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LABOR

Fetal skull
Sutures of skull

• Sagittal Suture (in between two parietal bones)

• Coronal Suture separates parietal bones from the frontal bone
• lambdoid Suture separating parietal bones from the occipital bone
• Bregma/ Anterior Fontanelle - diamond shaped space.
• Posterior Fontanelle -it is triangular shaped.

SPACES ON FETAL SKULL

• VERTEX :It is the quadrangular space between the coronal and lambdoid suture
• OCCIPITAL :Area between the two lambdoid suture
• SINCIPUT : It is the area between the coronal Suture and brow

DIAMETERS OF FETAL SKULL

TRANSVERSE DIAMETERS

- They are always smaller than the

anteroposterior ones.

1. BIPARIETAL DIAMETER- the diameter between the two parietal eminences. It is

9.5 cm.

2. BITEMPORAL DIAMETER -It extendsbetween the farthest points on the Coronal

Sutures. It is 8cm.

3. SUPERSUBPARIETAL DIAMETER - It is 8.5 cm.

4. BIMASTOID DIAMETER- It extends between the two mastoidprocesses.It is 7.5

cm .It is non-compressible diameter. It is the smallest diameter of the fetal skull.

ANTEROPOSTERIOR DIAMETERS

1. MENTOVERTICAL DIAMETER - It extends from highest point on the sagittal

suture to Mentum (Chin). It is 14 cm. It is the LONGEST diameter .

2. OCCIPITOMENTAL DIAMETER - It extends from occiput to chin . It is 12cm.

3. SUBMENTOVERTICAL DIAMETER- 11.5cm.

4. OCCIPITOFRONTAL DIAMETER - It is 11.5cm.

5. SUBOCCIPITOFRONTAL DIAMETER –It is 10 cm.

6. SUB OCCIPITO BREGMATIC .It is 9.5cm.

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7. SUBMENTOBREGMATIC– 9.5cm

• when, Neck is in the Neutral position → The largest diameter is Mento-Vertical

As the head extends or flexes

• Completely flexed → SUB-OCCIPITO BREGMATIC

• Lightly delfexed: SUB-OCCIPITO FRONTAL
• More deflexion : OCCIPITOFRONTAL
• Completely Extended → SUBMENTOBREGMATIC

FETAL ATTITUDE: Normally flexion

1 VERTEX PRESENTATION: The head is well flexed.

The diameter is Sub-occipitobregmatic i.e. 9.5 cm

2 VERTEX PRESENTATION with deflexed head. The

diameter is occipitofrontal.i.e. 11.5cm

3 BROWPRESENTATION: Head midway between Extension and Flexion (neutral

position).The diameter is Mento Vertical

4 FACEPRESENTATION: The neck of the foetus is completely extended. The diameter

is Submentobregmatic (9.5 cm)

MOULDING AfraTafreeh.com
• The shape of the foetalSkull gets altered during negotiation / passage through
pelvis.
• The compression of engaging diameter leads to elongation of the corresponding
diameter that is that is perpendicular to it.

MATERNAL PELVIS
Normal shape (most common) - Gynecoid

• Plane of inlet → upper border of symphysis pubis till sacral promontory

• Plane of least pelvic dimensions → lower of symphysis pubis till S 5

Between these two planes, lies cavity

• MID-PELVIS : the space between the plane of least pelvis dimensions to the
plane of greatest pelvic dimensions
• OBSTETRIC OUTLET: extending from plane of least
pelvic dimensions to the anatomic outlet below.

DIAMETERS OF THE INLET

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1. Transverse diameter of inlet: extends between the farthest point on

iliopectineal line on both sides
2. Oblique diameter: it extends from one side sacroiliac joint to the iliopubic
eminence of other side. Right or left diameter depends on the joint.
3. Anteroposterior diameter of inlet:
• TRUE CONJUGATE →extends from top of symphysis pubis till the sacral
promontory. It is 11cm.
• OBSTETRIC CONJUGATE → extends from a point posteriorly on the body
of symphysis pubis till the sacral promontory. It is 10.5cm.
• DIAGONAL CONJUGATE→ extends from lower border of symphysis pubis
till sacral promontory. It is 12cm. It can be measured clinically.
OBSTETRIC CONJUGATE=
DC – 1.5cm=10.5cm

INCLINATION OF PELVIS

• Normally, the plane of inlet of pelvis is inclined to the horizontal forming the
ANGLE OF INCLINATION, which is around55 ͦ
• Higher inclination - when there is sacralisation of lumbar vertebra. It is
associated with ROP-right occiput position and longer Labor.
• Midpelvis coincides with plane of least pelvis dimensions
• Plane passes through the level of ischial spines. The diameter is the INTER -
ISCHIAL spine diameter (IID).it is 10.5 cm, also called as the interspinous
diameter.
• Most important and smallest diameter of true pelvis –IID/interspinous diameter

OUTLET

1. OBSTETRIC OUTLET
• Space bounded above by plane of least pelvic dimensions and below by the
anatomical outlet.
• Anterior wall is deficient
• Transverse diameter of plane of the obstetric outlet passes through the ischial
spines

2. ANATOMICAL OUTLET
• The transverse diameter of outlet
• extends between the two ischial tuberosities,
called as INTERTUBEROUS diameter.
It is about 11cm.
• SUBPUBIC angle: angle between two ischiopubic rami.
It is about 85◦
• PUBIC ARCH: arch formed by ischiopubic rami, normally it is wide.

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PELVIC AXIS

• Anatomical axis → also called as CURVE OF CARUS. It is smooth.

• Obstetric axis→ path taken by fetal head.
It is abrupt. Q→ It takes forward turn
at the level of ischial spines.

PELVIC ASSESMENT

• Mainly clinical
• In multiparous women –done at the time of Labor
• In primigravidas–it is done around 37 weeks

CONTRACTED PELVIS

• When OC <10cm – contracted inlet (or DC<11.5 cm).

• IID <8cm- contracted cavity
• TDO<8cm – contracted outlet

RARE FORMS (grossly deformed pelvis )

• TRIRADIATE PELVIS: seen in osteomalacia and rickets

• NAEGELE’S PELVIS: single sacral ala is absent
• ROBERT’S PELVIS: both a la of sacrum absent

CEPHALOPELVIC DISPROPORTION: AfraTafreeh.com

Disproportion between size of fetal head and size of pelvic cavity

How to asses: TRIAL OF LABOUR>clinical assessment

• If mild CPD at inlet alone - give trial of Labor

• If CPD at cavity / outlet – caesarian section

FETUS IN UTERO
FUNDAL HEIGHT: we check whether the size of fetus corresponds with the age in
weeks

• At 12 weeks → fundus is palpable per abdominally, just above the pubic

symphysis.
• At 16 weeks→ fundus reaches midway between umbilicus and pubic symphysis
• At 24 weeks → reaches umbilicus
• At 28 weeks → reaches junction of lower one third and upper two third
• At 32 weeks → reaches at the junction of lower two third and upper one third
• At 36 weeks → fundus reaches
xiphisternum

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• At term → fundus back at 32 weeks

with the flanks full

LIE: relationship between the long axis of

fetus to centralized uterine axis

1. Longitudinal lie
2. Oblique lie
3. Transverse lie

UNSTABLE LIE:

By term, lie stabilizes.

