High-Risk Labor & Delivery

Client & Her Family

ABE NICOLAS
Bleeding During Pregnancy
Miscarriage/Abortion
Is the medical term for any interruption of a pregnancy
before a fetus is viable (able to survive outside the uterus
if born at that time).
A viable fetus is usually defined as a fetus more than 20-
24 weeks of gestation or one that weighs at least 500 g.
A fetus born before this point is considered a miscarriage
or premature or immature birth.
Is a spontaneous pregnancy loss before 20 weeks of
gestation.
Some 8% to 20% known pregnancies end in miscarriage,
with the majority happening before the 12th week.
The signs and symptoms of miscarriage vary from person to
person.
Symptoms may also vary depending on how far along you are.
Miscarriage symptoms may include:
1. Spotting or bleeding from the vagina
Bleeding may start as light spotting, or it could be heavier and
appear as a gush of blood. As the cervix dilates to empty, the
bleeding becomes heavier.
2. Abdominal cramping or pain in the lower back
Mild-to-severe lower back pain or abdominal pain or
cramping, either constant or intermittent.
3. Passage of tissue, fluid, or other products from the vagina
The tissue and heaviest bleeding should be passed in about 3-
5 hrs.
ABE
Spontaneous Abortion/Miscarriage
Is an early miscarriage if it occurs between 16 – 24 wks.
Is non- induced embryonic or fetal death or passage of products
of conception before 20 weeks gestation.
About 20% - 30% of women with confirmed pregnancies bleed
during the first 20 weeks of pregnancy
May result from certain viruses—most notably cytomegalovirus,
herpes virus, and rubella virus
Risk factors for spontaneous abortion include:
Extremes of age
History of spontaneous abortion
Cigarette smoking
Use of certain drugs (eg, cocaine, alcohol, high doses of caffeine)
A poorly controlled chronic disorder (diabetes, hypertension,
overt thyroid disorders) in the mother
Most common miscarriage causes:
Genetics
About 50% of all first trimester miscarriages are because of
chromosomal abnormalities.
Balanced Translocation
Blighted Ovum
Advanced maternal age: ↑ 35 years old at pregnancy term
Systemic Infections
Uterus or cervix infections can be dangerous to a developing
baby and lead to miscarriage.
Other infections that may pass to the baby or placenta can also
affect a developing pregnancy and may lead to loss.
Listeria, Rubella, Herpes simplex, Cytomegalovirus
Uterine Anatomical Abnormalities
If a woman’s uterus didn’t form correctly
when she was developing, it may be unable
to support a healthy pregnancy.
Uterine septum, Asherman’s Syndrome,
Uterine fibroids
Clotting disorders
In the case of pregnancy, blood clots can
form in the placenta.
This prevents nutrition and oxygen from
getting to the baby-to-be, and prevents
waste from being carried away
Antiphospholipid syndrome
ABE
Implantation failures
It must be kept in mind that the cause cannot be attributed to a single
patient (the mother)
but to THREE: her, him and the embryo.
Female factor
Uterine contractions
The uterus is a muscle and, therefore, any inappropriate stimulation
of the uterus increases contractions that could lead to expulsion of the
embryo.
Progesterone levels
Male factor
Meiosis
Spermatozoa precursor stem cells split their genetic load in half and
change from having 46 chromosomes to 23.
If there are abnormalities during this phase, they can affect the gamete’s
