COMPLICATIONS DURING LABOR AND BIRTH

A difficult labor—dystocia—can arise from any of the four main components of the labor process:
 the power, or the force that propels the fetus (uterine contractions)
 the passenger (the fetus)
 the passageway (the birth canal); or
 the psyche (the woman’s and family’s perception of the event)

ASSESSMENT

 conscientious assessment of labor progress

 fetal and uterine monitor: detect deviations
 frequent adjustment = to achieve a clear tracing
 explain the importance

COMPLICATION WITH THE POWER

 inertia - time-honored term to denote sluggishness of contractions/ force of labor less
than usual. (dysfunctional labor)
 Dysfunctional labor:
 Occurs anytime (primary: onset of labor) (secondary: later in labor)
 Risks: postpartum infection, hemorrhage, infant mortality
 Prolonged labor cause:
 Large fetus
 Hypotonic, hypertonic, uncoordinated contractions
INEFFECTIVE UTERINE FORCE

 Uterine contractions are basic forces that move fetus from the birth canal
 Occurs due to the interplay of contractile enzyme adenosine triphosphate and major
electrolytes (calcium, sodium, and potassium, specific contractile proteins (actin and
myosin), epinephrine and norepinephrine, oxytocin (a posterior pituitary hormone),
estrogen, progesterone, and prostaglandins.

HYPOTONIC CONTRACTIONS

 number contractions is unusually infrequent (> 2 or 3 occurring in 10 mins.)

 resting tone: less than 10 mmHg; strength of contractions: not more than 25 mmHg
 usually occurs at:
 latent phase
 after administration of analgesia (especially when cervix is NOT 3-4cm dilated, or
if bowel/ bladder prevents descent or firm engagement)
 overstretched uterus (multiple gestation)
 LGA fetus
 Lax uterus (grand multiparity)
 Usually feels less pain due to lack of intensity contractions (subjective tho)
 Hypotonic contractions → no cervical dilatation
 Exhausted uterus → not contract in postpartal period → hemorrhage
MANANAGEMENT
 Palpate uterine fundus after birth (1st hour)
 Obtain blood pressure
 Assess amount of lochia q 15 mins (1st hour)
 Ensure contractions aren’t hypotonic = hemorrhage

HYPERTONIC CONTRACTIONS

 an increase in resting tone to more than 15 mmHg

 intensity = no stronger than with hypotonic contractions.
 Occurs more frequently in latent phase.
 Cause:
- More than one uterine pacemaker is stimulating contractions
- Muscle fibers of myometrium do not repolarize or relax after contractions
 More painful = no relaxation = anoxia of uterine cells
→ NO OPTIMAL uterine artery filling = fetal anoxia
MANAGEMENT

 Apply uterine and fetal external monitor: to monitor if contractions are adequate/ no FHR
decelerations
 IF SO, abnormally long 1st stage of labor, lack of progress with pushing (second stage-
arrest) = CS may be necessary

UNCOORDINATED CONTRACTIONS

 more than one pacemaker may be initiating contractions, or receptor points in the
myometrium may be acting independently of the pacemaker.
 May occur closely = interfere with the blood supply to the placenta.
 May occur one on top of another and then a long period without any → difficulty in
resting / breathing
MANAGEMENT

 Apply fetal and a uterine external monitor and assess: rate, pattern, resting tone, and
fetal response to contractions for 15 minutes (more for early labor)
 Oxytocin administration: stimulate more effective and consistent pattern, low resting
tones.

DYSFUNCTIONAL LABOR & ASSOCIATED STAGES OF LABOR

Dysfunction at the First Stage of Labor

 Dysfunction that occurs with the first stage of labor involves:

1. prolonged latent phase
2. protracted active phase
3. prolonged deceleration phase
4. secondary arrest of dilatation
Prolonged Latent Phase

 a latent phase lasting longer than 20 hours in a nullipara or 14 hours in a multipara.

