Normal Labor PDF

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation
Normal Labor
Anatomy of female pelvis

False pelvis: so called because of no obstetric importance. True pelvis: so called because it is concerned with delivery.
The pelvic inlet (Brim):

Boundaries Boundaries: aries:
1. 2. 3. 4. 5. 6. 7. 8. 9. Promontory of sacrum Ala of sacrum Sacroiliac joint Ilio-pectineal line Ilio-pectineal eminence Upper border of superior pubic ramus Pubic tubercle Pubic ramus Upper border of symphysis pubis.
Diameters:
Anatomical anteroantero-posterior: (11 cm in average) o The widest antero-posterior diameter. o From the anatomical point of view. o Has no obstetric importance as it doesn't take into consideration the THICKNESS of symphysis pubis. Obstetric conjugate: (10.5 (10.5 cm in average) o It is of obstetric importance as it takes into consideration the thickness of symphysis pubis. o It is the diameter through which head of fetus passes. Diagonal conjugate: (12.5 (12.5 cm in average) o Is not an indicator on the inlet. o Importance: a) The only diameter that can be measured by examination. b) Gives an idea about obstetric and anatomical conjugate diameters. c) Can give an idea whether the pelvis is wide or narrow, allowing doctor to choose method of delivery. o Steps to measure it: a) Use the index and middle fingers to do PV examination for the pregnant woman. b) Push the vaginal wall till u reach promontory, with the lateral aspect touching the lower border of symphysis pubis.
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o
Results:
a) If you feel promontory narrow pelvis Cesarian section (CS) b) If you can't reach promontory (normally can't be reached) measure with a ruler then subtract 1.5 cm (the outcome is anatomical antero-posterior diameter) or 2 cm (the outcome is obstetric diameter) determine whether vaginal delivery or CS. c) If u feel the head of the fetus engagement or on the way to it. Anatomical transverse (13 (13 cm in average) o Not available for the fetus because it is NOT central, fetus head may hit the promontory. Obstetric transverse (12 (12 cm in average) o Bisects anatomical antero-posterior. Oblique diameter: o 2 oblique diameters o Called according to the sacro-iliac joint o RT oblique > LT oblique (LT oblique is limited by the pelvic colon which is present on the left, has no mesentery so it is not fixed)
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Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation The pelvic outlet: outlet:
Shape: Diamond Lozenge shaped???? Boundaries of anatomical outlet: Boundaries of obstetric outlet: Diameters:
AnteroAntero-posterior: (11 cm in average, 13 cm during delivery) o In case of delivery, the coccyx moves backwards, so the AP diameter increases. Transverse: o Bispinous (10.5 cm) o Bituberous (11 cm)
The pelvic cavity:

Shape Inlet (transverse oval) Mid cavity (rounded) (rounded) Outlet (longitudinal oval) Length (AP diameter)
11 cm 12.5 cm 13 cm
Width (transverse diameter)

13 cm 12.5 cm 11 cm
Passage of baby
Head passes IN through the transverse Rotation occurs in this plane Head passes OUT through the antero-posterior
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Plane of mid cavity:
Rounded. Diameter: 12 cm. Rotation of head of fetus occurs in this plane.
Axis of pelvis: Anatomical axis:

A curve connecting mid points of all antero posterior diameters. C shaped.
Obstetric axis:
- Direction taken by the head during its passage through the pelvis. - Downwards and backwards until level of ischial spine then downwards and forwards.
'Anatomical & obstetric axes'
'pelvic cavity'
Anatomy of fetal skull

Vault in fullfull-term is formed of individual bones: 2 frontal, 2 parietal, 2 temporal and
1 occipital.
Obstetrical definitions:
Lie: - Lie is according to adaptation and uterus shape. Attitude: - Fetus moves normally, and returns to FLEXION attitude. - Why flexion attitude? Because the length of the uterus is 35 cm & length of the fetus is 50 cm, so the fetus tries to adapt to this length.
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Presentation:
Presentations Cephalic Vertex Face Brow Breech Shoulder
- The ONLY NORMAL presentation is VERTEX presentation. (NOT all cephalic) Position: - It is the direction of the back of the fetus in relation to the back of the mother. - NORMAL position is when the back of the fetus is directed forwards [occipito-anterior whether RT or LT] i.e. If the back of the fetus is directed backwards, so it is abnormal position. - Why the normal position is that the back is directed forwards? So that the concavity of the fetal spine FITS into the convexity of the maternal spine. As pregnant women are normally in a state of lumbar lordosis.
Denominator: - The landmark of the presenting part. - According to the presentation. Stations: level of head of fetus in the pelvis. - When the biparietal diameter of the head of the fetus is at the level of the pelvic inlet [the head is engaged], the lower most part of the head is [felt by PV examination] is at the level of ischial spine. This is called station 0(zero). - If you feel the lowermost part of the head of the fetus [by PV] below the level of ischial spine by 1 cm, the head is ENGAGED. [The Biparietal diameter (widest transverse) of head of fetus is below the level of the inlet by 1 cm.] This is called station +1. - There are 7 stations:
Stations
-3 (floating) -2 -1 0 +1
Lower most part of head of fetus

Above ischial spine by 3 cm Above ischial spine by 2 cm Above ischial spine by 1 cm At level of ischial spine below ischial spine by 1
Biparietal diameter
Above plane of pelvic inlet by 3 cm Above plane of pelvic inlet by 2 cm Above plane of pelvic inlet by 1 cm At plane of pelvic inlet Below plane of
Engagement
Not engaged Not engaged Not engaged Engaged Engaged
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cm +2 +3 (deeply engaged) below ischial spine by 2 cm Below ischial spine by 13 cm pelvic inlet. Below plane of pelvic inlet. Below plane of pelvic inlet. Engaged Engaged
Asynclitism: (opposite of synclitism, no synclitism)

Synclitism: the 2 parietal bones of the fetus are on the same level. Asynclitism: the 2 parietal bones of the fetus are NOT on the same level, one parietal bone is at a lower level than the other. Etiology: The head of the fetus is tilted because of pelvic inclination, as pelvic inlet is not parallel to the horizontal plane, but the pelvic inlet makes an angle of 55 degrees with horizontal plane. So, head of fetus is tilted with this inclination.
Nomenclature, classification: - In multigravida: o Anterior abdominal muscles are weak (due to multiple pregnancies) Parietal bone of fetus related to anterior abdominal wall (anterior parietal bone) is at a lower level. As the anterior parietal eminence is at a lower level, this is called anterior parietal bone presentation. [Presentation is the lower most part of the fetus]. It is also called POSTERIOR Asynclitism, as the sagittal suture is directed posteriorly. o o When anterior parietal bone passes through inlet, then post. Parietal bone tries to pass & moves to a lower level, this is called correction of asyclitism. In correction of asynclitism in case of anterior parietal bone presentation, the posterior parietal bone meets the resistance of promontory which is short, so correction of asynclitism in case of anterior parietal bone presentation is easier.
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- In primigravida: o Anterior abdominal muscles are strong (no previous pregnancies), so anterior parietal bone (related to strong abdominal muscles) is at a higher level & posterior parietal bone is at a lower level, so this is called posterior parietal bone presentation [presentation is the lower most part of fetus]. It is also called anterior asynclitism as the sagittal suture is directed anteriorly. o When posterior parietal bone passes through inlet, then the anterior Parietal bone tries to pass, and moves to a lower level, this is called correction of asyclitism. o In correction of asynclitism in case of posterior parietal bone presentation, the anterior parietal bone meets the resistance of symphysis pubis which is long (3 cm), so correction of asynclitism in case of posterior parietal bone presentation is more difficult.
Which asynclitism is more favorable? o Anterior parietal bone presentation is more favorable. Anterior parietal bone presentation 1. Correction of asynclitism is easier as it meets resistance of promontory (short) 2. Baby is tilted forwards, so direction of contraction (direction of descent of fetus) is typically perpendicular to plane of pelvic inlet. [the same direction of axis of pelvis] 3. It occurs in multigravida, in whom labor is easier. Posterior parietal bone presentation Correction of asynclitism is easier as it meets resistance of symphysis pubis (long) Direction of contraction (direction of descent of fetus) is NOT typically perpendicular to plane of pelvic inlet. It occurs in primigravida, in whom labor is more difficult.
Importance of asynclitism: o Asynclitism facilitates angagement, as in asynclitism, one parietal bone is at a lower level than the other, so the diameter that passes through the inlet is superparietal subparietal
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diameter (9 cm) NOT the biparietal diameter (9.5 cm) [smaller diameter that passes through inlet.]. .
What's meant by labor?

-
Normal Labor
Normal labor:
a) Single
Means work / generation of movement against resistance.
Normal labor, fetus being:

b) Mature (37 weeks) c) Spontaneous d) Vertex presentation e) Viable f) Occipito-anterior g) Without interference (P.S. episiotomy is not considered interference, it is done a lot so it is considered 'routine') h) Without complications to mother or fetus i) j) Vaginal (through birth canal) Within 24 hours (never more than 24 hours)
Abnormal
Twins/ triple (even if vaginal) Before 37 weeks (8th month) even if with no abnormality / something to stimulate uterine contractions Any other presentation than vertex, even if face or brow
i.e. forceps
e.g. maternal intrapartum hge / fetal intracranial hge Cesarean section Prolonged labor
Theories of onset of labor:

Why does a pregnant woman give birth at a specified time? Why the uterus remains silent for 9 months then starts contractions in a specified time? Prostaglandins: Acts as local hormone (works where it is formed and produced) Formed in deciduas (endometrium of pregnancy) Action: 1) Stimulate uterine contractions 2) Makes cervix soft and dilated
Clinical applications: 1) If a pregnant lady is behind her delivery date , give her a PG suppository to induce labor
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2) A woman pregnant in 28 weeks (7th month) and give her anti-prostaglandin to delay labor until fetus is mature. Progesterone withdrawal: Pro = before, gesterone = gestation () progesterone
EstrogenEstrogen- progesterone theory: By the end of pregnancy, as delivery date is approached, the estrogen increases, therefore, relatively progesterone decreases. Estrogen - oxytocin: Formed and produced from posterior pituitary. Action: stimulates uterine contractions. Oxytocin is present during the whole period of pregnancy, but not working, oxytocin receptors have to be present on uterine muscles so that it can work. At the end of pregnancy, estrogen increases (and progesterone relatively decreases), estrogen increases the number of oxytocin receptors on uterine muscles, so the oxytocin (that was already present during the whole period of pregnancy) can work on uterine muscles, and cause uterine contractions. Clinical application: application: A woman pregnant in the 9th month. Same dose of oxytocin. Oxytocin has Great effect more receptors. Fetal suprarenals: When the fetus completes 37 weeks and becomes mature, the fetal supra-renals start producing DHEAS in increasing amounts. The DHEAs passes through the umbilical cord and reaches placenta, in placenta, DHEA converts into estrogen, estrogen increases, so progesterone relatively decreases. The large amount of estrogen increases number of oxytocin receptors in the uterine muscles. So the oxytocin (which is present during the whole period of pregnancy), works on receptors inducing uterine contractions and labor starts. Diagram: Diagram: A woman pregnant in the 5th month. Same dose of oxytocin. Oxytocin has a Minimal effect minimal receptors.
estrogen Relatively progesterone oxytocin receptors utrine contractions oxytocin acts
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- Anencephaly: The fetus is born without vault of the skull brain is exposed brain atrophy including pituitary atrophy NO ACTH from pituitary NO DHEAS from fetal supra-renals no estrogen rise no increase in oxytocin receptors no induction of labor maturation occurs without labor labor delayed sometimes till the 10th month. Clinical application: If you see anencephaly with ultrasound, Termination of pregnancy should be done as the fetus never survives. (No need to exhaust the mother when the fetus is known to die). Uterine distension: - Starling law: when a muscle is stretched, it contracts but within limits. - Why labor occurs only in the 9th month, when stretch is present during the whole period of pregnancy? o Because during the period of pregnancy, the rate of increase in fetal size = rate of increase in uterus size. o In the 9th month, rate of fetal size enlargement is more than the rate of increase in size of uterus stretch of uterine muscles contraction and labor. Clinical application: According to starling law and uterine distension theory: These cases do not reach maturity (37th week): 1) Twins 2) Triples (33 weeks) 3) Polyhydramnios Placental ischemia: During the period of pregnancy, placenta produces oxytocinase which breaks oxytocin. Late in pregnancy, when the placenta is old ( )oxytocinase formation by the placenta decreases, so oxytocin level increases. Stretch of the lower uterine segment.
Prostaglandin theory is the most important one
Forces of labor:
A. Uterine contractions and retractions: Mechanism: When any muscle contracts, it becomes shorter & thicker. After relaxation, it returns to the same thickness and length it was before contraction. Uterine muscle(s) have a different character, when it contracts, it becomes shorter and thinner, after relaxation, (no tone in it) it does not return to the same thickness and length it was before contraction.
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How it acts: o Uterus is divided into 2 segments: a) Upper uterine segment (UUS): Where contraction and retraction occurs.Acts as one unit. b) Lower uterine segment (LUS): o o o When the UUS contracts, it becomes shorter & thicker, So, when it contracts, it is pulled upwards, consequently pulling LUS ( )upwards. The LUS becomes thinner & longer, and pulls on the cervix which is already soft and dilated due to prostaglandins (PGs), making labor an easier process.
Character: o Polarity and fundal dominance:. Evidence: Impulses for contractions come from a certain area in the uterus called 'PHYSIOLOGICAL pace maker'. It is called physiological because anatomically it is not different from the rest of the uterus. Co-ordination: Impulses come out at the same time, but with different velocities, so they reach all muscles at the same time, so peak potential occurs in all muscles at the same time, enabling all of them to contract at the same time.
'Polarity & fundal dominance; evidence' -
'physiological pacemaker'
Myometrial physiology: Ca channels o Clinical application: if a pregnant lady shows preterm labor (early uterine contractions), give her calcium channel blocker. But follow her up because this will lower her blood pressure.
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Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation Prodroma of labor:
1) Lightening: : o - regurge to the acidic contents sphincteric action - reflux oesephagitis causing heart burn [although acidity decreases during pregnancy] . dypnea and heart burn o [Relief of upper respiratory tract symptoms] 2) Shelfing: .inlet plane o
3) Pelvic pressure symptoms. 4) Increased vaginal discharge: : o A. Urinary bladder: decreasing capacity increasing frequency of micturition. o Clinical application: it means she will deliver her baby soon o Ask her: do you go to the bathroom a lot? How many times do u go to the bathroom at night? Normally: one time per night. B. Pelvic veins: o Pressure on pelvic veins causes increase in the hydrostatic pressure in lower limb veins transudation increasing ankle edema [already present] o Pressure on pelvic veins causes increase in the hydrostatic pressure in vaginal veins transudation increased vaginal discharge. Pain in pelvic joint: Relaxin is produced during pregnancy causing subluxation of sacro-iliac joint, with increased load, stretch on sacroiliac ligament occurs, causing pain in pelvic joint. N.B. sacroiliac joint and ligament are the strongest joint and ligament in the body 5) False labor pain: . ) ( True labor pain: o o Regular: at regular intervals Gradually increasing in frequency: ....
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o o o o o Gradually increasing intensity: Gradually increasing in duration:
( .. ) Radiates to the back Cervical dilatation (detected by PV) ( ) cervix Expulsion of the show: mucous plug cervix = = = mucous plug Why the mucous plug is streaked with blood? i. ii. There are small blood vessels between decidua and bag of forewaters. UUS undergoes contractions and retractions, so it pulls in the LUS and pulls the deciduas also upwards, causing an increase in intra uterine pressure, which pushes the bag of membranes downwards. So, blood vessels between the deciduas (pushed upwards) and the bag of membranes (pushed downwards) are ruptured leading to slight bleeding. So, the mucous plug becomes streaked with blood.
iii.
N.B. membranes are adherent at the UUS, but loosely adherent at the LUS. Clinical application: " " "" : o " ..... " : o "" regular true labor pain " " : o " " : o " \ \ ": o PV :cervix bag of fore water In case of normal presentation, the head of the fetus separates the bag of fore water from the bag of hind water, so the bag of fore water preserves its shape, sharing in dilatation of the cervix. Unlike that, in malpresentations, the presenting part is not well applied; there is no separation, which increases the load on the fore water leading to early rupture. Conclusion: In malpresentation: (a) early rupture of membranes. (b) Prolonged labor due to deficiency in dilator effect of bag of fore water. : - " " : o
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true labor pain = " " : false labor pain = " " : " " : true labor pain = " " : " " : true labor pain = "... ": true pain " " : false labor pain = " " : . buscopan " : [An antispasmodic (hyoscine) relieves false labor pain, but with no effect on true labor pain] true labor pain = " " : .true false labor pain = " " o o o o o o o
o o o
A. First First stage of labor:

