COMPLICATIONS

DURING LABOR
AND BIRTH
LABOR
a series of continuous, progressive contractions of the uterus
that help the cervix dilate and efface (thin out)

Labor usually starts two weeks before or after

the estimated date of delivery

L a b o r is ty p ic a lly d iv id e d
in to th r e e s ta g e s : d ila tio n
a n d e ffa c e m e n t o f th e
c e r v ix , p u s h in g a n d th e
d e liv e r y o f th e p la c e n ta .
DYSFUNCTIONAL LABOR

◦ PROLONGED LABOR
◦ Failure to progress
◦ Refers to the prolongation in the duration of labor, typically in the first
stage of labor
ETIOLOGY

◦ POWER: Dysfunctional uterine activity

◦ PASSENGER: Malpresentation, malposition, fetal anomalies
◦ PASSAGES: Uterine malformation, pelvic tumors, uterine
over distention, CPD
◦ EXTRINSIC FACTORS: Patient not in labor, sedation, anxiety,
anesthesia, unripe cervix, chorioamnionitis
CLASSIFICATION
1. Prolonged latent Phase
2. Protraction disorders:
a. Protracted active phase
b. Protracted descent
3. Arrest disorders:
a. Secondary arrest of cervical
dilatation
b. Prolonged deceleration phase
c. Arrest of descent
d. Failure of descent
DIAGNOSIS

◦ Partogram
Recording of the condition of the mother, the condition of the fetus
and progress of labor
“Story of a patient in labor”
◦ Nomogram – labor stencil, a series of curves from patient admission
cervical dilatation to 10cm
PARTOGRAPH NOMOGRAM
MANAGEMENT

◦ Oxytocin augmentation
◦ Adequate analgesia
◦ Evaluation of maternal and fetal condition
◦ Evaluation of fluid balance
◦ When above measures fail: Operative Vaginal Delivery
or Cesarean Section
DYSTOCIA
DYSTOCIA
◦ Dystocia means a slow or difficult labor or birth.
◦ Shoulder dystocia is a birth injury (also called birth trauma) that
happens when one or both of a baby’s shoulders get stuck inside the
mother’s pelvis during labor and birth
It may be associated with abnormalities
involving:

◦ Abnormalities of the Passage

◦ Abnormalities of the Passenger
◦ Abnormalities of the Powers
 SHOULDER DYSTOCIA
◦ When fetal head is delivered. But shoulders are
stuck and cannot be delivered
◦ Failure of the shoulders to traverse the pelvis
spontaneously after delivery of the head
◦ The anterior shoulder becomes trapped behind
on the symphysis pubis, whilst the posterior
shoulder may be in the hollow of the sacrum or
high above the sacral promontory
BILATERAL SHOULDER DYSTOCIA

◦ The posterior shoulder is not in the

hollow of the pelvis. This presentation
often requires a cephalic replacement
◦ Both posterior and the anterior
shoulder do not cross the pelvic brim
UNILATERAL SHOULDER DYSTOCIA

◦ Usually easily dealt with by standard

techniques
◦ The posterior shoulder enters the pelvic
cavity while the anterior shoulder
hooked behind the symphysis pubis
Predisposing Factors

◦ Fetal Macrosomia
◦ Obesity
◦ Diabetes
◦ Post Maturity
◦ Multiparity
◦ Anencephaly
 Warning Signs and Diagnosis
◦ The delivery may have been uncomplicated initially,
but the head may have advanced slowly and the
chin may have had difficulty in sweeping over the
perineum.
◦ Once the head is delivered it may look as if it is

trying to return into the vagina, which is caused

by reverse traction
◦ Diagnosed when maneuvers normally used by the

midwife fail to accomplish delivery

Turtle Sign
• Appearance and retraction of the
fetal head (analogous to a turtle
withdrawing into its shell) and
the erythematous, red puffy fac
indicative of facial flushing
Management Principles
◦ DON’T’S
◦ Do not panic!!!
◦ Do not give traction over baby’s head
◦ Do not apply fundal pressure

