Abnormal labour process and management for nursing students

It is presentation about abnormal labour process for nursing students

1. UNIT - VIII ABNORMAL LABOUR – ASSESSMENT AND MANAGEMENT

2. Cephalo pelvic disproportion & Contracted pelvis Cephalo pelvic disproportion Definition Cephalo pelvic disproportion is the disparity in relation between the head of baby and the mother’s pelvis. It is a pelvis in which one or more of its diameter is reduced below the normal by one or more centimeter. Interpretation If head is pushed easily into pelvis with no overlapping of parietal bone on the pubic symphysis, normal inlet (no disproportion) . Slight pushing of head into pelvis with slight overlapping of parietal bone on symphysis, moderate disproportion .

3. Inability to push the head into pelvis with complete overlapping of parietal bone over pubic symphysis, severe disproportion . Assessment of CPD by Muller-Kerr method The fetal head is best pelvimeter in clinic practice. The most useful method to determine the cephalopelvic disproportion is the determination of the relationship between the size of the head and the pelvic brim. The relative size of the fetal head to the pelvis is more important than the absolute size of the pelvis. It is done by manual method. The patient lies on the examination table in modified dorsal position with the legs flexed or in lithotomy position after emptying the bladder and bowels. In vertex presentation, the obstetrician pushes the fetal head into the pelvis with the left hand. The finger of the right hand are inserted vaginally at the level of ischial spines while the thumb

4. r esides over the pubic symphysis. It estimates whether the vertex reaches the level of the ischial spines or not and whether there is any overriding of symphysis by the head. It can be done during pregnancy but is best done at the onset of labour to assess disproportion at the inlet. Interpretation Grade 0 : No disproportion Head can be easily pushed into the pelvis upto ischial spines. There is no overlap. Grade 1 : Minor disproportion Anterior surface of the head is in line with the posterior surface

5. of pubic symphysis. Vaginal delivery can be achieved with some moulding. Grade 2 : Moderate disproportion The anterior surface of the head is in line with the anterior surface of the symphysis as felt by thumb. Vaginal delivery may or may not occur. Caesarean delivery is better. Grade 3 : Severe disproportion The fetal head overrides the anterior surface of the symphysis as felt by thumb. Vaginal delivery cannot occur. Caesarean delivery is required.

6. Diagnosis Clinical: a) Abdominal method, b) Abdominovaginal method X-ray pelvimetry Cephalometry: a) Ultrasound, b) MRI Clinical Abdominal method The patient is placed in dorsal position with the thighs slightly flexed and separated. The head is grasped by the left hand. Two fingers (index and middle) of the right hand are placed above the symphysis pubis keeping the inner surface of the fingers in line with the anterior surface of the symphysis pubis to note the degree of overlapping, if any, when the head is pushed downwards and backwards.

7. Abdominovaginal method (Muller-Munro Kerr method) X-ray pelvimetry Lateral X-ray view with the patient in standing position is helpful in assessing cephalopelvic proportion in all planes of the pelvis – inlet, midpelvic and outlet. Cephalometry Ultrasound While a rough estimation of the size of the head can be assessed clinically, accurate measurement of the biparietal diameter would have been ideal to elicit its relation with the diameters of the planes of a given pelvis through which it has to pass. In this respect, USG measurement of the biparietal diameter or MRI

8. g ives superior information. The average biparietal diameter measures 9.4-9.8 cm at term. MRI MRI is useful to assess the pelvic capacity at different planes. It is equally informative to assess the fetal size, fetal head volume and pelvic soft tissues which are also important for successful vaginal delivery. Degree of disproportion and contracted pelvis It is based on clinical findings and pelvimetry: Severe disproportion When the obstetric conjugate is less than 7.5 cm (3”) then it is

9. said to be severe disproportion . Borderline disproportion When the obstetric conjugate is between 9.5 and 10 cm. In inlet the anterior posterior diameter is less than 10 cm and transverse diameter is less than 12 cm. Causes Nutritional deficiency Disease / injury to pelvic bones Developmental defects A large size baby Abnormal fetal position Problem with genital tract

10. Contracted pelvis Definition Anatomical - It is a pelvis in which one or more of its diameters is reduced below the normal by one or more centimetres. Obstetric - It is a pelvis in which one or more of its diameters is reduced so that it interferes with the normal mechanism of labor . Causes Common causes of contracted pelvis are Nutritional and environmental defects minor variation:- common major :- rachitic and osteomalacic – rare

11. Disease or injury affecting the bone of the pelvis :- fracture, tumours, tubercular arthritis. spine :- kyphosis, scoliosis, coccygeal deformity Lower limbs :- poliomyeitis, hip joint disease Develop - vertebral disorders Classification Classified by Type of distortion of pelvic architecture Degree of contraction

12. Type of distortion of pelvic architecture Pelvis aequabiliter justo minor Characterized by general reduction of all diameters; equally shortened usually by 1 – 2 cm. Occurs in short. Also occurs in women with massive skeletal bones and developed muscles, the pelvis has masculine features such as narrow sacrum, narrow pubic outlet {funnel-shaped ). Flat Pelvis Reduced anteroposterior diameters with normal transverse and oblique diameters. Has 2 types of contracture.

13. Simple flat (or platypellic) pelvis: Entire sacral platform is dislocated toward the symphysis hence all the anteroposterior diameters of all pelvic planes are reduced. Flat rachitic: Anteroposterior diameter of the pelvic inlet only is reduced. Generally Contracted Pelvis All diameters reduced but the anteroposterior diameters are shortened greater then the others. Usually connected with rickets of the childhood.

14. Rare forms of contracted pelvis Otto’s pelvis – develop as result of inflammatory process in the hip or knee. Beaked (rostrate) pelvis – under development of both sacral wings. Spondylolithetic pelvis – formed due to partial dislocation of last lumbar vertebra in front of 1 st sacral vertebra. Osteomalacic pelvis Scoliotic pelvis – only the lumber region cause deformity of the pelvis. The acetabulum is pushed inwards on the weight bearing side.

15. Classification by degree of contracture 4 degrees First degree: true conjugate < 11 cm but not < 9 cm , spontaneous delivery is possible Second degree: true conjugate = 9 - 7.5 cm spontaneous delivery possible but complications may arise Third degree: true conjugate 7.5 – 6 cm spontaneous delivery impossible, use C-section Fourth degree: true conjugate < 6 cm , impossible delivery, only way is C-section ; also known as absolutely contracted pelvis

16. Diagnosis History Rickets: is expected if there is a history of delayed walking and dentition. Trauma or diseases: of the pelvis, spines or lower limbs. Infantilism Previous tuberculosis of bones and joints Bad obstetric history e.g. prolonged labour ended by; difficult forceps, caesarean section or still birth.

17. Weight of the baby Evidence of maternal injuries such as complete perineal tear, vesico vaginal fistula , recto vaginal fistula General examination Abnormal gait Assess woman for stockily built with bull neck. Broad shoulder and short thigh Obese and male distribution of hair Stature : women < 150 cm or 5 feet Abdomen examination Pendulous abdomen in primigravida fetal head fails to enter a contracted pelvis at the end of

18. pregnancy and floats high above inlet, failed growth of uterus deviates upward and anteriorly. Non engagement in last 3-4 wks. in primigravida Shapes of abdomen Acuminate (pointed ) abdomen in primigravida with a resilient abdominal wall Pendulous abdomen in multiparous women

19. Abdominal method in CPD Patient is placed in dorsal position with thigh flexes and separated. The head is grasped by the left hand. 2 fingers (index and middle) of the right hand are placed above the symphysis pubis to note the degree of overlapping. If when the head is pushed downward and backward. The head can be pushed down in the pelvis without overlapping of the parietal bone on the symphysis pubis:- no disproportion. Head can be pushed down a little but there is slightly overlapping of the parietal bone evidence by touch on the under surface of finger overlapping by 0.5 cm :- moderate disproportion. Head can not be pushed down and instead the partial bone overhangs the symphysis pubis displacing the finger – sever disproportion.

20. Some times the degree of disproportion is difficult to found by this method because of Deflexed head Thick abdominal wall Irritable uterus High floating head

21. Abdominal vaginal method It is also called as MULLER – MUNRO KERR It is bimanual method . In vertex presentation, pushes fetal head into the pelvis with the left hand. The fingers of the right hand are inserted vaginally at the level of ischial spine while the thumb remain over the symphysis pubic. Results: The head can be pushed down up to the level of ischial spines and there is no overlapping of the parietal bone over the symphysis pubis:- no disproportion The head can be pushed down a little but not up to the level of ischial spine and there is slight overlapping of the parietal bone:- slight or moderate disproportion The head can not be pushed down and instead the parietal bone

22. overhangs the symphysis pubis displacing the thumb:- sever disproportion. Pelvimetry It is assessment of the pelvic diameters and capacity done at 38-39 weeks. It includes: Clinical pelvimetry: Internal pelvimetry for: inlet, cavity and outlet. External pelvimetry for: inlet and outlet. Imaging pelvimetry: X-ray. Computerised tomography (CT ). Magnetic resonance imaging (MRI) .