chromosomal make-up and, consequently, cause fertilization failure,
abnormal embryo development, implantation failure and premature
pregnancy loss.
 The Embryo
The combination of two reproduction cells: spermatozoa
and the oocyte → Analyze all of the embryo’s chromosomes.
Pre-implantation Genetic Diagnosis (PGD)
Refers specifically to when one or both genetic parents has a
known genetic abnormality and testing is performed on an
embryo to determine if it also carries a genetic abnormality.
Frequently followed by the difficult decision of pregnancy
termination if results are unfavorable.
If the corpus luteum on the ovary fails to produce enough
progesterone to maintain decidua basalis
The menstrual cycle has two phases: Follicular phase and the
Luteal phase
The primary purpose of the corpus luteum is to pulse out
hormones →progesterone
Teratogenic agent
Is a chemical, infectious agent, physical condition, or deficiency
that, on fetal exposure, can alter fetal morphology or
subsequent function.
The most critical period in the development of an embryo or in
the growth of a particular organ is during the time of most
rapid cell division.
The critical period for brain growth and development is from 3-
16 wks.
There are different kinds of miscarriages, including:
Threatened Miscarriage
(+) Abnormal bleeding → spotting (bright red), (+) abdominal
pain,
(-) cervical dilatation
During the first 20 weeks of pregnancy
Management
hCG may be drawn at the start of bleeding
and again in 48 hrs
If the placenta is still intact, the level in the
bloodstream should double, if it does not
double→ poor placental function is
suspected.
Avoidance of strenuous activity for 24-48 hrs
→ key intervention
Encourage the pregnant women to talk with
a sympathetic, supportive person about how
distressed they feel.
Coitus is usually restricted for 2 weeks after
the bleeding episode to prevent infection
and to avoid inducing further bleeding.
ABE
Imminent (Inevitable) Miscarriage
(+) Profuse bleeding (heavier), (+)
abdominal pain, (+) cervical
dilatation → most often the product
of conception are not expelled.
Most common in 1st trimester
Incomplete Miscarriage
(+) Heavy bleeding, (+) Abdominal
cramps, (+) Cervical dilatation, (+)
Tissue from the fetus or the placenta
stays in the uterus, (-/+) Uterus
cannot contract effectively, (+)
Danger of maternal hemorrhage.
Management
Most of these women will expel the fragments of
conception on their own without the need for
further medical or surgical treatment.
IV hydration and pain medication may be
required.
If the bleeding is severe, there may be a need for
blood transfusions patients should be admitted for
ongoing blood loss and monitor for shock and
possible surgical evacuation
The physician will usually perform a dilation and
curettage (D&C) to evacuate the remainder of the
pregnancy from the uterus.
Be certain a woman knows that the pregnancy is
already lost and that this procedure is being done
only to protect her from hemorrhage and
infection, not to end the pregnancy. ABE
 Missed (Silent) Miscarriage
Is one where the baby has died or not developed, but has not
been physically miscarried
In many cases, there has been no sign that anything was
wrong, so the news can come as a complete shock.
↑ Pregnancy hormones
(You may continue to feel pregnant and a pregnancy test may
well still show positive)
↓
Fundal height is measured → (-) In size can be demonstrated
↓
(-) FHT

