AN OVERVIEW OF THE PATHOLOGY OF LABOR

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AN OVERVIEW OF THE PATHOLOGY OF LABOR

By Dr. Ratnakar P. Kini

Objectives: The learner will be able to explain What are the signs and symptoms of pregnancy? How to diagnose pregnancy? The normal fetal presentation The mechanism of normal labor Abnormal fetal presentations Other factors affecting normal labor How to conduct labor in these circumstances?

This article is an overview of the pathology of labor. A labor is said to be pathological when normal delivery is not possible due to either maternal or fetal causes. This article includes (in the following order) Diagnosis of pregnancy Normal labor Fetal malpresentations Multiple pregnancies Maternal causes of pathology of labor Cephalopelvic disproportion Multiple choice questions

1. Diagnosis of pregnancy Diagnosis of pregnancy is not very difficult in most of the cases. But sometimes especially during the early months it may be difficult. In these circumstances the signs and symptoms that develop during the course of pregnancy may be helpful. Pregnancy is divided in to three trimesters. Each trimester has its own signs and symptoms.

Signs and symptoms of first trimester: Amenorrhea Cessation of menstrual periods Morning sickness This develops around 4-6 weeks of pregnancy in which the expectant mother develops nausea and vomiting Increase in the size of the breast and formation of secondary areola Bluish discoloration of the vagina- This is called Chadwicks or Jacquemiers sign and it develops around 4-8 weeks of pregnancy Hegars sign- Softening and compressibility of the isthmus of uterus is called Hegars sign. It is elicited by introducing two fingers in to the vagina behind the cervix with the fingers of the other hand pressing down in to the abdomen from above the pubic symphysis. In pregnancy the fingers of the two hands will almost meet as if there is no tissue in between and the cervix and the uterus will be felt as two separate masses. This sign is usually positive by 6-8 weeks of pregnancy and eliciting it should be avoided after 12 weeks of pregnancy.

Signs and symptoms of second trimester: Quickening Around 16 weeks of pregnancy, the fetal movements can be perceived by the mother. This is called quickening Skin Changes Stretch marks and linea nigra which is a linear pigmented area between the umbilicus and the pubis are seen Increase in the size of the uterus- After 12 weeks the uterus comes out of the pelvis and it can felt growing progressively Braxton Hicks contraction These are painless intermittent contractions of the uterus ( See in the later sections) Palpation of the fetal parts

Auscultation Fetal heart sounds can be heard from the 17-20th week of pregnancy Perception of fetal movements- Internal ballottement in which two fingers are introduced in to the vagina and gentle tap is given upwards. This is transmitted to the fetus which goes upwards and falls back on the fingers again after sometime. In external ballottement, the uterus is steadied with one hand applied to a side and with the other hand a gentle tap is given. The fetal parts may be felt by the opposite hand.

Signs and symptoms of third trimester: The fetal movements are easily felt The fetal parts are easily palpable The uterus fills the entire abdomen

Pregnancy tests: The following investigations are done to diagnose pregnancy:

Laboratory tests: Bio assay Immuno assay Heagglutination inhibition test Flocculation inhibition test Radio immuno assay Sub unit radio immuno assay Radio receptor assay ELISA test

Ultarsonography: This confirms pregnancy as fetus can be visualized depending on the duration of pregnancy.

2. Fetus in normal pregnancy

Attitude: The attitude of the fetus is the relation of the fetal parts to one another. Usually the fetus assumes the attitude of universal flexion in which the spinal column is bent forward, the head is flexed, the chin rests on the sternum, the arms are flexed and folded across the chest, the lower extremity are flexed so that the thighs rest on the abdomen, the legs bent at the knees and resting on the thighs with the feet crossed in an attitude of dorsiflexion.

Presentation: Presentation means the portion of the fetus which is in relation to the lower pole of the uterus and which is the first to engage when labor starts. Thus there are Cephalic In this the head is at the lower pole Podalic or breech In this the legs are at the lower pole Transverse and oblique Here neither the head nor the legs lie in the lower pole

Different presentations:

In cephalic presentation there can be different presenting parts Vertex Brow Face 5

Lie: It is the relation of the longitudinal axis of the fetus with that of the uterus. It could be Longitudinal when both are parallel to each other Oblique or transverse when they are at an angle to each other

Position: It is the relation of the presenting part of the fetus with the maternal pelvis. A particular bony land mark in the fetus is taken and its relation to the four different quadrants of the pelvis is noted. The bony land mark is called the denominator. The four quadrants are Right anterior Right posterior Left anterior Left posterior The different denominators are In vertex Occiput In face Chin or the mentum In brow Frontal prominence In breech Sacrum In shoulder Acromion

There are four different positions possible with each presenting part. Thus for example in vertex presentation the possible positions are (as illustrated on the following page):

Right occipito anterior - ROA Right occipito posterior - ROP Left occipito anterior - LOA Left occipito posterior - LOP

Fetal head and diameters: The passage of fetal head through the maternal pelvis is the most important factor in the delivery of the fetus. Two factors are responsible for it

Fetal head diameter Moulding of head

Fetal head diameters: The different head diameters are Sub- occipito bregmatic This is 9.5 cm and it is the engaging diameter in vertex presentation

Mento- vertical This is 13.5 cm and it is the engaging diameter in brow presentation and it is the largest diameter Occipito frontal _ This is 11.5 cm and it is the engaging diameter if the head is deflexed Sub mento bregmatic This is 9.5 cm and it is the engaging diameter in face presentation Biparietal diameter This is 9.5 cm. It is used during ultra sonography to assess the maturity of the fetus

Different engaging diameters: A.Suboccipito bregmatic B. Occipito frontal C.Mento vertical D. Sub occipito frontal

Moulding: Because the fetal skull bones are separated by membranes they can mould to become compact during difficult labors.

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Different fontanelles and bones:

3. Normal labor Labor is a process by which the products of conception, when they have reached full term or nearing it, are expelled by the mother. When a full term fetus presenting by the vertex is expelled by natural efforts, unaided, within a period of twenty four hours, it is called normal labor. If it sets in before 37 weeks of gestation, it is called pre term or premature labor. If the product of conception is expelled before 28 weeks of gestation, it is called abortion or miscarriage.

Changes in the uterine architecture during labor: Around the time of labor, the cervix undergoes a process called ripening because of which its flexibility increases. Then the cervix thins out and is taken in to the body of the uterus after which the differentiation of the body and cervix becomes difficult. This is called effacement of the cervix. Once the labor starts the uterus gets differentiated in to two parts- the upper and the lower uterine segment.

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Effacement and dilatation of cervix:

Upper uterine segment: It is upper half of the uterus during labor It is the active part during labor It is thicker than the lower segment and its thickness increases as labor advances During labor, it contracts and retracts. Lower uterine segment: It is the lower half of the uterus during labor It is the passive part during labor It is thinner and gets thinner as labor advances During labor, it gets stretched out to receive the descending fetus

The junction of the upper and the lower uterine segment is characterized by a ring of circular muscle fibers which form the physiologic retraction ring.

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Formation of lower uterine segment:

Uterine contractions There are two types of uterine contractions. Braxton Hicks contractions Labor contractions Braxton Hicks contractions: This occurs during ante natal period. The characteristic features are Painless Intermittent contractions Irregular in time and force Not coordinated No diminishing gradient Does not result in expulsion of the fetus

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Labor contractions: This occurs at the time of labor. The characteristic features are Painful Contraction is accompanied by retraction. Retraction is a process in which the uterine muscle after contraction does not relax to get back to original length, but remain at a shorter length, but the tension the same as before contraction. This helps to prevent the fetus from slipping back The contractions are more dominant in the fundus of the uterus There is a diminishing gradient of activity from the fundus through the body to the lower uterine segment.