23. Management Disproportion Moderate degree – preterm labor – induction of labour Severe degree – term labour - Caesarean section or Trial labor Caesarean section Elective cesarean section at term is indicated in: Major degree of contraction Major disproportion Absolute contraction Dead fetus Patient not fit for trial labor. The operation is done in planned way any time during last week of pregnancy. Emergency: when trial labor is failed

24. Trial labor It is the conduction of spontaneous labor in a moderate degree of disproportion, in an institution under supervision with watchful expectancy hoping for a vaginal delivery or Trial of labor is a test of labor allowing the patient to enter into active labor putting all variable ( power, passage and passenger) into test and determine whether vaginal delivery is possible or not . Conduction of trial labour Careful fetal and maternal monitoring by electronic fetal monitoring and non stress test. Oral feeding remain suspended and hydration is maintained by intravenous drip. Adequate analgesic is administered. Augmentation of labor by pitocin.

25. The progress of labor is mapped with partograph: progressive descent of the head progressive dilatation of the cervix After the membrane rupture, pelvic examination is to be done: to exclude cord prolapse to note the colour of liquor to assess the pelvis once or more to note the condition of the cervix including pressure of the presenting part of the cervix. In favorable cases, end spontaneously, forcep and ventouse. In unfavorable cases, do caesarean section. Successful trial: A trial is called successful, if a healthy baby is born vaginally, spontaneous or by forcep or ventouse with the mother in good condition .

26. Failure of trial labor: Delivery is by cesarean section or delivery of a dead baby spontaneously or by craniotomy is called failure of trial labor. Advantages of trial labour Lower incidence of caesarean section. A successful trial ensures the women a good future obstetrics. Disadvantages of trial labour May end before full cervix dilatation Increased fetal mortality and morbidity In failed trial operative risk increases .

27. Nursing management Check vitals every 4 hourly Monitor both contraction and fetus continuously Report immediately the sign of fetal distress Position the mother in ways to increase the pelvic diameter such as sitting or squatting which increase the outlet diameter and also aid in fetal descent Assess the fetus for hypoxia Provide support to the client and the family members in coping with stress of a complicated labor

28. Complications First stage Fetal distress Prolonged labor Second stage Delayed second stage Shoulder dystocia Third stage Retained placenta PPH Maternal injury

29. Malposition & mal-presentation of the fetal head Occipito-posterior position Face presentation Brow presentation Breech presentation

30. Occipito - posterior position Occipito posterior position is a cephalic presentation where the denominator occiput lies over the sacro iliac joint or over the sacrum. Thus three positions are described: Right occipito posterior position : Where the occiput overlies the right sacro iliac joint also called third position of vertex. It is most common. Left occipito posterior position : Where the occiput overlies the left sacro iliac joint also called fourth position of vertex. Direct occipito posterior position : Where the occiput lies over the sacrum.

31. Causes Idiopathic Shape of the pelvic inlet: The shape of the inlet significantly determines the position of the head at the onset of labour. In more than 50%, the occipitoposterior position is associated with either an anthropoid or android pelvis. The wide occiput can comfortably be placed in the wider posterior segment of the pelvis. Fetal causes: Deflexion of the fetal head favors occipitoposterior position due to following factors: Primary brachycephaly – This shortens the length of the lever from the frontal to atlantooccipital joint and thus reduces the effective movement of flexion. Position of the trunk, shape and size of fetal head can favor occipitoposterior position.

32. Anterior attachment of the placenta on uterine wall favors a posterior position by pushing the back of the fetus and head posteriorly. Abnormal uterine action in labour may cause occipitoposterior position as the weak contractions may fail to push the head into pelvic inlet and may hinder its flexion. Diagnosis Abdominal examination On inspection : Abdomen looks flat, below the umbilicus. On lateral grip : Fetal limbs are more easily felt near the midline on either side. the anterior shoulder is far away from the midline. On pelvic grip : The head is not engaged. The occiput and sinciput are felt at the same level.

33. On auscultation : The maximum intensity of the fetal heart sound is heard on the flank and often difficult to locate especially in LOP. It may also be heard in the midline near umbilicus especially in direct occipitoposterior position when the fetal heart is heard directly through the fetal chest. Vaginal examination The findings in early labour Elongated bag of membranes which is likely to rupture during examination. the sagittal suture occupies any of the oblique diameters of the pelvis. Posterior fontanel is felt near the sacroiliac joint. The anterior fontanel is felt more easily because of deflexion of the head and at times, is felt at a lower level than the posterior

34. o ne. In late labour The diagnosis is often difficult because of caput formation which obliterates the sutures and fontanels. In such cases, the ear is to be located and unfolded pinna points toward the occiput. Imaging There is not much role of X-ray or ultrasound. However, ultrasound may give information about descent and position of the head.

35. Mechanism of labour in O.P. Engaging diameters Suboccipito frontal diameter (10.5 cm) in a slightly deflexed head. Occipitofrontal diameter (11.5 cm) in a severely deflexed head. Transverse diameter of head is biparietal diameter (9.5 cm). Engagement is often delayed due to deflexion . Favourable mechanism Descent and flexion Good uterine contraction result in good flexion of the head. Descent occurs until the head reaches the pelvic floor.

36. Internal rotation of the head As the occiput is the leading part, it rotates 3/8 th of a circle anteriorly to lie behind the symphysis pubis. As the neck cannot sustain such amount of torsion the shoulder rotates about 2/8 th of a circle to occupy the right oblique diameter in ROP and the left oblique diameter in LOP with 1/8 th of a circle torsion of the neck still left behind. Thus the rest of the mechanism is like that of the right occipitoanterior in ROP and that of left occipitoanterior in LOP. Extension The occiput escapes under the pubic symphysis and head is crowned. The sinciput, face and chin sweep the perineum and the head is born by movement of extension.

37. Restitution There is movement of restitution to the extent of 1/8 th of a circle in the opposite direction of internal rotation of the head. External rotation The external rotation of the head occurs through 1/8 th of a circle in the same direction of restitution as the shoulder rotate from the oblique to anteroposterior diameter of the pelvis. Lateral flexion The anterior shoulder escapes under the pubic symphysis, the posterior shoulder sweeps under the perineum and the body is born by lateral flexion.

38. Unfavourable mechanism Incomplete forward rotation In this condition, the occiput rotates through 1/8 th of a circle anteriorly and the sagittal suture comes to lie in the bispinous diameter. Thereafter, further anterior rotation is unlikely and arrest in this position is called up deep transverse arrest. Nonrotation Both the sinciput and the occiput touch the pelvis floor simultaneously due to moderate deflexion of the head resulting in nonrotation of the occiput. The sagittal suture lies in the oblique diameter. Further mechanism is unlikely and the condition is called oblique posterior arrest.

39. Malrotation In extreme deflexion, the sinciput touches the pelvic floor first resulting in anterior rotation of the sinciput to 1/8 th of a circle and putting the occiput to the sacral hollow. This position is termed as occipitosacral position. This is in the true senses, persistent occipitoposterior position of the vertex. Mechanism of face to pubis delivery Descent More and more descent of fetal head takes place until the root of nose lies under the pubic symphysis. Flexion and extension

40. The sinciput, vertex and occiput are born successively by flexion followed by delivery of the face by extension. Thus, flexion and extension both occurs in delivery of the head. Restitution The fetal head rotates 1/8 th of the circle in the direction opposite to that of internal rotation. External rotation It occurs by 1/8 th of a circle in the direction of restitution turning the face of the fetus towards the left thigh in ROP position and the right thigh in LOP position.

41. Management of labour First stage Exclude contracted pelvis. Exclude presentation or prolapse of the cord. Adequate hydration by IV line with Ringer lactate solution or dextrose saline solution as labour is usually prolonged. Maintenance of partogram is very useful for these cases for scientific monitoring of progress of labour, regular and adequate descent of the fetal head, regular and adequate cervical dilatation. Frequent bladder emptying. Contractions are sustained, irregular and accompanied by marked backache which needs analgesia as pethidine or epidural analgesia .

42. Augmentation of labour with oxytocin for weak uterine contractions after ruling out any cephalopelvic disproportion. Avoid premature rupture of membranes by: Rest in bed. No straining Avoid high enema Minimize vaginal examinations . Second stage Wait for 60-90 minutes. During this period: Observe the mother and fetus carefully. Combat inertia by oxytocin unless it is contraindicated. Contraindications of oxytocin: Disproportion Incoordinate uterine contraction.

