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Abnormal labor is when the labor is onset in abnormal conditions

1. 3
rd
year Nursing student
5/23/2024
1
Eshetu T, UoG.

2. Abnormal labor
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Is any labor in which the pattern of labor progress is
significantly different from accepted and recognized
patterns of labor progress in terms of
Profile of uterine contractions
Decent of fetal presenting part
Cervical changes

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Labor Pattern
Diagnostic Criteria
Preferred
Rx
Exceptional Rx
Nullipara Multiparas
1.First stage disorder 1. Prolongation disorder
Prolonged Latent Phase >20hrs >14hrs Bed rest
Oxytocin
C/s delivery for
urgent problems
1.Protraction disorders
Active phase dilatation <1.2cm/hrs. <1.5cm/hrs. Expectant/
Support
C/s for CPD
Descent <1cm/hrs. <2cm/hrs.
1.Arrest disorders
Prolonged deceleration phase >3hr >1hr
CPD - C/s
No CPD –
Oxytocin
Rest if exhausted

C/ s delivery
Secondary arrest of dilatation >2hr >2hr
Arrest of descent >1hr >1hr
Failure of Descent No descent in deceleration phase
1.Second stage disorders
Prolonged 2
nd
SOL
Without epidural > 2 hrs.
Without epidural >
1 hr.
depends on identified cause and
presence of complications
With epidural
> 3 hrs.
With epidural
> 2 hrs.
Failure of descent No descent in second stage

4. Causes of Abnormal labor
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The „„3 Ps‟‟- act singly or in combination
1. Power: Dysfunctional ux contraction & poor maternal
effort
Types of utérine dysfunction
1. Hypotonic uterine dysfunction
•More common
•Uterine contractions have a normal gradient pattern
•But Pressure is insufficient to dilate the cervix

5. Causes of Abnormal labor
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2. Hypertonic or in-coordinate uterine dysfunction
•Either basal tone is elevated appreciably or
•The pressure gradient is distorted → may result from;
More forceful contraction of the uterine mid segment than
the fundus
From complete asynchrony of the impulses originating in
each cornu
From a combination of these two

6. Causes of Abnormal labor
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Various factors are implicated in uterine dysfunction
Analgesia
Chorioamnionitis
A higher station
Maternal age & obesity

7. Causes of Abnormal labor
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2. Passage:
The contracted pelvis & lower reproductive tract
3. Passenger: Macrosomia, malpresentation,
malposition
NB: Labor abnormality can be as a consequence of
combination of the three Ps. For example,
abnormality of passage and passenger can result
in Cephalo-Pelvic-Disproportion (CPD) or Feto-
Pelvic-Disproportion (FPD)

8. Sign & symptom of abnormal labour

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Failure or poor progress of labour
NB: Clinical Pelvimetry is used intrapartum to
check for adequacy of the pelvis in case of
prolonged second stage in prim gravid.
Diagnosis of labour abnormality is
Mainly clinical by
Close observation of progress of labour
Appropriate use of Partograph.

9. Complications of abnormal labour
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If not managed timely, abnormal Labor will
contribute to bad outcome of the
Maternal, Fetal and Neonate.
Obstructed labor, obstetric fistula, Uterine
rupture, hemorrhage, sepsis and maternal death
Fetal distress, asphyxia, and death

10. Management of abnormal labor
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Rule out false labor
False labor is characterized by change in cervical
effacement and dilatation after 4 to 8 hrs. of
revaluation.
Once false labor is ascertained explain to the
woman (and accompanying relatives) about
False or true labor & danger symptoms of pregnancy & labor.
Discharge the woman if she has no other problem
requiring inpatient management.
Rehydrate if there is sign of dehydration and give
psychological support for the mother

11. Management of abnormal labor
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1. Latent phase abnormalities
Dysfunctional uterine contraction is treated by
Augmentation of labor if there is no
contraindication.
Scarred cervix due to operations such as
Conization or cautery may lead to prolonged first
stage of labor. in such scenario C/S, delivery
should be considered.
Management of latent phase abnormality in the
presence of
Malpresentation and
Malposition depends on the specific abnormality.

12. Management….
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2. Active phase abnormalities
If the alert line is crossed, thorough assessment of the:-
Mother,
Fetes and
Progress of labor should be done to identify the cause.
In the absence of adequate uterine contractions:
Provide labor support:
Sometimes rehydration,
Emptying the bladder & encouraging the woman to be
more active and
Move around or adopt an upright position.

13. Management….
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Consider ARM & augmentation if no contraindication
Re-evaluation 2-4 hours later
Presence of adequate labor progress with above
interventions (Cervicogram remains to the left of
the action line):
 Expect vaginal delivery
Inadequate labor progress despite intervention
(Cervicogram crosses the action line):
Cesarean delivery.

14. Management….
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Crossing the action line:
When cervical dilatation crosses action line, must be
taken immediately depending on identified cause.
Management options of dysfunctional uterine
contraction include
Performing ARM, Rehydration, Augmentation & C/S
Presence of contraindication for Augmentation,
Features of CPD or thick meconium, NRFHR) are
indications for emergency C/S.

