Abnormal Uterine Action

Abnormal uterine action - Aetiology

• Parity: 96% primipara
• Age: occurs at any age but more common in elderly
• Maturity: commonest postdates
• Disproportion [relative or absolute] &
malpresentations
• Uterine distension: twins, hydramnios
• Uterine abnormalities:especially if asymmetry is
present. Fibroids usually have no influence on
uterine function
• Psychological influences ??
Abnormal uterine action - Types
• Over-efficient uterine action
▫ Precipitate labour: in absence of obstruction
▫ Excessive contraction and retraction: in presence of
obstruction
• Inefficient uterine action
▫ Hypotonic inertia
▫ Hypertonic inertia
 Colicky uterus
 Hyperactive lower uterine segment
▫ Constriction (contraction) ring
• Cervical dystocia
Over-efficient uterine action
• Precipitate labour: in absence of
obstruction
• Excessive contraction and
retraction: in presence of
obstruction
PRECIPITATE LABOUR

Definition: A labour lasting less

than 3 hours.

A labour is called precipitate when

the combined duration of first and
second stage is less than 2 hours.
Aetiology:
It is more common in multiparas
when there are;

strong uterine contractions,

small sized baby,

roomy pelvis,

minimal soft tissue resistance.

Complications
Maternal:
• Lacerations of the cervix, vagina and perineum.
• Shock.
• Inversion of the uterus.
• Postpartum haemorrhage:
• no time for retraction,
• lacerations.
• Sepsis due to:
• lacerations,
• inappropriate surroundings.
Foetal:
• Intracranial haemorrhage due to sudden
compression and decompression of the head.
• Foetal asphyxia due to:
• strong frequent uterine contractions
reducing placental perfusion,
• lack of immediate resuscitation.
• Avulsion of the umbilical cord.
• Foetal injury due to falling down.
 Management

• Before delivery: Patient who had previous precipitate

labour should be hospitalized before expected date of
delivery as she is more prone to repeated precipitate
labour.
• During delivery
* Inhalation anaesthesia: as nitrous oxide and oxygen is
given to slow the course of labour.
* Tocolytic agents: as ritodrine (Yutopar) may be effective.
* Episiotomy: to avoid perineal lacerations and
intracranial haemorrhage.
• After delivery
*Examine the mother and foetus for injuries.
 EXCESSIVE UTERINE CONTRACTION
AND RETRACTION
Physiological Retraction Ring
• It is a line of demarcation between the upper and lower uterine
segment present during normal labour and cannot usually be felt
abdominally.
Pathological Retraction Ring (Bandl’s ring)
This type of uterine contraction is predominantly due to obstructed
labour
• It is the rising up retraction ring during obstructed labour due to
marked retraction and thickening of the upper uterine segment
while the relatively passive lower segment is markedly stretched and
thinned to accommodate the foetus.
• The Bandl’s ring is seen and felt abdominally as a transverse groove
that may rise to or above the umbilicus.
• Clinical picture: is that of obstructed labour with impending rupture
uterus
• Obstructed labour should be properly treated otherwise the thinned
lower uterine segment will rupture.
Clinical features
Patient is in agony

Feature of exhaustion

Abdominal palpation reveals that

• Upper segment hard and tender
• Lower segment distended and tender
• Pathological retraction ring placed obliquely between umblicus and
symphysis pubis
• FHR usually absent
• Fetal parts not well defined
Internal examination revealed that
• Vagina dry hot and discharge offencive
• Cervix fully dilated
• Membrane absent
• Obstructed labour
 • Early detection during Antenatal and
Prevention intranatal period
• Delivery by cesarean session

• Exclude rupture of membrane

• Infusion of RL for correction of dehydration
• Administration of Inj. Pethedine for relief
Treatment of pain
• Parenteral antibiotic
• Cesarean delivery
 Inefficient
uterine action

Constriction Generalized
Hypotonic Hypertonic
(contraction) uterine
inertia inertia
ring contraction

Colicky
uterus

Hyperactive
lower uterine
segment
UTERINE INERTIA(HYPOTONIC UTERUS)

Definition

•The uterine contractions

are infrequent, weak and
of short duration.
*AetiologyUnknown but the following factors may be
incriminated:

*General factors:
• Primigravida particularly elderly.
• Anaemia and asthenia.
• Nervous and emotional as anxiety and fear.
• Hormonal due to deficient prostaglandins or oxytocin as in induced labour.
• Improper use of analgesics.

*Local factors:
• Overdistension of the uterus.
• Developmental anomalies of the uterus e.g. hypoplasia.
• Myomas of the uterus interfering mechanically with contractions.
• Malpresentations, malpositions and cephalopelvic disproportion. The
presenting part is not fitting in the lower uterine segment leading to absence
of reflex uterine contractions.
• Full bladder and rectum.
 Types

*Secondary inertia: inertia

*Primary inertia: weak
uterine contractions from
the start.
developed after a period of
good uterine contractions
when it failed to overcome
an obstruction so the
uterus is exhausted.
Clinical Picture
• *Labour is prolonged.
• Patient feels less pain during contraction
• *Uterine contractions are infrequent, weak and of short
duration. Less hardening of uterus felt during examination
• Uterus becomes relaxed after contraction , fetal parts easily
palpable
• *Slow cervical dilatation.
• *Membranes are usually intact.
• *The foetus and mother are usually not affected apart from
maternal anxiety due to prolonged labour.
• *More susceptibility for retained placenta and postpartum
haemorrhage due to persistent inertia.
• *Tocography: shows infrequent waves of contractions with
low amplitude.
Management

General measures:
• Examination to detect disproportion, malpresentation or malposition
and manage according to the case.
• Proper management of the first stage (see normal labour).
• Prophylactic antibiotics in prolonged labour particularly if the
membranes are ruptured.
Amniotomy:
• Providing that;
• vaginal delivery is amenable,
• the cervix is more than 3 cm dilatation and
• the presenting part occupying well the lower uterine segment.
• Artificial rupture of membranes augments the uterine contractions by:
• release of prostaglandins.
• reflex stimulation of uterine contractions when the presenting part is
brought closer to the lower uterine segment.
Oxytocin:
• Providing that there is no contraindication for it, 5 units of
oxytocin (syntocinon) in 500 c.c glucose 5% is given by IV
infusion starting with 10 drops per minute and increasing
gradually to get a uterine contraction rate of 3 per 10 minutes.
Operative delivery:
• Vaginal delivery: by forceps, vacuum or breech extraction
according to the presenting part and its level providing that,
• cervix is fully dilated.
• vaginal delivery is amenable.
• Caesarean section is indicated in:
• failure of the previous methods.
• contraindications to oxytocin infusion including
disproportion.
• foetal distress before full cervical dilatation.
 HYPERTONIC UTERINE INERTIA
(Uncoordinated Uterine Action)
• Types
• Colicky uterus: incoordination of the different
parts of the uterus in contractions.
• Hyperactive lower uterine segment: so the
dominance of the upper segment is lost.
Clinical Picture
• The condition is more common in
primigravidae and characterised by:
• Labour is prolonged.
• Uterine contractions are irregular and more
painful. The pain is felt before and throughout
the contractions with marked low backache
often in occipito-posterior position.
• High resting intrauterine pressure in between
uterine contractions detected by tocography
(normal value is 5-10 mmHg).
• Slow cervical dilatation .
• Premature rupture of membranes.
• Foetal and maternal distress.
Management
• General measures: as hypotonic inertia.
• Medical measures:
▫ Analgesic and antispasmodic as pethidine.
▫ Epidural analgesia may be of good benefit.
• Caesarean section is indicated in:
▫ Failure of the previous methods.
▫ Disproportion.
▫ Foetal distress before full cervical dilatation.
CONSTRICTION (CONTRACTION) RING

• Definition
• It is a persistent localised annular spasm of the
circular uterine muscles.
• It occurs at any part of the uterus but usually at
junction of the upper and lower uterine
segments.
• It can occur at the 1st, 2nd or 3 rd stage of
labour.
Aetiology
• Unknown but the predisposing factors are:
• Malpresentations and malpositions.
• Clumsy intrauterine manipulations under
light anaesthesia.
• Improper use of oxytocin e.g.
• use of oxytocin in hypertonic inertia.
• IM injection of oxytocin.
• Premature attempt of instrumental delivery
• Premature rupture of membrane
Diagnosis
• The condition is more common in
primigravidae and frequently preceded by
colicky uterus.
• The exact diagnosis is achieved only by
feeling the ring with a hand introduced
into the uterine cavity.
• It is revealed during
• caesarian section in first stage of labour
• Forcep application during second stage
and
• manual removal of placenta in third stage
Complications
• Prolonged 1st stage: if the ring occurs at the level
of the internal os.
• Prolonged 2nd stage: if the ring occurs around
the foetal neck.
• Retained placenta and postpartum
haemorrhage: if the ring occurs in the 3rd stage
(hour- glass contraction).
Pathological Retraction Constriction Ring
Ring
Occurs in prolonged 2nd stage Occurs in the 1st, 2nd or 3rd stage.

Always between upper and lower At any level of the uterus.

uterine segments
Rises up. Does not change its position.

Felt and seen abdominally. Felt only vaginally.

