CONTRACTED PELVIS AND OBSTETRICAL EMERGENCIESOBJECTIVES: General objectives: By the end of seminar group will be able to gain in depth knowledge in contrated pelvis and obstetrical emergencies Specific objectives: Group will be able to; Define contracted pelvis Variations of female pelvis List causes of contracted pelvis Discuss mechanism of labour in contracted labour Enumerate the diagnosis of contracted pelvis Define cephalopelvic disproportion List diagnosis of CPD Describe the effects of contracted pelvis Discuss the management of contracted pelvis Define obstetrical emergencies Classification of obstretrical emergency Discuss etiology, clinical manifestation, diagnosis and management List nursing diagnosis VVVVVVVVVVV VVContent Page no. s.no 1 Introduction 2 Definition 3 Contracted pelvis > causes > diagnosis > effects of contracted pelvis > management 4 , 5 cephalo pelvic disproportion 5 obstetrical emergencies v definition Y etiology ¥ clinical manifestation diagnosis ¥ manangemt ¥ nursing management Y nursing diagnosis 6 Summary 7 Conclusion 8 BibliographyCONTRACTED PELVIS: INTRODUCTION: The female pelvis may be altered in size and shape by errors of development by diseases of the pelvic bones and joints, by deformities of the pelvic column and lower extremities or because of accidents, Itis indeed difficult to define precisely what constitutes a contracted pelvis. Anatomically, contracted pelvis is defined as one where the essential diameters of one or more planes are shortened by 0.5 cm Depending upon the degree of contraction, the head may pass through the pelvis by abnormal mechanism or fail to pass due to absolute obstruction. DEFINITION: Obstetrical definition which states that alteration in size and/or shape of the pelvis of sufficient degree so as to alter the normal mechanism of labor in an average size of the baby - D.C.DUTTA VARIATIONS OF FEMALE PELVIS: The size and shape of the female pelvis differ so widely due to morphological factors such as developmental, sexual, racial and evolutionary that it is indeed difficult to define what the features of a normal pelvis are. However, on the basis of the shape of the inlet, the female pelvis is divided into four parent types. Gynecoid (50%) _Anthropoid (25%) Android (20%) _ Platypelloid (5%)But more commonly, intermediate forms with combination of features are found. They are termed as gyne-android or andro-gynecoid, etc. The first part of the nomenclature relates to features of the posterior segment and the second part relates to that of the anterior segment of the pelvis. All types of combinations are possible except anthropoid with platypelloid. It should be clear that the pelves which are not typically female are not necessarily contracted, although there may be deviation of normal mechanism of labor. However, slight contraction if associated with any of the three nongynecoid pelves has a more serious consequence because of the unfavorable shape. COMMON CAUSES: 1. Nutrition and environmental defects © Minor variation : common © Major variation: rachitic and osteomalacic-rare 2. Diseases or injuries effecting the bones of the pelvis — fracture , tumors , tubercular arthritis; spine- kyphosis, scoliosis, spondilolisthesis, coxygeal deformity ; lower limbs — polio myletis, hip joint diseases. 3. Developmental defects —neagel ‘s pelvis, Robert’s pelvis Rachitic flat pelvis — rickets is predominantly a disease of early child hood when the bones remain soft and unoccified. At this time if the child lies or sits in bed, changes occur in the soft pelvis due to weight bearing . the changes are : Inlet — sacral promonitory is pushed down wards and forwards producing a reniform shape of the inlet with marked shortening of the anterio- posterior diameter without effecting the tranverse diameter. Cavity : sacrum is flat and tilted backwards . there may be short angulation at the sacro coxygeal joint. Out let : body weight transmitted through the ischium in sitting position results in widening of the transverse diameter of the outlet and the pubic arch .Osteomalycic pelvis The deformity is caused by softening of the pubic bones due to calcium and vitamin D deficiency and lack of exposure to sunrise . The promonitory is pushed downwards and forwards Approximation of the two ischial tuborosities and marked narrowing of the pubic arch occurs . sacrum is markedly shortened and coccyx is pushed forward. Assymetrical or obliquely contracted pelvis : It is seen in negles pelvis , scholiotic pelvis due to diseases affecting one hip or sacro iliac joint, Tumors or fracture affecting one side of the pelvic bone during growing age. Negles pelvis : This type of pelvis is extremely rare. It is produced due to arrested development of ala of the sacrum. It may be: © congenital © acquired the pelvis is obliquely contracted at all levels but more marked in ‘the oulet. ileopectineal line on the affected side is almost straight. Method of delivery