Stages of Labor: Labor is divided in to three classic stages First stage or the stage of dilatation Second stage or the stage of expulsion Third stage or the stage of placental delivery

Stage of dilatation / First stage: First stage extends from the onset of true labor pains to the complete dilatation of the cervix. In primigravida, it lasts for about 12 hours and in multigravida, it lasts for about 5-6 hours. The following 5 phenomena occur during the first stage. Uterine contractions This true labor pains occurs in episodes lasting for 45 seconds to 1 minute. In the beginning each episode occurs at intervals of 30 minutes and in the end they occur every few minutes. The labor pains are felt in the sacral region and over the lower abdomen and sometimes down the legs.

Muco sanguineous discharge or show A small amount of cervical mucus mixed with blood is passed. It is an evidence for cervical dilatation and effacement.

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Dilatation of the cervix This is due to the contracting and retracting upper segment pulling the cervix up.

Fixation of the head The head becomes fixed at this stage if not fixed already in the last two or three weeks of pregnancy. If the head is not fixed by now, it indicated there are abnormalities.

Rupture of membranes This occurs after the complete dilatation of the cervix.

Stage of expulsion / Second stage: Second stage extends from the rupture of membranes to the expulsion of the fetus. In primigravida, it lasts for 1-2 hours and in multigravida, it lasts for half to one hour. The uterine contractions become stronger with a bearing down character. The accessory muscles of labor like diaphragm and the abdominal muscles begin to act and the fetus is pushed down the dilated cervical canal. The vulva widens when the presenting part is fixed under the symphysis pubis and this is called crowning of head. After the head is delivered, the patient puts in one last effort and the rest of the fetus is born.

Stage of placental delivery / Third stage: Third stage extends from the complete expulsion of the fetus to the extension of the placenta and membranes and firm contraction and retraction of the uterus subsequently. This stage extends for a period of about 15 minutes. The following 5 phenomena occur during the first stage. Uterine contraction After the delivery of the fetus, the uterus becomes firm, round and hard and lies at the level of the umbilicus. Rhythmic contractions may be felt.

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Separation of Placenta After the fetus is delivered the placenta shrinks and is forced down by the uterine contractions. There are two methods of placental separation. Duncans method In this method the placenta detaches by folding on to itself with its longitudinal axis lying along the longitudinal axis of the uterus. The margin of the placenta comes out through the cervix.

Schultzes method In this method a blood clot is formed behind the placenta and the placenta is thus separated from the uterus. The central part of the placenta thus comes out first with the attached cord like an inverted umbrella.

Methods of placental separation:

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Expulsion of the placenta After the placenta is detached from the uterus by any one of the two methods mentioned, it is expelled out. Control of hemorrhage The bleeding following hemorrhage is controlled by the following factors. The contraction and retraction of the uterus constricts the blood vessels The self occlusion of the blood vessels by vasospasm Formation of blood clots which occlude the lumen

Permanent contraction and retraction of the uterus The uterus thus comes to lie at the level of the umbilicus Some obstetricians call the stage of control of bleeding as the fourth stage of labor.

Stages of labor:

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Friedmans partography: Friedmans partography is the recording of the cervical dilatation and the fetal descent in a graph. This graph provides a reliable guide to the course of labor and with its help dysfunctional labor can be made out. The structures of the graph are (as illustrated on the following page) Duration of the labor in hours in the horizontal scale Cervical dilatation in centimeter in the left vertical scale marked in crosses Descent of fetal head or the stations in the right vertical scale marked in circles

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Measurement of fetal stations:

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Components of the graph: The onset of labor is defined as the onset of regular uterine contractions as perceived by the patient. Points are entered as they are obtained during each examination. There are two components during the first stage latent and active to be followed by second stage.

Active phase of the first stage of labor: This is divided in to three phases Acceleration phase with cervical dilatation of 2.5 -4 cm Phase of maximum slope with cervical dilatation of 4-9 cm Deceleration phase with cervical dilatation of 9-10 cm The normal curve is S or sigmoid shaped.

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Interpretation of the graph: Latent phase lasts for a maximum of 20 hours in primi and 14 hours in multigravidae. If it exceeds it is prolongation of labor The slope of the curve is 1.2 cm in primi and 1.5 in multigravidae. If it exceeds it si called prolonged dilatation pattern The deceleration phase in primi should not exceed 3 hours in primi and 1 hour in multi gravidae If it exceeds it is called prolonged deceleration phase.

Thus by plotting on the graph abnormalities or the pathological labor can be made out and proper intervention at the right time can be done.

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Mechanism of Normal Labor: The mechanism of labor means the steps by which the fetus adjusts and passes through the birth canal with least difficulty. Three factors interact with each other for effective conduction of labor. They are Pelvis and soft parts Fetus Uterine forces

Steps of normal labor: There are seven basic steps of delivery of head in normal labor which can be easily remembered with the help of the mnemonic EDFIERE E - Engagement D - Descent F - Flexion I - Internal rotation E - Extension and birth of fetal head R - Restitution E - External rotation

Engagement: This is the first step in the process of labor. It denotes that the greatest diameter of the head has passed through the greatest diameter of brim of the pelvis. The antero posterior diameter of the inlet of the pelvis is the narrowest one and hence the head never enters in that plane. The head gets engaged in the larger oblique or the transverse plane usually the transverse plane. The antero posterior suture or the sagital suture thus lie transverse in the pelvic cavity. But it is never in the midline- it is either found near the pubic bone when it is called posterior asynclitism or Litzmans obliquity or near the sacral prominence when it is called anterior asynclitism or Naegles obliquity. Naegles obliquity is seen in most of the cases.

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In primi gravida or the first time mothers the process of engagement occurs usually during the last few weeks of pregnancy. In multi gravida or mothers who have had delivered before, the process of engagement occurs only after the labor pain starts.

Descent: This is the second step in the process of labor. Descent occurs only if the head size of the fetus is proportionate to the inner diameter of the pelvis. The process of descent is brought about by Amniotic fluid pressure Uterine contractions In primi gravida, descent may occur even before labor pains have started. But in multi gravida, descent usually begins with engagement. The descent continues throughout the process of labor. As mentioned already, Naegles obliquity is common. So the anterior parietal bone keeps descending and the posterior parietal bone remains more or less stationary.

Flexion: This is the third step in the process of labor. As the head keeps descending, it meets resistance from either of the following two parts. Pelvic side wall Pelvic floor Because of the resistance, the head of the fetus flexes and the chin gets closer to the rib cage. Because of this, the head gets engaged with the narrowest diameter the sub occipito bregmatic diameter which is 9.5 cm instead of the previously engaged occipito frontal diameter which is 11.25 cm.

