Labor abnormality

 DYSTOSIA
MALPRESENTETION AND
MALPOSITION
Prolonged labor /LABOR
ABNORMALTY
CPD
OBSTRUCTED LABOR
PPH

DYSTOCIA

 Learning objectives
To define dystocia and list its main causes.
To discuses the difference between hypo and
hyperactive uterine dysfunction.
To list the major causes and complications of
macrosomia.
To define shoulder dystocia and enumerate the
steps in the management.
To discuss the clinical features and management
of hydrocephalus
To describe ideal obstetric pelvis and list the
indications for pelvic assessment.
To define and classify contracted pelvis.
4

 Dystocia
difficult labor
characterized by abnormally slow progress of
labor
is the most common indication for primary
c/section.
Dystocia is a consequence of faults in the five Ps
operating alone or in combination.
Power (uterine contraction and voluntary muscular
efforts)
Passage (bony pelvis and soft tissues of the birth
canal)
Passenger (the fetus)
Psyche
Physician

1. Faults in the power

Inefficient uterine contraction or uterine
dysfunction

Myometrial contractions in normal labor start at one of

the pacemakers located in the uterine cornu.
These contractions are characterized by triple
descending gradient, which constitutes

Propagation of contraction which is downward from the fundus

to the cervix.
Intensity of contraction that is longer in the upper part of the
uterus.
Duration of contraction that is longer in the upper part.
Peak of uterine contraction which occurs simultaneously in all
parts.
6

.Faults in the power

The net result of this is to provide effective uterine

contraction, which pushes fulfill the following.
Frequency of 3-4contractions per 10minutes
Duration of 45-60 seconds during each contraction
Intensity of 20-60mm Hg with resting tone of 10-15mm Hg
(fundus of the uterus can not be indented at the height of
contraction)

Any deviation from this pattern results in uterine

dysfunction.
In majority of uterine dysfunctions the cause is
unknowns.
In the remaining the following are implicated:
Minor to moderate degrees of CPD, which result in poor
application of the presenting part to the cervix.
Uterine over distension as in Polyhydraminos or multiple
pregnancy.
Anxiety and emotions (psychological factors), which suppress
release of oxytoxin from the posterior pituitary.
7

.Faults in the power

Uterine Dysfunction is
common in primigravida than in multipara (4% vs.
20%).
It leads to prolonged labor which in turn results
in maternal exhaustion,
increased risk of Intrapartum and postpartum infection of
the mother and fetus,
fetal distress and
operative deliveries.

There are two types of uterine dysfunction

In efficient
a.Hypotonic uterine dysfunction (uterine inertia)
b.Hypertonic uterine dysfunction (in coordinate
uterine action)

Over efficient

Hypotonic UD

Hypertonic UD

Resting tone decreased

Resting tone increased

Normal gradient patten with fundal

dominance present

Distored gradient pattern lower segment

dominance or complete assynchronism
of electricla impulses.

Contractions are decreased in intensity

with slight rise in pressure there fore,
less pain and uterus is indentable at the
height of contractions

Contraction are increased in intensity

but are disorganized therefore,
contractions are more painful leading to
ketosis

Responds favorably to oxytocin

Gets accentuated by oxytocin

.Faults in the power

Over efficient
Precipitated labor
Intense and frequent contraction
Delivery 1-2 hrs
Danger to fetus
Unattended labor
Anoxia
Intracranial hemorrhage

Danger to the mother

Genital laceration
10

2. Faults in the passenger

The fetus may be the cause of dystocia if
the presentation and position is abnormal.
it is big in size or
it is grossly malformed.

11

II. MALPRESENTATION
DEF:
MALPRESENTATION: a presentation other
than vertex
shoulder, breech, face, brow, asynclitism
Malpositon: a position other than occiput
anterior (RT, LT, direct) in vertex and mentum
anterior in face presentation
Can result in ill fitting presenting part in a normal
pelvis
Causes:
-abnormal pelvis
-abnormal shape of the uterus
-laxity of the uterus
-multiple pregnancy
12

..MALPRESENTATION

Complication:
-early rupture of the membrane with risk of
cord prolapse
-premature labor
-slow irregular, short lived contraction
-uncoordinated and excessively painful labor
after rupture of membrane
-prolonged labor, CPD and obstructed labor
-post partum hemorrhage
-fetal and maternal distress
13

..MALPRESENTATION
In the absence of contracted pelvis and/or big
sized fetus most malpresentations and
malpositions do not cause dystocia.
Significant dystocia is a rule in

Persistent occipito posterior presentation

deep transverse arrest
persistent brow presentation,
persistent mentoposterior (mentotransverse)
presentation,
breech with extended head, nuchal arm and
shoulder presentation
persistent posterior asynclitism

14

II- Macrosomia
Macrosomia is defined as fetal weight exceeding 4500grams.
The general rule is the larger the size of the fetus the higher
the chance of dystocia.
There is no clear cut fetal weight limit implicated in causing
dystocia.
In a woman with normal sized pelvis, dystocia, is unusual if
fetal weight is less than 3500grams.
The causes of macrosomia are

maternal diabetes mellitus especially of gestational type and

post date pregnancy.
Increasing parity,
increasing age and size of the mother are associated with
macrosomia.

Macrosomia should be suspected in a woman with

big abdomen,
fundal height of the uterus bigger than the calculated gestational age
from the LMP,
fetus seems large with minimum amount of amniotic fluid and nonengagement of fetal head at term.
15

..Macrosomia
Fetal weight can be estimated by
Johnson's formula and ultrasound.
Fetal weight in gram = fundal height in centimeters n*155

ischial spine

= 12 if the vertex is above the

= 11 if the vertex is below the

ischial spine
The anticipated complications of macrosomia are

deep transverse arrest,

shoulder dystocia,
postpartum hemorrhage from uterine atony or
genital tract tears and
obstructed labor and its complications.
16

Shoulder dystocia
Shoulder dystocia is an acute obstetric emergency
in which following the delivery of the head the
shoulders of the fetus can not be delivered despite
the performance of routine obstetric maneuvers
It results from impaction of the anterior shoulder
above the Symphasis pubis in an antero-posterior
diameter.
Risk factors for shoulder dystocia, which are
identified in only less than 50%,
include fetal macrosomia,
maternal obesity;
prolonged labor especially prolonged second stage of
labor,
previous history of shoulder dystocia and
difficult operative vaginal deliveries.
17

.Shoulder dystocia
Diagnostic features include
Turtle sign following the delivery of the head the neck
is retracted and the head recoils against the perineum
with the chin pressed against the maternal thigh.
Spontaneous restitution doesn't occur and the face
becomes plethoric.
Failure to deliver the shoulders with maternal expulsive
effort and gentle down ward traction on the fetal head.

