OBSTETRICs AND GYNECOLOGY NURSING

II

BY: Tensay Kahsay

Email: tensaykahsay@ymail.com
Learn More Study Less!!

 What is Presentation ?
is the part of the fetus which occupying the lower
uterine segment.
During the ANC period It is difficult clinically to
diagnose that the presentation is vertex, brow or
face , so it is used to say cephalic presentation.
What is position ?
is the relation shape of the denominator of the
presenting part to the pelvic brim
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Vertex

99%

Brow

1:1500

Face

1:500

Introduction
Malpresentation and malpositions are essentially
abnormalities of fetal position, presentation, attitude or
lie.
They collectively constitute the most common cause of
fetal dystocia.
Breech presentation is the commonest
malpresentation.
The other malpresentations are face presentation,
brow presentation, shoulder presentation, and
compound presentation.
The malpositions include occipito - posterior position
and persistent occipito transverse positions.
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 Breech presentation, which complicates 34% of all

pregnancies, occurs when the fetal pelvis or lower
extremities engage the maternal pelvic inlet.
Three types of breech are distinguished, according
to fetal attitude.
Frank breech, the hips are flexed with extended
knees bilaterally.
Complete breech, both hips and knees are flexed.
Footling breech, 1 (single footling breech) or both
(double footling breech) legs are extended below
the level of the buttocks.
Knee presentation is a rare form seen in a fetus with
extended thighs and flexed knees.
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Types of Breech Presentation -

 Fetal position in breech presentation is determined

by using the fetal sacrum as the point of reference
to the maternal pelvis.
This is true for frank, complete, and footling
breeches.
Eight possible positions are recognized: sacrum
anterior (SA), sacrum posterior (SP), left sacrum
transverse (LST), right sacrum transverse (RST), left
sacrum anterior (LSA), left sacrum posterior (LSP),
right sacrum anterior (RSA), and right sacrum
posterior (RSP).
The station of the breech presenting part is the
location of the fetal sacrum with regard to the
maternal ischial spines.
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Causes
Before 28 weeks, the fetus is small enough in
relation to intrauterine volume to rotate from
cephalic to breech presentation and back again with
relative ease.
As gestational age and fetal weight increase, the
relative decrease in intrauterine volume makes such
changes more difficult.
In most cases, the fetus spontaneously assumes the
cephalic presentation to better accommodate the
bulkier breech pole in the roomier fundal portion of
the uterus.
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 Breech presentation occurs when spontaneous version

to cephalic presentation is prevented as term
approaches or if labor and delivery occur prematurely
before cephalic version has taken place.
Some causes include oligohydramnios, hydramnios,
uterine anomalies such as bicornuate or septate uterus,
pelvic tumors obstructing the birth canal, abnormal
placentation, advanced multiparity, and a contracted
maternal pelvis.
In multiple gestations, each fetus may prevent the other
from turning, with a 25% incidence of breech in the first
twin, nearly 50% for the second twin, and higher
percentages with additional fetuses
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Diagnosis
A. Palpation and Ballottement
Performance of Leopold's maneuvers and ballottement of the uterus may
confirm breech presentation. Diagnostic error is common, however, if these
maneuvers alone are used to determine presentation.
B. Pelvic Examination
During vaginal examination, the round, firm, smooth head in cephalic
presentation can easily be distinguished from the soft, irregular breech
presentation if the presenting part is palpable. However, if no presenting
part is discernible, further studies are necessary (ie, ultrasound).
C. Radiographic Studies
X-ray studies will differentiate breech from cephalic presentations and help
determine the type of breech by locating the position of the lower
extremities. X-ray studies can reveal multiple gestation and skeletal defects.
Fetal attitude may be seen, but fetal size cannot readily be determined by xray .
C. Ultrasound
Ultrasonographic scanning by an experienced examiner will document fetal
presentation, attitude, and size; multiple gestation; location of the placenta;
and amniotic fluid volume. Ultrasound also will reveal skeletal and softtissue malformations of the fetus.
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Diagnosis
Leopolds maneuver reveals round, globular, smooth
head occupying the fundus, which will be ballotable if
adequate amniotic fluid is there and narrow and softer
breech occupies the lower pole of the uterus.
Fetal heartbeat will be heard more easily at or above
the umbilicus.
Pelvic examination in labour identifies the soft
irregular mass with anal orifice, the ischial
tuberosities, genital groove and external genitalia.
In footling and complete breech presentation one or
both feet are felt.
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 The important differential diagnosis at this point

is face presentation which should be
differentiated by the presence of the hard maxilla
and if the fetus is alive the presence of suckling.
Ultrasonography and plain film of the abdomen can
be done to confirm the diagnosis.

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Management

I. Antepartum management
Breech presentation diagnosed before 32 weeks
of gestation should be managed expectantly
with frequent follow up.
Spontaneous version to cephalic presentation
at the latter weeks of gestation is likely.
After 36 weeks the chance of spontaneous
version is less likely.

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 If the there are no contraindications external

cephalic version should be performed.
This requires expertise and facilities for
emergency caesarian section.
If external cephalic version is contraindicated a
decision on the mode of delivery(vaginal breech
delivery or elective caesarian section) has to be
made before labour starts.
For these reasons pregnant women with breech
after 36 weeks have to referred for hospital
management.
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II. Intra partum management vaginal breech

delivery
All breech deliveries should ideally be conducted in
a set up with caesarian section facility.
In the absence of such facility laboring mothers
with breech presentation in whom delivery is not
imminent (cervical dilatationof less than 8 cm)
should be referred.
Women in whom delivery is imminent should be
attended in the same health facility.
This justifies why all health workers dealing with
laboring women need to be skilled in conducting
vaginal breech delivery.
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Vaginal breech delivery trial should be allowed in:

Estimated fetal weight of less than 3500gms
Frank or complete breech with flexed head
Pelvis should be judged to be adequate with
favorable shape
Live fetus with normal heart rate pattern or
grossmalformation or dead fetus
No other obstetric factor (X factor)

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 There is no place for augmentation of

breech presentation with poor progress of
labour.
The mother should be instructed not to push till
full cervical dilatation is achieved.
In the second stage of labour, before conducting
delivery, pelvic examination should be done to
confirm full cervical dilatation.
Bladder must be emptied and the mothered
positioned into lithotomy position.

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There are three types of vaginal breech

delivery.

1. Spontaneous vaginal breech delivery where

the infant is expelled entirely spontaneously
with out any help other than support.
This occurs rarely except for premature babies
in a multipara.
It is associated with higher perinatal mortality.

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2. Assisted vaginal breech delivery (Partial breech

extraction): where the fetus is delivered upto the
level of the umbilicus spontaneously and the rest of
the body is delivered with the assistance of the
health professional using special maneuvers.
3. Total breech extraction: where the entire fetus is
delivered from the birth canal by the assistance of
the health professional.
It is associated with significant maternal and fetal
risks.
This procedure is only performed for the delivery of
the second twin.

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III. Techniques of assisted breech delivery

A. Delivery of the buttocks and legs

Instruct the mother to bear down with every contraction.

Do episiotomy when the fetal anus is visible and
perineum distended.
Allow the breech to be delivered with out intervention
up to the level of the umbilicus.
After the delivery of the buttocks, supporting the baby
around the hips without pulling and keeping it below the
horizontal is all that is needed.
Apply gentle and steady down word traction until the
lower halves of the scapula are delivered.

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B. Delivery of the arms and shoulders

After the lower border of the scapula is visible pull a

length of umbilical cord.
Ensure the back is facing to the right or left side
before delivering the arms.
Introduce two fingers into the vagina over the chest
of the fetus and feel for both arms.
If the arms are not felt it indicates extended or
nuchal arm.
If the arms cant be delivered spontaneously,
deliver the arms in one of the following ways:

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I. Lovset maneuver :
Holding the babys hip rotate the fetus by half a
circle (1800) keeping the back upper most and
applying downward traction at the same time.

This delivers the posterior arm, which now

becomes the anterior arm, beneath the pubic
arch.
by rotating the fetus counter clock wise to
deliver the right arm and often clock wise to
dislodge and deliver the left arm.

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C. Delivery of the head

Allow the baby to hang until the nape of the
neck or posterior hairline is visible.
Then deliver the head in one of the following
ways:
I. Mauriceau Smellie Veit maneuver
II. Wigand maneuver
III. by Pipers forceps

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I. Mauriceau Smellie Veit maneuver

Introduce the non-dominant hand into the vagina

over the face of the fetus which is supported by
the forearm.
Place the first (index) and the third (ring)
fingers on the right and left cheek bones and
place the second (middle) finger into the
babys mouth. Pull the jaw down to flex the
head.

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 At the same time introduce the dominant hand into

the vagina over the back of the fetus.
Put the first and third fingers over the shoulders
and the middle finger over the occipital
prominence.
Press down on the occiput to assist in flexion of
the head.
Ask an assistant to give supra pubic pressure by
the base of the hand.
Pull gently to deliver the head by making an arc
following the pelvic curve.

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II. Wigand maneuver

The procedure is like Mauriceau Smellie Veit
maneuvers but differs by
1. The dominant hand instead of being introduced in
to the vagina it is put on the supra pubic area to
provide supra pubic pressure.
2. An assistant is not needed to apply supra pubic
pressure.
III. Piper forceps: are used in for delivery of the after
coming head.

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D. Difficulties during vaginal breech delivery

I. Nuchal arms(extended arms found behind the
neck of the fetus) should be managed by Lovset
maneuver.
II. Extended arm is diagnosed when the arms
are not felt on the chest. Management is like
the nuchal arm.
III. Arrest of the after coming headcould be caused
by incompletely dilated cervix, extended head,
hydrocephalus or cephalopelvic disproportion
(contracted pelvis or big baby)

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Complications

Breech presentation is associated with high

perinatal morbidity and mortality.
obstructed labor, genital tract lacerations and
increased risk of operative delivery.
Fetal complications are cord prolapse, birth injury
(superficial tissue damage, edema and bruising,
fractures of the humerus, clavicle or femur,
dislocation of shoulder or hip, Erbs palsy, trauma to
internal organs especially a ruptured liver or spleen,
damage to adrenals, spinal cord damage or fracture of
the spine and intracranial hemorrhage) and associated
congenital malformations.

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FACE PRESENTATION

Face presentation is a kind of cephalic

presentation where the neck of the fetus is
fully extended so that the occiput lies on the
back and the face (area of the fetal face
between the orbital ridges and the chin.

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Dx

On vaginal examination, with sufficiently dilated

cervix, feeling the orbital ridges, eyes, nose and
mouth clinches the diagnosis.
The mouth may be open and the hard gums are
diagnostic and the fetus may suck the examining
finger.

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Mechanism of labour
The denominator is the mentum (chin). The
presenting diameter is submento- bragmatic
which is 9.5 centimeters.
Eight possible positions exist depending on the
relation of the chin to the various positions of the
pelvis.

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Management of labour
Caesarian section is indicated in the presence
of big baby, contracted pelvis, previous uterine
scar like previous caesarian section and elderly
primi or woman with bad obstetric history.
Augmentation of labour is generally
contraindicated.
Low forceps may be needed for mentoanterior
position in prolonged second stage.

