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Pemicu 3

Reproductive system
Liliani Labitta 405120026
• Mengkomplikasi 5–10% total kehamilan
• Salah 1 deadly triad (HT, hemoragi, infeksi)
• Sindrom preeklampsia (± HT kronis) paling bahaya
• HT gestasional biasanya diikuti tanda & gejala
preeklampsia  preeklampsia teridentifikasi pada
kehamilan 3.9%
• WHO: kematian maternal di seluruh dunia 16%
disebabkan oleh gg hipertensif

William Obstetrics 24th ed

• Gestational hypertension—evidence for the
preeclampsia syndrome does not develop and
hypertension resolves by 12 weeks
• Preeclampsia and eclampsia syndrome
• Chronic hypertension of any etiology
• Preeclampsia superimposed on chronic

William Obstetrics 24th ed

Gestational Hypertension
• BP ≥ 140/90 mmHg for the first time after
• Proteinuria is not identified
• (~½) Preeclampsia syndrome: headaches, epigastric
pain, proteinuria, and thrombocytopenia
• Chesley (1985): 10% eclamptic seizures develop
before overt proteinuria can be detected
• Transient hypertension: no evidence of preeclampsia,
BP  normal by 12 weeks postpartum.

William Obstetrics 24th ed

Preeclampsia syndrome
• Proteinuria = important diagnostic criterion, reflects
the system-wide endothelial leak, characterizes the
preeclampsia syndrome.

• Abnormal protein excretion:

– 24-hour urinary excretion >300 mg
– Urine protein:creatinine ratio ≥ 0.3
– Persistent 30 mg/dL (1+ dipstick) protein in random urine

William Obstetrics 24th ed

Diagnostic Criteria

William Obstetrics 24th ed

Severity of

William Obstetrics 24th ed

Symptoms of Preeclampsia
• Headaches, visual disturbances = premonitory symptoms
• Hepatocellular necrosis, ischemia, and edema  stretches
Glisson capsule  Epigastric or right upper quadrant pain,
• Platelet activation and aggregation, microangiopathic
hemolysis  thrombocytopenia
• Factors indicative of severe preeclampsia: renal or cardiac
involvement, obvious fetal-growth restriction
• The more profound signs & symptoms, the less likely can be
temporized, and the more likely delivery will be required

William Obstetrics 24th ed

• Preeclampsia + convulsion = eclampsia
• Seizures are generalized and may appear
before, during, or after labor
• ¼ eclamptic seizures develop beyond 48 hours

William Obstetrics 24th ed

Chronic Hypertension
• Predisposes superimposed preeclampsia syndrome
• D/ BP ≥ 140/90 mmHg before pregnancy or before
20 weeks’ gestation, or both
• Hard to diagnose and manage:
– BP in T2
– T3  BP return to originally hypertensive levels
• New-onset or worsening baseline hypertension +
new-onset proteinuria (other findings) = D/
superimposed preeclampsia

William Obstetrics 24th ed

Risk Factors
• Preeclampsia:
– Young and nulliparous
– Obesity, multifetal gestation, maternal age,
hyperhomocysteinemia, and metabolic syndrome
• Chronic HT with superimposed preeclampsia: older
• Incidence is markedly influenced by race and
ethnicity— and thus by genetic predisposition
• Other factors include environmental, socioeconomic,
and even seasonal influences

William Obstetrics 24th ed

Risk Factors
• The relationship between maternal weight and the
risk of preeclampsia is progressive
• IMT < 20 kg/m2 = 4.3%
• IMT > 35 kg/m2 = 13.3%

William Obstetrics 24th ed

• More likely to develop in women with the following
– Are exposed to chorionic villi for the first time
– Are exposed to a superabundance of chorionic villi, as with
twins or hydatidiform mole
– Have preexisting conditions of endothelial cell activation or
inflammation such as diabetes or renal or cardiovascular
– Are genetically predisposed to hypertension developing
during pregnancy

William Obstetrics 24th ed

• Cascade of events leading to the preeclampsia
– Abnormalities  vascular endothelial damage 
vasospasm, transudation of plasma, ischemic and
thrombotic sequelae

William Obstetrics 24th ed

Etiology of eclampsia
1. Placental implantation with abnormal trophoblastic
invasion of uterine vessels
2. Immunological maladaptive tolerance between
maternal, paternal (placental), and fetal tissues
3. Maternal maladaptation to cardiovascular or
inflammatory changes of normal pregnancy
4. Genetic factors including inherited predisposing
genes and epigenetic influences

