Chapter Six Abnormal Labour: 3/28/2023 Maternity and RH Lecture by Kusse U. 1

CHAPTER SIX
ABNORMAL LABOUR
3/28/2023 Maternity and RH Lecture by Kusse U. 1

Malpresentations and Malpositions

Introduction and Definitions
Presentation: the lowest pole of the fetus that

presents to the lower uterine segment.
Malpresentation: when the presentation is other

than the vertex, that is, breech, brow, face or shoulder.
About 95% of fetuses at term present by the vertex

(normal presentation) in labour.

Introduction…cont’d
Position is deﬁned by the relationship of the
denominator of the presenting part to points of the maternal
pelvis.
The denominator is the most deﬁnable peripheral point

in the presenting part, for example, occiput in vertex,
mentum in face and sacrum in breech presentation.

Causes of Malpresentations
Often no cause is identified but any condition

resulting in increased or decreased mobility of the
fetus predisposes to malpresentations.
These conditions are well known and fall into three

major groups (Fetal factors, Maternal factors and
placental factors)

Malpresentations…cont’d
1. Fetal factors: fetal anomalies like hydrocephalus,

multiple gestation, prematurity, Polyhaydraminos and
Oligohaydraminos.
2. Maternal factors: uterine anomalies like septate and

bicornuate uterus, contracted pelvis, submucus myoma,
grand multiparity and past history of malpresentations.
3. Placental factors: placenta previa.

1. Breech presentation
 Breech presentation is a fetal presentation where

the fetus lies longitudinally and the buttocks or
the lower extremities occupy the pelvic inlet with
the cephalic pole occupying the fundus.
 It accounts for 3-4% of all births but occurs in

15% of low birth weight (<2500gm) infants.

Breech…cont’d
 There are four types of breech presentation:
1. Frank breech presentation: the fetal hips are flexed

with extended knees so that the thighs are apposed to
the abdomen and the lower legs to the chest.
 The presenting part is the buttocks.
 It accounts for 60% - 65% of all breech presentations at

term and 40% before term.

Breech…cont’d
Frank breech
Breech…cont’d
2. Footling breech: one (single footling breech) or both

(double footling breech) hips and knees of the fetus are
extended below the level of the buttocks so that the feet
become the presenting part.
 It accounts for 25%-35% of breech presentations at
term and 50% before term.

Breech…cont’d
Footling breech (single)

Breech…cont’d
3. Knee presentation is a rare form.
 Seen in a fetus with extended thighs and flexed

knees.

Breech…cont’d
4. Complete breech presentation: both hips and knees

are flexed so that the buttocks and the feet become the
presenting part.
It accounts for 10% of all breech presentations at any

gestational age.

Breech…cont’d
Complete breech
Diagnosis
 There are no specific symptoms but occasional tightness or
discomfort in the upper abdomen may be reported.
 Obstetric palpation
 Lie is longitudinal
 The fundus contains a firm/hard, smooth and rounded

mass which dependently moves with the back
 Soft and irregular mass occupies the lower pole of the

uterus.

Diagnosis…cont’d
 Auscultation
The fetal heart beat is heard:
 Above the umbilicus if the breech is not
engaged
 Below the umbilicus if the breech is engaged

 Pelvic examination (during labour)
 Identifies the soft irregular mass with anal orifice, the
ischial tuberosities, genital groove and external
genitalia (male genitalia)
 In footling and complete breech presentation one or
both feet are felt
 When the membrane are ruptured the anal sphincter
grips the finger
 Fresh meconium seen on the examining finger
The important differential diagnosis at this point is face

presentation which should be differentiated by the presence
of the hard maxilla and if the fetus is alive the presence of
suckling.
 Ultrasonography can be done to confirm the diagnosis.

Management
I. Antepartum management
Breech presentation diagnosed before 32 weeks of

gestation should be managed expectantly with frequent follow
up to evaluate for:
 Spontaneous version to cephalic presentation at the
later weeks of gestation is likely.
 After 36 weeks the chance of spontaneous version is less

likely.

Cont’d…
If breech presentation persists beyond 36 weeks, external cephalic
version should be considered, if there is no contraindications.
This requires expertise and facilities for emergency C/S
If external cephalic version is contraindicated a decision on the

mode of delivery (vaginal breech delivery or elective C/S) has to be
made before labor starts.
For these reasons pregnant women with breech after 36 weeks

have to be referred for hospital management.

Cont’d…
 In a women considering vaginal breech delivery,

radiographic pelvimetry using x-ray, CT scan, MRI should
be performed to rule out women with borderline or
contracted pelvis b/c:
Vaginal delivery with contracted pelvis is associated

with a high rates of difficulty and significant trauma to
the mother and fetus.

Cont’d...
II. Management during labour (Intra partum)
 Patients with breech presentations are admitted to the
hospital with the onset of labor or when spontaneous
rupture of membranes occurs because of the increased
risk of umbilical cord complications.
 Upon admission, repeated ultrasound is obtained to
confirm the type of breech presentation and to ascertain
head flexion.
 All breech deliveries should ideally be conducted in a set
up with C/S facility.
Cont’d...
 Vaginal breech delivery trial should be allowed in: -
Estimated fetal weight of 2000-3500gms
Frank or complete breech with flexed head
Pelvis should be judged to be adequate with
favorable shape (with x-ray pelvimetry)
Live fetus with normal heart rate pattern or gross
malformation or dead fetus
No maternal and fetal indications for C/S

Cont’d...
 Evaluation at admission is like any laboring mother.
This confirms the diagnosis and identifies parameters

for allowing vaginal breech delivery.
Artificial rupture of membranes should not be done.

Cont’d...
First Stage of Labour

 Careful observation and warn mother not to push
 Vaginal examination should be done and fetal heart
beat checked following spontaneous rupture of
membrane to rule out cord prolapse.
 Sedation often necessary

Cont’d...
The occurrence of in-coordinate uterine action, arrest or delay
in cervical dilatation or failure of descent of breech warrants
urgent cesarean section.
There is no place for augmentation of breech presentation.
The mother should be instructed not to push till full cervical

dilatation is achieved.

Cont’d...
 In the second stage of labor, before conducting delivery,
pelvic examination should be done to confirm full cervical
dilatation.
Bladder must be emptied and the mother positioned in

lithotomy position.
Maternity and RH Lecture by Kusse U.

3/28/2023 27
Cont’d...
There are three types of vaginal breech delivery
1. Spontaneous vaginal breech delivery where the infant is

expelled entirely spontaneously without any help other
than support.
 This occurs rarely except for premature babies in a

multipara.
 It is associated with higher perinatal mortality.

Cont’d...
2. Assisted vaginal breech delivery (Partial breech
extraction)
 Where the fetus is delivered up to the level of the
umbilicus spontaneously and the rest of the body is
delivered with the assistance of the health
professional using special maneuvers.

Cont’d...
Deliver arms and shoulder by Lovset maneuver

Cont’d...
Delivery of the head by Mauriceau-Smellie-Veit maneuver

or Wigand maneuver or Pipers forceps breech_web.wmv

Cont’d...
3. Total breech extraction where the entire fetus is
delivered from the birth canal by the assistance of the
health professional.
It is associated with significant maternal and fetal

risks.
Third stage is managed actively and the genital tract

explored for tears.
3/28/2023 32
Techniques of total breech delivery
A. Delivery of the buttocks and legs
 Instruct the mother to bear down with every contraction.
 Do episiotomy when the fetal anus is visible and perineum

distended.
 Allow the breech to be delivered with out intervention up to the

level of the umbilicus.
 After the delivery of the buttocks, supporting the baby around

the hips without pulling and keeping it below the horizontal is
all that is needed.
Cont’d...
 The baby should be grasped with clean towel moistened
with warm water.
 Holding the baby around the hips avoids fetal visceral

damage.
 Ensure the anterior position of the sacrum and the back

until the lower border of the scapula is visible.

