abnormal labour

Obstetrics

1. Abnormal labour

Dr: Hayder Al-Shammaa

2. types

| :- Malposition and Mal-presentation of the
head ( occipito-posterior, face presentation
‚brow presentation)

Il:- Breech presentation
IIl:- Shoulder presentation( Transverse lie)

3. Risks of abnormal labour

Abnormal labour carries increased risks to the
mother and the fetus more than normal labour
, specially if the labour is attended by an
inexperienced personel

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Maternal risks of abnormal labour

prolonged labour

Infection

Obstructed labour
Anesthesia

Traumatic delivery
Hemorrhage

DVT

Pressure necrosis and fistula
death

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Fetal risks

Cord prolaps

. Hypoxia

. Infection (chorio-amnionitis, pneumonia)
. Traumatic injuries

. Meconium aspiration (pneumonitis)

. death

6. Malposition & mal-presentation of the
fetal head
1) Occipito-posterior position
2) Face presentation
3) Brow presentation

7. Labour in occipito-posterior position

The denominator is the occiput

The occiput occupy the posterior part of the
female pelvis ie. occiput near the sacrum

9. Occipito-posterior

10. Causes of O. P.

Anthropoid pelvis favor direct 0.9 position
Android pelvis favor oblique o.p. position
Anteriorly situated placenta

gross pendulous abdomen

Congenital malformations

Abnormal extensor tone
Polyhydramnious

Prematurity

Multiple pregnancy

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Diagnosis of occipito posterior

By abdominal exam.
Flat lower abdomen below the umbilicus

. easy to feel Fetal limbs anteriorly
. difficult to feel the Fetal back

. Head not engaged

. Fetal heart at the flanks

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Diagnosis of occipito posterior

By pelvic exam.
High presenting part
Bulging sausage shaped membranes
Or early rupture of membranes (cx.lessthan 3cm)
Easy to feel the anterior fontanel behind the pubic
symphysis
Difficult to feel the posterior fontanel near the sacrum
ear directed posteriorly (in excessive caput & edema)

14. Mechanism of labour in O.P.

Engagement in ROP (ROP 3times than LOP)
Engaging diameter is suboccipito-frontal 10.5
cm if the head well flexed .

Or occipito-frontal 11.5 cm if the head deflexed
(both larger than normal OA suboccipito-
bregmatic 9.5 cm)

This gives an oval shaped presenting part not
fit well on the cx. Of larger dimentions

15. Mechanism of labour in O.P.

Internal rotation:- if the head well flexed the
occiput will touch the pelvic floor first and
rotated anteriorly 3/8' of acircle 135 and
become occipito-anterior and the mechanism
then continue as in OA. But it takes longer time
to rotate

This occurs in 70% of cases

17. Mechanism of labour in O.P.

If the head is deflexed :- the sinciput touches the pelvic
floor first so rotates anteriorly and the occiput rotates
posteriorly through 1/8" of acircle (45 ) short rptation
giving direct occipitoposterior

The mechanism differs , descent continues and the head
delivers by acombination of flexion first, followed by
extention

The emerging diameter is occipito-frontal of 11.5 cm
causing great distension at the vulva and perineum and
perineal tears may occur unless episiotomy performed
Occurs in 10% of cases

18. Mechanism of labour in O.P.

Arrest of rotation at lateral position (right
occipito-lateral or left occipito-lateral)

No mechanism of labour

Deep transverse arrest

Need assist ed delivery

Occurs in 20% of cases

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Features of labour in O.P.

Sow progress (slow cx. dilatation, descent,
rotation)

. Backache is more

. Incoordinate uterine contraction
. Early rupture of membranes

. Higher chance for cord prolaps

Higher chance for infection

. Higher chance for perineal laceration
. Excessive moulding of the head may cause

tentorrial tear

20. Treatment of O.P.

Before the onset of labour , no attempt for correction

During first stage of labour

1.

2.

3.
4.

Correction of malposition cannot be done

Observation of uterine contraction, cx dilatation, descent,and
use partogram

Continuous fetal heart monitoring

Due to increased risk for operative delivery and anesthesia ,
give nothing by mouth, only occasional sips of water

Maintain maternal hydration by iv fluid

Oxytocin infusion is often indicated to correct incoordinate
uterine contractions

21. Treatment of O.P.

Cesarean section is indicated in first stage in
the following conditions

1. Failure to progress in spite of good uterine
contractions for 3 hours

2. Fetal distress
3. Maternal distress

22. Treatment of O.P.

Treatment in second stage

Mistaken diagnosis of 2" stage is not
uncommon, the patient have urge to
pushdown before full dilatation (pressure
effect of the large occiput on the pelvic plexus
p/v exam is essential to confirm the diagnosis

23. Rx of 2" stage continue

p/v to assess degree of deflexion
Determine excessive molding
Determine caput succidanium

If detect that , spontaneous labour is unlikeley
to occur

Pain relieve is essential in O.P.
Epidural analgesia , pethidine

24. Need assisted delivery
Fetal distress

Maternal distress
Failure to progress
Deep transverse arrest

25. Assisted delivery

Oxytocin

Manual rotation with or without forceps
extraction

Forceps rotation (Kielland forceps)
Vacuum extractor

Cesarean section

26. Manual rotation

Correction of malposition by manipulation with
the hand under epidural anesthesia
Disadvantage need anesthesia, hand take
additional space , may cause trauma, pulling is
not feasible

28. Kielland forceps rotation
Same disadvantages but ,can pull the head

Vacuum extraction ( Vantouse , Kiwi)
Advantages

Applied without anesthesia, not take extra space,
easy to use minimal skills

34. Face presentation

The head is fully extended

1/300 deliveries

Causes : same as O.P.

The denominator is the mentum (chin)

Mento-posterior no mechanism of labour the
chest try to enter the pelvis at the same time
with the head (sternobregmatic 16- 18cm)

36. Mechanism of labour in mento anterior

Engagement in mentolateral ML or RMA

Engaging diameter is the submento bregmatic 9.5
cm

Descent occurs slowly

Rotation occur late in 2™ stage

Engagement occur at +2 or +3 station

Delay in 2™ stage due to oblique line of thrust from
the back to the head

The face deliver by flexion
Emerging diameter is the submentovertical cm

37. Diagnosis of face presentation

Abdominal findings:- Longitudinal lie, cephalic ,
a groove can be felt between the head and
back , the head is high

p/v feel the chin, mouth, jaws, nose, orbital
ridge

38. management

Exclude CPD, hypertension , placenta previa,
other risk factors , estimated fetal wt 3.5kg

If any of the above cesarean section safer
Manage as in case of O.P.

39. Brow presentation

1/1000

Incomplete extension

It is usually atransient presentation , either change
to vertex or to face

Causes as face

Diagnosis

On abdominal exam as in face but the groove is less
prominent

p/v :- feel ant. Fontanel, orbital ridge, roote of the
nose, eyes, but not the chin

41. Mechanism of labour in brow

No mechanism of labour . The engaging
diameter isthe mentovertical 14 cm so
cesarean section is indicated in persistent brow

42. Thank you