders; The shoulders enter in
the same oblique diameter of the
brim as the buttocks
The anterior shoulder rotates
forwards one eighth of a circle along
the right side of the pelvis and
escapes under the symphysis pubis
Sunday, March 2, 2025 125ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
BREECH PRESENTATION
The posterior shoulder sweeps the
perineum and the shoulders are born
Internal Rotation of the head; The
head enters in the transverse
diameter of the pelvic brim
The occipito rotates along the left or
right side of the pelvis
Sunday, March 2, 2025 126ABNORMAL LABOR: BY PAUL NYONGESA
The posterior shoulder sweeps the
perineum and the shoulders are born
Internal Rotation of the head; The
head enters in the transverse
diameter of the pelvic brim
The occipito rotates along the left or
right side of the pelvis
Sunday, March 2, 2025 126ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
The sub-occipital region (nape of
the neck) impinges under surface
of the symphysis pubis
External Rotation of the Body;
The body turns so that the back is
uppermost, a movement which
accompanies internal rotation of
the head.
Sunday, March 2, 2025 127ABNORMAL LABOR: BY PAUL NYONGESA
The sub-occipital region (nape of
the neck) impinges under surface
of the symphysis pubis
External Rotation of the Body;
The body turns so that the back is
uppermost, a movement which
accompanies internal rotation of
the head.
Sunday, March 2, 2025 127ABNORMAL LABOR: BY PAUL NYONGESA
Birth of the Head; The chin, face and
sinciput sweep the perineum and the
head is born in flexed attitude
Management of 1
st
stage of labour
Like normal labour
Epidural analgesia may be used to
inhibit urge to push pre-maturely
Sunday, March 2, 2025 128ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
sinciput sweep the perineum and the
head is born in flexed attitude
Management of 1
st
stage of labour
Like normal labour
Epidural analgesia may be used to
inhibit urge to push pre-maturely
Sunday, March 2, 2025 128ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
BREECH PRESENTATION
Management of the 2
nd
stage of
labour
Reassure the mother
Confirm full dilation by VE
Sunday, March 2, 2025 129ABNORMAL LABOR: BY PAUL NYONGESA
Management of the 2
nd
stage of
labour
Reassure the mother
Confirm full dilation by VE
Sunday, March 2, 2025 129ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
Types of births
i. Spontaneous breech delivery;
little assistance from the attendant
ii. Assisted breech delivery;
assistance to deliver extended arms,
legs and head
iii. Breech extraction; manipulative
delivery carried out by obstetrician
Sunday, March 2, 2025 130ABNORMAL LABOR: BY PAUL NYONGESA
Types of births
i. Spontaneous breech delivery;
little assistance from the attendant
ii. Assisted breech delivery;
assistance to deliver extended arms,
legs and head
iii. Breech extraction; manipulative
delivery carried out by obstetrician
Sunday, March 2, 2025 130ABNORMAL LABOR: BY PAUL NYONGESA
Spontaneous complete breech
delivery:
Position the mother’s buttocks at
the edge of the bed to allow the
baby to hang
Apply supra-pubic pressure to the
head if required
Sunday, March 2, 2025 131ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
delivery:
Position the mother’s buttocks at
the edge of the bed to allow the
baby to hang
Apply supra-pubic pressure to the
head if required
Sunday, March 2, 2025 131ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
BREECH PRESENTATION
Hands off the breech until the
buttocks extend the perineum
Perform a medio-lateral episiotomy
to avoid compression of a moulded
head
The buttocks are expelled by an aided
bearing down effort of the mother
Sunday, March 2, 2025 132ABNORMAL LABOR: BY PAUL NYONGESA
Hands off the breech until the
buttocks extend the perineum
Perform a medio-lateral episiotomy
to avoid compression of a moulded
head
The buttocks are expelled by an aided
bearing down effort of the mother
Sunday, March 2, 2025 132ABNORMAL LABOR: BY PAUL NYONGESA
With the same contraction the
baby is born up to the umbilicus
Pull a loop of cord to prevent
traction of the cord, this should be
handled gently to avoid inducing
spasm and should be nipped under
the pubic arch to avoid anoxia
Sunday, March 2, 2025 133ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
baby is born up to the umbilicus
Pull a loop of cord to prevent
traction of the cord, this should be
handled gently to avoid inducing
spasm and should be nipped under
the pubic arch to avoid anoxia
Sunday, March 2, 2025 133ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