◦ DO’S
◦ Call for extra help
◦ Clear the infant’s mouth and nose
◦ Involve the anesthetist and pediatrician
◦ Perform episiotomy if not performed earlier
HELPERR
For Shoulder Dystocia
◦H Call for Help
◦E Evaluate for Episiotomy
◦L Legs: McRoberts Maneuver
◦P External Pressure-suprapubic
◦E Enter: Rotational Maneuver
◦R Remove the posterior arm
◦R Roll the patient to her hands and knees
 Management

◦ Pre-procedure steps and considerations

Explain procedure to patient
Follow general principles of basic care
and infection prevention
Perform Episiotomy
◦ Perform the Mc Roberts Maneuver
McRoberts Maneuver
Management

RUBIN’S MANEUVER
If the shoulder is not delivered: insert a
hand into the vagina and apply pressure to the
anterior shoulder in the direction of the baby’s
sternum to rotate the shoulder and decrease
the shoulder diameter.
If needed, apply pressure to the
posterior shoulder in the direction of the baby’s
sternum
WOOD’S MANEUVER
◦ Insert a hand into the vagina
◦ Grasp the humerus of the posterior arm
keeping the arm flexed at the elbow, sweep
the arm across the chest, grasp the hand and
deliver the entire arm.
◦ With one hand on each side of the fetal head,
apply firm continuous traction downward to
move the anterior shoulder under the
symphysis pubis
◦ CLEIDOTOMY
◦ Another option is to fracture
the baby’s anterior clavicle to
decrease the width of the
shoulder. This is done by
pressing the anterior clavicle
against the symphysis pubis
◦ After birth, facilitate urgent
and immediate newborn care
or transfer of the newborn.
ZAVANELLI MANEUVER
◦ Pushing back the delivered fetal head into the birth canal in
anticipation of performing a cesarean section in cases of
shoulder dystocia.
◦  Generally performed only after other attempts to free the
child have failed
◦ GASKIN MANEUVER
◦ Rolling the patient safely and rapidly. This is said to change the position
and dimensions of the pelvis which may help delivery of the infant
FETAL COMPLICATIONS

◦ Fetal Fractures
◦ Erb’s Palsy
◦ Perinatal Asphyxia
◦ Brachial Plexus Injury
◦ Neonatal Death - rare
MATERNAL COMPLICATIONS

◦ Postpartum Hemorrhage
◦ Vaginal Lacerations
◦ Cervical Lacerations
◦ Puerperal Infection
POST PROCEDURE CARE

◦ Repair Episiotomy
◦ If needed, provide emotional support to the
woman and family following a traumatic birth
and possible death of the newborn or injury to
the baby.
 MALPOSITIONS /
MALPRESENTATIONS

.
◦ Left and right occipital-anterior are the only
normal presentations and positions.
◦ Malposition: Occipito-posterior
◦ Malpresentations: Anything except vertex as face,
brow, breech, shoulder, cord and complex
presentations
CAUSES
1. Defects in the Powers:
-Pendulous abdomen; laxity of the abdominal muscles.
-Dextro-rotation of the uterus: rotation of the uterus in anti-
clockwise
2. Defects in the Passages
-Contracted pelvis
-Android pelvis
-Pelvic Tumor
-Uterine anomalies
-Placenta Previa
CAUSES
Defects in the Passenger
3.

-Preterm fetus
-Intrauterine Fetal Death
-Macrosomia
-Multiple Pregnancy
-Congenital Anomalies
-Polyhydramnios
-Coils of the cord around the neck which favors face
presentation
SIGNS OF SUGGESTIVE
MALPRESENTATIONS
◦ Pendulous abdomen
◦ Non-engagement of the presenting part in the last 3-4 week
in primigravida
◦ Premature rupture of membranes or its rupture early in
labor
◦ Delay in the descent of the presenting part during labor
◦ Vaginal examination, Xray or ultrasonography are more
conclusive
COMPLICATIONS OF
MALPRESENTATIONS AND
MALPOSITIONS
◦ PROM
◦ Cord presentation and prolapse
◦ Prolonged labor
◦ Obstructed labor with incidence of rupture uterus
◦ Increased incidence of instrumental and operative delivery
◦ Increased incidence of trauma to the genital; tract
◦ Increased incidence of post partum hemorrhage and puerperal
infection
◦ Increased incidence of perinatal mortality
OCCIPITO-POSTERIOR POSITION

