notes/DC Dutta Obstetrics 10th Edition_12.txt

Figs. 26.10A to H: Mechanism of labor in breech presentation: Right Sacroanterior (RSA).
• -·· Bl Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse

of  the  pelvic  outlet.  The  trunk  simultaneously  rotates externally through I/8th of a circle.
■   Delivery of the posterior shoulder followed by the anterior one is completed by anterior flex.ion of the delivered trunk.
■   Restitution and external rotation: Untwisting of the trunk occurs putting the anterior shoulder toward the right thigh in LSA and left thigh in RSA. External rotation of the shoulders occurs to the same direction because of internal rotation of the occiput through I/8th of a circle anteriorly. The fetal trunk is now positioned as dorsoanterior.
Head (Figs. 26.1 0A to H)
■   Engagement occurs either through the opposite oblique diameter as that occupied by the buttocks or through the transverse diameter. The engaging diameter of the head is suboccipitofrontal (10 cm).
■   Descent with increasing fle.ion occurs.
■   Internal rotation of the occiput occurs anteriorly, through I/8th or 2/8th of a circle placing the occiput behind the symphysis pubis.
■   Further descent occurs until the subocciput hinges under the symphysis pubis.
■   Head is born by flexion-chin,  mouth,  nose,  forehead, vertex and occiput appearing successively. The expulsion of the head from the pelvic cavity depends entirely upon the bearing-down efforts and, not at all, on uterine contractions.
Sacroposterior position: In sacroposterior position, the mechanism is not substantially modified. The head has to rotate through 3/8th of a circle to bring the occiput behind the symphysis pubis.

COMPLICATIONS OF VAGINAL BREECH DELIVERY

MATERNAL: Labor is usually not prolonged. But because of increased frequency of operative delivery, including cesarean section, the morbidity is increased. The risks include trauma to the genital tract, operative vaginal delivery ( episiotomy, forceps), cesarean section, sepsis and  anesthetic  complications.  As  a  consequence, maternal morbidity is slightly raised. Frank breech acts as an effective cervical dilator. Flexed breech, although, theoretically might cause delay in first stage, but rarely so because of its prevalence among multiparae.
FETAL: The fetal risk in terms of perinatal mortality is considerable in vaginal breech delivery. The corrected (excluding fetal abnormality) perinatal mortality ranges from 5  to  35  per  1,000  births.  The  overall  perinatal mortality  in  breech  still  remains  9-25%  compared with  1-2% for nonbreech deliveries.  Perinatal  death (excluding congenital abnormalities) is 3 to 5 times higher than the nonbreech presentations. The factors which significantly influence the fetal risk are-(a) skill of the obstetrician, (b) weight of the baby, ( c) position of the legs, and (d) type of pelvis. The fetal mortality is least in frank breech and maximum in footling presentation, where the chance of cord prolapse is also more. Gynecoid and anthropoid pelvis are favorable for the aftercoming head. The fetal risk in multipara is no less than that of

primigravida. This is because of increased chance of cord prolapse associated with flexed breech.

THE DANGERS TO THE BABY
l.  Intrapartumfetal death, especially with preterm babies 2.  Injury  to head, brain and skull-(a)  Intracranial hemorrhage: Compression followed by decompres­
sion during delivery of the unmolded aftercoming head results in tear of the tentorium cerebelli and hemorrhage in the subarachnoid space. The risk is more with preterm babies, (b) Minute hemorrhages, (c) Fracture of the skull.
3.  Birth asphyxia: It is due to:
a.  Cord  compression  soon  after  the  buttocks  are
delivered and also when the head enters into the pelvis. A period of more than 10 minutes will produce asphyxia of varying degrees.
b. Retraction of the placental site.
c.  Premature attempt at respiration (amniotic fluid, vaginal fluid) while the head is still inside.
d. Delayed delivery of the head.
e.  Cord prolapse. It is less (0.5%) in frank breach. f.   Prolonged labor.
4.  Birth injuries (7%): The following injuries are inflicted during manipulative deliveries. It is 13 times more than the vertex presentation.
♦    Hematoma-over the sternomastoid or over the thighs.
♦   Fractures-the common sites are femur, humerus, clavicle, hip joint and odontoid process. There may be dislocation of the hip joint, mandible or 5th and 6th cer­ vical vertebrae and epiphyseal separation (Fig. 26.11).





















Fig. 26.11: Birth injury following assisted breech (frank) delivery showing dislocation of the left knee joint.
Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse	-

•   Visceral  injuries  include  rupture  of  the  liver, kidneys, suprarenal glands, lungs, arms and legs and hemorrhage in the testicles.
•   Nerve-medullary  coning,  spinal  cord  injury, stretching of the cervical and brachial plexus to cause either Erb's or Klumpke's palsy.
•   Long-term neurological damage.
Some of the injuries may prove fatal and contribute to perinatal mortality. Long-term (neurological) morbidity of the surviving infants should not be underestimated.
5.  Congenital malformations are double compared to babies with cephalic presentation (congenital dislocation of the hip, hydrocephalus and anencephaly are common).

TYPES OF PROCEDURE AND THE NEONATAL OUTCOME
1.  Entrapment of the after coming head due to delivery of a breech fetus through the partially dieted cervix.
2.  Nuchal arms due to breech traction cause delay in delivery of fetal head. There is increased birth asphyxia.
3.  Deflection or hypertension of the head cause impaction of the occipital part of the head behind the symphysis pubis. This may lead to fracture of cervical vertebra, injury  to spinal cord,  medullary  hemorrhage  and perinatal mortality.
4.  Hasty delivery or delay in delivery, both may result in birth asphyxia due to umbilical cord compression. There  is  excessive  pressure  on  fetal  body  and  the after coming fetal head.  Breech  delivery  needs an experienced  obstetrician  to  perform/ execute  the maneuver with gentleness and skill.

PREVENTION OF THE FETAL HAZARDS
+   The incidence of breech can be minimized by external cephalic version where possible.
+   If the version fails or is contraindicated, delivery is done by elective cesarean section.
+   Vaginal breech delivery should be conducted by a skilled obstetrician along  with an organized team consisting of a skilled anesthetist and neonatologist.
+   Vaginal  manipulative delivery should be  done  by a skilled person with utmost gentleness, especially during delivery of the head.
I ANTENATAL MANAGEMENT
Antenatal management in breech presentation consists of: ♦   Identification of the complicating factors related with
breech presentation.
♦   External cephalic version, if not contraindicated (Box 26.1).
♦   Formulation of the line of management, if the version fails or is contraindicated (Flowchart 26.3).
Identification of complicating factor: It can be detected by clinical examination, supplemented by sonography. Sonography is particularly useful to detect congenital malformations of the fetus, the precise location of the placental site and congenital anomalies of the uterus.


+  Antepartum hemorrhage (placenta previa or abruption)-big
risk of placental separation.
+  Fetal causes-hyperextension of the head, large fetus (>3.5 kg),
congenital abnormalities (major), dead fetus, fetal compromise (IUGR).
+   Multiple pregnancy.
+  Ruptured membranes-with drainage of liquor.
+   Known congenital malformation of the uterus. +  Abnormal cardiotocography (nonstress test).
+  Contracted pelvis.
+   Previous cesarean delivery(> 1 )-risk of scar rupture (previous 1
LSCS is not an contraindication for ECV).
+  Obstetric complications: Severe pre-eclampsia, obesity, elderly
primigravida, bad obstetric history (BOH), oligohydramnios. +  Rhesus isoimmunization.
Breech with extended legs is not a contraindication for version

External Cephalic Version (ECV): The success rate of version is about 65% (60% in multi and 40% in primigravida) {for technique-p. 540). Successful version reduces the risk of cesarean section. Prior sonography should be a routine. Fetal wellbeing should be monitored with Doppler or real time USG  scanning.  The procedure should be abandoned in case of any fetal distress or failure of multiple attempts (usually >4). After the procedure, FHR monitoring should be continued for 1 hour to ensure stability. Anti-D immune globulin to be given if the mother is Rh negative. Vaginal breech delivery had 5 fold higher mortality rate in comparison to cephalic presentation.
Time of version:  ECV has been considered from 36 weeks in primi and 37 weeks in a multigravida. While version in the early weeks is easy but chance of reversion is more (spontaneous version in PG at >36 weeks: 8%. Spontaneous reversion to breech after successful ECV: 3%). Late version may be difficult because of increasing size of the fetus and diminishing volume of liquor amnii. However, the use of uterine relaxant (tocolysis) has made the  version  at  later  weeks  less  difficult. It  minimizes chance  of  reversion  and  should  fetal  complications develop, it can be effectively tackled by cesarean section. Hypertonus or irritable uterus can be overcome with the use of tocolytic drugs (tocolytic drugs with doses-p. 475). Epidural analgesia may be used selectively.
Benefits of ECV are:  (i) Reduction in the incidence of breech presentation at term,  {ii) Reduction in the incidence of breech delivery (vaginal or cesarean) and the associated complications (vide above), (iii) Reduction in the incidence of cesarean delivery by 5%.
Predictors of success are: (i) Multigravida, (ii) Non­ engagement of breech,  (iii) Tocolysis,  (iv)  Maternal weight <65 kg,  (v) Posterior placenta, (vi) Complete breech, {vii) AFI >10, {vii) Average size baby.
Successful version is likely in cases of: (i) Complete breech,  (ii)  Nonengaged  breech,  (iii)  Sacroanterior position (fetal back anteriorly), {iv) Adequate liquor, (v) Nonobese patient.
ID Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse
Flowchart 26.3: Scheme for management of breech presentation.
I Management of breech presentation  I












i
Successful
l

Delivery as vertex







+
Satisfactory labor progress
i
Assisted breech delivery

I	Antenat.al asses ment	I
Fetal: Wellbeing, weight, attitude
I•
I
• Maternal: Health (obstetric and medical) and maternal pelvis (clinical)
!	!
External Cephalic Version (ECV)	Elective cesarean section (238 weeks) To be done	• Estimated fetal weight: >3.5 kg or <1.5 kg.
• Hyperextended head.
• Around 36 weeks or after.	• Associated complications (obstetric and/or medical).
• In the labor suite.
• With  ocolytics if needed.
• Pelvic inadequacy.
• Fetal tmonitoring (CTG).before	• Absence lof expertise for idelivery.
• Antenata  fetal comprom se.
• Patient request.
and after the procedure
• Fetal factors: Footling presentation, FGR (EFW <10th centile) Fails	• 21 Prior CD.
i
!

i	l
Trial of vaginal                            Elective cesarean breech delivery                         delivery (238 weeks)
• Informed consent.
• Average fetal weight (2-3.5 kg). • Frank or complete breech.
• Flexed fetal head. • Adequate pelvis.
• Availability of an experienced obstetrician and a neonatologist. • Rapid CD is possible when needed.
+
CS in labor (if breech not on perineum after 2 hours of full cervical dialatation) ■ Arrest of progress
■ Fetal distress (non-reassuring FHR)
■ Cord prolapse



Causes  of  failure  of  version:  (1)  Breech  with extended legs-early engagement of presenting part and  difficult  to  flex  the  trunk  because  of  splinting action  of  the  limbs;  (2)  Scanty  liquor  or  big  size baby;  (3)  Mechanical-obesity,  increased tone of the abdominal  muscles  and  irritable  uterus;  ( 4)  Short cord-either relative (common) or absolute; (5) Uterine malformations-septate or bicornuate.
Dangers of version: The  dangers of version  are: (1) premature onset of labor; (2) premature rupture of the membranes; (3) placental abruption and bleeding; (4) entanglement of the cord round the fetal part or formation  of  a  true  knot  leading  to  impairment  of fetal circulation and fetal death; (5) increased chance of  fetomaternal   bleed   and  alloimmunization;   (6) Amniotic fluid embolism; and (7) Rupture of uterus. (8) A transient bradycardia is common (<3 minutes). If it persists >6 minutes ➔ CAT I CS. Immunoprophylaxis with  anti-D  gammaglobulin  is  to  be  administered in  nonimmunized  Rh-negative mother  (Ch.  23).  The perinatal  mortality  should not  exceed  beyond  1 %.  A reactive cardiotocographic trace should be obtained after the procedure.
Management, if version fails or is contraindicated: The pregnancy is to be continued with usual checkup and,

unexpectedly, one may find that spontaneous version has occurred. But if the breech persists, the assessment of the case is to be done with respect to-(1) age of the mother, especially in primigravidae; (2) associated complicating factors;  (3)  size of the baby;  and  (4)  pelvic capacity. Clinical assessment of the pelvis should be done in all primigravidae and in selected multigravidae with previous history suggestive of pelvic inadequacy. CT or MRI may be the alternative. Ultrasonographic examination is the gold standard for decision making. Two methods of delivery can be planned.
♦    To perform an elective cesarean section (Table 26.2). ♦  To allow spontaneous labor to start and vaginal breech
delivery to occur.
♦  Induction of labor is not usually recommended (RCOG-2017).
Elective Cesarean Section (CS): Because of decrease in skill and experience of vaginal breech delivery and rise in perinatal mortality and morbidity, there is a trend to liberalize the use of cesarean section in breech (ACOG-2018).
The indications of CS in breech are: •  Big baby (estimated fetal weight >3.5 kg),  small baby ( <1.5 kg) estimated fetal weight <1.5 or >3.5 kg• hyperextension of the head (stargazing fetus) • footling presentation (risk of cord prolapse) • suspected pelvic contraction or
Chapter 26: Complicated Labor: Mal position, Mal presentation and Cord Prolapse


Table 26.2: Selection criteria for the route of breech 9_elivery.
Assisted Vaginal Breech
Delivery (AVDJ	Cesarean Delivery (CD)
•   Frank breech presentation.	•  Unfavorable factors-fetal:
■   Gestational age: >34	Unengaged podalic pole,
weeks.	footing breech.
•  Estimated fetal weight              ■  Estimated fetal weight 2000-3500 g.                                  <!3500 g or sl 500 g.
■  Fetal head: Flexed.	■  Fetal head: Deflexed/
11      Pelvis is deemed adequate.	hyperextended.
•  Women admitted in	■  Pelvic inadequacy suspected. advanced labor with	11      Women:
no fetal or maternal	• Elderly. contraindications for	• Poor obstetric history.
assisted vaginal breech	• Pregnancy following ART.
delivery.	■  Non-reassuring FHR on EFM.

severe IUGR • any associated complications (obstetric or medical) is often considered for CS in breech. The overall incidence of CS in breech ranges from 80 to 100%; out of which about 80% is elective. Delivery of preterm breech (weight <1,500 g) by cesarean section is commonly done but it should be reserved in selected centers, equipped with intensive neonatal care unit.
Vaginal breech delivery: Criteria to be fulfilled are­ (i) average fetal weight (between 1.5 kg and 3.5 kg), (ii) flexed fetal head, (iii) adequate pelvis, (iv) without any other (medical or obstetric) complications, (v) availability of facilities for emergency cesarean section (anesthetists, neonatologist),  {vi)   facilities  for   continuous  labor monitoring (preferably electronic), and {vii) presence of obstetrician  experienced with vaginal breech delivery, {viii) Zatuchni-Andros score 2:4,  (ix)  Detailed informed consent explaining the risk of higher perinatal mortality and morbidity than cesarean delivery (ACOG-2018), and (x) Frank breech is preferred.
Zatuchni and Andros: Score system (1965) used six parameters (parity, gestational age, estimated fetal weight, previous breech delivery, cervical dilation in cm and the station) with score points 0, 1, and 2. This score can ascertain the likelihood of successful vaginal delivery. A score <4 predicts poor prognostic index.
Women should be informed that planned cesarean section leads to a small reduction in perinatal mortal­ ity compared with planned  vaginal breech delivery (RCOG-2017).
I MANAGEMENT OF VAGINAL BREECH DELIVERY

FIRST STAGE: The management protocol is similar to that mentioned in normal labor. The following are the important considerations. Spontaneous onset of labor increases the chance of successful vaginal delivery.
■   Vaginal examination is indicated-{a) at the onset of labor for pelvic assessment, (b) soon after rupture of the membranes to exclude cord prolapse.

■  An intravenous line is sited with Ringer's solution, oral intake is avoided, blood is sent for group and crossmatching (considering the chance of CS).
■  Adequate analgesia is given, epidural is preferred but it increases the CS rate.
■  Fetal status and progress oflabor are monitored.
■  Oxytocin infusion may be used for augmentation of labor. It is not a routine. May be used with epidural.
Indications  of  cesarean  section  (CS):  (a)  Cases seen  for  the  first  time  in  labor  with  presence  of complications (25%); (b) Arrest in the progress of labor; (c) Nonreassuring FHR pattern (fetal distress); (d) Cord presentation or prolapse.

SECOND STAGE: There are three methods of vaginal breech delivery:
■  Spontaneous (10%): Expulsion of the fetus occurs with very little assistance. This is not preferred.
■  Assisted  breech:  The  delivery  of  the  fetus  is  by assistance from the beginning to the end. This method should be employed in all cases (see below).
■   Breech extraction (partial or total): When part or the entire body of the fetus is extracted by the obstetrician. It is rarely done these days as it produces trauma to the fetus and the mother. Indications are:  (a) Delivery of the second twin after IPV, (b) Cord prolapse, (c) Extended legs arrested at the cavity or at the outlet.