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BROW PRESENTATION

Brow presentation is a kind of cephalic

presentation in which there is partial extension
of the fetal head so that the brow (area
between the anterior fontanel and the orbital
ridges) becomes the presenting part.
Finding the frontal suture, anterior fontanel,
the orbital ridges and the base of the nose
on vaginal examination with dilated cervix
clinches the diagnosis.

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Brow

1:1500

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Mechanism of labour

The denominator is the anterior fontanel or the

frontal bone.
The presenting diameter is mentovertical diameter
which is 13 centimeters.
Engagement does not occur as this diameter is larger
than the diameters of the pelvic inlet.
Unless it reverts to either face or vertex
presentation, there is no mechanism of labour for brow
presentation.
Spontaneous delivery of a term brow is unlikely.
If no intervention is made the end result is obstructed
labor.
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Compound presentation

Compound presentation is prolapse of a fetal

extremity alongside the presenting part.
Prolapse of the hand in cephalic presentation is
most common, followed by prolapse of an upper
extremity in breech presentation.
Prolapse of a lower extremity in cephalic
presentation is relatively rare.
Compound presentations are uncommon.

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Causes

Obstetric factors that prevent descent of the

presenting part into the pelvic inlet predispose to
prolapse of an extremity alongside the presenting
part (ie, prematurity, cephalopelvic disproportion,
multiple gestation, grand multiparity, and
hydramnios).
Because of poor application of the presenting part
to the cervix found in compound presentations,
umbilical cord prolapse is common and is a major
contributor to fetal loss during labor.

40

Diagnosis

The diagnosis of compound presentation is made by

palpation of a fetal extremity adjacent to the presenting
part on vaginal examination.
The diagnosis is usually made during labor; as the
cervix dilates, the prolapsed extremity is more easily
palpated alongside the vertex or breech.
Compound presentation may be suspected if poor
progress in labor is noted, particularly when the
presenting part fails to engage during the active phase.
If the diagnosis of compound presentation is
suspected but uncertain, ultrasound can be used to
locate the position of the extremities and search.

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Management
Management of compound presentation depends on gestational
age and type of presentation.
Given that 50% of compound presentations are associated with
prematurity, viability of the fetus should be documented prior to
delivery. If the fetus is considered nonviable, labor should be
permitted and vaginal delivery anticipated.
Labor can be allowed and vaginal delivery anticipated in viable
cephalic presentations with a prolapsed hand. These cases
generally pose no difficulty in labor or delivery because the hand
moves upward into the lower uterine segment as the vertex
descends into the birth canal.
Umbilical cord prolapse is a risk in all cases of compound
presentation, and continuous FHR monitoring should be
performed to detect fetal distress or changes in the FHR.
Umbilical cord complications should be managed by immediate
cesarean delivery.

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Shoulder presentation (transvrese lie)

Shoulder presentation is a presentation in which the

long axis of the fetus is at right angles to the axis of
the uterus so that the presenting part becomes
the shoulder.
It is the most dangerous of the fetal presentations.
Occasionally the lie is oblique but this does not
persist as the uterine contractions during labour
make it longitudinal or transverse.

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Diagnosis

Diagnosis is easy but can be overlooked/missed.

On abdominal examination, the uterus is
transversely oval with the fundus scarcely above the
umbilicus.
The fundal height is less than expected for the period
of gestation.
There is no fetal pole in the fundus and the pelvic inlet.
The fetus lies crosswise with head in one side of
the abdomen.
In labour vaginal examination identifies the shoulders
and/ or the ribs .

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Dx cont.

These findings may be obscured after

membrane rupture in late labour.
A very high and unreachable presenting part on
vaginal examination highly suggests transverse
lie.
Ultrasound confirms the diagnosis and identifies
the possible causes.

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Management

If transverse lie is diagnosed antenatal, refer

the patient to hospital as term approaches.
If shoulder presentation is diagnosed during
labour, refer the patient immediately to hospital.
Shoulder presentation diagnosed before term
shouldbe managed expectantly since there is a
chance of spontaneous version.

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Complications

Cord prolapse
Uterine rupture with possible maternal death.
This is especially true in neglected shoulder
presentation.

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Umbilical cord presentation and prolapse

It is decent of the umbilical cord into the lower

uterine segment.
Intermittent or continuous compression by the
presenting part compromises the fetal
circulation causing fetal hypoxia and eventually
death.
It may take the following forms:

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 Overt cord prolapse: presentation of the cord

beyond the cervix after rupture of the
membranes, so that loop of cod is palpable or
visible during examination.
Occult cord prolapse: with ruptured
membranes the cord has prolapsed along side
the presenting part but not in front of it. This is not
palpable during vaginal examination
Cord presentation: the cord is in front of the
presenting part with intact membranes so that it is
felt through the membranes during vaginal
examination.
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Causes

Any obstetric condition that predisposes to poor

application of the fetal presenting part to the cervix can
result in prolapse of the umbilical cord.
Cord prolapse is associated with prematurity (< 34
weeks' GA), abnormal presentations (breech, brow,
compound, face, transverse), occiput posterior
positions of the head, pelvic tumors, multiparity,
placenta previa,& CPD.
In addition, cord prolapse is possible with hydramnios,
multiple gestation, or PROM occurring before
engagement of the presenting part.
Attempted external cephalic version, and expectant
management of preterm PROM.

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Cont

Generally
Maternal factors are contracted pelvic inlet, multi
parity, tumor.
Fetal factors are malpresentation, long umbilical
cord, low lying placenta, prematurity, multiple
gestation, conditions that cause rupture of
membranes before engagement of the
presenting part like in PROM and
polyhydraminos

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Dx

Diagnosis of overt cord prolapse is done by

finding loops of cord in the vagina or cervix.
Feeling loops of cord through the membrane
ahead of the presenting part diagnoses cord
presentation.
Diagnosis of occult cord prolapse is suspected by
finding variable deceleration following rupture of
the membranes.

52

Management
I.

Cord presentation- emergency caesarian section if the

fetus is mature or is nearing maturity.
II. Occult cord prolapse perform pelvic examination to
rule out overt prolapse. Put in a position that corrects
the fetal decelerations.

If this does not correct it and the deceleration persists

deliver the fetus by the fastest route (instrumental delivery
or C/S.
III. Overt cord prolapse depends on presence of cord pulsation
and cervical dilatation.
If there is no pulsation await spontaneous delivery with or
without destructive delivery.
If pulsations are felt deliver by the fastest route (caesarian
section if cervix is not fully dilated, instrumental delivery if
cephalic and cervix is fully dilated, total breech extraction
if breech and cervix is fully dilated).

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 Note: If fetus is viable (FHB positive and

cord pulsating) until the patient is ready for
caesarian section put the patient in kneechest position, apply continuous up ward
pressure against presenting part , put the cord
inside the vagina and give oxygen to the mother

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Complications

Complications are maternal(complications of

operative deliveries) and neonatal (prognosis
depends on the degree and duration of umbilical
cord compression occurring before the
diagnosis is made and neonatal resuscitation is
begun.
If the duration of complete cord occlusion is less
than 5 minutes, the prognosis is good).

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Prevention and early detection

Artificial rupture of membrane should be
avoided until the presenting part is well
applied to the cervix.
After spontaneous or artificial rupture of
membrane, careful and prompt pelvic
examination should be done to rule out cord
prolapse.
Before doing ARM, check for the presence of
cord.

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Malpositions (vertex-malposition)
Occipito posterior (OP)may be normal in early labor.
Most change by spontaneous rotation to
occipitoanterior position.
Diagnosis is easily made by manual vaginal
examination when one finds the posterior
fontanel directed towards the sacrum.
Women may complain of continuous and severe
backache worsening with contractions.
In the absence of CPD, augmentation of labour
is possible for hypotonic uterine action.

57

 Possibilities for vaginal delivery in persistent

occipitoposterior position include spontaneous
vaginal delivery with generous episiotomy,
forceps delivery with or without rotation, vacuum
delivery and caesarian section for CPD.

58

Shoulder Dystocia

59

60

 Dystocia is difficult labor, which is

characterizedby abnormally slow progress of
labor.
It is the most common indication for primary
caesarian section.
Dystocia is a consequence of faults in the
five Ps operating alone or in combination.

61

Dystocia is the consequence of four distinct

abnormalities that may exist singly or in
combination:
Abnormalities of the powersuterine contractility
and maternal expulsive effort.
Abnormalities involving the passengerthe
fetus.
Abnormalities of the passagethe pelvis.
Abnormalities of soft tissues of the reproductive
tract that form an obstacle to fetal descent

62

1. Faults in the power (Inefficient uterine contraction

or uterine dysfunction)
Myometrial contractions in normal labor start from one
of the pacemakers located in the uterine cornu.
Propagation of contraction which is downward from the
fundus to the cervix.
Intensity of contraction that is stronger in the upper part of the
uterus.
Duration of contraction that is longer in the upper part.
Peak of uterine contraction which occurs simultaneously in all
parts.
The net result of this is to provide effective uterine
contraction, which pushes the fetus downwards, thus
dilating the cervix.

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In normal labor effective uterine contraction should

fulfill the following.
Frequency of 3-4 contractions per 10 minutes
Duration of 45-60 seconds during each
contraction
Intensity of 20-60 mm Hg with resting tone of 1015 mm Hg (fundus of the uterus can not be
indented at the height of contraction)

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 Any deviation from this pattern results in uterine

dysfunction.
majority of uterine dysfunctions the cause is unknown. In
the rest the following are implicated:
CPD, which result in poor application of the presenting
part to the cervix.
Uterine overdistension:
Anxiety and emotions (psychological factors), which
depress release of oxytocin from the posterior pituitary.
Uterine Dysfunction is common in primi than in multiparas
(4% vs. 2%).
It leads to prolonged labor which intern results in
maternal exhaustion, increased risk of intrapartum and
postpartum infection of the mother and fetus, fetal distress
and operative deliveries.
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There are two types of uterine dysfunction

a. Hypotonic uterine dysfunction (uterine inertia)
Resting tone decreased
Contractions are decreased in intensity with
slight rise in pressure therefore, less pain and
uterus is indentable at the height of the contraction
Responds favorably to oxytocin

66

b. Hypertonic uterine dysfunction (in coordinate

uterine action)
Resting tone increased
Distorted gradient pattern lower segment
dominance or complete assynchronism of
electrical impulses.
midsegment of the uterus with more force than the
fundus.
Contractions are increased in but are disorganized,
therefore, contractions more painful leading to
ketosis.
gets stress by oxytocin

67

2. Faults in the passenger

1. The fetal head & Molding: size of the head-big

in macrosomic fetus
2. Fetopelvic relationships
I. Attitude:
II. Fetal Lie:
III. Fetal Presentation:
IV. Fetal position:

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I- Malpresentation
In the absence of contracted pelvis or/and
big sized fetus most malpresentations and
malpositions do not cause dystocia.
Significant dystocia is a rule in shoulder
presentation, persistent brow presentation,
persistent mentoposterior presentation and
breech with extended head, nuchal arm and
hydrocephalus.

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II- Macrosomia
Macrosomia is defined as fetal weight exceeding 4000
grams.
causes of macrosomia are maternal DM especially of
gestational type and post date pregnancy. Increasing
parity, increasing age are associated with macrosomia.
Macrosomia should be suspected in a woman with
bigabdomen, fundal height of the uterus bigger than
the calculated GA from the LMP, fetus seems large
with minimum amount of amniotic fluid and nonengagement of fetal head at term.