William Obstetrics 24th ed

Abnormal trophoblastic invasion of uterine vessels

William Obstetrics 24th ed

Maladaptation to inflammatory changes
of normal pregnancy

William Obstetrics 24th ed

Genetic factors

• Preeclampsia is a
multifactorial, polygenic
• 20 – 40% for daughters of
preeclamptic mothers
• 11 – 37% for sisters of
preeclamptic women
• 22 – 47% percent for twins
• There is a genetic component
for gestational hypertension
and for preeclampsia

William Obstetrics 24th ed

HELLP Syndrome
• Describes severe preeclampsia: Hemolysis, Elevated
Liver enzymes, and Low Platelet count.
• Occurs in up to 20% of pregnancies complicated by
severe preeclampsia.
• Clinical presentation is variable:
– 12–18% of affected women are normotensive
– 13% do not have proteinuria
– At diagnosis: 30% of women are postpartum, 18%are term,
and 52% are preterm

HELLP Syndrome
• Clinical presentation is variable:
– Common: right upper quadrant or epigastric pain, nausea,
and vomiting
– Others: Malaise or nonspecific symptoms like acute viral
– Any patient with these symptoms or signs of preeclampsia
should be evaluated with complete blood count, platelet
count, and liver enzyme determinations

HELLP Syndrome

Prevention of Pre-eclampsia
• Antioxidants: vitamins C and E are not
• Calcium: may be useful in populations with
low calcium intake
• Low-dose aspirin (60 to 80 mg): beginning in
the late first trimester may have slight effect
to reduce preeclampsia and adverse perinatal

Hypertension in Pregnancy (Report of the ACOG Task Force on Hypertension in Pregnancy)

Obstetrics & Gynecology, Vol. 122, No. 5, November 2013
Management of Preeclampsia &
HELLP syndrome
• Timing of delivery: In women with
preeclampsia without severe features is 37
0/7 weeks of gestation.
• Postpartum management: Nonsteriodal
antiinflammatory agents may contribute to
increased BP and should be replaced by other
analgesics in

Hypertension in Pregnancy (Report of the ACOG Task Force on Hypertension in Pregnancy)

Obstetrics & Gynecology, Vol. 122, No. 5, November 2013
Management of Eclampsia
• Protect the airway, minimize the risk of
aspiration  place on her left side, suction
mouth, administer O2
• Intubation should be immediately available
• Close observation, soft padding, use of side
rails on bed  help prevent trauma
• Convulsion ended, patient stabilized  plan
prompt delivery

Management of Eclampsia
• Avoid unnecessary interventions & iatrogenic
• MgSO4 =DOC
• Total of 8 g of magnesium sulfate should not
be exceeded over a short period of time

• Premature rupture of membranes (PROM) = > 37
weeks' gestation and has presented with rupture of
membranes (ROM) prior to the onset of labor
• Preterm premature rupture of membranes
(PPROM) = ROM < 37 weeks' gestation
• Spontaneous premature rupture of the membranes
(SPROM) = ROM after or with the onset of labor
• Prolonged ROM = any ROM that persists for more
than 24 hours and prior to the onset of labor

• Programmed cell death & activation of catabolic
enzymes at term  ruptured membranes
• Preterm PROM ≈ same mechanisms
– Underlying pathologic processes (inflammation and/or
infection of the membranes)
– Clinical factors: low socioeconomic status, low body mass
index, tobacco use, preterm labor history, urinary tract
infection, vaginal bleeding at any time in pregnancy,
cerclage, and amniocentesis

Clinical Signs
• PROM: leakage of fluid, vaginal discharge, vaginal
bleeding, and pelvic pressure, but not having
• D/ ROM = speculum vaginal examination of the cervix
and vaginal cavity
– Fluid pool in vagina/Fluid leakage from cervix
– Ferning of the dried fluid under microscopic examination
– Alkalinity of the fluid as determined by Nitrazine paper
• Early PROM  USG: absence of or very low amounts of
amniotic fluid in the uterine cavity

• ROM at term 90%  spontaneous labor in 24 h
• Risk of intrauterine infection increases with the duration of
• Induction of labor, as opposed to expectant management,
decreases the risk of chorioamnionitis without increasing
the cesarean delivery rate
• Neonatal risks of expectant management of PROM:
infection, placental abruption, fetal distress, fetal
restriction deformities and pulmonary hypoplasia, and
fetal/neonatal death

• Vast majority  to active labor and deliver
soon after PPROM
• Appropriate therapy and conservative
management  ~50% of all remaining
pregnancies deliver each subsequent week
after PPROM

• Initial evaluation:
– Sterile speculum examination
– Cervical cultures
– Maternal vital signs & fetal monitoring
– USG: gestational age, fetal weight, fetal
presentation, and amniotic fluid index
– Digital examination should be avoided, but visual
inspection of the cervix can accurately estimate
cervical dilatation

