Normal & abnormal labor and peuperium .pptx

Normal & abnormal labor and peuperium.
For nursing students
Also for medical students and midwife for final review before exam
Obstetrics.
Post partum hemorrhage
Peuperal sepsis
Breach presentation
Face presentation
Shoulder dystocia
Assisted delivery
Cesarean section

1. Anatomic Considerations in Labour

2. ✅ Fetal Head Anatomy Importance : The fetal head is the largest, least compressible part of the fetus — it determines the mechanics of labour . Structure : Base : Firmly united, ossified, non-compressible → protects the brainstem. Vault (Cranium) : Thin, weakly ossified bones (occipital, parietal, frontal, temporal); compressible and connected by sutures → allows moulding . Sutures : Frontal : Between frontal bones, glabella → bregma . Coronal : Bregma → lateral, separates frontal & parietal bones. Sagittal : Between parietal bones, bregma → lambda. Lambdoid : Lambda → lateral, separates parietal & occipital bones. Fontanelles : Anterior ( bregma ) : Diamond-shaped (2×3 cm), closes ~18 months. Posterior (lambda) : Y-shaped, smaller, closes ~6–8 weeks. Landmarks : Chin ( mentum ), glabella, brow ( sinciput ), bregma , vertex, lambda, occiput. Diameters : AP diameters : Suboccipitobregmatic : 9.5 cm (well flexed). Occipitofrontal : 11–12.5 cm (deflexed). Mentovertical (brow) : 13.5 cm. Submentobregmatic (face) : 9.5 cm. Transverse : Biparietal : 9.5 cm (largest). Bitemporal : 8 cm (smallest).

3. ✅ Maternal Pelvic Anatomy pelvis : Bones : Sacrum (5 fused), coccyx (3–5 fused), 2 innominate bones (ilium, ischium, pubis). Divisions : False pelvis (above linea terminalis ); true pelvis (below) → forms birth canal. Pelvic planes : Pelvic inlet : Fetus “engages” here; largest diameter enters transversely. Zone of cavity : Plane of greatest diameter → internal rotation starts. Mid-pelvis : Least diameter → arrests often occur here. Pelvic outlet : Fetus exits here; aligned in anteroposterior position. Plane AP Diameter Transverse Diameter Pelvic inlet 11.5 cm 13.5 cm Zone of cavity 12.5 cm 13.5 cm Mid-pelvis 12.5 cm 12.5 cm Pelvic outlet 13.5 cm 11.5 cm → AP diameter increases, transverse diameter decreases as fetus descends. → Fetal head enters transversely, rotates to align with widest pelvic diameters.

4. Type Features Commonness Gynecoid Round inlet, straight side walls, spacious, wide arch 50% Android Triangular inlet, convergent side walls, narrow anterior pelvis <30% Anthropoid Oval inlet (AP > transverse), straight side walls, posterior space 20% Platypelloid Oval inlet (AP < transverse), flat sacrum, wide subpubic arch 3%

5. ✅ Key Labour Terminology Lie : Fetal long axis vs. maternal long axis → longitudinal or transverse. Presentation : Part over pelvic inlet → cephalic (vertex), breech, face, brow, shoulder. Attitude : Fetal posture → flexion vs. extension (affects diameters & positions). Position : Relation of denominator to maternal pelvis: Cephalic : denominator = occiput → occipitoanterior (OA), occipitoposterior (OP), occipitotransverse (OT). Face/brow : denominator = mentum . Breech : denominator = sacrum. Station : Descent level relative to ischial spines: 0 = at spines; -5 = pelvic inlet; +2 to +3 = perineal floor. Engagement : Largest diameter passes pelvic inlet: Cephalic: biparietal diameter. Breech: bi-ischial diameter. Synclitism : Synclitic : sagittal suture central → biparietal diameter aligned. Asynclitic : sagittal suture off-center → allows slightly larger head to engage.

6. Labour

7. 1. DEFINITION AND DIAGNOSIS OF LABOUR Labour Definition : Contractions : Must be of sufficient frequency, strength, and duration to cause: Cervical effacement : Shortening from normal 3–4 cm to paper-thin. Cervical dilatation : Progresses from 0 cm → 3–4 cm (active phase onset) → 10 cm (complete dilatation). Show : Blood-tinged mucus release (key early sign). Ruptured membranes : Sudden gush of fluid; critical to assess color/odor (foul smell suggests infection). Diagnosis Confirmation : Vaginal exam : Essential to document effacement/dilatation. Abdominal palpation : Uterine contractions every 2–3 minutes lasting 60–90 seconds in active labour . Differential Diagnoses : Braxton-Hicks : Most common mimic; irregular, painless, no cervical change . Abruptio placentae : "Woody-hard" uterus ± bleeding; constant pain (vs. intermittent contractions). PROM : Confirm with pooling test ; if no labour onset within 24 hours , induction indicated.

