MIDWIFERY

RUGENDO M. MORRIS
COURSE OUTLINE:

1. Prolonged pregnancy
2. Induction of labour
3. Abnormal labour
◦ Trial of labour
◦ Obstructed labour
4. OBSTETRIC EMERGENCIES:
i. Ruptured uterus
ii. Cord presentation
iii. Cord prolapse
iv. Vasa praevia
v. Shoulder dystocia
6. OBSTETRIC OPERATIONS:
i. Caesarean section
ii. Vacuum extraction
iii. Forceps delivery
iv. Symphysiotomy
7. MALPOSITIONS AND MALPRESENTATIONS OF THE
OCCIPUT;
i. Occipito posterior position
ii. Deep transvese arrest
iii. Breech presentation
iv. Face presentation
v. Shoulder presentation
vi. Brow presentation
vii. Compound lie
viii. Unstable lie
PROLONGED PREGNANCY

DEFINITION
• Pregnancy equal to or more than 42 completed weeks( 294

days from the first day of the last menstrual period, LMP).
• The expected date of delivery( EDD) is calculated on the basis

of Naegele’s rule, the assumption being that the cycle is 28

days and that ovulation occurs on the 14th day
INCIDENCE
 The frequency or incidence of prolonged pregnancy is quoted
as anything from 5-10%. Incidence in england is given at 4%
ASSOCIATED RISKS
• Viewed from the perspective of the mother, foetus, and

neonate with regard to morbidity and mortality

• For the mother:
 Large for gestational age
 Macrosomic infant eg shoulder dystocia
 Genital tract trauma
 PPH and operative birth
• For the foetus:
 Decrease in liquor volume( oligohydramnios)
 Placental insufficiency( placental dysfunction)
PREDISPOSING FACTORS:
 Nulliparity

 Previous prolonged pregnancy

 Male foetus

 Pre-pregnancy BMI>25Kg/M2

 anencephaly
SPECIFIC MGT

• Purpose: to ensure optimum outcome for the mother and

the baby
• Increased antenatal surveillance including a non stress test
(NST) and ultrasound estimation of amniotic fluid
volume(AFV)
• A biophysical profile and Bishops score.
• Membrane sweep: to attempt initiate the onset of labour
physiologically. Sweeping membranes is designed to
separate the membranes from their cervical attachment by
introducing the examining fingers into the cervical os and
passing them circumferencialy around the cervix
• Active mgt: induction of labour at 41 or 42 completed
weeks
INDUCTION OF
LABOUR
DEFINITION
 Induction of labour is the stimulation of
uterine contractions b4 the onset of
spontaneous labour.
 It is an obstetric intervention that should be

used when elective birth will be beneficial to

the mother & the baby
 The purpose of induction is to effect the

birth of the baby, thereby ending the

pregnancy
 Indications for induction of
labour
 When the health or well being of the mother or
the foetus would be endangered if the pregnancy
continues
 Prolonged pregnancy because after 42 weeks
there is danger of placental insufficiency
 Pre-eclampsia, where both mother and baby are
in danger, with the mother in danger of eclampsia
and the baby in danger of placental insufficiency
 Signs of intrauterine growth retardation(IUGR),
which can be detected by abdominal examination
or serial ultrasound scan
 Placental insufficiency more common in
primigravida aged over 35 years
 Poor obstetric history, for example, history of
stillbirth or intra uterine growth retardation in
previous pregnancies
 Polyhydramnios, foetal abnormalities
 Spontaneous rupture of membranes. If membranes
rupture spontaneously after 36 weeks gestation and
labour does not commence within 12 hours, danger
of intra uterine infection is very high
 Previous large baby, where weight was over 4kg.
Induction is indicated between38 - 40 weeks. Foetal
size tends to increase with successive pregnancies
 Indications cntd…

 Diabetes mellitus, noting that intrauterine death tends to

occur near term so induction is indicated between 36 - 38
weeks
 Rhesus iso-immunisation, where rhesus antibodies are
present in the maternal serum and the titre is high, labour
should be induced to save the life of the baby
 Unstable lie when placenta praevia and pelvic
abnormalities have been excluded
 Genital herpes, where labour is usually induced after 38
weeks gestation if disease is in remission
 Previous precipitate labour which tends to recur so
induction is indicated at 38 weeks
 Intrauterine foetal death
 Contraindications to induction
of labour
 Cephalopelvic disproportion
 Unreliable estimated date of delivery. Confirm
estimated date of delivery and maturity by ultrasound
 Malpresentation
 Oblique or transverse lie
 Foetal compromise, that is, if the foetus could not
stand the uterine contractions due to prematurity or
placenta insufficiency. In such cases caesarean section
is preferred
 Psychological factors, for example, if the mother is
against induction, her decision should be respected
 Placenta previa
Favourable factors for
induction
 38 or more weeks of gestation
 Bishop's score of six or more
 Where 3/5ths of the head or less is palpable

above the pelvic brim

methods of induction
 Medical, where drugs alone are used and
the amniotic sac remains intact
 Surgical, where the membranes are

artificially ruptured and sweeping of the

membranes
 A combination of medical and surgical

intervention
 Medical Induction
Use of prostaglandins
 Prostaglandins play an important role in cervical ripening

process & contribute to contractibility of the uterus in labour

 PGE2 & PGF2 are produced from the cervix & also from the

foetal membranes
 Intravaginal prostaglandin E2 are used in the form of

pessaries (2.5mg), vaginal tablets (3-6mg) or gel (2.5-5mg).

 A nelatone urinary catheter is attached to a syringe

containing the gel while membranes are intact.In case of

intrauterine infection, Introduce the gel to the posterior
vaginal fornix.
 The dose varies from 2.5mg-5mg. If there is no change

overnight, prostaglandin may be added/repeated, but if the

cervix ripens overnight, then pessaries of prostaglandin E2
may be introduced to the vagina.
The following steps should be taken to ensure
adequate care of the mother during the
procedure;
 Maximum of an hour is needed to allow

absorption of the prostaglandin, so the mother

should be asked to stay in for this period
 Observations are carried out as in normal labour
 After one hour, if foetal heart is normal, the

mother should be allowed to walk around

 After four hours, if labour has not been

established, a vaginal examination should be

done to reassess the cervical dilatation
 If there has been some progress, artificial

rupture of the membranes is done and a

syntocinon drip is commenced two hours later to
 Oral prostaglandin is usually used to induce
labour where the membranes have ruptured.
 Commonly used method is misoprostol ( PGE1)

which is given at a dosage of 50mcg sublingual

or inserted in the posterior vaginal fornix or
orally.
 Assessement is done after 6 hours and a

maxium of three inductions are given.If mother

is not in labour after the three doses,consider
oytocin infusion with or without rupture of the
membranes,or caesarean section.
 NB: Do not give oxytocin less than 6 hours after
there are several complications
associated with prostaglandin;
 The mother may suffer discomfort due to

painful contractions.
 The induction may be ineffective.
 Over-stimulation of the uterus can cause

foetal and maternal distress

The use of oxytocin
 The amount and rate of oxytocin must be

carefully calculated and administered.

 Usually 500mls of normal saline with five units

of syntocinon is commenced after a vaginal

examination. The drip is started at 15 drops per
minute and increased by ten drops after every
half-hour to a maximum of 60 drops. Using two
bottles of the same solution is preferred so that
in the event of discontinuation of oxytocin, the
intravenous line will still be open
Factors Which Should be Observed and
Recorded During Oxytocin Infusion
 Dosage of oxytocin, the name and amount
of solution
 Rate of flow
 Vital signs and foetal heart rate every 15-30

minutes
 Vaginal examination findings four hourly
 Maintain intake and output chart
 Record in the chart any other treatment

that is given
Possible Complications of
Oxytocin Use
 Hypertonic uterine contraction causing foetal
distress
 Tetanic and tumultuous contractions, which

can result in abruptio placenta

 Birth injury due to rapid expulsion of the

baby
 Mother may develop hypertension with

frontal lobe headache

Note:If any one of the above signs occurs,
stop the syntocinon drip immediately
and inform the doctor
Medical Induction cntd…
 The Bishop Score is an objective method of
assessing whether the cervix is favourable
for induction of labour
Bishops score
Each score is awarded 0 - 3 and the range
of scores is
0 - 13. A total score of six or over is
favourable. However a score of nine or more
will have a safe, successful induction.
 Surgical Induction (Amniotomy)
 In the case of an uncomplicated pregnancy, a sweep
of the membranes is an effective method of
inducing labour. After a vaginal examination, the
index finger is swept through the cervical os to
detach foetal membranes from the deciduas.The
action produces prostaglandin.
 Amniotomy is an Artificial Rupture of the
Membranes (ARM), which is carried out to induce
labour when the cervix is favourable.
 A well fitting presenting part is essential to avoid
prolapse of the cord or rupture of the membranes.
Allow the descent of the presenting part to the
cervical os. This raises the level of prostaglandin
which stimulates strong contractions to hasten
 This method of induction may be combined
with oxytocin drip and this is referred to as
combined method.
 This method has likelihood of delivery within

12 hours, requires less analgesia and

reduces the risk of Post Partum
Haemorrhage (PPH
Hazards Associated with Artificial
Rupture of Membranes (ARM)
 Intrauterine infection due to contaminated
instruments
 Cord prolapse
 Early foetal heart deceleration
 Bleeding due to vasa praevia or placenta

previa
 Responsibilities of the MW & care of
a mother for induction of labour

 The midwife should communicate properly with

the patient by giving her factual & unbiased
information regarding induction of labour
 All maternal & foetal observations should be well

recorded on the partograph

 A record of discussions & info given during labour

is also documented in the mother’s notes

 Monitor the well being of the mother & foetus

throughout the process of induction. Observe for

side effects of oxytocin
 Observation of maternal pulse rate, bp, pulse &
temp recorded on the partograph
 Record the frequency, duration & strength of

uterine contractions every 15-30 mins on the

partograph
 Continous monitoring of the foetal heart rate.

The midwife should be vigilant for signs of

foetal distress
ABNORMAL LABOUR

DEFINITION:
• A pathophysiological process in the conduct of labour

PROLONGED LABOUR
definition
 Prolonged labour is active labour with regular uterine

contractions and progressive cervical dilatation, which lasts

for more than 12 hours in both multiparas and primigravidas.
 Labour is prolonged when it exceeds the number of hours
considered to be normal for a nulliparous or a multiparous
woman. WHO defines prolonged labour as one that exceeds
18hrs in a primiparous woman
 Different terms are used for prolonged labour at different

times or for different reasons.

CLASSIFICATION PER STAGE
 Delay in latent phase of labour

• The latent phase lasts from the onset of labour to three

centimetre dilatation of the cervical os.

 This is the period when structural changes occur in the
cervix and it becomes softer and shorter( from 3cm to
<0.5cm), its position more central in relation to the
presenting part. This takes place in 8-10 hrs
 During this time, a woman needs support & encouragement

from those caring for her, making sure there is adequate

food and fluid intake
 Delay in active phase of labour

• This is the period of time when the cervix dilates from 3cm-

10cm with rotation and descent of the presenting part

  This part is most contentious because the
expectation is that progress once labour is
diagnosed is a cervical dilatation of 1cm/hr
 Delay in second stage of labour
• The second stage of labour can be divided into
passive( pelvic) phase & active(perineal) phase
• Delay in this stage may be due to:-
 malposition causing failure of the vertex to
descend and rotate,
 ineffective contractions due to prolonged first
stage
 large foetus & large vertex
 absence of desire to push with epidural analgesia
 A full bladder or a full rectum can also impede
progress
CAUSES

• There are 7 cardinal Ps with regard to causes of abnormal and

prolonged labour
1). Patient: certain factors in the patient may contribute to
prolonged labour namely, a full bladder, dehydration, keto-
acidoses, inadequate pain relief, anxiety and tension.
• An exhausted mother may not be prepared well for labour

because of the metabolic changes

• Psychological causes, for instance; tension and fear of the

unknown tend to prolong labour, most commonly in women

who are primigravidae
2).Power: the contractions
• Uterine powers; although the uterus has prepared itself
metabolically for labour, as labour continues, the smooth
muscle uses up its metabolic reserves and becomes tired
• Excess contraction( hypertonia) makes the uterus too
exhausted
• Hypotonia( contractions that are too mild)may result from
an exausted uterus or because the receptors are not strong
enough to signal enough contraction
• Atonic uterus: a uterus that is not contracting at all
• Incoordinate uterus: uterus that is not contracting uniformly
3). passage
• Pelvic abnormalities (passage), where contracted pelvis and

tumours of the pelvis cause poor progress in labour

4). Passanger. The passangers are:
 The foetus
 Placenta
 Amniotic fluid
 The cord

For the foetus;

• Conjoined twins
• Premature labour
• Postmature labour
• Foetal distress
• Malpresentation and malposition
• Macrosomia and microsomia
For the placenta:
• Abruptio placenta
• Placenta praevia
• Infections eg TB, syphyllis affect the placenta

For the amniotic fluid;

• Amniotic fluid embolism. Occurs when the amniotic fluid
enters the maternal circulation via the uterus or the placental
site leading to maternal collapse
• Chorioamnionitis( infection to the amniotic fluid)
• Oligohydramnios and polyhydramnios
For the cord:
• Cord prolapse: where the cord lies infront of the presenting

part and the membranes are ruptured

• A short cord causing placental separation

• Knotting of the cord

• Cord around the neck of the foetus

5). Place of delivery
• Delivery units/ hospitals must be easily accessible, affordable &
available for the patient to facilitate normal labour and delivery
• They must also be equipped with all the necessary apparatus
to handle an obstetric emergency including prompt referral
systems
6). Person attending
 Lack of adequate skills, knowledge and competence can cause
labour to be abnormal eg when a caregiver ruptures the
membranes prematurely causing cord prolapse can change
labour from normal to abnormal
 Lack of knowledge on to interpret a partograph

7.The partograph
• This is a graphical presentation of the progress of labour. Lack

of knowledge on how to chart and interprete it may cause

delay causing abnormal labour
DIAGNOSIS OF PROLONGED LABOUR
 Findings from history and physical examination or as
interpreted from the partograph that is correctly charted
will guide in the diagnosis of prolonged labour.
 History

◦ At what time did the contractions begin?

◦ How frequent are the contractions?
◦ When did the membranes (water) break?
 Examination
 The frequency, duration and intensity of the contractions
 Determine the foetal position and identify any evidence of

cephalopelvic disproportion and /or foetal malposition

 Evaluate foetal heart rate
 Determine whether the mother’s bladder is full.