Internal rotation: This is the fourth and the most important step in the process of labor. During descent when the presenting part reaches the ischial spines, internal rotation occurs. The ultimate aim of the step is to bring the occiput of the fetus towards the pubic symphysis. For the internal rotation to be effective Flexion should be complete

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Uterine contractions should not be weak Pelvic floor should not be weak or lacerated If at the time of engagement, the occiput is at the transverse plane, then the head has to rotate 90 degrees to bring the occiput towards the pubic bone. If it is at the anterior oblique plane, it has to rotate 45 degrees. If the occiput is on the left, it has to rotate to the right to get near the pubic bone. If it is on the right, it has to rotate to the left for the same purpose. Some times rotation happens in the opposite direction and the labor gets delayed requiring further assistance. At the end of internal rotation, the presenting part enters the longest diameter of the outlet of the pelvis which is the antero posterior diameter.

Extension & birth of fetal head: This is the fifth step in the process of labor and is very important for the delivery of head. At the end of the internal rotation, the occiput of the fetus lies near the pubic bone and the chin remains flexed near the pelvic bone of the mother. The uterine contractions from above and the pelvic floor resistance from below cause extension of the head. As a result of it, the occiput gets hitched at the pubic bone. The face does not have any such resistance and it starts sweeping over the perineum. Thus frontal parts, orbital ridges, nose, mouth and chin are delivered with the occiput acting as a fulcrum. During this process, the pelvic floor gets stretched and it has to be supported well. If it is not done properly, laceration of the pelvic floor may occur.

Restitution: This is the sixth step of the process of labor. During internal rotation, occiput rotaes towards pubic bone and there is twisting of the neck. Once the head is delivered, the chin moves in the same direction and untwists the twisted neck.

External rotation: This is the last step of the process of labor. In this step, there is internal rotation of the shoulder with simultaneous external rotation of the head. Because of this step, the anterior shoulder gets hitched at the pubic bone like how it occurred for the occiput. Once this happens,

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the posterior shoulder sweeps over the perineum and is delivered by the process of lateral flexion of the spine. The anterior shoulder slips forward and gets delivered. The rest of the body of the fetus slips down and gets delivered. 10 -15 minutes later, the placenta and the membranes get separated and delivered. Once they are delivered, the uterus contracts and retracts and bleeding stops.

Mechanism of labor

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4. Fetal malpresentations

Abnormal presentations of the fetus which interferes with the normal labor are called malpresentations. Caesarian sections are done nowadays in most of the cases which has brought down both the maternal and infant mortality rates. The following discussion is about all the possible treatment modalities during pathology of labor.

A.Occipitoposterior

Occipito posterior is a fetal malpresentation. It is the most common fetal malpresentation comprising nearly 25-30% of all vertex presentation. In this malpresentation, the occiput of the fetus lies in the posterior plane of the pelvis either on the right or the on the left side.

Causes: The presentation of the fetus is decided by the diameter of the pelvic inlet. Usually the head engages in the longest inlet diameter and in most of the cases it is the transverse diameter. This is in the case of gynecoid pelvis. But in android and anthropoid pelvis the oblique diameter is more than the transverse diameter and so the head engages in the oblique plane either in the anterior quadrant or the posterior quadrant. If it engages in the posterior plane, it results in the occipito posterior position.

Clinical findings: The fetal parts are more easily felt than usual The fetal parts are felt nearer the midline The head is slightly deflexed The maximum intensity of the heart beat is in the flanks The posterior fontanelle is nearer the sacral hollow

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Course of labor: The steps of labor are the same. Prolongation of labor is the biggest problem of occipito posterior positions. The few differences are Since the head is a little deflexed, the engaging diameter is the 11.5 cm occipito frontal instead of the 9.5 cm sub occipito bregmatic diameter. This leads to difficult and prolonged second stage of labor. In 10% of the cases the head may not rotate at all or rotate only partially (resulting in deep transverse arrest) or rotate in the opposite direction in to the sacral hollow (malrotation). In the first two instances the delivery has to be assisted. In the last case delivery occurs with the face of the fetus facing the pubis of the mother (normally only the occiput faces the maternal pubis). This face to pubis delivery is always associated with laceration of the perineum.

Nature of assistance: It depends on The level of arrest The nature of pelvis Arrest at the level of the pelvic brim: Caesarian section is indicated Forceps application is not recommended Arrest in the mid cavity: This is the commonest type. This usually occurs at the level of the ischial spines. All the factors should be examined and assessed under anesthesia. There are three options available to deliver in this type of arrest. Manual rotation and forceps application and delivering Rotation with forceps and delivering Caesarian section

Manual rotation and forceps application: This method is preferred When the pelvis is adequate in diameter

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When the arrest is due to deflexed head Under anesthesia, with one hand in the vagina, the fetal head is grasped and the head is pushed upwards and brought in to the position of flexion. This makes rotation easier. Now with the other hand the shoulder is located on the abdominal wall and with both hands the fetus is manually rotated and the occiput is brought to the front. Now the forceps is applied and the delivery is completed. Manual rotation is difficult If the head is impacted Liquor is in adequate The pelvis is android in type

Rotation with forceps: This is preferred when manual rotation is not possible. This is done under anesthesia. Kielland forceps are advantageous than the axis traction forceps. If not properly done it can cause intra cranial hemorrhages in fetus.

Caesarian section: Caesarian section is indicated When the pelvic shape does not allow rotation at all as in android and platypelloid pelvis Elderly primigravida

B. Brow Presentation

When the portion of the fetal head between the anterior fontanelle and the glabella forms the presenting part, it is called the brow presentation. In this presentation the head lies midway between complete flexion and complete extension. This presentation is an unstable presentation meaning it either gets converted in to a vertex presentation or the face presentation. Hence it is a rare presentation.

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Causes: The causes of brow presentation are Contraction of pelvis Big baby Obliquity of uterus Tumors in the neck of the child Cord around the neck Spasm of the sternomastoid muscle When the fetal head is conical Multiparity

Clinical finding: The clinical findings are The cephalic prominence is felt at a higher level and on the same side of the back The chin lies at a lower level On vaginal examination, the root of the nose and the orbital ridges can be made out

Course of labor: As said earlier, the brow presentation is rare and unstable as it gets converted in to a face or vertex presentation. If the brow presentation persists, labor does not progress. This is because the presenting diameter in brow presentation is the longest. The presenting diameter is mento vertical which is 13.5 cm and the pelvis is not adequate to allow progress of labor. If the pelvis is larger and the head of the baby is very small due to prematurity, labor can progress. The head is delivered face to pubis and the rest of the body is delivered as in vertex presentation.

Delivery in brow presentation always results in injuries to both mother and child. In mother Laceration of the perineum Shock

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In the child Intra cranial injuries Asphyxia

Management: In brow presentation, time should be allowed for the fetus to get in to either face or vertex presentation which normally occurs and spontaneous delivery is possible in both these cases. If the fetus is large or the pelvis is inadequate and if brow presentation persists, then caesarian section is done to deliver the baby.

C. Face Presentation

When part of the fetal cephalic pole between the chin and the frontal eminence forms the presenting part, it is called face presentation. It is due to complete extension of the fetal head. The engaging diameter is sub mento bregmatic which is 9.5 cm.

Causes: The causes of face presentation are the same as that of brow presentation. Contraction of pelvis Big baby Obliquity of uterus Tumors in the neck of the child Cord around the neck Spasm of the sternomastoid muscle When the fetal head is conical Multiparity

Positions possible: The chin is the denominator and the positions possible are Left mento anterior this is the commonest

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Right mento anterior Left mento posterior Right mento posterior

Clinical findings: The clinical findings are The cephalic prominence is felt on the same side as the back By vaginal examination, the face, chin, mouth and nose are easily palpated. Sometimes face presentation may be wrongly diagnosed as breech as the mouth felt is mistaken for anus. The points to differentiate are, The palpating finger may be meconium stained and the grip of the sphincter can be felt in breech but not in face presentation In face presentation the mouth does not lie at the level of the ischial spines whereas in breech presentation, the anus lies at the level of the ischial spines.