The uterus is tonically retracted, The uterus is not tonically retracted

tender and the foetal parts cannot be and the foetal parts can be felt.
felt

Maternal distress and foetal distress Maternal and foetal distress may not
or death. be present.

Relieved only by delivery of the May be relieved by anaesthetics or

foetus. antispasmodics.
Management
• Exclude malpresentations, malposition and
disproportion.
• In the 1st stage: Pethidine may be of benefit.
• In the 2nd stage: Deep general anaesthesia and
amyl nitrite inhalation are given to relax the
constriction ring:
▫ If the ring is relaxed, the foetus is delivered
immediately by forceps.
▫ If the ring does not relax, caesarean section is carried
out with lower segment vertical incision to divide the
ring.
• In the 3rd stage: Deep general anaesthesia and
amyl nitrite inhalation are given followed by
manual removal of the placenta.
Generalized tonic contraction
• In this pronounced retraction occurs involving
whole of the uterus up to the level of internal os.
Thus there is no physiological differentiation of
active upper segment and passive lower segment
of uterus
• There is no thinning of lower segment and no
chance of uterine rupture
• Uterine contraction ceases and the whole uterus
undergoes a tonic muscular spasm holding fetus
inside
Causes

Failure to overcome the

obstruction

Injudicious administration
of oxytocics
Clinical feature
• Patient in labour having sever and continuous
pain
• Abdominal examination- uterus smaller in size
tender and tense
• Fetal part not well defined
• FHR not audible
• Vaginal examination – jammed head with big
caput , dry and edematous vagina
Treatment
Correction of dehydration – rapid infusion
of RL

Antibiotic

Pain relief

CS done in majority of cases

Destructive operation if fetal death

CERVICAL DYSTOCIA

• Definition
• Failure of the cervix to dilate within a reasonable
time in spite of good regular uterine
contractions.
Varieties

• Organic (secondary) due to:

▫ Cervical stances as a sequel to previous amputation,
cone biopsy, extensive cauterisation or obstetric
trauma.
▫ Organic lesions as cervical myoma or carcinoma.
• Functional (primary):
▫ In spite of the absence of any organic lesion and the
well effacement of the cervix, the external os fails to
dilate.
▫ This may be due to lack of softening of the cervix
during pregnancy or cervical spasm resulted from
overactive sympathetic tone.
Complications

• Annular detachment of the cervix

• Rupture uterus.
• Postpartum haemorrhage
Management

• Organic dystocia:
▫ Caesarean section is the management of choice.
• (II) Functional dystocia:
▫ Pethidine and antispasmodics: may be effective.
▫ Caesarean section: if
 medical treatment fails or
 foetal distress developed.
Abnormal uterine action - Types
• Hypotonic: abnormal weak action with normal spread of
contraction wave
A) Primary uterine inertia: contractions weak, short-lived,
nfrequent; cervix partially dilated
B) Secondary uterine inertia: may follow hypertonic or
dystonic uterine action
• Hypertonic: abnormally strong action with normal spread
of contraction; little relaxation between contractions
A) Precipitate labour in the absence of obstruction
B) Bandl’s ring - exaggerated physiological retraction ring -
in the presence of obstruction
Abnormal uterine action - Types
• Dystonic
* Incoordinate uterine action: Abnormal pattern of
contractions giving rise to a hypertonic lower segment or a
colicky type of contraction with development of a
contraction ring
=> Hypertonic lower uterine segment due to reversal of
contraction pattern
=>Localized tonic contraction caused by colicky activity
=> Generalized tonic contraction causes the whole uterus to
go into a state of sustained and powerful hypertonus
moulding itself to foetus-> Active retention of foetus

* Cervical dystocia: rarely caused by disorderly uterine

action
=> Primary caused by anatomical or physiological defect -
annular detachment of cervix
=>Secondary caused by fibrosis after trauma-> tear of
cervix possibly extending to uterus
AMNIOTIC FLUID EMBOLISM
(AFE)
 AMNIOTIC FLUID EMBOLISM
• AFE is thought to occur when amniotic fluid , fetal cells,
hair, or other debris enter the maternal circulation.
• This condition occurs when amniotic fluid enters the
maternal circulation through a tear in membranes or
placenta
 AMNIOTIC FLUID EMBOLISM
• Overall incidence ranges from 1 in 8,000 to 1 in 80,000
pregnancies.
• 75 % of survivors are expected to have long-term neurologic
deficits.
• If the fetus is alive at the time of the event, nearly 70 % will
survive the delivery but 50% of the survived neonates will incur
neurologic damage.
 AMNIOTIC FLUID EMBOLISM
• Time of event:
- During labor.
- During C/S.
- After normal vaginal delivery.
- During second trimester.
• AFE syndrome has been reported to occur as
late as 48 hours following delivery.
 Risk factors of AFE
• Advanced maternal age • Placenta accreta
• Multiparity • Polyhydramnios
• Meconium • Uterine rupture
• Cervical laceration • Maternal history of allergy or
• Intrauterine foetal death atopy
• Very strong frequent or uterine • Chorioamnionitis
tetanic contractions • Macrosomia
• Sudden foetal expulsion (short • Male fetal sex
labour) • Oxytocin (controversial)

Nevertheless, these and other frequently cited risk factors

are not consistently observed and at the present time
Experts agree that this condition is not preventable.
 Pathophysiology
- Poorly understood.
- Cotton (1996), has proposed a biphasic model.
Phase 1:
Amniotic fluid and fetal cells enter the maternal
circulation  biochemical mediators  pulmonary artery
vasospasm  pulmonary hypertension  elevated right
ventricular pressure  hypoxia  myocardial and pulmonary
capillary damage,  left heart failure  acute respiratory
distress syndrome
Phase 2:
 biochemical mediators  DICHemorrhagic phase
characterized by massive hemorrhage and uterine
atony.
 Clinical presentation
The classic clinical presentation of the syndrome
has been described by five signs that often occur
in the following sequence:
(1) Respiratory distress
(2) Cyanosis
(3) Cardiovascular collapse cardiogenic shock
(4) Hemorrhage
(5) Coma.
 Clinical presentation

• A sudden drop in O2 saturation can be the initial

indication of AFE during c/s.
• More than 1/2 of patients die within the first hour.
• Of the survivors 50 % will develop DIC which
may manifest as persistent bleeding from
incision or venipuncture sites.
The coagulopathy typically occurs 0.5 to 4 hours
after phase 1.
 Clinical presentation

• 10-15% of patients will develop grand mal

seizures.
• enlarged heart, or pulmonary edema.
• ECG may show a right strain pattern with ST-T
changes and tachycardia.
 Laboratory investigations
in suspected AFE
Non specific
• complete blood count
• coagulation parameters
including FDP, fibrinogen
• arterial blood gases
• chest x-ray
• electrocardiogram
• echocardiogram
Specific
• cervical histology
• serum tryptase
• serum sialyl Tn antigen
• zinc coproporphyrin
• PMV analysis (if PA
catheter in situ)
 Differential diagnosis
Obviously depends upon presentation
• Anaphylaxis (Collapse) • Haemorrhage (APH ; PPH)
• Pulmonary embolus • Septic shock
(Collapse) • Drug toxicity (MgSO4, total
• Aspiration (Hypoxaemia) spinal, LA toxicity)
• Pre-eclampsia or • Aortic dissection
eclampsia (Fits,
Coagulopathy)
 Management of AFE
GOALS OF MANAGEMENT:
• Restoration of cardiovascular and pulmonary
equilibrium
- Maintain systolic blood pressure
>90 mm Hg.
- Urine output > 25 ml/hr
- Arterial pO2 > 60 mm Hg.
• Re-establishing uterine tone
• Correct coagulation abnormalities
 Management of AFE
• As intubation and CPR may be required it is necessary
to have easy access to the patient, experienced help,
and a resuscitation tray with intubation equipment, DC
shock, and emergency medications.
• IMMEDIATE MEASURES :
- Set up IV Infusion, O2 administration.
- Airway control  endotracheal intubation
maximal ventilation and oxygenation.
• LABS : CBC,ABG,PT,PTT,fibrinogen,FDP fibrin
degradation product.
 Management of AFE
• Treat hypotension, increase the circulating volume and
cardiac output with crystalloids.
• After correction of hypotension, restrict fluid therapy to
maintenance levels since ARDS follows in up to 40% to 70%
of cases.
• Steroids may be indicated (recommended but no evidence
as to their value)
• Dopamine infusion if patient remains hypotensive
(myocardial support).
• Other investigators have used vasopressor therapy such as
ephedrine or levarterenol with success (reduced systemic
vascular resistance)
 Management of AFE
In the ICU

