PATHOLOGIC OBSTETRICS

ABNORMAL LABOR (PASSENGER)

DR. SAN JOSE
OLFU • FUMC  COLLEGE OF MEDICINE
Ref: Williams Obstetrics 26th Edition

OUTLINE: • Mechanism of labor consists of the following cardinal movements:

• FACE PRESENTATION
• BROW PRESENTATION ▪ Descent
• TRANSVERSE LIE o Brought about by the same factors as in cephalic
• COMPOUND PRESENTATION presentations
• COMPLICATIONS WITH DYSTOCIA.
▪ Internal rotation
o The objective is to bring the chin under the symphysis
INTRODUCTION pubic
o Results from the same factors as in vertex
CASE: presentations
A 28 year old G1 PO, PU 38 weeks, comes in labor, with BMI ▪ Flexion
22 kg/m2, stable vital signs, FH of 32 cm. with a single baby in cephalic ▪ Extension & External rotation (accessory movement)
presentation, FHT140/min. IE: cervix 5 cm dilated, 75% effaced, o Results from the relation of the fetal body to the deflected
ruptured BOW, mentum directed towards sacrum, station ( -3). head
Questions on the case
• What is the diagnosis?
• How is breech presentation ruled out?
• What are the risk factors for this malpresentation?
• Discuss the management for this case.
• in what type of this presentation is vaginal delivery possible?

FACE PRESENTAION
• NECK is hyperextended, occiput is in contact with the fetal back
and the chin (mentum) is
presenting
• Fetal face may present with the • With the chin anterior, internal rotation of the face brings the chin
chin (mentum) anteriorly or under the symphysis pubis
posteriorly, relative to the
maternal symphysis pubis
• The occiput is the longer end of
the head level
• The chin is directly posterior
• Vaginal delivery is impossible
unless the chin rotates anteriorly

ETIOLOGY AND DIAGNOSIS

• Etiology
▪ Prematurity
▪ Marked enlargement of the neck or coils of cord about the
neck may cause extension
Note: mechanism of labor for Right Mento-Posterior position with
▪ Anencephalic fetuses
subsequent rotation of the mentum anteriorly and delivery
▪ Contracted pelvis → inlet contraction
▪ Very large fetus
Management
▪ Multiparous women
• During labor
▪ Hydramnios
▪ fetal heart rate monitoring is best done with external devices
• Diagnosis
to help avoid face or eye injury
▪ Vaginal examination
▪ Because face presentations among term-size fetuses are
o Palpation of the distinctive facial features of the mouth
more common with some degree of pelvic inlet contraction,
and nose, the malar bones, and particularly the orbital
cesarean delivery rates are substantially higher than with
ridges (differentiate it from breech)
occiput presentation.
▪ Radiographic examination
• In the absence of a contracted pelvis, and with effective labor,
o Demonstration of the hyperextended head with the
successful vaginal delivery usually will follow → Mentum Anterior
facial bones at or below the pelvic inlet
• Cesarean delivery → mentum posterior
MECHANISM OF LABOR ▪ pelvic inlet contraction
• The fetal face may present with the chin (mentum) anteriorly, ▪ Do not attempt to manually rotate to vertex, or rotate mentum
transversely, or posteriorly, relative to the maternal symphysis posterior to anterior or do internal podalic version
pubis • attempts to convert a face presentation manually to an occiput one,
• Although some mentum posterior presentations persist, most a to rotate a posterior chin to a mentum anterior position, or to
convert spontaneously to an anterior position, even as late as complete internal podalic version and extraction → dangerous and
second-stage labor not recommended.
• Face presentations rarely are observed above the pelvic inlet
BROW PRESENTATION
• The brow generally presents, converted into a face presentation
after further extension of the head during descent • Rare presentation because it often converts to face or occiput
presentation

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 PATHOLOGIC OBSTETRICS
ABNORMAL LABOR (PASSENGER)
• Fetal head between the orbital ridge ▪ contracted maternal pelvis
and anterior fontanel presents at the • Diagnosis → recognized by inspection alone
pelvic inlet ▪ Abdominal examination
• Fetal head occupies a position o Abdomen is unusually wide, whereas the uterine fundus
midway between full flexion (occiput) extends to only slightly above extends only slightly above
and extension (mentum or face) o No fetal pole is detected in the fundus, ballotable head is
• Engagement of fetal head and found in one iliac fossa and the breech in the other
delivery will not occur unless the o Back up (anterior) → a hard resistance plane extends
head is small or pelvis is unusually across the front of the abdomen
large o back down (posterior) → irregular nodulations
• The attitude of the head in brow representing the small parts are felt through the
presentation: → partially extended abdominal
▪ Face presentation → Fully ▪ Vaginal examination
extended o early stages of labor → the side of the thorax or the
▪ Occiput presentation → Fully flexed "gridiron" feel of the ribs
▪ Cinciput → partially flexed o Advanced labor → the scapula and clavicle are palpated
• Causes and etiology are the same as of the face presentation
• Unstable → may convert to occiput or face
• Management → same as face presentation
• Diagnosis
▪ Abdominal palpation → when both the occiput and chin
can be palpated easily
▪ Vaginal examination → palpation of the frontal sutures,
large anterior fontanel, orbital ridges, eyes, and root of the
nose