Complications of shoulder dystocia are

post partum hemorrhage from genital tract tears and
uterine rupture,
birth injuries (fractures, brachial plexus injury) and
fetal asphyxia and death.

18

.Shoulder dystocia
Shoulder dystocia requires prompt and skillful
management.
The following steps are useful.
Step1
Stop maternal expulsive efforts
Stop desperate pulling on the fetal head.
Call for help.

Step2
Disimpact the anterior shoulder by one combination of the
following maneuvers.
McRoberts maneuver (hyper flexion of both thighs on the maternal
abdomen)
Rubins maneuver (application of suprapubic pressure in lateral
direction on the posterior aspect of the anterior shoulder).
19

.Shoulder dystocia
Step3
Rotational maneuvers (effective anesthesia needed)
Wood screws maneuver rotating the posterior shoulder
backward through 1800(half circle).
Rubin rotational maneuver-Rotating the posterior shoulder
forward through 1800.

Step4
Extraction of posterior arm

Step5
if the above fail perform symphysiotomy and
Abdominal rescue (zavanelli manuever )
clediotomy if fetus is died
20

III-Congenital malformations
1.Hydrocephalus
Hydrocephalus is progressive enlargement of the
cranium resulting from excess accumulation of
cerebrospinal fluid in the ventricle of the brain.
It accounts for 12% of malformations at birth and
occurs in 1:1000 deliveries.
In one third associated defects like spinal bifida are
found.
Breech presentation is found in one third of cases.
Significant dystocia from gross CPD is a rule.
Clinical features, which may lead in diagnosis,
are broad firm, mass above Symphasis in cephalic presentation
and
in labor finding on vaginal examination of tense large fontanel,
Widened suture line and indentable thin cranial bones
21

.Hydrocephalus

Definite diagnosis requires

ultrasound examination, which shows dilated
ventricles.
Plain x-ray of abdomen may show large globular
head with small face and thin cranial bones.

The management of diagnosed hydrocephalus

is drainage of excess cerebrospinal fluid by
cephalocentesis (ventriculocentesis).
This procedure involves passing long needle through
the dilated suture lines in to the ventricles.
It can be done vaginally (after 3-4cm cervical dilation
in cephalic presentation or after the body and
shoulders are delivered in breech presentation) or
transabdominally before the onset of labor.
22

2. Others

Malformations that may cause dystocia

include

congenital goiter and other neck swellings,

Abdominal masses including ascites,
distended fetal bladder,
enlargement of liver, kidneys and spleen and
conjoined twins.

Diagnosis is often difficult and should be

suspected if dystocia arises after delivery
of the head often stillbirth is the end
result.
23

3. Faults in the passage

3.1. Bony dystocia

The true pelvis has an inlet, mid-cavity and outlet.

An ideal obstetric pelvis fulfills the following:

Inlet

Round or transversely oval pelvic brim without undue projection of

the sacral promontory.
the inclination of the birth should be less than 550 below the
horizontal,
obstetric conjugate (anteroposterior diameter) of 12cm and
available transverse diameter of 12.5cm.

Mid cavity

shallow with straight side walls

ischial spines do not project unduly
large sciatic notches with sacrospinous ligament accommodating
two fingers (3.5cm).

Outlet

with rounded sub pubic angle of 850 or more (two fingers)

with inter tuberous distance of at least 10cm (4 knuckles).
24

CONTRACTED PELVIS

results if one or more of the critical internal

diameters of the pelvis are shortened by 2cm or
more.

It is classified in to:
I.
Generally contracted pelvis-includes

II.

contracture of the inlet, mid cavity and outlet.

Inlet contracture

III.

anteroposterior diameter of less than 10cm

transverse diameter of less than 12cm.

Mid cavity contracture

IV.

anteroposterior diameter of less than 11.5cm

transverse diameter of less than 9.5cm.

Outlet contracture

intertuberous diameter of less than 8cm

25


I.

The causes of contracted pelvis are classified as follows.

Normal development of the pelvic bones but with
abnormal shape:
android type pelvis (triangular brim) and
platypelloid type pelvis (flat oval brim which is more common
in women with short stature).

II. Nutritional deficiency from rickets (Vitamin D deficiency) in

child hood and osteomalacia in adult.
III. Diseases or injury in the spines /limbs
kyphosis, scoliosis
pelvis tumors,
fractures
poliiomyelitis in childhood

IV. Congenital disorders

spines (spondtolistesis, high assimilation pelvis),

pelvis ( Naegles pelvis and Robertss pelvis) and

congenital dislocation of hips

26

 Pelvic assessment
The capacity of the pelvis can be assessed by
clinical and
x-ray pelvimetry.

Pelvic assessment is indicated in(before labor )

Primigravida at term with unengaged head.
Primigravida with height less than 1.5meters or age less than 18years.
Multipara with history of prolonged labor, stillbirth, early neonatal death or
severe neonatal injury.
Women to be induced or augmented.
Before trial of scar in lady with previous cesarean section.
Women with abnormal presentation (face, breech and brow)

Clinical pelvic assessment should be done

after emptying the bladder and
putting the woman in lithotomy position.

Then one should assess the following:

Reach ability of sacrum promontory. If reachable measure the diagonal
conjugate.
Smoothness and concavity of sacrum.
Straightness of the sidewall and projection of the ischial spine.
Size of sub pubic angle and intertuberous distance.
Soft tissue masses and strechability of the perineum.

27

 Management
The management of contracted pelvis depends on
the degree of contracture and
presence of other obstetric complications notably malpositions,
malpresentations and macrosomia.
Regardless of other obstetric complications, grossly contracted
pelvis should be managed by
cesarean section preferably electively.

