Professional Documents
Culture Documents
DYSTOSIA
MALPRESENTETION AND
MALPOSITION
Prolonged labor /LABOR
ABNORMALTY
CPD
OBSTRUCTED LABOR
PPH
DYSTOCIA
Learning objectives
To define dystocia and list its main causes.
To discuses the difference between hypo and
hyperactive uterine dysfunction.
To list the major causes and complications of
macrosomia.
To define shoulder dystocia and enumerate the
steps in the management.
To discuss the clinical features and management
of hydrocephalus
To describe ideal obstetric pelvis and list the
indications for pelvic assessment.
To define and classify contracted pelvis.
4
Dystocia
difficult labor
characterized by abnormally slow progress of
labor
is the most common indication for primary
c/section.
Dystocia is a consequence of faults in the five Ps
operating alone or in combination.
Power (uterine contraction and voluntary muscular
efforts)
Passage (bony pelvis and soft tissues of the birth
canal)
Passenger (the fetus)
Psyche
Physician
Uterine Dysfunction is
common in primigravida than in multipara (4% vs.
20%).
It leads to prolonged labor which in turn results
in maternal exhaustion,
increased risk of Intrapartum and postpartum infection of
the mother and fetus,
fetal distress and
operative deliveries.
Over efficient
Hypotonic UD
Hypertonic UD
Over efficient
Precipitated labor
Intense and frequent contraction
Delivery 1-2 hrs
Danger to fetus
Unattended labor
Anoxia
Intracranial hemorrhage
11
II. MALPRESENTATION
DEF:
MALPRESENTATION: a presentation other
than vertex
shoulder, breech, face, brow, asynclitism
Malpositon: a position other than occiput
anterior (RT, LT, direct) in vertex and mentum
anterior in face presentation
Can result in ill fitting presenting part in a normal
pelvis
Causes:
-abnormal pelvis
-abnormal shape of the uterus
-laxity of the uterus
-multiple pregnancy
12
..MALPRESENTATION
Complication:
-early rupture of the membrane with risk of
cord prolapse
-premature labor
-slow irregular, short lived contraction
-uncoordinated and excessively painful labor
after rupture of membrane
-prolonged labor, CPD and obstructed labor
-post partum hemorrhage
-fetal and maternal distress
13
..MALPRESENTATION
In the absence of contracted pelvis and/or big
sized fetus most malpresentations and
malpositions do not cause dystocia.
Significant dystocia is a rule in
14
II- Macrosomia
Macrosomia is defined as fetal weight exceeding 4500grams.
The general rule is the larger the size of the fetus the higher
the chance of dystocia.
There is no clear cut fetal weight limit implicated in causing
dystocia.
In a woman with normal sized pelvis, dystocia, is unusual if
fetal weight is less than 3500grams.
The causes of macrosomia are
..Macrosomia
Fetal weight can be estimated by
Johnson's formula and ultrasound.
Fetal weight in gram = fundal height in centimeters n*155
ischial spine
ischial spine
The anticipated complications of macrosomia are
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
It results from impaction of the anterior shoulder
above the Symphasis pubis in an antero-posterior
diameter.
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.
17
.Shoulder dystocia
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 doesn't occur and the face
becomes plethoric.
Failure to deliver the shoulders with maternal expulsive
effort and gentle down ward traction on the fetal head.
18
.Shoulder dystocia
Shoulder dystocia requires prompt and skillful
management.
The following steps are useful.
Step1
Stop maternal expulsive efforts
Stop desperate pulling on the fetal head.
Call for help.
Step2
Disimpact the anterior shoulder by one combination of the
following maneuvers.
McRoberts maneuver (hyper flexion of both thighs on the maternal
abdomen)
Rubins maneuver (application of suprapubic pressure in lateral
direction on the posterior aspect of the anterior shoulder).
19
.Shoulder dystocia
Step3
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 1800.
Step4
Extraction of posterior arm
Step5
if the above fail perform symphysiotomy and
Abdominal rescue (zavanelli manuever )
clediotomy if fetus is died
20
III-Congenital malformations
1.Hydrocephalus
Hydrocephalus is progressive enlargement of the
cranium resulting from excess accumulation of
cerebrospinal fluid in the ventricle of the brain.
It accounts for 12% of malformations at birth and
occurs in 1:1000 deliveries.