• Chorioamnionitis, advanced labor, fetal distress, and
placental abruption with nonreassuring fetal surveillance
 immediate delivery of the fetus with PPROM is indicated
• Maturity documentation: amniocentesis or collection of
vaginal fluid
• Noncephalic fetus with advanced cervical dilatation (≥3
cm): risk of cord prolapse > benefits of expectant
management delivery
• Initial evaluation  clinically stable  expectant
management of PPROM

Medical Management
• Antibiotics
– IV group B streptococcus (GBS) coverage for at least the
first 48 hours of preterm PROM latency prophylaxis
• Corticosteroid
– Recommended for PPROM: reduce the risks of respiratory
distress syndrome, perinatal mortality, and other
• Tocolytic
– Tocolysis for 48 hours to administer steroids and allow
acceleration of fetal lung maturity

• A complication of pregnancy caused by
bacterial infection of the fetal amnion and
chorion membranes

Signs and Symptoms
• Maternal fever (intrapartum temperature >37.8°C)
• Significant maternal tachycardia (>120 beats/min)
• Fetal tachycardia (>160-180 beats/min)
• Purulent or foul-smelling amniotic fluid or vaginal
• Uterine tenderness
• Maternal leukocytosis (total blood leukocyte count
>15,000-18,000 cells/μL)

Signs and Symptoms
• Risk of neonatal sepsis  increased when at least 2
of the above criteria are present
• Silent chorioamnionitis is prominent
• Signs and symptoms of maternal chorioamnionitis
are subjective
• Evaluation and treatment of an infant should be
consulted regarding whether chorioamnionitis is

• Pregnant woman may be asymptomatic,
• Or may appear ill, even toxic, and she may
exhibit hypotension, diaphoresis, and/or cool
or clammy skin
• Not always associated with placental evidence
of inflammation IF maternal fever is the sole
criterion for the diagnosis

• Examination for suspected sepsis in the neonate:
– Behavioral abnormalities (eg, lethargy, hypotonia, weak cry, poor suck)
– Pulmonary: Tachypnea, respiratory distress, cyanosis, pulmonary
hemorrhage, and/or apnea
– Cardiovascular: Tachycardia, hypotension, prolonged capillary refill
time, cool and clammy skin, pale or mottled appearance, and/or
– Gastrointestinal: Abdominal distention, vomiting, diarrhea, and/or
bloody stools
– Central nervous system: Thermal regulatory abnormalities, behavioral
abnormalities, apnea, and/or seizures
– Hematologic and/or hepatic: Pallor, petechiae or purpura, and overt

• Laboratory test:
– Asymptomatic pregnant mothers who present
with premature labor or premature rupture of
• Examination of amniotic fluid
• Maternal blood studies
• Maternal urine studies
• Maternal group B streptococcal screening test

• Laboratory test:
– Amniotic fluid &
urogenital secretions :
• Polymerase chain
• Bacterial cultures
• Leukocyte count
• Fetal fibronectin,
• Gram staining insulinlike growth
• pH factor binding protein-
• Glucose concentration 1, and sialidase levels
• Endotoxin, lactoferrin, • Proteomic profiling
and/or cytokine levels

• Early delivery, supportive care, AB
• Pharmacotherapy
– Antibiotic agents used in the treatment of
chorioamnionitis include the following:
– Aqueous crystalline penicillin G
– Clindamycin or cephalosporin: For penicillin-allergic
– Ampicillin
– Cefotaxime
– Gentamicin

• Nonpharmacotherapy (Supportive care of septic neonate):
– Warmth, monitoring of vital signs
– Preparedness to perform a full resuscitation, including
intubation, providing positive-pressure ventilation
– Treatment of hypovolemia, shock, and respiratory and/or
metabolic acidosis
– Surfactant replacement therapy
– Glucose homeostasis
– Assessment and treatment of thrombocytopenia and
coagulopathy, if present  surgical option

• Surgical option, if:
– Epidural or brain abscess
– Subcutaneous abscesses
– Infections localized to the pleural space
– Certain intra-abdominal infections (especially if
intestinal perforation is present)
– Bone or joint infections

• Normal labor = uterine contractions that
result in progressive dilation and effacement
of the cervix resulting in uncomplicated
vaginal deliveries, time limits and progress
• Abnormal labor = Failure to meet these
milestones  increased risk of an unfavorable

• Dystocia of labor = difficult labor or
abnormally slow progress of labor
• Dysfunctional labor = failure to progress (lack
of progressive cervical dilatation or lack of
descent), and cephalopelvic disproportion

3 stages of labor (Friedman, 1955)
• Stage 1: uterine contractions  complete cervical
– Latent phase: irregular uterine contractions occur with slow and
gradual cervical effacement and dilation
– Active phase: increased rate of cervical dilation and fetal
descent. Starts at 3-4 cm cervical dilation and is subdivided into
the acceleration, maximum slope, and deceleration phases.
• Second stage: complete dilation of the cervix to the
delivery of the infant
• Third stage: delivery of the placenta