I ASSISTED BREECH DELIVERY
Breech  delivery  should  be  conducted  by  a  skilled obstetrician.  The  following  are  to  be  kept  ready beforehand, in addition to those required for conduction of normal labor: (1) Anesthetist-to administer anesthesia as and when required; (2) An assistant-to push down the fundus during contraction;  (3) Instruments and suture materials for episiotomy; (4) A pair of obstetric forceps for the aftercoming head, if required; (5) Appliances for resuscitation of the baby, if asphxiated; (6) Neonatologist.
Principles in conduction: (1) Never to rush; (2) Never pull from below but push from above; (3) Always keep the fetus with the back anterior. (4) Have patience to allow maternal expulsive forces.
It  is expected  that  good  uterine contractions and maternal expulsive forces will maintain the flexion of the fetal head and result in descent and safe delivery.
Never to rush and never to pull-early aggressive and hasty pull affects breech delivery adversely by-(a) Entrapment of the aftercoming fetal head through the incompletely dilated cervix; (b) Traction from below results in deflection of the head posing longer occipitofrontal diameter  (11.5  cm)  at  the  pelvic  inlet  (Fig.  26.12); (c) Increased risk of nuchal displacement of arms.
Steps:
■  The patient is brought to the table when the anterior buttock and fetal anus are visible. She is placed in
· ID Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse
c.  If the back remains posteriorly, rotate the trunk to bring the back anteriorly (sacroanterior).


Never to pull from below










Fig. 26.12: Aggressive pull causes deflexion and entrapment of the aftercoming head.

lithotomy position when the posterior buttock distends the perineum.
■  To avoid aortocaval compression, the woman is tilted laterally (15°) using a wedge under the back.
■   Antiseptic cleaning is done, bladder is emptied with an "in and out" catheter.
■  Epidural/pudenda! block is done along with perineal infiltration.
■   Episiotomy   should   be   made   in   all   cases   of primigravidae and selected multiparae. Its advantages are-(a) to straighten the birth canal which especially facilitates the delivery of breech with extended legs where lateral flexion is inadequate; (b) to facilitate intravaginal manipulation and for forceps delivery, (c) to minimize compression of the aftercoming head. The best time for episiotomy is when the perineum is distended and thinned by the breech as it is "climbing" the perineum. The bitrochanteric diameter is under the symphysis pubis.
■   Oxytocin may be used. Epidural anesthesia is helpful for ease of maneuvers.
11    The  patient  is  encouraged  to  bear  down  as  the expulsive force from above ensure flexion of the fetal head and safe descent. The "no touch to the fetus" policy is adopted until the buttocks are delivered along with the legs in flexed breech and the trunk slips up to the umbilicus.
■   Soon after the trunk up to the umbilicus is born. The following are to be done:
a.  The extended legs (in frank breech) are to be decomposed by pressure on the knees (popliteal fossa) in a manner of abduction and flexion of the thighs (Fig. 26.13).
b.  The umbilical cord is to be pulled down and to be mobilized to one side of the sacral bay to minimize compression. There may be transient abnormality in cord pulsation at this stage which has got no prognostic significance. An attempt of hasty delivery for this reason alone should be avoided.

d. The baby is wrapped with a sterile towel to prevent slipping when held by the hands and to facilitate manipulation, if required.
■  Delivery of the arms: The assistant is to place a hand over the fundus and keep a steady pressure during uterine contractions to prevent extension of the arms. Soon, the anterior scapula is visible. The position of the arm should be noted. When the arms are flexed, the vertebral border of the scapula remains parallel to the vertebral column and when extended there is winging of the scapula (parallelism is lost). The arms are delivered one after the other only when one axilla is visible, by simply hooking down each elbow with a finger. It is immaterial as to which arm is to be delivered first. The baby should be held by the feet over the sterile towel while the arms are delivered (Figs. 26.14 and 26.15).
■  Delivery of the aftercoming head: This is the most crucial stage of the delivery.  The time between the delivery of  umbilicus  to delivery of  mouth  should preferably be 5-10 minutes. There are various methods of delivery for the aftercoming head. Each one is quite safe and effective in the hands of an expert, conversant with that particular technique. The following are the common methods employed:
a.  Burns-Marshall method (Fig. 26.16A): The baby is allowed to hang by its own weight. The assistant is asked to give suprapubic pressure with the flat of hand in a downward and backward direction, the pressure is to be exerted more toward the sinciput. The aim is to promote flexion of the head so that favorable diameter is presented to the pelvic cavity. Not more than 1-2 minutes are required to achieve





















Fig. 26.13: Delivery of the extended leg by flexion and abduction at the knee.
Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse     &I














Fig. 26.15:  Delivery of the anterior arm.






Fig. 26.14: Delivery of the posterior arm.

the objective. When the nape of the neck is visible under the pubic arch, the baby is grasped by the ankles with a finger in between the two. Maintaining a steady traction and forming a wide arc of a circle, the trunk is swung in upward and forward direction (Fig. 26.l 6B). Meanwhile, the left hand is to guard the perineum and slipping the perineum off successively the face and brow. When the mouth is cleared off the vulva, there should be no hurry. Mucus of the mouth and pharynx is cleared by mucus sucker. The trunk is depressed to deliver rest of the head.

b.  Forceps delivery: Forceps can be used as a routine. The head must be in the cavity.
The advantages are-(a) delivery can be controlled by giving pull directly on the head and the force is not transmitted through the neck,  (b)  flexion is better maintained, and (c) mucus can be sucked out from the mouth more effectively. The head should be brought as low down as possible by allowing the baby to hang by its own weight aided by suprapubic pressure. When the occiput lies against the back of the symphysis pubis, an assistant raises the legs of the child  as much to facilitate  introduction of the blades from below. Too much elevation of the trunk may cause extension of the head. The forceps pull maintains an arc, which follows the axis of the birth canal (Fig. 26.17). Ordinary forceps with usual



Pressure by assistant




















Fig. 26.16A: Delivery of aftercoming head by
Burns-Marshall method.	Fig. 26.16B: Continuation of the Burns-Marshall method.
D Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse
with the limbs hanging on either sides. The middle and the index fingers of the left hand are placed over the malar bones on either sides (modification of the original method, where the index finger was introduced inside the mouth). This maintains flexion of the head. The ring and little fingers of the pronated right hand are placed on the child's right shoulder, the index finger is placed on the left shoulder and the  middle  finger is placed  on  the  suboccipital region (Figs. 26.18A and B). Traction is now given in downward and backward direction till the nape of the neck is visible under the pubic arch. The assistant gives suprapubic pressure  during  the period to maintain flexion. Thereafter, the fetus is carried in upward and forward direction toward the mother's abdomen releasing the face, brow and, lastly,  the trunk is depressed to release the occiput and vertex.
11    Resuscitation of the baby: The baby may be asphyxi­ ated and need to be resuscitated.




Fig. 26.17: Delivery of the aftercoming head by forceps.

length of shank, as in Das's variety, is quite effective. Piper forceps is especially designed (absent pelvic curve) for use in this condition. The head should be delivered  slowly  (over  I  minute)  to reduce compression-decompression forces as that may cause intracranial bleeding.
c.  Malar flexion and shoulder traction (modified Mauriceau-Smellie-Veit technique): The technique is named  after  the three great obstetricians who described the use of the grip independently. The baby is placed on the supinated left forearm (preferred)

THIRD STAGE: The third stage is usually uneventful. The placenta is usually expelled out soon after delivery of the head. If prophylactic oxytocin is to be given, it should be administered IM following delivery of the head.
Preterm breech: ECV with preterm breech present­ ation is not recommended. CS is commonly done when fetal weight is less than 1,500 g. However, it is not yet known whether the better perinatal outcome is due to the CS or the greater use of antenatal steroids and/ or better neonatal care.
Spontaneous delivery: Often the cervix is incompletely dilated. This may allow the delivery of the smaller body but the relatively larger diameter after coming head may be entrapped. Prompt delivery is mandatory; (a) to avoid the risk of severe hypoxia and fetal death (b) further closure of the cervix. Gentle downward traction on the shoulders


















rn
Figs. 26.18A and B: Delivery of the aftercoming head by malar flexion and shoulder traction: (A) Original Mauriceau-Smellie-Veit; (Bl Modification (preferred).
Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse     -
combined with fundal pressure applied by an assistant may ensure delivery. Use of inhalation anesthesia may be helpful. If it fails, Duhrssen's incisions are made to release the entrapped head and delivery. Incisions are made at 6 o'clock and ifneeded at 2 o'clock and 10 o'clock position.

MANAGEMENT OF COMPLICATED BREECH DELIVERY
When a woman presents in advanced labor,  it may be difficult to decide what would be ideal mode of delivery. However, if breech is not visible at the perineum even after 2 hours of full cervical dilatation, it may be possible to deliver the baby by CS. Simulated teaching using manne­ quins and model pelvis with an experienced trainer can improve the skill and performance of such maneuvers.
DELAY IN DESCENT OF THE BREECH: The breech may be arrested:
♦   At the outlet	♦ In the cavity	♦ At the brim

♦   Arrested at the outlet: The causes are-(a) big size baby with extended legs (the most common), (b) weak uterine contractions, (c) rigid perineum, and (d) outlet contraction.
Management: If the outlet is contracted and/or the baby is big, cesarean section even at this stage, is the method of choice.
♦   In  the  absence  of  outlet  contraction  and  fetopelvic disproportion: Liberal episiotomy and fundal pressure with or without groin traction (either single groin or both the groins) usually become effective (Figs. 26.19A and B). The index finger(s) is placed in the groin fold and traction (along with uterine contraction) is exerted more toward the trunk than toward the femur (risk of fracture femur). In presentday obstetrics, such maneuvers are not advocated.
♦   Arrest of the breech at or above the level of ischial spines: The causes  may be: (i)  Pelvic contraction, (ii) Big baby,




















Fl



Fig. 26.19B: Both groin traction.

(iii) Weak uterine contraction. The best treatment in such cases is delivery by cesarean section. By the time cervix is fully dilated,  the breech should descend down to the perineum. This is called trial of breech. If this fails to occur, fetopelvic disproportion is likely.
♦   Frank breech extraction  (Pinard's maneuver)-is done by intrauterine manipulation (for breech decomposition) to convert a frank breech to a footling breech. This is possible when the membranes have ruptured recently. In Pinard's maneuver, the middle and the index fingers (Figs. 26.20A to C) are carried up to the popliteal fossa. It is then pressed and



















m



Fig. 26.19A: Single groin traction: Delivery of breech with one finger in the groin.

Figs. 26.20A to C: Pinard's maneuver: (A) Flexion and abduction of popliteal fossa; (Bl To catch, hold the ankle; (C) To pull down by movement of abduction.
ml Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse
abducted so that the fetal leg is flexed. The fetal foot is then     along the curve of the sacrum while the baby is pulled slightly grasped at the ankle and breech extraction is accomplished.        upward. With firm pressure over the humerus, the posterior arm is pushed over the baby's face. The extended anterior arm is delivered
EXTENDED ARMS: One or both the arms may be fully stretched
along  the  side  of  the  head  or  lie  behind  the  neck  (nuchal
from the anterior aspect by introducing the right hand in the same displacement). The cause is usually due to faulty technique in	manner, while the baby's trunk is depressed toward the perineum.
delivery-using unnecessary traction, forgetting the principle of	LOVSET'S MANEUVER: It is widely practiced in preference
'never pull but push from above'. Arrest occurs with the delivery	to the classical method of bringing down an arm. The
of the trunk up to the costal margins.
The diagnosis is made
(I) Wider applicability-it
following are the advantages:
by noting the winging of the scapula and absence of the flexed     can be applied even when the classical method becomes difficult; (2) Intrauterine manipulation is nil; (3) A single
limbs in front of the chest.
The management calls for the urgent delivery
Management:
of the arms, first the posterior and then the anterior one. The	manipulation is effective to all types of displacement of delivery of the arm may be accomplished by adopting any one of
the arms; ( 4) General anesthesia is usually not needed.
the following methods: (a) Classical, (b) Lovset.                                        Principles: Because of the curved birth canal, when the Classical: It works with the same principle as with Lovset's      anterior shoulder remains above the symphysis pubis, the
maneuver. In addition, it needs intrauterine manipulation while	posterior shoulder will be below the sacral promontory.
the patient is under general anesthesia. First, the posterior arm is
If the fetal trunk is rotated keeping the back anterior and
delivered followed by the anterior arm. Left hand is introduced	 maintaining a downward traction, the posterior shoulder will appear below the symphysis pubis.
Procedure (Figs. 26.21A to C): The baby (wrapped in a warm dry towel) is grasped, using both hands by femoropelvic grip keeping the thumbs parallel to the vertebral column.  The  maneuver  should  start  only when the inferior angle of the anterior scapula is visible underneath the pubic arch.
Step-I: The baby is lifted  slightly to cause lateral flexion. The trunk is rotated through 180° keeping the back anterior and maintaining a downward traction. This will bring the posterior arm to emerge under the pubic arch which is then hooked out.
Step-2:  The trunk  is  then  rotated  in  the  reverse direction keeping the back anterior to deliver the erstwhile anterior shoulder under the symphysis pubis.
Nuchal displacement of arm is where the arm is flexed at the elbow and extended at the shoulder and lies behind the fetal head. After grasping the baby at the pelvic girdle with thumbs along the sacrum, the trunk is rotated 180° toward the fingertips of the trapped arm. This may draw the elbow forward and render it amenable to Lovset's maneuver. If this fails, the arm is forcibly extracted by hooking. In that case, fracture almost always follows.

ARREST OF THE AFTERCOMING HEAD
♦  Atthe brim: The causes of arrest are-(1) deflexed head; (2) contracted pelvis; and (3) hydrocephalus.
Management: (1)  If the arrest is due to a deflexed head,  the delivery  is  to  be  completed  by  malar  flexion  and  shoulder traction along with suprapubic pressure by the assistant. The head  is  to  be negotiated through  the  brim  in  the  transverse diameter  and  rotated  in  the  cavity.  Forceps  should  not  be applied in high head.
(2) If the arrest of the head is due to contracted pelvis or hydrocephalus, perforation of head is to be done.
♦   In the cavity: The causes of arrest of the head in the cavity are-(1) deflexed head, and (2) contracted pelvis.
The best management is delivery of the head by forceps which is effective in both the circumstances. Malar flexion
Figs. 26.21A to C: Lovset's maneuver.	and shoulder traction may be effective only in deflexed head.
Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse     ED

♦   At the outlet: The causes of arrest are-(1) rigid perineum, and (2) deflexed head.
Episiotomy followed by forceps application or malar flexion and shoulder traction is quite effective.
•   Delivery of the head  through  an  incompletely dilated cervix: The  common causes are-(1) premature  baby, (2) macerated baby, (3) footling presentation, and (4) hasty delivery of breech before the cervix is fully dilated.
Management: If the baby is living, the cervix is to be pushed up while traction of the fetal trunk is made by malar flexion and shoulder traction (shoe-horn method). If necessary, Duhrssen's incision can be made at 2 and 10 o'clock position on the cervix.


If the baby is dead, perforation of the head is better than watchful expectancy, hoping for full dilatation of the cervix.
■   Occiput posterior position of the head: It usually occurs in spontaneous breech delivery. The delivery is accomplished by modified Prague maneuver. One hand of the operator supports the shoulders from below while the other hand gently lifts the baby's trunk upwards towards the maternal abdomen. This action flexes the head within the birth canal and the occiput is delivered slowly over the perineum. In premature baby, the delivery of the head may be completed as face-to-pubis by reversed  malar flexion  and shoulder traction (Prague's maneuver) method or by forceps.





Breech Presentation
>  In breech presentation, the podalic pole presents at the pelvic brim, and the lie is longitudinal. It is the most common malpresentation. >  Types of breech presentation are: complete, frank, footling and knee presentation.
►  Prematurity is the most common cause of breech presentation.
►  Ultrasonography is the most informative besides confirmation of diagnosis.
►   Dangers to the baby following vaginal breech delivery and high mortality are due to: Prematurity, congenital malformation, injury to the skull, intracranial hemorrhage, birth asphyxia due to prolonged labor, cord compression or cord prolapse, birth injury (rupture of liver, fracture of femur, cervical and brachiaI plexus injury).
►  Management of breech presentation: External Cephalic Version (ECV) is done after 36 weeks of pregnancy if not contraindicated. ECV has many benefits in selected cases and is safe. Use of tocolytics and epidural anesthesia may increase the success rate. However, ECV has got complications also.
►  Management of breech delivery is by-(a) elective cesarean section after 38 weeks or (b) vaginal delivery (assisted breech delivery), or (c) cesarean delivery in labor. Induction of labor is not recommended.
►  Trial of labor (vaginal breech delivery) is considered for cases with-(a) fetal weight between 2.0 kg and 3.5 kg, (b) adequate pelvis,
►   (c) frank or complete breech, (d) flexed or neutral head, (e) in presence of a skilled obstetrician, and with (f) detailed informed consent explaining the higher perinatal mortality and morbidity compared to cesarean delivery (ACOG-2018). Center should have the facilities for emergency cesarean delivery when needed.
►  Routine cesarean section for breech presentation after delivery of the first twin in spontaneous labor is not recommended (RCOG-2017). >  All doctors and midwives should develop the skills of vaginal breech delivery using simulators.



