ABNORMAL LABOR

BY DR. ASHEBIR T.(Assistant Professor Of

Obstetrics And Gynecology)
 INTRODUCTION
• There are several labor abnormalities that may
interfere with the orderly progression to
spontaneous delivery.
• Generally, these are referred to as dystocia.
• Dystocia literally means difficult labor and is
characterized by abnormally slow labor progress.
 Epidemiology of Dystocia
• The precise incidence of dystocia is difficult to
determine.
• Dystocia is more common in nulliparous
women (25% to 30%) than in multiparous
women (10% to 15% ) and is more common in
the first stage of labor than in the second
stage of labor.
 Causes of dystocia
• Causes of abnormal labor categorized
classically as abnormalities of:-
 The power (uterine contractions or maternal
expulsive forces),
 The passenger (position, size, or presentation
of the fetus), or
 The passage (pelvis or soft tissues).
 Risk Factors for Dystocia
Abnormal labor can be the result of one or more
factors relating to the cervix, uterus, maternal
pelvis, or fetus.
 Older maternal age
 Pregnancy complications
 Nonreassuring fetal heart rate
 Epidural anesthesia
 Macrosomia
 Overdistension of the uterus (twins and fibroids)
 Cont’d…
 Contracted pelvis and malpresentation
 Injudicious administration of sedatives,
analgesics and oxytocin.
 Nulliparity
 High station at full dilatation
 Chorioamnionitis
 Postterm pregnancy
 Obesity
 UTERINE DYSFUNCTION
• There are two types of uterine dysfunction.
 Hypotonic uterine dysfunction
 Hypertonic uterine dysfunction or incoordinate
uterine dysfunction
 Hypotonic uterine dysfunction
 Contraction intensity is diminished; duration is
shortened; good relaxation in between
contractions and the intervals are increased.
 General pattern of uterine contractions of labor is
maintained but intrauterine pressure during
contraction is below 25 mm of Hg.
 Common type of disordered uterine contraction
but is comparatively less serious.
 Cont’d…
Hypocontractile uterine activity may be due to:-
 Drugs (including general or regional anesthesia),
 Prolonged labor,
 Fetopelvic disproportion,
 Uterine rupture,
 Chorioamnionitis,
 Dehydration, and excessive uterine distention.
Mx is augmentation
 Hypertonic state of the uterus
 Increased frequency and/or duration of uterine
contractions cause rise in baseline tone.
• Hyperstimulation/tachysystole may be defined
as
 More than 5 contractions in 10 minutes, or
 Contractions lasting 2 minutes or more, or
 Contractions of normal duration occurring
within 1 min of each other, plus FHB changes.
 Cont’d…
• Excessive uterine activity (hyperstimulation or
tachysystole) is usually caused by
administration of uterotonic drugs
• Noniatrogenic tachysystole is usually related
to:-
 Abruptio placenta or
 Chorioamnionitis.
 Management 
• Removing the prostaglandins (vaginally inserted).
• If oxytocin is being infused, it should be discontinued
if there is hyperstimulation.
 Placing the woman in the left lateral position,
administering oxygen and increasing intravenous
fluids.
 If there is no prompt response to these measures,
administer a tocolytic.
 If there is tachysystole only re-evaluate
the oxytocin infusion rate (decrease the dose or
discontinuation for a brief period of time).
 Fetopelvic disproportion
• Fetopelvic disproportion arises from
diminished pelvic capacity, excessive fetal size,
or more usually both.
• Any contraction of the pelvic diameters that
diminishes its capacity can create dystocia.
• There may be a contraction of the pelvic inlet,
the midpelvis, or the pelvic outlet, or a
combinations of these.
 Contracted Inlet
• The pelvic inlet is contracted if:-
 Anteroposterior diameter is < 10 cm or
 Transverse diameter is < 12 cm OR
 Diagonal conjugate < 11.5 cm.
• Cephalic presentations is common, but the head
floats freely or rests in one of the iliac fossae.
• Face and shoulder presentations are encountered
three times more frequently, and the cord
prolapses four to six times more often.
Contracted Midpelvis
• Interspinous diameter <8cm (N = 10.5cm)
• More common than inlet contraction
• No precise manual method of measuring mid
pelvic dimension but prominent spine, convergent
pelvic side wall , narrow sacrosciatic notch suggest
contraction.
Contracted outlet
• Narrowing of the pubic arch or interischial
tuberous diameter < 8cm
• Rare without concomitant midplane contraction
• Causes perineal tears  b/c of perineal distension.
 Soft tissue dystocia
• Anatomic abnormalities of the reproductive tract
• Congenital anomalies
Bicornuate ux  cause mal presentation
Longitudinal and transverse vaginal septa
• Scarring of the birth canal
From injury to the birth canal  tissue rigidity
and dystocia
• Pelvic tumors
• low lying placenta
 Abnormality of the passenger (Fetal
dystocia)
Is abnormal labor caused by mal position or mal
presentation , excessive size of the fetus or fetal mal
formation
Malposition or malpresentation
The most common cause of fetal dystocia.
Fetal size alone is seldom a suitable explanation for
failed labor.
 Complications of dystocia
• Maternal Complications
 Intrapartum chorioamnionitis and postpartum
pelvic infection.
 Postpartum hemorrhage from atony.
 Uterine tears with hysterotomy
 Uterine Rupture
 Fistula Formation
 Pelvic Floor Injury
 Postpartum Lower Extremity Nerve Injury
 Cont’d…
• Perinatal Complications
 Peripartum fetal sepsis
 Caput succedaneum and molding
 Mechanical trauma such as nerve injury,
fractures, and cephalohematoma.
Specific abnormalities
 Prolonged latent phase
• Prolonged latent phase refers to a latent phase
lasting longer than 20 hours for nulliparas
women and 14 hours or longer for multiparas
women.
• Cervical dilation below 4 cm after 8 hours of
true labor(WHO).
• The overall incidence of prolonged latent phase
in spontaneously laboring women is 4 to 6%.
 Initial assessment
Uterine contractions with cervical dilatation< 4 cm