15. Management
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3. 2
nd
SOL abnormality
Abnormal progress in the second stage is entertained
if there is not progressive descent (or head rotation to
a favorable position) with uterine contraction.
Management depends on
Identified cause & presence of complications.
The management options are
Augmentation of labor (particularly in primigravid),
Caesarean delivery,
Instrumental vaginal delivery (in the absence of CI)
Destructive vaginal delivery (if prerequisites are
fulfilled).

16. Malposition and Malpresentation
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•Malposition – any positions of the vertex other than OA
of the fetal head relative to the maternal pelvis
Occiput posterior
Persistent occiput transverse position
•Malpresentation - all fetal presentations other than
vertex
Face
Brow
Breech
Shoulder
Compound

17. Occipito-posterior position
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Where the occiput is placed posteriorly either over
The sacroiliac joint (ROP/LOP) or
Directly over the sacrum (DOP)
•It is the most common fetal malposition
incidence
•At the onset of labor10%
•term fetuses before labor, 15 – 20%
•Only 5% are OP at vaginal delivery because
•Most(90%) spontaneously rotate to an OA during
labor

18. Occipito-posterior position
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19. Risk factors
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•Nulliparity
•Maternal age greater than 35 years
•Obesity
•Previous OP delivery
•Shape of pelvic inlet (Anthropoid & android pelvis)
•GA ≥41 weeks, Birth weight ≥4000 grams
•Anterior placenta – leads the fetus to remains in
dorso-posterior position

20. Diagnosis
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History
Physical examination
 Abdominal findings
Vaginal examination
Ultra sound

21. Diagnosis
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2.1. Abdominal findings:-
•Flattened lower part of the abdomen
•Anteriorly palpable fetal limbs, difficult to outline
the back clearly
•Fetal heart heard in the flank

22. 2.2. On vaginal examination:-
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Elongated bag of membrane which is likely to
rupture during examination
Posterior fontanelle towards the sacrum
Anterior fontanelle felt anteriorly if neck is extended

23. Diagnosis
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3. Ultrasound

24. Management
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•If the pelvis is grossly adequate follow labor closely
with anticipation of spontaneous rotation to OAP
1. If there is rotation to occiput anterior, expect
vaginal delivery as occiput anterior
2. Incomplete rotation→ occipito-transverse position

25. Management
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Expect vaginal delivery
If there is good progress of labor
Vacuum delivery can be tried
If there is arrest of fetal descent at low station
(station at or below +2), women with adequate
pelvis.
Deliver by c/s if there is:-
Arrest of fetal descent at high station (station above
+2)

26. B. Malpresentation
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1. Face presentation
•Hyperextension of the fetal head
•Complete extension→ occiput is
in contact with the back
•Fetal chin(mentum) is the
leading part
•1 in 500 live births overall

27. Risk factors
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•Anencephaly
•Anterior neck mass
•Multiple nuchal cords
•CPD
•Prematurity
•Severe hydrocephalus
•Multiparity
•Polyhydramnios

28. Diagnosis
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Suggestive abdominal finding:
On abdominal examination
Groove may be felt between the occiput and the
back
Fetal limbs are felt anteriorly in MA presentation
Head seems big and is not engaged

29. Diagnosis
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•More often discovered by vaginal examination
 Fetal chin, mouth and nose are palpated

30. Management
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•Identify position of the mentum
1. Mento-anterior: Chin anterior- 60% to 80%
Adequate pelvis → follow the progress of labor
Forceps delivery- when indicated and prerequisites
for out let forceps are met
70% to 80% of infants can be delivered vaginally,
either spontaneously or by low forceps
12% to 30% require cesarean delivery

31. Management
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2. Mento-posterior: Chin posterior - 20% to 25%
•In the early admissions→ follow labor progress with
anticipation of vaginal delivery
•25% to 33% of infants will rotate & deliver
vaginally with MA
•Persistent MP presentation:
•MP in the later part of the first stage (after 6cm of
cervical dilatation) or in the SSOL
•If fetus is alive → Cesarean delivery
•If the fetus is dead → Craniotomy

32. Impacting of an
Open fetal mouth
against
The sacrum

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Management

33. MATERNAL AND FETAL COMPLICATION
FACE PRESENTATION
Delay of labor
Chance of perineal
damage is more
Postpartum
hemorrhage
Increased morbidity

Obstructed labor
Utrine rupture
Increased risk of
operative delivery
Neonatal infection
Fetal facial bruising


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34. Brow presentation
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•The rarest variety of cephalic presentation
•1/500 to 1/4000 deliveries, averagely 1 in 1500
•Midway between full flexion and full extension
•Presenting part→ brow (the part of the head
between orbital ridges and anterior fontanel)
•The position is commonly unstable and converts to
either vertex or face presentation

35. Risk factors
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•CPD
•Prematurity
•Multiparity
•Hydrocephalus
•Anterior neck mass
•Multiple nuchal cords
•Macrosomia
•Polyhydramnios