43. Uterine scar Grand multipara Fetal distress One of the following will occur: Long internal rotation 3/8 th circle: Occurs in about 90% of cases and delivery is completed as in normal labour. Direct occipito posterior (face to pubis): Occurs in about 6% of cases. The head can be delivered spontaneously or by aid of outlet forceps. Episiotomy is done to avoid perineal laceration.

44. Deep transverse arrest (1%) and persistent occipito posterior (3 %): The labour is obstructed and one of the following should be done : Vacuum extraction (ventouse): Proper application as near as possible to the occiput will promote flexion of the head. Traction will guide the head into the pelvis till it meets the pelvic floor where it will rotate. Manual rotation and extraction by forceps: Under general anesthesia the following steps are done: Disimpaction: The head is grasped bitemporally and p ushed slightly upwards.

45. Flexion of the head. Rotation of the occiput anteriorly by the right hand vaginally aided by. Rotation of the anterior shoulder abdominally towards the middle line by the left hand or an assistant. Fix the head abdominally by an assistant, apply forceps and extract it. Rotation and extraction by forceps: Kielland’s forceps Barton’s forceps Scanzoni double application Caesarean section It is indicated in: Failure of the above methods. Contracted pelvis

46. Placenta previa Prolapsed pulsating cord before full cervical dilatation Elderly primigravida Craniotomy If the fetus is dead.

47. Face presentation Face presentation is a type of cephalic presentation in which the presenting part is the face. The head is hyperextended so that occiput is in contact with the fetal back and the chin (mentum) is the denominator. Position Left mento anterior : Chin points to left ilio pubic eminence. Right mento anterior: Chin points to right ilio pubic eminence. Right mento posterior : Chin points to right sacro iliac joint. Left mento posterior: Chin points to left sacro iliac joint.

48. Etiology Maternal Highpariety with pendulous abdomen. Inlet pelvic contraction Obliquity of the uterus Advanced maternal age Multiple pregnancy Hydramnios Placenta previa Cornual implantation of placenta Premature rupture of membrane Any pelvis mass or tumor Fetal

49. Fetal congenital malformation Tumors of neck Macrosomic fetus Prematurity Increased tone of the extensor group of neck muscles or spasm of sternocleidomastoid muscle Dolichocephalic head with long anteroposterior diameter Coils of cord around or about t he neck may also cause extension of fetal head Diagnosis Abdominal examination Inspection Because of “S” shaped spine, there is no visible bulging of the

50. flanks . Palpation Mentoanterior position Fundal grip Breech is felt. Lateral grip Fetal limbs are easily felt in front. Fetal back is felt with difficulty as it is posterior. Pelvic grip

51. Head seems big and is not engaged. Cephalic prominence is due to occiput and is on the side of the neck. Due to extension of head, there is a less marked depression (groove) between back and occiput. Auscultation Fetal heart sounds are best heard over the chest of the fetus anteriorly in midline. Vaginal examination The chin is felt anteriorly towards pubis. X-ray or ultrasound

52. Anterior chin Mentoposterior position Fundal grip Breech is felt. Lateral grip Fetal limbs are not easily felt being posterior. Fetal back is felt with ease as it is anterior. Pelvic grip Head apparently appears bigger in size and remains high. Cephalic prominence is due to occiput and is on side of the back.

53. Due to extension of head, there is a much more marked depression (groove) between back and occiput. Auscultation Fetal heart sounds are heard with difficulty in the flanks as the chest of the fetus is to the back of the mother. Vaginal examination The chin is felt posteriorly towards sacrum. X-ray or ultrasound Posterior chin

54. Mechanism of labour Lie : Longitudinal Attitude : Extension of head and back Presentation : Face Position : Left Mento anterior position Denominator : Mentum Presenting part : Left malar bone Engagement The diameter of engagement in the pelvis is the left oblique diameter. The engaging diameter of the head is Submento bregmatic (9.5cm) in fully extended head or submentovertical (11.5 cm) in partially extended head.

55. Descent with Extension Descent takes place with increasing extension. The mentum becomes leading part. Internal rotation of the head This occurs when chin reaches the pelvic floor and rotates forwards 1/8 th of a circle. The chin escapes under the symphysis pubis. Flexion The head is born by flexion. Delivering the chin, face, brow, vertex and lastly the occiput. Submento vertical diameter emerges through the vulval outlet .

56. Restitution This occurs through 1/8 th of the circle opposite to the direction of internal rotation. Internal rotation of the shoulder The shoulders enter the pelvis in the left oblique diameter and the anterior shoulder reaches the pelvic floor first and rotates forwards 1/8 th of a circle along the right side of the pelvis. External rotation of the head This occurs simultaneously. The chin moves the further 1/8 th of a circle to the same direction of restitution.

57. Lateral flexion The anterior shoulder escapes under the symphysis pubis, the posterior shoulders weeps the perineum and the body is born by a movement of lateral flexion. Clinical course Irregular face ill in the lower uterine segment Chance of cord prolapsed is more Delay of labour due to weak uterine contraction, absence of moulding of the facial bones delayed engagement, late internal rotation, arrest and obstruction of the fetus. Chance of perineal damage Postpartum haemorrhage

58. Management Overall assessment is done to note Pelvic adequacy Size of the baby Associated complicating factors like elderly primigravida, severe preeclampsia, post caesarean pregnancy and Postmaturity Congenital fetal malformation Position of the mentum Indications of elective or early caesarean section Contracted pelvis Big baby Associated complicating factors

59. Vaginal delivery First stage The midwife should inform the doctor of this deviation from the normal. Routine observations of maternal and fetal conditions are made as in a normal labour. Care should be taken to avoid infection or injury to the eyes during vaginal examinations. Immediately following rupture of the membranes, a vaginal examination is performed to exclude cord prolapsed because the face is an ill fitting presenting part. Descent of the head should be observed and a vaginal examination performed every 2-4 hours to assess cervical dilatation and descent of the head.

60. Second stage Elective episiotomy may be performed to avoid extensive perineal lacerations. When the face appears at the vulva, extension must be maintained by holding back the sinciput and permitting the mentum to escape under the symphysis pubis before the occiput is allowed to sweep the perineum. If the head is not descending in the second stage, the doctor should be informed. In Mentoposterior position If the anterior rotation of the chin occurs, spontaneous or forceps delivery with episiotomy is all that is needed. If incomplete or malrotation, early decision for the method of delivery is to be taken soon after full dilatation of the cervix.

61. The following methods may be employed to expedite the delivery . Caesarean section is preferred method and is commonly done. Manual rotation of the chin anteriorly followed by immediate forceps extraction is rarely done. Complications Maternal complications Prolonged labour Increased risk of maternal morbidity due to operative delivery Obstructed labour in persistent Mentoposterior position Rarely rupture uterus Postpartum haemorrhage Infection

62. Fetal complications Increased fetal mortality and morbidity due to: The face after delivery is edematous and swollen. Laryngeal edema can also occur and so the baby must be watched carefully for the first 24 hours to detect any breathing difficulty. Cord prolapse Increased operative delivery Neonatal sepsis Birth asphyxia due to cord prolapse and prolonged labour Congenital malformations, like anencephaly, are more common in face presentation.

63. Brow presentation Brow presentation is the most unfavourable variety of the cephalic presentations in which the presenting part is the brow, forehead, sinciput or frontum which is the area between the anterior fontanelle and coronal sutures above and the nasion, glabella and orbital ridges below. The attitude is one of partial extension between full flexion and full extension. The presenting diameter is the mentovertical which is the largest diameter of the fetal head. Position Brow anterior: Brow is towards symphysis pubis in anterior segment of pelvis. Brow posterior: Brow is in posterior segment of pelvis.

64. Etiology The causes are similar to that of face presentation and include any factor that interferes with flexion of the head. Diagnosis Abdominal examination The lie is longitudinal with breech in the fundus of the uterus. The head is at the pelvis, feels very big and is not engaged. The back is posterior and is on the mother’s right and posterior, it may be difficult to palpate. The small limb parts on the left and anterior. The cephalic prominence (occiput) and the back are on the same side (the right).

65. The depression (groove) between cephalic prominence and the back is less prominent. Ultrasonography and radiography USG and radiography is confirmatory and also helps in excluding congenital malformations of the fetus. Auscultation Fetal heart sounds are heard best in the left lower quadrant of the maternal abdomen. Vaginal examination The anteroposterior diameter of the head is in the right oblique diameter of the pelvis.

66. The brow, the area between the nasion and the bregma presents and is felt in the left anterior quadrant of the pelvis. The vertex is in the right posterior quadrant. The bregma is palpated easily. The frontal suture is felt but sagittal suture is usually out of reach. Identification of the supraorbital ridges is a key to diagnosis. One needs to differentiate it from face and vertex presentations. Mouth may be felt but chin is not felt. If chin is felt it is a face presentation. Conical bag of membranes may be felt. Mechanism of labour The presenting diameter (mentovertical) being very large, there is no mechanism of labour for persistent brow presentation. Spontaneous delivery is unlikely.