8. 2. STAGES OF LABOUR - First Stage : Latent phase : Primiparas : 6–18 hours (dilatation 0 → 3–4 cm). Multiparas: 2–10 hours . Active phase : Dilatation rate : 1 cm/hour (slower rates signal abnormal labour ). Duration : Typically 4–6 hours (3–4 cm → 10 cm). Second Stage : Duration : Primiparas : ≤3 hours (with epidural: ≤4 hours ). Multiparas: ≤30 minutes . Critical action : Maternal pushing only after 10 cm dilatation to avoid cervical edema. Third Stage : Duration : 0–30 minutes (placenta delivery). Active management : IM syntometrine within 1 minute of delivery reduces PPH risk by 60% .

9. Event Mechanism Key Notes Engagement Passage of the largest diameter of the fetal head through the pelvic inlet - Assessed via abdominal palpation ("fifths" method) - Engagement = ≤2/5 head palpable - ❗Risk of cord prolapse if membranes rupture before engagement (esp. non-cephalic) Descent Downward movement of the presenting part through the birth canal - Driven by uterine contractions, maternal pushing, gravity - Assessed by station (vaginal exam) Includes: • Moulding – skull bones override • Caput – scalp swelling • Flexion – chin to chest Internal Rotation Head rotates from transverse to anteroposterior direction within the pelvis - Aligns the fetal head with pelvic outlet - Leads to either occipitoanterior (favorable) or occipitoposterior positions Extension Fetal head extends as it passes under the pubic symphysis - Vaginal outlet is upward-facing - Crowning = head remains visible between contractions - Episiotomy may be performed Delivery of Head Occurs by extension (OA) or flexion then extension (OP) - OA: occiput → brow → nose → mouth → chin - OP: brow/occiput first (flexion), then face/chin (extension) Restitution External rotation of head after delivery to align with shoulders - Head returns to original engagement position - Shoulders rotate internally to AP diameter Expulsion Shoulders and body delivered after the head - Anterior shoulder under pubic symphysis - Posterior shoulder over perineum - Body follows with gentle traction 3. FETAL MECHANISMS (CEPHALIC PRESENTATION)

10. Management of first stage of labour Monitoring Category What to Assess Frequency / Notes Vaginal Examination - Cervical effacement & dilatation - Amniotic fluid color (if ruptured) - Fetal station, caput, molding Every 4 hours (≥3–4 cm = active phase; expect ~1 cm/hour) Abdominal Examination - Uterine contraction frequency - Fetal head engagement Every 30 minutes (Ideal: ~4 contractions per 10 min) Maternal Monitoring - Blood pressure - Pulse - Pain score BP: Every 4 hours Pulse: Every 30 min Pain score: Regularly Fetal Monitoring - Intermittent auscultation - OR Cardiotocography (CTG) IA: Every 15 min CTG: Continuous (if available/high-risk) Mobility & Position - Encourage walking - Use lateral recumbent if in bed Enhances uteroplacental perfusion Initial Management - IV access & fluids - Analgesia as needed - Baseline investigations: CBC, Blood group & Rh, Crossmatch, Urine dipstick, Hepatitis B & HIV, GBS swab On admission

11. Management of 2nd and 3rd stage Labor Stage Key Events & Actions Monitoring / Clinical Notes Second Stage (Full dilation → Baby delivery) 🔹 Fetal Descent: – Vaginal exam: every 30 min – Abdominal palpation: fifths palpable 🔹 Pushing: – Begin with urge – Coordinate with contractions 🔹 Delivery Techniques: – Ritgen maneuver (support head & chin) – Gentle traction for shoulders/body 🔹 Episiotomy (if needed): – Mediolateral (preferred) – Midline (easier repair, more risky) 🔸 Fetal Heart Rate: – IA: every 5 min – OR CTG: continuous (if available) 🔸 Maternal Position: – Encourage upright or lateral 🔸 Cord Clamping: – After 15–20 sec (delay in preterm) – Collect cord blood: G6PD, TSH, ± ABGs 🔸 Neonate: – APGAR score – Trauma check – Vitamin K if indicated Third Stage (Baby → Placenta delivery) 🔹 Placental Separation Signs: – Cord lengthens – Gush of blood – Fundus becomes firm & rises 🔹 Active Management: – Controlled cord traction – Uterine massage – IM Syntometrine (ergometrine + oxytocin) 🔸 Perineal Tear Repair: – 1st°: Skin/mucosa – 2nd°: Perineal muscles – 3rd°: Anal sphincter (a/b/c) – 4th°: Rectal mucosa – Use Vicryl Rapid for mucosa/muscle – Use PDS for sphincter – Perform PR before & after to check suture integrity – Ensure bleeding control & analgesia

12. 5. PAIN MANAGEMENT Epidural : Needle size : 16–20G at L2–L5 . Effect on labour : ↑ Instrumental delivery risk (↓ pushing sensation). Pethidine : Dose : 50–100 mg IM ; avoid if delivery expected within 1–3 hours (neonatal depression). Entonox : Self-administered; onset 15–30 seconds .