3/28/2023 34
Cont’d...
 In frank breech, if the legs can not be delivered
spontaneously, it can be assisted by splinting the medial thigh
of the fetus with the position parallel to the femur and
exerting pressure laterally so as to sweep the legs away from
the midline (Pinnard maneuver).
 Apply gentle and steady down word traction until the lower
halves of the scapula are delivered.

Cont’d...

Cont’d...

Cont’d...
B. Delivery of the arms and shoulders
 After the lower border of the scapula is visible pull a

length of umbilical cord. Ensure the back is facing to the
right or left side before delivering the arms.
 Introduce two fingers into the vagina over the chest of the
fetus and feel for both arms. If the arms are not felt it
indicates extended or nuchal arm.
 If the arms can’t be delivered spontaneously, deliver the

arms in one of the following ways:
Cont…
I. Lovset maneuver
 Holding the baby’s hip rotate the fetus by half a circle

(1800) keeping the back uppermost and applying
downward traction at the same time.
 This delivers the posterior arm, which now becomes the

anterior arm, beneath the pubic arch.

Cont….
 This may be assisted by placing one or two fingers on the

upper part of the arm flexing it, which sweeps the arm over
the chest.
 Then reverse the rotation (half a circle (1800) keeping the

back upper most to deliver the remaining arm beneath the
symphysis.

Cont….
II. Delivery of the posterior arm followed by anterior (or the
reverse)
 Put one or two fingers into the vagina over the back of the
baby.
 Slip the fingers over the shoulders, place them parallel to

the humerus and apply downward pressure to deliver the
arm.

Cont’d…

Cont’d...
C. Delivery of the head
 Allow the baby to hang until the nape of the neck or

posterior hairline is visible. Then deliver the head in
one of the following ways:-
I. Mauriceau-Smellie-Veit maneuver
II. Wigand maneuver
III. Pipers forceps

Cont’d…
 The index and middle fingers of 1 of the operator's
hands are applied over the maxilla as the body rests on
the palm and forearm of the operator.
 Two fingers of the operator's other hand are applied on

either side of the neck with gentle downward traction.
 At the same time, the body is elevated toward the pubic

symphysis, allowing for controlled delivery of the
mouth, nose, and brow over the perineum.
Cont’d…
 Ask an assistant to apply gentle supra pubic pressure by

the base of the hand.
 Pull gently to deliver the head by making an arc following

the pelvic curve.

Cont’d…
II. Wigand maneuver
 The procedure is like Mauriceau-Smellie-Veit maneuvers but

differs by:
 One hand instead of being introduced into the vagina it is

put on the supra pubic area to provide supra pubic
pressure.
 An assistant is not needed to apply supra pubic pressure.

Mauriceau Maneuver

Cont’d…
III. Pipers forceps

 Used electively or when the Mauriceau-Smellie-Veit
maneuver fails to deliver the after-coming head.
 May only be used when the cervix is completely dilated

and the head is engaged in the pelvis.

Pipers forceps

Complications
Breech presentation is associated with high maternal and
perinatal morbidity and mortality.
Maternal complications include: obstructed labor, genital

tract lacerations and increased risk of operative delivery.

Cont’d…
Fetal complications are :-
Birth anoxia due to umbilical cord prolapse and

compression
 Cerebral damage due to hypoxia
Birth injury (damage to brachial plexus, fracture of long

bones)
Intracranial hemorrhage due to trauma

Cont…
 Facial nerve paralysis due to the twisting of the
neck.
 Fracture to femur, tibia, humorous or clavicle
 Damage to spinal cord due to wrong handling
Pneumonia due to premature inspiration.
Nuchal arms

2. Face presentation
 Face presentation is a kind of cephalic presentation where

the neck of the fetus is fully extended so that the occiput lies
on the back which results in the face to present to the pelvic
canal.
 With this presentation, the head is hyperextended so that

the occiput is in contact with the fetal back, and the chin
(mentum) is presenting.

Face Presentation

Diagnosis
 Antenatal diagnosis is often difficult.
 Diagnosis is usually made in labor by vaginal examination.
 Diagnosis by Leopold maneuver is based on finding long

ovoid uterus with no bulges in the flanks, S-shaped ill
defined fetal back with marked depression between the
occiput and the back, and palpation of the cephalic
prominence on the same side at the fetal back.

 FHB is heard on the side of the feet in mento transverse

and difficult to identify in mento-posterior.
 On vaginal examination, with sufficiently dilated cervix,

feeling the orbital ridges, eyes, nose and mouth clinches
the diagnosis.

 Confusion may arise with breech presentation in

prolonged labor with edema of the presenting part.
 The mouth may be open and the hard gums are

diagnostic and the fetus may suck the examining
finger.

Management of face presentation
Follow up in the first stage of labor is like in vertex

presentation.
 Labor may be slow but as long as it is progressing nothing

special need to be done.
Exclude fetal anomalies and contracted pelvis
Episiotomy is necessary because of over distension of the

vulva.

Management…cont’d
Mento-anterior
 Suspected CPD or any other indication for CS ⇒ CS
 Grossly adequate pelvis, manage labor as vertex
anterior-SVD
 When the second stage is prolonged- Forceps
delivery can also be used.
 Vacuum delivery is contraindicated.
Mento-posterior
(I) Wait for long anterior rotation of the mentum
 Cesarean delivery if:

Suspected CPD or any other indication for CS
Persistent (no rotation or late admission)
 Early admission with rotation to mento anterior ⇒ expect

vaginal delivery

(II) Failure of long anterior rotation or development of foetal

or maternal distress at any time, is managed by:
1. Caesarean section: which is the safest and the current
alternative in modern obstetrics.
2. Manual rotation and forceps extraction as mento-
anterior , or
3. Rotation and extraction by kielland forceps.
4. Craniotomy : if the foetus is dead.

Cesarean section is indicated in the presence of big baby,
contracted pelvis, previous uterine scar like previous
cesarean section and a woman with bad obstetric history.
 Persistent mento-posterior position, poor progress of

labor and fetal distress are indications for CS.
Appropriate evaluation before or at the start of labor and

proper follow up of labor is, therefore, essential.

Complications
 Cord prolapse
 Facial bruising and swelling which disappear in one week

and 1-2 days respectively.
 Cerebral hemorrhage,
 Extensive perineal lacerations,
 Increased operative delivery and obstructed labor.

3. Brow presentation
 Brow presentation is a form of cephalic presentation in

which there is partial extension of the fetal head so that
the brow (area between the anterior fontanel and the
orbital ridges) becomes the presenting part.
 The fetal head assumes a position midway between full

flexion (occiput or vertex) and extension (face).

Brow presentation…cont’d
 Except when the fetal head is small or the pelvis is

unusually large, engagement of the fetal head and
subsequent delivery cannot take place as long as the
brow presentation persists.
 It occurs in 0.06 % of deliveries

Brow presentation

Diagnosis
During pregnancy:
 It is difficult.
 The occiput and sinciput may be felt at the same
level.
 Ultrasonography and X-ray may be helpful.

During labour:
 In addition to the previous findings, vaginal examination

reveals the following features:
Frontal bones,
Supra-orbital ridges, and
Root of the nose but not the chin.

 Finding the frontal suture, large anterior fontanel, the

orbital ridges and the base/root of the nose on vaginal
examination with dilated cervix clinches the diagnosis but
neither the mouth nor the chin is palpable.

