Abnormal Labor

Multiple Pregnancy
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Types:
1. Monozygotic (Uniovular/identical)
- developed from fertilization of single ova which after
fertilization, by a single sperm, has undergone division
to form two or more embryos
- Accounts about 1/3rd of all twins
2. Dizygotic (Binovular/non-identical/fraternal)

- Twins results from two separate ova

- Accounts about 2/3rd of all twins

- the walls of the chorionic sacs maybe in close

 D/c b/n Mono- & Dizygotic twins
Characteristics Monozygotic Dizygotic twins

Ovum One Two

Spermatozoa One Two
Placenta One Two (may be fused)
Chorion One (few have two) Two
Amnion Two (rarely one) Two
Sex Same Different or same sex
Genetic materials Same genetic makeup Different
Blood group Same Same or different
Physical/mental Similar Different/similar like
character other sisters & brothers
Risks:
- Race /ethnicity (black, white Asia)
- Heredity (genotype of mother)
- Maternal age (35-40 years)
- Parity - Multiparas than primiparas
- Infertility therapy (clomid/gonadothriphin)
- Assisted reproductive technology
- Previous multiple pregnancy: the incidence of another
multiple pregnancy is 10 times the normal incidence.
- Maternal size - Dizygotic twin is more common in tall
& large women
 SUPERFECUNDATION:

It is the fertilization of the two different ova released in the

same cycle by separate act of the coitus within short period of
time.

SUPERFETATION:

It is the fertilization of the two ova released in

the different menstrual cycles. The nidation
and development of one fetus over another
fetus
is theoretically possible until the decidual space
is
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obliterated by 12 weeks of pregnancy.
FOETUS PAPYRACEOUS OR COMPRESSUS:
It is a state which occurs if one of the fetus dies early .The dead
fetus is compressed and flattened between membrane of the living
fetus and the uterine wall. It may occur in both the twins but more
commonly occurs in uniovular twins. It
may occur in both varieties of twins, but is more common
in monozygotic twins and is discovered at delivery or
earlier by sonography

VANISHING TWINS:

Serial USG in multiple pregnancy since early gestation reveals

occasional death of one fetus and continuation of pregnancy with
the surviving one. The dead fetus if within 14 weeks simply vanishes
by reabsorption.
10
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 Fetus acardiacus occurs only in monozygotic
twins. Part of one fetus remains amorphous and
becomes
parasitic without a heart

12
The number of membranes and placentation in monozygotic
twins depends on the time when division occurs as
follow:
 0-4 days = dichorionic & diamniotic (DCDA) with two
placenta (may be fused) => 33%
 4-8 days = monochorionic & diamniotic (MCDA) =>
66%
 8-13 days = monochorionic & monoamniotic (MCMA)
= 1%
 > 13 days = conjoined (Monsters) => very rare
• Sometimes the viscera or limbs are shared
Placentation in monozygotic twins
Diagnosis:
History:
 History of risk factors (family history of twins,
ovulatory drug intake, etc)
 Early on set of PIH
 Exaggerated minor disorders of pregnancy like
hyperemesis gravidrum.
 Rapid uterine growth
 Unexplained wt gain
• Abdominal examination:
 Inspection: - the size of the ux is larger than GA after
the 20th week.
 Palpation:
 Fundal height is greater than expected for the period
of gestation.
 two fetal poles (head or breech) may be felt at fundus.
 two fetal backs or limbs on both sides of the abd.
 Difficult pelvic palpation
 Auscultation: - FHB with the d/c of at least 10 beats
per minutes counted at the same time by two persons.
 Ultrasound and X –ray are diagnostic.
Complications:
 Exacerbation of minor disorders.
 Pressure symptoms: - ankle edema, varicose veins,
dyspnoea, hemorrhoids, backache and indigestion are
more marked.
 Anaemia
 Pregnancy induced Hypertension.
 Polyhydramnios
 Placenta praevia
 Placenta abruption
 Preterm
 Intra uterine hypoxia, IUGR, IUFD
 Birth asphyxia
 Malpresentation (87% first twin is cephalic)
 Premature rupture of the membrane (PROM)
 Cord prolapse
 Obstructed labor
 Prolonged labor
 Locked Twins. This occurs when the first and second twin
presents by:
 Cephalic- cephalic (42%)

