Complications during labor and delivery

Course Outline:
1. Dysfunctional labor
a. Dystocia
b. Malpositions and malpresentation
c. Multiple pregnancy
d. Precipitate labor
e. Premature rupture of membranes
2. Hemorrhagic complications
a. ruptured uterus
b. inversion of the uterus
c. lacerations
3. Infant complications
a. pre-maturity
b. post maturity
c. birth injuries

I. DYSFUNCTIONAL LABOR

A. DYSTOCIA

Dystocia literally means difficult labor and is characterized by abnormally slow labor progress. It arises from four
distinct abnormalities that may exist singly or in combination:

1. Abnormalities of the powers ( expulsive forces) –the uterine contractions may be insufficiently strong or
inappropriately coordinated to efface and dilate the cervix—uterine dysfunction. Also, there may be
inadequate voluntary maternal muscle effort during second-stage labor.
2. Abnormalities of the passenger- size, presentation, position, or developmental abnormalities of the fetus
(ex hydrocephalus, anencephaly)
3. Abnormalities of the passage - maternal bony pelvis (pelvic contraction) and soft tissues of the
reproductive tract causing an obstacle in fetal descent (tumors, myoma, full bladder, full rectum, vaginal
septum)

Dystocia is the most common current indication for primary cesarean delivery.

Common Clinical Findings in Women with Ineffective Labor

Inadequate cervical dilation or fetal descent:
   Protracted labor—slow progress
   Arrested labor—no progress
   Inadequate expulsive effort—ineffective pushing
Fetopelvic disproportion:
   Excessive fetal size
   Inadequate pelvic capacity
   Malpresentation or position of the fetus
Ruptured membranes without labor
Abnormalities of the expulsive forces (POWER)
 Uterine contraction plays the major role in cervical dilatation in addition to the descent of the fetus. Such
contractions should be effective and adequate if: duration 45-60 sec, frequency is every 2-3min, intensity
>50mmHg, and regular, occurs 4-5in 10 min duration.

1. Hypotonic uterine dysfunction

- there is no basal hypertonus and uterine contractions have a normal gradient pattern (synchronous),
but pressure during a contraction is insufficient to dilate the cervix.
- Number of contractions: low or infrequent (not more than 2-3/10 min)
- Resting tone of uterus: <10mmHg
- Strength of contraction: does not rise to >25 mmHg
- Occur during active phase of labor
- Pressure during contraction is insufficient to dilate the cervix
- considered as the most common cause of poor progress in labor.
- Risk factors: administration of analgesia, bowel or bladder distention preventing descent of the fetus,
over distended uterus (multiple gestation, large babies, polyhydramnios, multiparity)
- Treatment: Labor augmentation (oxytocin)
2. Hypertonic uterine dysfunction
- incoordinate uterine dysfunction, either basal tone is elevated appreciably or the pressure gradient is
distorted. Gradient distortion may result from contraction of the uterine midsegment with more force
than the fundus or from complete asynchronism of the impulses originating in each cornu or a
combination of these two.
- painful ineffective and associated with increased uterine tone.
- There is a high resting basal tone between contractions. Therefore, uterine circulation does not return
to normal between contractions and consequently fetal distress is more common.
- Occur during latent phase of labor
- Can result to fetal anoxia
- Management: hydration, bed rest, mild sedation, tocolytics to reduce high uterine tone

ABNORMAL LABOR PATTERNS, DIAGNOSTIC CRITERIA AND METHODS OF TREATMENT

Labor Pattern Nulliparas Multiparas Preferred Exceptional
treatment Treatment
Prolongation disorder >20 hr >14 hr Bed rest Oxytocin or
Prolonged Latent phase cesarean delivery
for urgent cases
Protraction disorders
Protracted active-phase <1.2cm/hr <1.5cm/hr Expectant Cesarean delivery
Dilatation management and for CPD
Protracted descent <1cm/hr <2cm/hr support

Arrest disorders
Prolonged deceleration >3hr >1hr
phase Evaluate for CPD Rest if exhausted
Secondary arrest of >2hr >2hr CPD: cesarean Cesarean delivery
Dilatation section
Arrest of descent >1hr >1hr No CPD: Oxytocin
Failure of descent No
descent in
decelerati
on phase

 Indications of Oxytocin:
 o In the event of unsatisfactory progress (<0.5cm/hr for 4 hours or arrest of descent for over 1
hour), in the active phase of labor, Oxytocin is indicated. Oxytocin should be used to achieve
adequate contractions before operative delivery is considered. Prior to the use of Oxytocin,
consideration should be given to the appropriate use of analgesia, hydration, rest and
amniotomy. Women should be encouraged to keep bladders empty, catheterization may be
considered. Inappropriate use of Oxytocin may produce hyperstimulation and decreased
transplacental oxygen transport to the fetus causing fetal distress. Risk of rupture in
grandmultiparity and in patients with previous uterine surgery is increased with the use of
Oxytocin.