13. FETAL DISTRESS: INTERVENTION THRESHOLDS CTG Abnormalities : Late decelerations : > 50% of contractions → uteroplacental insufficiency. Loss of variability : < 5 bpm for > 90 minutes → fetal acidosis. Fetal Blood Sampling : Scalp pH : ≤7.20 → urgent delivery; <7.0 → neonatal encephalopathy risk. Technique : 2x2mm lancet stab; pH result in 5 minutes . Interventions : Amnioinfusion : 500–800 ml NS for meconium/cord compression. Tocolytics : Terbutaline 0.25 mg IV for hyperstimulation . Delivery : Emergency C-section if scalp pH ≤7.20 or pathological CTG. Meconium Management : Intrapartum : Amnioinfusion reduces MAS risk by 50% . Neonatal : No nasal suction ; immediate intubation for ET suction.

14. Key Clinical Priorities Labour Progress : Active phase dilatation <1 cm/hour → augment with oxytocin. Fetal Distress : Late decelerations + loss of variability → fetal scalp pH stat . If pH ≤7.20 → deliver within 30 minutes . PPH Prevention : Syntometrine + controlled cord traction ( avoid in hypertension ). Episiotomy : Restrictive use ; mediolateral reduces anal injury risk. Cord Clamping : Delay 15–20 seconds for preterm neonates.

15. 1. DEFINITION & CORE PRINCIPLES Definition : Intentional initiation of true labour in a non- labouring patient with intact membranes. Two Methods : Surgical : Amniotomy (artificial rupture of membranes) + IV oxytocin . Requires favourable cervix (modified Bishop’s score >5 ). Medical : Vaginal prostaglandins (PGE1/misoprostol or PGE2/ dinoprostone ). Used for unfavourable cervix (Bishop’s score ≤5 ). KEY INDICATIONS Maternal : Intrauterine fetal death (IUFD), polyhydramnios , social reasons. Fetal : Fetal compromise, IUGR, oligohydramnios , post-date pregnancy (>41 weeks) , maternal diabetes, fetal abnormalities. Both : Hypertensive disorders, placental abruption, PROM, chorioamnionitis , SLE/chronic renal disease. Induction of Labour

16. 3. ABSOLUTE CONTRAINDICATIONS Maternal : Contracted pelvis, prior uterine surgery, previous caesarean section (↑ uterine rupture risk). Fetal : Preterm fetus (without lung maturity), acute distress, malpresentation (breech/transverse) , major placenta praevia , vasa praevia . Parameter 0 Points 1 Point 2 Points Cervical dilatation 0 cm 1–2 cm 3–4 cm Cervical length >2 cm 1–2 cm <1 cm Cervical direction Posterior Axial Anterior Cervical consistency Firm Medium Soft Fetal station -3 -2 -1 4. MODIFIED BISHOP’S SCORE Score Interpretation : >5 : Favourable → surgical induction. ≤5 : Unfavourable → medical induction.

17. 5. SPECIAL SCENARIOS Previous Caesarean : Surgical induction possible if Bishop’s score >5. Avoid prostaglandins (↑ uterine rupture risk). Twin Pregnancy : Only if first twin is cephalic . 6. CRITICAL RISKS & COMPLICATIONS General : Iatrogenic prematurity (incorrect dates). Failed induction → ↑ instrumental/C-section rates. Surgical ( Amniotomy ) : Cord prolapse, chorioamnionitis . Medical (Oxytocin) : Uterine hyperstimulation (>7 contractions/10 mins → fetal hypoxia). Uterine rupture (especially with prior C-section). Water intoxication (hyponatremia due to antidiuretic effect). Uterine atony → postpartum hemorrhage.

18. Abnormal Labour Progress .

19. Primary Dysfunctional Labour Labour progresses slower than expected from the start. 1st Stage : Prolonged latent phase : >20 hrs (nulliparous) or >14 hrs (multiparous). Prolonged active phase : cervical dilatation <0.5–1 cm/hour after 3–4 cm. 2nd Stage : Descent of presenting part <1 cm/ hr (nulliparous) or <2 cm/ hr (multiparous). Or: 2nd stage duration >2 hrs in nullips (>3 hrs if regional anesthesia) or >1 hr in multip (>2 hrs if regional anesthesia). Usual cause: poor uterine contractility . Secondary Arrest of Labour Labour progresses normally at first, then abruptly stops/slows significantly . 1st Stage : arrest of dilatation. 2nd Stage : arrest of descent. Signs: large caput succedaneum , excessive moulding , edematous cervix & vulva. Usual cause: cephalopelvic disproportion (CPD) . Types of Poor Labour Progress

20. Factor What to check Key points Power Uterine contractions Frequency: ~4/10 mins; amplitude: >50 mmHg. Poor contractility = ~90% cases. Risk: older age, obesity, primips. Passage Pelvis Inadequate dimensions → CPD. Passenger Fetus Big baby ( macrosomia ), abnormal baby (hydrocephalus), malpositions (persistent OT/OP), malpresentations (brow, face, transverse). Assessing Poor Progress — The “3 Ps”

21. ✅ Prolonged Latent Phase (1st Stage) Analgesia : Pain → ↑sympathetic activity → ↓ uterine contractility (β2 adrenergic). ✅ Prolonged Active Phase (1st Stage) Artificial Rupture of Membranes (ARM/ Amniotomy ) If membranes intact. Encourages prostaglandin release → stronger contractions. Augmentation with IV Oxytocin ( Syntocinon ) 1st line if poor contractility. Titrate carefully to avoid hyperstimulation /uterine rupture. ⚡️ Important: Syntometrine & prostaglandins are NOT used for augmentation ( Syntometrine = 3rd stage only; prostaglandins = induction only). Caesarean Section 2nd line if adequate contractions for 2–4 hrs but no progress → suspect CPD → C-section. Management of Poor Labour Progress