 Causes:
- Unripe cervix at the beginning of labor
- excessive use of an analgesic early in labor
 uterus at hypertonic state, inadequate relaxation between contractions; mild contractions
(> 15mmHg in monitor printout) thus, ineffective.
MANAGEMENT

 Help uterus to rest

 Provide adequate fluid for hydration and pain relief w/ a drug such as (morphine sulfate)
 Changing the linen and the woman’s gown
 Darkening room lights, and decreasing noise and stimulation.
 IF NOT effective, CS or amniotomy (artificial rupture of membranes) + oxytocin
infusion

Protracted Active Phase

 associated with:
- fetal malposition or cephalopelvic disproportion (CPD)
- although it may reflect ineffective myometrial activity
 This phase is prolonged if:
- Nullipara: NO cervical dilatation a rate of at least 1.2 cm/hr
- Multipara: 1.5 cm/hr
- Primigravida: longer than 12 hours active phase
- Multigravida: longer than 6 hours active phase
 Dysfunctional labor during the dilatational division of labor is hypotonic.
MANAGEMENT

 Cause of delay is CPD/ malpresentation: Cesarean birth

 If CPD is not present: augment labor w/ oxytocin

Prolonged Deceleration Phase

 Deceleration extending beyond 3 hours in a nullipara or 1 hour in a multipara.

 most often results from abnormal fetal head position
 A cesarean birth is frequently required

Secondary Arrest of Dilatation

 No progress in cervical dilatation for longer than 2 hours.

 Cesarean birth may be necessary.
Dysfunction at the Second Stage of Labor

 Dysfunction that occurs with the second stage of labor involves prolonged descent and
arrest of descent.


Prolonged Descent

 Occurs if the rate of descent:

- nullipara: less than 1.0 cm/hr
- multipara: 2.0 cm/hr
 Suspected if the second stage lasts over 2 hours in a multipara
Prolonged active phase of dilatation + prolonged descent + good quality and duration of
contractions, effacement and beginning dilatation have occurred =
Suddenly, contractions become infrequent and of poor quality, and dilatation stops.
Until everything is within normal limits (except: CPD, faulty contractions, poor fetal
presentation)
MANAGEMENT
 Advice to rest and fluid intake
 Artificial ROM (Unruptured membranes)
 IV oxytocin (induce uterus to contract effectively)
 Semi-fowler’s position, squatting, kneeling, or more effective pushing may speed
descent.

Arrest of Descent

 Results when no descent has occurred for:

- 2 hours in a nullipara
- 1 hour in a multipara
 Failure of descent: expected descent of the fetus does not begin or engagement or
movement beyond 0 station does not occur.
 Most likely cause during 2nd stage of labor: CPD
MANAGEMENT

 Cesarean birth
 No contraindication for VB: Oxytocin to assist labor
PRECIPITATE LABOR

 Precipitate dilatation: cervical dilatation that occurs at a rate of 5 cm or more per

hour in a primipara or 10 cm or more per hour in a multipara
 Precipitate birth: strong uterine contractions (few, rapidly occurring contractions)
often defined as a labor that is completed in fewer than 3 hours.
 occurs in: grand multiparity, induction of oxytocin
 strong contractions may cause: premature separation of placenta/ lacerations of
the perineum
 Rapid labor may cause: subdural hemorrhage
 Predicted through a labor graph:
during the active phase of dilatation:
- rate is greater than (1 cm every 12 minutes) in a nullipara
- (1 cm every 6 minutes) in a multipara
MANAGEMENT
 By week 28 of pregnancy caution multiparas that labor may be brief as her past
(to plan for transportation or alternative birthing center)
 GRAND MULTIPARAS & W/HISTORIES: birthing room converted to birth
readiness before full dilatation is obtained (should sudden birth occur)

INDUCTION AND AUGMENTATION OF LABOR

 Intervention when labor contractions are ineffective

 Induction of labor means labor is started artificially.
 Augmentation of labor: assisting labor that has started spontaneously but is not
effective
 Induction should not be initiated before the time of 39 weeks AOG unless with:
o preeclampsia, eclampsia, severe hypertension
o diabetes
o Rh sensitization
o PROM
o intrauterine growth restriction
 May cause Uterine rupture or PSOP, thus used cautiously for women with:
o Multiple gestation
o Polyhydramnios
o Grand parity
o Older than 40 years
o Have previous uterine scars
 CONSIDERATIONS before induction of oxytocin:
o The fetus is in a longitudinal lie.
o The cervix is ripe, or ready for birth.
o The presenting part is the fetal head (vertex) and is engaged.
 o There is no CPD.
o The fetus is estimated to be mature by date (over 39 weeks)