67. Rarely, with large pelvis in a multiparous woman, a small baby may deliver vaginally with brow reaching the pelvic floor, rotating forwards and born by a mechanism similar to that of a vertex face to pubis. Posterior brow has no mechanism of labour. Complications Maternal complications Obstructed labour and rupture uterus Risk of operative delivery Fetal complications Birth asphyxia Fetal death

68. Caput and moulding There is usually a large caput on fetal head. There is moulding with compression of submentovertical diameter and elongation of Occipitofrontal diameter. Management Antepartum If diagnosed antepartum (rarely), it is better to wait till the onset of labour as many cases correct to vertex or face presentation. Contracted pelvis and congenital malformations of the fetus are to be excluded. Caesarean delivery

69. Elective caesarean delivery is the management of choice for persistent brow presentation in labour which should be done early for better outcome. If there are features of obstructed labour, caesarean delivery is performed immediately even if the fetus is dead. Craniotomy If the labour becomes obstructed and the baby is dead, craniotomy is done. Ruptured of the uterus should be excluded. Note: IN examination, students should answer that caesarean delivery should be done for brow presentation.

70. Breech presentation Breech presentation is a type of malpresentation in which the podalic pole (fetal buttocks or the lower extrimities) presents at the pelvic inlet and the denominator is sacrum. Position Left sacro anterior Left sacro posterior Right sacro anterior Right sacro posterior Types Complete breech or flexed breech presentation Incomplete breech presentation

71. Complete breech presentation In this presentation, hips and knees are flexed and the feet are present in the pelvis. Incomplete breech presentation In this presentation, there is incomplete flexion with extension at one or two joint. Three types are possible. Frank breech It is breech with extended legs where the knees are extended while the hips are flexed. More common in primigravida.

72. Footling presentation Longitudinal lie. Incomplete or footling, breech presentation The hip and knee joints are extended on one or both sides. More common in preterm singleton breeches. Knee presentation The hip is partially extended and the knee is flexed on one or both side. Knee is the presenting part. It is rare. Etiology Maternal factors Multiparity causing uterine relaxation Uterine obliquity

73. Placenta previa Cornuofundal attachment of placenta Uterine anomalies like bicornuate or Septate uterus Uterine fibroids in the lower segment or other pelvic tumors Contracted pelvis Hydramnios Oligohydramnious Previous breech delivery Fetal factors Prematurity is the most common cause Multiple pregnancy Hydrocephalus, as the bulky head occupies the roomier fundus and other anomalies like anencephaly Trisomies 13,18,21, myotonic dystrophy

74. Intrauterine fetal death Very long or short umbilical cord Extended legs Diagnosis Inspection A transverse groove may be seen above the umbilicus in sacroanterior corresponds to the neck. If the patient is thin, the head may be seen as a localised bulge in one hypochondrium. Palpation Fundal grip : The head is felt as a smooth, hard, round ballotable mass which is often tender .

75. Umbilical grip : The back is identified and a depression corresponds to the neck may be felt. First pelvic grip : The breech is felt as a smooth, soft mass continuous with the back. Trial to do ballottement to the breech shows that the movements is transmitted to the whole trunk. Auscultation FHS is heard above the level of the umbilicus. However in frank breech it may be heard at or below the level of the umbilicus. Vaginal examination Conical bag of membranes. Presenting part is high up. In flexed breech, both ischial tuberosities, anus, sacrum , buttocks

76. and feet are palpated. After further descent, external genitalia can be felt. In extended breech, feet are not felt. In footling presentation, feet are the presenting part with buttocks higher up. Sacrum is usually in the anterior quadrant. Posteriorly placed sacrum is less favourable for vaginal delivery. Ultrasonography It is used for the following: To confirm the diagnosis. To detect the type of breech. To detect gestational age and fetal weight To exclude hyperextension of the head. To exclude congenital anomalies. Diagnosis of unsuspected twins .

77. Mechanism of labour Lie : Longitudinal Attitude : Complete flexion Presentation : Breech Position : Left sacroanterior Denominator : Sacrum Presenting part : Anterior (left) buttock The bitrochanteric diameter (10 cm), enters the pelvis in the left oblique diameter of the brim. The sacrum points to the left iliopectineal eminence. Engagement It occurs when the bitrochanteric diameter has passed through the inlet of pelvis.

78. Compaction Descent takes place with increasing compaction, owing to increased flexion of the limbs . Internal rotation of the buttocks The anterior buttock reaches the pelvic floor first and rotates forwards 1/8 of a circle along the right side of the pelvis to lie underneath the symphysis pubis. The bitrochanteric diameter is now in the anteroposterior diameter of the outlet. Lateral flexion of the body The anterior buttock escapes under the symphysis pubis, the posterior buttock sweeps the perineum and the buttocks are born by a movement of lateral flexion.

79. Restitution of the buttocks The anterior buttock turns slightly to the mother’s right side. Internal rotation of the shoulders The shoulders enter the pelvis in the same oblique diameter as the buttocks, the left oblique. The anterior shoulder rotates forwards 1/8 of a circle along the right side of the pelvis and escapes under the symphysis pubis, the posterior shoulder sweeps the perineum and the shoulders are born. Internal rotation of the head The head enters the pelvis with the sagittal suture in the transverse diameter of the brim. The occiput rotates forwards

80. along the left side and the suboccipital region (the nape of the neck) impinges on the under surface of the symphysis pubis. External rotation of the body At the same time the body turns so that the back is uppermost. Birth of the head The chin, face and sinciput sweep the perineum and the head is born in a flexed attitude.

81. Management External cephalic version External cephalic version is the use of external manipulation on the mother’s abdomen to convert a breech to a cephalic presentation. It regains its importance after increased rate of caesarean sections nowadays. Timing : ECV has been considered from 36 weeks onward. While version in early weeks is easy but chance of reversion is more. Late version may be difficult because of increasing size of the fetus and diminishing volume of liquor amni. Caesarean section

82. Indications Large fetus Preterm fetus but estimated weight is still more than 1.25 kg Footling or complete breech Hyperextended head Contracted pelvis Uterine dysfunction Complicated pregnancy with: Hypertension Diabetes mellitus Placenta previa Pre labour rupture of membranes for 12 hours Post term Intrauterine growth retardation Placental insufficiency Primigravida

83. Vaginal delivery Criteria to be fulfilled are: Average fetal weight between 1.5 kg and 3.5 kg Flexed fetal head Adequate fetal pelvis Without medical or obstetric complications Availability of facilities for emergency caesarean section Facilities for continuous labour monitoring Presence of obstetrician experienced with vaginal breech delivery Informed consent Frank breech is preferred

84. Management of vaginal breech delivery First stage The management protocol is similar in normal labour. Spontaneous onset of labour increases the chance of successful vaginal delivery. The following are the important considerations: Vaginal examination is indicated At the onset of labour for pelvic assessment Soon after rupture of the membranes to exclude cord prolapse An intravenous line is started with Ringer’s lactate solution, oral intake is avoided, blood is sent for group and cross matching Adequate analgesia is given, epidural is preferred. Fetal status and progress of labour are monitored. Oxytocin infusion may be used for augmentation of labour.

85. Second stage There are three methods of vaginal breech delivery: Spontaneous (10%) : Expulsion of the fetus occurs with very little assistance. This is not preferred. Assisted breech : The delivery of the fetus is by assistance from the beginning to the end. This method should be employed in all cases. Breech extraction (partial or total) : When part or the entire body of the fetus is extracted by the obstetrician. It is rarely done these days as it produces trauma to the fetus and the mother.

86. Assisted breech delivery This is the method of delivery in far majority of cases. The following are to be kept ready beforehand: Anesthetist An assistant Instruments and suture materials for episiotomy A pair of obstetric forceps Appliances for resuscitation of the baby Neonatologist Delivery of the buttocks When the buttocks are distending the perineum, the woman is placed in the lithotomy position and the vulva is swabbed and draped with sterile towels. The bladder is usually catheterized at this stage.

87. The patient is asked to bear down during uterine contraction and relax in between until the perineum is distended by the buttocks. An episiotomy is done especially in primigravida to avoid much lateral flexion of the spines, perineal lacerations and intracranial haemorrhage due to sudden compression and decompression of the after coming head. The women is encouraged to push with the contractions and the buttocks are delivered spontaneously. If the legs are flexed, the feet disengage at the vulva and the baby is born as far as umbilicus. A loop of cord is gently pulled down to avoid traction on the umbilicus. Spasms of the cord vessels can be caused by manipulating the cord or by stretching it. If the cord is being nipped behind the pubic bone it should be moved to one side. The midwife should feel for the elbows, which are usually on the

88. chest. If so, the arms will escape with the next contraction. If the arms are not felt, they are extended. Delivery of the shoulders The uterine contraction and the weight of the body will bring the shoulders down on to the pelvic floor where they will rotate into the anteroposterior diameter of the outlet. It is helpful to wrap a small towel around the baby’s hips, which preserves warmth and improves the grip on the slippery skin. The midwife now grasps the baby by the iliac crests with her thumbs held parallel over his sacrum and tilts the baby towards the maternal sacrum in order to free the anterior shoulder. When the anterior shoulder has escaped, the buttocks are lifted towards the mother’s abdomen to enable the posterior shoulder and arm to pass over the perineum.