• To assess the effectiveness of treatment and resuscitation, it

is prudent to continuously monitor ECG, pO2, CO2, and urine
output.
• There is support in literature for early placement of arterial,
central venous, and pulmonary artery catheters to provide
critical information and guide specific therapy.
 Management of AFE
In the ICU
• Central venous pressure monitoring is important to
diagnose right ventricular overload and guide fluid infusion
and vasopressor therapy. Blood can also be sampled from
the right heart for diagnostic purposes.
• Pulmonary artery and capillary wedge pressures and
echocardiography are useful to guide therapy and evaluate
left ventricular function and compliance.
• An arterial line is useful for repeated blood sampling and
blood gases to evaluate the efficacy of resuscitation.
 Sympathomimetic Vasopressor agent
Dopamine
• Dopamine increases myocardial contractility and systolic
BP with little increase in diastolic BP. Also dilates the renal
vasculature, increasing renal blood flow and GFR.
• DOSE: 2-5 mcg/kg/min IV; titrate to BP and cardiac output.
• Contraindications: ventricular fibrillation, hypovolemia,
pheochromocytoma.
• Precautions: Monitor urine flow, cardiac output, pulmonary
wedge pressure, and BP during infusion; prior to infusion,
correct hypovolemia with either whole blood or plasma, as
indicated; monitoring central venous pressure or left
ventricular filling pressure may be helpful
 Maternal Mortality in AFE
• Maternal death usually occurs in one of three
ways:
(1) sudden cardiac arrest,
(2) hemorrhage due to coagulopathy, or
(3) initial survival with death due to acute
respiratory distress syndrome (ARDS) and
multiple organ failure
 Further issues in the
Management
• Transfer:
Transfer to a level 3 hospital may be required once the
patient is stable.
• Deterrence/Prevention:
Amniotic fluid embolism is an unpredictable event.
• Risk of recurrence is unknown. The recommendation for
elective cesarean delivery during future pregnancies in an
attempt to avoid labor is controversial.
• Perimortem cesarean delivery:
After 5 minutes of unsuccessful CPR in arrested mothers,
abdominal delivery is recommended.
 SUMMARY
• AFE is a sudden and unexpected rare but life
threatening complication of pregnancy.
• It has a complex pathogenesis and serious
implications for both mother and infant
• Associated with high rates of mortality and
morbidity.
• Suspect AFE when confronted with any pregnant
patient who has sudden onset of respiratory
distress, cardiac collapse, seizures, unexplained
fetal distress, and abnormal bleeding
• Obstetricians & midwives should be alert to the
symptoms of AFE and strive for prompt and
aggressive treatment.
 Cesarean section (CS)

• Caesarean section or c-section, is a

delivary of the foetus through incisions in
anterior abdominal (laparotomy) and
uterine wall (hysterotomy)
• It is usually performed when a vaginal delivery would put the
baby's or mother's life or health at risk.

• The following indications are the most frequent:

1. Extreme dgree of contracted pelvic (one or more of the diameters is

reduced and interferes with normal mechanism of labour.
Degrees of contracted pelvis:
 Minor degree: the true conjugate is 9-10 cm.
 Modrate degree: the true conjugate is 8-9 cm.
 Sever degree: the true conjugate is 6-8 cm.
 Extreme degree: the true conjugate is less than 6 cm.
2. Cephalopelvic disproportion: the head of the foetus is too largeto
come through the pelvis.
3. Uterine Inertia: Inefficient uterine contraction.
4. Placenta pravia: Implamtation of placenta in the lower uterine
segment.
5. Premature separation of placena: Cesarean
section is indicated when,the foetel distress
occurs, when effective labour does not follow
rupture of membrane and when vaginal can not be
anticipeted within 2 hours.
6. Malposition and malpresentation
7. Pre-eclamsia
8. Diabetes ( causes over size of the foetus. Cesarean
section should be done in the 1st four weeks in
primigravidae.
9. Cardiac diseases.
10. Vaginal scaring.
11. Carcinoma of the cervix.
12. Cervical dystoctia (failure of the cervix to dilate
in spite of strong contraction of the uterus).
13. A previous uterine incision.
14. Prolapse of the umbilical.
15. Foetal distress.
16. Bad post obstetric history (baby habitually dies in
the uterus.
17. Failure of labour to progress despite adequate
stimulation.
Dead of foetus
1) Elective timing: (before the onset of labour
by one week.
2) Selective timing: (after the onset of labour, it
is preferred.
• The classical caesarean section:
• A midline longitudinal (vertical) incision which allows a
larger space to deliver the baby. However, it is rarely
performed today as it is more prone to complications.

• The lower uterine segment section:

• It is the a procedure most commonly used today; it involves a
transverse cut just above the edge of the bladder and results in
less blood loss and is easier to repair.
 Indications of classical
caesarean section

1. when the lower segment is abnormally vascular.

2. when the lower segment can not identified due to
adhesion.
3. when caesarean section is done after mother‫י‬s death.
4. Cases needs rapid delivery.
5. When the foetus lie is transverse and can not be
corrected.
6. When hysterectomy will follow caesarean section
Advantages of the lower segment:
• The wound is extra peritoneal so less risk of infection.
• Healing scar is better.
• The risk of rupture of the scar is less.
• Hemorrhage is less.
• Placenta is away from the incision.
Disadvantages of the lower segment:
• The operation requires more skill and experience.
• The incision may extend down to the bladder.
Disadvantages of classical operation:
• More liable to chest infection.
• More liable to intestinal distension.
• The scar is more liable to rupture.
• Respiratory complications: due to inhibitory effects of pain,
immobilization in post operative period and anaesthesia.
• So
 encourage deep breathing exercises.
 teach the patient huffing and coughing (the abdomen must
be supported by the patient‫י‬s hands and/or towel)
• Excessive abdominal pain due to:
Wound infection.
Haematoma.
Excessive localized edema.
Nerve entrapment syndrome (ilioinguinal or iliohypogastric nerve)
• Deep venous thrombosis due to (hypercoagulability, decrease
venous tone
 Signs and symptoms of DVT: in about 50%
• Edmatous limb.
• Erythrocyanotic appearance.
• Dilated superficial veins.
• Elevated skin temperature.
 Prophylactic role to prevent DVT:
o Application of compression stocking.
o Early ambulation.
o Avoidance of pressure under thighs and calves
o Avoidance of sitting with knees acutely flexed.
o Deep breathing exercises.

o Circulatory and leg exercises.

• Dependent edema. (generalized retension of fluid)
aggravated by decreased movements of the lower
limb muscles.
• to prevent dependent edema:
 Vigorous foot and ankle exercises.
 elevation of L.L.

 If sever apply stoking and intermittent pressure.

• Intestinal complications.
• Haemorrhage.
• It is done when there is inability to stop
bleeding from the uterine incision or
multiple fibroids in old patient.
• It is an excision of a portion of both
fallopian tube.
• It is done after 3rd or 4th cesarean section.
• It is done after mother‫י‬s death, to save the
life of a living foetus, It is done within 10
minutes of maternal death.
• For elective cases, prior to surgery the
mother is pain free and alert, to prepare her
emotionally and physically for post operative
delivery.
Pre-operative goals:
1. Improve pulmonary function and prevent post operative
pulmonary complications( pneumonia….)
2. Improve circulation and prevent post operative circulatory
complications (DVD, edema ….)

3. Prepare patient emotionally and physically

 Methods:
 Discussion to minimize or eliminate negative feeling about delivery.
 Demonstrate the patient how to mobilize early with minimum amount of
strain or pain.
 Teach the patient how to cough and huff to get red of expectoration.
 Deep breathing exercises.
 Circulatory exercise.
 Post- operative management:
 In recovery area. Observation of level of consciousness, blood
pressure, heart rate, respiration and vaginal blood loss.
 Nursing care, including regular assessment of temperature, blood
pressure, heart rate, color, lochia, wound appearance, bleeding, bladder
function and urine output, oral fluid intake.
Post-operative goals:
1. Improve pulmonary function and prevent post operative
pulmonary complications( pneumonia….)
2. Improve circulation and prevent post operative
circulatory complications (DVD, edema ….)
3. Decrease incisional pain associated with coughing,
movement or breast feeding.
4. Improve healing of incision and prevent adhesion
formation.
5. Prevent pelvic floor dysfunction.
6. Improve lactation and prevent sagging of the breast.
7. Correct posture.
Methods:
 Deep breathing exercises.
 Circulatory exercise.
 Early ambulation.
 Arm exercises.
 Postural correction.
 Pelvic floor exercises.
 Abdominal strengthening exercises.
 Electrotherapy to decrease incisional pain and to
promote wound healing.
 Positioning instruction.
 Physical therapy for
early post-operative days
 1st day:
 Breathing ex‫י‬s.
 Circulatory ex‫י‬s.
 Leg ex‫י‬s.
 Static abdominal contraction.
 2nd day:
 Repeat previous ex‫י‬s, add the following:
 Early ambulation to:
 Prevent muscle wasting.
 Prevent constipation.
 Prevent retension of urine
 Prevent respiratory and vascular complication.
 Arm ex‫י‬s. Half lying position.
 3rd day:
 Repeat previous ex‫י‬s, add the following:
 Pelvic floor ex‫י‬s
 4th day:
 Repeat previous ex‫י‬s, add the following:
 Pelvic rocking ex‫י‬s
 Scapular retraction.
 5th day:
 Repeat previous ex‫י‬s, add the following:
 Hip shrugging.
 Postural correction ex‫י‬s.
 6th day:
 Repeat previous ex‫י‬s, add the following:
 Pelvic rotation ex‫י‬s.
 7th day:
 Repeat previous ex‫י‬s, add the following:
 Lateral flexion (1st step)
 Trunk rotation (1st step)
 Trunk flexion (1st step).
CONTRACTED PELVIS
DEFINITION