Course of Labor: The mechanism is the same as that normal labor in vertex presentation expect that the role of occiput in normal labor is taken by chin in face presentation. The steps of labor are Descent with increased extension Internal rotation of chin Flexion Restitution External rotation If the chin is anterior, there is 45 degrees internal rotation to bring the chin to the pubis. If it is posterior, there is 135 degrees internal rotation to bring the chin to the pubis.

Management: The engaging diameter is 9.5 cm which is the same as the normal vertex presentation. So a normal labor is always possible. Difficulty of labor occurs when the chin rotates in the opposite

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direction and results in mento posterior position in which case normal labor is virtually impossible. In these cases caesarian section is usually done.

D. Breech Presentation

When the cephalic part of the fetus occupies the upper pole or the fundus of the uterus and the podalic pole becomes the presenting part, it is called the breech presentation. The bisiliac diameter is the engaging diameter. There are two main types of breech presentation Complete Incomplete

A. Complete B& C. Incomplete

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Complete breech presentation: In this presentation, the fetus maintains the attitude of universal flexion with the thighs flexed at the hips and legs at the knees.

Incomplete breech presentation: In this presentation, there are varying degrees of extension of the podalic pole. There are three types of incomplete breech presentation. Frank breech Knee presentation Footling

Frank breech:

This is also called extended breech. In this presentation, the thighs are flexed, but the legs are extended so that the lower limbs lie along the ventral surface of the fetus.

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Knee presentation:

In this presentation, the thigh is extended and the leg is flexed at the knee.

Footling presentation:

In this presentation, both the thigh and the legs are extended.

Causes: Anything that interferes with the normal shape of the fetal ovoid or change the shape of the uterine ovoid may result in breech presentation. Some of the causes are Obliquity of the uterus Multi parity Fibroids Placenta previa Ovarian tumors Contracted pelvis Septate uterus It is an important cause in recurrent breech presentation. Hydramnios Multiple pregnancy Fetal anomalies like hydrocephalus

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Positions possible: The sacrum is the denominator and the positions possible are Left sacro anterior the commonest Right sacro anterior Right sacro posterior Left sacro posterior

Clinical findings: The clinical findings in breech presentation are The cephalic pole lies at the fundus and the podalic pole at the lower level. The fetal heart sounds are heard above the level of the umbilicus. Vaginal examination reveals ischial tuberosties on both side and anus in the middle. In complete breech, the feet are felt along the sides. In extended breech, the feet are not felt. In footling presentation only the feet are felt.

Course of labor: The delivery in breech presentation occurs in three stages. They are Delivery of the breech Delivery of the shoulders Delivery of the head

Delivery of breech: There are three stages of delivery of breech. They are Descent with compaction Internal rotation Lateroflexion The breech enters the pelvis with the bisiliac diameter. All the body parts get a little more flexed which is called compaction and then the descent occurs which brings the anterior buttock to the floor of the pelvis.

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Then internal rotation occurs which brings the anterior buttock to the pubis where it gets hitched up. This is followed by lateroflexion which makes the posterior buttock to sweep through the perineum and get delivered. This is followed by the delivery of the anterior buttock. Once both the buttocks are delivered, the body up to the shoulders slips down.

Delivery of the shoulders: The shoulders are delivered in a similar way with internal rotation making the anterior shoulder hitching against the pubis. The posterior shoulder sweeps through the perineum and is delivered followed by delivery of the anterior shoulder.

Delivery of the head: The delivery of the head is similar to that of the shoulders. Here the occiput gets hitched against the pubis and face is delivered to be followed by the delivery of the occiput.

Complicated breech: A few conditions are associated with increased risk to the fetus and if they are present, the presentation is called complicated breech presentation. The factors are Prematurity Maternal toxemia Ante partum hemorrhage Fetal abnormalities Contracted pelvis Maternal hypertension Extended legs, arms Cord prolapse Difficulty in delivering the head Primi gravida Low Birth Weight baby Big baby Complete breech

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In these cases the fetus is affected by any of the following complications. Intra cranial injuries Fracture of long bones like humerus and femur Birth asphyxia Brachial plexus injury

Management:

During ante natal Period: Breech presentation is common up to 34 weeks of pregnancy. If it persists beyond that, then a complete evaluation to find out the cause is done. Then efforts are taken to covert the breech in to vertex presentation by external cephalic version. Breech delivery is associated with a greater fetal mortality than vertex delivery after external cephalic version.

In external version, with gentle movements are done with the fetus held from outside the abdomen of the mother and is converted in to vertex presentation. In the following conditions the external version is contra indicated. Multiple pregnancy Ante partum hemorrhage Ruptured membranes 38

Decreased liquor Contracted pelvis Congenital anomalies of the uterus

Delivery: If external cephalic version is successful, then the fetus is delivered vaginally. If external version is not possible the either vaginal delivery or caesarian section is done depending on the situation.

Caesarian section: If external version is not successful, caesarian section is done, if there is Feto pelvic disproportion Fetus weighs more than 3.5 kg Primi gravida, elderly primi If uterine inertia persists for more than 12 hours after rupture of membranes Pre eclampsia Cord prolapse Bad obstetric history Hyperextension of the head Intra uterine growth retardation Diabetes mellitus Previous difficult labor Uterine anomalies Footling presentation Contracted pelvis There has been a considerable increase in the incidence of caesarian sections in breech presentations and it has improved the fetal prognosis.

Vaginal delivery in breech presentation: There are three options available to deliver the baby with breech presentation. Spontaneous breech delivery

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Assisted breech delivery Routine breech extraction There is not much difference between spontaneous breech delivery and assisted breech delivery, as all deliveries need some assistance in delivering the head and the shoulder. Routine breech extraction is usually not recommended.

Assisted Breech Delivery: The initial preparation includes Clearing the bowels at the onset of pains Bed rest to prevent premature rupture of membranes and cord prolapse which is more common in the flexed breech and footling presentation than the extended one Monitoring fetal heart rate Sedation with pethidine after the onset of labor pains In the absence of prolapse of cord the labor is allowed to continue. When the babys anus is visible at the outlet, pudendal block anesthesia is given and medio lateral episiotomy is done. This episiotomy helps in delivering the after coming head. With increasing uterine contractions, the breech emerges out of the vulval outlet. In flexed breech, a foot may be caught in the vagina. These can be released by hooking it out with the finger. With further contractions, the baby is born as far as umbilicus. Now the body of the baby is steadied and it is covered with a sterile towel to prevent premature respiratory efforts due to the cutaneous stimulus. Gentle fundal pressure is given to facilitate delivery of arms. Normally the arms are flexed and are easy to deliver. If it is not flexed, the delivery is prolonged and Lovsets maneuver is done to deliver the arms. Lovsets maneuver: Gentle traction of the feet is done and the babys back is brought to the right or left. This brings the axillary fold in to view below the symphysis pubis. A finger is passed along the arm down to the elbow and is flexed. The arm drops down. Now the other shoulder is brought under the pubic symphysis and the same procedure is repeated and the other arm is delivered.

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Once the two arms are delivered, only the head remains to be delivered. In most of the cases it is delivered spontaneously aided by gravity. Sometimes assistance may be needed in the form of Marshall Burns technique to deliver the head.