 Cephalic-breech (27%)

 Cephalic- transverse (18 %)

 Breech-breech (5%)

 Others (8%)
 Fetal abnormality like conjoined twin ( 1:50,000
deliveries/1:600 twin)
 Types of conjoined (Siamese) twin:
** anterior connection (thoracopagus)
** posterior connection (pygopagus)
** cephalic connection (craniopagus)
**caudal connection (sacropagus)
 Fetus-in-fetu (endoparasite)
 Acardiac twin - rare ( 1:35,000 birth) => high risk in
utero cardiac failure
 Acephalus  a fetus born without a head
 Undiagnosed twins - with poor ANC follow up 50%
twins diagnosed during labor “ surprising twin”
 Delay in the birth of the second twin
 Post partum hemorrhage
  Twin-to-twin transfusion = discordant twin (weight
difference of 20% or Hb difference of 5g/dl b/n twin
A/B)

anemia,  polycythaemia,
hypovolaemia,  hypervolaemia,
microcardia,  polyuria and
polyhydramnios.
oligouria and
oligohydramnios
.
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Management:
During Pregnancy
 Advice on calories, protein, Fe, folic acid and vits
 Early diagnosis and treatment of complications
 Advice on adequate rest & restricting long travel
 Recommend U/S at 18-20wks to detect congenital
anomalies
 Frequent ANC check up to detect coxns
 Alleviate minor discomfort
 Refer or admit to hospital
During labor and delivery
 Delivery should be in a hospital
 A team of experienced health care professionals is
necessary for safety
 1st stage of labor:
 is managed as usual unless there is an indication for C/S

- Twin A vertex/twin B non vertex

* Twin A => vaginal delivery
* Twin B => SVD, ECV, assisted breech delivery,
breech extraction, internal podalic version or C/S
 Twin A non vertex => C/S
 Routine c/s:
* conjoined twin
* placenta previa
* interlocking twins
 Induction/augmentation is contraindicated

 be prepared to receive two immature babies.

 If fetal distress occurs during labor, hasten the delivery

by vacuum, forceps, episiotomy or often by c/s.
 For preterm, neonatal care unit should be informed

 Two incubators should be in ready.

2nd stage of labor
 An obstetrician, anesthetist and pediatrician should be
present
 Resuscitation & extra delivery equipment should be
prepared
 An elective episiotomy may be considered if there are
complication like preterm labor and fetal distress
 After delivery of the first twin an abdominal exam is
made to ascertain the lie, presentation and position of the
second fetus and to auscultate the fetal heart
 Label babies as “Twin one” and “Twin two”
 Note time of delivery & sex of the child
 3rd Stage of Labor:
 Immediate clamping of the cord is essential after
delivery of the first twin to avoid bleeding from a
uniovular second twin
 Perform the AMTSL without delay & look for signs &
prevent PPH.
 Examine placenta for completeness & deviation from
the normal.
 Check aminocity/chorioncity
 CORD PROLAPSE/PRESENTATION

 Cord presentation and prolapse describe a situation in

which the umbilical cord is felt anterior to the fetal
presenting part on vaginal exam
 It is life-threatening(emergency) to the fetus since blood
flow through the umbilical vessels is usually
compromised from compression of the cord b/n the fetus
and the uterus, cervix, or pelvis

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1. Cord (funic) presentation: - is descent of umbilical
cord lies in front of the presenting part in an intact
membrens or it is a condition in which cord is felt
anterior to the fetal presenting part on vaginal
examination while the membrane is intact.
- As long as the membranes are not ruptured, the risk of
compression and asphyxia is low

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2. Cord prolapsed is a situation in which the umbilical
cord is felt anterior to the fetal presenting part on vaginal
examination with ruptured membranes.
 Prolapse of the umbilical cord exposes the cord to
intermittent compression which, depending on the
duration and intensity of compression, lead to fetal
hypoxia, Brian damage & death.

