COMPLICATIONS OF

LABOR…
PRETERM
LABOR…
• is defined as one where the labor starts before
the 37th completed week, counting from the
first day of LMP.
• Cause unknown. Often multifactorial
• Clinical features similar to that in normal labor
 RISK
FACTOR
• History: previous history, assisted reproductive
techniques, asymptomatic/recurrent UTI, smoking,
maternal stress
• Complications:
– Maternal:
• Pre-eclampsia, APH, PROM, polyhydraminos
• Cervical incompetence, uterine malformation
• Acute fever, pyelonephritis, diarrhea, appendicitis, infections
• Hypertension, diabetes, heart disease, severe anemia
– Fetal: multi-fetal gestation, congenital malformation, IUD
– Placental: infarction, thrombosis, previa/abruption
• Iatrogenic: elected – if any medical/obstetrics
complication
• Idiopathic
 MANAGEMENT
• To prevent preterm onset of labor
– Primary care: reduce risk factors
– Secondary care: early detection and prohylactic treatment
(tocolytics)
– Tertiary care: reduce mortality(steroids)
• Arrest preterm labor
– Bed rest
– Adequate hydration and prophylactic antibiotics
– Prophylactic cervical cerclage
– Tocolytics (nifedipine, atosiban, progesterone)
– MgSO4 dosing and monitoring – prophylaxis of pre-eclampsia
• Appropriate management
• Effective neonatal care
 MANAGEMENT IN
LABOR
• First stage:
– Adequate bed rest: to prevent ROM
– Adequate oxygenation and anesthesia
– Maternal and fetal monitoring
– NICU to be prepared before-hand
• Second stage:
– Slow and gentle birth
– Episiotomy
– Cord clamped immediately (to prevent hypervolemia
and hyper-bilirubinemia)
• Spontaneous rupture of the membranes any
time beyond 28th week of pregnancy but
before the onset of labor is called pre-labor
rupture of the membranes (PROM)
• If after 37wks but before onset of labor:
PROM
• If before 37th wk : preterm PROM (PPROM)
PRE-LABOR RUPTURE
OF MEMBRANES…
 CAUSES
• Increases friability of membranes
• Decreased tensile strength of membranes
• Polyhydraminos
• Cervical incompetence
• Multi-fetal gestation
• Infections – UTI, chorio-amnionitis, lower genital
tract infection
• Previous history
• Low BMI
 CLINICAL
FEATURES
• Watery discharge – gush of fluid or slow leak
• Careful Speculum examination: liquor escaping
through the cervix
• USG
• Avoid digital PV examination
• Investigations
– CBC, CRP, Urine analysis, Vaginal swab for culture
– Estimation of phosphatidylglycerol and L:S ratio
– USG and cardio-tocography /non-stress test
 COMPLICATIONS
…
• Preterm labor and prematurity
• Ascending infections: chorio-amnionitis and fetal
infections, endometritis
• Cord prolapse
• Dry labor
• Placental abruption, retained placenta, maternal
sepsis
• Fetal pulmonary hypoplasia
• Neonatal sepsis, RDS, IVH, NEC, cerebral palsy,
fetal death
MANAGEMENT…
• Preliminaries – Aseptic examination, avoid
digital PV examination, bed rest
• Monitor maternal pulse, FHR & start
prophylactic broad spectrum antibiotics &
corticosteroids
• Assess for amnionitis, placental abruption,
fetal distress/death
– if present then expeditious delivery, broad
spectrum antibiotics and NICU care
• Pregnancy <34 weeks
– Bed rest, antenatal corticosteroids, broad
spectrum antibiotics
– Steroids not given in presence of frank infection
– Dose:
Betamethasone: 12mg – 2 doses – 24hours apart OR
dexamethsone 6mg – 4doses – 6hours apart