Marshall Burns technique: Supra pubic pressure is given to promote flexion and descent of the head Traction done holding the feet The fetus is swung in an arc over the mothers abdomen This delivers the head.

Mauriceau Smellie Viet Technique: This technique is used if there is difficulty in delivering the head after it has entered the pelvic cavity. The fetus is supported with the left forearm with the index or the middle finger in the mouth of the baby The index and the middle finger of the right hand are slipped over the clavicles from behind Traction is now given till the nape of the neck is seen The head is now delivered with the Marshall Burns technique

Complications of the breech presentations: Breech deliveries are associated with a lot of complications which are responsible for the increased morbidity and mortality. Some of the complications are Premature dilatation of membranes and incomplete dilatation of the cervix Prolapse of the cord Extended arms Nuchal position of the arms Difficulty in delivering the after coming head Fetal impaction Uterine inertia

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Complication of breech deliveries in the fetus: The following complications can occur in the fetus with breech presentation due to the process of labor. Fracture of long bones Fracture dislocation of cervical vertebra Intracranial hemorrhage Injury to soft parts Injury to nerve roots

E. Transverse or Oblique Lie

Transverse lie is a position in which the long axis of the fetus is approximately perpendicular to that of the mother. A true transverse lie rarely occurs as in almost all instances it either gets converted in to an oblique lie because the heavier cephalic pole slips down to one of the iliac fossa. An oblique lie is a position in which the long axis of the fetus lies at an acute angle to that of the mother. It is an unstable lie as during labor it gets converted in to either vertex or breech presentation.

Causes: The causes of transverse lie anything which causes any other malpresentation. They include Contracted pelvis Placenta previa Tumors complicating pregnancy Multiparty Hydramnios Uterine anomalies

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Positions possible: Two anatomical parts are used as denominators in oblique lie presentations- the dorsum and the acromion. The positions described with dorsum as denominator are Left dorso anterior Left dorso posterior Right dorso anterior Right dorso posterior The positions described with acromion as the denominator are Left acromio anterior Left acromio posterior Right acromio anterior Right acromio posterior

Clinical findings: Transverse and oblique lie presentations dont pose any difficulty in diagnosing. The diagnostic features are Transversely stretched uterus Fundus at a lower level than it normally should be for that gestational period Head in one of the iliac fossae Fetal heart sound heard at the level of the umbilicus During labor a vaginal examination will show the hand, elbow or the shoulder

Course of the labor: In oblique and transverse lie spontaneous delivery is virtually impossible. Sometimes spontaneous version occurs due to which the presentation is converted into either vertex or breech presentation. There are some extremely rare forms of deliveries which occur in these presentations like Spontaneous evolution Birth corpore conduplicate

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In these the fetus is folded up and delivered. These are possible only in premature babies and macerated babies. As the labor advances there is formation of upper and lower uterine segments as usual. But as delivery is impossible, a pathological retraction ring called the Bandls ring is formed at the junction of the upper and lower uterine segments which may rise even up to the level of the umbilicus depending on the severity. A stage is reached when no further stretching of the uterus is possible and this results in rupture of the uterus. Immediately after the rupture, the woman feels a little relieved. But soon she goes in to shock as the placenta and the fetus slip in to her abdomen.

Management: Antenatal period: If oblique lie is diagnosed during the later weeks of pregnancy, external version is done to convert it in to a vertex presentation unless there are any contra indications.

During labor: During early labor, if membranes are intact, external version is done. If it is not successful, caesarian section is done In primi gravida it is better to go for caesarian section In multi gravida, if cervix is adequately dilated, internal podalic version and breech extraction is done If there is cord prolapse or hand prolapse, caesarian section is done if cervix is not fully dilated. Classical caesarian section is a better option than the lower segmental caesarian section in these circumstances as it is associated with a better prognosis. If cervix is fully dilated, delivery is conducted in two stages internal version and later extraction. It is associated with high fetal mortality and so it is usually done when the fetus is dead

Delayed Cases: In delayed cases the fetus is usually dead. So in these cases the patient is anaesthetized and the dead fetus is delivered after decapitation

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If the uterus is on the verge of rupturing caesarian section is done If rupture of uterus has occurred, laparotomy and hysterectomy is done

F. Cord Prolapse and Cord Presentation

Prolapse of the cord is a condition in which the umbilical cord lies in front of the presenting part after the rupture of the membrane. Cord presentation is a condition in which the umbilical cord lies in front of the presenting part before the rupture of the membrane.

Cord Prolapse

Cord presentation

Causes: The causes of cord prolapse include Conditions which prevent the proper fitting of the presenting part to the pelvic brim Contracted pelvis Malpresentations 45

Placenta previa Tumors in the lower segment

Polyhydramnios Artificial rupture of membranes Accidental rupture of membranes during vaginal examination Unduly long umbilical cord Battledore placenta

Clinical findings: In cord presentation the pulsations of the cord may be felt through the intact membranes. Sometimes it may not be felt. This happens during uterine contractions. The pulsations can be again felt after the contractions ceases. The other instance when the cord pulsation may not be felt in cord presentation is when the fetal circulation is interfered as in case of cord compression. In this case auscultation of the fetal heart sounds will indicate fetal distress where the heart rate is either above 160 per minute or below 120 per minute. In cord prolapse, a loop of the cord may be found lying outside the vagina.

Course of the labor: The course of the labor is not influenced by the cord but by the presentation, uterine contraction and the adequacy of the pelvis. The only problem due to the cord prolapse is that it may get compressed by the presenting part leading to fetal distress.

Management: The management depends on two factors. The factors responsible for the cord prolapse and presentation Whether the fetus is alive or dead

Cord Presentation: If the cord presentation is due to contracted pelvis, then the management is as per the guidelines for managing labor in contracted pelvis. In all the other cases, the only aim is to

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prevent rupture of membranes and subsequent cord prolapse. When this is being done efforts are done to correct the presentation. One such effort is the postural method.

Postural method: The patient is made to adopt knee- chest, knee elbow or the Trendlenburgs position. In these positions, the fundus lies at a lower level and the umbilical cord slips back in to the uterus due to gravity. After the umbilical cord has slipped down in to the uterus, the woman is made to lie on her back and the presenting part is pressed down in to the brim of the pelvis and a tight abdominal binder is applied. During the process the fetal heart is monitored. If any irregularity is found, there are chances that the umbilical cord has slipped down again.

Cord Prolapse: Cord prolapse is always a problem for the fetus. More the interval between the prolapse and the delivery more is the danger for the fetus. So if an early diagnosis and a prompt management is of utmost importance in case of cord prolapse. Once cord prolapse is diagnosed the management is done as per the following guidelines If cord pulsation is felt and the cervix is less than three fifth dilated immediate caesarian section is done. Till the caesarian section is done efforts like postural methods and manually pushing the cord back through vagina In oblique lies internal podalic version and immediate extraction is done If the vertex is in the mid cavity, delivery is completed with the help of forceps In multi gravida, using a Willets traction forceps the fetal head is pulled down to allow engagement. This should be done only after pushing the cord above the presenting part If no cord pulsation is felt and the fetus is dead, no active measure is needed

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G. Compound presentation

In compound presentation, more than one fetal part presents at the pelvic brim at the onset of labor.