FACE PRESENTATION

Face is a rare variety of cephalic presentation where the presenting part is the face. The attitude of the fetus shows complete flexion of the limbs with extension of the spine. There is complete extension of the head so that the occiput is in contact with the back. The denominator is mentum.
Position: There are four positions of the face according to the relation of the chin to the left and right sacroiliac joints or to the right and left iliopubic eminences. Face presentation results most likely from complete extension of deflexed head of a vertex presentation. The numbering of the face positions is obtained as follows (Box 26.2).

The most common position is Left Mentoanterior (LMA)-As the ROP position is 5 times more common than LOP and as the conversion of face occursfrom deflexed OP, LMA is the commonest. Overall anterior positions are more
frequent than the posterior one.
Incidence: Its frequency is about 1 in 500 births. Face presentation  present  during  pregnancy  (primary) is rare, while that developing after the onset of labor (secondary) is common. It occurs more frequently in multiparae (70%).
Etiology: The cause of extreme extension of the head is not clear in all the cases. The following are the factors, which are often associated.





1st vertex (LOA)
2nd vertex (ROA)
3rd vertex (ROP)
4th vertex (LOP)


becomes
becomes
becomes
becomes


1st face➔
2nd face➔
3rd face➔
4th face->


Right Mentoposterior	{RMP)
Left Mentoposterior	(LMP)
Left Mentoanterior	(LMA)
Right Mentoanterior	(RMA)
&I Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse
Maternal: (1) Multiparity with pendulous abdomen;	occurs. Arrest occurs in all these positions with average (2)  Lateral obliquity of the uterus,  especially,  if it is	size  pelvis  and  fetal  head.  Unlike  persistent  occiput directed  to  the  side  toward  which  the  occiput  lies;	posterior, where occasional face-to-pubis delivery occurs, (3) Contracted pelvis is associated in about 40% cases. Flat	there is no possibility of spontaneous delivery in persistent pelvis favors face presentation; (4) Pelvic tumors.	mentoposterior. This is because the relatively short neck
Fetal:  (I)  Congenital  malformations  (15%)-(a)	cannot clear off the total length of the sacrum (12 cm). As
The  most  common  one  is  anencephaly.  The  almost	such the thorax is thrust in, resulting bregmaticosternal
nonexistent neck with absence of the cranium makes it	diameter (18 cm or 7") to occupy the pelvis (Fig. 26.22).
easy to feel the facial structure even with semi-extended	As a result, the labor becomes inevitably obstructed.
head, (b) Congenital goiter-prevalent in endemic areas,
I
(c)  Dolichocephalic head with long anteroposterior	DIAGNOSIS diameter, (d) Congenital bronchocele. (2) Twist of the
Antenatal diagnosis is rarely made.  Diagnosis is made
cord several turns round the neck. (3) Increased tone of	 only during labor but in about half, the detection is made at the time of delivery.
the extensor group of neck muscles.
I MECHANISM OF LABOR	ABDOMINAL FINDINGS
MENTOANTERIOR 60-80% (LMA OR RMA)	Inspection: Because of "S11 -shaped spine,  there is no
The principal movements are like those of corresponding	visible bulging of the flanks.
occiput anterior position. The exceptions are increasing	Palpation (Fig. 26.23): The diagnostic features in men­ extension instead of flexion and delivery by flexion instead    toanterior and mentoposterior are described in Table 26.3. of extension of the head.
VAGINAL EXAMINATION
The  diagnostic  features  are  pal  ating  the  mouth
oblique diameter-right in iLMA, ileft inaRMA, with the	with hard alveolar margins, nose,pmalar eminences, glabella to the opposite sacroiliac joint. The engaging	labor, because of high head and sausage-shaped bag of (3¾") in fully extended head or submentovertical 11.5 cm	membranes, the parts are not clearly defined. In late labor,
is the
Engagement: The diameter  of eng  gement
mentum related to  one  il opub c  eminence  and  the
supraorbital ridges and the mentum
In early
(Fig. 26.24).
is submentobregmatic  9.5 cm
diameter of the head
the parts are often obscured due to edema. It is often
because pof tlong edistance  between  the  mentum  and	confused with breech presentation.
(4½ ") in   ar ially  xtended head.
Engagement is delayed
biparietal plane (7 cm). Descent with increasing extension	The distinguishing features are:
occurs till the chin touches the pelvic floor.	1. The mouth and the malar eminences are not in a line;
Internal rotation: Internal rotation of the chin occurs	but in breech, the anus and the ischial tuberosities are
in one line.
through 1/Bth of a circle anteriorly, placing the mentum
behind the symphysis pubis. Further descent occurs till	2.  Sucking effect of mouth. the submentum hinges under the pubic arch.	3. Hard alveolar margins.

Delivery of the head: The head is born by flexion delivering  the  chin,  face,  brow,  vertex and lastly the occiput. The diameter distending the vulval outlet is submentovertical-11.5 cm  ( 4½ "). Restitution occurs through  I/8th of a circle opposite to the direction of internal rotation. External rotation occurs further I/8th of circle to the same side of restitution so that ultimately the face looks directly to the left thigh in LMA and right thigh in RMA. This follows delivery of the anterior shoulder followed by the  posterior  shoulder  and the  rest  of the trunk by lateral flexion.
MENTOPOSTERIOR (20-25%) (RMP OR LMP)
The cardinal movements in the mechanism of mentopos­ terior positions are like those of occiput posterior position. The salient differentiating features are:
(1) In the mentoposterior position, anterior rotation of the mentum occurs in only 20-30% cases.
(2) In the rest (70-80%), incomplete anterior rotation, nonrotation or short posterior rotation of the mentum


















Fig.  26.22:  Head  cannot  extend  further,  nor  flexion   is possible.  Bregmatic  sternal diameter (18 cm or 7") cannot be accommodated in the pelvis resulting in obstructed labor.
Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse     ID :Ti!ble.26,-3:_Diagno tic features in fac  presentation.



















Fig. 26.23: Chief  features to be recognized on abdominal examination in face presentation.


Lateral grip






Pelvic grip






Auscultation


.Mentoanterior
1. Fetal limbs are felt anteriorly.
2. Back is on the flank and is  difficult to palpate.
3. The chest is thrown anteriorly against the uterine wall and is often mistaken for back.
1. Head seems big and is not engaged.
2. Cephalic prominence is to the side toward which back lies.
3. Groove between the head and back is not so prominent.
FHS is distinctly audible anteriorly through the chest  wall of the fetus toward the side of limbs.

Mentoposterior
1. Back is felt to the front and  better palpated  only towards  the podalic  pole because of extension of spine.

1. Same.

2. Same.


3. The groove is prominent.

FHS is not so distinct and is audible on the flank toward the side of limbs.



4. Absence of meconium staining on the examination fingers. The mentum and the mouth should be clearly identified to exclude brow presentation and to identify the position. The examination should be conducted gently,  as  there  is  chance  of  injury  to  the  eyes. Assessment of the pelvis should be done as a routine.
SONOGRAPHY:  This  should  be  done  to  confirm  the diagnosis, to exclude bony congenital malformation of the fetus and to note the size of the baby.
CLINICAL COURSE: In spite of the fact that the engaging diameter of the head in flexed vertex and the extended face presentation is the same-9.5 cm (3¾"), the clinical course of the latter is adversely affected because of the following:


















Fig. 26.24: Vaginal  touch picture showing landmarks in mentoanterior position.

11    Irregular face ill fits with the lower uterine segment. The poor  ball  valve  action  results in formation of elongated bag of membranes which is likely to rupture early.
■  Chance of cord prolapse is more.
■  Delay of labor,  in  all  the stages,  is common.  The causes  are-(a)  weak  uterine  contractions,  (b) absence of molding of the facial bones, (c) delayed engagement- the  distance  between the biparietal plane to chin is 7 cm and to occiput is only 3  cm (Figs. 26.25A and B), (d) late internal rotation, and (e) arrest and, at times, insuperable obstruction if mentoposterior fails to rotate anteriorly.
11    Chance of  perineal damage is more because  of a wide biparietal diameter-9.5 cm (3¾") stretches the perineum and submentovertical diameter  11.5  cm 4½") emerges out of the introitus (Fig. 26.26).
11    Postpartum hemorrhage is more likely due to atonic uterus and trauma following operative delivery.
PROGNOSIS: Maternal-in mentoanterior, the maternal risk is not much increased. However, there is increased morbidity  due   to  operative  delivery  and   vaginal manipulation. In neglected cases, the risks of impacted mentoposterior leading to obstructed labor and ruptured uterus are not uncommon.
Fetal-fetal prognosis is, however, adversely affected due  to-(a)  cord  prolapse,  (b)  increased  operative delivery,  (c) cerebral congestion due to poor venous return from the head and neck, and (d) neonatal infection due to prolonged labor (40% ).
CAPUT AND MOLDING: Due to poor venous return from the head and neck, marked caput forms, distorting the entire face. The lips and the eyelids are markedly swollen
ID Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse
Y




































Figs. 26.25A and B: (A) Vertex presentation-head engaged; (Bl Face presentation-head not yet engaged.

with considerable appearance of bruising. There is no compression of the facial bones but there is elongation of occipitofrontal diameter {Fig. 9.5). The extended attitude of the head, swelling of the face and the elongation of the head subside within a few days.

I MANAGEMENT

Overall assessment of the case is to be done to note­ ( I) pelvic adequacy ( clinical); (2) size of the baby; (3) associated  complicating  factors,  if  any,  like  elderly primigravidae,  severe  pre-eclampsia,  postcesarean pregnancy   and   postmaturity;   ( 4)   congenital   fetal malformation; and (5) position of the mentum.
Indications  of elective  or  early  cesarean  section: (1)  Contracted  pelvis;  (2)  Big  baby;  (3)  Associated complicating factors.

Fig. 26.26: Submentovertical diameter (11.5 cm or 4 ,'') emerges out of the introitus.

I VAGINAL DELIVERY MENTOANTERIOR
First stage: In uncomplicated cases, a wait and watch policy  is adopted.  Labor  is  conducted  in  the  usual procedure and the special instructions, as laid down in occiput posterior positions, are to be followed.
Second stage: One should wait for spontaneous delivery to occur. Perineum should be protected with liberal mediolateral  episiotomy.  In  case  of  delay,  forceps delivery is done.
MENTOPOSTERIOR
First stage: In uncomplicated cases,  vaginal delivery is allowed with strict vigilance hoping for spontaneous anterior rotation of the chin,
Second stage: (I) If anterior rotation of the chin occurs, spontaneous or forceps delivery with episiotomy is all that needed. (2) In incomplete or malrotation: Early decision for the method of delivery is to be taken soon after full dilatation of the cervix. The following methods may be employed to expedite the delivery.
■   Cesarean  section  is the  preferred method and is commonly done these days.

BROW PRESENTATION

Brow is the rarest variety of cephalic presentation where the presenting part is the brow and the attitude of the head is short that of degree of extension necessary to produce face presentation, i.e., the head lies in between full flexion and full extension. The denominator is the forehead (frontum: Fr).
INCIDENCE: The incidence of brow is very rare, about 1 in  1,000 births. However, it may persist temporarily while  a  deflexed head tends  to  become  extended to produce a face presentation. This happens especially in flat pelvis where the biparietal diameter is held in the sacrocotyloid diameter.
CAUSES: The causes of persistent brow are more or less the same as those of face presentation. The position is
Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse     DI

commonly unstable and converts to either vertex or face presentation.
DIAGNOSIS: Antenatal  diagnosis  is rarely made.  The findings are more or less like those of face presentation. The cephalic prominence and the groove between it and the back are less prominent (Fig. 26.27). The head feels very big and is non engaged.
Vaginal examination: During  labor  the position is to be confirmed on vaginal examination by palpating supraorbital ridges and anterior fontanel. If the anterior fontanel is on mother's left, with the sagittal suture in transverse pelvic diameter,  it is left frontum transverse position. In late labor, the landmarks may be obscured by caput formation.
Sonography  is  confirmatory  and  also  helps  in excluding bony congenital malformation of the fetus.
MECHANISM  OF  LABOR:  Diameter  of  engagement  is through the oblique  diameter  with  the brow anterior or posterior.  As the engaging diameter of the head is mentovertical (14 cm), there is no mechanism of labor in an average-size baby with normal pelvis. However, if the baby is small and the pelvis is roomy with good uterine contractions,  delivery can occur in mentoanterior brow position. The brow descends until it touches the pelvic floor. Internal rotation and descent occur till the root of the nose hinges under the symphysis pubis. The brow and the vertex are delivered by flexion followed by extension to deliver the face. The mechanism is more or less the same as face-to-pubis delivery.  Usual restitution and external rotation occur. There is no mechanism in posterior brow position.






















Fig. 26.27: Chief features to be recognized during abdominal examination in brow presentation.

TRIAL OF  LABOR: Brow presentation when transitory, trial of labor may be a possibility. Correction of brow with flexion to occiput presentation or complete extension to a face presentation occurs. In such a situation, though rare, trial of labor may be possible.
COURSE AND PROGNOSIS: In case of persistent brow presentation, there is the risk of obstructed labor. It is an important cause of rupture of uterus in multiparae. On occasions (10%), there may be spontaneous conversion of brow into face or vertex presentation.
MANAGEMENT
During  pregnancy:  If  the  presentation  is  diagnosed during pregnancy and there is no other contraindications for vaginal delivery, trial of labor may be appropriate.
Elective cesarean section: Cases with persistent brow presentation are delivered by elective cesarean section. During labor: (1) In uncomplicated cases, if spontane­ ous correction to either vertex or face fails to occur early in labor, cesarean section is the best method of delivery.
(2)  Manual correction to  face  or  vertex  with full dilatation of cerix is contraindicated.

TRANSVERSE LIE

When the long axis of the fetus lies perpendicularly to the maternal spine or centralized uterine axis, it is called transverse lie. But more commonly, the fetal axis is placed at an acute angle or oblique to the maternal spine and is then called oblique lie. In either of the conditions, the shoulder usually presents over the cervical opening during  labor  and as  such  both are collectively called shoulder presentations.
POSITION: The position is determined by the direction of the back, which is the denominator. The position may be-(1) dorsoanterior, which is the most common (60%). The flexor surface of the fetus is better adapted to the convexity of the maternal spine (Figs. 26.28A and B); (2) dorsoposterior; (3) dorsosuperior; or (4) dorsoinferior. The  last  two  are  rare.  In dorsoposterior,  chance  of fetal extension is common with increased risk of arm prolapse. According to the position of the head, the fetal












Figs. 26.28A and B: Positions of transverse lie: (A) Dorsoanterior; (B) Dorsoposterior.
ID Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse

position is termed right or left, the left one being more common than the right.
INCIDENCE: The incidence is about 1 in 200 births. It is common in premature and macerated fetuses, 5 times more  common  in  multiparae  than  primigravidae. Transverse lie in twin pregnancy is found in 40%  of cases.
ETIOLOGY:  The  causes  are-(1)   Multiparity-lax and pendulous abdomen, imperfect uterine tone and extreme uterine obliquity are the responsible factors; (2) Prematurity-center of the gravity lies almost in the middle of the body; (3) Twins-it is more common for the second baby than the first one to be in transverse position; (4) Hydramnios; (5)  Contracted pelvis; (6) Placenta previa; (7) Pelvic tumors; (8) Congenital malformation of the uterus-arcuate or subseptate; and (9) Intrauterine death.
I DIAGNOSIS ABDOMINAL EXAMINATION
Inspection:   The   uterus  looks  broader   and   often asymmetrical, not maintaining the pyriform shape.
Palpation:
♦  The  fundal  height   is   less  than  the  period  of amenorrhea.
♦   Fundal  grip:  Fetal  pole  (breech  or  head)  is  not palpable.
♦    Lateral  grip:  (a)  Soft,  broad and  irregular  breech is felt to one side of the midline and smooth, hard and globular head is felt on the other side. The head is usually placed at a lower level on one iliac fossa, (b)  The  back  is felt  anteriorly across the  long axis in dorsoanterior or the irregular small parts are felt anteriorly in dorsoposterior.
♦  Pelvic grip: The  lower  pole  of the uterus  is found empty. This, however, is evident only during pregnancy but during labor, it may be occupied by the shoulder.
Auscultation:  FHS  is  heard  easily  much  below  the umbilicus in dorsoanterior position. FHS is, however, located  at  a  higher  level  and  often  indistinct  in dorsoposterior position.
Ultrasonography:  Ultrasound  examination  confirms the diagnosis when there is any doubt in abdominal or vaginal examination. Obese women may make clinical examination difficult. Difficulties of clinical examination are overcome with ultrasonography to make the diagnosis early and correctly.
VAGINAL EXAMINATION
During pregnancy, the presenting part is so high that it cannot be identified properly but one can feel some soft parts.
During labor: Elongated bag of the membranes can be felt if it does not rupture prematurely. The shoulder is
















Fig. 26.29: Woman in labor with hand prolapse.

identified by palpating the following parts-acromion process, the scapula, the clavicle and axilla (Fig. 26.29). The characteristic landmarks are the feeling of the ribs and intercostal spaces (grid iron feel). On occasion, the arm is found prolapsed.  It should be remembered that the findings of a prolapsed arm is confined not only to  transverse lie but it may also  be associated with compound presentation. Frequently, a loop of cord may be found alongside the arm.
Determination of position: Thumb of the prolapsed hand,  when supinated,  points toward the head,  the palm corresponds to the ventral aspect. The angle of the scapula, if felt, indicates the position of the back. The side to which the prolapsed arm belongs, can be determined by shaking hands with the fetus. If the right hand is required for this, the prolapsed arm belongs to right side and vice-versa.
I CLINICAL COURSE OF LABOR
There is no mechanism of labor in transverse lie and an average size baby fails to pass through an average size pelvis. If the lie remains uncorrected and the labor is left uncared, the following sequence of events may occur (Flowchart 26.4).
UNFAVORABLE EVENTS  (COMMON):  •  There  may  be premature rupture of the membranes with escape of good amount of liquor because of absence of ball valve action of the presenting part. • The hand of the corresponding shoulder may be prolapsed with or without a loop of cord. •  The cord may be prolapsed in isolation.  •  There is increased chance of ascending infection from the lower genital tract.  • With increasing uterine contractions, the shoulder becomes wedged and impacted into the pelvis and the prolapsed arm becomes swollen and cyanosed. • Gradually features of obstructed labor supervene.
The pathological anatomy of the uterus is like that of  tonic  uterine  contraction  and  retraction.  There  is formation of a pathological retraction ring (Fig. 26.30).
Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse	Im Flowchart 26.4: Clinical course of labor in transverse lie left uncared for.

