Obstructed laborObstructed labor

DefinitionDefinition

►When there is poor or no progress of When there is poor or no progress of labour in spite of good uterine contraction.labour in spite of good uterine contraction.

►Incidence :Incidence :- 1 -2% of referral cases in - 1 -2% of referral cases in developing country.developing country.

Maternal causes (fault in passage) Maternal causes (fault in passage)

1.1. Contracted pelvisContracted pelvis

2.2. Pelvic tumor:- fibroid, ovarian tumorPelvic tumor:- fibroid, ovarian tumor

3.3. Tumor of rectum, bladder or pelvic bone.Tumor of rectum, bladder or pelvic bone.

4.4. Abnormality in uterus & vagina:-stenosis Abnormality in uterus & vagina:-stenosis in Cx. & vagina, contraction ring in in Cx. & vagina, contraction ring in uterus, vaginal septum, rigid perineum.uterus, vaginal septum, rigid perineum.

44

55

Cervix in labor

Fetal causes (fault in the passenger)Fetal causes (fault in the passenger)

1.1. Macrosomic babyMacrosomic baby

2.2. MalpresentationMalpresentation

3.3. Malposition:- Malposition:-

4.4. Malformed fetus:- hydrocephalus, fetal Malformed fetus:- hydrocephalus, fetal Ascitis, conjoint twinsAscitis, conjoint twins

5.5. Locked twinsLocked twins

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Shoulder dystocia is called if shoulders cannot be delivered with gentle traction

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Diagnosis Diagnosis ►Partograph will recognizePartograph will recognize

impending obstruction earlyimpending obstruction early

. . ►history of-prolonged labour and -the labour pain history of-prolonged labour and -the labour pain

become severe and frequent and -bearing down.become severe and frequent and -bearing down.

General examination:- General examination:-

Features of maternal distress i.e.Features of maternal distress i.e.

Exhaustion & keto acidosisExhaustion & keto acidosis

Dehydration Dehydration

Tachycardia >100/mTachycardia >100/m

Raise temperatureRaise temperature

Scanty urineScanty urine

Abdominal examinationAbdominal examination

-The retraction ring (bandl’s ring) is seen and -The retraction ring (bandl’s ring) is seen and felt between the tonically contracted upper felt between the tonically contracted upper segment of the uterus and the distended , segment of the uterus and the distended , tender and stretched lower segment.tender and stretched lower segment.

- Distended urinary bladder.Distended urinary bladder.

- FHS shows evidence of fetal distress or even FHS shows evidence of fetal distress or even absent.absent.

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Vaginal examination:-Vaginal examination:-- The vulva usually swollen and edematous.The vulva usually swollen and edematous.- The vaginal is dry, hot ,balloned.The vaginal is dry, hot ,balloned.- The cervix is almost fully dilated or hangingThe cervix is almost fully dilated or hanging- ..- The presenting part is extremely moulded and The presenting part is extremely moulded and

jammed in the pelvis.jammed in the pelvis.

- With large caput formation.With large caput formation.

Management Management

►Preventive:-Preventive:-- Proper assessment of pregnant woman Proper assessment of pregnant woman

during ANC.during ANC.

- Proper assessment in early labour to detect Proper assessment in early labour to detect the cause if any.the cause if any.

- Partograph have to strictly follow.Partograph have to strictly follow.

Curative Curative

A.A. Immediate managementImmediate management

B.B. General managementGeneral management

C.C. Obstetric management Obstetric management

Immediate management Immediate management

1.1. Correct maternal dehydrationCorrect maternal dehydration

2.2. prevent contraction by tocolytic drugsprevent contraction by tocolytic drugs

3.3. Blood sample for grouping and cross Blood sample for grouping and cross matching.matching.

B. General management :-B. General management :-

1.1. Assessment of mother general condition.Assessment of mother general condition.

2.2. Broad spectrum antibiotics.Broad spectrum antibiotics.

3.3. Catheterization.Catheterization.

4.4. Sodium bicarbonate infusion to correct Sodium bicarbonate infusion to correct acidosis.acidosis.

C. Obstetric managementC. Obstetric management 1-1-Vaginal delivery:-Vaginal delivery:-

(Destructive opt.) dead fetus(Destructive opt.) dead fetus

-if head is low and vaginal delivery is not risky, forceps -if head is low and vaginal delivery is not risky, forceps extraction may be done in alive foetus also.extraction may be done in alive foetus also.