22. ✅ Prolonged Descent (2nd Stage) Augment with IV oxytocin (if poor contractions). Assisted vaginal delivery (if contractions adequate): Vacuum extraction. Forceps (depending on station and position). ✅ Arrested Labour Depends on cause: CPD : Absolute indication for C-section. Shoulder dystocia : Follow Obstetric Emergencies protocol. Malpositions : Persistent OT → manual or Kielland forceps rotation. Persistent OP → vacuum ± mediolateral episiotomy. Malpresentations : Manage as per type.

23. ⚡️ Shoulder Dystocia & Erb’s Palsy: Excessive neck lateral flexion → upper brachial plexus injury. Anterior shoulder: excessive traction. Posterior shoulder: compression at sacral promontory. Maternal Fetal Maternal tachycardia Significant caput, excessive moulding Edematous cervix/lips Fetal hypoxia Distended lower uterine segment Uterine rupture Inadequate uterine relaxation Shoulder dystocia → Erb’s palsy Haematuria → bladder necrosis → VVF Neglected labour Complications of Abnormal Labour Progress

24. Malpresentation 🔑 Definition Malpresentation : Any fetal presentation other than cephalic (vertex) .

25. Definition: Fetal buttocks or feet present into maternal pelvis . Incidence: ~1 in 25 deliveries ( 4% ). ~25% of all fetuses before 28 weeks are breech but usually rotate to vertex; persistent breech after 34 weeks is significant. Key etiology & associations: Prematurity ( major factor ) Multiple gestation Fetal structural abnormalities (e.g. hydrocephalus) Placenta praevia Polyhydramnios Uterine abnormalities (e.g. bicornuate uterus) Contracted maternal pelvis Pelvic tumours Breech Presentation

26. 🔍 Classification ⚡️ Risks Cord prolapse Head entrapment (esp. preterms — large head-to-body ratio) Birth trauma (e.g. Erb’s palsy) Perinatal mortality: 2.5% vs 1.2–1.6% (non-breech) 🔎 Diagnosis Antenatal: Abdominal palpation , confirmed by ultrasound . Type Features % Frank breech Thighs flexed, knees extended 65% Complete breech Thighs & knees flexed 25% Footling breech One/both thighs extended, feet below buttocks 10%

27. 🩺 Management ✅ Investigate: Rule out fetal/uterine structural abnormalities if breech persists >34 weeks. ✅ External Cephalic Version (ECV): Offered at 37 weeks . Done under ultrasound by experienced obstetrician with tocolytics , CTG before & after , anti-D Ig if indicated. Success rate: 35–76%. Complications: abruptio , cord compression, PROM → cord prolapse, uterine rupture, fetomaternal hemorrhage. Must be done in a hospital with emergency C-section facilities (patient NBM, IV access). Contraindications: Placental insufficiency, placenta praevia , hypertension, IUGR, oligohydramnios , previous uterine surgery. ✅ Caesarean Section: Standard of care for term breech if ECV contraindicated or declined. Term Breech Trial (2000): Elective C-section significantly reduces perinatal morbidity/mortality ( 1.6% vs 5.0% , p <0.0001). ✅ Assisted Breech Delivery: Rare; used for no C-section facilities , mother’s wish , or breech 2nd twin . Principles: Allow natural descent until umbilicus. Frank breech: Pinard maneuver (popliteal pressure flexes knee to bring foot down). Grasp pelvis (not abdomen) → gentle traction until scapulae visible. Shoulders: Sweep arms across chest. If arms extended above head ( nuchal arms ) → Lovset maneuver (rotate baby to deliver arms). Head delivery: Burns Marshall maneuver: Hang baby until occiput visible → rotate legs up. Mauriceau-Smellie-Veit maneuver: One hand in vagina with fingers on fetal maxilla/mouth & skull for flexion. Outlet forceps: Piper forceps (Wrigley forceps locally).

28. Definition: Fetal face (chin to orbits) is the presenting part due to hyperextension of fetal neck . Incidence: 1 in 500 deliveries. Presenting diameter: Submentobregmatic = 9.5 cm (same as suboccipitobregmatic ). 🔑 Etiology & Associations Often no cause found. Extreme prematurity. High parity. Polyhydramnios . Placenta praevia . Fetal goitre (neck extension). Anencephaly (always face presentation). ⚡️ Issues May cause abnormal labour progress . Risk of fetal facial injuries , perineal trauma . Perinatal morbidity/mortality: Similar to cephalic. 🔎 Diagnosis Usually intra-partum by vaginal exam : feel mouth, nose, malar bones, orbital ridges. Positions at diagnosis: 60% mentoanterior 25% mentoposterior 15% mentotransverse Face Presentation

29. 🩺 Management ✅ Vaginal Delivery: Possible if mentoanterior → chin rotates under pubic symphysis → neck flexes → delivery. Low forceps can be used if needed ( vacuum NOT used ). Mentoposterior/mentotransverse: Vaginal delivery impossible (neck cannot extend further) → 50% spontaneously rotate to mentoanterior → manage expectantly first. Oxytocin augmentation is controversial . ✅ Caesarean Section: Required for persistent mentoposterior or mentotransverse that do not rotate.

