Professional Documents
Culture Documents
JEHAD AL-HARMI
DEPARTMENT OF OBS & GYN
FACULTY OF MEDICINE/KUWAIT UNIVERSITY
You should know-1
• Obstetrical history & examination
• Definition of labor
• Mechanism of labor initiation
• Anatomical considerations:
– The female pelvis
– The fetal skull
• The stages of labor
You should know-2
• The mechanism of labor (vertex, OA)
• Management of normal labor
• Pain relief during labor
• Drugs commonly used during labor
• Induction of labor (IOL)
• Abnormalities of labor
• Malpresentations (breech, brow, face & shoulder presentations)
You should know-3
• Labor in multifetal gestation
• Preterm labor
• Vaginal birth after cesarean section (VBAC)
• Shoulder dystocia
• Complications of the third stage:
– Retained placenta
– Uterine inversion
Obstetrical History-1
• Biodata:
– Name, age, nationality, occupation
• Marital status:
– Duration of marital life, previous marriages & if any
resulted in offspring, consanguinity
• Gravidity = pregnancy
– Nulligarvida
– Primigravida
– Multigravida
Obstetrical History-2
• Parity = delivery of an infant (alive or dead)
weighing 500 g or more which is approximately
20/52
• Nullipara, primipara, multipara, grandmultipara (5
or more)
• G P (T + P + A + L)
• Remember:
– Multiple pregnancy
– Ectopic pregnancy
Obstetrical History-3
Current pregnancy:
– LNMP:
• Accuracy
• Regularity & length of menstrual cycle
• Confounding factors: OCP, lactation, spotting,
Hartman’s sign
– Nigel’s rule:
• To calculate EDD from LMP. Assuming:
– Duration of pregnancy = 266 days from conception
– Ovulation occurs 14 days prior to onset of menstruation
Obstetrical History-4
• Nigel’s rule:
– Add 7 days & subtract 3 months
– 40% deliver within 5/7; 67% within 10/7
– What if cycle length 21 days? Or 35 days?
• Calculate & report gestational age (GA) in
weeks not months
• Exceptions: IVF. 2 dates (EC & ET)
• Obstetrical calculator or calendar
Obstetrical calculator or
calendar
• Two concentric circles
• Outer circle EXAMPLE
represents days &
months of the year – LMP 06/04/2008
• Inner circles – EDD 13/01/2009
represents weeks of
gestation – Today 06/10/2008
– GA 26 weeks
• Arrows indicate
current status
Obstetrical History-5
Other methods to determine GA:
– Date of first positive pregnancy test
• Urine 4-5/52 after LMP
• Serum 8-10/7 after conception
– Uterine size during first half of pregnancy Caution!
– Time of quickening (16-20/52)
– Time of detection of fetal heart beats (FHB)
• Doptone 10-12/52
• Pinard 18-20/52
Obstetrical History-6
Uterine fundus:
– Just above symphysis
pubis: 12/52
– At umbilicus: 20-22/52
– At xiphisternum: 36/52
– What happens after
36/52?