89. As the shoulders are born the head enters the pelvic brim and descends through the pelvis with the sagittal suture in the transverse diameter. Delivery of the head It is delivered by one of the following method: Forceps delivery The obstetrician usually applies forceps to the aftercoming head to achieve a controlled delivery. Burns Marshall method The obstetrician grasps the baby’s ankles from behind with

90. f orefinger between the two. The baby is kept on the stretch with sufficient traction to prevent the neck from bending backwards. The occipital region and not the neck should pivot under the apex of the pubic arch. The feet are taken up through an arc of 180 o until the mouth and nose are free at the vulva. The right hand may guard the perineum in order to prevent sudden escape of the head. An assistant may now clear the airway and the baby will breath. The mother should be asked to take deliberate, regular breaths, which allow the vault of the skull to escape gradually, taking 2 to 3 minutes. Jaw flexion and shoulder traction ( Mauriceau-Smellie-Veit maneuver) The method is used when there is delay in descend of the head

91. because of extension. The baby is laid astride the right arm with the palm supporting the chest. Two fingers are inserted well back into the mouth to pull the jaw downwards and the flex the head (two fingers may be placed on the malar bones and the middle finger in the mouth, if they can be accommodated). Two fingers of the left hand are hooked over the shoulders with the middle finger pushing up the occiput to aid flexion. Traction is applied to draw the head out of the vagina and when the suboccipital region appears, the body is lifted to assist the head to pivot around the symphysis pubis. Once the face is free, the airway may be cleared and the vault delivered slowly.

92. Resuscitation of the baby The baby may be asphyxiated and need to be resuscitated. Third stage The third stage is usually uneventful. The placenta is usually expelled out soon after delivery of the head. If prophylactic ergometrine is to be given, it should be administered intravenously with the crowning of the head. Breech extraction When part or the entire body of the fetus is extracted by the obstetrician. It is rarely done these days as it produces trauma to the fetus and the mother.

93. Indication Maternal or fetal distress Prolonged second stage To shorten the second stage in maternal respiratory and heart disease Prolapsed pulsating cord with fully dilated cervix Technique Like assisted breech delivery except that It is done under general anaesthesia Both legs are bringing down Traction on the legs is done helped by fundal pressure to deliver the breech and the trunk The after – coming head is delivered by jaw flexion, shoulder

94. Management of complicated breech delivery Arrest of the buttocks at the pelvic brim Oxytocin drip, if contraindicated do caesarean section. Breech extraction – if cervix is fully dilated. Arrest of the buttocks at the pelvic outlet Groin traction Living fetus Traction is done by the index or the index and the middle fingers put in the anterior groin in a downward and backward direction.

95. The traction is done towards the trunk to avoid dislocation of the femur . Traction is done during uterine contractions and aided by fundal pressure. When the posterior buttocks appears traction is done by the 2 index fingers in both groins in a downward and forward direction. Dead fetus Groin traction is done by breech hook . Bringing down a leg (Pinard’s method) Under general anaesthesia Press by 2 fingers in the popliteal fossa of the anterior leg to flex

96. traction or forceps. It then grasp the ankle and bring it down. This will prevent the anterior buttock from over riding the symphysis pubis. If the posterior leg is brought down first it must be rotated anteriorly with the trunk then bring the other leg which is now becomes posterior. Arrest of the shoulder Classical method Under epidural or general anesthesia As there is more space posteriorly, bring down the posterior arm first by using 2 fingers pressing against the cubital fossa and sweep the arm in front of the foetal body to avoid fracture humerus .

97. The anterior arm is then brought down by the same manoeuvre. If this is difficult rotate the body 180 to make the anterior arm posterior and bring it down . Lovset method Under epidural or general anesthesia. Gentle downward and backward traction is applied to the fetus by grasping its pelvis till the inferior angle of the anterior scapula appears, the fetal trunk is rotated 180 to bring the posterior shoulder anteriorly emerging beneath the symphysis pubis. So the arm can be brought down. The trunk is again rotated 180 in the opposite direction to bring the other shoulder anteriorly emerging beneath the symphysis so the second arm can be brought down. The back should be kept always anterior during rotation .

98. Arrest of the after coming head Prague manoeuvre When the occiput rotates posteriorly and the head extends, the chin hags above the symphysis pubis. Fetus is grasped from its feet and flexed towards the mother’s abdomen, while the other hand is doing simultaneous traction on the shoulders to deliver the head by flexion .

99. Complications Impacted breech Cord prolapse Birth injury Fracture of humerus Erb’s palsy Trauma to the internal organs Damage to the adrenals Spinal cord damage Intracranial haemorrhage Fetal hypoxia Premature separation of the placenta Maternal trauma

100. Transverse lie or Shoulder presentation Definition In transverse lie, the long axis of the fetus is approximately at right angle to the long axis of the mother or maternal spine or centralized uterine axis. Etiology Maternal causes Multiparity due to relaxed uterus and pendulous abdomen Placenta previa Contracted pelvis Hydramnios

101. Uterine malformation Bicornuate uterus Arcuate uterus Septate uterus Sub Septate uterus Fibroids Fundal insertion of placenta Pelvis tumors Fetal causes Prematurity Multiple pregnancy Fetal malformation Fetal death

102. Positions The scapula is the denominator Left scapulo a nterior Right scapulo anterior Right scapulo posterior Left scapulo posterior Diagnosis During pregnancy Inspection The abdomen is broader from side to side. The abdomen is unusually wide, where as fundal height is less extending to only slightly above the umbilicus.

103. Palpation Fundal height: The fundal height is less than the period of gestation. Fundal grip: The fundus feels empty. Umbilical grip: The head is felt on one side while the breech one the other. In transverse lie, they are at the same level, while in oblique lie one pole, usually the head as it is heavier, is in a lower level. Pelvic grip: Empty lower uterine segment. Auscultation FHS are best heard on one side of the umbilicus towards the fetal head.

104. Ultrasound or X ray Confirms the diagnosis and may identify the cause as multiple pregnancy or placenta previa. During labour In addition to the previous findings, vaginal examination reveals: The presenting part is high. Membranes are bulging. Premature rupture of membranes with prolapsed arm or cord is common. The dorsum of the supinated hand points to the fetal back and the thumb towards the head. The right hand of the fetus can be shacked, correctly by the right hand of the obstetrician and the left hand by the left one. When the cervix is sufficiently dilated particularly after rupture of

105. the membranes, the scapula, acromion, clavicle, ribs and axilla can be felt. Management External cephalic version Can be done in late pregnancy or even early in labour if the membranes are intake and vaginal delivery is feasible. In early labour, if version succeeded apply abdominal binder and rupture the membranes as if there are uterine contractions. Internal podalic version It is mainly indicated in 2 nd twin of transverse lie and followed by breech extraction.

106. Prerequisites General or epidural anesthesia Fully dilated cervix Intact membranes or just ruptured Caesarean section It is the best and safest method of management in nearly all cases of persistent transverse or oblique lie even if the baby is dead. As rupture of membranes carries the risk of cord prolapse, an elective caesarean section should be planned before labour commences.

107. Neglected shoulder Clinical picture Exhaustion and distress of the mother. Shoulder is impacted may be with prolapsed arm and /or cord. Membranes are ruptured since a time. Liquor is drained. The uterus is tonically contracted. The fetus is severely distressed or dead. Management Caesarean section is the safest procedure even if the baby is dead. A classical or low vertical incision in the uterus facilitates extraction of the fetus as a breech in such a condition.

108. Compound presentation Definition It is the presence of a limb alongside the presenting part usually the arm presents with the head. Etiology Interference of adaptation of the presenting part to the pelvic brim which may be: Fetal causes Malpresentations Prematurity

109. Multiple pregnancy Polyhydramnios Maternal causes Contracted pelvis Pelvis tumours Diagnosis Vaginal examination reveals limb beside the head. Management Exclude: Contracted pelvis and cord prolapse

110. First stage Nothing is done as most cases arm will be displaced spontaneously away form the head. Second stage Forceps extraction with or without reposition of the arm : Reposition of the arm tried first, if difficult apply forceps without reposition but do not include the arm in the blades. This is done if the head is engaged. Caesarean section : It is indicated in Non engagement of the head Contracted pelvis Other indications for caesarean section Craniotomy : If the fetus is dead and labour is obstructed.