Follow labor Assess progress at the 4th hour

Cervical dilatation <4 cm Cervical dilatation > Cervical dilatation <4cm

Contractions cease 4 cm Contractions persist

Manage as false Mange as active first stage Follow labor Assess progress at
labor of labor with partograph the 8th hour

Cervical dilatation >4 cm Cervical dilatation <4 cm

Contractions ceased Contractions persist

Augmentation +Artificial Rupture of Membranes (ARM)

 RISK FACTORS FOR PROLONGED LATENT
PHASE 
• Unfavorable cervix
• Transverse and occiput posterior position
• Sedation and analgesia
Maternal age, infant birth weight, pelvic
capacity, and gestational age do not have
significant effects on length of the latent
phase.
 MANAGEMENT
• There are few management options for truly
laboring women with prolonged latent phase:
 Therapeutic rest
 Uterotonic drugs
• Before considering these options, evaluate for
obstetrical problems such as no therapeutic rest
in preeclampsia, abruptio placenta,
chorioamnionitis, or a nonreassuring fetal heart
rate pattern:- no uterotonic drugs in fetal
malpresentation or a hysterotomy scar.
 Therapeutic rest 
• It involves administration of parenteral analgesic
like morphine subcutaneously (15 to 20 mg) or
intramuscularly (10 mg) or other opioid
analgesics like pethidine.
• Approximately 85 percent of women treated with
these regimens will wake up in the active phase
of labor, 10 percent diagnosis of false labor, and 5
percent will have a persistent dysfunctional
pattern
 Augmentation
• Unless the CPD is gross, the diagnosed of CPD is
considered after a good trial of labor.
• Oxytocin infusion is successful in bringing the
patient into active labor in approximately 9 out of
10 cases.
• Prostaglandins have not been studied as a
treatment for women diagnosed with prolonged
latent phase.
 Amniotomy
• Before amniotomy is performed, confirm that the
presentation is vertex, and no umbilical cord or
other fetal part, is presenting and is well applied to
the cervix.
• Also Check for active infection.
• After ARM see for improvement in uterine
contraction over next 1 hr.
• It also used to assess the quantity of fluid and the
presence of meconium.
• Routine rupture of the membranes does not
accelerate spontaneous labor.
 Outcome
 It have been reported that prolonged latent
phase is associated with:-
 A higher risk of subsequent labor abnormalities,
and
 That newborns are more likely to be exposed to
thick meconium, have depressed five-minute
Apgar scores, and require NICU admission.
 It is associated with a 2.5-fold increase in risk for
primary cesarean section.
 Protracted Active Phase Dilation
• Active-phase disorders may be divided into
protraction and arrest disorders.
• Protraction is defined as a slow rate of cervical
change less than 1.2 cm/h for the nullipara
and less than 1.5 cm/h for the multipara.
• Less than 1cm/hr cervical dilatation for a
minimum of 4hrs (WHO).
 Causes
• Protracted active phase dilation is a common
dysfunctional labor pattern.
• A protracted active phase may be due to:-
(i) Inadequate uterine contractions
(ii) Cephalopelvic disproportion
(iii) Malposition or malpresentation
(iv) Epidural anesthesia.
 Management
Inadequate uterine contractions are
implicated :-
 Provide labor support
 Do ARM and augment as protocol.
Perform emergency CS if there is an
indications.
 Secondary arrest
 Secondary arrest is defined as cessation of previously
normal active phase cervical dilatation for a period of
2 hours or more.
 This time criterion is the same for nulliparas and
multiparas.
 Rouse and associates have challenged the “2-hour
rule” on the grounds that a longer time, that is, at
least 4 hours, is necessary before concluding that the
active phase of labor has failed.
 Secondary arrest, which occurs in 5–10% of labors in
most series
 Cont’d…
• Based on a workshop convened by the United