– Lightening
Obstetrical Examination-3
Leopold maneuvers:
• Clockwise from upper
left corner
– Determination of
fundal level
– Fundal grip
– Lateral grips
– First pelvic grip
Obstetrical Examination-5
Leopold maneuvers:
– Second pelvic grip
• Determine:
– SFH & EFW
– Lie
– Presentation
– Position
– Station
– FHR
Obstetrical Examination-6
• Palpation of fetal parts after
28/52
• Description of relationship
of fetus to maternal trunk
and pelvis:
– Lie: relationship of long axis
of fetus to long axis of uterus
• Longitudinal
• Oblique
• Transverse
Obstetrical Examination-7
• Attitude: relationship
of various fetal body
parts to one another
– Flexion
– Extension
Obstetrical Examination-9
Presentation:
– The presenting part of the fetus is that part
which is in or over the pelvic brim
– Cephalic:
• Well-flexed head vertex
• Completely extended face
• Deflexed brow
Obstetrical Examination-10
Presentation:
– Breech:
• Flexed hips, extended knees frank
• Flexed hips & knees complete
• Extended hips & knees footling
– Shoulder
– Cord
Obstetrical Examination-11
• Position: relationship of a denominator
(bony point) on the presenting part to the
right or left side of the maternal pelvis
– Vertex occiput
– Face mentum/chin
– Breech sacrum
• 8 positions for each presentation
Obstetrical Examination-12
Obstetrical Examination-13
• Station:
– The relationship between the presenting part & the
pelvis
• Engagement:
– When the widest diameter of the fetal head has passed
through the pelvic brim
Obstetrical Examination-14
• P/A the station is
described in fifths above
the pelvic brim
– 5/5 floating
– 2/5 engaged
• P/V the station is
described in cm above or
below the ischial spines
– Engaged = 0 station
Obstetrical Examination-15
Auscultation:
– FHS:
• Doptone 10-12/52
• Pinard 24/52
• Location: anterior shoulder
– Uterine and funic souffle
Definition of Labor
• Braxton-Hicks contractions
• Shape:
– Oval & in one plane
• Boundaries:
– Anteriorly: SP
– Laterally: upper margin of pubic bone & iliopectineal line
– Posteriorly: sacral promontory
• Dimensions:
– AP = 11 cm Transverse = 13.5 cm
The Pelvic Cavity
• Shape:
–Imaginary plane between inlet & outlet
• Boundaries:
–Anteriorly: middle of SP
–Laterally: pubic bone, obturator fascia & inner aspect of
ischial bone. Ischial spine!
–Posteriorly: junction between S2 & 3
• Dimensions:
–AP = transverse = 12 cm
The Pelvic Outlet
• Shape:
– Diamond shaped in 2 planes
• Boundaries:
– Anteriorly: lower margin of SP
– Laterally: descending ramus of pubic bone, ischial
tuberosity & sacrotuberous ligament
– Posteriorly: last piece of sacrum (not coccyx)
• Dimensions:
– AP = 13.5 cm Transverse = 11 cm
Clinical Pelvimetry
• Pelvic inlet:
– Sacral promontory
• True conjugate (TC)= AP of inlet
• Diagonal conjugate (DC) measured clinically
• TC = DC − 1.5 cm
• Pelvic cavity:
– Anterior surface of sacrum & ischial spine
• Pelvic outlet:
– Subpubic arch & intertuberous diameter
Types of Female Pelvis-1
Gynecoid:
– Rounded brim with
widest transverse
diameter slightly
behind its center
– Rounded subpubic
arch
Types of Female Pelvis-2
Platypelloid:
– Flat pelvis
– Elliptical brim with a
wide transverse
diameter
– Wide subpubic arch
Types of Female Pelvis-3
Android:
– Heart-shaped brim
– Convergent side walls
– Prominent ischial spines
– Straight sacrum
– Narrow subpubic arch
– Both AP & transverse
diameters of outlet reduced
– Funnel-shaped cavity
Types of Female Pelvis-4
Anthropoid:
– AP diameter of pelvis
> transverse diameter
– Deep pelvis; sacrum
often has 6 segments
– Narrow subpubic arch
but wide sacrosciatic
notches
– Large AP diameter of
outlet
Fetal Skull-1
• Vault
• Face
• Base
Fetal Skull-2
Vault:
– Parietal & parts of occipital, frontal & temporal bones
– Bones not well ossified by birth