30. Brow Presentation Definition: Fetal brow (between orbits & bregma ) presents due to partial extension of the fetal neck (between full extension → face presentation, and flexion → cephalic). Incidence: 1 in 1400 deliveries. Presenting diameter: Mentovertical diameter (13.5 cm, the largest possible anteroposterior diameter of the fetal head). Etiologies & Associations: Similar to face presentation (e.g., prematurity, polyhydramnios , high parity). Issues: Can cause abnormal labour progress; perinatal morbidity & mortality similar to cephalic. Diagnosis: Head often does not engage due to large diameter. Vaginal exam: may feel anterior fontanelle & supraorbital ridges; sulcus between occiput & back. Often diagnosed late in labour . Management: Expectant: 50–70% spontaneously convert to face or cephalic. Caesarean section: For persistent brow presentation.

31. Transverse Lie — Shoulder & Compound Presentations Compound presentation: Fetal extremity (usually hand) prolapses alongside presenting part; complete extremity prolapse = shoulder presentation. Incidence: 1 in 700 deliveries. Spontaneous version: Occurs in 80–85% of cases. Etiologies & Associations: Prematurity, multiple pregnancy, polyhydramnios, placenta praevia, multiparity, uterine abnormalities. Issues: High risk of cord prolapse. Diagnosis: Uterus ovoid, wide transversely with empty lower pole; fetal head in flank. Symphysial fundal height lower than expected. Confirmed by ultrasound. Management: ECV: Attempt at 37 weeks, stabilizing induction & controlled amniotomy. Caesarean: If persistent malpresentation.

32. SHOULDER DYSTOCIA Definition: Shoulder dystocia is an obstetric emergency where, after delivery of the fetal head, the anterior shoulder becomes impacted behind the maternal pubic symphysis , preventing delivery of the body. Pathophysiology: Delay in delivery of shoulders due to cephalopelvic disproportion , macrosomia , or inflexibility of the fetal shoulders. Mechanical impaction causes compression of the umbilical cord → fetal hypoxia if not managed rapidly.

33. Risk Factors: Fetal macrosomia (>4000–4500g) Maternal diabetes mellitus Obesity Post-term pregnancy Previous history of shoulder dystocia Prolonged second stage of labor Operative vaginal delivery (forceps/vacuum) Clinical Features: “Turtle sign” (retraction of the fetal head against perineum) Failure of shoulders to deliver with usual traction Difficulty with delivery of the face and chin

34. Management Call for help immediately and initiate specific maneuvers: Primary Maneuvers (ALARMER mnemonic): A – Ask for help L – Legs: McRoberts maneuver ( hyperflex thighs onto abdomen) A – Anterior shoulder disimpaction with suprapubic pressure R – Rubin’s maneuver (rotate shoulder inward) M – Maneuvers (Woods screw: rotate posterior shoulder) E – Episiotomy (only if needed to allow space) R – Remove posterior arm Last Resorts: Clavicular fracture Zavanelli maneuver (cephalic replacement + cesarean) Symphysiotomy (rare, for extreme cases) Complications: Fetal : Brachial plexus injury ( Erb’s palsy), clavicle fracture, hypoxia, death Maternal : PPH, perineal trauma, uterine rupture

35. UMBILICAL CORD PROLAPSE Definition: Cord prolapse is the descent of the umbilical cord through the cervix , into or beyond the vagina ahead of the presenting part , leading to cord compression and fetal hypoxia. Types: Overt prolapse : Cord visible/palpable in vagina Occult prolapse : Cord lies alongside the presenting part Cord presentation : Cord lies between cervix and presenting part before rupture

36. Risk Factors: Malpresentation (breech, transverse) Prematurity Polyhydramnios Long cord High presenting part (unengaged) Multiple pregnancy Iatrogenic: AROM with high presenting part Diagnosis : Visual/palpation of cord in vagina Sudden fetal bradycardia or variable decelerations after ROM Confirm by per vaginal examination

37. Management : Obstetric emergency! Immediate action required. Call for help Elevate presenting part manually to relieve pressure Knee-chest or Trendelenburg position Tocolytics (e.g., terbutaline ) if needed to reduce contractions Avoid handling the cord Emergency Cesarean Section is the definitive treatment If delivery is imminent and cervix is fully dilated, expedite vaginal delivery Fetal Outcome : Highly dependent on interval between prolapse and delivery Prolonged compression → hypoxia, cerebral palsy, death

38. AMNIOTIC FLUID EMBOLISM (AFE) Definition: AFE is a rare, catastrophic obstetric emergency caused by the entry of amniotic fluid into maternal circulation , triggering a massive anaphylactoid reaction → cardiopulmonary collapse + DIC . Pathophysiology: Amniotic fluid (with fetal squamous cells, hair, vernix ) enters maternal bloodstream Triggers immune-mediated response , not true embolism Causes pulmonary vasospasm , right heart failure, and coagulopathy