 It has been suggested that before the diagnosis of arrest during first-stage labor is made, both of these
criteria should be met: (1)The latent phase has been completed, and the cervix is dilated 4 cm or more,
and (2)uterine contraction pattern of 200 Montevideo units or more in a 10-minute period has been
present for 2 hours without cervical change.

 The following are reported causes of uterine dysfunction

o Epidural analgesia – can slow labor

o Chorioamnionitis – maternal intrapartum infection is associated with prolonged labor

o Maternal position during labor – no conclusive evidence that ambulation or upright maternal
posture improves labor

OBSTRUCTED LABOR
- Failure of descent of the fetus in the birth canal for mechanical reasons in spite of good, adequate
uterine contractions. It complicates 1-3% of all labors
- Risk associated with neglected obstructed labor:
o Maternal: sepsis, uterine rupture, hemorrhage, fistula, death
o Fetus: asphyxia, sepsis, death
- Etiology:
o Fetal: malpresentation (face, brow, shoulder or arm, breech, compound);
malposition (persistent occiput transverse, persistent occiput posterior);
malformations (hydrocephalus, abdominal tumors, cystic hygroma, conjoined twins)
o Maternal: small pelvis (childhood malnutrition, contracted or deformed bony pelvis);
soft tissue tumors of the pelvis (myoma, ovarian tumor, rectal tumor)

MALPRESENTATION

1.Face presentation
- The head is hyperextended so that the occiput is in contact with the fetal back, and the chin
(mentum) is presenting. The fetal face may present with the chin (mentum) anteriorly or posteriorly,
relative to the maternal symphysis pubis. Although many may persist, many mentum posterior
presentations convert spontaneously to anterior even in late labor. If not, the fetal brow (bregma) is
pressed against the maternal symphysis pubis. This position precludes flexion of the fetal head
necessary to negotiate the birth canal.
- Face presentation occurs in 1:500 deliveries.
- Causes of face presentations are numerous and include conditions that favor extension or prevent
head flexion. Prematurity, marked enlargement of the neck or coils of cord around the neck, fetal
malformations, anencephaly, hydramnios, and multiparity are risk factors.
 - Diagnosis is by vaginal examination and palpation of facial features. In the absence of a contracted
pelvis, and with effective labor, successful vaginal delivery usually will follow.
- Management: Because face presentations among term-size fetuses are more common when there is
some degree of pelvic inlet contraction, cesarean delivery frequently is indicated. Attempts to convert
a face presentation manually into a vertex presentation, manual or forceps rotation of a persistently
posterior chin to a mentum anterior position, and internal podalic version and extraction are
dangerous and not attempted. For chin anterior: maybe delivered vaginally, chin posterior: CS

2.Brow Presentation

- This rare presentation is diagnosed when that portion of the fetal head
between the orbital ridge and the anterior fontanel presents at the pelvic
inlet. The fetal head thus occupies a position midway between full flexion
(occiput) and extension (face). Except when the fetal head is small or the
pelvis is unusually large, engagement of the fetal head and subsequent
delivery cannot take place as long as the brow presentation persists.

- Rarest, occurs 1 in 1400 deliveries

- The causes of persistent brow presentation are the same as those for face
presentation.

- A brow presentation is commonly unstable and often (50-75%)converts to a

face or an occiput presentation.

- Persistent brow presentation makes vaginal delivery impossible, hence

managed with cesarean section.

- The presentation may be recognized by abdominal palpation when both the

occiput and chin can be palpated easily, but vaginal examination is
usually necessary. The frontal sutures, large anterior fontanel, orbital
ridges, eyes, and root of the nose are felt on vaginal examination, but
neither the mouth nor the chin is palpable. The considerable molding
essential for vaginal delivery of a persistent brow characteristically
 - .

