EMERGENCY OBSTETRICS

ABORTION
Definition – Abortion is the process of partial or complete separation of the products of
conception from the uterine wall with or without partial or complete expulsion from the uterine
cavity before the age of viability of 28 weeks for developing countries like Nigeria.
Classification

ABORTION

Spontaneous Induced

Or

Isolated Recurrent Legal Illegal

MTP

Septic

Threaten Inevitabl Complet Incomple Missed Septic

ed e e te

Abortion can be classified into two, spontaneous abortion and induced abortion.
Spontaneous abortion could either be isolated or recurrent.

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Either of the two i.e. isolated or recurrent could result to any of the following:

- Threatened
- Inevitable
- Complete
- Incomplete
- Missed
- Septic abortion
Induced abortion could be legal abortion (Medical termination of pregnancy)
or illegal abortion which can result to septic abortion.
Spontaneous Abortion/Miscarriage
Definition: Termination of pregnancy before the age of viability which could be 24 or 28 weeks
depending on if it is a developed world or developing or under developed world. It can also be
said to be termination of pregnancy with the fetal weight less than 500gms
Spontaneous Abortion Classified

SPONTENOUS

THREATENED INEVITABLE

MISSED
COMPLETE INCOMPLETE

Causes SEPTIC

- Unknown
- Genetic – chromosomal abnormalities such as autosomal-trisomy, and monosomy
- Endocrine – low levels of progesterone as in the case of polycystic syndrome,
diabetes mellitus and untreated thyroid disease, luteal phase defects.

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 - Maternal illness and infection e.g. syphilis, mycoplasma and toxoplasma gondii
- Maternal febrile condition e.g. influenza, pyelitis, malaria
- Cardio vascular illness
- Hepatic disease
- Renal disease
- Abnormalities of the uterus e.g. bicorn ate, sub-septate
- Submucosal fibroid
- Asherman syndrome
- Cervical incompetence
Features of incompetent cervix include shortening of the cervical canal to <25mm and
funneling of the internal cervical OS.
- Autoimmune factor e.g. anti-phospholipid syndrome
- Thrombophilic defects e.g. defect in natural inhibitors of coagulation e.g. anti-
thrombin III.
- Auto immune factors.
Incidence
About 15-20% of clinical pregnancies end in miscarriage. If those with biochemical evidence of
pregnancy (Serum Positive HCG are included), the rate may be about 30%. Majority of
miscarriages occur before the 13th week although 1-2% occur between 13 and 24 weeks
Threatened abortion
Signs and symptoms

- Slight bleeding, spotting

- Uterine contraction is just mild cramping
- No passing of tissue
- No cervical dilation
Management
Bed rest
Sedation
Avoid stress
Avoid orgasms

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Future treatment depends on the woman’s response to treatment
Inevitable abortion
Causes

- Advancing maternal age

- Increased parity
- Chronic infections
- Premature dilation of the CX
- Anomalies of reproductive tract
- Chronic debilitating diseases
- Inadequate nutrition
- Recreational drug use
Signs and symptoms
Bleeding – moderate
Uterine cramping – mild to severe
No passage of tissue
Presence of cervical dilation
Treatment
Prompt termination of pregnancy is accomplished by dilations and curettage
Incomplete Abortion
S/S
Bleeding is heavy and profuse
Uterine cramping severe
There is passage of tissues
There is cervical dilation with tissue in the cervix
Treatment
Prompt termination of pregnancy by dilation and curettage
Complete Abortion
Bleeding – slight
Uterine cramping is slight
There is passing of tissue

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No cervical dilation
Treatment
No further intervention may be needed if uterine contractions are adequate to prevent
hemorrhage and there is no infection
Missed Abortion
Bleeding – none only spotting
Uterine cramping – none
No passage of tissues
No cervical dilation
Treatment
If spontaneous evacuation of the uterus does not occur within one month, pregnancy is
terminated by method appropriate to the duration of pregnancy. Blood clotting factors are
monitored until uterus is empty. DIC and Coagulability defect of blood with uncontrolled
hemorrhage may develop in cases of fetal death after the twelfth week, if products of conception
are retained for longer than 5 weeks.
Septic Abortion
S/S
Bleeding varies usually malodorous
Uterine contraction varies
Passage of products varies
Cervical dilation usually open
Treatment
Immediate termination of pregnancy by method approximate to dilation of pregnancy. Cervical
culture and sensitivity studies are done and broad – spectrum antibiotics therapy e.g. ampicillin,
gentamycin started. Treatment of septic shock is initiated if necessary.
Recurrent abortion (habitual abortion)
Bleeding varies
Cramping varies
Passage of tissue is present
Cervical dilation present
Treatment

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Treatment varies depending on type
Prophylactic cerclage may be done if premature cervical dilation is the cause.
Nursing management is as for a patient that has undergone evacuation under anaesthesia.
Discharge teaching for the women after early miscarriage

- Advise her to report any heavy, profuse, or bright red bleeding to health care provider
- Reassure the woman that scanty dark discharge may persist for 1 – 2 weeks
- To reduce the risk of infection remind the woman not to put anything into the vagina
until bleeding has stopped (e.g. no tampens, no vaginal intercourse) to take antibiotics
as ordered
- Acknowledge that the woman has experienced a loss and that time is required for
recovery. She may have mood swings and depression
- Refer her to support groups, clergy or professional counseling as needed
- Advice the woman that, attempts at pregnancy should be postponed for at least 2
months to allow her body to recover.