39. Risk Factors: Advanced maternal age Multiparity Cesarean delivery Instrumental delivery Placenta previa or abruption Uterine rupture Induction of labor Clinical Presentation: Often occurs during labor or within 30 minutes postpartum Initial Phase (Respiratory/Cardiac collapse): Sudden dyspnea Hypoxia, cyanosis Hypotension → shock Seizure or loss of consciousness Pulmonary edema Cardiac arrest

40. Second Phase (Hemorrhagic): Severe DIC → uterine atony Massive postpartum hemorrhage Bleeding from puncture sites Diagnosis: Clinical diagnosis : No definitive lab test May show: ↓ O₂ saturation Coagulopathy: ↑ PT, aPTT , ↓ fibrinogen, thrombocytopenia ABG: hypoxia, acidosis Echo: RV dysfunction

41. Management: Immediate multidisciplinary resuscitation: Supportive Measures: ABC resuscitation : oxygen, intubation, fluids, vasopressors High-flow O₂ , mechanical ventilation Left lateral tilt to reduce aortocaval compression Cardiac monitoring + support Hematologic Support: Massive transfusion protocol Platelets, FFP, cryoprecipitate, PRBCs Treat DIC aggressively Delivery: If cardiac arrest occurs, perform perimortem cesarean within 4–5 min Prognosis: High maternal mortality (up to 30–40%) Neurologic injury common in survivors Neonatal outcome depends on speed of delivery and resuscitation

42. Assisted (Instrumental) Delivery

43. Forceps Delivery Definition: Instrument for traction & rotation of fetal head when maternal effort is insufficient. Parts: Cephalic curve: Inner blade curve to fit fetal head. Pelvic curve: Lower blade curve to fit birth canal. Types: Wrigley: Pelvic & cephalic curves; for outlet forceps. Neville-Barnes: Standard; pelvic & cephalic curves; detachable traction rod. Kielland : Minimal pelvic curve for rotation; sliding lock for asynclitic heads; less used due to training needs & higher risk. Types of operations: Outlet forceps: Scalp visible at introitus without labia separation; head at perineum; sagittal suture anteroposterior ; rotation <45°. Low forceps: Skull leading point at station +2 cm or more. Mid forceps: Head engaged but skull above +2 cm station. Indications: Prolonged 2nd stage. Immediate/impending fetal compromise. Stabilize aftercoming head in breech. Maternal benefit (hypertension, cardiac/pulmonary disease).

44. Prerequisites: Fully dilated cervix, ruptured membranes, head engaged, clinical assessment of presenting part/position/size/pelvis adequacy. Bladder emptied. Adequate anaesthesia (local for outlet; regional for others). Technique: Insert left blade first, then right. Align sagittal suture between blades. Lock, apply traction in sync with contractions. Pajot maneuver: Pull parallel to birth canal axis → downward then upward. Episiotomy may be needed at crowning. Abandon for caesarean if failed (no progress). Complications: Failure rate 7%. Maternal: Birth canal injuries (higher than vacuum). Fetal: Facial bruising, CN VII injury, brachial plexus injury.

45. Vacuum Extraction Definition: Suction cup applied to fetal head. Types: Kiwi cup, Ventouse (silicone cup). Indications: Same as forceps, except: Forceps preferred for preterm, certain malpresentations (breech, face). Prerequisites: Same as forceps; must be cephalic presentation. . Technique Place cup 3 cm posterior to anterior fontanelle , over sagittal suture. For OA: place directly on presenting part. For OP: slide cup as far back as possible (Kiwi cup only). Suction: Kiwi: pump to green zone. Ventouse : use foot pump. Apply traction with contractions, parallel to birth canal axis. Detachment = pop-off. Abandon for caesarean if no progress or 2 pop-offs.

46. Complications: Failure rate 12%. Maternal: Less birth canal injury than forceps. Fetal: Chignon, cephalohematoma , subgaleal hematoma, retinal hemorrhages (overall more fetal morbidity than forceps).

47. Caesarean Delivery

48. Indications Abnormal labour progress Malpresentation: Breech presentation (standard of care; supported by term breech trial) Persistent brow presentation Persistent mentoposterior or mentotransverse face presentation Persistent transverse lie Repeat caesarean: Previous lower segment caesarean section (LSCS) is not an absolute indication. Previous classical CS is an indication. Fetal distress Previous full-thickness non-transverse uterine incision e.g., myomectomy for fibroids (high uterine rupture risk with vaginal delivery) Placenta praevia: Major = absolute indication (blocks cervical os). Minor = relative indication (NVD possible if edge ≥2 cm from os).