The alteration in size and

or shape of the pelvis of
sufficient degree so as
to alter the normal
mechanism of labour in
an average size baby is
called contracted pelvis
TYPES OF PELVIS
1-GYNECOID
• Typical female pelvis found in 50% of
women
• Rounded—slightly oval inlet
• Straight pelvic sidewalls with roomy pelvic
cavity
• Good sacral curve
• Ischial spines are not prominent
• Pubic arch is wide
2-ANDROID
• Typical male pelvis found in 1/3
white women 1/6 non-white
• Pelvic brim is heart shaped
• Pelvis funnels from above
downwards (convergent sidewalls)
• Narrow pubic arch
• Prominent spines
3-ANTHROPOID
• 25% white women & 50% nonwhite
• Pelvic brim APD > TD
• Long & narrow pelvic canal with long sacrum
• Straight pelvic sidewalls
4-PLATYPELLOID
• 3% of women
• Pelvic brim TD >>>APD  kidney shape
• Sacral promontory pushed forwards
CEPHALO-PELVIC
DISPROPORTION…

Disproportion between fetal head & maternal pelvis is called

cephalo-pelvic disproportion
INCIDENCE…

It various from place to place. In Africa

it is 15% (especially due to high
prevalence of rickets), in India it
average 5%. In western countries the
incidence is the lowest (2%).
ETIOLOGY…

Nutritional & environmental defect.

Disease or injuries affecting the pelvis,

spines & bones of the lower limbs.

Developmental defect affecting the

pelvis bone.
CLASSIFICATION…

Nutritional & environmental

• Minor variation- common.
• Major-rachitic & osteomalacic- rare.
Developmental defect
• Naegele’s pelvis & Robert’s pelvis.
• High or low assimilation pelvis.
 • Pelvic- tumors, fractures,
Disease tubercular arthritis.
or • Spinal- kyphosis, scoliosis,
coccygeal deformity.
injuries • Lower limbs- congenital
of the dislocation of hip,
poliomyelitis in childhood,
bones hip joint disease.
 Diagnostic Evaluation…
From history: -
History of rickets or polio in childhood.
Past history of pelvic trauma or fractures.
In multipara suspect contract pelvis from past obstetric history
of-
Prolonged labor.
Instrumentation.
Fresh stillbirth.
Neonatal convulsions or mental retardation in previous child.
Previous LSCS or rupture uterus.
 FROM EXAMINATION…
General Examination: -
• Height <5 feet/ 150 cm (140 cm in India),
small feet (shoe size less than 3).
• Abnormal gait suggest abnormalities in the
pelvis, spine or lower limbs.
• Spinal deformity.
• Limb deformity.
• Manifestation of rickets- Square head, pigeon
chest bowlegs & rosary beads in the costal
ridges.
 Obstetric examination…
Mal-presentation
Mal-position
Pendulous abdomen: in a primi-gravida.

 Assessment of the pelvis (pelvimetery): -

Clinical pelvimetery
Radio-pelvimetery
 Degree of
disproportion…

Grade 0: - Head goes there is no overlap.

Grade +1(Minor Disproportion): - The anterior

surface of the head is in the line with the anterior
surface of the Symphysis. During labor the head is
engaged due to moulding & vaginal delivery can
be achieved.
 CONT…
Grade +2(Moderate Disproportion): - The
anterior surface of the head is in the line
with the anterior surface of the symphysis.
Vaginal delivery may or may not occur.

Grade +3 (Marked Disproportion): - The

head over-ride the anterior surface of the
symphysis. Vaginal delivery cannot occur.
EFFECT OF CONTRACTED
PELVIS ON PREGNANCY …
There is more chance of
incarceration of the retroverted
gravid uterus in the flat pelvis.

Abdomen becomes pendulous

specially in multigravida with
lax abdominal wall.

Mal-presentation is increased 3-
4 times & so also increased
frequency of unstable lie.
 EFFECT OF CONTRACTED
PELVIS ON LABOR…
There is increased incidence of early rupture of
membrane.
Incidence of cord prolapsed is increased.
Cervical dilation is slowed.
There is increased tendency of prolonged labor & in
neglected case, obstructed labor with features of
exhaustion, dehydration, keto-acidosis & sepsis.
There is increased incidence of operative
interference, shock, postpartum hemorrhage &
sepsis.
MANAGEMENT…

Preterm induction of labour

Elective caesarean section.

Trial labour
NURSING MANAGEMENT…

Anxiety related to emergency & unplanned

caesarian section as evidence by contracted pelvis.

Fluid volume deficit related to fluid restriction

during labour process as evidence by observation.

Pain related to labour as evidence by verbalization

& facial expression.
CONT…
Risk for injury to the newborn related to instrumental delivery.

Ineffective breast feeding related to limited maternal experience

& caesarian section.
METHODS OF
TERMINATION…
Forceps with episiotomy.

Trial forceps.

Caesarean section.
COMPLICATION…
Maternal: -
During pregnancy: -
Retroverted gravid uterus.
Mal-presentation.
Pendulous abdomen.
Non-engagement.
Pyelonephritis.
During labor: -
Inertia, slow cervical dilation & prolonged labor.
Premature rupture of membrane & cord prolapsed.
Obstructed labor & rupture uterus
Genitor-urinary fistula.
Injury to the pelvic joints or nerves from difficult forceps delivery.
Post-partum hemorrhage.
CONT…
Fetal: -
Intracranial hemorrhage.
Asphyxia.
Fracture skull.
Nerve injuries.
Intra-amniotic infection.
CORD PRESENTATION AND
CORD PROLAPSE
DEFINITION

In both conditions a loop of the cord is

below the presenting part. The
difference is in the condition of the
membranes; if intact it is cord
presentation and if ruptured it is cord
prolapse.
INCIDENCE
1 in 200 pregnancies
 More often in transverse lie than oblique/
cephalic.
 Ranges from 0.14- 0.62%
CLINICAL TYPES OF CORD

OCCULT
PROLAPSE

CORD CORD
PRESENTATION PROLAPSE
RISK FACTORS
 Breech presentation
PROM( pre mature rupture of
membranes)
 Large fetus
 Multiple gestation
 Long cord

 Pre term labour

 ETIOLOGY

FETOMATERNAL OBSTETRIC
FACTORS INTERVENTION
FETOMATERNAL FACTORS

Fetal Malpresentation

Prematurity

Multiple gestation

Multiparity

Rupture of membranes

Polyhyhramnios
OBSTETRICAL INTERVENTIONS
 Artificial rupture
 Internal scalp electrode application

 Intra uterine pressure Catheter placement

 Forcep application

 Manual rotation of head

 Stabilizing induction
 DIAGNOSIS
 Heart rate monitoring of the baby
 Pelvic examination to see and feel the umbilical cord present
in the vagina
 USG
RISK TO THE MOTHER

 PPH
 3rd or 4th degree laceration

 Uterine rupture

RISK TO BABY
 Brachial plexus injury

 Hypoxia and

 Death
PREVENTION

Early
diagnosis
External fetal
monitoring
No artificial
rupturing
 MANAGEMENT OF CORD
PRESENTATION

 No attempts to replace the cord.

 Keep patient in sim’s position/

Knee chest position.

 If vaginal delivery not possible then caesarean section.

MANAGEMENT OF CORD
PROLAPSE
Cord prolapse

Baby living Maturity of Cervical

or dead the baby dilatation

Baby alive Baby dead

•Confirm with
ultrasound
•Wait for spontaneous
delivery
or
•Destructive operation
 Baby alive

Caesarean Immediate Immediate vaginal

delivery vaginal delivery delivery possible
not possible

Vertex Breech

A. First aid B. Definitive •Forcep or •Breech extraction

management ventouse
Bladder filling in experts hands
To lift the only
Caesarean
presenting part off
the cord section
Posture- elevated
sim’s, trendelenburg,
or knee chest
NURSING DIAGNOSIS
 Risk of injury to the fetus related to interuption of blood flow
due to prolapsed cord
Interventions:
 If cord prolapse is suspected, perform a vaginal exam to determine:
 Cervical length/effacement & dilatation
 Station of presenting part
 If cord is palpated determine if pulsations are present
 Continue to effectively communicate with the women & support person.
 If you can see cord protruding from the vagina:
 Do not try to replace the cord above the presenting part
 At the peripheral level: the women is asked to maintain sims/ knee chest
position.
 Gloved fingers will be introduced into the vagina untill definitive
treatment is instituted.
 Fear and anxiety related to potential loss of fetus as
evidenced by frequent questioning
FETAL MALPRESENTATION
and MALPOSITION
Presented by:
Ms. Liji George
Left and right occipito-anterior are the only
normal presentations and positions.
Malposition: occipito-posterior.
Malpresentations: anything except vertex
as face, brow, breech, shoulder, cord and
complex presentations.
Causes of Malpresentations and
Malpositions
1.Defects in the powers:
> Pendulous abdomen: laxity of the
abdominal muscles.
> Dextro-rotation of the uterus: rotation of
the uterus in anti-clock wise favours
occipito-posterior in right occipito-anterior
position.
Causes of Malpresentations and
Malpositions
2. Defects in the passages:
> Contracted pelvis.
> Android pelvis.
> Pelvic tumours.
> Uterine anomalies as bicornuate,
septate or fibroid uterus.
> Placenta praevia.
Causes of Malpresentations and
Malpositions