Most common lie is LONGITUDNAL LIE.

Even after 37 weeks, if lie has not become stable then it is called UNSTABLE LIE
(oblique lie)

Most common cause → Idiopathic>placenta previa>Polyhydramnios

Q→ most common location of placenta in unstable lie: fundal>placenta in lower

segment

PRESENTATION → Part of fetus that occupies the birth canal (LUS). E.g. Cephalic
(head), breech (buttocks) etc.

PRESENTING PART →That part on presentation that directly overlies the internal os.
E.g.

• Cephalic→ PP- vertex, face,sinciput(brow)

• Breech→ PP- buttocks, feet, knee

DENOMINATOR

Bony prominence on presentation that is used to describe the position

• Vertex →occiput
• FACE → chin(mentum)
• Brow →sinciput
• Breech → sacrum

POSITIONS (8 positions)

• Most common is LOT (LEFT OCCIPITO TRANSVERSE)>LOA (LEFT

OCCIPITOANTERIOR)

EVALUATION

Female lying in dorsal position→

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FUNDAL HEIGHT:

• Stand at right side of women-

• Measured by ulnar border of hand
• If uterus is dextrorotatory or levorotatory
• → first correct the position of uterus i.e.
centralize the uterus

SYMPHYSIOFUNDAL HEIGHT (cm)

• Legs straightened and then measure the SFH

• Cm side of the tape should be away from you
• After 24 weeks → SF height corresponds to gestational age in weeks (upto 36
weeks)

LEOPOLD’S MANOUVRES

1. Fundal grip
2. Lateral grip
3. PAWLICK’S GRIP: done using single hand, we grasp fetal head. It tells us that if
a ballotable head is present in lower part, if presentation is cephalic or not.
4. PELVIC GRIP: performed while facing patient’s legs
Interpretation: AfraTafreeh.com
• Ifthe hands are diverging, it shows that the head is engaged / likely
engaged.
• If hands are converging → free head
• We can know whether the head is flexed or not
(by palpating occiput or sinciput)
• If sinciput is higher that occiput →well flexed head
• If both at same level →deflexed head

MECHANISM OF LABOUR
CARDINAL STEPS

1. Engagement
2. Descent
3. Flexion
4. Internal rotation
5. Extension
6. External rotation
7. Expulsion
1. ENGAGEMENT:

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• Largest transverse diameter (biparietal diameter) crossed the pelvic

brim(inlet)
• Station (position of leading point of skull in relation to ischial spines) →”O”
• The head is 1/5th or 0/5th palpable above the pelvic brim

• In primigravidas →engagement occurs before onset of Labor

• In multigravidas →engagement occurs late in Labor
• Q→ If primary gravid has free head at term?
CAUSES:
• Deflexed head (most common)
• CPD (cephalopelvic disproportion)
• Placenta previa

MECHANISM OF LABOUR

• Describing from LOT

• Engaging diameter of
fetal head → suboccipitobregmatic
Engagement

2. DESCENT & 3. FLEXION

• Second and third steps occur simultaneously
• Most important factor favoring descent and flexion is UTERINE
CONTRACTIONS.
• In the end, the maternal bearing down efforts are going to cause the final
decent
• As the head reaches the “O” station (i.e. pelvic floor) → occiput undergoes
internal rotation
3. INTERNAL ROTATION: Occiput undergoes internal rotation by 2/8 of a circle →
comes and lie behind the symphysis
pubis
• HART’S RULE: Direction of muscle
fibers of the pelvic diaphragm is
towards mid-line leading to elastic
recoil of muscles causing occiput to
be pushed anteriorly.

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 • When the internal rotation happens and the occiput rotates by 2/8 of circle
at the same time the shoulder also rotates 1/8 of a circle anteriorly in same
direction, leaving only 1/8 tension at the level of the neck.

5. EXTENSION:

• Head is born by extension

• First the vertex and occiput area comes out and
then the face (vertex →brow →face)
• Restitution:untwisting of neck

6. EXTERNAL ROTATION:

Initially shoulders are in oblique diameter

Need to come back in Anteroposterior diameter

Internal rotation of the shoulders is seen

as external rotation of head

• Occiput lies to the left thigh of mother in LOT position

• Internal rotation of shoulders by 1/8 of circle which is seen externally as
AfraTafreeh.com
external rotation of head.
• The occiput comes to lie facing the left maternal thigh.

PHYSIOLOGY OF LABOUR

( U n d e rs t a nd i n g o f n o r m a l L a bo r )

PHASES OF LABOUR / PARTURITION

PHASE 1:

• Uterine quiescence
• Cervical softening (increased vascularity, cellular hypertrophy and hyperplasia)

PHASE 2: Preparatory phase/phase of activation

• Increased oxytocin receptors in myometrium and gap junctions

• CERVICAL RIPENING: cervix becomes soft &dilatable. It occurs because of
increased prostaglandins in cervix ( PGE2 and PGF2α)

Q→ what are biochemical changes in ripening?

o Increased hyaluronic acid

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o Collagen breakdown
o Increased water content
o Decreased chondroitan and dermatan sulphate
• Formation of lower uterine segment → formed by expansion of isthmus. At
term the LUS measures 5cm.
• Descent of head into the pelvis causes relief of maternal symptoms and it is
called as LIGHTENING

PHASE 3: Stages of Labor are included

PHASE 4: Uterine involution (puerperium)

CAUSES OF ONSET OF LABOUR:

• Increased uterine stretch

• PGs increase in amnion / chorion / decidua / myometrium
• Fetal endocrine cascade
• There is increased estrogen as compared to
• progesterone leading to uterine contraction initiation
• Increased fetal or maternal stress leads to increased cortisol and hence
leading to initiation of Labor

NORMAL LABOUR

• Also called as EUTOCIA

1. Labor is spontaneous in onset and at term
2. Labor progresses normally (no undue prolongation) and without assistance
3. Baby and mother should be healthy
4. Term →37 – 42 weeks
• EDD is at 40 weeks or 280 th day
• >/= 42 weeks →post term/ post maturity. it is different from
post EDD / post dated
• 37-38 + 6 weeks → early term
• 39-40+ 6 weeks →full term
• 40 – 41 + 6 weeks → late term

Stages of Labor, uterine contractions, Labor pains

STAGES OF LABOUR

STAGE 1: Onset of uterine contractions (true Labor pains to full dilatation of cervix
i.e. 10cm)