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Types of cord prolapse:
 Occult cord prolapse:

- when cord lie adjacent (alongside) to the presenting part

• An occult prolapse often cannot be diagnosed with
certainty, but is suggested by clinical features (eg, fetal
bradycardia) and findings at cesarean delivery
 Overt cord prolapse:
- The cord is being felt inside the cervix, the vagina below
the presenting part or even hanging outside the introitus
 Exposure of umbilical cord to air cause irritation &
cooling of the cord, resulting in vasospasm of cord
vessels
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Generally, there are three type of cord accidents:
 Incidence:
The incidence of overt prolapse:
- in cephalic presentation  0.5%
- in frank breech  0.5%
- in complete breech  5%
- footling breech  15%
- transverse lie  20%
The incidence of occult prolapse is unknown b/c it can be
detected only by fetal heart rate changes.
Cause:
=> causes are feto-maternal factors that lead to ill filling
presenting part.
- pre-maturity (< 34 wk gestation)
- malpresentation
- multiple gestation
- multiparity
- polyhydramnios
- low birth weight
- placenta previa
- CPD
- long umbilical cord
- PROM occurring before engagement
- ARM 35
 Diagnosis:
Vaginal exam
 Cord hanging outside the introits.
 Cord felt in the vagina or inside the cervix anterior to
the presenting part.
If membrane is intact, cord presentation is diagnosed
If membrane is ruptured cord prolapse can be
diagnosed
Occult cord can only be diagnosed by detection of
abnormal FHB
 Ultrasound 36
Management:
Immediate management
If cord is pulsating
 Put mother in knee-chest position
 Initiate oxygen administration by face mask 6 L/min
 Insert bladder catheter and infuse the bladder with 0.5 L
of saline
 Replace the cord into the vaginal canal (not into the
uterus)
 Push fetal presenting part upwards via the examining
hand in the vagina to relieve compression of the cord by
the presentation
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Prepare for immediate delivery
 First stage of labor: Emergency C/S
 Second stage of labor:
Forceps/vacuum delivery if other conditions are
met
Breech extraction if other conditions for breech
extraction are met.
 Non-pulsatile cord: Manage as any other labor as the
cord prolapse will not alter the course of labor
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Complications:
Maternal:
 c/s:- anesthtesia related risk
- operative complications
- hemorrhage
 vaginal delivery: - laceration of the cervix, vagina or
perineum

Fetal:
 hypoxic, acidosis, asphyxia, brain damage & death

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 Mal presentation and malposition

