Abnormal labour

Dr: Hayder Al-Shamma’a

 objectives
• List the types of Malposition and
malpresentations
• Able to identify patients with malposition and
malpresentations
• List the maternal and fetal risks of malposition
and malpresentations
• List the causes
• Describe the treatment
 types
• I :- Malposition and Mal-presentation of the
head ( occipito-posterior, face presentation
,brow presentation)
• II:- Breech presentation
• III:- Shoulder presentation(Transverse lie) and
compound presentatiom
Vertex presentation Brow presentation Face presentation
complete breech Footling breech
Transverse lie
Shoulder presentation
 Risks of abnormal labour
• Abnormal labour carries increased risks to the
mother and the fetus more than normal
labour , specially if the labour is attended by
an inexperienced personnel
 Maternal risks of abnormal labor
1. prolonged labor
2. Infection
3. Obstructed labor
4. Anesthesia
5. Traumatic delivery
6. Hemorrhage
Intra-partum

7. DVT with risk of PE

8. Pressure necrosis and fistula

9. death
 Fetal risks
1. Cord prolaps
2. Hypoxia
3. Infection (chorio-amnionitis , pneumonia)
4. Traumatic injuries
5. Meconium aspiration (pneumonitis)
6. death
Malposition & mal-presentation of the
fetal head
1) Occipito-posterior position
2) Face presentation
3) Brow presentation
 Labour in occipito-posterior position

• The denominator is the occiput

• The occiput occupy the posterior part of the

female pelvis ie. occiput near the sacrum
I- occipito-posterior
 Causes of O. P.
• Anthropoid pelvis favor direct o.p position
• Android pelvis favor oblique o.p. position
• Anteriorly situated placenta
• gross pendulous abdomen
• Congenital malformations of baby/uterus
• Abnormal extensor tone
• Polyhydramnious
• Prematurity
• fibroids
• Multiple pregnancy
Twins/Triplet
 Diagnosis of occipito posterior
• By abdominal exam.
1. Flat lower abdomen below the umbilicus
2. easy to feel Fetal limbs anteriorly
3. difficult to feel the Fetal back
4. Head not engaged
5. Fetal heart at the flanks
 Diagnosis of occipito posterior
• By pelvic exam.
1. High presenting part*
2. Bulging sausage shaped membranes*
3. Or early rupture of membranes (cx.less than 3cm)*
4. Easy to feel the anterior fontanel behind the pubic
symphysis
5. Difficult to feel the posterior fontanel near the sacrum
6. ear directed posteriorly (in excessive caput & edema)

* (signs of malpresentation , malposition in general )

 Mechanism of labour in O.P.
• Engagement in ROP (ROP 3times than LOP)
• Engaging diameter is suboccipito-frontal 10.5
cm if the head well flexed .
• Or occipito-frontal 11.5 cm if the head
deflexed (both larger than normal OA
suboccipito-bregmatic 9.5 cm)
• This gives an oval shaped presenting part not
fit well on the cx. Of larger dimentions
 Mechanism of labour in O.P.
• Internal rotation:- if the head well flexed the
occiput will touch the pelvic floor first and
rotated anteriorly 3/8th of a circle 135˚ and
become occipito-anterior and the mechanism
then continue as in OA. But it takes longer
time to rotate
• This occurs in 70% of cases
10.5

11.5

9.5

9.5
 Mechanism of labour in O.P.
• If the head is deflexed :- the sinciput touches the pelvic
floor first so rotates anteriorly and the occiput rotates
posteriorly through 1/8th of a circle (45˚) short rptation
giving direct occipitoposterior
• The mechanism differs , descent continues and the
head delivers by a combination of flexion first, followed
by extension
• The emerging diameter is occipito-frontal of 11.5 cm
causing great distension at the vulva and perineum and
perineal tears may occur unless episiotomy performed
• Occurs in 10% of cases
 Mechanism of labour in O.P.
• Arrest of rotation at lateral position (right
occipito-lateral or left occipito-lateral)
• No mechanism of labour
• Deep transverse arrest
• Need assisted delivery
• Occurs in 20% of cases
 Features of labour in O.P.
1. Slow progress (slow cx. dilatation, descent,
rotation)
2. Backache is more
3. Incoordinate uterine contraction
4. Early rupture of membranes
5. Higher chance for cord prolaps
6. Higher chance for infection
7. Higher chance for perineal laceration
8. Excessive moulding of the head may cause
tentorial tear
the umbilical cord drops
(prolapses) through the
open cervix into the vagina
ahead of the baby
 Treatment of O.P.
Before the onset of labour , no attempt for correction
During first stage of labour
1. Correction of malposition cannot be done
2. Observation of uterine contraction, cx dilatation,
descent,and use partogram
3. Continuous fetal heart monitoring
4. Due to increased risk for operative delivery and
anesthesia , give nothing by mouth, only occasional sips of
water
5. Maintain maternal hydration by iv fluid
6. Oxytocin infusion is often indicated to correct
incoordinate uterine contractions
 Treatment of O.P.
• Cesarean section is indicated in first stage in
the following conditions
1. Failure to progress in spite of good uterine
contractions for 3 hours
2. Fetal distress
3. Maternal distress
 Treatment of O.P.
• Treatment in second stage
• Mistaken diagnosis of 2nd stage is not
uncommon, the patient have urge to
pushdown before full dilatation (pressure
effect of the large occiput on the pelvic plexus
• p/v exam is essential to confirm the diagnosis
 Rx of 2nd stage continue
• p/v to assess degree of deflexion
• Determine excessive molding
• Determine caput succidanium
• If detect that , spontaneous labour is unlikeley
to occur
• Pain relieve is essential in O.P.
• Epidural analgesia , pethidine
Need assisted delivery
Fetal distress
Maternal distress
Failure to progress
Deep transverse arrest
 Assisted delivery
• Oxytocin
• Manual rotation with or without forceps
extraction
• Forceps rotation (Kielland forceps)
• Vacuum extractor
• Cesarean section
 Manual rotation
• Correction of malposition by manipulation
with the hand under epidural anesthesia
• Disadvantage need anesthesia, hand take
additional space , may cause trauma, pulling is
not feasible
• Kielland forceps rotation
• Same disadvantages but ,can pull the head