111. Unstable lie Definition This is a condition where the presentation of the fetus is constantly changed even beyond 36 th week of pregnancy when it should have been stabilised. Causes The causes are those which prevent the presenting part to remain fixed in the lower pole of the uterus. Such conditions are: Grand multipara with lack of uterine tone and pendulous abdomen Hydramnios

112. Contracted pelvis Placenta previa Pelvic tumours Complications Cord entanglement is a possible risk. Risk of cord prolapse is there once the membranes rupture. Perinatal death is high. Management Antenatal At each antenatal visit, the presentation and the lie are to be checked. If there is no contraindication, external version is to be done to correct the malpresentation.

113. Hospitalization The patient is to be admitted at 37 th week. Premature or early rupture of membranes with cord prolapse is the real danger with the lie remaining oblique. After admission, the investigation is directed to exclude placenta previa, contracted pelvis or congenital malformation of the fetus with the help of sonography for localisation of the placenta. Formulation of the line of the treatment Elective caesarean section is done in majority of the cases specially in the presence of complicating factors like pre eclampsia, placenta previa, contracted pelvis, etc. Stabilising induction of labour: External cephalic version is done after 37 weeks – oxytocin infusion is started to initiate effective

114. u terine contractions. This is followed by low rupture of the membranes. Labour is monitored for successful vaginal delivery. This procedure may be done even after the spontaneous onset of labour.

115. Premature labour or preterm labour Definition Preterm labour is defined as one where the labour starts before the 37 th completed week, counting from the first day of the last menstrual period. Etiology History Previous history of induced or spontaneous abortion or preterm delivery. Pregnancy following assisted reproductive techniques Asymptomatic bacteriuria or recurrent urinary tract infection

116. Smoking habits Low socioeconomic and nutritional status Maternal stress Complication in present pregnancy Maternal Pregnancy complications such as preeclampsia, antepartum haemorrhage, premature rupture of the membranes, polyhydramnios Uterine anomalies such as cervical incompetence, malformation of uterus Medical and surgical illness such as acute fever, acute pyelonephritis, diarrhoea, acute appendicitis, toxoplasmosis and abdominal operation

117. Chronic disease such as hypertension, nephritis, diabetes, decompensated heart lesion, severe anemia, low body mass index Genital tract infection such as bacterial vaginosis, beta hemolytic streptococcus, chlamydia and mycoplasma Fetal Multiple pregnancy Congenital malformation Intrauterine death Placental Infarction Thrombosis Placenta previa or abruption

118. Idiopathic Premature effacement of the cervix with irritable uterus and early engagement of the head. It is presumed that there is premature activation of the same system involved in initiating labour at term. Diagnosis Regular uterine contraction with or without pain (at least one in every 10 minutes). Dilatation ( ≥ 2 cm) and effacement (80%) of the cervix. Length of the cervix ≤ 2.5 cm and funnelling of the internal os. Pelvic pressure, backache and vaginal discharge and bleeding.

119. Management Bed rest Although its role is doubtful. It is often recommended in left lateral position. In utero transfer If local facilities are inadequate to treat the preterm infant, an in utero transfer should be done to a higher center. Sedation Especially useful in threatened preterm labour. Morphine or pethidine with promethazine have been used.

120. Hydration Adequate hydration is advised. Prophylactic cervical cerclage Women with prior preterm birth and short cervix in the present pregnancy may be beneficial. First stage The woman is put to bed to prevent early rupture of membranes. Oxygen is given by mask to ensure adequate fetal oxygenation. Strong sedatives or acceleration of labour is to be avoided. Epidural analgesia is the choice.

121. Progress of labour should be monitored clinically or by electronic monitoring. In case of delay or anticipating a tedious traumatic vaginal delivery. It is better to deliver by caesarean section. Second stage The birth should be gentle and slow avoid rapid compression and decompression of fetal head. Liberal episiotomies should be done under local anesthesia, especially in primigravida to minimize head compression. Tendency to delay must be curtailed by low forceps. The cord must be clamped immediately at birth to prevent the development of hypervolemia and hyperbilirubinemia. Place the baby in intensive neonatal care unit under the care of neonatologist.

122. Place of caesarean section Routine caesarean delivery is not recommended. Preterm features before 34 weeks presented by breech are generally delivered by caesarean section. Lower segment vertical or “J” shaped incision may have to be made to minimize trauma during delivery. This is due to poor formation of the lower uterine segment. Immediate management of the preterm baby following birth The cord is to be clamped quickly to prevent hypervolemia and development of hyperbilirubinemia. The cord length should be about 10-12 cm in case exchange transfusion will be required due to hyperbilirubinemia. The air passage should be cleared of mucus promptly and gently. The stomach contents are also be sucked out .

123. Adequate oxygenation must be provided. The baby should be wrapped in a sterile warm blanket lowered. Vitamin K 1 mg to be injected intramuscularly to prevent haemorrhage manifestations. Bathing is not appropriate for the preterm baby.

124. Disorders of uterine actions Precipitate labour Definition A labour is called precipitate when the combined duration of the first and second stage is less than 3 hours. It is common in multipara and may be repetitive. Rapid expulsion is due to the combined effect of hyperactive uterine contractions associated with diminished soft tissue resistance. Labour is short as the rate of cervical dilatation is 5 cm/hr or more for the multiparous women. Risk factors

125. Maternal risk factors Extensive laceration of the cervix, vagina and perineum PPH due to uterine hypotonia that develops subsequent to unusal vigorous contractions Inversion Uterine rupture Infection Amniotic fluid embolism Fetal risk factors Intracranial stress and haemorrhage because of rapid expulsion without time for moulding of the head. The baby may sustain serious injuries if delivery occurs in standing position, bleeding from the torn cord and direct hit on

126. t he skull, brachial plexus injury are real hazards. Management The patient having previous history of precipitate labour should be hospitalized prior to labour. During labour, the uterine contraction may be suppressed by administering either or magnesium sulphate during contractions. Delivery of the head should be controlled. Episiotomy should be done liberally. Elective induction of labour by low rupture of membranes and conduction of controlled delivery is helpful. Oxytocin augmentation should be avoided.

127. Prolonged labour Definition The labour is said to be prolonged when the combined duration of the first and second stage is more than the arbitrary time limit of 18 hours. Causes of prolonged labour First stage : Failure to dilate the cervix is due to: Fault in power includes abnormal uterine contraction such as uterine inertia or Incoordinate uterine contraction. Fault in the passage includes contracted pelvis, cervical dystocia, pelvic tumour or even full bladder.

128. Fault in the passenger includes malposition and malpresentation, congenital anomalies of the fetus. Others includes early administration of sedatives and analgesics before the active labour begins. Second stage : Sluggish or non descent of the presenting part in the second stage is due to: Fault in the power includes uterine inertia, inability to bear down, regional (epidural) analgesia, constriction ring. Fault in the passage includes cephalopelvic disproportion, android pelvis, contracted pelvis, undue resistance of the pelvic floor or perineum due to spasm or old scarring, soft tissue pelvic tumor. Fault in the passenger includes malposition, malpresentation, big baby, congenital malformation of the baby.

129. Diagnosis Prolonged labour is usually due to some cause in mother and fetus. The past history of the patient should be noted and examination should be performed in all cases to find out the cause of prolonged labour. Abdominal examination is performed for uterine contractions, malpresentations and fetal heart. Vaginal examination is very informative about any deflexed head, malposition, malpresentation, contracted pelvis, cervical dystocia, etc. it also gives information about dilatation of the cervix and slow descent or non descent of the presenting part and degrees of moulding and caput formation in cephalic presentation. Imaging (X-ray, CT or MRI) are useful in determining the fetal station and position as well as pelvic shape and size in selected cases.

130. Dangers Fetal The fetal risk is increased due to the combined effects of: Hypoxia due to diminished uteroplacental circulation, especially after rupture of the membranes. Intrauterine infection Intracranial stress or haemorrhage following prolonged stay in the perineum and/or increased molding of the head. Increased operative delivery Maternal There is increased incidence of:

131. Maternal distress Postpartum haemorrhage Trauma to the genital tract – concealed or revealed such as cervical tear, rupture of uterus. Increased operative delivery Puerperial sepsis Subinvolution Management Prevention Antenatal or early Intranatal detection of the factors likely to produce prolonged labour. Use of partograph helps early detection. Selective and judicious augmentation of labour by low rupture

132. of the membranes followed by oxytocin drip . Change of posture in labour other than supine to increase uterine contractions, emotional support, avoidance of dehydration in labour and use of adequate analgesia for pain relief. Actual treatment Careful evaluation is to be done to find out: Cause of prolonged labour Effect on the mother Effect on the fetus In a nulliparous patient, inadequate uterine activity is the most common cause of primary dysfunctional labour. Whereas in a multiparous patient, cephalopelvic disproportion is the most common cause .