49. Types of Caesarean Deliveries 1) Classical Caesarean Section Incision: Vertical through upper uterine segment myometrium (skin incision can still be transverse Pfannenstiel ). Indications: Preterm breech (undeveloped lower segment) Transverse back-down fetal position Poor lower segment access (fibroids/adhesions) Some anterior placenta praevia (risk of major hemorrhage if LSCS attempted) Planned caesarean hysterectomy Implications: Higher risk of postpartum hemorrhage, infection, thromboembolism (vs. vaginal delivery) Future uterine rupture risk 4–7% (increased with induction of labour) Requires repeat caesarean in all future pregnancies

50. 2) Lower Segment Caesarean Section (LSCS) Incision: Transverse (Joel Cohen) in lower uterine segment, after bladder flap created. Indications: Most other indications not requiring a classical CS. Implications: Higher risk of postpartum hemorrhage, infection, thromboembolism (vs. NVD) Risk of uterine rupture in future pregnancies <1% (higher with induction) Increased risk of placenta praevia & placenta accreta in future pregnancies

51. Complications & Risks Intra-operative: Anesthesia risks Bleeding (may need transfusion or hysterectomy) Bladder, bowel, ureteric injuries Amniotic fluid embolism Post-operative: Postpartum hemorrhage Infection (wound, endometritis , other) Longer hospital stay & recovery vs. NVD Long-term: Post-operative adhesions (complicates future pelvic surgeries or repeat CS) Uterine rupture risk in future pregnancies Higher risk of abnormal placentation (placenta accreta , placenta praevia )

52. Pre-Operative Management Consent: Informed consent from mother. IV access & catheterization: Large-bore IV; bladder catheter. Pre-op bloods: FBC, PT/PTT, GXM (4–6 units cross-matched), urea/ creatinine ; ECG & CXR if indicated. Aspiration pneumonia prophylaxis ( Mendelson syndrome): Elective CS: Nil-by-mouth + H2-antagonist (e.g., ranitidine). Emergency CS: Sodium citrate + metoclopramide. Intubation: Cricoid pressure, cuffed tube, rapid sequence, gastric emptying before extubation . Thromboprophylaxis: Low-risk: Early mobilization, hydration. Moderate-risk: IV heparin + TED stockings. High-risk: IV heparin until 5 days post-op + TED stockings. Antibiotic prophylaxis: IV cefazolin after baby delivered & cord clamped (prevents fetal drug exposure); reduces wound, endometrial & UTI infections.

53. Vaginal Birth After Caesarean (VBAC ( Trial of labour : Offered if only one or two previous LSCSs with incision not extending into cervix/upper uterus. Benefits over repeat CS: Shorter hospital stay & recovery. Lower neonatal RDS rates. Increases likelihood of successful future VBACs. Overall success rate: ~70%.

54. Peuperium Definition Puerperium : 6-week period after delivery when the body returns to the non-pregnant state.

55. Normal Puerperal Changes ✅ Uterus: Shrinks from ~1kg to 200–300g by 3 weeks. Descends ~1 finger breadth/day; no longer palpable after 2 weeks. ✅ Cervix: Regains firmness by day 3. Internal os closes in 3 days; external os by 3 weeks. ✅ Vagina & Perineum: Swollen and bluish after birth; tone returns by 6 weeks. Kegel exercises help regain pelvic floor strength. ✅ Lochia (PV discharge): Rubra (red): Days 1–3 Serosa (yellowish): Up to ~10 days Alba (white): Up to 6 weeks ✅ Cardiovascular: Increased peripheral resistance post-delivery. Cardiac output & plasma volume normalize within 2 weeks → diuresis & weight loss. ✅ Menstruation & Ovulation: If not breastfeeding: menses returns by 6–8 weeks. If exclusively breastfeeding: amenorrhea up to 6 months.

56. Early Puerperium Monitoring & Management ✔ Vital signs: Temperature (sepsis), BP (PPH). ✔ Physical exam: Breasts: Check for mastitis/abscess. Fundal height: Detect retained products. Lochia: Watch progression; foul smell = endometritis . Limbs: DVT signs. Urinary: Check for retention/incontinence. ✔ Patient education: Teach Kegel exercises. Breastfeeding support. Discuss contraception & family planning. ✔ Other: Administer Anti-D if indicated. Check rubella immunity. At 6 weeks: check glucose (GDM resolution) & BP/proteinuria (preeclampsia resolution).

57. Common Puerperal Complications 🔹 Perineal injury: Pain, infection (rare); treat with analgesia & wound care. 🔹 Bladder issues: Retention common if epidural used. Stress incontinence common but resolves. Rare: fistulas → surgical repair. 🔹 Bowel: Constipation, hemorrhoids; manage with stool softeners. 🔹 Mastitis: Ensure milk drainage, antibiotics ( Flucloxacillin ), possible abscess drainage. 🔹 Backache: Common (25%); may last months. 🔹 Postnatal blues/depression: Blues: Days 3–5, common (50–70%). Depression: ~10% within 1 year; needs counseling & support.

58. Post-Partum Hemorrhage (PPH ( Classification Primary PPH: >500 mL blood loss vaginally (>1000 mL if caesarean) within first 24 hours . Secondary PPH: Abnormal bleeding after 24 hours up to 6 weeks post-delivery.