Symptom: Painless vaginal bleeding

 Management
1. UTZ can establish the fetus has died
↓
Often the embryo actually died 4-6 weeks
before the onset of miscarriage symptoms or
failure of growth was noted.
2. D&C will be done
3. If the pregnancy is over 14 wks.
Labor will be induced.
 Generic Name: Misoprostol
Brand Name: Cytotec
(Prostaglandin suppository)
Classes: Gastrointestinal Agents, Other; Prostaglandins, Endocrine
↓
Dilate the Cervix
Induction of Labor (Off-label)
25 mcg (1/4 of 100-mcg oral tablet) intravaginal initially, then repeat at
intervals not to exceed q3-6hr
Not to be used in patients with previous cesarean delivery or major uterine
surgery
The most common side effects:
Diarrhea
Stomach pain
Nausea
Upset stomach
Vaginal bleeding or spotting/ heavy menstrual flow
Menstrual cramps
 Generic Name: Mifepristone
Brand Name: RU486, Mifeprex
Indication: For the medical termination of intrauterine pregnancy
through 70 days gestation
In combination with Misoprostol
Action: Locks a natural substance (progesterone) that is
needed for your pregnancy to continue.
↓
Used for elective termination of pregnancy
Common side effects:
Abdominal cramping
Allergic reactions such as closing of the throat, swelling of the
lips, and tongue, or face
Uterine bleeding
Uterine cramping
 Incompetent Cervix
In the female reproductive system, the
cervix is the lower end of the uterus.
The cervix is the part of the uterus which
opens into the vagina.
Before pregnancy, the cervix is normally
firm and closed. During pregnancy, the
cervix softens, shortens and dilates so you
can give birth.
Incompetent cervix occurs when the cervix
opens too early and silently during the
pregnancy without pain or contractions.
Some women may feel mild discomfort or
spotting starting between 14-20 wks of
pregnancy.
Be on the lookout for:
A sensation of pelvic pressure
A new backache
Mild abdominal cramps
A change in vaginal discharge
Light vaginal bleeding
Risk factors:
Cervical trauma
Some surgical procedures used to treat cervical abnormalities associated.
D&C could also be associated
A cervical tear during a previous labor and delivery
Congenital conditions
Uterine abnormalities and genetic disorders affecting a fibrous type of protein
that makes up your body's connective tissues (collagen)
Race
African-American women seem to have a higher risk of developing cervical
insufficiency
Significantly has higher rate of CI (3.2%) ABE
Management
Progesterone supplementation
If you have a history of premature birth,
your doctor might suggest weekly shots of
a form of the hormone progesterone.
Hydroxyprogesterone caproate
Makena
Repeated ultrasounds
Doctor might begin carefully monitoring
the length of your cervix by giving you
ultrasounds every 2 wks.
From 16-24 wks. of pregnancy
If your cervix begins to open or becomes
shorter than a certain length, your doctor
might recommend cervical cerclage
Management
Cervical Cerclage
↓
Refers to a variety of procedures that use
sutures or synthetic tape to reinforce the cervix
during pregnancy in women with a history of a
short cervix.
It can be done through the vagina (transvaginal
cervical cerclage) or, less commonly, through the
abdomen (transabdominal cervical cerclage)
↓
Usually performed at 12 to 14 weeks of
pregnancy, the stitches are typically removed
around week 37 at the time of a scheduled
cesarean section
Doctors do not use a cerclage if you are pregnant
with twins or multiples
Management

Vaginal Pessary
Is a prosthetic device that can be
inserted into the vagina to support its
internal structure.
It needs to be fitted by a medical
professional as they can cause vaginal
damage and fail to improve symptoms
if fitted incorrectly.
You’ll return to the clinic a week later
to check the device’s fit.
 Placenta Previa
Physiology:
The placenta is an organ that grows
inside the lining of your uterus during
pregnancy.
It connects to the umbilical cord and
carries oxygen and nutrients from you
to your unborn child.
It also moves waste away from your
baby.
Normally, the placenta attaches
toward the top of the uterus, away
from the cervix.
As your cervix opens during labor, it
can cause blood vessels that connect
the placenta to the uterus to tear ABE
 Placenta Previa / Low-lying
Placenta

Is an obstetric complication that

classically presents as painless
vaginal bleeding in the third
trimester secondary to an
abnormal placentation near or
covering the internal cervical os

Placenta blocks the opening to

the cervix that allows the baby to
be born.

It can cause severe bleeding

during pregnancy and delivery
 Happens in about 1:200
pregnancies
Risk Factors:
Smoke cigarettes or use of
cocaine
Maternal age ↑35 y/o
Have had a C-section before
Have had other types of
surgery on your uterus
Multiple pregnancies
PLACENTA PREVIA
Symptoms:
Bright red bleeding from the
vagina during the second half
of your pregnancy.
It can range from light-heavy,
and it's often painless
Uterine contractions
Uterine cramping
Back pressures/pain
 Types of Placenta Previa
Complete Placenta Previa Marginal Placenta Previa
Occurs when the placenta Occurs when the placenta is
completely covers the opening located adjacent to, but not
from the womb to the cervix covering, the cervical opening

Partial Placenta Previa Low Lying Placenta

Occurs when the placenta If the placenta attaches
partially covers the cervical instead to the lower part of
opening the uterus