Mal presentation
-The term mal presentation encompasses any fetal
presentation other than vertex, including breech, face,
brow, shoulder & compound presentations.
- The most common mal presentation is breech
Etiology
- Both fetal and maternal factors contribute to the
occurrence of mal presentation.
Fetal factors:
- Prematurity - major predisposing factor.
- low birth weight (< 2500 g).
- Fetal structural anomalies (e.g., hydrocephalus,
anencephaly)
- Uterine anomalies (e.g., bicornuate uterus)
- Multiple gestation
Etiology, cont…
- placenta previa
- hydramnios
- contracted pelvis
- pelvic tumors that obstruct the birth canal
- high parity
 In prolonged labor with facial edema, face presentation
becomes a differential diagnosis of breech presentation
on vaginal exam.
BREECH PRESENTATION.
- Occurs when the fetal buttocks or lower
extremities present into the maternal pelvis.
Incidence:
 3-4% of all deliveries.
 Prior to 28 weeks, approximately 25% of
fetuses are in a breech presentation
- As the fetus grows and occupies more of the
uterus, it tends to assume a vertex presentation to
accommodate best to the confines and shape of the
uterus
Classifications
There are three types of breech presentation:
1. Frank breech
- occurs when both fetal thighs are flexed at hip and both
lower extremities are extended at the knees.
- At term, 65% of breech fetuses are frank
2. Complete breech
- has both thighs flexed and one or both knees flexed
(sitting in a “squat” position).
3. Incomplete (or footling) breech
- has one or both thighs extended and one or both knees
or feet lying below the buttocks.
01/22/2025 45
Position
DIAGNOSIS
- Can often be made by the Leopold exam in
which the firm, round ballotable fetal head is
palpated in the fundal region and the softer,
smaller breech occupies the lower uterine
segment above the symphysis pubis.
- FHR is heard above than expected for vertex
presentation
- In a frank breech in labor, the fetal buttocks, anus,
sacrum, and ischial tuberosities can be palpated on
vaginal exam.
- With a complete breech, the feet, ankles and often
the buttocks are palpable through the dilated cervix.
- With an incomplete breech, one or both fetal feet
can be felt
- but ultrasound may required for definitive diagnosis
Pregnancy management
- Exclude fetal and uterine anomalies
- ECV may be considered in a breech presentation at
term before the onset of labor.
- ECV is a third alternative to vaginal delivery or C/S for
the breech fetus
 Criteria for Vaginal Delivery or C/S
V/D C/S
 Frank  EFW > 3.5 kg
 GA > 34 wks  Footling presentation
 FW = 2 - 3.5 kg  Contracted pelvis
 Adequate pelvis  Deflexed head
 Flexed head  Arrest of labor
 Nonviable fetus  GA 28-34 wks
 No contraindication for SVD  Elderly Primigravida
 Good progress of labor  Poor obstetric history
 Staff skilled in breech  Fetal distress
delivery
Vaginal breech delivery
Three types of vaginal breech deliveries:
1. Spontaneous breech delivery - the entire infant delivers
vaginally without manual aid
2. Assisted breech delivery - the fetus is allowed to deliver
spontaneously until umbilicus. then, delivery of the legs,
trunk, and arms are assisted manually; the head may be
delivered manually or with forceps
3. Breech extraction - in which manual assistance is applied by
traction in the groins or on the lower extremities before
delivery of the buttocks
Assisted Breech Delivery.
.- Since, breech presentation can present in a setting in which
C/S is impossible or unsafe, vaginal delivery of the breech
continues to be an important practitioner skill.
- Once the fetus has delivered spontaneously to the
umbilicus, gentle downward traction is exerted until the
scapulae appear at the introitus.
- Assist delivery of the legs by pushing and abducting the
popliteal fossa (Pinard maneuver).
 After delivery of scapulae, the shoulders are delivered by
sweeping each arm in turn across the fetal chest until
only the fetal head remains undelivered (Loveset
Maneuver).

 Once the shoulders have been delivered, the head is

delivered by manual flexion of the fetal head with the
operator’s fingers applied to the fetal maxilla or with
Piper forceps.
Partial breech extraction.
(A) after spontaneous delivery to the umbilicus, traction is
applied to the infant’s pelvis. When the scapulae are
visible, rotation of the trunk allows delivery of the
anterior shoulder.
(B) delivery of the anterior shoulder by downward traction.
(C) Delivery of the posterior shoulder by upward traction.
The posterior arm is freed digitally by splinting the
fetal humerus (inset)
(D) delivery of the aftercoming head using the Mauriceau-
Smellie-Viet maneuver.
(E) Delivery of the aftercoming head using Piper forceps.
Abdominal pressure is applied to maintain flexion of the
fetal head.
 Summary for Breech extraction