Wait for spontaneous onset of

• Pregnancy 34th -37th weeks labor for 24-48 hours

• Pregnancy >37th weeks If fails then

Induction of labor or LSCS

PROLONGED AND POST
TERM PREGNANCY…
• a pregnancy continuing beyond 2 weeks of the
expected date of delivery (> 294 days) is called
postmaturity or post-term pregnancy.
• Unknown causes
• Factors related;
– Wrong dates
– Hereditary
– Primipara, previous history, sedentary, elderly
multiparae
– Congenital anomalies: anaencephaly
– Placental factors
 COMPLICATIONS
•
…
Placental ageing  placental calcification and infarction 
insufficiency
• Fetal hypoxia and distress due to placental insufficiency,
meconium stained liquor and oligohydraminos
• Labor
– Fetal hypoxia and acidosis
– Labor dysfunction, meconium aspiration
– Cord compression
– Shoulder dystocia
– Birth trauma – non-molding (hardening of skull bones)
– Operative delivery
• Delivery
– Meconium aspiration – Chemical pneumonitis, atelectasis/collapse,
pulmonary hypertension
– Hypoxia and respiratory failure
– Hypoglycemia and polycythemia
– NICU admission
 DIAGNOSIS
…
• Menstrual history: regular/irregular cycles,
contraceptive history, LMP
• Clinical findings:
– Weight records: stationary/decreasing
– Girth of abdomen: amniotic fluid content
– False labor pains
– Obstetrics palpation: height of uterus, size of fetus
and hardness of skull bones
• Internal examination
– Cervical ripeness
– Color of amniotic fluid: greenish-yellow/saffron
MANAGEMENT…
• Be sure of fetal maturity and fetal surveillance
• Uncomplicated cases can be induced
– If cervix unripe  6hrly PGE2 given PV then ripe
– If cervix ripe  artificial rupture of membrane
done  oxytocin drip given  delivery
• Complicated cases  LSCS
INTRA-UTERINE FETAL
DEATH
• Ante-partum death beyond the period of
viability is termed as IUD
• Delivery of macerated fetus
 CAUSES
…
• Maternal (5-10%)
– HTM, DM, fever, infections, thrombophilia, auto-
immune, prolonged/obstructed labor, ruptured
uterus, post-term pregnancy
• Fetal
– Chromosomal anomalies, infections, Rh-
incompatibility
• Placental
– APH, cord(prolpse, knot, around neck), twins
• Iatrogenic – drugs,
• Idiopathic
 CLINICAL
FEATURES…
• Absence of fetal movements
• Signs:
– Per abdomen
– Gradual regression of fundal geight
– Uterine tone diminised and flaccid feels
– No fetal movements felt
– Absent FHR
– NST: flat trace
– Egg shell cracking feel of fetal head
• Complications:
– Psychological upset, infections, blood coagulation disorder
(silent DIC), uterine inertia, retained placenta and PPH
 INVESTIGATION
S…
• USG
– Lack of cardia and fetal motions
– Oligohydraminos
– Collapsed/overlapping skull bones
• X-rays abdomen (rarely done)
– Spalding sign: irregular overlapping of skull bones (7th day)
– Hyperflexion of spine and hyperextension of neck.
– Crowding of rib shadows
– Robert’s signs: appearance of gas shadows in chambers of
heart and great vessels (12hrs)
• Blood
 MANAGEMENT…
• Prevention:
– Preconceptional counselling and care, screening and
early diagnosis
– Breaking bad news
• Expectant attitude: spontaneous expulsion within
2 weeks
• Methods of delivery
– Oral mifepristoe (200mg) and PV 25mcg misoprostol 4
hourly
– intravaginally 25-50mcg misoprostol 4 hourly
– 5-10 U of oxytocin in 500ml of RL
– Cesarean – previous 2 or more LSCS, placenta previa,
transverse lie
• Post-partum suppression of lactation
• Bereavement management - counselling
PROLONGED
LABOR…
• The labor is said to be prolonged when the
combined duration of the first and second