 3.Defects in the passenger:

> Preterm foetus.
>Intrauterine foetal death.
> Macrosomia.
> Multiple pregnancy.
> Congenital anomalies as anencephaly and
hydrocephalus.
> Polyhydramnios.
> Coils of the cord around the neck favours
face presentation.
Fetal Malpresentation

Fetal malpresentation refers to fetal

presenting part other than vertex and
includes breech, transverse, face, brow,
and sinciput.
Malpresentations may be identified late in
pregnancy or may not be discovered until
the initial assessment during labor.
Related Factors
 The woman has had more than one pregnancy
 There is more than one fetus in the uterus
 The uterus has too much or too little amniotic
fluid
 The uterus is not normal in shape or has
abnormal growths, such as fibroids
 Placenta previa
 The baby is preterm
Types of Malpresentation
 :BREECH
*Complete (Flexed) Breech Presentation
*Footling Breech Presentation
* Frank (Extended) Breech Presentation
* Kneeling Breech Presentation
 VERTEX
*Brow Presentation
*Face Presentation
*Sincipital Presentation
 TRANSVERSE

The diagnosis of abnormal fetal presentations is commonly made

with a combination of Leopold’s Maneuver, Vaginal
examination, and Ultrasound
Types of Malpresentation
 BREECH: Breech presentation means that
either the buttocks or the feet are the first body
parts that will contact the cervix.
 Breech presentations occurs in approximately
3% of the births and are affected by fetal
attitude.
 Breech presentations can be difficult births, with
the presenting point influencing the degree of
difficulty.
Types of Breech Presentation
Frank breech Complete Breech

The baby's bottom The baby's hips and
comes first, and the knees are flexed so that
legs are flexed at the the baby is sitting
hip and extended at the crosslegged, with feet
knees (with feet near beside the bottom.
the ears). 65-70% of
breech babies are in the
frank breech position.
Types of Breech Presentation
Footling Breech Kneeling Breech

One or both feet come The baby is in a

first, with the bottom at kneeling position, with
a higher position. This one or both legs
is rare at term but extended at the hips
relatively common with and flexed at the knees.
premature fetuses This is extremely rare
Maternal Risks
 Prolonged labor r/t decreased pressure exerted
by the breech on the cervix.
 PROM may expose client to infection.
 Cesarean or forceps delivery.
 Trauma to birth canal during delivery from
manipulation and forceps to free the fetal head.
 Intrapartum or postpartum hemorrhage.
Fetal Risks
 Compression or prolapse of umbilical
cord.
Entrapment of fetal head in incompletely
dilated cervix.
 Aspiration and asphyxia at birth.
 Birth trauma from manipulation and
forceps to free the fetal head.
Management
 If the woman is in early labor and the
membranes are intact, attempt External
Cephalic Version.
 Tocolytics, such as Terbutaline 0.25 mg IM, can
be used before ECV to help relax the uterus.
 If ECV is successful, proceed with normal
childbirth. If ECV fails or is not advisable, deliver
by caesarean section.
Management
 Attempt external version if:
Breech presentation is present at or after
37 weeks (before 37 weeks, a successful
version is more likely spontaneously revert
back to breech presentation)
Vaginal delivery is possible
* Membranes are intact and amniotic fluid
is adequate; * * There are no
complications (e.g. fetal growth restriction,
uterine bleeding, previous caesarean
delivery, fetal abnormalities, twin
pregnancy, HPN, fetal death).
Management
 VAGINAL BREECH DELIVERY.
A vaginal breech delivery by a skilled health
care provider is safe and feasible under the
following conditions:
- complete or frank breech
- adequate clinical pelvimetry
- fetus is not too large
- no previous caesarean section for
cephalopelvic disproportion
- flexed head.
Management :
 CESAREAN SECTION for breech presentation.
A cesarean section is safer than vaginal breech
delivery and recommended in cases of:
- Double footling breech
- Small or malformed pelvis
- Very large fetus
- Previous cesarean section for cephalopelvic
disproportion
- Hyperextended or deflexed head.
Types of Malpresentation
TRANSVERSE
In a transverse lie, a fetus lies horizontally
in the pelvis so that the longest fetal axis is
perpendicular to that of the mother.
The presenting part is usually one of the
shoulders (acromion process), an iliac
crest, a hand, or an elbow.
Management

If an infant is preterm and smaller than

usual, an attempt to turn the fetus to a
horizontal lie may be made.
Most infants in transverse lie must be born
by cesarean birth, however, because they
cannot be turned and cannot be born
normally form this “wedged” position.
Types of Malpresentation
SINCIPUT
 FACE
The sinciput The face presentation is
presentation occurs caused by hyper-
when the larger extension of the fetal
diameter of the fetal head so that neither the
head is presented. occiput nor the sinciput
Labor progress is is palpable on vaginal
slowed with slower examination.
descent of the fetal
head.
Management :
In the chin-anterior position prolonged
labor is common. Descent and delivery of
the head by flexion may occur.
In the chin-posterior position, however, the
fully extended head is blocked by the
sacrum. This prevents descent and labor
is arrested.
Management :
Chin-Anterior Position
If the cervix is fully dilated:
*Allow to proceed with
normal childbirth;
*If there is slow progress
and no sign of obstruction,
augment labor with
oxytocin;
*If descent is unsatisfactory,
deliver by forceps.
If the cervix is not fully
dilated and there are no
signs of obstruction:
*augment labor with
oxytocin
Chin-Posterior Position
If the cervix is fully dilated:
*Deliver by caesarean
section.
If the cervix is not fully
dilated
*Monitor descent, rotation
and progress. If there are
signs of obstruction, deliver
by caesarean section.
*Do not perform vacuum
extraction for face
presentation.
Types of Malpresentation
 BROW: The brow presentation is caused by
partial extension of the fetal head so that the
occiput is higher than the sinciput.
 MGT: If the fetus is alive or dead, deliver by
caesarean section.
 *Do not deliver brow presentation by vacuum
extraction, outlet forceps or symphysiotomy.
Nursing Care of Clients with
Malpresentations
 Observe closely for abnormal labor patterns.
 Monitor fetal heart beat and contractions continuously.
 Anticipate forceps-assisted birth.
 Anticipate cesarean birth for incomplete breech or
shoulder presentation.
 Be prepared for childbirth emergencies such as
cesarean section, forceps-assisted delivery, and
neonatal-resuscitation.
 Position pt. in Trendelenburg or knee-chest position.
 Manually raise the presenting part aseptically
 Fetal Malpresentation Pathophysiology
Predisposing factors
*Genetic
*Multiple gestation
*Hydraminos
* Preterm Birth
Baby move their
Cephalic Vaginal
head down the
Presentation Delivery
birth canal

First 36 week In the last

s baby weeks In 3-4 wks At the 37 or 38th wk
Pathophysiology
changes the baby Before due date of pregnancy
position shifts
Many times less Sometimes doctors can
Turn the fetus to present
If DOES NOT
Head by pressing on the
happen
Women's abdomen
Precipitating factors Before labor begins
Vertex, breech/
*fetal anamolies shoulder
*Large Tumor transverse
• Neural Tube Defect
• *Congenital
malformation of uterus
Vaginal Breech delivery
* Fibroid Tumor CS
With forcep assistance
Anxiety
 Provide client and family teaching,
 Be available to client for listening and talking
 Provide client support and encouragement.
 Encourage client to acknowledge and express
feelings.
 Encourage breathing exercises to relieve
anxiety.
Fear
Provide client and family teaching,
 Note for degree of incapacitation.
Stay with the client or make arrangements to
have someone else be there.
Provide opportunity for questions and answer
honestly.
Explain procedures within level of client’s ability
to understand and handle.
Risk for Injury
 Observe closely for abnormal labor patterns.
 Monitor fetal heart beat and contractions
continuously
 Be prepared for childbirth emergencies such as
cesarean section, forceps-assisted delivery, and
neonatal-resuscitation.
 Maintain sterility of equipments
 Anticipate forceps-assisted birth.
 Anticipate cesarean birth for incomplete breech
or shoulder presentation.
Risk for infection
Stress proper hand washing techniques of
all caregivers.
Maintain sterile technique.
Cleanse incision site daily and prn.
Change dressings as needed.
 Encourage early ambulation, deep
breathing, coughing, and position change.
Fetal Malposition
 Refers to positions other than an occipitoanterior
position.
 Malpositions include occipitoposterior and
occipitotransverse positions of fetal head in
relation to maternal pelvis.
 It is usually seen in multipara or those with lax
abdominal wall.
 Fetal malpositions are assessed during labor.
Left Occipitoanterior Rotation
 (A) A fetus in cephalic presentation, LOA
position.. The fetus rotates 1/8th of the circle and
comes under the symphysis pubis
 (B) Descent and flexion
 (C) Internal rotation complete.
 (D) Extension; the face and chin are born
Types of Fetal Malposition
Occipitoposterior Occipitotransverse
Position Position
Arrested labor may occur It is the incomplete
when the head does not rotation of OP to OA
rotate and/or descend. results in the fetal head
Delivery may be being in a horizontal or
complicated by perineal transverse position (OT).
tears or extension of an
episiotomy.
Aetiology

> The shape of the pelvis: anthropoid and

android pelvises are the most common cause
of occipito-posterior due to narrow fore-
pelvis.
>Maternal kyphosis: The convexity of the foetal
back fits with the concavity of the lumbar
kyphosis.
> Anterior insertion of the placenta: the foetus
usually faces the placenta (doubtful).
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Aetiology

>Other causes of malpresentations: as

a. placenta praevia,
b. pelvic tumours,
c. pendulous abdomen,
d. polyhydramnios,
e. multiple pregnancy.