Cervical Ripening

 change in the cervical consistency from firm to soft

 first change of the uterus in early labor

 score of 8 or greater, the cervix is ready for birth and should respond to induction
 To help a cervix “ripen,” a number of methods can be instituted:

1. “Stripping the membranes”

- Simplest method
- or separating the membranes from the lower uterine segment manually, using
a gloved finger in the cervix
- performed during an office visit
- Possible complications:
 include bleeding from an undetected low-lying placenta
 inadvertent rupture of membranes
 possible infection if membranes should rupture
2. Hygroscopic suppositories
- suppositories of seaweed that swell on contact with cervical secretions which
gradually and gently urge dilatation (laminaria technique).
- can be held in place by gauze sponges saturated with povidone-iodine or an
antifungal cream
3. Insertion of a prostaglandin
- Dinoprostone (Prepidil, Cervidil)
- Placed into the posterior fornix of the vagina, by the cervix.
- If put in the evening, cervical dilatation occurs in the morning
- Women remain in bed (side-lying) preventing loss/leakage
- Monitor FHR, and VS for side effects:
 Vomiting
 Fever
 Diarrhea
 Hypertension
 - Follows oxytocin 12 hrs later (beginning it sooner might lead to
hyperstimulation of the uterus)
- Use caution with women w/:
 Asthma
 renal or cardiovascular disease
 glaucoma
 past cesarean births
- Misoprostol (off label)

Induction of Labor by Oxytocin

 Only for term pregnancy

 Always given IV so if uterine hyperstimulation occurs, it can be quickly discontinued
o Hyperstimulation (tachysystole): needs 60 to 90 seconds between
contractions to receive adequate oxygenation from placenta blood vessels
o 5 or more contractions in 10 mins / more than 2 minutes in duration or occurring
within 60 seconds of each contractions.
MANAGEMENT (if hyperstimulation occurs)

 Turn onto her left side to improve uterus blood flow

 Administer IV fluid bolus to dilute the level of oxytocin in the maternal blood
stream
 Administer oxygen by mask at 8 to 10 L.
 Prescribe terbutaline to relax the uterus.
 Immediately discontinue IV infusion
 Take PR and BP q hour. Monitor contractions and FHR conscientiously.
 Monitor frequency, duration, and strength of contractions during infusion.
 Monitor I/O and watch for signs of possible water intoxication, such as headache or
vomiting.
 Monitor for decreased urine flow: halt the infusion.
 Administer tocolytic (terbutaline)
 Observe the infant closely for hyperbilirubinemia and jaundice

Augmentation by Oxytocin

 used if labor contractions begin spontaneously but then become weak, irregular, or
ineffective
 precautions same as for primary oxytocin induction of labor
 Be certain the drug is increased in small increments only & monitor FHR well.

UTERINE RUPTURE

 occurs most often in women who have a previous cesarean scar

 Contributing factors:
 o prolonged labor
o abnormal presentation
o multiple gestation
o unwise use of oxytocin
o obstructed labor
o traumatic maneuvers of forceps or traction.
 Uterine rupture → fetal death will follow (unless immediate cesarean birth can be
accomplished)
 Symptoms: sudden, severe pain during a strong labor contraction “a “tearing” sensation”
Complete: endometrium, myometrium, and peritoneum layers ruptures
 Uterine contraction immediately stops in a complete rupture
 Distinct swellings in the abdomen: retracted uterus and the extrauterine
fetus.
 Hemorrhage: abdominal cavity and vagina
 Signs of hypotensive shock
 FHR fades, then absent
Incomplete: leaving the peritoneum intact
 Less evident signs
 localized tenderness; persistent aching pain (over lower uterine segment)
 signs and symptoms will gradually reveal fetal and maternal distress
 confirmed through ultrasound
MANAGEMENT