◦ A vertex presentation with fetal back

directed posteriorly
◦ Incidence: 10% at onset of labor
MANAGEMENT

1. CESAREAN SECTION
The pelvis should be reassessed and if the pelvis is android
or there is evidence of disproportion CS should be done
To avoid intracranial hemorrhage due to traumatic
vaginal delivery
MANAGEMENT
 FACE PRESENTATION
◦ A cephalic presentation where the attitude is
one of complete extension, presenting part is
the face (area between chin and glabella) and
denominator is the chin or mentum.
◦ Primary face presentation: present before the
onset of labor and are rare
◦ The chin serves as the reference point in
describing the position of the head
BROW PRESENTATION
◦ It is the least common among cephalic
presentation and most unfavorable
◦ The presenting diameter is verticomental 13.5
cm which is largest of fetal head
◦ The cause is similar to face presentation and
include any factor that interferes with flexion
of the head
SHOULDER PRESENTATION
◦ It is transverse lie in which the
long axis of the fetus is
perpendicular (90%) to long axis
of mother
◦ Shoulder of baby comes in the
lower segment of uterus
MANAGEMENT

◦ In modern practice, persistent transverse lie in labor

is delivered by CESAREAN SECTION whether the
fetus is alive or dead
COMPOUND PRESENTATION
◦ Occurs when a extremity (usually an arm less
commonly lower limb) prolapses alongside the
presenting part
◦ Both the prolapsed arm and the fetal head
present in the pelvis simultaneously

◦ SUSPECT COMPOUND PRESENTATION WHEN:

1. Active labor is arrested
2. The fetus fail to engage
3. The prolapsed extremity is palpated directly
MANAGEMENT
1. Don’t manipulate the prolapsed extremity.
◦ Spontaneous delivery in 75% of vertex / upper extremity presentation
◦ Do continuous FHR monitoring because of associated occult cord prolapse

2. Reduce the extremity if:

Prolapse extremity prevent descent of fetus gently reduce by pushing it
upward above the pelvic brim and hold it until a contraction pushes the head into
the pelvis

3. Do CS if:
◦ Non reassuring FHR trace
◦ Cord Prolapsed
◦ Failure of labor to progress
MULTIPLE PREGNANCY

.
MULTIPLE PREGNANCY
◦ Any pregnancy which two or more embryos or fetuses present in the
uterus at the same time
◦ Simultaneous development of two fetuses (twins) is the commonest:
although rare development of tree fetuses (triplets) four fetuses
( quadruplets) five fetuses (quintuplets) or six fetuses (sextuplets) may
also occur
◦ It is considered as a complication of pregnancy due to:
The mean gestational age of delivery of twins is approximately
36 weeks
The perinatal mortality and morbidity increase
FACTORS THAT INFLUENCE
TWINNING
◦ Race
◦ Heredity
◦ Maternal age and parity.
◦ Increasing parity.
◦ Nutritional Factors
◦ Pituitary Gonadotropin
◦ Infertility Therapy
◦ Assisted Reproductive Technology
TWINS PREGNANCY
◦ Varieties
DIZYGOTIC TWINS; most commonest (2/3) and results from
the fertilization of two ova
Results from fertilization of two ova leading to fraternal twin
MONOZYGOTIC TWINS (1/3) results from the fertilization of
single ovum
Results from fertilization of one ova leading to identical twin
GENESIS OF DIZYGOTIC TWINS
◦ Fertilization of more than one egg by more than one sperm
◦ Results from fertilization of two ova, most likely rupture from
two distinct graafian follicles usually of the same or one from
each ovary, by two sperms during single ovarian cycle
◦ There are two placenta either completely separated or more
commonly fused at the margin
◦ Each fetus is surrounded by a separate amnion and chorion
◦ Sex of the fetus may differ (Non-identical)
◦ Genetic features (blood group, finger prints) also differs
MONOZYGOTIC TWINS