The management of borderline contracted pelvis depends on the

presence of other obstetric complications
Cesarean section should be done in the presence of
macrosomia fetus,
Malpresentation in a normal sized fetus and
conditions which need induction/ augmentation
in the absence of these a trial of labor should be given before a
decisions of cesarean section.
28

3.2. Soft tissue dystocia

Cause

Management

A. Cervical dystocia
Rigid cervix from stenosis

Digital dilation, cervical incision

Congultination of the cervix

Digital dilation, cervical incision

Cervical cancer with infiltration

Cesarean section

B. Vagina
Septum (transverse or longitudinal)

Incision or cesarean section

Incomplete atresia

Cesarean section

Annular stricture

Manual dilatation, incision or cesarean

section

Extensive scarring

Manual dilatation, incision or cesarean

section

Gartner duct cyst

Aspirate aseptically

Tetanic contraction of levator ani

Anesthesia

Vulvar scar

Generous episiotomy

C. Pelvic masses
Myoma, ovarian cyst

Cesarean section

29

Malpresentation
and
Malposition
30

 Persistent occiput posterior presentation

deep transverse arrest
persistent brow presentation,
persistent mentoposterior (mentotransverse)
presentation,
breech with extended head, nuchal arm and
shoulder presentation
Persistent posterior asynclitism
31

Ociptoposterior position
13 % of all vertex presentation
Cause is unknown, but Associated with:
pendulous abdomen,
abnormal pelvis and
the placenta is anterior

Diagnose

The back is not anterior

The limbs are anterior
There is a saucer like depression around the umbilicus
FHR at the sides of the flanks and descends down
Vaginal examination
anterior fontanelle is felt in the anterior part of the pelvis near ileo
pectineal eminence
32

.Ociptoposterior position
Out come of the labor
Long internal rotation
the pelvic floor causes further flexion of the head and
rotates anteriorly to 450 then to 900rotation and delivered
normally

Short internal rotation

If flexion is incomplete ,rotation of the head takes place
posteriorly brings the occiput in the hollow of the sacrum
delivery hear is face to pubis

Deep transverse arrest

Arrest of the long rotation causes the head to be left in
the occiput lateral position :
delivery is possible by rotation or c/s

NB. only 10% of these persist in occiput

posterior

33

..Ociptoposterior position
Management
augmentation if there is inefficient uterine
contraction
Spontaneous vaginal delivery
Forceps delivery either after rotation to
anterior (keilland forceps )or direct delivery
Manual rotation
Vacuum delivery (there could be passive
rotation)
34

deep transverse arrest

Occiput transverse position is transient
Could persist
Abnormal pelvic arthecture (flat pelvis)
Inadequate uterine contraction

Mx
Augmentation in the case of inadequate
uterine contraction in the absence of CPD
Manual /forceps rotation and delivery in
OA/OP by forceps
c/s if contracted pelvis /abnormal pelvic
arthecture
35

Brow presentation

Sinciput is the presenting part

Deflexed (partial extended)
Diameter of the presenting is 13.5 cm
Incidence 1:1000
Cause :
Lax uterus ,multiple pregnancy, Hydramnios
Deflexed fetal head
hypotonous muscle

-thyroid tumor
Anencephaly
Abnormal shape of the pelvis
36

Brow presentation
Diagnosis
palpation-the head is high and does not enter the pelvis
vx examination
station high
smooth hair less area is felt, with part of bregma at one site
orbital ridge may be felt

Management
Early observation ;can be converted into face/ vertex
Late (persistent brow presentation) c/s
Dead :craniotomy

37

Face presentation
Extended attitude and face lies in the
lower uterine segment
Cause :
Lax uterus ,multiple pregnancy, hydraminous
Deflexed fetal head hypotonous musle

-thyriod tumur
Anencephaly
Abnormal shape of the pelvis persistent
mentoposterior (mentotransverse)
presentation,
38

Face presentation
Diagnose
Inspection :irregular abdomen and the shape of the fetus
spine is that of an s
Palpation;
prominent occiput is felt on the same side as the sinciput which
is lower than the occiput .
a deep groove is felt between fetal back and head
Auscultation: The fetal beat is heard clearly at the center

Vaginal examination:
High presentating part
Soft irregular mass ,gum felt and , sucking of finger

Complication

Obstructed labor
Cord prolapse
Facial bruising
Cerebral hemorrhage and maternal trauma
39

Face presentation
mechanism of delivery
an increase in extension the chin rotates
rather than occiput engaging diameter is submento bregmatic
9.5cm

Labor ;
extra discomfortsedation
Note position and do PV when membrane ruptured
Let labor continue for mentoanterior, and early
mentotransverse/mentoposterior
When the face distends the perineum do episiotomy
Allow the chin to be delivered 1st and flex the head to allow to
deliver the occiput
Delivery of persistent mentoposterior/ transverse is not possible
C/S
40

Breech
Breech presentation
Def: fetus buttock in the lower part of the uterus
Incidence 3-4% at term
Types
-frank-hip flexed and leg extended commonest
-complete :hip and leg are flexed
Presenting part is bulky and consists of buttock ,external
genitalia, feet
-footling-hip and leg are extended .one /both feet present
-knee: one/both the hips are extended with knees flexed
41

.Breech
Cause
-no cause is identified ,but the following circumstances favor
breech presentation

polyhydraminos

prematurety

multiple pregnancy

placenta previa

contracted pelvis

uterine abnormality

Abnormal fetus (hydrocephalus, anencephalus)

extended leg
42

.Breech
Diagnosis
Hx
Fetal kick ,low in the abdomen
Maternal sub costal discomfort

P/E
Palpation
lie is longitudinal
fundus occupied by a firm, smooth, rounded, mass which dependently moves
with the back
a soft and irregular mass occupy the lower uterine segment

Auscultation
The fetal heart beat is heard above the umbilicus if the breech is not engaged
below the umbilicus if is engaged

Vaginal examination

No suture or fontanelle are felt ,

the anal sphincter grips the finger
ischial tuberousity ,genital groove and external genitalia
fresh meconium seen on the examining finger
foot may be felt in case of footling breech

43

Diagnosis
confirmation by U/S(
GA, BPP, placenta localization,
attitude, malformation, fetal weight
X-ray (dx, attitude, pelvimetry

44

.Breech
Management
ANC
EXTERNAL cephalic version
After 36 weeks

selected vaginal breech delivery

EFW <3500gm
Frank/complete breech
Flexed head
Adequate pelvis
Gross fetal malformation which is incompatible with extra uterine life

primary c/s

EFW>3500gm
Any degree of contracted pelvis
Hyper extended head
Poor obstetric performance ,infertility, primigravida >35 age
No labor but there is maternal and fetal indication for termination 45

.Breech
Labor
Mode: depends on fetal size, pelvic size ,attitude
of the head ,type of breech, number of fetus,
progress of labor, other obstetric indication
Principle of management
-intelligent observation
-avoidance of unnecessary interference
-Promote action carried out with manual
dexterity when assistance is needed
-avoidance of fetal injury and hypoxia
46

Mechanism of breech delivery

The denominator of breech presentation is the
sacrum and the diameter is bitrochantric diameter.
eight possible positions are recognized:
bitrochantric diameter which is 10 cm enters the pelvis in
the oblique diameter
Decent occurs with further flexion.
Internal rotation ordinarily takes place when breech
reaches levator musculature which brings the
bitrochantric diameter to anteroposterior position.
Further decent with flexion brings the breech to the pelvic
outlet.
Delivery of the buttocks, first the anterior to be followed
by the posterior, occurs by lateral flexion.
47

.Mechanism of breech delivery

As the truck is delivered the shoulders enter the pelvic inlet in
the transverse diameter causing rotation of the trunk so that
the back faces up.
The shoulders descend in the birth canal and at the level of the pelvic
floor internal rotation occur causing external rotation of the body.
At this point, the back is directed to the left side of the mother, which
indicates readiness for the delivery of the shoulders.
The shoulders are then delivered by lateral flexion, anterior followed by
posterior.