States NICHD, SMFM, and ACOG proposed that
first stage arrest of labor be defined as:
• Cervical dilation ≥6 cm dilation and ruptured
membranes with:
• No cervical change for ≥4 hours despite adequate
contractions
• No cervical change for ≥6 hours with inadequate
contractions
 Management
 Amniotomy and oxytocin therapy can be initiated
if uterine activity is found to be inadequate.
 The majority of gravidas respond to this
intervention, and resume progression of cervical
dilatation and achieve vaginal delivery.
 Perform CS if there is an obstetric indication.
 Combined Disorder
• A combined disorder of active phase dilatation is
defined as arrest of dilatation occurring when a
patient has previously exhibited a primary
protracted labor.
• This pattern is associated with less favorable
outcomes with regard to vaginal delivery when
compared with patients with secondary arrest
alone.
 Prolonged deceleration phase
• Prolonged deceleration phase >3
hrs(nulliparous) and >1 hr (multiparous).
• Prolonged deceleration phase is relatively
rare, occurring in only 1–3% of labors.
• Prolonged deceleration phase is strongly
associated with descent disorders and most
closely related to secondary arrest.
 SECOND STAGE OF LABOR
 Fetal descent largely follows complete
dilatation.
 Moreover, the second stage incorporates
many of the cardinal movements necessary
for the fetus to negotiate the birth canal.
 Accordingly, disproportion of the fetus and
pelvis frequently becomes apparent during
second stage labor.
 Cont’d…
• Although perinatal outcomes are not
compromised with a prolonged second stage of
labor, maternal morbidities increase with
prolonged second stages lasting greater than 2
hours.
• Effective management of the second stage should
be individualized.
• More detailed maternal/fetal assessment with
carefully considered intervention seems optimal.
 Protracted Descent
• Protracted descent should be diagnosed in
nulliparous labor when descent is proceeding at
less than l cm/h and in multiparous labor when
descent is proceeding at less than 2 cm/h, at least
for 1 hour.
• The cause of protracted descent often includes
malposition and relatively mild degrees of
fetopelvic disproportion
• Slow descent frequently is associated with the use
of epidural anesthesia.
 Management
• Protracted descent requires skillful and attentive
management.
• If there is inadequate contraction, augment as
protocol.
• If protracted descent occurs in a labor already
complicated by preceding dysfunctional labor
patterns in the presence of oxytocin augmentation,
it would be best to proceed with cesarean delivery.
 Arrest of Descent
• It is defined as descent has stopped entirely for at
least 1 hr
• Based on a workshop convened by the NICHD,
SMFM, and ACOG proposed that second stage
arrest of labor be defined as:
• No progress (descent or rotation)
• Nulliparous women: ≥4 hrs with epidural
anesthesia and ≥3 hrs without epidural anesthesia
• Multiparous women: ≥3 hrs with epidural
anesthesia and ≥2 hrs without epidural anesthesia
 Management
Once a second stage arrest disorder is diagnosed, the
obstetrician has 4 options:
1) Continued observation,
2) Oxytocin
 When arrest of descent has not been preceded by other
dysfunctional labor patterns, is extremely sensitive to
oxytocin augmentation.
1) Operative vaginal delivery, or
2) Cesarean delivery.
• Based on the basis of clinical assessment of the woman
and the fetus and the skill and training of the obstetrician.
 Prolonged 2 stagend

 The second stage in nulliparas was limited to 2

hours and extended to 3 hours when regional
analgesia was used.
 For multiparas, 1 hour was the limit, extended
to 2 hours with regional analgesia.
 Prolonged second stage defined by no delivery
of fetus occur 2 hours after full dilatation of
cervix.
Labor Pattern Diagnostic Criteria Preferred Exceptional
Nulliparas Multiparas Treatment Treatment