ECTOPIC GESTATION OR PREGNANCY

Definition – one where the implantation occurs at a site other than the uterine cavity.
Prevalence
About 1% of all pregnancies are ectopic and the life threatening outcome of this condition calls
for appropriate treatment for the mother.
Types
 Tubal pregnancy
 Ovarian pregnancy
 Cervical pregnancy
 Abdominal pregnancy

Tubal Pregnancy
This occurs when the transport of the fertilized ovum into the uterine cavity is interfered with.
The implantation can occur at any point along the tube although the ampulla is the commonest
site, followed by the isthmus and the interstitial portion is the least common.
Causes of Tubal Pregnancy

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Any alteration of the normal function of the uterine tube in transporting the gametes contributes
to the risk of tubal pregnancy.
 Congenital abnormalities of the tube such as hypoplasia, undue tortuosity of the tube and
diverticula.
 Previous infection e.g post abortive sepsis, puerperal sepsis, gonorrhea and tuberculosis
these result to alteration of the ciliated lining or the peristaltic action of the tube. It can
also result to the adhesions both inside and surrounding the tube restricting normal
functioning of the tube.
 Surgery on the uterine tube – reconstructive surgery for infertility or reversal of tubal
ligation
 Use of intrauterine contraceptive device. They protect from pregnancy in the uterus but
not from tubal pregnancy
 Assisted reproductive techniques like “in vitro fertilization” (IVF) and embryo transfer.
The transferred embryo may get injected into the tube.
 Induction of ovulation with gonadotrophic hormones.
 Endometriosis
Physiology of Tubal Pregnancy
Here the blastocyst erodes the epithelium and attached itself to the muscle layer. It grows and
expands within the wall distending the tube. Maternal vessels are exposed and the pressure
caused by the resultant blood flow can destroy the embryo. The uterus enlarges in size, and in the
body, the changes associated with pregnancy occur under the influence of hormones.
Outcomes of Tubal Pregnancy
The outcome of tubal pregnancy could be one of the following:
 Tubal abortion: pregnancy in the ampulla or infundibulum of the tube may be aborted
through the fimbriated end into the peritoneal cavity.
 Tubal Mole: Following the bleeding around the embryo from the site of implantation, the
death of the embryo occurs and the formed layers of clots, distend the tube. The mole
may need to be removed.
 Tubal rupture: Tubal wall distended by the pregnancy and penetrated by the trophoblast
to such an extent that it ruptures.

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  Pelvic haematocel. A considerable collection of blood forms in the pouch of douglas or
utero vesicular pouch. Initially, it is fluid, later forms a mass which becomes firm as it
gets absorbed.
 Secondary abdominal pregnancy: Sometimes, the embryo from the ruptured tubal
pregnancy gets implanted on the pelvic peritoneum and a secondary abdominal ectopic
pregnancy develops.
Clinical Presentation
 Amenorrhea present in 75 – 95% of pregnancy
 In the remaining cases, tubal pregnancy ruptures before the menses is missed
 There may be history of vaginal spotting
 Localized acute lower abdominal pain
 Pain is sharp and stabbing in nature
 May feel dizziness, nausea and vomiting
 Shoulder pain indicates bleeding into the peritoneal cavity
 Severe pallor, rapid and thready pulse, tachypnea and low blood pressure
 Low abdominal tenderness on abdominal examination which is rebounding, guarding and
shifting dullness due to hemoperitoneum
 Pelvic examination shows tenderness on transverse cervical movements, lateral forniceal
tenderness, adnexal mass and vascular pulsations on the side of the ectopic pregnancy
 Ultrasound enables an accurate diagnosis.
Treatment
 Resuscitate patient in acute rupture
 Exploratory laparotomy under controlled anaesthesia
 Ruptured tube repaired or removed by salpingostomy or salpingectomy respectively
 Suction the ectopic pregnancy if the tubal pregnancy is in process of tubal abortion to
make it complete.
 Offer mother follow up support and information regarding subsequent pregnancies.
 Offer client needed psychological supports as client is passing through grieve.

Abdominal Pregnancy

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 - Very rare
- Could be primary or secondary: If primary, implantation of fertilized ovum is in the
peritoneal surface. Secondary is the outcome of tubal rupture or abortions.
- The embryo which is still alive due to its chorionic attachment to the uterine tube gets
attached to the pelvic peritoneum, omentum, intestine etc.
- The fetus grows in peritoneal cavity but most of the fetus or embryos do not survive and
the product of conception is reabsorbed or calcifications occurs.
- In the fate of continuation, the client feels persistent low abnormal pain, nausea,
vomiting, constipation, diarrhea distension and urinary frequency
- There may be vaginal spotting or haemorrhage
- Fetal movements are painful
- Abdominal examination reveals tenderness and superficiality of the fetal parts.
- There is abnormal fetal lie and loud fetal heart sound
- Ultrasonography confirms the diagnosis
Treatment
- Delivery is by laparotomy
- Severe bleeding may follow the separation of the placenta and if attachment is to the
intestine, the placenta is left in situ.
- Risk of infection may follow placenta in situ but it is considered a safe option.
- Fetal mortality very high
- Fetal growth retardation is high and deformity in about 20 – 40% of cases due to
oligohydraminious.
- The fetus may die when membrane ruptures or in the immediate neonatal period from
respiratory distress.

