High Risk Pregnancy

HIGH RISK PREGNANCY
Definition: Any existing or developing condition or factor that prevents or impedes the normal progress of pregnancy to the delivery of a viable,
healthy, term infant.
Assessment of Risk Factors:
1. Age- under 17 or over 35 (greater risk over 40)
Pregnant adolescents have higher incidence of prematurity, pregnancy induced hypertension, cephalopelvic disproportion, poor nutrition
and inadequate antepartal care.
Women over 35 are at increased risk for chromosomal disorders (Down Syndrome), PIH, and Cesarean delivery
2. Parity
Multiparity
Grand multiparity
Short intervals between pregnancies
3. Past Health History
Diabetes
Heart disease
Renal condition
Essential hypertension
Anemia
Thyroid disorder
Physical abuse
4. Past Obstetrical History
Lack of antepartal care
Abortions
Ectopic pregnancy
Preterm labor and delivery
Iontrauterine growth retardation
Congenital malformations
5.
6.
Cesarean births
Previous fetal loss
PIH
DM
Vaginal bleeding
Multiple gestation
Large infants
Current Obstetrical History
PIH
Infections
- STD
- TORCH
- Other viral diseases
- Bacterial infections (TB)
Hemorrhage
Exposure to toxic environmental agents
Use o f drugs
Multiple gestation
Abnormal presentation
Premature rupture of membranes
Chronic health problems (DM, Cardiac disease, Anemia)
Coexisting medical problems
Abnormal antenatal test result
Socioeconomic-cultural status
Low socioeconomic status
Malnutrition or deprivation
Drug or alcohol addiction
Smoking
ASSESSMENT OF HIGH RISK PREGNANCIES:

1. History and Physical Examination
2. Laboratory exams
a. Alpha-fetoprotein (AFP) enzyme blood test
- elevated levels may identify the pregnant woman carrying a baby with neural tube defects (spina bifida and anencephaly)
- if the AFP is elevated for two samples, it is followed by ultrasonography and amniocentesis for further confirmation done at 14 to 16
weeks gestation
b. Ultrasonography
-
High-frequency sound wave testing

- discerns multiple pregnancy, placental location and gestational age by measurement of bi-parietal diameters
a.visualization during first 20 weeks of gestation is improved if the bladder is full; a full bladder is not necessary after 20 weeks gestation
b. a level II sonogram may be performed to assess formation of organs
c. considerations:
- encourage fluid and refrain from voiding before the test

c. Chorionic villi sampling (CVS):
- supplies some data as amniocentesis but can be done after 10 weeks
1. aspiration of villi done during the eighth to twelfth week of pregnancy
2. considerations:
a. instruct to drink fluid so that bladder is full
b. after test, monitor for uterine cont5ractions, vaginal discharge and teach to observe for signs of infection
d. Amniocentesis
- aspiration of amniotic fluid used to detect sex, chromosomal or biochemical defects, fetal age, L/S ratio (2/1 ratio indicates lung maturity),
increased bilirubin level associated with Rh disease, and phosphatidylglycerol (PG), which appears in amniotic fluid after thirty-fifth week, indicating
fetal lung maturity.
1. test done with sonogram; usually after 12 to 15 weeks of gestation
considerations:
a. have client void
b. after test monitor for uterine contractions, vaginal discharge
c. teach to observe for signs of infection
d. encourage rest
e. Non-Stress test (NST)

- done to observe for accelerations of FHR in response to fetal movement over a 30 to 40 minute period
1. Classification of results:
a. a test is negative or reactive if:
(1) baseline FHR is 120 to 160
(2) there are two accelerations in 10 minutes, each increasing the FHR by 15 and lasting 15 seconds
(3) the tracing shows variability of 10 or more beats per minute
b. test is positive or non-reactive if the three criteria are not met
C. considerations:
a. fasting is not necessary
b. observe the fetal monitor
c. explain test to decreased anxiety
d. evaluate response to procedure
f. Contraction stress test (CST):

- to demonstrate whether a healthy fetus can withstand a decreased oxygen supply during the stress of a contraction produced by
exogenous oxytocin (pitocin) or stimulation of nipples manually or by moist heat; if late decelerations appear, the fetus may be compromised
because of uteroplacental insufficiency
1. Classification of results
a. negative: no late decelerations with a minimum of three contractions in 10 minutes; indicates that the fetus has good
chance of surviving labor
b. positive: persistent and late decelerations occurring with more than half the contractions; indicates need for
considering premature intervention
c. suspicious:
late decelerations occurring in less than half of uterine contractions; test should be repeated in
24 hours
2. Nursing considerations:
a. void before test
b. monitor fetal heart rate for 30 minutes before test
c. monitor ,mother after test to observe for possible initiation of labor
d. evaluate response to procedure
g. Biophysical profile (BPP):
- assess breathing movements, body movements, tone, amniotic fluid volume and FHR reactivity (NST)
- a score of 2 is assigned to each finding, with a score of 8 to 10 indicating a healthy fetus
1. used for fetus that may have intrauterine compromise
2. nursing considerations:
a. provide emotional support
b. evaluate response to procedure
h. Maternal assessment of fetal activity:
- need to contact physician or nurse midwife when there are fewer than 10 fetal movements in a 12 hour period.
- fewer than three fetal movements in an 8 hour period, or no fetal movements in he morning
1. used to determine viability of fetus
2. nursing considerations:
a. teach how to record and report movements
HEALTH DISORDERS COMPLICATING PREGNANCY

I.
DIABETES MELLITUS
- Is defined as glucose intolerance with its onset during pregnancy
MAJOR RISK FACTORS FOR DM:

1. Age older than 30 years old
2. Being obese or overweight
3. Family history of DM
4. History of DM in prior pregnancy
5. History of poor obstetric outcome
6. African-American, Hispanic or Native American Ethnicity
7. HPN
8. Previous infant weighing more than 8 lbs.
9. Previous unexplained fetal demise or death
Initial signs:
3PS:
1.POLYURIA
-
Excessive urination
2.POLYDYPSIA
-
Excessive thirst
3.POLYPHAGIA
- Excessive hunger
Maternal signs and symptoms:
-
Excessive thirst
Hunger
Weightlessness
Blurred vision
Frequent urination
Rglycosuria and ketonuria
Signs of PIH
Polyhydramnios
Fetus large for gestational age (LGA)
Recurrent UTI and vaginal yeast infection
Late signs:
1. Fatigue
2. Weakness
3. Sudden vision changes
4. Tingling or numbness in hands
Screening
50gms. Oral glucose tolerance test
Blood glucose is measured after 1 hour
A level above 140 mg/dl is abnormal
If result is abnormal, a 3 hour glucose tolerance test is done
Normal values of GTT are:
1. Fasting blood glucose level: less than 105 mg/dl

2. At 1 hr: less than 90 mg/dl
3. At 2 hrs: less than 165 mg/dl
4. At 3 hrs: less than 145 mg/dl
- Two or more abnormal values confirm GDM.
Management:
1. Perform daily fetal kick counts.

2. Drink 8-10 glasses of water each day to prevent bladder infection and maintain hydration.
3. Wear proper, well fitted footwear when walking.
4. Engage in a regular exercise but avoid exercising in extreme temperatures
5. avoid simple sugars which raise blood glucose levels.
6. Educate on s/sx of hypoglycemia and treatment needed:
Sweating, tremors, cold clammy skin,headache, feeling hungry, blurred vision, disorientation, irritability
Treatment: drink 8 oz. of milk and eat two crackers or glucose tablets
7. Educate on s/sx of hyperglycemia and treatment needed:

dry mouth, frequent urination, excessive thirst, rapid breathing
Feeling tired, flushed skin, headache, drowsiness
Treatment: Notify physician as hospitalization may be required
8. Wear a medic alert tag at all times
9. Wash hands frequently
10. Have a proper diet
Calories in the diet must consist of 50% to 60% CHO, 12% to 20% CHON, and 20 to 30% FATS.
Complications of gestational diabetes mellitus
Maternal complications:
1. Pregnancy Induced Hypertension

2. Placental disorders
3. Stillbirth
4. Macrosomia (LGA)
5. Hydramnios
Fetal Diabetic complications:
1. Macrosomia
2. Congenital anomalies
3. Neural tube defects

Best drug management is for patient to have an insulin therapy as oral hypoglycemic agents (OHAS) are teratogenic.
II.
CARDIOVASCULAR DISORDERS
1. HEART DISEASE
Data base:
A.
origin: 90% rheumatic (incidence expected to decrease as incidence of rheumatic fever decreases), 10% congenital lesions or syphilis
B.
normal hemodynamics of pregnancy that adversely affect the client with heart disease
C.
functional or therapeutic classification of heart disease during pregnancy

1. Class I:
no limitation of physical activity; no symptoms of cardiac insufficiency or angina
2. Class II: slight limitation of physical activity; may experience excessive fatigue, palpitation, angina or dyspnea; slight limitations as
indicated
3. Class III: moderate to marked limitation of physical activity; dyspnea, angina and fatigue occur with slight activity and bed rest is
indicated during most of pregnancy
4. Class IV: marked limitation of physical activity; angina, dyspnea and discomfort occur at rest; pregnancy should be avoided;
indication for termination of pregnancy
Care of Pregnant Clients with Heart Disease:
A.
Assessment
1. prenatal period:
vital signs, weight gain, dietary patterns, emotional outlook, knowledge about self-care, sign of heart failure, stress factors
such as work, household duties
2. intra-partal period:
vital signs (heart rate will increase), respiratory changes (dyspnea, coughing, crackles); FHR patterns
3. Post-partal period:
signs of heart failure or hemorrhage related to fluid shifts; intake and output
Implementation
1. Prenatal period:
a. teach importance of rest and avoidance of stress
b. instruct regarding use of elastic stockings and periodic elevation of legs
c. teach appropriate dietary intake: adequate calories to ensure appropriate, but not excessive, weight gain, limited, not restricted, salt intake
d. administer medications as ordered: heparin, furosemide (Lasix), digitalis, betablockers (inderal)
e. monitor for signs of heart failure, such as respiratory distress and tachycardia
2. Intra-partal period:
a. encourage mother to remain in semi-fowlers or left lateral position position
b. provide continuous cardiac and fetal monitoring
c. assist with forceps birth in second stage of labor to avoid work of pushing
3. Post-partal period: most critical time because of increased circulating blood volume after birth of placenta
a. institute early ambulation schedule; apply elastic stockings
b. monitor for signs of heart failure such as respiratory distress and tachycardia
c. monitor for heart rate: accelerated heart rate of mother in latter half of pregnancy puts extra workload on her heart
d. provide for adequate rest; the increase in oxygen consumption with contractions during labor makes length of labor a significant
factor
e. provide close supervision: sudden tachycardia during birth or sudden bradycardia and normal increase in cardiac output following
birth may cause cardiac arrest
COMPLICATIONS DURING PREGNANCY

1. SPONTANEOUS ABORTION
Description
Spontaneous abortion is the expulsion of the fetus and other products of conception from the uterus before the fetus is capable of living outside of the
uterus.
1. Types of spontaneous abortions
o
Threatened abortion - is characterized by cramping and vaginal bleeding in early pregnancy with no cervical dilation. It may subside or
an incomplete abortion may follow.
Imminent or inevitable abortion is characterized by bleeding, cramping and cervical dilation. Termination cannot be prevented.
Incomplete abortion is characterized by expulsion of only part of the products of conception (usually the fetus). Bleeding occurs with
cervical dilation.
Complete abortion is characterized by complete expulsion of all products of conception.
Missed abortion is characterized by early fetal intrauterine death without expulsion of the products of conception. The cervix is
closed, and the client may report dark brown vaginal discharge. Pregnancy test findings are negative.
Recurrent (habitual) abortion is spontaneous abortion of three or more consecutive pregnancies.
Figure 1 Three Types of Spontaneous Abortion

Etiology
Spontaneous abortion may result from unidentified natural causes or from fetal, placental or maternal factors.
1. Fetal Factors
a. Defective embryologic development

b. Faulty ovum implantation
c. Rejection of the ovum by the endometrium
d. Chromosomal abnormalities
2. Placental Factors
a. Premature separation of the normally implanted placenta
b. Abnormal placental implantation
c. Abnormal placental function
3. Maternal Factors
a. Infection
b. Severe malnutrition
c. Reproductive system abnormalities (eg, incompetent cervix)
d. Endocrine problems (eg, thyroid dysfunction)
e. Trauma
f. Drug ingestion
Pathophysiology
The fetal or placental defect or the maternal condition results in the disruption of blood flow, containing oxygen and nutrients, to the developing
fetus. The fetus is compromised and subsequently expelled from the uterus.
Assessment Findings
1. Associated findings The client and family may exhibit a grief reaction at the loss of pregnancy, including:
a. Crying
b. Depression
c. Sustained or prolonged social isolation
d. Withdrawal
2. Clinical Manifestations include common signs and symptoms of spontaneous abortion.

a. Vaginal bleeding in the first 20 weeks of pregnancy
b. Complaints of cramping in the lower abdomen
c. Fever, malaise or other symptoms of infection
3. Laboratory and diagnostic study findings
a. Serum beta hCG levels are quantitatively low

b. Ultrasound reveals the absence of a viable fetus.
Implementation
1. Provide appropriate management and prevent complications
Assess and record vital signs, bleeding and cramping of pain.
Measure and record intravenous fluids and laboratory test results. In instances of heavy vaginal bleeding; prepare for surgical intevention (D &
C) if indicated.
Prepare for RhoGAM administration to an Rh-negative mother, as prescribed. Whenever the placenta is dislodged (birth, D & C, abruptio)
some of the fetal blood may enter maternal circulation. If the woman is Rh negative, enough Rh-positive blood cells may enter her circulation
to cause isoimminization, the production of antibodies against Rh-positive blood, thus endangering the well-being of future pregnancies.
Because the blood type of the conceptus is not known, all women with Rh-negative blood should receive RhoGAM after an abortion.
Recommended iron supplements and increased dietary iron as indicated to help prevent anemia.
2. Provide client and family teaching
Offer anticipatory guidance relative to expected recovery, the need for rest and delay of another pregnancy until the client fully recovers.
Suggest avoiding intercourse until after the next menses or using condoms when engaging in intercourse.
Explain that in many cases, no cause for the spontaneous abortion is ever identified.
3. Address emotional and psychosocial needs.
ECTOPIC PREGNANCY
Description
Implantation of products of conception in a site other than the uterine cavity (e.g., fallopian tube, ovary, cervix, or peritoneal cavity.)
Sites of ectopic pregnancy. Numbers indicate the order of prevalence.
Etiology
Ectopic pregnancy can result from conditions that hinder ovum passage through the fallopian tube and into the uterine cavity, such as:
1. Salpingitis
2. Diverticula
3. Tumors
4. Adhesions from previous surgery
5. Transmission of the ovum from one ovary to the opposite fallopian tube.
Pathophysiology
The uterus is the only organ capable of containing and sustaining a pregnancy. When the fertilized ovum implants in other locations the body
is unable to maintain the pregnancy.
Assessment Findings
1. Associated findings
Suspect ectopic pregnancy in a client whose history includes a missed menstrual period, spotting, or bleeding pelvic or shoulder pain, use of
intrauterine device, pelvic infections, tubal surgery, or previous ectopic pregnancy.
Be aware of grief and lost manifestations in the client and family.
2. Common clinical manifestations. (The client with ectopic pregnancy may report signs and symptoms of a
normal pregnancy or may have no
symptoms at all.)
Dizziness and syncope (faintness)
Sharp abdominal pain and referred shoulder pain
Vaginal bleeding
Adnexal mass and tenderness
A ruptured fallopian tube can produce life threatening complications, such as hemorrhage, shock, and peritonitis.
Blood samples for hemoglobin value, blood type, and group, and crossmatch.
A pregnancy test reveals elevated serum quantitative beta hCG.
Ultrasound will confirm extrauterine pregnancy.
Management
1. Ensure that appropriate physical needs are addressed and monitor for
Complications. Assess vital signs,
bleeding, and pain.
2. Provide client and family teaching to relieve anxiety.
Explain the condition and expected outcome.

o
Maternal prognosis is good with early diagnosis and prompt treatment, such as laparotomy, to ligate bleeding vessels and repair or
remove the damaged fallopian tube.
Pharmacologic agents, such as methotrexate followed by leucovorin, may be given orally when ectopic pregnancy is diagnosed by
routine sonogram before the tube has ruptured. A hysterosalpingogram usually follows this therapy to confirm tubal patency.
Rh-negative women must receive RhoGAM to provide protection from isoimmunization for future pregnancies
b. Describe self-care measures, which depend on the treatment.

Gestational Trophoblastic Disease (Hydatidiform mole)
Description
1. Hydatidiform mole is an alteration of early embryonic growth causing placental disruption,
rapid proliferation of abnormal cells, and destruction of the embryo.
1. There are two distinct types of hydatidiform moles-complete and partial.

o In a complete mole, the chromosomes are either 46XX or 46XY
but are contributed by only one parent and the chromosome material duplicated.
This type usually leads to choriocarcinoma.
o
A partial mole has 69 chromosomes.

There are three chromosomes for every pair instead of two.
This type of mole rarely leads to choriocarcinoma.
Etiology
The etiology of hydatidiform moles is unknown. Genetic, ovular, or nutritional abnormalities could possibility be responsible for trophoblastic disease.
Pathophysiology
1. A hydatidiform mole is a placental tumor that develops after pregnancy has occurred; it may be benign or malignant. The risk of malignancy is greater with a
2. The embryo dies and the trophoblastic cells continue to grow, forming an invasive tumor.
3. It is characterized by ploriferation of placental villi that become edematous and form grapelike clusters. The fluid- filled vesicles grow rapidly,
causing the uterus to be larger than expected for the duration of pregnancy.
4. Blood Vessels are absent, as are a fetus and an amniotic sac.
Assessment Findings
1. Clinical manifestation
a. Vaginal bleeding (may contain some of the edematous villi)
b. Uterus larger than expected for the duration of the pregnancy.
c. Abdominal cramping from uterine distention.
d. Signs and symptoms of preeclampsia before 20 weeks gestation
e. Severe nausea and vomiting
a. hCG serum levels are abnormally high.
b. Ultrasound reveals characteristics appearance of molar growth.
Nursing Management
1. Ensure physical well being of the client through accurate assessment and interventions.
Review pertinent history and history of this pregnancy.

Prepare for suction curettage evacuation of the uterus (induction of labor with oxytocic agents or prostaglandins is not recommended because of the increase
Administer intravenous fluids as prescribed.
2. Provide client and family teaching.
Ensure appropriate follow-up and self-care by explaining that frequent possibility of recurrence of the problem or progression to choriocarcinoma. Also explai
monitored for 1 year.