Prolongation Disorder
Prolonged latent phase > 20 hr > 14 hr Bed rest Oxytocin or
cesarean delivery
for urgent
problems
Protraction Disorders
Protracted active- < 1.2 cm/hr 1.5 cm/hr Expectant Cesarean
phase dilatation and delivery for CPD
support
Protracted descent < 1 cm/hr < 2 cm/hr
Arrest Disorders
Prolonged deceleration > 3 hr > 1 hr Evaluate Rest if exhausted
phase for CPD: Cesarean
CPD: delivery
Secondary arrest of > 2 hr > 2 hr cesarean
dilatation No CPD:
Arrest of descent > 1 hr > 1 hr oxytocin
Failure of descent No descent in deceleration
phase or second stage
 Precipitate labor
• Precipitous labor is a labor which terminates
in expulsion of the fetus in less than 3 hours.
OR
• A rate of cervical dilatation of 5 cm/hr or
faster for nulliparous and 10 cm/hr for
multiparous
• Characterized by uterine contractions more
frequently than every 2 minutes
• Incidence: Complicates ~ 2 % live births of
which the majorities (93%) are multiparous.
 Precipitate labor cont’d…
• The uterus that contracts with unusual vigour
before delivery is likely to be hypotonic after
delivery.
• Hemorrhage from the placental implantation
site as the consequence
• Maternal:
 PPH secondary to birth canal soft tissue
laceration, uterine atony
 Increased risk of amniotic fluid embolism
 Cont’d…
• Fetal:
 Risk of fetal morbidity & mortality increases
 Increased risk of placental abruption, hypoxia.
 Delivery most likely unattended → birth injury
Management:
• General measures
 Discontinue oxytocin or remove misoprostol if in
use
 Be ready for management of maternal & fetal
complications.
MALPRESENATATION AND
MALPOSITION
 INCIDENCE 
• The most common presentation is vertex, which
occurs in 96 percent of fetuses at term.
• Non-vertex fetuses are considered to have a
malpresentation.
• At term, the types and estimated incidences of
malpresentations are :
 Breech (1/33 deliveries)
 Face (1/600 to 1/800 deliveries)
 Brow (1/500 to 1/4000 deliveries)
 Compound (1/1500 deliveries)
 Transverse lie(1/300 deliveries)
 Risk factors
• Generally, factors associated with
malpresentation include:-
(1) Diminished vertical polarity of the uterine
cavity.
(2) Increased or decreased fetal mobility.
(3)Cephalopelvic disproportion.
Maternal Fetal
• Great parity   • Prematurity  
• Pelvic tumors   • Multiple gestation  
• Pelvic contracture   • Hydramnios  
• Uterine • Macrosomia  
malformation • Hydrocephaly  
• Trisomies  
• Anencephaly  
• Myotonic dystrophy  
• Placenta previa
 Face Presentation
• In a face presentation, the fetal neck is
hyperextended so that the occiput touches the
back.
• The presenting part is that part of the fetal face
between the orbital ridges and the chin.
• The fetal chin (mentum) is chosen as the point
of designation during vaginal examination.
• The incidence is approximately 1 in 550 births.
 Etiology and risk factors 
• The cause of face presentation is unknown.
• It is presumed to occur because of factors that favor
extension or prevent flexion of the fetal neck.
• A common risk factor is an anomalous fetus,
particularly one with anencephaly, massive
hydrocephalus, or an anterior neck mass.
• Other risk factors are:Multiple nuchal cord loops,
cephalopelvic disproportion, prematurity/low birth
weight, polyhydramnios, previous cesarean delivery,
black race, and multiparity.
 Diagnosis 
• The diagnosis of face presentation is usually made
late in the 1st stage or in the second stage of labor .
• Landmarks indicating a face presentation are
orbital ridge and orbits, saddle of the
nose,mouth,and chin
• Imaging studies can be performed to confirm the
diagnosis is uncertain or internal examination
cannot be done, it show hyperextended fetal neck
• A face may be mistaken for a breech on blind
digital examination.
 Course  
• At the time of diagnosis, nearly 60 percent of face
presentations will be in the MA position, 26
percent will be MP, and 14 percent will be MT.
• Thirty to 50 percent of fetuses in MP and MT
positions will spontaneously convert to the MA
position during the course of labor.
• This is important since at term only mentum
anterior face presentations are likely to deliver
vaginally.
 Management
• By comparison, the widest diameter of the fetal
head negotiating the pelvis in face presentation is
the trachelo-bregmatic or trachelo-parietal
diameter average length 12.6 cm
• Despite the increased diameter, over 75 percent
of mentum anterior fetuses are delivered
vaginally, whereas persistent mentum posterior
and transverse fetuses require cesarean birth.
 Cont’d…
• In the case of an average or small fetus,