At the time the shoulders rotate internally the head engages in

the transverse diameter of the inlet.
The head after decent rotates internally, at the pelvic floor.
This causes rotation of the rest of the body so that the back faces up.
Further decent results in the delivery of the head by flexion (the face
sweeps the perineum).
48

.Mechanism of breech delivery

NB labor in breech is considered as a trial
Management of labor
1st stage of labor

careful observation
warn not to push
vaginal examination when membrane ruptured
sedation
Augmentation is contraindicated
The occurrence of in coordinate uterine action, uterine
inertia, arrest or delay in cervical dilatation or failure of
descent of breech warrants urgent cesarean section.

Prepare for delivery

49

.Mechanism of breech delivery

Second stage
spontaneous breech: delivery no
interference
Rarely done except for premature babies
High perinatal morbidity and mortality

50

.Second stage
Assisted vaginal breech delivery (partial breech
extraction) where the fetus is delivered up to the
level of the umbilicus spontaneously and the rest of
the body is delivered with the assistance of the
health professional using special maneuvers.
Delivery of the frank breech
full dilatation of the cervix needed before the mother push
active push is not necessary until the buttock is distending the
vulva
encourage to push with contraction once the buttock distends the
vulva
the buttock are delivered spontaneously
episiotomy may be necessary
wait until it reach the level of the umbilicus
51

partial breech extraction

Delivery of the shoulder
The baby should be grasped with clean towel
moistened with water. Holding the baby around the
hips avoids fetal visceral damage.
Ensure the anterior position of the sacrum and the
back until the lower border of the scapula is visible.
Apply gentle and steady down word traction until
the lower halves of the scapula are delivered.
tilt the baby towards the maternal sacrum to free
the anterior shoulder
when the anterior shoulder is born lift the buttocks
towards the mothers abdomen to enable the
posterior shoulder and arm to pass over the
perineum
52

partial breech extraction

Delivery of the head
Allow the baby to hang until the nape of the neck or posterior hairline
is visible. Then deliver the head in one of the following ways:
Mauriceau smelli viet method :While the fetal body lies on the palm of
the hand and forearm ,the index and middle finger applied over the
maxilla to keep head flexed The two fingers of the other hand are
hooked over the fetal neck .grasping the shoulder ,gentile downward
traction applied until suboccipit region become visible under the
symphysis pubis .gentle suprapubic pressure by an assistant helps to
keep the head flexed .the body of the fetus is then elevated towards the
mother s abdomen and delivery of the head effected
II. Forceps delivery Pipers forceps
Electively /if MSV failed

III. Wigand maneuver

The procedure is like mauriceau Smellie veit maneuvers but differs by
1. The dominant hand instead of being introduced in to the vagina it is put
on the supra pubic area to provide supra pubic pressure.
2. An assistant is not needed to apply supra pubic pressure.

53

 Complete breech extraction

Delivery with no assistance from the mother the entire fetus is
delivered from the birth canal by the assistance
the fetus is extracted with its breech when delivery is not possible
but there is a condition for emergency delivery
As alternative to c/s
Indications
Fetal distress in the second stage of labor breech
Cord prolapse
Need for rapid delivery of the second twin (distress, abruption, cord
prolapse ).currently idicated

Precondition
Cervix fully dilated
No CPD
No uterine scar

Technique
Introduce one arm into the abdomen ,grasp both feet of the fetus and
bring to the vagina by gentle traction .may need to do for each turn by
turn but never pull a single limb out of the vulva with out finding the
other
Continue traction until delivery of the hip ,and then follow as with
assisted breech delivery

54

 Third stage of labor

Managed actively
Look for cervical and genital tract tear

55

 Difficulty of breech delivery

Arrest of delivery of the legs
if the legs can not be delivered spontaneously, it
can be assisted by splinting the medial thigh of the
fetus with the position parallel to the femur and
exerting pressure laterally so as to sweep the legs
away from the midline (Pinnard maneuver).

56

.Difficulty of breech delivery

Delivery of extended arm

I. Lovset maneuver
Holding the babys hip rotate the fetus by half a circle (1800) Keeping the
back uppermost and
applying downward traction at the same time. This delivers the posterior
arm, which now becomes the anterior arm, beneath the pubic arch. This
may be assisted by placing one or two fingers on the upper part of the
arm flexing it, which sweeps the arm over the chest. Then reverse the
rotation (half a circle (1800) keeping the back upper most to deliver the
remaining arm beneath the symphysis.
II. Delivery of the posterior arm followed by anterior (or the reverse) put one
or two fingers in to the vagina over the back of the baby. Slip the fingers
over the shoulders, place them parallel to the hummers and apply
downward pressure to deliver the arm.
III. Extraction of the posterior arm
It is useful when there is extended arm and the Lovset maneuver is not
successful
57

.Difficulty of breech delivery

C. Delivery of the head
Nuchal arms: extended arms found behind the neck of the fetus
Rotate in a direction to bring the arms anterior
managed by Lovset maeuver

Extended arm is diagnosed when the arms are not felt on the chest.
Management is like the nuchal arm

Arrest of after coming head

could be caused by incompletely dilated cervix, extended head,
hydrocephalus or Cephalopelvic disproportion (contracted pelvis or big
baby)

if incomplete dilated cervix is the cause of Arrest of the after coming

head
Try to slip it
Duhressens incition

Arrest of after coming head at the pelvic inlet

Symphsiotomy
Zavanelli manouever(abdomonal rescue )
58

 Danger of breech presentation

After coming head entrapment
Cerebral damage due to hypoxia
Asphyxia (fetal/neonatal)- prolapse /pressure
of the cord
Prematurity
Intracranial hemorrhage
Visceral injury
Erbs palsy damage of the brachial plexus
Facial nerve palsy-twisting of the neck
Fracture /dislocation
Spinal cord damage
59