36. Diagnosis
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History
Physical examination
Abdominal
Vaginal

37. Diagnosis
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Suggestive abdominal finding:
•More or less like those of face presentation, However,
•The cephalic prominence and
•The groove b/n it and the back are less prominent
•The head feels very big and is none-egaged
On vaginal examination: More often detected
•Anterior fontanelle and orbits are felt

38. Management
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•Women with a clinically adequate or proven pelvis
can undergo a trial of labor if brow is diagnosed in
the early stag.
•Since many will convert to a more favorable
presentation
•In women with a narrow or contracted pelvis
 C/s early

39. Management of persistent brow
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•Persistent brow presentation is brow presentation in;
The later part of the first stage- after 6cm of cx
dilatation,
The second stages of labor
•Engagement of the fetal head and subsequent delivery
can not take place in persistent brow
•Except in small fetal head or the pelvis is unusually
large

40. Management
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•If the fetus is alive deliver by cesarean section
•If the fetus is dead;
Perform craniotomy if prerequisite are met
Deliver by cesarean section if:-
The cervix is not fully dilated or station is high
The operator is not proficient in craniotomy

41. 3. Breech presentation
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•The fetal buttock and/or feet are the presenting
part occupying the lower pole of the uterus
•Overall occurs in 3% to 4% of labor
•More common in remote from term
•At term, breech presentation persists in
approximately 2–5%

42. Incidence of breech presentation
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43. Types of breach presentation
•Frank breech- 50– 70%
•Complete or
flexed breech- 5 -10%
•Footling/ incomplete
breech- 10- 40%
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44. Type of breech prese…..
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•Frank breech (50-70%) - lower extremities are flexed at
the hips and extended at the knees
•Complete breech (5-10%) - both hips & knees are
flexed
•Footling or incomplete (10- 40% - one or both hips are
extended. As a result, one or both feet or knees lie
below the breech

45. Risk factors
Prematurity
High parity
Multiple pregnancy
Uterine abnormality
(eg, bicornuate or
septate uterus, fibroid,
tumor previa)

Pelvic masses
Fetal anomalies
Absolute CPD
Previous breech
Unknown

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46. Diagnosis
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1. History
2. Physical examination
2.1. On abdominal palpation
2.2. Per-vaginal examination (Pv)
Soft & irregular parts are felt through the Cx
opening
Palpation of ischial tuberosities, sacrum and the
feet by the sides of the buttock

47. Diagnosis
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In frank breech, no feet are appreciated, but;
Ischial tuberosities, anal opening and sacrum will be
felt and are in a straight line
Complete breech, the feet may be felt alongside
the buttocks
Perform clinical pelvimetry and look for cord
presentation or prolapse

48. Diagnosis
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3. Ultrasound
To confirm clinical diagnosis
To assess fetal attitude
To assess amniotic fluid volume to consider ECV
To estimate fetal weight, and
To investigate for fetal anomalies and other
predisposing factors

49. Management
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1.Antepartum
2.During labor
3.Delivery
1. Antepartum
Fetuses remote from term No intervention
External cephalic version near term
Asses for congenital anomaly
Estimate fetal weight near term
Pelvimetry

50. Management
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•Ideally, every breech birth should take place in a hospital
capable of performing an emergency caesarean section
•At 37 or more weeks of gestation;
If no any contraindication for ECV, consider ECV
If the ECV fails, consider vaginal breech delivery or CS
If there is absolute indication for CS plan for CS

51. Mode of delivery in breech presentation
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1-Cesarean delivery
A- absolute indications for C/S are:-
oEstimated fetal weight >3500 grams.
oAny degree of pelvic contracture.
oFootling presentations.
oBreech presentation with hyper extended
head.
oBreech with other poor obstetric performance.
oOld primigravida

52. Mode of delivery in breech presentation
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2. VAGINAL BREECH DELIVERY.
Cases with no absolute maternal or fetal indications
for direct C/S.
EFW<3500 grams.
Frank or complete breech.
Flexed head and adequate pelvis.
Gross fetal malformations judged to be
incompatible with extra uterine life

53. Types of vaginal breech delivery
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1. Spontaneous breech delivery
2. Assisted breech delivery.
3.Total breech extraction

54. Labor management in breech delivery
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Admission evaluation . Hx, PE, US exam
1-first stage of labor-
Securing IV line.
Progress of labor is not remarkably different,
Avoid ARM
Augmentation is contra-indicated in breech.
Experienced obstetrician
Anesthesiologist
Pediatrician

55. Second stage of labor
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Delivery of the buttocks and legs:
•If tight perineum perform an episiotomy
Pinard‘s maneuver
•Pushing behind the knee so that it bends; then grasp
the ankle and deliver the foot and leg

56. 2. Lovset‟s maneuver
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Delivery of the arms and shoulders
•Delivery is more difficult and can be aided by
rotating the fetus through a half circle draw the
elbow toward the face
•Hold the fetus around the bony pelvis with thumbs
across the sacrum
•The fetus is turned 180 degree while downward
traction is applied at the same time,
•So that the posterior arm emerges under pubic
arch & then hooked
•The position is restored & anterior arm is
delivered in the same manner