Labor curve

Abnormal labor indicator

First stage labor
• Diagnosis of abnormal labor during the latent phase is
uncommon and likely an incorrect diagnosis.
• Abnormalities of cervical dilation (protracted and arrest)
• Descent abnormalities (protracted and arrest)
• 95th percentile for 4 cm to 5 cm dilation = 6 hours, with the
active phase defined as beginning at 6 cm
• The maternal risk of a first stage greater than the 95th
percentile (>30 h) is associated with a higher cesarean
delivery rate and chorioamnionitis, and a higher incidence of
neonatal ICU admissions in the absence of any other of the
major morbidities

First stage labor
The 95th percentiles of cumulative duration of labor from admission among singleton
term nulliparous women with spontaneous onset of labor, vaginal delivery, and
normal neonatal outcomes. Reprinted from Seminars in Perinatology, Vol 36(5), El-
Sayed YY, Diagnosis and Management of Arrest Disorders: Duration to Wait, pgs 374-
8, Oct 2012, with permission from Elsevier.

Second stage labor
• 95th percentile for nulliparous women:
– 2.8 hours (168 min) without regional anesthesia
– 3.6 hours (216 min) with regional anesthesia
• 95th percentiles for multiparous women:
– 2 hours with regional anesthesia
– 1 hourwithout regional anesthesia
• Risks of both maternal and perinatal adverse outcomes rising
with increased duration of the second stage:
– > 3 hours in nulliparous women
– > 2 hours in multiparous women

Second stage labor
• In general, abnormal labor is the result of
problems with one of the following three P' s:
– Passenger (infant size, fetal presentation [occiput
anterior, posterior, or transverse])
– Pelvis or passage (size, shape, and adequacy of
the pelvis)
– Power (uterine contractility)

• Prolonged latent phase:
– Oversedation
– Entering labor early with a thickened or uneffaced
– May be misdiagnosed in the face of frequent
prodromal contractions

• Protraction of active labor is more easily
diagnosed and is dependent upon the 3 P' s.
– Passenger: infant's size (eg, macrosomia) or
– Pelvis: too small or narrow to allow passage of the
– Both the passenger and pelvis cause abnormal
labor by a mechanical obstruction, referred to as
mechanical dystocia

– Power:
• Adequate frequency, but the lack intensity
• Scarring or fibroids  disruption of communication
between adjacent segments of the uterus 
contraction pattern fails to result in cervical effacement
and dilation
• This is called functional dystocia

• Definition: uterine contractility x frequency
• Montevideo units (MVUs) = strength of contractions (mmHg)
x frequency/10 min [by intrauterine pressure transducer]
• For example: 3 contractions in 10 minutes that each reach a
peak of 60 mmHg are 60 X 3 = 180 MVUs.
• Contraction pattern should repeat every 2-3 minutes
• Adequate = force >200 MVUs during a 10-minute contraction
• D/ = patient in the active phase, >200 MVUs for ≥2 h with no
cervical change

Pelvis or passage way
• The shape of the bony pelvis (eg, anthropoid
or platypelloid) can result in abnormal labor.
• Extremely short or obese, or who has had
prior severe trauma to the bony pelvis 
increased risk of abnormal labor.

Size and/or presentation of infant
• Abnormal labor secondary to the passenger, the size
of the infant, and/or the presentation of the infant
• Differential in size between the fetal head and the
maternal bony pelvis
• Fetal presentation: asynclitism or head extension
– Asynclitism: malposition of the fetal head within the pelvis
– Fetal macrosomia and other anomalies (including
hydrocephalus, encephalocele, fetal goiter, cystic hygroma,
hydrops, or any other abnormality that increases the size
of the infant)

• Nulliparous with singleton cephalic
presentations at term  high-dose oxytocin (6
mU/min increase every 15 min  max 40
mU/min)  < 7 uterine contractions/15 min.
– If vaginal delivery has not occurred or is not
imminent 12 hours after admission or for fetal
compromise  caesarian section

• Amniotomy once patient reached the active phase
• Arrest or protraction fails to respond to conservative
measures, or if the fetal heart pattern is
nonreassuring  operative vaginal delivery or
cesarean delivery
– Operative delivery with use of forceps or vacuum may
increase associations for shoulder dystocia and neonatal

• Nothing by mouth as a precaution should the need for an
emergent cesarean delivery arise
• Ice chips, or clear liquid diet
• Active and mobile while in the latent and early active phase is
– However, once rupture of membranes has occurred or signs of fetal
nonreassurance exist, then bed rest and continuous fetal monitoring is