adequate pelvis, and hypotonic labor, oxytocin
may be considered
• No absolute contraindication to oxytocin
augmentation of hypotonic labor in face
presentations exists.
• An arrest of progress despite adequate labor
should call for cesarean delivery.
 Cont’d…
• Abnormalities of the fetal heart rate occur
more frequently with face presentations.
• For this reason, these fetuses should be
continuously monitored during labor, ideally
with an external device.
• An internal device may cause facial or
ophthalmic injuries if improperly placed.
 Mentum anterior
• Oxytocin augmentation may be given if indicated
and the fetal heart rate pattern is reassuring.
• Outlet forceps should only be used by
experienced practitioners.
• Since engagement does not occur until the face is
at +2 station, forceps should only be applied to
the face that is bulging the perineum.
• Attempts at version, extraction, or midforceps
delivery should be avoided, as they are associated
with maternal trauma and neonatal injury.
 Mentum posterior
• In the mentum posterior position, the neck,
head, and shoulders must enter the pelvis
simultaneously; however, the pelvis is usually
not large enough to accommodate the fetal
trunk in this position.
• In addition, the fetal neck must extend the
length of the maternal sacrum (average 12
cm) in order to reach the perineum.
 Cont’d…
• Lastly, an open fetal mouth may act as a fulcrum
against the sacrum preventing further descent.
• Therefore, the MP face presentation
will not deliver vaginally unless spontaneous
rotation occurs or the fetus is very small (eg,
very preterm).
• In one series, 11 of 12 fetuses in the MT position
and 2 of 10 patients with MP delivered vaginally
after spontaneous rotation to MA.
 Cont’d…
• Attempts to convert a face presentation
manually into a vertex presentation (manual
or forceps rotation) and internal podalic
version and extraction are dangerous and
should not be attempted.
• But, in lack of surgical facilities and inability to
arrange maternal transport, or absolute
maternal refusal to allow a cesarean birth, it
can be attempted.
 Neonatal outcome 
• Neonates who were in face presentation often have
significant facial edema and skull molding.
• This usually resolves within the first 24 to 48 hours
of life.
• Difficulty in ventilation during resuscitation has
been reported and attributed to tracheal and
laryngeal trauma and edema.
• Therefore, equipment and personnel to perform
endotracheal intubation should be readily available
at the time of delivery.
• Perinatal mortality, varies from 0.6% to 5%.
 BROW PRESENTATION
• The fetus in the brow presentation occupies a
longitudinal axis with the fetal neck extended, but
not to the degree in face presentation.
• The area presenting in the birth canal typically
extends from the anterior fontanelle to the brow
(orbital ridge), but does not include the mouth and
chin.
• The brow presentation is often a transitional state.
• Persistent brow presentation is not compatible
with vaginal birth unless the fetus is very small.
 Diagnosis 
• The diagnosis of brow presentation is usually made
late in the second stage of labor.
• On abdominal palpation when both the occiput
and chin can be palpated easily.
• On digital examination, landmarks are forehead,
saddle of the nose, and orbits.
• The frontal bones are the point of designation
• Face presentation is excluded because the mouth
and chin are not palpable.
 Cont’d…
• Detection of a brow presentation by
abdominal palpation is unusual in practice.
• More often, a brow presentation is detected
on vaginal examination.
• Frontum anterior is reportedly the most
common position at diagnosis, occurring
about twice as often as either transverse or
posterior positions.
 Course
• The head in brow presentation engages
transversely at the pelvic brim.
• As the fetus descends into the birth canal,
internal rotation to brow anterior occurs and
causes the occiput to become wedged in the
sacral hollow.
• Internal rotation may result in a mentum anterior
face presentation or vertex occiput posterior
position. Conversion to occiput anterior is rare.
 Course…
• If internal rotation does not occur, the mento-
parietal diameter (13.4 cm) presents at the pelvic
inlet and must pass through it for engagement to
occur.
• Therefore, the possibility of dysfunctional,
prolonged labor and CPD is high if this presentation
persists.
• Successful vaginal delivery of a persistent brow
presentation is only possible in an extremely small
or macerated infant, or with an unusually large
maternal pelvis.
 Course…