ABE
Management
Place the Px. immediately on bed rest in a
side-lying position for 48 hrs.
To ensure an adequate blood supply to the
pregnant woman and fetus.
Immediately start assessing:
Duration of the pregnancy
Time the bleeding began
Px’s estimation of the amount of blood
discharge
Ask her to estimate in terms of cups or
tablespoons ( a cup is 240 ml; a tablespoon
is 15 ml)
Color of the blood
Whether there was accompanying pain?
What she has done for bleeding
Whether there were prior episodes of
bleeding during the pregnancy
Whether she had prior cervical surgery for
premature cervical dilatation

If the bleeding stops:

The Px. can be sent home with a referral
for bed rest & home care
 Abruptio Placenta
Occurs when the placenta partly or
completely separates from the inner
wall of the uterus before delivery.
(Usually after 20 wks. gestation)
May involve any degree of placental
separation, from a few millimeters to
complete detachment.
This can decrease or block the baby's
supply of oxygen and nutrients and
cause heavy bleeding in the mother.
It often happens suddenly.
If left untreated, it endangers both
the mother and the baby

ABE
Risk factors: Symptoms:
Chronic high blood pressure Most likely to occur in the
(hypertension) last trimester of
Hypertension-related problems pregnancy, especially in
during pregnancy, including the last few weeks before
preeclampsia, or eclampsia delivery
A fall or other type of blow to the Vaginal bleeding
abdomen
(Although there might not
Smoking be any)
Cocaine use during pregnancy Abdominal pain
Early rupture of membranes, which Back pain
causes leaking amniotic fluid before
Uterine tenderness or
the end of pregnancy
rigidity
Infection inside of the uterus
Frequent uterine
Maternal age: ↑40 y/o contractions ABE
 Management
Complications: If you’re less than 34 weeks pregnant

Maternal blood loss You might have be admitted into the

Disseminated hospital for monitoring.
intravascular
coagulation (DIC)
Hematoma formation
If your baby appears to be doing fine
and you stop bleeding, you eventually
Fetal compromise
might be able to go home.
If chronic → growth
restriction and
Oligohydramnios You might also be given
Rh sensitization Corticosteroids to help your baby’s
lungs develop faster in case you do go
into labor early
 Management

If you’re more than 34 weeks pregnant

You might still be able to have a vaginal delivery if the

abruption doesn’t seem severe.

If it is, and it’s putting your health or your baby’s health at

risk, you’ll need a C-section right away.

You might also need a blood transfusion

 Preterm Premature Rupture Of
Membranes (PPROM)
In this condition, the sac (amniotic
membrane) surrounding your baby
breaks (ruptures) before week 37 of
pregnancy.
Once the sac breaks, you have an
increased risk for infection.
You also have a higher chance of
having your baby born early.
(30% Pre-term deliveries)
It can result from a physiologic
weakening of the membranes
combined with the forces caused by
uterine contractions.
18 hrs. delivery (dry labor)
 Preterm Premature Rupture Of
Membranes (PPROM)
In this condition, the sac (amniotic
membrane) surrounding your baby
breaks (ruptures) before week 37 of
pregnancy.
Once the sac breaks, you have an
increased risk for infection.
You also have a higher chance of
having your baby born early.
(30% Pre-term deliveries)
It can result from a physiologic
weakening of the membranes
combined with the forces caused by
uterine contractions.
18 hrs. delivery (dry labor) ABE
Causes:
Uterine infection
Sexually Transmitted Infections
Smoking
Prior PPROM
Overstretching (distension) of the uterus and amniotic
sac
Trauma
Complications:
Perinatal morbidity → neonatal sepsis, umbilical cord
prolapse, abruptio placenta, and fetal demise
(-) Preterm Deliveries if:
Sometimes, when a slow leak is present and infection
has not developed → contractions may not start for a
few days or longer.
Sometimes a leak high up in the amniotic sac may reseal
itself so that preterm labor does not start or subsides.
In rare cases, a pregnancy can be carried to term if
PPROM occurs in the second trimester. ABE
Symptoms:
A rapid gush that feels like you’ve peed in your pants
*Sudden painless gush of fluid leaks out of the vagina or a
steady leakage of small amounts of watery fluid
A leak that starts and stops
Flecks of meconium in the fluid
Change in color and consistency of fluid coming out of the
vagina
↓ in the size of uterus
Characteristics:
Amniotic fluid is usually clear to pale
yellow in color.
It should be odorless, or slightly sweet
in odor—although some say it has a
bleach-like smell.
The amount of fluid increases
throughout pregnancy until about 34
wks.
The fluid is made up of water,
electrolytes, proteins, carbohydrates,
lipids, phospholipids, and urea, as well
as fetal cells.
Amniotic fluid normally has a pH of 6.5
or ↑ ABE
Diagnosis:
Nitrazine Test
Involves putting a drop of fluid
obtained from the vagina onto paper
strips containing Nitrazine dye
The strips change color depending
on the pH of the fluid
The strips will turn blue if the pH is
greater than 6.0. A blue strip means
it’s more likely the membranes have
ruptured