CLINICAL COURSE OF LABOR IN TRANSVERSE LIE


Unfavorable (common)	Favorable (rare)


Early rupture of the membranes



Prolapse of the hand
l
and/or	-----➔    I Fetal death
• Drainage of liquor.
17
• Intrauterine infection.
• Poor dilatation of the cervix.
Contraction of the upper segment ++ Stretching of the lower segment++


Spontaneous correction
• Early labor • Baby small
l

Version	Rectification
!	!

Breech	Vertex


Spontaneous	Spontaneous
expulsion	evolution

Baby
small or
macerated
Uterine contraction++

Double-up	Expulsion of
fashion                   breech and trunk followed by head


Formation of Sandi's ring -➔   j  Fetal death
■ Appearance of dehydration
I
________,
and exhaustion.	j Maternal death
r
■ Ketoac1dos1s. ■ Sepsis.


Multigravid

Rupture uterus

Primigravid

Uterine exhaustion


Maternal death



Primigravidae, in response to obstruction, the uterus becomes inert and features of exhaustion and sepsis are only evident.

Thick upper segment














Internal os






Fig. 26.30: Pathologic anatomy of the uterus in neglected shoulder presentation.

In multiparae, the uterus reacts vigorously in response to obstruction and ultimately, the lower segment gives way as a result of marked thinning of its wall.
Neglected shoulder: By neglected shoulder, it means the series of complications that may arise out of shoulder presentation when the labor is left uncared. Such complications are impacted shoulder ➔ obstructed labor➔  rupture of uterus with clinical evidences of dehydration, ketoacidosis, shock and sepsis. These put the mother and the fetus at risk.
FAVORABLE EVENTS (RARE): These are the rare events:
(I)  Spontaneous rectification or version: Where the fetal lie is changed spontaneously from transverse to longitudinal either as vertex (rectification) or as breech (version). This may occur in multiparae with a small size fetus in early labor where some amount of liquor is present.
(2)  Spontaneous evaluation: With progressive uterine contractions the fetus may gradually be expelled with the following body parts successively as: breech, trunk followed by delivery of the head.
(3)   Spontaneous expulsion: This extremely rare where a prematu_re (as in macerated) fetus is expelled at as doubled up
fashion with apposed chest and abdomen.
These events are very rare and occur only when the baby is premature or macerated.
PROGNOSIS: In a well-supervised pregnancy and labor, the maternal and the fetal outlook is not unfavorable with the increased use of cesarean section. However, increased
JI Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse

maternal  morbidity  following  early  rupture  of  the membranes and increased operative delivery, is inevitable.
But in uncared pregnancy and labor,  the outlook of the mother and the fetus is very much unpredictable. The maternal  risk  is increased due to dehydration, ketoacidosis, septicemia, ruptured uterus, hemorrhage, shock and peritonitis-sequences of neglected shoulder. Marked increase of fetal loss is due to cord prolapse, tonic  contraction  of  the  uterus,  ruptured  uterus  and neonatal sepsis.  The overall perinatal mortality is as high as 25-50%.

MANAGEMENT OF SHOULDER PRESENTATION

ANTENATAL: External cephalic version should be done in all cases beyond 36  weeks provided  there is no contraindication. If the lie fails to stabilize even at 36th week, the case is to be managed as outlined in unstable lie (Flowchart 26.5).
If version fails or is contraindicated:
♦  The patient is to be admitted at 36th weeks, because risk  of  early  rupture of  the membranes  and  cord prolapse  is  very  much  there.  Elective  cesarean delivery (after 37 completed weeks) is the preferred method of delivery.
PATIENT SEEN IN LABOR: The principles in management are as outlined below:
EARLY LABOR
■  External cephalic version in selected cases: Provided there is good amount of liquor amnii and there is no contraindication.
■  Cesarean section is the preferred method of delivery if version fails or is contraindicated. Difficulties are faced during cesarean section as the lower uterine segment is poorly developed. A low transverse incision is commonly made. Otherwise uterine incision may be low vertical or T shaped.
■   Internal  version   and  breech  extraction  is  not recommended. The complications both to the mother and the fetus are high.
Intraoperative cephalic version is often successful when done after the use of anesthesia and uterine relaxation.

Flowchart 26.5: Management of shoulder presentation (transverse lie).

Admission at 36 weeks


External cephalic version (contraindication are)


LATE LABOR
■  Baby alive:  Cesarean Delivery (CD) is to be done. Internal version: In modern obstetric practice, is not recommended except in the case of second twin.
■  Baby dead: Cesarean delivery, even in such cases, is much safer than evisceration (p. 552).

UNSTABLE LIE

This is  a condition  where  the  presentation  of  the fetus constantly changes even beyond 36th week of pregnancy when it should have been stabilized.
CAUSES:  The  causes  are  those  which  prevent  the presenting part to remain fixed in the lower pole of the uterus. Such conditions are: (1)  Grand multipara with lack of uterine tone and pendulous abdomen-the most common cause; (2) Hydramnios; (3) Contracted pelvis; (4) Placenta previa; (5) Pelvic tumor.
Complications:  Cord  entanglement  is  a  possible risk. Risk of cord prolapse is there once the membranes rupture. Perinatal death is high.
MANAGEMENT: ANTENATAL: At each antenatal visit, the presentation and the lie are to be checked. If there is no contraindication, external version is to be done to correct the malpresentation. Hospitalization: The patient is to be admitted at 36th week.  Premature or early rupture of the membranes with cord prolapse is the real danger with the lie  remaining  oblique.  After  admission,  the investigation is directed  to exclude  placenta  previa, contracted pelvis and assessment of liquor volume with the help of sonography.

FORMULATION OF THE LINE OF TREATMENT
•  Elective cesarean section is done in majority of the cases, especially in the presence of complicating factors like pre-eclampsia, placenta previa, contracted pelvis.
•  Stabilizing induction of labor:  External cephalic version is done (if not contraindicated) after 37 weeks ➔ oxytocin infusion is started to initiate effective uterine contractions. This is followed by low rupture of the membranes (amniotomy). Labor is monitored for successful vaginal delivery. This procedure may be done even after the spontaneous onset of labor.

COMPOUND PRESENTATION (Syn: Complex Presentation)

Compound  presentation  is  the  presence  of  a  fetal extremity  alongside  the  presenting  part.  Hand  in cephalic presentation is most common. Hand in breech presentation is relatively rare.




Fails


Cesarean delivery


Successful


Delivery as vertex

When a cephalic presentation is complicated by the presence of a hand or a foot or both alongside the head or presence of one or both hands by the side of the breech, it is called compound presentation. The most common one being the head with hand (Fig. 26.31) and
Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse     iD CORD PROLAPSE




















Fig. 26.31: Compound presentation-head with hand.

the rarest one being the presence of head, hand and a foot. The incidence is about 1 in 300 to 1 in 1000 deliveries.
ETIOLOGY: Conditions preventing engagement of the head can result in slipping of either upper or lower limbs by the side of the head. Prematurity (the most common), contracted pelvis, pelvic tumors, multiple pregnancy, high head with premature or early rupture of the membranes and hydramnios are the known etiological factors.
DIAGNOSIS:  The  diagnosis  is  not  difficult  when  the cervical os is sufficiently dilated to feel the limb by the side of the presenting part, especially after rupture of the membranes. Premature or early rupture of the membranes occurs in about one-third of the cases. Cord prolapse is to be excluded because of its frequent association-I 0-15%.

MANAGEMENT: Factors to he considered are-(1) Stage of labor; (2) Viability of the fetus; (3) Singleton or twins; (4) Pelvic adequacy; and (5) Associated cord prolapse. The  fetal  risks in  compound  presentation  are  birth trauma and cord prolapse.
Indication of cesarean section: Term singleton live fetus associated with pelvic inadequacy or cord prolapse should be safely delivered by cesarean section.
Expectant  management:  In a case with nonviable fetus, labor is allowed in anticipation to vaginal delivery. Vaginal delivery is also anticipated in a viable fetus with cephalic presentation with a prolapsed hand. These cases do not pose any dificulty as the hand moves upwards with the descent of the head into the birth canal. The proposed hand may be pushed upwards, after/during uterine contractions. However, labor process needs to be monitored very carefully (preferably by electronic fetal monitoring). Elevation of the prolapsed limb with descent of the presenting part usually talces place spontaneously.

There are three clinical types of abnormal descent of the umbilical cord by the side of the presenting part. All these are placed under the heading cord prolapse.
+   Occult prolapse: The cord is placed by the side of the presenting part and is not felt by the fingers on internal examination. It could be seen on ultrasonography or during cesarean section.
+  Cord (funic) presentation: The cord is slipped down below the presenting part and is felt lying in the intact bag of membranes.
+  Cord prolapse: The cord is lying inside the vagina or outside the vulva following rupture of the membranes (Fig. 26.32).
INCIDENCE: Incidence varies widely from 0.5% (cephalic presentation) to 20%  in transverse lie. It is mostly confined to parous women.
ETIOLOGY:  Anything  which  interferes  with  perfect adaptation of the presenting part to the lower uterine segment, may favor cord prolapse. Too often, more than one factor operates. The following are the associated factors: (1) Malpresentations-the most common being transverse (5-10%) and  breech (3%),  especially  with flexed legs or footling and compound (10%) presentation; (2) Contracted pelvis;  (3) Prematurity; (4) Twins;  (5) Hydramnios; (6) Placental factor-minor degree placenta previa with marginal insertion of the cord or long cord; (7) Prematurity;  (8)  Iatrogenic;  (9)  Procedure related-(a) low rupture of the membranes, (b) manual rotation of the head, (c) ECV, (d) IPV, (10) Stabilizing induction.

DIAGNOSIS: Occult prolapse: It is difficult to diagnose. The possibility should be suspected if there is persistence of  variable deceleration,  bradycardia  of  fetal  heart rate pattern detected on continuous electronic fetal monitoring. Intrapartum Ultrasonography (IUSG) is very informative (Ch. 24, p. 335 and 41, p. 603). Cord presentation: The diagnosis is made by  feeling  the
















Fig. 26.32: Woman in labor with cord prolapse.
ID Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse

pulsation of the cord through the intact membranes. Cord prolapse: The cord is palpated directly by the fingers and its pulsation can be felt if the fetus is alive. Cord pulsation may cease during  uterine  contraction which, however, returns after the contraction passes off. Temptation to pull down the loop for visualization or unnecessary handling is to be avoided to prevent vasospasm. Prompt USG Doppler study for cardiac function or auscultation for FHS to be done for fetal assessment.
PROGNOSIS:  Umbilical  cord  prolapse results in  cord compression.  This  happens  as the cord lies between the presenting part and the pelvic inlet, cervix or the vaginal wall. Umbilical cord compression reduces fetal circulation.  Depending on the duration and severity of compression, there is fetal hypoxia, brain damage or even death. Apart from cord compression, there is vasospasm of the cord vessels due to irritation and the temperature variance when the cord comes out.  Perinatal mortality associated with all cases of overt umbilical cord prolapse is about 20%. Prognosis for intrapartum cord prolapse is improved. Overall prognosis depends on the gestational age, degree, duration and severity of cord compression. When the prolapsed cord occlusion has occurred for  ".5 minutes  or  intermittent/partial occlusion has  occurred over  a  prolonged  period,  fetal  damage  or  death  may occur. If the delivery is completed, within 10-30 minutes, the fetal mortality can be reduced to 5-10%.  The overall perinatal mortality is about 15-50%.
Maternal: The maternal risks are  incidental due to emergency operative delivery, especially through the vaginal route.  Operative delivery  involves the risk  of anesthesia, blood loss and infection.
PREVENTION AND EARLY DETECTION: (1) Patient with malpresentation or poorly applied cephalic presentations

should be considered as high risk for cord prolapse.  (ii) USG examination may be helpful to determine fetal lie and cord position.  (iii) ARM should be avoided until the presenting  part is well  applied  to the  cervix.  (iv) Pelvic examination should be a routine to rule out cord prolapse following spontaneous rupture of membranes. (v)  Careful  needling  of  the  membranes,  and  slow release of the amniotic fluid can be performed until the presenting part is fixed against the cervix.

I MANAGEMENT
CORD  PRESENTATION:  The   aim  is  to  preserve  the membranes and to expedite the delivery.
♦  Once the diagnosis is made, no attempt should be made to replace the cord, as it is not only ineffective but  the  membranes inevitably  rupture leading  to prolapse of the cord.
♦    If  immediate  vaginal  delivery  is  not  possible, cesarean section is the best method of delivery. During the time of preparing the patient for operative delivery, she is kept in exaggerated Sims position.
♦  A rare occasion is when a fetus with longitudinal lie, good uterine contractions, cervix nearly full dilated and without any evidence of fetal distress.
Patient should be placed in left lateral maternal position. Oxygen is administered and electronic fetal monitoring is started. With full dilatation of the cervix, delivery is completed by forceps. Alternatively Cat I CS is done.
CORD PROLAPSE: Management protocol is to be guided by: (1) Baby living or dead; (2) Viability of the baby; and (3) Degree of dilatation of the cervix (Flowchart 26.6).
BABY  LIVING:  I.  Definitive  treatment:  •  Cesarean delivery is the best treatment when the baby is suficiently


Flowchart 26.6: Scheme of management of cord prolapse.

Cord prolapse


• Baby living or dead

• Viability of the baby.
• Cervical dilatation.








Immediate Cesarean delivery
l
(treatment of choice)


Baby alive
I



Immediate safe vaginal
delivery possible (normal CTG)

Baby dead
■ Confirm with ultrasound.
■ Wait for spontaneous delivery.

Immediate vaginal
delivery not possible


Resuscitation	First aid	Definite management


Vertex
Forceps or
ventouse.


Breech
Breech extraction in
expert hands only.

■ Bladder filling.	Cesarean Delivery (CD)
■ To lift the presenting part off the cord.
■ Posture-exaggerated and elevated Sims.
position or Trendelenburg or knee chest.
position-to refer to an equipped hospital.
Chapter 26: Complicated Labor: Malposition, Malpresentation and Cord Prolapse	il

mature and is alive. Just prior to making the abdominal incision,  the fetal heart should be auscultated once more to avoid unnecessary section on a dead baby.
II. Immediate safe vaginal delivery is possible:  • If the head is engaged,  delivery is to be completed by forceps. Ventouse may not be ideal in such circumstances as it takes a longer time. • Vaginal delivery is allowed when the fetus is previable or dead.
III. Immediate safe vaginal delivery is not possible: First aid management: The aim is to pressure on the cord till such time when the patient is prepared for assisted delivery or reaches an equipped hospital.
♦    If an oxytocin infusion is on, this should be stopped.
At this time intravenous fluid and 02 by face mask is
given.
♦    Bladder filling is done to raise the presenting part off the compressed cord till such time that patient


has delivered (either by CS or vaginally). Bladder is filled with 400-750 mL of normal saline with a Foley's catheter, the balloon is inflated and the catheter is clamped. Bladder is emptied before cesarean delivery.
♦    To lift the presenting part off the cord, by the gloved fingers introduced into the vagina. The fingers should be placed inside the vagina till definitive treatment is instituted.
♦    Postural treatment-exaggerated and elevated Sims position with a pillow or wedge under the hip or thigh; Trendelenburg  or knee-chest position  has  been traditionally mentioned but may be tiring and irksome to the patient.
♦    To replace  the cord  into  the  vagina  to minimize vasospasm due to irritation.
BABY  DEAD:  Labor  is  allowed  to  proceed  awaiting spontaneous delivery.
Prolonged Labor, Obstructed
Labor, Dystocia Caused by
CHAPTER ii	Fetal Anomalies


I) ❖ Prolonged Labor
►  Treatment
❖ Obstructed Labor ►  Treatment


►  Shoulder Dystocia
❖ Dystocia Caused by Fetal Anomalies
►  Hydrocephalus


❖ Neural Tube Defects (NTD) ►  Anencephaly
❖ Conjoined Twins




PROLONGED LABOR

DEFINITION: The  labor  is  said  to  be  prolonged  when the combined duration of the first and second stage is more than the arbitrary time limit of 18 hours. The prolongation may be due to protracted cervical dilatation in  the  first  stage  and/ or  inadequate  descent  of  the presenting part during the first or second stage of labor. But it recommends  diagnosis  of  arrest  of  labor  after 6 cm of dilatation. Generally, if a patient with membrane rupture remains at 2:6 cm dilatation for more than 4 hours in the setting of an adequate contraction pattern or for more than 6 hours with inadequate contraction pattern with oxytocin, the women is said to have active phase arrest  of  labor.  Prolonged  labor  is  not  synonymous with ineficient uterine contraction. Inefficient uterine contraction can be a cause of prolonged labor, but labor may also be prolonged due to pelvic or fetal factor.
PROLONGED LATENT PHASE
Latent phase is the preparatory phase of the uterus and the cervix before the actual onset of labor. Mean duration of latent phase is about 8 hours in a primi and 4 hours in a multi. Whether prolonged latent phase has got any adverse effect on the mother or on the fetus, it is not clearly known. A  latent phase that  exceeds  20  hours in primigravidae or 14 hours in multiparae is called prolonged.
Prolonged  latent phase may be worrisome to the patient but does not endanger the mother or the fetus.
Management: Expectant management is usually done unless there is any indication (for the fetus or the mother) for expediting the delivery. Rest and analgesic are usually given. When augmentation is decided, medical methods (oxytocin or prostaglandins) are preferred. Amniotomy is  usually avoided.  Prolonged  latent  phase is not an indication for any intervention or cesarean  delivery.