3.Transverse Lie
- Also called oblique or unstable lie. In this position, the long axis of the fetus is approximately
perpendicular to that of the mother. In a transverse lie, the shoulder is usually positioned over the
pelvic inlet. The head occupies one iliac fossa, and the breech the other. This creates a shoulder
presentation in which the side of the mother on which the acromion rests determines the designation
of the lie as right or left acromial.
- Some of the more common causes of transverse lie include: (1) preterm fetus, (2) abdominal wall
relaxation from high parity, (3) placenta previa, (4) abnormal uterine anatomy, (5) hydramnios, and
(6) contracted pelvis. Women with four or more deliveries have a 10-fold incidence of transverse lie
compared with nulliparas. A relaxed and pendulous abdomen allows the uterus to fall forward,
deflecting the long axis of the fetus away from the axis of the birth canal and into an oblique or
transverse position.
- Active labor in a woman with a transverse lie is usually an indication for cesarean delivery.

A transverse lie is usually recognized easily, often by

inspection alone. The abdomen is unusually wide,
whereas the uterine fundus extends to only slightly
above the umbilicus. No fetal pole is detected in the
fundus, and the ballottable head is found in one iliac
fossa and the breech in the other. The position of the
back is readily identifiable. When the back is anterior, a
hard resistance plane extends across the front of the
abdomen. When it is posterior, irregular nodulations
representing fetal small parts are felt through the
abdominal wall. On vaginal examination, in the early
stages of labor, if the side of the thorax can be reached,
with further dilatation, the scapula and the clavicle are
distinguished on opposite sides of the thorax.

4.Compound Presentation
 In a compound presentation, an extremity prolapses
alongside the presenting part, and both present
simultaneously in the pelvis.
 In most cases, the prolapsed part should be left alone,
because most often it will not interfere with labor. If the
arm is prolapsed alongside the head, the condition
should be observed closely to ascertain whether the arm
retracts out of the way with descent of the presenting
part. If it fails to retract and if it appears to prevent
descent of the head, the prolapsed arm should be pushed
gently upward and the head simultaneously downward
by fundal pressure. In general, rates of perinatal
mortality and morbidity are increased as a result of
concomitant preterm delivery, prolapsed cord, and
traumatic obstetrical procedures.
5.Breech presentation
- When the buttocks of the fetus enter the pelvis before the head, the presentation is breech. Breech
presentation is more common remote from term because the bulk of each fetal pole is more similar.
Most often, however, as term approaches, the fetus turns spontaneously to a cephalic presentation.
Breech presentation persists in 3-4% of singleton deliveries at term.
- Factors that predispose to breech presentation are: prematurity, Hydramnios, high parity with uterine
relaxation, multiple fetuses, oligohydramnios, hydrocephaly, anencephaly, previous breech delivery,
uterine anomalies, placenta previa, fundal placental implantation, and pelvic tumors.
- Types of breech presentation:
1. Frank breech – the lower extremities are flexed at the hips and extended at the knees, the feet lie
in close proximity to the head
2. Complete breech – one or both knees are flexed
3. Incomplete breech – one or both hips are not flexed, and one or both feet or knees lie below the
breech presentation ex: footling breech

- Diagnosis: This is made by abdominal and vaginal examination. On abdominal examination, the first
Leopold maneuver, the hard, round, readily ballottable fetal head may be found to occupy the fundus.
The second maneuver indicates the back to be on one side of the abdomen and the small parts on the
other. With the third maneuver, if not engaged, the breech is movable above the pelvic inlet. After
engagement, the fourth maneuver shows the firm breech to be beneath the symphysis. On vaginal
examination, both ischial tuberosities, the sacrum, and the anus usually are palpable in frank breech
presentation. Suspected breech presentation is best confirmed with an ultrasound.
 - Complications: In persistent breech presentation, an increased frequency of the following
complications can be anticipated: prolapsed cord, placenta previa, congenital anomalies, uterine
anomalies and tumors, difficult delivery, increased maternal and perinatal morbidity.
- Maternal morbidity: Because of the greater frequency of operative delivery, there is a higher rate of
maternal morbidity for pregnancies complicated by persistent breech presentation. This includes
increased risk for genital tract lacerations, uterine atony and post-partum hemorrhage, infection and
uterine rupture.
- Perinatal morbidity and mortality: The major contributors to perinatal loss are preterm delivery,
congenital anomalies, and birth trauma. , Fetal injuries include fracture of the humerus and clavicle,
brachial plexus injury, and skull fractures.
- Management: Reviews on term breech delivery showed that planned cesarean section has lower
perinatal or neonatal mortality or serious neonatal morbidity compared to vaginal breech delivery.
Perinatal death was also reduced in the planned cesarean group.
- Women with fetus in breech presentation should be referred to health care provider with experience
with vaginal breech delivery and/or a facility that has a cesarean section capability. The primary
health care provider should have an assistant immediately available to resuscitate the newborn.
- Head entrapment is a possibility with a baby in breech presentation. This is more likely in preterm
baby.