Cervical Pregnancy
 Occurs due to implantation in the cervical canal.
 Rapid passage of the fertilized ovum or fertilization of the ovum after it reaches the
cervical canal.
 Very rare and may not last beyond 20 weeks
Signs and symptoms

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  Painless bleeding soon after the time of implantation
 Palpation of the cervical mass with distension and thinning of the cervical wall
 Partial dilation of the external OS and a slightly out enlarged uterine fundus
Treatment
Remove the product of conception by curettage and packing the cervical canal or total abdominal
hysterectomy.

Obstructed Labour
Obstructed labour occurs when there is no progress in the decent of the presenting part with
strong uterus contraction.
Obstruction usually occurs in the pelvic brim but can also occur at the outlet.
Causes of Obstructed Labour
-. CPD or disproportion between the size of the mother’s pelvis & the fetus. Here the size of
the fetus is large in relation to the mother’s pelvis.
- Deep transverse Arrest which is an outcome of posterior position.
- Mal-presentation, such as transverse, Brow or persistent mentoposterior position
- Pelvic Mass: occlusion of the lower uterus segment or Cervix by tumors such ovarian
pelvic or by fibroid.
- Fetal abnormalities such as conjoined twins, locked twins, hydrocephalus, fetal ascites,
compound presentation, uterine abnormalities e.g. Bicornette uterus, cervical dystocia,
prolapse or nervous operations seamings.
Signs & Symptoms Early signs
- Failure of the presenting part to enter the brim despite good uterus contraction
- Slow Cervix dilatation due to high presenting part
The Cervix hangs loosely as an empty sleeve because the presenting part is not applied to
it.
- Formation of large bag of fore water
- Early rupture of membrane resulting from pressure exerted on the large bags of fore
water by the uterine contraction.
Late Signs

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A good midwife must not allow these late signs of obstruction to occur. Early detection of the
early signs prevents the occurrence of the late signs which endangers the women’s life.
There is sign of the following
- Constant pain
- dehydration
- Ketosis
- Pyrexia
- Tachycardia
- Tenderness of the lower segment
- Molding of the uterus round the fetus because no relaxation between contraction.
- Urinary output is poor, little urine obtain on catheter
- Hematuria
There is continuous state of tonic contraction
There is thinning and elongation of the lower uterine segment and shortening and
thickening of upper uterine segment
- Appearance of retraction ring or Bandl’s ring seen as an oblique ring above the
symphysis pubis and is similar in appearance to a full bladder
Vaginal examination Reveals
Vagina hot and dry
Presenting part high, feels wedged and immovable
- Excessive moulding of the fetal skull with formation of a large caput seccendenum
- Evidence of fetal distress may be observed.
Management
Prevention: This is the most important aspect of the management
- At risks mothers should be detected during antenatal period. This is achieved through HX
of prolonged or difficult births
- ANC assessment which includes abdominal examinations to rule out mal-presentation,
signs of CPD
- Appropriate referral should be made before the onset of labour
- Management should be adjusted to ensure safe delivery.
- As a midwife, Advocate for an elective C/S for the woman during labour.

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 - Early detection of lack of decent by careful assessment of the progress of labour.
- Comparing the abdominal findings with vaginal examination to confirm decent of the
presenting part through the pelvis.
- Observe the maternal and fetal condition-vital signs and fetal heart monitoring
- Assess the nature of the uterine contraction e.g. length, strength and frequency of
contractions.
- When obstruction is suspected with above precautions, medical aids should be sort.
- Start I.V. infusion to correct dehydration
- Obtain blood for grouping and cross matching
- Antibiotic should be administered as ordered by the obstetrician to combat any infection
that may be present.
- Keep accurate maternal and fetal records of observation of conditions
- Record any discussions with the mother and family.
Medical Intervention
If obstruction is diagnosed in the first stage of labour, delivery by C/S is carried out.
In second stage delivery by assisted birth may be employed or C/S when this fails.
Management in the rural area or community
When mother is in at home,
- Arrangement for immediate transfer to a nearby maternity hospital or unit with facilities
for immediate C/S.
- Blood for grouping and cross matching should be obtained.
- I.V. infusion should be set up before transfer
- Keep detailed record
- Arrange for expert care for the baby who is likely to be shocked and asphyxiated.
- Inform the parents and relatives that baby may need special care after birth.
- If the baby is dead, C/S may still be the mode of delivery as vaginal delivery may not be
achieved.
- Medical intervention C/S is the preferred method of delivery.
Complications
Maternal