Encourage the woman to empty the bladder

frequently. If not able to pass urine then
catheterize
 Inspect the external genitalia to determine the

presence of liquid and /or blood

 Vaginal exam with sterile gloves every four

hours (or at a different frequency when

indicated.
Criteria for referral
 Refer all patients with prolonged labour to a

comprehensive EOC facility ( CEOC) if not

available in your facility.
Referral process
 Explain the dangers of prolonged labour to the

family
 Write a referral note and refer immediately to

the hospital.
 A skilled health care provider must escort the

woman and continue to monitor her condition.

 Monitor maternal vital signs 1/2 hourly
 Monitor foetal heart rate 1/2 hourly
 Measure the urine volume
 Ensure IV fluids (5% dextrose) continue during

transfer
 Broad-spectrum antibiotics should be started

before departure.
LABORATORY INVESTIGATIONS
 Blood grouping and cross match two units
 Urine for albumin, sugar, acetone
MGT OF PROLONGED LABOUR

 Monitor maternal vital signs: Temperature 2-4

hourly, Pulse ½ hourly, Respirations and BP 4
hourly
 Monitor foetal heart rate ½ hourly
 Measure the urine volume every 2-4 hours

(encourage mother to void regularly)

 Start I.V fluid (5 dextrose)
 Start broad spectrum antibiotics
 Oxygen by mask
 First choice antibiotics:

◦ IV Ampicillin 500mg 6 hourly for 3 days

◦ IV Gentamicin 80 mg 8 hourly for 7 days
◦ Followed by Amoxicillin 500mg oral 8 hourly for 7 days
Second choice line antibiotics
 IV second generation Cephalosporin

 IV amoxicillin/clavulanic acid 1.2g stat dose

followed by oral preparation

Second stage
 Maternal expulsive efforts increase fetal risk by

reducing the delivery of oxygen to the placenta.

While spontaneous maternal “pushing” should be
allowed, prolonged effort and holding the breath
should not be encouraged. If malpresentation
and obvious obstruction have been ruled out,
labor should be augmented with oxytocin.
 If there is no descent after augmentation and:

◦ If the head is not more than 1/5 above the symphysis

pubis, delivery should be by vacuum extraction or
forceps
◦ If the head is between 1/5 and 3/5 above the
symphysis pubis, and birth is taking place in a facility
where safe caesarean section is not possible, delivery
should be by vacuum extraction and symphysiotomy
◦ If the service provider is not proficient in
symphysiotomy, immediate referral is required for
delivery by caesarean section
◦ If the head is more than 3/5 above the symphysis
pubis, delivery must be by caesarean section.
◦ If the woman arrived very late and the foetus is dead,
do destructive obstetric procedure
Third Stage
 Perform active management of third stage of

labour:
◦ Cutting and clamping of the cord
◦ CCT
◦ Administration of an oxytocic agent
Management of prolonged labour when
there is uterine dysfunction
 Hypotonic dysfunction

◦ If the foetal heart rate is normal, the cervical Os is

≥4cm and there is no evidence of foetal
malpresentation or CPD, perform ARM then wait for 1-
2 hours for improvement of contractions. If
contractions do not pick up, start on 5IU oxytocin in
500ml of physiologic solution such as Normal Saline,
Ringer’s lactate or 5% dextrose at a rate of 10 drops
per minute.
 Increase the rate of oxytocin administration at
10 drops per minute every 30 minutes to
maximum 60 drops per minute or until 3
contractions every 10 minutes each lasting 20-
40 seconds are achieved.
 If the liquor is meconium stained, deliver by

caesarean section if she is not fully dilated or

there is evidence of Cephalo -Pelvic
Disproportion (CPD).
TRIAL OF LABOUR

DEFINITION;
 Trial of labour is a test of labour conducted where there is a

minor or moderate degree of Cephalopelvic Disproportion

(CPD) in which it is difficult to decide whether delivery per
vagina is possible because of a previous caesarean section
INDICATIONS FOR TRIAL OF LABOUR

• Borderline obstruction with a favourable

outcome. After adequate supervision, it is
established that the presenting part is
capable of flexing adequately to pass
through the pelvic brim
• When the progress of labour is sufficient,
as observed both in the descent of the
presenting part and by dilatation of the
cervix
CONTRAINDICATING FACTORS TO TRIAL OF LABOUR

 Grossly contracted pelvis

 Medical or obstetrical complications
 Malpresentations, for example, breech
 Elderly primigravida
 Cases where trial of labour failed before
 Cases of two previous caesarean Sections
 Where the reason for the first scar is likely to be
repeated, for example, in cephalopelvic
disproportion
 Where the previous scar wound did not
heal with the first intention
 Where pregnancy occurs within six

months of a caesarean section

 Where there is over-distension due to

multiple pregnancy or polyhydramnios

 Multiparity
Mgt of trial of labour

Explain the situation to the mother and prepare her

for possible operative intervention.
Assess patient carefully on admission to ascertain
the following:
• Whether the mother is in established labour
• Presentation of foetus
• Check for flexion of the head
• State of foetal heart; that is, rate, rhythm and
volume
• General condition of mother physically and
emotionally
• Confine the mother to bed to prevent early
rupture of membranes
• Close observations of temperature and blood
pressure every four hours
  Observe foetal heart rate and maternal
pulse quarterly to half hourly
• You should always observe for signs of
foetal and maternal distress.
• Accurately observe and record for
onset,strength, frequency and duration of
the contractions.
• Closely observe the descent of the head
every one to two hours per abdominal
palpation by the same midwife if possible.
• Encourage the mother to pass urine
every two hours and test for acetone to
exclude acidosis
• A vaginal examination should be done
every four hours to assess the level of the
presenting part, the degree moulding and
flexion, the dilation of the cervix (whether
progressive or not), the consistency of
the cervix and the presence or absence of
caput.
• You should also check whether the
membranes are intact or ruptured.
• Encourage adequate hydration by giving
intravenous 5% dextrose
DURING PREGNANCY
 Early ANC (first half of pregnancy)
 Review history
 Obstetric U/S scan in first half of pregnancy
 Counsel patient on the risks and benefits of

undergoing trial of scar

 Pelvic assessment at 36 weeks;

clinical/radiological
 Estimate weight of baby
 Admit in early labour
 IV line and GXM
 Consent for C/S
 Partograph (pulse, BP, FHR, contractions,

descent, cervical dilatation, colour of liquor, PV

TRIAL OF SCAR
 VAGINAL BIRTH AFTER CAESAREAN
SECTION (VBAC) is commonly referred to
as Trial of scar
 Conditions for trial of scar
i. Only one previous C/S which must be LUSCS
ii. Non-recurring indication for previous C/S;
foetal distress, cord prolapse,
malpresentation, placenta praevia etc.
iii. No post-operative sepsis after previous C/S
iv. Parity <5, where previous delivery was via
SVD
v. Cephalic presentation
vi. Estimated foetal weight ≤3500g
vii. Adequate pelvis with true conjugate 10.5cm
viii. No other indication for C/S
ix. Facilities for blood transfusion available
CRITERIA
 After adequate supervision, it is established
that the presenting part is capable of flexing
adequately to pass thru the pelvic brim
 All the facilities for assisted birth are readily

available
 Progress of labour is sufficient, both in descent

of the presenting part and the dilatation of the

cervix
 Time limits as to the duration of the trial are set
Predictors of decreased chances of success
 Maternal obesity
 Short maternal stature
 Macrosomia
 Increase maternal age>40yrs
 Recurring indications e.g. CPD, failed

second stage
 Gestational age >41wks
 Pre-conceptional or gestational diabetes

mellitus
 Increased inter-pregnancy weight gain
Increased rate of uterine
rupture
 Classical hysterotomy
 Single layer closure
 Induction of labour
 Use of prostaglandins
 Short inter-pregnancy interval
 Infection after prior C/S
OBSTRUCTED LABOUR
DEFINITION:
 Obstructed labour means that, in spite of strong

uterine contraction, the foetus cannot descend

because of mechanical factors. Obstruction usually
occurs at the brim, but it may occur in the mid cavity
or pelvic outlet.
DEFINITION OF CEPHALOPELVIC DISPROPORTION
(CPD):
 This occurs when foetal head is large in comparison

with the pelvis. Cephalopelvic disproportion may be

due to a small pelvis with a normal sized head, or a
normal pelvis with a large foetus or a combination of a
large baby and small pelvis. This means it is difficult
or impossible for the foetus to pass safely through the
 Cephalopelvic disproportion may be:
 Marginal CPD, which means that the problem

may be overcome during labour. The

relaxation of the pelvic joints and moulding of
the foetal skull may enable vaginal delivery.
Half of these patients will need an operative
delivery.

 True CPD: This means the pelvis is small or

abnormally shaped and/or foetus is unusually
large or abnormal e.g. hydrocephalus.
Operative delivery will be needed.
Factors associated with obstructed
labour
 Childhood malnutrition leading to contracted
pelvis
 History of previous still birth, or previous

prolonged labour
 Young age of mother (under 17 years)
 Female genital mutilation/cutting
 Some medical illnesses like diabetes mellitus
 Pelvic abnormalities following childhood

illnesses like polio or pelvic injuries

Causes of obstructed labour
Common factors predisposing to obstructed labour
include:
 Cephalopelvic disproportion
 Foetal macrosomia e.g. in poorly controlled diabetes

mellitus in pregnancy
 Malpresentation e.g. brow, shoulder, face with

mentoposterior, breech
 Foetal abnormalities e.g. hydrocephalus
 Multiple gestation with locked twins
 Abnormalities of the reproductive tract e.g. pelvic

tumour, cervical or vaginal stenosis, tight perineum

and FGM/FGC scar.
 Underdeveloped pelvis e.g. adolescent pregnancy
 Childhood malnutrition leading to contracted pelvis
Diagnosis of obstructed
labour
History
Relevant points to find out from the
woman or her family are:
 Her age, parity, gravidity
 History of previous operative delivery
 History of previous stillbirth
 Duration of previous labour and outcome
 Duration of current labour
 Duration of ruptured membranes
Physical Examination
 General examination

The following may be observed:

 Signs of physical and mental exhaustion
 Dehydration- dry mouth,
 Acetone breath due to ketoacidosis.
 Fever
 Shock - rapid pulse, anuria or oliguria, cold

extremities, pale complexion, low blood

pressure.

 NB: Shock may be due to a ruptured uterus or

sepsis
Abdominal examination
 The foetal head may be palpable above the pelvic

brim
 There may be frequent and strong uterine

contractions
 The uterus may have gone into tetanic

contractions and sits tightly moulded around the

foetus
 Bandl’s ring may be evident. This is when the

border of upper and lower uterine segments

becomes visible and/or palpable during labour. It is
usually seen as a depression across the abdomen
at about the level of the umbilicus. This is a late
sign of obstructed labour occurring mostly in
primigravida.
 The uterus may stop contracting especially in
Vaginal examination
Signs of obstruction include:
 Oedema of the vulva present, especially if the

woman has been pushing for a long time

 Foul smelling - meconium stained liquor
 Absence of amniotic fluid (fluid has already

drained away)
 Catheterization will produce concentrated urine

which may contain blood

 Hot and dry vagina
 Oedema of the cervix.
 Incomplete dilatation of the cervix
 Large caput succedaneum can be felt
 May palpate a severely moulded head, or a
Partograph reading
Examination of the partograph may reveal:
 Foetal heart rate of more than 160/minute or

less than 120/minute indicating foetal distress

 Foul smelling meconium-stained liquor
 Severe moulding
 Severe caput formation
 The rate of cervical dilatation slows or remains

static in spite of strong contraction

 Maternal tachycardia and pyrexia
 Scanty urine with ketonuria.
MANAGEMENT OF OBSTRUCTED
LABOUR
a) Resuscitation of the Mother
 Perform a rapid assessment of the airway,

breathing and circulation and manage as

appropriate.
b) Rehydrate the patient
 Aim to maintain normal plasma volume and to

prevent or treat dehydration and ketosis. Put up an

intravenous infusion; use a large bore needle or
cannula.
 If the woman is in shock give IV fluids e.g. normal

saline. Run 1 litre in the first 15 minutes or as

quickly as possible. If the woman is mainly starved
and exhausted, give 1-2 litres of 5 or 10% dextrose
c) Catheterize
 Insert an indwelling urinary catheter using

aseptic technique and monitor urine output.

d) Give antibiotics
 If there are signs of infection, or the

membranes have been ruptured for 18 hours or

more, or the period of gestation is 37 weeks or
less, give antibiotics as follows:
 Ampicillin 2 g every 6 hours, and
 Gentamicin 5 mg/Kg body weight IV every 24

hours.
 If the woman is delivered by caesarean section,

continue antibiotics and give Metronidazole 500

mg IV every 8 hours until the woman is fever-
free for 48 hours.
(e.) Deliver the baby
Cephalo -pelvic disproportion:
 If cephalo -pelvic disproportion is confirmed,

delivery should be by caesarean section

 If the fetus is dead: - delivery should be by

craniotomy - if this is not possible, delivery

should be by caesarean section.
Complications of obstructed labour
Maternal complications
 Maternal death
 Uterine rupture
 Obstetric fistula
 Puerperal sepsis
 Neurological injury e.g. foot drop
 Spontaneous symphysiotomy and/or

osteitis pubis
Foetal complications
 Foetal distress
 Foetal injury
 Birth asphyxia
 Neonatal sepsis eg. Chorioamnionitis
 Intrauterine foetal death
REFERRAL PROCESS
 Explain the dangers of obstructed labour to the
family
 Write a referral note and refer immediately to a

hospital with comprehensive obstetric care.

 A skilled health care provider must escort the

woman and continue to monitor her condition.