 Administer emergency fluid replacement therapy as prescribed

 Anticipate the use of IV oxytocin to attempt to contract the uterus and minimize
bleeding
 Prepare for a laparotomy (to control bleeding and birth the fetus)
 Advice not to conceive again (unless it occurred on the inactive lower segment)
 Physician may conduct CS hysterectomy (removal of uterus) or tubal ligation

INVERSION OF THE UTERUS

 Uterus turning inside out with either birth of the fetus or delivery of the placenta
 CAUSES:
o traction applied to the umbilical cord to remove the placenta
o pressure is applied to the uterine fundus when the uterus is not
contracted
o placenta is attached at the fundus
 Inverted fundus may lie within the:
o uterine cavity or the vagina
o or in total inversion, it may protrude from the vagina.
 SIGNS:
o Sudden gush of blood from the vagina
 o Fundus not palpable in the abdomen
o Signs of blood loss: hypotension, dizziness, paleness, or diaphoresis
o Extent of exhaustion: 10 minutes (since bleeding cannot be halted)
MANAGEMENT

 Never attempt to replace an inversion (increases bleeding)

 Never attempt to remove the placenta if it is still attached (bleeding)
 Discontinue oxytocin (makes uterus more tense and difficult to replace)
 Insert and IV fluid (large-gauge needle to replace blood as well)
 Administer oxygen by mask, and assess V/S
 Prepare to perform CPR (when heart fails from the sudden blood loss)
 General anesthesia or possibly nitroglycerin or a tocolytic drug by IV (to relax
the uterus)
 PCP, replace fundus manually (oxytocin after to keep uterus in place and well
contracted)
 Antibiotic therapy: since uterine endometrium was exposed
 CS: to prevent repetition of uterine inversion

AMNIOTIC FLUID EMBOLISM

 When amniotic fluid is forced into an open maternal uterine blood sinus after a
membrane rupture or partial premature separation of the placenta
 More likely cause:
 humoral or anaphylactoid response to amniotic fluid in the maternal
circulation
 May occur during labor, postpartum
 Associated with:
 induction of labor
 multiple pregnancy
 polyhydramnios
 Signs and symptoms:
 sharp pain and inability to breathe (pulmonary artery constriction)
 paleness, turn to bluish gray
 mins later, becomes unconscious, and her fetus is put in danger as
placenta blood circulation halts
MANAGEMENT

 Oxygen administration by face mask or cannula

 May need CPR; but CPR won’t relieve pulmonary constriction

Death may occur w/in minute

COMPLICATION WITH THE PASSENGER

PROLAPSE OF THE UMBILICAL CORD

 A loop of the umbilical cord slips down in front of the presenting fetal part
 May occur at any time after the membranes rupture if the presenting fetal part is not
fitted firmly into the cervix.
 It tends to occur most often with:
 PROM
 Fetal presentation other than cephalic
 Placenta previa
 Intrauterine tumors preventing the presenting part from engaging
 Small fetus
 CPD preventing firm engagement
 Polyhydramnios
 Multiple gestation
ASSESSMENT

 First discovered only after the membranes have ruptured

 FHR unusually slow
 Variable deceleration FHR pattern
 Cord may be visible at the vulva (inspection)
MANAGEMENT

 Relieving pressure on the cord, thereby relieving the compression

 Place a gloved hand in the vagina and manually elevate the fetal head off
the cord
 Place woman in a knee–chest or Trendelenburg position (to cause the
fetal head to fall back from the cord)
 Administering oxygen at 10 L/min by face mask
 Tocolytic agent: reduce uterine activity and pressure on the fetus
 Amnioinfusion: relieve pressure
 Cover exposed portion with a sterile saline compress to prevent drying
(incase exposed to room air)
 BIRTHING METHOD: upward pressure on the presenting part, in the
woman’s vagina, to keep pressure off the cord until the baby can be born
by cesarean birth.