70

II. Shoulder dystocia

Shoulder dystocia is an acute obstetric emergency
in which following the delivery of the head the
shoulders of the fetus can not be delivered despite
the performance of routine obstetric maneuvers.
Risk factors for shoulder dystocia, which are
identified in only less than 50%, include fetal
macrosomia, maternal obesity; prolonged labor
especially prolonged second stage of labor,
previous history of shoulder dystocia and difficult
operative vaginal deliveries.

71

Pathophysiology

Size discrepancy between fetal shoulders and

maternal pelvic inlet
Macrosomia
Large chest:BPD
Absence of truncal rotation
Fetal shoulders remain A-P or descent
simultaneously

72

Diagnostic features include

Turtle sign following the delivery of the head the

neck is retracted and the head recoils against the
perineum with the chin pressed against the
maternal thigh.
Spontaneous restitution doesnt occur and the face
becomes plethoric/ fullness of the blood vessels
Failure to deliver the shoulders with maternal
expulsive effort and gentle down ward traction on
the fetal head.

73

The following steps are useful to deliver shoulder dy.

Step1- Stop maternal expulsive efforts. Stop

desperate pulling on the fetal head. Call for help.
Step2- Disimpact the anterior shoulder by one or
combination of the following maneuvers.
McRoberts maneuver (hyper flexion of both legs
on the maternal abdomen)
Rubins maneuver(application of suprapubic pressure
in lateral direction on the posterior aspect of the
anterior shoulder)

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Step 3- Rotational maneuvers (effective

anesthesia needed)
Wood screws maneuver rotating the
posterior shoulder backward through 1800(half
circle).
Rubin rotational maneuver-Rotating the
posterior shoulder forward through 180 0.
Step 4- Extraction of posterior arm
Step 5- if the above fail perform symphysiotomy
and clediotomy

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Management
Goal: Safe delivery before neontal asphyxia
and/or cortical injury
7 minutes!!!
Episiotomy
Suprapubic Pressure
McRoberts Maneuver
Woods or Rubin Maneuvers
Zavenelli
Push back the delivered fetal head into
birth canal and perform an emergent c/s
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McRoberts Maneuver
42% success rate
+ Suprapubic pressure = 54-58%
Brings pelvic inlet and outlet into more vertical
alignment
Flattens sacrum
Cephalad rotation of pubic symphysis
Elevates anterior shoulder and flexes fetal
spine

77

HELPER Algorithm
H: Call for Help; Shoulder dystocia is called if
shoulders cannot be delivered with gentle traction
E: Evaluate for Episiotomy: Not routinely
indicated; maybe needed when attempting intravaginal maneuver
L: Legs (McRoberts): Hyperflexion and abduction
of hipsinitial maneuver

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HELPER Algorithm cont.

P (Suprapubic Pressure): No fundal pressure;

combination of McRoberts and suprapubic
pressure resolves most shoulder dystocias
Enter (Internal Maneuvers):
Woods: Insert hand into posterior vagina and
rotate posterior shoulder clockwise or
counterclockwise
Rubin: Push posterior or anterior shoulder
toward fetal chest to adduct shoulders
Remove: Delivery posterior arm
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Complications

Maternal
Hemorrhage from genital tract tears and
uterine rupture
4th degree laceration
Fetal
birth injuries Fractures of humerus or clavicle
Brachial plexus injury (Erbs/Klumpkes palsy)
Asphyxia/cord compression and death.

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81

IV- Congenital malformations

1. Hydrocephalus
Hydrocephalus is progressive enlargement of
the cranium resulting from excess
accumulation of cerebrospinal fluid in the
ventricles of the brain.
Definite diagnosis requires:
ultrasound examination, which shows dilated
ventricles.
Plain x-ray of abdomen may show large globular
head with small face and thin cranial bones.

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 The management of diagnosed hydrocephalus is

drainage of excess cerebrospinal fluid by
cephalocentesis (ventriculocentesis).
This procedure involves passing long needle
through the dilated suture lines into the ventricles.
It can be done vaginally (after 3-4 cm cervical
dilation in cephalic presentation or after the body
and shoulders are delivered in breech
presentation) or transabdominally before theonset
of labor.

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Others
Malformations that may cause dystocia
include congenital goiter and other neck
swellings, abdominal masses including ascitis,
distended fetal bladder, enlargement of liver,
kidneys and spleen and conjoined twins.

84

3. Faults in the passage

Bony dystocia
The true pelvis has an inlet, mid-cavity and
outlet. An ideal obstetric pelvis fulfills the
following:

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Measurements of gynacoid pelvis

86

 The cavity should be shallow with straight

sidewalls from which the ischial spines do not
project unduly and large sciatic notches with
sacrospinous ligament accommodating two
fingers (3.5cm).
The pelvic inlet usually is considered to be
contracted if its shortest anteroposterior diameter
is less than 10 cm or if the greatest transverse
diameter is less than 12 cm.

87

CPD
CPD means it is difficult or impossible for the fetus to
pass safelly through the mother pelvis due to either to a
matenal pelvis that is too narrow for the fetal head or a
large fetal head relative to the mother pelvis.
Small or contracted pelvis in developming countries like
Ethiopia is generally due to malnutrtion in childhood
persisting into adult life and early marriage.
CPD can not usually be diagnosis before the 37th weeks of
pregnancy because before that the baby head has not
reached birth size.
if the mother s pelvis and the fetal skull are the average
size, there is just sufficient room for the baby s head to
pass through the pelvic canal if the head rotates to present
to the widest dimension of the pelvis
88

Contracted pelvis

It results if one or more of the critical

internal diameters of the pelvis are shortened
by 2cm or more. It is classified into:
I. Generally contracted pelvis-involves contracture
of the inlet, midcavity and outlet.
II. Inlet contracture anteroposterior diameter of
less than 10 cm OR transverse diameter of less
than 12 cm.

89

III. Midcavity contracture anteroposterior

diameter of less than 11.5cm or transverse
diameter of less than 9.5cm.
IV. Outlet contracture- intertuberous or interischial
spinous diameter diameter of less than 8cm

90

The causes of contracted pelvis are classified as

follows.
I. Normal development of the pelvic bones but with
abnormal shape: android type pelvis and
platypelloid type pelvis
II. Nutritional deficiency from rickets (Vitamin D
deficiency) in child hood and osteomalacia in adult.
III. Diseases or injury in the spines (kyphosis,
scoliosis), pelvis (pelvic tumors, fractures) and the
limbs (poliomyelitis in childhood)
IV. Congenital disorders of spines, pelvis and the
limbs(congenital dislocation of hips)

91

Pelvic assessment

The capacity of the pelvis can be assessed by

clinical and X-ray pelvimetry. Pelvic assessment
is indicated in:
Primigravida at term with unengaged head.
Primigravida with height less than 1.5 meters or age
less than 18 years.
Multipara with history of prolonged labor,
stillbirth, early neonatal death or severe neonatal
injury.
Women to be induced or augmented.

92

Cont.

Before trial of scar in woman with previous

caesarian section.
Women with abnormal presentation (face, breech
and brow).

93

Degrees of contracted pelvis

Mild- Where the anterior parietal bone is at level

with symphysis pubis.
Moderate - The head slightly overlaps at the edge
of the pubis
Severe- The head bulges over the symphysis pubis

94

Methods of determining C.P.D.

1. Determining the degree of overlap by placing the

fingers on the symphysis pubis while pressing the
head down and with the other.
2. Head fitting - Sitting patient up method - patient
lies on the bed. Place the patient to set up by her
own effort. The effort should force the head into the
pelvis and the Nurse will feel its slip /movement
from place past her hand.
3. Head filling - left hand grip method - Grasp head
with left hand and push it downward and backward
if a sense of giveness felt there is no overlap or
C.P.D.
95

 Clinical pelvic assessment should be done after

emptying the bladder and putting the woman in
lithotomy position. Then one should assessthe
following:
Reachability of sacrum promontory. If reachable
measure the diagonal conjugate.
Smoothness and concavity of sacrum.
Straightness of the sidewall and projection of the ischial
spine.
Size of sub pubic angle and intertuberous distance.
Soft tissue masses and strechability of the perineum

96

Management
The management of contracted pelvis depends on the
degree of contracture and presence of other obstetric
complications notably malpositions, malpresentations and
macrosomia.
Regardless of other obstetric complications, grossly
contracted pelvis should be managed by caesarian section
preferably electively.
The management of borderline contracted pelvis
depends on the presence of other obstetric
complications.
Caesarian section should be done in the presence of
macrosomic fetus, malpresentation in a normal sized fetus
and conditions which need induction/ augmentation.
In the absence of these a trial of labor should be given
before a decision of caesarian section.
97

Trial of Labour

Definition: - A test given to a woman with mild or

moderate CPD to see if she can deliver her baby
with least damage to her self & baby.
The out come of a trial of labour depends on :1. The trenght of uterine contraction
2. The stretch of the pelvic joints & ligaments
3. The degree of moulding
4. The attitude of the nurse

98

Management of a trial of labour

- The trial of labour must be carried out in the hospital
where there is a service for caeseraen section at
any time.
1. The Pregnancy is allowed to go to term
2. Careful observation are kept. Descent of the head
assessed frequently. Strict asepsis is maintained
as there is possibility of caeserean section FH and
mothers pulse and B/P is also observed
N.B:- Desent is the most important observation

99

3. Keep fasting as patient may need aneshtetic,

she may be allowed asips of water.
4. Keep her as comforatable and as dry as
possible
5. Stay with patient, talk to her have the labour is
progressing, and help her to be relaxed.

100

The following conditions needs consultancy

with obstetrician:a) Head still high after 6-8 hrs of good contraction
b) Rupture of membrane before full dilation.
c) Un satisfactory uterine action
d) Change of vertex to face or brow
e) Fetal distress
f) Maternal distress

101

A trial of labour has failed when one of the

following occurs:
1. Fetal distress
2. Maternal distress
3. Failure to advance after 6-8hrs of good
contraction
When any of the three complications occurs
ceaserean section will be done

102

A trial of scar /VBAC

When a woman has had a scar of ceaserean

section or hysterotomy is given chance to deliver
vaginally.
This trial is given to see if the scar is strong
enough to withstand the labour. Like trial of
labour it has to be conducted in hospital.

103

Conditions in which trial of scar is considered are:

- spontaneous labour
- only one cesearean section scar
- vertex presentation
- No cephalo pelvic disproportion
- No doubt about the presentation.
A failure of trial scar is indicated by:
- Pain and tenderness over the scar
- Slight vaginal bleeding
- slight raise in pulse
Vacuum is usually applied in 2nd stage if there is no
sign of rupture.

104

Delivery

Write and discuss about Criteria for vaginal or

cesarean delivery for breech presentation.
submit in the next class.