is by cesarean section.Roberts pelvis : Ala of the both sides are absent and the sacrum is fused with the innominate bones. Kyphotic pelvis : The sacrum is tilted backwards in the upper part and forwards in the lower part. It is narrow and straight . the anterio postrio diameter of the inlet is increased but is diminished at the outlet sub pubic angle is narrow does the feature is extreme fanneling of the pelvis. MECHANISM OF LABOR IN CONTRACTED PELVIS WITH VERTEX PRESENTATION FLAT PELVIS: In the flat pelvis, the head finds difficulty in negotiating the brim and once it passes through the brim; there is no difficulty in the cavity or outlet. The head negotiates the brim by the following mechanism: © The head engages with the sagital suture in the transverse diameter. © Head remains deflexed and engagement is delayed. © The anterio posterior diameter is too short; the occiput is mobilized to the same side, to occupy the sacral bay. The bi parietal diameter is thus placed in the sactocotyliod diameter (9.5cm) and the narrow bi temporal diameter is placed in the narrow conjugate. © Engagement is occurs by exaggerated parietal presentation so that the super sub parictal diameter (8.5 cm) instead of the bi parietal diameter (9cm) passes through the pelvic brim. ‘© Moulding may be extreme and often there is an indentation or even a fracture of one parietal bone. ‘© Once the head negotiates the brim, there is no difficulty in the cavity and the outlet and normal mechanism follows.© In this type of pelvis the shape remains unaltered, but all the diameters in the different planes—inlet, cavity and outlet—are shortened. There is difficulty from the beginning to the end. DIAGNOSIS OF CONTRACTED PELVIS: During the past couple of decades, there has been a gradual decline in the incidence of severe degree of contracted pelvis. This is due to an improved standard of living and of nutrition in particular. But of significance is the presence of fetopelvic disproportion due either to inadequate pelvis or big baby or more commonly a combination of the both. Past history: +} Medical: the past history of fracture, rickets, osteomalacia, tuberculosis of the pelvis joints or spines, poliomyelitis is to be enquired. > Obstetrical: a history of prolonged and a tedious labor followed by either spontaneous or difficult instrumental delivery is suggestive of pelvic contraction. Difficult vaginal delivery is ending in still born or carly neonatal death. Weight of the baby, evidences of maternal I juries such as is complete perineal tear, vesico vaginal or recto vaginal fistula, if, available, are of useful guide. Physical examination: > Stature: A small woman of less than 5 ft is likely to have a small pelvis. > Stigma: deformities (congenital or acquired) of pelvic bones, hip joint, spine. Abdominal examination: © Inspection: pendulous abdomen specially in primigravidae. > Obstetrical: in primigravidae usually there is engagement of the head before the onset of the labor. Presence of malpresentation in primigravidae, gives rise to a suspicion of pelvis of pelvie contraction. Assessment of the pelvis (Pelvimetrty):*& Assessment of the pelvis can be done by bimanual examination: clinical pevimetry or by imaging studies- radiopelvimetry, computed tomography (CT) and Magnetioc resonance image (MRI). % Clinical Pelvimetry: this is done manually. & Time: in vertex presentation, the assessment is done at any time beyond 37 weeks but better at beginning of the labor. Because of softening of the tissues, assessment can be done effectively during this time. & Procedures: The patient has to empty the bladder. The pelvic examination is done with the patient in dorsal position taking aseptic preparations. The following features are to be noted simultaneously: (1) State of the cervix; (2) To note the station of the presenting part in relation to ischial spines; (3) To test for cephalopelvic disproportion in nonengaged head (described later); (4) To note the resilience and elasticity of the perineal muscles. Steps: The intemal examination should be gentle, thorough, medical and purposeful. Sacrum: the sacrum is smooth, well curved and usually inaccessible beyond lower three pieces. Sacrosciatic notch: the configuration of the notch denotes the capacity of the posterior segment of the pelvis and the side walls of the lower pelvis. Ischial spines: spines are usually smooth and difficult to palpate. Liopectenial lines: to note for any breaking suggestive of narrow pelvis fore pelvis. Posterior surface of the symphysis pubis; it normally forms a smooth rounded curve. Sacro coccygeal joint: its mobility and presence of hooked occurs, if any are noted.Pubic arch: normally the pubic arch is rounded and should accommodate the palmer aspect of the two fingers. Pubic angle: the inferior pubic rami are defined in female, the angle roughly corresponds to the fully abducted thumb and index fingers. In narrow angle, it roughly corresponds