In one third associated defects like spinal bifida are
found.
Breech presentation is found in one third of cases.
Significant dystocia from gross CPD is a rule.
Clinical features, which may lead in diagnosis,
are broad firm, mass above Symphasis in cephalic presentation
and
in labor finding on vaginal examination of tense large fontanel,
Widened suture line and indentable thin cranial bones
21
.Hydrocephalus
2. Others
Inlet
Mid cavity
Outlet
CONTRACTED PELVIS
It is classified in to:
I.
Generally contracted pelvis-includes
II.
Inlet contracture
III.
IV.
Outlet contracture
25
I.
26
Pelvic assessment
The capacity of the pelvis can be assessed by
clinical and
x-ray pelvimetry.
27
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
cesarean section preferably electively.
Management
A. Cervical dystocia
Rigid cervix from stenosis
Cesarean section
B. Vagina
Septum (transverse or longitudinal)
Incomplete atresia
Cesarean section
Annular stricture
Extensive scarring
Aspirate aseptically
Anesthesia
Vulvar scar
Generous episiotomy
C. Pelvic masses
Myoma, ovarian cyst
Cesarean section
29
Malpresentation
and
Malposition
30
Ociptoposterior position
13 % of all vertex presentation
Cause is unknown, but Associated with:
pendulous abdomen,
abnormal pelvis and
the placenta is anterior
Diagnose
.Ociptoposterior position
Out come of the labor
Long internal rotation
the pelvic floor causes further flexion of the head and
rotates anteriorly to 450 then to 900rotation and delivered
normally
33
..Ociptoposterior position
Management
augmentation if there is inefficient uterine
contraction
Spontaneous vaginal delivery
Forceps delivery either after rotation to
anterior (keilland forceps )or direct delivery
Manual rotation
Vacuum delivery (there could be passive
rotation)
34
Mx
Augmentation in the case of inadequate
uterine contraction in the absence of CPD
Manual /forceps rotation and delivery in
OA/OP by forceps
c/s if contracted pelvis /abnormal pelvic
arthecture
35
Brow presentation
-thyroid tumor
Anencephaly
Abnormal shape of the pelvis
36
Brow presentation
Diagnosis
palpation-the head is high and does not enter the pelvis
vx examination
station high
smooth hair less area is felt, with part of bregma at one site
orbital ridge may be felt
Management
Early observation ;can be converted into face/ vertex
Late (persistent brow presentation) c/s
Dead :craniotomy
37
Face presentation
Extended attitude and face lies in the
lower uterine segment
Cause :
Lax uterus ,multiple pregnancy, hydraminous
Deflexed fetal head hypotonous musle
-thyriod tumur
Anencephaly
Abnormal shape of the pelvis persistent
mentoposterior (mentotransverse)
presentation,
38
Face presentation
Diagnose
Inspection :irregular abdomen and the shape of the fetus
spine is that of an s
Palpation;
prominent occiput is felt on the same side as the sinciput which
is lower than the occiput .
a deep groove is felt between fetal back and head
Auscultation: The fetal beat is heard clearly at the center
Vaginal examination:
High presentating part
Soft irregular mass ,gum felt and , sucking of finger
Complication
Obstructed labor
Cord prolapse
Facial bruising
Cerebral hemorrhage and maternal trauma
39
Face presentation
mechanism of delivery
an increase in extension the chin rotates
rather than occiput engaging diameter is submento bregmatic
9.5cm
Labor ;
extra discomfortsedation
Note position and do PV when membrane ruptured
Let labor continue for mentoanterior, and early
mentotransverse/mentoposterior
When the face distends the perineum do episiotomy
Allow the chin to be delivered 1st and flex the head to allow to
deliver the occiput
Delivery of persistent mentoposterior/ transverse is not possible
C/S
40
Breech
Breech presentation
Def: fetus buttock in the lower part of the uterus
Incidence 3-4% at term
Types
-frank-hip flexed and leg extended commonest
-complete :hip and leg are flexed
Presenting part is bulky and consists of buttock ,external
genitalia, feet
-footling-hip and leg are extended .one /both feet present
-knee: one/both the hips are extended with knees flexed
41
.Breech
Cause
-no cause is identified ,but the following circumstances favor
breech presentation
polyhydraminos
prematurety