MULTIPLE PREGNANCY

Twin fetuses usually result from fertilization of two separate ova–dizygotic or fraternal twins. Less often, twins
arise from a single fertilized ovum that subsequently divides–monozygotic or identical twins. Either or both
processes may be involved in the formation of higher numbers. Quadruplets, for example, may arise from as few
as one to as many as four ova.
Incidence: The frequency of monozygotic twin births is relatively constant worldwide—approximately one set per
250 births, and is largely independent of race, heredity, age, and parity. There is now evidence that the incidence
of zygotic splitting is also increased following ART. In contrast, the incidence of dizygotic twinning is influenced
remarkably by race, heredity, maternal age, parity, and, especially, fertility treatment.

Diagnosis: A maternal personal or family history of twins, advanced maternal age, high parity, and large maternal
size are weakly associated with multifetal gestation. Recent administration of either clomiphene citrate or
gonadotropins or pregnancy accomplished by ART are much stronger associates. Clinical examination with
accurate measurement of fundic height is essential. With multiple fetuses, uterine size is typically larger during
the second trimester than expected. In general, it is difficult to diagnose twins by palpation of fetal parts before
the third trimester. Even late in pregnancy, it may be difficult to identify twins by abdominal palpation, especially
if one twin overlies the other, if the woman is obese, or if there is hydramnios. If uterine palpation leads to the
diagnosis of twins, it is most often because two fetal heads have been detected, often in different uterine
quadrants. On ultrasound, separate gestational sacs can be identified early in twins.

Pregnancy outcome: Spontaneous abortion is more likely with multiple fetuses. The incidence of congenital
malformations is appreciably increased. Malformations include defects resulting from twinning itself (conjoined
twinning, neural-tube defects, acardiac anomaly), defects resulting from vascular interchange between
monochorionic twins and defects resulting from fetal crowding ( clubfoot or congenital hip dislocation)
Management:

Many complications of labor and delivery are

encountered more often with multiple fetuses than with
singletons. These include preterm labor, uterine
contractile dysfunction, abnormal presentation, umbilical
cord prolapse, premature separation of the placenta, and
immediate postpartum hemorrhage. An appropriately
trained obstetrical attendant should remain with the
mother throughout labor. Blood transfusion products
should be available. An ultrasound machine should be
available to help evaluate position and status of fetus.

The planned method of delivery must consider the lie and

presentation of each fetus. Vaginal delivery should be
the goal unless there are specific contraindications.

- first twin cephalic: vaginal delivery should be expected to progress similar to singleton pregnancy.
- first twin breech - inform the woman of possible complications and she must make an informed decision on the
mode of delivery. The possibility of “locked” twin should also be informed.
- first twin transverse – Cesarean section
- second twin cephalic - first twin delivered vaginally, 2nd twin deliver vaginally
- second twin breech – first twin delivered vaginally, vaginal breech extraction of 2 nd twin
- second twin transverse - First twin delivered vaginally, external version or internal podalic version can be
attempted and the second twin delivered vaginally, otherwise Cesarean section should be done.

PRECIPITATE LABOR

Definition: Precipitous labor is extremely rapid labor and delivery. It may result from an abnormally low resistance
of the soft parts of the birth canal, from abnormally strong uterine and abdominal contractions, or rarely absence
of painful sensations and thus a lack of awareness of vigorous labor. Precipitous labor terminates in expulsion of
the fetus within 1 hour in multipara and 3 hours in a primipara.

Maternal Effects: Precipitous labor and delivery seldom are accompanied by serious maternal complications if the
cervix is effaced appreciably and compliant, if the vagina has been stretched previously, and if 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. It is in these
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.

Fetal and Neonatal Effects: Adverse perinatal outcomes 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. Resistance of the birth canal may rarely cause intracranial
trauma. Erb or Duchenne brachial palsy was associated with precipitous labor. During an unattended birth, the
newborn may fall to the floor and be injured, or it may need resuscitation that is not immediately available.
Treatment: Oxytocin if used should be stopped immediately. Tocolytics can be given. To avoid fetal and birth
canal injuries, episiotomy is done. Post-partum, the patient should be monitored because post-partum
hemorrhage can be a complication.