Causes: Any factor that prevents complete filling and occlusion of the pelvic inlet by the presenting part, results in compound presentation. Multiparity with lax abdominal wall Contracted pelvis Small fetus

Types: There are many possible combinations of compound presentation. Some of the possible types are Head and hand - common Head and foot Hand and foot Head, hand and foot

Clinical features: Vaginal examination is the only way by which it can be diagnosed. Diagnosis by abdominal palpation as in other presentations is virtually impossible. Vaginal examination shows more than one fetal part. Sometimes cord prolapse may be seen.

Course of labor: The prolapsed part hardly interferes with labor and labor proceeds normally.

Management: If the arm is prolapsed completely, it has to be moved back above the vertex under anesthesia after which the vertex is pushed down by fundal pressure or pulled down by Willets forceps and made to engage in the pelvic brim

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In primi gravida caesarian section is done If fetal heart sounds are inaudible, the fetus is dead and so it is delivered after perforating its head In head and foot presentation, if the head is not engaged, the foot is pulled down and the fetus is extracted by breech. If the head is engaged, the labor is allowed to progress keeping an eye on the status of the fetus and the mother. If fetal distress occurs, the delivery is expedited with the help of forceps. If the fetus is dead, craniotomy and subsequent delivery is done If there is an associated cord prolapse, the treatment should be in lines of treatment of cord prolapse irrespective of the type of compound presentation

5. Multiple Pregnancy

Multiple pregnancy means development of more than one fetus in the uterus simultaneously. It could be Triplets or three fetuses Quadruplets or four fetuses Quintuplets or five fetuses Sextuplets or six fetuses Causes: Hereditary predisposition as autosomal dominant trait but mainly transmitted through females Intake of ovulation inducing drugs like clomiphene

Types: Twin pregnancies are the most common and well studied types of multiple pregnancies.There are two types, Monozygous and dizygous twins.

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Monozygous Twins: Monozygous twins develop from one fertilized egg that splits within the first 15-16 days of development. The genetic make of these twins are identical but they look different in some cases. They are also called identical twins. One interesting features of monozygous twins is that the rate of monozygous twins is relatively constant an all races. Monozygous twins may be having varying combinations of placenta and amnion depending on the timing of the splitting of ovum. Thus they could be Monochorionic monoamniotic - 4% of twins Monochorionic diamniotic- 65% of twins Dichorionic diamniotic 30% of twins

Dizygous twins: Dizygous twins develop from two fertilized eggs. The rate of dizygous twin varies in different races. In United States two thirds of the twins are dizygous and the incidence is 8 per 1000 pregnancies. Dizygous twins always have dichorionic diamniotic placentation.

Clinical features: Uterus larger for the gestational age Palpation of multiple and excess fetal parts Auscultation of multiple heart beats Increased maternal serum alpha fetoprotein levels Ultrasonography confirms the diagnosis

Risks of multiple pregnancies: This can be divided in to maternal and fetal risks. Maternal risks: Hyperemeis gravidorum Anemia Preeclampsia Gestational diabetes Polyhydramnios

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Fetal risks: Increased incidence of congenital anomalies Fetal growth disturbances Vascular communications Death of the fetus Premature delivery Conjoint twins where the twins are joined either in the head, thorax or abdomen

Presentations possible: The combinations of presentations in decreasing frequency are Both vertex Vertex and breech Both breech Vertex and shoulder Breech and shoulder Both shoulders

Course of labor: In uncomplicated twins labor usually occurs at term. But in other cases it occurs prematurely. As the fetus are small spontaneous delivery is the rule unless there are any complications. The first of the twins is delivered followed by an interval of up to thirty minutes which may sometimes be longer to be followed by the birth of the second of the twin. The various steps of labor depend on the presentation of the fetuses.

Management: During antenatal period: As premature labor with associated prolapse of cord is common in multiple pregnancies, the patient should be hospitalized during the last few weeks of pregnancy and the complications if any should be treated.

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During labor: In longitudinal lie the first fetus is delivered spontaneously and the cord is ligated at two places and cut inbetween The second twin is delivered as early as possible as more the interval between the two deliveries more is the risk to the fetus If the second fetus is of vertex or breech an oxytocin infusion is started to expedite the delivery if it is prolonged. If it is breech and if delivery is getting delayed, internal podalic version and extraction is done In twins with malpresentations or contracted pelvis caesarian section is done

Complications: Prolongation of labor Prolapse of cord Premature separation of cord Interlocking of twins and prolongation of labor When both are vertex This is treated by putting the patient in

Trendlenberg position and pushing the head of the second fetus out of pelvis When one is vertex and the other is breech This is treated by pushing the head of the second fetus out of pelvis. If it is not possible, the only other option is decapitation of the first fetus to be followed by delivery of the torso , second fetus and the head of the first fetus in that order First fetus breech and the second transverse This is treated by pushing the second fetus out of the way. If it is not possible, caesarian section is done to deliver the twins

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6. Dystocia due to anomalies of the expulsive forces

Dystocia due to expulsive forces are divided in to two categories. Dystocia due to over efficient uterus o Precipitate labor o Tonic contraction of the uterus Dystocia due to in efficient uterus o Hypotonic inertia o Incoordinate uterine action

A. Precipitate Labor When labor is terminated in a disproportionately shorter time than anticipated, it is called precipitate labor. It is due to strong uterine forces.

Causes: Precipitate labor is more common in the multiparae than the primi gravidae.In multiparae, the soft parts are lax and the passages are ready for an easy delivery. Precipitate labor is also common among women with cardiac diseases and anemia.

Complications: The complications can be divided into maternal and fetal complications. Maternal complications: Laceration of the cervix, vaginal walls and perineum Post partum hemorrhage Inversion of the uterus Puerperal sepsis Fetal complications: Asphyxia Intra cranial hemorrhage Snapping of cord Physical injuries

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Management: It is very difficult to anticipate precipitate labor in any patient. Only during delivery, a diagnosis can be made. If there is a history of precipitate labor, precautions can be undertaken as soon as the labor pains starts. The patient is hospitalized immediately and anesthetized to prevent strong uterine contractions. If precipitate labor occurs with tears it should be promptly sutured.

B.Tonic Contraction of the uterus

In this condition, the uterus is in a state of continuous contraction and retraction so that there is no relaxation or rhythmic action of the uterine musculature.

Causes: Tonic contraction occurs in conditions in which the labor is obstructed. In these cases the uterus, tries to contract vigorously to overcome the obstruction. The other causes being inadvertent use of ergot alkaloids or pituitary extracts .

Clinical features: The features include Dehydration Abdominal pain Nausea and vomiting Hard tender uterus with prominent round ligaments Pathological retraction ring Absent fetal heart sounds Large obscure presenting part As the labor progresses the upper and lower uterine segments get prominently demarcated by the in between, pathological retraction ring called the Bandls ring. If no intervention is done, the tense uterus ruptures and the patient collapses.

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Complications of tonic contraction of uterus: The complications are divided in to maternal and fetal complications. Maternal complications: Rupture of uterus Post partum hemorrhage Puerperal sepsis Fistula formation Fetal complication: Asphyxia Intra uterine death

Management: Management is divided in to prophylactic and therapeutic managements. Prophylactic treatment: Diagnosing causes of obstruction in the ante natal period itself and treating accordingly Avoiding inadvertent use of ergot alkaloids Curative treatment: Sedation with opiods like morphine Delivering the fetus which is usually dead by craniotomy or decapitation Hysterectomy in case of rupture of uterus

C.Hypotonic Inertia In this condition the contractions of the uterus is very weak and the fetus does not descend down.