 Delivery of legs(Pinnard M.)---delivery of arms and

shoulders(spontaneous if at chest)---(Loveset M if
extended, half circle) or if fail--- to mother inner thigh,
posterior then anterior---delivery of
Head(MSVM)
 FACE PRESENTATION
-Occurs when the fetal head is hyper-extended such that the
fetal face, between the chin and orbits, is the presenting
part, mentum is the denominator
Incidence: 1 in 500 deliveries.
Presenting diameter: Submento vertical, 11.5 cm
Diagnosis
Leopold’s palpations:
Third maneuver: occipital prominence is on the same side
of the back indicating a hyper extended cephalic
presentation
PV: The supra orbital ridges; the fetal nose; eyes; mouth
opening and gums are felt.
Differentiation from breech presentation:
- Anus is on the same line as the two eminences (ischial
tuberosities), while the mouth is at right angles to the
two prominences (chick bones);
- Anus has a tone in breech presentations while none in
mouth but rather feel the gums;
- Meconium is more prominent in breech presentations
and not much in face unless distressed;
- If not too edematous the eyes and nose can be felt in
the face
- confirmed by sonography
- Forceps, but not vacuum, can be applied to assist if
pre requisites are met.
- However, if the mentum rotates posteriorly, the fetal
head will be unable to extend farther to complete the
expulsive process.
- Thus mento posterior and persistent mento
transverse must be delivered by C/S
- Approximately half of the mento posterior and mento
transverse presentations spontaneously rotate to a
mento anterior position.
- When delivered by SVD or low forceps, perinatal
morbidity and mortality for face presentations are
similar to those for vertex presentations
Simpson forceps applied to a mento anterior face
presentation.
 BROW PRESENTATION
- It occurs when the presenting part of the fetus is b/n the
orbital ridges & root of nose anteriorly and the coronal
sutures and anterior fontanel posteriorly .
- Leopold’s palpation – is not much indication except
perhaps a “military” attitude with both cephalic
prominences at the same level
- This type of presentation arises as the result of extension
of the fetal head such that it is midway b/n flexion and
hyperextension.
- With a brow presentation, the presenting diameter is the
mento-vertical diameter(14 cm), which is much longer
than the presenting diameter for a face or a vertex
presentation.
Brow presentation
 Brow presentation, cont …
 Brow presentation is often a transitory presentation
in early labor as the head is descending and engaging
- 50-75% will convert either to face or vertex presentation,
and will subsequently delivery vaginally
- vaginal delivery is impossible, unless the fetus is very
small or the maternal pelvis is very large.
- If unattended, a persistent brow in a mature fetus will
lead to obstruction above the mid pelvis or even at the
inlet
 Diagnosis:
- On PV - the brow area of the fetal skull is felt
- Check for presence of edema over the brow
- Careful clinical pelvimetry should be performed early in
labor to rule out a contracted pelvis
- Also rule out presence of cord
 Mgt:
In early labor:
- If not contra-indicated for vaginal delivery, monitor labor
progress and await spontaneous reversion to face or
vertex
In late in labor:
- Expedite delivery by C/S as the chance of vaginal
delivery is slim
- Induction and augmentation of labor is contraindicated
in a fetus with a brow presentation
- VBAC is contraindicated in a fetus with brow
presentation
 Shoulder Presentation
- It occurs with the fetus is in the transverse lie.
- In late labor, shoulder presentation may be accompanied
by a hand prolapse.
- Diameter attempting to be delivered in shoulder
presentations is the crown-rump length
- Possible positions of shoulder presentation include: dorso
anterior; dorso posterior; dorso superior and dorso
inferior
- The shoulder presentation cannot be delivered. In rare
circumstances when the fetus is very small and the pelvis
is capacious, a shoulder presenting fetus can be delivered
doubled up ( “conduplicacio corpore”).
 Dianosis:
Leopold’s palpations - Transverse lie diagnosed.
PV:- In delayed and neglected cases the hand may prolapse.
- Cord prolapse (20%).
- Depending on the position of dorsum, shoulder, hands or
parts of ribs may be felt.
- Sonography is confirmatory
Mgt:
- After 34th week- diagnostic work up for possible
etiology.
- External cephalic version could rarely performed.
- In dead fetus: with fully dilated cervix, decapitation
with or without initial embryotomy.
- In an alive fetus: caesarean delivery.
Shoulder presentation- Note the transverse lie of the
fetus with the back down, which cannot be delivered
vaginally.
A compound presentation
 occurs when a fetal extremity prolapses alongside the
presenting part and both parts enter the maternal pelvis
at the same time.
 occurs more frequently with premature gestations
 It is a vertex presentation with hand(s) or feet felt
alongside the fetal head on vaginal exam OR
 A breech presentation with hand(s) felt alongside the
breech
 If the hand is felt anterior or lower to the vertex it then is
a “ hand prolapse” (shoulder presentation) rather than a
compound presentation
 The tips of the fingers of the hand or feet are felt
alongside the fetal head on vaginal exam
 The tips of the fingers of the hand are felt alongside the
breech
 Always assess the pelvic capacity as well as the presence
of cord in compound presentations diagnosed in labor