Mechanism of labor
 The denominator is the anterior fontanel or the frontal bone.
Engagement does not occur as this diameter is larger than the

diameters of the pelvic inlet. Unless it reverts to either face or
vertex presentation, there is no mechanism of labor for brow
presentation.
Spontaneous delivery of a term brow is unlikely.
If no intervention is made the end result is obstructed labor.

Management
 In the absence of other conditions that mandate
cesarean section, determination of the pelvic capacity
and fetal size must be made.
 Emergency cesarean section is indicated for

 Macrosomia and
 Contracted pelvis.

 In early labor, in the absence of such conditions,
management is expectant. This is based on the
assumption that a brow may spontaneously revert to
face or vertex, which occurs in 30 % of the cases.
 If it persists, the fetus has to be delivered by CS.
 Augmentation of labor for arrested labor is not

recommended.

4. Compound presentation
 Compound presentation is a presentation in which an
extremity (hand or foot) prolapses or descends along
side of the presenting part.
 The most common type is upper extremity prolapsing

with vertex.
 Other varieties are upper extremity with breech or

rarely lower extremity with vertex.
 Incidence is 1 in 1000 pregnancies.

4. Compound presentation…cont’d

Causes of compound presentation
 Obstetric factors that prevent descent of the
presenting part into the pelvic inlet predispose to

prolapse of an extremity alongside the presenting
part (i.e, prematurity, cephalopelvic disproportion,
multiple gestation, grand multiparity, and
hydramnios).

Diagnosis
 Is made on vaginal examination in labor by

palpating fetal extremity adjacent to the presenting
part.
 The diagnosis is usually made during labor; as the

cervix dilates, the prolapsed extremity is more easily
palpated alongside the vertex or breech.

 Compound presentation may be suspected if poor

progress in labor is noted, particularly when the
presenting part fails to engage during the active phase.
 If diagnosis is suspected but uncertain, ultrasound or

X-ray can be used to locate the position of the
extremities and search for malformations.

Management
 Management depends on:
 Viability of the fetus

Type of presentation and whether the hand or
foot is prolapsing.

 Viability of the fetus should be documented prior to
delivery since compound presentation is associated
with prematurity.
 Labor should be allowed and delivery anticipated, if

the fetus is considered non-viable, has gross
congenital malformation or is dead.

 In viable fetus, if hand is prolapsing with vertex, labor
could be allowed to continue with the hope of
spontaneous retraction of the hand as labor progresses.
 Any attempt to reduce the extremity by digital

manipulation is contraindicated. Persistent cases should
under go cesarean section.
 Vertex with foot and breech with hand are indications

for cesarean section.
 In most cases, the prolapsed part should be left

alone, because most often it will not interfere with
labor.
 If the arm is prolapsed alongside the head, the

condition should be observed closely to ascertain
whether the arm retracts out of the way with descent
of the presenting part.

 If it fails to retract and if it appears to prevent

descent of the head, the prolapsed arm should be
pushed gently upward and the head simultaneously
downward by fundal pressure.

5. Shoulder presentation
 Shoulder presentation is a presentation in which the long
axis of the fetus is at right angles to the axis of the uterus so
that the presenting part becomes the shoulder.
 A transverse lie becomes a shoulder presentation in labour.
It is the most dangerous of the fetal presentations.
 Incidence is 1:300 deliveries at term but is higher in

preterm birth.
Transverse lie

Neglected shoulder presentation

Causes
 Laxity of uterus
 Placenta previa,
 Hydraminous,
 Multiple pregnancy
 Uterine abnormality
 Preterm pregnancy

Diagnosis
 On abdominal examination
Uterus is transversely oval.
Fundal height is less than expected for the period of
gestation.
There is no fetal pole in the fundus and the pelvic
inlet.

 Vaginal examination
A very high and unreachable presenting part highly

suggests transverse lie.
In labor vaginal examination identifies the shoulders

and/or the ribs or in neglected cases the hand prolapsing
through the vulva.
 Ultrasound
 Confirms the diagnosis and identifies the possible
3/28/2023
causes. Maternity and RH Lecture by Kusse U. 88
Mechanism of labor
 Spontaneous delivery of a fully developed newborn is
impossible with a persistent transverse lie.
 After rupture of the membranes, if labor continues, the fetal

shoulder is forced into the pelvis, and the corresponding
arm frequently prolapses.
 After some descent, the shoulder is arrested by the margins

of the pelvic inlet, with the head in one iliac fossa and the
breech in the other.
Mechanism of labor…cont’d
As labor continues, the shoulder is impacted firmly in the

upper part of the pelvis.
The uterus then contracts vigorously in an unsuccessful

attempt to overcome the obstacle.
With time, a retraction ring rises increasingly higher and

becomes more marked.
With this neglected transverse lie, the uterus will

eventually rupture.
Management
 When diagnosed at antenatal clinic after 36 weeks
external version will be attempted.
 In labour cesarean section is method of choice when
attempt of external version have failed.
When membrane have ruptured before; if there is cord
prolapses, if arm prolapses even with dead fetus cesarean

section is mandatory.

External cephalic version

6. Unstable lie
 When the lie is found to vary, breech, vertex or

shoulder, presenting from one examination to another
after 36th weeks of pregnancy.
 Causes: Lax uterine muscles, Multiparty,

Polyhydraminous

Management
 Admission in hospital at the 36-37 week and remain in the
hospital until delivery.
Attempts are made by the obstetrician to correct the

abnormal presentation by external version. If unsuccessful,
cesarean section is considered.
Some times AROM is done after correcting the transverse

lie to ensure that the woman goes into labour with vertex
presentation.
Cont’d…
An oxytocic drip is usually given after version.
Extreme caution and close observation is mandatory

throughout labour.
Monitoring of Fetal Heart Beat frequently is very

important.
The bladder and the rectum should be emptied -

preservation of the longitudinal lie.

7. Umbilical cord presentation and prolapse
It is decent of the umbilical cord into the lower uterine

segment.
Prolapse of the umbilical cord to a level at or below the

presenting part exposes the cord to intermittent compression
between the presenting part and the pelvic inlet, cervix, or
vaginal canal.

Cont’d…
 Compression of the umbilical cord compromises
fetal circulation and, depending on the duration and
intensity of compression, may lead to fetal hypoxia,
brain damage, and death.

Cont’d…
It may take the following forms:
 Overt cord prolapse: presentation of the cord beyond

the cervix after rupture of the membranes, so that loop of
cod is palpable or visible during examination.
 Occult cord prolapse: with ruptured membranes the

cord has prolapsed along side the presenting part but not
in front of it. This is not palpable during vaginal
examination.
Maternity and RH Lecture by Kusse U. 98
3/28/2023
Cont’d…
Cord presentation: the cord is in front of the presenting
part with intact membranes so that it is felt through the
membranes during vaginal examination.

Incidence
Incidence varies with the type of presentation.
 For overt cord prolapse it is 0.5% in cephalic, 0.5% in

frank breech, 5 % in complete breech, 15 % in footling
breech and 20% in transverse lie.
 The incidence of occult prolapse is unknown because it

can be detected only by fetal heart rate changes characteristic
of umbilical cord compression.

Cont’d…

Causes
Any obstetric condition that predisposes to poor application
of the fetal presenting part to the cervix can result in prolapse of
the umbilical cord.
Cord prolapse is associated with prematurity (< 34 weeks'

gestation), abnormal presentations (breech, brow, compound,
face, transverse), occiput posterior positions of the head, pelvic
tumors, multiparity, placenta previa, low-lying placenta, and
cephalopelvic disproportion.

Cont’d…
In addition, cord prolapse is possible with hydramnios,

multiple gestation, or premature rupture of the membranes
occurring before engagement of the presenting part.