– Joined by membranes at the sutures
– Moulding: alteration of the shape of the skull by
overriding of the cranial bones with reduction of some
of its diameters
– Caput & chignon
Fetal Skull-3
Sutures:
– Sagittal: between the superior borders of
parietal bones
– Frontal: the forward continuation of the
sagittal suture; between the two parts of the
frontal bone
– Coronal: between the parietal & frontal bones
Fetal Skull-4
• Fontanelles:
– Anterior (bregma): kite-shaped; where the sagittal,
frontal & coronal sutures meet
– Posterior: triangular; where the two parietal & coronal
bones meet
• Vertex:
– Area bounded by the two parietal eminences & the two
fontanelles
Fetal Skull-5
Presentation Diameter Value (cm)
Transverse Biparietal 9.5
Vx, well-flexed Suboccipitobregmatic 9.5
Vx, deflexed Suboccipitofrontal 10
Persistent OP Occipitofrontal 11
Brow Mentovertical 13.5
Face Submentobregmatic 9.5
Symptoms & Signs of Labor
• Contractions
• “Show”
• ROM
• Abdominal examination
• Pelvic examination:
– Manual or digital
– Speculum
• CTG
Stages of Labor
• Definition:
– Induction vs. augmentation
• Indications:
– Maternal
– Fetal
• Contraindications:
– Absolute
– Relative
IOL-2
• Methods:
– Stripping or sweeping the membranes
– ARM or amniotomy
– Mechanical dilatation: 24-Fr Foley or laminaria
– PGE2
– Pitocin, oxytocin or syntocinon
• Patient preparation including informed consent
IOL-3
• Bishop’s score:
– Total = 0 – 13; favorable ≥ 7
• Protraction of descent:
– Definition:
• Descent < 1 cm/h in primipara
• Descent < 2 cm/h in multipara
– Causes & management
• Arrest of descent:
– Definition: no descent for 2 hours
– Causes & management:
• Operative vaginal delivery
• CS
Malpresentations-1
Breech:
– Incidence: 2-3% at term
– Risk factors: fetal, maternal & placental
– Options for delivery:
• External cephalic version (ECV)
• Elective CS
• Trial of vaginal delivery, assisted breech delivery (ABD)
Malpresentations-2
ABD:
– Pre-requisites:
• Not footling
• No neck flexion (star-gazing)
• EFW < 3800 grams
• No previous scar
• Experienced operator & assistant
• No other medical complications
Malpresentations-3
ABD:
– Maneuvers:
• Allow spontaneous delivery until umbilicus
• Abduct thighs to deliver legs
• Rotate back anteriorly
• Gently pull until scapulae are visible
• Rotate trunk to deliver arms
• Maintain held flexion:
– “Mauriceau-Smellie-Veit maneuver
– “Piper forceps”
– Assistant
Malpresentations-4
Face:
– Incidence:
• Approximately 1 in 2000 at term
– Management:
• Expectant in early labor
• Mento-anterior allow trial of vaginal delivery
• Mento-posterior CS
Malpresentations-5
• Brow:
– No mechanism of labor
• Shoulder:
– Transverse lie
– Delivery by CS
VBAC-1
• Incidence: CS rate ~ 20%
• Indications for CS
• Types of uterine incisions
• Pre-operative preparation for CS
• Complications of CS:
– Intra-operative
– Post-operative:
• Short-term
• Long-term
VBAC-2
• Definition:
– Impaction of fetal shoulders against maternal
pelvis (usually: anterior shoulder above or
behind SP)
• Incidence:
– In general 0.6 – 1.4%
– 4000-45000 grams 3 – 5%
– > 4500 grams 8 – 20%
Shoulder Dystocia-2
• Risk factors:
– Macrosomia
– Diabetes
– Dysfunctional labor
– Operative vaginal delivery
• Complications:
– Maternal
– Fetal: asphyxia & trauma
Shoulder Dystocia-3
• Management:
– HELP!!! HELP!!! HELP!!!
– Episiotomy
– McRobert’s maneuver:
• Sharp flexion of maternal legs upon abdomen
– Suprapubic pressure
– Woods corkscrew maneuver:
• Rotating posterior shoulder 180º
– Delivery of the posterior shoulder
Shoulder Dystocia-4
• Management:
– Rubin maneuver:
• Displacing anterior shoulder towards chest
– Deliberate fracture of the clavicle(s)
– Zavanelli maneuver:
• Flexion of fetal head & replacement into uterus followed
by CS
– Symphysiotomy or deliberate fracture of SP
THE END