cervix
A. Factors causing dilatation:
1. Uterine contraction and retraction:

UUS contracts and retracts, pulling on LUS, pulling on cervix: cervix opens: Dilatation cervix is pulled and becomes incorporated with LUS, so it shortens: Effacement. [i.e cervix is taken off, also there is some sort of change in cervical consistency]
2. Dilating effect of bag of forwaters:

o o o Upper part of the membranes is adherent to the decidua, while lower part is loosely attached to the deciduas This lower part forms bag of forewater [it is called bag of forewater because it lies infront of head of fetus.] This bag of forewater is pushed by the head of the fetus [which is pushed by contraction and retraction], so the bag of forewater FORCIBELY enters into the cervix causing its dialatation. In normal presentations, the bag of forewater is separated from the bag of hind water [behind head] by the head, so amount of water in bag of forewater in normal presentations is little. In malpresentations, the bag of forewater is continuous with the bag of hind water, so when the cervix is slightly dilated, large amount of water passes from hind water to
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forewater and becomes focused in a small point which can't stand the pressure of water leading to i. Early rupture of membranes [before full cervical dilatation], so the effect of fore water is lost, leading to: ii. Slower rate of cervical dilatation.
normal
'malpresentation'
In malpresentations: higher incidence of: i. ii. Early rupture of membranes Delayed delivery [rate of cervical dilatation is slower]
3. Pressure of the presenting part (vertex) on the cervix and LUS causes reflex augmentation of contractions (Fergusson's reflex) after rupture of membranes. o In malpresentations, presenting parts cause less pressure, less stretch, so, less reflex, leading to less contractions in mal presentations.
4. Changes in cervix: induced by prostaglandins, cervix , so facilitating dilatation and effacement.
B. Pattern:
Dilatation: opening of cervical canal from above downwards.
o Assessment of dilatation:
Steps:
PV cervix
Results:1 finger = 2 cm
closed = ( )cervix tip of finger dilated (1 cm dilated) = ( ) 1 finger dilated (2 cm dilated) = cervix 2 finger dilated (4 cm dilated) = cervix = ( ) cervix Finger dilated (6 cm dilated) 3 - - - - -
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4 finger dilated (8cm dilated) = cervix fully dilated (10 cm dilated) = (5 finger dilated ) cervix - -
How can you detect full cervical dilatation? when u can't differentiate between cervix and LUS, both are continuous with each other. So, they become one part called birth canal. What should you do when you can't find cervix by examination? if you can't fine cervix, this means cervix is fully dilated,
Effacement: shortening of the cervix (pulled upwards) and its incorporation into the lower
uterine segment.
Assessment of effacement:
Steps:
PV -
( . ) cervix -
Results:
:cervix formed = effacement . - 20% effaced = ( .) % - 60% effaced = ( .) % - fully effaced (100% effaced) = - How can you tell cervix is fully effaced? Where thickness of lower uterine segment equals thickness of cervix.
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Assessment of Dilatation 1 finger dilated / 2 cm dilated 4 finger dilated / 8 cm dilated Fully dilated / 10 cm dilated cervix effacement 20% effaced 80% effaced Fully effaced / 100% effaced
effacement or dilatation o o In primigravida Closed/formed In multipara: Closed/formed closed/fully effaced fully dilated/fully effaced fully dilated/fully effaced.
e.g.: 5cm dilated/60% effaced
: In a pregnant woman, cervix is 60% effaced, 5 finger dilated: multipara?? In a pregnant woman, cervix is 100% effaced, 1 finger dilated: primigravida In a pregnant woman, cervix is fully effaced, closed: primigravida In a pregnant woman, cervix is formed, fully dilated: impossible once fully dilated, must be fully effaced (fully dilated) Phases: Freidman curve (name more common) [cervicogram] Rate of cervical dilatation is not constant. Rate of cervical dilatation is not a straight line. Freidman curve: Sigmoid shape: S shaped
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a. latent phase: - Rate of cervical dilatation is slow at the beginning. - Latent phase duration differs between primigravida and multipara. b. active phase: - Once cervical dilatation reaches 3 4 cm, the rate starts to get faster. - Active phase is constant for primigravida and multipara, which is 4 hours. a. Acceleration phase: rate of dilatation is increasing. b. Plane of maximum slope. c. Deceleration phase: rate is starting to decrease. Clinical application: o The rate of cervical dilatation is slow in the beginning, if you dont know this, you might falsely think the rate is actually slow when its not, and give the woman oxytocin, or do a Cesarian Section, which is wrong. o When the active phase starts (cervix 3 or 4 cm dilated), this means there are about 4 more hours (duration of active phase is constant) till the end of labor process. o If the cervix is 3 or 4 cm dilated, and the rate of cervical dilatation is still slow, this means something is wrong.
B.Second B.Second stage of labor:

-
Mechanism of normal labor:

1. descent: due to: a) Contraction and retraction
LABOR IS A PROCESS OF ADAPTATION
b) Auxiliary forces (+ no resistance as cervix is fully dilated and effaced) c) Unfolding of the fetus [uterus length is 35 cm, fetal length is 35 cm folded/55 cm unfolded] when circular muscle fibers of the uterus contract, they push on the back of the fetus (which is flexed and folded), straightening it, increasing fetal length and causing its descent.
2. engagement: The longest diameter of the head of the fetus (which is the antero-posterior diameter) passes through the widest diameter of the pelvic inlet (which is the oblique diameter)
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N.B. as long as the occiput is directed anteriorly (back of fetus to the front), whether right or left, the position is normal. How can the head of the fetus move and adjust itself to enter the pelvic inlet? a) Uterine contraction move the fetus b) Pelvis of the mother moves with her movement, so, the pregnant woman is advised to walk and move in her 9th month of pregnancy to make the entrance of the fetal head into the pelvic inlet easier. Head of fetus engages in RT oblique. This means that the AP diameter of the head of fetus passes through the RT oblique of the pelvic inlet. This means head of fetus engages with the AP diameter passing in the RT oblique. 3. Increased flexion: o Mechanism: a) Head of fetus descends until it reaches pelvic floor (levator ani). b) Head of fetus pushes against pelvic floor, so pelvic floor stretches. By its elasticity, pelvic floor recoils pushing head of fetus upwards.
N.B. elasticity is ability to recoil again after stretch. o Result: When flexion of the head of fetus is increased, the antero-posterior diameter of the head of fetus (related to pelvic cavity) will be the smallest diameter which is suboccipitobregmatic (9.5 cm). Transverse diameter of the head of fetus is biparietal diameter (9.5 cm). So, the part of fetal head related to pelvic cavity will be circular, with a diameter of 9.5 cm.
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4. Internal rotation: o Mechanism: a) Uterine contractions and retraction (and other forces) push the head of the fetus against the levator muscle. b) The head of fetus at this moment is a circle (9.5 cm diameter) in a circular plane (12.5 cm) [plane of mid-cavity], so head can rotate. c) The levator is directed forwards, downwards and medially, so the head of the fetus rotates in the same direction of levator. d) It is called internal because the occiput turns to the inside. o Direction and degrees: a) Direction of internal rotation is the same direction of levator muscle [forwards, downwards and medially]. b) Degree: look diagram:
N.B.; the anterior and posterior shoulders remain in their position after internal rotation.
Occiput becomes below symphisis pubis. 5. extension: o suboccipital region hinges below symphysis pubis, so occiput becomes away from action of uterine contractions and retraction ( not affected by them).
By extension, head of fetus comes out.
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6. Restitution: o When internal rotation occurs, the head rotates 45 degrees downwards, forwards and medially, but the shoulders remain in their place after rotation. o After extension, the head comes out and becomes free, so it restitutes in the opposite direction of internal rotation, so that the fetus becomes coordinated with the shoulders (undo twist of internal rotation).
How can you know the position from restitution? when extension occurs and the head comes out, notice the direction of restitution: If the occiput turns left = LT occipito-anterior. If the occiput turns right = RT occipito-anterior. 7. external rotation of the head and internal rotation of the shoulders: o Head of the fetus must undergo extension and restitution. o If head of the fetus entered the pelvic cavity with its AP diameter passing through the RT oblique [the position is LT occipito-anterior], so the shoulders of the fetus will enter the pelvis in the LT oblique. o The anterior shoulder is the one which enters the pelvis first. It descends until it reaches the pelvic floor. o The shoulders undergo internal rotation in the same mechanism of internal rotation of the head. o Internal rotation of the shoulders leads to external rotation of the head. In other words, external rotation of the head is explained by internal rotation of the shoulder.
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Why the shoulders perform internal rotation, not external rotation: because the anterior shoulder reaches the pelvic floor first. Because the anterior shoulder cuts a shorter distance distance (symphysis pubis), but the posterior shoulder cuts a longer distance (the sacrum), so the anterior shoulder rotates anteriorly internal rotation.
C. Third stage of labor:

o Mechanisms:
Schultz's mechanism
Placenta separates from the centre. So, When the blood vessels are cut, some bleeding occurs, forming a retro-placental hematoma, facilitating the separation of the placenta, making it quicker, and therefore decreasing the bleeding.
Duncan's mechanism
The placenta separates from the lower pole. When the blood vessels are cut, bleeding occurs directly without hematoma (clotting). Placental separation is slower, so more blood is lost.
Placental separation is faster (because hematoma makes separation faster) Less bleeding because placental separation is faster. fetal surface
Placental separation is slower because there is no hematoma, more bleeding because placental separation is slow lower pole
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Looks like an inverted umbrella Descends sliding
Can you control (choose) the method of placental separation? No, because it occurs without interference from the dr. can not be chosen. What stops the bleeding? uterine contractions and retractions squeeze the blood vessels, facilitating the formation of blood clot, stopping the bleeding.
Effect of labor on the mother: 1st stage:

Vital signs in the 1st stage are normal. If the pregnant woman has high temperature during this stage, this is abnormal. If the pulse rate is 100/min during the 1st stage, this is abnormal.
2nd stage:
Unavoidably: a) Pulse, temperature and blood vessels increase. b) Temperature may or may not be increased to 37.5 degrees. c) As a result of straining (bearing down), conjunctival congestion, some times to the extent of conjunctival hge occurs. Clinical application: 2nd stage If the pregnant lady is heart diseased, because in the 2 stage the pulse increases, so the cardiac output increases. If the Pregnant lady suffers from pre-eclampsia, because in the 2nd stage, the blood pressure increases. For theses reasons, doctors should try to decrease the duration of the 2nd stage in these two cases.
nd
Effect of labor on the fetus: a. Molding:

Mechanism: vertex is formed of individual bones so the 2 parietal bones get nearer from each other, then overlap each other and overlap the occiput. advantage: The head of fetus get smaller Disadvantage: if excessive may lead to intracranial hge
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Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation b. Caput succedaneum:
i. Cervical caput:
- Mechanism: Rupture of membranes occurred &there are strong uterine contractions but the cervix is still not fully dilated. So head of fetus is compressed against the cervix (not fully dilated). The compression causes blockage of venous return causing edema (cervical caput) - Characters: size: equal size of cervix at the time of rupture of membranes (small) Significance:
ii. ii.
Pelvic caput:
- Mechanism: The head of fetus is large or the bony pelvis is narrow, so the head of fetus is compressed against bony pelvis, This compression causes blockage of venous return causing edema (pelvic caput). - character:
Size: the size of pelvic caput = size of bony pelvis. Significance:

This caput indicates mechanical obstruction, which may cause uterine rupture and death of fetus, then mother. This caput indicates fast management which is probably cesarean section.
Clinical significance:
You may falsely think that the caput is the head of the fetus. As the caput increases in size, you may think the fetus is descending, although the head might still be at the inlet.
Head delivery has not occurred yet, so u ask the mother to bear down, you use the forceps. LUS ruptures. So, you have to differentiate between caput and head of fetus. How to differentiate between caput and head of fetus? Steps: 1- PV examination 2- Apply firm pressure with your finger on the presenting part. Results: If you feel bone head of fetus. Pitting edema (scalp) caput If you can detect fontanelles and sutures head of fetus. If you can not detect fontanelles and sutures (obscured) caput.
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How to differentiate between cervical caput and pelvic caput? Cervical caput Pelvic caput Occurs in the first stage, cervix is some sort of closed (not fully dilated) Small (size of cervix at time of rupture of membranes) Area around the small caput is normal Occurs in the second stage, after full cervical dilatation. large (size of bony pelvis) Caput is taking large area of scalp
iii. iii.
Artificial caput:
- Mechanism of ventouse (vacuum extractor) . cup caput scalp . caput
- Indication: a. Deflexed head which can not rotate (increased flexion is essential for internal rotation) - Site of application of the cup: Put the cup on the occiput to increase flexion of the head, this increased flexion helps in internal rotation. Vacuum extractor can't be used in intra-uterine fetal death. Because the vacuum works by producing a caput (which is edema). This is a vital process that can not occur in a dead fetus.
Management of normal labor:

Management on admission:
A. Full history: extremely basic, extremely important. - Name, ageetc.. - Gravida, para Gravida: Para: Examples: 3rd gravida, P2 = 3rd gravida, P1 = 2nd gravida, P1 with 2 children = () Primigravida = First day of last menstrual period: // period ) )
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Importance of first day of last menstrual period: to calculate expected date of delivery We add 7days &9months to first day of last period EX: 1st day of LMP 10/6/2006 7/9 EDD 28/12/2006 EX: 1st day of LMP 28/8/2006 7/9 EDD 5/6/2006 EX: 1st day of LMP 30/12/2006 7/9 EDD 6/10/2007 We add 14 or 15 days &9months to 1st day of LMP SIGNIFICANCE OF EXPECTED DATE OF DELIVERY: preterm normal labor Expected delivery date or sonar for date of delivery? EDD is definitely used Sonar is just for confirmation (sonar is used if you are not sure of 1st day of lmp) Sonar just suggest the duration of pregnancy according to the size of fetus. fertilization? intercourse
1st day of LMP Ovulation Fertilization Pregnancy Delivery
2 weeks
24 hrs
38 weeks
weeks) ) = : ovulation& fertilization fertilization +ve pregnancy test : ) B. Reviewing antenatal recording (if available) C. General examination: Height of mother: the more the mother is long the more the pelvis is wide the more the delivery is easy (considering fetus is of average size) vital signs: normal in 1st stage.
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D. Abdominal examination - Fundal level: - How to palpate the fundal level? By the ulnar surface of the lt hand &sweep by this surface till you meet the fundus - determine the level of fundus - Fundal level is handbreadth from xyphysternum at 32weeks& at 40 weeks.
'Different levels of fundus during pregnancy' If the fundal level is handbreadth from xyphysternum how to know whether 32 or 40weeks?? Simply ask the mother or from expected date of delivery Fundal grip: o Steps: 1- Detect the fundal level by the previously discussed steps. 2- Fix fundus by one hand &palpate by the other hand. 3- Palpate &feel what is in the fundus. o Importance: from contents of fundus you can detect presentation. o Results: If the fundus contains something soft (buttocks) so presentation is cephalic If the fundus contains something hard (skull) so presentation is breech. If the fundus contains nothing so presentation is shoulder. umbilical grip: o Steps: palpate the fetus on each side of umbilicus o Importance: from the surface of fetal parts at umbilicus you can detect the position o Results: if you feel convex firm smooth surface at the back of the umbilicus so the back is anterior (position is occipto anterior ) then detect whether the back is directed to the rt or lt (ltor rt occiptoanterior ) - if you feel nods so the back is posterior (position is occiptoposterior) First pelvic grip: o Steps: look at the diagram at page 79 obstetrics book o Importance &results: to make sure of the presentation to know if the head of fetus is engaged or not yet [if you can palpate only small parts of the head (most of the head entered) so the head is engaged.]
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Second pelvic grip: o Steps: look at the diagram Put one hand at the occiput & the other hand at the chin. o importance& results: a. To detect degree of flexion: - if one hand is at the lower level than other hand so the head is well flexed - If both hands are at the same level so the head is deflexed. b. To detect twins. c. To detect fetal heart sounds:
Instruments &equipment used:

i. Penard's stethoscope :
place to put :
if occipto anterior put it on the back of baby at his scapula (as the baby is in flexion altitude so you cant reach heart from front of fetus ) if occipto posterior put it on the flanks of mother (related to back of fetus ) () ii. Doptone (sonicad): is not a microphone it is an ultrasound equipment Normal fetal heart rate is 120-160 beat / min. Abnormal pattern may indicate asphyxia. E. Vaginal (pervaginal) examination: Assessment of pelvic capacity: steps: try to reach promontory of sacrum Importance& results: .to determine whether pelvis is wide enough or narrow . If you can reach promontory by your fingers so pelvis is narrow . If you can't reach promontory by your fingers measure the diagonal diameter (from lower border of symphsis pubis to promontory) by rules. Cervical dilatation &effacement: look 1st stage of labor Exclusion of cord presentation & prolapse: - Normal: there is no loop of cord in front of head of fetus - Abnormal: o A loop of cord proceeding (in front of) the head of fetus o If a loop of cord is preceding the head while membranes are still intact it is called cord presentation (because cord becomes the lowest part of fetus) o If a loop of cords is preceding the head after rupture of membranes it is called cord prolapse.
Membranes: whether intact or ruptured o Intact membranes: (bag of fore water) o Ruptured membranes ( fluid) ( presenting part) - If clear so normal If greenish so meconium staining & this indicate fetal stools which may be due to asphyxia
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presentation: o If you feel posterior fontanelle easily but you can't feel anterior fontanelle so the presentation is vertex o If you feel eyes &nose etc so the presentation is face (may be brow) Position: o The post fontanelle is in the same direction of back so you can detect the position (direction of back) Engagement &station: o Detect the relation between the lowest part of the head of fetus &the level of iscial spine. Degree of deflexion: o If you feel the post fontanelle easily but cant reach the ant fontanelle so the head is well flexed o If you can feel both ant &post fontanelle so the head is deflexed.
Management of the first stage:

1. Asepsis: 2. Observation of 3 items: a. The mother: vital signs: normal or within normal in 1st stage b. The fetus: Fetal heart sounds should be heard by: - Fetal stethoscope or sonicad doptone - Normal fetal heart sounds 120 /160 beats /min c. labor: we should observe progression of labor: - characters of contraction: frequency strength duration - cervical dilatation - descend of the fetus 3. Nutrition: - Mother needs &calories anaesthesia vomiting Inhalation under anaesthesia As source of calories, ) ( - In latent phase: - In active phase: Give her iv glucose as source of calories &line of iv 4. Analgesia / sedation: Importance: - To relieve pain caused by uterine contractions - To relieve anxiety: Pregnant (especially primigravida) may be afraid of labor causing sympathetic stimulation leading to spasm of the cervix so the cervix will not dilate (although contraction is continuous)
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Precautions: a. Excessive sedatives: You should avoid excessive sedatives otherwise may weaken &decrease efficiency of uterine contractions. b. Late administration: you should stop administration &not give sedatives within 2 hours before 2nd stage otherwise sedatives given to mother may pass to fetus causing depression of respiratory centre. This will not affect the fetus intra uterine. But if sedatives is given late depression of respiratory centre of the fetus may continue after birth so the newborn can't breathe
You should give proper sedation: Proper in dose Proper in time
5. Evacuation of bladder& rectum:
Why to evacuate it?

Urinary bladder full urinary bladder causes inhibition of uterine contraction. Full urinary bladder will interfere with engagement &descent of fetus. Rectum full rectum causes reflex inhibition of uterine contraction. When the head of the fetus descends it presses on the rectum causing the feces to come out from rectum causing contamination of episiotomy incision. How to evacuate it? Urinary bladder a- ask the patient to micturate catheter b- Catheter: when mother can't go & micturate try to avoid catheter as it is - Irritable to mother - Carry risk of urinary infection due to contamination of catheter tip from external urethra Rectum By enema (not asking mother to defecate) Enema evacuate rectum totally 6. P.V. examination:
There are are two rules for PV examination

a- Pv should be minimized why? Because PV examination carries risk of intra uterine infection. Incidence of intra uterine infection & puerperium is directly proportional to number of PV examination b- Pv is required at least three times: 1st: on admission for diagnosis of onset of labor 2nd: at rupture of membranes & gush of fluids Mother should be examined rapidly examine it fluids whether there is loop of cord presented or not (cord prolapse presented or not) If there is cord prolapse as the head of the fetus descends the umbilical cord will be compressed between the head of fetus &bony pelvis this may cause fetal death Color of amniotic fluid: Clear: normal Greenish: meconium staining which indicate asphyxia 3rd: with onset of 2nd stage.
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7. Instructions: Intact membranes: if mother wants to walk she can but membranes should be intact. If membranes are ruptured walking may cause flowing out of the amniotic fluid so contractions of uterus will be transmitted directly to the umbilical cord causing stoppage of fluid inside the umbilical cord leading to decreased nutrition of the fetus. On the contrary, with intact membranes, walking should be encouraged as it helps descent & engagement of the head of fetus. Ruptured membranes Mother should not walk Mother should stay rest in bed on her left side Why not on her back?? If mother rest on back the heavy (7-8kg) pregnant uterus will press on IVC decreasing venous return to heart dec. cardiac output dec. perfusion of placenta Dec. oxygen delivery to the fetus Why not on her RT side?? Because pregnant uterus is dextro-rotated Because of sigmoid colon which is present on left side Mother should not not bear down on 1st stage, why? a. Because the cervix is still not full dilated cervix is still closed if mother bears down in 1st stage (with cervix not fully dilated) this will increase intraabdominal pressure causing overstretching of the cervical ligaments (which carry &support uterus) so mother will be liable to develop prolapse after this delivery. b. Mother may get exhausted from useless bearing down in the 1st stage so she may not be able to bear down in 2nd stage (in which bearing down is very important for descend of fetus). 8. Partogram:
Example: what do you conclude from this partogram?
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Example: what do you conclude from this partogram?
Partogram allows proper evaluation
Management of second stage of labor:

Diagnosis
a. full cervical dilatation ( cervix ) b. Reflex bearing down during contraction mother bear down unavoidably When head of fetus reach cervix causes reflex bearing down c. A desire to evacuate the rectum or bladder Explanation: fetus presses on the rectum causing irritation of the rectum causing reflex desire to evacuate
don't allow her to go to WC why?