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 - Trauma from the pressure offetal head or during assisted birth.
- VVF which results to diseases. (Prolonged compression of the tissues causes necrosis of
the bladder and vaginal walls which results to urinary in continence.
- Intrauterine infection as a result of prolonged rupture of membrane
- Rupture of the uterus from neglected obstructed labour.
- Haemorrhage from uterine rupture
- Possible death of mother
Fetal
- still birth from hypoxia.
- Permanent brain damage if alive from hypoxia
- Pneumonia from ascending infection or meconium aspiration.
Refusal of treatment
You might be confronted with the situation of the partners refusing to consent to the proposed
management. This does not exonerate you from being guilty if you did not carry out your duty of
providing care and support at a level appropriate to her experience while you wait for assistance.
- Recount the consequences of refusal to the family and record.
- Maintain the trust of the woman and her family despite their refusal.
- Your priorities and accountability should be to the woman.
- Record all conversations with all stakeholders
- If possible, get a written consent for the refusal

UTERINE RUPTURE
Uterine rupture is a break in the continuity of the uterine wall.
Incidence- it is a named obstetric injury but a severe one which occurs in 1500 – 2000 births
Causes during pregnancy
Causes during labour and birth
a. Over distension of the uterus e.g multiple pregnancy.
Uterine Factors
1. HX of hysterostomy: which include myomectomy, c/s, metroplastry, corneal resections
2. Separation of the scar of a previous classical cesarean birth.

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 3. Trauma – Motor vehicles accident, rational difficult forceps, extension of a cervical.
Laceration oxytocin in agents, attempts at operative vaginal delivery. Breech extraction
through an incomplete cx dilation, internal podalic version and extraction, destructive
operations,
4. Uterine over distention such as in polyhydraminous, multiple gestation fetal macrosomia.
5. Congenital uterine abnormalities such as septed uterus
6. Mal-presentation such as transverse lie, brow and oblique lie
7. Placenta percreta & invasive mole
8. Choriocarcinoma: These last two points can cause rupture before labour.
9. Weak uterine walls from damages from previous operative procedures such as rigorous
curettage, induced abortion (perforation) manual removal of the placenta
10. Multigravidity is a risk factor .
11. Labour stimulation e.g oxytocin induction
12. Intense spontaneous uterine contraction
Classification of uterine rupture
It can be;
a) Complete
b) Incomplete
Complete rupture extends through the entire uterine wall into the peritoneal cavity or broad
ligament.
Incomplete uterine rupture is one that extends into the peritoneum but not into the peritoneal
cavity or broad ligament bleeding in incomplete rupture is usually internal.
Incomplete rupture may also be a partial separation at an old c/s scar and may go unnoticed
unless the woman undergoes a subsequent c/s birth or other uterine surgery.
Signs & symptoms
a) There may or not be pain ( no pain in incomplete)
b) Vomiting
c) Faintness
d) Increase abdominal tenderness
e) Hypotomic uterine contraction
f) Lack of labour progress

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 g) Bleeding and affects of blood loss will be noted
h) Sudden sharp shooting pain in her lower abdomen. Complaining that “something have”
or “gave way”.
i) Signs of hypovolemic shock due to hemorrhage
(Hypertension, tachypnea, pallor cool clamuy skin)
j) Fetal parts may be palpable through the abdomen.
Fetal signs
The fetus may or may not show any signs of
- late decelerations, decreased variability, increased or decreased heart rate or other non-
reassuring signs.
- Fetal heart tone may be lost.
- Fetal heart rate may be absent if the placental is separated.
- Fetal parts may be palpable through the abdomen.
Care management
Prevention is the best treatment
- Advice women who have undergone classical c/s birth not to attempt vaginal delivery in
subsequent pregnancies.
- Women at risk for uterine rupture are assessed and closely monitored during labour.
- Women whose labour is induced with oxytocin are monitored for signs of uterine hyper-
stimulation as this can precipitate uterine rupture. Discontinue oxytocin infusion if there
is hyper-stimulation or decrease and administer a tolytic drug to decrease the intensity of
the contraction.
- Assess women for excessive bleeding especially if the fundus is firm and there are signs
of hemorrhagic shock.
Nurses note
- Start intravenous fluid.
- Transfuse blood product as prescribed
- Administer oxygen
- Assist with the preparation for immediate surgery

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 - Support woman and her family by giving them information about the treatment as both
fetal and maternal mortalities are high
- Provide information about spiritual support services or suggest that the family contact
their own support system.

Medical intervention
If rupture occurs, the type of medical intervention depends on the severity
A small rupture may be managed with a laparotomy and birth of the baby, repair of the
laceration and blood infusion if required.
Incomplete rupture, hysterectomy and blood transfusion is the usual treatment.

AMNIOTIC FLUID EMBOLISM (AFE)

Amniotic Fluid Embolism occurs when fluid containing particles of debris for instance, vernix,
hair, skin cells meconium enters the maternal circulation and obstructs the pulmonary vessels,
causing respiratory distress and circulatory collapse. This can happen any time there is an
opening the amniotic sac or an opening in the maternal uterine vein accompanied by enough
intra-uterine pressure to force the amniotic fluid into the veins (eg if the placenta separates or if
there are rapid or strong contractions that cause the uterus to rupture or lacerate.
This condition is associated with maternal mortality rate as high as 86% and fatal mortality of
about 50%,
When the amniotic fluid contains particles such as meconium, mucus, fat globules, lanugo,
bacterial products and debris from a dead fetus, it is more damaging because emboli can then
form more readily.
If thick meconium is involved, maternal death occurs most often because it clogs the pulmonary
vein more completely than other debris.
- Where death does not occur immediately serious coagulation problem such as
disseminated intravascular coagulatory (DIC) usually occurs
- The pulmonary blood vessels can be adversely affected by the substances in the amiotic
fluid by causing vasospasm or pulmonary hypertension. It can also result to cardiac
di8sfunction causing left ventricular failure.
- Hemorrhage also result.