105

Case

History
You are asked to see a woman in the antenatal
clinic. She is 37 years old and pregnant with her
third child. Her previous children were both born by
vaginal delivery after induction of labour for post
dates.
First-trimester ultrasound confirmed her menstrual
dates and she is now 36 weeks. At her last
appointment at 36 weeks gestation, the nurse
suspected that the baby was in a breech
presentation. An appointment has been made for
an ultrasound assessment and to discuss the
situation.
106

Obstructed labor

107

Session objective
At the end of this session students will be able to:
List the main causes of obstructed labour and describe
how each factor contributes to the development of this
complication.
Describe the clinical signs of obstructed labour and the
common maternal and fetal complications that result
from OL.
Describe the management of obstructed labour and
ways of preventing it through your actions.
Explain how social changes at community level could
affect the risk of obstructed labour occurring.
108

Obstructed labor

Introduction
Obstructed labor (OL) is failure of descent of
the fetus in the birth canal for mechanical
reasons arising from either the passage or
passenger in spite of adequate uterine
contraction.
The obstruction usually occurs at the pelvic brim,
but occasionally it may occur in the pelvic cavity or
at the outlet of the pelvis.
OL is one of the major causes of maternal mortality
in developing countries
109

 OL is a totally preventable labour complication.

Obstructed labour is associated with a high
perinatal mortality and morbidity (fetal and
newborn deaths, and disease and disability
occurring around the time of the birth).
It contributes to 22% of the maternal mortality in
Ethiopia.
This shocking figure is certainly an underestimation
of the problem, because deaths due to OL are often
classified under other complications (such as
sepsis, PPH or ruptured uterus).

110

 When labour is prolonged because of failure to progress,

there is a high risk that the descent of the fetus will become
obstructed.
When is labour classed as prolonged in the different stages
of labour?
Prolonged latent phase of labour: when true labour lasts
for more than about 8 hours without entering into the active
first stage.
Prolonged active phase of labour: when true labour takes
more than about 12 hours without entering into the second
stage.
Prolonged second stage of labour:
Multigravida mother: when it lasts for more than 1
hour.
Primigravida mother: when it lasts for more than 2
hours.
111

Causes

CPD remains to be the commonest cause of OL

Malpresentation and malposition is the other
major cause of OL. Included neglected shoulder
presentation, impacted big breech, and arrested
after coming head in breech, persistent brow
In the presence of borderline contracted pelvis
mentoanterior and persistent occipitoposterior
positions may cause OL.
deep transverse arrest, shoulder dystocia and soft
tissue obstruction.

112

Causes of passenger and passage failures that

lead to prolonged and possibly obstructed
labours
Passenger
Head:
Large fetal head (big for that pelvis)
Fetal abnormalities (Hydrocephalus)
Presentation and position:
Brow, face, shoulder
Persistent malposition
Twin pregnancy:
Locked twins (locked at the neck)
Conjoined twins

113

Cont
Passage
Bony pelvis:
Contracted (due to malnutrition)
Deformed (due to trauma, polio)
Soft tissue:
Tumour in the pelvis
Viral infection in the uterus or abdomen
Scars (from female circumcision) Abnormalities
of the reproductive tract

114

Clinical signs of obstructed labour

A key sign of an OL is if the widest diameter of the

fetal skull remains stationary above the pelvic brim
because it is unable to descend.
You should be able to detect this by careful
palpation of the mothers abdomen as the uterus
relaxes and softens between contractions.
However, if the uterus has gone into tonic
contraction (it is continuously hard) and sits tightly
moulded around the fetus, it will be very difficult to
feel whether the fetus is making any progress in the
birth canal.

115

A. Assessment of clinical signs of obstruction

Obstructed labour is more likely to occur if:
The labour has been prolonged (lasting >12 hours)
The mother appears exhausted, anxious and weak
Rupture of membranes and passing of amniotic
fluid was premature (several hr before labour
began)
The mother has abnormal vital signs: fast pulse
rate, above 100 beats/minute; low BP(DBP <60),
RR above 30 breaths/minute & raised T0.

116

Findings in PV examination of any of the ff signs would

suggest the presence of OL:
Foul-smelling meconium draining from the mothers vagina.
Concentrated urine, which may contain meconium or blood.
Edema of the vulva (female external genitalia, including
the labias), especially if the woman has been pushing for a
long time. Vagina feels hot and dry to your gloved examining
finger because of dehydration.
Oedema of the cervix.
A large swelling over the fetal skull can be felt (caput).
Malpresentation or malposition of the fetus.
Poor cervical effacement; as the result the cervix feels like
an empty sleeve or folder.
Bandls ring may be seen.

117

B. Bandls ring
Bandls ring is the name given to the depression between
the upper and lower halves of the uterus, at about the level
of the umbilicus.
It should not be seen or felt on abdominal examination
during a normal labour , but when it becomes visible and/or
palpable Bandls ring is a late sign of OL.
Above this ring is the grossly thickened, upper uterine
segment which is pulled upwards (retracted) towards the
mothers ribs.
Below the Bandls ring is the distended (swollen),
dangerously thinned, lower uterine segment.
The lower abdomen can be further distended by a full
bladder and gas in the intestines.
118

Bandls ring

(a) Normal shape of pregnant abdomen during labour, in a woman lying on her back;

(b) Bandls ring in the abdomen of a woman with obstructed labour.

119

C. Evidence from the partograph

partograph is a key tool in detecting an abnormal or
prolonged labour.
OL is revealed by recordings on the partograph of the rate
of cervical dilatation (which should progress at a rate of at
least 1.2-1.5 cm per Hr) and the rate of fetal head descent.
(a) shows a partograph record of a normal labour with
progressive cervical dilatation and fetal head descent.
However in (b) you can quickly see that there is evidence of
a prolonged first or second stage of labour because:
the cervical dilatation measurement has crossed the Alert
line and if no action is taken it will cross the Action line,
despite strong uterine contractions; the fetal head is not
descending.

120

Normal progress of labour Vs OL

(a) Normal cervical dilatation and fetal head descent recorded on a partograph.
(b) Cervical dilatation has stopped and the record line has crossed the Action line.

121

The cervical dilation record on the partograph

should not cross the Alert and/or Action line. If this
occurs you should consider this to be a prolonged
and possibly obstructed labour and make an
urgent referral.

122

Management of obstructed labour

There are several things that you can do to try to

relieve the obstruction if the record of cervical
dilatation reaches the Alert line on the
partograph, and before it approaches the Action
line.

123

Rx cont
I.

Resuscitation: It should be started as soon as the

diagnosis is made using the available facilities and
resources
A .Fluid and electrolyte replacement to tackle
dehydration and acidosis and control
Infuse crystalloids fast
Monitor urine output by inserting indwelling plastic
catheter
B. Control infection
In all cases infection must be assumed and IV
broad spectrum antibiotics should be commenced
prophylactically.
124

Rx cont
II. Preintervention preparation
Catheterize the bladder as described above.
Empty the stomach by nasogastric tube.
Determine hemtocrite and blood group. Cross match
at least 1 unit of blood
Give antacids orally

125

III. Relief of obstruction

Unless there are contraindications vaginal route is
preferred route of delivery.
caesarian section is indicated in the following
conditions:
Alive fetus with incomplete cervical dilatation or
preconditions for instrumental delivery not fulfilled
Imminent or definite uterine rupture even if the fetus is
dead
Dead fetus when criteria for destructive delivery are not
met
126

Vaginal route of delivery is contraindicated in

the following conditions
Ruptured uterus (manipulation may extend the tear
Imminent uterine rupture (manipulation may
complete the rupture)
Alive fetus with high station or incomplete dilatation
of the cervix
Dead fetus where the criteria for embryotomy are
not fulfilled

127

IV. Post intervention care

Increase fluid and electrolyte intake (parenteral

or oral) to reverse dehydration
Continue antibiotics (initially parenteral later
oral) to complete full coarse
Institute continuous bladder drainage by
indwelling catheter for 5-7 days

128

Refer the mother urgently to a health facility

where a surgical service is available

129

Dont delay in referring a woman

whose labour may be obstructed

130

Complications
The immediate and late complications of OL are responsible
for the high maternal mortality, stillbirth and early neonatal
death
The immediate complications include
Atonic postpartum hemorrhage and Shock
Uterine rupture (rare in primigravidas)
Intra and post partum infection leading to peritonitis, sepsis
and septic shock
Maternal tetanus
Fetal cerebral birth trauma
Fetal distress
Facial injury
Fetal and early neonatal infection and sepsis
131

The late complications include :

Fistulas(vesico-vaginal fistula and recto-vaginal fistula)
Vaginal stenosis and stricture
Foot drop(sciatic and common peroneal nerve injury)
Contracture of joints and ostitis pubis
Perinatal asphyxia & mental retardation
The mother small intestine becomes paralyzed and
stops movement (paralytic ileus)
Slow return of the uterus to its pre-pregnancy size

Death for the mother and fetus.

132

Complication cont
Fistula
Fistula is an abnormal opening (usually as a result
of ruptured tissues) between the:
Vagina and the urinary bladder
Vagina and rectum
Vagina and urethra
Vagina and ureter

133

Cont
As a result of the fistula, urine or faeces get into the
vagina and exit in an uncontrolled way.
A woman with a fistual can leak urine or faeces
while walking, or doing any daily activities, and the
waste stains her clothes and creates a bad smell.
Leads to stigmatise or an outcast from the society.
Other consequences of fistula may include constant
depression, and many physical illnesses and
infections of the reproductive tract, bladder and
kidneys, which may even result in the woman taking
her own life.

134

135

Prevention of obstructed labour

Even with aggressive management OL is associated
with high mortality and morbidity both to the mother
and the fetus. Therefore, health programs should
focus on prevention of OL, which is considered to be
a largely preventable condition.
As a general rule, OL should never occur in a patient
who has received optimal ANC and intrapartum
care.
This can be achieved by non-sophisticated and
non-expensive methods tailored to the immediate
resources of the community

136

The measures that should be undertaken to prevent

OL include
Provision of accessible family planning methods and abortion if
Provision of universal quality ANC to all pregnant women to
identify risk factors
Provision of intrapartum care (Using the partograph for early
detection )
Provision of a good referral system.
Community education on:
Harmful traditional practices (early marriage, female genital
mutilation, harmful maneuvers in labor).
Importance of good nutrition in childhood and pregnancy
Empowering women.
Importance of ANC and supervision of labor by skilled
personnel and Birth preparedness and complication readiness

137

Case Study
W/ro Tadelech lives in Mekit Woreda. The journey from
village to city can take days, and she lives far from even a
health post. Tadelech is 25 years old and has already
delivered two children safely in the village. This is her third
pregnancy. Contractions started at 40 weeks of gestation.
After two days of labour Tadelech is carried on a homemade stretcher to your health post. When you examine
Tadelech, finds two swellings (masses) over the abdomen,
with a depression between them at about the level of the
womans umbilicus. You also find that the babys head is not
engaged (it is just above the pelvic brim). On vaginal
examination, you estimate that Tadelechs cervix is 8 cm
dilated and the station of the fetal head is 3. Tadelechs
vagina is hot and dry and she has oedema of the vulva.
138

Questions
1. From the case study what signs do you find that
indicate prolonged or obstructed labour?
2. How do you manage Tadelechs condition?
Generally
a. What OL?
b. Mention the cause of OL?
c. Elaborate the Clinical findings of OL?
d. Describe the Rx of OL?
e. How can you reduce the risks of a prolonged and
obstructed labour?