2. Caesarean section:-2. Caesarean section:-

-A live fetus -A live fetus

-Over distended lower segment with impending rupture even the -Over distended lower segment with impending rupture even the foetus is dead.foetus is dead.

Active management of 3Active management of 3rdrd stage of labor. stage of labor.

AA

CONTROLLED CORD TRACTION

Complication Complication

Maternal-Rupture of uterus-VVF-RVF-PPH-Puerperal sepsis-Shock -Maternal death

Fetal -intra uterine asphyxia-Intracranial haemorrhage-Neonatal infection-Acidosis-Foetal death

Shoulder Dystocia

DefinitionDefinition• impaction of anterior shoulder above impaction of anterior shoulder above

symphysissymphysis

• inability to delivery shoulders by usual inability to delivery shoulders by usual

methodsmethods

IncidenceIncidence• 1 to 2 per 1000 deliveries1 to 2 per 1000 deliveries

• 16 per 1000 deliveries of babies > 16 per 1000 deliveries of babies >

4000 g4000 g

Failure to deliver fetal shoulder without utilizing Failure to deliver fetal shoulder without utilizing facilitating maneuversfacilitating maneuvers

Normal DystociaNormal Dystocia

PathophysiologyPathophysiology

The fetal bisacromial diameter The fetal bisacromial diameter normally enters the pelvis at an normally enters the pelvis at an oblique angle with the posterior oblique angle with the posterior shoulder ahead of the anterior shoulder ahead of the anterior one,one,

Then Rotation to the anterior-Then Rotation to the anterior-posterior position at the pelvic posterior position at the pelvic outlet with external rotation of outlet with external rotation of the fetal head. the fetal head.

PathophysiologyPathophysiology

In shoulder dystocia there is In shoulder dystocia there is

– Absence of truncal rotationAbsence of truncal rotationFetal shoulders remain A-P or descent simultaneouslyFetal shoulders remain A-P or descent simultaneously

Risk FactorsRisk Factors• post-term pregnancypost-term pregnancy

• maternal obesitymaternal obesity

• fetal macrosomiafetal macrosomia

• previous shoulder dystociaprevious shoulder dystocia

• operative vaginal deliveryoperative vaginal delivery

• prolonged labourprolonged labour

• poorly controlled diabetespoorly controlled diabetes

Risk factors are present in

< 50% of cases

DiagnosisDiagnosis• head recoils against perineum, ‘turtle’ signhead recoils against perineum, ‘turtle’ sign

• spontaneous restitution does not occur spontaneous restitution does not occur

• failure to deliver with expulsive effort and failure to deliver with expulsive effort and usual gentle directionusual gentle direction

ComplicationsComplications

• Fetal/neonatal Fetal/neonatal - deathdeath- asphyxia and sequelaeasphyxia and sequelae- fractures - clavicle, humerusfractures - clavicle, humerus- brachial plexus palsybrachial plexus palsy

• MaternalMaternal- postpartum hemorrhagepostpartum hemorrhage- uterine ruptureuterine rupture

ManagementManagement

Goal: Safe delivery before neontal Goal: Safe delivery before neontal asphyxia and/or cortical injuryasphyxia and/or cortical injury

7 minutes!!!7 minutes!!!

Prophylactic Cesarean?Prophylactic Cesarean?

Not recommended by ACOGNot recommended by ACOG

Exceptions:Exceptions:– Consider if…Consider if…

>5000g in mother without DM>5000g in mother without DM

>4500g in mother with DM>4500g in mother with DM

• PPanicanic

• PPullingulling (on the head)(on the head)

• PPushingushing (on the fundus)(on the fundus)

• PPivoting ivoting (sharply angulating the (sharply angulating the head, using the coccyx as a fulcrum)head, using the coccyx as a fulcrum)

Avoid the P’s

Ask for help

Lift - the buttocks - the legs

Anterior disimpaction of shoulder - rotate to oblique - suprapubic pressure

Rotation of the posterior shoulder - Woods’ manoeuver

Manual removal of posterior armMove patient toALL four position

} McRobert’s manoeuver

Remember Alarm

• get the mother on your sideget the mother on your side

• partner, coachpartner, coach

• nursingnursing

• notify physician back up or notify physician back up or

other appropriate other appropriate

personnelpersonnel

Ask for HELP

LLifting the legs and buttocks -ifting the legs and buttocks -McRobert’s ManeuverMcRobert’s Maneuver