 Monitor maternal vital signs 1/2 hourly
 Monitor foetal heart rate 1/2 hourly
 Ensure IV fluids (5% dextrose) continue during

transfer
 Start on intravenous antibiotics (Ampicillin

500mg and Gentamicin 80mg)

 OBSTETRIC
EMERGENCIES
Broad objective:
 By the end of this session, the KRCHN student will be able
to describe and manage various obstetric emergencies to
include;
Specific objectives; the student should be able to describe and manage
the following:
i. Ruptured uterus
ii. Cord presentation
iii. Cord prolapse
iv. Vasa praevia
v. Shoulder dystocia
vi. Amniotic fluid embolism
vii. Acute uterine inversion
viii. Obstetric shock
RUPTURE OF THE UTERUS
INTRODUCTION:
 This is a serious complication, which should not occur in

today’s obstetric care where there is good prenatal and

intra partum care
 This is one of the most serious complications in

midwifery & obstetrics. It is often fatal for the foetus &

may also be responsible for the death of the mother
DEFINITION:
 Rupture of the uterus is defined as a complete

separation or tear in the wall of the uterus with or

without expulsion of the foetus. It may be complete
when the visceral peritoneum is involved or incomplete
when the visceral peritoneum is intact...
 Rupture of the uterus is defined as being
complete or incomplete
 Complete rupture
 Also known as intraperitoneal
 This is a tear in the wall of the uterus, which

involves the endometrium,myometrium and

perimetrium/peritoneum
 This involves a tear in the wall of the uterus,

with or without expulsion of the foetus

 In complete uterine rupture, the uterus

communicates directly with the peritoneal

cavity and bleeding occurs into the peritoneal
cavity
 Incomplete or Extra
Peritoneal
 This is the tearing of the uterus, which
involves the endometrium and myometrium.
Tears can occur prenatally, during labour or
delivery and may endanger the lives of both
mother and foetus
 In incomplete rupture, bleeding occurs behind

the visceral peritoneum

 PREDISPOSING FACTORS
Predisposing factors include those that contribute to
over distension of the uterus such as:
 Neglected obstructed labour
 Previous operations on the uterus ( e.g. caesarean

section, myomectomy, previous uterine rupture)

 Obstetric manoeuvres on the uterus (e.g. external

cephalic version, breech extraction, internal podalic

version)
 Harmful obstetric practice e.g. Application of fundal

pressure
 High parity
 Multiple pregnancies
 Large foetus
Diagnosis of ruptured uterus
 A patient with ruptured uterus may present
with hemorrhagic or neurogenic shock from
bleeding or vasovagal stimulation, respectively.
 Resuscitate and manage maternal shock

expeditiously as per guidelines. It is important

to note that even though rupture of the uterus
is more commonly associated with labour, it
can occur before onset labour or even long
before term pregnancy especially when the
uterus has been scarred.
History
 During history taking, explore the presence of risk

factors
 Suspect rupture of the uterus if the following signs

and symptoms are present:

◦ Shock (Signs of hypovolemia and shock include:
tachycardia, hypotension, cold clammy extremities,
sweating, restlessness and confusion).
◦ Abdominal distension/free fluid (Paracentesis may
be positive in the presence of haemoperitoneum
but its absence does rule out ruptured uterus.
◦ Abnormal uterine contour (Bandl’s ring)
◦ Tender abdomen and especially tenderness over
the lower segment of the uterus and abdominal
distension.
◦ Easily palpable fetal parts or dislodged presenting
part
 Absent fetal movements and fetal heart sounds
 Rapid maternal pulse (Suspect rupture if the

fetus suddenly becomes distressed and the

mother’s pulse starts rising).
 Speculum vaginal examination may reveal

vaginal bleeding. (Digital vaginal examination

must be avoided unless placenta praevia has
been ruled out).
Investigations
 Blood for grouping and cross matching
 Urinalysis for Haematuria, protein, sugar and

acetone.
Signs of ruptured uterus
Signs of ruptured uterus include:
 Rupture may be gradual with vaginal bleeding

 Pain and tenderness at the central

region/abdomen are present or pain over

previous c/s scar
 Abnormalities of the foetal heart rate & pattern

 Maternal tachycardia & Poor progress in labour

 Diagnosis is difficult; therefore close monitoring

is very important
The Causes of Ruptured Uterus

Prenatally, a ruptured uterus may occur due to

a weak scar. During labour and delivery or
when not in labour a ruptured uterus may
occur as a result of:
 Obstructed labour, for example in

malpresentation, cephalopelvic disproportion,

contracted pelvis
 Excessive or injudicious use of oxytocin

 Intrauterine manipulation, for example,

internal cephalic version of second twin

 Forceps delivery and vacuum extraction
The Causes of Ruptured Uterus
ctd
 Rigid cervix with strong contractions
 Breech delivery
 Multiparity, due to the degeneration of the

uterine muscle
 Previous scar
 Manual removal of placenta
 Perforation of uterus
 Early Signs of Scar
Rupture
 Early signs of scar rupture include a constant lower
abnormal pain. This pain worsens during a contraction.
There is fresh vaginal bleeding, which may be mistaken
for show.
 Contractions may continue but the cervical os fails to

dilate. Pulse rate is raised due to shock and tends to

increase slowly.
NOTE
 Vigilant observation is required for a mother with a

uterine scar showing the above signs so that she can

be sectioned before rupture occurs.
 Epidural analgesia masks the early signs, and is

therefore contraindicated in the mother with a

caesarean scar.
Early Signs of Scar
Rupture ctd
 In the advanced stage, the mother complains of
severe and drastic pain, which is continuous and
does not correspond to the uterine action. When
the scar rupture contraction ceases, the mother
rapidly becomes shocked. Rupture through a scar
has less chance of infection than a rupture due to
obstructed labour.
 The presenting part does not descend to the pelvic
brim in spite of strong contraction.
 The cervical os dilates slowly and hangs loosely like
an empty sleeve and the membranes rupture early
or the bag of water is elongated like a sausage
The Late Signs of Scar
Rupture
 Mother is dehydrated, shows ketosis and is
in severe pain
 Rapid pulse and pyrexia of over 38°C
 Poor urinary output, concentrated with

ketosis and often blood stained

 Uterus gets moulded round the foetus
 Strong uterine pain, which does not relax

between contractions
 The Late Signs of Scar Rupture
ctd
 A Bandle's ring
 On vaginal examination, the vagina is hot and
dry
 Presenting part is high, wedged and immovable
 There is over lapping of foetal bones and big
caput succedaneum
 The mother is exhausted before the rupture, and
she will probably cry out during the rupture and
complain of a sharp pain in the lower abdomen
 She feels something has given way and
 soon presents with shock
Rupture Secondary to Manipulation
 The general condition of the mother will

change, and this could be discovered when

the hand is still in the uterus. After any
difficult manipulation, the uterus must be
explored to rule out injury or rupture.
Caesarean section is preferred to difficult
manipulation
Rupture Secondary to Oxytocic Drugs
 This is common when close monitoring is

not done. There is less danger when these

drugs are used as a dilute in an intravenous
drip. The risk is much greater in multipara
where many cases of rupture have followed
unmonitored use of oxytocic drugs
 The management of a ruptured uterus

a) Emergency Treatment
 Start resuscitation.
 Set up IV line with a wide bore branula and

start Ringer’s lactate solution or normal saline

 Give oxygen by face mask
 Transfuse blood
 Catheterise for continuous bladder drainage
 Provide loading dose of parenteral antibiotics
 Monitor vital signs
 The management of a ruptured
uterus ctd
b) Definitive management
 Surgery-laparotomy
 Perform the quickest and safest operative

procedure (e.g. repair with or without tubal

ligation, or subtotal hysterectomy)
 Continue with IV fluids
 Broad-spectrum parenteral antibiotics
 Continuous bladder drainage (keep bladder

catheter for 10-14 days)

c) Precautions to take in order to avoid
complications
 Resuscitate patient adequately before surgery
 Cross match enough blood
 Administer parenteral broad spectrum

antibiotics
 If the uterus was repaired and tubal ligation

was not performed for desired for future

fertility, counsel the patient on need for both
future antenatal care and delivery by elective
caesarean section in a level 4 or above health
care facility. If hysterectomy was done, counsel
woman on consequences (amenorrhea,
infertility).
d) Follow up
Complications of ruptured
uterus
 Paralytic ileus
 Peritonitis
 Septicaemia
 Urinary tract infection
 Renal failure
 Death
 The foetus may experience complications

such as birth asphyxia, stillbirths in

complete rupture and neonatal death.
 Prevention of Uterus
Rupture
 Prevention is possible through good antenatal care after a
thorough history taking.
 Refer high risk patients with previous scars and contracted

pelvis for assessment.

 Vigilant observations in labour, especially in trial and

induction of labour are necessary. You should be able to

recognise,at an early stage, signs of obstructed labour and
ruptured uterus.
 Maternal education is important in case of risk factors such as

a previous scar.
 The community should be educated on pregnancy and

childbirth complications. They should be advised on the need

to deliver in a hospital rather than at home.
CORD PRESENTATION
 This is a condition where the cord lies in front of
the presenting part BEFORE the membranes
have ruptured
 This is diagnosed on vaginal examination when

the cord is felt behind intact membranes

 Mgt of cord presentation
 Under no circumstance should the membranes
be ruptured.
 The midwife should discontinue the vaginal

examination in order to reduce the risk of

rupturing the membranes
 Continuous foetal heart monitoring
 Help the mother adopt a position that will reduce

the likelihood of cord compression

CORD PROLAPSE

 Cord prolapse is a term used when the umbilical

cord lies in front of the presenting part AFTER
the membranes have ruptured.
Diagnosis of cord presentation and cord
prolapse is made on:
 Vaginal examination by palpating cord under the

intact membranes (cord presentation)

 Vaginal examination after rupture of the

membranes reveals loops of the cord in the birth

canal (cord prolapse).
Potential predisposing risk
factors
 Premature rupture of the amniotic sac
 Polyhydramnios (having a large volume of

amniotic fluid. The cord may be forced out with

the more forceful gush of waters.
 Long umbilical cord
 Foetal malpresentation
 Multiparity
 Multiple gestation
Differential Diagnosis
 Foetal membranes
 Footling breech or compound presentations.
 Causes of Cord Prolapse
 Any condition in which the presenting part does
not fit well into the lower uterine segment will
permit the umbilical cord to slip down in front of
the presenting part, for example,
malpresentation and malposition, breech
presentation, face and brow presentation,
shoulder presentation resulting from transverse
lie and occipito posterior position
 Causes of Cord Prolapse
ctd
 Contracted pelvis: because the membranes may

rupture before the head has engaged.

 Certain placental and cord conditions like low
implantation of the placenta,
 marginal insertion of the cord and a long cord.
 High head: the membranes rupture spontaneously
when the foetal still high
 Prematurity: there is more room between the small
foetal head and the maternal pelvis.
 Polyhydramnios: the cord is likely to be swept
down in a gush of liquor when the membranes
rupture spontaneously.
Management of Cord Prolapse
Emergency Treatment
 The aim of management is to deliver the foetus

as quickly as possible before hypoxia and death

occurs due to cord compression.
 Remove pressure by elevating the buttocks or

putting patient in knee chest or exaggerated

left lateral position
 Give oxygen to the mother by mask
 Establish IV line with 5% dextrose
 Monitor the foetal heart appropriately, every 5

minutes
 Counsel mother on the condition of the foetus.
Knee chest position
If the cord is pulsating and patient is in
first stage of labour:
 Replace the cord into the vagina.
 Transfer the mother to a healthcare facility

capable of providing comprehensive emergency

obstetric care for urgent caesarean section.
 Carry a delivery kit during transfer and

maintain knee chest position during transfer.

 In the comprehensive Emergency Obstetric

Care facility, deliver by emergency caesarean

section if the baby is alive and the patient is
not in second stage of labour.
If the cord is pulsating and patient is in
second stage of labour:
 Rule out cephalopelvic disproportion and other

malpresentations
 If in doubt about pelvic capacity, perform

emergency caesarean section

 If pelvis and presentation are normal, deliver by

assisted vacuum extraction ( hasten 2nd stage

by giving an episiotomy).
If the cord is not pulsating and patient is in
first or second stage of labour:
 Rule out any contraindication to vaginal

delivery (e.g. CPD, mal-presentation)

 Allow normal labour to progress & she delivers

a fresh still birth.

 Subsequent Management
 Postpartum and neonatal care as appropriate
 Counsel mother on infant feeding and care,

diet, family planning and sexual relationships

 Provide supportive counselling if baby is dead.
Precautions to take in order to
avoid complications
Apply any of the following principles prior to
definitive management:
 Avoid iatrogenic cord prolapse (correct skill for

artificial rupture of membranes –ARM )

 Remove pressure from the cord
 Keep the cord warm
 Refer promptly
 Deliver quickly
 Be prepared for neonatal resuscitation.
VASA PRAEVIA
 This condition occurs when there is a
velamentous insertion and the blood vessel
from the cord lies over the os, in front of the
presenting part. This endangers the life of the
foetus.
 Vasa praevia may be diagnosed antenatally

using ultrasound
 Vasa praevia can be felt on vaginal examination

when the membranes are still intact. A

speculum examination should be undertaken if
this is suspected
Ruptured vasa praevia
 When the membranes rupture in a case of
vasa praevia, a foetal vessel may also
rupture. This leads to exsanguination
( bloodloss to a degree sufficient to cause
death) of the foetus unless birth occurs
within minutes
 DIAGNOSIS
 Fresh vaginal bleeding, especially if it
commences at the same time as rupture of the
membranes
 Fetal compromise dispropotionate to blood loss

may be suggestive of vasa praevia

 Management of Vasa
Praevia
 inform the doctor immediately.
 Take the foetal heartbeat and, if the foetus is

alive, administer oxygen and prepare the

mother for an emergency caesarean section.
 A paediatrician should be present at the time

of delivery of the baby.

 The baby's haemoglobin level should be

estimated and transfused as necessary.