Discuss the need to prevent pregnancy for at least 1 year after diagnosis and treatment.
Inform the client that oral birth control agents are not recommended because they suppress pituitary luteinizing hormone, which may interfere with serum hCG measurement.
Describe and emphasize signs and symptoms that must be reported (i.e., irregular vaginal bleeding, persistent secretion from the breast, hemoptysis,
and severe persistent headaches). These symptoms may indicate spread of the disease to other organs.
DISSEMINATED INTRAVASCULAR COAGULATION

Disseminated intravascular coagulation (DIC) is a condition in which blood clots form throughout the bodys small blood vessels. It is an acquired
disorder of blood clotting that result from excessive trauma or similar underlying stimulus. These blood clots can reduce or block blood flow through
the blood vessels, which can damage the bodys organs.
Frequency
DIC occurs in approximately 1% of all hospitalized patients.
It affects both sexes equally.
No age predilection is known.
Causes
Disseminated intravascular coagulation occurs in the following conditions:
Cancer especially certain types of leukemia
Abruption placenta
Pre-eclampsia
Amniotic fluid embolism
Trauma and burns
Extensive surgery
Infection in the blood by bacteria or fungus or sepsis
Severe liver disease
Severe tissue injury as in burns and head injury
Physiology of blood clotting

Normal blood clotting is a balance between the clotting or hemostatic system and the fibrinolytic or the dissolving system of the bloodstream. When a
blood vessel is injured, excessive blood loss is prevented by rapid occurrence of local vasoconstriction at the site of trauma or injury. As the vessel
wall is torn, collagen located beneath the skin is released and exposed. As a result, platelets swell and become adherent and are irregularly shaped.
Adenosine diphosphate is then released and attracts additional platelets and binds these platelets together, a process known as platelet aggregation.
A platelet plug then seals the injured vessel as a result of the aggregation. To prevent blood from passing through the platelet plug, it is strengthened
by fibrin threads. This is how blood clotting occurs.
However, to prevent too much clotting, a proteolytic enzyme formed from plasminogen known as plasmin or fibrinolysin digests the fibrin threads that
are present. This causes the lysis of the clot along with consumption of blood clotting factors. The fibrin degradation products prevent the production
of more fibrin and platelet aggregation, thus normal blood clotting occurs.
In summary, normal blood clotting occurs as a result of the balance between the clotting and dissolving system. Too much hemostatic system would
pose negative effects to the body. Excessive fibrinolytic activity taking place in a human body would also result to massive blood loss.
Pathophysiology
In disseminated intravascular coagulation (DIC), there is an imbalance between the clotting and the dissolving activities. Extreme clotting takes place
because of a damage that begins at one point in the circulatory system. This damage depletes the availability of the clotting factors such as the
platelets and fibrin from the general circulation.
Signs and symptoms
Bleeding on multiple sites in the body. Uncontrolled bleeding from puncture sites from injections or IV therapy.
Blood clots. Ecchymoses and petechiae form on the skin.
Drop in blood pressure
Sudden bruising
The toes and fingers are pale, cyanotic or mottled and feels cold
Laboratory results with DIC
Thrombocytopenia
Large platelets on the blood smear
Prolonged prothrombin and partial thromboplastin times
Markedly low serum fibrinogen levels
Elevated fibrin splits
Management
IV administration of heparin.
Blood transfusion (for blood loss)
Treat underlying disease condition

PLACENTA PREVIA
Data Base:
A.
Definition
1. an abnormal implantation of the placenta in the lower uterine segment
B.
Types:
1. type I Low-lying:
- placenta is at lower uterine segment next to os; uterus stretches with gestation, placenta moves away from os
2. Type II Marginal:
- placental edge is at the os, but does not cover it
3. Types III partial:
- placental edge partially covers the os
4. type IV complete:
- placenta is centered over the cervical os
C.
Clinical findings
1. painless, bright red bleeding: hemorrhage in the third trimester
2. soft uterus in the latter part of pregnancy
3. signs of infection may be present
D.
Therapeutic interventions
1. ultrasonography to confirm the presence of placenta previa
2. depends on location of placenta, amount of bleeding and status of the fetus
3. home monitoring with repeated ultrasounds may be possible with type I-low lying
4. control bleeding
5. replace blood loss if excessive
6. cesarean birth, if necessary
7. betamethasone is indicated to increase fetal lung maturity
Nursing Care of Clients with Placenta Previa:

A.
Assessment
1. presence of bright-red blond with absence of pain
2. vital signs indicating shock (hypovolemic)
3. changes in or absence of FHR

4. level of anxiety (usually increases)
B.
Analysis/Nursing Diagnosis
1. ineffective cardiopulmonary tissue perfusion in mother and fetus related to hemorrhage and interruption of placental oxygen supply
2. fear related to acuteness of physical status and possible death of fetus and/or mother
3. anticipatory grieving related to outcome of pregnancy and threat of termination of child bearing ability
C.
Planning/Interventions
1. no admission vaginal examination; if vaginal examination is to be performed, double setups (vaginal and cesarean) must be provided
2. maintain bed rest in semi-fowlers position
3. monitor FHR continuously; will be normal if placenta is functioning
4. monitor maternal vital signs continuously; assess color for pallor or cyanosis; administer oxygen
5. assess perineal pads to determine blood loss; monitor hgb and Hct; prepare for cesarean birth if bleeding persist
6. administer intravenous therapy and .or blood replacement
Hypertensive Disorders
Hypertension in Pregnancy
Circulating blood volume increases by 50% during pregnancy. All of this extra blood volume places stress upon the maternal vasculature. Most
expecting women are able to adapt physiologically to these changes while do not. If the body is unable to effectively adapt, the pregnant woman will
develop a hypertensive disorder. This increases the cardiac demand and can lead to issues in the kidneys.
Potential Complications of Uncontrolled Maternal Hypertension
Acute renal or hepatic failure
Antepartum hemorrhage
Intrauterine growth restriction
Perinatal death
Postpartum hemorrhage
Maternal death (Roberts, Ford, Algert, et al., 2011)
Forms of Hypertensive Disorders in Pregnancy
Chronic hypertension
Pregnancy induced or pregnancy associated hypertension (non-proteinuric)
Preeclampsia (proteinuric)
Eclampsia (proteinuric and convulsive)
HELLP syndrome (not a hypertensive disorder but related)
The Big Picture of Hypertensive Disorders

Clinically speaking, pregnancy induced hypertension, preeclampsia, and eclampsia are essentially the same condition, just in different progressions.
Whenever a woman exhibits manifestations of a hypertensive disorder, the health care team directs treatment to control current symptoms and
prevent progression of the condition.
Increased Risk of Hypertensive Disorders
Primagravida (first pregnancy)
Extremes in maternal age, either under 18 years old or over 40 years old
Obesity, which places increased demands on the vasculature
Family or personal history
Multi-fetal gestation, twins, triplets, etc.
Periodontal disease, which has been linked to cardiac and vascular disease
While hypertension is a vascular condition, not cardiac, high blood pressure impacts the later due to increased cardiac demand and other
manifestations
Chronic Hypertension
What is Chronic Hypertension?
Hypertension not associated with pregnancy
Systolic > 140 mm/Hg or diastolic > 90 mm/Hg
Refers to expecting moms that had primary (no known pathological cause unrelated to the vasculature) or secondary hypertension (eg: from
another condition such as hepatic failure) prior to becoming pregnant
The vasculature may be additionally stressed by the increased blood volume
Moms should be monitored closely may lead to a more severe condition
Gestational Hypertension
Onset of hypertension after 20 weeks gestation in previously normotensive women
Does not get better or go away
The only thing that will cure the hypertension or end it is delivery
Usually resolves by the 12th week postpartum; otherwise, its considered to be primary hypertension
Preeclampsia
Hypertension diagnosed after 20 weeks of gestation and persistent up to 6 weeks postpartum
Kidneys are beginning to be impacted, not filtering right, and spilling protein into the urine, causing proteinuria
There are several subcategories based upon severity superimposed preeclampsia
The International Society of the Study of Hypertension (ISSH) sets guidelines that define the levels of preeclampsia
Preeclampsia
What is Preeclampsia?
Characterized by the development of hypertension and proteinuria in previously normotensive women after 20 weeks of gestation or in the early
postpartum period (up to 6 weeks postpartum)
Kidneys are beginning to be impacted, not filtering right, and spilling protein into the urine
The International Society of the Study of Hypertension (ISSH) defines several subcategories based upon severity superimposed preeclampsia
Can develop prior to 20 weeks of gestation if accompanied by the presence of trophoblastic disease
Blood pressure must be taken on two occasions and six hours apart for a positive diagnosis to be made
ISSHs Definition of Preeclampsia
Mild preeclampsia: 140/90 mm/Hg with proteinuria 1 + to 2+ and slight elevation of liver enzymes
Severe preeclampsia: 160/110 mm/Hg or higher, with 3+ to 4+ proteinuria and elevation of liver enzymes (Roberts, Ford, Algert, et al., 2011)
Epidemiology and Etiology of Preeclampsia
The leading cause of maternal death nationwide
Approximately 6% of the population is impacted by preeclampsia
Increased Risk for Preeclampsia
First pregnancy or new partner with this pregnancy.
Extremes of maternal age: younger than 19 or older than 40
Obesity
Personal or family history of preeclampsia
Exposure to abundance of trophoblast tissue (multi-fetal gestation, hydatidiform mole/molar pregnancy)
Poor outcome in previous pregnancy (intrauterine growth restriction, placental abruption, fetal demise)
Preexisting medical or genetic conditions (chronic hypertension, renal disease, diabetes mellitus type 1, collagen disease)
Thrombophilias (antiphospholipid antibody syndrome, protein C, protein S, antithrombin deficiency)
Periodontal disease
Clinical Manifestations of Preeclamsia
Debilitating headache
Sudden onset of edema in the extremities
Visual burring and flashing lights
Upper right epigastric pain
Hyperreflexia
Elevated liver enzymes
Meconium staining (baby is stained by its own meconium)
Potential Complications Of Preeclampsia
Possible complications in the liver, kidneys, brain and the clotting system
Baby- impaired growth and prematurity
Life threatening. deaths are attributable to eclampsia, rather than preeclampsia
Perinatal mortality is high following preeclampsia, and even higher following eclampsia
If not properly managed, it may lead to eclampsia
The most serious complications include convulsions or coma when progressed to eclampsia
Treatment of Preeclampsia
Treatment includes antihypertensives and magnesium sulphate
Sometimes antiplatelet agents, primarily low dose aspirin, and calcium supplementation are used to avoid complications
Anticipated Assessments Findings
Elevated blood pressure
Excessive edema in hands or face
Proteinuria greater than +1
Headaches, blurred vision, abdominal pain, dyspnea
Eclampsia
What is Eclampsia?
Cardinal features: hypertension with proteinuria and convulsions
Defined as the new onset of hypertension after 20 weeks gestation, proteinuria, and the presence of convulsions
The later is serious due to risk of abdominal trauma and uterine contractions
Trauma sustained during a grand-mal seizure may lead to abrupto placenta (a ruptured placenta); uterus contract, blood flow to the uterus is
impaired, risk of abdominal trauma and abrupto placenta
Hypertension Disorders
Clinical Manifestations of Hypertension Disorders
Sudden and severe headache in the morning, extreme swelling in the arms or legs from decrease in circulatory output
From decrease in circulatory output
Visual disturbances
3+ urine
As it progresses, it goes to severe preeclampsia
Next progression is eclampsia
Collaborative Management
Padded side rails
Keep bed in the lowest position
Provide a quiet and comfortable environment
Dietary changes
Frequent office visits
Non-stress tests
Assess urine protein frequently
Activity restrictions
Hospitalization once moderate or higher preeclampsia occurs
Treatment for Hypertensive Disorders

Treatment Options
Magnesium sulphate
Antihypertensives
Antiplatelet agents, primarily low dose aspirin
Calcium supplementation
Treatment of gestational diabetes to maintain glycemic control
Magnesium Sulphate
What is Magnesium Sulphate?
Administered to reduce blood pressure
The drug depresses the central nervous system
Relaxes smooth muscle to prevent uterine contractions
Causes vasodilator by relaxing the vasculature
Magnesium sulphate has a narrow therapeutic window
Its easily toxic
Target levels: 4-7 mEq/L
Administering Magnesium Sulphate
Drug is titrated based upon the patients response
Magnesium sulphate is always given as IV piggyback as it must be diluted since its toxic to the veins
Urinary output should increase, which is an indication of increased kidney perfusion
Potential Complications of Magnesium Sulphate
Experience is often unpleasant;
May produce a feeling of heat, flushing, diaphoresis
Anxiety and panic as the mom may feel like she is not breathing (although she is)
Monitoring Patients on Magnesium Sulphate
Vitals are assessed every 15 minutes
Blood pressure
Respiration rate, depth, and characteristics
Deep tendon reflexes
Weight checks
Deep tendon reflexes are assessed to determine if the response is normal (2+) as the central nervous system is being depressed
Magnesium sulphate antidote: calcium gluconate
HELLP Syndrome
What is HELLP Syndrome?
H= Hemolysis
E= Elevated
L = Liver enzymes
L= Low
P= Platelets
Characteristics of HELLP Syndrome
Occurs after 20 weeks gestation or develops within 48 hours of delivery
Commonly associated with primary hypertension or preeclampsia but may be a separate disorder
15-20% of cases involve normotensive status and normal protein levels in the urine
Clinical Manifestation of HELLP Syndrome
Malaise
Nausea
Low platelets (less than 100,000)
Potential Complications Associated with HELLP
Abruptio placenta
Stroke
Pulmonary edema
Hypertension
DIC
COMPLICATIONS DURING LABOR AND BIRTH

1. Dysfunctional labor
Description
Dysfunctional labor is difficult, painful, prolonged labor due to mechanical factors.
Etiology
1.
2.
3.
4.
Fetal factors (passenger) include unusually large fetus, fetal anomaly, malpresentation, and malposition
Uterine factors (powers) include hypotonic labor, hypertonic labor, precipitous labor, and prolonged labor.
Pelvic factors (passage) include inlet contracture, midpelvis contracture, and outlet contracture.
Psyche factors include maternal anxiety and fear and lack of preparation.
Pathophysiology
Uterine contractions are ineffective secondary to muscle fatigue or overstretching.
Assessment Findings
Clinical manifestations include irregular uterine contractions and ineffective uterine contractions in terms of contractile
strength and duration.
Management
1. Optimize uterine activity. Monitor uterine contractions for dysfunctional patterns; use palpation and an electronic monitor.
2. Prevent unnecessary fatigue. Check the clients level of fatigue and ability to cope with pain.
3. Prevent complications of labor for the client and infant.
o Assess urinary bladder; catheterize as needed.
o Assess maternal vital signs, including temperature, pulse, respiratory rates, and blood pressure.
o Check maternal urine for acetone (an indication of dehydration and exhaustion).
o Assess condition of fetus by monitoring FHR, fetal activity, and color of amniotic fluid.
4. Provide physical and emotional support.
o Promote relaxation through bathing and keeping the client and bed clean, back rubs, frequent position changes
(sidelying), walking (if indicated), and by keeping the environment quiet.
Coach the client in breathing and relaxation techniques.
5. Provide client and family education.
o
f. Support the Patient.

(1) Malposition and Malpresentations
Left and right occipito-anterior are the only normal presentations and positions.
Malposition: occipito-posterior.
Malpresentations: anything except vertex as face, brow, breech, shoulder, cord and complex presentations.
Causes of Malpresentations and Malpositions
Defects in the powers:
Pendulous abdomen: laxity of the abdominal muscles.
Dextro-rotation of the uterus: rotation of the uterus in anti-clock wise favours occipito-posterior in right occipito-anterior position.
Defects in the passages:
Contracted pelvis.
Android pelvis.
Pelvic tumours.
Uterine anomalies as bicornuate, septate or fibroid uterus.
Placenta praevia.
Defects in the passenger:
Preterm fetus.
Intrauterine fetal death.
Macrosomia.
Multiple pregnancy.
Congenital anomalies as anencephaly and hydrocephalus.
Polyhydramnios.
Coils of the cord around the neck favours face presentation.

Signs Suggestive of Malpresentations
Pendulous abdomen.
Nonengagement of the presenting part in the last 3-4 weeks in primigravida.

Premature rupture of membranes or its rupture early in Labor.
Delay in the descent of the presenting part during Labor.
Vaginal examination, X-ray or ultrasonography are more conclusive.
Complications of Malpresentations and Malpositions

Cord presentation and prolapse.
Prolonged Labor due to hypotonic or hypertonic inertia.
Obstructed Labor with higher incidence of rupture uterus.
Increased incidence of instrumental and operative delivery.

Increased incidence of trauma to the genital tract.
Increased incidence of postpartum hemorrhage and puerperal infection.
Increased incidence of perinatal mortality.

OCCIPITO-POSTERIOR POSITION
Definition
It is a vertex presentation with fetal back directed posteriorly.
Incidence
10% at onset of Labor.
Right occipito-posterior (ROP) is more common than left occipito-posterior (LOP) because:
The left oblique diameter is reduced by the presence of sigmoid colon.
The right oblique diameter is slightly longer than the left one.
Dextro-rotation of the uterus favours occipito-posterior in right occipito-anterior position.
Etiology
The shape of the pelvis: anthropoid and android pelvises are the most common cause of occipito-posterior due to narrow fore-pelvis.
Maternal kyphosis: The convexity of the fetal back fits with the concavity of the lumbar kyphosis.
Anterior insertion of the placenta: the fetus usually faces the placenta (doubtful).
Other causes of malpresentations: as
placenta praevia,
pelvic tumours,
pendulous abdomen,
polyhydramnios,
multiple pregnancy.
Diagnosis
During pregnancy
Inspection:
The abdomen looks flattened below the umbilicus due to absence of round contour of the fetal back.
A groove may be seen below the umbilicus corresponding to the neck.
Fetal movement may be detected near the middle line.
Palpation:
Fundal grip:
The breech is felt as a soft, bulky, irregular non-ballotable mass.
Umbilical grip:
The back felt with difficulty in the flank away from the middle line.
The anterior shoulder is at least 3 inches from the middle line.

The limbs are easily felt near, or on both sides, of the middle line.
First pelvic grip:

The head is usually not engaged due to deflexion.
The head is felt smaller and escapes easily from the palpating fingers as they catch the bitemporal diameter instead of the biparietal diameter in occipito-anterior.
Second pelvic grip:
The head is usually deflexed.

Auscultation:
FHS are heard in the flank away from the middle line.
In major degree of deflexion, the FHS may be heard in middle line.
Ultrasonography or lateral view x-ray.
During Labor
In addition to the previous findings vaginal examination reveals:
The direction of the occiput.
The degree of deflexion.

Mechanism of Labor
A certain degree of deflexion is present due to:
Opposition of the two convexities of the fetal and maternal spines prevents flexion and promotes deflexion.
The longer biparietal diameter (9.5cm) enters the narrow sacro-cotyloid diameter (9cm) while the shorter bitemporal diameter (8cm) enters the longer oblique diameter (12cm).
As a result of deflexion, the occipito-frontal diameter 11.5 cm enters the pelvis leading to delayed engagement.
Taking in consideration the rule that the part of the fetus that meets the pelvic floor first will rotate anteriorly, the degree of deflexion determines the mechanism of Labor as follow:
Normal mechanism (90%)
Deflexion is corrected and complete flexion occurs. The occiput meets the pelvic floor first, long anterior rotation 3/8 circle occurs bringing the occiput anteriorly and the fetus is delivered norma
Abnormal mechanism (10%)
Deep transverse arrest (1%):

In mild deflexion, the occiput rotates 1/8 circle anteriorly and the head is arrested in the transverse diameter.
Persistent occipito-posterior (3%):
In moderate deflexion, the occiput and sinciput meet the pelvic floor simultaneously, no internal rotation and the head persists in the oblique diameter.
Direct occipito-posterior (face to bubis) (6%):
In marked deflexion, the sinciput meets the pelvic floor first, rotates 1/8 circle anteriorly and the occiput becomes direct posterior.
In deep transverse arrest and persistent occipito-posterior no further progress occurs and Labor is obstructed as the head cannot be delivered spontaneously.
In direct occipito-posterior, the head can be delivered by flexion supposing that the uterine contractions are strong and there is no contracted pelvis. However, perineal lacerations are
as:
the vulva is distended by the large occipito-frontal diameter 11.5 cm,

the perineum is overstretched by the large occiput.
Factors favour long anterior rotation
Well flexed head

Good uterine contractions.
Roomy pelvis.
Good pelvic floor.