• Presence of uterine contractions of sufficient
frequency and intensity to effect progressive
effacement and dilation of the cervix prior to
term gestation
• Occurring at 20-37 weeks’ gestation, preterm
labor precedes almost half of preterm births
and is the leading cause of neonatal mortality
in the United States

Essential update: FDA warns against extended
magnesium sulfate injections in pregnancy

• The US Food and Drug Administration (FDA)

– Administration of magnesium sulfate injections to
pregnant women for more than 5-7 days as a
means of stopping preterm labor can lead to low
calcium levels and bone abnormalities in the fetus
– transient osteopenia and fractured bones,
hypocalcemia and skeletal abnormalities in

• Decidual hemorrhage such as abruption and mechanical factors
such as uterine overdistention from multiple gestation or
• Cervical incompetence (eg, trauma, cone biopsy)
• Uterine distortion (eg, müllerian duct abnormalities, fibroid uterus)
• Cervical inflammation as a result of, for example, bacterial vaginosis
(BV) or trichomonas
• Maternal inflammation/fever (eg, urinary tract infection)
• Hormonal changes (eg, mediated by maternal or fetal stress)
• Uteroplacental insufficiency (eg, hypertension, insulin-dependent
diabetes, drug abuse, smoking, alcohol consumption)

Risk assessment
Physical assessment
• Speculum & digital exam: integrity of the cervix, prior injury to
the cervix, asymptomatic bacteriuria, sexually transmitted
disease (STD), and symptomatic BV
• Prior preterm deliveries (may be one of the strongest
predictors of recurrent preterm birth)
Cervical length
• Short cervical length in T2 (increased risk of preterm labor and
deliver), ≤ 25 mm at 28 weeks  49% preterm delivery < 35

Risk assessment
Laboratory tests: In patients with a history of midtrimester loss,
laboratory tests for risk assessment include the following:
– Rapid plasma reagent test
– Gonorrheal and chlamydial screening
– Vaginal pH/wet smear/whiff test
– Anticardiolipin antibody
– Lupus anticoagulant antibody
– Activated partial thromboplastin time
– One-hour glucose challenge test
* TORCH (toxoplasmosis, other infections, rubella, cytomegalovirus
infection, herpes simplex): IgG, IgM screening whenever the historical
or clinical suspicion is present

• Contractions of sufficient frequency and
intensity to effect progressive effacement and
dilation of the cervix at 24-37 weeks’ gestation
• If suspected but not confirmed  vaginal fetal
fibronectin (FFN) sample  pelvic cervical
examination  diagnosis remains in doubt 
FFN specimen sent to the lab for analysis

Management Goals
1. Early identification of risk factors associated with preterm birth
2. Timely diagnosis of preterm labor
3. Identifying the etiology of preterm labor
4. Evaluating fetal well-being
5. Providing prophylactic pharmacologic therapy to prolong
gestation and reduce the incidence of respiratory distress
syndrome (RDS) and intra-amniotic infection (IAI)
6. Initiating tocolytic therapy when indicated
7. Establishing a plan of maternal and fetal surveillance with
patient/provider education to improve neonatal outcome

• Progesterone
• Tocolytic agents
– Criteria: > 6 contractions/h  cervical change or
presumed prior cervical change (transvaginal
cervical length < 25 mm, >50% cervical
effacement, or cervical dilation ≥20 mm)
– Magnesium sulfate (MgSO4)
– Indomethacin
– Nifedipine

• Corticosteroid
– Crosses placenta  speed up development of
fetal lungs, brain, and digestive organs
– Administered at 24 and 34 weeks
– Reduced the risk of respiratory distress syndrome
– Recommended dosage:
• Betamethasone 12 mg, 2 doses, per-day
• Dexamethasone 6 mg, 4 doses, per 6h

• Preterm labor  high risk neonatal Group B
streptococci sepsis
• Prophylactic AB: administered when D/ of
preterm labor is made  until delivery or min
72 h
• Patients should be re-treated if preterm labor
recurs or when the patient enters labor at
term depending upon culture results

• Pregnancy that extend to or beyond 42 weeks
(294 days) of gestation
• Frequency: ±3-12%
• Risk factors for actual postterm pregnancy:
primiparity, prior postterm pregnancy, male
gender of the fetus, and genetic factors
maternal genetic factors, obesity

• Most frequent cause of a postterm pregnancy
diagnosis is inaccurate dating
• Last menstrual period (LMP) = traditional way
to estimated due date (EDD)
– Many inaccuracies: irregular cycles, hormonal
birth control, first trimester bleeding
– Regularity and length of cycles must be taken into
account when estimating gestational age