This test, however, can produce false

positives
↓
If blood gets in the sample or if
there is an infection present
Management
Monitoring for signs of infection, such
as fever, pain, increased fetal heart
rate.
Antibiotics should be administered to
patients with preterm PROM because
they prolong the latent period and
improve outcomes
Corticosteroids should be given to
patients with preterm PROM between
24-32 weeks’ gestation to decrease the
risk of intraventricular hemorrhage,
respiratory distress syndrome
In very few cases of PPROM, the
membranes may seal over and the fluid
may stop leaking without treatment
ABE
 Fetal Distress
Refers to the compromise of the fetus due
to inadequate oxygen (birth asphyxia) or
nutrient supply.
Uteroplacental insufficiency
Signs of Fetal distress:
Changes in the baby’s heart rate
Decreased fetal movement
Meconium in the amniotic fluid
Abnormal levels of amniotic fluid
Oligohydramnios/ Polyhydramnios
↓
Can lead to oxygen deprivation and birth
injuries
Maternal High blood pressure
Vaginal bleeding/cramping
Insufficient/Excessive maternal weight gain
Risk Factors
Maternal age ↑ 40 y/o
Obesity
Smoking
Diabetes and other chronic diseases
Pregnancy-induced hypertension
Recurrent antepartum hemorrhage
Post-term pregnancy
Multiple pregnancy
Stillbirth

ABE
Management
Requires fetal monitoring with a view to
induction of labor or planned caesarean section.
Ensuring the mother has adequate oxygen &
well-hydrated.
Turning the Px. onto one side, can reduce the
baby’s distress
Tocolytic drugs → Betamimetic therapy appears
to be able to reduce the number of fetal heart
rate abnormalities and reduce uterine activity
MgSO4, Nitroglycerin, Terbutaline
Significant meconium → defined as dark green
or black amniotic fluid that is thick or tenacious,
or any meconium-stained amniotic fluid
containing lumps of meconium.
ABE
Management

In laboring Px’s with meconium-stained

fluid
Amnioinfusion → Refers to the
instillation of fluid into the amniotic
cavity.
Augmenting amniotic fluid volume may
decrease or eliminate problems
associated with a severe reduction or
absence of amniotic fluid.
To prevent or treat FHR decelerations
related to oligohydramnios or to dilute
thick meconium staining of the
amniotic fluid.
The procedure can be performed by
transcervical or transabdominal routes
ABE
 Umbilical Cord Prolapse
Is where the umbilical cord
descends through the cervix, with
(or before) the presenting part of
the fetus.
During delivery, the prolapsed
cord can become compressed by
baby’s body.
The umbilical cord delivers blood
from the placenta to the baby,
cord prolapse can compromise a
baby’s oxygen supply.
It must be dealt with immediately
so the fetus doesn't put pressure
on the cord, cutting off oxygen
Subsequently, fetal hypoxia occurs
via two main mechanisms:

Occlusion → The presenting part

of the fetus presses onto the
umbilical cord, occluding blood
flow to the fetus.