multiple pregnancy
placenta previa
contracted pelvis
uterine abnormality
extended leg
42
.Breech
Diagnosis
Hx
Fetal kick ,low in the abdomen
Maternal sub costal discomfort
P/E
Palpation
lie is longitudinal
fundus occupied by a firm, smooth, rounded, mass which dependently moves
with the back
a soft and irregular mass occupy the lower uterine segment
Auscultation
The fetal heart beat is heard above the umbilicus if the breech is not engaged
below the umbilicus if is engaged
Vaginal examination
43
Diagnosis
confirmation by U/S(
GA, BPP, placenta localization,
attitude, malformation, fetal weight
X-ray (dx, attitude, pelvimetry
44
.Breech
Management
ANC
EXTERNAL cephalic version
After 36 weeks
EFW <3500gm
Frank/complete breech
Flexed head
Adequate pelvis
Gross fetal malformation which is incompatible with extra uterine life
primary c/s
EFW>3500gm
Any degree of contracted pelvis
Hyper extended head
Poor obstetric performance ,infertility, primigravida >35 age
No labor but there is maternal and fetal indication for termination 45
.Breech
Labor
Mode: depends on fetal size, pelvic size ,attitude
of the head ,type of breech, number of fetus,
progress of labor, other obstetric indication
Principle of management
-intelligent observation
-avoidance of unnecessary interference
-Promote action carried out with manual
dexterity when assistance is needed
-avoidance of fetal injury and hypoxia
46
careful observation
warn not to push
vaginal examination when membrane ruptured
sedation
Augmentation is contraindicated
The occurrence of in coordinate uterine action, uterine
inertia, arrest or delay in cervical dilatation or failure of
descent of breech warrants urgent cesarean section.
50
.Second stage
Assisted vaginal breech delivery (partial breech
extraction) where the fetus is delivered up to the
level of the umbilicus spontaneously and the rest of
the body is delivered with the assistance of the
health professional using special maneuvers.
Delivery of the frank breech
full dilatation of the cervix needed before the mother push
active push is not necessary until the buttock is distending the
vulva
encourage to push with contraction once the buttock distends the
vulva
the buttock are delivered spontaneously
episiotomy may be necessary
wait until it reach the level of the umbilicus
51
53
Precondition
Cervix fully dilated
No CPD
No uterine scar
Technique
Introduce one arm into the abdomen ,grasp both feet of the fetus and
bring to the vagina by gentle traction .may need to do for each turn by
turn but never pull a single limb out of the vulva with out finding the
other
Continue traction until delivery of the hip ,and then follow as with
assisted breech delivery
54
55
56
Extended arm is diagnosed when the arms are not felt on the chest.
Management is like the nuchal arm
Transverse lie
lax uterus ,
pp,
Hydramnios ,
multiple pregnancy,
uterine anomaly,
preterm ,
macerated fetus
Diagnosis
uterus is broad and fundal height is less than expected
the hand /the rib can be felt
arm may prolapsed (if in labor
60
..Transverse lie
Management
at ANC ;
at 36 weeks external version can be attempted
at labor ;
c/s
late labor with ruptured membrane ,
prolapsed cord
version in early labor /and membrane not ruptured
.Transverse lie
Complication
Maternal
-Obstructed labor
-Uterine rupture
-Death
-Puerperal sepsis
-PPH
fetal
-fetal death
-Prematurity
-malformation
-arm prolapse
62
63
64
65
Rx
Rest
Sedatives
Morphine
Hydration
Augmentation
66
2..Protracted disorders
Protracted dilatation of the cervix
<1.2cm/hr in primi and <1.5 cm/hr in multi
Protracted descent
Rate of descent is <1cm/hr and <2cm/hr in primi and multi
respectively
Causes
CPD
Anesthesia
Sedatives
Inefficient uterine contraction
Rx
1st rule out CPD ,and asses fetal condition
If there is CPD c/s
No CPD and fetal condition is good augmentation
67
3.Arrest disorders
Prolonged deceleration phase
>3hr in deceleration phase of active phase
Arrest of descent
No descent for more than 1 hr after it starts to descent
Causes
CPD
Malposition
Anesthesia and sedatives
Inefficient uterine contraction
Rx
Augmentation in the absence of CPD and good status of the
fetus
Prognosis
Poor for vaginal delivery
68
4.Precipitated labor