• Ultrasonographic dating early in pregnancy can improve the
reliability of the EDD
• Estimation range varies
– Crown-rump length (CRL) = 3-5 days
– USG performed at 12-20 weeks = 7-10 days
– 20-30 weeks = 2 weeks
– After 30 weeks = 3 weeks
– Pregnancy that is 35 weeks by a 31-week ultrasound could actually be
anywhere from 32 weeks to 38 weeks (35 wk +/-3 wk)
– If the calculated ultrasonographic gestational age varies from the LMP
more than the respective range of error, it is used instead to establish
the final EDD

Management Plan
• Impending postterm pregnancy (>40 wk of
gestation but < 42 wk), 3 options:
– Elective induction of labor
– Expectant management of the pregnancy
– Antenatal testing

Fetal & Neonatal Risks
• Perinatal mortality
• Meconium aspiration
 tachypnea, cyanosis, and reduced pulmonary compliance

• Neonatal acidemia
• Low Apgar scores
• Macrosomia (fetal weight ≥4,5kg) other
complication & birth injury
– Prolonged labor, CPD, shoulder dystocia  orthopedic or neurologic injury

Fetal & Neonatal Risks
• Fetal dysmaturity (postmaturity) syndrome:
chronic IUGR from uteroplacental insufficiency
• Oligohydramnios  umbilical cord
• Encephalopathy
• Death in the first year of life

Maternal Risks
• Increase in labor dystocia
• Increase in severe perineal injury (3rd and 4th degree
perineal lacerations)
• 2x rate of cesarean delivery
• Latter  higher risks of complications: endometritis,
hemorrhage, thromboembolic disease
• Emotional impact
• Increased maternal morbidity

Timing of Delivery
• First decision to be made: whether to deliver
• In certain cases (eg, nonreassuring surveillance,
oligohydramnios, growth restriction, certain
maternal diseases), the decision is straightforward
• To consider:
– certainty of gestational age
– cervical examination findings
– estimated fetal weight
– patient preference, past obstetric history

Timing of Delivery
• Routine induction at 41 weeks:
– Must be well-dated and low-risk pregnancy
– Decrease caesarian section rate
– Lower rate of adverse outcomes: shoulder
dystocia and meconium aspiration syndrome
– More cost-effective
• At 40 weeks' has few benefits, multiple
reasons not to allow a pregnancy > 42 weeks

• Minimally invasive interventions
– Stripping or sweeping of the fetal membranes: digital
separation of the membranes from the wall of the cervix
and lower uterine segment  release endogenous
prostaglandins from the cervix
– Unprotected sexual intercourse causes uterine
contractions through the action of prostaglandins in semen
and potentially release of endogenous prostaglandins
similar to stripping of the membranes.

• Delivery in which additional maneuvers are
required to deliver the fetus after normal
gentle downward traction has failed
• Occurs when the fetal anterior shoulder
impacts against the maternal symphysis
following delivery of the vertex
• Or less commonly, from impaction of the
posterior shoulder on the sacral promontory

Risk Factors
• Maternal • Labor related
– Abnormal pelvic – Assisted vaginal delivery
anatomy (forceps or vacuum)
– Gestational diabetes – Protracted active phase
– Post-dates pregnancy of first-stage labor
– Previous shoulder – Protracted second-stage
dystocia labor
– Short stature
• Fetal
– Suspected macrosomia

• Maternal • Fetal
– Postpartum hemorrhage – Brachial plexus palsy
– Rectovaginal fistula – Clavicle fracture
– Symphyseal separation – Fracture of the humerus
or diathesis, with or – Fetal hypoxia, with or
without transient without permanent
femoral neuropathy neurologic damage
– Third- or fourth-degree – Fetal death
episiotomy or tear
– Uterine rupture

• Labor induction in women with gestational
diabetes who require insulin may reduce the
risk of macrosomia and shoulder dystocia
• Cesarean deliveries to prevent one permanent
brachial plexus injury in a patient without
diabetes who had a fetus suspected of
weighing more than 4,000 g

Preliminary Concern Management
• Umbilical cord compression  fetal pH drop
±0.14 per minute during delivery of the fetal
• “Head and shoulder maneuver” to “deliver
through” until the anterior shoulder is visible

Reduction Maneuver & HELPERR
• Shoulder dystocia  “turtle sign.”
• The HELPERR mnemonic is a clinical tool that offers a
structured framework for coping with shoulder dystocia
1. Increase the functional size of the bony pelvis through flattening of
the lumbar lordosis and cephalad rotation of the symphysis (i.e., the
McRoberts maneuver)
2. Decrease the bisacromial diameter (i.e., the breadth of the
shoulders) of the fetus through application of suprapubic pressure
(i.e., internal pressure on the posterior aspect of the impacted
3. Change the relationship of the bisacromial diameter within the bony
pelvis through internal rotation maneuvers