MECHANISM OF LABOR
• Very small fetus and a large pelvis
▪ Labor is generally easy → vaginal delivery is favorable
• Larger fetus
▪ Usually difficult, because engagement is impossible until
there is marked molding that shortens the occipitomental
• Diameter or, more commonly, until there is either flexion to an
occiput presentation or extension to a face presentation
• Persistent Brow
▪ vaginal delivery is difficult and management is same as
difficult and management is same as

TRANSVERSE LIE
ETIOLOGY AND DIAGNOSIS
• The fetus' long axis lies approximately perpendicular to that of the
mother
• The shoulder is usually positioned over the pelvic inlet
• The head → occupies one iliac fossa, and the breech the other
• Shoulder presentation
▪ The side of the mother on which the acromion rests
determine the designation of the position as right or left
acromial
▪ The back may be directed anteriorly or posteriorly and also
superiorly or inferiorly
• Note: Palpation in transverse lie, right acromiodorsoanterior
position. A. First maneuver. B. Second maneuver. C. Third
maneuver. D. Fourth maneuver
MECHANISM OF LABOR
• Spontaneous delivery of a fully developed newborn is impossible
with a persistent transverse lie
• Rupture of the membranes → the fetal shoulder is forced into the
pelvis corresponding arm frequently prolapses shoulder is arrested
by the margins of the pelvic inlet
• Margins of the pelvic inlet (head in one iliac fossa and the breech
in the other)
▪ Shoulder impacted in the upper pelvis
▪ Uterus contracts vigorously → pathologic retraction ring
(neglected transverse lie) → rupture of the uterus
• Bandl ring → extreme form – pathologic
▪ Uterine contraction ring rises increasingly higher and
becomes more marked

Neglected shoulder presentation. A thick muscular

band forming a pathological retraction ring has
developed just above the thin lower uterine
segment. The force a generated during a uterine
contraction is directed centripetally at and above the
level of the pathological retraction ring. This serves
to stretch further and possibly to rupture the thin
lower segment below the retraction ring → (P.R.R.
= pathological retraction ring)

• Transverse lie complicates approximately 0.3 percent of births

• Common causes: → etiology
▪ abdominal wall relaxation from high parity
▪ preterm fetus • If the fetus is small (<800g) and pelvis is large → vaginal
▪ placenta previa spontaneous delivery is possible despite persistence of the
▪ abnormal uterine anatomy abnormal lie
▪ hydramnios