stage is more than the arbitrary time limit of
18 hours.
• Due to
– Protracted cervical dilatation
– Inadequate descent
• Prolonged latent phase
– >20hrs in primi and >14hrs in multiparous women
– Causes
• Unripe cervix
• Malposition and malpresentation
• Cephalo-pelvic disproportion
• PROM
• Induction of labor
• Early onset of regional anesthetic
– Management:
Rest and analgesia
Augmentation (oxytocin or Prostaglandins)
Not an indication for cesarean delivery
 CAUSES
…
• First stage (failure to dilate cervix)
– Fault in power: abnormal contraction(inertia), in-
coordinated contraction
– Fault in passage: contracted pelvis, pelvic tumor or full
bladder
– Fault in passenger: malposition and malpresentation,
congenital anomalies(hydrocephalus)
– Injudicious use of sedatives and analgesics
• Second stage(non-descent)
– Fault in power: uterine inertia, exhaustion, analgesia,
constriction ring
– Fault in passage: CPD, spasm or old scaring, tumor
– Fault in passenger: malposition and malpresentation,
big baby, congenital malformation
 TREATMENT…
• Prevention
– Antenatal detection
– Use of partograph
– Selective and judicious augmentation
– Change of posture, emotional support, avoid
dehydration
• Actual treatment
– First stage delay
• Verify fetal position and station
• Amniotomy and oxytocin infusion
• Pain relief
• LSCS if unsafe vaginal delivery
– Second stage delay
• Assisted delivery
– Forceps and vacuum delivery
• LSCS
OBSTRUCTED
LABOR…
• Obstructed labor is one where in spite of good uterine
contractions, the progressive descent of the presenting
part is arrested due to mechanical obstruction.
• Causes:
– Fault in passage
• Bony: CPD, contracted pelvis
• Soft tissue obstruction: cervical dystocia due to prolapse or
previous operative scarring, cervical or broad ligament fibroid,
impacted ovarian tumor or the non-gravid horn of a bicornuate
uterus below the presenting part.
– Fault in passenger
• Transverse lie, brow presentation, hydrocephalus, fetal ascites, big
baby, locked twins
• Effect on mother
– Immediate: exhaustion, dehydration, genital
sepsis, injury of genital tract, ruptured uterus,
– Remote: fistula, vaginal atresia
• Effect on fetus
– Asphyxia
– Intra-cranial haeorrhage
– Infection
– Fetal hypoxia and maternal acidosis
 TREATMENT…
• Principles:
– Relieve obstruction
– Combat dehydration and ketoacidosis
– Control sepsis
• Obstetrics management
– Rule out rupture of uterus
• Vaginal delivery
• Cesarean section
SHOULDER
DYSTOCIA…
• Shoulder dystocia occurs when either the
anterior or the posterior (rare) fetal shoulder
impacts on the maternal symphysis or on the
sacral promontory respectively
 RISK
FACTORS:
(1) Previous shoulder dystocia,
(2) Macrosomia (>4.5 kg),
(3) Diabetes,
(4) Obesity (BMI >30 kg/m2),
(5) Induced labor,
(6) Prolonged first stage or second stage of labor,
(7) Secondary arrest of labor,
(8) Postmaturity,
(9) Multiparity,
(10) Anencephaly,
(11) Mid-pelvic instrumental delivery (more following ventouse
than forceps),
(12) Fetal ascites.
 COMPLICATIO
NS:
• Fetal: asphyxia, brachial plexus injury,
humerus fracture, clavicle or sternomastoid
hematoma during delivery.
• Maternal: PPH (11%), cervical laceration,
vaginal tear, perineal tear (3rd and 4th
degree), rupture of uterus, bladder, sacroiliac
joint dislocation and morbidity
• Diagnosis: (1) Definite recoil of the head back
against the perineum, (2) Inadequate
spontaneous restitution, (3) Fetal face becomes
plethoric, (4) Failure of shoulder to descend.