PREMATURE RUPTURE OF MEMBRANES

Definition: Pre-labor rupture of the membranes (PROM) may occur when the fetus is ≥37 weeks gestation of
before 37 weeks gestation (Preterm PROM). The risk to the pregnancy is increased after the occurrence of PROM
whether term or before term, primarily due to the increased risk of infection for both the woman and the fetus.
The latent period is the interval between the rupture of the membranes and the onset of labor. The duration of
the latent period varies inversely with the gestational age. Almost 90% of women at term will be in spontaneous
labor within 24 hours of membrane rupture. For the woman who is remote from term, the latent period will be
longer.

Incidence: Term PROM: 2-10% of pregnancies; PPROM – 2-3% of pregnancies, but accounts for 1/3 of preterm
delivery cases.

Etiology:
- Idiopathic
- Infection - bacterial vaginosis
- Polyhydramnios
- Cervical incompetence
- Uterine abnormality
- Following cervical cerclage or amniocentesis
- Trauma including motor vehicle accident or domestic violence
- Previous cervical surgery (conization or cone biopsy)
- Past history of PROM
- Others: lifestyle, stress, smoking, nutrition, race, use of illegal drugs, coitus, low socioeconomic use

Diagnosis: Routine pelvic examination is not recommended because of the increased risk of ascending infection.
However, sterile speculum examination for confirmation of PROM, assessment of cervical status, and exclusion of
cord prolapsed is appropriate. Ultrasound is not diagnostic; however, it makes diagnosis less likely in the
presence of normal amniotic fluid. A history of vaginal fluid leakage including amount, timing, odor, persistence
and color should be taken. On speculum exam, fluid pooling in posterior fornix is diagnostic of PROM. Other tests
include: Ferning test – obtain a sample of fluid from the posterior fornix, place it on a glass slide, let dry for 10 min
then observe for ferning under microscope; ph testing of fluid (nitrazine test) – the normal vaginal fluid is 4.5-6.0,
amniotic fluid pH is 7.1-7.3.

Complications
- Term PROM: fetal or neonatal infection, maternal infection, umbilical cord compression or prolapsed
- Preterm PROM: preterm labor and delivery, fetal or neonatal infection, maternal infection, umbilical
cord compression or prolapsed, increased cesarean rate, fetal deformation from severe
oligohydramnios

Management At any gestational age, initial management is to confirm the diagnosis because management
depends on the gestational age. Maternal and fetal well-being is assessed and the presence of associated
conditions that will require immediate delivery must be determined. The risks of preterm birth versus
intrauterine infection, abruptio placenta, and cord compression that could occur with expectant management
should be considered. If there is evidence of these mentioned complications, delivery is indicated regardless of
gestational age.
Avoid digital examination whenever possible unless the woman is in labor. For term PROM, management
generally included labor stimulation if contractions did not begin after 6 to 12 hours. Labor induction with
intravenous oxytocin is the preferred management. Labor induction resulted to significantly fewer intrapartum
and postpartum infections, lower rates of chorioamnionitis, metritis, and NICU admission. There were no
significant differences in cesarean delivery rates. Expectant management was associated with increased adverse
outcomes.

Antibiotic is indicated and presence of infection should be monitored. Antibiotic therapy could improve the
outcome in PROM by : (a) prevention or treatment of infection may reduce maternal or fetal/neonatal morbidity
(b) may prolong pregnancy and delay the progression to preterm birth by treating or preventing ascending
infection.

For preterm PROM 34-36 weeks AOG, conservative management has been associated with an eightfold increase
in amnionitis. Hence, these women are best managed by expeditious delivery with labor induction. For PPROM
<34 weeks, expectant management is usually preferred. The woman must be transferred to an institution with a
neonatal intensive care unit. The most effective intervention to improve newborn outcomes for patients in
preterm labor is the administration of corticosteroids.

B. HEMMORHAGIC COMPLICATIONS

A. RUPTURED UTERUS

Definition: Uterine rupture is an uncommon but serious obstetric emergency associated with an increase in fetal
and maternal mortality and morbidity. Uterine rupture may develop as a result of preexisting injury or anomaly, it
may be associated with trauma, or it may complicate labor in a previously unscarred uterus.

Classification: Complete uterine rupture involves the full thickness of the uterine wall, with or without expulsion
of the fetus and/or the placenta and includes rupture of the membranes at the site of the rupture. It usually
presents as an emergency which threatens the life of both the woman and her baby. Incomplete rupture or
uterine dehiscence occurs when the uterine wall ruptures but the visceral peritoneum remains intact. It is usually
asymptomatic and the diagnosis is made incidentally at the time of cesarean section.