to the fully abducted middle and index fingers. Transverse diameter of the outlet: it is measured by placing the knuckles of the first inter phalengeal joints or knuckles of the clenched fist between the ischial tuberositie, Anterio posterior diameter of the outlet: the distance between the inferior margin of the symphysis pubis and the skin over the sacro coccygeal joint can be measured with the metjod employed for diagonal conjugate. X-ray pelvimetry: is of limited value in the diagnosis of pelvic contraction or cephalopelvic disproportion. Apart from pelvic capacity there are several other factors involved in successful vaginal delivery. These are the fetal size, presentation, position and the force of uterine contractions. X-ray pelvimetry cannot assess the other factors. It cannot reliably predict the likelihood of vaginal delivery neither in breech presentation nor in cases with previous cesarean section. X-ray pelvimetry is a poor predictor of pelvic adequacy and success of vaginal delivery. However, X-ray pelvimetry is useful in cases with fractured pelvis and for the important diameters which are inaccessible to clinical examination. Computed tomography :(CT) involves less radiation exposure (44-425 millirad) and is easier to perform. Accuracy is greater than that of conventional X-ray pelvimetry (Fig. 24.8). Three images (lateral, AP and axial slice) are taken. Magnetic resonance imaging (MRI) :is more accurate to assess the bony pelvis. It is also helpful to assess the fetal size and maternal soft tissues which are involved in dystocia, It has got no radiation risk, hence biologically safe. It is expensive, requires more time and availability is limited. Ultrasonography: is usefull to measure the fetal head dimensions in the intrapartum phaseCEPHALOPELVIC DISPROPORTION INTRODUCTION: The disparity in relation between the head and the pelvis is called cephalo pelvic disproportion. Disproportion may be either due to an average size of the baby with a small pelvis or due to big baby with normal size pelvis or due to combination of both the factors. Pelvic inlet contraction: is considered when the obstetric conjugate is< 10 cm or the greatest transverse diameter is < 12 cm or diagonal conjugate is < 11 cm. Contracted Midpelvis: Midpelvis is considered contracted when the sum of the interischial spinous and posterior sagittal diameters of the midpelvis (normal: 10.0 + 5 = 15.0 cm) is 13.0 cm or below. Contracted outlet: is suspected when the interischial tuberous diameter is 8 cm or less, A contracted outlet is often associated with midpelvic contraction. Isolated outlet contraction is a rarity. Disproportion at the outlet may not give rise to severe dystocia, but may cause perineal tears. The head is pushed backwards as it cannot be accommodated beneath the symphysis pubis. As the head is the largest part of the fetus, it is more important to know whether the greatest diameter of the head passes through the different planes of the pelvis. Thus, from the clinical point of view, identification of the cephalopelvic disproportion is more logical than to concentrate entirely on the measurements of a given pelvis, as the fetal head is the best pelvimeter. Thus, disproportion may be limited to one or more planes. Absence of cephalopelvic disproportion at the brim usually, but not always, negates its presence at the midpelvic plane. On the other hand, isolated outlet contraction without midpelvic contraction is a rarity. Thus, a thorough assessment of the pelvis and identification of the presence and degree of cephalopelvic disproportion are to be noted while evaluating a case of contracted pelvis. DEFINITION:The disparity in the relation between the head and the pelvis is called cephalopelvic disproportion. - D.CDUTTA Diagnosis of the cephalo pelvic disproportion at the brim: The presence and degree of cephalo pelvic disproportion at the bri can be ascertained by the following: ¥ Clinical abdominal method ¥ Imaging Pelvimetry Y Cephalometry ¥ Ultrasound Y Magnetic resonance Imaging (MRI). v Xray. Clinical: In multigravidae, a previous history of spontaneous delivery of an avarege size baby, resonble rules out contracted pelvis. But in a primigravida with noon engagement of the head even at labour, one should rule out disproportion. Abdominal method: The patient is placed in dorsal position with the thighs slightle flexed and separated. The head is grasped by the left hand. Two fingers ( index and middle) of the right hand are placed above symphysis pubis keeping the inner surface of the fingers in line with the anterior surface of the symphysis pubis to note the degree of the overlapping if, any, when the head is pushed down wards and backwards. Inferences: © The head can be pushed down in the pelvis without overlapping of the parietal bone on the symphysis pubis —no disproportion. © Head can be pushed down a little but there is slight overlapping of the parietal bone evidenced by