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Maternal Risk factors
- Multipanuity
- Difficult labour
- Abruption placentae
- Oxytocin introduction of labour
- Fetal problems e.g. macrosonia, death and meconium passage

Signs and symptoms

Sign:
Respiratory distress
 Restlessness
 Dyspnoea
 Cyanosis
 Pulmonary oedema
 Respiratory arrest
Circulatory collapse
 Hypotension
 Tachycardia
 Shock
 Cardiac arrest
Hemorrhage
 Coagulation failure: bleeding from incisions, veinpuncture sites, trauma (llaceration:
petechiae, ecchymoses purpuna
 Uterine atony
Intervention
- Oxygenate
 Administer oxygen by face mask (8-10L.mm) or resuscitation bag delivery 100% oxygen
 Prepare for intubation or mechanism ventilation
 Initiate or assist with cardiopulmonary resuscitation
 Tilt the pregnant woman 30 degrees to side to displace uterus

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  Maintain Cardiac Output and Replace fluid losses
 Position woman on her side
 Administer IV Fluids
 Administer blood: packed cell, fresh frozen plasma
 Insert indirrelling catheter and measure hourly urine output
 Correct coagulation failure
 Monitor fetal and maternal status
 Prepare for emergency birth once the woman is stabilized
 Provide emotional support to woman, partner and family

CORD PRESENTATION AND PROLAPSE

Cord Presentation: This is when the umbilical cord lies in front of the presenting part with the
membranes still intact while Cord prolapse is when the cord lies in front of the presenting part
with the fetal membranes ruptured; umbilical cord prolapse may be occult (hidden or not visible)
lying long side the presenting part. Cord prolapse may be occult at any time whether the
membranes are ruptured or intact. The most commonly seen is frank prolapse directly after the
membranes have ruptured when the gravity washes the cord in front of the presenting part.
Incidence: It occurs in 1:400 births
Predisposing Factors
1. High Presenting part: (head) when there is spontaneous rupture of the membrane when
the head if high, loop of cord may pass between the uterine wall and the fetus thereby
lying in front of the presenting part. When the presenting part now descends, the cord
becomes cut of and becomes occluded.
2. Mal-presentation:
a. Breech: as a result of the proximity of the umbilicus to the buttocks and ill-fitting
nature of the presenting part, breech presentation usually results in cord prolapse.
Here the degree of compression is less than in cephalic presentation though there is
still de of asphyxia.
b. Polyhydraminous: In polyhydraminous, when there is spontaneous rupture of
membrane the cord is likely to prolapse as a result of gravity which washes the cord
in front of the presenting part.

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 3. Multiparity: Mal-presentation is very common in multiparity and as a result premature
rupture of membrane before the head is engaged is very common which is likely to result
to prolapse of cord.
4. Prematurity: When a fetus is small in relation to the size of the uterus and the pelvic,
the cord is likely to be prolapsed.
5. Multiple pregnancies: Multiple pregnancies are usually associated with mal-
presentation especially of the 2nd twin which may allow for cord prolapse.
Cord presentation Diagnosis
On V.E, the cord is felt behind the intact membranes.
Cord presentation can also be suspected when there is irregularity in the fetal heart rate. It means
that the cord may have been in front or by the side of the presenting part and is being compressed
by the presenting part.
Cord Prolapse Diagnosis:
1. When the cord is felt in front of or by the side of the presenting part on vaginal
examination.
2. On inspection of the vulva, a loop of cord may be seen at the vulva
3. It is more commonly felt at the vagina or in case of the high head at the cervical OS.
4. The fetal heart rate may be abnormal especially bradycardia
5. Suspicion CTG may be as a result of cord prolapse.
6. Prolonged deceleration of the fetal heart and variable deceleration may result from cord
compression following cord prolapse.
Management of Cord Presentation
Principles of management

a. Membranes should not be ruptured

b. VE should be discontinued to reduce the risk of rupturing the membrane
c. Seek for medical help
d. Monitor the fetal heart regularly and record especially during contraction
e. Place the Patient in position that will lift the weight off the presenting part on the cord
Outcome – C/S most likely to be done.
Cord prolapse
1. At the diagnosis of cord prolapse urgent assistance is sought by the midwife.

