1. Dr: Hayder Al-Shamma’a
Abnormal labour
Dr: Hayder Al-Shamma’a

2. Objectives The student must be able to define abnormal labour
Should be able to list the types
Should be able to list the risks of abnormal labour on the mother and fetus
Should understand the mechanism of labour for each type
Should be able to diagnose abnormal labour

3. Objectives continue Able to manage first stage of labour
Know the rational for the management
Able to list the management of the second stage

4. types
I :- Malposition and Mal-presentation of the head ( occipito-posterior, face presentation ,brow presentation)
II:- Breech presentation
III:- Shoulder presentation(Transverse lie)

5. Risks of abnormal labour
Abnormal labour carries increased risks to the mother and the fetus more than normal labour , specially if the labour is attended by an inexperienced personel

6. Maternal risks of abnormal labour
prolonged labour
Infection
Obstructed labour
Anesthesia
Traumatic delivery
Hemorrhage
DVT
Pressure necrosis and fistula
death

7. Fetal risks Cord prolaps Hypoxia
Infection (chorio-amnionitis , pneumonia)
Traumatic injuries
Meconium aspiration (pneumonitis)
death

8. Malposition & mal-presentation of the fetal head
Occipito-posterior position
Face presentation
Brow presentation

9. Labour in occipito-posterior position
The denominator is the occiput
The occiput occupy the posterior part of the female pelvis ie. occiput near the sacrum

11. Occipito-posterior

12. 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

13. Diagnosis of occipito posterior
By abdominal exam.
Flat lower abdomen below the umbilicus
easy to feel Fetal limbs anteriorly
difficult to feel the Fetal back
Head not engaged
Fetal heart at the flanks

15. Diagnosis of occipito posterior
By pelvic exam.
High presenting part
Bulging sausage shaped membranes
Or early rupture of membranes (cx.less than 3cm)
Easy to feel the anterior fontanel behind the pubic symphysis
Difficult to feel the posterior fontanel near the sacrum
ear directed posteriorly (in excessive caput & edema)

16. Mechanism of labour in O.P.
Engagement in ROP (ROP 3times than LOP)
Engaging diameter is suboccipito-frontal 10.5 cm 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 not fit well on the cx. Of larger dimentions

17. Mechanism of labour in O.P.
Internal rotation:- if the head well flexed the occiput will touch the pelvic floor first and rotated anteriorly 3/8th of a circle 135˚ and become occipito-anterior and the mechanism then continue as in OA. But it takes longer time to rotate
This occurs in 70% of cases

19. Mechanism of labour in O.P.
If the head is deflexed :- the sinciput touches the pelvic floor first so rotates anteriorly and the occiput rotates posteriorly through 1/8th of a circle (45˚) short rptation giving direct occipitoposterior
The mechanism differs , descent continues and the head delivers by a combination of flexion first, followed by extention
The emerging diameter is occipito-frontal of 11.5 cm causing great distension at the vulva and perineum and perineal tears may occur unless episiotomy performed
Occurs in 10% of cases

20. Mechanism of labour in O.P.
Arrest of rotation at lateral position (right occipito-lateral or left occipito-lateral)
No mechanism of labour
Deep transverse arrest
Need assisted delivery
Occurs in 20% of cases

21. Features of labour in O.P.
Slow progress (slow cx. dilatation, descent, rotation)
Backache is more
Incoordinate uterine contraction
Early rupture of membranes
Higher chance for cord prolaps
Higher chance for infection
Higher chance for perineal laceration
Excessive moulding of the head may cause tentorrial tear

22. Treatment of O.P.
Before the onset of labour , no attempt for correction
During first stage of labour
Correction of malposition cannot be done
Observation of uterine contraction, cx dilatation, descent,and use partogram
Continuous fetal heart monitoring
Due to increased risk for operative delivery and anesthesia , give nothing by mouth, only occasional sips of water
Maintain maternal hydration by iv fluid
Oxytocin infusion is often indicated to correct incoordinate uterine contractions

23. Treatment of O.P.
Cesarean section is indicated in first stage in the following conditions
Failure to progress in spite of good uterine contractions for 3 hours
Fetal distress
Maternal distress

24. Treatment of O.P. Treatment in second stage
Mistaken diagnosis of 2nd stage is not uncommon, the patient have urge to pushdown before full dilatation (pressure effect of the large occiput on the pelvic plexus
p/v exam is essential to confirm the diagnosis

25. Rx of 2nd stage continue p/v to assess degree of deflexion
Determine excessive molding
Determine caput succidanium
If detect that , spontaneous labour is unlikeley to occur
Pain relieve is essential in O.P.
Epidural analgesia , pethidine

26. Need assisted delivery
Fetal distress
Maternal distress
Failure to progress
Deep transverse arrest

27. Assisted delivery Oxytocin
Manual rotation with or without forceps extraction
Forceps rotation (Kielland forceps)
Vacuum extractor
Cesarean section

28. Manual rotation
Correction of malposition by manipulation with the hand under epidural anesthesia
Disadvantage need anesthesia, hand take additional space , may cause trauma, pulling is not feasible

30. Kielland forceps rotation
Same disadvantages but ,can pull the head, also it need a great deal of experience
Vacuum extraction ( Vantouse , Kiwi)
Advantages
Applied without anesthesia, not take extra space, easy to use minimal skills

33. No comment !!!!!!
بدون تعليق

34. No comment !!!!!

35. 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 the chest try to enter the pelvis at the same time with the head (sternobregmatic 16-18cm)

37. 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

38. Diagnosis of face presentation
Abdominal findings:- Longitudinal lie, cephalic , a groove can be felt between the head and back , the head is high
p/v feel the chin, mouth, jaws, nose, orbital ridge

39. 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.

40. 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

42. Mechanism of labour in brow
No mechanism of labour . The engaging diameter is the mentovertical 14 cm so cesarean section is indicated in persistent brow

43. Thank you