Transverse lie

Presenting part is the shoulder

Transverse lie
1:250-00
Cause

lax uterus ,
pp,
Hydramnios ,
multiple pregnancy,
uterine anomaly,
preterm ,
macerated fetus

Diagnosis
uterus is broad and fundal height is less than expected
the hand /the rib can be felt
arm may prolapsed (if in labor
60

..Transverse lie
Management
at ANC ;
at 36 weeks external version can be attempted
at labor ;
c/s
late labor with ruptured membrane ,
prolapsed cord
version in early labor /and membrane not ruptured

NB. the cervix is not fully dilated and fetus

not accessible c/s even if the baby is dead
61

.Transverse lie
Complication
Maternal
-Obstructed labor
-Uterine rupture
-Death
-Puerperal sepsis
-PPH

fetal
-fetal death
-Prematurity
-malformation
-arm prolapse

62

63

Abnormal patterns of labor

64

1.Prolonged latent phase

2.Protracted disorders
3.Arrest disorders
4.Precipitated labor

65

1.Prolonged latent phase

If it is more than 8 hr
Causes

Excessive sedation before full establishment of labor

Conductive /general anesthesia
Labor started with unfavorable cx
Inefficient uterine contraction
Fetopelvic disproportion

Rx
Rest
Sedatives
Morphine

Hydration
Augmentation

Prognosis is good with 85% of the cases deliver

vaginally

66

2..Protracted disorders
Protracted dilatation of the cervix
<1.2cm/hr in primi and <1.5 cm/hr in multi

Protracted descent
Rate of descent is <1cm/hr and <2cm/hr in primi and multi
respectively

Causes

CPD
Anesthesia
Sedatives
Inefficient uterine contraction

Rx
1st rule out CPD ,and asses fetal condition
If there is CPD c/s
No CPD and fetal condition is good augmentation
67

3.Arrest disorders
Prolonged deceleration phase
>3hr in deceleration phase of active phase

Arrest of cervical dilatation

No dilatation for more than 2 hrs

Arrest of descent
No descent for more than 1 hr after it starts to descent

Causes

CPD
Malposition
Anesthesia and sedatives
Inefficient uterine contraction

Rx
Augmentation in the absence of CPD and good status of the
fetus

Prognosis
Poor for vaginal delivery

68

4.Precipitated labor
Rapid course of labor
Cervical dilatation of 5cm /hr for primi and 10cm/hr in multi
Causes
Lax birth canal
Excessive contraction
Oxytoxin

Complication

Amniotic fluid embolism

PPH
Laceration of the birth canal
Asphyxia ,intracranial hemorrhage ,unattended delivery

Rx
If already delivered ,see for birth canal laceration and tear
If not born

Sedation
Tocolytic
Stop oxytoxin
With previous history admit and induction
69

CPD

70

CPD
Def: when the fetal head failed to pass through
the pelvis
Can be
absolute: the fetal head to big to pass the normal
pelvis or the pelvis is too narrow to pass a normal
sized fetus
relative: a normal sized fetus unable to pass an
adequate pelvis as a result of abnormal attitude
/position :persistent occiput ,mentoposterior
,persistent brow ,posterior asynclytism
71

.CPD
Causes are
Contracted pelvis
Big baby
Abnormal presentation
Abnormal position

72

CPD
Diagnosis is
By labor abnormality after the power problem is ruled out
Protracted or arrest disorders
In the 1st stage /second stage

By signs of overt CPD

Capute ,moulding meconium
Usually in the second stage /sometimes in the late second stage

NB .the following could help us in suspecting

possibility of CPD but they are not a definitive
method of diagnosing CPD

Hx of prolonged labor with still birth/neonatal death,

instrumental deliveries
pendulous abdomen
short women with short finger and feet
Unengaged head /unable to do head to pelvic fitting test

73

 Management
Mild and moderate of contracted pelvis needs
-trial of labor
Severely contracted pelvis needs C/S
c/s /instrumental depending
on the degree of CPD
Station of the fetus

74

75

OBSTRACTED LABOR
AND
RUPTURED UTERUS
76

Learning Objectives
To define obstructed labor and uterine rupture.
To list the important causes of obstructed labor
and uterine rupture
To enumerate the immediate and late
complications of obstructed labor.
To discuss the clinical features of obstructed labor
and uterine rupture.
To outline the management of obstructed labor
and uterine rupture.
To discuss the prevention of obstructed labor.
77

1. OBSTRUCTED
1.1. Definition
Obstructed labor is failure of descent of the
fetus in the birth canal for mechanical
reasons arising from either the passage or
passenger in spite of adequate uterine
contraction.
It is an absolute condition, which should be
applied only when further progress is
impossible without assistance.
78

1.2. Importance
is one of the major causes of maternal and
perinatal mortality in developing countries.
Its incidence is mainly related to
the availability, accessibility and quality of ante partum
and Intrapartum services in the community
to a lesser extent to the incidence of fetopelvic
disproportion in the community.

should never occur in communities where

obstetric care is optimal even if disproportion is
prevalent.
Therefore, is considered as a sign of major failure
in obstetric care.
79

1.3. Causes
Cephalopelvic disproportion (CPD) remains to be the
commonest cause of.
Contracted pelvis (which is prevalent in developing countries where
childhood malnutrition and early marriage are common) is
responsible for most of the CPD.
Macrocosmic babies and
fetal malformations account for minor proportion of CPD.

Malpresentation is the other major cause of Included in

here are

neglected shoulder presentation

impacted big breech, and arrested after coming head in breech,
persistent brow and mentoposterior presentations.
In the presence of borderline contracted pelvis,
mentoanterior and
persistent Ociptoposterior positions may cause OL.

Others rare causes of OL include

deep transverse arrest,
shoulder dystocia and
soft tissue obstruction.

80

1.4.Complications
The immediate and late complications of OL are
responsible for the
high maternal mortality,
Stillbirth and early neonatal morbidity

complications is immense in developing countries where

health service coverage is low and resources are scarce.
The immediate complications include
Atonic postpartum hemorrhage
Uterine rupture (rare in primigravidas)
Intra and post partum infection leading to peritonitis, sepsis
and septic shock
Maternal tetanus
Fetal cerebral birth trauma
Fetal distress and death
Fetal and early neonatal infection and sepsis
81

 The late complications include:

Fistulas (vesico-vaginal fistula and recto-vaginal
fistula)
Vaginal stenosis and stricture
Foot drop (sciatic and common perineal nerve
injury)
Contracture of joints and ostitis pubis
Perinatal asphyxia & mental retardation

82

1.5. Clinical features

Women with obstructed labor invariably
give history of prolonged labor with early rupture of membranes.
Usually these women did not receive ANC during pregnancy.
On examination,

they are exhausted, anxious and weak.