• A persistent brow presentation requires
engagement and descent of the largest (mento-
occipital) diameter or profile of the fetal head.
• One unexpected cause of persistent brow
presentation may be an open fetal mouth pressed
against the vaginal wall, splinting the head and
preventing either flexion or extension.
 Management
• Women with a clinically adequate or proven pelvis
can be allowed to labor.
• In one review, when brow presentation was
diagnosed early in labor, 67 to 75 percent of fetuses
spontaneously converted and delivered vaginally;
when diagnosed late in labor, 50 percent
spontaneously converted and delivered vaginally.
 Cont’d…
• Labor should be monitored closely, with cesarean
delivery if:-
 Progress is protracted or arrested,
 When there is CPD
 Persistent brow presentation
• Version is not recommended, as the risk of
perinatal mortality or uterine rupture is high.
• If managed appropriately, it do not result in
increased serious maternal or neonatal morbidity.
 Compound presentation
• Compound presentation is defined as
presentation of a fetal extremity alongside the
presenting part.
• It may involve one or more extremities (eg,
hand, arm, foot) with the vertex or the breech.
• The majority of compound presentations are
represented by the fetal hand or arm
presenting with the vertex
 Incidence and etiology 
• Compound presentation complicates from 1 in
700 to 1 in 1000 deliveries .
• Risk factors are:-
 Low birth weight and prematurity.
 Multiple gestation,
 Polyhydramnios, or a large pelvis.
 Rupture of membranes when the presenting
part is still high.
 External cephalic version.
 DIAGNOSIS 
• During a cervical examination, the examiner will
feel an irregular shape beside or in advance of the
vertex or breech.
• Consider it when the head remains high or
unengaged after rupture of membranes or when
there is a delay in the active phase.
• Recognition late in labor is common, and as many
as 50 percent of persisting compound
presentations are not detected until the second
stage.
 MANAGEMENT
• The management of compound presentation is
debatable.
• Some experts recommend attempting to
reposition the fetal extremity, while others
discourage.
• There is consensus that oxytocin should be
avoided.
• For women with normal progressing labor,
observation alone is recommended.
 Cont’d…
• Gently pushing the small part upward into the
uterine cavity while simultaneously applying
fundal pressure is another option .
• Cesarean delivery:-
 Failure to resolve spontaneously or after this
gentle maneuver
 If labor becomes protracted or arrested or the
umbilical cord prolapses.
 Nonreassuring fetal heart rate patterns. 
 OUTCOME 
• As with other malpresentations, fetal risk is
directly related to the method of management.
• Seventy-five percent of vertex/upper extremity
combinations deliver spontaneously.
• A fetal mortality rate of 4.8 percent has been
noted if no intervention is required compared
with 14.4 percent with intervention other than
cesarean delivery.
 Cont’d…
• A 30-percent fetal mortality rate has been observed
with internal podalic version and breech extraction.
• Fetal risk in compound presentation is specifically
associated with birth trauma and cord prolapse.
• Cord prolapse occurs in 11 to 20 percent of cases,
and it is the most frequent single complication of this
malpresentation.
• Compound presentation may cause neurologic and
musculoskeletal damage to the involved extremity.
 TRANSVERSE LIE
• The fetus is in a transverse lie when its longitudinal
axis is perpendicular to the long axis of the uterus.
• A transverse lie can occur in either of two
configurations:
 The curvature of the fetal spine is oriented upward
(also called "back-up" or dorsosuperior), in which
case the fetal small parts present at the cervix.
 The curvature of the fetal spine is oriented
downward (also called "back-down" or
dorsoinferior), such that the fetal shoulder presents
at the cervix
 Natural history 
• Most fetuses in transverse lie early in pregnancy
convert to a cephalic (or breech) presentation by
term.
• The later in pregnancy the transverse lie is
diagnosed, the more likely it is to persist.
• When the diagnosis was first made between 20 to
25 weeks of gestation, 2.6 percent persisted as
transverse lie at term.
• By comparison, when the diagnosis was first made
at 36 to 40 weeks, 11.8 percent persisted to the
time of delivery.
 ETIOLOGY
• Some of the more common causes of
transverse lie include:
(1) Abdominal wall relaxation from high parity,
(2) Preterm fetus,
(3) Placenta previa,
(4) Abnormal uterine anatomy,
