1. Labor and birth at risk
Miss Shurouq Qadous

2. Postterm pregnancy, Labor And Birth
A postterm pregnancy (also sometimes called a postdate or prolonged pregnancy) is one that extends beyond the end of week 42 of gestation, or 294 days from the first date of LMP.
The exact cause of postterm pregnancy is still unknown.
Postterm pregnancy is more common in primiparous women than in other women.
A woman who experiences one postterm pregnancy is more likely than others to experience it again in subsequent pregnancies.

3. Maternal and fetal Risks
Maternal risks are often related to labor dystocia ( a long, difficult, or abnormal labor), such as increased risk for perineal injury related to fetal macrosomia.
Interventions such as induction of labor with prostaglandins or oxytocin, forceps – or vacuum – assisted birth, and cesarean birth are more likely to be necessary.
Woman may also experience fatigue, physical discomfort, and psychological reactions.
Fetal Risks
Abnormal fetal growth
Macrosomia (birth weight > 4000g)

4. Macrosomic infants increased risk for birth injuries caused by difficult forceps – assisted births and shoulder dystocia.
After 43 to 44 weeks of gestation the placenta begins to age.
Decreased amniotic fluid (< 400 ml), oligohydraminos is the most complication associated with postterm pregnancy.
- Other potential complications include meconium – stained amniotic fluid, an increased chance of meconium aspiration, and low Apgar scores.

5. Dysmaturity syndrome (occurs in approx
Dysmaturity syndrome (occurs in approx. 20% of neonates born after postterm pregnancies). Dysmaturity syndrome characterized by dry, cracked, peeling skin, long nails, meconium staining of the skin, nails, and umbilical cord, loss of subcutaneous fat and muscle mass.

7. Care Management
The woman is encouraged to assess;
Fetal activity daily
NST , assessment of amniotic fluid volume
During labor
Continuously EFM
amnioinfusion

8. Malposition Malpresentation

9. The most common fetal malposition is persistent occipitoposterior position (i.e., right occipitoposterior [ROP] or left occipitoposterior [LOP]. Labor, especially the second stage, is prolonged; the woman typically complains of severe back pain from the pressure of the fetal head (occiput) pressing against her sacrum.

12. Face presentation
Brow presentation

13. Malpresentation (the fetal presentation is something other than cephalic , or head first). Breech presentation is the most common form of malpresentation, occurring in 3% to 4% of all labors. Three types of breech presentation are: 1- frank breech (hips flexed, knees extended) 2- Complete breech ( hips &knees flexed) 3- Footling breech (when one foot{single footling} or both feet {double footling} present before the buttocks)

17. Breech presentations are associated with,
Multifetal gestation
Preterm birth
Maternal and fetal anomalies
Hydramnios, and oligohydramnios
Fetuses with neuromuscular disorders
Diagnosis
Abdominal palpation and vaginal examination
U/S
* A risk of prolapse of the cord exists if the membranes rupture in early labor.

18. Criteria for attempting a vaginal birth from a breech presentation are:
Frank or complete breech presentation
EFW between 2000 and 3800g
Normal (gynecoid) maternal pelvis
Flexed fetal head

22. External cephalic version (ECV) may be tried to turn the fetus to a vertex presentation. ECV may be attempted after 36 to 37 weeks of gestation

24. Cesarean birth

25. Cesarean birth. Is the birth of a fetus through a transabdominal incision in the uterus.
Indications for C/S:
Fetal macrosomia
Advanced maternal age
Obesity
Gestational diabetes
Multifetal pregnancy
Cephalopelvic disproportion
Placenta previa, placental abruption
Hx. Of previous C/S
Malpresentation
Non reassuring fetal status
Elective C/S
maternal HIV
Active maternal herpes lesions

26. Types of C/S
Elective C/S ( C/S on request or C/S on demand )
Forced C/S
A woman’s refusal to undergo C/S birth when indicated for fetal reasons is often described as a maternal fetal conflict.
- Unplanned C/S or emergency C/S

28. Preoperative care Explain to the Pt & husband & obtain consent
Inform anesthetist, OR staff, pediatrician
100% oxygen mask in case of fetal distress
Transfer to the theatre, IV , take blood for Hb, x-match 2 U of blood
Catheterize the bladder
Prophylactic antibiotics ↓↓ incidence of infection
Inform pediatrician if the mother had opiates in the last 4 hrs
Preferable to use spinal or epidural anesthesia