. She is going to deliver now . The rectum is already evacuated by enema this is just a reflex desire d. Contractions increase in strength & duration: Contractions may last for one minute (very strong) e. Rupture of membranes: Rupture of membranes mostly occurs during the 1st stage It might occur at onset of 2nd stage
In lithotomy position:
Asepsis sterilization of the vulva & perineum: by diluted antiseptic solution application of sterile towels & leggings: (area of vulva exposed) to prevent contamination of the vulva. What is your rule as obstetricians in 2nd stage of normal labor? Nothing except for preventing perineal lacerations Why lacerations of perineum occur? When extension of head of fetus occur. This will cause stretch of the vulva. Value of stretch of vulva is proportional to the circumference of head of fetus. The transverse diameter of fetal head (biparietal diameter) can't be changed so the value of stretch of vulva depends on the antroposterior diameter of the fetal head. Antroposterior Antroposterior diameter has 2 possibilities: a. If the head of fetus remains flexed &comes out through the vulva while flexed so the AP diameter which comes out is the subocciptofrontal (10cm) b. If the head of the fetus undergoes extension &comes out through the vulva while extended so the AP diameter which comes out is the occiptofrontal (11.5) causing high stretch on the preneum causing lacerations of the preneum.
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How to prevent the perineal lacerations? Your role is to allow the head of fetus to come through the vulva while the head is flexed (AP = 10 cm) & to prevent extension of the head which makes (AP diameter = 11.5) Use antiseptic dressing & press on the perineum. This pressure will be transmitted to the forehead preventing it from moving down by uterine contractions & bearing down. At the same time the occiput moves down by uterine contractions & bearing down and without any resistance, so the head Remains flexed & doesnt undergo extension & comes out with AP suboccipitofrontal (10cm) Crowning: is passing of the biparietal diameter of the fetal head through the vulval ring (vulval ring is around the head) When &how &how to allow extension to occur? a. After occurrence of crowning: after coming out of the head through the vulval ring b. You should allow head to extend gradually. You should allow head to extend only between contractions. Otherwise the head of the fetus may come out very rapidly (by forces of contractions) &lacerated the perineum
Episiotomy:
- Definition: perineum - Why perineum? When the head of fetus pass through the vulva it can cause: Lacerations of the perineum or Maximum lateral stretch or maximum lateral retraction of the levators &perineal muscles - This maximum lateral stretch can cause: Prolapse after this delivery with stress incontinence Inelastic levator ani this elasticity is very important for rotation of head of fetus in the next labor. When elasticity is lost this wouldnt help rotation of fetal in next labor [episiotomy is a clear cut with proper healing] - Structures cut in episiotomy: 1- Mucosa of post vaginal wall 2- Superficial &deep transverse perineal muscles 3- Skin of perineum 4- Medial fibers of levator muscles The medial fibers of levator ani is cut at distance 2.5cm from beginning of incision, midway between anus and ischial tuberosity. You will pass through ischio-rectal fossa (that contains mainly fat, lymphatics and nerve endings)
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Is levator incised in episiotomy? Yes when the incision is 2.5cm deep medial fibers of levator are cut. - Anesthesia: a. General anesthesia by pethidine or inhalation of nitrous oxygen b. Local infiltration anesthesia: can be used Disadvantage: takes some time 5-10min c. pudendal n. block: pudendal n. passes around ischial spine Try to reach ischial spine & inject by needle to produce anesthesia of this area
d. Episiotomy without anesthesia: when?? Local infiltration anesthesia How??

Do it when uterine contractions are at their peak. do it by sharp scissor do it very rapid If you do so mother won't feel pain, but anesthesia should given during repair.
Timing:
Dont do it early: because of blood loss & the area of the perineum is congested by the head of the fetus which will increase the blood loss Do it before the head of fetus undergoes crowning if done after just crowning head will stretch the perineum & episiotomy will not be of benefit in this case.
Types:
a. median median: : site: midline advantages: 1- Least vascular area so blood loss is little 2- Symmetrical incision so Repair is easy Incision is better cosmetically Incision cause less pain Disadvantage: 1- Extension can occur by very strong extension of head of fetus. The incision of median episiotomy may extend to the anal sphincter (with nerve damage) &cause damage to the rectal wall ..Complete perineal tear. 2- Restricted space as it may extend to anus. b. mediolateral: Site: from vulva to midpoint between the anal sphincter &ischial tuberosity Advantages: 1- Gives more space (not limited by anus) so you can enlarge the incision. Enlargement incision is required in: - if head of baby is larger than the average size so possibility to lacerate perineum is higher - Malpresentation require enlargement of incision even if you make support * if you make large episiotomy .it is called mediolateral * if you make very large episiotomy .it is called generous episiotomy Generous episiotomy: Definition: mediolateral episiotomy reaching to the ischiorectal fossa How to know that you reach ischiorectal fossa? Incision is full with fat Will never extend to rectum
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Disadvantages:
1- Post operative pain 2- More bleeding than mediolateral c. J shaped episiotomy:
Advantages: gain the advantage of both median & mediolateral incisions disadvantages:
Very difficult to do it during labor Repair is difficult
Types of sutures:
a. Interrupted sutures: Technique: Advantages: b. continuous: Technique:
Advantages:
Healing is faster More haemostatic as the suture compresses the bv causing homeostasis Disadvantages:
Types of
Absorbable: a. catgut: intestine of sheep b. chromic catgut: catgut with chromium salt Non absorbable: Not absorbed either left on place or removed by the surgeon Made of silk or nylon More thick less thick Thickness 2/0 is thinner than 0, 2/0 is thicker than 3/0 6 5 4 3 2 1 0 2/0 3/0 4/0 5/0 There is no 1/0 it is called 0 in gynecology 2/0-4/0 can be used
Repair of episiotomy:
We make anatomical repair or repair in layers. We use absorbable interrupted sutures made in layers.
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Delivery of shoulders &body:

Mechanism:
a. by traction of the fetus downward &backward till the ant shoulder appears below the symphsis pubis. b. Change direction of traction downward &forward to make post shoulder come out then c. All the body will slip
How to hold the fetus:
While delivering the body of the fetus moves your hand on the back of the fetus till your hand reaches the legs of the fetus Locking mechanism . Locking mechanism: safe what happen if you dont hold from legs? From abdomen: abdominal vesical injury or even may rupture from arms: Problems in locking mechanism: Should not be used if you suspect or afraid from intracranial he of the fetus. in this case support the head of the fetus by your hand - Aspiration of nose and: rubbingof the back of the fetus respiratory passages of the fetus contain secretions (mucus and blood), when the fetus is delivered and takes the first inspiration, the secretions will be inhaled. So during delivery after the head under goes extension put a suction apparatus on the nose of the fetus to suck these secretions and prevent their inhalation. Rub or hit the back of the baby to produce fetal respiratory centers stimulation, causing reflex initiation of respiration. You have to cut the cord: cutting and clumping the cord: Clamp causes crushing of blood vessels
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Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation fetal circulation:
umbilical cord contains fetal blood vessels on Fetal heart pumps deoxygenated blood to the aorta iliac artery internal iliac artery umbilical artery(in umbilical cord) placenta. Placenta acts as a lung to the fetus, in which the blood of the fetus gets rid of co2 and wastes, And receives o2 and nutrients from the maternal blood present in sinusoids. Fetal blood becomes oxygenated, passes along umbilical vein (umbilical cord) then through portal vein or IVC back to the fetal heart.
Exchange of gases in the placenta; placental barrier: Placenta is formed of repeated units of chorionic villi. In placenta, fetal tissues enter inside maternal tissues. Chorionic villi enter inside maternal tissues, causing erosion and damage to the muscular layer in maternal blood vessels, so maternal BV become opened to each other forming sinusoids. (containing maternal blood) Exchange of gases at placenta occurs by simple diffusion according to concentration gradient.
Placental barrier:
a. Wall of fetal BV b. Mesoderm c. Trophoblast (cyto & syncityotrophoblast) NO maternal blood vessels in the barrier. i.e.they lost their elastic recoil and got transformed into sinusoids.
Milking of the cord:

fetus cord Physiologically: not important because constantly the amount of the fetal blood in this part of the cord is constant &cant be reduced. May be harmful as the amount of blood passing to the fetus will increase these additional RBCs will be destroyed leading to hyperbilirubinimia neonatal jaundice
perineal lacerations: how to deal with if occur?? Do or not suture?? - rule :the more sutures you do, the more the incidence of infection. Infection
If the lacerations occurred are less than 1cm or with little bleeding dont do suture If the lacerations occurred are more than 1cm or with active bleeding suture
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Management of 3rd stage:

I. conservative method: Placenta will be separated without external (*********) by the mechanism discussed before. Wait for signs of placental separation:
a) Gush of blood through vagina - Placenta is separated at the line present in the diagram causing rupture of maternal sinusoids leading to gush of blood. - Once you see gush of blood, this means that placenta is separated. b) Elongation of the cord: - As the placenta is separated and descending, the apparent part of the cord increases, so the cord seems as if it elongates. c) The body of the uterus becomes smaller, harder and globular firm and globular d) suprapubic bulge: - As the placenta descends, it reaches the lower uterine segment (LUS) causing its distension, this LUS distension appears in the form of suprapubic bulge. 4. Drugs: - Once the placenta is separated, give ergometrine. - ergometrine causes tonic spasm ( ) to decrease bleeding i.e. post partum hemorrhage, and closes the cervix - therefore ergometrine differs from oxytocin in: ERGOMETRINE Contractions On cervix Timing tonic spasm closes cervix 1. NEVER given before labor: if given cervix will be closed, so fetus will die inside the closed uterus which will rupture 2. given after labor OXYTOCIN contractions dilates cervix before labor: helps labor
can be given after labor
II. Active method: A. Ergometrine - Steps: Ergometrine active IV line IV line fetus Mechanism: uterine spasm, causing expulsion of the placenta
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-
Advantages:
a. Placental separation is very rapid b. Rapid separation minimizes postpartum hemorrhage c. Time saving
Disadvantages:
a. 1% of cases , the placenta is abnormally adherent so if ergometrine is given, the cervix will be closed while placenta is still inside the uterus (i.e. Retained placenta ) - Some Doctors take this into consideration and they wait for signs of placental separation , others take the risk of this 1% but yet they get benefit from advantages of conservative method (rapid, less bleeding, time saving) B. Controlled cord traction - Steps: o Fix the uterus with one hand above the symphysis pubis and then pull the cord out using the other hand. - Advantages and disadvantages: same as ergometrine
Rope of membranes:
Membranes are very thin and can be cut and left inside the uterus, the Parts left act as necrotizing agents that predispose to infection. When placnta is separated, roll it several times so that the membranes (Attached to placenta) become like a rope. This rope of membranes is strong and won't be cut.
Missing lobe of placenta:

Look at the placenta after its separation to make sure that all lobes of the placenta are present and that there is no missed lobe of placenta left inside the uterus. th
Management of 4 stage
-
4th stage = the first hour of labor Significance: in this hour, sometimes the uterus may not continue contractions, while maternal sinusoids are still opened, this causes Atonic Postpartum Hemorrhage. This bleeding may be hidden inside the uterus, mother may be shocked and die within minutes or hours. Role of obstetricians: You should stay beside the mother during this stage. How to know if there is Atonic Postpartum Hemorrhage? measure the pulse regularly place a clean pad under the vulva and check the amount of bleeding , if increased this indicates hemorrhage Place your hand over the uterus, do you feel its firm or tonic or not?
Management of newborn
1. clear air passages : look before Aspiration of nose and: rubbingof the back of the fetus respiratory passages of the fetus contain secretions (mucus and blood), when the fetus is delivered and takes the first inspiration, the secretions will be inhaled. So during delivery after the head under goes extension put a suction apparatus on the nose of the fetus to suck these secretions and prevent their inhalation.
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Rub or hit the back of the baby to produce fetal respiratory centers stimulation, causing reflex initiation of respiration. You have to cut the cord: cutting and clumping the cord: Clump causes crushing of blood vessels. 2. Ligation of the cord: Umbilical stump cord cord ) ( disposable clamp If disposable clamps are not available use silk ligature Ligation should be performed under strict precautions as it may act as a source of infection and cause septicemia for the baby You have to place the clamp away from the fetus body as the stump may contain a herniated intestinal loop
3. Warming - the problem: The fetus passes from the uterus (with temperature 37.5 degrees) to the temperature of the room ( 22 degrees) Baby can't regulate his body temperature, so he may develop chilling attack (hypothermia) which may lead to apnea attack. - How to prevent? ! 4. Inspection For congenital anomalies as some congenital anomalies require surgical interference within 24 hours. 5. Identification Identification band = tied over the baby's hand with the mother's name written over. Its important for medico legal importance. 6. Antibiotic for ophthalmia neonatorum. neonatorum.
SOME ORAL QUESTIONS:

Q. why use 2 clamps not just one in cutting the cord? And where to cut the cord if there is only one clamp?
A. - - The clamp you used at the placental side to extrude the placenta by controlled Traction method???? - They may be twins - If there is one clamp cut on the placental side and not at the fetal side Q. why isn't the placenta separated in the second stage? A. in the second stage the fetus or part of it is still occupying a part of the uterus so the size of the uterus can still accept the inelastic placenta, but at the end of 2nd stage and start of the 3rd stage, the fetus is expelled and the uterus still contracts and retracts, so the size of uterus decreases so the inelastic placenta separates.
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Malpresentation & Malposition

Malpresentation = any presentation except vertex Malposition = any position except occipito-anterior
Etiology
A. causes in the passenger : [ the fetus ] 1- Prematurity: Prematurity: in preterm fetus the head is relatively larger than his body , so the appropriate adaptation in this case is the breech presentation where the large head is situated in the uterine fundus (which is wider ). Normally the fetus is expected to be delivered with cephalic presentation by the week 30-32 so if labor occurred earlier the fetus will present by breech presentation
Prematurity
Breech
Intracranial hemorrhage
2- large fetus 3- dead fetus: in dead fetus the fetal muscles are without tone and the ligaments are disfunctioning so the fetus and his spine won't take the flexion attitude leading to malpresentation and malposition 4- congenital anomalies as anencephaly or hydrocephalus , where hydrocephalus; is enlargement of the fetal head due to cerebrospinal ciculation obstruction leading to enlargement of CSF spaces, so the adaptation of this large head will be in the wide uterine fundus i.e.breech presentation. - Clinical application: If the fetus is presenting by breech presentation, he is suspected to have hydrocephalus so do ultrasonography to diagnose. 567Multiple pregnancies Polyhydraminos Coils of the cord around the neck of fetus preventing flexion of the head and subsequently the vertex or brow presentation, and these coils extend the head so presentation is face.
B. causes in the passages:

1. contracted pelvis: - Shape of pelvis can change the position and presentation. - Android and anthropoid in occipito-posterior position and face presentation 2. Uterine fibroids [soft tissue obstruction] - Fibroid can change shape of uterus (normally pyriform) - so can change the position and presentation of fetus 3. Uterine anomalies - septate uterus shoulder presentation 4. Pelvic tumors [soft tissue obstruction]
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C. causes in the powers
laxity of the abdominal and uterine muscles : a. In multipara , the uterus and abdominal wall become weak and lax , so uterus shape becomes as diagram, this shape favors transverse lie (shoulder presentation) b. In primigravida , the uterine and abdominal wall are strong so the uterus shape is still pyriform which favors cephalic presentations.
Complications
a. In malpresentations and malpostions, the presenting part is neither properly adapted to the pelvic inlet, not properly applied to the cervix and lower uterine segment. b. In malpresentation and malposition, the bag of forewaters is continuous with the bag of hind waters (as the presenting part is not properly occupying the pelvic inlet) so in the 1st stage when the cervix is slightly dilated, large amount of amniotic fluid passes from the hindwaters to the forewaters and becomes focused on one point which can NOT stand the pressure of increased amniotic fluid leading to rupture of membranes before full cervical dilatation (premature rupture).
'Focus on a point before full dilatation' c. As the presenting part is not properly adapted to pelvic inlet so loop of cord may descend between head of fetus and bony pelvis leading to: i. Cord presentation (before rupture of membranes) ii. Cord prolapse (after rupture of membranes)
'Cord presentation'
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d. The presenting part is not properly situated in the lower uterine segment, so doesnt cause significant pressure on them, so there is NO Fergusson's reflex (no reflex augmentation of uterine contractions Inertia) - NO Fergusson's reflex, therefore: i. Early rupture of membranes occurs, so there is no dilating effect of bag of forewater on cervix, so rate of cervical dilatation is slow. ii. In addition to mechanical obstruction - This causes prolonged labor exhaustion of uterus Atonic Postpartum Hemorrhage - You do PV to the mother with NO amniotic fluid, increasing incidence of intrauterine infection leading to puerperal sepsis. ????? -
Occipito-posterior positions
Definition:
Back (occiput) is directed posteriorly with vertex presentation [malposition with normal presentation]
Incidence:
25% at the onset of labor ; after the onset of labor (2nd stage) 90% of this 25% occipito posterior become as normal labor [ refer to mechanism of labor in occipito-posterior] - In right occicpito-posterior the anteroposterior diameter occupies the right oblique, while in left occipito-posterior (O.P.) the anteroposterior diameter occupies the left oblique so right OP is more common than left OP.
Etiology:
i.
-
{labor is a case of adaptation}
o Shape of pelvic inlet:
Gynecoid pelvis:
Transverse oval. Adapted to delivery & helps normal positioning.
ii. ii .
Android pelvis:
Inlet: triangular or heart shaped Narrow fore pelvis. Cavity and shape: o Funnel shaped o Converging sidewalls
Outlet: o Outlet is narrow (converging sidewalls) so the 2 ischial tuberosities are near each other (bituberous diameter is small). o pubic angle is acute Android pelvis is NOT adapted to delivery
Relation between android pelvis and occipito-posterior position and its mechanism of labor:
a. the widest diameter in android pelvis is the oblique but the fore pelvis is narrow and doesn't allow the fetal head to pass so the biparietal will pass through another diameter called SACROCOTYLOID ( from the promontory of sacrum to the ilio-pectineal eminence)
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N.B. sacrocotyloids are named right and left according to the iliopectineal eminence while obliques are named right and left according to sacroiliac joint.
b. In right occipitoposterior : - The occiput is directed to the back and right. - Biparietal diameter of the head of fetus occupies the right sacrocotyloid diameter of pelvic inlet. - The anteroposterior diameter of the head of fetus occupies the right oblique diameter of pelvic inlet. - The wide biparietal diameter occupies the narrow????? Posterior part of the pelvis. - As it occupies the obliques it is called OBLIQUE OCCIPITOPOSTERIOR. - Biparietal of fetal head= 9.5 cm. - Sacrocotyloid of pelvic inlet= 9.5 cm. - As both diameters are equal this will delay the engagement and the head will perform asynclitism for easier engagement - now the head is well flexed and the biparietal and cant pass through while the uterine contractions is still taking place , so the uterine contractions will push the bitemporal diameter ( as it is relatively smaller) DEFLEXION OCCIPTO POSTERIOR positions DEFLEXION
the deflexion will increase the anteroposterior diameter of the head through its way out more delay of engagement
Therefore engagement is delayed due to: 1. biparietal of fetal head = sacroctyloid of pelvic inlet= 9.5 cms 2. deflexion increases the antero posterior diameter of the head
Deflexion in occipito-posterior: i. Biparietal diameter of fetal head faces the resistance of sacrocotyloid diameter of pelvic inlet, so give the chance of bitemporal diameter of fetal head to pass and descend. ii. Deflexion occurs at the level of pelvic inlet.
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iii. iii .
Anthropoid pelvis
Cavity and shape: ! Inlet: Transverse diameter is short while anteroposterior diameter is long Outlet: Bituberous diameter is short, sciatic notch is wide.
Relation between anthropoid pelvis & occipitoposterior position:

Best adaptation for the fetal head is that the head enters with its anteroposterior diameter in the anteroposterior diameter of pelvic inlet this is called DIRECT OCCIPITO-POSTERIOR [occiput is directly posterior, not left nor right]
Oblique occipitoposterior: - Anteroposterior diameter of fetal head occupies one of the oblique diameters of pelvic inlet. - Occiput is directed posteriorly to the right or to the left. - Occurs in android pelvis.
Direct occipitoposterior: Anteroposterior diameter of fetal head occupies the anteroposterior of pelvic inlet. Occiput is directed directly posterior Occurs in anthropoid pelvis
results of deflexion: a. delayed engagement : see above b. degree of deflexion determines mechanism of labor By uterine contractions and asynclitism, engagement occurs and head passes through inlet and deflexion may be corrected.
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Correction of deflexion: deflexion
1. Correction of ALL deflexion:

So head of fetus becomes well flexed, the occiput is the lowest part and touches the pelvic floor first, as the pelvic floor is directed downwards, forwards and medially, the occiput rotates from posterior position to anterior position by 3/8 th of a circle long anterior rotation o because the occiput reached the pelvic floor first which is directed downwards, forwards and medially
This position is called Direct occipito anterior, In this case, occiput hinges below symphysis pubis and delivery is completed as NORMAL LABOR. (Delivery can be completed vaginally). 2nd stage of labor in oblique occipito posterior is prolonged, as the head undergoes long ant. rotation & with this rotation , the shoulders & body of fetus will rotate by the same degree . Why we say that incidence of OP is 25 % at onset of labor? o Because 90% of this 25% undergoes long ant. Rotation in the 2nd stage to become Direct Occipito anterior position & is completed as Normal labor. [It is Not Occipito posterior any more]. The occiput is the lowest part & touches the pelvic floor first. As the pelvic floor is directed downwards, forewards & medially, the occiput rotates but As head is mildly deflexed [i.e it is Not fully] so it is not circular , it is OVAL So the occiput rotates from posterior position by ONLY 1/8th of a circle. Deep Transverse Arrest transverse diameter ) (midcavity) ( This case is Not delivered vaginally because the head is arrested ( Obstructed labor )
2. Mild degree of Defluxion :

-
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3. Moderate degree of Deflexion :
The occiput & sinciput are at the same level & touch the pelvic floor at the same time. Both occiput & sinciput are exposed to the downward, foreward & medial direction of pelvic floor. Two equal forces in opposite directions. So the head remains in its original position which is oblique occipito posterior. This is called "persistent oblique occipito posterior" This case is not delivered vaginally because it is obstructed labor.
4. Marked degree of De flexion :

The sinciput is the lowest part & touches the pelvic floor first. As the pelvic floor is directed downwards, forwards & medially. So the sinciput rotates Anteriorly by 1/8th of a circle rotation, at the same time the occiput rotates Posteriorly by same degree (-1/8th rotation ) The occiput now is directed directly posteriorly. This called Direct occipito-posterior.
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Summary of Results of correction of Deflexion :
a) Correction of All deflexion (90% ) Direct Occiptoanterior delivered vaginally but with Prolonged 2nd stage b) Mild degree of Deflexion (1%) 3/8 cird
Long ante rotation Rotation
Deep Transverse arrest c) Moderate degree of Deflexion (3%)
Obstructed Labor
1/8th circle No rotation ratalion
Persistent oblique Occipio posterior
obstructed labor
d) Marked degree of Deflexion (6%) Direct occipito posterior delivered vaginally by face to pubis ()
"Face to Pubis "mechanism of delivery of Direct occipito posterior : -1/8 cird

In direct occipito posterior, the occiput is directed directly posteriorly while the face of fetus faces the sym. Pubis.So it is called face to pubis. Mechanism: - The sinciput (face / forehead) hinges below symphysis Pubis. So the head undergoes flexion, causing the vertex to come out, but still the face is not delivened, you need a movement of extension of the head to deliver the face, you can extend the head by a forceps. - While the head is delivered & is coming out from the vulva , the AP diameter of the head in this case (occipto frontal = from occiput to the root of the nose ) = 11.5 cm, very large while will cause stretch of the perineum & vulva leading to perineal tear, So do generous episiotomy in direct occipto posterior to prevent perineal tear .
N.B.: 1. Direct Occipito posterior is position. 2. face to Pubis is mechanism of delivery of Direct Occipito posterior 3. Face is presentation 4. Face to Pubis is mechanism of delivery
Summary of mechanisms of delivery of Occipitoposterior position:

a) Vaginal 96% 90% Direct occipito anterior as normal 6% direct occipito Posterior prolonged b) Cesarean Section 1% deep transverse Arrest 4% 3% Persistant oblique occipitoposterior
Obstructed Labor
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Making Decision in delivery of occipito posterior whether vaginal or cesarean section / Factors favoring Lang ant. Rotation : (Vaginal) 1- Well flexed head. 2- Wide pelvis. 3- Elastic Pelvic floor. 4- Strong uterine Contractions. 5- Intact membranes. In ORDER (CS) 1- Deflexed head () 2- Narrow pelvic cavity (android) 3- lax or rigid pelvic floor flexion 4- Inertia 5- Early rupture. a) Degree of Deflexion b) Factors favoring long Anterior Rotation. Why Restitution & External rotation do NOT occur? o Because the body of fetus rotates & corrects its position rotation of the head.
Diagnosis
'You have to search for any abnormality as contracted pelvis, placenta previa, to decide whether to perform CS or not.' 'Any mother with 2 risk factors CS' A. During pregnancy:
I. Abdominal examination :
Fundal level: according to gestational age Fundal grip: buttocks (soft) umbilical grip: Nods of limbs First pelvic grip .bitemporal diameter - second pelvic grip : to determine degree of deflexion - Auscultation of FHS : flanks of the mother o long ant rotation : o midline (direct occipitoanterior : position ) II. Ultrasonography: by sonar, bony pelvis can Not be assessed - Confirm that there is single fetus. - Confirm that the fetus is viable. - Confirm gestional age: sonar is used for confirmation of gestational age because it is already calculated from 1st day of last menstrual period. - Confirmation of presentation & position. - Congenital anomalies. - Amount of amniotic fluid. - Position of insertion of placenta: Normal or Not? Why? o If there is ONLY one risk factor (the mal presentation or malpositation), you can deliver vaginally. If you find 2 or more risk factors (The mal presentation or mal position + other risk factor e.g. placenta previa..etc) You must do cesarean section. -
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B. during labor: I. Abdominal examination & ultrasonography : as above II. PV examination : - Pelvic capacity: ( android) - cervical dilatation & effacement (usually slow): .malposition - State of membrane: early rupture is common; membranes are already ruptured because of Bone Vault mechanism.
Presentation : Vertex presentation (not cephalic) Position : o Occiput is the demominator. It is in the same direction of the back. o You should differentiate between posterior fantanelle & anterior fontanelle because there may be a degree of deflexion . Engagement /Station Degree of deflexion : deflexed" head" ant fontanelle well flexed "head" : ant. Fontanelle -
Management:
Management of 1st stage : o You should give more care because of early rupture of membrane prolonged duration Occurrence of risks. o How to care : - asepsis - Proper sedation - Nutrition - Partogram - Enema: Because in mal presentation, there is already inertia so enema to evacuate rectum is done to prevent further inertia produced by full rectum. - Do Not do frequent PV for fear of risk of infections II. II. Management of 2nd stage : o Direct occipito anterior: 90% of cases of oblique occipito posterior positions undergo long anterior rotation during the 2nd stage, Become direct occipitoanterior & complete as in NORMAL Labor. So during 2nd stage wait until long ant. Rotation occurs. But 2 rules for waiting for occurrence of long ant. Rotation: a. The conditions are convenient : Do Not wait if narrow pelvis dry membranes or marked deflexion etc b. Maximum 2 hours waiting : 2 hours is the maximum duration of 2nd stage in Normal labor. Do Not wait for more than 2 hours because Blood pressure is increasing, metabolism is hanging/??????? etc I.
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You can give Oxytocin (except if contraindicated) to stimulate uterine contraction which can help rotation. Deep transverse arrest & Persistent oblique Occipito posterior - If they are left, they will develop caput. - So management manageme is: a. Do Cesarean Section. b. Use ventouse. - In these 2 positions, there is a degree of deflexion which interferes with rotation. - Ventouse increases Flexion of the head. - Put ventouse on the occiput & pull it, this will correct the deflexion & increase Flexion exion of the head. So the head can undergo rotation & come out. - With ventouse No need for bearing down because we pull by the vetouse. Direct Occipito posterior: Look at the mechanism first we need. a. Forceps: because the movement of flexion then extension can Not occur spontaneously by it self. b. Generous episiotomy
Face presentation
Definition: Face is a presentation in which the head is extended. Etiology:
I. Secondary face: During pregnancy, it was Not Face, but during labor, it becomes face. - More common, more important. Contracted pelvis especially flat. In this case, the presentation (during labor) is vertex & the position is occipito posterior. During labor, the biparietal diameter of fetal head (9.5 ( cm) is trying to pass through the sacrocotyloid diameter of the pelvic inlet (9.5cm). ( cm). As both diameters are just equal, the fetal head will face resistance & will not be able to pass through the inlet delayed engagement. During the delayed engagement, uterine contractions are still acting on the head leading to deflexion of the head, and then the head becomes midway between Flexion & extension (in this case presentation esentation is brow) then the head becomes extended (now presentation is face). Some times the biparietal diameter of the fetal head remains obstructed at the inlet() even, often extended. Why face presentation is more common with FLAT pelvis? biparietal diameter Sacrocotyloid diameter . face presentation Socrocotyloid Pelvis flat pelvis . face Presentation extension -
Mechanism:
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II. II. Primary face : a. Anencephaly: because the fetus with anencephaly has a very short neck ) ( so there is No Flexion of the head. b. Swelling in the neck: in the front aspect of the neck as cystic hygroma, preventing flexion of the neck. c. Loops of cord around the neck. Preventing flexion. d. Hyper tonicity (tone )in extensors of the neck.
Positions:
Presentation Position ( position ) presentation denominator - back fetus ( 1st position) Position - positions . - Positions in vertex presentation In vertex presentation, the denominator is the occiput (acceptant Or occipito post). o The occiput is in the same direction of the back of the fetus. o FIRST Position (in which the back is directed to the anterior & to the left) is Lt occipito anterior o Second position ( ) is Rt Occipito anterior. o Third position ( ) is Rt Occipito posterior. o Fourth position ( ) is Lt Occipito posterior. -
Position in Face Presentation :