57. Delivery of the arms and shoulders
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58. Delivery of the head
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•When the nape of the neck is visible, Apply fundal
pressure to maintain flexion and deliver the upcoming
head
•Mauriceau Smellie Veit Maneuver (MSV):
•Index and middle finger of one hand are applied over
the maxilla, to flex the head, while the fetal body rests on
the palm of the same hand and forearm
•Two fingers of the other hand are hooked over the fetal
neck and grasp the fetal shoulders
•Apply gentle downward traction to deliver the head
•Forceps delivery: Specialized type of obstetric forceps
(Piper) can be used when the MSV cannot be
accomplished easily

59. Delivery of the after coming Head
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60. Complications of breech delivery
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Increased perinatal & maternal mortality & morbidity.
Cord prolaps 15% in footling and 5% in complete
breech presentation.
Increased operative interventions especially C/S
delivery.

61. 5.Transverse lie/ Shoulder presentation
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•When the long axis of the fetus is perpendicular to
the longitudinal axis of the mother/uterus
•Shoulder presentation→ when the shoulder is the
presenting part in a transverse lie
•Acromion determines the label of the position as
right or left acromial
•The back may be directed anteriorly or posteriorly,
superiorly or inferiorly
•Complicates approximately 0.3%

62. Dorsoanterior position
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63. Causes
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•Abdominal wall relaxation from high parity,
Hydramnios
•Preterm fetus
•Placenta previa
•Abnormal uterine anatomy
•Contracted maternal pelvis

64. Diagnosis
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1. History
2. Physical examination
2.1. Abdominal findings:
2.2. Vaginal finding
3. U/s- Confirmatory

65. Diagnosis
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Abdominal findings:
•Neither the fetal head nor the breech is felt in the
upper and lower part of the uterus
•The abdomen is transversely elongated than
longitudinally
•Fundal height is less than gestation age
Vaginal finding:
•The shoulder or the prolapsed arm is felt
U/s- Confirmatory

66. Management
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•Spontaneous delivery of a fully developed
newborn is impossible.
•CS delivery if in active labor
•Consider ECV during pregnancy after 36 weeks
of gestation until early in labor with intact fetal
membranes, if operator is experienced
•If ECV fails deliver by CS
Note: Neglected shoulder presentation leads to
obstructed labor and associated complications

67. Asynclytism
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Asynclytism refers to abnormalities in descent and
engagement of the vertex through the pelvic brim in
which the sagittal suture is pushed laterally to the
anterior or posterior pelvic segments rather than its
normal central location
As a result, the vertex attempts to engage into the pelvis
with one of the parietal bones predominantly presenting

68. Asynclitism
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Asynclytism results in difficulty of the vertex
engagement and descent and may result in
obstructed labor if not spontaneously resolved
Anterior Asynclytism has a more likely chance of
spontaneous resolution and vaginal delivery
compared to a posterior asynclitism

69. Types & possible causes of asynclitism
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70. Management
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In anterior Asynclytism, if pelvis is adequate and
the mother is in early labor one can await for
spontaneous reversion and vaginal delivery.
Posterior asynclitism is considered an indication for
caesarean delivery.

71. Compound Presentation
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Compound presentation is a vertex presentation with a
single or double hand or feet felt alongside the fetal
head on vaginal exam Or
A breech presentation with a single or double hand felt
alongside the breech presentation
If the hand is felt anterior or lower to the vertex and not
alongside it then it is a “ hand prolapse” rather than a
compound presentation

72. Diagnosis of Compound Presentation
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The tips of the fingers of the hand or feet are felt
alongside the fetal head on vaginal exam
The tips of the fingers of the hand are felt
alongside the breech
Always assess the pelvic capacity as well as the
presence of cord in compound presentations
diagnosed in labor

73. Management of Compound Presentations
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74. Cephalo pelvic disproportion/CPD/
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•Is disparity b/n the fetal head & maternal pelvis
•Which leads to inability of the fetal head to pass
through the maternal pelvis for mechanical reasons
•Fetopelvic disproportion arises from
Diminished pelvic capacity/ alteration in shape,
Abnormal fetal size or presentation, or
More usually from both

75. CPD
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Cephalo pelvic disproportion/CPD
It occurs At
The may be contracted only or in combination
1.Pelvic inlet,
2.Cavity /midpelvis, or
3.Pelvic outlet

76. CPD
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1. Contracted Inlet
•Anteroposterior diameter of the inlet, called
obstetrical conjugate,
•Is commonly approximated by manually measuring
the diagonal conjugate,
• Is approximately 1.5 cm less than the diagonal
conjugate

77. CPD
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•To measure the diagonal conjugate, a hand with the
palm oriented laterally extends its index finger to the
promontory
•The distance from the finger tip to the point at which
the lowest margin of the symphysis strikes the same
finger ‟s base is the diagonal conjugate
•Inlet contraction usually is defined as a diagonal
conjugate <11.5 cm