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 2. Explain the findings to the pt and the relations and the emergency but reassurance that
may be needed
3. Dicscontinue any oxtytocin infusion on, but continue iv fluid or increase existing rate.
4. Vaginal examination is carried out to
a. Assess the degree of cervical dilation
b. Identify the presenting part
c. Identify the station of the present part
5. Note the time
6. If the cord pulsates, it should be handled as little as possible to avoid spasm which comes
as a result of handling or reduction in temperature
7. Frequent fetal heart monitoring should be carried out.
8. The midwife relieves the pressure of the presenting part on the cord by inserting her
gloved fingers holding the presenting part off the umbilical cord.
9. The midwife should help the mother to change her position to raise her pelvis and
buttocks. Knee chest position is used to move the fetus towards the diaphragm thereby
reliving the compression on the cord.
10. If the cord protrudes from the vagina, wrap loosely in saturated warm normal saline
towel.
11. Administer oxygen to the woman by mask at 8-10l/m until birth is accomplished.
She can be helped to lie on an exaggerated sim position –lying on the left side with a wedge or a
pillow elevating her hips.
The foot of the bed may be raised.
The above measures need to be maintained until delivery vaginally or by C/S is done.
Medical Management
Aim
Speeding up the delivery to reduce the mortality and morbidity associated with this condition.
The Treatment of choice is C/S in cases where the baby is alive and delivery is not imminent or
vaginal delivery cannot be indicated.
If the Pt. is in 2nd stage, she could push with the aid of episiotomy to speed up the delivery,
especially in multiparous mothers. If the presentation is cephalic, assisted delivery may be
carried out e.g. ventous or forceps delivery.

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Community management
If cord prolapse is diagnosed in the community and the fetus is thought to be still alive, the pt is
transferred to the hospital immediately. All the necessary precautions to relieve compression
should be carried out and the obstetrician should be informed and should be prepared for
emergency C/S on animal.

Vasa Praevia
This is a condition where the fetal blood vessel lies over the OS before the presenting part. This
is very common in a valenmentous insertion of the cord.
Hence the fetal vessel from valenmentous insertion of the cord may cross to the area of the
internal OS especially in a low lying placenta. During engagement, this could be cut off with the
membrane are a fore membrane. The fetus in this condition is in great danger owing to the risk of
rupture of the vessels following the rupture of the membranes. The rupture of the vessels leads to
exerbation (deprivation of blood)of the fetus.
Signs and Symptoms
1. On V.E. Vasa praevia may be palpated when the membranes are intact
2. Could be seen in ultrasound
3. Could also be seen in speculum examination
Signs of Ruptured of Vasa Praevia
1. Slight vaginal bleeding that commences with membrane rupture
2. Fetal distress that does not correspond with the loss of blood.
Diagnosis:
Singer’s alkali – denaturation test can be done though in practice it is not possible as the time is
so short that it may not be possible to save the baby’s life.
Management

- The midwife should seek for assistance

- Fetal heart rate should be monitored
- The mode of delivery will depend on the parity and the fetal condition
- If the fetus is alive and the pt is a multiparous mother and in 2 nd stage, delivery should be
expedited (hastened) but if the mother is in the first stage emergency C/S should be
carried out.

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Management of the Baby
A pediatrician should be present at the delivery of the baby
If alive, HB should be estimated after resuscitation
This baby should require blood transfusion although this emergency carries a high mortality rate.

Episiotomy
Definition:
Episiotomy is a surgically planned incision on the perineum and the posterior vaginal wall
during the second stage of labour in order to enlarge the vaginal introitus to facilitate easy and
safe delivery of the fetus-spontaneous or manipulative. It is in fact an inflicted second-degree
perineal injury. It is the most common obstetric operation performed.
Objectives
 To enlarge the vaginal introitus so as to facilitate easy and safe delivery of the fetus-
spontaneous or manipulative
 To minimize the over-stretching and rupture of the perineal muscles and fascia.
 To reduce the stress and strain on the fetal head.
Indications
Episiotomy is recommended in selective cases rather than as a routine. A constant care during
the second stage reduces the incidence of episiotomy and periteal trauma
 Inelastic (rigid) perineum
Where the perineum is causing arrest or delay in the decent of the presenting part as in
elderly primipgravidae
 Anticipating Perineal tear
a. Big baby
b. Face to pubic delivery
c. Breech delivery
d. Shoulder dystocia
 Operative vaginal delivery
a. Forceps delivery
b. Ventouse delivery
 Previous Perineal surgery

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 a. Pelvic floor repair
b. perineal reconstructive surgery.
Common indications
- threatened perineal injury in primigravidae
- rigid perineum
- forceps, breech, occipito-posterior or face delivery
Time of Episiotomy
The bulging thinned perineum during contraction just prior to crowning (when 3-4cm of the head
is visible) is the ideal time.
During forceps delivery, it is made after the application of the blades.
Advantages
Maternal
a. a clear and controlled incision is easy to repair and heals better than the lacerated wound
that might occur otherwise.
b. It helps to reduce the trauma to the pelvic floor muscles which helps to reduce the
incidence of prolapse and perhaps urinary incontinence.
c. Helps to reduce the duration of the second stage of labour
Fetal
It minimizes intra cranial injuries, especially in premature babies or after coming head of breech.
Types
1. Medio-lateral
2. Lateral
3. Median
4. J. shaped
Medio lateral:
The incision is made downward and outwards from the midpoint of the fourchette either to the
right or to the left. It is directed diagonally in a straight line which runs about 2.5cm away from
the anus (Midpoint between the anus and the Ischial Tuberosity).
Median: The incision commences from the centre of the fourchette and extends posteriorly
along the midline for about 2.5cm.