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• CONDUPLICATO CORPORE
▪ The fetus, which is doubled upon itself in a position
▪ Fetus compressed w/ head forced into the abdomen →
portion of thoracic wall below the shoulder, most dependent
part, appears at the vulva, head & thorax → pelvic cavity →
expelled
▪ Fetus become ball possible to be delivered vaginally
MANAGEMENT
• In general, active labor in transverse lie is an indication for
cesarean delivery
• Because neither the feet nor the head of the fetus occupies the
lower uterine segment
• Low transverse incision may lead to difficult fetal extraction →
vertical hysterotomy incision is indicated
▪ With dorsoposterior or back up position – one or both feet
can be grasped through a low transverse incision and
delivered by breech extraction
• Before labor or early in labor → with the membranes intact →
external cephalic version (ECV) is worthwhile
▪ Candidate selection and ECV technique mirror those for the
breech fetus
▪ ECV success rates are high and exceed those for breech
fetuses
OBLIQUE LIE
• Called an unstable lie
• When the long axis forms an acute angle
• Usually only transitory, because either a longitudinal or transverse
lie commonly results when labor supervenes
Additional:
UMBILICAL CORD PROLAPSE
COMPOUND PRESENTATION
• An extremity prolapses alongside the presenting part or with both
presenting in the pelvis simultaneously
The left hand is lying in front of the vertex. With further labor, the hand and
arm may retract from the birth canal and the head may then descend
normally
• Causes:
▪ Conditions that prevent complete occlusion of the pelvic
inlet by the fetal head, including preterm birth
PROGNOSIS AND MANAGEMENT
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PATHOLOGIC OBSTETRICS
ABNORMAL LABOR (PASSENGER)
• Perinatal loss → increased as a result of preterm delivery,
prolapsed cord, and traumatic obstetrical procedures
• In most cases, the prolapsed part left alone, because most often it
will not interfere with labor
• Prolapsed arm alongside the head-
• Ascertain whether the arm retracts out of the way with descent of
the presenting part → fails to retract → prolapsed arm pushed
gently upward, and the head downward by fundal pressure
PERSISTENT OCCIPUT POSTERIOR POSITION
• 2-10 % of deliveries → adequate antero-posterior diameter +
narrow midpelvis = Anthropoid pelvis (oval Antero posteriorly)
• Most common cause of Prolonged 2nd stage of Labor
• Transverse narrowing of the midpelvis is undoubtedly a contributing
factor
• Usually undergo spontaneous anterior rotation followed by
uncomplicated rotation followed by uncomplicated → vaginal
delivery
• Risk Factors:
▪ Failure of Internal Rotation
▪ Epidural analgesic
▪ Nulliparity
▪ Greater fetal weight
▪ Prior Occiput posterior position delivery
• Morbidity associated with POP:
▪ Prolonged second stage of labor
▪ Increased CS delivery and operative vaginal delivery
▪ Increased blood loss → (vaginal delivery) – due to the
laceration
▪ Higher order vaginal lacerations (3rd and 4th degree
lacerations)
• The possibilities for vaginal delivery are:
▪ Spontaneous delivery
▪ Forceps delivery with the occiput directly posterior
▪ Manual rotation to the anterior position followed by
spontaneous or forceps delivery
▪ Forceps rotation of the occiput to the anterior position and
delivery
• Delivery of Persistent Occiput Posterior
▪ Spontaneous Vaginal Delivery → Roomy pelvic outlet or
relaxed perineum – multiparas
▪ Manual rotation to occiput anterior and spontaneous delivery
→ Resistant vaginal outlet or firm perineum
PERSISTENT OCCIPUT TRANSVERSE POSITION
• Associated with PLATYPLOID type of Pelvis
• Transitory
▪ the occiput tends to rotate to anterior position in the absence
of a pelvic architecture abnormality or asynclitism
• Spontaneous anterior rotation usually is completed rapidly → the
choice of spontaneous delivery or delivery with outlet forceps
• Delivery
▪ Application of Kielland forceps to the fetal head to rotate the
occiput to the anterior position, and then deliver the head
either with the same forceps or with Simpson or Tucker-
McLane forceps
▪ Difficult rotation is expected on platypelloid and android
(heart-shaped) pelvis – CS delivery due to prolonged 2nd
stage of labor
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 PATHOLOGIC OBSTETRICS
ABNORMAL LABOR (PASSENGER)
COMPLICATION WITH SHOULDER DYSTOCIA
• 0.6 1.4% incidence
• Head to body delivery time
▪ Normal birth → 24 second
▪ Shoulder dystocia → > 60 seconds or 1 min
• Fetal shoulder become wedged behind symphysis pubis and fail to
deliver with downward traction and pushing
• EMERGENCY → because the umbilical is compressed within the
birth canal
• neonates experiencing shoulder dystocia had significantly greater
shoulder-to-head and chest-to-head disproportions compared with
those of equally macrosomic newborns delivered without dystocia
▪ True of babies of diabetic Mothers → they have wider
shoulder span