Amnioinfusion
 the addition of a sterile fluid into the uterus to supplement the amniotic fluid and reduce
compression on the cord
 sterile double-lumen catheter introduced through the cervix into the uterus
 IV tubing is then attached (warmed normal saline, usually 500m)
 Place woman in a lateral recumbent position.
Fetal Blood Sampling
 Obtaining a sample of blood from the fetal scalp during a vaginal exam

MULTIPLE GESTATION

 pregnancies with two or more fetuses

 NVSD: instruct to come to the hospital early in labor
 engaged in an activity to make the time pass more quickly/practice breathing exercise
 minimize the need for analgesia or anesthesia → minimize any respiratory difficulties the
infants (due to immaturity)
 Be sure two separate FHR are heard in doppler/fetal heart monitor
MANAGEMENT
 Clamp/tie both ends of cord permanently (prevents hemorrhage on an open cord
end)
 Oxytocin is not given ASAP (may compromise circulation to the unborn)
 Internal podalic version, for a breech delivery.
 Careful assessments after delivery (twin-to-twin transfusion)
 Assess the woman carefully in the immediate postpartal period (risk for hemorrhage
due to uterine atony, risk for infection: prolonged labor)

PROBLEMS WITH FETAL POSITION, PRESENTATION, OR SIZE

Occipitoposterior Position

 The occiput (assuming the presentation is vertex) is directed diagonally and posteriorly,
either to the right (right occipitoposterior [ROP]) or to the left (left occipitoposterior [LOP])
 Rotation from a posterior position can be aided by having the woman assume a hands-
and-knees position, squatting, or lying on her side
 Shifting the weight from right to left or “lunging” or swinging her body right to left while
elevating her left foot on a chair widens the pelvic path and makes fetal rotation easier
 Tend to occur in women with android, anthropoid, or contracted pelvises
 Suggested by a dysfunctional labor pattern such as a prolonged active phase, arrested
descent, or fetal heart sounds heard best at the lateral sides of the abdomen.
 Increases risk of cord prolapse
 Symptoms:
o Pressure and pain in her lower back because of sacral nerve compression
MANAGEMENT

 Apply counterpressure on the sacrum (back rub)

 Rebozo method of jiggling and massaging the uterus
 Be certain a woman voids approximately every 2 hours (may impede descent)
 Oral sports drink or IV glucose solution to replace glucose stores
  CS birth: transverse arrest, persistent occipitoposterior position
 If forceps are used to rotate fetus, observe for:
o hemorrhage from cervical lacerations
o infection in the postpartum period

Breech Presentation

 Types of breech presentations: complete, frank, and footling

 Breech presentation has higher risk for:
 Developing dysplasia of the hip
 Anoxia from a prolapsed cord
 Traumatic injury to the after-coming head (possibility of intracranial hemorrhage
or anoxia)
 Fracture of the spine or arm
 Dysfunctional labor
 Early rupture of the membranes because of the poor fit of the presenting part
 Meconium staining

 Cervical pressure on the buttocks and rectum → meconium stain

 Meconium excretion → meconium aspiration
ASSESSMENT

 FHR high in the abdomen

 Leopold maneuvers & vaginal examination reveal presentation (confirmed by ultrasound)
MANAGEMENT

 Always monitor FHR and uterine contractions frequently (early detection of fetal distress:
such as prolapsed cord or arrest of descent)
BIRTH TECHNIQUE

 Push after full dilatation is achieved

 Pressure changes instantly → tentorial tears→ gross motor and mental incapacity or
lethal damage
 Born gradually → hypoxia; born suddenly → intracranial hemorrhage
Straddled (right forearm) → place 2 right fingers to the mouth → left hand slid in
woman’s vagina, along the infant’s back → pressure on the occiput to flex head

Face Presentation

 Asynclitism – fetal head presenting in a different angle

 Head and back are both felt on the same side of the uterus
(Leopold Maneuver)
 FHR may be transmitted to forward-thrust chest
 Confirmed thru a vaginal exam (ultrasound)
 Something abnormal is usually causing the face presentation:
- contracted pelvis
- placenta previa
- relaxed uterus of a multipara
- prematurity
- polyhydramnios
- fetal malformation
 anterior chin: be born without difficulty
 posterior chin: CS birth
 infants born in face presentation:
- facial edema
- purple from ecchymotic bruising
MANAGEMENT