• Management principles: Extra help is to be called

(a) To clear infant’s mouth and nose
(b) Not to give traction over baby’s head
(c)Never to apply fundal pressure as it causes
further impaction of the shoulder
(d)To perform wide mediolateral episiotomy as it
provides space posteriorly
(e)To involve the anesthetist (as analgesia is ideal)
and the pediatrician (for infant’s resuscitation).
 TREATMENT…
• Suprapubic pressure
• McRoberts maneuvre: Abbduct matermal
thigh and hyperflex them onto abdomen.
Apply suprapubic pressure
• Woods maneuvre: posterior shoulder is
rotated to anterior position, Apply suprapubic
pressure
• All fours position
 HYDROCEPHALUS
…
• Excessive accumulation of cerebrospinal fluid (0.5–1.5 L) in the
ventricles with consequent thinning of the brain tissue and
enlargement of the cranium.
• Usually associated with congenital anomalies.
• Diagnosis:
– Larger, globular and softer head
– Head high-up in pelvis and impossible to push down
– FHS is high up above the umbilicus
– USG:
• Globular cranial shadow
• Wide fontanels and sutures with Thinner vault bones
• Dilated ventricles with thinning of cerebral cortex
– Internal examination
• Gaping sutures and fontanels
• Cracking sensation on pressing the head
• In breech presentation, however, the diagnosis is not made until the
after coming head is arrested at the brim.
• Presence of open spina bifida points strongly toward hydrocephalus.
MANAGEMENT…
• Principle is to decompress the hydrocephalic
head in labor either in vertex or in breech
presentation.
• This is also done during cesarean delivery before
incising the uterus.
• Bladder is evacuated before hand.
• Once the labor is established and the cervix is 3–
4 cm dilated, decompression of the head is done
by a sharp pointed scissors or with a wide bore
(17 gauge) long needle.
PRECIPITATE
LABOR…
• A labor is called precipitate when the combined duration of
the first and second stage is less than 3 hours.
• It is common in multiparae.
• Rapid expulsion is due to the combined effect of hyperactive
uterine contractions associated with diminished soft tissue
resistance.
• Maternal risks include:
Extensive laceration of the cervix, vagina and perineum
PPH due to uterine hypotonia that develops subsequent
to unusual vigorous contractions,
Inversion, Uterine rupture, Infection, Amniotic fluid
embolism.
• The fetal risks include—
intracranial stress and hemorrhage, bleeding from the
torn cord and direct hit on the skull, brachial plexus injury
are real hazards.
 TREATMENT
…
• The patient having previous history of precipitate labor
should be hospitalized prior to labor.
• During labor, the uterine contraction may be
suppressed by administering ether or magnesium
sulfate during contractions.
• Delivery of the head should be controlled.
• Episiotomy should be done liberally.
• Elective induction of labor by low rupture of
membranes and conduction of controlled delivery
is helpful.
• Oxytocin augmentation should be avoided.
RUPTURE OF
UTERUS…
• Disruption in the continuity of the all uterine
layers (endometrium, myometrium and
serosa) any time beyond 28 weeks of
pregnancy is called rupture of the uterus.
• Causes:
– Spontaneous
• Pregnancy: dilatation and curettage, grand multipare
congenital malformation of uterus, placenta percreta
• Labor: obstructed labor, grand multiparae
– Scar rupture
• Classical cesarean/hysterotomy scar
– Iatrogenic
• Oxytocins, prostaglandins, fall or blow to abdomen,
forceps, manual removal of placenta
• Scar dehiscence—
– disruption of part of scar and not the entire length.
– fetal membranes remain intact.
– bleeding is almost nil or minimal.