o o o o o o In face presentation , the denominator is the chin/ mentum (so positions are either mentoanterior or mentoposterior) The mentum is in the opposite direction of the back of the fetus First position (in which the back is directed to the anterior & to the Lt) is Rt mento posterior. Second position ( ) is Lt mento posterior. Third position ( ) is Lt mento anterior. Fourth position ( ) is Rt mento anterior.
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Why is Mentoanterior more common than Mentoposterior? Because in mentoant., the back is directed to the post. & most cases of face presentation were originally occipitoposterior in position (secondary face)
Mechanism of Labor:
Face (a) mento anterior I. (b) mento position Vertex (a) occipitoanterior (b) occipitoposterior
Mento anterior: (chin is directed interiorly ) a. See secondary face to know how extension occurred & how the face becomes the presentation. - When the head become Extended, the Anteropost. Diameter (of fetal head) which will undergo engagement becomes the submento-bregmatic diameter (submento: from Junction of neck & chin bregmatic: to centre of bregma - = 9.5cm). This 9.5cm is considered very long as the pelvis is flat narrow ( ) so this leads to delayed engagement. - Also the biparietal diameter is obstructed & can not pass through the inlet until the FACE becomes the presentation so the biparietal will be the LAST part to pass through the inlet (to say that engagement occurred, the biparietal widest transverse diameter must pass through the inlet) , so this leads to more delayed engagement. - The Face presentation is a MAL presentation, so there is inertia, leading to more delayed engagement. - Moulding (which facilitate engagement of the head) does Not occur in face bones, so the 9.5cm of the submento-bregmatic of the fetal head remains constant, so leads to more delayed engagement . - delayed engagement in face presentation : i. AP = 9.5 cm + flat pelvis ii. Biparietal is the diameter to pass through the inlet. iii. Inertia. iv. Molding does not occur in face bones. b. After engagement, the lowest pout of the head of fetus is the chin. The chin is the first part to touch the pelvic floor. As the pelvic floor is directed down words, (chin rotates anteriorly)
After internal rotation, the chin hinges below the symphysis pubis & the head comes out by a movement of the Flexion.
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c. The head comes out by a movement of flexion, so the AP of fetal head that comes out & stretch the vulva is the subment vertical dimater (submemto = from Junction of neck & chin vertical (vertex) = to midway bet. Ant. Fontanelle, Post. Fontanelle) = 11.5cm. This 11.5cm of sub. Mento-vertical is very large which may cause perineal laceration so we should do Generous Episiotomy. II. II. Mento posterior : ( Chin is directed posteriorly posteriorly ) o Possibilities: as Occipito Posterior 1- the chin rotates anteriorly by 3/8 circle Long anterior rotation direct mento-anterior is delivered as mento anterior(By movement of flexion)
2- the chin rotates anteriorly by 1/8 circle Deep transverse In mid-cavity
arrest
3- The chin remains in its place with No progress
Persistent oblique mento posterior.
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e.g. obstructed labor with out disproportion 4- The chin rotates posteriorly by 1/8 circle direct memto posterionly.
Out come of mento posterior positions & comparison with the out come of occipito posterior : Mento posterior 1- Direct mento /occipito anterior - 2/3 ONLY - delivered vaginally Occipito posterior - 90% - delivered vaginally
2- Deep transverse arrest 3- Persistent oblique mento/ occipito posterior 4- Direct mento /occipito posterior
-Obstructed labor - obstructed labor - Never delivered vaginally - obstructed labor (mechanical obstruction)
- 1% - obstructed labor - 3% - obstructed labor - 6% - can be delivered vaginally by Flexion then extension of the head
N.B.s: 1- 96% of occipito post. Positions can be delivered vaginally, while ONLY 2/3 of mento post. Positions can be delivered vaginally. 2- Direct occipito post. Can be delivered vaginally, while Direct mento post. is NEVER delivered vaginally 3- Why direct memto post is NEVER delivered vaginally? For a direct post, position to come out, it must undergo Extension, in direct mentopost. The head is already extended fully & can Not be extended anymore, if the head undergoes Flexion, it will reenter (not practical)
Diagnosis:
A. During pregnancy :
I- Abdominal examination:
o o o o o o o Fundal level: according to gestational age. Fundal grip : buttocks Umbilical grip : mento ant or post For example: if back is ant., so position is mento post. 1st pelvic grip. 2nd pelvic grip. FHS: Generally , FHS are heard over the back of the fetus
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If mentoposterior (back is anterior), hear FHS from front of mother. If mento anterior (back is posterior): the fetus is not taking Flexion attitude, he is taking extension attitude, so FHS can be heard both sides front & flanks of the mother. II- Ultrasonography; by sonar, bony pelvis can Not be assessed. - confirm that it is single - confirm that the fetus is viable or dead - confirm gestational age - Exclusion of congenital anomalies: Very Important. 1- Cystic hygroma can be drained after birth. 2- Loops of cord Anencephaly (most important) fetus is incompatible once diagnosed, terminate pregnancy. No reason to wait. - Site of placenta : Face presentation + any abnormality 2 risk factors (as placenta previa) Cesarean Section B. During Labor:
I. Abdominal examination : (as above ) II. II . Vaginal examination :

Assessment of bony pelvis : If not good + Face presentation Cesarean Section 2 risk factors Assessment of cervical dilatation & effacement: Usually slow because it is mal presentation & there is inertia. Assessment of state of membranes: early rupture of membranes. Exclusion of cord presentation & prolapse, then assessment of color amniotic fluid. Presenting part : 1. Face eyes, nose, gums and teeth). 2. Take care when you are examining other wise you may injure the fetus. 3. Denominator is the chin, from chin you can conclude the position whether mento anterior or mento posterior. The chin is important to differentiate between face & brow, How: 1. In Brow , you can feel eyes & noses but there is No chin in Brow 2. In face, you MUST feel chin. Why : 1. Face can be delivered vaginally 2. Brow is NEVER delivered vaginally 3. N.B The Face may be mistaken as breech : Why? o in face presentation, the head is mostly obstructed so edema occurs in the face in the from of 2 swelling (one above & one below the mouth ) with a groove in between (the mouth) so the face this case looks like the buttocks o Generally, PV is difficult, you are not looking, you are just feeling. o The presenting part may be still in a higher level How to differentiate? look at breech
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Management: Management:
If face presentation + other risk factor (twins, contracted pelvis, abnormal placenta) Cesarean section If Face presentation Only with No other risk factors. So management will be: - 1st stage: Proper Sedation, Nutrition - 2nd stage : management of 2nd stage is according to the position
1. Mento anterior :
Do generous episiotomy; because the head comes out by a movement of flexion, so the Ant. Post diameter of fetal head that comes out & stretches the vulva is the submento vertical diameter 9 submento = from junction of neck & chin vertical ( vertex ) = to mid way bet . Ant, fontanelle & post fontanelle) = 11.5 cm .This l1.5 cm of submento vertical is very large; may cause perineal lacerations.
2. Mento posterior: Wait for 1 hour : Waiting for occurrence of long anterior rotation so that the position will be direct mento
anterior. For maximum 1 hour ONLY because ONLY 2/3 of mento-posterior undergoes long ant. Rotation & becomes Direct mento anterior. on the other hand ,in occipito-posterior, wait for 2 hours ( the whole duration of 2nd stage ) because 90% (promising ) of occipitoposterior undergoes long ant rotates & because Direct occipito anterior . If long ant rotation occurs Direct mento anterior management as mento anterior (generous episiotomy ) If long ant. rotation did Not occur Deep transverse arrest Management is Persistent oblique mento post Cesarean Section Direct mento posterior You can not use Ventouse (unlike 1. Persistent oblique occipitopost. & 2. Deep transverse arrest of occipito post ) Because: To use the Ventouse, you should put it in occiput. In face presentation, you can not reach occiput. You can Not put Ventouse on the face Face Abnormal presentation 2/3 of mento posterior is delivered vaginally - Direct mento anterior Presentation: face Mechanism: face Vertex Normal presentation 90% of occipito posterior is delivered vaginally - Direct occpito posterior Vertex face to pubis
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Brow presentation
Definition: cephalic presentation in which head is midway between Flexion & extension. Mechanism of delivery:
The AP diameter which may pass through the pelvic inlet is the mento vertical (from chin to midway bet Ant & post fontanelle) = 13.5 cm. So the head will Not engage & labor is obstructed i.e. No mechanism. Except in cases : 1. Transient brow : brow In cases of occipito posterior which changes into mentoanterior (by extension), the presentation changes from vertex then to brow than to face; Brow acts as a transitional zone bet vertex & face. Management: Management wait for some while so that it may change of face. 2. preterm : preterm is much more smaller than term So the 13.5 cm of mento vertical will be smaller than that, and fetus can be delivered vaginally Denominator is frontal borne Denominator in brow presentation is of NO significant importance because there is No mechanism of labor. Brow is delivered by CS. PV examination; you feel eyes, supraorbital ridges, but there is NO CHIN. You can Do EITHER wait for some while, it may become face presentation (mento anterior in position) OR CS directly.
Diagnosis:
Management:
Breech presentation
Breech in brief:
The buttocks and/or the feet are presenting. The biggest problem in labor (which is the head and shoulders of the fetus are postponed). The body of fetus is not a problem in labor because the buttocks are small and capable of compression In breech, the first part is the body then shoulders then the head (the sequence is reversed)
What is the problem?

