Abnormal labour

Malpresentatio
n

Prolapsed
Umbilical Cord

Shoulder
Dystocia

Obstetric
Lacerations

Episiotomy

Caesarean
section

Normal foetal presentation (i.e., cephalic or vertex) is with foetal head down, chin tucked,
and occiput directed toward birth canal. Abnormal presentations:

Face (i.e., full hyperextension of neck) presentation occurs rarely and usually
undergoes normal vaginal delivery if chin is anterior.

Brow (i.e., partial hyperextension of neck) presentation occurs very rarely and
requires caesarean delivery if the head does not spontaneously correct to a normal
presentation.

Breech presentation is the most common malpresentation:

o Frank breech: 75% of cases; hips flexed and knees extended
o Complete breech: hips and knees flexed
o Footling breech: one or both legs extended
o Risk factors: prematurity, multiple gestation, polyhydramnios, uterine
o anomaly, placenta previa
o H/P abdominal examination (i.e., Leopold maneuvers) detects foetal head in
abdomen, vaginal examination may detect presenting part
o Radiology US confirms foetal orientation
o Treatment most cases will resolve before labour; external cephalic version may
be applied to abdomen at 37 weeks gestation to attempt repositioning of foetus
(up to 75% effective); caesarean section performed in most cases
o Complications cord prolapse, head entrapment, foetal hypoxia, abruption
placentae, birth trauma
Umbilical cord prolapse is an obstetric emergency because if the cord gets compressed,
foetal oxygenation will be jeopardized, with potential foetal death.
Prolapse can be occult (the cord has not come through the cervix but is being compressed
between the foetal head and the uterine wall), partial (the cord is between the head and
the dilated cervical os but has not protruded into the vagina), or complete (the cord has
protruded into the vagina).
Risk Factors. Rupture of membranes with the presenting foetal part not applied firmly to
the cervix, malpresentation.
Management. Do not hold the cord or try to push it back into the uterus. Place the patient
in knee-chest position, elevate the presenting part, avoid palpating the cord, and perform
immediate caesarean delivery.
This diagnosis is made when delivery of the foetal shoulders is delayed after delivery of
the head. It is usually associated with foetal shoulders in the anterior-posterior plane, with
the anterior shoulder impacted behind the pubic symphysis. It occurs in 1% of deliveries
and may result in permanent neonatal neurologic damage in 2% of cases.
Risk Factors: Maternal diabetes, obesity, and postdates pregnancy, which are associated
with foetal macrosomia. Even though incidence increases with birth weight, half of
shoulder dystocias occur in foetuses <4,000 grams.
Management. Includes suprapubic pressure, maternal thigh flexion (McRoberts
maneuver), internal rotation of the foetal shoulders to the oblique plane (Woods
corkscrew maneuver), manual delivery of the posterior arm, and Zavanelli maneuver
(cephalic replacement).
Perineal lacerations are classified by the extent of tissue disruption between the vaginal
introitus and the anus.
First degree: involve only the vaginal mucosa. Suture repair is often not needed.
Second degree: involve the vagina and the muscles of the perineal body but do not
involve the anal sphincter. Suturing is necessary.
Third degree: involve the vagina, the perineal body, and the anal sphincter but not the
rectal mucosa. Suturing is necessary to avoid anal incontinence.
Fourth degree: involve all the way from the vagina through to the rectal mucosa.
Complications of faulty repair or healing include rectovaginal fistula.
This is a surgical incision made in the perineum to enlarge the vaginal opening and assist
in childbirth. It is one of the most common female surgical procedures.
False arguments: less perineal pain; more rapid return of sexual activity; less urinary
incontinence; less pelvic prolapse.
Disadvantages: more perineal pain than with lacerations; longer return to sexual activity;
more extensions into the anal sphincter and rectum.
Possible indications: shoulder dystocia, non-reassuring fetal monitor tracing, forceps or
vacuum extractor vaginal delivery, vaginal breech delivery, narrow birth canal.
Delivery of fetus through incision in uterine wall
Types

Vertical: vertical incision in anterior muscular portion of the uterus (i.e., classic) or
lower uterine segment (i.e., low vertical); chosen when foetus lies in transverse
presentation, adhesions or fibroids prevent access to lower uterus, hysterectomy
is scheduled to follow delivery, cervical cancer is present, or in post-mortem
delivery to remove living fetus from dead mother

Operative
vaginal
delivery

Oligohydramni
os

Polyhydramnio

Low transverse: transverse incision in lower uterine segment; decreased risk of

uterine rupture, bleeding, bowel adhesions, and infection (preferred to classic
technique and performed more commonly)
Indications:

Maternal: eclampsia, prior uterine surgery, prior classic C section, cardiac disease,
birth canal obstruction, maternal death, cervical cancer, active genital herpes, HIV

Fetal: acute fetal distress, malpresentation, cord prolapse, macrosomia

Combined maternal and fetal: failure to progress in labor, placenta previa,

abruption placentae, cephalopelvic disproportion
In subsequent pregnancies, vaginal delivery can be attempted only if transverse C section
was performed.
If vertical incision has been used previously, repeat caesarean delivery must be performed
because of risk of uterine rupture.
Complications: haemorrhage, infection and sepsis, thromboembolism, injury to
surrounding structures; future pregnancies are at increased risk of placenta previa,
placenta accreta, and miscarriage
Operative delivery 1013% of births UK. Operative obstetrics refers to any method used to
deliver the foetus other than uterine contractions and maternal pushing efforts. It may
include vaginal or caesarean routes.
Conditions of use: the head must be engaged, the membranes ruptured, the position of
the head known and the presentation suitable; cephalopelvic disproportion must be
absent (moulding not excessive); the cervix must be fully dilated; the uterus contracting;
and analgesia adequate (epidural or perineal infiltration if episiotomy).
Obstetric forceps are metal instruments used to provide traction, rotation, or both to the
foetal head.
Complications
Maternal: lacerations to the vagina, cervix, perineum, and uterus.
Foetal-neonatal: soft-tissue compression or cranial injury caused by incorrectly placed
forceps blades.
Indications: Prolonged second stage, avoid maternal pushing, breech presentation
Ventouse are cuplike instruments that are held against the foetal head with suction.
Traction is thus applied to the foetal scalp, which along with maternal pushing efforts,
results in descent of the head leading to vaginal delivery.
Advantages Over Forceps
Precise knowledge of foetal head position and attitude is not essential.
The vacuum extractor does not occupy space adjacent to the foetal head.
Perineal trauma. Third- and fourth-degree lacerations are fewer.
Foetal head rotation occurs spontaneously at the station best suited to foetal head
configuration and maternal pelvis.
Disadvantages Over Forceps
Cup pop-offs. Excessive traction can lead to sudden decompression as the cup suction
is released.
Scalp trauma. Scalp skin injury and lacerations are common.
Subgaleal hemorrhage and intracranial bleeding are rare.
Neonatal jaundice arises from scalp bleeding.
Complications
Maternal: vaginal lacerations from entrapment of vaginal mucosa between the suction
cup and foetal head.
Neonatal: neonatal cephalohematoma and scalp lacerations are common; lifethreatening complications of subgaleal hematoma or intracranial hemorrhage, although
uncommon, are associated with vacuum duration >10 min.
Deficiency of amniotic fluid in gestational sac (amniotic fluid index ,5 cm)
Associated with IUGR, foetal stress, foetal renal abnormalities, or poor foetal health.
Significance of timing
a. First trimester: frequently results in spontaneous abortion
b. Second trimester: may be due to fetal renal abnormalities, maternal cause (e.g.,
preeclampsia, renal disease, HTN, collagen-vascular disease), or placental
thrombosis
c. Third trimester: associated with premature rupture of membranes (PROM),
preeclampsia, abruptio placentae, or idiopathic causes
H/P: possibly asymptomatic; fundal height may be small for gestational age
Radiology: US used to determine amniotic volume and perform foetal assessment;
amniotic fluid index will be ,5 cm, with no pockets at least 2 cm in size
Treatment: expectant management if foetus responds well to tests of well-being;
induce delivery of viable foetus if risk of foetal demise is significant (poor response of
foetus to tests of well-being); hydration, and bed rest may improve amniotic volume
Complications: spontaneous abortion, intrauterine fetal demise; abnormalities in limb,
facial, lung, and abdominal development caused by compression
Excess of amniotic fluid in gestational sac (amniotic fluid index 25 cm)

Can result from insufficient swallowing of amniotic fluid (e.g., oesophageal atresia) by
foetus or increased foetal urination related to maternal diabetes, multiple gestation, foetal
anaemia, or chromosomal abnormalities
H/P: fundal height may be larger than expected for gestational age
Radiology: US used to assess amniotic fluid volume; amniotic fluid index will be 25 cm or
will show one pocket of at least 8 cm
Treatment: only administered if mother is uncomfortable or if a threat of preterm labour
exists; pregnancies of 32 weeks gestation treated with amnioreduction and
indomethacin; pregnancies 32 weeks gestation treated with amnioreduction alone
Complications: preterm labour, PROM, foetal malpresentation, maternal respiratory
compromise