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Diagnosis
During pregnancy
Inspection:
>The abdomen looks flattened below the
umbilicus due to absence of round contour
of the foetal back.
>A groove may be seen below the umbilicus
corresponding to the neck.
>Foetal movement may be detected near
the middle line.

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Diagnosis
 Palpation:
>Fundal grip:The breech is felt as a soft, bulky,
irregular non-ballotable mass.
>Umbilical grip:
a. The back felt with difficulty in the flank away
from the middle line.
b.The anterior shoulder is at least 3 inches from
the middle line.
c.The limbs are easily felt near, or on both
sides, of the middle line.
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Diagnosis
> First pelvic grip:
a.The head is usually not engaged due to
deflexion.
b.The head is felt smaller and escapes
easily from the palpating fingers as they
catch the bitemporal diameter instead of
the biparietal diameter in occipito-anterior.
> Second pelvic grip: The head is usually
deflexed.
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Auscultation

>FHS are heard in the flank away from the

middle line.
> In major degree of deflexion, the FHS may
be heard in middle line.

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During labour

In addition to the previous findings vaginal

examination reveals:
* The direction of the occiput.
* The degree of deflexion.

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Left Occipito-posterior Rotation
Mechanism of Labour
 (A) Fetus in cephalic presentation LOP position. View is
from outlet. The fetus rotates 135 degrees from this
position.
 (B) Descent and flexion.
 (C) Internal rotation beginning. Because of the posterior
position, the head will rotate in a longer arc than if it were
in an anterior position.
 (D) Internal rotation complete.
 (E) Extension; the face and the chin are born.
 (F) External rotation; the fetus rotates to place the
shoulder in an anteroposterior position
During labour

Normal mechanism (90%)

Deflexion is corrected and complete
flexion occurs. The occiput meets the
pelvic floor first, long anterior rotation 3/8
circle occurs bringing the occiput anteriorly
and the foetus is delivered normally.

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During labour
 Abnormal mechanism (10%)
 >a.Deep transverse arrest (1%): In mild
deflexion, the occiput rotates 1/8 circle
anteriorly and the head is arrested in the
transverse diameter.
 > b.Persistent occipito-posterior (3%):In
moderate deflexion, the occiput and sinciput
meet the pelvic floor simultaneously, no
internal rotation and the head persists in the
oblique diameter.
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 >c.Direct occipito-posterior (face to bubis) (6%):
1.In marked deflexion, the sinciput meets the pelvic
floor first, rotates 1/8 circle anteriorly and the
occiput becomes direct posterior.
2. In deep transverse arrest and persistent occipito-
posterior no further progress occurs and labour is
obstructed as the head cannot be delivered
spontaneously.
3. In direct occipito-posterior, the head can be
delivered by flexion supposing that the uterine
contractions are strong and there is no contracted
pelvis. However, perineal lacerations are more
liable to occur as:
*the vulva is distended by the large occipito-frontal
diameter 11.5 cm,
* the perineum is overstretched by the large occiput.
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Factors favour long anterior rotation

> Well flexed head

> Good uterine contractions.
> Roomy pelvis.
> Good pelvic floor.
> No premature rupture of membranes.

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Causes of failure of long anterior rotation

> Deflexed head.

> Uterine inertia.
>Contracted pelvis: rotation of the head
cannot easily occur in android pelvis due
to projection of the ischial spines and
convergence of the side walls.
>Lax or rigid pelvic floor.
>Premature rupture of membranes or its
rupture early in labour.
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Management of Labour
 First stage
> Exclude contracted pelvis.
> Exclude presentation or prolapse of the cord.
> Inertia and prolonged labour are expected so
oxytocin may be indicated unless there is
contraindication.
> Contractions are sustained, irregular and
accompanied by marked backache which
needs analgesia as pethidine or epidural
analgesia.

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Management of Labour

 First stage
> Avoid premature rupture of membranes by:-
 rest in bed,
 no straining,
 avoid high enema,
 minimise vaginal examinations.
> The other management and observations as
in normal labour.
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Second stage
Wait for 60-90 minutes.
a.During this period:
> Observe the mother and foetus carefully.
>Combat inertia by oxytocin unless it is
contraindicated.
b. Contraindications of oxytocins:
> Disproportion.
> Incoordinate uterine action.
>Uterine scar e.g. previous C.S, hysterotomy,
myomectomy, metroplasty or previous
perforation.
> Grand multipara.
> Foetal distress.
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Second stage
c. One of the following will occur:
> Long internal rotation 3/8 circle: occurs in
about 90% of cases and delivery is
completed as in normal labour.
>Direct occipito-posterior (face to pubis):
occurs in about 6% of cases, the head can be
delivered spontaneously or by aid of outlet
forceps, Episiotomy is done to avoid perineal
laceration.
> Deep transverse arrest (1%) and persistent
occipito-posterior (3%)
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The labour is obstructed and one of the
following should be done:
1.Vacuum extraction (ventouse):
a. Proper application as near as possible
to the occiput will promote flexion of the
head.
b.Traction will guide the head into the
pelvis till it meets the pelvic floor where it
will rotate.

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2.Manual rotation and extraction by forceps:
a. Under general anaesthesia the following
steps are done:
b.Disimpaction: the head is grasped
bitemporally and pushed slightly upwards.
c.Flexion of the head.
d.Rotation of the occiput anteriorly by the right
hand vaginally aided by,
e.Rotation of the anterior shoulder abdominally
towards the middle line by the left hand or an
assistant.
f.Fix the head abdominally by an assistant,
apply forceps and extract it.
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Caesarean section:
Caesarean section:
It is indicated in:
>Failure of the above methods.
> Other indications for C.S. as;
 contracted pelvis,
 placenta praevia,
 prolapsed pulsating cord before full cervical
dilatation, and
 elderly primigravida.

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Craniotomy

Craniotomy: if the foetus is dead.

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Maternal risks:

prolonged labor
 potential for operative delivery
extension of episiotomy,
3rd or 4th degree laceration of the
perineum.
Maternal symptoms

 Intense back pain in labor

 Dysfunctional labor pattern
prolonged active phase
secondary arrest of dilatation
 arrest of descent
Diagnosis:
Abdominal examination – the lower part of
the abdomen is flattened, fetal limbs are
palpable anteriorly and the fetal flank.
 Vaginal examination – the posterior
fontanelle is toward the sacrum and the
anterior fontanelle may be easily felt if the
head is deflexed
Ultrasound
Nursing MGT :
 Encourage the mother to lie on her side from the
fetal back, which may help with rotation.
* Pelvic – rocking may help with rotation.
* Knee – chest position may facilitate rotation.
 Apply sacral counter – pressure with heel of
hand to relieve back pain.
 Continue support and encouragement:
 Keep client and family informed progress.
 Praise client’s efforts to maintain control.
Management :
 If there are signs of obstruction or the fetal heart rate is
abnormal at any stage, deliver by caesarean section.
 If the membranes are intact, rupture the membranes
with an amniotic hook or a Kocher clamp.
 If the cervix is not fully dilated and there are no signs of
obstruction, augment labor with oxytocin.
 If the cervix is fully dilated but there is no descent in the
expulsive phase, assess for signs of obstruction.
Management :
 If the cervix is fully dilated and if:
* the leading bony edge of the head is above -2
station, perform caesarean section;
* the leading bony edge of the head is between
0 station and -2 station, Delivery by Vacuum
Extraction and Symphysiotomy.
* If the operator is not proficient in
symphysiotomy, perform caesarean section;
* If the bony edge of the fetal head is at 0 station,
deliver by vacuum extraction or forceps.
Management :
 SYMPHYSIOTOMY
A surgical procedure in which the cartilage of the
symphysis pubis is divided to widen the pelvis
allowing childbirth when there is a mechanical
problem.
 Currently the procedure is rarely performed in
developed countries, but is still routine in
developing countries where cesarean section is
not always an option.
Management :
 Forceps - provides traction or a means of
rotating the fetal head.
*Risks: fetal ecchymosis or edema of the face,
transient facial paralysis, maternal lacerations,
or episiotomy extensions.
 Vacuum extraction - Provides traction to shorten
the second stage of labor.
* Risks: newborn cephalhematoma, retinal
hemorrhage and intracranial hemorrhage.
Nursing Diagnoses:
 Impaired gas exchange
* Encourage the mother to lie on her side from
the fetal back, which may help with rotation.
*Knee – chest position may facilitate rotation.
*Pelvic – rocking may help with rotation.
* Monitor FHB appropriately
* Be prepared for childbirth emergencies such
as cesarean section, forceps-assisted delivery,
and neonatal-resuscitation.
 Pain
*Encourage relaxation with contractions. *Apply
sacral counter – pressure with heel of hand to
relieve back pain.
*Provide comfortable environment.
*Teach breathing exercises for use during early
labor until client receives pharmacologic relief.
*Monitor physical response for example,
palpitations/rapid pulse
Nursing Diagnoses:
Fatigue
* Assess psychological and physical
factors that may affect reports of fatigue
level
*Monitor physical response for example,
palpitations/rapid pulse *Monitor fetal heart
beat and contractions continuously.
*Refraining from intervening with client
during contraction.
 Anxiety
* Keep client and family informed progress.
*Provide support during labor through personal
touch and contact. These methods convey
concern.
*Continue support and encouragement.
*Make the client feel she is somewhat in control
of her situation.
* Provide client and family teaching.
*Identify client’s perception of the threat
presented by the situation.
 Induction and
Augmentation of labor
 Common indications for
induction
 Membrane rupture without spontaneous onset of
labor
 Maternal hypertension
 Non-reassuring fetal status
 Post term pregnancy
 GENERAL CONCEPTS
 Elective induction
:not recommended
-increase c/sec (especially, nulliparas)