STAGE 2: Full dilation to expulsion to fetus

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STAGE 3: Delivery of placenta

STAGE 4: 1hr period of observation to ensure mother and baby’s health

PHYSIOLOGICAL: slight temperature increase (not >100 F and shivers can happen
during this stage

STAGE 1: It has 2 aspects

1. Uterine contractions
2. Cervical dilatation and effacement

UTERINE CONTRACTION

Characteristics:

1. Pacemaker is at cornu of uterus

(right > left)
2. Fundal predominance
3. Wave of contraction travels @2cm/second and depolarizes the whole uterus in
15 seconds
4. The contractions have regular pattern with increasing intensity (rise in
intrauterine pressure)and duration.
5. Painless “BRAXTON HICKS” → 8-10mm Hg. they do not cause Labor initiation
6. Uterine contractions are palpable when the intensity is >10mm Hg
AfraTafreeh.com
7. Q→ When do the uterine contractions start becoming painful /capable of causing
cervical dilation?
A→ When 15mm Hg intensity is crossed
8. Moderate contractions → when the pressure is around 40mm Hg
9. 1st stage of Labor (25-50 mm Hg )
10. In 2nd stage of Labor → uterine contraction intensity is 100 – 120 mm Hg
11. In 3rd stage of Labor → uterine contractions intensity is still 100 - 120 mmHg. As
there needs to be delivery of placenta and bleeding control
• Measurement of intensity is given by MONTEVIDEO UNITS
o Increase in intensity = 40 units
o Number of contractions in 10 minutes
o E.g. If there as 3 contractions in 10 minutes
with increase in intensity of 40mm Hg.
o intensity = No. of uterine contractions in
10 minutes X Average increase in
intensity in each contraction
o = 3 X40 =120MV units
• CLINICALLY: We put the palm on the uterus, when the uterine contraction is there
the uterus hardens (at the peak of uterine contractions we cannot indent the
uterine wall with our finger. Thus, it is a moderate intensity contraction.

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DILATATION AND EFFACEMENT

• Release of cervical mucus plug with bloody d ischarge is calledSHOW

• Effacement→ progressive shortening of cervical length. It precedes dilatation in
primarygravidas
• In multiparous women → effacement and dilatation occur together
↓
As effacement progresses and dilatation begins there is formation of bag of
membranes (BOM)
↓
When the entire cervix is effaced, the cervical length gets incorporated in
lower uterine segment (LUS) thus LUS measures 10cm during Labor.
Q→ what causes Labor pains?
• Pain due to uterine contraction in early Labor
↓
Pain impulse travel via “inferior hypogastric nerve “/ plexus (the nucleus is called
as FRAKENHAUSER GANGLION)
↓
To T10 – L1 segments (so pain is referred to whole abdomen)
• Pain due to cervical dilatation. Travels via sacral plexus (S2, S3 and S4). So,
pain is referred to the back
• Pain from the lower genital tract travels via pudendal nerve (S2,S3,S4)

PAIN RELIEF DURING LABOUR:

• Meperidine (50 -100 IM)

• Promethaxine (25mg i.m.)
• Fentanyl
• Inhaled nitrous oxide
• Epidural analgesia :
o Bupivicaine (most commonly used)
o Level of block during Labor needs to be at T10 level)

o Q→ During caesarian section the level of block need to be till T4, to

block the parietal peritoneum pain transmission as well .

• Complications of epidural analgesia:

o Prolonged Labor
o Increased use of oxytocin
o Increased chances of operative vaginal delivery due to prolonged
second stage (due to decreased bearing down efforts of women)
o No adverse neonatal effects are seen.

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 DIAGNOSIS & EVALUATION OF LABOUR
• Diagnosis of Labor
• Evaluation of a woman in Labor
• Monitoring of progress of Labor
1. DIAGNOSIS OF LABOUR
• Whether she has true Labor pains or false Labor pains
• TRUE LABOUR PAIN:
o Increasing intensity, duration and frequency
o History of show / leaking per vaginum
o Pain is not relieved by enema / sedatives
o Most definitive of true Labor pains:
▪ Progressive dilation and effacement of cervix
▪ Formation of forewaters or BOM (bag of membranes) → BOM acts
like a wedge to dilate the ce rvix. It usually ruptures after full
dilatation of cervix
2. EVALUATION OF A WOMAN IN LABOUR
1. History
2. General Examination
3. Per abdomen examination → to establish condition of fetus
in uterus
P/V →
AfraTafreeh.com
• Posterior fontanelle
(triangular) → placed anteriorly
• Anterior fontanelle
(diamond shaped)→
placed posteriorly + locate the
sagittal suture
↓
So, this is LOA (left occipitoanterior)
• FHS is evaluated
• Information gained on P/V Examination :
• Cervical dilation
Cervical effacement
BOM (present or not)
Leaking P/V(color of liquor)
• P/V confirms the position of
the fetus
• Locate fontanelle
• Locate sagittal suture
• P/V shows the station of head
• “O” → level of ischial spine
(both fingers one fetal head and

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other on ischial spine are at same

level)
• Above 0 → (-)
• Below 0 → (+)

MONITORING PROGRESS OF LABOUR →PARTOGRAM

• Friedmans curve
• WHO partogram
• Abnormalities of Labor progression

FRIEDMANS CURVE

• Stage 1 of Labor is divided into

1. Latent phase (Avg duration = 8-12 hrs)
2. Active phase (WHO ≥ 4cm dilatation)
▪ The dilatation proceeds faster during active phase. It includes
o Acceleration phase
o Phase of maximum slope
o Deceleration phase
▪ The average rate of cervical dilatation in active phase
o In primarygravidas→ 1.2 cm/hr
o In multigravidas →1.5cm/hr
• Stage 2 →maternal bearing down efforts come into play, most of the descent
of fetal head occurs in the 2nd stage

MODIFIED WHO PARTOGRAM

• There is no latent phase,

No clinical intervention is usually done in the
latent phase
• Plotting begins in active phase
• Partogramis a Labor room utility tool, helpful in monitoring Labor and
identifying problems in progression of Labor.

DETAILS IN THE PARTOGRAM

• Patient details
• Hospital number
• Date and time of admission
• Time of rupture of membranes
• Fetal heart rate
• small boxes equal to 30 minutes and big boxes equal to 1hr
• Low risk women in active Labor→ FSH is monitored every 30 minutes
• In high risk women → FSH is monitored every 15 minutes

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 • Status of amniotic fluid → C – clear fluid, M – meconium
• Status of molding
• Cervical dilatation and descent are planned on Y -axis
• Time is plotted on X -axis
• Contractions are plotted every 30 min.
• 4 boxes means that patie nt is having 4 contractions every 10 minutes. So,
number of boxes equals to number of contractions in 10 minutes. Complete
shading of boxes means good contractions. If the boxes are obliquely lined
that means these are moderate contractions. If boxes are d otted → mild
contractions
• Oxytocin given, or any other drug i.v. fluid given is noted
• Maternal Pulse& BP
• Urine protein and ketone and volume

CHARTING

• First plot is on alert line/ always left of alert line

• Concept of alert line was given by PHILPOTT & CAST LE
• The graph of alert line corresponds to cervical dilatation @ 1 cm/hr.
• If the graph of cervical dilatation is to the left of alert line → dilatations is
proceeding @ > 1cm/hr
• For the process of cervical dilatation and descent of fetal head 3Ps are
important AfraTafreeh.com
1. Passage (birth canal)
2. Passenger (fetus)
3. Power (uterine contractions)
• P/V can be repeated 2 hourly according to the need.