78. 2. Contracted Midpelvis
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•More common than inlet contraction
•It frequently causes transverse arrest of the head
•Inter-spinous diameter <10cm→Suspected Midpelvic
contraction
•When it measures <8 cm, the midpelvis is contracted
•If the spines are prominent,
•The pelvic sidewalls converge

79. CPD
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80. Outlet contracture
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•Inter-ischial tuberous diameter of 8 cm or less
•Often-associated mid-pelvic contraction
•Isolated outlet contraction is a infrequency

81. Diagnosis
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•Properly taken history, P/E and appropriate use of
labor graph allow easy and early identification
1. History
•Primigravid (especially teenage pregnancy)
•Prolonged labor or Previous history
•Previous history of perinatal death
•Previous history of obstetric trauma
•Properly documented obstetric record (e.g.
intraoperative direct measurement of the obstetric
conjugate)

82. Diagnosis
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2. P/E; Intrapartum evaluation
•Generally CPD, with very few exceptions, is
diagnosed after a properly conducted trial of
labor
•Findings that may indicate CPD are:-
Abnormal progress of labor:
Arrest and protraction disorders of cervical
dilatation, or crossing an alert or action line on a
partograph
Failure of head descent especially in the presence
of arrested or protracted cervical dilatation

83. Diagnosis
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High station of the head in late AFSOL or SSOL
may suggest CPD, particularly in primigravid
woman
Failure of progress of labor after correction
of inadequate uterine activity (by amniotomy or
oxytocin infusion or both)

84. Diagnosis
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•Abnormal clinical pelvimetry:
Obstatrical conjugate is less than 10 cm
Inter-tuberous diameter of less than 8 cm (a fist
size) indicates a grossly contracted pelvis
Abnormal measurements of clinical pelvimetry
also include
•Easily reachable sacral promontory,
•Prominent ischial spines,
•Convergent pelvic side walls,
•Flat sacrum, narrow sub pubic angle

85. Diagnosis
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Molding
•Severe moldings (+2/+3) at a higher station
•Hallmark feature of CPD
Caput Succedaneum
•A severe degree of caput has been associated with
prolonged labor and CPD
•Scalp edema hampers identification and assessment
of the suture lines

86. Diagnosis
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Fetal Macrosomia
•Clinical, maternal or u/s estimation of fetal
size have the potential for identifying
macrosomic pregnancies at risk for CPD
Fetal distress
•In the presence of marked CPD, the fetus
responds with fetal heart rate abnormalities,
falling PH and passage of meconium
Imaging
•Ultrasound examination may reveal macrosomia
or congenital anomalies e.g. hydrocephalus

87. Management of CPD
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Trial of labor
•In a woman with suspected CPD
•It is done in an equipped and staffed hospital for
operative procedures in case vaginal delivery fails
CPD is suspected;
•If there is previous history of prolonged labor
with bad obstetric history or operative delivery,
•If the parturient is teenage,
• In the presence of borderline pelvis or if the
cervicogram is crossing the alert line without signs of
CPD

88. Management of CPD
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Borderline pelvis is entertained;
If the obstetric conjugate is 8 to 10 cm
•If there is no other risk factor (such as previous CS),
trial of labor is the best diagnostic approach
•The trial continues as long as labor progresses well
and as long as there is reassuring fetal and
maternal status

89. Route of delivery
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•Generally, presence of CPD during labor is an
indication for caesarean delivery
•In permanent absolute disparities
Severe pelvic contracture (OC of 6-8 cm) or
Extreme pelvic contracture (OC < 6 cm)), there is
no possibility of vaginal delivery and elective
cesarean section should be done

90. Route of delivery
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•Induction & augmentation of labor is CI in fetal
macrosomia
•Cesarean delivery is recommended for macrosomic
fetus with estimated fetal weight of greater than
4.5kg regardless of the status of labor
•Fetal hydrocephalus may be managed by
cephalocenthesis
•Craniotomy is indicated if the fetus is dead and
prerequisites for destructive delivery are fulfilled

91. Discharge counseling and education
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•A woman who delivered by CS should be explained
about the indication (CPD) and the need for repeat CS in
future pregnancy
•Besides verbal explanation, a written note should be
given
•Previous CS for CPD can be followed at a nearby health
center and referred after 36 -37 weeks of gestation

92. Complications
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Maternal: -
•Prolonged/obstructed labor: the end result is
obstructed labor and its associated complications
•PPH
•Maternal sepsis
Fetal / neonatal
Fetal distress
Perinatal asphyxia
Neonatal infections
Perinatal death

93. OBSTRUCTED LABOR/ OL
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•OL is failure of descent of the fetus in the
birth canal for mechanical reasons in spite of
good uterine contraction
•An outcome of neglected and mismanaged labor
CAUSES
Maternal:
Contracted pelvis / cephalopelvic disproportion
(commonest)
Soft tissue abnormalities (e.g. tumor previa, vaginal
septum, tight perineum, uterine congenital anomalies)