139

Summary
Obstructed labour is failure of descent of the fetus
through the birth canal (pelvis) because there is an
impossible barrier (obstruction) preventing its descent
in spite of strong uterine contractions.
Causes of obstructed labour are CPD, abnormal
presentations, fetal abnormalities and abnormalities of
the maternal reproductive tract.
Causes of prolonged labour are abnormality in one or
more of the three Ps: passenger and passage.
The best diagnostic tool for you to identify prolonged
labour is the partograph.
140

Summary cont
The clinical features of obstructed labour include mother
stay in labour for more than 12 hours, exhausted and
unable to support herself, unbalanced vital signs,
dehydrated, Bandls ring formation in the abdomen, bladder
full above the symphysis pubis, big caput and big moulding,
may be edematous vaginal opening
Common maternal complications of obstructed labour
include sepsis, haemorrhage, shock paralytic ileus,
postpartum haemorrhage, fistula formation &death.
Common fetal complications of obstructed labour are
severe asphyxia, neonatal sepsis and death.
Early referral can save the life of the woman and the baby
in case of obstructed labour.
141

Thank you!!!
if you have question well come

142

UTERINE RUPTURE
Ruptured uterus is defined as a tear in the wall of
the uterus which commonly occurs in the lower
segment of the uterus.
The tear could be anterior, posterior, lateral or
combination of these. It could be transverse,
vertical or combination.
In most, it occurs in the intrapartum period but
antepartum rupture can occur especially in women
with classic/ vertically c/s scar or scars related
to other gynecologic surgeries
143

Rupture of the uterus is classified into two

categories.
Complete (true) - the tear extends through the
whole thickness of the uterus including the
myometrium and the peritoneum so that there
is free communication with the peritoneal cavity.
Incomplete (occult) - the tear extends through
the myometrium but not through the overlying
peritoneum so that there is no free
communication with the general peritoneal
cavity.

144

What factors can you suggest that would increase

the risk of a ruptured uterus occurring?

145

Key
Uterine rupture may occur if the labour is obstructed due to:
Cephalopelvic disproportion
Persistent malpresentation or malposition
Multiple pregnancy (twins or more babies, especially if
they are locked at the neck or conjoined/fused
together).
Physical obstruction preventing the baby from
descending (e.g. a tumour in the abdomen or uterus).
Scarring of the uterus
abdominal massage during labour is a common cultural
practice, particularly when labour is prolonged

146

Group discussion (5minutes)

I. Which one do you think high risk for uterine
rupture?
A. multiparous
B. primigravidia
Why?

147

 Because by 28 weeks the fetus will have reached a

substantial size and weight, so the multiparous
womans uterus will already have been stretched.
As a result of this stretching it makes delivery
expected to be easier in subsequent pregnancies
which is, in fact, usually the case.
Despite this fact, multiparous women are more
likely than primiparous (first-time) mothers to
experience uterine rupture if their labour is
obstructed.

148

Causes
The commonest cause of uterine rupture is neglected
obstructed labor especially in multipara.
The next common cause is rupture or dehiscence of a
previous C/S scar.
Other causes include
Oxytocin or prostaglandin administration
Difficult instrumental delivery like high or mid forceps
Difficult destructive delivery
Internal podalic version and breech extraction
Difficult manual removal of placenta
Other surgical scars on the uterus(repaired ruptured uterus,
myomectomy)
Vigorous fundal pressure and sharp penetrating trauma
149

Warning signs of imminent uterine rupture

Frequent, strong uterine contractions, occurring
more than 5 times in every 10 minutes, and/or each
contraction lasting 6090 seconds or longer.
FHR above 160 beats/minute, or below 120
beats/minute, persisting for more than 10 minutes
this is often the earliest sign of obstruction affecting
the fetus.
Bandls ring formation
Tenderness in the lower segment of the uterus.
Possibly also vaginal bleeding.
150

How can the partograph aid you in spotting the

potential imminence of uterine rupture?

151

Answer
Since you use it to chart the frequency and
duration of contractions, as well as changes to
the fetal heart rate, you will quickly see if either
of these is in the warning zone indicated

152

Clinical features

Diagnosis of uterine rupture is usually reached

using clinical symptoms and signs.
But at times it is difficult especially in those with
scar on the uterus and those under regional
anesthesia.
Diagnosis in these cases often needs manual
exploration of the uterus and even exploratory
laparatomy.
Clinical features are variable and are largely
dependant on the time elapsed after the rupture, the
site and extent of the rupture, the degree of fetal and
placental extrusion.
153

C/m Cont

The usual symptoms of impending (imminent)

uterine rupture are
Worsening abdominal pain especially
suprapubic persisting between contraction
Strange feeling of the fetus moving upwards
Tender swollen abdomen

154

The usual symptoms in uterine rupture

include:
Sudden cessation of contraction and fetal
movement often following a sharp tearing pain at
the height of the 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
Easily palpable fetal parts, absent movement
and fetal heart sounds
155

The clinical signs are also variable and include

Normal vital signs to profound shock (tamponade
effect and involved blood vessels)
Variable pallor
Variable abdominal tenderness and distension
Absent uterine contraction and fetal heart beat
In anterior rupture, defect in the uterine wall and
easily palpable fetal parts
Variable shifting dullness
Presenting part may be jammed or retracted with
variable vaginal bleeding
Feeling a defect on vaginal examination or seeing the
defect at laparatomy makes definitive diagnosis of
uterine rupture.

156

Management
The life of the patient depends on the speed and
efficacy with which hypovolemia is corrected,
hemorrage is controlled and infection is treated.
In places where surgical intervention cannot be
provided, early referral should be undertaken only after
resuscitative measures are initiated.
When labour ends with a ruptured uterus, the usual
consequences for the woman (if she survives), are
losing her baby and losing her uterus.

157

A. Supportive management
This has the objective of initiation of treatment for
impending or full blown shock, intrapartum
infection and preparing the woman for
laparatomy.
Components include:
Opening intravenous line with wide bore cannula.
Vigorous infusion of crystalloids.
Initiation of parenteral antibiotics covering the
mixed organisms like obstructed labour.

158

Cont

Performing laboratory tests for hemoglobin and

blood group/RH status.
Preparing at least two units of cross matched
blood.
Inserting naso-gastric tube and folley catheter

159

B. Definitive management
Immediate laparatomy should be performed.
The surgical options include
total abdominal hysterectomy
sub- total abdominal hysterectomy
repair of the rupture with bilateral tubal ligation
b/c there is an increase risk of rupture of uterus
with subsequent pregnancy the option of
permanent contraceptive need to be discussed
with the women after the emergency is over

160

Thank you!!!
if you have question well come

161

Precipitous Labor and Delivery

Not only can labor be too slow, but it also can be

abnormally rapid.
Precipitousthat is, extremely rapidlabor and
delivery may result from an abnormally low
resistance of the soft parts of the birth canal,
from abnormally strong uterine and abdominal
contractions, or rarely from the absence of
painful sensations and thus a lack of awareness
of vigorous labor.

162

Definition
precipitous labor terminates in expulsion of the fetus in less
than 3 hours.
Short labors, defined as a rate of cervical dilatation of 5
cm/hr or faster for nulliparas and 10 cm/hr for multiparas,
were associated with abruption, meconium, postpartum
hemorrhage, cocaine abuse, and low Apgar scores.
Maternal Effects
Precipitous labor and delivery seldom are accompanied by
serious maternal complications; if the cervix is effaced
appreciably and compliant, the vagina has been stretched
previously, and the perineum is relaxed.
Conversely, vigorous uterine contractions combined with a
long, firm cervix and a noncompliant birth canal may lead to
uterine rupture or extensive lacerations of the cervix, vagina,
vulva, or perineum.
163

 In latter circumstances that the rare condition of

amnionic fluid embolism most likely develops.
The uterus that contracts with unusual vigor
before delivery is likely to be hypotonic after
delivery, with hemorrhage from the placental
implantation site as the consequence.
Postpartum hemorrhage from uterine atony

164

Effects on Fetus and Neonate

Perinatal mortality and morbidity from precipitous labor
may be increased considerably for several reasons.
The tumultuous uterine contractions, often with
negligible intervals of relaxation, prevent appropriate
uterine blood flow and fetal oxygenation.
Additionally, resistance of the birth canal may cause
intracranial trauma, although this is rare.
brachial palsy was associated with such labors in one
third of cases.
Finally, during an unattended birth, the newborn may
fall to the floor and be injured or may need
resuscitation that is not immediately available.

165

Treatment
Unusually forceful spontaneous uterine contractions
are not likely to be modified to a significant degree
by analgesia.
The use of tocolytic agents such as magnesium
sulfate is unproven in these circumstances. Use of
general anesthesia with agents that impair uterine
contractibility, such as halothane and isoflurane, is
often excessively heroic.
Certainly, any oxytocin agents being administered
should be stopped immediately

166

Quiz (7minutes )
Discuss on uterine rupture (5pts)
Consider the following Point during your
discussion.
a. what is Ux rupture ?(0.5)
b. Causes?(1)
c. clinical investigations or manifestation (2)
d. Management and prevention(1.5)

167

Postdates Pregnancy

Postterm pregnancy is a pregnancy that

extends to or beyond 42 weeks or 294 days.
More recently it has been used to refer to any
pregnancy that goes beyond 41 weeks.
Postdates pregnancy is a pregnancy that
extends beyond 40+0 weeks plus one or more
days (anytime past the estimated due date).
Prolonged pregnancy is any pregnancy past
42weeks; synonymous with postterm.

168

There are a variety of methods for establishing

the EDD.
A. Length of gestation: The overall length of gestation is
calculated from the first day of the last menstrual period
(LMP) based on a 28 day cycle and is often cited as
280 days or 40.0 weeks
B. Date of conception : Basal body temperature before
and after conception can be used reliably to determine
the onset of pregnancy
C. Menstrual dating: The standard method for EDD
calculation using LMP is by Naegeles Rule
D. First Trimester Ultrasound : For the most accurate
estimation of gestational age, first trimester ultrasound
has a margin of error of +/ 5 days
169

Complications
i) Perinatal Mortality: Research suggests that the
perinatal risk seems to be higher for intrauterine
growth restricted or small for gestational age infants
than it is for average for gestational age infants born
after 40 weeks.
ii) Macrosomia and Shoulder Dystocia
Post-term infants have a higher risk of being
macrosomic, and therefore have a greater risk of
shoulder dystocia.
Shoulderdystocia can cause maternal trauma,
perinatal morbidity (hypoxia, nerve injury, broken
bones, damaged tissues) and in rare cases, perinatal
mortality
170

iii) Meconium Aspiration Syndrome

Meconium stained fluid and meconium aspiration
syndrome increases beyond 40 weeks gestation.
Meconium aspiration is associated with respiratory
distress and pulmonary infection
iv) Oligohydramnios
Oligohydramnios may be due to declining placental
function. Complications include umbilical cord
compression, resulting in transient or permanent
decreased oxygenation to the fetus.

171

Other Complications
Increased incidence of non-progressive labour
Increased incidence of instrumental delivery
Increased incidence of caesarean section delivery
Contributing Factors

Nulliparity
High BMI
Previous history of postdates pregnancy
Male fetal gender

172

Prevention

Calculating the estimated due date (EDD) by the

most accurate method available may assist in
preventing post-term pregnancy.
In general, the opportunity for accurate
assessment of gestational age decreases with
the passage of time. Once the pregnancy has
been dated with the most accurate data
available, the EDD should not be changed.