• Flexion of thighs on abdomen

requires assistance

• 70% of cases are resolved

with this maneuver alone

Lifting the legs and buttocks -McRobert’s Maneuver

• suprapubic pressure applied suprapubic pressure applied with heel of clasped hand from with heel of clasped hand from the posterior aspect of the the posterior aspect of the anterior shoulder to dislodge anterior shoulder to dislodge itit

Anterior Disimpaction - 1) Suprapubic PressureAbdominal approach

Suprapubic PressureSuprapubic Pressure

Adduction of the most accessible shoulder moves the fetus into an oblique position and decreases the bisacromial diameter

Anterior Disimpaction - 2) Rubin Manoeuver

• vaginal approach

RRotate the posterior shoulder - Woods’ otate the posterior shoulder - Woods’ manoeuvermanoeuver

Abduct posterior shoulder exerting pressure on Abduct posterior shoulder exerting pressure on anterior surface of posterior shoulderanterior surface of posterior shoulder

MManual removal of the posterior armanual removal of the posterior arm

grasp the posterior arm and sweep it across the anterior chest to deliver

MMove patient to All-Fours Maneuver(Gaskin Maneuver)ove patient to All-Fours Maneuver(Gaskin Maneuver)

Changes pelvic dimensions in a similar way to Changes pelvic dimensions in a similar way to Mc Roberts maneuverMc Roberts maneuver

Apply downward traction to disimpact the Apply downward traction to disimpact the posterior shoulderposterior shoulder

EpisiotomyEpisiotomy

• May facilitate Wood’s Manoeuver or May facilitate Wood’s Manoeuver or allow room for delivery of the posterior allow room for delivery of the posterior armarm

As a last resortAs a last resort

• clavicular fractureclavicular fracture

• cephalic replacement (Zavenelli cephalic replacement (Zavenelli manoeuvre)manoeuvre)

• symphysiotomysymphysiotomy

AfterwardsAfterwards• be prepared for PPHbe prepared for PPH

• inspect for maternal lacerations inspect for maternal lacerations and traumaand trauma

• examine the baby for evidence of examine the baby for evidence of injuryinjury

• explain the delivery and explain the delivery and manoeuversmanoeuvers

• chart what was donechart what was done

• Anticipate and be prepared (most are unpredictable)

• Stay calm, don’t panic, pull, push or pivot

• Remember the “ALARM-E”

Finally

Ask for help

Lift - the buttocks - the legs

Anterior disimpaction - suprapubic pressure(abdominal) - - rotate to oblique (vaginal)

Rotate the posterior shoulder - Woods’ manoeuver

Manual removal of the posterior arm,OR Move patient to ALL four position

Episiotomy - consider

} McRobert’s Manoeuver

ALARM-E”

A 25 year-old healthy woman has a normal labor A 25 year-old healthy woman has a normal labor and a spontaneous delivery of the fetal head. On and a spontaneous delivery of the fetal head. On expulsion of the head, a shoulder dystocia is expulsion of the head, a shoulder dystocia is recognized. Before instituting maneuvers the next recognized. Before instituting maneuvers the next step is to: step is to: – A) Tell the patient not to pushA) Tell the patient not to push– B) Apply fundal pressureB) Apply fundal pressure– C) Increase or initiate Oxytocin administrationC) Increase or initiate Oxytocin administration– D) Cut a large episiotomyD) Cut a large episiotomy

AnswerAnswerA) Tell the patient not to pushA) Tell the patient not to push– The training and experience of clinician The training and experience of clinician

should dictate sequence of maneuvers that should dictate sequence of maneuvers that will be used; however, initially it is best to do will be used; however, initially it is best to do nothing that will further impact the anterior nothing that will further impact the anterior shoulder above the pubic symphysis. The shoulder above the pubic symphysis. The simplest way to avoid further impaction is to simplest way to avoid further impaction is to ask the patient to stop pushing. ask the patient to stop pushing.

Thank you !!! Thank you !!!