Diagnosis
 Overt cord prolapse can be diagnosed simply by
visualizing the cord protruding from the introitus or by
palpating loops of cord in the vaginal canal.
 The diagnosis of funic presentation is made by pelvic

examination if loops of cord are palpated through the
membranes.

Cont’d…
 Occult prolapse is rarely palpated during pelvic

examination.
 This condition can be inferred only if fetal heart rate

changes (variable decelerations, bradycardia, or both)
associated with intermittent compression of the
umbilical cord are detected during monitoring.

Cont’d…
Variable fetal heart rate decelerations will occur during
uterine contractions, with prompt return of the heart rate to
normal as each contraction subsides.
If cord compression is complete and prolonged, fetal

bradycardia occurs.
Persistent, severe, variable decelerations and bradycardia

lead to development of hypoxia, metabolic acidosis, and
eventual damage or death.
Cont’d…
 As the fetal status deteriorates, activity lessens and
eventually ceases.
 Meconium staining of the amniotic fluid may be noted

at the time of membrane rupture.

Management
Overt Cord Prolapse
 The diagnosis of overt cord prolapse demands immediate

action to preserve the life of the fetus.
 It depends on presence of cord pulsation and cervical

dilatation.
 If there is no pulsation await spontaneous delivery with or

without destructive delivery.

Cont’d…
 If pulsations are felt deliver by the fastest route (cesarean
section if cervix is not fully dilated, instrumental delivery if
it is cephalic and cervix is fully dilated, total breech
extraction if breech and cervix is fully dilated).
 Alternatively, 400–700 mL of saline can be instilled into

the bladder in order to elevate the presenting part and
relief pressure on the cord.

Cont’d…
 Note: If fetus is viable (FHB positive and cord pulsating)

until the patient is ready for cesarean section put the
patient in knee-chest position, apply continuous up ward
pressure against presenting part, put the cord inside the
vagina and give oxygen to the mother.

Occult Cord Prolapse
If cord compression patterns (variable decelerations) of the

fetal heart rate are recognized during labor, an immediate
pelvic examination should be performed to rule out overt
cord prolapse.
If occult cord prolapse is suspected, the patient should be

placed in the lateral Sims or Trendelenburg position in an
attempt to alleviate cord compression.

Cont’d…
If the fetal heart rate returns to normal, labor can be

allowed to continue, provided no further fetal insult occurs.
Oxygen should be administered to the mother, and the fetal

heart rate should be continuously monitored electronically.

Cont’d…
Amnio-infusion can be performed via an intrauterine
pressure catheter in order to instill fluid within the uterine
cavity and possibly decrease the incidence of variable
decelerations.
If the cord compression pattern persists or recurs to the

point of fetal jeopardy (moderate to severe variable
decelerations or bradycardia), a rapid cesarean section
should be accomplished.
Funic Presentation
The patient at term with funic presentation should be delivered
by CS prior to membrane rupture. However, there is no
consensus on management if the fetus is premature.
The most conservative approach is to hospitalize the patient on

bed rest in the Sims or Trendelenburg position in an attempt to
reposition the cord within the uterine cavity.

Cont’d…
Serial ultra-sonographic examinations should be

performed to ascertain cord position, presentation, and
gestational age.

Prevention and early detection
 Artificial rupture of membranes should be avoided
until the presenting part is well applied to the cervix.
 After spontaneous or artificial rupture of membranes,

careful and prompt pelvic examination should be done
to rule out cord prolapse.
 Before doing ARM, check for the presence of cord.

Occipito posterior position (OPP)
 It is a vertex presentation in which the occiput is placed

posteriorly. It can be:-
1. Right occipto-posterior (the commonest)
2. Left occipto-posterior
3. Direct occipto-posterior

Direct OPP

Left OPP

Right OPP

Causes
1. Pelvic Factors:- 50% of cases are associated with

anthropoid pelvis or android pelvis .
2.Fetal Factors:- Marked deflection of the fetal head due to

high pelvic inclination or anterior wall placenta.
3.Uterine Factor:- Abnormal uterine contraction which may

be the cause or effect .

Diagnosis
Features suggesting the diagnosis include :-
 Backache during labour
 Flattening of the abdomen below the umbilicus.
 The fetal limbs are more easily felt near the midline
on both side
 The head in unengaged and feel larger than usual.

Cont’d…
Vaginal examination :-
 Elongated bag of membrane which is likely to rupture

early.
 High deflexed head with the anterior fontanelle in the

centre of the pelvis.

Mechanism of Labour
* First and second stage of labour usually prolonged.
 Membrane usually rupture early with the hazards of

cord prolapse and infection.
 In favorable circumstances (90% of cases) good uterine

contraction result in good flexion of the head and the
occipt rotates anteriorly and deliver as occipito-anterior
position.

Management
Unless there is fetal hypoxia or other complication, labour is

allowed to proceed with the following special instructions.
 Provide adequate analgesia
 Prevent dehydration with intravenous fluid
 Promote uterine contraction with oxytocin
 Good monitoring for progress of labour, fetal and maternal

conditions

 In the majority of cases anterior rotation of the occipt

is completed and the baby is delivered as occipto-
anterior.
 Indirect occipto-posterior delivery as face to pubis

may occur, the perineum should be protected by a
generous episiotomy.

 Persistent – occipito posterior and deep transverse
arrest.
 If the fetal head is not engaged C/S is the treatment of
choice.
 If the fetal head is engaged the treatment will be one of
the following.
1) Manual rotation and delivery by forceps as occipto-
anterior.
2) Rotation to occipito-anterior and extraction using
forceps
3) Vacuum extraction
4) Caesarean section if the above lines of treatment fail

or there is other complicating factor
5) Craniotomy when the fetus is dead

MULTIPLE PREGNANCIES

Multiple pregnancies
 Definition:- pregnancy carrying more than one fetus.
 Twin pregnancy occurs approximately 1 in 100

pregnancies
 Triplets occur 1 in every 8000- 9000 pregnancies.
 Types:
1. Monozygotic (Uniovular or identical) and
2. Dizygotic (Binovular or non-identical)
Monozygotic
 Monozygotic or single ovum twins are known as identical
twins.
 Monozygotic twins develop from one ovum which has been

fertilized by one spermatozoon, always of same sex
 Most share one placenta and one chorion
 A few have two chorions and two placentas

Monozygotic…cont’d
 The fetal circulations often communicate in the placenta

which results in foeto-foetal transfusion.
 They have similar physical and mental characters as well as

the blood group but not finger prints.
 Errors in development are more likely in monozygotic

twins and conjoined twins are more common.

Locked/conjoined twins

Mechanism of twining

Monozygotic twins

Dizygotic Twins
 Dizygotic or double ova twins develop from the
fertilization of two ovum and two spermatozoa
 More common than monozygotic twins.
 These twins have two placenta may be fused to form one

amniotic sacs, two chrions and no connection between
fetal circulations.

Dizygotic…cont’d
 The babies may or may not be of the same sex and their
physical and mental characteristics can be as different as
in any members of one family.
 They have : - two placenta, -two chorions, - two

amnions, - two umbilical cords.

Difference b/n monozygotic and dizygotic twins
Monozygotic Dizygotic
One ovum Two ovum
One spermatozoa Two spermatozoa
One placenta Two placenta (may be fused)
One chorion (few have two) Two chorion
Same sex Different or same sex

Diagnosis of twin pregnancy
History
 Family history of multiple pregnancy
 Recent intake of ovulatory drugs
 Increased foetal movement
Inspection:
 More enlargement of the abdomen.

Palpation:
 Fundal level: higher than that corresponds to the

period of amenorrhea.
 Fundal grip: can detect multiple fetal poles. At

least, 3 poles should be palpated to diagnose twin
pregnancy.