133. Preliminaries In an equipped labour ward, prolonged labour is unlikely to occur in modern obstetric practice. But cases of neglected prolonged labour with evidences of dehydration and ketoacidosis are admitted not infrequently to the referral hospitals in the developing countries. Correction of ketoacidosis should be made urgently by rapid intravenous infusion of ringer’s solution. Definitive treatment First stage delay Vaginal examination is done to verify the fetal presentation, position and station.

134. Clinical pelvimetry is done. If only uterine activity is suboptimal: Amniotomy and/or oxytocin infusion is adequate. Effective pain relieve is given by intramuscular pethidine or by regional analgesia. For the management of secondary arrest, especially in multipara one should be very careful to use oxytocin. Caesarean section is done when vaginal delivery is unsafe (malpresentation, malposition, big baby or CPD). Second stage delay Short period of expectant management is reasonable provided the FHR is reassuring and vaginal delivery is imminent. Otherwise appropriate assisted delivery, vaginal (forceps, ventouse) or abdominal should be done. Difficult instrumental delivery should be avoided.

135. Obstetrical emergencies and their management Presentation and prolapse cord Cord prolapse is said to have occurred when the umbilical cord following rupture of the membranes lies either in the vagina or outside the introitus. Classification Umbilical cord presentation The umbilical cord lies alongside or below presenting part with membranes still intact. Umbilical cord prolapse

136. The membranes are ruptured. The umbilical cord may occupy any one of the following positions. Occult prolapse The umbilical cord lies along side the presenting part and is not palpable on vaginal examination. Cord prolapse In which the cord descends down and lies in vagina. Cord may protrude outside vagina and is visible from outside. It is most dangerous. Etiology

137. Fetal factors Mal presentation Prematurity Multiple pregnancy Maternal factors Cephalopelvic disproportion High presenting part Multiparous women Cord and placental factors Long cord Low lying placenta

138. Battledore placenta Iatrogenic Artificial rupture of membranes with a mobile presenting part Version or manual rotation Flexion of extended head Disengaging head to facilitate rotation Diagnosis Occult prolapse Occult prolapse is suspected on finding variable deceleration of fetal heart rate pattern detected on continuous electronic fetal monitoring.

139. Cord presentation The pulsation of the umbilical cord are felt through the intact membranes on vaginal examination. For early diagnosis, vaginal examination should be performed in the following conditions. Unexplained fetal distress when presenting part is not well engaged. Ruptured membranes with high presenting part In malpresentations on rupture of membranes In markedly premature fetus In twin pregnancy Cord prolapse Cord prolapse is usually diagnosed either on a routine vaginal examination performed after spontaneous or artificial rupture

140. o f membranes or on examination performed after detection of abnormal fetal heart rate pattern on cardiotocography. Cord pulsations are felt if fetus is alive. However, sometimes cord pulsations may not be felt even in live fetus due to vasospasm. Ultrasound examination must be done in all cases for fetal cardiac activity before making a diagnosis of intrauterine fetal death. Management Cord presentation Once the diagnosis is made, no attempt should be made to replace the cord, as it is not only ineffective but the membranes inevitably rupture leading to prolapse of the cord.

141. If immediate vaginal delivery is not possible or contraindicated, caesarean section is the best method of delivery. During the time of preparing the patient for operative delivery, she is kept in exaggerated sim’s position to minimize cord compression. A rare occasion is a multipara with longitudinal lie having good uterine contractions with the cervix 7-8 cm dilated, without any evidence of fetal distress. Watchful expectancy can be adopted till full dilatation of the cervix, when the delivery can be completed by forceps or breech extraction. Cord prolapse Baby living Definitive treatment

142. Caesarean section is the best treatment when the baby is sufficiently mature and is alive. Just prior to making abdominal incision, the fetal heart should be auscultated once more to avoid unnecessary section on a dead baby. The operation should be done quickly up to the delivery of the baby. Immediate safe vaginal delivery is possible If head is engaged , delivery is to be completed by forceps. Ventouse may not be ideal in such circumstances as it takes a longer time. If breech , the delivery is to be completed by breech extraction and in transverse lie, it should be completed by internal version followed by breech extraction. The same also applies in cases where the head is not engaged in second baby of twins .

143. Immediate safe vaginal delivery is not possible First aid management The aim is to minimize pressure on the cord till such time when the patient is prepared for assisted delivery or is transferred to an equipped hospital. If an oxytocin infusion is on, this should be stopped. At this time intravenous fluid and O 2 by face mask is given. Bladder filling Bladder filling has been done to raise the presenting part off the compressed cord till such time that patient has delivered. Bladder is filled with 400-750 ml of normal saline with a Foley’s catheter, the balloon is inflated and the catheter is clamped.

144. Bladder is emptied before caesarean delivery. To lift the presenting part off the cord To lift the presenting part off the cord, by the gloved fingers introduced into the vagina. The fingers should be placed inside the vagina till definitive treatment is instituted. Postural treatment Exaggerated and elevated Sim’s position with a pillow or wedge under the high or thigh, Trendelenburg or knee chest position has been traditionally mentioned but may be tiring and irksome to the patient. To replace the cord into the vagina

145. Baby dead No active intervention is required and spontaneous vaginal delivery is allowed. An abnormal fetus can also be allowed to deliver vaginally. When the fetus is too premature to survive it can also be delivered vaginally.

146. Vasa previa It is the term used when fetal blood vessel lies over the os in front of the presenting part as they lie in the membranes in the lower part of the uterus at the cervical opening. In normal pregnancy, the blood vessels of the umbilical cord and the placenta are insulated inside the amniotic sac. However in vasa previa, the blood vessels are present at membranes as in case of velamentous insertion or in multi lobed placenta. It can occur as a complication of placenta previa or low lying placenta. When the condition is not detected in advance, the blood vessels can rupture during labour. Risk factors Placenta previa

147. Velamentous insertion of umbilical cord Multi lobed placenta Multiple pregnancy Diagnosis Diagnosis is made by ultrasound with a colour doppler. Complications During labour with cervical dilatation blood vessels at cervix may rupture or get compressed. There is rapid blood loss with decreased blood supply to fetus. It can cause fetal distress or fetal death. Management

148. Hospitalise the mother in third trimester to ensure rapid access to medical care if blood vessels rupture. Perform caesarean section around 37 weeks of pregnancy or earlier if bleeding. Amniotic fluid embolism Amniotic fluid embolism is a rare obstetric emergency that frequently results in death or neurological impairment of the women and her fetus. Recently a new name has been proposed for the disorder: anaphylactoid syndrome of pregnancy. The proposed new name resulted from research that indicates that amniotic fluid embolism more resembles anaphylaxis and septic shock than it does pulmonary embolism.

149. Definition Passage of amniotic fluid into the maternal circulation leads to sudden collapse during labour but can only be confirmed at necropsy. Pathology The condition is more common with strong uterine contraction, whether spontaneous or induced, occurs after rupture of membranes particularly when there are open maternal blood vessels in the placental site or in cervical lacerations. The embolism passes to the pulmonary vessels leads to: Sudden death Shock Later death due to DIC and postpartum haemorrhage.

150. Clinical picture The onset is acute with sudden collapse, cyanosis and severe dystocia. This is soon followed by twitching, convulsions and right side heart failure, with tachycardia, pulmonary oedema and blood stained frothy sputum. If death does not occur in this stage, DIC develops within 1 hour leading to generalised bleeding. Investigation Arterial blood gases demonstrate acidosis and hypoxemia. Bleeding time is usually prolonged. ECG: Evidence of right side heart failure. X-ray: Non specific mottled chest appearance. Evidence of

151. p ulmonary edema may be seen on a chest X-ray. Laboratory tests: Evidence of DIC. Treatment Urgent treatment includes: Oxygen: Endotracheal intubation and positive pressure respiration is usually indicated as the patient is often unconscious. Aminophylline: 0.5 gm slowly IV to reduce bronchospasm. Isoprenaline: 0.1 gm IV to improve pulmonary blood flow and cardiac activity. Digoxin and atropine: If central venous pressure is raised and pulmonary secretions are excessive. Hydrocortisone: 1 gm IV followed by slow IV infusion causes vasodilatation and improves tissue perfusion.

152. Bicarbonate solution: If there is respiratory acidosis. Low molecular weight dextran: Reduces platelets aggregation in vital organs. Heparin: For treatment of DIC if there is no active bleeding. The women often progresses quickly to full cardiopulmonary arrest and requires advanced cardiac life support, including mechanical intubation and ventilation. Delivery of the infant by caesarean within 5 minutes after the start of cardiopulmonary resuscitation is recommend. Typically, disseminated intravascular coagulopathy is treated with massive fluid restoration and blood product replacement therapy. Once the woman is in stable condition, she require care in an adult intensive care unit. Vaginal delivery: Is safer than C.S. if the baby is not yet delivered.