 When benefits
-mother or fetus > continuing the pregnancy

 Emergent indication
-ruptured membranes with chorioamnionitis
severe preeclampsia
 GENERAL CONCEPTS
 Relative indication
- at term with history of rapid labor reside an
appreciable distance from hospital (mountain, winter)

 Complication
- increase chorioamnionitis and c/sec
c/sec: poorly prepared for labor (ex. unripe cervix or
a myometrium unable to achieve effective synchronous
contraction)
 CONTRAINDICATIONS
 Uterine contraindications
:prior disruption (classical incision or uterine surgery)
placenta previa

 Fetal contraindication
:macrosomia
fetal anomaly- hydrocephalus, malpresentation
nonreassuring fetal status

 Maternal contraindication
:maternal size, pelvic anatomy ,medical condition
(ex.genital herpes)
PREINDUCTION CERVICALRIPENING

 Important factor of labor induction

:the condition or favorability of the cervix
:physical characteristics of the cervix and lower seg.
:presenting part, station

 Quantifiable method ‘BISHOP SCORE’

:if score > 9, usually successful
:IV oxytocin stimulation
PREINDUCTION CERVICAL
RIPENING
 Phamacological techniques
:Prestaglandin E2 (PGE2)
-local application of PGE2 gel (dinoprostone)
-Cx ripening
-dissolution of collagen bundle
increase submucosal water content
-low-dose PGE2 (1988)
 increase successful induction
decrease prolonged labor
reduce total and maximal oxytocin dose
PREINDUCTION CERVICAL
RIPENING
-PGE2 gel (Prepidil): 2.5-mL sylinge
contains dinoprostone(0.5mg)
less uterine activity
greater efficacy in women with very unripe Cx
-Crevidil(10-mg dinoprostone vaginal insert)
slower release than gel
shorten the interval from induction-to-delivery
can be removed (when hyperstimulation occur)

:Patient selection
-Bishop score < 4
PREINDUCTION CERVICAL
RIPENING
:Administration
-continuous Ut activity & FHR monitoring
-remain recumbent for at least 30 min
-observation 30 min~2hrs
-contraction occur
in the first hour and show peak in the first 4 hrs
FHR recording
-minimum safe time interval (PGE2oxytocin)
;not be established
usually, 6 to 12 hrs
PREINDUCTION CERVICAL
RIPENING
 Side effect
-Ut hyperstimulation
(>6 contraction in 10 min for a total of 20 min)
begins within 1 hr
remove
irrigation of Cx, vagina: not be helpful

-systemic effect
nausea, vomiting, diarrhea
glaucoma, hepatic and renal ds, asthma
 PREINDUCTION CERVICAL
RIPENING
: Prostaglandin E1 (PGE1)
-Misoprostol (Cytotec)
` available as a 100㎍ tablet for prevention of ulcer
` preinduction cervical ripening and labor induction
inexpensive
stable at room temperature
easily administered orally
placed into the vagina but not cervix
intravaginal 25㎍ every 3 to 6 hr
 Vaginal misoprostol
- misoprostol PV > intracervical PGE2 gel
- `recommend 25㎍ dose PV
decrease the need for oxytocin
higher rates of vaginal delivery within 24hrs
reduce induction-to-delivery intervals
caution : hyperstimulation with fetal heart rate
change
 ` if 50㎍ dose,
-tachysystole, meconium passage & aspiration
- increased c/sec rate (hyperstimulation)

 : prior uterine surgery – risk of uterine rupture

not use Misoprostol
 Oral Misoprostol
- Windrim(1997) orally administration = intavaginal
(cervical ripening,labor induction)
- Bennett(1998) but more frequent FHR abnormal
- Adair(1998) 200㎍ oral; more frequent abnormal
Ut contractility
- Wing (1999) 50 ㎍ oral < 25㎍ vagina
(cervical ripening, labor induction)
 100㎍ oral = 25㎍ intravagina
 Mechanical techniques
: EASI (extra-amnionic saline infusion)
-foleys catheter with 30cc ballooning
-rapid improvement in Bishop score shorter labor
-c/sec rate 4~46%
 Hygroscopic cervical dilators
: rapid improvement of cervical status
: no beneficial effect on c/sec rate or delivery interval

: low cost, ease of placement, quickly removed

: longer interval-to-delivery time (compare with EASI)

: some benefit for initiation for cervical dilation
 Membrane stripping
: performed by inserting the index finger as far
through the internal os as possible and rotating
twice through 360 degrees to separate the
membranes from the lower segment
: safe and decreased incidence of postterm gestation
: not increase-membrane rupture, infection, bleeding
: increased plasma prostaglandins
: benefit- < 48hrs, < 1 week , < 41 weeks
 LABOR INDUCTION AND AUGMENTATION
WITH OXYTOCIN
 Oxytocin
: first polypeptide hormone synthesized
: following delivery to induce or augment labor
 Induction
: stimulation of contraction before the spontaneous
onset of labor, with or without ruptured membranes
 Augmentation
: stimulation of spontaneous contractions that are
considered inadequate because of failure of
progressive dilatation and descent
- oxytocin IV infusion to augment inadequate labor
due to uterine dysfunction
exclude fetopelvic disproportion

- fetal heart rate and contraction pattern be obsreved

closely
 Technique for administration of intravenous oxytocin
: variety of methods
: the goal produce cervical change
fetal descent
: avoiding hyperstimulation and nonreassuring
(hyperstimulation: >5 in 10 mins or >7 in 15 mins )
( >60~90 seconds )
: if hyperstimulation  oxytocin stop!!!
-rapidly decreases the frequency of contractions
concentration in plasma rapidly falls half-life is
approximately 5 minutes
: uterine response- withthin 3~5 mins
steady state- 40 mins
depends on preexisting uterine activity
sensitivity &
cervical status
: uterine response
- GA 20~30 weeks : increase
GA 34 ~ at term : unchanged but, sensitivity
: important factors of oxytocin dosage
-cervical dilatation, parity, gestational age
: methods – diluted into 1000ml of a balanced salt
solution ( lactated Ringer solution) by infusion
pump
- avoid bolus
- only IV route

 typically, 10~20 unit in 1000 ml

(10,000~20,000mU 10~20 mU/ml)
 Oxytocin is avoided
-abnormal fetal presentation
uterine overdistention (hydramnios, large fetus,
or multiple fetus)
high parity ( >6 )
previous uterine scar

-not contraindication
prior cesarean delivery
dead fetus unless CPD
 Oxytocin dosage
high-dose(4~6mU/min) vs low-dose (0.5~1.5 mU/min)
low-dose 1mU/min, interval 20 mins
high-dose 6mU/min, interval 20 mins
Max 42mU/min
if hyperstimulation, reduce 3mU/min
this flexible high-dose protocol
: delivery time forceps delivery
chorioamnionatis neonatal sepsis
but, c/sec (fetal distress, 3% 6%)
 Risk versus benefits
: uterine rupture- uncommon today
rare in parous women, unless scarred

: water intoxication
-oxytcin is similar to arginine vasopressin
antidiuretic action
renal free water clearance decrease
adequate water + oxytocin convulsion, coma
death
 Amniotomy
: artificial rupture of the membrane
commonly used to induce or augment labor
: amniorrhexis- rupture only amnion, not chorion

: other indication of amniotomy

-internal monitoring when fetal jeopardy
intrauterine assessment of contractions when
labor has been unsatisfactory
: nonintervention group
-60% : > 8cm dilatation before membrane rupture
-38% : amniotomy due to internal monitoriong
labor augmentation

: prevent risk of cord prolapse

- fundal and suprapubic pressure
rupture during a contraction
fetal monitoring
 Elective amniotomy
: 5cm dilatation
accelerated spontaneous labor within 1 to 2 hrs
without increasing c/sec and need of oxytocin
 Amniotomy induction
:used to induce labor but, it implies a firm commitment
to delivery
:disadvantage
-the unpredictable and occasionally long interval to
the onset of labor