No premature rupture of membranes.
Causes of failure of long anterior rotation
Deflexed head.
Uterine inertia.
Contracted pelvis: rotation of the head cannot easily occur in android pelvis due to projection of the ischial spines and convergence of the side walls.
Lax or rigid pelvic floor.
Management of Labor
First stage
Exclude contracted pelvis.
Exclude presentation or prolapse of the cord.

Inertia and prolonged Labor are expected so oxytocin may be indicated unless there is contraindication.
Contractions are sustained, irregular and accompanied by marked backache which needs analgesia as pethidine or epidural analgesia.
Avoid premature rupture of membranes by: rest in bed,

no straining,
avoid high enema,
minimise vaginal examinations.
The other management and observations as in normal Labor.

Second stage
Wait for 60-90 minutes.
During this period:
Observe the mother and fetus carefully.

Combat inertia by oxytocin unless it is contraindicated.
Contraindications of oxytocins:
Disproportion.
Incoordinate uterine action.
Uterine scar e.g. previous C.S, hysterotomy, myomectomy, metroplasty or previous perforation.
Grand multipara.
Fetal distress.
One of the following will occur:

Long internal rotation 3/8 circle:
occurs in about 90% of cases and delivery is completed as in normal Labor.
Direct occipito-posterior (face to pubis):

occurs in about 6% of cases.
the head can be delivered spontaneously or by aid of outlet forceps.
Episiotomy is done to avoid perineal laceration.

Deep transverse arrest (1%) and persistent occipito-posterior (3%):
The Labor is obstructed and one of the following should be done:
Vacuum extraction (ventouse):

Proper application as near as possible to the occiput will promote flexion of the head.
Traction will guide the head into the pelvis till it meets the pelvic floor where it will rotate.
Manual rotation and extraction by forceps:
Under general anaesthesia the following steps are done:
Disimpaction: the head is grasped bitemporally and pushed slightly upwards.

Flexion of the head.
Rotation of the occiput anteriorly by the right hand vaginally aided by,
Rotation of the anterior shoulder abdominally towards the middle line by the left hand or an assistant.
Fix the head abdominally by an assistant, apply forceps and extract it.
Rotation and extraction by a forceps:
Kiellands forceps:
Single application for rotation and extraction of the head as this forceps has a minimal pelvic curve.
Bartons forceps:
Originally was designed for deep transverse arrest.
It has a hinge in one blade between the blade proper and shank to facilitate application.
The axis of the handle to that of the blades is 55o i.e. the angle of the pelvic inlet to the outlet.
It is used for rotation only then conventional forceps is applied for extraction unless it has an axis traction piece so it can be used for rotation and extraction.
Scanzoni double application:
The conventional forceps is applied to rotate the occiput anteriorly then the forceps is removed and reapplied so that the pelvic curve of the forceps is directed anteriorly and extract th
This method is out of modern obstetrics as it is hazardous to the mother and fetus.
N.B. The head should be engaged for manual or forceps rotation to be done.
Caesarean section:
It is indicated in:
Failure of the above methods.
Other indications for C.S. as;
contracted pelvis,
placenta praevia,
prolapsed pulsating cord before full cervical dilatation, and
elderly primigravida.
Craniotomy:
if the fetus is dead.

Actually speaking, the methods used in modern obstetrics are vacuum extraction and Caesarean section.
Complications
See complications of malpresentations and malposition (mentioned before).
Face Presentation
Definition
It is a cephalic presentation in which the head is completely extended.
Incidence
About 1:300 Labors.
Etiology
Primary face:
It is less common.
It occurs during pregnancy.

It is usually due to fetal causes which may be:
Anencephaly: due to absence of the bony vault of the skull and the scalp while the facial portion is normal.
Loops of the cord around the neck.

Tumours of the fetal neck e.g. congenital goitre.
Hypertonicity of the extensor muscles of the neck.
Dolicocephaly: long antero-posterior diameter of the head, so as the breadth is less than 4/5 of the length.
Dead or premature fetus.
Idiopathic.
Secondary face:
It is more common.
It occurs during Labor.
It may be due to:

Contracted pelvis particularly flat pelvis which allows descent of the bitemporal but not the biparietal diameter leads to extension of the head.
Pendulous abdomen or marked lateral obliquity of the uterus.
Further deflexion of brow or occipito posterior positions.

Other causes of malpresentations as polyhydramnios and placenta praevia.
Positions
Right mento-posterior (RMP).

Left mento-posterior (LMP).
Left mento-anterior (LMA).
Right mento-anterior (RMA), are the more common positions.
Right mento-transverse (lateral), left mento-transverse, direct mento-posterior and direct mento-anterior are rare and usually transient positions.
The first position (RMP) corresponds to the first normal position (LOA) as the back should be to the left and anterior in the first position.
Mento-anterior are more common than mento-posterior as most cases arise from more deflexion of the head in occipito-posterior position usually in flat contracted pelvis.
Diagnosis
During pregnancy (difficult)
The back is difficult to feel.
The limbs are felt more prominent in mento-anterior position.

The chin may be felt on the same side of the limbs as a horseshoe-shaped rim in mento-anterior position.
In mento-posterior, a groove may be felt between the occiput and the back particularly after rupture of the membranes.
Second pelvic grip: the occiput is at a higher level than the sinciput.
The FHS are heard below the umbilicus through the fetal chest wall in mento-anterior position.
Ultrasound or X-ray: confirms the diagnosis and may identify associated fetal anomalies as anencephaly.
During Labor
Vaginal examination shows the following identifying features for face:
supra-orbital ridges,
the malar processes,
the nose (rubbery and saddle shaped),
the mouth with hard areolar ridges.

the chin.
Late in Labor, the face becomes edema tous (tumefaction) so it can be misdiagnosed as a buttock (breech presentation) where the two cheeks are mistaken with buttocks and the mouth with anus
processes with the ischial tuberosities. The following points can differentiate in-between:
Face Presentation
Frank Breech
The fetal mouth and malar processes form the apexes of a triangle.
The anus is on the same line with the ischial tuberosities.
The gum is felt hard through the mouth.
No hard object through the anus.
The examining finger may be sucked by the fetal mouth during vaginal examination.
The anus does not suck the finger.
Mechanism of Labor
Mento-anterior position
Descent.
Engagement by submento-bregmatic diameter 9.5 cm.
Increased extension.
Internal rotation of chin 1/8 circle anteriorly.
Flexion: is the movement by which the head is delivered in mento-anterior position when the submental region hinges below the symphysis. The vulva is much distended by the submento-ve
cm.
Restitution.
External rotation.
Engagement is delayed because:
The biparietal diameter does not pass the plane of pelvic inlet until the chin is below the level of the ischial spines and the face begins to distend the perineum.
Moulding does not occur as in vertex presentation.

Mento-posterior position
Long anterior rotation 3/8 circle (2/3 of cases):

so the head is delivered as mento-anterior.
In about 1/3 of cases one of the following may occur:
Deep transverse arrest of the face: when the chin rotates 1/8 circle anteriorly.
Persistent mento-posterior: when no rotation occurs.

Direct mento-posterior: When the chin rotates 1/8 circle posteriorly.
In the last 3 conditions no further progress occurs and Labor is obstructed.

Direct mento-posterior, unlike direct occipito-posterior, cannot be delivered because:
Delivery should occur by extension while the head is already maximally extended.
As the length of the sacrum is 10 cm and that of neck is only 5 cm, the shoulders enter the pelvis and become impacted while the head still in the pelvis, thus the Labor is obstructed.
Management of Labor
Exclude: Fetal anomalies and Contracted pelvis.
Mento-anterior
First stage: as in occipito-posterior.
Second stage:
Spontaneous delivery usually occurs.
Forceps delivery may be indicated in prolonged 2nd stage.
Episiotomy is necessary because of over distension of the vulva.

Mento-posterior
First stage: as mento-anterior.
Second stage:
Wait for long anterior rotation of the mentum 3/8 circle and the head will be delivered as mento-anterior. During this period oxytocin is used to compete inertia which is common in such
there is no contraindication. Failure of this long rotation is more common than in occipito-posterior position so earlier interference is usually indicated.
Failure of long anterior rotation 3/8 circle or development of fetal or maternal distress at any time, is managed by:
Caesarean section: which is the safest and the current alternative in modern obstetrics.
Manual rotation and forceps extraction as mento-anterior, or
Rotation and extraction by Kielland forceps.
In the last 2 methods the head should be engaged but they are hazardous to both the mother and fetus so they are nearly out of modern obstetrics.
Craniotomy: if the fetus is dead.
The face of the fetus is edema tous after delivery so the mother is assured that this will be spontaneously relieved within few days.
Complications
See complications of malpresentations and malposition.
Definition
It is a cephalic presentation in which the head is midway between flexion and extension.
Incidence
Brow Presentation
About 1:1000 Labor.

Etiology
As face presentation.
Diagnosis
During pregnancy:
It is difficult.
The occiput and sinciput may be felt at the same level.

Ultrasonography and X-ray may be helpful.
During Labor:
In addition to the previous findings, vaginal examination reveals the following features:
frontal bones,
supra-orbital ridges, and

root of the nose but not the chin.
Mechanism of Labor
Persistent brow:
The engagement diameter is the mento-vertical 13.5 cm which is longer than any diameter of the inlet so there is no mechanism of Labor and Labor is obstructed.
Transient brow:
may occur during conversion of vertex into face presentation. So if brow is flexed to become vertex or extended to become face it may be delivered.
Management
Early in the first stage:
Exclude contracted pelvis, if present do caesarean section.

The case is considered as transient brow, observed carefully and given a chance for spontaneous conversion into either face or vertex.
The rest of management as other malpresentation.
In the second stage:
The case is considered as persistent brow so:
Caesarean section is done if the fetus is living.

Craniotomy if the fetus is dead.
Complex (Compound) Presentation
Breech Presentation
Definition
It is the presence of a limb alongside the presenting part usually the arm presents with the head.
Incidence
About 1:800 labors.
Etiology
Interference of adaptation of the presenting part to the pelvic brim which may be:
Fetal causes:
Malpresentations.
Prematurity.
Multiple pregnancy.
Polyhydramnios.
Maternal causes:
Contracted pelvis.
Pelvis tumours.
Diagnosis
Vaginal examination reveals limb beside the head.

Management
Exclude:
contracted pelvis and

cord prolapse.
First stage
Nothing is done as in most cases the arm will be displaced spontaneously away from the head.
Second stage
Forceps extraction with or without reposition of the arm: reposition of the arm is tried first, if difficult apply forceps without reposition but do not include the arm in the blades. This is done i
engaged.
Caesarean section: is indicated in

Nonengagement of the head.
Contracted pelvis.
Other indications for caesarean section.

Craniotomy: if the fetus is dead and labor is obstructed.
BREECH PRESENTATION
Definition
It is a longitudinal lie in which the buttocks is the presenting part with or without the lower limbs.
Incidence
3.5% of term singleton deliveries and about 25% of cases before 30 weeks of gestation as most cases undergo spontaneous cephalic version up to term.
Etiology
In general, the fetus is adapted to the pyriform shape of the uterus with the larger buttock in the fundus and smaller head in the lower uterine segment.
Any factor that interferes with this adaptation, allows free mobility or prevents spontaneous version, can be considered a cause for breech presentation as:
Prematurity: due to
relatively small fetal size,

relatively excess amniotic fluid, and
more globular shape of the uterus.
Multiple pregnancy: one or both will present by the breech to adapt with the relatively small room.
Poly-and oligohydramnios.
Hydrocephalus.

Bicornuate and septate uterus.
Uterine and pelvic tumours.

Placenta praevia.
Types
Complete breech:
The feet present beside the buttocks as both knees and hips are flexed.
More common in multipara.
Incomplete breech:
Frank breech:
It is breech with extended legs where the knees are extended while the hips are flexed.
More common in primigravida.
Footling presentation:
The hip and knee joints are extended on one or both sides.
More common in preterm singleton breeches.
Knee presentation:
The hip is partially extended and the knee is flexed on one or both sides.
Positions
Left sacro-anterior.
Right sacro-anterior.
Right sacro-posterior.
Left sacro-posterior.
Left and right sacro- transverse (lateral).
Direct sacro-anterior and posterior.

Sacro-anterior positions are more common than sacro-posterior as in the first the concavity of the fetal front fits into the convexity of the maternal spines.
Diagnosis
During pregnancy
Inspection:
A transverse groove may be seen above the umbilicus in sacro-anterior corresponds to the neck.
If the patient is thin, the head may be seen as a localised bulge in one hypochondrium.
Palpation:
Fundal grip: the head is felt as a smooth, hard, round ballottable mass which is often tender.
Umbilical grip: the back is identified and a depression corresponds to the neck may be felt.
First pelvic grip: the breech is felt as a smooth, soft mass continuous with the back. Trial to do ballottement to the breech shows that the movement is transmitted to the whole trunk.
Auscultation:
FHS is heard above the level of the umbilicus. However in frank breech it may be heard at or below the level of the umbilicus.
Ultrasonography:
It is used for the following:
To confirm the diagnosis.
To detect the type of breech.
To detect gestational age and fetal weight: Different measures can be taken to determine the fetal weight as the biparietal diameter with chest or abdominal circumference using a sp
To exclude hyperextension of the head.

To exclude congenital anomalies.
Diagnosis of unsuspected twins.
During Labor
In addition to the previous findings, vaginal examination reveals;
The 3 bony landmarks of breech namely 2 ischial tuberosities and tip of the sacrum.
The feet are felt beside the buttocks in complete breech.

Fresh meconium may be found on the examining fingers.
Male genitalia may be felt.
Mechanism of Labor
Delivery of the buttocks
The engagement diameter is the bitrochanteric diameter 10 cm which enters the pelvis in one of the oblique diameters.
The anterior buttock meets the pelvic floor first so it rotates 1/8 circle anteriorly.
The anterior buttock hinges below the symphysis and the posterior buttock is delivered first by lateral flexion of the spines followed by the anterior buttock.
External rotation occurs so that the sacrum comes anteriorly.

Delivery of the shoulders
The shoulders enter the same oblique diameter with the biacromial diameter 12 cm (between the acromial processes of the scapulae).
The anterior shoulder meets the pelvic floor first, rotates 1/8 circle anteriorly, hinges under the symphysis, then the posterior shoulder is delivered first followed by the anterior shoulder.
Delivery of the after-coming head
The head enters the pelvis in the opposite oblique diameter.
The occiput rotates 1/8 circle anteriorly, in case of sacro- anterior position and 3/8 circle anteriorly in case of sacro- posterior position.
Rarely, the occiput rotates posteriorly and this should be prevented by the obstetrician.
N.B.
The head is delivered by movement of flexion in:
Direct occipito-posterior (face to pubis).

Face mento-anterior.
The after coming head in breech presentation.
The head is delivered by extension in normal labor only i.e. occipito anterior positions.
Management of Breech Presentation
External Cephalic Version
It regains its importance after increased rate of caesarean sections nowadays.
Timing: After the 32nd weeks up to the 37th week and some authors extend it to the early labor as long as the membranes are intact and there is no contraindications.
Version is not done earlier because:
Spontaneous version is liable to occur.
Return to breech presentation is liable to occur.

If labor occurs the fetus will have a lesser chance for survival.
Version is difficult after 37th weeks due to:
Larger fetal size.

Relatively less liquor.
More irritability of the uterus.

The aim:
To detect cephalo-pelvic disproportion.
Cephalic delivery is safer for the mother and fetus.
Success rate: 50-70%.

Causes of failure:
Large sized fetus.

Oligo- or polyhydramnios.
Short umbilical cord.
Uterine anomalies as bicornuate or septate uterus.

Irritable uterus. Tocolytic drugs may be started 15 minutes before the procedure to overcome this.
Obesity.
Rigid abdominal wall.

Frank breech because the legs act as a splint.
Contraindications:
Contracted pelvis.
Multiple pregnancies.
Hydrocephalus.
Antepartum haemorrhage.
Uterine scar.
Hypertension as the placenta is more susceptible to separation.
Elderly primigravida.
Ruptured membranes.
Anaesthesia during version is contraindicated as pain is a safeguard against rough manipulations.
Complications:
Accidental haemorrhage due to separation of the placenta.
Rupture of membranes.
Preterm labor.
Fetal distress.
Cord presentation or prolapse.
Entangling of the cord around the fetus.

Isoimmunization in Rh-negative mothers due to feto-maternal transfusion.
Caesarean Section
Indications:
Large fetus i.e. > 3.75 kg estimated by ultrasound.
Preterm fetus but estimated weight is still more than 1.25 kg.
Footling or complete breech: as the presenting irregular part is not well fitting with the lower uterine segment leading to;
Less reflex stimulation of uterine contractions.

Susceptibility to cord prolapse.
Early bearing down as the foot passes through partially dilated cervix and reaches the perineum.
Hyperextended head: diagnosed by ultrasound or X-ray.

Contracted pelvis: of any degree.
Uterine dysfunction.
Complicated pregnancy with:

Hypertension.
Diabetes mellitus.
Placenta praevia.
Pre labor rupture of membranes for 12 hours.
Post-term.
Intrauterine growth retardation.
Placental insufficiency.
Primigravidas: breech in primigravida equals caesarean section in opinion of most obstetricians as the maternal passages were not tested for delivery before.
Vaginal Delivery
Prerequisites:
Frank breech.
Estimated fetal weight not more than 3.75 kg.
Gestational age: 36-42 weeks.
Flexed head.
Adequate pelvis.
Normal progress of labor by using the partogram.
Uncomplicated pregnancy.
Multiparas.
An experienced obstetrician.
In case of intrauterine fetal death.
N.B.
During vaginal delivery, prematures are more susceptible to:
hypoxia,
trauma, and
retained after-coming head as the partially dilated cervix allows the passage of the body but the less compressible relatively larger head will be retained.
However, caesarean section should only be done if the premature fetus has a reasonable chance of post natal survival.
Management of Vaginal Breech Delivery
First stage: as other malpresentations.

Second stage: The fetus may be delivered by one of the following methods:
Spontaneous breech delivery:
This is rarely occurs in multipara with adequate pelvis, strong uterine contractions and small sized baby. The baby is delivered spontaneously without any assistance but perineal laceratio
Assisted breech delivery:
This is the method of delivery in far majority of cases.
The assistance is indicated for delivery of the shoulders and after-coming head and the infant is allowed to be delivered up to the umbilicus spontaneously.
Delivery of the buttocks:
The golden rule is to Keep your hands off.
The patient is asked to bear down during uterine contractions and relax in between until the perineum is distended by the buttocks.
An episiotomy is done especially in primigravida to avoid much lateral flexion of the spines, perineal lacerations and intracranial haemorrhage due to sudden compression and dec
after coming head.