touch on the under surface of the fingers(overlapping by 0.5 cm or 1/4" which is the thickness of the symphysis pubis) —moderate disproportion. Head cannot be pushed down and instead the parietal bone overhangs the symphysis pubis displacing the fingers — severe disproportion. The abdominal method can be used as a screening procedure: At times, it is difficult to elicit due to deflexed head, thick abdominal wall, irritable uterus and high-floating head. Abdominovaginal method (Muller-Munro Kerr): This bimanual method is superior to the abdominal method as the pelvic assessment can be done simultancously. Muller introduced the method by placing the vaginal finger tips at the level of ischial spines to note the descent of the head. Munro Kerr added placement of the thumb over the symphysis pubis to note the degree of overlapping. Lower bowel is emptied, preferably by enema. The patient is asked to empty the bladder. The patient is placed in lithotomy position and the internal examination is done taking all aseptic precautions. Two fingers of the right hand are introduced into the vagina with the finger tips placed at the level of ischial spines and thumb is placed over the symphysis pubis. The head is grasped by the left hand and is pushed in a downward and backward direction into the pelvis. Inferences: (1) The head can be pushed down up to the level of ischial spines and there is no overlapping of the parietal bone over the symphysis pubis —no disproportion; (2) The head can be pushed down a little but not up to the level of ischial spines and there is slight overlapping of the parietal bone — slight or moderate disproportion; (3) The head cannot be pushed down and instead the parietal bone overhangs the symphysis pubis displacing the thumb — severe disproportion. Limitations of clinical assessment:(1) The method is only applicable to note the presence or absence of disproportion at the brim and not at all applicable to elicit midpelvic or outlet contraction; (2) The fetal head can be used as a pelvimeter to elicit only the contraction in the anteroposterior plane of the inlet but when the contraction affects the transverse diameter of the inlet, itis of less use. X-ray pelvimetry: Lateral X-ray view with the patient in standing position is helpful in assessing cephalopelvic proportion in all planes of the pelvis —inlet, midpelvic and outlet. Cephalometry: While a rough estimation of the size of the head can be assessed clinically, accurate measurement of the biparietal diameter would have been ideal to elicit its relation with the diameters of the planes of a given pelvis through which it has to pass. In this respect, ultrasonographic measurement of the biparietal diameter or Magnetic Resonance Imaging (MRI) gives superior information. The average biparietal diameter measures 9.4-9.8 cm at term. Magnetic Resonance Imaging (MRI): MRI is useful to assess the pelvic capacity at different planes. It is equally informative to assess the fetal size, fetal head volume and pelvic soft tissues which are also important for successfull vaginal delivery Degree of disproportion and contracted pelvis: Based on the clinical and supplemented by imaging pelvimetry, the following degrees of disproportion at the brim are evaluated: (1) Severe disproportion: Where obstetric conjugate is < 7.5 cm (3"). Such type is Tare to see. (2) Borderline: Where obstetric conjugate is between 9.5 cm and 10 cm. When both the anteroposterior diameter (< 10 cm) and the transverse diameter (< 12 cm) of the inlet are reduced, the risk of dystocia is high than when only one diameter is contracted. EFFECTS OF CONTRACTED PELVIS ON PREGNANCY AND LABOR:Pregnancy: The general course of pregnancy is not much affected. However, the following may occur: (1) There is more chance of incarceration of the retroverted gravid uterus in flat pelvis (2) Abdomen becomes pendulous especially in multigravida with lax abdominal wall (3) Malpresentations are increased three to four times and so also increased frequency of unstable lie. Labor: The course of events in labor is greatly modified depending upon the degree of pelvic contraction and presentation of the fetus: (1) There is increased incidence of early rupture of the membranes, (2) Incidence of cord prolapse is increased (3) Cervical dilatation is slowed (4) There is increased tendency of prolonged labor and in neglected cases, obstructed labor with features of exhaustion, dehydration, ketoacidosis and sepsis (5) There is increased incidence of operative interference, shock, postpartum; and hemorrhage and sepsis. Maternal injuries: The injuries of the genital tract may occur spontaneously or following operative delivery There is increased maternal morbidity and mortality Fetal hazards: Fetal risks are due to trauma and asphyxia The net effect leads to increased perinatal mortality and morbidity. MANAGEMENT OF CONTRACTED PELVIS (INLET CONTRACTION) The prerequisite in the formulation of