ABNORMALITIES OF LABOUR PROGRESSION PROLONGED

LATENT PHASE ARREST OF DILATATION
• According to latest ACOG guidelines, the latent phase is considered till 6cm
• This recommended is made after the ZHANG et alstudy. (2002) →

▪ Slow progress till 6cm but increases after that

▪ After 6cm rapid dilatation occurs

LATENT PHASE DISORDERS

• Between 0-6 cm
• Average duration of latent phase in
a) Primary gravidas → 12 hrs
b) Multigravidas → 8 hr

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• Prolonged latent phase when in

a) Primary gravidas →> 20 hr crossed
b) Multigravidas →>14 hr

CAUSES

• Excessive sedation
• Epidural analgesia
• Poor cervical condition
• Poor contractions

Q→ Primary gravida women in early Labor with 2cm dilatation and 80% effacement
for last 10hrs. what is the diagnosis?

Diagnosis- still in latent phase

Management –

• Wait and watch

• Just monitor
• Pain relief and sedation
• No oxytocin for augmentation

ACTIVE PHASE DISORDERS (≥6cm)

1. Protracted dilatation
• Rate of dilatation <1.2cm/hr in primarygravidas
• Rate if dilatation <1.5cm/hr in multigravidas
• E.g. → Primary gravida women who is 6 cm dilatated and 80% effaced at 2pm
and she is having moderate contractions. Later at 6pm, she is 8cm dilatated
with 90% effacement
• In 4 hr only 2cm dilatation is a slow progress. So, we will check whether the
contractions are adequate or not
• She could be having adequate or inadequate contractions
• Adequate contractions →
▪ good contractions. 3 in 10 minutes each lasting for 45 seconds or when the
intensity is around 200 MV units
▪ If good contractions, and yet there i s slow progress of active phase
dilatation, we should rule out
o CPD (cephalopelvic disproportion)
o Pelvic inadequacy
o Occipitoposterior position
• If Inadequate contractions →
▪ If BOM is present we will go for ARM(artificial rupture of membranes) →
augmentation of Labor →if contractions don’t increase → oxytocin is given
▪ If BOM is absent → oxytocin infusion is given

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 If grade 3 molding or large caput is seen, these are signs suggestive of CPD.

MOLDING: alteration in fetal head shape to negotiate the birth canal. Grades of
molding -

1. Bones touch sagittal suture

2. Bones overlap but they can be pushed apart
3. Fixed overlapping of bones

Caput succedaneum

• Swelling in the layers of the scalp

• If severe swelling is there or it is increasing
overtime, there could be underlying CPD

ARREST OF DILATATION

• Despite uterine contractions there is no dilation

• No cervical dilation after 4 hr of good contraction
or after 6 hr of oxytocin
• The dilatation should be at least 6cm
• It can be only diagnosed after rupture of membranes
has occurred
• Management → caesarian section

DISORDERS OF DESCENT AfraTafreeh.com

• Protracted / slow descent → rate of descent is <1cm/hr
• It mainly occurs in the second stage because descent mainly takes place in
second stage
• Average duration of second stage in primigravidas is about 1hr and in
multigravidas is about 30 minutes
• Earlier limit for diagnosing arrest was
o In primary gravidas→ 2hr
o In multigravidas →1hr
• Latest recommendation
o No descent or no rotation of fetal head even after 3 hrs have passed in
primigravidas and 2hrs In multigravidas, provided the mother and fetus
are doing okay
o + 1 hr if epidural is given

E.g. → Primary gravida who has fully dilated cervix for 2 hrs and descent is stuck at
“0” station

• Firstly, asses the contractions → if the contractions are adequate

• Rule out CPD, Pelvis inadequacy, occipitoposterior position
• Look for caput or molding
• FHS status / CTG → if everything is fine we can allow on more hour

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• If she has CPD, caput++, grade 3 molding or FHR is not reassuring → caesarian
section is done

OBSTRUCTED LABOUR

• Obstruction to delivery of baby

• Tonically contracted upper segment is there
• Dilated and thinned out lower uterine segment
• Pathological retraction ring is there → BANDL” S RING
• The ring keeps moving upwards as the LUS keeps dilating
• The ring can be palpated per abdominally not per vaginally

DANGERS

• Risk of fetal death

• Rupture of uterus
• Maternal sepsis
• Chorioamnionitis
• Obstetric fistula (vesicovaginal fistula / urethrovaginal fistula) – late
sequelae

CLINICAL FEATURES

• Woman is Dehydrated
• Tachycardia
• Low B.P
• P/A →
o Tonically contracted upper segment
o Thinned and stretched LUS
o Palpable ring per abdominally
o Suprapubic bulge
o Fetal distress/ IUD
• P/V →
o Hot and dry vagina
o Features of CPD
o Molding
o Caput
o Hematuria

MANAGEMENT

• Resuscitation
• Caesarian section/ even if the baby is dead

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 RI GH T O CCI PUT PO SI T I O N AND T Y PES O F PELV I S

Types of pelvis

Normal pelvis→ gynecoid

• 4 parent pelvic types are there and in totality there

are combinations of these 4 and hence 14 pelvic types
are there overall
• 4 parent pelvic types are → according to CALDWELL
MOLOY CLASSIFICATION
1. ANDROID TYPE
• Male type of pelvis
• Inlet
▪ Triangular
▪ Anteriorly narrow
▪ Convergent side walls
▪ IID→ narrow
▪ Prominent ischial spines
▪ Sub-pubic angle → narrow(acute)
▪ Transverse diameter is also narrow
• Associated with ROP AfraTafreeh.com
• Associated with deep transverse arrest
• Increased incidence of caesarian section
• Associated with DYSTOCIA DYSTROPHICA SYNDROME
▪ Abnormal Labor
▪ Short and obese women
▪ Short thighs
▪ Stockily built
▪ Android pelvis
▪ Features of PCOS/ Infertility
2. ANTHROPOID PELVIS
• Only pelvis in which AP diameter >transverse
(anteroposteriorly oval)
• Associated with direct OP position
• Associated with face to pelvis delivery