94. CAUSES …
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Fetal:
Macrosomia
Malpresentations/Malposition
Locked twins, conjoined twins
Fetal anomalies e.g. hydrocephalus

95. DX
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History
•Abnormally prolonged labor
•Early ROM or PROM -Fever
•Most do not have ANC
•Painful contractions
•Previous pregnancy complicated by prolonged labor,
stillbirth or early neonatal death
•Previous instrumental deliveries & CS
•Medical history; particularly rickets, osteomalacia, or
pelvic injury

96. Clinical findings
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General condition of the patient:-
•Exhausted due to severe pain and lack of sleep
•Anxious, terrified and uncontrollable
•Dehydration is nearly always present
•Deep and rapid respiration as a result of ketoacidosis
Clinical signs of infection:-
Pyrexia and tachycardia
Purulent vaginal discharge
•Severe intrapartum infection results in septic shock
with circulatory collapse, hypotension, and a rapid pulse
with subnormal temperature

97. Abdominal findings
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•Distention of the bowel as a result of acidosis and
hypokalemia
•Three tumor abdomen; Due to:-
Grossly thickened and retracted upper uterine
segment above Bandl‘s ring
Thinly distended lower uterine segment below the ring;
Fully distended and/or edematous bladder further
distending the lower abdomen

98. Abdominal findings
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•Retraction ring of Bandl marks the junction
between thickened and retracted upper
segment and thinned lower uterine segment
•The three tumor abdomen‖ and retraction ring
of Bandl are warning signs of an impending
uterine rupture
Fetal Status
Abnormal fetal heart rate
IUFD

99. Three tumors Abdo
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100. Vaginal examination findings
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•Edema of lower vagina and vulva (canula sign)
•Meconium- stained and foul-smelling discharge
•Bleeding may be seen
•Edema of the cervix & poorly applied to the head.
•Little or no descent of the presenting part
•Increasing molding
•Excessive caput
•Malpresentation/position
•Shoulder with or without prolapsed arm in
transverse lie,

101. MANAGEMENT
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•Initial management of OL involves resuscitation
and monitoring of the life endangering
conditions
•Identification and treatment of the causes
•Secure good venous access; preferably with two
large-bore cannulae and give crystalloids
•Send an urgent blood sample:
Blood group and Rh, cross-match, complete blood
count

102. Management cont‟d…
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Give broad spectrum antibiotics:
Ampicillin 2gm Q 6hrs or
Ceftriaxone 1g IV BID, PLUS
Gentamicin 80mg IV Q 8hrs, PLUS
Metronidazole 500 mg IV TID
OR
Gentamicin 80mg IV Q 8hrs PLUS
Clindamycin 900 mg IV Q 8hrs

103. Management
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•Empty the bladder
Catheterization may be difficult or impossible
•Empty the stomach:
insert NG tube, particularly in the
presence of distended abdomen

104. Management
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Delivery:
•Alive fetus: do emergency cesarean delivery
•Dead fetus
With presence of imminent signs of uterine rupture:
Perform C/S or destructive delivery under direct vision
Without imminent signs of uterine rupture:
Perform destructive delivery if prerequisites are fulfilled

105. Postoperative care and follow up
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•Intensive resuscitation & close monitoring until her
condition improves
•IV antibiotics should be continued until the patient
is fever free for 48 hours and Shift the medications
to PO antibiotics to complete 7-10 days treatment
•Give analgesics
•Breast care for those with SB or neonatal deaths
•Explain the condition & counsel on future pregnancy
•After prolonged obstructed labor, keep the catheter
for at least 10 days

106. COMPLICATIONS
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•Atonic PPH,
•Uterine rupture,
•Peripartum infection leading to various organ failures
•Maternal death,
•Fetal distress,
•Fetal & neonatal infections, and death

107. COMPLICATIONS
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Late complications:
•Fistula (vesico-vaginal, rectovaginal) & its aftermath,
•Foot drop (sciatic, common peroneal nerve),
•Infertility following postpartum PID or hysterectomy,
•Psychological trauma due to the painful labor
experience, loss of the baby and social isolation

108. Cord presentation and prolapse
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1. Cord presentation:
Presentation of UC below the level of the
presenting part with intact fetal membranes
2. Cord prolapse
Descends alongside or beyond the fetal presenting
part in the presence of ruptured membranes.

109. Types of Cord prolapse
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1. Overt UC prolapse: Protrusion of the UC in
advance of the fetal presenting part with ruptured
fetal membranes.
2. Occult UC prolapse: Cord descends alongside, but
not past, the presenting part with intact / ruptured
fetal membranes.