 There is high mortality associated with this

condition
SHOULDER DYSTOCIA
DEFINITION: This describes the Impaction of the
anterior shoulder against the symphysis pubis
after delivery of the fetal head.
Shoulder dystocia is said to have occurred when
there is:
 Failure of the shoulder to rotate spontaneously

into anterior, posterior diameter of the pelvis

outlet after delivery of the head
 The anterior shoulder becomes trapped behind

or on the symphysis pubis while the posterior

shoulder may be in the hollow of the sacrum or
high above the sacral promontory
INCIDENCE
 Shoulder dystocia is not a common
emergency. The incidence is reported as
varying between 0.37% and 1.1%
PREDISPOSING FACTORS
Maternal:
 Abnormal pelvic anatomy
 Gestational diabetes
 Post-dates pregnancy
 Previous shoulder dystocia
 Short stature
 High pre pregnancy weight and increased

weight gain
 Abnormal pelvic anatomy
Fetal;
Suspected macrosomia
Labor related ;
◦ Assisted vaginal delivery (forceps or vacuum)
◦ Protracted active phase of first-stage labor
◦ Protracted second-stage labour
◦ Prior shoulder dystocia
DIAGNOSIS
The following signs are indicative of possible
shoulder dystocia:
◦ The shoulders fail to deliver shortly after the foetal head.
◦ The fetal head retracts against perineum (“turtle
sign”)
◦ The face of the baby becomes erythematous, red and
puffy - indicative of facial flushing.
◦ Gentle traction does not effect delivery
Warning signs
 There is slow advance of the head and
failure of the head to rotate externally
following restitution
 Slow crowning of the head
 There are difficulties in extension of the face

during delivery of the head

 There is slow restitution of the occiput to

the lateral position

MANAGEMENT OF SHOULDER
DYSTOCIA
 Shoulder dystocia is an obstetrical emergency,
with foetal demise occurring within about 5
minutes if the infant is not delivered, due to
compression of the umbilical cord within the birth
canal. Several algorithms have been proffered to
facilitate rapid delivery in case of shoulder
dystocia. The basic principles are similar.
 A common treatment algorithm is ALARMER;

which stands for:

 Ask for help. This involves requesting the help of

an obstetrician, a paediatrician for subsequent

resuscitation of the infant and anaesthesia in
case if surgical intervention.
 Leg hyper flexion (McRobert’s manoeuvre)
 Anterior shoulder disimpaction (apply

suprapubic pressure)
 Rubin manoeuvre
 Manual delivery of posterior arm
 Episiotomy
 Roll over on all fours (Gaskin Manoeuvre)
 Also commonly used is the HELPERR
Mnemonic. This is a clinical tool that offers a
structured framework for coping with shoulder
dystocia. These manoeuvres are designed to do
one of three things:
◦ Increase the functional size of the bony pelvis through
flattening of the lumbar lordosis and cephalad
rotation of the symphysis (i.e., the McRobert's
manoeuvre);
◦ Decrease the biacromial diameter (i.e., the breadth of
the shoulders) of the foetus through application of
suprapubic pressure (i.e., internal pressure on the
posterior aspect of the impacted shoulder);
◦ Change the relationship of the biacromial diameter
within the bony pelvis through internal rotation
manoeuvres.
THE HELPERR MNEMONIC
H Call for help.
 This refers to activating the pre-arranged protocol

or requesting the appropriate personnel to

respond with necessary equipment to the labor
and delivery unit.
E Evaluate for episiotomy.
 Episiotomy should be considered throughout the

management of shoulder dystocia but is

necessary only to make more room if rotation
maneuvers are required. Shoulder dystocia is a
bony impaction, so episiotomy alone will not
release the shoulder. Because most cases of
shoulder dystocia can be relieved with the
McRobert's maneuver and suprapubic pressure,
many women can be spared a surgical incision.
L Legs (the McRobert's maneuver)
 This procedure involves flexing and abducting

the maternal hips, positioning the maternal

thighs up onto the maternal abdomen. This in
effect straightens the lumbosacral lordosis,
Increases AP diameter of pelvis, Flexes the fetal
spine and as a result Reduces >40% of
shoulder dystocia.
 Nurses and family members present at the

delivery can provide assistance for this

maneuver
P Suprapubic pressure
 The hand of an assistant should be placed

suprapubically over the fetal anterior shoulder,

applying pressure in a cardiopulmonary
resuscitation style with a downward and lateral
motion on the posterior aspect of the fetal
shoulder. The aim is to adduct the anterior
shoulder. This maneuver should be attempted
while continuing downward traction. Initially
this is continuous, but may involve a rocking
motion
 E Enter maneuvers (internal rotation)
 These maneuvers attempt to manipulate the fetus to
rotate the anterior shoulder into an oblique plane and
under the maternal symphysis.
 In the Rubin maneuver, the posterior shoulder should
be approached from behind and the scapula
adducted and rotated in the direction of fetal chest to
oblique position,thus rotating the anterior shoulder
away from the symphysis pubis .
 If the above fails, the Woodscrew maneuver may be
applied. In this case the posterior shoulder is
approached from the front and gently rotated towards
the symphysis pubis to make it anterior.
 When this fails, the Reverse woodscrew maneuver
may be applied; In this instance the posterior
shoulder is approached from behind and rotated In
the opposite direction from Rubin or woodscrew
 These maneuvers can be difficult to perform
when the anterior shoulder is wedged beneath
the symphysis. At times, it is necessary to push
the fetus up into the pelvis slightly to accomplish
the maneuvers. McRobert's maneuver should
continue throughout this process.
R Remove the posterior arm.
 Removing the posterior arm from the birth canal

also shortens the bisacromial diameter, allowing

the fetus to drop into the sacral hollow, freeing
the impaction. The elbow then should be flexed
and the forearm delivered in a sweeping motion
over the fetal anterior chest wall. Grasping and
pulling directly on the fetal arm may fracture the
humerus.

R Roll the patient.
 The patient rolls from her existing position to

the all-fours position. This usually increases the

pelvic diameters. Often, the shoulder will
dislodge during the act of turning, so that this
movement alone may be sufficient to dislodge
the impaction. In addition, once the position
change is completed, gravitational forces may
aid in the disimpaction of the fetal shoulders.
MANOEUVRES OF LAST RESORT FOR
SHOULDER DYSTOCIA
Deliberate clavicle fracture
 Direct upward pressure on the mid-portion of

the fetal clavicle; reduces the shoulder-to-

shoulder distance.
Zavanelli maneuver
 Cephalic replacement followed by cesarean

delivery; involves rotating the fetal head into a

direct occiput anterior position, then flexing and
pushing the vertex back into the birth canal,
while holding continuous upward pressure until
cesarean delivery is accomplished.
 Tocolysis may be a helpful adjunct to this
procedure, although it has not been proved to
enhance success over cases in which it was not
used. 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.
Use of General anesthesia
 Musculoskeletal or uterine relaxation with

halothane (Fluothane) or another general

anesthetic may bring about enough uterine
relaxation to effect delivery. Oral or intravenous
nitroglycerin may be used as an alternative to
general anesthesia.
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.
SYMPHYSIOTOMY
 Intentional division of the fibrous cartilage of the

symphysis pubis under local anesthesia has been

used more widely in developing countries. It
should be used only when all other maneuvers
have failed and capability of cesarean delivery is
unavailable
COMPLICATIONS OF SHOULDER
DYSTOCIA:
Maternal
 Postpartum hemorrhage –commonest (11%)
 Rectovaginal fistula
 Symphysis separation or diastasis, with or

without transient femoral neuropathy

 Third- or fourth-degree episiotomy or tear with

anal sphincter damage

 Uterine rupture
 Soft tissue injuries
Fetal
 Brachial plexus palsy- commonest 3-15%
 Clavicle fracture
 Fetal death
 Fetal hypoxia, with or without permanent

neurologic damage
 Fracture of the humerus
 Prevention
 If shoulder dystocia is anticipated on the basis of risk
factors, preparatory tasks can be accomplished before
delivery. Key personnel can be alerted, and the patient and
her family can be educated about the steps that will be
taken in the event of a difficult delivery.
 The patient's bladder should be emptied, and the delivery

room cleared of unnecessary clutter to make room for

additional personnel and equipment.
 Glycaemia control and weight control for at risk patients is

also helpful in preventing foetal macrosomia. Patients may

also be encouraged to deliver in alternative positions that
favour increased pelvic diameters.
AMNIOTIC FLUID EMBOLISM
 This is a very rare catastrophic condition.
 Amniotic fluid embolism occurs when amniotic

fluid enters the maternal circulation via the

uterus or placental site
 An emboli is formed which obstructs one of the

pulmonary arteries or alveolar capillaries.

 It is associated with strong contractions, the

membranes having ruptured.

 The body responds into two phases;
In the initial phase, the pulmonary artery goes
into vaso spasm causing hypoxia, hypotension,
pulmonary oedema & cardiovascular collapse
In the second phase, there is left ventricular
failure, haemorrhage, and blood coagulation
disorders followed by pulmonary oedema
Mortality & morbidity rates are high though
early diagnosis may lead to better outcome
 Predisposing factors to
amniotic fluid embolism
 Hypertonic uterine action
 Placenta abruptio, where the barrier between

maternal circulation and amniotic sack is

breached and the placenta bed is disrupted
 Procedures like insertion of intrauterine catheter
 Rupture of membranes i.e artificial rupture of

membranes( ARM)
 Caesarean section
Signs & symptoms of amniotic fluid
embolism
 Foetal compromise
 Respiratory;
Cyanosis
Dyspnoea
Respiratory arrest
 Cardiovascular
Tachycardia
Hypotension
Pale clammy skin/ shivering
Cardiac arrest
 Signs & symptoms of amniotic
fluid embolism ctd
 Haematological
Haemorrhage from placental site
Coagulation disorders, DIC(disseminated intravascular
coagulopathy)
 Neurological
Restlessness, panic
Convulsions
Pain less likely
 Clinical signs & symptoms
 Premonitory signs & symptoms( restlessness,
abnormal behaviour, respiratory distress &
cyanosis) may occur before collapse
 Maternal hypotension
 Hypertonic uterus
 Uterine hypoxia
 Cardiopulmonary arrest
 Blood coagulopathy
 Management of Amniotic Fluid
Embolism
Emergency action:
The following procedures should be followed when
trying to manage the condition:
 Call the dr. and the resuscitation team

 Administer oxygen

 Commence resuscitation at once

 Give aminophyllin slowly to reduce bronchial

spasm
 Give fresh blood or fibrinogen to combat

hypofibrinogen anaemia
 Maintain an intake and output chart, checking on

urinary output

Complications of amniotic fluid
embolism
 DIC( disseminated intravascular
coagulopathy)
 Severe haemorrhage
 Uterine atony
 Acute renal failure
 Hypovolaemic hypotension
 Perinatal morbidity & mortality
Effect of amniotic fluid
embolism on the foetus
 Perinatal morbidity & mortality are high
where amniotic fluid embolism occurs
before birth of the baby
ACUTE INVERSION OF THE UTERUS

 This is rare but potentially life threatening

complication of the 3rd stage of labour. Occurs
in approximately 1:20,000 births
 Inversion of the uterus refers to when the

uterus has turned inside out. It occurs when the

placenta fails to detach from the uterus as it
exits, pulls on the inside surface, and turns the
organ inside out
 A midwife’s awareness of the precipitating

factors enables her to take preventive

measures to avoid this emergency
Inversion can be classified as
follows:
 First degree; where the fundus reaches the
internal os.
 Second degree; where the corpus of the

uterus is inverted to internal os.

 Third degree; where both the uterus, cervix

and vagina are inverted and rare visible at the

vagina.
Classification of inversions is also based on the
time they occur;
 Acute inversion; refers to immediate

prolapsed after delivery while the placenta is

still attached. Occurs within the first 24hrs
 Sub acute inversion; occurs after the first

24hrs & within 4 weeks

 Chronic inversion; occurs after 4 weeks & is

rare
Causes of acute uterine inversion
 Mismanagement in the 3rd stage of labour
involving excessive cord traction to manage the
delivery of the placenta actively
 Combining fundal pressure & cord traction to

deliver the placenta

 Use of fundal pressure while the uterus is atonic

to deliver the placenta

 Pathologically adherent placenta
Causes of acute uterine inversion ctd…
 Spontaneous occurrence of unknown cause
 Primiparity
 Foetal macrosomia
 Short umbilical cord
 Sudden emptying of a distended uterus
 Warning signs & diagnosis
How to diagnose acute inversion of the uterus;
 Haemorrhage between 800ml –1,880ml, which

depends on the degree of placenta adherent on the

uterine wall
 Shock due to pain, which is caused by the

stretching of peritoneal nerves and the ovaries

being pulled
 No fundus is palpable abdominally
 If inversion is partial, the fundus will not be visible

per vagina
 On vaginal examination a mass may be felt
 Management of acute uterine
inversion
 The hydrostatic method of replacement
involves the instillation of several litres of
warm saline infused though a giving set into
the vagina. The pressure of the fluid builds up
in the vagina & restores the uterus to the
normal position
 If the inversion not replaceable manually, a

cervical constriction ring may be developed.

Drugs can be given to relax the constriction &
facilitate the return of the uterus to its normal
position
BASIC LIFE SUPPORT MEASURES
 BLS refers to the maintenance of an airway &
support for breathing
 The basic principles are
AIRWAY
BREATHING
CIRCULATION
OBSTETRIC SHOCK
 Shock refers to the collapse of the circulation
system, which results in the reduction of blood
flow to the tissue. This causes dysfunction of
organs and cells. In obstetric shock, the condition
may be due to complications of pregnancy and
labour
 Classification/types of shock
 Hypovolaemic, which is as a result of
reduction in intravascular volume.
 Cardiogenic, which is due to the inability of

the heart to pump blood.

 Neurogenic; results from an insult to the

nervous system as in uterine inversion

 Septic/toxic; occurs with a severe generalized

infection
 Anaphylactic; may occur as a result of severe

allergy or drug reaction

 The causes of obstetric
shock
 Haemorrhage during pregnancy, labour and

puerperium
 Obstetric trauma such as difficult instrumental

delivery, forcible breech extraction, manual

removal of placenta or caesarean section
 Prolonged labour
 Fluid loss, for instance, excessive diuresis or

hyperemesis gravidarum
 Supine hypotensive syndrome
 Pulmonary embolism, which may dislodge and

cause oxygen deprivation

 Reaction due to blood transfusion or rugs
 Management of Hypovolaemic
Shock
 Urgent resuscitation measures should be
applied to prevent irreversible damage to the
patient.
 The first thing you should do is to maintain a

clear airway by turning her on one side. If she is

unconscious, insert an airway by turning her on
one side and administer oxygen
 Management of Hypovolaemic
Shock ctd…
 Find the source of bleeding, whenever possible
and try to stop the bleeding. Replace fluid
immediately.
 Take blood for a cross match and give blood

transfusion as and when ready.

 Meanwhile a plasma expander such as dextran,

haemocel or glucose saline (1 litre) should be

administered as soon as possible
 When the blood is ready, the first 1,200mls
should be given rapidly (within 30 minutes).
The doctor should remain with the patient
during this exercise. Avoid excessive warmth as
it will interfere with the constriction of the
peripheral blood vessels, which usually occurs
in response to shock.
 Elevate the foot of the bed by 30cm. This will
raise blood pressure 10mm Hg by gravity. This
allows the blood to flow to vital centres in the
brain.
 Hydrocortisone 100-500mg is given slowly in

cases of suparenal failure. A sedative may be

necessary in the case of restlessness to calm
an apprehensive patient.
 Septic Shock
 This is also known as endotoxic or bactereamic
shock. The main cause of septic shock is
gramnegative organism such as Escherichia coli
& Bacillus Proteus
 Drug therapy for septic
shock
 Use quick fluid therapy including glucose,
saline, Ringers lactate or whole.
 An injection of dopamine, 20mg per kilogram,

is infused in the vasodilation stage.