173

Methods include:
- Naegele's rule
- adding 280 days to the first day of the last
normal menstrual period (LNMP)
- adding 266 days to the conception date
- ultrasound dating (more accurate the earlier the
gestation)

174

Management Options

Assess
Reviewing EDD.
Reviewing fetal movement count with client
Assess maternal and fetal conditions
Decide on the management with each
advantage and disadvantage
Discuss with obstetrician

175

Options between 41+0 and 42+0 weeks of pregnancy

Expectant Management versus Induction of Labour
Prior to 41+0 weeks gestation discuss the risks and
benefits of induction of labour versus expectant
management, and offer induction of labour anytime
between 41 and 42 weeks.
Nurse are required to refer their clients for a physician
consultation visit at 42 weeks.
Both induction and expectant management remain
options after 42 weeks.
Postterm pregnancy alone is not an indication for
transfer of care. The nurse remains the primary care
provider in the hospital unless a specific indication for
transfer of care arises.
176

FETAL DISTRESS

177

Session objectives

At the end of this session student will be able:

To define fetal distress and describe its
pathophysiologic basis.
To list the etiology of fetal distress with emphasis
to iatrogenic causes.
To discuss the diagnostic features of fetal distress.
To describe the management of fetal distress.

178

Definition
Fetal Distress is the sign of inability to
withstand the stress of labor leading to
asphyxia, which if prolonged, places the fetus at
risk of permanent neurologic injury, multiple
organ failure and eventually death.
There is no single indicator that definitely
diagnoses fetal distress but abnormal fetal heart
rate patterns is usually used in the diagnosis.

179

Pathophysiology
A normally grown fetus has stored reserves of glycogen
and fat to be used at times of stress like labor.
In labor temporary cessation of placental transfer of
oxygen and nutrients occur during uterine contraction.
This results in anaerobic metabolism with accumulation of
lactic acid and carbon dioxide that increases as labor
progresses.
This is normally corrected between each contraction
provided there is adequate oxygen carrying capacity of
the mother, adequate perfusion of the placenta,
adequate relaxation period between contractions
(resting tonus), good umbilical blood flow (patent vessels)
and adequate fetal energy reserve.
180

Cont

Failure to correct this mild form from

pathological conditions results in progressive
accumulation of lactic acid and carbon dioxide.
This results in acidosis and reduction of oxygen
ending up in asphyxia .
The net effect is change in fetal heart beat, which
forms the basis fir diagnosis and in extreme cases
passage of muconium.

181

Etiology

In general all forms of fetal distress originate

from deficient delivery of oxygen to the fetus.
Some occur as the result of sudden catastrophic
events like massive abruptio placenta and cord
prolapse.
Some are iatrogenic in origin.

182

I. Uterine and placental factors

Increased tone and frequency of contraction
from oxytocin induction and augmentation and
precipitate labor
Decreased placental surface area from abruptio
placenta
Uteroplacental insufficiency from post term
pregnancy and hypertensive disorders of
pregnancy

183

II. Umbilical cord

Cord prolapse either iatrogenic or spontaneous
Cord compression from oligohydramnios and
entanglement and knot
III. Fetal factors
Limited or exhausted reserve like in intrauterine
growth restriction, prolonged labor and fetal
anemia (like isoimmunization)

184

IV. Maternal factors

Decreased oxygenation from cardiac and
respiratory diseases, severe anemia, smoking
Decreased blood pressure from sudden
maternal shock (example APH), supine
hypotension syndrome and conduction anesthesia

185

Diagnosis
The diagnosis of FD is usually based on:
I. Abnormal fetal heart rate patterns
An abnormal FHR pattern is associated with high
false positive rate; therefore, it should be used as
a screening method for which additional
methods (scalp PH) are needed for confirmation.
In the absence of confirmatory tests combination of
abnormal patterns should be used to increase the
sensitivity.

186

The abnormal patterns include

Baseline bradycardia is classified as moderate
(fetal heart beat of 80-100/min for >3 min) and
severe (fetal heart beat of <80 /min for >3 min)
Baseline tachycardia is classified as mild (fetal
heart beat of 161-180 /min for >15 min) and
severe (fetal heart beat of > 180 / min for > 15 min)
Repeated late deceleration
Severe recurrent variable deceleration (drop of
FHB to < 70/ min with duration of > 60 sec)
Reduced beat to beat variability

187

II. Fetal scalp blood PH and gas analysis

Currently, it is the best method to assess the

acid base status of the fetus. It needs special
gas analyzer and is not available in all settings.

188

Management
The management of fetal distress has two components
I. Correction of the potential insults
(intrauterineresuscitation)
Put the mother in left lateral position
Start intravenous infusion of fluids(dextrose in saline with
40 %glucose)
Give oxygen by mask at the rate of 8-10 liters/minute
Discontinue oxytocin
Correction of hypotension of regional anesthesia
For cord prolapse put in knee chest position and disimpact
the presenting part
Others - amnioinfusion for cord compression
-acute tocolysis with terbutaline till delivery
189

II. Remove the fetus from the hostile environment

Deliver the fetus by the most expeditious route.
This is accomplished by caesarian section (if in the
first stage or if prerequisites for instrumental
delivery are not met in the second stage) or by
instrumental delivery (if in the second stage).

190

Questions
1. Describe the pathophysiology of fetal distress.
2. Enumerate the causes of fetal distress.
3. Discuss the management of fetal distress

191

 Read about disseminated intravascular

coagulation (DIC)
Amniotic fluid embolism

192

OPERATIVE DELIVERIES

193

Session objectives
At the end of this session student will be able to:
Describe instrumental deliveries (obstetrics forceps
and vacuum extractor).
identify the indications, contraindication,
prerequisites, techniques and complications of
instrumental deliveries.

194

Operative delivery
An operative delivery refers to an obstetric
procedure in which active surgical measures are
taken to accomplish delivery in the presence of
maternal and fetal risks.
Operative delivery can be divided into :
I. operative vaginal delivery and destructive
delivery
II. cesarean delivery

195

Brain storming

A. what is instrumental deliveries?

B. Why instrumental deliveries are used ?

196

Instrumental delivery

Forceps delivery and vacuum delivery constitute

instrumental deliveries.
These are techniques used to assist a mostly in
the second stage of labour to speed up the
progress.
Except for some variations the indications,
prerequisites and complications of these
procedures are similar.
They are entirely different in the technique used.

197

Forceps delivery

Forceps delivery is a means of extracting the

fetus with the aid of paired metallic instrument
called obstetric forceps.
Each part of the obstetric forceps is composed of
a blade, shank, lock and the handle.

198

Spares of Obstetrics forceps

199

Classification of Forceps Delivery

Based on station forceps delivery is classified as:

Outlet forceps: head has reached the pelvic floor
and is visible at the vulva.
Low forceps: head at station +2 cm or lower but
has not reached pelvic floor.
Mid forceps: head is engaged but station is above
+2. It should be done in an OR.
High forceps: head is above station 0 and is not
engaged.

200

Indications
Fetal distress in the second stage of labor
Prolonged second stage of labor: inefficient
uterine contraction or maternal exhaustion or
malpositions.
Maternal conditions which need shortening of
the second stage of labor, where pushing is
contraindicated like cardiac disease, HDP and
previous C/S.
After coming head of breech

201

Prerequisites (for outlet and low forceps)

Well documented indication should be present

Cervix must be fully dilated
Membranes must be ruptured
Presenting part must be either vertex, mento
anterior face presentation or after coming head
of breech
Head must be engaged and station below +2
Exact position of the head should be determined

202

Cont
Prerequisites (for outlet and low forceps)

No gross CPD
Maternal bladder should be empty
Appropriate anesthesia should be given and
prophylactic episiotomy done
Adequate skill and experience

203

Technique of out let forceps delivery

A Anesthesia adequate /epidural or pudendal
appropriate positioning/ lithotomy &
Clean and drape the vulva.
B Bladder

cathterization

C Cervix

fully dilated / membranes ruptured

D Determine position, station, pelvic adequacy

E Equipment complete working forceps
Lubricate the blades with antiseptic
solution
204

Contmnemonic
F Forceps phantom application
Lt blade , LT hand, maternal Lt side pencil grip &
vertical insertion with Rt thumb directing blade
Rt blade , RT hand, maternal Rt side pencil grip &
vertical insertion with Lt thumb directing blade
Lock blades (If difficulty is encountered, remove
the blades and recheck the position of the fetal head)

205

SAMPLE APPLICATION

206

SAMPLE APPLICATION

207

Both blades introduced. The 2 handles are brought

together and locked. If application is correct, the handles
lock precisely, without the need for force.

208

209

Contmnemonic
Check application:
Post fontanelle 1cm above the plane of the shanks
Sagittal suture lies in the midline of the shanks
/perpindicular to the plane of the shanks
The operator can not place more than a fingertip
between the fenestration of the blade & the fetal head
on either side

210

Contmnemonic
G Gentle traction applied with contraction & maternal
expulsive efforts
H Handle elevated traction in the axis of the birth canal
do not elevate handle to early
I Incision

consider episiotomy if laceration

imminent
As head crowns make episiotomy

J Jaw

remove forceps when jaw is reachable

or delivery assured

211

212

213

 Following the delivery of the placenta,

inspect the lower genital tract for tear and
episiotomy for extension.
Repair episiotomy and any tear.
Provide care for the neonate and check for
complications on the neonate.
Document your findings

214

Complications of forceps delivery

Fetal
The fetal laceration of face and scalp,
cephalhematoma, facial nerve injury, fracture of
face and skull, intra cranial bleeding and increased
risk of MTCHT.
Maternal
The maternal complications include tears of
genital tract (perineal, vaginal, and cervical),
episiotomy extension and uterine rupture with or
without bladder rupture.

215

 forceps delivery case.FLV

forceps delivery.FLV

216

Review questions

1. List the indications of forceps delivery

2. List the prerequisites to forceps delivery.
3. List the complications of forceps delivery.

217

VACUUM-ASSISTED VAGINAL DELIVERY:

The vacuum extractor is a traction instrument used as
an alternative to the obstetric forceps.
It is designed to deliver the fetal head by drawing the
scalp into the cup forming an artificial caput called the
chignon.
The vacuum extractor has advantages over forceps
it needs limited space in the birth canal.
it brings about autorotation of the fetal head at
the level of the pelvis.
Generally anesthesia is not required and the mother
shares in the delivery and helps to push
Episiotomy is not always necessary
218

Prerequisites:

Preparation of equipment prior to the procedure

Complete cervical dilatation (can be applied >= 8cm)
Ruptured membranes
Vertex presentation
Empty bladder
No evidence of CPD
Cesarean section capability
Live fetus at term and need for anesthesia is less and
routine prophylactic episiotomy is not a must
It can be applied for higher stations. Head must be engaged
station 0 or below (descent of less than 2/5)
An experienced operator.
219

Indications:

The indications for vacuum delivery are:

Non -reassuring fetal heart rate pattern/FHB
shortening of the second stage of labor for fetal or
maternal reasons
prolonged second stage of labor not due to
dystocia. Why?
Generally
The indications are similar to forceps delivery
except after coming head of breech.

220

Contraindication:

The contraindications for vacuum delivery are:

Breech presentation
Unengaged vertex
Incompletely dilated cervix
Clinical evidence of CPD
Deflexed attitude of fetal head
Fetal conditions (e.g. thrombocytopenia)
Known bone demineralization condition (e.g.
osteogenesis imperfect).
221

The classification of vacuum

Outlet vacuum is the application of vacuum when

(a) the fetal scalp is visible at the introitus. (b) the
fetal skull has reached the pelvic floor or at or on
the perineum.
Low vacuum is the application of vacuum when
the leading point of the fetal skull is at station +2 or
greater and not on the pelvic floor.
Mid vacuum is the application of vacuum when the
head is engaged but the leading point of the fetal
skull is above station +2.