• Scar rupture—
– disruption of the entire length of the scar.
– complete separation of all the uterine layers including
serosa.
– rupture of the membranes with.
– varying amount of bleeding from the margins or from its
extension.
– uterine cavity and peritoneal cavity become continuous.
• Fetus and placenta: may or may not escape out of the
uterus
 DIAGNOSIS
…
• Scar rupture:
– dull abdominal pain, slight PV bleeding, tender uterus, FHS
irregular or absent,
– sense of give away with acute abdominal pain and collapse
• Labor:
– Distended tender lower segment with fetal distress or
absent FHS
– Sense of give away, constant pain dull aching pain,
superficial fetal parts, absence of uterine contour, two
distinct swelling
– PV – recession of presenting part, bleeding
• Shock, internal hemorrhage,
MANAGEMENT…
• Preventive:
– At risk patient – mandatory hospital delivery
– Judicious use of oxytocin
– Careful monitoring
– Avoid undue prolongation, vaginal birth, forceps
delivery
• Treatment:
– Lapartomy: hysterectomy, repair or repair and
sterilisation
– Resuscitation
MALPOSITION, MAL-
PRESENTATION CORD
PROLAPSE
 MALPOSITION…
OCCIPUT-POSTERIOR POSITION
• Malposition refers to any position of the vertex
other than flexed occipito-anterior one.
• That is occiput lies over sacrum or sacro-iliac joint
• Causes:
– Shape of pelvis – anthropoid or android
– Anterior Low lying placenta
– Abnormal uterine contractions
– Abnormal fetal skull
 DIAGNOSIS
…
• Abdomen: flat below umbilicus
• Palpation:
– Fetal limbs near midline and back in the flanks
– Head not engaged
• Auscultation: FHS heard on the flank or or the
midline
MANAGEMENT…
• 90% cases: internal rotation of head by 3/8th
of a circle remaining as usual.
• 10% cases: no rotation or minimal rotation
– Assisted vaginal delivery
– Liberal episiotomy
– Cesarean section
BREECH
PRESENTATION…
• Longitudinal lie with buttocks at the pelvic
brim
• Complete: flexed breech
• Incomplete: varying degrees of extension
– Frank breech: with extended legs
– Footling presentation
– Knee presentation
 FACTORS RESPONSIBLE…
• Unknown
• Prematurity
• Factors preventing spontaneous version:
– Frank breech, twins, oligohydraminous, short
cord, IUD, congenital anomalies of uterus
• Hydrocephalus, placenta previa, contracted
pelvis
• Trisomies, anencephaly
 COMPLICATIONS
…
• Maternal:
– Trauma to genital tract
– Operative delivery
– sepsis
• Fetal:
– Intra-partum fetal death
– Injuries to brain and skull: hemorrhage, fractures
– Birth asphyxia – d/t cord compression, prolapse, prolonged
labor, respiration while still inside womb
– Birth injuries – hematoma, fractures, visceral injuries,
nerve damage
– Congenital dislocation of hip
 DIAGNOSIS
…
• Clinical
• USG:
– Confirms clinical diagnosis
– Type of breech
 MANAGEMENT…
• Antenatal:
– Screening and identification
– External cephalic version
– Assisted vaginal breech delivery
– Elective cesarean delivery
• Criteria for vaginal breech delivery
– Avg fetal weight(1.5 – 3.5kgs)
– Flexed fetal head
– Adequate pelvis
– No any medical or obstetric complication
– Availabilty of OT and its components
• Indications of Cesarean Section (CS):
– Cases seen for the first time in labor with presence of
complications;
– Arrest in the progress of labor;
– Nonreassuring FHR pattern (Fetal distress);
– Cord presentation or prolapse.
 VAGINAL BREECH
DELIVERY…
• Spontaneous: very little assistance
• Assisted breech: assistance from beginning to
end
• Principle:
– Never to rush
– Never pull from below but push from above
– Always keep the fetus with the back anteriorly
• Positioning and toileting
• Episiotomy
• Patient is asked to bear down, NO TOUCH TO THE
FETUS policy is adopted till the buttocks are
delivered (with legs in flexed breech) up to the
trunk with the umbilicus.
• In frank breech: after buttocks are delivered – the
extended legs is delivered by pressure on
popliteal fossa in manner of abduction and
flexion of the thighs.
• Umbilical cord is pulled and mobilised to one side
• If back is posterior – rotated to make back
anterior
• Arms are delivered by hooking down each elbow
with finger.
• Delivery of the head is the most crucial step
• Delivery of the head should be within 5-
10mins of delivery of umbilicus.
• Techniques:
– Burns-Marshall method
– Forcep delivery
– Malar flexion and shoulder traction
• Resuscitation of the baby
• Other methods in arrest of descent:
– Pinard’s method
– Loveset maneuvre
TRANSVERSE
LIE…
• When the long axis of the fetus lies
perpendicularly to the maternal spine or
centralized uterine axis, it is called transverse lie.
• If obliquely placed – Oblique Lie
• Causes:
– Multiparity
– Prematurity
– Twins
– Hydraminos
– Contracted pelvis
– Placenta previa
– Pelvic tumors
– Congenital malformation of uterus
– IUD
 DIAGNOSIS
…
• Inspection
– broader and often asymmetrical uterus
• Palpation
– Fundal height is less than period of amenorrhoea
– Fundal grip: empty
– Lateral grip: buttocks and head on either side of
midline with back felt anteriorly
– Pelvic grip: empty
• Auscultation: FHS heard usually higher area
• PV: prolapse of hand/leg or a loop of cord
 MANAGEMENT…
• Antenatal: admitted at 37th wks – elective LSCS
• In ROM
• Early Labor:
– External cephalic version
– Cesarean section
• Late Labor:
– Baby alive – LSCS
– Baby dead – LSCS