Cause of Uterine rupture: The most common cause of uterine rupture is separation of a previous cesarean
hysterotomy scar. Other common predisposing factors to uterine rupture are previous traumatizing operations or
manipulations such as curettage, perforation, or myomectomy; grand multiparity, neglected labor, breech
extraction, uterine instrumentation and congenital uterine anomalies. Excessive or inappropriate uterine
stimulation with oxytocin, can also cause rupture. Uterine rupture can be traumatic or spontaneous. Traumatic
rupture can occur following blunt abdominal trauma, difficult forceps delivery, unusual fetal enlargement such as
hydrocephaly, and breech extraction. Spontaneous rupture can occur with Oxytocin stimulation. Similarly, in
women of high parity, a trial of labor with suspected cephalopelvic disproportion, high cephalic presentation, or
abnormal presentation, such as a brow, must be undertaken with caution.

Presentation: the signs and symptoms associated with rupture of the uterus include: severe shock (rapid, weak
pulse, low blood pressure, pallor, sweating, rapid breathing, anxiousness, confusion or unconsciousness, scanty
urine output, maternal tachycardia), collapse, marked abdominal tenderness, abnormal uterine contour (during
labor or birth), easily palpable fetal parts, absent fetal heart sounds and movements or abnormalities in the fetal
heart rate, diminished baseline uterine pressure, loss of uterine contractility, abnormal labor or failure to
progress, abdominal pain, recession of the presenting part, hemorrhage.
Following vaginal delivery, a defect or opening in the uterine wall maybe palpated on manual removal of a
placenta or manual exploration of the uterine fundus for possible retained placental fragments.
Management: Vigorous resuscitation is promptly required. Emergency laparotomy is indicated. Where
operating facility is not available, refer and arrange immediate transfer. Hysterectomy should be considered the
treatment of choice when intractable bleeding occurs or when uterine rupture sites are multiple

Complication: Perinatal morbidity and mortality rates are increased with rupture of a prior uterine incision during
labor. Hysterectomy may be necessary to control hemorrhage hence the loss of future childbearing. Other
complications are: blood loss and the need for blood transfusion, bladder, ureteral and bowel injuries, thrombo-
embolic complications, febrile morbidity.

B. INVERSION OF THE UTERUS

Uterine inversion is a condition in which the inner surface of the fundus comes out through the cervix. occurs
rarely, approximately 1 in every 25,000 deliveries. It is often iatrogenic, meaning it is caused by health care
providers, often resulting from overly rigorous umbilical cord traction. Uterine inversion is more common in
grand multiparous women. A large purplish mass appears at the introitus. The placenta may still be attached.
The woman will quickly become unstable.

Types: Acute inversions occur immediately or within 24 hours after delivery. This is the most common type of
uterine inversion. Subacute inversion occurs after the first 24 hours and within 4 weeks after delivery. Chronic
inversion occurs after more than 4 weeks after the delivery. Another classification is based on the anatomical
severity of the inversion. Complete uterine inversion occurs if the uterus extends beyond the level of the cervix,
with a dark, beef-looking mass seen inside the vagina or outside the introitus. Incomplete uterine inversion occurs
when the uterus does not extend beyond the cervix

Risk factors: Inversion of the uterus is principally a complication of the third stage of labor and the most common
cause is traction applied to the umbilical cord while uterus is relaxed. Other factors are primiparity, uterine
hypotonia secondary to twin pregnancy and betamimetics, placenta accreta, fundal myoma, short umbilical cord,
congenital weakness or anomalies of the uterus.

Management: Uterine inversion is most often associated with immediate life-threatening hemorrhage. Delay in
treatment increases the mortality rate appreciably. It is imperative that a number of steps be taken urgently and
simultaneously:

 Immediate assistance is summoned to include anesthesia personnel and other physicians

  The recently inverted uterus with placenta already separated from it may often be replaced simply by
pushing up on the fundus with the palm of the hand and fingers in the direction of the long axis of the
vagina
 Adequate large-bore intravenous infusion systems are established, and crystalloid and blood are given to
treat hypovolemia
 If still attached, the placenta is not removed until infusion systems are operational, fluids are being given,
and a uterine-relaxing anesthetic such as a halogenated inhalation agent has been administered. In the
meantime, if the inverted uterus has prolapsed beyond the vagina, it is replaced within the vagina
 After removing the placenta, steady pressure with the fist is applied to the inverted fundus in an attempt
to push it up into the dilated cervix. Alternatively, two fingers are rigidly extended and are used to push
the center of the fundus upward. As soon as the uterus is restored to its normal configuration, the
tocolytic agent is stopped. An oxytocin infusion is begun while the operator maintains the fundus in its
normal anatomical position.