the line of management of contracted inlet is to ascertain the degree of disproportion by clinical examination and supplemented by imaging pelvimetry. Due consideration is given to the associated complicating factor, if any.Minor degrees of inlet contraction does not give rise to much problem and the cases are left to have a spontaneous vaginal delivery at term. The moderate and the severe degrees are to be dealt by any one of the following: © Induction of labor © Elective cesarean section at term e Trial labor Induction of labor prior EDC: Induction 2-3 weeks prior to the EDC may be considered only in cases with minor to moderate degrees of pelvic contraction. It is not favored nowadays. However, in a selected multigravida with previous history of difficult vaginal delivery, this method may be considered 2-3 weeks before the date. In any case, one should be certain about the fetal gestational age. Elective cesarean section at term: This is commonly done. Elective cesarean section at term is indicated in— (1) major degree of inlet contraction and also in (2) moderate degree of inlet contraction associated with outlet contraction or complicating factors like elderly primigravida, malpresentation, post-cesarean pregnancy, etc. If there is no doubt about the maturity of the fetus, the operation is done in planned way any time during last week of pregnancy. In doubtful maturity, investigations are done to ascertain maturity otherwise the operation is withheld till the pains start or the membranes rupture, whichever occurs carly. TRIAL LABOR Definition: It is the conduction of spontaneous labor in a moderate degree of cephalopelvic disproportion, in an institution under supervision with watchful expectancy, hoping fora vaginal delivery.Every arrangement should be made available for operative delivery, either vaginal or abdominal, if the condition so arises. Aims: A trial labor aims at avoiding an unnecessary cesarean section and at delivering a healthy baby. The phrase “trial” was used originally to test for pelvic adequacy but subsequently its use has been extended to test numerous factors other than the pelvic capacity. For example, the trial is conducted to test the integrity of the scar in a woman with prior cesarean delivery when she goes into labor. Contraindications: (1) Associated midpelvic and outlet contraction (2) Presence of complicating factors like elderly primigravida, malpresentation, postmaturity, post-cesarean pregnancy, pre-eclampsia, medical disorders like heart disease, diabetes, tuberculosis, etc, (3) Where facilities for cesarean section is not available round the clock. Conduction of trial labor: The management of a trial labor requires careful supervision and consideration, The following guidelines are prescribed. The labor should ideally be spontaneous in onset. But in cases where the labor fails to start even on due date, induction of labor may be done. Oral feeding remains suspended and hydration is maintained by intravenous drip. ‘Adequate analgesic is administered. The progress of the labor is mapped with a partograph (a) progressive descent of the head and (b) progressive dilatation of the cervix. To monitor the maternal health . Fetal monitoring is done clinically and/or using EFM.If there is failure to progress due to inadequate uterine contraction, augmentation of labor may be done by amniotomy along with oxytocin infusion. On no account should the procedure be employed before the cervix is at least 3 cm (2 fingers) dilated. After the membranes rupture, pelvic examination is to be done: (a) To exclude cord prolapse (b) To note the color of liquor; (©) To assess the pelvis once more and (d) To note the condition of the cervix including pressure of the presenting part on the cervix. Successful outcome depends on: (1) Degree of pelvic contraction (2) Shape of the pelvis—flat pelvis is better than android or generally contracted pelvis (3) Favorable vertex presentation—anterior parietal presentation with less parietal obliquity is favorable (4) Intact membranes till full dilatation of cervix (5) Effective uterine contractions and (6) Emotional stability of the woman, © Unfavorable features: © Appearance of abnormal uterine contraction © Cervical dilatation less than 1 cm per hour in the active phase (protracted active phase) © Descent of fetal head less than 1 cm per hour (protracted active phase) inspite of regular uterine contractions; © Arrest of cervical dilatation and nondescent of fetal head in spite of oxytocin therapy©. Early rupture of the membranes © Formation of caput and evidence of excessive molding © Fetal distress. How long the trial to be continued? It is indeed difficult to set an arbitrary time limit which is applicable to all cases. One should individualize the case. So long as the progress is satisfactory (evidenced by descent of the head and progressive cervical dilatation) and the maternal and fetal condition remain good, trial may be