153. Nursing care Immediate assistance if a labouring or postpartum woman report dyspnoea. Administer oxygen via face mask. Measure the vital signs, particularly the blood pressure and pulse. Hypotension, tachycardia and other signs of shock are usually evident. Initiate CPR, if needed, and be prepared to assist with a caesarean delivery at the bedside, if needed. Be prepared to assist the RN during fluid resuscitation and blood product administration. Anticipate transfer to the ICU as soon as the woman is stable enough to transfer.

154. Rupture of uterus Definition Dissolution in the continuity of the uterine wall any time beyond 28 weeks of pregnancy is called rupture of uterus. Causes During pregnancy Spontaneous Rupture of a uterine scar Abruption placenta with severe concealed haemorrhage. Anterior saculation in case of incarcerated retroverted gravid

155. u terus or posterior saculation due to previous ventrofixation of the uterus. Rupture of a rudimentary horn at the 4 th – 5 th month. Perforating vesicular mole. Traumatic Perforation during vaginal evacuation External trauma During labour Spontaneous Obstructed labour Rupture of a uterine scar Grand multipara

156. Traumatic Internal version Manual separation of placenta Destructive operations Extending cervical tear due to forceps and ventouse applications before full cervical dilatation Improper use of oxytocin Types Complete Uterine rupture involving the whole uterine wall including the peritoneum.

157. Incomplete Uterine rupture not involving the peritoneal coat. Sites It depends upon the cause of rupture. In obstructed labour It is usually in lower uterine segment Usually oblique or transverse More on the left side due to: Dextrorotation of the uterus Left occipito positions are more common.

158. Extended tear Extended tear may pass laterally injuring the uterine vessels leading to broad ligament haematoma formation. This rupture may involve the ureter or bladder. In rupture scar At the site of scar. Clinical picture Impending rupture Before actual rupture the following manifestations may be detected:

159. Lower abdominal pain Tender uterine scar Vaginal spotting Actual rupture Symptoms Sudden severe abdominal pain: It is differentiated from labour pain being continuous. If the patient was in labour there is cessation of uterine contractions. Shoulder pain on lying down due to irritation of the phrenic nerve by accumulating blood under the diaphragm. Silent rupture: Minimal symptoms may occur in rupture lower segment scar due to presence of fibrosis and minimal internal haemorrhage.

160. Signs General examination Variable degree of collapse are present according to amount of blood loss. This may appear postpartum in case of traumatic rupture uterus. Abdominal examination Scar of the pervious operation. Fetal parts are prominent and felt easy. The presenting part recedes upwards. Abnormal fetal attitude and lie. FHS usually not heard. The uterus is felt separated from the fetus.

161. In incomplete rupture, the fetus still inside the uterus with suprapubic painful tender swelling which is an accumulated blood in the vesico uterine pouch. Vaginal examination The presenting part recedes upwards. Vaginal bleeding may be present. Contracted pelvis may be detected. A cervical tear may be found extending to the lower uterine segment and a broad ligament hematoma may be present. Management Prophylactic

162. Early detection of causes of obstructed labour as contracted pelvis and malpresentation. Proper use of oxytocins. Version is not done if liquor amni is drained. Forceps application and breech extraction should not be done before full cervical dilatation. Elective caesarean section for susceptible scars for rupture as upper segment C.S. Exploration of the genital tract after difficult or instrumental delivery. Curative Blood transfusion and anti shock measures. Immediate laparotomy. Deliver the fetus and placenta.

163. Explore the rupture site: If it is amenable for repair and the patient did not complete her family repair is done. If it is not amenable for repair, hysterectomy or subtotal hysterectomy is less time consuming so it is done if there is no cervical tear. Exploration of the other viscera mainly the bladder. Internal iliac artery ligation may be needed in case of broad ligament hematoma as the uterine artery is usually retracted and difficult to be identified. Vaginal repair: May be amenable if there is slight extension of a cervical tear with accessible apex. Hysterectomy.

164. Complications Maternal Shock Haemorrhage Paralytic ileus Bladder, ureter or visceral injuries Infection Fetal Death due to asphyxia from detachment of the placenta.

165. Shoulder dystocia Difficulties encountered in the delivery of shoulders in a cephalic presentation after the head is born is termed as shoulder dystocia. It is diagnosed when manoeuvres are required to deliver the shoulders in addition to downward traction and episiotomy. A head to body deliver time exceeding 60 seconds (normal 24 seconds) is also used to defined shoulder dystocia. Risk factors Maternal obesity Multiparity Maternal diabetes Macrosomia

166. Post term pregnancies Past history of macrosomic baby Increased maternal weight gain Past history of shoulder dystocia Mid pelvic instrumental delivery Anencephaly Fetal ascites or abdominal distension Mechanism Shoulder dystocia occurs when the shoulders try to enter the pelvis with the bisacromial diameter in the anteroposterior diameter of the inlet instead of the normal oblique diameter. Usually the posterior shoulder can negotiate past the sacral promontory but the anterior shoulder gets impacted against the pubis symphysis. Rarely both shoulders impact above the inlet.

167. Complications Maternal Postpartum haemorrhage Lacerations of vagina, cervix and perineum Rupture uterus Fetal Risk of fetal death due to asphyxia and injuries Meconium aspiration syndrome can occur Erb’s palsy is due to injury to the spinal nerves C 5 , C 6 and C 7 from downward traction on the brachial plexus during delivery of the anterior shoulders Klumpke’s paralysis is due to injury to C 8 and T 1 spinal nerves

168. a nd results in claw hand deformity. Fracture of the clavicle. There can also be fracture of humerus. Management First line maneuvers Call for help, mobilize assistance, an assistants, an anesthetist and a paediatrician. A large episiotomy is given and the baby’s mouth and nose are cleaned. Avoid fundal pressure. McRobert’s maneuver and suprapubic pressure : This is the single most effective intervention and must be performed first. It consists of forcible abduction of the maternal legs by sharply

169. f lexing them on abdomen after removing stirrups. This tends to free anterior shoulder. Suprapubic pressure will abduct and rotate the anterior shoulder of fetus to enter into the oblique diameter of pelvis. Second line maneuvers Delivery of posterior shoulder : First by placing hand deep into vagina along the sacral curve and the posterior arm is swept across the chest followed by its delivery. Then the anterior shoulder is easily delivered. Wood’s corkscrew maneuver : In this, under pubic symphysis posterior shoulder is progressively rotated anteriorly by 180 in a corkscrew manner releasing the impacted anterior shoulder. Suprapubic pressure is also given.

170. Rubin’s maneuver: First fetal shoulder are rocked from side to side by pressing on maternal abdomen. If it fails, then with the vaginal hand the accessible fetal shoulder is pushed towards the anterior surface of fetal chest causing abduction of shoulder and reducing shoulder to shoulder diameter and displacement of anterior shoulder from behind symphysis pubis. Third line maneuvers Third line maneuvers are rarely required. They are the last resort. Cleidotomy : Deliberate fracture of one or both clavicles can be done with scissors or other sharp instrument to free the impacted shoulder. It is performed for living anencephalic fetus or in a dead fetus.

171. Zavanelli maneuver : In this maneuver, the fetal head is flexed and the fetus is replaced within the uterus. Uterine relaxation is performed by giving 0.25 mg terbutaline subcutaneously. Thereafter, the fetus is delivered by emergency caesarean section. This maneuver is generally not practiced. Symphysiotomy : It can also be performed rarely as a last resort. (Symphysiotomy id a surgical procedure in which the cartilage of the pubic symphysis is divided to widen the pelvis allowing childbirth when there is a mechanical problem.)

172. Obstetrical shock Shock is defined as a clinical condition arising out of an inability of the circulatory system to provide adequate tissue perfusion causing cellular hypoxia and organ damage. It is a systemic disorder affecting multiple organ systems. Types and causes of obstetrical shock Haemorrhagic shock Non haemorrhage shock Trauma due to difficult forceps delivery, forced breech extraction, internal podalic version, manual removal of placenta, use of Crede’s method of placental delivery and caesarean section and acute inversion of uterus. Fluid loss due to hyperemesis gravidarum and excessive diuresis.

173. Septic shock Hypertensive disorder of pregnancy Anesthetic accidents Hypertensive drugs, mismatched blood transfusion or anaphylactic reaction to drugs, like iron dextran can cause shock. Cardiogenic shock Neurogenic shock Pulmonary embolism Supine hypotension syndrome Hypovolemic or haemorrhagic shock It is due to excessive blood loss due to abortion, ectopic pregnancy, antepartum haemorrhage or rupture uterus, traumatic PPH and atonic postpartum haemorrhage.

174. Clinical picture Patient usually presents with low blood pressure, a rapid and thread pulse, pallor, cold clammy extremities, air hunger, diminution of vision, oliguria and anuria.