BREECH PRESENTATION
Check if elbows are on the chest as is the case
with complete breech
As soon as the shoulders are born, let the baby
hang by its weight for one or two minutes
When the hairline appears, grasp the baby by
the feet and hold on the stretch applying
sufficient traction to prevent fracture of the neck
Move the feet through an arch of 180 degrees
until the mouth and nose are free at the vulva
Hold the baby upside down and
Do mechanical suction of the airway
Sunday, March 2, 2025 134ABNORMAL LABOR: BY PAUL NYONGESA
Check if elbows are on the chest as is the case
with complete breech
As soon as the shoulders are born, let the baby
hang by its weight for one or two minutes
When the hairline appears, grasp the baby by
the feet and hold on the stretch applying
sufficient traction to prevent fracture of the neck
Move the feet through an arch of 180 degrees
until the mouth and nose are free at the vulva
Hold the baby upside down and
Do mechanical suction of the airway
Sunday, March 2, 2025 134ABNORMAL LABOR: BY PAUL NYONGESA
Ask the mother to pant through an
open mouth, “breathing out the head”
One or two minutes should elapse to
allow slow delivery of the vault of the
head to prevent a tentorium tear
The Apgar score is usually about 8-7
Sunday, March 2, 2025 135ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
open mouth, “breathing out the head”
One or two minutes should elapse to
allow slow delivery of the vault of the
head to prevent a tentorium tear
The Apgar score is usually about 8-7
Sunday, March 2, 2025 135ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
BREECH PRESENTATION
Assisted extended leg delivery;
Apply downward traction until
popliteal fossae appear at the vulva
An episiotomy is made as the
buttocks extend the perineum
Apply pressure at the popliteal
fossae with abduction of the thigh
Sunday, March 2, 2025 136ABNORMAL LABOR: BY PAUL NYONGESA
Assisted extended leg delivery;
Apply downward traction until
popliteal fossae appear at the vulva
An episiotomy is made as the
buttocks extend the perineum
Apply pressure at the popliteal
fossae with abduction of the thigh
Sunday, March 2, 2025 136ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
The knee flexes
This aids extraction of the feet and
avoid fractures of lower limbs
The foot is swept over the baby’s
abdomen and the feet are born
Wait until the baby is delivered up
to the umbilicus
Sunday, March 2, 2025 137ABNORMAL LABOR: BY PAUL NYONGESA
The knee flexes
This aids extraction of the feet and
avoid fractures of lower limbs
The foot is swept over the baby’s
abdomen and the feet are born
Wait until the baby is delivered up
to the umbilicus
Sunday, March 2, 2025 137ABNORMAL LABOR: BY PAUL NYONGESA
Pull a loop of cord to prevent
traction of the cord
Feel for the elbow at the chest,
which should not be felt with
extended hands
Sunday, March 2, 2025 138ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
traction of the cord
Feel for the elbow at the chest,
which should not be felt with
extended hands
Sunday, March 2, 2025 138ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
Delivery of the extended hands
(Love set manoeuvre);
Grasp the baby at the iliac crest with
thumbs at the sacrum and the back
uppermost during a contraction
Wrap a small towel around the baby’s
waist to prevent it from being slippery
Sunday, March 2, 2025 139ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
(Love set manoeuvre);
Grasp the baby at the iliac crest with
thumbs at the sacrum and the back
uppermost during a contraction
Wrap a small towel around the baby’s
waist to prevent it from being slippery
Sunday, March 2, 2025 139ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
Rotate the baby 180
o
anti-clockwise
Apply downwards traction while
the body is rotated 180
o
anti-
clockwise until the axilla is visible
The arm that was posterior is
now anterior
Sunday, March 2, 2025 140ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
o
anti-clockwise
Apply downwards traction while
the body is rotated 180
o
anti-
clockwise until the axilla is visible
The arm that was posterior is
now anterior
Sunday, March 2, 2025 140ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
BREECH PRESENTATION
Splint the humerous with the two
first fingers of your left hand to
avoid breaking it
The elbow is drawn downwards
and is delivered under the pubic
arch with body upper most
Wait for the next contraction
Sunday, March 2, 2025 141ABNORMAL LABOR: BY PAUL NYONGESA
Splint the humerous with the two