CAUSES OF PROLONGED LABOR: Any one or combination of the factors in labor could be responsible.
First stage: Failure to dilate the cervix is due to:
♦   Fault  in  power:  Abnormal  uterine contraction such as uterine inertia (common) or incoordinate uterine contraction.
♦    Fault  in  the  passage:  Contracted  pelvis,  cervical dystocia, pelvic tumor or even full bladder.
♦    Fault in the passenger: Mal position [ Occiput Posterior (OP)]  and malpresentation (face, brow), congenital anomalies of the fetus (hydrocephalus).
Too  often  deflexed  head,  minor  degrees of  pelvic contraction  and  disordered  uterine  action have  got sinister effects in causing non-dilatation of the cervix.
■  Others: Injudicious (early) administration of sedatives and analgesics before the active labor begins.
Second  stage:  Sluggish  or  nondescent  of  the presenting part in the second stage is due to:
♦  Fault in the power:  (1)  Uterine inertia; (2)  Inability to  bear  down;   (3)   Regional   (epidural)   analgesia; (4) Constriction ring.
♦   Fault in the passage: (1) Cephalopelvic disproportion, android pelvis, contracted pelvis; (2) Undue resistance of the pelvic floor or perineum due to spasm or old scarring; (3) Soft tissue pelvic tumor.
♦    Fault    in    the    passenger:	(1)    Malposition (occipitoposterior); (2) Malpresentation; (3) Big baby; (4) Congenital malformation of the baby.
DIAGNOSIS: Prolonged labor is not a diagnosis but it is the manifestation of an abnormality, the cause of  which should be detected by a thorough abdominal and vaginal examination.  During vaginal examination,  if a  finger is accommodated in between the cervix and the head during  uterine  contraction  pelvic  adequacy  can be reasonably established. Intranatal imaging (USG or MRI) is of help in determining the fetal station and position as well as pelvic shape and size.
Chapter 27: Prolonged Labor, Obstructed Labor, Dystocia Caused by Fetal Anomalies    ED

First  stage:  First  stage  of  labor  is  considered prolonged when the duration is more than 12 hours. The rate of cervical dilatation is <0.5 cm/h in a primi and 0.5-1.3 cm/h in a multi. The rate of descent of the presenting part is <l cm/h in a primi and <2 cm/h in a multi. In a partograph (WHO-2020), the labor process is divided into: (i) Latent phase that ends when the cervix is 5 cm dilated, (ii) Active phase that starts with cervical dilatation  of  5  cm.  Currently,  consortium  on  safe labor suggest a revision of the definition of normal and protracted labor. Following this; the active phase did not start until 6 cm of cervical dilatation. The consortium on safe labor did not specifically address the duration for diagnosis of arrest of labor. It suggests a slower rate of cervical change than Friedman's work.
Normal  minimum  rate  of  cervical  change  varies from 0.5 to 0.7 cm/hr for nulliparous women and for multiparous women 0.5 to 1.3 cm/hr.
Labor  care  guide:  (WHO):  Active phase starts  from 5 cm of cervical dilatation. Fixed 1 cm/hour 'alert line' and the corresponding 'action line' has been removed. Based  on  evidence  the  time  limits  at  each cm of cervical dilatation during the active first stage of labor varies.  There  is  variability  in  the  rate  of  progress of labor between women. The lines have been removed but the parameters remains same. There is a section for intensified monitoring for the second stage oflabor.
Disorders of the active phase: Active phase disorders may be divided into:  (A)  protraction  and  (B)  arrest disorders (Table 27.1).
Abnormal  labor  is  that  does  not  fall  within  95th percentile of labor progress. Abnormal labor is divided

into-(A) Protracted disorders or (B) Arrest disorders. Protracted labor  is  slower  than  expected  progress whereas arrest of labor is defined as complete cessation of progress. The exact cause of abnormal labor is not always  understood.  Often  the causes are  grouped  into (A) Uterine factors: Contractions either poor in strength or poorly coordinated  (uterine dysfunction). (B) Fetal factors: Abnormal presentation,  position,  excess  fetal size, fetal anomalies or (C) Maternal bony pelvis or soft tissues abnormality to cause an obstacle for fetal descent.
(A) Protracted active phase: When the rate of cervical dilatation is <0.7 cm/h in a primipara and <1.3 cm/h in a multipara after the onset of active phase (5 cm dilatation). A protracted active phase may be due to: (i) inadequate uterine  contractions,  (ii)  cephalopelvic  disproportion, (iii) malposition (OP) or malpresentation (brow), or (iv) regional (epidural) anesthesia.
(B) Arrest  disorder:  Diagnosis  of  arrest  of  labor is  made  after  6  cm  of  cervical  dilatation.  Generally if  a patient with membrane rupture remains at ?.5 cm dilatation for  more  than 4  hours in the setting of an adequate contraction pattern or for more than 6 hours without an adequate  contraction  pattern,  the  women is said to have active phase arrest of labor. Failure of cervical dilatation over a period of 2 hours in the active phase of labor is called arrest of dilatation. It is commonly due to inefficient uterine contractions. No descent for a period of more than 2 hours is called arrest of descent. It  is commonly due to CPD.
Secondary arrest  (Fig. 27.I) is defined  when  the active phase of labor (cervical dilatation) commences normally  but  stops  or  slows  down  significantly   for


 bli21.1: J ;    tl  met  s9f   :ntJ·;' . ;! :-•  .. ,. Traditional criteria and
"
\
.
labor phase	treatment	Obstetrical care consensus criteria

Labor disorder LATENT PHASE Prolongation disorder Prolonged latent phase.



ACTIVE PHASE Protraction disorders
•  Protracted active phase dilation. Protracted descent.
•
Arrest disorders
■  Prolonged deceleration phase. •  Secondary arrest of dilation.
•  Arrest of descent.


Nulliparous


>20 hr





•  <1.2 cm/hr •  <1 cm/hr

■  >3 hr ■  >2 hr •  >1 hr


Multiparous


>14 hr





• <1.5 cm/hr ■  <2 cm/hr

■  >1 hr ■  >2 hr >1 hr
•


Nulliparous


•  Supportive care: • Oxytocin or
amniotomy.
• CD not indicated.


•  Expectant care. •  CDforCPD.

■  CDforCPD.
■  No CPD: Oxytocin.

Multiparous


•  Supportive care:
• Oxytocin or amniotomy. • CD not indicated.



CD not indicated.


CD indications:
■  Ruptured membranes and no progress after 4 hours of adequate contractions. OR



■  Failure of descent.	 No descent in deceleration phase or second stage.

■  No progress  after  6 hr of inadequate contractions despite oxytocin stimulation.

[CD: Cesarean Delivery; CPD: Cephalopelvic Disproportion; (ACOG, Cohen)]
!J Chapter 27: Prolonged Labor, Obstructed Labor, Dystocia Caused by Fetal Anomalies
 10	I TREATMENT

8
6

4

·2:  2
0
0             4             8             12           16            20           24 Duration of labor (hours)
Fig.  27.1:  Partographic  analysis  of  labor  to  detect   types   of prolonged  labor-protracted  latent  phase,  protracted  active phase and secondary arrest.

2 hours or more prior to full dilatation of the cervix. It is commonly due to malposition or CPD.
Second stage arrest: No progress (descent or rotation) when pushing for over 3 hours in nulliparous women and over 2 hours in multiparous women is called second stage arrest. One hour more is allowed if epidural anesthesia is used (ACOG).
Disorders of the second stage: It may be due to one or a combination of several underlying abnormalities like CPD, malposition (OP), malpresentation, inadequate uterine contradictions or asynclitism.
DANGERS: Fetal: The fetal risk is increased due to the combined effects of:
(1)   Hypoxia  due  to  diminished  uteroplacental circulation, especially after rupture of the membranes; (2) Intrauterine infection, pneumonia; (3) Intracranial stress  or  hemorrhage  following  prolonged  stay  in the perineum and/or  supermoulding of the head;  (4) Increased operative delivery. Prolonged second stage of labor  is often associated with variable and delayed decelerations.  Scalp blood pH  estimations show fetal acidosis (Ch.  39,  p.  569).  All  these result in increased perinatal morbidity and mortality.
Maternal:  There   is   increased   incidence   of: (1)  distress;  (2)  chorioamnionitis;  (3)  Postpartum hemorrhage; (4) trauma to the genital tract-concealed (undue stretching of the perinea! muscles which may be the cause of prolapse at a later period) or revealed such as cervical tear, rupture uterus;  (5) increased operative delivery (vaginal instrumental or difficult cesarean); (6) puerperal sepsis;  (7)  subinvolution. The sum effects of all these lead to increased maternal morbidity and also increased maternal deaths.


PREVENTION
■   Antenatal or early intranatal detection of the factors likely to produce prolonged labor  (big  baby,  small women, malpresentation or position).
■   Use ofpartograph (Fig. 34.4) helps early detection.
■   Selective amniotomy and judicious augmentation of labor by low rupture of the membranes followed by oxytocin drip.
■   Change of posture in labor other  than supine  to increase uterine contractions,  emotional support, presence  of  a  labor  companion,  avoidance  of dehydration in labor and use of adequate analgesia for pain relief.
■  Respectful maternity care is to be provided (Ch. 13).
ACTUAL TREATMENT: Careful evaluation is to be done to  find  out:  (1)  cause  of prolonged  labor;  (2)  effect on the mother; (3) effect on the fetus. In a nulliparous patient, inadequate uterine activity is the most common cause of primary  dysfunctional labor. Whereas in a multiparous patient, cephalopelvic disproportion (due to malposition) is the most common cause.
Preliminaries: In an equipped labor ward, prolonged labor is unlikely to occur in modern obstetric practice. But in low resource settings, cases of prolonged labor with evidences of dehydration and ketoacidosis are admitted to the referral hospitals. Correction of dehydration and ketoacidosis (isotonic drinks reduce ketosis) should be made urgently by rapid intravenous infusion of Ringer's solution.
Definitive  treatment:  First  stage  delay:  Vaginal examination is done to  verify the fetal  presentation, position  and station.  Clinical pelvimetry is done.  If only  uterine  activity is suboptimal,  (1)  amniotomy and/ or  oxytocin  infusion  is  adequate;  (2)  effective pain relief is given by regional (epidural) analgesia. (3) cesarean section is done when vaginal delivery is unsafe (malpresentation, malposition, big baby or CPD).
Second-stage  delay:   Short  period  of  expectant management is reasonable provided the FHR (electronic monitoring)  is  reassuring  and  vaginal  delivery  is imminent.  Otherwise,  appropriate  assisted  delivery, vaginal  (forceps,  ventouse)  or  abdominal  (cesarean) should be done. Dficult instrumental delivery should be avoided.





►  Prolonged labor is defined when the combined duration of first and second stage of labor is more than 18 hours.
►  Prolonged latent phase is defined when the duration is more than 20 hours in a primigravida.  Normally, it lasts for 8 hours in a primigravida. Latent phase ends when the cervix is 5 cm or more dilated.
►   Prolonged labor may be due to abnormality of any one or combination of the factors, e.g., passage (pelvis, cervix); passenger (fetal size, presentation, position, congenital malformation) and the power.
Contd...
Chapter 27: Prolonged Labor, Obstructed Labor, Dystocia Caused by Fetal Anomalies
DI· •··

Contd...
>   Mal presentation and ma Iposition are associated with poor adaptation of the presenting part to the cervix. This causes poor progress of labor.
>   Detection of prolonged labor in the first stage or in the second stage can be made on careful clinical examination and using a partograph.
>   In a primigravida, inadequate uterine contraction is the most common cause of primary dysfunctional labor. In a multigravida, cephalopelvic disproportion is the most common cause.
>   In the active phase of labor, the cervix should dilate at least at the rate of 1 cm per hour.
>   Dangers of prolonged labor are both to the mother and the fetus. Management is primarily aimed in prevention, early detection and appropriate intervention.
>   Maternal supine position and dehydration in labor should be avoided. There should be adequate pain relief.
>   Common causes of prolonged labor are abnormal  uterine  contractions,  abnormal presentation and position of the fetus and cephalopelvic disproportion.
>   Dangers of prolonged labor are: (Al Fetal: Hypoxia, intrauterine infection. (Bl Maternal: Chorioamnionitis, increased operative delivery and PPH.
>   Protraction disorders are defined when the progress of labor is slower than normal, whereas arrest disorders are defined where there is complete cessation of progress.
>  Combined disorder in active phase is defined as the arrest of dilatation of the cervix or descent of the fetal head occurring in a woman who has previously developed protracted labor. Women with combined disorder often have less favorable chance of vaginal delivery. Patient needs to be evaluated as regard uterine contractions, pelvic adequacy, fetal presentation, position, station and estimated fetal weight.


OBSTRUCTED LABOR

DEFINITION: Obstructed labor is the one where, in spite of good uterine contractions, the progressive descent of the presenting part is arrested due to mechanical obstruction. This may result either due to factors in the fetus or in the birth canal or both, so that further progress is almost impossible without assistance.
INCIDENCE: In the developing countries, the prevalence is about 1-2% in the referral hospitals.

CAUSES
♦  Fault  in  the  passage:  (1)   Bony:  Cephalopelvic disproportion and contracted pelvis are the common causes.   Secondary  contracted   pelvis   may   be encountered in multiparous women.  (2) Soft tissue obstructions: This includes cervical dystocia due to prolapse or previous operative scarring,  cervical or broad ligament fibroid,  impacted  ovarian  tumor or the nongravid horn of a bicornuate uterus below the presenting part.
♦  Fault in the passenger: (1) Transverse lie; (2) Brow presentation;  (3)  Congenital  malformations of the fetus-hydrocephalus  ( commonest),  fetal  ascites, double monsters;  (4)  Big baby,  occipitoposterior position;  (5)  Compound presentation;  (6)  Locked twins.

MORBID ANATOMICAL CHANGES
Uterus: The morbid anatomical changes in response to obstruction have already been described in relation to the formation of pathological retraction ring or Band!'s ring.
Bladder: The bladder becomes an abdominal organ and due to compression of urethra between the presenting part and symphysis pubis, the patient fails to empty the bladder. The transverse depression at the junction of the

superior border of the bladder and the distended lower segment is often  confused  with  the Bandl's  ring.  The bladder walls get traumatized, which may lead to blood­ stained urine, a common  finding in obstructed  labor. The base of the bladder and urethra, which are nipped in between the presenting part and symphysis pubis, may undergo pressure necrosis. The devitalized tissue becomes infected and later on may slough off resulting in the development of genitourinary fistula.

EFFECTS ON THE MOTHER Immediate:
1.  Exhaustion is due to a constant agonizing pain and anxiety.
2.  Dehydration is due to increased muscular activity without adequate fluid intake.
3.  Metabolic acidosis is due to accumulation of lactic acid and ketones.
4.  Genital  sepsis  is  an  invariable  accompaniment, especially  after  rupture  of  the  membranes  with repeated   vaginal   examination   or   attempted manipulation outside.
5.  Injury to the genital tract includes rupture of the uterus which may be spontaneous in multiparae or may be traumatic following instrumental delivery.
6.  Postpartum hemorrhage  and  shock  may  be  due to isolated or combined effects of atonic uterus or genital tract trauma. All these lead to an increased maternal morbidity and mortality. The deaths are due to rupture of the uterus, shock and sepsis with metabolic changes.
Remote:  Even  if  the  patient survives,  the  following legacies may be left behind: (1) genitourinary fistula or rectovaginal fistula, (2) variable degree of vaginal atresia, (3) secondary amenorrhea following hysterectomy due to rupture or due to Sheehan's syndrome.
· E9 Chapter 27: Prolonged Labor, Obstructed Labor, Dystocia Caused by Fetal Anomalies
!