Hydrocortisone is given, 100mgs IV stat,
followed by 100mg six hourly until the pulse
and blood pressure are stabilised
 Antibiotics are commenced immediately after
the specimens for culture and other
investigations are completed. These include:
Gentamycin 80mg IV eight hourly
Metronidazole 500mg IV eight hourly
Ampicillin 500mg IV six hourly
 These should be administered until the bowel
sound returns. You should then continue with
400mg metronidazole orally eight hourly for
10 days

END
 OBSTETRIC
OPERATIONS
GENERAL OBJECTIVE:
 By the end of this session, the student nurse

should be able to describe and manage the

various obstetric operations
SPECIFIC OBJECTIVES:
To describe and manage clients undergoing the
following procedures/operations:
◦ Caesarean section
◦ Vacuum extraction
◦ Forceps delivery
◦ symphysiotomy
CAESAREAN SECTION
DEFINITION:
 A Caesarean section also C-section, etc., is a

surgical procedure in which one or more incisions

are made through a mother's abdomen
(laparotomy) and uterus (hysterotomy) to deliver
one or more babies, or, rarely, to remove a dead
foetus.
 Surgical delivery of a previable foetus using

Caesarean section procedures is termed

hysterotomy.
INDICATIONS OF A C/S
These may be divided into maternal, foetal or combined.
A) Maternal Indications - Definite indications
 Previous uterine scar
 Previous Lower Uterine Segment C/S due to a recurring

reason e.g. contracted pelvis or a previous scar with a

concomitant obstetric complication
 History of two (2) or more previous C/S
 After High vertical /classical C/S
 Previous ruptured uterus
 Previous myomectomy
 Severe Pre ecclampsia (PET) or eclampsia with

unfavourable cervix
 Life-threatening antepartum haemorrhage (APH) or
Placenta praevia type IIb-IV
 Contracted pelvis (congenital, fracture)
 Following repair of obstetric fistula (VVF, RVF)
 Medical illness; severe heart or respiratory disease, severe

hypertension, cerebral aneurysm, musculoskeletal

disorders, severe neurological disorders (C/S is then safer
than vaginal delivery).
 Prolonged labour, uterine inertia, cervical dystocia and

failed induction
 Pelvic tumours obstructing labour (fibroids, entrapped

ovarian tumour, genital warts)

 Invasive carcinoma of the cervix
 Infections: (HIV, active Herpes Simplex Virus II, Human

Papilloma Virus, Hepatitis B Virus)

Relative indications
C/ Section may also be considered in the following conditions
 Postdatism
 Elderly primigravida
 Prior infertility

 Bad obstetric history

B) Foetal
 Foetal distress /Poor biophysical profile score
 Malpresentation and malposition;
 Cord presentation and/or cord prolapse
 Multiple pregnancy: (1st non-cephalic, retained 2nd twin, extreme

prematurity, discordant foetal growth, single amniotic sac,

conjoined twins, >2 foetuses)
 Foetal Macrosomia: estimated weight > 4000g
 Foetal anomalies: (e.g. hydrocephalus, sacral tumour, Conjoined

twins)

C) Feto-maternal
 Failure to progress in labour
 Perimortem C/ Section
 Lack of competency by service provider in

assisted delivery techniques

Types of Caesarean Section

Based on uterine incision ;

 Lower segment section, which is the operation of

choice. The lower segment of the uterus forms

after 32 weeks gestation & is less muscular than
the upper segment of the uterus
 Classical section
 Extraperitonial caesarean section
 Caesarean hysterectomy
Advantages of lower
segment section are;
 Blood loss is minimal
 Incision is easy to repair
 The risk of rupture during labour is lessened as

the lower uterine segment has less uterine

activity
 The operation is associated with lower incidence

of postoperative infection
 Classical Caesarean
Section
The incision is made directly into the wall of
the body of the uterus. The procedure is
rarely performed
 its indications are:
Gestation of less than 32 weeks (i.e before the
lower segment has formed)
Placenta previa which is Anteriorly situated
An hour glass contraction (constriction ring)
 It is always performed through a midline
incision
 Extra Peritoneal Caesarean
Section Procedure

Access to the lower uterine segment is

secured by appropriate dissection of tissues
around the bladder to by pass the peritoneal
cavity and the baby is extracted.
As the peritoneal cavity is not disturbed there
is no risk of introducing infection from
infected liquor or infection from the uterus
 Caesarean Section
Hysterectomy

This is also known as Porro’s Operation.

 The removal of the uterus follows after

caesarean section, due to other conditions of

the uterus; such as placenta accreta, multiple
fibroids, tumours of the uterus and so on.
 On rare occasions and in conjuction with

other gynaecological disorders this operation

may be used for sterilisation purposes
 Elective Caesarean Section
 Based on timing of the operation, C Section
maybe:
◦ Elective C/S (planned procedure) or
◦ Emergency C/S
The decision to deliver by caesarean section is
made during pregnancy before the onset of labour
Some reasons for this decision are absolute while
others depend on combination of factors and the
opinion of the obstetrician
Definite indications of an elective c/section are;
◦ CPD
◦ Major degree of placenta praevia
◦ High order multiple pregnancy with three or more
foetuses
Other possible indications of an elective c/s
are;
 Breech presentation
 Moderate to severe pre-eclampsia
 A medical condition that warrants the

exclusion of maternal effort

 DM
 Intrauterine growth restriction
 APH
 Certain foetal abnormalities e.g.

hydrocephalus
If the indication for c/s pertains specifically to one
pregnancy, such as placenta praevia, vaginal
delivery may be expected on subsequent
occasions
Certain conditions warrant repeated c/s. CPD due
to contracted pelvis will recur & a uterus which
has been scared twice or more carries a greater
risk of uterine rupture
 Emergency caesarean
section
 This is carried out when adverse conditions
develop during pregnancy or labour
 The psychological preparation of the mother

for the operation is of paramount

importance. You should be prepared to deal
with the different feelings of different
mothers.
 Definite Indications of an
emergency caesarean section

 APH
 Cord prolapse
 Uterine rupture
 CPD diagnosed in labour
 Fulminating PET
 Eclampsia
 Failure to progress in the first or second stage of
labour
 Foetal compromise/distress if delivery is not
imminent
 Pre-Operative Care For Elective
Caesarean Section
The following are characteristic of pre-operative care during an
elective caesarean section:
 The doctor explains the procedure to the mother and her

partner and consent is obtained.

 Physical examination is carried out to make sure the mother is fit

for general anaesthesia

 Blood for haemoglobin, cross match and two pints of blood are

kept ready.
 Antacid therapy. It is a common practice for women with any risk

factors to receive antacid therapy throughout labour & if not

given, it should be administered immediately a decision for c/s is
made. In order to minimize the secretion of gastric acid the
anaesthetist may also prescribe preparations such as ranitidine
 Other Preoperative medications are given
 Mother is admitted and not fed overnight
 A bath is taken in the morning.
 Pubic shave is also done
 Bowel care. If c/s is elective, two glycerine
suppositories are administered on the evening b4
operation in order to empty the rectum
 A retention catheter is inserted to ensure an
empty bladder throughout the operation.
 An intravenous infusion is started as per
prescription.
 Valuables are kept safely.
 Nail polish, dentures, glasses or contact lenses
are removed.
 Theatre gown, leggings and scarf are put on the
mother.
 Pre-operative medication is usually administered

half an hour before the operation (1m atropine

and analgesic).
 Foetal heart, foetal position, and presentation are

determined.
 Maternal observations are recorded: pulse,

respiration, blood pressure and temperature.

 A urinalysis is carried out for albumin
 Post Operative Care
 This is the same care given to any woman who has
undergone a major abdominal operation.
 Observations. Bp & pulse are recorded every ¼ hour in the

immediate recovery period

 Temperature is recorded every 2 hrs
 Inspect the wound every ½ hour to detect any bloodloss
 Inspect the lochia. Drainage should be small initially
 Nurse the pt in the left lateral/recovery position until she is

fully conscious since the risk of airway obstruction or

regurgitation & silent aspiration of the stomach contents are
still present
 Analgesia is prescribed & is given as required
 Fluids are introduced gradually followed by a light diet
 The mother should breast feed as soon as her condition

permits. If for any reason she cannot breast feed, the breast
should manually be expressed from the third day to prevent
engorgement of the breasts.
 Four hourly vulva swabbing should be done if the patient is

confined to bed
 Prophylactic antibiotics should be administered to prevent

infections
 Care in the postnatal ward
 When mother & baby are transferred to the
postnatal ward, check BP, pulse & temp every
4hrs
 Ct intravenous infusion
 The urinary catheter remains in situ until the

woman is ambulant
 Observe the lochia & the wound every 4 hrs

initially
 Ensure that the mother has adequate rest
 Encourage the woman to move her legs &

perform legs & breathing exercises

 The physiotherapist should teach chest

physiotherapy
 Prophylactic low dose heparin is often

prescribed
 Monitor urinary output carefully both b4 & after
removal of catheter. Women may have difficulty
in micturition initially & the bladder may be
incompletely emptied. Any haematuria must be
reported to the doctor
 Give appropriate analgesia as frequently as

possible. Intramuscular opiates are given within

the 1st 48hrs & thereafter oral analgesics
 Observe the mother when breastfeeding &

assist where necessary

Complications
Maternal Complications
 Immediate:

◦ Anaesthetic - difficult intubation, Mendelson’s syndrome,

hypotension, spinal headache
◦ Haemorrhage – lacerations, uterine atony, placenta praevia or
accreta
◦ Complications of blood transfusion
◦ GI and urinary tract injuries
◦ Death (risk of death is 7x that of vaginal delivery)
 Late
◦ General post-op. complications; atelectasis, pneumonia, paralytic
ileus, UTI, thromboembolism
◦ Infection (endometritis, wound infection)
◦ Intestinal obstruction (adhesions especially after classical)
 ◦ Uterine scar dehiscence /rupture in subsequent
pregnancy (10x more likely in classical than LUSCS)
◦ Chronic abdominal pain
 Fetal Complications
◦ Prematurity
◦ Respiratory depression
◦ Intracranial haemorrhage (due to small incision)
INTRODUCTION TO VACUUM
EXTRACTION( VENTOUSE DELIVERY)
Younge invented the basic idea for the vacuum
extractor in 1706 when he used a glass suction cup.
In 1849, Simpson designed the instrument, but at
the time it was hardly used.
In 1774, Mostron introduced the modern vacuum
extractor.
There are opinions about the value in assisting
delivery by this method and it is rarely used these
days. However, it is still useful in remote areas
DEFINITION:
 Ventouse is a vacuum device used to assist the delivery of a

baby when the second stage of labour has not progressed

adequately. It is an alternative to a forceps delivery and
caesarean section. It cannot be used when the baby is in
the breech position or for premature births.
 This technique is also called vacuum-assisted vaginal

delivery or vacuum extraction (VE). The use of VE is

generally safe, but it can occasionally have negative effects
on either the mother and the child
 The ventouse or vacuum extractor consists of a cup which

is attached to the foetal scalp by suction, & the means of

providing the vacuum
advantages
 It does not add to the presenting diameters
 If correctly positioned brings about flexion of

the head & natural rotation

 An episiotomy may not be required.
 The mother still takes an active role in the

birth.
 No special anesthesia is required.
 The force applied to the baby can be less

than that of a forceps delivery, and leaves no

marks on the face.
 There is less potential for maternal trauma

compared to forceps and caesarean section.

disadvantages
 The operator may be too hasty in applying
traction b4 the suction has been built up, so
that the cup comes off
 The baby will be left with a temporary lump

on its head, known as a chignon.

 There is a possibility of cephalohematoma

formation
chignon
The vacuum Extractor
 Modern extractors are constructed of varied
materials including polyethylene or silastic and
stainless steel. Several features are found in all
VE designs. These include:
◦ A mushroom shaped vacuum cup of varied
composition and depth
◦ A cup including a fixed internal vacuum grid or guard
◦ A combined vacuum pump / handle or a vacuum port
to permit a vacuum hose attachment
◦ A handle, wire or chain for traction
Prerequisites for vacuum
 Informed consent
 The clinician must be competent in the use of

the vacuum extractor and knowledgeable of the

VE indications.
 The pregnancy should be term, the foetus alive

or FSB (foetal heart stopped during labour) and

in vertex presentation
 The patient should have an empty bladder

either by catheterization or spontaneous

voiding
 Full cervical dilation
 Ruptured membranes, an engaged foetal head,

and no suspicion of cephalopelvic disproportion.

Indications for vacuum delivery:

Maternal indications
 Prolonged second stage of labour (In general,

second stages of more than 2 hours without

epidural anaesthesia.
 Shortening of the second stage of labour: This

may be necessary in case of Maternal illness

(e.g. cardio-respiratory, neuromuscular,
cerebrovascular when voluntary expulsive efforts
are contraindicated); Haemorrhage; Severe Pre
eclampsia.
 Presumed foetal jeopardy/foetal distress: That is

in case of Foetal compromise necessitating

immediate delivery in 2nd stage or Non-
Contraindications to Vacuum Extraction
 Vacuum operation is contraindicated in the
following instances:
◦ Operator inexperience
◦ Inability to achieve a correct application
◦ An inadequate trial of labour
◦ Lack of a standard indication
◦ Gestational age less than 37 weeks
◦ Uncertainty concerning foetal position and station
◦ Known or suspected foetal coagulation defects
◦ Suspicion of cephalopelvic disproportion
◦ Non-vertex presentation(e.g. breech, face, brow)
◦ Absence of contractions
◦ Incomplete cervical dilation & Unengaged head
THE PROCEDURE
 The ABCEFGHIJ Mnemonic has been used to
facilitate the remembering of the steps in VE
 A: Ask for help; Address the patient (counsel on

procedure and obtain informed consent); ensure

adequate Anaesthesia as necessary
 B: BLADDER -Empty the Bladder
 C: CERVIX-Confirm that the Cervix is fully dilated
 E: Equipment and Extractor-prepare them by

ensuring that they are ready to use

 F: FLEXION POINT-Apply the vacuum cup over

sagittal suture 3cm in front of posterior Fontanel.