31. Postnatal Care or postoperative
- V/S & blood loss must be monitored
- Uterine fundus palpated
- Deep breathing & coughing encouraged
- Early mobilization
- Fluid therapy &diet
- Bladder & bowel function
- Wound care
- Lab test
- Breast care
- Prophylaxis for thromboembolism

32. Complications Maternal complications includes:
aspiration, hemorrhage, endometritis, abdominal wound dehiscence or infection
UTI, injuries to the bladder or bowel
Complications related to anesthesia
Fetal complications includes:
Fetal hypoxia (due to maternal positioning, maternal hypotension caused by regional anesthesia)
Fetal injuries (scalpel lacerations)

33. Obstetric Emergencies

34. Prolapsed Umbilical cord

35. Prolapse of the umbilical cord occurs when the cord lies below the presenting part of the fetus.
- Umbilical cord prolapse may be occult (hidden rather than visible) at any time during labor whether or not the membranes are ruptured.
Most commonly seen is frank (visible) prolapse directly after rupture of membranes.
Contributing factors include:
Long cord (longer than 100cm), malpresentation (breech or transverse lie), or an unengaged presenting part.

38. Management - Pressure on the cord may be relived by the examiner putting a sterile gloved hand into the vagina and holding the presenting part off of the umbilical cord.

43. If the cervix is fully dilated, a forceps – or vacuum - assisted birth can be performed for the fetus in a cephalic presentation, otherwise C/S is indication.
If the cord is protruding from vagina, wrap loosely in a sterile towel saturated with warm sterile normal saline solution.
Administer O2 ( 8 – 10 L/min by nonrebreather facemask) until birth is accomplished.
Continue FHR monitor

44. Rupture of the Uterus
Ruptures of the uterus, in which complete nonsurgical disruption of all uterine layers takes place, is a rare but very serious obstetric injury that occurs in 1 in 2000 births.
Risk factors
TOL for attempted VBAC
Previous uterine scar
Labor induction
Multiple prior cesarean births
Multiparity
Trauma

45. A uterine rupture is classified as either complete or incomplete
A uterine rupture is classified as either complete or incomplete. A complete rupture extends through the entire uterine wall into the peritoneal cavity or broad ligament. An incomplete rupture extends into the peritoneum but not into the peritoneal cavity or broad ligament. Bleeding is usually internal. An incomplete rupture also may be a partial separation at an old cesarean scar and may go unnoticed unless the woman undergoes a subsequent cesarean birth or other uterine surgery.

48. Signs and symptoms vary with the extent of the rupture
- Nonreassuring FHR tracing, including variable and late decelerations, bradycardia
- Loss of fetal station
- Woman may experience constant abdominal pain, uterine tenderness, a change in uterine shape, cessation of contractions
- May exhibit signs of hypovolemic shock caused by hemorrhage (i.e., hypotension, tachypnea, pallor, and cool, clammy skin).
If the placenta separates, the FHR will be absent. Fetal parts may be palpable through the abdomen.

49. Management - Prevention is the best treatment
Management - Prevention is the best treatment. Women who have had a previous classic cesarean birth are advised not to attempt vaginal birth in subsequent pregnancies. Women at risk for uterine rupture are assessed closely during labor. Women whose labor is induced with oxytocin or prostaglandin (especially if their previous birth was cesarean) are monitored for signs of uterine hyperstimulation, because this can precipitate uterine rupture. If hyperstimulation occurs, the oxytocin infusion is discontinued or decreased, and a tocolytic medication may be given to decrease the intensity of the uterine contractions.

50. - If rupture occurs, the type of medical management depends on the severity. - A small rupture may be managed with a laparotomy and birth of the infant, repair of the laceration, and blood transfusions, if needed. - For a complete rupture, hysterectomy and blood replacement is the usual treatment.

51. Amniotic Fluid Embolism
Also known as Anaphylactoid syndrome of pregnancy (ASP) It is characterized by the sudden, acute onset of hypoxia, hypotension, or cardiac arrest, and coagulopathy. ASP occurs during labor, during birth, or within 30 minutes after birth.

52. Maternal factors
Multiparity
Placental abruption
Oxytocin induction of labor
Fetal problems
Macrosomia
Death, and meconium passage

55. Thanks