Arterial Vasospasm → The

exposure of the umbilical cord to
the cold atmosphere results in
umbilical arterial vasospasm,
reducing blood flow to the fetus

ABE
Certain pregnancy complications
may increase the risk of cord
prolapse:

Breech delivery
Delivering two or more babies
vaginally (the second baby is more
likely to experience cord prolapse)
Preterm labor
Polyhydramnios
Prolonged labor

ABE
Management
Manually elevate the presenting part
by lifting the presenting part off the
cord by vaginal digital examination.
Avoid frequent handling the cord to
reduce vasospasm.
Encourage into left lateral position
with head down and pillow placed
under left hip OR knee-chest position.
This will relieve pressure off the cord
from the presenting part.
Consider the use tocolytic drugs.
Delivery is usually via emergency
Caesarean section.
If fully dilated and vaginal delivery
appears imminent, encourage pushing
or consider instrumental delivery. ABE
 Problems with Fetal Position,
Presentation, or Size
Fetal position
Relationship of the chosen portion of the
fetal presenting part to 1 of the 4
quadrants or transverse diameter of birth
canal
In defining position the following
determining points are used:
O → Occiput (Cephalic/Vertex
Presentation)
M →Mentum or Chin (Face Presentation)
S → Sacrum (Breech Presentation)
A →Acromion or Scapula (Shoulder
Presentation)
 Occiput posterior (OP)
Occiput →The back of the head or skull.
Caused by the adaptation of the fetal head
to a pelvis having a narrow fore pelvis
PREVALENCE:
Before labor
15-20% of term fetuses in cephalic
presentation are OP.
But only 5% are OP at vaginal delivery
↓
Most OP fetuses spontaneously rotate to an
anterior position (OA) during labor
Some persistent OP positions may be due
to an android maternal pelvis
↓
Can inhibit rotation to the occiput anterior
(OA) position
ABE
Why would posterior position matter in
labor?
The head is angled so that it measures
larger
The top of the head molds less than the
crown
Left Occiput posterior (LOP) → is the
most common fetal malposition
When facing forward, the baby is in the
occiput posterior position. If the baby is
facing forward and slightly to the left
(looking toward the mother's right thigh)
This presentation can lead to more back
pain (sometimes referred to as "back
labor")
Slow progression of labor
Right occiput posterior
position (ROP)
The fetus is facing forward and
slightly to the right (looking
toward the mother's left thigh)
This presentation may slow
labor and cause more pain
Babies can deliver in the
posterior position, but the
pelvis needs to be large
enough and it usually takes
longer.
Forceps are often used to
deliver babies in this position
ABE
 Occiput Anterior
Right Occiput Anterior (ROA)
Is usually the easiest
The back of the baby is slightly off position for the fetal
center in the pelvis with the back head to traverse the
of the head toward the mother's maternal pelvis
right thigh
The back of the baby is more on
the mother’s right side than on
her left side
Kicks are only in the upper left
and a bulge rises in the upper
right occasionally
FHT is easy to hear in front on the
lower right

ABE
Left Occiput Anterior (LOA)
The baby's head is slightly off
center in the pelvis with the back
of the head toward the mother's
left thigh
Has the reputation as the best
fetal position (smallest diameter
to fit the pelvis)
The crown of the LOA baby’s head
most often enters the pelvis first
Tucking the chin helps the baby fit
the pelvis in a way that the baby’s
head can mold (shape) most
effectively to fit the pelvis
ABE
 Occiput Transverse (OT)

Is a type of fetal cephalic

malposition in which the sagittal
suture and fontanels align in the
transverse plane of the maternal
pelvis or are <15 degrees from
the transverse plane