The legs are hooked out but without traction.
When the umbilicus appears, a loop of the cord is hooked to prevent traction or compression of the cord and detect its pulsation.
The fetus is covered with warm towel to prevent premature stimulation of respiration.
Delivery of the shoulders:
Gentle steady downward traction is applied to the fetal pelvic girdle during uterine contractions with gradual rotation of the fetus to bring the shoulders in the antero-posterior dia
When the anterior scapula appears below the symphysis, both arms are delivered by hooking the index finger at the elbow and sweep the forearm across the chest of the fetus
The back is rotated anteriorly.
Kristeller manoeuvre: gentle fundal pressure is done during uterine contractions to guide the head into the pelvis and maintain its flexion.
Delivery of the after-coming head:

It is delivered by one of the following methods:
Jaw flexion- shoulder traction (Mauriceau-Smellie-Veit) method:
Two fingers of the left hand, (as originally described) or better on the malar eminencies (the maxillae) to avoid dislocation of the jaw.
The index and ring finger of the right hand are placed on each shoulder while the middle finger is pressing against the occiput to promote flexion and act as a splint for the neck, preventing hy
hence cervical spine injury.

Traction is commenced downwards and backwards till the nape of the fetus appears, the body is lifted towards the mothers abdomen.
Burns Marshalls method:
The fetus is left hanging so that its weight exerts gentle downwards and backwards traction. When the nape appears, grasp the feet and left the body towards the mothers abdomen.
Forceps:
Pipers forceps is more suitable than the ordinary forceps as it has a perineal but not pelvic curve and has longer shanks. It is applied from the ventral aspect of the fetus.
Traction is applied downwards and backwards till the nape appears, then downwards and forwards to deliver the head by flexion.
Forceps delivery has the following advantages:

It promotes flexion of the head.
Traction is applied on the head and not on the neck.
It prevents sudden compression and decompression of the head.

It protects the head from compression by pelvic bones or rigid perineum.
Breech extraction:
Indications:
Maternal or fetal distress.
Prolonged second stage.

To shorten the second stage in maternal respiratory and heart diseases.
Prolapsed pulsating cord with fully dilated cervix.
Technique:
Like assisted breech delivery except that: It is done under general anaesthesia.
Both legs are bringing down.

Traction on the legs is done helped by fundal pressure to deliver the breech and the trunk.
The after coming head is delivered by jaw flexion shoulder traction or forceps.
Complicated Breech Delivery
Arrest of the buttocks at the pelvic brim

Causes
Management
Inefficient uterine contractions
Oxytocin drip, if contraindicated do caesarean section Breech extraction if cervix is fully dilated
Contracted pelvis
Caesarean section
Large sized baby
Caesarean section
Arrest of the buttocks at the pelvic outlet

Causes
Management
Inefficient uterine contractions
Breech extraction
Contracted outlet.
Caesarean section
Rigid perineum
Episiotomy
Extended legs (frank breech)
Breech deeply impacted: Groin traction
Groin traction:
Living fetus:
traction is done by the index or the index and middle fingers put in the anterior groin in a downward and backward direction.
The traction is done towards the trunk to avoid dislocation of the femur.
Traction is done during uterine contractions and aided by fundal pressure.
When the posterior buttock appears traction is done by the 2 index fingers in both groins in a downward and forward direction.
Dead fetus:
Groin traction is done by breech hook.
Bringing down a leg (Pinards method):
Under general anaesthesia.
Press by 2 fingers in the popliteal fossa of the anterior leg to flex it then grasp the ankle and bring it down. This will prevent the anterior buttock from over-riding the symphysis pubis.
If the posterior leg was brought down first it must be rotated anteriorly with the trunk then bring the other leg which is now becomes posterior.
N.B. The foot has the following features differentiating it from the hand:
Presence of the heel.

Absence of the mobile thumb.
The toes are shorter than the fingers.
Arrest of the shoulders

Causes
Management
The shoulders are delivered by:
Classical method or
Extension of the arms: due to traction on the breech before full dilatation of the cervix.
Lvsets method.
Nuchal position of the arm: The forearm is displaced behind the neck due to rotation of the trunk in a wrong direction.
Rotation of the fetal trunk in the direction of the finger tips of th
Classical method:
Under epidural or general anaesthesia.
As there is more space posteriorly, bring down the posterior arm first by using 2 fingers pressing against the cubital fossa and sweep the arm in front of the fetal body to avoid fracture humer
The anterior arm is then brought down by the same manoeuvre. If this is difficult rotate the body180o to make the anterior arm posterior and bring it down.
Lvset method:
Under epidural or general anaesthesia.

Gentle downward and backward traction is applied to the fetus by grasping its pelvis till the inferior angle of the anterior scapula appears, the fetal trunk is rotated 180o to bring the posterior
emerging beneath the symphysis pubis. So the arm can be brought down.
The trunk is again rotated 180o in the opposite direction to bring the other shoulder anteriorly emerging beneath the symphysis so the second arm can be brought down.
The back should be kept always anterior during rotation.
Arrest of the after coming head

Causes
Management
(A) Faults in the head
Living fetus: Symphysiotomy
1- Large head
Dead fetus: Craniotomy
2- Hydrocephalus
Craniotomy
3- Extended head
Jaw flexion shoulder traction
4- Posterior rotation of the

occiput
Jaw flexion shoulder traction till the sinciput hinges below the symphysis then deliver the head by flexion. If the head is extended do Prague manoeuv
(B) Faults in passages
Living fetus: Symphysiotomy
1- Contracted pelvis
Dead fetus: Craniotomy
2- Rigid perineum
Episiotomy + forceps delivery

Dhrssen cervical incisions especially if the fetus is living: 2 incisions of 1-2 cm are made with scissors at 2 and 10 oclock then sutured after delivery. A
3- Incompletely dilated cervix
6 oclock may be needed
Prague manoeuvre:
When the occiput rotates posteriorly and the head extends, the chin hangs above the symphysis pubis.
Fetus is grasped from its feet and flexed towards the mothers abdomen, while the other hand is doing simultaneous traction on the shoulders to deliver the head by flexion.
Complications of Breech Delivery

Maternal:
Prolonged labor with maternal distress.
Obstructed labor with its sequelae may occur as in impacted breech with extended legs.
Laceration especially perineal.
Postpartum haemorrhage due to prolonged labor and lacerations.

Puerperal sepsis.
Fetal :
Fetal mortality:
Is about 4% in multipara and 8% in primigravida which may be due to:

Intracranial haemorrhage: is the commonest cause of death due to sudden compression and decompression of the head as there is no gradual moulding of the head.
This can be avoided by:
Forceps delivery of the after -coming head.

Episiotomy.
Slow delivery of the head.
Vitamin K to the mother early in labor.

Fracture dislocation of the cervical spines prevented by avoiding lifting the body towards the mothers abdomen until the nape appears below the symphysis.
Asphyxia due to:

Cord prolapse or compression by the head.
Premature stimulation of respiration leading to inhalation of mucus, liquor or blood. This can be avoided by covering the body of the fetus with warm towels during delivery.
Rupture of an abdominal organ: from rough manipulations avoided by grasping the fetus from its hips only.
Non-fatal injuries:
Fracture femur, humerus or clavicle.
Dislocation of joints or lower jaw.

Injury to the external genitalia.
Brachial plexus injury.
Lacerations to the sternomastoid muscles.
Shoulder Presentation (Transverse or Oblique lie)
Definition
The longitudinal axis of the fetus does not coincide with that of the mother.
These are the most hazardous malpresentations due to mechanical difficulties that occur during labor .
The oblique lie which is deviation of the head or the breech to one iliac fossa, is less hazardous as correction to a longitudinal lie is more feasible.
Incidence
3-4% during the last quarter of pregnancy but 0.5% by the time labor commences.
Etiology
Factors that
change the shape of pelvis, uterus or fetus,
allow free mobility of the fetus or

interfere with engagement as:
Maternal:
Contracted pelvis.
Lax abdominal wall.
Uterine causes as bicornuate, subseptate and fibroid uterus.

Pelvic masses as ovarian tumours.
Fetal causes:
Positions
Multiple pregnancy.
Polyhydramnios.
Placenta praevia.
Prematurity.
The scapula is the denominator
Left scapulo-anterior.
Right scapulo-anterior.
Right scapulo-posterior.
Left scapulo-posterior.
Scapulo-anterior are more common than scapulo-posterior as the concavity of the front of the fetus tends to fit with the convexity of the maternal spines.
Diagnosis
During pregnancy
Inspection:
The abdomen is broader from side to side.
Palpation:
Fundal level: lower than that corresponds to the period of Amenorrhea.

Fundal grip: The fundus feels empty.
Umbilical grip: The head is felt on one side while the breech one the other. In transverse lie, they are at the same level, while in oblique lie one pole, usually the head as it is heavier, is in a
iliac fossa.
First pelvic grip: Empty lower uterine segment.
Auscultation:
FHS are best heard on one side of the umbilicus towards the fetal head.
Ultrasound or X-ray:
Confirms the diagnosis and may identify the cause as multiple pregnancy or placenta praevia.
During labor
In addition to the previous findings, vaginal examination reveals:
The presenting part is high.
Membranes are bulging.
Premature rupture of membranes with prolapsed arm or cord is common. The dorsum of the supinated hand points to the fetal back and the thumb towards the head. The right hand of the fe
correctly by the right hand of the obstetrician and the left hand by the left one.
When the cervix is sufficiently dilated particularly after rupture of the membranes, the scapula, acromion, clavicle, ribs and axilla can be felt.
Mechanism of Labor
As a rule no mechanism of labor should be anticipated in transverse lie and labor is obstructed.
If a patient is allowed to progress in labor with a neglected or unrecognized transverse lie, one of the following may occur:
Impaction:
This is the usual and most common outcome.
The lower uterine segment thins and ultimately ruptures.

The fetus becomes hyperflexed, placental circulation is impaired, cord is prolapsed and compressed leading to fetal asphyxia and death.
Spontaneous rectification:
Rarely the fetal lie may be corrected by the splinting effect of the contracted uterine muscles so that the head presents.
Spontaneous version:
Rarely, by similar process the breech may come to present.
Spontaneous expulsion:
Very rarely, if the fetus is very small or dead and macerated, the shoulder may be forced through the pelvis followed by the head and trunk.
Spontaneous evolution:
Very rarely, the head is retained above the pelvic brim, the neck greatly elongates, the breech descends followed by the trunk and the after -coming head, i.e. spontaneous version occurs in
Management
External cephalic version

Can be done in late pregnancy or even early in labor if the membranes are intact and vaginal delivery is feasible. In early labor, if version succeeded apply abdominal binder and rupture the mem
uterine contractions.
Internal podalic version

It is mainly indicated in 2nd twin of transverse lie and followed by breech extraction.
Prerequisites:
General or epidural anaesthesia.

Fully dilated cervix.
Intact membranes or just ruptured.
Caesarean section
It is the best and safest method of management in nearly all cases of persistent transverse or oblique lie even if the baby is dead.
As rupture of membranes carries the risk of cord prolapse, an elective caesarean section should be planned before labor commences.
Neglected (Impacted) shoulder

Clinical picture (impending rupture uterus)
Exhaustion and distress of the mother.

Shoulder is impacted may be with prolapsed arm and / or cord.
Membranes are ruptured since a time.
Liquor is drained.
The uterus is tonically contracted.
The fetus is severely distressed or dead.
Management
Caesarean section is the safest procedure even if the baby is dead. A classical or low vertical incision in the uterus facilitates extraction of the fetus as a breech in such a condition.
Any other manipulations will lead eventually to rupture uterus so they are contraindicated.
UNSTABLE LIE
Definition
A fetus which changes its lie frequently from transverse to oblique to longitudinal.
Etiology
Polyhydramnios.
Prematurity and IUFD.
Contracted pelvis.
Placenta praevia.
Pelvic tumours.
Multiparae with a lax uterus and abdominal wall.
Management
External cephalic (or even podalic) version:

Can be done whenever the woman is examined but in majority of cases it will recur so it is better to defer it until full term (37-40 weeks).
After correcting the fetal lie to longitudinal, apply an abdominal binder, start oxytocin infusion and do amniotomy when the uterine contractions started and the presenting part is well se
brim.
Caesarean section is indicated in:
Failure of external version .

Some do it selectively in cases discovered after 40 weeks gestation
Cord Presentation and Prolapse
Definitions
In both conditions a loop of the cord is below the presenting part. The difference is in the condition of the membranes; if intact it is cord presentation and if ruptured it is cord prolapse.
Incidence: 1:200.
The Risk
As long as the membranes are intact there is no risk. In cord prolapse, the fetal perinatal mortality is 25-50% from asphyxia due to:
mechanical compression of the cord between the presenting part and bony pelvis and
spasm of the cord vessels when exposed to cold or manipulations.
The prognosis is worse when the cord is more liable for compression as in:
Primigravida than multipara.
Cephalic than breech presentation or transverse lie.
Partially than fully dilated cervix.

Generally contracted than flat pelvis.
Anterior than posterior position of the cord.
Etiology
The presenting part is not fitting in the lower uterine segment due to:
Fetal causes:
Malpresentations: e.g. complete or footling breech, transverse and oblique lie.
Prematurity.
Anencephaly.
Polyhydramnios.
Multiple pregnancy.
Maternal causes:
Contracted pelvis.
Pelvic tumours.
Predisposing factors:
Placenta praevia.
Long cord.
Sudden rupture of membranes in polyhydramnios.
Diagnosis
It is diagnosed by vaginal examination . If the cord is prolapsed it is necessary to detect whether it is pulsating i.e. living fetus or not i.e. dead fetus but this should be documented by auscultat
Ultrasound: occasionally can diagnose cord presentation.

Management
Cord presentation
Caesarean section: for contracted pelvis.

In other conditions the treatment depends upon the degree of cervical dilatation:
Partially dilated cervix: prevent rupture of membranes as long as possible by:

putting the patient in Trendelenburg position,
avoiding high enema,
avoiding repeated vaginal examination.

When the cervix is fully dilated manage as mentioned later .
Fully dilated cervix: the fetus should be delivered immediately by:

Rupture of the membranes and forceps delivery: in engaged vertex presentation.
Rupture of the membranes and breech extraction: in breech presentation.
Rupture of the membranes + internal podalic version + breech extraction: may be tried in transverse lie otherwise,
Caesarean section: is indicated as well as for non-engaged vertex and other cephalic malpresentations.
Cord prolapse
Management depends upon the fetal state:
Living fetus:
Partially dilated cervix: Immediate caesarean section is indicated. During preparing the theatre minimise the risk to the fetus by:
putting the patient in Trendelenburg position,
manual displacement of the presenting part higher up,
if the cord protrudes from the vulva, handle it gently and wrap it in a warm moist pack.
giving oxygen to the mother.
Fully dilated cervix: the fetus should be delivered immediately as in cord presentation.
Dead fetus:
Spontaneous delivery is allowed.
Caesarean section: is the safest procedure in obstructed labor as destructive operations are out of modern obstetrics.
Multiple Pregnancy
Definition
Pregnancy carrying more than one fetus.
Incidence
According to Hellins formula: twins 1:80, triplets 1:802, quadruplets 1:803 etc
The following factors are associated with higher incidence:
Racial: more in black women.

Familial: whether the wifes or the husbands family has a history of multiple pregnancies.
Induction of ovulation: particularly with gonadotrophins.
Multiparas than primiparas.

Maternal age: incidence increases with increasing age up to 40.
Previous multiple pregnancy: the incidence of another multiple pregnancy is 10 times the normal incidence.
Varieties
Binovular (dizygotic = non-identical) twins:
developed from two separate ova which may or may not come from the same ovary and fertilised by two separate spermatozoa.
The twins are of the same or different sex.
The similarity between them is not more than that between members of the same family.
They have: two placenta, two chorions, two amnions, two umbilical cords.
Binovular twins are 4 times more common than the uniovular variety.
Uniovular (monozygotic = identical) twins:
developed from a single ovum which after fertilization, by a single sperm, has undergone division to form two embryos.
The twins are of the same sex.

They have similar physical and mental characters as well as the blood group but not finger prints.
The fetal circulations often communicate in the placenta which results in fetofetal transfusion with one twin having polycythaemia, hypervolaemia,dominant heart, polyuria and polyhyd
other twin will have anaemia, hypovolaemia, microcardia, oligouria and oligohydramnios. The latter twin may die and retained till term where it is seen flat and compressed and called fet
retained dead fetus may cause disseminated intravascular coagulation.
The placentation and development in uniovular twins depend on the time when division occurs as follow:
Day post- fertilization
Placentation
Inc
0-3
2 placentas, 2 chorions, 2 amnions & 2 umbilical cords as binovular twins but 2 identical twins (monozygotic).
23%
4-7
One placenta, one chorion, 2 amnions & 2 umbilical cords with vascular connections.
75%
One placenta, one chorion, one amnion & 2 umbilical cords (monoamniotic monochorionic).
8-11
Higher fetal loss due to cord entanglement.
1%
Conjoined twins (monsters), joined by the head (craniopagus), chest (thoracopagus), abdomen (omphalopagus), back (pygopagus) or pelvic
>11
(ischiopagus). Sometimes the viscera or limbs are shared.
<1%
Superfecundation: is fertilization of two ova produced in the same menstrual cycle by two spermatozoa deposited in two separate acts of coitus.
Superfoetation: is fertilization of two ova produced in two different menstrual cycles by two separate spermatozoa. Actually, this cannot occur in human as ovulation is suppressed once pregnanc
Diagnosis
History
Family history of multiple pregnancy (wife and/ or husband).
Recent intake of ovulatory drugs.

Increased fetal movement.
Inspection
More enlargement of the abdomen.

Palpation
Fundal level: higher than that corresponds to the period of Amenorrhea.
Fundal, umbilical and first pelvic grips: can detect multiple fetal poles. At least, 3 poles should be palpated to diagnose twin pregnancy.
Fetal limbs: felt as multiple knobs.
Auscultation
Fetal heart sounds: are heard with maximum intensity in 2 separate points by 2 observers with a minimum difference of 10 beats per minute.
Arnaux sign: occasionally, the superimposition of two fetal heart sounds produces a galloping rhythm.
Ultrasonography
Diagnosis of twins:
At 7th week: two separate gestation sacs can be identified.
At 8th week: separate fetal bodies can be detected.

At 12th week: separate heads can be distinguished.
If routine scanning of all pregnant women is carried out at 16 weeks twins should rarely be missed.
Detection of:
Presentations and positions.
Gestational age.
X-ray
Congenital anomalies.
Polyhydramnios.
Placental site.
If ultrasound is not available it can detect fetal heads and vertebral columns.
Vaginal examination during labor
The presenting part is small if compared to the oversized abdomen.
Differential Diagnosis
From other causes of oversized uterus (see before).
Risk of Multiple Pregnancy
During pregnancy:
Anaemia: because of the increased fetal demand for iron and folic acid.
Hyperemesis gravidarum.
Pregnancy induced hypertension.
Polyhydramnios .
Abortion and preterm labor.
Placenta praevia due to the presence of 2 placentae or one large placenta.
Pressure symptoms: dyspnoea, palpitation and edema of the lower limbs.
Congenital anomalies: double its incidence in singleton pregnancy.
During labor:
Complications of malpresentations:
In 45% of cases both twins present by head.
In 35% one fetus presents by the head and the other by the breech.
In 10% both present by breech.