 In early labor, expect the gradual regression of the

extremity upward as the vertex is pushed downwards by
uterine action
 In late labor, expedite delivery by caesarean section.
 MAL POSITIONS
Occipito- posterior position.
 In a vertex presentation when the occiput is placed
posteriorly over the sacrum/sacroiliac joint
ROP – Occiput on right sacroiliac joint
LOP – Occiput on left sacroiliac joint
DOP – occiput points towards sacrum
 In most of cases (90%) the occiput rotates to the anterior
Causes:
 CPD
 Fetus- deflection of fetal head
 Uterus – abnormal uterine contraction.
 Pendulous abdomen esp. in multipara
Diagnosis
Inspection: - Abdomen looks flat below the umbilicus.
Palpation:
Fundal height corresponds with period of gestation.
Fundal palpation - breech at the fundus
Lateral palpation - Fetal back is felt on right flank of
mother in ROP or in left flank in LOP.
Fetal limbs are felt easily as knob like structure anteriorly
Pelvic grip - Head is often not engaged.
- Cephalic prominance (sinciput) is not so prominent as
found in well flexed occipito-anterior.
Auscultation - FHB is best heard in flank in direct
occipito-posterior/ROP but difficult in LOP.
Vaginal examination:

1. Finding depends upon degree of flexion of head.

2. Conformed Dx is made during 2nd stage of labour

on rupture of membrane by:

a) Sagittal suture- occupies any of the oblique

diameter of pelvis.

b) posterior fontanelle - felt near the sacroiliac joint

c) anterior fontanelle - felt near the iliopectineal

eminence
Management during 1st stage of labor:
 Early diagnosis
 Assess for fetal & maternal condition, and
pelvic adequacy
 Bed rest to prevent rupture of membrane
 Partograph to be strictly maintain
 Early C/S in contracted pelvis
 Cephalopelvic disproportion (CPD)
- CPD is a disproportion) b/n the fetal head and the
mother’s pelvis
- CPD is failure of the fetus to pass safely through the
birth canal b/c the fetal head being relatively larger than
the maternal pelvic size.
- Pelvis-fetal size discordance leads to arrest of labor
requiring C/S
• It is one of the commonest cause of different
complications in labor and is a very common indication
of C/S
• Clinical & radiologic assessment of the maternal pelvis
and fetal size are inexact with poor predictive value
 CAUSES
• Fetal abnormalities:
hydrocephalus or tumor
Locked twins
Shoulder dystocia
Large fetus
postterm pregnancy
• Abnormalities of the reproductive tract
Uterine abnormalities
Fibroid
Ovarian/pelvic tumors
Contracted pelvis
S/S:
 Risk assessment
- Malnutrition, rickets or osteomalacia
- Previous labor abnormalities
- Young age of mother (under 18 years of age)
- Female genital cutting
 abnormal progress of labor and certain physical
findings support the diagnosis of CPD.
 Severe caput and molding
 Fetus does not engage (remains floating)
 PROM
 Signs of malpositions and malpresentations
 Obstructed/prolonged labor
Diagnoses:
 Clinical pelvimetry
 Radiologic pelvimetry (X-ray or CT scan)
 Ultrasound
 Interventions

 Convey confidence in client’s ability to cope with

current situation
 Monitor FHB, uterine contractions.
 Catheterize or help to void every 2 hours
 Instruct in methods to conserve energy
 Massage gently

 Cesarean section if fetus is alive

 Destructive delivery if dead
 Trial of labor if minor CPD
 Trial of labor

•Trial of labor is an attempt offered for vaginal delivery in

the presence of minor degree of CPD. Vaginal birth is
attempted:
Under an expert obstetrician observation
In well equipped and staffed facilities
In vertex presentation
In well maternal/fetal condition
Outcome dependent on:
- The effectiveness of uterine contractions
- The ‘give’ of the pelvic joints (stretching)
- Flexion of the fetal head
- The degree of moulding
Contra-indication:
Severe degree of CPD
Mal-presentation/mal-position
Previous uterine scare
History of difficult delivery
Older woman with history of long infertility
Lack of capability of continuous monitoring,
emergency surgical facility and staffs
Any other contra-indication for SVD
• Ambulation and upright positions can increase pelvic
capacity, effectiveness of the uterine action and flexion
of the fetal head.
 Prolonged Labor
- It is defined retrospectively when all the stages of labor
(from onset of true labor to delivery) last > 24 hrs
 “The Sun Should Never Set Twice in a Woman With Labor ’’