C. GENITAL TRACT LACERATIONS

Trauma resulting from the birth process can result in significant blood loss, suddenly due to lacerated blood
vessels or by trickle hemorrhage over several hours. The source of trauma must be quickly identified and
treated. Bleeding may result from injury to the cervix, vagina or perineum, or the anus and rectum. Genital
trauma is classified by the tissue involved:
 First degree tears – involve the perineal skin and vaginal mucosa, but the underlying muscles are intact
 Second degree tears – involve the perineal skin, vaginal mucosa, and underlying muscles. Vaginal tears
may be central or may extend up one or both sides of the vagina.
 Third degree tears – involve damage to the above structures, as well as complete transaction of the anal
sphincter
 Fourth degree tears – involve the rectal mucosa in addition to structures mentioned above.

III.INFANT COMPLICATIONS

A. PREMATURITY
 Preterm birth is defined as delivery before 37 completed weeks. It was implicated in approximately two
thirds of deaths during the first year of life.
 A variety of morbidities, largely due to organ system immaturity, are significantly increased in infants born
before 37 weeks' gestation compared with those delivered at term. Late preterm infants—34 to 36 weeks
—were associated with increased morbidity rates compared with those of term infants. Attention has also
been given to increasingly small preterm infants—very low-birthweight and extremely low-birthweight.
These infants predominantly suffer not only the immediate complications of prematurity but also long-
term sequelae such as neurodevelopmental disability.
 It appears generally accepted that births before 26 weeks, especially those weighing less than 750 g, are
at the current threshold of viability and that these preterm infants pose a variety of complex medical,
social, and ethical considerations.
 There are four main direct reasons for preterm births
1. Delivery for maternal or fetal indications in which labor is induced or the infant is delivered by prelabor
cesarean delivery
2. Spontaneous unexplained preterm labor with intact membranes
3. Idiopathic preterm premature rupture of membranes (PPROM)
4. Twins and higher-order multifetal births.

Major Short- and Long-Term Problems in Very-Low-Birthweight Infants

Organ or System Short-Term Problems Long-Term Problems
Pulmonary Respiratory distress syndrome, air leak, Bronchopulmonary dysplasia, reactive
 bronchopulmonary dysplasia, apnea of
prematurity
Gastrointestinal or Hyperbilirubinemia, feeding intolerance,
nutritional necrotizing enterocolitis, growth failure
Immunological Hospital-acquired infection, immune
deficiency, perinatal infection
Central nervous Intraventricular hemorrhage,
system periventricular leukomalacia,
hydrocephalus
Ophthalmological Retinopathy of prematurity
Cardiovascular Hypotension, patent ductus arteriosus,
pulmonary hypertension
Renal Water and electrolyte imbalance, acid–
base disturbances
Hematological Iatrogenic anemia, need for frequent
transfusions, anemia of prematurity
Endocrinological Hypoglycemia, transiently low thyroxine
levels, cortisol deficiency
airway disease, asthma
Failure to thrive, short-bowel syndrome,
cholestasis
Respiratory syncytial virus infection,
bronchiolitis
Cerebral palsy, hydrocephalus, cerebral
atrophy, neurodevelopmental delay,
hearing loss
Blindness, retinal detachment, myopia,
strabismus
Pulmonary hypertension, hypertension in
adulthood
Hypertension in adulthood
 
Impaired glucose regulation, increased
insulin resistance

The following considerations should be given to women in preterm labor:

1. Confirmation of preterm labor
2. For pregnancies less than 34 weeks in women with no maternal or fetal indications for delivery, close
observation with monitoring of uterine contractions and fetal heart rate is appropriate. Serial
examinations are done to assess cervical changes
3. For pregnancies less than 34 weeks, corticosteroids are given for enhancement of fetal lung maturation
4. Consideration is given for maternal magnesium sulfate infusion for 12 to 24 hours to afford fetal
neuroprotection
5. For pregnancies less than 34 weeks in women who are not in advanced labor, some practitioners believe
it is reasonable to attempt inhibition of contractions to delay delivery while the women are given
corticosteroid therapy and group B streptococcal prophylaxis.
6. For pregnancies at 34 weeks or beyond, women with preterm labor are monitored for labor progression
and fetal well-being
7. For active labor, an antimicrobial is given for prevention of neonatal group B streptococcal infection.

B. POSTMATURITY

Definition: Post term, postmature or postdate pregnancy is 42 completed weeks (294 days) or more from the
first day of the last menstrual period. The incidence ranges from 4-19%.