3. PLATYPELLOID PELVIS
• Flat pelvis
• TD>>AP diameter (transversely oval)
• Associated with brow and face presentation

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ASYNCLYTISM

• It can be anterior or posterior

o ANTERIOR ASYNCLYTISM
▪ Presenting part → anterior parietal
bone
▪ Sagittal suture is deflected
posteriorly towards sacral promontory
▪ More common in multi
o POSTERIOR ASYNCLYTISM
▪ Presenting part →posterior parietal bone
▪ Sagittal suture is tilted anteriorly (towards pubic
symphysis)
▪ Seen more commonly in primigravidas
▪ Exaggerated asynclytism → CPD
▪ In flat pelvis head engages through exaggerated parietal
presentation → engaging diameter is super- subparietal
(8.5cm)

ROP

• It is the most common malposition

• CAUSES: Android pelvis > deflexed head
• Factors favoring deflexed head are:
▪ High inclination of pelvis (sacrum is flatter)
▪ Anterior placenta
▪ Ineffective uterine contractions
• It is more common in primary gravidas

DIAGNOSIS: (P/V, P/A)

• Unengaged head
• Deflexed head
• Delayed engagement
• FHS is better heard near flanks .In normal LOA or LOT
position, FHS is heard near midpoint of spino -umblical line

• P/V →
o locate the occiput and direction of sagittal suture
o loose hanging BOM (in ROP) which can rupture
easily

MECHANISM OF LABOUR IN ROP:

At the onset of Labor >20% in ROP → as Labor progresses → 5% remain in ROP

Labor P a g e 19 | 39
 • >95% case of out there is favorable outcome i.e. anterior rotation of occiput
• Internal rotation is favored because of
o presence of average gynecoid pelvis
o average sized baby
o flexion of head
o good uterine contractions
o anterior rotation of occiput is 3/8 of a circle – 135 degrees
• in 5% cases there is incomplete rotation or non -rotation
o incomplete rotation → leads to DTA i.e. deep transverse arrest
o non-rotation leads to oblique posterior arrest
o Malrotation of occiput posteriorly leads to
direct OP position / persistent OP position

CLINICAL MANAGEMENT

ROP→ wait and watch and allow progress

DTA →

• “0” station
• Forceps rotation and vaginal delivery
• Manual rotation and vaginal delivery
• These are possible only if the pelvis is adequate
• Preferred → caesarian section AfraTafreeh.com

DIRECT OP POSITION

• Diagram – 42:48
• Face to pubis delivery
• Occipitofrontal diameter is engaged which is 11.5cm which is coming out of vulval
outlet
• It is a larger diameter so chances of perineal injury are more
• Initially flexion → occiput out → face is born by extension

BREECH PRESENTATION
• Most common malpresentation
• More common in multigravidas
• Incidence of breech
o 28 weeks → 25%
o 32 weeks → 11%

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 AfraTafreeh.com

o Term →3%

TYPES OF BREECH PRESENTATION:

1. Breech with extended legs→

2. Complete breech →

3. Incomplete breech →

Further,
• Frank breech with extended legs → seen more commonly in primigravidas
• Footling breech
• Knee presentation – rare

• Most dangerous is the footling breech as it can lead to cord prolapse

• Risk of cord prolapse → transverse lie> footling breech> complete breech>
frank > cephalic

CORD PROLAPSE

• After rupture of membranes, the umbilical cord com es out into vagina or even
outside the vagina. This is called as cord prolapse. It is different from cord
presentation, where the membranes are intact.
• Due to cord prolapse the umbilical vessels are exposed to low temperature in
vagina or outside environme nt→this may lead to intense vasoconstriction of
umbilical vessels → fetal hypoxia → fetal death (in minutes)
• Immediately delivery is the option i.e. caesarian section unless the vaginal
delivery is imminent

CAUSES OF BREECH:

• Prematurity (most common cause)

• Multiparity (in multigravidas, usually complete/ flexed breech is there whereas
in primigravidas usually frank breech is there)
• Hydrocephalus
• Placenta previa
• Contracted pelvis
• Uterine anomalies→ recurrent breech

Labor P a g e 21 | 39
 • Oligohydramnios
• Twins (multiple pregnancy)

BREECH VAGINAL DELIVERY

• Spontaneous breech delivery → when extreme preterm breech or aborting beech

is there
• Assisted breech vaginal delivery → delivery of arms
and head is assisted but delivery of legs, buttocks
and trunk is spontaneous
• Complete breech retraction
• Most common position in breech delivery → left
sacroanterior(LSA)
• While delivering the trunk, the back is kept
anteriorly and held from pelvic girdle,umbilical cord is pulled to side to prevent
its compression
• Once axilla is visible, delivery of shoulders is done
and arm is delivered by hooking out the elbow

DELIVERY OF HEAD

BURNS MARSHALL METHOD

• We do not push from above (from fundus)

• AfraTafreeh.com
We donot pull from below
• Head engages through sub-occipitofrontal diameter
• Ask the assistant to give supra -pubic pressure to maintain flexion of head
• Head delivers by flexion
1. MAURICEAV SMELLIE VIET (MSV) METHOD
• It maintains the flexion of the head and protects the neck
too
• Malar flexion and shoulder traction
2. PIPERS FORCEPS
• Lacks pelvic curve
• Best method (neck is totally protected) for delivery of
after coming head

When back rotates posteriorly i.e. dorsopos terior position then

head is delivered by PRAGUES MANOUVER

If head is stuck with incompletely dilated cervix → incision is given

on the cervix at 2 o clock and 10 o clock → DUHRSSENS INCISION

DELIVERY OF EXTENDED ARMS

• We perform LOVESETS MANOUVER

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 AfraTafreeh.com

Delivery of buttocks by GROIN TRACTION →

Delivery of extended legs →.

We do PINARDS MANOUVER

COMPLICATIONS OF BREECH DELIVERY :

• Main cause of perinatal morbidity → prematurity

• Most common cause of death in breech delivery → intracranial hemorrhage

CLINICAL MANAGEMENT

• Breech vaginal delivery

• External cephalic version
• Direct caesarian section
I. BREECH VAGINAL DELIVERY → If a woman comes in advanced Labor

II. ECV→ Offered to all pregnant women with breech presentation who meets the
criteria of ECV
III. Absolute indication of CS in breech – footling breech&Breech with extended
head also called as STARGAZER BREECH

OTHER INDICATIONS where CS is preferred in breech presentation :

• Previous CS with breech

• Preterm breech
• Hydrocephalus

EXTERNAL CEPHALIC VERSION

Q→ primary gravida -37 weeks, on routine checkup diagnosed with breech and pelvis is
adequate. What to do next ?