59. Causes Primary PPH (most common causes): Uterine atony (80%) — risk ↑ with: Multiple gestation, polyhydramnios , induction/augmentation with oxytocin, halothane anesthesia, fibroids, placental abruption. Retained products of conception (RPOC). Low placental implantation (lower uterine segment contracts poorly → persistent bleeding). Genital tract injuries: e.g., tears, hematomas (concealed, painful, can exsanguinate). Uterine inversion/rupture. Coagulopathy: pre-existing or acquired (e.g., abruptio placentae, amniotic fluid embolism). Secondary PPH: Poor epithelialization of placental site (80%) . Retained products of conception. Endometritis .

60. Management of PPH & Obstetric Shock ✅ Initial steps: Resuscitate: establish IV access, catheterize, monitor vitals. Group & crossmatch blood; FBC, PT/PTT if not done. Palpate uterus (check for atony ). Speculum exam: look for injuries, RPOC, inversion, hematomas. ✅ If uterine atony : Uterine massage . Uterotonics : IV oxytocin: 40–80 U in 1 L saline. IM ergometrine / methylergometrine : 0.2 mg Contraindicated in severe HTN, pre- eclampsia , severe cardiac disease. Per rectal misoprostol. IM carboprost ( Hemabate ): 0.25 mg every 15 min, max 3 doses. (PGF2α analogue; faster if intra- myometrial : onset 4 min vs 20 min.) If bleeding persists: Tamponade : bimanual compression, uterine packing, balloon catheter ( Bakri balloon). Uterine artery embolization (IR). Surgery (last resort): B-Lynch suture (fertility-preserving), stepwise arterial ligation (uterine → ovarian → internal iliac), hysterectomy.

61. ✅ If RPOC : Always inspect placenta for completeness. Manual removal under GA if necessary. ✅ If genital tract injury : Repair all tears; first suture above apex to catch retracted vessel. Hematomas → urgent surgical drainage, ligation, possible bilateral hypogastric artery ligation. ✅ If uterine inversion : Stabilize patient. Replace uterus by elevating fundus with cupped hand. If fails: relax uterus with nitroglycerin or GA → reattempt. Once replaced: oxytocin to contract uterus before hand removal. Rarely: surgery to incise cervical constriction ring if needed. ✅ If coagulopathy : Correct coagulopathy with appropriate transfusions. Amniotic fluid embolism → intensive supportive care (CPR, ventilation, inotropes). ✅ If poor epithelialization : Ergometrine + antibiotics; curettage if bleeding persists.

62. Puerperal Sepsis Definition Puerperal pyrexia: Temp ≥38°C in first 14 days postpartum. Causes Most common: Anaerobic Streptococci (e.g., Peptostreptococcus , Peptococcus ). Others: Bacteroides fragilis , E. coli, enterococci. Ascending infection → endometritis → parametritis → pelvic peritonitis.

63. Clinical Features Fever on day 2–3. Increasing uterine tenderness. Foul-smelling lochia; sudden stop in flow → possible cervical os occlusion → endometritis . Parametritis /peritonitis: fluctuating temp, chills, rigors. Cause Typical timing Key notes Atelectasis Day 1 Usually resolves spontaneously. Wound infection Day 2–3 Inspect wound. UTI After Day 2 Flank pain, hematuria, LUTS → urinalysis/culture. Pneumonia Any time Nosocomial/aspiration; cough, pleuritic pain → CXR. Mastitis Any time Examine breasts. Pelvic thrombophlebitis Days 7–10 Persistent spiking fever; managed with LMWH. Thromboembolism Any time See below. Differential Diagnoses for Puerperal Pyrexia

64. Management Full history & exam to exclude differentials. Send aerobic/anaerobic cultures: blood, endocervical , uterine cavity, urine . Start IV broad-spectrum antibiotics: Ampicillin/cephalosporin + aminoglycoside; add Clindamycin if B. fragilis or penicillin allergy. Suspect pelvic abscess if no improvement → confirm with pelvic US or CT → surgical drainage.

65. Thromboembolism Risk Factors Maternal: Obesity, age >35. Caesarean delivery. Clinical Features DVT: Low-grade fever, tachycardia, swollen painful calf. PE: Dyspnea, pleuritic chest pain, tachycardia. Management Confirm DVT: Doppler US. Confirm PE: CT pulmonary angiogram or V/Q scan. Treatment: IV heparin. ✅ Prevention: Early ambulation. Good hydration. TED stockings ± intermittent pneumatic calf compression.

66. ✅ Contraception Post-Delivery When to Start No contraception needed first 21 days postpartum (ovulation earliest ~day 27). After 21 days, contraception if pregnancy not desired. Options 🔹 Lactational Amenorrhea: Reliable only if exclusive breastfeeding + amenorrhea , up to 6 months . 🔹 IUD: Good option; Mirena helpful for menorrhagia. Insert 2–3 weeks after delivery (earlier = high expulsion risk). 🔹 Progestogen -only: POP, etonogestrel implant, injectable progesterone safe. 🔹 Sterilization: Interval tubal ligation: 2–3 weeks postpartum (less failure vs immediate). Can do during elective C-section. Vasectomy also an option. 🔹 COCs: Not recommended for breastfeeding mothers as they may interfere with milk production. 🔹 Barrier methods: Encourage as additional precaution.