Perinatal Mortality: Perinatal mortality rates increased after the expected due date was passed. The major
causes of death included gestational hypertension, prolonged labor with cephalopelvic disproportion,
"unexplained anoxia," and malformations. Children born postterm had more developmental abnormalities
compared with those born before 42 weeks. The rate of cesarean delivery for dystocia and fetal distress was
significantly increased at 42 weeks compared with earlier deliveries. More infants of postterm pregnancies were
admitted to intensive care units. Finally, the incidence of neonatal seizures and deaths doubled at 42 weeks.

Postmaturity syndrome: Postmature infants present a unique and characteristic appearance. Features include
wrinkled, patchy, peeling skin; a long, thin body suggesting wasting; and advanced maturity because the infant is
open-eyed, unusually alert, and appears old and worried. Skin wrinkling can be particularly prominent on the
palms and soles. The nails are typically long. Most such postmature infants are not technically growth restricted
because their birthweight seldom falls below the 10th percentile for gestational age. On the other hand, severe
growth restriction—which logically must have preceded completion of 42 weeks—may be present.

Complications:
1. Fetal distress and oligohydramnios - The volume of amnionic fluid normally continues to decrease after 38
weeks and may become problematic. Oligohydramnios is associated with antepartum fetal jeopardy and
intrapartum fetal distress due to cord compression. Moreover, meconium release into an already reduced
amnionic fluid volume causes thick, viscous meconium that may cause meconium aspiration syndrome
2. Fetal growth restriction and stillbirth - Stillbirths were more common among growth-restricted infants
who were delivered after 42 weeks.
3. Macrosomia - The velocity of fetal weight gain peaks at approximately 37 weeks. Although growth
velocity slows at that time, most fetuses continue to gain weight.

C. BIRTH INJURIES
 There are a number of birth injuries that can potentially complicate all types of deliveries. Some are more
likely associated with "traumatic" delivery by forceps or vacuum, and others follow otherwise
uncomplicated spontaneous delivery.
1. Head injury- The fetus or infant can sustain a number of traumatic head injuries during labor or at
delivery. They can be external and obvious or intracranial and even covert. Some are
spontaneous, whereas others are associated with instrumented deliveries.
 Spontaneous intracranial hemorrhage - Fetal or neonatal intracranial hemorrhage can
occur at any of several sites. It usually occurs spontaneously as the result of immaturity
and generally does not result from traumatic delivery or obstetrical factors.
 Traumatic intraventricular hemorrhage - can be due to forceps delivery or breech
delivery.
 Cephalhematoma - hemorrhage over one or both parietal bones, and palpable edges can
be appreciated as the blood reaches the limits of the periosteum.

2. Nerve injuries
 Spinal injury- Overstretching of the spinal cord and associated hemorrhage may follow
excessive traction during delivery, and there may be actual fracture or dislocation of the
vertebrae. Spinal cord injuries were associated with forceps rotations during delivery and
also can occur during breech delivery.
 Brachial plexopathy - Damage to the upper plexus is called Erb or Duchenne paralysis and
involves C5 and C6 and occasionally C7. Injury leads to paralysis of the deltoid and
infraspinatus muscles and the flexor muscles of the forearm. Damage to the lower plexus
—C8 and T1—results in Klumpke paralysis, in which the hand is flaccid. Total involvement
of all brachial plexus nerve roots results in flaccidity of both arm and hand. Horner
syndrome on the affected side—ptosis and pupillary meiosis resulting from interruption of
nerve fibers in the cervical sympathetic chain.
 Facial paralysis - Pressure on the facial nerve as it emerges from the stylomastoid
foramen can cause damage resulting in facial paralysis. It most commonly is associated
with normal spontaneous or cesarean delivery. Only approximately 20 percent are
associated with forceps deliveries.
3. Skeletal and muscle injuries
 Fractures- Clavicular fractures are common, unpredictable, and unavoidable
complications of normal birth with incidence of 3-18 per 1000 livebirth. Humeral
fractures are not common. Difficulty encountered in the delivery of the shoulders in
cephalic deliveries and of extended arms in breech deliveries often produces such
fractures. Up to 70 percent of cases, however, follow uneventful delivery. Mandibular
fractures and skull fractures
References:
Clinical Practice Guidelines on Obstetric Hemorrhage, POGS, Inc. 2014
Cunningham, Leveno, et al, Williams Obstetrics 23 rd Edition, Mc Graw Hill Companies, Inc, 2010
Festin, Mario, Manual of Obstetric and Gynecologic Emergencies, University of the Philippines manila, 2008