Auscultation:-
 Fetal heart sounds: are heard with maximum
intensity in 2 separate points by 2 observers with
a minimum difference of 10 beats per minute.

Ultrasonography:
 At 7th week: two separate gestation sacs can be
identified.
 At 8th week: separate fetal bodies can be detected.
 At 12th week: separate heads can be distinguished.

Management of multiple pregnancies
(A) During pregnancy:
 Frequent antenatal visits: to detect early any complication

mentioned before and manage it.
 Proper diet: with prophylactic supplementation of iron and

folic acid.
 Adequate rest: to improve placental blood flow and avoid

preterm labour.

(B) During labour:

 Delivery should be in a hospital
 A team of experienced obstetrician, assistant,
anaesthetist and neonatologist is necessary for
safety.
 First stage: is managed as usual unless there is an
indication for caesarean section.

Second stage:
(I) Delivery of the first twin:
• Cephalic presentation: proceed as normal usually there is no

problem.
• Breech: C/S is safer for fear of locked twins, although

vaginal delivery may pass without this complication.
• Immediate clamping of the cord is essential after delivery of

the first twin to avoid bleeding from a uniovular 2nd twin.

(II) Delivery of the second twin:
 It depends upon its presentation;
(1) Longitudinal lie ( vertex or breech)

 Amniotomy is done during uterine contraction which
may be delayed up to 5 minutes
 If delay is more than 5 minute, start oxytocin drip.
 Delivery of the second twin is usually easy due to
dilatation of the maternal passages by delivery of the first
twin.
If there is fetal distress or cord prolapse, rapid

delivery is indicated by:
 Breech extraction in breech presentation.
 Forceps delivery in engaged vertex presentation.
 Vacuum extraction or rarely internal podalic version and

breech extraction may be indicated in non-engaged head.

(2) Transverse or oblique lie:
 External cephalic or podalic version is done then do
amniotomy and deliver the fetus as cephalic or by breech
extraction respectively or ,
 Internal podalic version and breech extraction under

general or epidural anesthesia.

Caesarean section is indicated in :
1. The first baby is transverse lie.
2. Prolapsed pulsating cord or foetal distress in the first
stage.
3. Retained second twin when it is;
• Transverse lie,
• Membranes are ruptured,
• Uterus is retracted and
• Cervix is not fully dilated

4. Conjoined twins.
5. Triplets or more are safer delivered by C.S.
6. Other indications of C.S as placenta praevia, contracted

pelvis ....etc.
Third stage of labour:

 Active management and observation is indicated to guard
against PPH.

Complications
Maternal complications of multiple pregnancies:
Anaemia and abortion;
Pregnancy-induced hypertension and pre-eclampsia;
Excess amniotic fluid;
Poor contractions during labour;
Retained placenta and postpartum haemorrhage.

Complications
Placental/fetal complications:
Placenta previa
Abruptio placentae
Placental insufficiency
Preterm delivery
Low birth weight
Malpresentation
Cord prolapse
 Congenital anomalies

COMPLICATIONS OF LABOUR

Obstructed labour
 Obstructed labour: is the failure of descent of the fetus in
the birth canal for mechanical reasons arising from either
the passage or the passenger in spite of adequate uterine
contraction.
 It is arrest of vaginal delivery of the foetus due to

mechanical obstruction.
 It is one of the major causes of maternal and perinatal

mortality in developing country.
Causes of obstructed labour
Maternal
1. Bony obstruction: contracted pelvis, tumours of

pelvic bone
2. Soft tissue obstruction: cervical dystocia, vaginal

stenosis and tumours

Causes of obstructed labour
Fetal causes
1. Malpresentations and malpositions
2. Large sized fetus (Macrosomia)
3. Congenital anomalies, e.g. Hydrocephalus
4. Locked-conjoined twins

Management of obstructed labour
(A) Preventive measures:
 Careful observation, proper assessment, early detection and

management of the causes of obstruction.
(B) Cuartive measures:
 CS is the safest method even if the baby is dead as labour
must be immediately terminated and any manipulations
may lead to rupture uterus.
**Non-operative methods like oxytocin have no place in the
management of OL.
Uterine Rupture
 Ruptured uterus: is defined as a tear in the wall of the
uterus which commonly occurs in the lower segment of
the uterus.
 Tear could be anterior, posterior, lateral or combinations

of these.
 It can be transverse, vertical or combination of these
 Mostly occur in intrapartum period

Classifications of uterine rupture
Complete (true): tear extends through the whole

thickness of the uterus, there is free communication
with peritoneal cavity.
Incomplete (occult): tear extends through the

myometrium but not through the overlying, no free
communication with the general peritoneal cavity.

Causes of uterine rupture
 Neglected obstructed labour-
commonest cause  Difficult manual removal
 Rupture or dehiscence of a of placenta
previous CS scare- 2nd
common cause  Other surgical scar on the
 Oxytocin and prostaglandin uterus (repaired ruptured
administration uterus, myomectomy)
 Difficult instrumental
 Vigorous fundal pressure
delivery
 Internal podalic version and and sharp penetrating
breech extraction trauma
Clinical pictures
Usual symptoms of impending (imminent) uterine

rupture are:
 Worsening abdominal pain especially suprapubic
pain persisting between contractions
 Strange feeling of the fetus moving upwards

Clinical pictures
Usual symptoms in ruptured uterus

 Sudden cessation of contraction and fetal movement
 Temporary relief of pain followed by diffuse,
continues abdominal pain
 Variable degree of vaginal bleeding depending on the
degree of fetal impaction
 Gross hematuria in anterior wall rupture with bladder
rupture
Management
Supportive management
 Open IV line with wide bore cannula
 Vigorous infusion of crystalloids
 Initiation of parentral antibiotics covering multiple
organisms
 Hemoglobin and blood group determination, x-matching
 Preparing at least two units of cross matched blood
 Insert NG tube and folley catheter

Management
Definitive management
 Total abdominal hysterectomy
 Sub-total abdominal hysterectomy
 Repair of the rupture with BTL

Premature Rupture of Membrane (PROM)
Rupture of the membrane after 28th week of gestation and

before the onset of labor.
Term PROM-rupture of the membrane after 37th weeks of

gestation.
Preterm PROM-rupture of the membrane before 37 weeks of

gestation.
Latency period-a period b/n rupture of membrane and the

starting of labor.
Causes
 In majority of cases no clear cause can be found
 Vaginal infection, bacterial vaginosis and group B

streptococcus
 Cervical incompetence
 Abnormal membrane

Diagnosis
History
Sudden gush of liquor fluid per vagina followed by persistent
uncontrolled leakage
Physical examination
Moist perineum with amniotic fluid seen flowing from
vagina
Speculum examination
Visualization of amniotic fluid in the vagina

Diagnosis
+Ve Nitrazin paper test

Alkaline amniotic fluid turns yellow nitrazin reagent
to blue colour. Blood, cervical mucus and alkaline
urine give false +ve results.
+ve Litmus test

Changes from red to blue is based on the alkaline
nature of the amniotic fluid.
Diagnosis
Ultrasound
Marked decrease or absent liquor
Confirm gestational age and exclude fetal anomalies

Complications
1- Preterm labour: amniotic fluid contains prostaglandins.
2- Chorioamnionitis: the amniotic fluid has bacteriostatic

properties and acts as a mechanical barrier against infection
3- Fetal sepsis
4- Lung hypoplasia, if occurs before 24 weeks

Management
The management depends mainly on the GA.
1. 36 weeks or more: IOL
2. < 36 weeks: expectant management, unless there is an

evidence of chorioamnionitis.