• Ultrasound → should be done

• to find location of placenta, confirm the type of breech
• Size of baby head
• Extension of baby head
• Amount of liquor
• After confirming the prerequisites → ECV is performed

PRE- REQUISITES WITH ECV

• >36 weeks
• Mother should be healthy; no preeclampsia
• No gross congenital anomaly in baby
• Liquor should be adequate (membranes intact)
• There should be no contraindications for vaginal delivery

Labor P a g e 23 | 39
 • It can be done in early Labor also
• It can be facilitated with tocolysis (can improve chances of success)

CONTRAINDICATIONS

ABSOLUTE:

• Prematurity
• Placenta previa
• Inadequate pelvis
• Multiple pregnancy
• Known uterine anomaly
• Preeclampsia
• IUGR with deranged doppler
• Absent membranes (oligohydramnios)
• Post-maturity

RELATIVE CONTRAINDICATIONS

• Previous CS with breech

• Macrosomia
(CS is preferred in these situations)

ECV – AfraTafreeh.com

Complications of ECV:

- Cord compression
- Placental abruption
- Fetal distress (due to above two)
- Urgent need for CS may arise.

OTHER MALPRESENTATIONS
TRANSVERSE LIE

• Shoulder presentation
• Denominator → acromian process
• P/A → pelvic grip is empty
• P/V → we can feel acromian and grid like ribs

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 AfraTafreeh.com

CAUSE:

• Prematurity – most common cause overall

• Most common cause at term – placenta previa
• Pelvis associated is platypelloid

MANAGEMENT

• >36weeks& not in Labor → external cephalic version (after fulfilling the

criteria)

• In advanced Labor or with absent membranes or neglected shoulder presentation

→ caesarian section
• Rarely extreme prematurity + dead and macerated fetus – in these conditions
the fetus doubles up and on itself and delivers vaginally. It is called as
CORPORA CONDUPLICATA

FACE PRESENTATION

• Engaging diameter is submentobregmatic (9.5cm)

• Causes:
o Anencephaly > prematurity > multiparity
o Thyroid mass
o Tumor of neck
o Multiple loops of cord around neck
o associated with flat pelvis

MENTO-ANTERIOR POSITION

• Vaginal delivery is possible

• Head delivers by flexion

MENTO-POSTERIOR POSITION

• Vaginal delivery is not possible if persistent MP is there

• Caesarian to be done

BROW POSITION

• Mentovertical diameter (14cm)

• Head between complete extension and flexion (neutral
position / MILITARY PRESENTATION)
• Cause: most common → platypelloid pelvis
• Brow position in early Labor → wait and watch
• Brow position in late Labor → cesarian section

Labor P a g e 25 | 39
 INSTRUMENTAL DELIVERY VACUUM AND FORCEPS
Indications – to cut short the second stage of Labor

• Fetal distress
• Maternal exhaustion
PRE-REQUISTE FOR INSTRUMENTATION (Mnemonic – FORCEP)
• Fully dilated (vacuum can be used in incompletely dilated cervix & can be used in
unrotated or incompletely rotated head)
• OA/OP position
• Ruptured membranes
• Rotated head
• Consent
• CPD should be ruled out
• Engaged head
• Empty bladder
• +2 station and beyond

CONTRAINDICATIONS OF INSTRUMENTATION

• CPD or contracted pelvis

• Known bony deformities of fetus (osteogenesis imperfecta)
AfraTafreeh.com
• Known coagulation disorder in fetus

SPECIAL FORCEPS

• After coming head of breech

• Face presentation
• Dead baby

CORRECT APPLICATION OF VACUUM

• silastic cup

• Placement of vacuum –→ center of cup at flexion

point (6cm behind the anterior fontanelle or 3cm in
front of posterior fontanelle)
• Suction required →0.8 kg/cm2

Labor P a g e 26 | 39
 AfraTafreeh.com

FORCEPS

• Simpson’s forceps → It has fenestrated plates.

They are preferred in primigravidas with a
molded fetal head
• Tucker Mc lane → It is better for rounded
fetal heads, as seen in case of multigravidas
• Wrigley’s forceps →
o outlet forceps → used when the head is on the
perineum or head is distending the vulval outlet
o low forceps → when applied at +2 station
• Keilland’ s forceps →
o with sliding lock
o rotational forceps
o no longer clinically used, as high and mid -
cavity forceps are not used now a days

APPLICATION OF FORCEPS

• Left blade is inserted first with left hand

• Right blade is inserted with right hand

CORRECT APPLICATION OF
FORCEPS

• The blades are equidistant from lambdoid suture and sagittal

suture → forceps lock easily
• Applied in occipitomental diameter
• If not correctly applied →blades do not lock

COMPLICATIONS

FORCEPS

• Perineal tears more common

• Depressed skull fractures
• Brachial plexus injury
• Facial nerve injury
• Anterior eye injury
• Intracranial hemorrhages

Labor P a g e 27 | 39
VACUUM

• Acute perinatal injuries – more common

• Cephalohematoma
• Subgaleal hemorrhage
• Retinal hemorrhage
• Shoulder dystocia
• Intracranial hemorrhage

CEPHALOHEMATOMA Vs CAPUT SUCCEDANEUM

CEPHALOHEMATOMA

• Collection of blood
• Beneath the periosteum
• Does not cross the suture line
• It is not evident im mediately after delivery
• It will increase in 3 days and th ereafter decrease
• MANAGEMENT →
o No tapping and draining
o Look for fetal anemia
o Jaundice

CAPUT SUCCEDANEUM
AfraTafreeh.com
• Scalp oedema
• Overlying periosteum
• Cross the suture line
• Evident after immediately birth and disappear few hours later.

THIRD STAGE LABOUR & AMTSL

• Mechanism of placental separation
• Immediately after delivery
o Reduction in size of uterus
o Marked retraction of uterine muscle fibers
↓
Shearing force between the placenta and
decidua

Q→ What is the plane of separation?

→ spongy layer of decidua basalis

Q→ What is the most important factor for placental separation?

1. Uterine contractions

Labor P a g e 28 | 39
 AfraTafreeh.com

• Uterine contractions are also the main factor controlling bleeding after
delivery
• Middle layer of uterus muscle forma Criss cross pattern around blood
vessels. So, called as LIVING LIGATURES
2. Thrombosis in torn sinuses
3. Apposition of uterine walls

METHODS OF PLACENTAL SEPERATION

I. Most common is central i.e. SCHULTZ METHOD

• Retroplacental collection of blood /
hematoma
• Fetal side/ shiny side comes out of introitus
• Visible/ apparent blood loss is less

II. Marginal i.e. MATHEW DUNCAN”S

• More bleeding
• Dirty/ maternal side comes out at introitus

EXPECTANT MANAGEMENT OF THIRD STAGE

• Wait for the signs of placental separation

• Ask the women to bear down
• Pull at cord once uterine contractions are there

Q→Most definitive sign?