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Lateral: The incision starts from about 1cm away from the centre of the fourchette and extends
laterally. It has got many drawbacks including chance of injury to the Bartholin’s ducts. It is
totally condemned.
J-shaped: The incision begins in the centre of the fourchette and is directed posteriorly along the
midline for about 1.5cm and then directed downwards and outwards along 5 or 7 O’clock
position to avoid the anal sphincter. Apposition is not perfect and the repaired wound tends to be
puckered. This is also practiced widely.
Steps of Mediolateral Episiotomy
Step 1: Preliminaries
- Clean and swab the perineum thoroughly with an antiseptic lotion and drape the patient
- Apply or inject local anesthesia to the perineum especially in proposed line of infiltration
with 10mls of 1% lignocaine solution
Step 2
- Place two fingers in the vagina between the presenting part and the posterior vaginal wall
- Insert a curved or straight blunt pointed sharp scissors in between the fingers and the
posterior vaginal wall and the other on the skin.
- Incision should be made at the height of a uterine contraction when you will
accurately estimate the extent of the incision from the stretched perineum.
- Make a deliberate cut starting from the centre of the fourchette extending laterally
either to the left or to the right.
- Direct the incision diagonally in a straight line which runs about 2.5cm away from the
anus.
- Make an adequate incision to serve the purpose for which it is needed i.e. according
to the need of the individual case.
- Try not to make the incision too early to avoid bleeding
Structures cut are
 posterior vaginal wall
 superficial and deep transverse perineal muscles
 bulbospongiosus and part of levator rani
 fascia covering these muscles .
 Transverse perineal branches of pudendal vessels and nerves

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  Subcutenous tissues and skins
Step 3
 Timing of repair is done soon after the expulsion of the placenta
 Control oozing of blood during this period with a sterile gauze by applying pressure on the
oozing area
 If there is obvious bleeding vessel, use artery forceps to clamp and legate to control bleeding.
 Early repairs prevent sepsis and eliminates patients apprehension of stitches
Preliminaries
 Place patient in a lithotomy positions.
 Ensure good lighting from behind
 Clean the perineum and wound area with antiseptic solution
 Remove blood clots from the vagina and the wound area.
 Drape the patient properly and repair under strict aseptic precaution
 Pack the vagina with a vaginal pack if the repair field is obscured by oozing of blood from
above.
 Do not forget to remove the pack after the repair is completed.
Repair proper
The repair is done in three layers following these principles:
 Perfect hemostasis
 Obliteration of the dead space
 Suture without tension
Do the repair in the following order
a. Vaginal mucosa and sub-mucosal tissues
b. Perineal muscles
c. Skin and subcutaneous tissues
NB:
Remember to carry out your preliminaries
Vaginal mucosa sutured first – The first suture is placed at or just above the apex of the tear.
Thereafter the vaginal walls are apposed by interrupted sutures with polyglucolic acid suture
(Dexon) or no ‘O’ chromic catgut from above down wards till the forchette is reached.

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The suture should include the deep tissues to obliterate the dead space. A continuous suture may
cause puckering and shortage of the posterior vaginal wall.
If nylon or silk is used to suture the skin, record the number of stitches in your report.
Post-Operative Care
1. Dressing. The wound is to be dressed each time following urination and defecation to keep
the area clean and dry. The dressing is done by swabbing with cotton wool swabs soaked in
antiseptic solution followed by application of antiseptic powder or ointment ( Furacin or
Neosporin)
2. Comfort: to relieve pain in the area, magnesium sulphate compress or application of infrared
heat may be used. Ice pack reduces swelling and pain also. Analgesics such as ibuprofen may be
given when required.
3. Ambulance: The patient is allowed to move out of the bed after 24 hours. Prior to that, she is
allowed to roll over on to her side or even to sit but only with thighs apposed.
4. Removal of stiches – when the wound is sutured by catgut or dexon which will be absorbed,
the sutures need not be removed. But if non-absorbable material like silk or nylon is used, the
stitches are to be cut on the 6 th day. The number of the stitches removed should be checked with
the record of the stitches given.
Complications of Episiotomy
We have immediate and remote complications.
Immediate:
(1) Extension of the incision to involve the rectum, common in median episiotomy or during the
delivery of undiagnosed occipito posterior even with small mediolateral episiotomy
2. Vulva Haematoma
3. Infection which presents with throbbing pain on the perineum, rise in temperature, wound area
looks moist, red and swollen and offensive discharge which comes out through the wound
margins.
Treatment
a. Encourage and facilitate the drainage of pus by cutting one or two stitches.
b. Dress the wound locally with an antiseptic powder or ointment.
c. Apply magnesium sulphate compress or apply infrared heat to the area to reduce eodema
and pain.