In 10% one is transverse lie and the other is cephalic or breech.
Very rare that both twins lie transversely.
Premature rupture of membranes.
Cord prolapse.
(Dysfunctional uterine action: of all types may occur due to overdistension of the uterus and malpresentations.
Locked twins: occurs when the after-coming head of the first breech fetus is locked with the head of the second cephalic fetus. This is managed by:
Disimpaction: tried under general anaesthesia by grasping the head of the second twin, rotating and pushing it up. If failed do,
Sacrification of the first fetus: which is usually dead by decapitation, the second twin can then be delivered followed by extraction of the head of the first twin.
Retained second twin.

Postpartum haemorrhage due to:
atony results from overdistended uterus and prolonged labor,
large placental site,

placenta praevia or early separation of the placenta after delivery of the first twin.
Management
During pregnancy
Frequent antenatal visits: to detect early any complication mentioned before and manage it.
Proper diet: with prophylactic supplementation of iron and folic acid.

Adequate rest: to improve placental blood flow and avoid preterm labor.
Prophylactic tocolytics or cerclage: is of no actual benefit.
During labor
Delivery should be in a hospital .
A team of experienced obstetrician, assistant, anaesthetist and neonatologist is necessary for safety.
First stage: is managed as usual unless there is an indication for caesarean section (see later).
Second stage:
Delivery of the first twin:
If it is cephalic: proceed as normal usually there is no problem.

If it is breech: caesarean section is safer for fear of locked twins, although vaginal delivery may pass without this complication.
Immediate clamping of the cord is essential after delivery of the first twin to avoid bleeding from a uniovular second twin.
Delivery of the second twin: It depends upon its presentation;
Longitudinal lie (vertex or breech):
Amniotomy is done during uterine contraction which may be delayed up to 5 minutes.

If delay is more than 5 minute, start oxytocin drip.
Delivery of the second twin is usually easy due to dilatation of the maternal passages by delivery of the first twin.
If there is fetal distress or cord prolapse, rapid delivery is indicated by:
breech extraction in breech presentation.

Forceps delivery in engaged vertex presentation.
Vacuum extraction or rarely internal podalic version and breech extraction may be indicated in non-engaged head.
Transverse or oblique lie:

a. External cephalic or podalic version is done then do amniotomy and deliver the fetus as cephalic or by breech extraction respectively or,
b. Internal podalic version and breech extraction under general or epidural anaesthesia.

The first baby is transverse lie.
Prolapsed pulsating cord or fetal distress in the first stage.

Retained second twin when it is;
transverse lie,
membranes are ruptured,

uterus is retracted and
cervix is not fully dilated.
Conjoined twins.
Triplets or more are safer delivered by C.S.
Other indications of C.S. as placenta praevia, contracted pelvis, etc.
Third stage of labor:

Active management and observation is indicated to guard against postpartum haemorrhage.
Abnormal Uterine Action
Classification
Over-efficient uterine action
Precipitate labor: in absence of obstruction
Excessive contraction and retraction: in presence of obstruction

Inefficient uterine action
Hypotonic inertia
Hypertonic inertia
Colicky uterus
Hyperactive lower uterine segment
Constriction (contraction) ring

Cervical dystocia
PRECIPITATE LABOR
Definition
A labor lasting less than 3 hours.
Etiology
It is more common in multiparas when there are;
strong uterine contractions,

small sized baby,
roomy pelvis,
minimal soft tissue resistance.
Complications
Maternal:
Lacerations of the cervix, vagina and perineum.
Shock.
Inversion of the uterus.
Postpartum haemorrhage:
no time for retraction,
lacerations.
Sepsis due to:
lacerations,
inappropriate surroundings.
Fetal :
Intracranial haemorrhage due to sudden compression and decompression of the head.
Fetal asphyxia due to:

strong frequent uterine contractions reducing placental perfusion,
lack of immediate resuscitation.
Avulsion of the umbilical cord.
Fetal injury due to falling down.
Management
Before delivery
Patient who had previous precipitate labor should be hospitalized before expected date of delivery as she is more prone to repeated precipitate labor.
During delivery
Inhalation anaesthesia: as nitrous oxide and oxygen is given to slow the course of labor.
Tocolytic agents: as ritodrine (Yutopar) may be effective.
Episiotomy: to avoid perineal lacerations and intracranial haemorrhage.
After delivery
Examine the mother and fetus for injuries.

EXCESSIVE UTERINE CONTRACTION AND RETRACTION
Physiological Retraction Ring
It is a line of demarcation between the upper and lower uterine segment present during normal labor and cannot usually be felt abdominally.
Pathological Retraction Ring (Bandls ring)
It is the rising up retraction ring during obstructed labor due to marked retraction and thickening of the upper uterine segment while the relatively passive lower segment is markedly stretche
accommodate the fetus.

The Bandls ring is seen and felt abdominally as a transverse groove that may rise to or above the umbilicus.
Clinical picture: is that of obstructed labor with impending rupture uterus (see later).
Obstructed labor should be properly treated otherwise the thinned lower uterine segment will rupture.
HYPOTONIC UTERINE INERTIA
Definition
The uterine contractions are infrequent, weak and of short duration.
Etiology
Unknown but the following factors may be incriminated:
General factors:
Primigravida particularly elderly.
Anaemia and asthenia.
Nervous and emotional as anxiety and fear.

Hormonal due to deficient prostaglandins or oxytocin as in induced labor.
Improper use of analgesics.
Local factors:
Overdistension of the uterus.
Developmental anomalies of the uterus e.g. hypoplasia.

Myomas of the uterus interfering mechanically with contractions.
Malpresentations, malpositions and cephalopelvic disproportion. The presenting part is not fitting in the lower uterine segment leading to absence of reflex uterine contractions.
Full bladder and rectum.
Types
Primary inertia: weak uterine contractions from the start.
Secondary inertia: inertia developed after a period of good uterine contractions when it failed to overcome an obstruction so the uterus is exhausted.
Clinical Picture
Labor is prolonged.
Uterine contractions are infrequent, weak and of short duration.
Slow cervical dilatation.

Membranes are usually intact.
The fetus and mother are usually not affected apart from maternal anxiety due to prolonged labor.
More susceptibility for retained placenta and postpartum haemorrhage due to persistent inertia.
Tocography: shows infrequent waves of contractions with low amplitude.
Management
General measures:
Examination to detect disproportion, malpresentation or malposition and manage according to the case.
Proper management of the first stage (see normal labor).

Prophylactic antibiotics in prolonged labor particularly if the membranes are ruptured.
Amniotomy:
Providing that;
vaginal delivery is amenable,
the cervix is more than 3 cm dilatation and
the presenting part occupying well the lower uterine segment.
Artificial rupture of membranes augments the uterine contractions by:
release of prostaglandins.
reflex stimulation of uterine contractions when the presenting part is brought closer to the lower uterine segment.
Oxytocin:
Providing that there is no contraindication for it, 5 units of oxytocin (syntocinon) in 500 c.c glucose 5% is given by IV infusion starting with 10 drops per minute and increasing gradually t
contraction rate of 3 per 10 minutes.

Operative delivery:
Vaginal delivery: by forceps, vacuum or breech extraction according to the presenting part and its level providing that,
cervix is fully dilated.

vaginal delivery is amenable.
failure of the previous methods.

contraindications to oxytocin infusion including disproportion.
fetal distress before full cervical dilatation.

HYPERTONIC UTERINE INERTIA (Uncoordinated Uterine Action)
Types
Colicky uterus: incoordination of the different parts of the uterus in contractions.

Hyperactive lower uterine segment: so the dominance of the upper segment is lost.
Clinical Picture
The condition is more common in primigravidae and characterised by:
Labor is prolonged.
Uterine contractions are irregular and more painful. The pain is felt before and throughout the contractions with marked low backache often in occipito-posterior position.
High resting intrauterine pressure in between uterine contractions detected by tocography (normal value is 5-10 mmHg).
Slow cervical dilatation .
Premature rupture of membranes.
Fetal and maternal distress.
Management
General measures: as hypotonic inertia.
Medical measures:
Analgesic and antispasmodic as pethidine.
Epidural analgesia may be of good benefit.

Failure of the previous methods.
Disproportion.
Fetal distress before full cervical dilatation.
CONSTRICTION (CONTRACTION) RING

Definition
It is a persistent localised annular spasm of the circular uterine muscles.
It occurs at any part of the uterus but usually at junction of the upper and lower uterine segments.
It can occur at the 1st, 2nd or 3 rd stage of labor.
Etiology
Unknown but the predisposing factors are:
Malpresentations and malpositions.
Clumsy intrauterine manipulations under light anaesthesia.

Improper use of oxytocin e.g.
use of oxytocin in hypertonic inertia.
IM injection of oxytocin.
Diagnosis
The condition is more common in primigravidae and frequently preceded by colicky uterus.
The exact diagnosis is achieved only by feeling the ring with a hand introduced into the uterine cavity.
Complications
Prolonged 1st stage: if the ring occurs at the level of the internal os.
Prolonged 2nd stage: if the ring occurs around the fetal neck.
Retained placenta and postpartum haemorrhage: if the ring occurs in the 3rd stage (hour- glass contraction).
Pathological Retraction Ring
Constriction Ring
Occurs in prolonged 2nd stage.
Occurs in the 1st, 2nd or 3rd stage.
Always between upper and lower uterine segments.
At any level of the uterus.
Rises up.
Does not change its position.
Felt and seen abdominally.
Felt only vaginally.
The uterus is tonically retracted, tender and the fetal parts cannot be felt.
The uterus is not tonically retracted and the fetal parts can be felt.
Maternal distress and fetal distress or death.
Maternal and fetal distress may not be present.
Relieved only by delivery of the fetus.
May be relieved by anaesthetics or antispasmodics.
Management
Exclude malpresentations, malposition and disproportion.
In the 1st stage: Pethidine may be of benefit.
In the 2nd stage: Deep general anaesthesia and amyl nitrite inhalation are given to relax the constriction ring:
If the ring is relaxed, the fetus is delivered immediately by forceps.
If the ring does not relax, caesarean section is carried out with lower segment vertical incision to divide the ring.
In the 3rd stage: Deep general anaesthesia and amyl nitrite inhalation are given followed by manual removal of the placenta.
CERVICAL DYSTOCIA
Definition
Failure of the cervix to dilate within a reasonable time in spite of good regular uterine contractions.
Varieties
Organic (secondary) due to:
Cervical stances as a sequel to previous amputation, cone biopsy, extensive cauterisation or obstetric trauma.
Organic lesions as cervical myoma or carcinoma.

Functional (primary):
In spite of the absence of any organic lesion and the well effacement of the cervix, the external os fails to dilate.
This may be due to lack of softening of the cervix during pregnancy or cervical spasm resulted from overactive sympathetic tone.
Complications
Annular detachment of the cervix: surprisingly the bleeding from the cervix is minimal because of fibrosis and avascular pressure necrosis leading to thrombosis of the vessels before detachm
Rupture uterus.
Postpartum haemorrhage: particularly if cervical laceration extends upwards tearing the main uterine vessels.
Management
Organic dystocia:
Caesarean section is the management of choice.
(II) Functional dystocia:
Pethidine and antispasmodics: may be effective.
Caesarean section: if
medical treatment fails or
fetal distress developed.
Prolonged Labor
The term is applied mainly to the prolongation of the first stage of labor.
The labor pattern is recorded on the partogram and prolonged labor can be identified as follow (Friedman 1983):
Pattern
Diagnostic criterion
Prolonged latent phase
Nulliparas
Multiparas
20 hours or more
14 hours or more
Primary dysfunctional labor

(protractional disorder)
Nulliparas
Multiparas
< 1.2 cm / hour

< 1.5 cm / hour
Prolonged deceleration phase

(7-10 cm dilatation)
Nulliparas
Multiparas
3 hours or more
1 hour or more
Secondary arrest of dilatation
Arrest
2 hours or more
Protracted descent
Nulliparas
Multiparas
< 1cm / hour

< 2cm / hour
Arrest of descent
Arrest 1 hour or more
Prolonged 2nd stage
No descent in the 2nd stage
The progression of labor is judged by two criteria:
The cervical dilatation.
Descent of the presenting part.

Most of the errors occur when the condition is diagnosed as there is no progress while the patient is still in the latent phase or even did not go into labor from the start.
Causes
Excessive analgesia.
Disproportion.
Malpresentations and malpositions.

Management
Reassessment of the condition.
Pain relief: Pethidine or epidural analgesia.
Amniotomy: if membranes still intact.

Oxytocin: if amniotomy does not bring good uterine contractions and there is no contraindication for it.
Failure of the above measures.

Disproportion.
Malpresentations not amenable for vaginal delivery.
Contraindications to oxytocin.
Fetal distress.
Obstructed Labor
Definition
It is the arrest of vaginal delivery of the fetus due to mechanical obstruction.
Etiology
Maternal causes
Bony obstruction: e.g.
Contracted pelvis.
Tumours of pelvic bones.
Soft tissue obstruction:
Uterus: impacted subserous pedunculated fibroid, constriction ring opposite the neck of the fetus.
Cervix: cervical dystocia.
Vagina: septa, stenosis, tumours.

Ovaries: Impacted ovarian tumours.
Fetal causes
Malpresentations and malpositions: e.g.
Persistent occipito-posterior and deep transverse arrest,

Persistent mento-posterior and transverse arrest of the face presentation.
Brow,
Shoulder,
Impacted frank breech.
Large sized fetus (macrosomia).
Congenital anomalies: e.g.

Hydrocephalus.
Fetal ascitis.
Fetal tumours.
Locked and conjoined twins.
Diagnosis
It is the clinical picture of obstructed labor with impending rupture uterus (excessive uterine contraction and retraction).
History
prolonged labor,
frequent and strong uterine contractions,
rupture membranes.
General examination
It shows signs of maternal distress as:
exhaustion,
high temperature ( 38oC),

rapid pulse,
signs of dehydration: dry tongue and cracked lips.
Abdominal examination
The uterus:
is hard and tender,
frequent strong uterine contractions with no relaxation in between (tetanic contractions).
rising retraction ring is seen and felt as an oblique groove across the abdomen.
The fetus:
fetal parts cannot be felt easily.
FHS are absent or show fetal distress due to interference with the utero-placental blood flow.
Vaginal examination
Vulva: is edema tous.

Vagina: is dry and hot.
Cervix: is fully or partially dilated, edema tous and hanging.
The membranes: are ruptured.

The presenting part: is high and not engaged or impacted in the pelvis. If it is the head it shows excessive moulding and large caput.
The cause of obstruction can be detected.
Differential diagnosis
Constriction ring.
Full bladder.
Fundal myoma.
Complications
Maternal:
Maternal distress and ketoacidosis.
Rupture uterus.
Necrotic vesico-vaginal fistula.

Infections as chorioamnionitis and puerperal sepsis.
Postpartum haemorrhage due to injuries or uterine atony.
Fetal :
Asphyxia.
Intracranial haemorrhage from excessive moulding.
Birth injuries.
Infections.
Management
Preventive measures:
Careful observation, proper assessment, early detection and management of the causes of obstruction.
Curative measures:
Caesarean section is the safest method even if the baby is dead as labor must be immediately terminated and any manipulations may lead to rupture uterus.
Contracted Pelvis
Definition
Anatomical definition: It is a pelvis in which one or more of its diameters is reduced below the normal by one or more centimeters.
Obstetric definition: It is a pelvis in which one or more of its diameters is reduced so that it interferes with the normal mechanism of labor.
Factors influencing the size and shape of the pelvis
Developmental factor: hereditary or congenital.
Racial factor.
Nutritional factor: malnutrition results in small pelvis.
Sexual factor: as excessive androgen may produce android pelvis.
Metabolic factor: as rickets and osteomalacia.

Trauma, diseases or tumours of the bony pelvis, legs or spines.
Etiology of Contracted Pelvis
Causes in the pelvis
Developmental (congenital):
Small gynaecoid pelvis (generally contracted pelvis).
Small android pelvis.
Small anthropoid pelvis.

Small platypelloid pelvis (simple flat pelvis).
Naegeles pelvis: absence of one sacral ala.
Roberts pelvis: absence of both sacral alae.

High assimilation pelvis: The sacrum is composed of 6 vertebrae.
Low assimilation pelvis: The sacrum is composed of 4 vertebrae.

Split pelvis: splitted symphysis pubis.
Metabolic:
Rickets.
Osteomalacia (triradiate pelvic brim).
Traumatic: as fractures.
Neoplastic: as osteoma.
Causes in the spine
Lumbar kyphosis.
Lumbar scoliosis.
Spondylolisthesis: The 5th lumbar vertebra with the above vertebral column is pushed forward while the promontory is pushed backwards and the tip of the sacrum is pushed forwards leadin
contraction.
Causes in the lower limbs
Dislocation of one or both femurs.
Atrophy of one or both lower limbs.

N.B. oblique or asymmetric pelvis: one oblique diameter is obviously shorter than the other. This can be found in:
Naegeles pelvis.
Scoliotic pelvis.
Diseases, fracture or tumours affecting one side.
Diagnosis of Contracted Pelvis

History
Rickets: is expected if there is a history of delayed walking and dentition.
Trauma or diseases: of the pelvis, spines or lower limbs.
Bad obstetric history: e.g. prolonged labor ended by;

difficult forceps,
caesarean section or
still birth.
Examination
General examination:
Gait: abnormal gait suggesting abnormalities in the pelvis, spines or lower limbs.
Stature: women with less than 150 cm height usually have contracted pelvis.
Spines and lower limbs: may have a disease or lesion.

Manifestations of rickets as:
square head,
rosary beads in the costal ridges.

pigeon chest,
Harrisons sulcus and bow legs.
Dystocia dystrophia syndrome: the woman is
short,
stocky,
subfertile,
has android pelvis and
masculine hair distribution,
with history of delayed menarche.

This woman is more exposed to occipito-posterior position and dystocia.
Abdominal examination:
Nonengagement of the head: in the last 3-4 weeks in primigravida.

Pendulous abdomen: in a primigravida.
Malpresentations: are more common.
Pelvimetry
It is assessment of the pelvic diameters and capacity done at 38-39 weeks. It includes:
Clinical pelvimetry:
Internal pelvimetry for:
inlet,
cavity, and
outlet.
External pelvimetry for:

inlet and
outlet.
Imaging pelvimetry:
X-ray.
Computerised tomography (CT).
Magnetic resonance imaging (MRI) .
N.B. CT and MRI are recent and accurate but expensive and not always available so they are not in common use.
Internal pelvimetry (is done through vaginal examination)
The inlet:
Palpation of the forepelvis (pelvic brim):

The index and middle fingers are moved along the pelvic brim. Note whether it is round or angulated, causing the fingers to dip into a V-shaped depression behind the symphysis.
Diagonal conjugate:
Try to palpate the sacral promontory to measure the diagonal conjugate. Normally, it is 12.5 cm and cannot be reached. If it is felt the pelvis is considered contracted and the true conju
calculated by subtracting 1.5 cm from the diagonal conjugate .This assessment is not done if the head is engaged.
The cavity:
Height, thickness and inclination of the symphysis.
Shape and inclination of the sacrum.