EFFECTS ON THE FETUS
1.  Asphyxia results from tonic uterine contraction that interferes with the uteroplacental circulation or due to cord prolapse, especially in shoulder presentation.
2.  Acidosis due to fetal hypoxia and maternal acidosis.
3.  Intracranial hemorrhage is due to supermoulding of
the head leading to tentorial tear or due to traumatic delivery.
4.  Infection: All these lead to increased perinatal loss.
CLINICAL FEATURES: The clinical features are like those mentioned in tonic uterine contraction and retraction (p. 345).

I TREATMENT
PREVENTION
♦  Antenatal detection of the factors likely to produce pro­ longed labor (big baby, small women, malpresentation and position).
♦  Intranatal:  Continuous  labor  monitoring,  use  of partograph and timely intervention of a prolonged labor due to mechanical factors can prevent obstructed labor.  Failure in progress of labor  in spite of good uterine  contractions  for  a reasonable  period  (2-4 hours) is an impending sign of obstructed labor.
ACTUAL TREATMENT: The underlying principles are: (1) to relieve the obstruction at the earliest by a safe delivery procedure, (2) to combat dehydration and ketoacidosis, (3) to control sepsis.
Preliminaries:
1.  Fluid-electrolyte   balance   and   correction   of dehydration  and ketoacidosis are done by  rapid infusion of Ringer's solution; at least 1 liter is to be given in running drip. At least 3 liters of fluid is required to correct clinical dehydration.
2.  A vaginal  swab  is taken and sent  for culture and sensitivity test.
3.  Blood sample is sent for group and cross-matching and a bottle of blood should be at hand prior to any operative intervention.
4. Antibiotic: Ceftriaxone I g IV is administered.
5.  IV infusion,  metronidazole  is  given  for  anaerobic infection.
Obstetric  management:  Before  proceeding  for definitive operative treatment, rupture of the uterus must be excluded. A balanced decision should be taken about the best method of relieving the obstruction with least hazards to the mother. Frantic attempt to deliver a moribund baby by a method ignoring the risk involved to the mother is indeed bad obstetrics. There is no place of "wait and watch'  neither is any scope of using oxytocin to stimulate uterine contraction.
Vaginal delivery: The baby is invariably dead in most of the neglected cases and destructive operation is the


best choice to relieve the obstruction. If, however, the head is low down and vaginal delivery is not risky, forceps extraction may be done in a living baby. There is no place of internal version in obstructed labor. After completion of the delivery and expulsion of the placenta, exploration of the uterus and the lower genital tract should be done to exclude uterine rupture or tear.
Cesarean section: If the case is detected early with good fetal condition, cesarean section gives the best result.  But in late and neglected cases,  even if the fetal heart sound is audible, desperate attempt to do a cesarean section to save the moribund baby more often leads to disastrous consequences. Not infrequently, the baby is either delivered stillborn or dies due to neonatal sepsis.  The  postoperative  period  of  the  mother  also becomes stormy and, at times, ends fatally.
Symphysiotomy: The place of symphysiotomy has to be duly considered in the developing countries as an alternative to risky cesarean section. This can be done in a case of established obstruction due to outlet contraction with vertex presentation having good FHS.

MACROSOMIA  (generalized  fetal  enlargement):  Fetal Macrosomia is defined when the birth weight exceeds certain percentiles for a given population.  Empirically a newborn weight exceeding 4000 g is frequently used threshold to define macrosomia.
Risk factors for fetal macrosomia:
■   Hereditary, race.	■   Male baby.
■   Size of the parents.	■   Advanced maternal ■    Maternal obesity.                       age.
■   Poorly controlled GDM.	■   Previous history of ■   Post-maturity.                            macrosomic baby ■    Multiparty.                                  delive1y.

Diagnosis is suspected because of: (1) disproportionate increase in uterine size, (2) clinically, the fetus is felt big, (3) ultrasonographic measurements of fetal BPD, HC, FL and AC are done to predict the estimated fetal weight. Dangers involve both the fetus and the mother. Fetal hazards are: surprise dystocia due to cephalopelvic disproportion, shoulder dystocia (30%), brachia! plexus injury (2-15%), asphyxia, birth trauma, meconium aspiration and HIE. Overall, perinatal mortality and morbidity are high.
Maternal dangers include: Injmy to the maternal soft tissues [vagina, perineum, 3rd and 4th degree perinea! trauma (5%), uterine rupture], PPH (10%) and puerperal sepsis. Rate of CD is high (50%). Maternal morbidity is high. ■   Increased rate of maternal and perinatal morbidity.
■  Increased rate of cesarean delivery (>50%). ■   Risk of shoulder dystocia (30%).
■   PPH, perinea! laceration, infections are higher.
Management: (i) Prophylactic induction of labor (early) to reduce the risk of shoulder dystocia or (ii) Elective cesarean delivery; (a) especially in diabetic women with big baby to reduce perinatal hazards (shoulder dystocia);
Chapter 27: Prolonged Labor, Obstructed Labor, Dystocia Caused by Fetal Anomalies    ED

(b) In women with previous history of shoulder dystocia as risk of recurrence is 10 times higher.
I SHOULDER DYSTOCIA
Definition: The term shoulder dystocia is defined to describe a wide range of additional obstetric maneuvers to deliver the shoulder of the fetus after the head has been born and gentle traction has failed. Shoulder dystocia occurs when either the anterior or the posterior (rare) fetal shoulder impacts on the maternal symphysis or on the sacral promontory respectively. Overall incidence varies between 0.2% and 1 %.
Riskfactors: Are not always present. (A) Prelabor: (1) History of previous shoulder dystocia, (2)  Macrosomia (>4.5 kg), (3) Diabetes, (4) Obesity (BMI >30 kg/ m2), (5) Induced labor, (6) Multiparity; (B) Intrapartum: (7) Prolonged first stage or second stage of labor, (8) Secondary arrest of labor, (9) Postmaturity, (10) Oxytocin augmentation, (11) Anencephaly, (12) Mid-pelvic instrumental delive1y (more followingventouse than forceps), (13) Fetal ascites. Complications: (A) Neonatal: asphyxia, brachia! plexus injury (plexopathy) due to stretch, Erb (C5, C6), Klumpke palsy (CS, Tl), humerus fracture, clavicle or sternomastoid hematoma during delivery. Perinatal morbidity and mortality are high. (B) Maternal: PPH (11 %), cervical laceration, vaginal tear, perinea! tear (3rd and 4th degree), rupture of uterus, bladder, sacroiliac joint dislocation and morbidity.
Prevention of shoulder dystocia is not possible accurately even with antenatal ultrasonographic assessment.
Prediction: Shoulder dystocia neither could be predicted accurately nor could be prevented entirely. Prolonged first or second stage of labor, secondary arrest of labor (p. 379) and difficult mid-pelvic instrumental delivery are the important intrapartum observations to predict.
Diagnosis: (1) Definite recoil of the head back against the perineum (turtle neck sign); (2) Failure of spontaneous restitution of fetal head; (3)  Fetal face becomes plethoric; (4) Failure of shoulder to descend.
Management principles: Extra help is to be called (a) To clear infant's mouth and nose,  (b) Not to give traction over baby's head,  (c) Never to apply fundal pressure as it causes further impaction of the shoulder (Fig. 27.2),  (d) To perform wide mediolateral episiotomy as it provides space posteriorly, (e) To involve the anesthetist (as analgesia is ideal) and the pediatrician (for infant's resuscitation).
Considering the need of emergency management, shoulder dystocia drill should be practiced by the birth attendants.












Fig. 27.2: Fundal pressure should not be used as it causes further shoulder impaction.

Management: The following maneuvers are commonly employed. There is no evidence that any method is superior to another in releasing the impacted shoulder or reducing the chance injury (ACOG-2002).
a   Head and neck of the fetus should be grasped and taken posteriorly  while suprapubic  pressure  is applied by an assistant slightly toward the side of fetal chest.  This will reduce the bisacromial diameter and rotate the anterior shoulder toward the oblique diameter. This maneuver is simple as well as effective. It needs only one assistant. This procedure, when possible, may be done first (RCOG-2012).
11   McRoberts  maneuver:  Abduct  the maternal  thighs  and sharply hyperflex them onto her abdomen. There is rotation of symphysis pubis upward and decrease in angle of pelvic inclination. This straightens the lumbosacral angle, rotates the maternal pelvis upward and increases the anterior-posterior diameter of the pelvis. This maneuver is effective and is successful in about 90% of cases. Suprapubic pressure may be used together.
■  Wood's maneuver: General anesthesia is administered. The posterior shoulder is rotated to anterior position {180°) by a corkscrew movement. This is done by inserting two fingers in the posterior vagina. Simultaneous suprapubic pressure is applied.  This pushes the bisacromial diameter from the anteroposterior diameter to an oblique diameter. This helps easy entry of the bisacromial diameter into the pelvic inlet. Extraction of the posterior  arm:  The operator's hand is introduced into the vagina along the fetal posterior humerus in the sacral hollow. The arm is then swept across the chest and thereafter delivered by gentle traction. This procedure may cause either fracture clavicle or humerus or both.
11   "All Fours" position: Changing the mother on to all fours may increase the pelvic dimensions and allow the fetal position to shift. Downward traction on the posterior shoulder helps to free the impacted shoulder. This may be done for a mobile and slim woman in a community setting.
•   Other  techniques  may  be  used  when  all  the  above maneuvers have failed:
II  Deliberate fracture  of the  clavicle by  finger  pressure (fracture heals rapidly) or  cleidotomy:  One  or  both clavicles may be cut with scissors to reduce the shoulder girth. This is applicable to a living anencephalic baby as a first choice or in a dead fetus.
■  Zavanelli maneuver (pushing the fetus back to the uterus and delivering by cesarean section) or symphysiotomy is done rarely.
•  AMTSL and examination for perinea! trauma to be done as a routine.
•  All maternity staff should have shoulder dystocia training. Skill  drills  using  mannequins  in  simulation  improves management outcome when applied in real life.
,.      All the maneuvers employed must be documented correctly to avoid litigation.

DYSTOCIA CAUSED BY FETAL ANOMALIES ■ HYDROCEPHALUS
With the routine use of early pregnancy ultrasono­ graphy, most cases of fetal anomalies are diagnosed early. Termination of pregnancy is considered there after. Dystocia causes by major fetal anomalies are extremely rare these days.
ll Chapter 27: Prolonged Labor, Obstructed Labor, Dystocia Caused by Fetal Anomalies
Management: With the routine use of early pregnancy sonography, most cases are diagnosed early and managed. For late cases: Principle is to decompress the hydrocephalic head in labor either in vertex or in breech presentation. This is also done during cesarean delivery before incising the uterus. Bladder is evacuated beforehand. Once the labor is established and the cervix is 3-4 cm dilated, decompression of the head is done by a sharp pointed scissors or with a wide bore (17 gauge) long needle.






Fig. 27.3: Ultrasonogram showing hydrocephalus with hugely dilated ventricles (both).















Figs. 27.4A and B: (A) Anencephaly; (Bl USG showing anencephaly, with absence of fetal skull. The face is seen with prominent orbit. Courtesy: (A) Dr Mahesh Bharpilania; (B) Dr K Oswal.

Excessive accumulation of cerebrospinal fluid (0.5-1.5 L) in the ventricles with consequent thinning of the brain tissue and enlargement of the cranium occurs in 1 in 2,000 deliveries (Figs. 27.3 and 27.4). It is associated with other congenital malformations (aneuploidy) in one-third of cases and neural tube defects. Recurrence rate is about 5%. Breech presentation occurs in about 30% cases.
Hydrocephalus may be caused by various genetic and environmental  pathologies or due to some  other  CNS abnormalities.
Diagnosis: ■ Sonography (ventriculomegaly): There is enlargement of cerebral ventricles by CSF. The atrium normally measures between 5 and 10 mm from 15 weeks to term. When atrial width measures >15 mm, it is severe ventriculomegaly. The choroid plexus appears to dangle within the ventricle. The other findings are: (a) Cranial shadow is globular rather than normal ovoid, (b) Fontanels and sutures are wide, (c) Vault bones thinne1; (d) The lateral and third ventricles are dilated with marked thinning of the cerebral cortex, (e) Often the dilatation is due to stenosis of the aqueduct of Sylvius, agenesis of corpus callosum. ■ Internal examination during labor reveals: (a) gaping sutures and fontanels, and (b) crackling sensation on pressing the head.
In breech presentation, however, the diagnosis is not made until the aftercoming head is arrested at the brim. Presence of open spina bifida points strongly toward hydrocephalus.
Prognosis: Fetal outlook is extremely poor except in mild variety.

In  breech  presentation,  the  arrested head  can be decompressed by perforating the suboccipital region using a needle or a sharp pointed scissors under the guidance of two fingers of the left hand protecting the anterior vaginal wall. Decompression of the head (cephalocentesis) through the abdominal route using a large bore needle under ultrasound guidance may also be done.

NEURAL TUBE DEFECTS (NTD}

Anencephaly and spina bifida comprise 95% of NTD and the remaining 5% is encephalocele (Fig. 27.5). It is more common in lower socioeconomic group. Recurrence risk after one affected child is 4%.
I ANENCEPHALY
The incidence of anencephaly is about 1 in 1,000 births. The anomaly results from deficient development of the vault of the skull and brain tissue, but the facial portion is normal. The pituitaiy gland is often absent or hypoplastic. Typically, there is marked diminution of the size of the adrenal glands probably secondaiy to the absence of the pituitary gland.
About 70% of anencephalic fetuses are females. Genetic and environmental factors are probably involved (multifactoriai).
Diagnosis: In the first half of pregnancy, the diagnosis is made by elevated alpha-fetoprotein in amniotic fluid. Diagnosis with USG could be made as early as 10 weeks gestation. The findings around 10 weeks are: (a) absence of cranial vault, (b) angiomatous, brain tissue. Meningomyelocele­ extending from the base of the skull down to the neck, may be present along with axencephaly. Encephalocele is due to the protrusion of the meninges and the brain tissue through a defect in the cranium. A midline sac is often seen protruding through the skull (occiput) on ultrasonography.
Complications include:  (1) Hydramnios  (70%);  ( 2) Malpresentation-face or breech; (3) Preterm labor, especially when associated with hydramnios; (4) Tendency of postmaturity; (5) Shoulder dystocia; (6) Obstructed labor if the head and shoulders try to engage together because of short neck.
Management: Mostly it is confirmed by early sonography before 20 weeks and termination of pregnancy is done. The uterus is most often refractory to oxytocin because of low level of estriol as a result of insufficient production of its precursor cortisol from fetal adrenals. Use of prostaglandin vaginal gel
(PGE2) has been proved to be effective in resistant cases. During
labor, there is tendency of delay. Shoulder dystocia should be managed by cleidotomy.
Prevention: Prepregnancy counseling is essential. Folic acid supplementation: beginning 1 month before conception to about 12 weeks of pregnancy has reduced the incidence ofNTD significantly (85%). A dose of 5 mg daily is recommended. Risk of recurrence is about 4% in subsequent pregnancy.
Chapter 27: Prolonged Labor, Obstructed Labor, Dystocia Caused by Fetal Anomalies














Fig. 27.5: Encephalocele.	Fig. 27.6: Sonography showing fetal ascites.

Fig. 27.7: Huge fetal abdo­ minal  enlargement  due  to ascites.



ENLARGEMENT OF FETAL ABDOMEN
The enlargement of fetal abdomen sufficient to produce dystocia may be due to ascites, distended bladder or enlargement of kidney by a tumor or an umbilical hernia. Antenatal diagnosis can be made by sonography (Figs. 27.6 and 27.7) which shows an appearance resembling that of the "Buddha position''. In an unbooked case, the diagnosis is made when there is dificulty in delivery of the trunk following birth of the head. Confirmation is done by introducing the hand and palpating the hugely distended abdomen. The decompression of the abdomen is done by simple puncture with a wide bore needle which is soon followed by spontaneous delivery.
MONSTERS: The varieties of incomplete twinning result in development of groups of monsters. The condition is extremely rare and often causes surprise dystocia.

CONJOINED TWINS

Diagnosis: Ultrasonography: A thorough targeted USG is  done.  Diagnosis on ultrasonography:  (i)  Early  in first trimester monochorionicity and monoamnioncity and a bifid fetal pole. 3D-USG and MRI may be used to

confirm the diagnosis,  (ii) a continuous  external skin contour, (iii) body parts of twins (heads) are on the same level, (iv) no change in relative positions of twins on successive scans, (v) spines are in unusual close proximity and are extended, and (vi)  single placenta. 3D USG, color Doppler, fetal echocardiography and MRI can determine the extent of the organ sharing and also can classify the type of conjoined twining (Fig. 17.8).
Management:   Once   the  diagnosis  is  confirmed, pregnancy termination is an option. Patients need to be counseled as regards the prognosis depending on the degree of organ sharing between the fetuses. Multidisciplinary team approach is needed for management when pregnancy is continued. Survival rate in a well-selected case following separation has improved (80%). Cesarean section offers best chance of fetal survival as in few cases of conjoined twins can be surgically separated. It is commonly done when the diagnosis is made during pregnancy.
Destructive operation (evisceration and amputation of body parts) is an alternative when diagnosed in labor with dead fetuses. It is rarely done these days.