In normal presentation: In breech presentation:
! Vaginal or C.S The body of fetus came out so if there is disproportion you will wait until the body and shoulders pass BUT the head can't pass, SO: The fetus may asphyxiate If the fetus died you won't be able to get it out You won't be able to perform C-section
There are 2 problems:

1. larger less compressible parts are born and the head won't undergo moulding as it is descending in an upright manner 2. there is a STRONG relation between Intracranial hemorrhage, Prematurity and Breech
Breech and prematurity:

In preterm fetus, the head of fetus is relatively larger than his body, so the appropriate adaptation in this case is the breech presentation; the head of fetus (larger) is present in the uterine fundus (wider). If labor occurs during this time, the fetus will be delivered by breech presentation.
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Breech and intracranial hemorrhage:
- In breech presentation, the head is the last part to come out, so the head is exposed to SUDDEN compression and decompression which cause intracranial hemorrhage. - also prematurity acts as a cofactor in developing intracranial hemorrhage
SO, C-section is done [acceptable]

N.B After coming head = means that the head is the last part to come out.
Etiology
1. Prematurity: ( most important)
o o o Prematurity shows high breech presentation In 28 weeks gestation, the head of fetus is relatively larger so the best adaptation [to fit into pyriform uterus] is breech presentation. If the mother asked is this normal or not? Answer that the fetus will correct his position with continuous movements, and it's just a matter of time till maturity is reached If the mother entered into labor (e.g. rupture membranes) during prematurity, the presentation will be breech.
2. Hydrocephalus
o
the best adaptation of the large head is to fit into the large fundus
3. Frank breech
o o Means that the presenting part is the buttocks and the legs are extended in front of the chest, these extended legs prevent flexion of the spine. Flexion of the spine is the movement which cause version ( )of the fetus and corrects its position, so extended legs act as splints ( )preventing flexion of the spine and causing failure of spontaneous version of the fetus Frank breech occurs in primigravida because of strong uterine and abdominal wall muscles so narrowing the space available for the fetus inside the uterus
N.B. In etiology the shape of pelvis is NOT a cause of breech, pelvis has nothing to do with breech!
Types
1. complete breech Complete means that ALL components of the breech [buttocks and legs] are present The fetus 2. incomplete breech a. Breech with extended legs [frank breech] Frank means the only presenting part is the buttocks and the legs are extended in front of the chest. More common in primigravida because of strong uterine and abdominal muscles narrowing the space b. Footling:The presenting part is the leg
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Positions
How to determine the position in any presentation? First, specify the denominator of the presentation (to name the position after it) and determine its direction in relation to the back of the mother Then, determine the sequence of the positions by starting (with the first position) with the back of fetus is left and anterior then determine the rest of the positions as if you are rotating
Positions in breech presentation:

-
The denominator is the sacrum (sacro-anterior and sacro-posterior) The sacrum is in the same direction of the back of the fetus First position (in which is back is directed anteriorly and to the left) is left sacro-anterior Second position ( rotate back of fetus to the right side) is right sacro-anterior Third position (rotate back of fetus once more to the right) is right sacro-posterior Fourth position (rotate back of fetus once more to the right) is left sacro-posterior
Mechanism of labor
A. Sacroanterior o The widest transverse diameter of the presenting part (breech) is the bitrochantric diameter which is the diameter between the 2 trochanters of femur o The bitrochantaric diameter of the fetus passes through the oblique diameter of the pelvic inlet, so engagement occurs o the bitrochanatric diameter of the fetus is 10 cm while the oblique diameter of the pelvic inlet is 12.5 cm so engagement occurs very EASILY o the buttocks descend to the pelvic floor, the anterior buttock reaches pelvic floor first o the pelvic floor is directed downwards forwards and medially, so the anterior buttock undergoes 1/8 anterior rotation o anterior buttock hinges below the symphisis pubis and posterior buttock is delivered first B. Sacroposterior o the same as sacro-anterior, because the fetus has 2 buttocks and always there is one more anterior than the other and reaches pelvic floor first and undergo 1/8 anterior rotation For both sacro-anterior and sacro-posterior - The baby comes out - The head of fetus enters through the oblique or transverse diameter - The head is delivered while it is flexed = breech in flexion
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Mechanism of delivery of the head: In breech presentation IN flexion (flexed ) (In face presentation BY flexion flexion )
Diagnosis
A. during pregnancy
I. Abdominal examination
Fundal level - According to the gestational age - In frank breech, the size of buttocks is very smallm so the buttocks pass through the pelvic inlet early engagement so the fundal level is less than expected and size of the female abdomen is less than expected Fundal grip - Head: hard, globular with ballottement ( ) Umbilical grip - To determine the position (anterior or posterior) - Sacro-anterior is more common than sacro-posterior so that concavity of the fetal spine corresponds to convexity of maternal spine 1st pelvic grip - Buttocks (soft) 2nd pelvic grip Fetal heart sounds - FHS are auscultated over the scapula of the fetus - In breech, the fetus is inverted so FHS are auscultated ABOVE umbilicus of the mother - In frank breech [with early engagement], FHS can be heard AT umbilicus of the mother
II. II . Ultrasonography
Confirm that it's single not twin Confirm that it viable not dead Confirm the gestational age
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How sonar helps in taking the decision of management of a case of breech with hydrocephalus? CSF is present around spinal cord, brain and inside the ventricles Hydrocephalus occurs due to either overproduction of CSF OR obstruction of drainage, so CSF is retained inside the ventricles and causes compression on the brain cortex leading to CORTICAL ATROPHY How to know cortical atrophy has occurred in this case or not yet? By measuring the distance between the vertex and border of cortex You have to write in sonography report: a. Hydrocephalic or not? b. Cortical atrophy occurred or not?
How to manage a case of hydrocephalic fetus? A pregnant mother came to you and the fetus is presenting by breech, you have to perform sonar even if she is a multipara and the pelvis is normal. - By sonography you found the fetus is with hydrocephalus - detect if there is cortical atrophy or not: 1. if cortical atrophy didnt yet occur do CS (to conserve the fetus). 2. if cortical atrophy occurred vaginal delivery but the head will be stuck so puncture the head to allow it to pass.
Detection of extension of the fetal head:

If the head is extended the anteroposterior diameter will increase and the head will be obstructed ( even if its size is normal) and won't be able to pass through the pelvic inlet If you perform sonar for a case of breech and you detect extension of the fetal head, do caesarean section complete or frank or footling if footling, do CS as the ONLY descending part is the leg of fetus which will not help cervical dilatation also the space will be large in this case and umbilical cord may descend (cord presentation or prolapse) sonar calculates 1. biparietal diameter 2. femur length 3. circumference of abdomen
Detection of type of breech breech

-
Calculation Calculation of estimated fetal weight

-
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And from these sonar estimates the fetal weight. Estimated fetal weight gives an idea about size of the baby. If estimated fetal weight is more than 3.5 kg ( e.g 4 kgm) do NOT deliver vaginally.
Detection of polyhydraminos Condition of placenta: placenta previa + breech (2 (2 risk factors) III. III . X-ray
Is XX-ray dangerous or not? Effect of XX-ray depends on dose and timing:
CS
a. In first 8 weeks of gestation:

Effect of X-ray is ALL (abortion) or NON (baby not affected)
b. After 8th week

The graph is linear, the more the dose (exposure) of X-ray, the more the risk.
c. After 22 weeks of pregnancy:

A dose of ONE RAD is of no problem X-ray which is done during pregnancy is of dose 0.1 RAD so you can do X-ray during pregnancy Benefits: In breech X-ray is BETTER than sonar 1- pelvimetry : diameters of bony pelvis 2- extension of the head: if the head is extended, do CS How to assess bony pelvis (other than X-ray)? 1. Obstetric history (vaginal delivery more than once indicates suitable pelvis) When can you neglect using XX-ray? a. If there is indication of CS b. Do X-ray, if there is NO indication of CS or you want to deliver vaginally B. during labor
I. abdominal examination: as above II. II . PV examination:

For assessment of: Pelvic capacity: very important ! ! Breech - cervical dilation and effacement : (usually slow) specially in footling state of membrane: early rupture of membrane - Exclusion of cord presentation and prolapse Cord - Color of amniotic fluid a. Some of meconium may come out because body of the fetus enters inside the pelvis and gets compressed inside pelvis so meconium comes out. b. This meconium makes NO SENSE as it doesnt mean the fetus is asphyxiating. - presenting part: - Position - station and engagement
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Type of breech (you feel buttock frank breech or feet footling or both complete breech) Differential diagnosis of frank breech from face presentation: o Similarities: 2 swellings with opening in between - In face presentation: the head is mostly obstructed so edema occurs in the face in the form of 2 swellings (one above and below mouth) with a groove in between (mouth) - In breech presentation: 2 buttocks with anus in between o Is it possible that they may be mistaken? 1. The cervix is STILL PARTIALLY dilated 2. PV is done by ONLY ONE finger 3. The presenting part may be STILL ABOVE o How to differentiate? - Steps: groove - Results: If you found tongue and gums face presentation If you found muscular sphincter and your finger came out with some meconium breech presentation -
Management
I. Management during pregnancy External cephalic version - Definition: Cephalic version: rotate the fetus till it becomes in cephalic position. External: - Advantages: You converted malpresentation into normal presentation. You can detect if there is any disproportion in cephalic position as you'll find that the head resists engagement. - Timing: 32- 36 weeks. Before 32 weeks wait as the fetus may try to make spontaneous version. After 36 weeks rate of fetal growth becomes MORE than rate of uterine growth, so there is NO space for version. - Contraindications: Indications of CS. Hypertension where rotation is dangerous. - Technique a. No anesthesia ! b. tocolytics: to produce relaxation of uterine wall lax wall easier maneuver increased massage may lead to increase in contractions introduce the mother into premature labor. c. trendlenberg position: adjust the bed in an inclined position to keep the fetal buttocks away from the inlet. d. the vulva is exposed Pressing hard on the uterus rupture membranes fluid comes out. Pressing harder placental separation accidental hemorrhage blood comes out. - Steps Occiput
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flexion of fetal head occiput flexion of spine Buttocks Version = buttocks above + head below - Further management " " - Causes of failure: a. Obesity b. Rigid abdominal wall c. Extension of legs: the fetus can't flex his spine - Complications a. Failure of the procedure b. Placental separariton ( accidental hemorrhage) c. Premature rupture of membranes and premature labor d. Fetal injury: fracture of spine- asphyxia by cord e. Can NOT be done in sacro-posterior II. II. indications of CC-section in breech presentation
1. Contracted pelvis
Why CS? 2 risk factors, the head will be obstructed after coming out of the body The fetus may asphyxiate If it died you won't be able to take it out You can't perform CS How to know? By history: vaginal delivery more than once is suggestive of suitable pelvis By examination: PV By pelvimetry: radiological (X-ray)
2. Large fetus
estimated fetal weight MORE than 3.5 kg where fetal weight gives an idea about fetal size so increased estimated fetal weight indicates increased fetal size How to know? By sonar: which calculates biparietal diameter, femur length, circumference of abdomen and estimates fetal weight from these items
3. Premature fetus 4. Breech with extended head:

Why CS? if the head is extended, the antero-posterior diameter will increase and the head will be obstructed ( even if it's of normal size) and will not be able to pass through the inlet How to know? By sonar & by X-ray
5. Footling
the presenting part is ONLY the legs Why CS? a. Slow cervical dilatation i.e only legs
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b. cord presentation and prolapse ( wide space for the cord to decend)
6. The need for use of oxytocin ( induction of labor or uterine inertia)

oxytocin is used if a. There are NO uterine contractions at all b. For augmentation of weak contractions {NEVER use oxytocin in malpresentation} - if you thought about using oxytocin in malpresentation , perform CS - even if contractions are weak , don't use it - in normal presentation you can measure disproportion - in malpresentation you may not diagnose disproportion i.e. high incidence of unrecognized mechanical obstruction in malpresentation - if the case is malpresentation with disproportion and you gave oxytocin RUPTURE UTERUS Occipito-posterior is mal position and not mal presentation so you CAN give oxytocin
7. fetal or maternal distress: especially during the first stage 8. breech presentation in an elderly primigravida
primigravida : as primigravida has no history of previous vaginal deliveries so you can' suggest that her pelvis is suitable and not contracted elderly ( above 35 years): as a. rigidity in pelvic floor b. decreased fertility (Age of ovum is of the age the woman, increase together and its chance to be fertilized decreases by age with peak fertility at 25 years) So don't put this pregnancy in a risk and do CS immediately SCORING SYSTEM Helps the dr to take the decision whether CS or vaginal delivery Simplest type: 0 1 2 - parity ( previous deliveries) or primgravida [I dont know anything about her pelvis] - previous successful breech deliveries ( it has to be successful with no obstruction for instance) - gestational age (37 weeks is suitable as fetal size is small. If smaller CS) - estimated fetal weight: 2.5 3.5 kg is suitable If less than 2.5 IC hemorrhage in case of vaginal delivery If more than 3.5 mechanical obstruction in case of vaginal delivery - cervical dilatation - station Give points and calculate the score If 10-12 points vaginal delivery If less than 10 CS
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III. III. Management during labor first stage second stage A. spontaneous breech delivery: - Vaginal delivery for a case of breech presentation is NOT common - When vaginal? If baby is very small (26-27 weeks / <1.5 kg). DO NOT do CS as the fetus won't survive anyway and will die in the incubator from chest infection or liver affection. B. assisted ssisted breech delivery
1. NO traction
when the mother enters into the second stage don't pull the fetus from his legs as the cervix might not be fully dilated body will pass and the head will be stuck as the head has to be flexed in order to pass and in case of pulling the head will be extended and stuck. Also press on the buttocks with clean towel for 10 minutes to avoid descent of the body before full cervical dilatation Timing: When the buttocks produce maximum stretch of the vulva Benefits a. Protects the mother from perineal lacerations b. Protects the fetus from sudden compression and decompression and consequently from intracranial hemorrhage by widening the passage c. Widens the passage for the fetus so it can pass with minimal angle (decrease lateral flexion of spine) thus protects from fracture spine
2. Episiotomy
-
3. Delivery of the legs and buttocks 4. Delivery of the trunk

the thumb of both hands are applied on the sacrum ( bone ) as if you held the fetal body from any higher point you may lead to visceral injury ( kidney, suprarenal glands, liver or spleen). Warm towel is used: Hold the fetus and wrap it by a towel soaked in warm water, why? As the fetal body is slippery and the fetus comes out from uterus which is relatively warmer than the operation room which is relatively colder and this may produce stimulation of respiration the fetus will start to breathe while its head is still inside the uterus. now the fetus is coming out on his side with the anterior buttock turn the back of the fetus to become anterior this will make the shoulder enter the pelvis in the oblique diameter and the head enters in the opposite oblique pull the fetus till you see the axilla or the inferior angle of the scapula by this time it means that the shoulder is accessible introduce two fingers above the shoulder to push the arm downwards and do the same for the other shoulder Now the head is in the opposite oblique If the head undergoes extension it will be stuck inside and it wont be able to come out , so you have to keep the head in a flexed position but HOW ?
5. delivery of the shoulders