Persistent OT position is thought

to result from constraint to
rotation by the bony pelvis
and/or inadequate power from
contractions and pushing to
induce rotation
ABE
 Left Occiput Transverse (LOT)
When facing out toward the mother's
right thigh
This position is halfway between a
posterior and anterior position
Is an ideal starting position for labor
Baby’s back is on your left
Baby’s back may swing forward
temporarily and back to the left
The baby’s bottom could be on your
upper left until baby is large enough for
the spine to reach up and curl to the
right.
Either way, the kicks are to the right
The feet are clearly in your upper right
Hands may be felt wiggling or fluttering
on your lower right a couple times a day
and only when you are still
ABE
 Right Occiput Transverse (ROT)
When the baby is facing outward
toward the mother's left thigh
Like the previous presentation,
ROT is halfway between a
posterior and anterior position
Baby is on the mother’s right
Baby faces and kicks towards the
left side
Baby may not engage before
labor even in a first birth
The baby’s bottom rises up
underneath the right ribs once in
a while

ABE
ABE
 Fetal Malpresentations

Fetal Presentation → Refers to the

fetal anatomic part which is the first
part to proceed into and through
the pelvic inlet

Fetal Presenting Part → Refers to

the part of the fetus which is the
first to proceed into and through
the pelvic inlet
Refers to abnormal fetal vertex
positions in relation to the maternal
pelvis
The vertex position is the position
your baby needs to be in for you to
give birth vaginally (Head down)
ABE
 Breech
A breech baby has their buttocks coming
into mother’s pelvis before the head.
Usually, the buttocks will be born first, less
often the feet or knees emerge first (Closest
to the cervix)
Conditions that change the vertical polarity
or the uterine cavity, or affect the ease or
ability of the fetus to turn into the vertex
presentation in the third trimester include:
Placenta Previa
As the placenta is occupying the inferior
portion of the uterine cavity
Therefore, the presenting part cannot
engage
Uterine Myoma
Mainly larger myomas located in the lower
uterine segment, often intramural or
submucosal, that prevent engagement of
the presenting part
ABE
 Breech
Oligohydramnios
Fetus is unable to turn to vertex
due to lack of fluid
Polyhydramnios
Fetus is often in unstable lie,
unable to engage
Fetal Neuromuscular Disorders
Cause hypotonia of the fetus,
inability to move effectively
Prematurity
Baby born before 37 completed
weeks of gestation

ABE
3 main breech positions:
Frank breech
This is the most common type of
breech position
The buttocks are in place to come
out first during delivery
The legs are straight up in front of
the body, with the feet near the
head
Complete breech
The buttocks are down near the
birth canal
The knees are bent, and the feet
are near the buttocks
ABE
3 main breech positions:
Footling breech
One leg or both legs are stretched out
below the buttocks
The leg or legs are in place to come
out first during delivery.

Management
External Cephalic Version (ECV)
Is done most often before labor
begins, typically around 37 weeks.
Version is sometimes used during
labor before the amniotic sac has
ruptured
Is a procedure that externally rotates
the fetus from a breech presentation
→ cephalic presentation
ABE
Version may be attempted when:
The mother is 36 to 42 weeks
pregnant

But version may be more

successful if it is done as early as
possible after 36 weeks because
the fetus is smaller and is
surrounded by more amniotic fluid
and space to move in the uterus
The fetus is in the frank, complete
breech, or footling breech position
The fetus has not dropped into the
pelvis (has not engaged).
A fetus that has engaged is very
difficult to move
ABE
 External Cephalic Version (ECV)
Before the version attempt, you
may be given an injection of
tocolytic medicine to relax the
uterus and prevent uterine
contractions
(The most commonly used
tocolytic medicine → Terbutaline)
While the uterus is relaxed, your
doctor will attempt to turn the
fetus with both hands on the
surface of your abdomen
(One by the fetus's head and the
other by the buttocks)
The doctor pushes and rolls the
fetus to a head-down position
ABE
You will feel discomfort during
a version procedure, especially
if it causes the uterus to
contract
The amount of discomfort
depends on how sensitive your
abdomen is and how hard the
doctor presses on your
abdomen during the version
attempt
If your fetus appears to be in
distress, as shown by a sudden
drop in heart rate, the
procedure is stopped

ABE
Transverse/Oblique Lie /
Abnormal Fetal Lie and
Presentation

ABE