Abnormal labour

Dr: Hayder Al-Shamma’a

types

•I :- Malposition and Mal-presentation of thehead ( occipito-posterior, face presentation,brow presentation)

•II:- Breech presentation

•III:- Shoulder presentation(Transverse lie)

Risks of abnormal labour

•Abnormal labour carries increased risks to themother and the fetus more than normal labour, specially if the labour is attended by aninexperienced personel

Maternal risks of abnormal labour

1. prolonged labour2. Infection3. Obstructed labour4. Anesthesia5. Traumatic delivery6. Hemorrhage7. DVT8. Pressure necrosis and fistula9. death

Fetal risks

1. Cord prolaps

2. Hypoxia

3. Infection (chorio-amnionitis , pneumonia)

4. Traumatic injuries

5. Meconium aspiration (pneumonitis)

6. death

Malposition & mal-presentation of thefetal head

1) Occipito-posterior position

2) Face presentation

3) Brow presentation

Labour in occipito-posterior position

•The denominator is the occiput

•The occiput occupy the posterior part of thefemale pelvis ie. occiput near the sacrum

Occipito-posterior

Causes of O. P.

•Anthropoid pelvis favor direct o.p position•Android pelvis favor oblique o.p. position•Anteriorly situated placenta• gross pendulous abdomen•Congenital malformations•Abnormal extensor tone•Polyhydramnious•Prematurity•Multiple pregnancy

Diagnosis of occipito posterior

•By abdominal exam.

1. Flat lower abdomen below the umbilicus

2. easy to feel Fetal limbs anteriorly

3. difficult to feel the Fetal back

4. Head not engaged

5. Fetal heart at the flanks

Diagnosis of occipito posterior

• By pelvic exam.

1. High presenting part

2. Bulging sausage shaped membranes

3. Or early rupture of membranes (cx.less than 3cm)

4. Easy to feel the anterior fontanel behind the pubicsymphysis

5. Difficult to feel the posterior fontanel near the sacrum

6. ear directed posteriorly (in excessive caput & edema)

Mechanism of labour in O.P.

•Engagement in ROP (ROP 3times than LOP)

•Engaging diameter is suboccipito-frontal 10.5cm if the head well flexed .

• Or occipito-frontal 11.5 cm if the head deflexed(both larger than normal OA suboccipito-bregmatic 9.5 cm)

•This gives an oval shaped presenting part notfit well on the cx. Of larger dimentions

Mechanism of labour in O.P.

•Internal rotation:- if the head well flexed theocciput will touch the pelvic floor first androtated anteriorly 3/8th of a circle 135 andbecome occipito-anterior and the mechanismthen continue as in OA. But it takes longer timeto rotate

•This occurs in 70% of cases

Mechanism of labour in O.P.

• If the head is deflexed :- the sinciput touches the pelvicfloor first so rotates anteriorly and the occiput rotatesposteriorly through 1/8th of a circle (45 ) short rptationgiving direct occipitoposterior

• The mechanism differs , descent continues and the headdelivers by a combination of flexion first, followed byextention

• The emerging diameter is occipito-frontal of 11.5 cmcausing great distension at the vulva and perineum andperineal tears may occur unless episiotomy performed

• Occurs in 10% of cases

Mechanism of labour in O.P.

•Arrest of rotation at lateral position (rightoccipito-lateral or left occipito-lateral)

•No mechanism of labour

•Deep transverse arrest

•Need assisted delivery

•Occurs in 20% of cases

Features of labour in O.P.

1. Slow progress (slow cx. dilatation, descent,rotation)

2. Backache is more3. Incoordinate uterine contraction4. Early rupture of membranes5. Higher chance for cord prolaps6. Higher chance for infection7. Higher chance for perineal laceration8. Excessive moulding of the head may cause

tentorrial tear

Treatment of O.P.

Before the onset of labour , no attempt for correctionDuring first stage of labour1. Correction of malposition cannot be done2. Observation of uterine contraction, cx dilatation, descent,and

use partogram3. Continuous fetal heart monitoring4. Due to increased risk for operative delivery and anesthesia ,

give nothing by mouth, only occasional sips of water5. Maintain maternal hydration by iv fluid6. Oxytocin infusion is often indicated to correct incoordinate

uterine contractions

Treatment of O.P.

•Cesarean section is indicated in first stage inthe following conditions

1. Failure to progress in spite of good uterinecontractions for 3 hours

2. Fetal distress

3. Maternal distress

Treatment of O.P.

•Treatment in second stage

•Mistaken diagnosis of 2nd stage is notuncommon, the patient have urge topushdown before full dilatation (pressureeffect of the large occiput on the pelvic plexus

•p/v exam is essential to confirm the diagnosis

Rx of 2nd stage continue

•p/v to assess degree of deflexion

•Determine excessive molding

•Determine caput succidanium

•If detect that , spontaneous labour is unlikeleyto occur

•Pain relieve is essential in O.P.

•Epidural analgesia , pethidine

Need assisted delivery

Fetal distress

Maternal distress

Failure to progress

Deep transverse arrest

Assisted delivery

•Oxytocin

•Manual rotation with or without forcepsextraction

•Forceps rotation (Kielland forceps)

•Vacuum extractor

•Cesarean section

Manual rotation

•Correction of malposition by manipulation withthe hand under epidural anesthesia

•Disadvantage need anesthesia, hand takeadditional space , may cause trauma, pulling isnot feasible

•Kielland forceps rotation

•Same disadvantages but ,can pull the head

Vacuum extraction ( Vantouse , Kiwi)

Advantages

Applied without anesthesia, not take extra space,easy to use minimal skills

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Face presentation

•The head is fully extended

•1/300 deliveries

•Causes : same as O.P.

•The denominator is the mentum (chin)

•Mento-posterior no mechanism of labour thechest try to enter the pelvis at the same timewith the head (sternobregmatic 16-18cm)

Mechanism of labour in mento anterior

•Engagement in mentolateral ML or RMA•Engaging diameter is the submento bregmatic 9.5

cm•Descent occurs slowly•Rotation occur late in 2nd stage•Engagement occur at + 2 or + 3 station•Delay in 2nd stage due to oblique line of thrust from

the back to the head•The face deliver by flexion•Emerging diameter is the submentovertical 11cm

Diagnosis of face presentation

•Abdominal findings:- Longitudinal lie, cephalic ,a groove can be felt between the head andback , the head is high

•p/v feel the chin, mouth, jaws, nose, orbitalridge

management

•Exclude CPD, hypertension , placenta previa,other risk factors , estimated fetal wt 3.5kg

•If any of the above cesarean section safer

•Manage as in case of O.P.

Brow presentation

•1/1000• Incomplete extension• It is usually a transient presentation , either change

to vertex or to face•Causes as face•Diagnosis•On abdominal exam as in face but the groove is less

prominent•p/v :- feel ant. Fontanel, orbital ridge, roote of the

nose, eyes, but not the chin

Mechanism of labour in brow

•No mechanism of labour . The engagingdiameter is the mentovertical 14 cm socesarean section is indicated in persistent brow

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