→placenta will come to lie in LUS and in the vagina which leads to permanent
lengthening of cord

→ if we pull before separation or with uterus relaxed → lead to inversion of uterus

ACTIVE MANAGEMENT OF 3 RD STAGE OF LABOUR

• Routine management
• With AMTSL → the duration of third stage is 5 minutes
• It decreases blood loss during delivery. The most important component in this is
UTEROTONICS. They decrease blood loss by 50%

COMPONENTS OF AMTSL (WHO)

I. UTEROTONIC
• DOC→ oxytocin( 10 units i.m)
• Never given i.v bolus because it can cause dangerous hypotension and MI
• They are given immediately after delivery of baby (within 1 minute)
• Shelf life of oxytocin stored at room temperature is 3 months
• Oxytocin injections are sto red at 2-8 degrees
• WHO → alternative to oxytocin is oral MISOPRISTOL 600 microgram.

Labor P a g e 29 | 39
 II. DELAYED CORD CLAMPING
• Not earlier than 1 minute
• Waiting for 1-minute supplies additional 80 ml of blood to fetus → equals
to 50 micrograms of elemental iron
• It is also done in
o Preterm
o HIV +ve mother
o Rh -ve woman (Rhincompatibility)
• Indications of early cord clamping
o When baby needs resuscitation
o Known heart disease in baby
o Hydrops baby
o Mother is losing blood (E.g.abruption)
III. CONTROLLED CORD TRACTION (modified BRANDT
ANDREWS METHOD)
• Pressure given in upwards and backwards direction

CREDE”S METHOD

• Push the fundus from above

• Do not pull the cord from below
• It is used when
o Extreme prematurity AfraTafreeh.com
o IUD fetuses / macerated / cord is thin and friable

IV. INTERMITTENT UTERINE TONE ASSESMENT

PS. Note :

• According to government of India guidelines, components of AMTSL are -

o Uterotonic
o Control cord traction
o Massage

Therefore, remember - Not a component of AMTSL is -

o Early cord clamping

o Methergine

POSTPARTUM HEMORHHAGE (ATONIC PPH)

UTEROTONICS: Drugs which can cause uterine contractions

1. OXYTOCIN →

Labor P a g e 30 | 39
 AfraTafreeh.com

• Natural form is a nona-peptide &is synthesized in the paraventricular

nucleus of hypothalamus
• Then stored and released from posterior pituitary
• Also acts as milk ejection hormone in its natural form
• Oxytocin injection comes in various forms
o SYNTOCINON
o PITOCIN
• There are vials, each vial contains 1ml of solution which contains 5 units
/ml concentration of oxytocin
0
• This injection is stored at 2 -8 C. If stored at room temperature then
the shelf life is only of 3 months
• Can be given as a i.m injection (o nset of action → 3 minutes, duration of
action → 3 hrs) or i.v infusion (onset of action → immediate, duration of
action is 1 hour)
• Oxytocin injection is never given i.v bolus as it can cause
o Dangerous sudden hypotension
o Tachycardia
o MI
• It also causes water intoxication if used for long duration especially with
hypotonic solutions
• Therefore, Oxytocin infusion should be given with RL/NS not with
dextrose solution which is hypotonic

• Half-life of oxytocin → 3 minutes

2. METHERGIN (Methylergometrine)
• Used in a dose of 0.2 mg
• Can be given
o i.m (onset of action → 7 min)
o i.v (onset of action → 1.5 min)
• S/E of i.v infusion is sudden and severe hypertension

CONTRAINDICATIONS of Methergine

• Pre-eclampsia / eclampsia
• Woman with heart disease
• Rh incompatibility
• Second twin
• Peripheral vascular disease
3. MISOPROSTOL
• PGE1 analogue
• Cheaper
• Stored in room temperature
• 100mg/200mg tabs available
• S/E:

Labor P a g e 31 | 39
 1. N/V
2. Shivers
3. Fever
4. Pain abdomen
4. CARBOPROST
• PG2α analogue
• 1 vial contains 0.25 mg (given i.m)
• Trade name → HEMBATE, DINOPROST
• S/E → diarrhea
• C/I in asthmatics
• Can be given to hypertensives
• Can be considered as best drug among all of above
5. SYNTOMETRINE: combination of oxytocin and methergine
6. CARBETOCIN:
• Synthetic analogue of oxytocin
• An octapeptide
• Longer half life
• Recommended for prevention of PPH& only in elective C - section cases
• Used in a dose of 100microgram slow IV over 1 minute

POSTPARTUM HEMORRHAGE PRIMARY PPH

• Which occurs within 24 hrs. of delivery

AfraTafreeh.com
• Most common cause is atomicity
• Other causes:
o Genital tract trauma
o Retained tissue
o Uterine inversion
o Uterine rupture
o Coagulopathy

SECONDARY PPH:

• PPH which occurs after 24 hrs of delivery but can happen till 12 wee ks till
postpartum
• Most common cause is retained placental
tissue
• Other causes:
o Placental polyp
o Endometritis / infection

FACTORS PREDISPOSING TO ATONICITY:

DEFINITION OF PPH (in terms of blood loss)

• Blood loss is more than anticipated

Labor P a g e 32 | 39
 AfraTafreeh.com

• Average blood loss anticipated

o in a singleton vaginal delivery → 500 ml
o In twin VD/C-Section → 1000ml
• Any amount of blood loss that makes the woman symptomatic
• When there is fall in hematocrit>10% after delivery

MANAGEMENT OF PPH

• Whenever PPH/ atonicity is identified start acting immediately

• CALL FOR HELP
• Quick assessment
• Check shock index → HR/ SBP
o Normal = 0.5 – 0.7
o Women is symptomatic of PPH if the shock index → >0.9
• Do bimanual uterine compression (29:49)
o IV canula (2 wide bore)
o Rapid iv fluids
o Arrange blood
o Blood grouping and cross matching
o Catheterize the bladder
• Simultaneously start giving injectables
o Oxytocin 20 U in 500 NS infusion
o Methergin 0.2 mg IV
o Misoprostol 800 microgram per rectal
o Carboprost 0.25 mg i.m (can repeat every 15 minutes, for maximum8 doses)
• Look for completeness of placenta, rule out
genital tract trauma
• If uterus is still atonic then next step is
balloonuterine tamponade .
o Bakri balloon
▪ Maximum capacity → 500 ml
o Condom catheter →
• If uterus is still atonic then go for
surgical methods

SURGICAL METHODS

a) Compression sutures
• (B-lynch suture)

Labor P a g e 33 | 39
 • Hayman sutures
• Cho’s square sutures
• Pariera sutures
b) Stepwise devascularizationprocedures : involves
sequential ligation of arteries
• Bilateral uterine artery ligation
• Bilateral internal iliac artery ligation
• Bilateral ovarian artery ligation
• Never ligate common iliac artery
• Internal iliac artery ligation: diagra m
o Site:
▪ Anterior division of internal iliac artery
supplies the uterus
▪ Ligating 5cm distal to bifurcation of
common iliac artery ensures that the
posterior division of internal iliac artery
is spared
o Principle :
▪ We place a snug ligature so that the blood flow slows down and venous
circulation like state is achieved in ligated artery
▪ Pulse pressure decreases by 85%
▪ Thrombosis will occur when natural coagulating mechanism will take
AfraTafreeh.com
over on slowing of blood flow