first fingers of your left hand to
avoid breaking it
The elbow is drawn downwards
and is delivered under the pubic
arch with body upper most
Wait for the next contraction
Sunday, March 2, 2025 141ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
Rotating the body half circle
clockwise, make anterior arm
posterior
Using the right hand, splint the
humerous, draw it downwards and
deliver it under the pubic arch
Repeat the next side and deliver the
other hand
Sunday, March 2, 2025 142ABNORMAL LABOR: BY PAUL NYONGESA
Rotating the body half circle
clockwise, make anterior arm
posterior
Using the right hand, splint the
humerous, draw it downwards and
deliver it under the pubic arch
Repeat the next side and deliver the
other hand
Sunday, March 2, 2025 142ABNORMAL LABOR: BY PAUL NYONGESA
Delivery of the extended head
(Maurice, Smellie Vet
Manoeuvre);
Position hands and fingers to
extract extended head
Put the baby astride your left arm
with the palm supporting the chest
Sunday, March 2, 2025 143ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
(Maurice, Smellie Vet
Manoeuvre);
Position hands and fingers to
extract extended head
Put the baby astride your left arm
with the palm supporting the chest
Sunday, March 2, 2025 143ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
BREECH PRESENTATION
Place first and third fingers of your
left hand on the malar bones to flex
the head
Place the middle finger in the mouth
well back to aid flexion
Hook first and second right hand
fingers over the shoulders pulling
moderately in a downwards direction
Sunday, March 2, 2025 144ABNORMAL LABOR: BY PAUL NYONGESA
Place first and third fingers of your
left hand on the malar bones to flex
the head
Place the middle finger in the mouth
well back to aid flexion
Hook first and second right hand
fingers over the shoulders pulling
moderately in a downwards direction
Sunday, March 2, 2025 144ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
Exert a controlled traction in a
downwards direction as the head
descends in the curved birth canal
until the sub occiput area appears
after the appearance of the nape of
the neck up
Upward traction will inflict
fracture of the neck;
Sunday, March 2, 2025 145ABNORMAL LABOR: BY PAUL NYONGESA
Exert a controlled traction in a
downwards direction as the head
descends in the curved birth canal
until the sub occiput area appears
after the appearance of the nape of
the neck up
Upward traction will inflict
fracture of the neck;
Sunday, March 2, 2025 145ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
Instruct the mother to pant
Exert traction in upward direction
to allow for the birth of the head
Nose and mouth are free
Your assistance clears the airway
Vault is delivered slowly
Sunday, March 2, 2025 146ABNORMAL LABOR: BY PAUL NYONGESA
Instruct the mother to pant
Exert traction in upward direction
to allow for the birth of the head
Nose and mouth are free
Your assistance clears the airway
Vault is delivered slowly
Sunday, March 2, 2025 146ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
Delivery of the head (The Burns Marshall
method)
As soon as the shoulders are born, let the baby
hang by its weight for one or two minutes
When the hairline appears, grasp the baby by
the feet and hold on the stretch applying
sufficient traction to prevent fracture of the
neck
•Move the feet through an arch of 180 degrees
until the mouth and nose are free at the vulva
Hold the baby upside down and do mechanical
suction
Sunday, March 2, 2025 147ABNORMAL LABOR: BY PAUL NYONGESA
Delivery of the head (The Burns Marshall
method)
As soon as the shoulders are born, let the baby
hang by its weight for one or two minutes
When the hairline appears, grasp the baby by
the feet and hold on the stretch applying
sufficient traction to prevent fracture of the
neck
•Move the feet through an arch of 180 degrees
until the mouth and nose are free at the vulva
Hold the baby upside down and do mechanical
suction
Sunday, March 2, 2025 147ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
•Ask the mother to pant through an
open mouth, “breathing out the
head”
•Allow one or two minutes to allow
slow delivery of the vault of the
head to prevent a tentorium tear
Sunday, March 2, 2025 148ABNORMAL LABOR: BY PAUL NYONGESA
•Ask the mother to pant through an
open mouth, “breathing out the
head”
•Allow one or two minutes to allow
slow delivery of the vault of the
head to prevent a tentorium tear
Sunday, March 2, 2025 148ABNORMAL LABOR: BY PAUL NYONGESA
BREECH PRESENTATION