Vacuum extraction ( Vantouse , Kiwi)

Advantages
Applied without anesthesia, not take extra
space, easy to use minimal skills
Manual
Rotation
 Face presentation
• The head is fully extended
• 1/300 deliveries
• Causes : same as O.P.
• The denominator is the mentum (chin)
• Mento-posterior no mechanism of labour the
chest try to enter the pelvis at the same time
with the head (sternobregmatic 16-18cm)
 Mechanism of labour in mento
anterior
• Engagement in mentolateral ML or RMA
• Engaging diameter is the submento bregmatic 9.5
cm
• Descent occurs slowly
• Rotation occur late in 2nd stage
• Engagement occur at +2 or +3 station
• Delay in 2nd stage due to oblique line of thrust
from the back to the head
• The face deliver by flexion
face going out of pelvis
• Emerging diameter is the submentovertical 11cm
 Diagnosis of face presentation
• Abdominal findings:- Longitudinal lie, cephalic
, a groove can be felt between the head and
back , the head is high
• p/v feel the chin, mouth, jaws, nose, orbital
ridge
 management
• Exclude congenital malformation ,CPD,
hypertension , placenta previa, other risk
factors , estimated fetal wt 3.5kg
• If any of the above cesarean section safer
• Manage as in case of O.P.
 Brow presentation
• 1/1000
• Incomplete extension
• It is usually a transient presentation , either
change to vertex or to face
• Causes as face
• Diagnosis
• On abdominal exam as in face but the groove is
less prominent
• p/v :- feel ant. Fontanel, orbital ridge, roote of the
nose, eyes, but not the chin
 Mechanism of labour in brow
• No mechanism of labour . The engaging
diameter is the mentovertical 14 cm so
cesarean section is indicated in persistent
brow
 II- Breech presentation
• Occurs when the leading part of the fetus is
the buttock (breech)
• 2-3% of term pregnancy
• The denominator is the sacrum
 Causes of breech presentation
1. Prematurity ( at 30 wks. 25% breech )
2. Uterine abnormalities
3. Fetal factors prevent spontaneous version
4. Placenta previa
5. fibroids
6. Hydrocephaly
7. unknown
 Types of breech
I. Flexed breech (complete breech) , hips flexed ,
knees flexed.
common in multiparous women. The presenting
part is irregular and not fit well on the cx
II. Extended breech (frank breech) , Hips flexed ,
knees extended . common
in primigravida. Fits well on the cx
III. Footling breech ( incomplet), partial extension
of one or both hips ( the feet below the buttock
).
 Diagnosis of breech
• On abdominal examination:-
• Long. Lie
• Head felt at the fundus as hard rounded mass
smooth and ballotable
• Lower segment feels as firm irregular non
ballotable mass
• Fetal heart heard above the umbilicus .
• On vaginal examination:-
• Signs of mal-presentation
• Feel the soft buttocks
• Soft natal cleft
• Irregular hard sacrum
• Hard ischeal tuberosities
• The anus with tuberosities form a strait line
• The feet can be felt
 Mechanism of labor
• The largest diameter of the breech is the
bitrochanteric diameter of 10 cm
• Engagement of the bitrocanteric diameter in the
transverse or oblique diameter of the pelvis (Left
sacro-anterior or direct sacro-anterior)
• Descent in pelvic cavity followed by rotation one
buttock becomes anterior
• Further descend by lateral bend of the trunk
• Delivery of anterior buttock followed by the
posterior
 Mech. Of breech ..continue
• Then engagement of the shoulders
(bisacromial diametr in transverse or oblique
diameter followed by descend of the
shoulders and rotation
• One shoulder become anterior and delivered
first
 Mech. Of breech ..continue
• Engagement of the head now start to effect in
the oblique diameter of the pelvis (LOA) with
descend of the head it rotates to OA
• Rarely rotates to OP difficult labor !!!
• The head delivers by flexion
 Prognosis of breech delivery
• Perinatal mortalities is X4
1. Hypoxia
a) delayed delivery of the head
b) cord compression
c) reduced placental flow ( uterine retraction )
d)respiratory efforts aspiration of clots or meconium
2. Intracranial hemorrhage (rapid delivery of the head ,compression
decompression of the head ) as no time for moulding
3. Cervical spine injuries from excessive traction on the shoulder
4. Soft tissue injuries ( rupture spleen,liver and bowel)
5. Fractures of long bones
• Maternal risks
1. Increased operative deliveries
2. Increased Genital tract injuries
3. Increased Cesarean section
4. Increased Risks of anesthesia
But the major disadvantage of vaginal breech
delivery is burdened by the fetus
 Management of breech
• Wait to 36 wks
• Consider external cephalic version ECV if
1. No other indication for C/S
2. Technically possible ( normal liquor, fetal size,
relaxed uterus ,etc…..)
3. No contraindication.( previous C/S, APH, PE,
twins, bad obstetric history, abnormal baby,
infertility , etc….)
 Risks of ECV
1. Premature labour
2. Premature preterm rupture of membranes
(PPROM)
3. Feto-maternal transfusion
4. abruptioplacentae
5. Formation of knots in the cord
 Management of persistant breech
• Selection of cases for vaginal delivery
Assessment for medical or obstetrical risks
1. PE
2. diabetes
3. bad history
4. Rh isoimmunization
5. footling breech
6. previous C/S
7. suspected CPD
8. fetal wt ≥ 3.8 kg
9. gestational age ≥ 40 wks.
10. others like wish of the parents
All need elective C/S
 Management of vaginal breech
delivery
with continous monitoring/and NPO