This is known as the “Flexion point” – (proper
application results in flexion of foetal head when
traction applied)
 G: GENTLE TRACTION-Apply Gentle traction at
right angles to plane of cup only during
contractions. Note that Bending, rotary force, or
paramedian application will cause detachment!
 H= Halt
 Further attempts at vacuum extraction should

be stopped in the following circumstances: Halt

traction after a contraction and Reduce
pressure between contractions
◦ Halt procedure if there is:
◦ Disengagement of cup 3 times
◦ No progress in 3 consecutive pulls
◦ Total time that has elapsed after application is more
than 20 minutes– foetal injuries increase after 10
minutes of application time
 I= Incision
 Evaluate for Incision (episiotomy) when the

head is being delivered. An episiotomy may not

be necessary for vacuum per se, but in case of
subsequent shoulder dystocia or difficult
 J= Jaw
It is recommended that the vacuum cup is
removed when the Jaw is reachable
Complications of vacuum extraction
These complications occur mainly due to some
degree of disproportion where the cup has been
applied for long period and forceful traction
used
 Failure of the procedure
 Trauma to the foetal scalp
 Chignon, that is, oedema and bruising where

the cup had been applied, which can

occasionally get infected
 Some babies develop cephallohaematoma
 Intracranial haemorrhage
 Necrosis of the scalp
 Aponeurotic haematoma
cephallhaematoma
INTRODUCTION TO FORCEPS
DELIVERY
 Forceps delivery is a means of extracting the
foetus with the aid of obstetric forceps when it is
inadvisable or impossible for the mother to
complete the delivery by her own effort
 This procedure is performed by a forceps which is
an instrument that has two parts that cross each
other like scissors and lock at the intersection. The
lock may be of sliding type or of screw type.
 Each part consists of a handle, a lock, a shank and
a blade.
 The blade is joined to the handle by a shank.
 The blade has two curves, cephalic curve to fit the
head, and pelvic curve that correspond with the
curved axis of the pelvis.
forceps
types of forceps
There are several types of forceps including;
 Kielland’s, Simpson’s, Wrigley’s, Neville-

Barne’s, Haig-Fwerguson’s, Milne-Murray

and Diper forceps among others.
 Simpson forceps are the most commonly used
among the types of forceps and has an elongated
cephalic curve. These are used when there is
substantial molding, that is, temporary elongation
of the fetal head as it moves through the birth
canal
 Elliot forceps are similar to Simpson forceps but
with an adjustable pin in the end of the handles
which can be drawn out as a means of regulating
the lateral pressure on the handles when the
instrument is positioned for use. They are used
most often with women who have had at least one
previous vaginal delivery because the muscles and
ligaments of the birth canal provide less resistance
during second and subsequent deliveries. In these
cases the fetal head may thus remain rounder.
 Kielland forceps are distinguished by an
extremely small pelvic curve and a sliding lock.
They are the most common forceps used for
rotation. The sliding mechanism at the
articulation can be helpful in asynclitic births
(when the fetal head is tilted to the side), since
the fetal head is no longer in line with the birth
canal
 Wrigley's forceps are used in low or outlet

delivery, when the maximum diameter is about

2.5 cm above the vulva
 Piper's forceps have a perineal curve to allow

application to the after-coming head in breech

delivery.
Types of Forceps Delivery
 Low Forceps
Today the majority of forceps delivery is
carried out when the foetal head is on the
perineal floor whereby the internal rotation
may have already occurred. This is called
outlet forceps or low forceps delivery
Mid Forceps
This is when the head is higher in the pelvis
but engaged and the greater diameter has
passed the inlet. This is known as mid
forceps.
 High Forceps
If the head is not engaged, the procedure is
termed high forceps. This is an extremely
difficult and dangerous operation. A
caesarean section is usually preferred to
mid/high forceps.
Pre-requisites for forceps
delivery
Prerequisites for forceps delivery include:
 Presentation must be suitable
 Head has to be engaged
 The pelvic outlet needs to be adequate
 Good uterine contraction
 Membranes should be ruptured
 Bladder must be empty
 Cervix must be fully dilated
procedure
 The mother is given analgesia and placed in
the lithotomy position.
 The vulva is swabbed and draped.
 Catheterisation is done.
 The physician checks the exact position of

the foetal head by vaginal examination.

 The fingers of the right hand are passed in

the vagina.
 The left blade is applied first and held by the left
hand between the fingers and thumbs of the left
hand.
 The blade is then passed between the head and

the palm or surface of the right fingers. The

handle is carried backwards towards the middle
well over the mother’s abdomen to the right side
almost parallel with her right inguinal ligament.
 The above position of the blade will ensure the

instrument follows the directions of both the

pelvic and cephalic curve.
 After ascertaining it lies in the correct position

next to the head, the fingers of the right hand are

withdrawn.
 Indications for use of forceps
delivery

 Delay in second stage of labour

 Foetal compromise/distress in 2nd stage of

labour
 Maternal distress/exhaustion
 Malposition e.g. OPP
 Breech presentation: forceps are usually used

to deliver the after-coming head in a

controlled fashion
 contraindications
The following are contraindications to forceps-assisted
vaginal deliveries:
 Any contraindication to vaginal delivery

 Inability to obtain adequate informed consent

 A cervix that is not fully dilated or retracted

 Inability to determine the presentation and fetal

head position
 Inadequate pelvic size

 Confirmed cephalopelvic disproportion

 Unsuccessful trial of vacuum extraction (relative

contraindication)
 Inadequate facilities and support staff
Complications of forceps delivery

Maternal complications;
 Trauma or soft tissue damage
 Haemorrhage from the above
 Dysuria or urinary retension which may

result from bruising or oedema to the

urethra
 Painful perineum
 Postnatal morbidity
neonatal complications
 Marks on the baby’s face caused by the

pressure of the forceps

 Excessive bruising from the forceps
 Facial palsy, resulting from pressure from a

blade compressing a facial nerve

 Cephalhaematoma: an effusion of blood under

the periosteum which covers the skull bones

secondary to rupture of blood vessels crossing
the periosteum
 Cerebral irritability-causing cerebral oedema or

haemorrhage
SYMPHYSIOTOMY
DEFINITION
Symphysiotomy is a surgical procedure in which
the cartilage of the pubic symphysis is divided to
widen the pelvis allowing childbirth when there is
a mechanical problem. It is also known as
pelviotomy, synchondrotomy, pubiotomy,
and Gigli's operation after Leonardo Gigli, who
invented a saw commonly used in Europe to
accomplish the operation
Indications for symphysiotomy

The most common indications are;

 a trapped head of a breech baby
 shoulder dystocia which does not resolve with

routine manoeuvres
 obstructed labour at full cervical dilation when

there is no option of a caesarean section.

Currently the procedure is rarely performed
in developed countries, but is still routine
in developing countries where caesarean
section is not always an option
 Symphysiotomy results in a temporary increase
in pelvic diameter (up to 2 cm) by surgically
dividing the ligaments of the symphysis under
local anaesthesia. This procedure should be
carried out only in combination with vacuum
extraction.
 Symphysiotomy in combination with vacuum

extraction can be a life-saving procedure in areas

of the world where caesarean section is not
feasible or immediately available.
 Complications of
symphysiotomy
 urethral and bladder injury
 Infection
 pain and
 long-term walking difficulty.

Symphysiotomy should, therefore, be carried

out only when there is no safe alternative. It
is advised that this procedure should not be
repeated due to the risk of gait problems and
continual pain

END
 MALPOSITIONS OF
THE OCCIPUT &
MALPRESENTATIONS
GENERAL OBJECTIVE:
By the end of this session, the student nurse
should be able to describe and manage the
major malpresentations of the occiput and
occipitoposterior position
SPECIFIC OBJECTIVES:
 Describe and manage the following;

i. Occipito posterior position

ii. Deep transvese arrest
iii. Breech presentation
iv. Face presentation
v. Shoulder presentation
vi. Brow presentation
vii. Compound lie
viii.Unstable lie
OCCIPITO POSTERIOR POSITION(OPP)
 OPPs are the most common type of malposition
of the occiput & occur in approximately 10% of
labours.
 Occipito posterior position is a malposition of

the occiput. In this position, the vertex is

present but it occupies the posterior position
instead of the anterior part of the pelvis. As a
consequence, the foetal head is deflexed &
larger diameters of the foetal skull present
 The occipito posterior position can be either

left or right. The cause is not clear but it is

associated with abnormalities of the pelvis.
Right (A) and left (B) occipito
posterior position
Illustration of baby in mothers womb
Showing normal presentation
 Causes
 Direct cause unknown but may be associated
with an abnormally shaped pelvis
 In an android pelvis, the forepelvis is narrow &

the occiput tends to occupy the roomier

hindpelvis. The oval shape of the anthropoid
pelvis, with its narrow transverse diameter,
favours a direct opp
 Antenatal diagnosis
Abdominal examination
 Listen to the mother. The mother may complain of

backache and she may feel that her baby’s bottom is

very high up against her ribs. She may report feeling
movements across both sides of her abdomen
 On inspection, there is a saucer-shaped depression

at or just below the umbilicus. The depression is

created by the ‘dip’ between the head & the lower
limbs of the foetus
 On palpation, the head is high, as the engaged

diameter of 11.5cm (occipito frontal) and bi parietal

cannot enter the brim until flexion takes place. The
head feels large and the occiput and sinciput are on
the same level. The back is difficult to palpate. Limbs
are felt on both sides of the abdomen
 On auscultation, the foetal heart is heard on the
right flank. It could also be heard at the
umbilicus, either at the middle line or slightly to
the left.
Diagnosis during labour
 The woman may complain of continous &
severe backache worsening with contractions.
The absence of backache does not necessarily
indicate an anteriorly positioned foetus
 There is slow descent of the presenting part in

spite of good contractions becoz the large &

irregularly shaped presenting circumference
does not fit well onto the cervix. Early rupture
of membranes also occurs & the contractions
may be incoordinate
 On vaginal examination, findings depend upon
the degree of flexion of the head. Locating the
anterior fontanelle in the anterior part of the
pelvis is diagnostic but this may be difficult if
caput succedaneum is present. The Sagittal
sutures will be in the right/left oblique of the
pelvis
 Care in labour
 In the occipito posterior position you should
expect prolonged, painful labour due to poor
fitting of the presenting part, the deflexed head
does not fit well onto the cervix therefore does
not produce optimum stimulation for uterine
contractions
 The midwife can help to provide physical

support such as massage and other comfort

measures and suggest changes of posture and
position. The all-fours position may relieve
some discomfort
Care during first stage of labour

 Pain relieving is also believed to aid in the

rotation of the foetal head. Labour is prolonged
with incoordinate uterine action.
 Give intravenous fluid to ensure that the

mother is not dehydrated

 Uterine action should be regulated by the use of
syntocinon infusion
 Keep accurate records by plotting half-hourly

observations of the foetal heart, contractions and

every four hours record blood pressure in the
partograph.
 Maintain a strict intake and output chart.
 The mother may have the urge of early pushing due

to the occiput pressing on the rectum. You should

discourage her from pushing at this stage as this
will cause the cervix to be oedematous and delay
the onset of the second stage. Encourage her to
change her position and use breathing techniques,
as these will control the urge of early pushing
 Care during second stage of labour
 The second stage/ full dilatation of the cervix should be
confirmed by vaginal examination as the caput may be
seen at the vulva with the anterior lip of the cervix.
 If head is not visible at the onset of second stage, then the
midwife could encourage the woman to remain upright. This
position may shorten the length of 2nd stage & may reduce
the need for operative delivery
 Where contractions are weak & ineffective, syntocinon
infusions may be commenced to stimulate adequate
contractions & achieve advance
 Maternal & foetal conditions are closely observed
throughout 2nd stage. Length of 2nd stage is increased in opp
& chances of c/section are high
 During labour, one of the following may occur:
 Long internal rotation
 Short internal rotation
Characteristics of Long Internal
Rotation( mechanism of right opp)
 The lie is longitudinal
 The attitude is one of deflexion
 The presentation is vertex
 The presenting part is the middle or anterior

area of the left parietal bone

 The position is right occipito posterior
 The denominator is the occiput
 The occipito frontal diameter 11.5cm lies in the

right oblique diameter of the pelvic brim. The

occiput points to the right sacroiliac joint & the
sinciput to the left iliopectineal eminence
flexion
 There is increased flexion and descent takes

place with increasing flexion. The occiput

becomes the leading part
Internal rotation of the head
 The occiput reaches the pelvic floor first &

rotates forwards 3/8 of a circle along the

right side of the pelvis to lie under the
symphysis pubis. The shoulders follow,
turning 2/8 of a circle from the left to the
right oblique diameter
Crowning
 The occiput escapes under the symphysis

pubis & the head is crowned

Extension
 The sinciput, face and chin sweep the

perineum, the head is born by extension

restitution
 the occiput turns 1/8 of a circle to the right, undoes the

twist at the neck and the head rights itself with the
shoulders
Internal rotation of the shoulders
 The shoulder enters in the same oblique diameter of

the pelvis. Anterior shoulder reaches the pelvic floor

first and rotates 1/8 of a circle forward and lies under
the symphysis pubis
External rotation of the head
 accompanies the internal rotation of the shoulders. The

occiput turns a further 1/8 of a circle to the right

Lateral flexion
 Anterior shoulder escapes under the symphysis pubis,

while the posterior shoulder sweeps the perineum &

The body is born by movement of lateral flexion
Possible course and outcomes of
labour
 As with all labours, complicated or otherwise,
the mother should be kept informed of her
progress and proposed interventions so that
she can make informed choices and give
informed consent, ensuring the optimum
outcome for herself and her baby.
Long internal rotation
 This is the commonest outcome, with good

uterine contractions producing flexion and

descent of the head so that the occiput rotates
forward 3/8 of a circle as described above
Short internal Rotation-persistent
opp
 In cases of short internal rotation or persistent
occipito posterior position, the occiput fails to
rotate forward. It persists with the same
position. The sinciput reaches the pelvic floor
first and rotates forwards, while the occiput
sinks in the hollow of the sacrum.
 The baby is born face to pubis