Complications of breech
Impacted breech
Cord prolapse
Birth injuries
Maternal trauma
Premature separation of the placenta
Foetal hypoxia
Sunday, March 2, 2025 149ABNORMAL LABOR: BY PAUL NYONGESA
Complications of breech
Impacted breech
Cord prolapse
Birth injuries
Maternal trauma
Premature separation of the placenta
Foetal hypoxia
Sunday, March 2, 2025 149ABNORMAL LABOR: BY PAUL NYONGESA
SHOULDER PRESENTATION
•When the fetus lies with its long axis across the long
axis of the uterus (transverse lie), the shoulder is
most likely to present
Maternal causes
Lax abdominal and uterine muscles
Uterine abnormality
Contracted pelvis
Polyhydramnios
Fetal causes
Preterm pregnancy
Multiple pregnancy
Macerated fetus
Sunday, March 2, 2025 150ABNORMAL LABOR: BY PAUL NYONGESA
•When the fetus lies with its long axis across the long
axis of the uterus (transverse lie), the shoulder is
most likely to present
Maternal causes
Lax abdominal and uterine muscles
Uterine abnormality
Contracted pelvis
Polyhydramnios
Fetal causes
Preterm pregnancy
Multiple pregnancy
Macerated fetus
Sunday, March 2, 2025 150ABNORMAL LABOR: BY PAUL NYONGESA
SHOULDER PRESENTATION
Antenatal diagnosis
On abdominal palpation;
The uterus appears broad
The fundal height is less than
expected age of gestation
On pelvic and fundal palpation
Neither the head or breech is felt
Sunday, March 2, 2025 151ABNORMAL LABOR: BY PAUL NYONGESA
Antenatal diagnosis
On abdominal palpation;
The uterus appears broad
The fundal height is less than
expected age of gestation
On pelvic and fundal palpation
Neither the head or breech is felt
Sunday, March 2, 2025 151ABNORMAL LABOR: BY PAUL NYONGESA
Ultrasound
Intra-partum diagnosis
Abdominal palpation
Vaginal examination
Management; c/s
Sunday, March 2, 2025 152ABNORMAL LABOR: BY PAUL NYONGESA
SHOULDER PRESENTATION
Intra-partum diagnosis
Abdominal palpation
Vaginal examination
Management; c/s
Sunday, March 2, 2025 152ABNORMAL LABOR: BY PAUL NYONGESA
SHOULDER PRESENTATION
TRANSVERSE LIE
The long axis of the body of the
foetus is perpendicular to that of
the body of the mother
Sunday, March 2, 2025 153ABNORMAL LABOR: BY PAUL NYONGESA
The long axis of the body of the
foetus is perpendicular to that of
the body of the mother
Sunday, March 2, 2025 153ABNORMAL LABOR: BY PAUL NYONGESA
TRANSVERSE LIE
•Thus LADP (left acromio-dors0-posterior)
indicate that the baby’s lower shoulder is to
the mother’s left, and its back is towards her
back
•During labour, a presenting part which is so
high beyond the midwife’s finger should
arouse suspicion
•Later the shoulder is felt as a soft irregular
mass; ribs may be palpable in a small foetus.
Sunday, March 2, 2025 154ABNORMAL LABOR: BY PAUL NYONGESA
•Thus LADP (left acromio-dors0-posterior)
indicate that the baby’s lower shoulder is to
the mother’s left, and its back is towards her
back
•During labour, a presenting part which is so
high beyond the midwife’s finger should
arouse suspicion
•Later the shoulder is felt as a soft irregular
mass; ribs may be palpable in a small foetus.
Sunday, March 2, 2025 154ABNORMAL LABOR: BY PAUL NYONGESA
Compound presentation
The extremities lie alongside or
below the presenting part with
both limbs trying to enter the
pelvis simultaneously.
Sunday, March 2, 2025 155ABNORMAL LABOR: BY PAUL NYONGESA
The extremities lie alongside or
below the presenting part with
both limbs trying to enter the
pelvis simultaneously.
Sunday, March 2, 2025 155ABNORMAL LABOR: BY PAUL NYONGESA
BROW OR SINCIPUT
PRESENTATION
The brow, frontal sutures and
possibly the anterior fontanel are felt
This is midway between flexion and
extension, usually a temporary
presentation which converts to face
or occiput presentation during labour
At times it persists and caesarean
section is the answer
Sunday, March 2, 2025 156ABNORMAL LABOR: BY PAUL NYONGESA
PRESENTATION
The brow, frontal sutures and
possibly the anterior fontanel are felt
This is midway between flexion and
extension, usually a temporary
presentation which converts to face
or occiput presentation during labour
At times it persists and caesarean
section is the answer
Sunday, March 2, 2025 156ABNORMAL LABOR: BY PAUL NYONGESA
Reference
Rraser, D.M & Cooper, M.A(15
th
)
(2009) Myles Textbook for
Midwives. Philadelphia: Churchil
Livingstone
Sunday, March 2, 2025 157ABNORMAL LABOR: BY PAUL NYONGESA
Rraser, D.M & Cooper, M.A(15
th
)
(2009) Myles Textbook for
Midwives. Philadelphia: Churchil
Livingstone
Sunday, March 2, 2025 157ABNORMAL LABOR: BY PAUL NYONGESA
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