- A latent phase lasting > 14 hrs in a multi & 20 hrs in a

primigravida
- as established labor lasting > 12 hrs or an active phase over
6 hrs. (Obstetric mgt protocol 2014)
This may be due to one of the ‘4 Ps’ ‘powers’, ‘passenger’,
“psyche of the woman” and ‘passage’.
Causes of Prolonged Labor
Powers:
- is poor or uncoordinated uterine contractions
- is a major cause of prolonged labor
- Either the uterine contractions are not strong enough to efface
and dilate the cervix.
Passenger:
- The fetus is the ‘passenger’ travelling down the birth canal.
- Prolonged labor may occur if the fetal head is too large to pass
through the mother’s pelvis, or the fetal presentation is
abnormal
Passage:
- The passage is the birth canal; so labor may be prolonged if the
mother’s pelvis is too small for the baby to pass through or the
pelvis has an abnormal shape, or if there is a tumor or other
Diagnosis:
Commonly observed clinical signs include:
- Consistent use of parthograph can help recognize
prolonged labor timely
- Cervical dilatation graph passes to right of alert line or
- Cervical dilatation graph crosses the action line

Stage Disorders Nully Multi

1st stage Prolonged latent phase 20 hrs 14
Protracted dilation <1.2 cm/hr <1.5 cm/hr
Arrested cervical >2 hr >2hr
dilation
2nd Arrest of descent 2hr 1hr
stage
Management:
- If labor is not progressing well reevaluate the pt for
maternal well-being, fetal well being, fetal size, CPD,
malpresentation, malposition and in their presence refer
client to next higher level facility.
- After 6–12 hrs of rest with hydration, 85% of pts
spontaneously enter the active phase of labor, and
further progression in dilatation and effacement may be
expected.
 Obstructed Labor
 Obstructed labor is failure of descent of the fetus in the
birth canal for mechanical reasons, in spite of good
uterine contractions.
 It accounts for about 8% of maternal deaths globally.
 Obstructed labor is an outcome of a neglected and
mismanaged labor.
Causes
Maternal causes:
Contracted pelvis
Abnormal shaped pelvis
Soft tissue obstruction
 Tumors (pedunculated myoma, vaginal, ovarian)
 Cervical dystocia
Trauma to bony pelvis, polio, congenital deformity of
bony pelvis
Fetal causes:
 Malpresentations and malpositions:
Persistent occipito-posterior and deep transverse arrest,
Persistent mento-posterior and transverse arrest of the
face
Brow presentation,
Shoulder presentation,
Impacted breech presentation
 Large sized fetus ( macrosomia)
 Congenital anomalies:
Hydrocephalus
Fetal Ascites
Fetal tumors
 Locked and conjoined twins
CLINICAL PRESENTATION
History:
 Prolonged labor often extending to days
 PROM
 Painful contractions (eventually might cease due to
uterine hypotonia or rupture)
 Fever
Examination:
 Tachycardia and hypotension (Fast pulse & RR, low
BP, possibly also a raised temperature)
 Urinary retention, concentrated urine
 Exhausted, tired and anxious
 Dehydration and acidosis
 Shock (septic or hemorrhagic due to infection or
uterine rupture)
 Vagina feels hot and dry to your gloved examining
finger,
 Hyperactive uterine contractions
 Three tumour abdomen may be evident (bladder, lower
and upper uterine segments separated by pathological
Bandl’s ring.)
 Edematous vulva (Cannula sign), and cervix,
 foul smelling meconium stained liquor, severe caput and
moulding.
 Catheterization is often difficult b/c of the impacted
presenting part
MANAGEMENT
 If delivery is not imminent, resuscitation is the first
step before facilitating patient transfer
 Start IV infusion with RL or NS a liter in 15-20
mins
 Start initial dose of IV antibiotics (Ampicillin 2 gm,
Gentamycin 80 mg and metronidazole 500 mg)
 Catheterize bladder
 Transfer patient to hospital
 Discuss decision with woman and relatives.
 Quickly organize transport and possible financial aid
 Inform the referral center

 Accompany the woman

 During travel, watch IV infusion, keep record of all IV fluids,

medications given, time of administration and the woman’s
condition
 In a hospital admit the pt straight to the delivery unit or
operating theatre
 Do Hct, Blood group and Rh type, and CBC

 Vital signs should be checked regularly.