Side walls:
To determine whether it is straight, convergent or divergent starting from the pelvic brim down to the base of ischial spines in the direction of the base of the ischial tuberosity. Then re
index and middle finger of the base of ischial spines and the thumb of the other hand on the ischial tuberosity is detected. If the thumb is medial the side wall is convergent and if later
Ischial spines:
Whether it is blunt (difficult to identify at all), prominent (easily felt but not large) or very prominent (large and encroaching on the mid-plane).
The ischial spines can be located by following the sacrospinous ligament to its lateral end.
Interspinous diameter:
By using the 2 examining fingers, if both spines can be touched simultaneously, the interspinous diameter is 9.5 cm i.e. inadequate for an average-sized baby.
Sacrosciatic notch:
If the sacrospinous ligament is two and half fingers, the sacrosciatic notch is considered adequate.
The outlet:
Subpubic angle:
Normally, it admits 2 fingers.
Bituberous diameter:
Normally, it admits the closed fist of the hand (4 knuckle).
Mobility of the coccyx.

by pressing firmly on it while an external hand on it can determine its mobility.
Anteroposterior diameter of the outlet:
from the tip of the sacrum to the inferior edge of the symphysis.
FINDINGS INDICATING ADEQUATE PELVIS:

Data
Finding
Forepelvis (pelvic brim)
Round.
Diagonal conjugate
11.5 cm.
Symphysis
Average thickness, parallel to sacrum.
Sacrum
Hollow, average inclination.
Side walls
Straight.
Ischial spines
Blunt.
Interspinous diameter
10.0 cm.
Sacrosciatic notch
2.5 -3 finger breadths.
Subpubic angle
2finger breadths.
Bituberous diameter
8.0 cm).4 knuckles (
Coccyx
Mobile.
Anterposterior diameter of outlet
11.0 cm.
External pelvimetry
It is of little value as it measures diameters of the false pelvis.
Thoms, Jarchos or crossing pelvimeter can be used for external pelvimetry.
Interspinous diameter (25cm): between the anterior superior iliac spines.
Intercrestal diameter (28 cm): between the most far points on the outer borders of the iliac crests.
External conjugate (20 cm).
Bituberous diameter: can be measured by pelvimeter.
In rickets, the interspinous equals or even exceeds the intercrestal diameter.

Radiological pelvimetry
It is indicated mainly in borderline pelvic contraction.
Lateral view: The patient stands with the X-ray tube on one side and the film cassette on the opposite side.
It is the most important view as it shows the anteroposterior diameters of the pelvis, angle of inclination of the brim, width of sacrosciatic notch, curvature of the sacrum and cephalo-pelv
Inlet view: The patient sits on the film cassette and leans backwards so that the plane of the pelvic brim becomes parallel to the film.
Outlet view: The patient sits on the film cassette and leans forwards.
N.B. The measurements can be identified by using a graduated scale or Thoms perforated grid, in which the perforations are 1cm apart, while taking the X-ray film.The picture of the scale or grid
allows the measurement.
Cephalometry
Ultrasonography: is the safe accurate and easy method and can detect:
The biparietal diameter (BPD).
The occipito-frontal diameter.
The circumference of the head.
Radiology (X-ray): is difficult to interpret.

Cephalopelvic disproportion tests
These are done to detect contracted inlet if the head is not engaged in the last 3-4 weeks in a primigravida.
(1) Pinards method:
The patient evacuates her bladder and rectum.
The patient is placed in semi-sitting position to bring the fetal axis perpendicular to the brim.
The left hand pushes the head downwards and backwards into the pelvis while the fingers of the right hand are put on the symphysis to detect disproportion.
(2) Muller Kerrs method:

It is more valuable in detection of the degree of disproportion.
The patient evacuates her bladder and rectum.
The patient is placed in the dorsal position.

The left hand pushes the head into the pelvis and vaginal examination is done by the right hand while its thumb is placed over the symphysis to detect disproportion.
Degrees of Disproportion
Minor disproportion:
The anterior surface of the head is in line with the posterior surface of the symphysis. During labor the head is engaged due to moulding and vaginal delivery can be achieved.
Moderate disproportion (1st degree disproportion):
The anterior surface of the head is in line with the anterior surface of the symphysis. Vaginal delivery may or may not occur.
Marked disproportion (2nd degree disproportion):
The head overrides the anterior surface of the symphysis. Vaginal delivery cannot occur.
Degrees of Contracted Pelvis
Minor degree: The true conjugate is 9-10 cm. It corresponds to minor disproportion.
Moderate degree: The true conjugate is 8-9 cm. It corresponds to moderate disproportion.
Severe degree: The true conjugate is 6-8 cm. It corresponds to marked disproportion.
Extreme degree: The true conjugate is less than 6 cm. Vaginal delivery is impossible even after craniotomy as the bimastoid diameter (7.5 cm) is not crushed.
Mechanism of Labor in Contracted Pelvis

The Flat Rachitic Pelvis
Characters:
Inlet: reduced antero-posterior diameter.

The pelvic inclination: is exaggerated due to increased lumbar lordosis.
The sacrum has the following characters:
- The promontory is pushed forwards so the tip is pushed backwards.

- Diminished or obliterated concavity.
- Bent at the middle may be present.

The outlet has the following characters:
Increased antero-posterior diameter.
Increased bituberous diameter.

The interspinous equal the intercrestal diameter.
Mechanism of labor:
Engagement: with the sagittal suture in the transverse diameter.

Asynclitism with anterior parietal bone presentation so that the shorter subparietal supraparietal diameter (9cm) is passed instead of the biparietal (9.5cm) in the narrow true conjugate.
Lateral displacement of the head so that the bitemporal diameter is passed through the narrow true conjugate .
Deflexion of the head as the descent of the occiput is resisted by the lateral pelvic wall .
Correction of the asynclitism and deflexion with further descent of the head.
Rotation of the occiput 2/8 circle anteriorly and the head is delivered easily due to wide outlet.
Simple Flat Pelvis

Characters:
Reduced antero-posterior diameters of the inlet, cavity and outlet.
No rachitic manifestations.
Mechanism of labor:
The process passes as flat rachitic pelvis till the mid cavity where internal rotation and further descent cannot occur due to persistence of flattening of the pelvis and contracted outlet. So deep tra
common and vaginal delivery is obstructed.
Contracted Outlet (Funnel Pelvis)
Characters:
The pelvic capacity is diminished from the inlet to the outlet.

Subpubic angle is acute.
Convergent side walls.
Bituberous diameter is 8 cm or less.

Causes:
Android pelvis.
Anthropoid pelvis.
Osteomalacia.
High assimilation pelvis.

Spondylolisthesis.
Oblique pelvis.
20% of generally contracted pelvis.
Mechanism of labor:
Normal descent and engagement as the pelvic inlet is normal.

Extreme flexion and moulding of the head at the level of the jutting ischial spines.
Because of the narrow subpubic angle, the head is pushed backwards with more liability to perineal tears.
In case of occipito-posterior, the funnel pelvis interferes with long anterior rotation so persistent occipito-posterior and deep transverse arrest are common. The face to pubis position is more
brings the short bitemporal diameter in the narrow subpubic angle.
Management:
It depends on Thoms dictum:
If the sum of bituberous + posterior sagittal is >15 cm and bituberous diameter is >8cm: vaginal delivery is allowed with episiotomy and low forceps.
If the Thoms dictum is <15 cm or the bituberous diameter is <8cm: caesarean section is performed.
Symphysiotomy: may be done in distant areas with no facilities for C.S. and the fetus is living.
Management of Contracted Pelvis
It depends mainly on the degree of disproportion.
Minor disproportion (minor degree of contracted pelvis): vaginal delivery.
Moderate disproportion (moderate degree of contracted pelvis): trial labor, if failed caesarean section.
Marked disproportion (severe or extreme degree of contracted pelvis): caesarean section.

Trial of Labor
It is a clinical test for the factors that cannot be determined before start of labor as:
Efficiency of uterine contractions.

Moulding of the head.
Yielding of the pelvis and soft tissues.
Procedure:
Trial is carried out in a hospital where facilities for C.S is available.

Adequate analgesia.
Nothing by mouth.
Avoid premature rupture of membranes by:

rest in bed,
avoid high enema,
minimise vaginal examinations.

The patient is left for 2 hours in the 2nd stage with good uterine contractions under close supervision to the mother and fetus.
Suitable cases for trial of labor:
Young primigravida of good health.
Moderate disproportion.
Vertex presentation.
No outlet contractions.
Average sized baby.

Termination of trial of labor:
Vaginal delivery:
either spontaneously or by forceps if the head is engaged.
Caesarean section if:
failed trial of labor i.e. the head did not engage or

complications occur during trial as fetal distress or prolapsed pulsating cord before full cervical dilatation.
Indications of caesarean section in contracted pelvis
Moderate disproportion if trial of labor is contraindicated or failed.
Marked disproportion.
Extreme disproportion whether the fetus is living or dead.

Contracted outlet.
Contracted pelvis with other indications as;
elderly primigravida,
malpresentations, or
placenta praevia.
Complications of Contracted Pelvis
Maternal:
During pregnancy:
Incarcerated retroverted gravid uterus.
Malpresentations.
Pendulous abdomen.
Nonengagement.
Pyelonephritis especially in high assimilation pelvis due to more compression of the ureter.
During labor:
Inertia, slow cervical dilatation and prolonged labor.

Premature rupture of membranes and cord prolapse.
Obstructed labor and rupture uterus.
Necrotic genito-urinary fistula.

Injury to pelvic joints or nerves from difficult forceps delivery.
Postpartum haemorrhage.
Fetal :
Intracranial haemorrhage.
Asphyxia.
Fracture skull.
Nerve injuries.
Intra-amniotic infection.
Dystocia due to Oversized Fetus
CAUSE
MANAGEMENT
(I) Generalised fetal enlargement (macrosomia)
See later.
(II) Localised fetal enlargement

(1) Hydrocephalus
See later.
If small: no effect as it will be flattened or ruptured.
(2) Meningocele or encephalocele
If large: tapping of the cyst.
(3) Abdominal ascitis
Tapping.
(4) Abdominal tumours
Evisceration but if huge do caesarean section.
(5) Fetal monsters (conjoined twins)
Caesarean section is the safest.
(6) Shoulder dystocia
See later.
GENERALISED FETAL ENLARGEMENT (MACROSOMIA)

Definition
A fetal weight of more than 4 kg.
Causes
Genetic or constitutional: large women tend to give birth to large babies.
Diabetes and prediabetes.
Post-date (postmaturity).
Multiparity: The first baby is about 100 gm smaller than the next.
Hydrops fetal is.
Risk Factors
Excessive maternal weight gain during pregnancy.
Advanced maternal age.

Male fetus than female.
Previous macrosomic infant.
Diagnosis
Clinical palpation: can give a rough idea.
Ultrasonography: can calculate the fetal weight.
Hazards
Prolonged pregnancy
Cephalopelvic disproportion
Obstructed labor.
Shoulder dystocia.
Meconium aspiration syndrome.

Nerve and bone injuries.
Future baby obesity.
Management
Proper antenatal care: to prevent macrosomia and diagnose it before labor commences.
Caesarean section: is the safest for both mother and fetus .
HYDROCEPHALUS
Definition
It is an enlargement of the fetal head due to accumulation of excessive cerebro-spinal fluid (C.S.F) within the ventricles.
Incidence
0.5-1.8 per 1000 births. Incidence of recurrence in subsequent pregnancy is about 3%.
Etiology
Obstruction of Aqueduct of Sylvius which may be due to:
Genetic aberration as trisomies.

Infections: as cytomegalovirus, toxoplasmosis and rubella.
No detected cause.
Diagnosis
During pregnancy
Breech presentation in 50% of cases.
Head is large with soft bones.

During labor
Cephalic presentation:
High non-engaged head.
Thin compressible skull bones.
Wide sutures and large fontanels.
Breech presentation:
Retained large after-coming head.
Spina bifida is common (30%).

X-ray and ultrasound
Large head with biparietal diameter >12 cm (not in every case).
Dilated cerebral lateral ventricles each measures >1.5 cm and together >1/3 the biparietal diameter (more diagnostic).
Small face in relation to the head size.
The thickness of cerebral cortex which determines postpartum prognosis of the fetus can be measured by ultrasound.
Complications
Obstructed labor: with its sequel as rupture uterus. This is more common in mild degrees of hydrocephalus which cannot be detected before or during labor.
Fetus: Still birth or live birth with neurological manifestations and low growth rate.
Management
Antepartum
Ventriculo-amniotic shunt:
With the recent advances in intrauterine fetal therapy ventriculo-amniotic shunt with a one way valve can be done to drain the CSF from the cerebral ventricles into the amniotic cavity pr
compression of the brain tissues.
Induction of preterm labor: after draining of the fluid through a transabdominal needle puncture.
Intrapartum
Cephalic presentation:
If the cervix is dilated: transcervical aspiration by a needle or perforation through a gaping suture or fontanelle is done.
If the cervix is not dilated: transabdominal aspiration by a needle is done.

Traction on the collapsed head can then applied by Willets scalp forceps.
Breech presentation:
CSF is drained through:
perforation in the roof of the mouth, foramen magnum or behind the mastoid process.
Spinal tapping which is easier through spina bifida if present.

Postpartum
The living newborn should be referred for shunt operation to drain the cerebral ventricles into the jugular vein or right atrium.
SHOULDER DYSTOCIA
Definition
It is a difficulty in shoulder delivery.
Incidence
About 0.5% of deliveries.
Causes
Large shoulders which may be due to:

Maternal obesity.
Diabetic mothers.
Post-term pregnancy.
Anencephaly.
Failure of shoulder rotation.
Contracted and platypelloid pelvis.
Prediction
Presence of risk factors of macrosomia (see before).
Ultrasonographic assessment of fetal weight.
Clinical Picture
The head is delivered and the chin is applied firmly against the perineum.
There is no further progress in spite of gentle traction on the head.
Management
Prophylaxis
Proper antenatal care particularly for high risk mothers as diabetics.

Antepartum assessment of fetal weight: macrosomic babies should be delivered by caesarean section.
Shoulder dystocia
Calling urgently an anaesthetist and paediatrician.
The following methods are used in a rapid succession when the previous one failed:
Rotation of the anterior shoulder: if unrotated by fingers transvaginally to bring it in the antero posterior diameter.
Generous episiotomy + gentle downward traction + suprapubic pressure by an assistant obliquely to flex the anterior shoulder against the fetal chest.
Mc Roberts manoeuvre: It is sharp flexion of the maternal thighs against her abdomen. This can free the shoulders by:
backward displacement of the sacral promontory.
upward displacement of the symphysis pubis.
Decrease the inclination of the pelvic inlet.
Decrease in lumbar lordosis.

Woods screw manoeuvre:
Woods (1943) described this manoeuvre to rotate the fetus as a screw between the resisted promontory and symphysis.
Two fingers of the right hand is pressing from the posterior aspect of the posterior shoulder to rotate it 180o anteriorly where it escapes from below the symphysis.
The left hand is placed on the mothers abdomen and assists this rotation by pressing on the fetal buttock in the same direction of rotation.
Extraction of the posterior arm: by pressing with 2 fingers against the cubital fossa to sweep the posterior arm in front of the chest and deliver it giving space for the anterior shoulder to escap
the symphysis.This is aided by suprapubic pressure.

Zavanelli manoeuvre (cephalic replacement):
Prepare for caesarean section.

Subcutaneous terbutaline (tocolytic) is given to relax the uterus.
Rotate the head manually to the antero-posterior diameter (pre-restitution position).
Flex the head and press on it firmly and constantly to replace it intravaginally where it is supported by an assistant.
Immediate caesarean section is performed.
Clavicular fracture:
was described to reduce the diameter of the shoulders. It is done by upward pressure against its midportion to avoid injury of the subclavian vessels.
Cleidotomy:
It is cutting of the clavicle and usually reserved for a dead fetus.
Symphysiotomy:
It is advocated by some authors to overcome contracted pelvis in women living in uncivilised areas.
Complications
Fetal :
Asphyxia and death.
Brachial plexus injury causing Erbs palsy.

Fracture clavicle or humerus.
Maternal:
Injuries from manoeuvres which may extend up to rupture uterus.

Maternal Obstetric Injuries
These include:
Rupture of the uterus.
Cervical tears.
Vaginal tears.
Haematoma of the vulva.

Perineal tears.
Trauma to the pelvic joints and nerves.
Rupture of the Uterus

Incidence
About 1:4000, 95% of cases occur in multipara particularly grand multipara.
Causes
During pregnancy
Spontaneous:
Rupture of a uterine scar: e.g. previous C.S. especially upper segment, myomectomy, hysterotomy, uteroplasty or perforation.
Abruptio placenta with severe concealed haemorrhage.
Anterior sacculation in case of incarcerated retroverted gravid uterus or posterior sacculation due to previous ventrofixation of the uterus.
Rupture of a rudimentary horn at the 4th- 5th month.
Perforating vesicular mole.

Traumatic
Perforation during vaginal evacuation.
External trauma.
During labor:
Spontaneous:
Obstructed labor.
Rupture of a uterine scar.

Grand multipara: due to degeneration and overthinning of the uterine muscles.
Traumatic:
Internal version: particularly after drainage of liquor.

Manual separation of the placenta.
Destructive operations.
Extending cervical tear due to e.g. forceps or ventouse applications before full cervical dilatation.
Improper use of oxytocins.
Weak uterine scar may be a result to:
Imperfect suture with improper coaptation of the edges.
Bad haemostasis results in blood clot formation which prevents good coaptation and predisposes to wound infection.
Wound infection.
Subsequent implantation of the placenta over it.
Subsequent overdistension of the uterus e.g. polyhydramnios or multiple pregnancy.

Upper segment caesarean section scar is weaker than lower segment scar.
Repeated vaginal deliveries after a previous C.S. weaken the scar .
Types
Complete: involving the whole uterine wall including the peritoneum.
Incomplete: not involving the peritoneal coat.

Sites
It depends upon the cause of rupture.
In obstructed labor:
It is usually in lower uterine segment.
Usually oblique or transverse.
More on the left side due to;

dextrorotation of the uterus.
left occipito-positions are more common.
Extended tear may pass laterally injuring the uterine vessels leading to broad ligament haematoma formation. This rupture may involve the ureter or bladder.
In rupture scar:
At the site of the scar.

Clinical Picture
Impending rupture
Before actual rupture the following manifestations may be detected:
Lower abdominal pain.

Tender uterine scar.
Vaginal spotting (minimal bleeding).
Actual rupture:
Symptoms:
Sudden severe abdominal pain: It is differentiated from labor pain being continuous.
If the patient was in labor there is cessation of uterine contractions.
Shoulder pain on lying down due to irritation of the phrenic nerve by accumulating blood under the diaphragm.
Silent rupture: minimal symptoms may occur in rupture lower segment scar due to presence of fibrosis and minimal internal haemorrhage.
Signs
Variable degrees of collapse are present according to amount of blood loss. This may appear postpartum in case of traumatic rupture uterus.
Scar of the previous operation.
Fetal parts are prominent and felt easy.