Chorioamnionitis
1. Maternal pyrexia >38 C
2. Tender uterus
3. Foul smelling vaginal discharge
4. Fetal tachycardia

Expectant management
 Rest in hospital.
 Early detection of Chorioamnionitis
 High vaginal swab for culture.
 Prophylactic antibiotics for 10 days.
 Prophylactic steroids e.g. Dexamethazone 6 mg IM q 12

hours for 48 hours

Post-partum Hemorrhage (PPH)

Post partum haemorrhage
 Post partum haemorrhage is a blood loss of 500 mls

or more from the genital tract after delivery of the
baby
 It is important to note that a lower level of blood loss
can cause a woman’s condition to deteriorate

Post partum haemorrhage
Primary post partum haemorrhage-

 Is excessive bleeding occurring within 24 hours of
delivery
Secondary post partum haemorrhage

 Is excessive bleeding occurring between 24 hours
after delivery to 6 weeks post partum

Primary post partum haemorrhage
CAUSES- 4T’ s
 TONE – atonic uterus (most)
 TRAUMA – tears, episiotomy, ruptured uterus
 TISSUE – retained placenta, fragments
 THROMBIN – clotting failure, coagulopathy

1. Uterine atony
Risk factors
• Over distension of uterus
• Induction of labour
• Prolonged/precipitate labour
• Anaesthesia (halogeneted) & analgesia
• Tocolytics
• APH
• Grand multiparity
• Mismanagement of 3rd stage of Labour
• Full bladder

2. Retained placenta
• Simple adhesion
• Morbid adhesion: Accreta, Increta & Percreta
3. Traumatic
• Large episiotomy & extensions
• Tears & lacerations of perineum, vagina or cervix
• Haematoma
• Uterine rupture

4. Coagulation disorders
 Abruptio placentae
 Sepsis: IUD, PROM
 Massive blood loss
 Massive blood transfusion
 Eclampsia
 Amniotic fluid embolism
 Hepatitis

Signs of shock
Early signs Late signs

• Awake, aware • Confused
• Fast breathing • Fast shallow breathing
• Fast pulse • Very fast, weak pulse
• Pale • Marked pallor
• Sweating • Cold, clammy
• Low BP • Very low BP
• Urine output 30 ml/hr • Urine output <30 ml/hr

Management
• Call for help
• Rub up a contraction
• Give oxytocic drug
• Empty bladder
• Monitor woman’s condition – ABC
• Give oxygen
• IV fluids
• Check placenta
• Check trauma
• Bimanual compression

Management of PPH
Correction of hypovolemia
 Large bore IV line (two)
 Crystalloids (RL)-3ml/ml of blood loss
 Urine output (desired) –30ml/hr
 Whole blood/pack cell

Management of PPH
Ensure uterine contraction

• Palpate fundus
• Uterine massage
• Bimanual compression
• Compression of aorta against sacral promontory
• Foleys catheters

Emergency – Uterine Atony
Bleeding does not stop after placenta is delivered. and tears are
checked. Uterus is SOFT.
• Think ahead, shout for help !
• Check vital signs
3/28/2023
Maternity and RH Lecture by Kusse U. 185
Drug given during AMSTL Emergency :

Blood loss over 500ml
Oxytocin (10 IU 5 misoprostol tablets

intramuscularly) (rectally)
3 misoprostol tablets (orally) Oxytocin

Emergency – uterine atony
• Uterine massage, expel blood

clots
• Empty (catheterize) the

bladder

3/28/2023 187
• Bimanual uterine compression
• Aortic compression
• Referral in any case!
• Blood transfusion needed?
• Stitches?
• IV Fluids?
• Manual delivery of placenta
or placenta fragments?

3/28/2023 188
Compression of Abdominal Aorta
• Apply downward pressure

with closed fist over
abdominal aorta through
abdominal wall (just above
umbilicus slightly to patient’s
left)
• With other hand, palpate
femoral pulse to check
adequacy of compression:
• Pulse palpable = inadequate
• Pulse not palpable = adequate
• Maintain compression until
bleeding is controlled
189
Atonic Uterus!
First action is to massage uterus
CONTRA-
DRUG DOSE & ROUTE CONT. DOSE MAX DOSE
INDICATION
OXYTOCIN IM 10 U OR IV 20 u in Not > 40 U No IV admin., not

IV 20 U in 1000 1,000 ml at 40 infused at rate even slow IV push
ml NS at >60 drops/min. of 0.02–0.04 unless IV fluids are
drp/min OR 5-10 U/min. running
U slow IV push
ERGO- IM OR IV Repeat 0.2 mg Five doses High BP

METRINE Slowly 0.2 mg after 15 min. if (Total 1.0 mg) Heart disease
required every
4 hours
190
Atonic Uterus (cont.)
CONT. MAX CAUTIONS &

DRUG DOSE & ROUTE
DOSE DOSE CI
MISOPROSTOL ORAL/SL 200 mg 2000 mg Asthma

(CYTOTEC) INTRAVAG Every 4 hours Heart Dis*
RECTAL
200–800 mcg
(600mcg)
PROSTAGLANDIN IM only 0.25 mg Total 8 Asthma

F2a 0.25mg Every 15 Doses=2 mg Heart Dis*
minutes
191
Management of PPH
• If no s/s of uterine atony:
• Examine vagina, perineum, cervix for tears
• Start IV infusion or oral rehydration solution (ORS) –
if woman is conscious
• Keep woman warm; elevate legs
• Ensure urination (catheterize if needed)
• Proceed with assessment

Additional Management (cont.)
• If s/s of tears:
• If extensive tears (3rd or 4th degree), facilitate urgent
referral/transfer
• If 1st or 2nd degree tears, perform repairs
• If s/s of retained placenta, perform appropriate
management to deliver placenta
• If s/s of retained placental fragments, perform appropriate
management to remove fragments

Emergency – retained placenta
Placenta does not deliver after 30 minutes despite
controlled cord traction
• There may be no bleeding on the outside, but the woman
can bleed into the uterus!
• Make sure the bladder is empty
• Repeat administration of uterotonic drugs
• DO NOT give ergometrine; it delays expulsion
• Attempt manual removal of placenta if necessary
• REFER TO HOSPITAL IMMEDIATELY!

3/28/2023 194
Retained Placenta con’t
• If you can see the placenta, ask the woman to push it out
• If you can feel the placenta in the vagina, remove it
• If the placenta is still not delivered:

• Give oxytocin 10 units IM (if not already given for AMTSL) and
attempt CCT with the next contraction
• Catheterize the bladder using aseptic technique if not already done
• If CCT unsuccessful, attempt manual removal of the placenta

Managing Retained Placenta con’t
• Ensure bladder is empty
• Apply controlled cord traction; If it fails,
• Repeat oxytocin 10u IM: If no success of CCT in 30 min:
• Attempt manual removal of placenta:
• Give Pethidine or diazepam or Ketamine
• Give antibiotics: (Ampicillin 2g + Metronidazole 500 mg)
• Perform procedure and examine placenta for completeness
• Give Oxytocin 20 U/1,000 mL NS or RL at 60 drop/minute
• Monitor BP, pulse, pad and urine output closely
• Add ergot or prostaglandin if bleeding continues
• Transfuse PRN and treat for anemia

Retained Placenta (cont.)
• If bleeding continues, ACT NOW! Facilitate urgent

referral/transfer
• If bleeding stops, continue with basic care
• 2 to 3 hours after bleeding stops, measure the woman’s
hemoglobin:
• If hgb less than 7g/dl, facilitate urgent transfer
• If hgb is 7–11g/dl, treat anemia with iron/folate
• DO NOT give ergometrine as it causes tonic contractions
• AVOID forceful CCT and fundal pressure as they may cause
uterine inversion

Manual Removal of the Placenta
 Done in the health facility

 Requires antibiotics, possibly anesthetics,
sterile gloves, catherize bladder
 Hold cord firmly downwards with one hand
 Slowly insert other hand into uterus
 With one hand in the uterus, second
hand moves from cord to holding the fundus
 Carefully detach the placenta

3/28/2023 198
Emergency – Incomplete Placenta
 Placenta is delivered but not complete; a piece of the placenta is left inside
 There may be no bleeding, but this can cause delayed PPH and later
infection !
 Make sure the bladder is empty
 Repeat administration of uterotonic drugs
 DO NOT give ergometrine; it delays expulsion
• REFER TO HOSPITAL IMMEDIATELY!
Maternity and RH Lecture by

3/28/2023 Kusse U. 199
Key Practice:
Active Management of Third Stage of Labor

(AMTSL)
AMTSL is a key evidence-based practice for

preventing postpartum hemorrhage (PPH).