Rapid course of labor
Cervical dilatation of 5cm /hr for primi and 10cm/hr in multi
Causes
Lax birth canal
Excessive contraction
Oxytoxin
Complication
Rx
If already delivered ,see for birth canal laceration and tear
If not born
Sedation
Tocolytic
Stop oxytoxin
With previous history admit and induction
69
CPD
70
CPD
Def: when the fetal head failed to pass through
the pelvis
Can be
absolute: the fetal head to big to pass the normal
pelvis or the pelvis is too narrow to pass a normal
sized fetus
relative: a normal sized fetus unable to pass an
adequate pelvis as a result of abnormal attitude
/position :persistent occiput ,mentoposterior
,persistent brow ,posterior asynclytism
71
.CPD
Causes are
Contracted pelvis
Big baby
Abnormal presentation
Abnormal position
72
CPD
Diagnosis is
By labor abnormality after the power problem is ruled out
Protracted or arrest disorders
In the 1st stage /second stage
73
Management
Mild and moderate of contracted pelvis needs
-trial of labor
Severely contracted pelvis needs C/S
c/s /instrumental depending
on the degree of CPD
Station of the fetus
74
75
OBSTRACTED LABOR
AND
RUPTURED UTERUS
76
Learning Objectives
To define obstructed labor and uterine rupture.
To list the important causes of obstructed labor
and uterine rupture
To enumerate the immediate and late
complications of obstructed labor.
To discuss the clinical features of obstructed labor
and uterine rupture.
To outline the management of obstructed labor
and uterine rupture.
To discuss the prevention of obstructed labor.
77
1. OBSTRUCTED
1.1. Definition
Obstructed labor 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.
It is an absolute condition, which should be
applied only when further progress is
impossible without assistance.
78
1.2. Importance
is one of the major causes of maternal and
perinatal mortality in developing countries.
Its incidence is mainly related to
the availability, accessibility and quality of ante partum
and Intrapartum services in the community
to a lesser extent to the incidence of fetopelvic
disproportion in the community.
1.3. Causes
Cephalopelvic disproportion (CPD) remains to be the
commonest cause of.
Contracted pelvis (which is prevalent in developing countries where
childhood malnutrition and early marriage are common) is
responsible for most of the CPD.
Macrocosmic babies and
fetal malformations account for minor proportion of CPD.
80
1.4.Complications
The immediate and late complications of OL are
responsible for the
high maternal mortality,
Stillbirth and early neonatal morbidity
82
.
83
1.6. Management
The Principles in the management of OL
are:
Obstruction must be relieved with out delay,
Before doing so, one should rectify the effects
of prolonged labor (dehydration, acidosis and
Intrapartum infection) partially or fully.
Some form of operative delivery is always
needed to relieve the obstruction (vaginal or
abdominal).
Non-operative methods like oxytocin have no
place in the management of OL.
84
I. Resuscitation
B. Control infection
90
1.7. Prevention
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 antenatal and
Intrapartum care.
This can be achieved by non-sophisticated and
non-expensive methods tailored to the immediate
resources of the community where feasible,
hospital care for all is ideal.
91
92
2. UTERINE RUPTURE
2.1. Definition and types
- 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 of these.
- In most cases, it occur in the Intrapartum period
but ante partum rupture can occur especially in
women with classic cesarean section scar or scars
related to other gynecologic surgeries like
myomectomy.
93
2.2. Causes
By far the commonest cause of uterine rupture is
neglected obstructed labor especially in mutipara.
dehiscence of a previous cesarean section scar.
Other causes include
95
97
2.4. Management
The life of the patient depends
on the speed and efficacy with which
hypovolemia is corrected.
Hemorrhage is controlled and
infection is treated.
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 labor.
Performing laboratory tests for hemoglobin and
blood group/RH status.
Preparing at least two units of cross matched blood.
Inserting naso-gastric tube and Foley catheter.