Invariably there are signs of dehydration
Intrapartum, infection.
In multipart tumors abdomen is seen prior to rupture (bladder, lower
segment and thick upper segment with the Bandls ring in between).
Uterus may be hypotonic or may show strong contractions especially in
multipart.
Bladder is edematous and distended with very little urine in it.
Bowels are usually distended from acidosis induced hypokalemia.
Fetus may be in distress or dead.
Evidence of gross CPD (caput and significant molding) or
Malpresentation is found on pelvic examination.

.
83

1.6. Management
The Principles in the management of OL
are:
Obstruction must be relieved with out delay,
Before doing so, one should rectify the effects
of prolonged labor (dehydration, acidosis and
Intrapartum infection) partially or fully.
Some form of operative delivery is always
needed to relieve the obstruction (vaginal or
abdominal).
Non-operative methods like oxytocin have no
place in the management of OL.
84

I. Resuscitation

It should be started as soon as the diagnosis is made

using the available facilities and resources.
In referral cases, this has to be started at the peripheral
clinic and continued during transportation
The components are:
A. Fluid and electrolyte replacement to tackle dehydration and
acidosis

Open an intravenous line preferably with a wide bore indwelling

cannula
Infuse crystalloids fast. (for example, 5% dextrose in saline with
50% glucose added)
Monitor urine output by inserting indwelling plastic catheter
(Catheterization may be difficult if the presenting part is impacted
and may require digital dislodgement. Never use metallic catheter
as this causes urethral injury)

B. Control infection

In all cases, infection must be assumed and intravenous broad

spectrum antibiotics should be commenced prophylatically.
The chosen antibiotics should cover gram positive, gram negative
and anaerobic bacteria.
Initial loading dose followed by maintenance dose should be given.
85

II. Pre intervention preparation

Catheterize the bladder as described
above.
Empty the stomach by nasogastric tube.
Determine hemotocrite and blood group.
Cross match at least 2 units of blood
Give antacid orally
86

III. Relief of obstruction

One should decide on the best method of delivery
because it has an impact on the survival of the
mother and the newborn.
Unless there are contraindications vaginal route is
the preferred route of delivery.
The risks associated with abdominal delivery are
Peritonitis from peritoneal contamination by infected
uterine contents
Anesthetic risks like aspiration pneumonitis
Bladder and urethral damage
Bleeding from extension of the incision
Scar on the uterus with risk of future rupture in a mother
who may not return next time
87

 Abdominal delivery (cesarean section or

laparatomy for uterine rupture) is indicated
in the following conditions
Alive fetus with incomplete cervical dilatation
or even if cervix is fully dilated and
preconditions for instrumental delivery not
fulfilled
Imminent or definite uterine rupture even if
the fetus is dead
Dead fetus when criteria for destructive delivery
are not met
88

The modes in vaginal delivery include

Generous episiotomy if the cause is tight perineum
or scarring from genital mutilation
Vacuum is of limited value except as an adjunct to
symphysiotomy
Forceps has limited place except in deep
transverse arrest
Symphysiotomy limited experience
Destructive delivery (embryotomy)
Vaginal route of delivery is contraindicated in the
following conditions:
Ruptured uterus (manipulation may extend the
tear and or remove the tamponade effect)
Imminent uterine with
Alive fetus where the criteria for embryotomy are
89
not fulfilled

IV. Post intervention care

Increase fluid intake (parenteral or oral) to
reverse dehydration
Continue antibiotics (initially parenteral later
oral) to complete full course
Institute continuous bladder drainage by
indwelling catheter for 5-7days

90

1.7. Prevention
Even with aggressive management OL is
associated with high mortality and morbidity both
to the mother and the fetus.
Therefore health programs should focus on
prevention of OL, which is considered to be a
largely preventable condition.
As a general rule, OL should never occur in a
patient who has received optimal antenatal and
Intrapartum care.
This can be achieved by non-sophisticated and
non-expensive methods tailored to the immediate
resources of the community where feasible,
hospital care for all is ideal.
91

The measures that should be undertaken to prevent OL include:

Provision of accessible family planning methods
Provision of universal quality ANC to all pregnant women to identify risk
factors
Provision of Intrapartum care (includes use of partograph) by skilled
personnel who can identify Intrapartum risk factors and provide
appropriate management (ranges from early referral to provision of
treatment).
Provision of a well- organized and fully functional unit (hospital or health
center) for delivery of comprehensive emergency obstetric care. This
includes availability of functional operation theatre and blood transfusion
services.
Provision of a good referral system for immediate transfer or mothers.
Community education on:
- Harmful traditional practices (early marriage, female genital mutilation, harmful
maneuvers ).
- Importance of good nutrition in childhood and pregnancy
- Empowering women
- Importance of ANC and supervision of by skilled personnel.

92

2. UTERINE RUPTURE
2.1. Definition and types
- Ruptured uterus is defined as a tear in the wall of
the uterus which commonly occurs in the lower
segment of the uterus.
- The tear could be anterior, posterior, lateral or
combination of these. It could be transverse,
vertical or combination of these.
- In most cases, it occur in the Intrapartum period
but ante partum rupture can occur especially in
women with classic cesarean section scar or scars
related to other gynecologic surgeries like
myomectomy.
93

- Rupture of the uterus is classified in to two

categories.
Complete (true) the tear extends through the
whole thickness of the uterus including the
myometrium and the peritoneum so that there is
free communication with the peritoneal cavity
Incomplete (occult) the tear extend through
the myometrium but not through the overlying
peritoneum so that there is no free
communication with the general peritoneal
cavity
94

2.2. Causes
By far the commonest cause of uterine rupture is
neglected obstructed labor especially in mutipara.
dehiscence of a previous cesarean section scar.
Other causes include

Oxytocin or prostaglandin like high or mid forceps

Difficult instrumental delivery like high or mid forceps
Difficult destructive delivery
Internal podalic version and breech extraction
Difficult manual removal of placenta
Other surgical scars on the uterus (repaired ruptured uterus,
myomectomy)
Vigorous fundal pressure and sharp penetrating trauma

95

2.3. Clinical features

Diagnosis of uterine rupture is usually made using clinical
symptoms and signs.
But at times it is difficult especially in those with scar on the
uterus and those under regional anesthesia.
Diagnosis in these cases often needs manual exploration of the
uterus and even exploratory laparotomy.

clinical features are variable and are largely dependent on

the time elapsed after the rupture,
the Site and extent of the rupture,
the degree of fetal and placental Extrusion (the degree of Intra
peritoneal spill) and
the tamponade effect offered by the fetus.