222

Cont

vacuum above station +2 can be attempted

while simultaneously initiating preparation for a
cesarean delivery in case the vacuum maneuver
is unsuccessful.
Under no circumstances should vacuum be
applied to an unengaged head.

223

Vacuum Application
General Procedure: the procedure of vacuum delivery
is followed as ABCDEFGHIJ mnemonic
A Anesthesia - adequate
- Appropriate positioning & access
B Bladder - cathterization
C Cervix - fully dilated / membranes ruptured
D Determine - position, station, pelvic adequacy
E Equipment - inspect vacuum cup, pump, tubing,
- check pressure
224

F Fontanelle
position the cup over the posterior fontal
-ve pressure increase 10 cm H2O initially & between
cont
Sweep finger around cup to clear maternal tissue
Increase pressure to 60 cm H2O with the next
contraction
G Gentle traction
pull with contractions only
Traction in the axis of the birth canal
Ask the mother to push during cont
I incision if needed ?
H handling properly
J- if the Jaw visible remove the cup and control manually

225

In a fully flexed head the mento-vertical

diameter is along the pelvic axis.

226

AXIS ANIMATION

227

After determining position of the head, (A) insert the cup into the vaginal
vault, ensuring that no maternal tissues are trapped by the cup. (B) Apply the
cup to the flexion point 3 cm in front of the posterior fontanel, centering the
sagittal suture. (C) Pull during a contraction with a steady motion, keeping
the device at right angles to the plane of the cup. In occipitoposterior
deliveries, maintain the right angle if the fetal head rotates. (D) Remove the
228
cup when the fetal jaw is reachable

Mid pelvis

229

Pelvic Floor

230

Outlet

231

Outlet Vacuum

232

Cont
As soon as the head is delivered release the cup and
complete the delivery of the fetus and the placenta.
Following the delivery of the placenta, inspect
the lower genital tract for tear and episiotomy for
extension. Repair episiotomy and any tear.
Provide care for the neonate and check for
complications on the neonate.
Document your findings

233

Complications

The fetal and maternal complications are similar

to forceps delivery but generally occur at
reduced incidence.
Localized scalp edema which disappears in few
hours, scalp abrasions and lacerations and
necrosis of scalp from prolonged application of
the cup is usual.

234

Complications of vacuum assisted delivery:

Maternal Risks:
Perineal Injury (extension of episiotomy)
Vaginal and Cervical lacerations
Postpartum hemorrhage
Fetal Risks:
Intracranial hemorrhage
Cephalic hematoma
Facial / Brachial palsy
Injury to the soft tissues of face & forehead
Skull fracture
Localized scalp edema which disappears in few hours
scalp abrasions and lacerations and necrosis of scalp from
prolonged application of the cup is usual
235

Molding

236

Hematoma

237

Animation about vacuum delivery

vacuum demo.FLV

238

Review questions
1. List the indications of vacuum delivery.
2. List the prerequisites to vacuum delivery.
3. List the complications of vacuum delivery.

239

Destructive delivery

Session objectives
At the end of this session student will be able to:
Name the types destructive deliveries
Describe the prerequisites for destructive deliveries
Identify complications of destructive deliveries

240

Destructive delivery
Destructive delivery is vaginal operative delivery that
accomplishes delivery of the fetus by reducing its
size in a woman with obstructed labour with dead
fetus.
The advantages of destructive delivery over C/S
for a woman with OL and fetal death are:
The uterus will remain intact, thus avoids the risk
of rupture of the uterus in the subsequent
pregnancies.
Peritoneal contamination by infected uterine contents is
avoided
Risks of anesthesia and prolonged postoperative stay
in bed are avoided
241

Types of destructive delivery

I.

Craniotomy is destructive delivery done on the

head.
It involves reducing the size of the head by
removing the brain tissue through an opening
made in the skull of the fetus.
Depending on the presentation the brain tissue can
be approached through the suture lines and
fontanel or the palate or the foramen magnum.

242

II. Decapitation: is destructive delivery for

impacted shoulder presentation with hand
prolapse.

It involves severing the neck of the fetus

allowing the delivery of the rest of the body and
later the head.

243

III. Evisceration: is also a destructive operation for

impacted shoulder presentation with hand
prolapse.
It involves removing the abdominal and thoracic
viscera through an opening made in wall of the
thorax or abdomen.

244

IV. Clediotomy: is a destructive operation for

shoulder dystocia.

It is reduction of the biacromial diameter by

cutting the clavicles.
Note: Destructive operations should ideally be
performed in an OR under general ansthesia
with at least two units of cross matched blood
available.

245

Prerequisites
Clear indication- obstructed labour (gross CPD,
impacted shoulder presentation, shoulder presentation)
Fully dilated cervix
Dead fetus (need to be confirmed by ultrasound or
auscultation by three people)
Accessible presenting part for the type of procedure
selected ( head with decent of < 2/5 for craniotomy, neck
for decapitation, axilla or abdomen for evisceration)
Imminent rupture or rupture of the uterus ruled out
Access for immediate laparatomy and blood transfusion
Adequate skill and ansthesia

246

Complications

Major complications are rupture of the uterus,

genital tract lacerations (perineal, vaginal and
cervical), bladder and rectal damage.

247

Review questions

1. Name the types of destructive deliveries.

2. List the prerequisites destructive deliveries
3. complications of destructive delivery.

248

Caesarian section (c/s)

249

Session objective
At the end of this session student will be able to:
Describe the major types of caesarian section
with their advantages and disadvantages
List the major complications of caesarian section

250

Brain storming

What do you think about C/S ?

Why C/S is used ?
What is the role of nurses during C/S ?
What complication are related to C/S ?

251

Caesarian section (c/s)

Caesarian section is delivery of fetus or fetuses

along with the placenta and membranes by an
incision made through the abdominal and uterine
wall after the fetus has reached viability.
Caesarian section is classified as:
Elective,
Emergency

Primary

Repeat

252

Types of caesarian section incision

I. Lower segment transverse (Kerr) caesarian
section
In this type the lower segment is incised transversely
after incising and reflecting the vesico uterine fold of
peritoneum.
This is the most commonly done type of C/S and the
standard OR because it has the following advantages:
Less blood loss, easy to repair
Good wound healing therefore less risk of future
rupture
Less risk of adhesion formation because of its
peritoneal coverage.
253

The major disadvantages are:

Lateral extension with damage to uterine vessels
and ureters
Bladder injury especially in repeat cases.

254

II. Classic (Sanger) caesarian section

In this type uterine incision is made vertically

through the corpora uteri (upper segment).
It is simple and fast to perform but is associated
with a number of disadvantages:
More blood loss and difficult to close
Poor healing of the incision, therefore high chance
of future rupture
Risk of adhesion formation with bowel

255

Cont
Therefore it is not a routine method of C/S
and is only done upon specific indications.
Inaccessible lower segment because of dense
adhesions from previous caesarian section
Large myoma over the lower segment
Highly vascular lower segment from anterior
placenta previa
Fetal malformations like conjoined twin and
transverse lie with back down

256

III. Less common types

Lower segment vertical caesarian section
Delee incision J-shaped extension of the lower
segment transverse incision
Inverted T incision lower segment incision

257

Indications

Caesarian section is done in cases in which

vaginal delivery either is not possible or would
impose undue risks to mother or baby or
both. Some of the indications are clear and
absolute while others are relative

258

Common indications for C/S include:

Cephalopelvic disproportion
Mal presentations (transverse lie, breech,
persistent brow)
Cord presentation and prolapse
Fetal distress in the first stage of labor
Failed induction/ augmentation and instrumental
delivery
Ante partum hemorrhage (placenta previa,
abruption placenta)
259

Cont
Conditions with unripe cervix where rapid
delivery is needed like preeclampsia,
ecclampsia,
Previous C/S after failed trial of scar or electively
Carcinoma of the cervix
The X-factor relative indications, which
considered separately, might not warrant C/S
but when taken together constitute a valid
indication. Example is post term plus elderly
primigravida or prior infertility problem.
260

Procedure and patient care

Informed consent should be obtained.

An IV is opened and crystalloids started.
Hct and blood group should be determined.
Blood should be cross matched and be readily
available.
bladder emptying is done.
Prophylactic antibiotics, if indicated, are given.
gastric decompression by NG tube should be done
in emergency cases.
261

Cont
Both inhalational (general) and regional (spinal,
epidural) ansthesia can be used.
Proper preparation of the operative site is done.
Abdomen is opened by midline, paramedian or
transverse suprapubic incisions.
Fetus is extracted .
The cord is clamped and cut. The placenta is
delivered.

262

Cont

The edges of the uterine incision are caught by

Greenarmytage forceps.
Uterine incision closed in one or two layers by
chromic 0 or1.
Hemostasis secured.
peritoneum closed by continuous chromic 2/ 0.
Abdominal wall closed in layers.

263

Postoperatively

Postoperatively the level of consciousness, vital signs

and degree of vaginal bleeding should be monitored
frequently.
IV fluids are continued until the women taking fluids.
Do not give NPO until bowel sound returns.
Antibiotics and transfusion are given if indicated.
Encourage early ambulation.
Upon discharge ensure that she is taking regular diet,
wound is clean, dry and not infected and there is no
fever.
Counsel on future risks and need to have hospital
delivery in future pregnancies.

264

Complications

Complications occur during the operation or in

the post operative period.
Intra-operative complications include bladder
laceration especially in repeat cases, ureteral
injury, hemorrhage from damaged uterine
vessels, anesthetic complications, fetal blood loss
from incision through placenta or laceration at the
time of incision, trauma at time of extraction and
fetal hypoxia from venacaval compression and
anesthetic drugs.

265

Cont

Postoperative complications include

hemorrhage from atonia or incision site,
pelvic hematoma, endomyometritis, wound site
infection, deep vein thrombosis and future risk of
rupture of the scar in subsequent pregnancies.
Other post operative complications seen in any
surgical patient can be encountered.

266

Vaginal birth after caesarian (VBAC)

In the absence of absolute C/I a woman with C/S scar

can be given the chance to deliver vaginally.
Contraindications which mandate elective C/S are:
Classic or inverted T or low vertical incision with
extension
Two or lower segment incisions or type of incision is
unknown
Gross CPD from macrosomia (estimated wt > 3500
gm) or any degree of pelvic contracture
Multiple pregnancies
Malpresentation
Conditions that preclude vaginal delivery or need
induction
267

Review Questions

1. Describe the major types of caesarian section

with their advantages and disadvantages.
2. List the complications of caesarian section.
3. List contraindications for Vaginal birth after
caesarian (VBAC)

268

Obstetric Shock

A momentary pause in the act of death.

-John Collins Warren, 1800s

Shock is a symptom of its cause.

269

Session objective
At the end of this session student will be able to:
Identify the major types of obstetric shocks with
their Pathophysiology and clinical manifestations.
Describe management options for mother which
develops obstetric shocks (Resuscitation and
Special Circumstances

270

Introduction

Shock
One of the most common causes of death
Shock and Respiratory Failure together
account for majority of emergent ICU admissions
Shock mortality is high

271

Brain storming

What is obstetric shock ?