• First stage managed as high risk labor

• 2nd stage should be conducted by the most
senior resident available

• Patient should be in lithotomy position

• Iv fluid ,epidural anesthesia available
The second stage managed as follows

1. Spontaneous delivery till the umbilicus

2. Rapid assisted delivery of the trunk and

shoulders

3. Controlled delivery of the head in 4-6 minuets'

 Delivery of the head
• 3 methods
1. Burns Marshal method
2. Jaw flexion shoulder traction
3. Forceps for the after-coming head
Burns Marshal /Prague Seizure
method
Jaw flexion/ shoulder traction
Forceps for the after-coming head
 Transverse lie /oblique lie
shoulder presentation
• Transverse lie :- occurs when the longitudinal
axis of the fetus is perpendicular to the
longitudinal axis of the mother the presenting
part is the shoulder ( also named shoulder
presentation ).

• Oblique lie :- when the head or the breech is

slightly higher than the other side
Transverse lie
Oblique lie
• the denominator is the back ( dorsum )
• Dorso-anterior is more common than dorso-
posterior

• Incidence :- 1/250 – 1/500 deliveries

Right acromio-dorsoposterior
 Causes of transverse lie
1. Multiparity is the most common cause
2. Prematurity
3. Polyhydramnious
4. Multiple pregnancy
5. Contracted pelvis
6. Placenta previa
7. Fibroids of the lower segment
8. Congenital abnormalities of the uterus as
septate and arcuate uterus
 Diagnosis of transverse lie
• On abdominal examination:-
1) The abdomen is asymmetrically distended
2) Width more than length
3) Fundal height less than expected
4) Round heard mass at one iliac fossa , softer
breech at the other fossa
5) Absent presenting part ( pelvic grip feel
empty lower segment
On p/v examination:-
1) Can not feel the presenting part (high)
2) Bulging membranes or rupture membranes
3) Fetal arm or umbilical cord may prolaps to
the vagina
Hand prolaps
 Management of transverse lie
1. Before labour :-
Manage as breech do ECV *
2. During early labor:-
Before rupture membrane can try ECV
3. Advanced labor , failure of ECV or
contraindicated ECV :-
Cesarean section is the safest method even
incase of a dead fetus (TLSCS or easier LVCS)
 Unstable lie
• When the fetus changes its axis every visit
• Causes as t lie
• Management :-ECV each visit after 36 weeks
• ((same contraindication as ECV of breech)
• Admission to hospital at 36 weeks
• ECV and induction of labor at 38 wks
• Elective cs may be performed in selected cases
 Fetal malformation causes difficult
labor
• Hydrocehalus
• Diagnosed by U/S
• During labor feel widely separated sutures
• Big head cause obstructed labor rare in modern
practice
• Management : terminate pregnancy when the
head reaching 9.5 cm by induction of labor or by
CS (up to 12cm)
• Advanced obstructed labor perforate the head
and drain the CSF and deliver vaginally ( rare )
hydrocephalus
hydrocephalus
Conjoined twins cephalopagus
Thoracopagus