The presenting part recedes upwards.
Abnormal fetal attitude and lie.
FHS usually not heard.

The uterus is felt separated from the fetus .
In incomplete rupture, the fetus still inside the uterus with suprapubic painful tender swelling which is an accumulated blood in the vesico-uterine pouch.
Vaginal examination:
The presenting part recedes upwards.
Vaginal bleeding may be present.

Contracted pelvis may be detected.
A cervical tear may be found extending to the lower uterine segment and a broad ligament haematoma may be present.
Abruptio placentae.
Disturbed advanced extrauterine pregnancy.
Other causes of acute abdomen.
Management
Prophylactic:
Early detection of causes of obstructed labor as contracted pelvis and malpresentations.
Proper use of oxytocins.

Version is not done if liquor amnii is drained.
Forceps application and breech extraction should not be done before full cervical dilatation.
Elective caesarean section for susceptible scars for rupture as upper segment C.S.
Exploration of the genital tract after difficult or instrumental delivery.

Curative:
Blood transfusion and antishock measures.

Immediate laparotomy.
Deliver the fetus and placenta.
Explore the rupture site:

If it is amenable for repair and the patient did not complete her family repair is done.
If it is not amenable for repair hysterectomy. Subtotal hysterectomy is less time consuming so it is done if there is no cervical tear.
Exploration of the other viscera mainly the bladder.
Internal iliac artery ligation may be needed in case of broad ligament haematoma as the uterine artery is usually retracted and difficult to be identified.
Vaginal repair: may be amenable if there is slight extension of a cervical tear with accessible apex.
Complications
Maternal:
Shock.
Haemorrhage.
Paralytic ileus.
Bladder, ureter or visceral injuries.
Infection.
Fetal :
Death due to asphyxia from detachment of the placenta.
Cervical Lacerations
Etiology
Forceps, ventouse or breech extraction before full cervical dilatation.
Manual dilatation of the cervix.
Improper use of oxytocins.

Precipitate labor.
Predisposing Factors
Cervical rigidity.
Scarring of the cervix.
Edema as in prolonged labor.
Placenta praevia due to increased vascularity.

Types
Unilateral: more common on the left side due to:

Dextro-rotation of the uterus.
Left occipito-anterior position is the commonest.
Lateral .
Stellate: multiple tears extending radially from the external os like a star.
Annular detachment.
Diagnosis
Postpartum haemorrhage, in spite of well contracted uterus.
Vaginal examination: The tear can be felt.
Speculum examination: using a posterior wall self retaining speculum or vaginal retractors and 2 ring forceps to grasp the anterior and posterior lips of the cervix so the tear can be visualised
Complications
Rupture uterus due to upward extension.
Infection: cervicitis and parametritis.
Cervical incompetence leading to future recurrent abortion or preterm labor.

Ureteric injury: from the extension of the tear or during its repair.
Management
Immediate repair: is carried out under general anaesthesia with good light exposure.
An assistant applies downward pressure on the uterus while the operator is grasping the anterior and posterior lips in a downward direction.
The vaginal walls are held apart with retractors.
Interrupted cut gut dexon or vicryl sutures are taken starting from above the apex of the tear to control bleeding from the retracted blood vessels.
If the apex is not easily seen a traction on a stitch taken as high as possible in the tear will show the apex.
In cases of annular detachment: there is usually no bleeding due to ischaemia at the edges of detachment. Sutures are rarely indicated.
Vaginal Lacerations
Causes
Primary lacerations less common and caused by:
Forceps application.
Destructive operations.
Vacuum extraction if the cup sucks a part from the vaginal wall.
Secondary lacerations: more common and are due to extension from perineal or cervical tears.
Management
Immediate repair: Continuous locked cut gut sutures are taken starting from above the apex to control bleeding from the retracted blood vessels.
Tight pack: may be needed to control bleeding from a raw surface area. Foleys catheter should be inserted before packing and both are removed after 12-24 hours.
Haematoma of the Genital Tract
Vulval (Infra-Levator) Haematoma
Causes:
Traumatic due to:
incomplete haemostasis during repair of episiotomy or tear.
Direct trauma as kick or falling down.
Spontaneous: due to rupture of a varicose vein.

Clinical picture:
The haematoma usually appears 12-48 hours after delivery.
The collection of blood is limited by the levator ani above but laterally it may extend to fill the ischiorectal fossa reaching a volume of 500 ml or more.
There is a progressive enlarged, painful, tender, tense, bluish swelling at the vulva.
Manifestations of hypovolaemia (e.g. hypotension and rapid pulse) and anaemia may be present.
Management:
Small not- increasing haematoma: is managed conservatively as it usually resolves spontaneously. Prophylactic antibiotic may be given to guard against secondary infection.
Large increasing haematoma:

It is incised longitudinally,
evacuation of the clotted blood,

bleeding points are ligated,
the gap is closed in layers.
Vaginal (Supra-Levator) Haematoma

Causes:
Deep vaginal lacerations (see before).
Clinical picture:
The blood is collected paravaginally above the levator ani muscle.

It may not be visible externally.
It may not be painful until reaching a large size.
Manifestations of hypovolaemia and anaemia may be present.
Management:
As vulval haematoma.
Broad Ligament (Retroperitoneal) Haematoma
Causes
Upper vaginal,cervical or uterine tears which usually involve the vaginal or uterine artery.
Clinical picture:
Hypovolaemia, anaemia or shock: is usually present due to large amount of internal haemorrhage.
Swelling on one side of the uterus which increasing over a period of hours or days and may reach up to the lower pole of the kidney or even the diaphragm.
The uterus is felt separate and deviated to the opposite side.
Fever, ileus and unilateral leg edema : may develop later.
Management:
Small not-increasing haematoma: is managed conservatively as vulval haematoma.
Large increasing haematoma:

Laparotomy.
Incision in the anterior leaflet of the broad ligament.
Evacuation of the blood clots.

Securing haemostasis, bilateral internal artery ligation or hysterectomy may be indicated.
Perineal Lacerations
Anatomy
The perineal body is a pyramidal mass of tissues about 4 4 cm between the lower vagina anteriorly, the anal canal and lower rectum posteriorly.
It is composed of the following layers respectively:
Skin.
Superficial fascia.
Perineal muscles;
external anal sphincter,
superficial and deep perinei muscles,

bulbocavernosus, and
ischiocavernosus.
The decussation of the levator ani muscles between the vagina and rectum forms the apex of the perineal body.
N.B. - All the perineal muscles, except the ischiocavernosus, are inserted in the central part of the perineal body.
They contract during intercourse and defecation.

During delivery, they may be markedly stretched and teared.
Etiology
Lack of perineal elasticity:
Elderly primigravida.
Excessive scarring from a previous operation as posterior colpoperineorrhaphy.

Friability due to perineal edema .
Marked perineal stretch:
Allowing head extension before crowning.

Macrosomic baby.
Face to pubis delivery.
Forceps delivery.
Narrow subpubic angle pushing the head backward.
Rapid perineal stretch:

Precipitate labor.
Rapid delivery of the after-coming head in breech presentation.
Degrees
First degree: involves the perineal skin, fourchette and the posterior vaginal wall.
Second degree: involves the previous structures + the muscles of the perineal body but not the external anal sphincter.
Third degree: involves the previous structures + the external anal sphincter.
Fourth degree: involves the previous structures + the anterior wall of the anal canal or rectum.
N.B
Incomplete perineal tear = 1st or 2nd degrees.

Complete perineal tear = 3rd or 4th degrees.
Hidden perineal tear: The levator ani muscle is teared without apparent perineal tear predisposing to future prolapse.
Complications
Puerperal infection.
Incontinence of stool and flatus in unrepaired or imperfectly repaired 3rd or 4th degree tear.
Residual recto-vaginal fistula in imperfectly repaired 4th degree tear.
Future genital prolapse.

Dyspareunia due to tender vaginal scar.
Prevention
Proper management of second stage of labor.

Episiotomy in the proper time.
Treatment
Any perineal tear should be repaired within 24 hours.
Incomplete perineal tear:
Can be repaired under local infiltration anaesthesia.

First degree tear: The vaginal wall is repaired with continuous locked or interrupted sutures and the skin with interrupted sutures.
Second degree tear:
The perineal muscles are approximated by interrupted chromic cut gut sutures including the torn ends of the levator ani.
The vagina is sutured as in the 1st degree tear.

The superficial perineal muscles are sutured by interrupted chromic cutgut.
The skin is sutured as in the 1st degree tear.
Complete perineal tear:

Third degree tear:
The torn ends of the external anal sphincter is identified and sutured together by interrupted cutgut.
The levator ani muscles are approximated in front of the rectum.

The vagina, superficial muscles and skin are sutured as before.
Fourth degree tear:

The rectal wall is sutured by 2 layers of inverted interrupted cutgut not including the mucosa.
The external sphincter, levator ani, superficial muscles and skin are sutured as before.
Post-operative care
The perineal wound is kept clean and sterile by using antiseptic solution after each micturition or defecation.
In the complete perineal tear:
Intravenous fluid for 48 hours,

clear fluids for the next 24 hours,
soft, low residue diet for an additional 48 hours,
regular diet after that,

laxatives are not used in the first 4-5 days, but stool softeners are allowed.
Prophylactic antibiotic is given.
Complications of the Third Stage of Labor
Postpartum haemorrhage
Include:
Retained placenta.
Obstetric shock (collapse).

POSTPARTUM HAEMORRHAGE
Definition
It is excessive blood loss, from the genital tract after delivery of the fetus exceeding 500 ml or affecting the general condition of the patient.
Types
Primary postpartum haemorrhage:
Bleeding occurs during the 3rd stage or within 24 hours after childbirth. It is more common.
Secondary postpartum haemorrhage:

Bleeding occurs after the first 24 hours until 6 weeks (the end of puerperium).
PRIMARY POSTPARTUM HAEMORRHAGE

Etiology
Placental site haemorrhage
Atony of the uterus:
is the cause of primary postpartum haemorrhage in more than 90% of cases.

The factors that predispose to uterine atony are:
Severe anaemia.
Overdistension of the uterus.
Uterine myomas.
Prolonged labor exhausting the uterus.
Prolonged anaesthesia and analgesia.
Full bladder or rectum.
Idiopathic.
Retained placenta.
Disseminated intravascular coagulation (DIC).
Traumatic haemorrhage
Rupture uterus, cervical, vaginal, vulval or perineal lacerations.
Diagnosis
General examination
The general condition of the patient is corresponding to the amount of blood loss.
In excessive blood loss, manifestations of shock appear as hypotension, rapid pulse, cold sweaty skin, pallor, restlessness, air hunger and syncope.
Abdominal examination
In atonic postpartum haemorrhage: The uterus is larger than expected, soft and squeezing it leads to gush of clotted blood per vagina.
In traumatic postpartum haemorrhage: The uterus is contracted. Combination of the 2 causes may be present.
Vaginal examination
In atony: Bleeding is usually started few minutes after delivery of the fetus.
It is dark red in colour.
The placenta may be not delivered.

In trauma: Bleeding starts immediately after delivery of the fetus.
It is bright red in colour.
Lacerations can be detected by local examination.
Management
Prevention
During pregnancy:
Detection and correction of anaemia.
Hospital delivery with ready cross-matched blood for high risk patients as:
Previous postpartum haemorrhage.
Polyhydramnios and multiple pregnancy.

Grand multipara.
During labor:
Proper use of analgesia and anaesthesia.

Avoid prolonged labor by proper oxytocin which should be extended to the end of the 3rd stage if used.
Avoid lacerations by:

Proper management of the 2nd stage.
Follow the instructions for instrumental delivery (see later).
Routine use of ecbolics in the 3rd stage of labor.

Routine examination of the placenta and membranes for completeness.
Postpartum:
Exploration of the birth canal after difficult or instrumental delivery as well as precipitate labor.
Careful observation in the fourth stage of labor (1-2 hours postpartum).
Treatment
(I) Restoration of blood volume:

Urgent cross-matched blood transfusion with the other antishock measures is given. Colloids and/or crystalloids therapy can be started till availability of the blood.
(II) Arrest of bleeding:
i) Placental site bleeding:
(a) Before delivery of the placenta:
The placenta should be delivered by;

Ergometrine and massage with gentle cord traction if failed,
Brandt -Andrews manoeuvre if failed do,
Crds method if failed do,
manual separation of the placenta.

(b) After delivery of the placenta:
The following steps are done in succession if each previous one fails to arrest bleeding:
Inspection of the placenta and membranes: any missed part should be removed manually under anaesthesia.
Massage of the uterus and ecbolics as:
Oxytocin drip: 10-20 units in 500 ml glucose 5% or normal saline. It may be given (5 units) directly intramyometrial in case of C.S.
Ergometrine (Methergin): 1-2 ampoules (0.25-0.50 mg) IV or IM.

Syntometrine 0.5 mg IV if available.
Prostaglandins (PGs):
0.25 mg methyl PG F2 IM (Prostin methyl ester) or
1 mg PG F2 intramyometrial in case of C.S. or
20 mg PG E2 (Prostin E2) rectal suppositories every 4-6 hours.
Bimanual compression of the uterus:
Under general anaesthesia, the uterus is firmly compressed for 5-30 minutes between the closed fist of the right hand in the anterior vaginal fornix and the left hand abdominally b
the uterus.
The compression is maintained until the uterus is firmly contracted. During this period, blood transfusion, oxytocin and ergometrine are given.
Bilateral uterine artery ligation:
The surgeon stands on the left side of the patient to control the procedure more.
The uterus is grasped by the assistant and elevated upwards and to the opposite side of the uterine artery which will be ligated to expose the vessels coarse through the broad ligam
A large atraumatic needle with no. 1 chromic cutgut, O-vicryl or O-Dexon is passed through and into the myometrium from anterior to posterior 2-3 cm medial to the uterine vesse
The needle is brought forward through avascular area in the broad ligament lateral to the uterine artery and vein. The suture is tied anteriorly.
In case of caesarean section, the sutures are placed 2-3 cm below the level of uterine incision under the reflected peritoneal flap which should be displaced downwards with the bla
of the ureters.
If caesarean section was not done, peritoneal incision is not indicated and bladder can be simply pushed downwards.
Uterine artery ligation is haemostatic by reducing the pulse pressure to the uterus as 90% of its blood supply is from the uterine vessels.
Collateral circulation and recanalization of the uterine vessels will be established within 6-8 weeks.
It has a success rate of 95%.

Bilateral ligation of ovarian supply to the uterus:
If bleeding continues after uterine arteries ligation a second mass bilateral ligation is done high up in the site of anastomosis between the uterine and ovarian arteries near the corn
Bilateral internal iliac artery ligation:

The posterior peritoneum lateral to the infundibulo-pelvic vessels is opened.
The ureter is indentified on the posterior leaf of the broad ligament and retracted medially.
The bifurcation of the common iliac artery at the level of the sacroiliac joint is identified and the internal iliac vessels are identified and ligated with no.1 non-absorbable silk suture
Most surgeons do not close the peritoneum over this area.
It has a success rate of 40%.

Hysterectomy:
Subtotal hysterectomy which is more rapid and easy than total hysterectomy is done.
Other less commonly used methods to arrest bleeding:

Uterine packing:
Under general anaesthesia.
Foleys catheter is applied.

Packing the whole uterus, cervix and vagina with a sterile gauze starting from the fundus downwards in tightly packed layers where each roll of gauze is tied to the next.
It is removed after 6-12 hours.
Foleys balloon:
A large Foleys catheter balloon is inflated to control haemorrhage from lower uterine segment which may result from placenta praevia or cervical pregnancy.
Aortic compression:
The aorta is compressed manually against the lumbar spines through the abdomen providing temporary control of heavy bleeding till preparing for surgical interference.
Radiographic trans-arterial immobilisation:
By a trained radiologist selective immobilisation of the pelvic vessels may be done using the angiographic technique.
Lacerations:
are dealt with (see maternal obstetric injuries).
Complications
Maternal death in 10% of postpartum haemorrhages.

Acute renal failure.
Embolism.
Sheehans syndrome.
Sepsis.
Anaemia.
Failure of lactation.
SECONDARY POSTPARTUM HAEMORRHAGE
Etiology
Retained parts:
of the placenta, membranes, blood clot or formation of a placental polyp.
Infection:
separation of infected retained parts.
infected C.S. wound.
infected genital tract lacerations.

infected placental site.
Fibroid polyp: necrosis and sloughing of its tip.
Subinvolution of the uterus.

Local gynaecological lesions: e.g. cervical ectopy or carcinoma.
Choriocarcinoma.
Puerperal inversion of the uterus.
Estrogen withdrawal bleeding: if Estrogen was given for supression of lactation.
Treatment
It depends on the cause:
Retained parts:
with minimal bleeding:

can be spontaneously expelled using:
ergometrine and
antibiotics.
with severe bleeding:
vaginal evacuation under anaesthesia is indicated.
Infection: antibiotics.
Other causes: treatment of the cause.
Retained Placenta
Definition
Failure of placental delivery within 30 minutes after delivery of the fetus.
Incidence: 1%.
Causes
Retained separated placenta due to:
Atony of the uterus: due to causes mentioned before.

Constriction ring.
Rupture uterus: where the placenta passes to the peritoneal cavity.
Retained non-separated placenta due to:
Atony of the uterus.
Abnormal adherence of the placenta which may be:

Simple adhesion: Manual separation can be done easily.
Morbid adhesion:
Placenta accreta: There is deficient or absent decidua basalis so that chorionic villi penetrate the superficial layer of the myometrium either partially (partial placenta accreta) or co
placenta accreta).
Placenta increta: The chorionic villi penetrate deeply in the myometrium.
Placenta percreta: Penetration up to the peritoneal coat.
The condition is more associated with placenta praevia due to defective decidual reaction in the lower segment.
Clinical Picture
Bleeding: occurs only if the placenta is separated partially or completely.

Uterus: is lax in case of atony.
Vaginal examination may reveal:
Constriction ring.
Rupture uterus.
Morbid placental adherence where there is no plane of cleavage.

Management
Uterine atony
Ergometrine and massage with gentle cord traction if failed do,

Brandt-Andrews manoeuvre if failed do,
Crds method if failed do,
Manual separation of the placenta.

Constriction ring
Deep anaesthesia and amyl nitrite inhalation are given before manual separation of the placenta.
Morbid adherence of the placenta
Simple adhesion and partial placenta accreta: Manual separation is usually successful.
Complete accreta: Hysterectomy is the treatment. If the patient is young and in need of more children, the umbilical cord is cut short and placenta is left in situ to undergo autolysis. The patie
antibiotics to guard against infection and methotrexate to enhance the autolysis.
In case of rupture uterus

Manage as in rupture uterus.
Crds method
The bladder is evacuated.

The uterus is massaged to induce contraction.
The fundus is grasped by 4 fingers behind and the thumb in front to squeeze the placenta.
The fundus is then pushed downwards and backwards to expel the placenta.
Complications
Shock.
Partial separation of the placenta causing postpartum haemorrhage.
Retained parts of the placenta or membranes.
Failure due to:
obesity,
non-co-operative patient,
placenta accreta,
rigidity of the abdominal wall, or
constriction ring.
Manual Removal of The Placenta
The procedure is done under general anaesthesia.
The right hand is introduced along the umbilical cord into the uterus.
The lower edge of the placenta is identified and by a sawing movement from side to side the placenta is separated from its bed.
Grasp the placenta and deliver it out.