(5) Polyhydramnios
(6) Contracted pelvis.
(7) Fetal anomaly
 COMPLICATIONS 
• Prolapse of the umbilical cord
• Placenta previa
• Fetal trauma
• Prematurity contribute to morbidity from
transverse lie.
• Uterine rupture (in developing regions)
• Reported perinatal mortality for unstable or
transverse lie varies from 3.9 percent to 24
percent, with maternal mortality as high as 10
percent.
 Diagnosis
• The diagnosis can be made by abdominal
palpation using Leopold's maneuvers (fetal head
in one or the other of the mother's flanks).
• Location of the fetal back (up or down) may be
more difficult, especially if the patient is obese.
• Sensitivity for detecting non-cephalic presentation
(breech, oblique, or transverse lie) by abdominal
palpation at 35 to 37 weeks of gestation is only 70
percent.
 Cont’d…
• If transverse lie is suspected by abdominal
palpation, a vaginal examination should be
postponed until placenta previa has been
excluded.
• Ultrasound examination is used to confirm the
diagnosis and determine the precise position of
the fetus.
 MANAGEMENT 
• Management of transverse lie depends upon
the clinical circumstances at the time the
diagnosis is made.
• Important factors to consider include the
position of the placenta, length of gestation,
viability of the fetus, whether labor has begun,
and whether membranes have ruptured.
 Cont’d…
• Placenta previa — Patients with coexistent
placenta previa must be delivered by cesarean.
• Previable or dead fetus
 Placenta previa has been ruled out, vaginal
delivery can be attempted.
 Collapse of the fetal body allows delivery by this
route in many cases.
 Internal podalic version may also be considered.
 Cont’d…
• Viable fetus — there are two options:
 Cesarean delivery
 Version of the fetus to a longitudinal lie
• Intrapartum or ruptured membranes — cesarean
delivery is generally recommended.
• However, if membranes are intact, version to either a
cephalic or breech presentation may be considered.
• Second twin :This situation can often be resolved
successfully with internal podalic version and total
breech extraction.
 Cont’d…
• Antepartum 
 If no contraindications to a vaginal delivery,
one option is external version to cephalic
presentation, followed by ARM while the
vertex is held in position, and induction of
labor.
• If the fetus is small—usually < 800 g—and the
pelvis is large, spontaneous delivery is possible
despite persistence of the abnormal lie.
 Cesarean delivery
•  The dorsosuperior (back up) transverse lie may
be delivered as a footling breech through a low
transverse incision in a well developed lower
uterine segment.
• The dorsoinferior position does not allow the
obstetrician to easily grasp the fetal feet.
• Consequently, a vertical incision or inverted-T in
the uterus is usually employed in these cases and
when the lower uterine segment is poorly
developed.
 Persistent occiput posterior position
• Fifteen to 20 percent of term fetuses are in
occiput posterior (OP) position before labor.
• Most of these fetuses rotate intrapartum:
• The incidence at vaginal birth is approximately 5
percent.
• Persistence of the OP position is important
because it can be associated with labor
abnormalities and maternal and neonatal
complications.
 RISK FACTORS AND CONSEQUENCES 
Precise reason not known
• Nulliparity
• Maternal age greater than 35 years
• Obesity
• African-American race
• Previous OP delivery
• Decreased pelvic outlet capacity
• Gestational age ≥41 weeks
• Birth weight ≥4000 g
• Prolonged first and/or second stage of labor
 MANAGEMENT
• The management of a definite arrest of descent
of the OP fetus is less clear.
• No randomized trials comparing the various
approaches have been conducted.
• Options include:
 Rotation to OA position manually or with forceps
 Operative delivery from OP position
 Cesarean delivery
 Cont’d…
• A study in which manual rotation from the OP or
OT position was reported that 90% were
successfully rotated to an OA.
• Manual rotation is more successful in multiparous
women and women less than 35 years of age.
• Cesarean delivery is common after a failed
manual rotation.
• In forceps rotation to OA (scanzoni maneuver ),
Kielland forceps, which do not have a pelvic curve,
are ideal.
 Operative vaginal delivery from the OP
position 
• Forceps or vacuum can be used to deliver the
fetus from the direct OP position.
• Delivery from OP position rather than rotation is
probably preferable, if pelvis is adequate.
• OP position is associated with a significantly
higher rate of failed operative vaginal delivery