HELPERR Mnemonic

HELPERR Mnemonic
• H = Call for Help
– Activating the pre-arranged protocol or requesting
the appropriate personnel to respond with
necessary equipment to the labor and delivery
• E = Evaluate for Episiotomy
– Necessary to make more room if rotation
maneuvers are required

HELPERR Mnemonic
• L = Legs (the McRoberts maneuver)
– Flexing and abducting the maternal hips, positioning the
maternal thighs up onto the maternal abdomen

HELPERR Mnemonic
• P = Suprapubic Pressure
– The hand of an assistant
should be placed
suprapubically over the fetal
anterior shoulder, applying
pressure in a CPR style with a
downward and lateral motion
on the posterior aspect of the
fetal shoulder. This maneuver
should be attempted while
continuing downward traction

HELPERR Mnemonic
• E = Enter maneuvers
(internal rotation)
– Manipulate the fetus to
rotate the anterior
shoulder into an oblique
plane and under the
maternal symphysis

HELPERR Mnemonic
• R = Remove the posterior arm
– Shortens the bisacromial diameter  fetus drop
into the sacral hollow, freeing the impaction

HELPERR Mnemonic
• R = Roll the patient
– To all-fours position  shoulder will dislodge
during the act of turning

Maneuver of Last Resort
• If the maneuvers described in HELPERR are
unsuccessful, several techniques have been
described as “last-resort” maneuvers
• Once the infant is delivered, quick assessment
and employment of resuscitation efforts, if
necessary, are vital

Maneuver of Last Resort
• Deliberate clavicle fracture
– Direct upward pressure on the mid-portion of the
fetal clavicle; reduces the shoulder-to-shoulder

Maneuver of Last Resort
• Deliberate clavicle fracture
– Direct upward pressure on the mid-portion of the
fetal clavicle; reduces the shoulder-to-shoulder

Maneuver of Last Resort
• Zavanelli maneuver
– Cephalic replacement followed by cesarean delivery;
Rotating fetal head OAP  flex and push back  holding
continuous upward pressure until cesarean delivery is
– Tocolysis may be a helpful
– An operating team, anesthesiologist, and physicians
capable of performing a cesarean delivery must be
present, and this maneuver should never be attempted if a
nuchal cord previously has been clamped and cut

Maneuver of Last Resort
• General anesthesia
– Musculoskeletal or uterine relaxation with halothane
(Fluothane) or another general anesthetic may bring about
enough uterine relaxation to affect delivery
– Oral or intravenous nitroglycerin may be used as an
alternative to general anesthesia

Maneuver of Last Resort
• Abdominal surgery with hysterotomy
– General anesthesia is induced and cesarean incision
performed, after which the surgeon rotates the infant
transabdominally through the hysterotomy incision,
allowing the shoulders to rotate, much like a Woods
corkscrew maneuver. Vaginal extraction is then
accomplished by another physician.

• Abnormal position of the cord in front of the
fetal presenting part, so that the fetus
compresses the cord during labor, causing
fetal hypoxemia
• May be contained within the uterus (occult) or
may protrude into the vagina (overt)

Occult prolapse
• Cord compressed by shoulder or head
• Fetal heart rate pattern shows progression to
hypoxemia (eg, severe bradycardia, severe
variable decelerations)
• Changing the woman’s position may relieve
pressure on the cord
• Abnormal fetal heart rate pattern persists 
immediate cesarean delivery

Overt prolapse
• Occurs with ruptured membranes
• More common: breech presentation or
transverse lie
• Can also with vertex presentation if
membranes rupture (spontaneously or
iatrogenically) before the head engaged

Overt prolapse
• Treatment:
– Gently lift the presenting part  hold it off the
prolapsed cord  restore fetal blood flow while
immediate cesarean delivery is done
– Placing the woman in the knee-to-chest position
and giving her terbutaline 0.25 mg IV once may
help by reducing contractions.

• Cesarean delivery is defined as the delivery of
a fetus through surgical incisions made
through the abdominal wall (laparotomy) and
the uterine wall (hysterotomy).