Causes: The possible causes include Developmental defects of the uterus Hormonal imbalances

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Clinical features: Contractions are weak, decreased in amplitude in and frequency Uterus flabby on palpation and never hardens even at the height of contractions This condition is harmful to neither the fetus nor the mother. The only cause of concern is that if the membranes ruptures prematurely, intrauterine infections can occur which have deleterious effects on both the mother and the fetus.

Management: Hypotonic inertia is managed with infusion of oxytocin. After cephalopelvic disproportion and malpresentations are ruled out, 2.5 units of oxytocin in 500 ml of 5% dextrose is given as infusion. Some up to 10 units may be needed in 24 hours. During this infusion, fetal monitoring is done. If there are any signs of fetal distress, then the infusion is stopped. If oxytocin infusion is not proved to be effective, then the only option available is delivering by caesarian section.

D. Incoordinate Uterine action In this condition, the uterine contractions are irregular and hence ineffective. The resting tone of the uterus is increased. The normal resting tone is 5 mm of Hg. In incoordinate uterine action the tone may rise even up to 30 mm of Hg causing severe pain.

Clinical features: The features include Severe abdominal pain due to increased resting tone of uterus which occurs well before the uterine contractions and lasts even after the contractions Increased frequency of micturition Dilatation of the stomach Anxious patient Prolongation of labor

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Management: The patient is sedated and well hydrated Oxytocin is avoided The normal uterine action is established after sometime If its does not occur and if the patient is an elderly primi or if there is malpresentation or cephalopelvic disproportion, then caesarian section is done If the cervix is fully dilated and head engaged, the fetus is delivered with the help of a forceps.

6. Dystocia due to abnormalities of maternal soft parts

Vulva, cervix and uterus form the maternal soft parts. Abnormalities of these parts can lead to difficulties in labor.

Abnormalities of the vulval outlet: Atresia of the vulva incomplete closure of the vulva. This is treated by episiotomy Rigid perineum Episiotomy is done to aid delivery Edema of vulva If edema is marked hot compresses are given Elephantoid growth of vulva Bilateral episiotomy is done to aid delivery Healed scars Caesarian section is done Hematoma of vulva Before delivering the hematoma is incised and the clots are cleared

Abnormalities of the vagina: Incomplete atresia Caesarian section is done Double or septate vagina- If it is longitudinal normal delivery is possible. If it is transverse, it has to be incised and normal delivery is possible

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Abnormalities of cervix: Organic rigidity of the cervix- If head is engaged forceps delivery is done. If the head is unengaged or if there is malpresenation caesarian section is done Functional rigidity- It is due to incoordinate uterine actions and is managed as discussed in the section above Labor following operation for prolapse- If the cervix does not dilate caesarian section is done. If it dilates and if the labor is prolonged, there are chances of recurrence of prolapse and hence delivery should be expedited by doing episiotomy Malposition of cervix- In milder cases normal delivery is possible. In sever cases caesarian section is done

Abnormalities of the uterus: Malformations of the uterus: The different malformations are Arcuate uterus There is a depression in the fundus Uterus diadelphys Two separate uterus with their own vagina and cervix Uterus bicornis bicollis The upper parts of uterus are divided and lower parts are fused with a septum in between Uterus bicornis unicollis - the upper parts are divided and the lower parts are normal Uterus septus A septum is present in the cavity along the whole length Uterus sub septus A septum is present in the cavity but not along the whole length Uterus unicornis In this there is a non communicating rudimentary horn attached to the normal uterus The complications include abortion, weak uterine action, post partum hemorrhage and adhesion of placenta. In most of the cases vaginal delivery occurs. Occasionally caesarian section might be necessary if there is prolongation of labor

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Displacement of the uterus: Retroversion or backward displacement: The patient usually complains of retention of urine. The bladder is drained and infection is treated. The retroversion is treated by making the patient adopt knee chest position for half an hour everyday. The uterus corrects itself as it grows.

Ante version and ante flexion: These are anterior displacements and are normal. Only when they are exaggerated they become pathological. The labor is usually prolonged as dilatation is delayed. There may be associated malpresentation and the membranes may rupture prematurely. Proper antenatal care along with applying abdominal corset, avoiding heavy exercises can revert the uterus to normal position. The labor is managed according to the presentation of the fetus and if the pelvis is contracted caesarian section is done.

Prolapse of uterus: In first and second degree prolapses, spontaneous rectification is possible as the uterus grows and rises in to the pelvis. In third degree prolapse, abortion, urinary infection and damage to cervix can occur. In this condition the patient is put to bed with the foot end raised. The cervix is treated for its injuries and infection. Later the cervix is pushed inside. As the uterus grows and rises in to the pelvis the prolapse is totally rectified. If these steps are not possible and if the mother has completed her family, termination of pregnancy followed by Fothergills operation for prolapse of uterus is done. The other option available is applying ring pessary till 20 weeks of pregnancy by which time the uterus rises in to the pelvis.

Fibroids complicating pregnancy: Fibroids are benign tumors of the uterus. They may be present during pregnancy complicating labor. During the earlier weeks of pregnancy they may be asymptomatic. During later weeks they may produce the following symptoms. Pain due to degeneration and also sometimes due to torsion of the uterus Pressure symptoms like to pressure on adjacent structures

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The treatment options available are Enucleation of the fibroid alone and allowing the pregnancy to continue especially when the pregnancy is between 20-28 weeks Caesarian section In younger women Caesarian hysterectomy in elderly women and with multiple fibroids

7. Contracted Pelvis If one or more of the diameters in one or more of the planes is shorter than normal, then the pelvis is called a contracted pelvis. There are no universal standards to define a normal pelvis. It varies in different countries. Various factors like socio economic factors and genetic factors influence the shape and size of the pelvis.

Munro Kerrs Classification of contracted pelvis: 1. Pelvic deformity due to faulty development Justo major pelvis Justo minor or generally contracted pelvis Simple flat non rachitic pelvis Naegles pelvis imperfect development of one sacral ala Roberts pelvis imperfect development of both sacral alae Split pelvis- imperfect development of pubis Assimilation pelvis 2. Pelvic deformity due to diseases of the pelvic bones and joints Rickets Osteomalacia Fractures Diseases of the sacro iliac and sacro coccygeal joints Sub luxation of sacro iliac joint 3. Pelvic deformity due to diseases of the spine Kyphosis

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Scoliosis Spondylolisthesis 4. Pelvic deformity due to diseases of the pelvic bones and joints Coxitis Dislocation of one or both hip joints Atrophy or loss of one limb

Diagnosis of Contracted pelvis: A pelvis has an inlet, cavity and outlet. The contraction may affect all the three levels or just any one level. A pelvis contracted in all the diameters in the inlet is also contracted in the cavity and the outlet. A contraction in one diameter is sometimes compensated by an increase in other diameters. The diagnosis of contracted pelvis is done with the following methods. Physical examination Obstetric examination External pelvimetry Internal pelvimetry

Physical Examination: The following physical features in a woman are associated with contracted pelvis Short stature Pendulous abdomen Deformities of spine especially the lumbar region Shortening of the lower limb Tilting of the pelvis Waddling gait Rickets

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Obstetric examinations: Obstetric examination around term may give a clue to contracted pelvis. If in a primi gravida, at term, the head is floating and not engaged, then contracted pelvis should be suspected. But one should remember that a deflexed head closely mimic it.