OBSTRUCTED LABOR
►   Obstructed labor is the arrest of descent of the presenting part despite good uterine contractions. This occurs due to mechanical obstruction.
►   Common causes are: CPD, soft tissue obstruction (impacted ovarian tumor) or fetal malpresentation or position.
►   Effects on the mother or the fetus are worse compared to prolonged labor. Perinatal and maternal morbidity and mortality are high. ►   Actual management includes: To correct maternal dehydration, ketoacidosis, sepsis and to deliver the woman. Cesarean delivery is
commonly done when the fetal condition is good.
►   Management is primarily aimed in prevention. The actual management is to relieve the obstruction and to deliver the fetus safely. ►  Dystocia may also be due to macrosomia or due to fetal anomalies (hydrocephalus, anencephaly or conjoined twins.
►  Shoulder dystocia (difficulties during delivery of the shoulders) may be due to several factors. Dangers are mainly to the fetus. Hazards could be minimized if management principles are strictly followed. McRoberts maneuver along with suprapubic pressure is found successful in about 90% of cases.
►   Conjoined twins: 30 USG, color Doppler, fetal echocardiography and MRI can confirm the diagnosis and also can determine the extent of organ sharing. Multidisciplinary team approach is essential in the management.


Complications of the Third Stage of Labor







CHAPTER OUTLINE  '.
❖ Postpartum Hemorrhage (PPH)
❖ Primary Postpartum Hemorrhage ► Causes
► Prevention
►  Management of Third-stage Bleeding


► Steps of Manual Removal of Placenta ► Management of True Postpartum
Hemorrhage
► Actual Management
❖ Secondary Postpartum Hemorrhage ❖ Retained Placenta


►  Management
► Management of Unforeseen Complications during Manual Removal of Placenta
❖ Morbid Adherent Placenta ❖ Inversion of the Uterus




Of all the stages of labor, third stage is the most crucial one for the mother.  Fatal  complications may appear unexpectedly in an otherwise uneventful first or second stage. The following are the important complications: (1) Postpartum hemorrhage; (2) Retention of placenta; (3) Shock-hemorrhagic or non-hemorrhagic; (4) Pulmonary embolism either by amniotic fluid or by air; (5) Uterine inversion (rare).

POSTPARTUM  HEMORRHAGE  (PPH)
DEFINITION:  Quantitative definition  is arbitrary and is related to the amount of blood loss in excess of 500 mL following birth of the baby (WHO). It may be useful for statistical purposes. As the effect of the blood loss is important rather than the amount of blood lost,  the clinical definition, which is more practical, states,  "any amount of bleeding from or into the genital tract following birth of the baby up to the end of the puerperium, which adversely affects  the  general condition  of  the  patient evidenced by rise in pulse rate and falling blood pressure, is called postpartum hemorrhage".
Visual estimation of blood loss is inaccurate. Therefore, clinical  signs  and  symptoms  should  be  included  in assessment of PPH (RCOG-2016).
Postpartum hemorrhage defined as the excessive bleeding following delivery (>500 mL in vaginal delivery or >1000 mL in cesarean delivery accompanied by signs and symptoms of hypovolemia (ACOG-2017).
The  average  blood  loss  following  vaginal  delivery, cesarean delivery and cesarean hysterectomy is 500 mL, 1000 mL and 1500 mL respectively.
Depending upon the amount of blood loss, PPH can be:  • Minor ( <IL),  • Major (>lL) or  • Severe (>2L).
INCIDENCE: The incidence widely varies mainly because of lack of uniformity in the criteria used in definition. The incidence is about 4-6% of all deliveries.

TYPES:  ■  Primary {early)	11   Secondary {late) Primary:  Hemorrhage  occurs  within  24  hours
following  the  birth  of  the  baby.  In  the  majority, hemorrhage occurs within two hours following delivery. These are of two types:
■  Third-stage  hemorrhage:  Bleeding  occurs  before expulsion of placenta.
■  True  postpartum  hemorrhage:  Bleeding  occurs subsequent to expulsion of placenta (majority).
Secondary: Hemorrhage occurs beyond 24 hours and within puerperium, also called delayed or late puerperal hemorrhage.
Another classification of PPH has been proposed, wherein the volume loss is assessed in conjunction with clinical signs and symptoms (Ch. 39, Table 39.4).

PRIMARY POSTPARTUM HEMORRHAGE I CAUSES
Four basic pathologies are expressed as the four Ts' (RCOG): Tone (atonicity),  tissue  (retained  bits,  blood clots),  trauma  (genital  tract  injury)  and  thrombin ( coagulopathy).
■  Atonic.	11    Traumatic.
■  Retained tissues.	11    Blood coagulopathy (thrombin). ■   Atonic uterus  (80%): Atonicity of the uterus is the
commonest cause of postpartum hemorrhage. With the separation of the placenta, the uterine sinuses, which are torn, cannot be compressed effectively due to imperfect contraction and retraction of the uterine musculature and bleeding continues. The following are the conditions, which often interfere with the retraction of the uterus as a whole and of the placental site in particular.
♦    Grand  multipara:  Inadequate  retraction  and frequent  adherent  placenta  contribute  to  it. Associated anemia may also probably play a role.
Chapter 28: Complications of the Third Stage of Labor     ED

♦    Overdistension  of  the  uterus  as  in  multiple pregnancy,  hydramnios  and  big  baby  (>4 kg). Imperfect retraction and a large placental site are responsible for excessive bleeding.
♦   Malnutrition  and  anemia   ( <9.0  g/dL):   Even slight amount of blood loss may develop clinical manifestations of postpartum hemorrhage.
♦    Antepartum hemorrhage (both placenta previa and abruption}: The causes of excessive bleeding are mentioned in Ch. 19.
♦    Prolonged labor  (>12  hours}:  Poor  retraction, infection (amnionitis), dehydration are important factors (tone).
♦   Anesthesia: Depth of anesthesia and the anesthetic agents (ether, halothane) may cause atonicity.
♦    Initiation or augmentation of delivery by oxytocin: Postdelivery uterine atonicity is likely unless the oxytocin is continued for at least one hour following delivery.
♦   Uterine  fibroid  causes  imperfect  retraction mechanically.
♦    Mismanaged third stage oflabor: This includes-Ca) Too rapid delivery of the baby preventing the uterine wall to contract so rapidly, (b) Premature attempt to deliver the placenta before it is separated, (c) Kneading and fiddling the uterus, (d) Pulling the cord. All these produce irregular uterine contractions leading to partial separation of placenta and hemorrhage, (e) Manual separation of the placenta increases blood loss during cesarean delivery.
♦    Placenta: Morbidly adherent (accreta, percreta), partially or completely separated and/or retained (due to constriction ring of uterus) cause PPH.
♦    Precipitate labor: In rapid delivery, separation of the placenta occurs following the birth of the baby. Bleeding continues  before  the  onset  of uterine retraction. Bleeding may be due to genital tract trauma also.
♦    Other causes of atonic hemorrhage are:
11    Obesity (BMI >35).
■  Previous history of PPH. 11    Age (>40years).
11    Drugs: Use of tocolytic drugs (ritodrine ), MgSO 4, nifedipine.
■   Traumatic (20%}: Trauma to the genital tract usually occurs  following  operative  delivery;  even  after spontaneous delivery. Blood loss from the episiotomy wound is often underestimated. Similarly, blood loss in cesarean section amounting to 800-1000 mL is most often ignored.  Trauma involves usually the cervix, vagina, perineum (episiotomy wound and lacerations), paraurethral region and rarely, rupture of the uterus occurs.  The  bleeding  is  usually  revealed  but  can rarely be concealed (vulvovaginal or broad ligament hematoma).

■    Retained tissues  (5-10%):  Bits of placenta, blood clots cause PPH due to imperfect uterine retraction. USG of an echogenic mass is suggestive of returned tissues.
■    Thrombin: Blood coagulation disorders, acquired or congenital, are less common causes of postpartum hemorrhage. The blood coagulopathy may be due to diminished procoagulants (washout phenomenon) or increased fibrinolytic activity. The firmly retracted uterus can usually prevent bleeding. The conditions where  such  disorders  may  occur  are  abruptio placentae, jaundice in pregnancy, thrombocytopenic purpura,  severe  pre-eclampsia,  HELLP  syndrome, amniotic fluid embolism or in IUD. Specific therapy following coagulation screen, including recombinant activated factor VII (rF VIia) may be given.
■    Combination of atonic and traumatic causes.
DIAGNOSIS AND CLINICAL EFFECTS: In the majority, the vaginal bleeding is visible outside, as a slow trickle. Rarely, the bleeding is totally  concealed as either  vulvovaginal or broad ligament hematoma. The effect of blood loss depends  on-(a)  Predelivery  hemoglobin  level,  (b} degree of pregnancy-induced hypervolemia, and ( c) speed at which blood loss occurs. Alteration of pulse,  blood pressure and pulse pressure appears only after class 2 hemorrhage (20-25% loss of blood volume). On occasion, blood loss is so  rapid  and brisk that death  may  occur within a few minutes.
State of uterus, as felt per abdomen, gives a reliable clue as regards the  cause  of bleeding.  In  traumatic hemorrhage,  the uterus is found well contracted. In atonic hemorrhage,  the uterus is found flabby  and becomes hard on massaging. However, both the atonic and traumatic cause may coexist. Even following massive blood loss from the injured area, a state of low general condition can make the uterus atonic.
PROGNOSIS: Postpartum hemorrhage is one of the life­ threatening emergencies. It is one of the major causes of direct maternal deaths both in the developing and developed countries. Prevalence of malnutrition and anemia, inadequate antenatal and intranatal care and lack of blood transfusion facilities,  substandard care are some of the important contributing factors. There is  also  increased  morbidity.  These  include  shock, transfusion reaction, puerperal sepsis, failing lactation, pulmonary embolism, thrombosis and thrombophlebitis. Late sequelae include Sheehan's syndrome (selective hypopituitarism) or rarely diabetes insipidus.

I PREVENTION

Postpartum hemorrhage cannot always be prevented. However, the incidence and especially its magnitude can be reduced substantially by assessing the risk factors and following the guidelines as mentioned below:
     Chapter 28: Complications of the Third Stage of Labor
 

However, most cases of PPH have no identifiable risk factors.
■   Antenatal
♦  Improvement of the health status of the woman and to keep the hemoglobin level normal (>10 g/dL) so that the patient can withstand some amount of the blood loss.
♦  High-risk patients who are likely to develop postpartum hemorrhage (such as twins, hydramnios, grand multipara, APH, history of previous PPH, severe anemia) are to be screened and delivered in a well-equipped hospital.
♦  Blood grouping should be done for all women so that no time is wasted during emergency.
♦  Placental localization must be done in all women with previous cesarean delivery by USG or  MRI  to  detect placenta accreta or percreta.
♦  All women with prior cesarean delivery must have their placental site determined by ultrasound/MRI to determine morbid adherent placenta.
♦  Women with morbid adherent placenta are at high risk of PPH.  Such a  case should be delivered by  a senior obstetrician. Availability of blood and/or blood products must be ensured  beforehand.  Multidisciplinary   team approach should be made in such a case.
■   Intranatal
♦  Active management of the third stage, for all women in labor should be a routine as it reduces PPH by 60%.
♦  Cases with induced or augmented labor by oxytocin, the infusion should be continued for at least one hour after the delivery.
♦  Women delivered by cesarean section, oxytocin 5 IU slow  IV is to be given to reduce blood loss. Carbetocin (long-acting oxytocin) 100 mg IV (to be given over  1 minute), is very useful to prevent PPH.
♦  Exploration of  the uterovaginal canal for evidence of  trauma  following  difficult  labor  or  instrumental delivery.
♦  Observation for about two hours after delivery to make sure that the uterus is hard and well contracted before sending her to ward.
♦  Expert obstetric anesthetist is needed when the delivery is conducted under general anesthesia. Local or epidural anesthesia is preferable to general anesthesia, in forceps, ventouse or breech delivery.
♦  During cesarean section  spontaneous separation and delivery ofthe placenta reduces blood loss (30%).
♦  Examination of the placenta and membranes should be a routine to detect at the earliest any missing part.
All said and done, it is the intelligent anticipation, skilled supervision,   prompt   detection   and  effective  institution of therapy that can prevent a normal case from undergoing disastrous consequences.

I MANAGEMENT OF THIRD-STAGE BLEEDING

The principles in the management are:
■   To  empty  the  uterus  of  its  contents  (removal  of placenta) and to make it contract.
■   To replace the blood. On occasion, patient may be in shock. In that case patient is managed for shock first.
■   To ensure effective hemostasis in traumatic bleeding.


STEPS OF MANAGEMENT
a  Placental site bleeding	11   Traumatic bleeding Placental site bleeding
■   To palpate the fundus and massage the uterus to make it hard. The massage is to be done by placing four fingers behind the uterus and thumb in front. However, if bleeding continues even after the uterus becomes hard, suggests the presence of genital tract injury.
■   To start crystalloid solution (normal saline or Ringer's solution) with oxytocin (1 L with 20 units) at 60 drops per  minute and to arrange for blood transfusion,  if necessary.
■   Oxytocin 10 units IM or methergine 0.2 mg is given intravenously. Carbetocin, a longer acting oxytocin derivative is found (100 µg)  as effective as oxytocin infusion.
■   To catheterize the bladder.
■   To give antibiotics (Ampicillin 2 g and metronidazole 500 mg IV}.
During  this  procedure,   if  features  of  placental separation are evident, expression of the placenta is to be done either by fundal pressure or controlled cord traction method. If the placenta is not separated, manual removal of placenta under  general anesthesia is to  be  done (Flowchart 28.1). In case the patient is in shock, she is resuscitated first before undertaking manual removal. If the patient is delivered under  general anesthesia, quick manual removal of the placenta solves the problem. In cases where oxytocin 10 units is given IM with the delivery of the anterior shoulder, manual removal is done promptly when two attempts of controlled cord traction fail. Placenta is normally separated and is delivered within 5 minutes of delivery of the baby in 50% of the cases and within 15 minutes in 90% of cases.
Management of traumatic bleeding: The uterovaginal canal is to be explored under general anesthesia after the placenta is expelled and hemostatic sutures are placed on the offending sites.

STEPS OF MANUAL REMOVAL OF PLACENTA (MRP)

Step-I: The operation is done under general anesthesia. In extreme urgency where anesthetist is not available, the operation may have to be done under deep sedation with 10 mg diazepam given intravenously. The patient is placed in lithotomy position. With all aseptic measures, the bladder is catheterized.
Step-II: One hand is introduced into the uterus after smearing with the antiseptic solution in cone-shaped manner following the cord, which is made taut by the other hand (Fig. 28.1 ). The fingers of the uterine hand should locate the margin of the placenta.
Step-III: Counterpressure on the uterine fundus is applied by the other hand placed over the abdomen. The abdominal hand should steady the fundus and guide the movements of the fingers inside the uterine cavity until the placenta is completely separated.
Step-IV: As soon as the placental margin is reached, the fingers are insinuated between the placenta and the uterine wall with the
Chapter 28: Complications of the Third Stage of Labor

Flowchart 28.1:  Scheme of management of third-stage hemorrhage  (The Golden "1  hour").

I	Management	I
• Control the fundus, massage and make ii hard.
• Injection methergine 0.2 mg IV injection; carbetocin 100  19 IV. • To start normal saline drip with oxytocin and arrange for blood
transfusion.
• Catheterize the bladder.
!	!
Placenta separated	Not separated
l

Express the placenta out	Manual removal under GA by controlled cord traction                                                                                                                   j
t
Traumatic hemorrhage should be tackled with sutures.



back of the hand in contact with the uterine wall. The placenta is gradually separated with a sideways slicing movement of the fingers, until whole of the placenta is separated (Figs. 28.2A and B).
Step-V: When the placenta is completely separated, it is extracted by traction of the cord by the other hand. The uterine hand is still inside the uterus for exploration of the cavity to be sure that nothing is left behind.
Step-VI: Intravenous methergine 0.2 mg is given and the uterine hand is gradually removed while massaging the uterus by the external hand to make it hard. After the completion of manual removal, inspection of the cervicovaginal canal is to be made to exclude any injury.
Step-VII: The placenta and membranes are inspected for completeness and be sure that the uterus remains hard and contracted. Intravenous (IV) antibiotic is given at the time of Manual Removal of Placenta (MRP).
Difficulties: (1) Hour-glass contraction leading to dificulty in introducing the hand, (2) Morbid adherent placenta which may cause difficulty in getting to the plane of cleavage of placental separation. In such a case placenta is removed gently in fragments using an ovum forceps.
Complications: (1) Hemorrhage due to incomplete removal; (2) Shock; (3) Injury to the uterus; (4) Infection; (5) Inversion (rare); (6) Subinvolution; (7) Thrombophlebitis; (8) Embolism. In such














Fig. 28.1: Introduction of the hand into the uterus in a cone-shaped manner following the taut umbilical cord.

cases, placenta is removed in fragments using an ovum forceps or a flushing curette.