-
6. Delivery of after coming head

-
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Press on the fundus to preserve the flexion of head till it comes out o problem: NOT enough
i.
BurnsBurns-Marshall method:
An assistant is asked to press on the fundus to preserve the flexion of the head while you are observing the delivery of the fetus, and as soon as you see the symphisis pubis, grab the fetus from his legs and take him out o problem: this move can extend the head of fetus
ii. ii .
jaw flexion shoulder traction

An assistant is asked to press on the fundus to preserve the flexion of the head while you use your middle finger (of the right hand) to support the head in a flexion position by placing it on the occiput. Then place your index finger of the same hand on one shoulder and your ring finger of the same hand on the other shoulder to pull the fetus.
Problem: the neck of the fetus may be overstretched damage of roots of brachial plexus paralyzed upper limbs on birth. Or over stretch of the neck tearing in the sternomastoid fibrosis torticolis. Forceps: BEST PROCEDURE iii. iii. Place the forceps blades on the after coming head Place the forceps on the ventral aspect of the fetus but the arms and legs will bother you, so pass a towel from underneath the body of the fetus and ask the nurse or the assistant to pull the towel upwards o What are the uses of a towel soaked in warm water in breech? 1. as the fetus body is slippery , it allows you to get good control on your fetus grip 2. the fetus comes out from uterus which is relatively warmer than the operation room which is relatively colder and this may produce stimulation of respiration the fetus will start to breath while its head is still inside the uterusm so we use the warm towel to to prevent this from hapeening 3. during using the forceps and to avoid being bothered by the legs and arms, pass a towel from underneath the body of the fetus and ask the nurse or the assistant to pull the towel upwards away from your field o
advantages of forceps:
a. Promotion of flexion (as it has a special design) b. Traction is directly applied to the head so it prevents overstretch of he neck as in case of jaw flexion shoulder c. Prevent sudden compression and decompressions it produce compression with a certain degree (steady) therefore NO intracranial hemorrhage
Can the fetus bear the usage of the forceps? If he is full term, he can bear it If preterm, he won't bear it and you will perform CS
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o Type of forceps: PIPER'S forceps: Has a perineal curve, why? So that the handle is kept away from body of fetus doesn't bother you in the delivery easy usage of forceps.
C. Breech extraction . In spontaneous and assisted breech delivery, NO traction is applied . In breech extraction, we apply TRACTION . Indications: a. to shorten the second stage - Maternal or fetal distress If the fetus or the mother is in distress during the second stage e.g. fetus with 80 beats/ min You have to deliver the fetus either by CS but it consumes time in preparing for the operation Or Pull the fetus from his legs ( breech extraction) How to deal with fetal distress? -if during 1st stage CS (as you have time to prepare for CS operation) If during 2nd stage extraction -
-Maternal disease e.g. cardiac A mother with heart disease won't bear the 2nd stage of labor as BP + HR CO heart failure b. breech with extended legs: - as the fetus enters pelvis easily as buttocks are small in size but it is difficult for it to come out of pelvis as extended legs prevents lateral flexion of spine and lateral flexion of spine is essential for exit of buttocks . Technique 1. Preparation . You will introduce your hand into the uterus, SO - you have to give general anesthesia or it will cause : Preparation: Irritation of the uterus tonic spasm Shock to the mother Anesthesia
Bladder evacuation Complete strict asepsis

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- you have to perform complete aseptic precautions 2. Bringing down the legs a) Complete breech b) Frank breech Introduce 2 fingers into the uterus and press on the popliteal fossa flexion of the knee passively the leg will descend pull it out Do the same for the other leg Complicated breech delivery: delivery: arrest of the fetus - Arrest of : 1. Buttocks 2. Shoulders 3. after coming head - Causes and management of arrest of after coming head: A) Causes in the head 1. Large head (or narrow pelvis) - Management: if dead craniotomy ( perforate fetal skull so head collapse and now you can apply traction) If still viable symphysiotomy (use the scalpel and cut the symphysis pubis and take the fetus out) - symphysis pubis is cartilage so less vascular healing is weak so tit remains opened Advantage: Disadvantage: ! 2. Hydrocephalus: if the fetus suffers from cortical atrophy he is considered dead so don't perform CS - Management: Lumbar puncture: place a needle in the subarachnoid space and let CSF flow out for half an hour Or Craniotomy if due to obstruction as puncture is not useful Or suprapubic puncture : introduce a needle through the maternal abdominal wall and uterus then into the head of fetus and take a CSF sample B) Causes in the passages 1. contracted pelvis: as large head
Complications of breech delivery

A] Maternal complications B] Fetal complications - Fetal mortality 1. Intracranial hemorrhage - Management according to gestational age If full term episiotomy and forceps If preterm CS 2. Fracture of cervical spine 3. Asphyxia 4. Injury of abdominal organs - Prevention: place your thumb on the sacrum 5 fracture vertebral column: because of lateral flexion
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- Prevention: episiotomy What causes death in a breech fetus? Birth injuries (visceral injury- fracture spine- IC hge) Asphyxia Prematurity
Complex presentation
Define: the fetals hand beside his head MANAGEMENT:IF MANAGEMENT: THE FETAL LIMB PRODUCES OBSTRUCTION THEN : C/S IF DOESNT PRODUCES OBSTRUCTION THEN : C/S
Unstable Lie
Define: not stable changes his position Ex:shoulder presentation changes sometimes May be oblique Management: if presentation becomes cephalic spontaneously as its unstablethen:use abdominal binder -if during the 37,38, 39 weeks then produce induction of labor NB: give her induction of labour 2 be birthed as full term better than he goes back 2 breech or shoulder position
Cord presentation & prolapse

presentation: intact mambrane prolapse: rupture membrane Etiology: tiology: - Interferance with adaptation of the presenting part to pelvic inlet - Labour is a process of adaptation if the pelvic part is properly fitting the pelvic inlet then it wont allow the cord 2 pass from hind water 2 forewater - If the presenting part is not properly fitting, so cord presentation or prolapse occur
Fetal malpresentation or prematurity small head Maternal contracted pelvis the shape of the pelvis Predisposing factors: - Abnormal long cord normal length is 50-55 cm - Low insertion of the placenta ex:placenta previa the umbilical cord is nearer & lower DIAGNOSIS: - Pv examination: Cord presentation : if u feel it through the membranes Cord prolapse: if you hold it by hands NB:some cases are misleading, occult cord presentation & prolaose ie:the loop is obstructed beside the head Occult: is that the cord is neither seen nor felt while descending but there is asphyxia which affects FHS leading 2 variable deceleration
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if u hear variable deceleration,this means compression of the cord leading 2 decreased circulation of the featus which occurs when the loop descends & the head follows it also vasoconistriction of the umbilical cord vessels increases asphyxia MANAGEMENT: Cord presentation: - the problem is with the INTACT MEMBRANES ,so the cord is surrounded by fluids so the cord isnt compressed BUT if there is rupture of the membranes occurred then the cord will be compressed & we dont know the exact time of the rupture of the membranes MANAGEMENT MANAGEMENT SCHEME: SEARCH FOR ANY OTHER RISK FACTOR: If found which mostly occur as the etiology of the cord presentation is risk factors then do C/S IF NO RISK FACTOR PRECEED 2 THE NEXT STEP a) PREVENT THE RUPTURE OF THE MEMBRANES TO PRVENT THE CONVERSION OF CORD PRESENTATION 2 CORD PROLAPSE BY: - DECREASE THE FREQUENCY OF PVOTHERWISE U MAY CAUSE RUPTURE - BEND THE BED TOWARDS THE MOTHERS HEAD THUS THE FLUID PASSES UPWARDS TOWARDS THE FUNDUS AWAY FROM THE CERVIX - AVOID STRAINING POSSIBILITIES: a) If succeeded, succeeded, no rupture of membranes occurred till the second stage ,so deliver immediately before cord prolapse - if cephalic: use forceps - if breech : do breech extraction but its supposed that breech is delivered by breech extraction {second risk factor } b) if failed failed & rupture of membranes occurred with cord prolapse then proceed to the next step - u then only have 8-12 mins to deliver the fetus otherwise he will die - u should make sure that the fetus is still living as u dont know exactly when the rupture of membranes occurred as the fetus might have died{ rupture of the membrane & the prolapse occurred from more than 12 mins } so if the fetus has died there is no need then for c/c NB: HOW TO ASSESS THE VITALITY OF THE FEATUS, i.e.: i.e.: HOW TO KNOW IF THE VIABLE OR DEAD? 1. Hold the cord& feel the pulse if pulsating OR not NB: u cant depend on the fetal pulse as it may be very week or u may falsely fell pulsation of ur finger 2. FHS - if there is FHS: c/s is indicated - if no FHS dead featus then: if there is mechanical obstructionso c/s , if no mechanical obstruction then let it be vaginal Preparation of c/s in case of a living featus with cord prolapse : A. Trendelberg POSITION bend the table to a lower position at the side of the mothers head so that the presenting part wouldnt press on the cord B. The patient lies on her left side so that the uterus wont compress on the IVC so increase the venous return so increase the cardiac output so increase the placental perfusion C. Oxygen mask : let the mother breethe pure oxygen this increases oxygen supply to the featus so that gives the doctor sometime -
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Shoulder presentation
Definition: shoulder presentation = transverse lie Etiology: 1. Laxity of the abdominal and uterine muscles weak wall allows baby to lie transversly. This is related to multiple pregnancies. E.g. Multipara 5 parity > 1 ; grand multipara > 5 ???????? 2. Uterine fibroid especially fibroid in the fundus. 3. Mullerian anomalies: bicornuate uterus. Denominator: scapula, of no significant importance as shoulder presentation is delivered by CS. Mechanism of labor: A pregnant woman, 37 weeks. When you examine her, the baby is in shoulder presentation. The next day when you examine her again, you find the baby in vertex or breech presentation. This is because of the laxity of the wall, which gives the fetus the freedom to rotate and become vertex or breech. So this fetus can be delivered vaginally, especially that the mother is a mutipara. Diagnosis: A. during pregnancy: i. abdominal examination: fundal level: lower than expected according to the gestational age fundal grip: fundus is empty Umbilical grip: one hand can feel the head, and the other can feel the buttocks. FHS: at one side of the umbilicus. ii. ii. Ultrasonography: Nothing characteristic. B. During labor: i. Abdominal: see before ii. ii. Pervaginal examination: As usual Presenting part: Scapula, ribs Ribs give grid iron sensation . Management: i. During pregnancy:
External cephalic version

Definition: External: Cephalic version: (cephalic)
External cephalic version in shoulder is more promising than breech i. Half the distance. ii. Laxity of uterine walls facilitates the procedure.
Internal podalic version: Definition: (breech) Disadvantage: breech is a malpresentation, BUT (advantage) it can be delivered
vaginally [shoulder can never be delivered vaginally. Prepared by: Mohamed El Far & LORD GEMI Printed & edited by: Heba Saif Mohamed Abdel Mawla Revised by: Black Eagle
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Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

The pelvic inlet (Brim):

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

The pelvic cavity:

Width (transverse diameter)

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

Axis of pelvis: Anatomical axis:

'Anatomical & obstetric axes'

Anatomy of fetal skull

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

Presentations Cephalic Vertex Face Brow Breech Shoulder

Lower most part of head of fetus

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

Asynclitism: (opposite of synclitism, no synclitism)

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

What's meant by labor?

Means work / generation of movement against resistance.

Normal labor, fetus being:

Theories of onset of labor:

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

estrogen Relatively progesterone oxytocin receptors utrine contractions oxytocin acts

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

Prostaglandin theory is the most important one

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

'Polarity & fundal dominance; evidence' -

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

A. First First stage of labor:

A. Factors causing dilatation:

1. Uterine contraction and retraction:

2. Dilating effect of bag of forwaters:

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

4. Changes in cervix: induced by prostaglandins, cervix , so facilitating dilatation and effacement.

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

e.g.: 5cm dilated/60% effaced

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

B.Second B.Second stage of labor:

Mechanism of normal labor:

LABOR IS A PROCESS OF ADAPTATION

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

By extension, head of fetus comes out.

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

C. Third stage of labor:

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

Effect of labor on the mother: 1st stage:

Effect of labor on the fetus: a. Molding:

Size: the size of pelvic caput = size of bony pelvis. Significance:

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

Management of normal labor:

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

Instruments &equipment used:

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

Management of the first stage:

Detailed Lectures of Obstetrics Normal Labor & Malpresentation Malpresentation

5. Evacuation of bladder& rectum:

Why to evacuate it?