External pelvimetry: Only external pelvimetry of the outlet is used nowadays. The external pelvimetry of the inlet is not used nowadays as it is less accurate. The pelvic outlet diameters commonly measured are (as illustrated on the following page):

The transverse diameter This is the distance between the inner surfaces of the two ischial tuberosities.It is measured with Jarchos or Thomas calipers or by putting the patient in the lithotomy position and measuring it with a ruler. The average diameter is 10.5 11 cm.

The antero posterior diameter This is the distance between the tip of the sacrocooccyx and the under margin of the pubic symphysis.It can be measured with an ordinary pelvimeter. The average diameter is 12.5 cm.

The posterior sagital diameter This is the distance between the mid part of the transverse diameter and the sacrococcygeal tip. The average diameter is about 7 cm.

The sub pubic arch This is measured by direct palpation during the course of a vaginal examination by sweeping the fingers side to side.The normal arch is about 85 degrees.

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Posterior sagital 7 cm

Internal Pelvimetry: There are two methods of doing internal pelvimetry. By vaginal examination By instruments Using instruments for internal pelvimetry is cumbersome and the results are also not accurate. Hence internal pelvimetry with instruments is not done nowadays.

Vaginal examination: This is one of the most important as well as valuable methods of assessing the pelvic capacity. It is usually done after the 36th week of pregnancy. The following are assessed during the vaginal examination. The sub pubic arch The ischial spines The sacral concavity 63

The length of the sacrotuberous ligament The pelvic sidewalls The diagonal conjugate

The sub pubic arch This is measured by direct palpation during the course of a vaginal examination by sweeping the fingers side to side.The normal arch is about 85 degrees.

The ischial spines - There should not be marked projection of these spines

The sacral concavity The concavity from the promontory to the tip should be well developed. In a well developed sacrum, it is difficult to palpate at the middle and higher levels. A straight sacrum which is usually seen in the android pelvis may result in transverse arrest.

The length of the sacrotuberous ligament- In a well developed pelvis two fingers can be placed on it which indicates pelvic adequacy at the lower level.

The pelvic sidewalls- They should be either parallel or divergent and never convergent. The convergent sidewalls, as in the android pelvis, may result in difficulty during labor.

The diagonal conjugate - The middle and forefinger are passed in to the vagina till the promontory is reached. With the forefinger of the other hand, the level of the sub pubic ligament is measured. The diagonal conjugate is the distance between the tip of the middle finger and the point marked by the fore finger of the other hand. It is normally about 12.5 cm. A true conjugate is 2 cm less than this. Some features of the pelvis may influence this measurement Depth of the pubic symphysis Inclination of pubic symphysis Height of the promontory False promontory

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Cephalo-pelvic disproportion (CPD): Sometimes the pelvis may have normal diameters. But the fetal head may be very big causing difficulty in labor. This mimics contracted pelvis and it is called cephalo pelvic disproportion. Cephalo pelvic disproportion can be assessed by Munro Kerr Muller method.

Munro Kerr Muller method of assessing cephalo pelvic disproportion: The patient is made to lie on the dorsum Standing by the side of the patient the obstetrician grasps the fetal head with the left hand and pushes against the pelvic brim The other hand is passed into the vagina and with the thumb the fetal head is palpated above the pubic symphysis The degree of overriding of the head gives an estimate of the cephalo pelvic disproportion and it is categorized into no, mild and major cephalo pelvic disproportion This has to be done during active labor because the deflexed head prior to labor gives a false impression of cephalo pelvic disproportion. This deflexed head becomes flexed during active labor

The other methods used are Radiological examination This is rarely used because of the hazards of radiation. In the United States, Precision stereoscope is being popularized by Caldwell and Moloy. The four views taken are Lateral Antero posterior Supero inferior picture of the brim Outlet

Cephalometry: The diameter of the fetal skull is measured by ultarsonogram and cephalo pelvic disproportion can be assessed.

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Implications of pelvimetry: The inlet: In pelvis with obstetric conjugate above 9.5 cm vaginal delivery is possible In pelvis with obstetric conjugate below 8.5 cm vaginal delivery is not possible and caesarian section is done Between 8.5 and 9.5 cm, it is difficult to establish the prognosis

The cavity: If the distance between the spines is less than 9.5 cm vaginal delivery is difficult and caesarian section is done In straight sacrum vaginal delivery is difficult as forward rotation of the fetus is not possible If the pelvic side walls are convergent it results in deep transverse arrest

The outlet: Most of cases of the outlet contraction are associated with contraction of the cavity A sub pubic arch below 75 degrees results in difficult labor When the sum of the transverse and the posterior sagital diameters of the outlet is 15cm or more, vaginal delivery is possible

Management in contracted pelvis and cephalo pelvic disproportion: Two methods are commonly employed for delivering in these cases. Elective Caesarian section Trial labor

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Elective Caesarian section: Caesarian section is called elective if it is done before the onset of labor. In contracted pelvis and cephalo pelvic disproportion, elective caesarian section is done if there are Gross contracted pelvis and cephalo pelvic disproportion Elderly primi Bad obstetric history Toxemia of pregnancy Post maturity Persistent malpresentation A few advise caesarian section after the onset of labor pains indicating the following advantages. The lower segment is well formed and this helps during the operation The bleeding is less as the uterus has started contracting The fetus would have the maximum intra uterine existence and its benefits A well dilated cervix aids in proper drainage of the lochia

But there are a few disadvantages like It is an emergency procedure The labor pains may start sometimes well after term and this may affect the fetus because of placental insufficiency Trial Labor: A few points need mention for explaining trial labor. Gross contracted pelvis and cephalo pelvic disproportion are rare nowadays The deflexed fetal head flexes during labor The fetal head undergoes moulding and the pelvic ligaments relax. These eliminate the borderline disproportion Uterine contractions become stronger only after the rupture of membranes Taking these factors into consideration, borderline cases can be subjected to trial vaginal delivery or trial labor.

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Selection of patients for trial labor: The patients with the following criteria are selected Contraction only at the inlet Platypelloid pelvis Young woman Vertex presentation The fetus must not be post mature

Contraindications for trial labor are Eclampsia Fetal malpresentations Elderly primigravida Outlet contraction Cardiac disease Post maturity Post caesarian

Conduct of trial labor: The patient should be mentally well prepared The general condition of both mother and fetus are periodically assessed The patient is sedated After rupture of the membranes, the following is assessed by vaginal examination o o o o o Nature of cervix Position and situation of the head Any possible cord prolapse Reassessment of the degree of disproportion Degree of moulding of the fetal head and the caput formation The signs of good prognosis are Good uterine contraction Early engagement of head

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Rupture of membranes after full cervical dilatation Well thinned out and effaced cervix closely applied to the vertex Flat pelvis with no contraction Vertex anterior position The signs of bad prognosis are Weak uterine contraction Slow descent of head Premature rupture of membranes Uneffaced partially dilated cervix Android or generally contracted pelvis Occipito posterior pelvis When the head presents at the outlet instead of waiting for the spontaneous delivery to occur, it is better to deliver the head with the help of a forceps.

Indications for termination of trial labor: Trial labor is terminated and caesarian section is done to deliver the fetus in the following conditions Fetal distress Maternal distress Delivery not accomplished within 12 hours of onset of good uterine contractions

References: Mudaliar and Menons Clinical Obstetrics Images from Google images, Sweet Haven Publishing services, www.who.int,

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