 Observe patent airway

 Observe for lip edema (Gavage feeding may be done)
 Transferred to NICU for 24hrs
 Reassure that edema is transient

Brow Presentation

 Rarest of the presentations

 Occurs in a multipara or with relaxed abdominal muscles
 CS birth: unless spontaneously corrects
 May leave extreme ecchymotic bruising on the face (soft spot)
o Reassurance that the child is well after birth.
Transverse Lie

 Occurs in women with

- pendulous abdomens
- uterine fibroid tumors that obstruct the lower uterine segment
- contraction of the pelvic brim
- congenital abnormalities of the uterus
- polyhydramnios
- hydrocephalus (infant)
- prematurity (has room for free movement, multiple gestation/ short umbilical cord)
 Obvious on inspection; confirmed by Leopold maneuvers; further confirm thru ultrasound
 Mature fetus cannot be delivered; CS is necessary.

Oversized Fetus (Macrosomia)

 Weighs more than 4,000 to 4,500 g (approximately 9 to 10 lb)

 Most frequent to women with gestational DM
 Associated with multiparity
 Overstretching of the fibers of the myometrium → Uterine dysfunction during labor/birth
 Cause: fetal pelvic disproportion or even uterine rupture from obstruction
 A woman may be left with perineal laceration.
 CS: method of choice
 Pelvimetry or ultrasound: compare fetus’ and pelvic size
 NSVD MAY POSE risk for:
- risk of cervical nerve palsy
- diaphragmatic nerve injury
- fractured clavicle (bc of shoulder dystocia)
- mother: hemorrhage

Shoulder Dystocia

 Opt to occur with diabetes, in multiparas, and in postdate pregnancies

 (2nd stage of labor) fetal head is born but the shoulders are too broad to enter and be born
through the pelvic outlet.
 MAY POSE DANGER TO:
 Mothers: Vaginal or cervical tears
 Fetus: cord compression, fractured clavicle or brachial plexus injury
 Suspected in prolonged 2nd stage of labor, arrest of descent, crowning (retracts)
MANAGEMENT

 Help or ask mother to flex her thighs sharply on her abdomen (McRoberts maneuver); widen
pelvic outlet
 Apply suprapubic pressure (to dislodge shoulders)
 Fetal Anomalies

 Fetal anomalies of the head such as:

o hydrocephalus (i.e., fluid-filled ventricles)
o anencephaly (i.e., absence of the cranium)
are a final category of fetal factors that can complicate birth because the fetal presenting part
does not engage the cervix well.

COMPLICATION WITH PASSAGE

INLET CONTRACTION

 Narrowing of:
o pelvis’ anteroposterior diameter to less than 11 cm
o diameter to 12 cm or less
 More likely caused by:
- rickets early in life (lack of calcium)
- inherited small pelvis
 Fetal head normally engages between weeks 36 and 38 of pregnancy (primi)
IF NOT, suspect:
- a fetal abnormality (larger than usual head)
- pelvic abnormality (smaller than usual pelvis)
 Engagement does not occur in multigravidas until labor begins
 Primigravida: pelvic measurements taken before week 24 of pregnancy

OUTLET CONTRACTION

 narrowing of the transverse diameter: to less than 11 cm

 measured through sonogram, made manually.

TRIAL LABOR

 To determine whether labor will progress normally

 Conducted when a borderline (just adequate) inlet measurement and the fetal lie and
position are good
THERAPEUTIC MANAGEMENT

 Monitor FHR, and uterine contractions frequently

 Urge to void every 2 hours (fetal head to use all space)
 After 6 to 12 hours + inadequate progress + fetal distress = discontinue, CS birth
 EXTERNAL CEPHALIC VERSION

 Turning of a fetus from a breech to a cephalic position before birth

o done as early as early as 34 to 35 weeks
o usually, 37 – 38 weeks
 Contraindications:
- multiple gestation
- severe oligohydramnios
- small pelvic diameters
- a cord that wraps around the fetal neck
- unexplained third trimester bleeding (placenta previa)