ACOG/SMFM guidelines released for
prevention of primary cesarean delivery
• Prolonged latent (early)-phase labor should be permitted
• The start of active-phase labor can be defined as cervical
dilation of 6 cm, rather than 4 cm
• In the active phase, more time should be permitted for labor
to progress
• Multiparous women should be allowed to push for 2 or more
hours and primiparous women for 3 or more hours; pushing
may be allowed to continue for even longer periods in some
cases, as when epidural anesthesia is administered

ACOG/SMFM guidelines released for
prevention of primary cesarean delivery
• Techniques to aid vaginal delivery, such as the use of forceps,
should be employed
• Patients should be encouraged to avoid excessive weight gain
during pregnancy
• Access to nonmedical interventions during labor, such as
continuous support during labor and delivery, should be
• External cephalic version should be performed for breech
• Women with twin gestations should, if the first twin is in
cephalic presentation, be permitted a trial of labor

• Separate the mother and the fetus in an
attempt to save the fetus of a moribund
• Resolve maternal or fetal complications not
amenable to vaginal delivery
• The leading indications for cesarean delivery
(85%) are previous cesarean delivery, breech
presentation, dystocia, and fetal distress

Maternal Indications
• Repeat cesarean delivery
• Obstructive lesions in the lower genital tract:
malignancies, large vulvovaginal condylomas,
obstructive vaginal septa, and leiomyomas of the
lower uterine segment that interfere with
engagement of the fetal head
• Pelvic abnormalities that preclude engagement or
interfere with descent of the fetal presentation in

Relative Maternal Indications
• Left heart valvular stenosis, dilated aortic valve root,
certain cerebral arteriovenous malformations
(AVMs), and recent retinal detachment
• Previously undergone vaginal or perineal reparative
• Labor dystocia is a very commonly cited indication
for cesarean delivery, but it is not specific

Fetal Indications
• Situations in which neonatal morbidity and mortality
could be decreased by the prevention of trauma
• Malpresentations (eg, preterm breech presentations,
non-frank breech term fetuses)
• Certain congenital malformations or skeletal
• Infection
• Prolonged acidemia

Indications: benefit mother & fetus
• Abnormal placentation (eg, placenta previa,
placenta accreta)
• Abnormal labor due to cephalopelvic
• Situations in which labor is contraindicated

• When maternal status may be compromised
(eg, mother has severe pulmonary disease)
• If the fetus has a known karyotypic
abnormality (trisomy 13 or 18) or known
congenital anomaly that may lead to death

CD on Maternal Request (ACOG & NIH)
1. Unless there are maternal or fetal indications for
cesarean delivery, vaginal delivery should be
2. Should not be performed before 39 weeks’
gestation without verifying fetal lung maturity
3. Not recommended for women who want more
4. The inavailability of effective analgesia should not
be a determinant for CDMR

CD on Maternal Request (NIH)
1. CDMR has a potential benefit of decreased risk of
hemorrhage for the mother and decreased risk of
birth injuries for the baby
2. CDMR requires individualized counseling by the
practitioner of the potential risks and benefits of
both vaginal and cesarean delivery

Preoperative management
1. Minimum preoperative fasting time: 2 hours from
clear liquids, 6 hours from a light meal, and 8 hours
from a regular meal
– Patients are usually asked not to eat anything for 12
hours prior to the procedure
2. Placement of an intravenous (IV) line
3. Infusion of IV fluids (eg, lactated Ringer solution or
saline with 5% dextrose)

Preoperative management
4. Placement of a Foley catheter (to drain the bladder
and to monitor urine output)
5. Placement of an external fetal monitor and
monitors for the patient’s blood pressure, pulse,
and oxygen saturation
6. Preoperative antibiotic prophylaxis
7. Evaluation by the surgeon and the anesthesiologist

Preoperative management
• Laboratory testing
– Complete blood count
– Blood type and screen, cross-match
– Screening tests for human immunodeficiency
virus, hepatitis B, syphilis
– Coagulation studies (eg, prothrombin and
activated partial thromboplastin times, fibrinogen

Preoperative management
• Imaging studies
– In labor and delivery, document fetal position and
estimated fetal weight
– Ultrasonography is commonly used to estimate
fetal weight
– A prospective study reported the sensitivity of
clinical and ultrasonographic prediction of
macrosomia, respectively, as 68% and 58%

• Laparotomy via midline infraumbilical,
vertical, or transverse (eg, Pfannenstiel,
Mayland, Joel Cohen) incision
• Hysterotomy via a transverse (Monroe-Kerr) or
vertical (eg, Kronig, DeLee) incision
• Fetal delivery
• Uterine repair
• Closure

Post-operative management
• Routine postoperative assessment
• Monitoring of vital signs, urine output, and
amount of vaginal bleeding
• Palpation of the fundus
• IV fluids; advance to oral diet as appropriate
• IV or intramuscular (IM) analgesia

Post-operative management
• Ambulation on postoperative day 1; advance
as tolerated
• Breastfeed, initiate within a few hours after
• Discharge on postoperative day 3 or 4, if no
• Discuss contraception as well as refraining
from intercourse for 4-6 weeks postpartum

• Maternal mortality and morbidity with cesarean
delivery is 2x vaginal delivery
• Infection
• Thromboembolic disease
• Anesthetic complications
• Surgical injury
• Uterine atony
• Delayed return of bowel function