Therefore, a high index of suspicion is needed for

diagnosis for those not presenting classically.
96

 The usual symptoms of impending (imminent)

uterine rupture are
Worsening abdominal pain especially suprapubic
persisting between contraction
Strange feeling of the fetus moving upwards

The usual symptoms in uterine rupture include

Sudden cessation of contraction and fetal movement
often following a sharp tearing pain at the high of the
contraction
Temporary relief of pain followed by diffuse continuous
abdominal pain
Variable degree of vaginal bleeding depending on the
degree of fetal impaction
Gross hematuria in anterior wall rupture with bladder
rupture

97

 The clinical signs are also variable and include:

Normal vital signs to profound shock (tamponade effect
and involved blood vessels)
Variable pallor
Variable abdominal tenderness and distension
Absent uterine contraction and fetal heart beat
In anterior rupture, defect in the uterine wall and easily
palpable fetal parts
Variable shifting dullness
Presenting part may be jammed or retracted with
variable vaginal bleeding

Feeling a defect on vaginal examination or seeing

the defect at laparatomy makes definitive
diagnosis of uterine rupture.
98

2.4. Management
The life of the patient depends
on the speed and efficacy with which
hypovolemia is corrected.
Hemorrhage is controlled and
infection is treated.

In places where surgical intervention cannot

be provided, early referral should be
undertaken only after resuscitative measures
are initiated
99

A. Supportive management
This has the objective of initiation of treatment for
impending or full blown shock, Intrapartum infection
and preparing the woman for laparatomy.
Components include
Opening intravenous line with wide bore cannula.
Vigorous infusion of crystalloids.
Initiation of parenteral antibiotics covering the mixed
organisms like obstructed labor.
Performing laboratory tests for hemoglobin and
blood group/RH status.
Preparing at least two units of cross matched blood.
Inserting naso-gastric tube and Foley catheter.
100

B. Definitive management
Immediate laparatomy should be performed.
The surgical options include
Total abdominal hysterectomy
Sub-total abdominal hysterectomy
Repair of the rupture with bilateral tubal ligation

101

Postpartum haemorrhage

102

Postpartum haemorrhage
Definition:
Vaginal bleeding in excess of 500 ml
following childbirth till 6 weeks
estimation of blood loss notoriously inaccurate

Change in vital signs

Drop in HCT 10%

May occur
Immediately or later
As a gush or as a steady trickle
103

One of the major causes of

maternal death

104

Maternal Death and PPH

Over half a million women die during
pregnancy and childbirth each year
99% in developing countries
150,000 women bleed to death
105

Timing of maternal deaths

106

Death can occur with in

2 hours
107

Time from onset of complication to

death

PPH
APH
Ruptured uterus
Eclampsia
Obstructed labor
Sepsis

2h
12 h
1d
2d
3d
6d

108

 Two types
-primary: if occur with in 24 hour
-secondary: after 24 hours

109

Natural mechanism of
preventing bleeding postpartum

- Uterine contraction
- Coagulation
mechanism
110

Causes

Uterine atony 90%

Retained placental fragments
Trauma to genital tract
Coagulation disorders

111

 Causes are
primary
Atony
Retained product of conceptus (part/whole placenta,
membrane)
Genital trauma
Bleeding disorder
Uterine inversion

Secondary
Chorioamnitis
retained products

112

 Atonic PPH
-80% of the cause for PPH
-Failure of the uterus to contact
-Cause
RPC
incomplete separation of the placenta
prolonged labor and obstructed labor
precipitates labor
polyhydraminous, multiple pregnancy, big baby
APH (PP, abruption)
Adherent placenta
Full bladder
Prolonged anesthesia
Fibroids
Grad multi

113

 Diagnosis
Uterus soft and no contracted

114

 Management

call for help

bimanual compression
massage the uterus until contracts and
give oxytoxin 10 IU IM
insert IV line ,oxytoxin 20 IU in the bag to run at rate
of 60 drops /minute
empty bladder
if placenta delivered and is complete continue
massage and oxytoxin ;if placenta is incomplete
remove fragments
if placenta is not delivered CCT, if not successful
manual removal
still remain soft ergometrine ,but Aortic compression
115
above, left of umbilicus

 Surgery if medical treatment fails

Uterine, utero-ovarian artery ligation
Hysterectomy
Others balloon/condom

116

 Traumatic PPH
From laceration of the cervix, vaginal wall, perineum, ruptured
uterus
Cause
difficult delivery
face to pubis, after coming head breech,
instrumental delivery
delivery through undilated cervix

not controlling the head at delivery

precipitated labor
big baby
old scar tissue
Obstructed labor /oxytocin

Management:

rule out 1st uterine rupture

explore the area of tear and apex
clump the bleeder and suture
make sure that the uterus is well contracted
Vx, Cx, Perineal laceration repair
Uterine rupture repair, hysterectomy

117

 Types of perineal lacerations

1st degree ;vaginal mucosa and the skin of the
perineum
2nd degree: deep layer of the perineal muscle
3rd degree: involves the anal sphincter
4th degree: involves the rectum
Management
repair with in 24 hrs
keep on low residual diet
vulva swabbing each time the patient pas stool

Prevention
good cooperation of the patient
control the delivery of the head ,keep it flexed to bring a
small diameter
deliver the shoulder in anteroposterior diameter and lift up
the posterior shoulder
perform episiotomy when the perineum is very tight
118

 Retained placenta
no delivery of the placenta after 30 minute of
delivery of the fetus
Cause :

poor uterine contraction

hour glass contraction-erigometrine
full bladder
mismanagement of third stage labor

Management
Placenta visible
ask woman to push it out

Placenta in the vagina

remove it using CCT
119

 Placenta in uterus
empty bladder,
give oxytocin 10 IU IM, secure IV line and put her on oxytoxine
drip
attempt CCT,
manual exploration
method

support the uterus on one hand

insert the second hand following the cord until it reaches the placenta
feel for cleavage line /partially separated placenta
If there is cleavage line manual removal of the placenta
try to remove by ulnar boarder of the hand until completely
separated
bring it out in your hand ,examine it
antibiotics-ampicilline 2gm stat )
No cleavage line -consider adherence