AMTSL is a 3-part process
1. Administer a uterotonic drug within
one minute of the birth
2. During the next strong uterine contraction, apply

controlled cord traction to deliver the placenta

AMTSL is a 3-part process
3. After placenatal delivery, gently, but firmly massage

the uterus to stimulate contractions and decrease
vaginal blood loss

AMTSL: Uterotonics
Within one minute after delivery, palpate abdomen

to rule out the presence of another baby
1. Give ONE of the following uterotonic drugs:

• Oxytocin 10 IU IM
• Ergometrine 0.5 mg
• Ergo (0.5mg)+ Oxy (5 IU)= Syntometrine
• Misoprostol 600 mcg – 3 tablets orally

Vigilant Monitoring: The Fourth Stage of Labor
The woman's conditions should be closely monitored

after the delivery
• every 15 minutes for the first two hours;
• then hourly for hours three and four
• then four-hourly until 12 hours
3/28/2023 Maternity and RH204

Lecture by Kusse U.
During this time she needs to be checked for

• vaginal blood loss
• Pulse
• blood pressure
• firmness of her uterine fundus
• Frequent urination to (a full bladder prevents uterine
contraction)
 Mother should be clean, warm, comfortable and with her

baby
 Teach the mother about danger signs, in which case

to get help from a skilled attendant immediately.

 The mother is at greatest risk for PPH immediately after the

birth;
 A woman should be vigilantly monitored during the first hours
after birth
 The delivery of the placenta does not mark the end of risk for
bleeding, but rather may be the point when problems most
commonly begin.
 The first hours after birth are so important to the woman’s
health and survival that it is called “the fourth stage” to receive
the attention it deserves
3/28/2023 Maternity and RH207

Lecture by Kusse U.
Retained Placenta

Retained Placenta
Failure of placental delivery within 30

minutes after delivery of the fetus.

Causes
 Atony of the uterus.
 Abnormal adherence of the placenta which may be
i) Simple adhesion: Manual separation can be done

easily.

Causes
ii) Morbid adhesion:

a. Placenta accreta: chorionic villi penetrate the
superficial layer of the myometrium either partially
or completely
b. Placenta increta : The chorionic villi penetrate
deeply in the myometrium.
c. Placenta percreta: Penetration up to the peritoneal
coat.

Management
 Morbid adherence of the placenta

• Simple adhesion and partial placenta accreta:
 Manual separation is usually successful.
• Complete accreta: Hysterectomy.

Reading Assignment
Operative Deliveries

Operative deliveries
Instrumental delivery
 Forceps and vacuum deliveries constitute
instrumental delivery
 Are used to assist a laboring mother mostly in the
second stage of labour
 Except for some variations, the indications,
prerequisites and contraindications are similar
 Entirely different in the type of instrument and the
technique used to apply the instrument

Forceps delivery
 It is the means of extracting the fetus with the aid of

paired metallic instrument called obstetric forceps.
 Classifications of forceps delivery
 Based on the station and degree of rotation of the
head, forceps delivery is classified as:
 Outlet forceps
 Low forceps
 Mid forceps
 High forceps

Forceps delivery…cont’d
 Outlet forceps: head has reached the pelvic floor and is

visible at the vulva with the sagittal sutures in the antero-
posterior or one of the oblique diameter
 Low forceps: head at station +2 cm or lower but has not

reached pelvic floor

 Mid forceps: head is engaged but station is above +2. It

should be done as a trial of forceps in an operating
theatre.
 High forceps: head is above station 0 and is not engaged.

Indications
 Fetal distress in the second stage
 Prolonged second stage: inefficient uterine contraction or

maternal exhaustion or malpositions
 Maternal conditions which need shortening of the second stage,

where pushing is contraindicated like cardiac diseases,
hypertensive disorders of pregnancy and previous C/S
 After coming head of breech presentation

Pre-requisites for forceps delivery
1. Presentation must be vertex or by face with the chin

anterior
2. Head must engaged.
3. The position of the head must be known
4. The cervix must be fully dilated.
5. The membranes should be ruptured
6. Adequate pelvis

Other prerequisites include:
 Informed consent
 Emptying the urinary bladder
 Appropriate analgesia
 Adequate facilities and back up personnel
 Knowledge, experience and skill in the use of the

instrument and manage complications.

Complications of forceps delivery
1. Maternal lacerations 6. Cephalhematoma

2. Minor external ocular 7. Subaponeurotic
trauma hemorrhage
3. Retinal hemorrhage 8. Intracranial hemorrhage
4. Fetal skull fractures 9. Scalp laceration
5. Facial nerve palsies
221
Vacuum delivery
• Is an operative vaginal procedure to facilitate vaginal

delivery with an application of a cup over the fetal head
for brief duration and minimal traction forces.

Vacuum delivery

Vacuum delivery
Indications and pre-requisites
• Are generally like that for forceps delivery except for :-
face and
after –coming head

Vacuum delivery
Contra indications
1. Cephalopelvic disproportion
2. High station (above 0-station)
3. Non- vertex presentations
4. Extreme prematurity
5. Known macrosomia
6. Recent scalp blood sampling

Complications
• Scalp laceration or • Subconjunctival

bruising hemorrhage
• Subgaleal hematoma • Clavicular fracture
• Cephalhematoma • Shoulder dystocia
• Intra-cranial • Injury to 6th and 7th
hemorrhage cranial nerves
• Neonatal jaundice
226
Recommendations Regarding Vacuum Delivery
 The classification of vacuum deliveries should be the same as
that utilized for forceps
 The same indications and contraindications utilized for
forceps deliveries should be applied
 The vacuum should not be applied to an unengaged vertex,
that is, above 0 station.
 The individual performing or supervising the procedure
should be an experienced operator.
 The operator should be willing to abandon the procedure if it
does not proceed easily or if the cup pops off more than
three times.
Caesarean Section (C.S)
• An operative procedure to deliver a viable foetus or

more (i.e. after 28 weeks or 20 weeks according to
the ACOG) through an abdominal and uterine
incisions.

Indications for CS
Maternal indications
 Contracted pelvis and  Previous uterine scar as
CPD hysterotomy
 Pelvic tumours  Previous successful
 Antepartum repair of vesico-vaginal
haemorrhage fistula.
 Hypertensive disorders  Previous caesarean
with pregnancy section
 Abnormal uterine
action
Fetal indications
 Malpresentations and malposition
 Prolapsed pulsating cord or foetal distress before full

cervical dilatation.
 Diabetes mellitus
 Bad obstetric history as recurrent IUFD in last weeks

of pregnancy or repeated intranatal foetal death.
Contraindications
1- Dead foetus: except in;

• Extreme degree of pelvic contraction.
• Neglected shoulder.
• Severe accidental haemorrhage.
2- Disseminated intravascular coagulation: to minimise
blood loss.
3- Extensive scar or pyogenic infection in the
abdominal wall e.g. in burns.