than OA.
• There is no demonstrated advantage to forceps
over vacuum delivery for OP fetuses.
 Occiput transverse position(OT)
• Most fetuses enter the maternal pelvis in the OT
position; left occiput transverse (LOT) is more
common than right (ROT).
• With progressive descent, the occiput usually
rotates either anteriorly or posteriorly.
• Persistent OT position is defined as an OT position
that is maintained for an hour or more into the
second stage of labor.
• There are no reliable data on the frequency of
persistent OT, but it is uncommon.
 Cont’d…
Types
• High transverse arrest (arrest above station +2
on a -5 cm to + 5 cm scale)
• Deep transverse arrest (arrest below station
+2 on a -5 cm to + 5 cm scale)
• Cause
Pelvic dystocia
Ux dystocia
Platypelloid or android pelvis
 CLINICAL MANIFESTATIONS AND
DIAGNOSIS 
• OT position should be suspected if fetal descent is
protracted or arrested.
• The diagnosis is based on PV examination that the
fetal sagittal suture and fontanelles are palpable
in the transverse diameter of the pelvis.
• Anterior or posterior asynclitism, defined as
rotation of the sagittal suture away from or
toward the pubic symphysis, respectively, may
result in misdiagnosis of OT as either OA or OP.
 MANAGEMENT
• Oxytocin, if hypocontractile uterine activity is present.
• Expectant management
 If there is any progress in descent and the fetal heart rate
is reassuring, expectant management is the preferred
option.
• Cesarean delivery
 High transverse arrest despite adequate uterine activity
and maternal expulsive effort.
 Cesarean delivery, manual rotation, and instrumental
rotation are options for management of deep transverse
arrest.
 Shoulder Dystocia
Failure of the shoulders to spontaneously
traverse the pelvis after delivery of the fetal head.
A head to body delivery time exceeding 60
seconds (N.24 sec)
Normal downward traction needed for fetal
shoulder delivery is ineffective(ACOG).
It occurs in 0.2 to 3 percent of all births and
represents an obstetric emergency .
 DIAGNOSIS
Shoulder dystocia is a subjective clinical diagnosis.
It should be suspected when the fetal head
retracts into the perineum (ie, turtle sign) after
expulsion due to reverse traction from the
shoulders being impacted in the pelvic inlet.
The diagnosis can be made when the routine
practice of gentle, downward traction of the fetal
head fails to accomplish delivery of the anterior
shoulder.
 Risk factors
Most occur in the absence of risk factors,
Obesity
Multiparity
Diabetes
Prior shoulder dystocia (1 to 25 percent)
Prolonged 2nd stage
Macrosomia and Post term
Rapid delivery of the head, as can occur with
vacuum extraction or forceps or precipitous labor.
 COMPLICATION
Maternal consequences
PPH- atony, laceration
Fetal consequences
• Neuromusculoskeletal injury
 11 percent were associated with serious neonatal
trauma.
 Brachial plexus injury was diagnosed in 8%, and
2% suffered a clavicle, humeral, or rib fracture.
 Increased fetal morbidity and mortality.
 MANAGEMENT
• Techniques used to free the anterior shoulder
from its impacted position.
• Moderate suprapubic pressure with down ward
traction to the fetal head.
• The MC Roberts maneuver
 Hyperflexion of maternal legs upon to the
abdomen
 Cause straightening of the sacrum relative to the
lumbar vertebrae
 Cont’d…
• Rotation of the symphysis pubis toward the
maternal head
Decrease In angle of pelvic inclination
Pelvic rotation cephalad tends to free the
impacted anterior shoulder
• Woods cork screw maneuver
 Rotating the post shoulder 180 in a cork screw
fashion.
 Impacted ant shoulder could be released.
 Delivery of the post shoulder
 Sweeping the post arm of the fetus
across the chest followed by delivery of
the arm
 The shoulder then rotated into one of
the oblique diameter of the pelvis with
delivery of the ant shoulder
 Cont’d…
5. Rubin
a. The fetal shoulders are rocked from side to side
by applying force to the maternal abdomen
b. The pelvic hand pushes accessible fetal
shoulder toward the ant. surface of the chest
 Results in abduction of both shoulders
 Produce smaller shoulder to shoulder diameter
 Cont’d…
6. Fracture of the clavicle
 By pressing the ant clavicle against the ramus of the
pubis
 To free the shoulder impaction
7.Zavanelli maneuver
 Cephalic replacement into the pelvis and then
cesarean delivery.
8. Subcutaneous symphysiotomy.
 References

• Williams obstetrics 25th edition

• Gabbe normal & problem pregnancies 7th edition.
• Danforth's Obstetrics and Gynecology, 10th Edition
• ………..
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