continued safely. However, if any ominous feature appears, trial is to be terminated forthwith. Nowadays, there is a tendency to shorten the duration of trial. In spite of adequate uterine contractions, if there is arrest of descent or dilatation of the cervix for a reasonable period (3-4 hours) in the active phase, labor is terminated by cesarean section. Termination of trial labor: The methods of termination are any one of the following: Spontaneous delivery with or without episiotomy (30%). Forceps or ventouse (30%)—Difficult forceps delivery is to be avoided. Cesarean section (40%)—Judicious and timely decision for cesarean delivery is to be taken. However, in significant cases, the section is done even before full dilatation of the cervix, the indication being uterine inertia or fetal distress. Successful trial: A trial is called successful, if a healthy baby is born vaginally, spontaneously or by forceps or ventouse with the mother in good condition. Delivery by cesarean section or delivery of a dead baby, spontaneously or by craniotomy, is called failure of trial labor. Advantages of trial labor: (1) It eliminates unnecessary cesarean section electively decided upon (2) It eliminates injudicious use of premature induction of labor with its antecedent hazards(3) A successful trial ensures the woman a good future obstetrics. Disadvantages of trial labor: (1) Test of disproportion remains unproven when cesarean delivery is done due to fetal distress or uterine dysfunction (2) Increased perinatal morbidity or mortality due to asphyxia or intracranial hemorrhage when the trial is prolonged and/or ends in difficult delivery (3) Increased maternal morbidity due to the effects of prolonged labor and/or operative delivery (4) Increased psychological morbidity when trial ends with a traumatic vaginal delivery or in cesarean delivery. MIDPELVIC AND OUTLET DISPROPORTION: In clinical assessment, it is difficult to determine where the midpelvis ends and outlet begins. Moreover, isolated outlet contraction without midpelvic contraction is a rarity. As such, in practice the two problems are jointly considered as outlet contraction. Cephalopelvic disproportion at the outlet is defined as one where the biparietal-suboccipitobregmatic plane fails to pass through the bispinous and anteroposterior planes of the outlet. Management: Unlike inlet disproportion, clinical diagnosis of midpelvic and outlet disproportion can only be made after the head sufficiently comes down into the pelvis. (1) Elective cesarean section: Contraction of both the transverse and anteroposterior diameters of the midpelvic plane or minor contraction associated with other complicating factors is dealt by elective cesarean section. (2) To allow vaginal delivery: In otherwise uncomplicated cases with minor contraction, vaginal delivery is allowed under supervision with watchful expectancy. Molding and adaptation of the head and “give” of the pelvis may allow the head to pass through the contracted zone, Delivery is accomplished by forceps or ventouse with deep episiotomy to prevent perineal injuries, especially with narrow pubic arch. Labor progress should be mapped with a partograph tomake an carly diagnosis of dysfunctional labor due to disproportion. Oxytocin may be used to augment labor for adequate uterine contractions. If there is no dilatation of cervix or descent of the fetal head after a period of 2 hours in the active phase of labor, arrest of labor is considered. Once arrest disorder is diagnosed, cesarean delivery is the option. The principles of management rest on: (i) Cesarean section to avoid difficult forceps (ii) Forceps with deep episiotomy (iii) Symphysiotomy followed by ventouse or (iv) Craniotomy if the fetus is dead. COMPLICATIONS OF CONTRACTED PELVIS During pregnancy: v Incarcerated retroverted gravid uterus. Y Malpresentations. ¥ Pendulous abdomen. ¥ Nonengagement. ¥ Pyclonephritis especially in high assimilation pelvis due to more compression of the ureter. During labour: ¥ Inertia, slow cervical dilatation and prolonged labour. v Premature rupture of membranes and cord prolapse. Y Obstructed labour and rupture uterus. Y Necrotic genito-urinary fistula ¥ Injury to pelvic joints or nerves from difficult forceps delivery. Y Postpartum haemorrhage Foetal: ¥ Intracranial haemorrhage. ¥ Asphyxia, Fracture skull. Nerve injuries. ¥ Intra-amniotic infection.OBSTETRICAL EMERGENCIES: Obstetrical emergencies are life threatening medical conditions that occur in pregnancy or during labor or after delivery. 