MANAGEMENT

 Continuously record FHR and ultrasound

 Tocolytic agent: relax uterus
Process

 Locate and grasp fetus transabdominally by hands on the woman’s abdomen

 Exerted gentle pressure to rotate the fetus in a forward direction to a cephalic lie

FORCEPS BIRTH

 Birth done with the use of obstetrical forceps (steel blades that slide together along its
shaft to form a handle)
 COMPLICATIONS:
- rectal sphincter tears → dyspareunia, anal incontinence, or increased urinary stress
incontinence
 BUT is necessary with:
o Inability to push with contractions in the pelvic division of labor (regional
anesthesia/spinal cord injury)
o Cessation of descent in the 2nd stage of labor
o Abnormal fetal position.
o Fetal distress (due to prolapsed cord)
 May leave a transient erythematous mark on the newborn’s cheek (fade in 1-2 days)
MANAGEMENT

 Before forceps are applied:

 Membranes must be ruptured
 No CPD
 Cervix fully dilated
 Empty bladder
 Record FHR before and after forceps application
 Record time and amount of the first voiding (to rule out bladder injury)
  Assess the newborn to be certain no facial palsy exists from pressure

VACUUM EXTRACTION

 A fetus, if positioned far enough down the birth canal, may be born by vacuum
extraction.
 A soft, disk-shaped cup is pressed against the fetal scalp and over the posterior
fontanelle.
 Advantage: Less anesthesia
 Disadvantage:
 more perineal lacerations
 marked caput (7days visible)
 tentorial tears
 not applicable for preterm
 NO NO if fetal scalp blood sampling was done

ANOMALIES OF THE PLACENTA

 Normal placenta:
- 500 g (approximately 1/6 of the fetus
- 15 to 20 cm in diameter
- 1.5 to 3.0 cm thick
 Large in diabetic women
 Syphilis/ erythroblastosis: half as much the fetus
 Uterus w/scars or septum: wide in diameter

Placenta Succenturiata

 Placenta with one or more accessory lobes connected to the main placenta by blood
vessels

 Important to recognize to avoid it being retained causing hemorrhage.

 On inspection, the placenta appears torn at the edge, or torn blood vessels extend
beyond the edge of the placenta
Placenta Circumvallata

 The fetal side of the placenta is covered to some extent with chorion
 Ordinarily, the chorion membrane begins at the edge of the placenta and spreads to
envelop the fetus

Battledore Placenta

 In a battledore placenta, the cord is inserted marginally rather than centrally. This
anomaly is rare and has no known clinical significance either.

Velamentous Insertion of the Cord

 a situation in which the cord, instead of entering the placenta directly, separates into
small vessels that reach the placenta by spreading across a fold of amnion
 most frequently found with multiple gestations
 fetal blood supply may not be as generous → fetal anomalies
 examined carefully at birth (infant)

Vasa Previa

 Umbilical vessels of a velamentous cord insertion cross the cervical os and therefore
deliver before the fetus
 Vessels may tear with cervical dilatation:
 o Before inserting any instrument such as an internal fetal monitor, be certain to
identify structures (prevent accidental tearing = sudden fetal blood loss.
 If sudden, painless bleeding occurs with the beginning of cervical dilatation, either
placenta previa or vasa previa is suspected.
 Confirmed by ultrasound.
 CS birth

Placenta Accreta

 an unusually deep attachment of the placenta to the uterine myometrium (will not loosen
and deliver)
 Attempt to remove = extreme hemorrhage
 Hysterectomy or treatment with methotrexate (destroy still-attached tissue)

ANOMALIES OF THE CORD

Two-Vessel Cord

 Normal: AVA
 Absence of 1 artery = congenital heart and kidney anomalies
MANAGEMENT

 Check vessels immediately after birth (dried cord distorts cord appearance)
 Document no. of vessels (2 vessels = anomalies)

Unusual Cord Length

 Unusually short = PSOP

 Unusually long = easily compromised because of its tendency to twist or knot