Maternal Consequences Fetal Consequences

• Postpartum hemorrhage → • Fetal morbidity and
usually from uterine atony, mortality The McRoberts maneuver → The maneuver consists of removing the legs from
vaginal and cervical (Neuromusculoskeletal the stirrups and sharply flexing the thighs Up onto the abdomen, as shown by the
lacerations injuries) horizontal arrow. The assistant is also providing suprapubic pressure
• Brachial Plexus Injury simultaneously (vertical arrow)
• Clavicular fracture/Humeral • Delivery:
fracture/ Rib Fracture ▪ Delivery of the posterior → carefully sweeping the posterior
• Hypoxia arm of the fetus across the chest → delivery of the arm →
shoulder girdle is then rotated into one of the oblique
Predictors for Shoulder Dystocia diameters of the pelvis → subsequent delivery of the anterior
• Increasing fetal weight risk factors: shoulder
▪ Obesity
▪ Multiparity
▪ Diabetes Mellitus and Gestational Diabetes Mellitus
▪ Post term pregnancy → 75 % shoulder dystocia cases
Birthweight > 4000 grams
• Intrapartum Factors:
▪ Prolonged second stage
▪ Operative vaginal delivery Shoulder dystocia with impacted anterior shoulder of the fetus. The
▪ Prior shoulder dystocia operator's hand is introduced into the vagina along the fetal posterior
humerus, which is splinted as the arm is swept across the chest,
Note: keeping the arm flexed at the elbow
ACOG 2012 Conclusion on Studies about Shoulder Dystocia • (A) → The operator's hand is introduced into the vagina along the
• Most cases of shoulder dystocia cannot be accurately fetal posterior humerus, which is splinted as the arm is swept
predicted or prevented across the chest, keeping the arm flexed at the elbow
• Elective induction of labor or elective CS for all women • (B) → The fetal hand is grasped and the arm extended along the
suspected of having macrosomic fetus is not appropriate side of the face
• Planned CS maybe considered for non- diabetics with fetus • (C) → The posterior arm is delivered from the vagina
whose estimated weight is >5000 grams or for diabetics >4500 • Woods corkscrew maneuver
grams ▪ The hand is placed behind
the posterior shoulder of the
fetus and progressively
Management rotating the posterior
• Reduction in the interval of time from delivery of the head to delivery shoulder 180 degrees in a
of the body is of great importance to survival corkscrew fashion so the
• An initial gentle attempt at traction, assisted by maternal expulsive impacted anterior shoulder
efforts, is recommended could be released
• Large episiotomy • Rubin's maneuver
• Adequate analgesic ▪ the fetal shoulders are rocked
• Shoulder dystocia Techniques to free the anterior shoulder from from side to side by applying force
its impacted position beneath the symphysis pubis: to the maternal abdomen
▪ Moderate suprapubic pressure ▪ the pelvic hand reaches the most
▪ can be applied by an assistant while downward traction is easily accessible fetal shoulder,
applied to the fetal head which is then pushed toward the
▪ Pressure is applied with the heel of the hand on the anterior anterior surface of the chest
shoulder ▪ (a) → The shoulder-to- shoulder
▪ McRoberts maneuver diameter is shown as the distance
o consists of removing the legs from the stirrups and between the two small the two
sharply flexing them up onto the abdomen – increase the small
diameter of the outlet ▪ (b) → The more easily accessible
o causes straightening of the sacrum relative to the lumbar fetal shoulder (the anterior is
vertebrae, rotation of the symphysis pubis toward the shown here) is pushed toward the
maternal head, and a decrease in the angle of pelvic anterior chest wall of the fetus.
inclination Most often, this results in
o pelvic rotation cephalad tends to free the impacted abduction of both shoulders,
anterior shoulder reducing the shoulder-to-
o reduces the forces needed to free the fetal shoulder shoulder diameter and freeing the impacted anterior
shoulder.

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 PATHOLOGIC OBSTETRICS
ABNORMAL LABOR (PASSENGER)
• Deliberate fracture of the clavicle
▪ Pressing the anterior clavicle against the ramus of the pubis
to free the shoulder impaction
• Hibbard maneuver
▪ Pressure is applied to the fetal jaw and neck in the direction
of the maternal rectum, with strong fundal pressure applied
by an assistant as the anterior shoulder is freed
• Zavanelli maneuver
▪ Cephalic replacement into the pelvis and then cesarean
delivery
• Cleidotomy
▪ Cutting the clavicle with scissors or other sharp instruments
▪ Usually used for a dead fetus
• Symphysiotomy

Shoulder Dystocia Drill

• (1) Call for help → mobilize assistants, an anesthesiologist, and a
pediatrician. Initially, a gentle attempt at traction is Initially, a gentle
attempt at traction is made. Drain the bladder if it is
• (2) A generous episiotomy (mediolateral or episioproctotomy)
may afford room posteriorly
• (3) Suprapubic pressure is used initially by most practitioners
because it has the advantage of simplicity. Only one assistant is
needed to provide suprapubic pressure while normal downward
traction is applied to the fetal head
• (4) The McRoberts maneuver requires two assistants

Note:
If the above maneuvers fail
• Delivery of posterior arm
• Woodscrew
• Rubin's manever
• If it fails:
▪ Cleidotomy
▪ Zavanelli
▪ Symphysiotomy

Complications with Dystocia

• MATERNAL:
▪ Uterine rupture
▪ Pathological retraction ring
▪ Fistula formation
▪ Pelvic floor injury
▪ Infection
▪ Postpartum hemorrhage

END

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