Types of Caesarean Section
(A) According to timing:
1. Elective caesarean section: done at a pre-selected

time before onset of labour
2. Selective caesarean section: done after onset of

labour.

(B) According to the site of uterine incision:

• Upper segment CS (classical C.S.)- the incision is
always vertical.
• Lower segment CS (LSCS) : It is the commoner

type.

(C) According to number of the operation:
• Primary CS: for the first time.
• Repeated CS: with previous caesarean section(s).

Destructive Operations (Embryotomy)
Definition:
• These are a group of operations aims at reducing the

size of the head, shoulder girdle or trunk of the dead
foetus to allow its vaginal delivery.

Procedures
1- Craniotomy: perforation of the foetal head

(cranium).
2- Decapitation: severing of the foetal head from the

trunk
3- Spondylotomy: division of the vertebral column

Procedures
4- Evisceration: incision of the abdomen and/ or

thorax to evacuate its viscera so reducing its size and
allowing its vaginal delivery.
5- Cleidotomy: division of one or both clavicles to

reduce the biacromial diameter in shoulder dystocia
with a dead foetus.

Contraindications
 Living foetus except in certain congenital anomalies

 Extreme degree of contracted pelvis i.e. true
conjugate < 5.5 cm.
 Partially dilated cervix.
 Rupture or impending rupture uterus.
 Obstructing pelvic tumours.
 Cancer cervix with pregnancy

Complications
1. Rupture uterus
2- Injuries to the genital tract

Induction and Augmentation of
labour

Definition
Induction: implies stimulation of contractions before the
spontaneous onset of labor, with or without ruptured
membranes
Type
1. Medical - using drugs alone Syntocinon &
prostaglandin E
2. Surgical-aminiotomy or membranes sweep
3. Combined - medical & surgical.
Definition
Augmentation: refers to stimulation of

spontaneous contractions that are considered
inadequate because of failure of progressive cervical
dilatation and fetal descent.

Indications for Induction
 Prolonged pregnancy (post term pregnancy)

 Pre eclampsia, eclampsia and diabetes
 Evidence of diminished fetal well being or growth
 Gross congenital abnormality incompatible with life
 Poor obstetric history
 Placenta abruptio
 Intrauterine death

Indications for Induction
 Spontaneous / premature rupture of membrane
 Previous large baby
 Rhesus iso – immunization
 Unstable lie
 Genital herpes
 Polyhydramnios/oligohydramnios

Contraindications
Absolute contraindications
 CPD (Macrosomia and contracted pelvis)
 Transverse/oblique lie, footling breech
 Previous hx of C/S, myomectomy
 Major placenta previa
 Repaired fistula, pelvic tumors, cervical cancer
 Cord presentation
 Abnormal FHR pattern
 Absence of C/S facility

Contraindications
Relative contraindications
 Elderly primigravida/grand multiparity
 Uterine overdistension
 Frank breech

Prerequisites for induction
 Presence of clear indication
 No contraindication
 Presence of cesarean section facility
 Ripening of the cervix using prostagladins or folly

catheter

Factors affecting induction of labour
 Fetal maturity and viability
 Favorability of cervix
• Favorability of cervix is assessed by a score system
called “Bishop score”. It has to be done before
induction.
• The score is scored out of 20.
• Score ≥ 7 is favorable
Bishops Score System

Induction protocol

Complications of oxytocin
 Uterine hyperstimulation
 Fetal distress
 Uterine rupture
 Water intoxication
 Congestive heart failure
 Atonic PPH
Augmentation Of Labour
 Augmentation of labour refers to the process of

promoting more effective uterine contractions when
labour has already begun spontaneously but then
becomes weak, irregular or ineffective (hypotonic)
that assistance is needed to strengthen them.

Indications
 Prolonged latent phase
 Prolonged active phase
 Prolonged Second stage
 To prevent risks of fetal hypoxia from prolonged labor
 To prevent risks of infection from prolonged labor

Oxytocin dose for augmentation
 For augmentation the same regimen of oxytocin

used is half the dose used for induction in both
mutigravida and primigravida.
 Multigravida: 1.25 IU
 Primigravida: 2.5 IU

Chapter Six Abnormal Labour: 3/28/2023 Maternity and RH Lecture by Kusse U. 1

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Chapter Six Abnormal Labour: 3/28/2023 Maternity and RH Lecture by Kusse U. 1

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CHAPTER SIX

3/28/2023 Maternity and RH Lecture by Kusse U. 1

3/28/2023 Maternity and RH Lecture by Kusse U. 2

Presentation: the lowest pole of the fetus that

Malpresentation: when the presentation is other

About 95% of fetuses at term present by the vertex

3/28/2023 Maternity and RH Lecture by Kusse U. 3

The denominator is the most deﬁnable peripheral point

3/28/2023 Maternity and RH Lecture by Kusse U. 4

Often no cause is identified but any condition

These conditions are well known and fall into three

3/28/2023 Maternity and RH Lecture by Kusse U. 5

1. Fetal factors: fetal anomalies like hydrocephalus,

2. Maternal factors: uterine anomalies like septate and

3. Placental factors: placenta previa.

3/28/2023 Maternity and RH Lecture by Kusse U. 6

 Breech presentation is a fetal presentation where

 It accounts for 3-4% of all births but occurs in

3/28/2023 Maternity and RH Lecture by Kusse U. 7

1. Frank breech presentation: the fetal hips are flexed

 The presenting part is the buttocks.

 It accounts for 60% - 65% of all breech presentations at

3/28/2023 Maternity and RH Lecture by Kusse U. 8

2. Footling breech: one (single footling breech) or both

 It accounts for 25%-35% of breech presentations at

term and 50% before term.

3/28/2023 Maternity and RH Lecture by Kusse U. 10

Footling breech (single)

3. Knee presentation is a rare form.

 Seen in a fetus with extended thighs and flexed

3/28/2023 Maternity and RH Lecture by Kusse U. 12

4. Complete breech presentation: both hips and knees

It accounts for 10% of all breech presentations at any

3/28/2023 Maternity and RH Lecture by Kusse U. 13

 The fundus contains a firm/hard, smooth and rounded

 Soft and irregular mass occupies the lower pole of the

3/28/2023 Maternity and RH Lecture by Kusse U. 15

3/28/2023 Maternity and RH Lecture by Kusse U. 16

The important differential diagnosis at this point is face

 Ultrasonography can be done to confirm the diagnosis.

3/28/2023 Maternity and RH Lecture by Kusse U. 18

Breech presentation diagnosed before 32 weeks of

 After 36 weeks the chance of spontaneous version is less

3/28/2023 Maternity and RH Lecture by Kusse U. 19

This requires expertise and facilities for emergency C/S

If external cephalic version is contraindicated a decision on the

For these reasons pregnant women with breech after 36 weeks

3/28/2023 Maternity and RH Lecture by Kusse U. 20

 In a women considering vaginal breech delivery,

Vaginal delivery with contracted pelvis is associated

3/28/2023 Maternity and RH Lecture by Kusse U. 21

3/28/2023 Maternity and RH Lecture by Kusse U. 23

 Evaluation at admission is like any laboring mother.

This confirms the diagnosis and identifies parameters

Artificial rupture of membranes should not be done.

3/28/2023 Maternity and RH Lecture by Kusse U. 24

First Stage of Labour

3/28/2023 Maternity and RH Lecture by Kusse U. 25

There is no place for augmentation of breech presentation.

The mother should be instructed not to push till full cervical

3/28/2023 Maternity and RH Lecture by Kusse U. 26

Bladder must be emptied and the mother positioned in