MANAGEMENT OF TRUE POSTPARTUM HEMORRHAGE

PRINCIPLES: Simultaneous approach ■  Communication
11    Resuscitation Monitoring
11    Arrest of bleeding.
It is essential in all cases of major PPH (blood loss >1000 mL or clinical shock) (RCOG-2009).
The Golden "I hour" is the time at which resuscitation must be started to ensure best chance of survival. The probability of survival decreases sharply after the first hour if the patient is not effectively resuscitated.
■  Shock  Index  (SI)  is  used  as  a  valuable  guide  in monitoring and general management of a woman with PPH.  It is calculated: dividing the Heart Rate (HR) by
















Figs. 28.2A and B: The placenta is separated by: (A) Keeping the back of the hand in contact with the uterine wall; (Bl With slicing movements of the hand.
Chapter 28: Complications of the Third Stage of Labor


■   Fall of Systolic Blood Pressure (SBP) by 30 mm Hg. ■   Rise in heart rate by 30 beats/minute.
■  Rise in respiratory rate >30 breaths/minute. ■  Drop of hemoglobin or hemato.crit by 30%. ■   Fall of urine output <30 ml/hr.
■  With these observations, the patient has lost at least 30% of her blood volume. She is in moderate shock leading to severe shock.

SBP. The normal value is 0.5-0.7; however, with major hemorrhage it increases to 0.9-1.1. Change in SI is a better indicator to suggest early acute blood loss than the HR, SBP or DBP, when used alone.
MANAGEMENT
Immediate measures are to be taken by the attending house officer (doctor/midwife).
■   Call for extra help-involve the obstetric registrar (senior staff) on call.
■   Put in two large bore ( 14-gauge) intravenous cannulas. ■   Keep patient flat and warm.
■   Send blood for full blood count, group, cross-matching, diagnostic  tests  (RFT,  LFT),  coagulation  screen, including fibrinogen and ask for 2 units (at least) of blood.
■   Infuse rapidly 2 liters of normal saline (crystalloids) or plasma substitutes like haemaccel (colloids), an urea­ linked gelatin, to re-expand the vascular bed. It does not interfere with cross-matching (Flowchart 28.2).
■  Give oxygen by mask 10-15 L/min.
■   Start 20-40 units of oxytocin in 1 L of normal saline IV at the rate of 20-40 drops per minute. Transfuse blood as soon as possible.
■   One midwife/rotating houseman should be assigned to monitor the following-(i) Pulse, (ii) Blood pressure, (iii) Temperature, (iv) Respiratory rate and oximeter (Box 28.1), (v) Type and amount offluids (blood, blood products) the patient has received, (vi) Urine output (continuous catheterization),  (vii) Drugs-type, dose and time, (viii) Central venous pressure (when sited).
I ACTUAL MANAGEMENT



missing cotyledon or piece of membranes. If the uterus fails to contract, proceed to the next step.
Step-II: The uterus is to be explored under general anesthesia.  Simultaneous  inspection  of  the  cervix, vagina especially the paraurethral region is to be done to exclude coexistent bleeding sites from the injured area. In refractory cases:
■  Injection 15 methyl PGF2cr  250 µg IM in the deltoid
muscle every 15 minutes (up to maximum of 2 mg). OR
11   Misoprostol (PGE1) 1000 mg per rectum is effective.
■  Injection tranexamic acid 0.5 g or 1 g IV may be given in addition to oxytocin.
11    When uterine atony is due to tocolytic drugs, calcium gluconate (1 g IV slowly) should be given to neutralize the calcium blocking effect of these drugs.
Step-III: Uterine massage and bimanual compression.
Procedures: (a) The whole hand is introduced into the vagina in cone-shaped fashion after separating the labia with the fingers of the other hand, (b) The vaginal hand is clenched into a fist with the back of the hand directed posteriorly and the knuckles in the anterior fornix, ( c) The other hand is placed over the abdomen behind the uterus to make it anteverted, (d) The uterus is firmly squeezed between the two hands (Fig. 28.3). It may be necessary to continue the compression for a prolonged period until the tone of the uterus is regained. This is evidenced by absence of bleeding if the compression is released.
During the period, the resuscitative measures are to be continued. If, in spite of therapy, the uterus remains refractory and the bleeding continues, the possibility of blood coagulation disorders should be kept in mind and massive fresh whole blood transfusion should be given until specific measures can be employed. However, with oxytocics and blood transfusion, almost all cases respond well.  Uterine  contraction  and  retraction  regain  and



♦  Atonic
♦    Retained tissues


♦  Traumatic
♦    Coagulopathy (p. 580)

The first step is to control the fundus and to note the feel of the uterus. If the uterus is flabby, the bleeding is likely to be from the atonic uterus. If the uterus is firm and contracted, the bleeding is likely of traumatic origin.
Atonic uterus: Step-I: (a) Massage the uterus to make it hard and express the blood clot,  (b) Methergine 0.2 mg is given intravenously, (c) Injection oxytocin drip is started (10 units in 500 mL of normal saline) at the rate of 40-60 drops per minute, (d) Foley catheter to keep bladder empty and to monitor urine output, (e) To examine the
expelled  placenta and membranes,  for  evidence  of	Fig. 28.3: Bimanual compression of the uterus.
Chapter 28: Complications of the Third Stage of Labor     ml Flowchart 28.2: Scheme of management of true PPH.
I Management of True PPH   I





Skill drill for PPH using mannequins for all labor attendants
I	I

Immediate measures
♦ Call for extra help (communication).
♦  Commence IV line with two wide bore cannulas.
+ Send blood for cross-matching tests, coagulations screening, including fibrinogen level and ask for 2 units of blood (at least).
♦ Rapidly infuse normal saline/haemaccel 2 liters till blood is available. • To catheterize the bladder.
+ Top monitor pulse, BP, temperature, output, oximeter every 15-30 minutes. ♦ Body fluid replacement are essential.
♦ Massive transfusion may be necessary.
♦  Volume replacement should be quick and balanced. Crystalloid (warmed and isotonic) up to 2 L; colloid up to 1-2 L; cross-matched blood; FFP: 4 units for every 6 units of PRBC. Platelets (if count <SO x 109/L) and cryoprecipitate (if fibrinogen <1 g/L). This reduces the risk of dilutional coagulopathy.
+ lntraoperative Cell Salvage (IOCS) could be done where the anticipated blood loss is to cause anemia or expected to exceed 20% of the estimated blood volume.



To feel the uterus by abdominal palpation

■ Uterus atonic

• Massage the uterus to make ii hard.
• To add oxytocin 10-20 units in 500 ml of normal saline, at the rate of 40 drops per minute.
•  Injection methergine 0.2 mg IV (slowly). •  To examine the expelled placenta.


 
Uterus hard and contracted
l
l

Traumatic

Exploration

Hemostatic sutures on the tear sites


■ Uterus remains atonic	Commonly used oxytocics in the management of PPH
• E,ploraUoo of the "'""'	Drug	Dose	Route	Dose	Side	Contra-
1
• Blood transfusion	frequency	effects	indications
• To continue oxytocin drip	+Nausea	Not as IV
Oxytocin
First line:	Continuous
10-40
units in 1 L of
■ Uterus atonic (medical management)	IV;	IV	+Water	bolus,
• 15 methyl PGF    250 µg	crystalloid	Second	intoxication	otherwise
2a
none
line: IM
I M/intramyometrial	solution	(10 units)	• Hyponatremia
cerebral
edema,
OR
• Misoprostol 100 µg per rectum	convulsions
OR
• Hypertension
• Carbelocin 100 pg IM/IV	Methergine	0.2 mg	IM/IV; ne:	hours 2-4	+Vomiting	• Pre-eclampsia
Nausea
+
Every
First li
• Tranexamic acid 1 g IV (WHO)	Second	• Hypertension
i
j •
Uterus atonic	line: PO
15 methyl	0.25 mg	First line: IM;	Every	+Nausea	+Bronchial
PGF
Uterine tamponade (mechanical)	,.	Intrauterine :	15-90 min	+Vomiting	• Active cardiac,
Second line
asthma
(8 doses
+
Diarrhea
Ballooo lampoaade (Fig. 28.4(	maximum)	renal or hapatic • Bimanual compression (Fig. 28.3)
disease
• Tight intrauterine packing under	Misoprostol	600-1000 (19       First line: SL;	Single dose	+Fever	None
anesthesia
l
(PGE,)
Uterus atonic	(Table 34.6,	Second line: PR	• Tachycardia
■ Uterine arterial	p. 468)
embolization	Tranexamic	1 g in 10 ml	IV	30 min	Avoid in patients
with history of
■ Surgical methods	Acid (TXA)	VTE. Stepwise uterine devascularization, procedure                                          -
Bleeding controlled
• B-Lynch compression and multiple square sutures (Figs. 28.5A and B)
• Ligation of uterine artery and utero-ovarian anastomotic
♦ Continuous observation
-    in high dependency unit/ICU
vessels unilateral or bilateral (Fig. 28.6)
(any method)   • Ligation of anterior division of internal iliac artery
• Angiographic arterial lembolization with gelatin sponge	♦ Documentation of procedures
(unilateral or bilatera )
done in respect to time

• Hysterectomy: Sooner rather than later in cases with placenta accreta or uterine rupture. It may be reasonable to proceed for Hysterectomy after 3 doses of failed PGF ••
2
I	Guidelines for management of PPH: RCOG, FIGO and  ACOG	I
ID Chapter 28: Complications of the Third Stage of Labor

bleeding stops. But in rare cases, when the uterus fails to contract, the following may be tried desperately as an alternative to hysterectomy.
Step-IV: Uterine tamponade:
(a)  Tight intrauterine packing is done uniformly under general anesthesia.
Procedure: A 5 meters long strip of gauze, 8 cm wide folded twice is required. The gauze should be soaked in antiseptic cream before introduction. The gauze is placed high up and packed into the fundal area first while the uterus is steadied by the external hand. Gradually, the rest of the cavity is packed uniformly so that no empty space is left behind. A separate pack is used to fill the vagina. An abdominal binder is placed. Intrauterine plugging acts not only by stimulating uterine contraction but exerts direct hemostatic pressure  (tamponade effect) to the open uterine sinuses. Antibiotic should be given and the plug should be removed after 24 hours.
Intrauterine  packing is useful  in a case of uncon­ trolled postpartum hemorrhage where other methods have failed and the patient is being prepared for transfer to a ter­ tiary care center.
(b) Balloon tamponade (Fig. 28.4): Tamponade using various types of hydrostatic balloon catheter has mostly replaced uterine packing. Mechanism of action is similar to uterine packing. Foley catheter, Bakri balloon, Condom catheter or Sengstaken-Blakemore tube is inserted into the uterine cavity and the balloon is inflated with normal saline (200-500 mL). It is kept for 4-6 hours. It is successful in atonic PPH. This can avoid hysterectomy in 78% cases. It is considered the first line surgical intervention for most women with atonic PPH.
Other  measures:  ♦   A  non-pneumatic antishock garment  may  be  used  when  the  patient  is  being transferred  to  a  referral  center.   ♦   Compression  of the abdominal aorta may be a temporary but effective



















Fig. 28.4: Uterine tamponade using Bakri balloon.


measure. This allows time for resuscitation and volume replacement before any surgical intervention is done.
Step-V: Uterine Artery Embolization (UAE) (bleeding vessel)  under  fluoroscopy  (interventional  radiology) can be done using gelfoam. Success rate is more than 90% and it avoids hysterectomy. Internal iliac arterial balloons and catheters are also used.
Gelatin sponge (gelfoam) particles are injected into the bleeding vessel ( uterine artery or internal iliac vessels). Advantages are: (a) bleeding is controlled, (h) uterus is preserved and (c) future fertility is restored. Complication rate is less (3-5%).
Step-VI:   Surgical  methods  to  control  PPH   are many. An outline of stepwise uterine devascularization procedures are given below:
(a) B-Lynch compression suture (1997) and multiple square sutures: Both these surgical methods work by tamponade  (like bimanual compression) of  the  uterus (Figs. 28.5A and B). Success rate is about 80% and it can avoid hysterectomy. No. 1 catgut suture is used.
(b) Ligation of uterine arteries-the ascending branch of the uterine artery is ligated at the lateral border between upper and lower uterine segment. The suture (No. 1 chromic) is passed into the myometrium 2 cm medial to the artery (Fig. 28.6). In atonic hemorrhage, bilateral ligation is effective in about 75-90% of cases.
(c)  Ligation  of  the  ovarian  and  uterine  artery anastomosis, if bleeding continues, is done just below the ovarian ligament (Fig. 28.6). Rarely temporary occlusion of the ovarian vessels at the infundibulopelvic ligament may be done by rubber-sleeved clamps.
(d)  Ligation of anterior division of internal iliac artery ( unilateral or bilateral)-reduces the distal blood flow. It helps stable clot formation by reducing the pulse pressure up to 85%. Due to extensive collateral circulation, there is no pelvic tissue necrosis. Bilateral ligation (not division) can avoid hysterectomy in about 50% of the cases (Figs. 28.7 A and B).
Step-VII: Hysterectomy-rarely uterus fails to contract and bleeding continues in spite of the above measures. Hysterectomy has to  be considered involving  a second consultant. Decision of hysterectomy should be taken earlier in a parous woman. It is a life-saving measure. Depending on the case, it may be subtotal or total.










Figs. 28.SA and B: B-Lynch brace suture for control of atonic PPH.
Chapter 28: Complications of the Third Stage of Labor     DJ

Common iliac artery


ar
m
1
r,1.,,,,_   1 f: :   } i    al










Fig. 28.6: Ligation of the uterine artery and utero-ovarian artery (absorbable suture materials should be used).

Tranexamic  acid  is  an  anti-fibrinolytic  agent.  It prevents activation of plasminogen to plasmin. It reduces blood loss significantly (WHO).
TRAUMATIC PPH: The trauma to the perineum, vagina and the cervix is to be inspected under  good  light by speculum  examination  and hemostasis is  achieved by appropriate  catgut  sutures.  The  repair  is  done  under general anesthesia, if necessary.
Skill drill for management of PPH management for all birth attendants is essential to improve outcome.
Documentation of all measures adopted in respect of time should be done.
Read more Dutta's Clinics in Obstetrics, Ch. 12, 13, 14, 47, 48, 49.
!ll
ft     
!j•

SECONDARY POSTPARTUM HEMORRHAGE

CAUSES,  The  late  bleeding  usually  occms between 8th  and 14th day of delivery. The
causes  of  late  postpartum   hemorrhage	.
"i
are:   (1)   Subinvolution   of  the   placental	'-'   ·•· bed. (2) Retained bits ofcotyledon or membranes (most common);  (3)  Infection and separation of slough over a deep cervicovaginal laceration;  (4) Endometritis and subinvolution   of  the  placental  site-due  to  delayed healing    process;	(5)    Seconda1y    hemorrhage    from cesarean section wound usually occurs between 10 and 14 days. It is commonly due to-(a) separation of slough exposing a bleeding vessel, or (b) from granulation tissue; (6)  Withdrawal  bleeding  following  estrogen  therapy for suppression of lactation; (7) Other rare causes are: chorionepithelioma-occurs  usually  beyond   4   weeks of delivery; carcinoma cervix; placental polyp; infected fibroid,  uterine  arteriovenous  fistula  formation  and puerperal inversion of uterus.
DIAGNOSIS: The bleeding is bright red  and of varying amount.  Rarely,  it may be  brisk.  Varying  degrees  of anemia and evidences of sepsis are present. Internal

Lateral sacral
External
iliac artery	- I
External	Internal  Ureter ..	riliac vein    iliac artery
n
Figs. 28.7A and B: (A) Ligation of the internal iliac artery (right sided).  It  is  done  below  the  origin  of  the  posterior  division (anterior division); (B) Dissection of the hypogastric artery (right) and passage of silk threads with a right angle forceps. The internal iliac artery is gently lifted up with a Babcock's forceps. The artery is tied (with No. 1  slik) at two places and the artery is not transected in  between the  ties.  Pulsation  of  the branches of  external  iliac artery must be checked before and after the procedure.

examination  reveals evidences of sepsis,  subinvolution of  the  uterus   and  often  a  patulous  cervical   os. Ultrasonography is useful in detecting the bits of placenta inside the uterine cavity.
MANAGEMENT
Principles:
•  To assess the amount of blood loss and to replace it (blood transfusion).
•  To find out the cause and to take appropriate steps to rectify it.
Supportive therapy: (I) Blood transfusion, if necessaiy; (2)  To  administer  methergine  0.2  mg  intramuscularly, if the bleeding is uterine in origin;  (3) To administer antibiotics (clindamycin and metronidazole) as a routine.
Conservative: If the bleeding is slight and no apparent cause is detected, a careful watch for a period of 24 hours or so is done in the hospital.
Active  treatment:  As  the  most  common   cause  is due to retained bits of cotyledon or membranes, it is preferable to explore the uterus urgently under general anesthesia.  One  should  not  ignore the small  amount of bleeding;  as unexpected alarming hemorrhage may follow  sooner  or later. The  products are removed by ovum forceps. Gentle curettage is done by using flushing curette.  Methergine  0.2  mg  is  given  intramuscularly. The materials removed are to be sent for histological examination.