◦ Twins that developed by a single zygote

◦ Not affected by heredity
◦ Not related to induction of ovulation
◦ Constitutes 1/3 of twins
◦ These twins are multiple gestations resulting
from cleavage of a single, fertilized ovum
DIAGNOSIS
◦ Family history of twinning (maternal side)
◦ History of ovulation inducing drugs
◦ Abdominal Examination
a. Elongated shape of normal pregnant uterus is changed to a more
barrel shape and the abdomen is unduly enlarged
b. Height of the uterus is more than gestation age
c. Palpation of too many fetal parts
d. Finding two fetal heads
e. Two distinct fetal heart sounds at separate spots with a silent area
in between
Diagnosis
◦ Sonography
- Separate gestational sacs can b identified early in twin
pregnancy
- @ fetal heads or 2 abdomens should be seen in the
same plane
◦ Biochemical Test
- Amounts of Chorionic Gonadotrophin in plasma and in
urine are higher than those found with a singleton pregnancy
SYMPTOMS
◦ Minor ailments of normal pregnancy are often
exaggerated
◦ Increased nausea and vomiting in early months

◦ Palpitations, shortness of breath

◦ Tendency of swelling of legs, varicose veins and

hemorrhoids is greater
◦ Unusual rate of abdominal enlargement and

excessive fetal movement may be noticed

Complications of Twin Pregnancy
◦ MATERNAL
a. Exaggerated early symptoms (nausea, vomiting)
b. Increase miscarriage risk
c. Malpresentation
d. Increased minor disorders of pregnancy (backache, leg pain,
hemorrhoids, palpitations, dyspnea)
e. Anemia and placenta previa
f. Preterm labor and delivery
g. Risk of hypertensive diseases
h. Ante-partum hemorrhage
Complications of Twin Pregnancy
◦ DURING LABOR
a. PROM
b. Cord prolapse
c. Prolonged labor
d. Bleeding intrapartum (IPH) and post partum (PPH)
◦ DURING PUERPERIUM
a. Subinvolution
b. Increased risk of infections
c. Lactation failure
Complications of Twin Pregnancy

◦ FETAL
a. Still birth / neonatal death
b. Abortion
c. Single fetal death in twin pregnancy
d. IUGR
e. SGA (small for gestational age)
f. Higher risks of congenital anomalies
 CONGENITAL ANOMALIES IN
TWIN PREGNANCY
1.Neural Tube Defects
2.Cardiac anomalies
3.Bowel Atresia
4.Conjoint twins
5.TRAP sequence (Twin Reversed Arterial Perfusion)
ACARDIAC TWIN
◦ Twin reversed arterial perfusion
(TRAP) sequence is a rare (1 in 35,
000 births) but serious
complication of monochorionic,
monozygotic multiple gestation.
◦ There is usually a normally formed
donor twin who has features of
heart failure as well as recipient
twin who lacks a hear
(acardius)and other various other
structures
DISCORDANT TWINS

◦ Size inequality of twin fetuses which may be a

sign of pathological growth restriction in one
fetus, calculated using the larger twin as the
index
◦ Restricted growth of one fetus usually develops
late in 2nd and 3rd trimester
VANISHING TWIN & ABORTION
◦ Spontaneous cessation of cardiac activity in a
previously viable fetus of a multiple gestation
– VANISHING TWIN
◦ When fetal death occur after the first
trimester, results in a thin parchment like
body called FETUS PAPYRACEOUS
◦ Diagnosis made after delivery
◦ No effect on mother or the viable fetus
MANAGEMENT: ANTENATAL

◦ Routine screening for hypertension and

gestational diabetes
◦ Routine supplementation of Iron and Folic
Acid due to increased demand
◦ Fetal assessment (fetal lie, measurements and
activity, AFI)
MANAGEMENT:INTRAPARTUM

◦ Vaginal birth if cephalic is the presenting part

◦ VERTEX-VERTEX DELIVERY
The first twin is delivered in the same way as for
singleton.
After delivery, abdominal examination for the lie of the
second twin should be done
Amniotomy is performed and if delivery doesn’t take
place between 5-10 minutes there is augmentation of labor
with oxytocin infusion
PRECIPITOUS LABOR