Cause
 Failure of flexion. The head descends without

increased flexion and the sinciput becomes the

leading part. It reaches the pelvic floor first and
rotates forwards to lie under the symphysis
pubis
diagnosis
 In first stage of labour,Signs are mainly a
deflexed head & foetal heart heard in the flank
or in the midline. Descent is slow
 In 2nd stage of labour, there is delayed 2nd

stage. On VE, the anterior fontanelle is felt

behind the symphysis pubis but a large caput
succedaneum may mask this. If the pinna of
the ear is felt pointing towards the mother’s
sacrum, this indicates a posterior position
 Thelong occipitalfrontal diameter,
11.5cm, causes considerable dilatation of
the anus & gaping of the vagina while the
foetal head is barely visible & the broad
biparietal diameter distends the
perineum & may cause excessive bulging
Management of Face to Pubis
Delivery
 The sinciput emerges first from under the
symphysis pubis & the midwife should maintain
flexion by restraining it from escaping further,
allowing the occiput to sweep the perineum &
be born first
 Give an episiotomy when necessary: You should

watch for signs of buttonhole tear due to the

large presenting diameter. A buttonhole tear is
a rupture at the centre of the perineum.
 If you failed to diagnose this earlier you may be

extending the head thinking it is a vertex

delivery, until you see the hairless forehead
escaping under the pubis arch. You should then
flex the head towards the symphysis pubis
 The mother must be kept informed of progress
and participate in decisions. Pushing at this
time may not resolve the problem; the midwife
and the woman’s partner can help by
encouraging breathing exercises . A change of
position may help to overcome the urge to bear
down.
 If an operative delivery is required for the safe

delivery of a healthy baby then the mother’s

informed consent is required/obtained
 Assisted delivery via vacuum extraction is

necessary & is associated with lower incidence

of trauma to both the mother and the infant
Deep transverse arrest
 This is where the occiput fails to rotate forward.
This forces the sinciput to reach the pelvic floor
first and rotate forwards. The occiput then goes
into the hollow of the sacrum, which results in
the face to pubis delivery. At first there is good
flexion. The occipit reaches the pelvic floor and
begins to rotate but flexion is not maintained &
the OF diameter becomes caught at the narrow
bispinous diameter of the outlet. This arrest
may be due to poor contractions, a straight
sacrum or prominent ischial spines.
diagnosis
 On vaginal examination the sagittal suture
is on the transverse diameter of the pelvis
and both anterior and posterior fontanels
are palpable.
 The head is caught at the ischial spines.
 Management of Deep
Transverse Arrest
 Reassure the mother while explaining the position of
her labour. Take her consent for the operative
procedures which will be necessary.
 Pushing at this time may not resolve the problem &
the MW should encourage on breathing exercises. A
change in position may help overcome the urge to
bear down
 Inform the doctor of her situation. Encourage her to
breathe slowly and change her position to discourage
pushing.
 A vacuum extraction may be performed or the head
may be rotated with forceps and the baby delivered.
Vacuum extraction is associated with a lower
incidence of trauma to both the mother & the infant
 Conversion to Face or Brow presentation

 At the onset of labour with a deflexed head, an

extension ocassionally occurs instead of flexion.
When there is complete extension, the baby will
be born as face presentation but when there is
incomplete extension (this is refered to as
’military attitude‘), the presenting part turns to
brow. A delivery by caesarean section is
recommended.
 This is a rare complication of posterior positions

& is more commonly found in multiparous

women
Complications associated with OPP
 Obstructed labour, as a result of deflexed or partially
extended head that is impacted in the pelvis
 Maternal trauma, as a result of prolonged labour, or

instrumental delivery causing perineum tears. In

undiagnosed OPP, instrumental delivery may cause
third degree tears
 Neonatal trauma to the baby, if forceps or vacuum

extraction are used

 Cord prolapse which may cause hypoxia, that may

result in stillbirth
 Cerebral haemorrhage, due to the compression of a

large presenting part

 Asphyxia, leading to brain damage
FACE PRESENTATION
 Face presentation occurs when the head is one
of complete extension, the occiput of the foetus
being in contact with the spine
 Incidence about <1:500 & the majority develop

during labour from vertex presentations with

the occiput posterior( secondary face
presentation). Less commonly,the face presents
before labour( primary face presentation)
 In face presentation, the denominator is the
mentum & the presenting diameters are
submentobregmatic(9.5cm) &
bitemporal(8.2cm)
 causes
Anterior obliquity of the uterus
The pendulous abdomen of a multiparous woman
leans forward resulting in the alteration of the
direction of the uterine axis. This causes the
foetal buttocks to also lean forward and the force
of the contractions to be directed in a line
towards the chin, rather than occiput, which
usually results in extension of the head.
 Causes cntd…
 Contracted Pelvis
In the flat pelvis, the head enters in the transverse
diameter of the brim & the parietal eminences
may be held up in the obstetrical conjugate, the
head becomes extended & face presentation
develops
 Polyhydramnios

If the vertex is presenting & the membranes

rupture spontaneously, the resulting rush of fluid
may cause the head to extend as it sinks into the
lower uterine segment
 Causes cntd…
Congenital Abnormality
Anencephaly can be a foetal cause of face
presentation. In a cephalic presentation, becoz
the vertex is absent, the face is thrust forward &
presents. A tumour of the foetal neck may cause
extension of the head
Abdominal and Per Vaginal Diagnosis of a
Face Presentation
Antenatal dx
 Antenatal diagnosis is rare since face

presentation develops during labour in the

majority of cases.
 A cephalic presentation in a known

anencephalic fetus may be presumed to be a

face presentation.
Intrapartum dx
 On abdominal palpation, Face presentation may

not be detected, especially if the mentum is

anterior. The occiput feels prominent, with a groove
between head and back, but it may be
mistaken for the sinciput.
 The limbs may be palpated on the side opposite
to the occiput and the fetal heart is best heard
through the fetal chest on the same side as the
limbs. In a mentoposterior position the fetal
heart is difficult to hear because the fetal chest
is in contact with the maternal spine
 On vaginal examination; The presenting part is

high, soft and irregular. When the cervix is

sufficiently dilated, the orbital ridges, eyes,
nose and mouth may be felt. Confusion
between the mouth and anus could arise,
however. The mouth may be open, and the
hard gums are diagnostic. The fetus may suck
the examining finger.
 As labour progresses the face becomes
oedematous, making it more difficult to
distinguish from a breech presentation. To
determine position the mentum must be
located; if it is posterior, the midwife should
decide whether it is lower than the sinciput; if
so, it will rotate forwards if it can advance.
 In a left mentoanterior position, the orbital

ridges will be in the left oblique diameter of the

pelvis. Care must be taken not to injure or
infect the eyes with the examining finger.
There are six positions in a face presentation,
namely:
 Right mento-posterior
 Left mento-posterior
 Right mento-lateral
 Left mento-lateral
 Right mento-anterior
 Left mento-anterior
 The denominator is the mento, the
presenting diameters are the submento
bregmatic (9.5cm) and the bi-temporal
(8.2cm).
 Mechanism of a left
mentoanterior position
 Lie is longitudinal
 Attitude is one of extension of the head and the

back
 The presentation is face
 The position is left mento anterior. In a left mento

anterior position the orbital ridges will be in the

left oblique diameter of the pelvis
 The denominator is the mentum
 The presenting part is the left molar bone
 Engagement
 Extension

Descent takes place throughout and with

increasing extension and thus the mentum
becomes the leading part
 Internal Rotation of the Head

This occurs when the chin reaches the pelvic

floor and rotates forwards 1/8 of a circle. The
chin escapes under the symphysis pubis.
 Flexion takes place and the sinciput, vertex

and occiput sweep the perineum, the head is

born
 Restitution
This occurs when the chin turns 1/8 of a circle to
the mother’s left.
 Internal Rotation of Shoulders

The shoulders enter the pelvis in the left oblique

diameter and the anterior shoulder reaches
the pelvic floor first and rotates forward 1/8 of
a circle along the right side of the pelvis.
 External Rotation of the Head
This occurs simultaneously and the chin
moves a further 1/8 of a circle to the left
 Lateral Flexion

The anterior shoulder escapes under the

symphysis pubis, the posterior shoulder
sweeps the perineum and the body is born
by a movement of lateral flexion
 Possible course & outcome of
labour
 Prolonged labour- labour is usually prolonged
because the face is an illfitting presenting part &
does not usually stimulate effective uterine
contractions
 Mentoanterior positions- with good uterine

contractions, descent & rotation of the head

occurs & labour progresses to a spontaneous
delivery
 Mentoposterior positions- if head is

completely extended, so that the mentum

reaches the pelvic floor first, & the contractions
are effective, the mentum will rotate forwards &
the position becomes anterior
 Management of Labour in Face
Presentation
First stage
 Upon diagnosing the condition the first action

you must take is to inform the doctor about the

face presentation.
 Routine maternal and foetal condition

observations are done as in normal labour

(maternal pulse, foetal heart rate and
contraction) half hourly. Blood pressure and
temperature is done two hourly.
 Care should be taken not to infect or injure the

foetal eyes during VEs

 Empty the urinary bladder every two hours.
 Vaginal examination to determine cervical

dilation and descent of the head, is done every

four hours to monitor progress of labour.
 Immediately following rupture of the membranes,

a VE should be performed to exclude cord

prolapse as such an occurrence is more likely
becoz the face is an illfitting presenting part
 In mentoposterior positions, the midwife should

note whether the mentum is lower than the

sinciput since rotation and descent depends on
this. If the head remains high despite good
uterine contractions, the mother is prepared for
caesarean section
 Management of labour cntd…
Delivery
 When the face appears at the vulva, extension

must be maintained by holding back the sinciput

& permitting the mentum to escape under the
symphysis pubis before the occiput is allowed to
sweep the perineum. This way, the
submentovertical diameter(11.5cm) distends the
vaginal orifice instead of the mentovertical
diameter(13.5cm)
 Episiotomy is performed to avoid extensive

perineal lacerations
 Complications of face presentation
 Obstructed labour; Because the face, unlike the
vertex, does not mould, a minor degree of pelvic
contraction may result in obstructed labour
 Cord prolapse; A prolapsed cord is more common

when the membranes rupture because the face is

an ill-fitting presenting part.
 Facial bruising;The baby’s face is always bruised

and swollen at birth with oedematous eyelids and

lips;
 Cerebral haemorrhage;The lack of moulding of

the facial bones can lead to intracranial

haemorrhage caused by excessive compression of
the fetal skull , in the typical moulding of the fetal
skull found in this presentation;
 Maternal trauma; Extensive perineal lacerations
may occur at birth owing to the large
submentovertical and biparietal diameters
distending the vagina and perineum.There is an
increased incidence of operative delivery,
either forceps delivery or caesarean section,
both of which increase maternal morbidity.
BREECH PRESENTATION
Breech presentation occurs in about three
percent of labour . Due to the high risks to both
the mother and the baby, the present practice
is to book all mothers with breech presentation
for caesarean section.
In breech presentation, the foetus lies with the
buttocks in the lower pole of the uterus, after
34 weeks of pregnancy
Factors contributing to breech
presentation are
 Maternal causes include contracted pelvis,
polyhydramnios and multiple pregnancy
 Foetal causes include pre-term labour,

hydrocephalus, extended legs

 Types of breech presentation &
position
 Complete breech
Foetal attitude is one of complete flexion, with hips &
knees both flexed & feet tucked in beside the buttocks
 Breech with extended legs( frank breech)

the buttocks present with the hips flexed and the legs
extended against the abdomen and chest; this is the
most common type of breech presentation
 Footling breech

Rare. One or both feet present because neither hips nor

knees are fully flexed. The feet are lower than the
buttocks
 Knee presentation

Very rare. One or both hips are extended with the knees
flexed
Causes of breech presentation
 Extended legs
 Preterm labour
 Multiple pregnancy
 Polyhydramnios
 Hydrocephaly
 Uterine abnormalities
 Placenta praevia
 Diagnosis of breech
presentation
Antenatal dx:
 Abdominal examination;
 Listen to the mother: She may tell you that she

can feel that there is something very hard and

uncomfortable under her ribs that makes
breathing uncomfortable at times. If her baby’s
feet are in the lower pole of the uterus she may
feel some very hard kicks on her bladder
 Palpation: In primigravidae, diagnosis is more

difficult because of their firm abdominal

muscles. On palpation the lie is longitudinal
with a soft presentation
 The head can usually be felt in the fundus as a
round hard mass, which may be made to move
independently of the back by balloting it with one
or both hands
 Auscultation

 When the breech has not passed through the pelvic

brim the fetal heart is heard most clearly above the

umbilicus. When the legs are extended the breech
descends into the pelvis easily. The fetal heart is
then heard at a lower level
 Ultrasound examination
 This may be used to demonstrate a breech

presentation.
 X-ray examination
 Although largely superseded by ultrasound, X-ray

has the added advantage of allowing pelvimetry to

DX during labour:
 Abdominal examination;

◦ Breech presentation may be diagnosed on admission

in labour.
 Vaginal examination
◦ The breech feels soft and irregular with no sutures
palpable, although occasionally the sacrum
may be mistaken for a hard head and the
buttocks mistaken for caput succedaneum.
The anus may be felt and fresh meconium on
the examining finger is usually diagnostic. If
the legs are extended the external genitalia
are very evident
Pre-Natal Management of Breech
Presentation
 The midwife refers the mother to a doctor at
thirty two weeks if the breech presentation
persists.
 An x-ray may be done should there be any

doubts in diagnosis. It may reveal the following:

Shape and size of the pelvis
Size of foetus
Foetal abnormalities, for example; hydrocephally
Whether the legs are extended or flexed
ANTENATAL MANAGEMENT
 If the MW suspects or detects breech
presentation at 36weeks’ gestation or later, she
should refer the woman to a doctor
 The presentation may be confirmed by

ultrasound scan or occasionally by abdominal

xray
External cephalic version(ECV)
 ECV is the use of external manipulation on the
mother’s abdomen to convert a breech to a
cephalic presentation. ECV is offered at term by
an experienced & skilled practitioner
 The success of the procedure not only depends

on the skills & experience of the practitioner, but

also the position & engagement of the foetus,
liquor volume & maternal parity
 Ecv can reduce the number of babies presenting

by breech at term by 2/3 thus reducing the

c/section rates
 Procedure of performing ECV

 Ultrasound scan is performed to localise the placenta &

confirm the position & presentation of the foetus
 A 3o minute CTG is performed to establish that the
foetus is not distressed at the start of the procedure &
maternal bp & pulse are recorded
 Patient is asked to empty the bladder. The MW assists
the patient into a comfortable supine position
 Elevate the foot of the bed to help free the breech from
the pelvic brim
 The breech is displaced from the pelvic brim towards
the iliac fossa. simultaneous force is then used as with
one hand on each pole the operator makes the foetus
perform a forward somersault
 If the woman is rhesus negative, an
injection of anti-D immunoglobulin is given
as prophylaxis against iso-immunisation
caused by any placental separation. If the
version is performed immediately prior to
the onset of labour, this should be delayed
until after delivery when the blood group of
the baby is known
 Complications of ECV
 Knotting of the umbilical cord-this should be
suspected if bradycardia occurs & persists. The
foetus is immediately turned back to a breech
presentation
 Separation of the placenta-the MW should ask

the woman to report pain or vaginal bleeding

during and after the procedure
 Rupture of the membranes-if this occurs the cord

may prolapse becoz neither the head nor breech

is engaged
 Contraindications of ECV
 Presence of a previous uterine scar
 P.E.T or hypertension- becoz of the increased risk

of placenta abruption
 Multiple pregnancy
 Oligohydramnios- becoz too much force has to be

applied directly to the foetus & the version is

likely to be unsuccessful
 Ruptured membranes
 A hydrocephalic foetus
 Any condition which would require delivery by cs
 Mechanism of Labour in a Left
Sacro Anterior (LSA) Position
 The bitrochanteric diameter (10cm) enters in the
left oblique diameter of the pelvic brim. The
sacrum points to the left ilio-pectineal eminence
Summary of LSA Position
 Position :Left Sacro-Anterior, LSA
 Lie :Longitudinal
 Attitude :Complete flexion
 Presentation :Breech
 Denominator :Sacrum
 Presenting part :Anterior left buttock
Descent
 This takes place with increasing compaction
due to increased flexion of limbs
Internal Rotation of the
Buttocks
 The anterior buttock reaches the pelvic floor
first and rotates one eighth of a circle
forwards along the right side of pelvis to lie
underneath the symphysis pubis. The
bitrochanteric diameter is now in the
antero-posterior diameter of the outlet
Lateral Flexion of the Body