• In macerated or premature baby (without ROM)

– Spontaneous rectification or version
– Spontaneous evolution
– Spontaneous expulsion
CORD
PROLAPSE…
• Abnormal descent of the umbilical cord by the
side of the presenting part
• Types
– Occult prolapse – cord is placed by the side of
presenting part and not felt during PV
– Cord presentation – cord slips down below the
presenting part and lies in the bag of membrane
– Cord prolapse – cord lies inside the vagina or outside
the vulva following rupture of membrane
•
 CAUSES
• Mal-presentation – transverse lie, breech with
flexed legs or footling and compound
presentation
• Contracted pelvis
• Prematurity
• Twins
• Hydraminos
• Placenta previa with marginal insertion of cord
• Iatrogenic – low ROM
MANAGEMENT…
• Cord presentation –
– DO NOT REPLACE CORD BACK
– If vaginal delivery contra-indicated – LSCS done
• Cord Prolapse
– Baby living
• Definitive t/t – LSCS
• If head engaged – forcep delivery
• If breech – breech extraction
• Bladder filling with 400-750ml NS done via catheter and
clamped – lifts the presenting part of the compressed cord
– Baby dead
• Labor allowed to proceed – spontaneous delivery
RETAINED
PLACENTA…
• The placenta is said to be retained when it is
not expelled out even 30 minutes after the
birth of the baby (WHO 15 minutes).
• 3 steps – Separation, descent and finally
expulsion
• Causes:
– Separated but retained – poor efforts to push
– Adherent placenta – atonic uterus, prolonged
labor, uterine malformation
– Morbid adherent placenta
– Placenta incarcerated due to constriction ring
• Dangers…
– Hemorrhage
– Shock
• Blood loss
• Retained for more than 1 hour
– Puerperal sepsis
– Recurrence in next pregnancy
MANAGEMENT…
• Period of watchful expectancy
• Empty bladder
• Controlled cord traction
• Manual removal of placenta
• Hysterectomy with or without partial
cystectomy
INJURIES TO BIRTH
CANAL…
 PERINEUM…