:amniotomy (+ oxytocin) > oxytocin alone

early amniotomy (1~2cm) > late amniotomy (5cm)
:chorioamnionitis (23%), cord compresson (12%)
 Amniotomy for augmentation
: when spontaneous labor is abnormally slow
dysfunctional labor

: with oxytocin- shortened labor by 44 minutes

 Operative
Vaginal delivery

PRESENTED BY
MS. LIJI GEORGE
Indications
Maternal Benefit – Shorten the 2nd stage of labor,
decrease the amount of pushing
• Ie: maternal cardiac conditions (Eisenmenger’s, pulmonary
HTN) or history of aneurysm/stroke

Concern for immediate/potential fetal

compromise
• Ie: Prolonged terminal bradycardia

Prolonged 2nd stage

• Nulliparous = No progress for 3 hrs w/epidural or 2 hours w/o

epidural
• Multiparous = No progress for 2 hrs w/epidural or 1 hr w/o
epidural
Forceps

Obstetric forceps is a
pair of instrument
specially designed to
assist extraction of fetal
head and thereby
accomplishing delivery
of the fetus.
Varieties

Long curved forceps with or

without axis traction

Short curved forceps

Kiellands forceps
Parts of forceps
Long curved forceps

Is relatively
heavy about
37 cm long

In India Das
variety

Can be with
or without
axis traction
Short curved forceps or
Wrigley forceps

It is lighter

Weight less than long

curved forceps

Reduction in length
of shank and handles

Marked cephalic and

pelvic curve
Killands forceps

It is long almost
straight

Slight pelvic curve

Without axis traction

 Type of Forceps Delivery
 Outlet forceps
 Scalp visible at introitus w/o separating labia
 Fetal skull reached pelvic floor & head at/on
perineum
 Sagittal suture in AP diameter or LOA, ROA, or
posterior position
 rotation does not exceed 45º
 Low forceps
 Leading point of fetal skull at >= +2, not on pelvic
floor
 Rotation 45º or less (LOA/ROA to OA, or LOP/ROP
to OP); or rotation greater than 45º.
 Midforceps
 Above +2 cm but head engaged
 High forceps
 Head not engaged
 Not recommended
Criteria to be fulfilled prior
to forceps delivery
F- favorable head position and station

O- open OS

R- ruptured membranes

C- contractions present and constent

E- engaged head

E- empty bladder

P- pelvimetry- no major CPD

 Forceps-Assisted Vaginal
Delivery
Identify & apply
blades
• Place instrument in
front of pelvis with
tip pointing up &
pelvic curve
forward
• Apply left blade,
guided by right
hand, then right
blade with left hand
Lock blades
•Should articulate
with ease
Check for
correct
application
•Sagittal suture in
midline of shanks
•Cannot place more
than one fingertip
between blade and
fetal head
Apply traction
•Steady and
intermittent
•Downward and
then upward
•Remove blades
as fetus crowns
Risks: Forceps
Maternal Risks
• Perineal Injury (extension of episiotomy)
• Vaginal and Cervical lacerations
• Postpartum hemorrhage
Fetal Risks
• Intracranial hemorrhage
• Cephalic hematoma
• Facial / Brachial palsy
• Injury to the soft tissues of face & forehead
• Skull fracture
Ventouse
Vantouse is an instrument device
designed to assist delivery by creating
vacuum between it and the fetal scalp
Contraindication

Any Suspected
Suspected
presentation Preterm fetal
fetus
other than fetus<34 wks cagulation
macrosomia
vertex disorder
Condition to be fulfilled
There should be
slight bony
resistence
below the head

The head of
singleton baby
should be
engaged

Cervix should
be at least 6cm
dilated
After determining position of the head, (A) insert the cup into the vaginal
vault, ensuring that no maternal tissues are trapped by the cup. (B) Apply the
cup to the flexion point 3 cm in front of the posterior fontanel, centering the
sagittal suture. (C) Pull during a contraction with a steady motion, keeping
the device at right angles to the plane of the cup. In occipitoposterior
deliveries, maintain the right angle if the fetal head rotates. (D) Remove the
cup when the fetal jaw is reachable
Fetal Risks: VAVD

 Fetal
 Scalp lacerations: if torsion
excessive
 Cephalohematoma:
limited to suture line
 Subgleal hematoma:
crosses suture line
 Intracranial/retinal
hemorrhage
 Higher incidence of
cephalohematoma/retina
l hemorrhage/jaundice
compared to forceps
Prolonged Labour
Unit 7
Definition

The labour is said to be prolonged when

the combined duration of first and
second stage is more than the arbitrary
time limit of 18 hours
Prolongation may be due to protracted
cervical dilation in first stage , poor
desent of presenting part in first or
second stage

Labour is said to be when cervical

dilation and descent is <1cm /hr in 4 hrs
of observation
 Etiology

First stage – filure to dilate the cervix

• Fault in power-
• Uterine inertia
• Incardinated uterine contraction
• Fault in passage
• Contracted pelvis
• Cervical dystocia
• Pelvic tumor
• Full bladder
• Fault in passenger
• Malposition /malpresentation
• Congenital anomaly
• Other
• Injudicious administration of sedative and analgesics
 Second stage - sluggish or non descent of fetus

• Fault in power-
• Uterine inertia
• Inability to bear down
• Epidural analgesia
• Contraction ring
• Fault in passage
• Contracted pelvis , CPD , Android Pelvis
• Resistance of pelvic floor due to perineal spasm
• Pelvic tumor
• Fault in passenger
• Malposition /malpresentation
• Big baby
• Congenital anomaly
Complication

Fetal Maternal
• Hypoxia • Distress
• PPH
• Intrauterine • Trauma to genital
infection tract- cervical
• Intracranial tear, uterine
stress rupture
hemorrhage • Increased
operative
• Increased dewlivery
operative • Pueperial sepsis
delivery • Subinvolution
Treatment

• Early detection of factors of

prolonged labour
• Use Partograph
• Selective and judicious
Prevention augmentation of labour
• Change of posture in labour
• Avoid dehydration
• Use of adequate analgesic
 Actual mamagement
Preliminary
• If it’s a well equipped hospital
• Early detection of factors
• Correction of dehydration and ketoacidosis
• Rapid IV Rl
Definitive treatment
• First stage delay
• Vaginal examination
• Clinical pelvimetry
• Effective pain relief
• For secondry arrest – in multipara careful use of
oxytocin
• Unssafe vaginal delivery then CS is done
• Second stage delay
• Se for vaginal delivery possible if not then
• CS
Vasa Praevia
Vasa Praevia
 Vasa praevia, blood vessels involved in the baby's
circulation grow along the membranes in the lower
part of the uterus at the cervical opening. When the
condition is not detected in advance, the blood
vessels can rupture during labor.
 Rare - 1 in 3000
 Fetal vessels run in the membrane below the
presenting fetal part, unsupported by placental
tissue or umbilical cord
 Spontaneous or artificial rupture of membranes -
rupture these vessels - fetal exsanguinations.
 Hypoxia if the vessels are compressed between
baby & birth canal.
 Fetal mortality 33-100%, if not diagnosed
prenatally.
Pathology
 Unknown cause.
 Trophotropism - tendency of a plant to lean towards
sun to get light to survive. Lower segment not
nourishing - placenta grows upwards to reach more
nourishing tissue.
 Risk factors

Low lining placenta

bilobed or succenturiate placenta
Velamentous insertion of cord
Multple pregnancies
IVF pregnancies
Velamentous insertion of cord
 1% - singleton pregnancies, 8.7% - twin
pregnancies, higher in early pregnancy &
spontaneous abortion.
 Umbilical cord usually inserts on placental mass -
99% cases.
 Velamentous - cord inserted on chorioamniotic
membrane.
 Variable amount of cord unprotected by Wharton’s
jelly.
 Vasa praevia coexisting in 6% singleton pregnancies
with velamentous insertion.
Velamentous insertion of cord
Twin Placenta with a succenturiate lobe
Circumvallate Placenta.
 Symptoms
 Asymptomatic

 sudden onset of painless bleeding in 2nd or 3rd

trimester or at ARM/SRM.

 Heavy or small amount of bleeding. No sign symptom

of Placenta praevia or abruption.

 IUGR/ Congenital malformation

 Maternal risk: bleeding

Antenatal Diagnosis
 An avoidable tragedy.
 Changing ultrasound protocol for checking placental
cord connection.
 Can be diagnosed as early as 16 weeks .
 All suspected cases should be checked for vasa
praevia
Doppler scan to detect Vasa praevia - 1
Doppler scan to detect Vasa praevia - 2
Management
 If diagnosed prenatally
tocolytics,
bedrest
no vaginal exams
avoid heavy lifting, straining during bowel movement
regular scans
 Planned cesarean section can circumvent fetal risks.

 Delivery can be planned early enough to avoid

emergency, but late enough to avoid prematurity
 Baby requires aggressive resuscitation & blood
transfusion
Management

 If PV bleeding intrapartum

Speculum - fetal vessels.

Investigate for the source of bleeding