 Start Oxygen 6 L/min if there is fetal or maternal distress

Definitive Management options:

1) C/S delivery

- if FHB is positive

- if there is contraindication for destructive delivery

2) Destructive delivery

- if FHB is negative

- if no contraindication
Complications:
 Uterine rupture: - complete
- incomplete
 PPH, shock, severe anemia
 Bladder rupture
 Fetal asphyxia, intracranial hemorrhage
 Neonatal sepsis, fetal death or neonatal death
 Chorioamnionitis
 Peritonitis
 Intra-abdominal abscess collection
 Obstetric fistula (VVF, RVF or both)
 Foot drop
 Hip joint & knee joint contractures 97
 UTERINE RUPTURE
 It is a tear in the wall of the uterus which commonly occurs
in the lower uterine segment.
 The tear could be anterior, posterior, lateral or combination
of these.
 It could also be transverse, vertical or combination of
these.
 it commonly occurs in the intrapartum period but
antepartum rupture can occur especially in women with
classic C/S scar or scars related to other gynecologic
surgeries like myomectomy.
Type:
1. Complete (true) - the tear extends through the
whole thickness of the uterus including the
peritoneum so that there is free communication
with the peritoneal cavity.
2. Incomplete (occult) – the tear extends through
the myometrium but not through the overlying
peritoneum so that there is no free
communication with the peritoneal cavity.
 Causes
 The commonest cause is neglected obstructed.
 Previous uterine scar (C/S, repaired ruptured uterus,
myomectomy)
 Oxytocin or prostaglandin administration
 Difficult instrumental delivery like forceps
 Difficult destructive delivery
 Version
 Difficult manual removal of placenta
 Vigorous fundal pressure
Clinical Features
Dx is usually made using S/S. But, it is difficult especially
in those with scar.
S/S depends on:
 the time elapsed after rupture,
 the site and extent of rupture,
 the degree of fetal & placental extrusion (the degree of
intraperioneal spill) &
 the tamponade effect offered by the fetus.
Symptoms of impending (imminent) uterine rupture are:
 Worsening suprapubic pain especially persisting b/n
contraction
 Strange feeling of the fetus moving upwards
S/S in uterine rupture include:
 Sudden cessation of contraction & fetal mov’t often
following sharp tearing pain at the height of contraction
 Temporary relief of pain followed by diffuse, continuous
abdominal pain
 Variable degree of vaginal bleeding depending on the
degree of fetal impaction
 Gross hematuria in anterior wall rupture with bladder
rupture
 Normal vital signs to profound shock
 Pallor
 Abdominal tenderness and distension
 Absent contraction & FHB
 Easily palpable fetal parts
 Shifting dullness
 Vaginal bleeding
 Feeling a defect on PV or at laparatomy makes
definitive Dx
Management:
 The life of the pat depends on the speed & efficacy of:
- hypovolemia correction,
- hemorrhage control and
- infection treatment
 In places where surgical intervention cannot be provided,
early referral should be undertaken only after
resuscitative measures are initiated.
A. Supportive Management
prepare the woman for laparatomy
 Opening IV-line with wide bore cannula
Vigorous infusion of crystalloids (NS or RL)
 Initiation of parenteral antibiotics
 Catheterization
 Hemoglobin, blood group, RH factors
 Preparing at least two units of cross matched blood

B. Definitive Management
Immediate laparatomy and:
 Total abdominal hysterectomy
 Sub-total abdominal hysterectomy
 Repair of the rupture with bilateral tubal ligation
 Thank You!

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