110. RISK FACTORS

Malpresentation
Unengaged presenting
part
Prematurity
Multifetal gestation
PROM
Abnormal placentation
Multiparity
Polyhydramnios
Long UC
Pelvic deformities
Uterine
tumors/malformations
Congenital anomalies
Low birth weight less
than 2.5 kg.
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111. DIAGNOSIS
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1. Occult UCP: Presence of severe prolonged fetal
bradycardia or moderate to severe variable
decelerations after a previous normal tracing on
CTG/ Pinnard stethoscope or fetal death
2. Overt UCP: Presence of palpable cord (pulsatile or
non-pulsatile) on pelvic examination or visible cord
outside the introitus.
2. Cord presentation: Loops of cord are palpated
through the fetal membranes on digital vaginal
examination or seen in front of the presenting part on
ultrasound examination.

112. General Management
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Call for assistance.
Secure IV fluid.
Check for cord pulsation. If absent, confirm fetal heart
beat with fetoscope or U/S
Discontinue oxytocin if being given.
Careful pelvic examination immediately after
spontaneous rupture of fetal membranes.
Prepare for resuscitation of the newborn.
In cord presentation, do not rupture fetal membranes at
any stage of labor; deliver the fetus by CS.

113. General Management
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Monitor FHB while preparing for delivery
If the woman is in the first stage of labor, perform
the following in all cases:
Push the presenting part up to decrease pressure on
the cord and dislodge the presenting part from the
pelvis.
Place the other hand on the abdomen in the
suprapubic region to keep the presenting part out
of the pelvis.

114. General Management
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Once the presenting part is firmly held above the pelvic
brim, remove the other hand from the vagina.
Keep the hand on the abdomen until a caesarean section can be
performed.
If available, give tocolytics.
Perform immediate caesarean delivery.
Choice of anesthesia should be the quickest and safest for both
the mother and the fetus preferably – GA.

115. General Management
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Manuevers to reduce presenting part pressure on the cord:
Examiner„s hand is maintained in the vagina to elevate the
presenting part off of the umbilical cord while preparations
for an emergency C/S are being made.
Client be placed in steep Trendelenberg or knee-chest
position.
Do not manipulate the cord.
Avoid exposure of the cord to cold environment to avoid
cord spasm (keep in vagina).
Bladder filling: Insert Foley catheter into maternal bladder
then fill bladder with 500- 700 ml of normal saline with the
patient in Trendelenberg position (used during referral).

116. General Management
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If the woman is in the second stage of labor:
Expedite vaginal birth if deemed quicker than
cesarean section.
Obstetric vacuum is preferable over forceps, if
prerequisites are met.
If there is malpresentation or if prerequisites for
instrumental delivery are not fulfilled, deliver
immediately by CS.
NOTE: Delivery should be accomplished within 30
minutes from the time of diagnosis.

117. PREVENTION
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Avoid ARM if the presenting part is not well
applied/ engaged or perform ARM with
simultaneous downward fundal pressure.
Avoid disengaging fetal presenting part when
performing procedures.
Incidental finding of cord presentation on U/S
should be followed to decide mode of delivery.

118. Premature Rupture of Membrane

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119. Premature Rupture of Membrane
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•Is rupture of membranes (ROM) before the onset of
labor
•Can be term or preterm – Complicates 8 vs 3% of
pxs
•The single most common identifiable factor
associated with preterm delivery
•It is responsible for approximately one-third of
preterm births
•Prolonged PROM - for > 12 hours

120. Risk factors
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•The pathogenesis of spontaneous membrane rupture is
not completely understood
•Mechanical factors: Multifetal gestation,
polyhydramnios…
•Urogenital infections: UTI, cervicitis, bacterial vaginosis
•Previous history of preterm PROM, preterm labor
•Second and third trimester bleeding (e.g. abruptio
placenta).
•Other risk factors: Low socioeconomic status,
nutritional deficiencies, low BMI, smoking and connective
tissue disorders

121. Diagnosis
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•Is clinical, and is generally based on visualization
of amniotic fluid in the vagina
1. History;
•A sudden "gush“ of clear or pale-yellow fluid from
the vagina→ The classic clinical presentation
•Intermittent or constant leaking of small amounts of
fluid

122. Diagnosis
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Physical examination
Sterile speculum examination
•Direct observation of amniotic fluid coming out of the
cervical canal or
•Pooling
•The woman can be asked to push on her fundus or
cough to provoke leakage of AF from the cervical os
•For patients who are not in labor, examination of the
cervix and vagina should be performed using a
sterile speculum

123. Diagnosis
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•Sterile speculum examination can also help;
To check for the presence of cord prolapse
To assess cervical status or cervicitis
To sent amniotic fluid for maturity tests (if available)
•Digital examination should be avoided b/s;
It may decrease the latency period
Increase the risk of intrauterine infection

124. Diagnosis
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Laboratory tests
•Ferning test
Swab the posterior fornix
Spread some fluid on a slide & let it dry for at least
10‟
Examine it with a microscope and look for a fern-leaf
pattern (arborization)
The test is not affected by meconium, vaginal PH &
blood

125. Diagnosis
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Nitrazine paper test:
•Amniotic fluid usually has a pH range of 7.0 - 7.3
compared with the vaginal pH of 3.8 - 4.2 and pH of
urine of 5.0 - 6.0
•Hold a piece of nitrazine paper in a hemostat (artery
forceps)
•Touch it against the fluid pooled on the speculum
blade
•A change from yellow to blue indicates presence
of amniotic fluid (a PH >6 - 6.5)