• After surgical methods have failed, last alternative is hysterectomy

called PERIPARTUM HYSTRECTOMY (supracervical hysterectomy is done)

GENITAL TRACT TRAUMA AND HEMATOMAS

• Perineal tears
• Cervical tears → most common at 3 O clock. If bleeding they need to be stitched /
sutured.
1. PERINEAL TEARS
Classification
1st degree→ when only mucosa or skin is torn
o 2nd degree → mucosa/ skin + perineal muscles are
also torn (diagram – 1:54). E.g. episiotomy
o 3rd degree → mucosa/ skin + perineal muscles +
anal sphincter torn
▪ 3(a)- diagram →2:24 – external anal sphincter is
torn <50%
▪ 3(b) – diagram → 2:33 – external anal sphincter is torn ≥50%

Labor P a g e 34 | 39
 AfraTafreeh.com

▪ 3(c) – diagram → 2:40 –

internal anal sphincter also
torn
o
o
o
o

o 4th degree → diagram -2:56 – rectal mucosa is also torn

3rd and 4th degree is called as OASIS
(obstetric anal ` sphincter injuries)

EPISIOTOMY

• Best time to give episiotomy is during

crowning of the fetal head
• Types →
a. Midline episiotomy
b. Mediolateral episiotomy
a) MIDLINE EPISIOTOMY →
• Bleeds less
• Heals better
• Pains less
• Disadvantage → if it is extended posteriorly it involves anus and anal
sphincter
b) MEDIOLATERAL EPISIOTOMY
• Advantage → external anal sphincter spared if episiotomy extends
• Disadvantage
o Bleeds more
o Pains more
o Heals slower
o More dyspareunia

Remember, Episiotomy is not routine. It is given only when indicated. Routine

episiotomy does not prevent perineal injuries.

Q → What prevents perineal trauma during delivery?

• Perineal support
• Controlled delivery of fetal head

Labor P a g e 35 | 39
 RITIGEN MANOUVER

Repair of epi→ mucosa is stitched → then the muscle layer → then the skin
• 1st stitch is 1cm above the apex

REPAIR OF OASIS

• If diagnosed in Labor room

o Repair at the same time
o With superior / senior supervision
o Done in O.T
o Adequate anesthesia
• If diagnosed after 24 hrs→ repair after 3 months
• Sequence of repair
o rectal mucosa → internal anal sphincter →
eternal anal sphincter → rest repair same as
that of epi
o we do end to end anastomoses in external
anal sphincter
o overlapping technique for external anal sphincter repair is also acceptable
o suture used is → vicryl/ polyglactin 910

HEMATOMAS

They can be vulval or vaginal AfraTafreeh.com

VULVAL

• Branches of internal pudendal vessels are involved

• Most common presentation is pain
• Other features:
o Inability to pass urine
o Pallor
o Tachycardia
o Hypotension
• P/A → uterus is well contracted
• Local examination → swelling can be seen but still always do P/V also (there can
be vaginal hematoma too).

VAGINAL hematoma→ branches of uterine vessels are involved

MANAGEMENT

• If small <5cm, stable, mild pain, passing urine → conservative management with
analgesics + ice packs

Labor P a g e 36 | 39
 AfraTafreeh.com

• Excruciating pain, hematoma is increasing in size, size >5cm, symptomatic →

resuscitation + surgery (incision + drainage, identify the bleeding vessel and
ligate)

E.g. woman is in shock with no external bleeding. The uterus is well contracted and t he
local examination and the P/V are normal. Can this be a hematoma?

→ broad ligament hematoma can be there

E.g. Women in shock. The uterus is well contracted. The P/V and LE are normal but by
P/S examination → bleeding PV coming out through os.

→ there can be uterine tear / rupture

UTERINE INVERSION & AMNIOTIC FLUID EMBOLISM

Most common cause →

• Iatrogenic
• Mismanagement of 3rd stage
• Atonic uterus
• Morbidly adherent placenta

CLINICAL FEATURES:

• Neurogenic shock
• Hemorrhagic shock (cause of death)

MANAGEMENT

1. Method of manual reposition → JOHNSON’S METHOD. It is possible if placenta

has separated and uterus is relaxed
2. Hydrostatic method (O SULLIVAN’S METHOD)
3. Surgical method:
• Huntington’s method
• Haultain’s method

Q→ Shock after death → the most common cause is PPH

Q→ Shock immediately after delivery → inversion

Q→ Unexplained shock after delivery →

• Amniotic fluid embolism

• Very rare condition
• Diagnosis of exclusion
• Generally, clinically diagnosed

AMNIOTIC FLUID EMBOLISM

Labor P a g e 37 | 39
1ST PHASE:

• Sudden onset of breathlessness

• Hypertension (both pulmonary and systemic)
• Cardiac arrest / cardiogenic shock → hypotension

2ND PHASE: DIC (because amniotic fluid contains mucin, thromboplastin, tissue factors
etc.) that activate factor 7 and 10 → DIC

INDUCTION OF LABOUR
INDUCTION

• Women is not in Labor and has to start from very beginning

• i.e. Labor has to be initiated
• Drugs for cervical ripening are given if required (cervix unfavorable)
• Drugs which cause stimulation of uterine contractions are given

AUGMENTATION

• Labor has started but needs augmentation via drugs which increase contractions
• Contractions present but they are of less intensity

BEFORE IOL:
AfraTafreeh.com
• Confirm indication for induction of Labor
• Confirm gestational age
• Determine favorability of induction by using
Bishops score → in this, we do P/V
examination to check 5 cervical factors
o Dilatation of cervix
o Effacement
o Station
o Consistency (cervix is firm, medium or soft)
o Position (posterior, midposition, anterior)
o Total score 13
o Score of
▪ ≥6 → favorable
▪ ≥9 → high likelihood of success of vaginal delivery
(2cm, 80%, -1, soft, midposition)
▪ ≥4 → need for cervical ripening gents

CERVICAL RIPENING AGENTS

• Pharmacological agents
• Non- pharmacological agents

PHARMACOLOGICAL AGENTS

1. Prostaglandin E2

Labor P a g e 38 | 39
 AfraTafreeh.com

2. Prostaglandin E1
3. Mifepristone (RU-486)
4. Hyaluronic acid
5. Oxytocin

NON-PHARMACOLOGICAL / MECHANICAL AGENTS:

• Transcervical 36 F foley catheter (16:30)

• Hygroscopic dilators
• Stripping of membranes
• Artificial rupture of membranes → better method for augmentation than
induction of Labor

• Notes-

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