 The anterior buttock escapes under the

symphysis pubis. The posterior buttock
sweeps the perineum and the buttocks are
born by a movement of lateral flexion
Restitution of the Buttock
 The anterior buttock turns slightly to the
patient’s right side
Internal Rotation of the
Shoulders
 The shoulders enter in the same oblique
diameter of the brim as the buttocks. The
anterior shoulder rotates forwards one
eighth of a circle along the right side of the
pelvis and escapes under the symphysis
pubis. The posterior shoulder sweeps the
perineum and the shoulders are born.
Internal Rotation of the Head
 The head enters in the transverse diameter
of the pelvic brim. The occiput rotates along
the left or right side of the pelvis. The sub-
occipital region (nape of the neck) impinges
under surface of the symphysis pubis
External Rotation of the Body
 The body turns so that the back is
uppermost, a movement which
accompanies internal rotation of the head.
Birth of the Head
 The chin, face and sinciput sweep the
perineum and the head is born in flexed
attitude
 Management of labour
1st stage of labour
 Basic care at this stage is same as in normal

labour. In complete breech, there is a less well-

fitting presenting part & the membranes tend to
rupture early. A VE should be performed to
exclude cord prolapse
 An epidural block(analgesia) is offered to a

woman with breech presentation as it inhibits the

urge to push prematurely
2nd stage
 Confirm full dilatation of the cervix through a
VE b4 the woman commences active pushing&
reassure the mother
 Inform the obstetrician of the onset of 2nd

stage & a paediatrician should be present at

the time of delivery
The following procedure should be followed when
delivering the complete breech:
 Mother’s buttocks are positioned at the edge of

the bed to allow the baby to hang and apply

supra-pubic pressure to the head if required
 Give episiotomy when the buttocks extend the

perineum, to avoid compression of a moulded

head
 The buttocks should be expelled by an aided

bearing down effort of the mother

 With the same contraction the baby is born up to
the umbilicus
 Pull a loop of cord to prevent traction of the cord.

The cord should be handled gently to avoid

inducing spasm and should be nipped under the
pubic arch to avoid anoxia
 Check if elbows are on the chest as is the case

with complete breech

 The midwife can assist the expulsion of the

shoulder by wrapping a small towel around the

baby's hips as it is slippery and loses heat
 Hold the baby by the iliac crest to avoid crushing

of liver and spleen

 While the uterus is contracting and the woman
pushing, the anterior shoulder escapes under
the symphysis pubis
 Elevate the buttocks to allow the posterior

shoulder to sweep the perineum

 The back should be in the uppermost position

until the shoulders are born

 As soon as the shoulders are born, let the baby

hang by its weight for one or two minutes

 Types of delivery
 Spontaneous breech delivery(SBD)- occurs
with little assistance from the attendant
 Assisted breech delivery-the buttocks are

born spontaneously, but some assistance is

required for delivery of extended legs or arms &
the head
 Breech extraction-this is a manipulative

delivery carried out usually by an obstetrician &

is performed to hasten delivery in an emergency
situation such as foetal distress
Delivery of the head
Burns marshall method
 The mw or the doctor stands facing away from the

mother, and, with the left hand,grasps the baby’s

ankles from behind with forefingers between the
two ankles and hold the stretch, applying sufficient
traction to prevent fracture of the neck
 Move the feet through an arch of 180° until the

mouth and nose are free at the vulva

 You are now holding the baby upside down and

mechanical suction can be used to clear the airway

to avoid asphyxia
 At this stage, ask the mother to pant through an

open mouth, 'breathing out the head'. One or two

minutes should elapse to allow slow delivery of the
vault
 2nd stage breech with extended
legs
 Apply downward traction until popliteal fossae
appear at the vulva
 An episiotomy is made when the buttocks extend

the perineum
 Pressure is applied at the popliteal fossae with

abduction of the thigh

 The knee will flex and this will aid extraction of

the feet and avoid fractures of lower limbs

 The foot will be swept over the baby’s abdomen
and the feet are born
 You should now wait until the baby is delivered

up to the umbilicus, pull a loop of cord

 Feel for the elbow at the chest, which should not

be felt with extended hands

Mauriceau-smellie-veit
manoeuvre
( jaw flexion & shoulder traction)
 Mainly used where there is delay in descent of

the head because of extension

 The baby is laid astride the right arm with the

palm supporting the chest. Two fingers are

inserted well back into the mouth to pull the jaw
downwards & flex the head
 2 fingers of the left hand are hooked over the

shoulders with the middle finger pushing up the

occiput to aid flexion. Traction is applied to draw
the head out of the vagina
 Delivery of extended arms
(lovset manoeuvre)
 Extended arms are diagnosed when the elbows
are not felt on the chest after the umbilicus is
born
 Prompt action should be taken to prevent

hypoxia. This can be dealt with using lovset

manoeuvre( a combination of rotation&
downwrd traction) employed to deliver the arms
whatever position they are in
 When the umbilicus is born & the shoulders are

in AP diameter, the baby is grasped by the iliac

crests with the thumbs over the sacrum.
Downward traction is applied until the axilla is
visible
 Maintain a downward traction throughout. Body
is rotated through half a circle, 180 degrees, start
by turning the back uppermost
 Friction of the posterior arm against the pubic

bone as the shoulder becomes anterior sweeps

the arm infront of the face. This movement
allows the shoulders to enter the pelvis in the
transverse diameter
 The arm which is now anterior is delivered
 Body is rotated back in the opposite direction &

the 2nd arm is delivered in a similar fashion

Causes of Delayed Breech
 Delay in the first stage is rare, though it
may be caused by impaction due to a large
baby, a small pelvis or weak contractions in
which case a caesarean section is done
 Delay during the second stage is usually

caused by extended legs

 Delay in the Birth of the Head
 If an insufficiently dilated cervix holds up the
head, the baby will make gasping movements.
 You should swap the vaginal wall in contact with

the baby’s face and inserting two fingers make a

channel through which you can meet the baby.
 If the head is arrested high in the cavity,

disproportion may exist. Suprapubic pressure

may help, but application of forceps is
necessary.The doctor will use forceps for the
delivery of the coming head.
 Complications of breech
presentation
 Impacted breech- labour becomes obstructed
when the foetus is disproportionately large for
the size of the maternal pelvis
 Cord prolapse-more common in a flexed or

footling breech
 Birth injury

◦ Superficial tissue damage

◦ Factures of the humerus, clavicle or femur or dislocation
of the shoulder or hip caused during delivery of
extended arms or legs
◦ Erb’s palsy-caused by brachial plexus being damaged
by twisting the neck
◦ Trauma to internal organs- especially a ruptured liver or
spleen produced by grasping the abdomen
◦ Damage to the adrenals- by grasping the baby’s
abdomen, leading to shock caused by adrenaline release
◦ Spinal cord damage or fracture of the spine
◦ Intracranial haemorrhage- caused by rapid delivery of the
head which has had no opportunity to mould. Hypoxia
may also cause intracranial haemorrhage
Complications cntd…
 Foetal hypoxia- due to cord prolapse or cord
compression or due to premature
separation of the placenta
 Premature separation of the placenta
 Maternal trauma
SHOULDER PRESENTATION
 Occurs when the foetus lies with its long axis
across the long axis of the uterus( transverse lie)
 Occurs in approximately 1:300 pregnancies near

term. Only 17% of these cases remain as a

transverse lie at the onset of labour, the majority
are multigravidae
 The head lies on one side of the abdomen, with

the breech at a slightly higher level on the other.

The foetal back may be anterior or posterior &
the leading part is the arm, shoulder or the trunk
Causes of shoulder presentation
 Maternal causes
◦ Lax abdominal & uterine muscles especially in
multiparity. This is the most common cause &
is found in the multigravidae
◦ Uterine abnormality eg bicornuate or
subseptate uterus as well as uterine fibroids
◦ Contracted pelvis. This may prevent the head
from entering the pelvic brim
 Causes of shoulder
presentation cntd…
 Foetal causes
◦ Preterm pregnancy: the amount of amniotic fluid in
relation to the foetus is greater, allowing the foetus
more mobility than at term
◦ Multiple pregnancy: this is due to possibility of
polyhydramnios but the presence of more than one
foetus reduces the room for manoeuvre when amounts
of liquor are normal
◦ Polyhydramnios: the distended uterus is globular & the
foetus can move freely in the excessive liquor
◦ Macerated foetus: lack of muscle tone causes the foetus
to slump down into the lower pole of the uterus
◦ Placenta praevia: may prevent the head from entering
the pelvic brim
 Diagnosis of shoulder
presentation
Antenatal
 On abdominal palpation , the uterus appears

broad & the fundal height is less than expected

for the period of gestation
 On pelvic & fundal palpation, neither head nor

breech is felt. The mobile head is found on one

side of the abdomen & the breech at a slightly
higher level on the other
 Auscultation: FHS are best heard on one side of

the umbilicus towards the foetal head

 An ultrasound scan may be used to confirm the

lie & presentation

 Intrapartum diagnosis
 On abdominal palpation, findings are as above
but with membranes ruptured, the irregular
outline of the uterus is more marked. If the
uterus is contracting strongly & becomes
moulded around the foetus, palpation is very
difficult
 On VE, the shoulder is felt as a soft irregular

mass
Note; vaginal examination should not be
performed without first excluding
placenta praevia
 In early labour, the presenting part may not be
felt. The membranes usually rupture early becoz
of the ill-fitting presenting part with a high risk of
cord prolapse
 When the cervix is sufficiently dilated particularly

after rupture of the membranes, the scapula,

acromion, clavicle, ribs and axilla can be felt.
Possible outcome
 There is no mechanism for delivery of
shoulder presentation. If this persists in
labour, delivery should be via c/section to
avoid obstructed labour & subsequent
uterine rupture
 management
Antenatal;
 Ultrasound examination to detect& rule out

placenta praevia & uterine abnormalities

 Pelvic x-ray to detect a contracted pelvis
 Plan for Elective c/section
 Admit the patient for further investigations
Intrapartum management;
 If membranes still intact, external cephalic

version may be performed. Can be done in late

pregnancy or even early in labour if the
membranes are intact and vaginal delivery is
feasible. In early labour, if version succeeded
apply abdominal binder and rupture the
membranes as if there are uterine contractions
 If membranes already ruptured spontaneously, a

VE should be done to detect possible cord

prolapse
 Emergency c/section should be performed if;

◦ The cord prolapses

◦ When membranes already ruptured
◦ When external version is unsuccessful
◦ When labour has been in progress for some hours
Mgt cntd…
Internal podalic version
 It is mainly indicated in 2nd twin of

transverse lie and followed by breech

extraction.
Prerequisites:
 General or epidural anaesthesia.
 Fully dilated cervix.
 Intact membranes or just ruptured.
 complications
 Cord prolapse
 Prolapsed arm

 Neglected shoulder presentation- the shoulder

becomes impacted, having been forced down &

wedged into the pelvic brim. The membranes have
ruptured spontaneously & if the arm has prolapsed,
it becomes blue & oedematous. The uterus goes
into a state of tonic contraction, the overstreched
lower segment is tender to touch & the foetal heart
may be absent. All the maternal signs of obstructed
labour are present & the outcome if not treated in
time is a ruptured uterus & a still birth
With adequate supervision both antenatally &
during labour, this should never occur
BROW PRESENTATION
 In brow presentation, the foetal head is partially
extended with the frontal bone, which is bounded
by the anterior fontanelle & the orbital ridges,
lying at the pelvic brim
 The presenting diameter is mentovertical

(13.5cm), which exceeds all diameters in an

average pelvis
 Occurs in 1:1000 deliveries
 Causes of brow presentation
 Maternal.These include:
◦ lax uterine muscles in multigravidae
◦ contracted pelvis.
 Fetal.These include:
◦ polyhydramnios
◦ placenta praevia.
Diagnosis of brow presentation
 On abdominal palpation, the head is high,
appers undully large & does not descend
into the pelvis despite good contractions
 On vaginal examination, the presenting part

is high & may be diffucult to reach. The

anterior fontanelle may be found on the
side of the pelvis & the orbital ridges
 Management
 Inform the doctor immediately this presentation
is suspected
 Inform the mother about the possible outcome of

labour
 Vaginal delivery is extremely rare & obstructed

labour usually results

 c/section
complications
 Same as in face presentation with marked
obstructed labour
UNSTABLE LIE

 The lie is defined as unstable when after 36

weeks’ gestation, instead of remaining
longitudinal, it varies from one examination
to another between longitudinal & oblique
or transverse
 Causes of unstable lie
Any condition in late pregnancy that increases the
mobility of the foetus or prevents the head from
entering the pelvic brim may cause this
 Maternal causes;

◦ Lax uterine muscles in multigravudae

◦ Contracted pelvis
 Foetal causes;
◦ Polyhydramnios
◦ Placenta praevia
 Management of unstable lie
Antenatal mgt;
 Admit the patient to hospital to avoid

unsupervised onset of labour. Alternatively,

advice the woman to come to hospital as soon as
labour commences
 Ultrasonography to rule out placenta praevia

Intrapartum mgt;
 Induction of labour after 36 weeks’ gestation

when lie is longitudinal. The induction is

performed by commencing an intravenous
infusion of oxytocin to stimulate contractions. A
controlled rupture of the membranes is
performed so that the head enters the pelvis
 Ensure that the woman has an empty
rectum & bladder before the procedure, as a
loaded rectum or a full bladder can prevent
the presenting part from entering the pelvis
complications
 If labour commences with a lie other than
longitudinal, the complications are the same
as for a transverse lie
COMPOUND PRESENTATION
 When a hand, or occasionally a foot, lies
alongside the head, the presentation is said to be
compound
 Occurs with a small foetus or a roomy pelvis &

seldom is difficulty encountered except in cases

where it is associated with a flat pelvis
 On rare occasions, the head, hand & foot are felt

in the vagina, a serious situation which may

occur with a dead foetus
 If diagnosed during first stage, medical aid must

be sought. If during 2nd stage the midwife sees a

hand presenting alongside the vertex, she should
try to hold the hand back
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