126. Diagnosis
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Pad test
•Can be helpful when there is no pooling & no leakage
from cervix
Place a vaginal pad over the vulva & examine it one
hour later visually & by odorous
Wetting with no urine and no vaginal discharge
(vaginitis) may suggest PROM
If the diagnosis remains in question, repeat the test

127. Diagnosis
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U/s examination
•Performed to look for reduction of amniotic fluid
volume
•If the patient has a normal amniotic fluid volume, it
is very unlikely
• 50 – 70% of women with PPROM have low
amniotic fluid volume on initial sonography

128. DDX
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•Other causes of vaginal/perineal wetness such
Urinary incontinence,
Vaginal discharge (normal or related to infection),
Perspiration
•These causes should be considered in women with
negative clinical & laboratory findings for PPROM

129. Complications of PPROM
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Maternal Risks
•Chorioamnionitis- 15–25%
- Increases as the duration is more prolonged
•APH(2-5%), Retained placenta, PPH, postpartal sepsis
(15–20%)
•Cesarean delivery and its complications
Fetal Risks
•Infection and fetal distress
- Due to umbilical cord compression/ placental abruption
•Oligohydramnios and its complications
•Prematurity, preterm birth and its complications

130. Management of PROM
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At term,
•Half of expectantly managed deliver within 5 hours
•95% deliver within 28 hours of membrane
rupture
•Of all women with PROM before 34 weeks, 93%
deliver in <1 week

131. Management of PROM
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Depends on the ff. factors;
•Gestational age
•Presence or absence of maternal/fetal infection
•Presence or absence of labor
•Fetal lung maturity, well-being & presentation
•Cervical status (by visual inspection)
•Availability of neonatal intensive care

132. Management of PROM
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Confirm the GA of the fetus (using LMP, early U/S)
Perform ultrasound to determine fetal presentation & lie
Electronic fetal monitoring to identify occult umbilical cord
compression
Do biophysical profile or NST
Do CBC
Maternal leukocytosis or the presence of a left shift
supports the diagnosis of chorioamnionitis
Isolated leukocytosis in the absence of other s/s is
of limited value

133. Management of PROM
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Delivery vs Expectant
•Indications for expedite delivery
Onset of labor,
GA ≥ 37wks,
Evidence for non reassuring fetal status,
Evidence for chorioamnionitis,
Lethal congenital anomalies, IUFD,
If there is high risk of cord prolapse (e.g.,
transverse lie) and abruptio placenta

134. Management of PROM
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Note;
•If the gestational is below 34 weeks and both the
fetal and maternal conditions are stable, expectant
management can be considered for abruption
placenta in a setting where close follow up is
possible

135. Management of PROM
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Expectant management
Admit to the ward (Transfer patients with early
preterm PROM to a higher health facility with NICU,
if possible)
Avoid digital cervical (pelvic) examination
Advise bed-rest
Corticosteroids
•Betamethasone 12 mg IM 24 hours apart for two
doses or,
•Dexamethasone 6 mg IM 12 hours apart for four doses)
for lung maturity

136. Management of PROM
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Prophylactic Antibiotics
•Ampicillin 2gm IV QID PLUS
•Erythromycin 250mg P.O QID for 48 hours followed by
•Amoxicillin 500mg P.O TID & Erythromycin 250mg. P.O QID
for 5 days
•Azithromycin may be substituted for Erythromycin with
regimen of 500mg PO on day 1 followed by 250mg PO
daily for 6 days
•If there is onset of labor and in the absence of signs
of uterine infection, discontinue antibiotics after delivery
Neuroprotection (MGSO4)
If GA <32 weeks and preterm birth is likely within the next
24 hours

137. Management of PROM
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Rationale
•Prophylactic antibiotics are indicated to
Prolong latency and to reduce the risk of both
neonatal and maternal infection
Infection appears to be both a cause and
consequence of PPROM

138. Management of PROM
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Monitoring and Follow up
Monitor the following clinical features during
expectant management
•Maternal pulse & temperature - every 4-6 hours
•FHR - every 4-6hrs (& if possible CTG 2x daily)
•Uterine tenderness or irritability (or pain) – daily
•WBC count & differential - changes, every 2-3
days
•Amniotic fluid appearance & odor - daily

139. Management of PROM
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Labor and delivery for term PROM without infection:
•If cervix is favorable, labor is induced, unless there
are contraindications to vaginal delivery
•If cervix is unfavorable, ripen the cervix (preferably with
PO misoprostol)
•Institute Ampicillin 2gm IV QID for prolonged PROM
(>12hrs)
•Follow for features of chorioamnionitis (maternal
fever, tachycardia, leukocytosis, uterine tenderness,
offensive vaginal discharge and fetal tachycardia) and
start triple antibiotics if so
•The antibiotic should continue throughout labor and for at
least one dose after delivery