• WHILE MINOR INJURY IS QUITE COMMON ESPECIALLY DURING FIRST BIRTH,

GROSS INJURY (THIRD AND FOURTH DEGREE) IS INVARIABLY A RESULT OF
– Over-stretching
MISMANAGED SECOND STAGE OF LABOR. – Outlet contraction
• – Rapid stretching
CAUSES: – Shoulder dystocia
– Elderly primigravida – Forceps delivery
– Big baby – Scar in perineum
– Nulliparity – Precipitate labor
– Mid-line episiotomy
 CLASSIFICATION…
• First degree: Injury to perineal skin only

• Second degree: Injury to perineum involving perineal

body (muscles) but not involving the anal sphincter

• Third degree: Injury to perineum, involving the anal

sphincter complex (both external and internal)

• Fourth degree: Injury to perineum involving the anal

sphincter complex (EAS and IAS) and anal epithelium
MANAGEMENT…
• Recent tear repaired immediately following
delivery of placenta.
• Antibiotics given
• Positioning, toileting, local/general anesthesia
– Rectal and anal mucosa first sutured from above
downwards (interrupted sutures)
– Then Rectal muscles  then torn ends of sphinchter
(figure of 8 stitch)
– Repair of perineal muscles
– Vaginal wall and perineal skin
 AFTER CARE…
• High fiber diet from 3rd diet from day 3
onwards
• Lactulose BD
• Antibiotics
• Physiotherapy and pelvic muscle exercise
• Sitz bath
CEPHALO-PELVIC
DISPROPORTION
• The disparity in the relation between the head
and the pelvis is called cephalopelvic
disproportion.
• Disproportion may be either due to an
average size baby with a small pelvis or due to
a big baby (hydrocephalus) with normal size
pelvis or due to a combination of both the
factors.
 DIAGNOSIS
…
• Clinical:
– Previous history of spontaneous delivery of average size
baby rules out CPD
– But in primigravida, non-engagement of head suggest CPD
– Abdominal method: head is pushed down and seen
whether there is overlapping of symphysis pubis with
parietal bones.
– Abdomino-vaginal methods: bimanual examination, to see
if head can be pushed down towards ischial spine.
• Imaging:
– Lateral X-ray, USG measurement of bi-parietal diameter,
– MRI
MANAGEMENT…
• Inlet contraction:
– Spontaneous delivery
– Elective cesarean section
– Trial of labor
• Midpelvic and outlet disproportion:
– Elective cesarean section
– Assisted vaginal delivery
– Symphysiotomy
– Craniotomy if baby is dead
INJURIES TO BIRTH
CANAL…
 PERINEUM…

• WHILE MINOR INJURY IS QUITE COMMON ESPECIALLY

DURING FIRST BIRTH, GROSS INJURY (THIRD AND FOURTH
DEGREE) IS INVARIABLY A RESULT OF MISMANAGED
SECOND STAGE OF LABOR.
• CAUSES:

– Over-stretching – Outlet contraction

– Rapid stretching – Shoulder dystocia
– Elderly primigravida – Forceps delivery
– Big baby – Scar in perineum
– Nulliparity – Precipitate labor
– Mid-line episiotomy
 CLASSIFICATION…
• First degree: Injury to perineal skin only

• Second degree: Injury to perineum involving perineal

body (muscles) but not involving the anal sphincter

• Third degree: Injury to perineum, involving the anal

sphincter complex (both external and internal)

• Fourth degree: Injury to perineum involving the anal

sphincter complex and anal epithelium
MANAGEMENT…
• Recent tear repaired immediately following
delivery of placenta.
• Antibiotics given
• Positioning, toileting, local/general anesthesia
– Rectal and anal mucosa first sutured from above
downwards (interrupted sutures)
– Then Rectal muscles  then torn ends of sphinchter
(figure of 8 stitch)
– Repair of perineal muscles
– Vaginal wall and perineal skin
 AFTER
CARE…
• High fiber diet from 3rd diet from day 3
onwards
• Lactulose BD
• Antibiotics
• Physiotherapy and pelvic muscle exercise
• Sitz bath
POST PARTUM
HEMORRHAGE…
• The amount of blood loss in excess of 500 mL
following birth of the baby (WHO).
• “any amount of bleeding from or into the genital
tract following birth of the baby up to the end of
the puerperium, which adversely affects the
general condition of the patient evidenced by rise
in pulse rate and falling blood pressure is called
postpartum hemorrhage.
• Minor (<1L)
• Major (>1L)
• Severe(>2L)