.
PRECIPITOUS LABOR
◦ Rapid labor describes labor that’s quick and short.
◦ Precipitous labor is when the baby comes within
three hours of patient’s first regular contraction
◦ Typical labor lasts between six and 18 hours on
average.
SIGNS
◦ Contractions start suddenly – fast intense contractions
◦ Continuously painful and strong contractions with little to no build up in
intensity level.
◦ Patient needs an urge to push
Risk Factors for Precipitous Labor
• Patient have given birth before.
• Patient had precipitous labor before.
• The baby is on the smaller side.
• Patient’s uterus is exceptionally strong and efficient at contractions.
• Patient’s birth canal is soft and flexible.
• Patient high blood pressure.
• labor is induced with prostaglandins.
• Patient been exposed to certain drugs such as cocaine.
COMPLICATIONS
• Heavy bleeding or postpartum hemorrhage
• Shock (not enough blood and oxygen get to your organs and tissue).
• Higher risk of perineal tears and vaginal lacerations
• Retained placenta or placenta getting stuck in the uterus.
• Delivery in an unsterilized area, like a car.
• Emotional distress.
• Not receiving necessary antibiotics for certain infections (Group B
strep) before delivery, which puts your baby at risk for infection.
 MANAGEMENT
A. Check presence of an intact amniotic sac
B. Support the perineum and infant’s head
C. Assist with the actual delivery of the head
D. Coach the patient to pant/blow
E. Bulb Suction Amniotic Fluid from the Infant’s Mouth.
F. Allow Rotation
G. Check for a Nuchal Umbilical Cord.
H. Care for the Infant.
PREMATURE RUPTURE OF
MEMBRANES

.
UTERINE SAC
◦ a fluid-filled structure surrounding an embryo
during the first few weeks of embryonic development
◦ It is the first structure seen in pregnancy by
ultrasound as early as 4.5 to 5 weeks of gestational
age and is 97.6% specific for the diagnosis of
intrauterine pregnancy
◦ There are mainly two membranes of uterine sac
Chorion
Amnion
Amniotic / Uterine Sac
Function of Amniotic Sac
◦ The amniotic sac is filling with amniotic fluid,
this fluid provide protection to fetus and
function as cushion of fetus
◦ This fluid allows the fetus to move freely in
uterine cavity
◦ PRE Before time
◦ MATURE Developed
◦ RUPTURE Breakage
◦ MEMBRANE Layer
ETIOLOGY

◦ Weakening of membranes
◦ Extreme force of contraction of uterus
◦ Fetal Movement
RISK FACTORS
◦ Infection (STI, UTI, Bacterial Vaginosis, Amniotic Sac Infection)
◦ Smoking during pregnancy
◦ Previous history of PROM
◦ Previous history of Preterm labor
◦ Polyhydramnios
◦ Multiple gestation or pregnancy
◦ Hemorrhage or bleeding any time during pregnancy
◦ Invasive procedures (Amniocentesis)
◦ Cervical Insufficiency
SIGNS AND SYMPTOMS

◦ Painless leakage of fluid from vagina

◦ Due to loss of fluid fetal can easily feel through

belly
◦ Decrease uterine size

◦ Meconium present in fluid

◦ Abdominal pain

◦ Fetal heart sound altered

◦ Absence of steady labor contraction

DIAGNOSTIC EVALUATION

◦ History of collection of (previous labor,

maternal history, maternal illness)
◦ Fetal movement Assessment
◦ Fetal Position
◦ Blood analysis
COMPLICATIONS
Management According to
Classification
Fetal Age Management
Term > 37 Induction of labor.
Weeks Antibiotics if needed to prevent GBS transmission
Late 34-36 Same as for term
Preterm Weeks
Preterm 24-33 Watchful waiting
Weeks Tocolytics to prevent the beginning of labor
Magnesium Sulfate infusion for 24-48 hours.
One time dose of Corticosteroids before 34 weeks
Antibiotics needed to prevent GBS Trasnmission

Pre-viable < 24 Discussion of watchful waiting or induction of labor.

Weeks No latency antibiotics, corticosteroids, tocolysis or
MgSO4
MIDWIFERY MANAGEMENT

◦ Hospitalization of patient
◦ Evaluate patient for Labor, fetal distress,
infection
◦ Complete bed rest
◦ Observe fetal movement and fetal heart
sound
◦ Continuous assess the vital signs of mother