120

 Adherent placenta
Placenta grows into the uterine muscle
accreta- into the muscle
increta deep in the muscle
percreta-through the muscle

Management
Hysterectomy (definitive)
partial wegde resection/leave it to be absorbed if
no active bleeding

Inverted uterus
Immediate repositioning
121

 Hypo fibrinogenaemia
Clotting defects and the patient continuous to
bleeding in spite of treatment for the other types of
PPH
Cause

placental abruption
IUFD which is prolonged
amniotic fluid embolism
pre-eclampsia, eclampsia
intra uterine infection
hepatitis

Dx bedside clotting test

Management
fresh frozen plasma ,fresh blood, , platelet concentrate,
cryoprecipitate
fibrinogen
oxygen/IV fluid resuscitation

122

 Difference between atonic and traumatic PPH

Atonic
-Uterus is lax or soft
-Bleeding starts after
few minutes of birth
-Blood is dark red
in color

Traumatic
-well contracted
-immediately after
delivery
-bright red in colour

123

Management of PPH, IMPAC

General principles:

Call for help

Make rapid evaluation of general condition
Uterine massage
Resuscitation ABC
Catheterize the bladder
Identify the cause
inspect the placenta
Inspect the vx ,cx ,and uterine exploration
Bedside bleeding test

Stop the bleeding

Supportive measures eg, antishock
garment,antibiotics etc
124

 Consequences of PPH
Shock
puerperal anemia
fear of the further pregnancy
sheehans syndrome anterior pituitatry
infection

125

 Preventation of PPH

Previous history of PPH

Rx anemia and supplementation of iron
Patient at risk hospital delivery and x-match
Prevent obstructed labor
Rest in 1st stage of labor as much as possible prevent
dehydration
Keep bladder empty
Delivery heads slowly and control it
Avoid precipitated and prolonged labor
avoid unnecessary episiotomy
AMSTL-universal
Prevent infection with use of prophylactic antibiotics
Inspect the placenta and the membrane for
completeness
126

Summary
PPH is a major cause of maternal death.
PPH can not be predicted.
PPH kills fast implying prevention and
prompt diagnosis of the cause and
management is essential..

127

FETAL DISTRESS

128

Learning Objectives
To define fetal distress and describe its
Pathophysiology basis
To list the etiology of fetal distress with
emphasis to iatrogenic causes to discuss
the diagnostic features of fetal distress
To describe the management of fetal
distress

129

 Fetal distress is the sign of inability to

withstand the stress of labor leading to
asphyxia which if prolonged, places the
fetus at risk of
permanent neurological injury,
multiple organ failure and
eventually death.

There is no single indicator that definitely

diagnoses fetal distress but
abnormal fetal heart rate patterns and
fetal scalp PH determination
130

1. Pathophysiology
A normally growth fetus has stored reserves of glycogen and fat to be
used at times of stress like.
In labor, temporary cessation of placental transfer of oxygen and
nutrients occur during uterine contraction.
This results in anaerobic metabolism with accumulation of lactic acid
and carbondioxide that increases as labor progresses.
This is normally corrected between each contraction provided there is
adequate oxygen carrying capacity of the mother.
Adequate perfusion of the placenta. Adequate relaxation period
between contractions (resting tonus), good umbilical blood flow( patent
vessels) and adequate fetal energy reserve.
Failure to correct this mild form from pathological conditions results in
progressive accumulation of
lactic acid and carbondioxide. This results in acidosis and reducution of
oxygen einding up in
asphyxia.
The net effect is changein fetal heart beat, which forms the basis for
diagnosis and in extreme
cases passage of meconium.
131

2. Etiology
In general all forms of fetal distress originate from deficient delivery of oxygen to the fetus.
Some
occur as a result of sudden catastrophic events like massive abruptio placenta and cord
prolapse
. Some are iatrogenic in origin.
I. Uterine and placental factors

Increased tone and frequency of contraction from oxytocin induction and

augmentation and precipitate

Decreased placental surfacr area abruptio placenta

Uteroplacental isufficincy from post term pregnancy and hypertensive disorders of

pregnancy
II. Umbilical cord

Cord prolapse either latrogenic or spontaneous

Cord compression from oligohydramnios and entanglement and knot

III. Fetal factors

Limited or exhausted reserve like in intrauterine growth restriction, prolonged and

fetal anemia (example isoimmunization)
IV. Maternal factors

Decrease oxygenation from cardiac and respiratory diseases, severe anemia,

smoking

Decreased blood pressure from sudden maternal shock (example APH), supine
hypotension syndrome and conduction anesthesia
132

3. Diagnosis
The diagnosis of FD is usually based on
I. Abnormal fetal heart rate patterns
An abnormal FHR pattern is associated with high false positive rate; therefore, it
should be used as
a screening method for which additional methods (scalp PH) are needed for
confirmation. In the
absence of confirmatory tests combination of abnormal patterns should be used to
increase the
sensitivity. The abnormal patterns include.
Baseline bradcardia is classified as moderate (fetal heart beat of 80-100/min for
>3min ) and severe (fetal heart beat of <80/min for 3min)
Baseline teachcardia is classified as mild (feta heart beat of 161-180/min for
>15nin) and severe (fetal heart beat of >180/min for >15min)
Repeated late deceleration
Severe recurrent variable deceleration (drop of FHB to <70/min with duration of
>60sec)
Reduced beat to beat variability
II. Fetal scalp blood PH and gas analysis
Currently, it is the best method to assess the acid base status of the fetus. It needs
special gas
analyzer and is not available in all settings.
133

4. Management
The management of fetal distress has two
components
I. Correction of the potential insults (intrauterine
resuscitation)
Put the mother left lateral position
Start intravenous infusion of fluids ( dextrose in
saline with 40% glucose)
Give oxygen by mask at the rate of 8-10
liters/minute
Discontinue oxytocin
Correction of hypotension of regional anesthesia
For cord prolapse, put in knee chest position and
disipact the presenting part
134

* Others amnioinfusion for cord compression

- Acute tocolysis with terbutaline till delivery
II. Remove the fetus from the hostile environment
Deliver the fetus by the most expeditious route. This is accomplished by cesarean section (if
in the
first stage or if prerequisites fir instrumental delivery are not met in the second stage) or by
instrumental delivery (if in the second stage).

135