• Types
– Primary: within 24hrs of birth of baby
– Secondary: beyond 24hrs
 CAUSES
…
• Atonic uterus
• Traumatic
• Retained tissues
• Blood coagulopathy
 PREVENTION
• ANC
– Improve health status
– High-risk patient screened
– Blood grouping and arrangement of blood
– Placental localisation
• Intra-natal
– Active management of 3rd stage
– Oxytocin infusion for 1 hour
– Observation
– Examination of placenta
MANAGEMENT…
• Call for help
• Two wide bore iv cannulas for iv fluids
• Send for cross-matching and ask for 2pints of
blood
• Oxytocin 10U IM
• Catheterize bladder
• Antibiotics
• Manual removal of placenta(not done)
• Monitor vitals
 ATONIC UTERUS…
• Step 1:
– Massage uterus to make it hard, methergine 0.2mg iv,
oxytocin infusion 10-20U in 500ml NS, iv tranexamic acid
1gm in 100ml NS @1ml/min
– Examine expelled placenta
• Step 2:
– Exploration under general anesthesia, blood transfusion,
continue oxytocin drip
– Misoprotol 800mcg per rectum
• Step 3:
– Uterine massage and bimanual compression
• Step 4:
– Uterine tamponade (tight packing/ballooon tamponade)
• Step 5:
– Surgical control
– B-lynch compression sutyre
– Ligation of uterine arteries
– Ligation of ovarian and uterine artery anastomosis
• Step7:
– hysterectomy
EPISIOTOMY…
• A surgically planned incision on the perineum and
the posterior vaginal wall during the second stage
of labor is called episiotomy (perineotomy).
• It is in fact an inflicted second-degree perineal
injury. It is the most common obstetric operation
performed.
• Objective:
– Enlarge vaginal introitus
– Minimize tear or rupture of perineal muscle
 INDICATION
…
• Rigid perineum
• Anticipating tear: big baby, breech delivery,
shoulder dystocia
• Operative delivery: vacuum, forcep
• Previous perineal surgery

• TIMING
– Bulging thin perineum during contraction just
prior to crowning (3-4cm of head visible)
• Structures cut
– Posterior vaginal wall
– Superficial and deep perineal muscles, levator ani
– Fascia covering these muscles,
– Transverse perineal branches of pudendal vessels and
nerves
– Subcutaneous skin and fat

• Steps
– Antisepsis, local anesthesia
– Incision and then delivery of fetus
– Repair
• Vaginal mucosa and sub-mucosal tissues
• Perineal muscles
• Skin and Subcutaneous tissues
 COMPLICATIONS
• Immediate: …
– (1) Extension of the incision to involve the rectum.
– (2) vulval hematoma
– (3) infection: the clinical features are—(a) throbbing pain on the
perineum (b) rise in temperature (c) the wound area looks moist,
red and swollen and (d) offensive discharge comes out through
the wound margins. (IV).
– (4) Wound dehiscence is often due to infection, hematoma
formation or faulty repair.
(5) Injury to anal sphincter causing incontinence of flatus or
feces.
– (6) Rectovaginal fistula and rarely.
(7) Necrotizing fasciitis (rare) in a woman who is diabetic or
immunocompromised.
• Remote:
– (1) Dyspareunia
– (2) chance of perineal lacerations
– (3) scar endometriosis (rare).
 POST OP CARE…
• Dressing each time following urination and
defecation
• Relieve pain: MgSO4 compression, ice packs
and analgesic
• Ambulance after 24 hours
• Sitz bath