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 d. Give systematic antibiotic IV.
4. Wound dehiscence: This is often due to infection, haematoma formation or faulty repair
a. wound should be dressed daily until the ;local infection subsides and healthy granulation
tissue forms in the margins.
b. Secondary suture are applied under local anesthesia using cutting needle and nylon. The
margins are to be saucerise. Debridement of all the nacrotic tissues should be done.
Afterwards through and through sutures should be taken right from the bottom of the
wound. Post op dressing should be given and systemic antibiotics IV given as prescribed.
5. Injury to anal sphincter causing incontinence of flatus or faeces.
6. Recto-vaginal fistula very rare
7. Necrotizing fasciitis in woman who is diabetic or immune compromised
Remote:
1. Dyspareunia due to narrow vaginal introitus resulting from faulty technique of repair or
due to painful perinea scar.
2. Chance of perineal lacerations in subsequent labour if not managed properly
3. Scar endometriosis (rare)

PUERPERAL SEPSIS/ INFECTION OF THE GENITAL TRACT

Sepsis: infections associated with labor, puerperium and unsafe abortion which contributes to 20
– 25% of deaths.
Common Risk factors
- Antenantal intrauterine infection
- Caesarean section
- Cervical cerclage for cervical incompetence
- Prolonged rupture of membranes
- Prolonged labour
- Multiple vaginal examinations
- Internal fetal monitoring
- Instrumental delivery
- Manual removal of the placenta
- Retained products of conceptions

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 - Non-obstetric conditions such as Obesity, diabetes mellitius, human immune deficiency
virus.
Signs of puerperal pelvic infection
1. Pyrexia and tachycardia
2. Uterus –poorly contracted, tender and larger
3. Infected wounds caesarean/ perineal
4. Peritonitis
5. Paralytic ileus
6. Indurated adnexae (parametritis)
7. Bogginess in pelvic (abscess)
Symptoms of puerperal pelvic infection
- Malaise, headache fever rigors
- Abdominal discomfort, vomiting and diarrhoe
- Offensive lochia
- Secondary post-partum haemorrhage
Aetiology
- The vagina is normally colonized by organism with low virulence
- Puerperal infections is usually polymicrobial and involves contaminates from the bowel
that colonize the perineum and lower genital tract.
- Following birth, natural barriers to infection are temporarily removed and therefore
organisms with pathogenic potentials can ascend from the lower genital tract into the
uterine cavity.
- Placenta separation exposes a large raw area.
- Retained product of conception and blood clots within the uterus provide an excellent
culture medium for infection.
- Vaginal birth may be associated with lacerations on the genital tracts which may become
a focus for infection similar to iatrogenic wound, such as c/s or episiotomy.
- Transmission can occur by droplet infection, infected dust or by direct skin contact.
- The toxins produced by these organisms can result in a rapid deterioration into
septicaemic shock and yet produce minimal local signs.

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 - The midwife must ensure that hygiene and universal precaution in relation to hand-
washing and prevention and control of infection and strictly adhered to by all midwives
and health professionals. She must also advise the mother and her family in relation to
hygiene.
Investigation for puerperal genital infection
Investigation Abnormalities
1 Full blood count Anaemia, leucocytosis,
thrombocyctopoenia
2 Urea and electrolytes Fluid and electrolyte imbalance
3 High vaginal swab and blood culture Infection screen
4 Pelvic ultrasound Retained product, pelvic abscess
5 Clotting screen (haemorrhage or shock) Disseminated intravascular coagulation
6 Arterial blood gas (shock) Acidosis and hypoxia

The factors determining the clinical course and severity of puerperal infections;
a. The virulence of the offending organism.
b. Presence of haematoma or retained products of conception
c. Timing of antibiotics therapy and associated factors
Common methods of puerperal infection spread include:
- An ascending infection from the lower genital tract or primary infection of the placental
site which may spread through the fallopian tubes to the ovaries giving rise to
salphinago-oophoritis and pelvic peritonitis. It could progress to generalized peritonitis
and pelvic abscesses.
- Infection may spread by contiguity directly into the myometrium and the parametrium
giving rise to a metritis or parametritis also referred to as pelvic cellulitis. Pelvic
peritomitis and abscesses may occur.
- Infection may spread to distant sites through lymphatics and blood vessels infection from
the uterus can be carried by the uterine vessels into the interior venecava through the iliac
vessels or directly through the ovarian vessels.
This could give rise to septic thrombophenibitis, pulmonary infections or a generalized
septicaemia and endotoxic shock

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Medical Treatment
Mild to moderate infection can be treated with abroad spectrum antibiotics and depending on the
severalty the first few doses can be given intravenously (IV). With severe infection there is
release of inflammatory and vasoactive mediators in response to endotoxins produced during
bacteriolysis. The resultant local vasodilation causes circulatory embarrassment and poor tissue
perfusion. The phenomenon is known as septicaemic/septic/endotoxic shock and delay in
appropriate management could be fatal.
- Necrotizing fasciitis is a rare but frequently fatal infection of the skin, fascia and muscle.
This can originate from pereanial tears, episiotomies and c/s wounds. Perineal infections
can spread rapidly to involve the buttocks, thigh and lower abdominal wall.
- To manage this, wide debridement of the nacrotic tissue under general anesthesia is
absolutely essential to avoid mortality.
Prevention of puerperal Sepsis
- Increased awareness of the principles of general hygiene
- Use of antiseptic techniques
- Good surgical approach
- Risk high in c/s especially if performed after the onset of labour
- Prophylactic antibiotics can reduce the risk of post-operative infection

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