Examine the placenta and membranes for completeness.
The left hand is supporting the uterus abdominally throughout the procedure.
Complications
Perforation of the uterus.

Retained parts.
Infection.
Complications of Retained Placenta

Shock.
Puerperal sepsis.
Subinvolution.
Retained parts with subsequent haemorrhage, infection, placental polyp formation or choriocarcinoma.
Complications of the methods used for its separation.
Acute Inversion of the Uterus
Definition
The body of the uterus is partially or completely turned inside out.
Incidence
Very rare about 1: 20.000 deliveries.
Etiology
Spontaneous inversion caused by:
Precipitate labor.
Traction on a short cord by the fetus.

Straining or coughing while the uterus is lax, particularly if the cervix is torn or gaped.
Submucous fundal myoma.
Iatrogenic inversion caused by:
pressure on the fundus or,

traction on the cord while the uterus is lax.
Degrees
First degree: The fundus is just depressed.

Second degree: The inverted fundus protrudes through the cervix.
Third degree: The whole uterus, including the cervix, is inverted and may drag the vagina and appear outside the vulva.
N.B.
Incomplete inversion: First or second degree.
Complete inversion: Third degree.
Clinical Picture
Symptoms
Pain: in the lower abdomen.
Sensation of vaginal fullness: with a desire to bear down after delivery of the placenta.
Vaginal bleeding: unless the placenta is not separated.

Subacute inversion: There is minimal symptoms and the condition is discovered later when the patient develops blood stained offensive vaginal discharge due to infection.
Signs
Shock is out of proportion to the amount of blood loss as it is more neurogenic due to traction on the peritoneum and pressure on tubes, ovaries and may be the intestine.
Cupping of the fundus in the 1st and 2nd degrees.
Absence of the uterus in the 3rd degree.
Vaginal examination:
In the 2nd and 3rd degrees the inverted uterus appears as a soft purple mass in the vagina or at the vulva.
Management
Anti shock measures.
Manual reduction:
After resuscitation, the inverted uterus is reduced manually under anaesthesia, but do not delay reduction as the uterus will be edema tous and difficult to be replaced.
The part inverted last is replaced first so fundus is replaced finally.
If the placenta is still attached it is removed.

Massage the uterus and give ergometrine, IV oxytocin drip and antibiotics.
Hydrostatic reduction:
Replacement is possible by fluid pressure with warm saline delivered into the vagina through a wide bore tube from a container held at a height of about 60 cm. The vaginal introitus is clo
labia major together.
Surgical reduction:
It is indicated in subacute and chronic inversions.
The cervix is incised posteriorly or anteriorly either vaginally or abdominally to reposite the uterus.
Shock in Obstetrics
Definition
Shock is a condition resulting from inability of the circulatory system to provide the tissues requirements from oxygen and nutrients and to remove metabolites.
Types and Causes
Haemorrhagic shock excessive blood loss may be due to:
Causes of bleeding early in pregnancy.
Causes of antepartum haemorrhage.
Causes of postpartum haemorrhage.
Neurogenic shock painful conditions my be due to:

Disturbed ectopic pregnancy.
Concealed accidental haemorrhage.
Forceps or breech extraction before full cervical dilatation.
Rough internal version.

Crds method.
Rupture uterus.
Acute inversion of the uterus.

Rapid evacuation of the uterine contents as in precipitate labor and rupture of membranes in polyhydramnios. This is accompanied by rapid accumulation of blood in the splanchnic area
of pressure (splanchnic shock).

Cardiogenic shock: ineffective contraction of the cardiac muscle due to
Myocardial infarction.
Heart failure.
Endotoxic shock: generalised vascular disturbance due to release of toxins.
Anaphylactic shock: caused by sensitivity to drugs.
Other causes:
Embolism: amniotic fluid, air or thrombus.
Anaesthetic complications: as Mendelsons syndrome.
The shock may be caused by more than one factor as:

Incomplete abortion: leads to haemorrhagic and endotoxic shock.
Disturbed ectopic and rupture uterus: lead to haemorrhagic and neurogenic shock.
Classic Clinical Picture of Shock

Low blood pressure.
Rapid weak (thready) pulse.
Pallor.
Cold clammy sweat.
Cyanosis of the fingers.

Air hunger.
Dimness of vision.
Restlessness.
Oliguria or anuria.
HAEMORRHAGIC SHOCK
Classification of Haemorrhage
Class
Blood Loss%
Clinical Picture
15%
Normal pulse & blood pressure.

Tilt test +ve .
Tachycardia.
Tachypnoea.
Pulse pressure (<30mmHg).
II
20-25%
Low systolic pressure.

Delayed capillary filling.
Skin: cold, clammy and pale.
Severe drop in blood pressure.
Restlessness.
III
30-35%
Oliguria (<30 ml/hour).

Metabolic acidosis (blood pH <7.5).
Profound hypotension.
The carotid pulse is the only felt one.
IV
40-45%
Irreversible shock.
Tilt test
It is done in patient with considerable bleeding but the blood pressure and/ or pulse rate are normal.
When this patient is in a sitting position, she develops hypotension and / or tachycardia.
Phases of Haemorrhagic Shock
The normal pregnant woman can withstand blood loss of 500 ml and even up to 1000 ml during delivery without obvious danger due to physiological cardiovascular and haematological adaptati
pregnancy.
Phase of compensation
Sympathetic stimulation: It is the initial response to blood loss leading to peripheral vasoconstriction to maintain blood supply to the vital organs.
Clinical picture: Pallor, tachycardia, tachypnoea.
Phase of decompensation
Blood loss exceeds 1000 ml in normal patient or less if other adverse factors are operating.
Clinical picture: is the classic clinical picture of shock (see before).
Adequate treatment at this phase improves the condition rapidly without residual adverse effects.
Phase of cellular damage and danger of death
Inadequately treated haemorrhagic shock results in prolonged tissue hypoxia and damage with the following effects:
Metabolic acidosis: due to anaerobic metabolism initiated after lack of oxygen.

Arteriolar dilatation: caused by accumulation of metabolites leading to pooling and stagnation of blood in the capillaries and leakage of fluid into the tissues.
Disseminated intravascular coagulation: caused by release of thromboplastin from the damaged tissues.
Cardiac failure: due to diminished coronary blood flow.

In this phase death is imminent, transfusion alone is inadequate and if recovery from acute phase occurs residual tissue damage as renal and/ or pituitary necrosis will occur.
Management
Urgent interference is indicated as follow:
Detect the cause and arrest haemorrhage.
Establish an airway and give oxygen by mask or endotracheal tube.
Elevate the legs to encourage return of blood from the limbs to the central circulation.
Two or more intravenous ways are established for blood, fluids and drugs infusion which should be given by IV route in shocked patient. If the veins are difficult to find a venous cut down or
canulation is done.
Restoration of blood volume by:
Whole blood: cross-matched from the same group if not available group O-ve may be given as a life -saving.
Crystalloid solutions: as ringer lactate, normal saline or glucose 5%. They have a short half life in the circulation and excess amount may cause pulmonary edema .
Colloid solutions: as dextran 40 or 70, plasma protein fraction or fresh frozen plasma.
Drug therapy:
Analgesics: 10-15 mg morphine IV if there is pain, tissue damage or irritability.

Corticosteroids: Hydrocortisone 1gm or dexamethasone 20 mg slowly IV. Its mode of action is controversial; it may decrease peripheral resistance and potentiate cardiac response so it im
perfusion.
Sodium bicarbonate: 100 mEq IV if metabolic acidosis is demonstrated.

Vasopressors: to increase the blood pressure so maintain renal perfusion.
Dopamine: 2.5m g/ kg/ minute IV is the drug of choice.

-adrenergic stimulant: isoprenaline 1mg in 500 ml 5% glucose slowly IV infusion.
Monitoring:
Central venous pressure (CVP): normal 10-12 cm water.

Pulse rate.
Blood pressure.
Urine output: normal 60 ml/hour.

pulmonary capillary wedge pressure: Normal 6-18 Torr.
Clinical improvement in the: pallor, cyanosis, air hunger, sweating and consciousness.
Complications
Acute renal failure.
Pituitary necrosis (Sheehans syndrome).
Disseminated intravascular coagulation.
ENDOTOXIC (SEPTIC OR BACTERAEMIC) SHOCK

Obstetric Causes
Septic abortion.
Prolonged rupture of membranes.
Manipulations and instrumentations.
Trauma.
Retained placental tissues.
Puerperal sepsis.
Severe acute pyelonephritis.

Causative Organisms
Gram-negative bacilli: E.coli, proteus, pseudomonas and bacteroids. The endotoxin is a phospholipopolysaccharide released by lysis of its cell envelope.
A similar picture is produced from exotoxin of -haemolytic streptococci, anaerobic streptococci and clostridia.
Pathology
Release of endotoxin results in increased lysosomal permeability and cytotoxicity. The sequence of events thereafter may occur in few minutes and include:
Stimulation of the adrenal medulla and sympathetic nervous system constriction of arterioles and venules local acidosis arteriolar dilatation but with continuing constriction of the venul
pooling of blood haemorrhagic engorgement of bowel, liver, kidneys and lungs.
There is associated extensive disseminated intravascular coagulation due to sudden massive plasmin generation with which the antiplasmins cannot cope.
Clinical Features
Endotoxic shock passes with 2 main stages:
Reversible stage
It has 2 phases:
Early (warm) phase: there are;
hypotension,
tachycardia,
pyrexia,
rigors,
flushed skin,
patient is alert,
leucocytosis develops within hours.
Late (cold) phase: there are;

cold and clammy skin,
mottled cyanosis,
purpura,
jaundice,
progressive mental confusion,

coma.
Irreversible stage
Prolonged cellular hypoxia leads to:
metabolic acidosis,
acute renal failure,

cardiac failure,
pulmonary edema ,
adrenal failure and ultimately death.

Amniotic fluid embolism.
Pulmonary embolism.
Pulmonary aspiration syndrome.
Myocardial infarction.
Incompatible blood transfusion.
Management
It includes 3 major lines of treatment:

Restoration of circulatory function and oxygenation
Replacement of blood loss: by whole blood, if not available start with colloids or crystalloids. The CVP measurement is essential to guard against circulatory overload.
Corticosteroids: as;
Hydrocortisone 1gm IV / 6 hours or,
Dexamethasone 20 mg initially followed by 200 mg/day by IV infusion.
-adrenergic stimulants: as isoprenaline cause arteriolar dilatation, increase heart rate and stroke volume improving tissue perfusion. Blood volume must be normal prior to its administratio
Oxygen: if respiratory function is impaired.
Aminophylline: improves respiratory function by alleviating bronchospasm.

Eradication of infection
Antibiotic therapy:
Swabs for culture and sensitivity are taken first.
Antibiotic therapy is starting immediately till the result of culture and given by IV route. The therapy should cover the wide range of organisms:
Regimen 1
Antibiotic
Acts upon
Dose
Ampicillin or Cephalosporines
Aerobic gram+ organisms and gram- cocci.
500-1000 mg/6 hours.
Gentamycin
Aerobic gram- bacilli.
80 mg/ 8 hours.
(not to be given in the solutions).
Metronidazole
Anaerobic.
500 mg/ 8 hours.
Aerobic gram + organisms + gram- cocci + anaerobic

Regimen 2
Clindamycin
organisms.
600 mg/ 6 hours.
Gentamycin
Aerobic gram- bacilli.
80 mg/ 8 hours.
Surgical treatment:
is indicated when there is retained infected tissues as in septic abortion. It should be removed as soon as antibiotic therapy and resuscitative measures have been started by:
suction evacuation,
digital evacuation, or
hysterectomy in advanced infection with a gangrenous (clostridium welchii) or traumatised uterus.
Correction of fluid and electrolyte deficits

Disseminated intravascular coagulation
Heparin therapy (see DIC) except if there is active bleeding where the condition is best treated by fresh blood transfusion.
AMNIOTIC FLUID EMBOLISM
Definition
Passage of amniotic fluid into the maternal circulation leads to sudden collapse during labor but can only be confirmed at necropsy.
Pathology
The condition is more common with strong uterine contraction, whether spontaneous or induced, occurs after rupture of membranes particularly when there are open maternal blood vessels in t
in cervical lacerations.
The embolism passes to the pulmonary vessels leads to:
sudden death,
shock, or
Later death due to DIC and postpartum haemorrhage.

Clinical Picture
The onset is acute with sudden collapse, cyanosis and severe dyspnoea.
This is soon followed by twitching, convulsions and right side heart failure, with tachycardia, pulmonary edema and blood stained frothy sputum.
If death does not occur in this stage, DIC develops within 1 hour leading to generalised bleeding.
Investigations
ECG: evidence of right side heart failure.
X-ray: non-specific mottled chest appearance.

Lung scan: with technetium-99m albumin shows perfusion defect.
Laboratory tests: evidence of DIC.
Acute pulmonary edema .
Pulmonary aspiration (Mendelsons) syndrome.
Other coagulation defects.
Treatment
Urgent treatment includes:
Oxygen: endotracheal intubation and positive pressure respiration is usually indicated as the patient is often unconscious.
Aminophylline: 0.5 gm slowly IV to reduce bronchospasm.

Isoprenaline:0.1gm IV to improve pulmonary blood flow and cardiac activity.
Digoxin and atropine: if central venous pressure is raised and pulmonary secretions are excessive.
Hydrocortisone: 1 gm IV followed by slow IV infusion causes vasodilatation and improves tissue perfusion.
Bicarbonate solution: if there is respiratory acidosis.
Low molecular weight dextran: reduces platelets aggregation in vital organs.
Heparin: for treatment of DIC if there is no active bleeding.
Vaginal delivery: is safer than C.S. if the baby is not yet delivered.
CARDIAC ARREST
Definition
Sudden circulatory collapse caused by sudden failure of the heart to pump the blood adequately.
Types
Complete cessation of mechanical and electrical activity: asystole.
Rapid ineffective activity: ventricular tachycardia and ventricular fibrillation.
Slow ineffective activity: sinus bradycardia and complete heart block.

In practice, asystole and ventricular fibrillation account for almost all cases of cardiac arrest.
Causes
Any cause of obstetric shock can end by cardiac arrest, the commonest of which are:
Severe haemorrhage.
Hypoxia due to eclampsia or anaesthesia.
Mendelsons syndrome: gastric aspiration with pneumonitis.
Embolism of whatever the nature.
Diagnosis
Sudden collapse.
Loss of consciousness.
Absence of pulse including the carotid and femoral pulse.
Apnoea and cyanosis of variable degree.

Fixed dilatation of the pupils.
N.B. Attempts to auscultate the heart, to record blood pressure or ECG are only time wasting procedures unless the patient is already being monitored during surgery.
Management
Urgent pairs of hands are needed to save the patients life.

Put the patient in the dorsal position onto a firm surface, even the floor.
A single firm thump with the closed fist over the lower sternum may be sufficient to correct the condition otherwise,
The following ABC steps are carried out:
Airway:
Clear it: from vomitus, blood, teeth, foreign body etc.
Maintain it: Pull mandible and tongue forward.
Insert an airway.
Endotracheal intubation as soon as possible.
Breathing:
One of the following is used:

Mouth-to-mouth artificial respiration.
Mask and ambubag with 100 % oxygen.

Cuffed endotracheal tube with intermittent positive pressure of 100% oxygen.
Cardiac massage:
Using the heel of one hand, with the other on top, and with the arms extended, apply pressure to the lower sternum using the full body weight.
This should provide a palpable femoral or carotid pulse.
The optimal compressions is 60 / minute in a ratio of 4:1 to ventillation.
Drip and Drugs:

Sodium bicarbonate 8.4% solution: to counteract metabolic acidosis. Give 100 ml initially and a further 10 ml for each subsequent minute of inadequate circulation.
Cardiac stimulants (inotropic drugs): can be given IV or intracardiac e.g.
Adrenaline 0.5-1.0 mg.

Atropine 0.6 mg.
Isoprenaline 4 mg in 500 ml solution.
Dopamine 500 mg in 500 ml solution (1-3 m g/ kg/ min).
Calcium chloride 10% solution.
Electrocardiogram:
to assess the condition and response to the therapy.
Fibrillation treatment
Direct current (DC) defibrillator is used.

High Risk Pregnancy

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HIGH RISK PREGNANCY

ASSESSMENT OF HIGH RISK PREGNANCIES:

High-frequency sound wave testing

- encourage fluid and refrain from voiding before the test

e. Non-Stress test (NST)

f. Contraction stress test (CST):

HEALTH DISORDERS COMPLICATING PREGNANCY

MAJOR RISK FACTORS FOR DM:

Blood glucose is measured after 1 hour

A level above 140 mg/dl is abnormal

If result is abnormal, a 3 hour glucose tolerance test is done

Normal values of GTT are:

1. Fasting blood glucose level: less than 105 mg/dl

1. Perform daily fetal kick counts.

7. Educate on s/sx of hyperglycemia and treatment needed:

1. Pregnancy Induced Hypertension

Fetal Diabetic complications:

3. Neural tube defects

functional or therapeutic classification of heart disease during pregnancy

COMPLICATIONS DURING PREGNANCY

Complete abortion is characterized by complete expulsion of all products of conception.

Recurrent (habitual) abortion is spontaneous abortion of three or more consecutive pregnancies.

Figure 1 Three Types of Spontaneous Abortion

a. Defective embryologic development

2. Clinical Manifestations include common signs and symptoms of spontaneous abortion.

3. Laboratory and diagnostic study findings

a. Serum beta hCG levels are quantitatively low

1. Provide appropriate management and prevent complications

Assess and record vital signs, bleeding and cramping of pain.

2. Provide client and family teaching

3. Address emotional and psychosocial needs.

Sites of ectopic pregnancy. Numbers indicate the order of prevalence.

Be aware of grief and lost manifestations in the client and family.

normal pregnancy or may have no

Dizziness and syncope (faintness)

Sharp abdominal pain and referred shoulder pain

Adnexal mass and tenderness

3. Laboratory and diagnostic study findings

A pregnancy test reveals elevated serum quantitative beta hCG.

Ultrasound will confirm extrauterine pregnancy.

Complications. Assess vital signs,

bleeding, and pain.

2. Provide client and family teaching to relieve anxiety.

Explain the condition and expected outcome.

b. Describe self-care measures, which depend on the treatment.

Gestational Trophoblastic Disease (Hydatidiform mole)

1. There are two distinct types of hydatidiform moles-complete and partial.

A partial mole has 69 chromosomes.

Review pertinent history and history of this pregnancy.

2. Provide client and family teaching.

monitored for 1 year.

3. Address emotional and psychosocial needs.

DISSEMINATED INTRAVASCULAR COAGULATION

DIC occurs in approximately 1% of all hospitalized patients.

It affects both sexes equally.

No age predilection is known.

Cancer especially certain types of leukemia

Amniotic fluid embolism

Trauma and burns

Infection in the blood by bacteria or fungus or sepsis

Severe liver disease

Severe tissue injury as in burns and head injury