What are the common obstetric shocks ?
What clinical investigations used to suspect
obstetric shock ?
Management obstetric shock ?

272

Shock - Definition
Functionally, Shock represents a clinical
condition in which intravascular volume (and/or
perfusion) is below intravascular capacitance
(and/or demand)
Operationally, Shock is broadly divided into
three types:
Hypovolemic
Cardiogenic
Neurogenic
273

Shock - Obstetrics

In this course will focus predominantly on two

conditions that incite the pathophysiologic
cascade of shock:
Hemorrhagic
Septic

274

Shock - Pathophysiology

Primary pathophysiologic mechanism in shock is

impaired oxygen utilization by tissue
Impaired utilization may be from:
reduced perfusion
deficient uptake
abnormal relative perfusion

275

Obstetric Hemorrhagic Shock

Hemorrhagic = Hypovolemic
Leading cause of Obstetric death
Significant cause of morbidity during pregnancy
and immediately postpartum
May be poorly recognized due to physiologic
changes of pregnancy

276

Postpartum Hemorrhage

Pregnancy is normally a state of hypervolemia

and increased RBC mass Blood volume
normally increased by 30%-60% (1-2 L)
Pregnant patients are therefore able to tolerate
some degree of blood loss Estimated blood loss
is usually about 1/2 of actual loss!

277

Common Causes of Obstetric Hemorrhage

Antepartum
Abruptio Placenta
Trauma
Placenta Previa
Postpartum
Retained Placenta
Uterine Atony
Uterine Rupture
Lacerations
Coagulopathy

278

C/S

Hypotension
Signs of Organ Hypoperfusion
Mental Status Changes
Oliguria
Lactic Acidosis

279

Goals of Shock Resuscitation

Restore blood pressure

Normalize systemic perfusion
Preserve organ function

Obstetric Hemorrhage - Treatment

First step in treatment is recognition
Pregnant patients may have modified or
attenuated response to moderate blood loss
Blood loss may not be noted at vaginal delivery
due to distraction
Despite standards to the contrary, nursing staff
may be multi-tasked during critical post partum
period

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Treatment - Hemorrhagic Shock

Recognize and treat underlying condition!
Restore intravascular volume
Blood
Volume
Access
Monitor patient until resuscitation successful
Prevent/manage hypothermia
Treat coagulopathy

282

Volume Therapy - Hemorrhagic Shock

In addition to volume loss from hemorrhage itself,
vascular damage produces pronounced
intravascular volume depletion
First choice in treatment is crystalloid (Lactated
Ringers or 0.9 NS??)
NO compelling advantage for the use of colloid
- outcome not different
Volume = 3:1 - adjusted to clinical response

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 Endpoints (Positive and Negative)

improved blood pressure
improved mental status
resumption of urine output
pulmonary edema!!

284

Septic Shock
Septic (defined earlier) associated with documented
infection is termed SEPSIS
Severe sepsis indicates the presence of organ
dysfunction, hypoperfusion, and/or hypotension
Septic shock consists of severe sepsis refractory to
volume resuscitation
Multisystem dysfunction syndrome (MODS) is the
terminal phase of this sequence of events

285

Cont

Progression from bacteremia into septic shock is

poorly predictable
Exaggerated inflammatory response predicts
poorer outcome
Inflammatory mediators may mimic syndrome

286

Septic Shock - Obstetrics

Septic Shock is uncommon in Obstetric patients
Bacteremia rate (with infection) is approx. 8%10%
Up to 12% incidence of septic shock with
bacteremia

287

Septic Shock - Obstetrics

Infection Type:
Post C-section endomyometritis
post vaginal delivery endomyometritis
UTI/Pyelonephritis
Septic Abortion
Toxic Shock Syndrome

288

Septic Shock Cascade

Inciting Bacteremia

Mediator Release

Cell Injury

ARDS

Hypotension Acidemia
Impaired Immunogenic
Response

289

 Shock is a systemic disease!

Myocardial dysfunction is a progressive feature of
septic shockCO is initially increased (but not enough to meet
hypermetabolic demands)
Direct myocardial depression occurs as a late and
progressive finding
Initial low cardiac filling pressure aggravates
inadequate CO response
Oxygen debt becomes the predominant
hemodynamic feature of progressive shock
290

 Treatment of Septic Shock

Antibiotics
Volume
Mediator Therapy
Corticosteroids
Surgical
OB/GYN infections usually should be empirically
treated by broad spectrum therapy
Once patient with full blown septic shock,
outcome not appreciably improved in era of
antibiotics
291

Review questions

List the common obstetric shock

What treatment are provide for mother with
different obstetric shock
Prevention way helpful minimize obstetric shock

292

Version
Version is a procedure used to turn the fetal
presenting part from breech to cephalic presentation
(cephalic version) or from cephalic to breech
presentation (podalic version).
cephalic version is performed by manipulating the
fetus through the abdominal wall, the maneuver is
known as external cephalic version.
Podalic version is performed by means of internal
maneuvers and is known as internal podalic
version.
External cephalic version is regaining popularity,
whereas internal podalic version is rarely used
293

External Cephalic Version

External cephalic version is used in the management of
singleton breech presentations or in a nonvertex second
twin.
In carefully selected patients, it is safe for both mother
and fetus.
The goal is to increase the proportion of vertex
presentations near term, thus increasing the chance for
a vaginal delivery.
In the past, external cephalic version was performed
earlier in gestation but was accompanied by high
reversion rates, making additional procedures
necessary.
Now it is performed in patients who have completed 36
weeks of gestation so that the risk of spontaneous
reversion is decreased, and, if complications arise,
delivery of a term infant can be accomplished.
294

Indications
Patients with unengaged singleton breech
presentations of at least 36 weeks' gestation are
candidates for external cephalic version.
The procedure is more successful in multigravidas
and those with a transverse or oblique lie.
Use of fetal heart rate monitoring and real-time
ultrasonography are essential to document fetal
well-being during the procedure.
The use of tocolytics in external cephalic version is
controversial.
295

Contraindications
Contraindications to external cephalic version
include engagement of the presenting part in the
pelvis, marked oligohydramnios, placenta
previa, uterine anomalies, presence of nuchal
cord, multiple gestation, premature rupture of
membranes, previous uterine surgery (including
myomectomy or metroplasty), and suspected or
documented congenital malformations or
abnormalities (including intrauterine growth
retardation).
296

Complications
Complications are rare, occurring in only 12% of all
external cephalic versions.
Complications include placental abruption, uterine
rupture, rupture of membranes with resultant
umbilical cord prolapse, amniotic fluid embolism,
preterm labor, fetal distress, fetomaternal
hemorrhage, and fetal demise.
Thus, given the potential for catastrophic outcome,
this procedure should be performed in a facility where
immediate access to cesarean delivery is available.
Patients require extensive counseling regarding the
version procedure, with disclosure of all risks,
benefits, and alternatives so that an informed
medicolegal decision can be made.
297

Fetal Heart Rate Abnormalities

Fetal heart rate abnormalities can be readily
documented during external cephalic version by
intermittent electronic fetal monitoring (EFM) or
ultrasonographic surveillance.
Fetal bradycardia occurs in 20% of cases, but
normal cardiac activity usually will return if the
procedure is stopped for a short time. If significant
unremitting fetal cardiac alterations occur, the
attempt at version should be discontinued and
preparation for cesarean delivery undertaken
immediately.
298

Fetomaternal Transplacental Hemorrhage

Fetomaternal (transplacental) hemorrhage (FMH)
may occur during version and has been reported
to occur in 628% of patients undergoing external
cephalic version, although the amount of
hemorrhage rarely results in clinically significant
anemia.
The Kleihauer-Betke acid elution test should
be performed if this condition is suspected. In
cases of an Rh-negativeunsensitized woman,
Rh immune globulin should be administered after
external cephalic version to cover the calculated
amount of FMH.
299

Technique
External cephalic version is performed as follows:
1. Obtain informed consent from the patient.
2. Perform an ultrasound examination to verify presentation and to rule out fetal
or uterine abnormalities.
3. Perform a nonstress test. Results must be reactive.
4. If desired, administer a tocolytic to prevent contractions or irritability.
5. dminister anesthesia if desired.
6. Perform ECV. Place both hands on the patient's abdomen, and perform a
forward roll by lifting the breech upward while placing pressure on the head
downward toward the pelvis. If this maneuver is unsuccessful, a backward roll
can be attempted.
7.
Fetal well-being should be monitored intermittently with Doppler or real-time
ultrasound scanning. The procedure should be abandoned in case of any
significant fetal distress or patient discomfort, or if multiple attempts are
unsuccessful.
8. Following the procedure, external FHB monitoring should be continued for 1
hour to ensure stability. If the patient is Rh-negative, administer anti-D immune.
9. If the patient is stable, she can be sent home to await the onset of
spontaneous labor if the version is successful. If unsuccessful, the patient can
be scheduled for an elective cesarean section or a trial of labor with a breech
vaginal delivery planned if the mother is a good candidate.

300

Internal Podalic Version

Internal podalic version is now rarely used
because of the high fetal and maternal morbidity
and mortality associated with the procedure.
It is occasionally performed as a life-saving
procedure or in cases of a noncephalic second
twin .

301

Indications
Internal podalic version is the only alternative to cesarean
section for rapid delivery of the second twin in a
noncephalic presentation if external cephalic version fails.
Thus, when cesarean section is unavailable or when a lifethreatening condition arises (maternal hemorrhage due to
premature placental separation, fetal distress, prolapsed
umbilical cord), internal version may be required.
A life-threatening condition is the only indication for internal
podalic version. The cervix must be completely dilated, and
the membranes must be intact. A skilled operator is crucial
for safe performance of this procedure. In several French
studies, internal podalic version was found to be a reliable
and effective technique with excellent long-term maternal
and fetal prognoses.
302

Contraindications
Internal podalic version is contraindicated in cases
in which the membranes are ruptured or
oligohydramnios is present, precluding easy
version.
This procedure should not be performed through
a partially dilated cervix or if the uterus is firmly
contracted down on the fetal body.
However, recent studies have indicated that
intravenous nitroglycerin can be used to provide
transient uterine relaxation without affecting
maternal or fetal outcome.
303

Complications
Internal podalic version is associated with considerable
risk of traumatic injury to both fetus and mother
associated uterine rupture and hemorrhage caused 5% of
all maternal deaths.
Perinatal mortality rates were 525% (primarily due to
traumatic intracerebral hemorrhage and birth asphyxia).
Considerable birth trauma, including long bone fractures,
dislocations, epiphyseal separations, and central nervous
system deficits, was also linked to this procedure.
For these reasons, internal podalic version has been
abandoned with rare exceptions in favor of cesarean
section.
304

Technique
Internal podalic version is performed as follows:
1. Establish an intravenous line for administration of
parenteral fluids, including blood. Cross-matched
blood should be available in the hospital blood bank.
2. Administer anesthesia to achieve relaxation of the
uterus.
3. Place the patient in the dorsolithotomy position. Insert
a hand through the fully dilated cervix along the fetal
body until both feet are identified, and apply traction
to bring the feet into the pelvis and out the introitus.
Then, grasp both feet firmly. Perform an amniotomy.
Apply dorsal traction on both lower extremities until
both feet are delivered through the vagina. Then,
perform a total breech extraction for delivery of the
body
305