100
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
101
Postpartum haemorrhage
102
Postpartum haemorrhage
Definition:
Vaginal bleeding in excess of 500 ml
following childbirth till 6 weeks
estimation of blood loss notoriously inaccurate
May occur
Immediately or later
As a gush or as a steady trickle
103
104
106
PPH
APH
Ruptured uterus
Eclampsia
Obstructed labor
Sepsis
2h
12 h
1d
2d
3d
6d
108
Two types
-primary: if occur with in 24 hour
-secondary: after 24 hours
109
Natural mechanism of
preventing bleeding postpartum
- Uterine contraction
- Coagulation
mechanism
110
Causes
111
Causes are
primary
Atony
Retained product of conceptus (part/whole placenta,
membrane)
Genital trauma
Bleeding disorder
Uterine inversion
Secondary
Chorioamnitis
retained products
112
Atonic PPH
-80% of the cause for PPH
-Failure of the uterus to contact
-Cause
RPC
incomplete separation of the placenta
prolonged labor and obstructed labor
precipitates labor
polyhydraminous, multiple pregnancy, big baby
APH (PP, abruption)
Adherent placenta
Full bladder
Prolonged anesthesia
Fibroids
Grad multi
113
Diagnosis
Uterus soft and no contracted
114
Management
116
Traumatic PPH
From laceration of the cervix, vaginal wall, perineum, ruptured
uterus
Cause
difficult delivery
face to pubis, after coming head breech,
instrumental delivery
delivery through undilated cervix
Management:
117
Prevention
good cooperation of the patient
control the delivery of the head ,keep it flexed to bring a
small diameter
deliver the shoulder in anteroposterior diameter and lift up
the posterior shoulder
perform episiotomy when the perineum is very tight
118
Retained placenta
no delivery of the placenta after 30 minute of
delivery of the fetus
Cause :
Management
Placenta visible
ask woman to push it out
Placenta in uterus
empty bladder,
give oxytocin 10 IU IM, secure IV line and put her on oxytoxine
drip
attempt CCT,
manual exploration
method
120
Adherent placenta
Placenta grows into the uterine muscle
accreta- into the muscle
increta deep in the muscle
percreta-through the muscle
Management
Hysterectomy (definitive)
partial wegde resection/leave it to be absorbed if
no active bleeding
Inverted uterus
Immediate repositioning
121
Hypo fibrinogenaemia
Clotting defects and the patient continuous to
bleeding in spite of treatment for the other types of
PPH
Cause
placental abruption
IUFD which is prolonged
amniotic fluid embolism
pre-eclampsia, eclampsia
intra uterine infection
hepatitis
122
Traumatic
-well contracted
-immediately after
delivery
-bright red in colour
123
Consequences of PPH
Shock
puerperal anemia
fear of the further pregnancy
sheehans syndrome anterior pituitatry
infection
125
Preventation of PPH
Summary
PPH is a major cause of maternal death.
PPH can not be predicted.
PPH kills fast implying prevention and
prompt diagnosis of the cause and
management is essential..
127
FETAL DISTRESS
128
Learning Objectives
To define fetal distress and describe its
Pathophysiology 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
129
1. Pathophysiology
A normally growth fetus has stored reserves of glycogen and fat to be
used at times of stress like.
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 carbondioxide 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.
Failure to correct this mild form from pathological conditions results in
progressive accumulation of
lactic acid and carbondioxide. This results in acidosis and reducution of
oxygen einding up in
asphyxia.
The net effect is changein fetal heart beat, which forms the basis for
diagnosis and in extreme
cases passage of meconium.
131
2. Etiology
In general all forms of fetal distress originate from deficient delivery of oxygen to the fetus.
Some
occur as a result of sudden catastrophic events like massive abruptio placenta and cord
prolapse
. Some are iatrogenic in origin.
I. Uterine and placental factors
Decreased blood pressure from sudden maternal shock (example APH), supine
hypotension syndrome and conduction anesthesia
132
3. 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. The abnormal patterns include.
Baseline bradcardia is classified as moderate (fetal heart beat of 80-100/min for
>3min ) and severe (fetal heart beat of <80/min for 3min)
Baseline teachcardia is classified as mild (feta heart beat of 161-180/min for
>15nin) and severe (fetal heart beat of >180/min for >15min)
Repeated late deceleration
Severe recurrent variable deceleration (drop of FHB to <70/min with duration of
>60sec)
Reduced beat to beat variability
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.
133
4. Management
The management of fetal distress has two
components
I. Correction of the potential insults (intrauterine
resuscitation)
Put the mother 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
disipact the presenting part
134
135