1.VASA PREVIA This term is used when a fetal blood vessel lies over the os infront of the presenting part. This usually occurs when fetal vessels from a velamentous insertion of the cord cross the area of the internal os to the placenta. However, vasa previa may also occur when there is a succenteriate placenta since the vascular connections to the succenteriate lobe are also unprotected vessels coursing between the chorion and amnion. With fetal descend and rupture of the membranes, the vessels are subject to compression and rupture with resulting exsanguinations and anoxia of the fetus. Vasa previa occurs in less than 0.2 percent of pregnancies. While extremely rare it should be thought of as a possibility, any time the midwife is not positive of what she feels presenting at the cervical os. DEFINITION: It is an abnormality of the cord that occurs when one or more blood vessels from the umbilical cord or placenta cross the cervix but it is not covered by Wharton’s jelly. ‘This condition can cause hypoxia to the baby due to pressure on the blood vessels. Itisa life threatening condition. - D.C.DUTTA ETIOLOGY: These vessels may be from either © Velamentous insertion of umbilical cord placental lobe joined to the main disk of the placenta. © Low-lying placenta © Previous delivery by C-section.SYMPTOMS: The baby’s blood is a darker red color due to lower oxygen levels of a fetus © Sudden onset of painless vaginal bleeding, especially in their second and third trimesters ©. If very dark burgundy blood is seen when the water breaks, this may be an indication of vasa previa DIAGNOSIS: © Vasaprevia may sometimes be palpated on vaginal examination when the membranes are still intact. Pulsations felt my be synchronous with the fetal heart rate. © A speculum examination may be done to visualize the blood vessel. © It may also be visualized on ultrasound. Fresh vaginal bleeding, which commences at the time of rupture of membranes, may be due to ruptured vasa previa. MANAGEMENT: Immediate consultation with the physician is mandatory when the midwife believes the presenting part to the abnormal. The fetal heart rate should be monitored. If in the first stage of labor and the fetus is alive, an emergency cesarean section is carried out, If the mother is in the second stage of labor, delivery should be expedited and a vaginal birth may be achieved. The mode of delivery will be dependent on parity and fetal condition. A pediatrician should be present at delivery and if the baby is alive, hemoglobin estimation is necessary after resuscitation. The baby will require a blood transfusion, but the mortality rate is high with this emergency. NURSING MANAGEMENT: ¥ Assess bleeding, color, amount ¥ Administer IV fluids. Y Administer oxygen.¥ Strict vitals and FHS monitoring. Y Prepare patient for caesarean section. ¥ Reserve blood if (Het >30%). 2.PRESENTATION AND PROLAPSE OF THE UMBILICAL CORD There are three clinical types of abnormal descend of the umbilical cord by the side of the presenting part. All these are included under the heading cord prolapsed. © Occult prolapsed: The cord lies alongside but not in front of the presenting part and is not felt by the fingers on internal examination. © Cord presentation: The cord is slipped down below the presenting part and lies in front of it in the intact bag of membranes. © Cord prolapsed: The cord lies in front of the presenting part inside the vagina or outside the vulva following rupture of the membranes. INCIDENCE: Cord prolapse is about | in 300 deliveries. It occurs mostly in parous women especially in higher parities. PREDISPOSING FACTORS: These are same for both presentation and prolapsed of the cord. Any situation where the presenting part is neither well applied to the lower uterine segment nor well down in the pelvis may make it possible for a loop of cord to slip down in front of the presenting part. Such situations include: © Malpresentations Prematurity © Moltiple pregnancy ¢ Polyhydromnios © High head High parity MalpresentatioThe commonest malpresentation associated with cord prolapse is transverse followed by breech, especially complete or footling. This relates to the ill fitting nature of the presenting part and the proximity of the umbilicus to the buttocks. In this situation the degree of compression will be less than with a cephlic presentation, but there is still a danger of asphyxia. Face and brow presentations are less common causes of cord prolapse. Prematurity: The size of the fetus in relation to the pelvis and the uterus allows the cord to prolapse. Babies of very low birth weight, less than 1,500 gm are particularly vulnerable, Multiple pregnancy: Malpresentation of the second twin is common in multiple pregnancy. Polyhydramnios: The cord is liable to be swept down in the gush of liquor if the membranes rupture spontaneously. Controlled release of liquor with artificial rupture of membranes is sometimes performed to prevent this. High head: If the membranes rupture spontaneously when the fetal head is high, a loop of cord may pass between the uterine wall and the fetus resulting it lying in front of the presenting part. Multiparity: The presenting part may not be engaged when the membranes rupture and malpresenttion is more common. DIAGNOSIS Occult prolapsed: This is difficult to diagnose. the possibility should be suspected if there is :