CONTRACTED PELVIS

AND
OBSTETRICAL
EMERGENCIES

SUBMITTED TO SUBMITTED BY

MRS .DR.S.SUJATHA MADAM J.KALPANA

ASST.PROFF MSC (N) II YR

GCON GCON

HYDERABAD HYDERABAD
NAME OF THE STUDENT : MS. J.KALPANA

COURSE : MSC (N) II YEAR

SUBJECT : OBG

TOPIC :CONTRACTED PELVIS,OBSTETRICAL EMERGENCIES

GROUP : MSC (N)IIYEAR

PLACE : MSC CLASS ROOM

DATE : 16/02/2019

DURATION : 2HRS

METHOD OF TEACHING : LECTURER CUM DISCUSSION

SUPERVISED BY :MRS .HANSLI MADAM ,LECTURER

OBJECTIVES:

General objectives:

By the end of seminar group will be able to gain in depth knowledge in contrated
pelvis and obstetrical emergencies

Specific objectives:

 Group will be able to;

 Define contracted pelvis
 Variations of female pelvis
 List causes of contracted pelvis
 Discuss mechanism of labour in contracted labour
 Enumerate the diagnosis of contracted pelvis
 Define cephalopelvic disproportion
 List diagnosis of CPD
 Describe the effects of contracted pelvis
 Discuss the management of contracted pelvis
 Define obstetrical emergencies
 Classification of obstretrical emergency
 Discuss etiology, clinical manifestation, diagnosis and management
 List nursing diagnosis
 INDEX

Content Page no.

s.no

1 Introduction

2 Definition

3 Contracted pelvis

 causes
 diagnosis
 effects of contracted pelvis
 management

4 cephalo pelvic disproportion

5
obstetrical emergencies

 definition
 etiology
 clinical manifestation
 diagnosis
 manangemt
 nursing management
 nursing diagnosis

6 Summary

7 Conclusion

8 Bibliography
 CONTRACTED PELVIS

INTRODUCTION:

The female pelvis may be altered in size and shape by errors of

development by diseases of the pelvic bones and joints, by deformities of the
pelvic column and lower extremities or because of accidents. It is indeed difficult
to define precisely what constitutes a contracted pelvis. Anatomically, contracted
pelvis is defined as one where the essential diameters of one or more planes are
shortened by 0.5 cm Depending upon the degree of contraction, the head may pass
through the pelvis by abnormal mechanism or fail to pass due to absolute
obstruction.

DEFINITION:

Obstetrical definition which states that alteration in size and/or shape

of the pelvis of sufficient degree so as to alter the normal mechanism of labor in an
average size of the baby

- D.C.DUTTA

VARIATIONS OF FEMALE PELVIS:

The size and shape of the female pelvis differ so widely due to morphological
factors such as developmental, sexual, racial and evolutionary that it is indeed
difficult to define what the features of a normal pelvis are. However, on the basis
of the shape of the inlet, the female pelvis is divided into four parent types.

Gynecoid (50%) Anthropoid (25%) Android (20%) Platypelloid (5%)

 But more commonly, intermediate forms with combination of features are
found. They are termed as gyne-android or andro-gynecoid, etc. The first part of
the nomenclature relates to features of the posterior segment and the second part
relates to that of the anterior segment of the pelvis. All types of combinations are
possible except anthropoid with platypelloid. It should be clear that the pelves
which are not typically female are not necessarily contracted, although there may
be deviation of normal mechanism of labor. However, slight contraction if
associated with any of the three nongynecoid pelves has a more serious
consequence because of the unfavorable shape.

COMMON CAUSES:

1. Nutrition and environmental defects

 Minor variation : common
 Major variation: rachitic and osteomalacic-rare
2. Diseases or injuries effecting the bones of the pelvis – fracture , tumors ,
tubercular arthritis; spine- kyphosis, scoliosis, spondilolisthesis, coxygeal
deformity ; lower limbs – polio myletis, hip joint diseases.
3. Developmental defects – neagel ‘s pelvis, Robert’s pelvis

Rachitic flat pelvis – rickets is predominantly a disease of early child hood when
the bones remain soft and unoccified. At this time if the child lies or sits in bed,
changes occur in the soft pelvis due to weight bearing . the changes are :

Inlet – sacral promonitory is pushed down wards and forwards producing a

reniform shape of the inlet with marked shortening of the anterio- posterior
diameter without effecting the tranverse diameter.

Cavity : sacrum is flat and tilted backwards . there may be short angulation at the
sacro coxygeal joint.

Out let : body weight transmitted through the ischium in sitting position results
in widening of the transverse diameter of the outlet and the pubic arch .
 Osteomalycic pelvis

The deformity is caused by softening of the pubic bones due to

calcium and vitamin D deficiency and lack of exposure to sunrise .

 The promonitory is pushed downwards and forwards

 Approximation of the two ischial tuborosities and marked narrowing of the
pubic arch occurs . sacrum is markedly shortened and coccyx is pushed
forward.

Assymetrical or obliquely contracted pelvis :

It is seen in negles pelvis , scholiotic pelvis due to diseases affecting one

hip or sacro iliac joint. Tumors or fracture affecting one side of the pelvic bone
during growing age.

Negles pelvis :

This type of pelvis is extremely rare. It is produced due to arrested

development of ala of the sacrum. It may be:

 congenital
 acquired the pelvis is obliquely contracted at all levels but more marked in
the oulet. ileopectineal line on the affected side is almost straight. Method
of delivery is by cesarean section .
Roberts pelvis :

Ala of the both sides are absent and the sacrum is fused with the
innominate bones.

Kyphotic pelvis :

The sacrum is tilted backwards in the upper part and forwards in the lower
part. It is narrow and straight . the anterio postrio diameter of the inlet is increased
but is diminished at the outlet sub pubic angle is narrow does the feature is extreme
funneling of the pelvis.

MECHANISM OF LABOR IN CONTRACTED PELVIS WITH VERTEX

PRESENTATION

FLAT PELVIS:

In the flat pelvis, the head finds difficulty in negotiating the brim and
once it passes through the brim; there is no difficulty in the cavity or outlet. The
head negotiates the brim by the following mechanism:

 The head engages with the sagital suture in the transverse diameter.
 Head remains deflexed and engagement is delayed.
 The anterio posterior diameter is too short; the occiput is mobilized to the
same side, to occupy the sacral bay. The bi parietal diameter is thus placed
in the sactocotyliod diameter (9.5cm) and the narrow bi temporal diameter
is placed in the narrow conjugate.
 Engagement is occurs by exaggerated parietal presentation so that the
super sub parietal diameter (8.5 cm) instead of the bi parietal diameter
(9cm) passes through the pelvic brim.
 Moulding may be extreme and often there is an indentation or even a
fracture of one parietal bone.
 Once the head negotiates the brim, there is no difficulty in the cavity and
the outlet and normal mechanism follows.
  In this type of pelvis the shape remains unaltered, but all the diameters in
the different planes—inlet, cavity and outlet—are shortened. There is
difficulty from the beginning to the end.

DIAGNOSIS OF CONTRACTED PELVIS:

During the past couple of decades, there has been a gradual decline in the
incidence of severe degree of contracted pelvis. This is due to an improved
standard of living and of nutrition in particular. But of significance is the presence
of fetopelvic disproportion due either to inadequate pelvis or big baby or more
commonly a combination of the both.

Past history:

Medical: the past history of fracture, rickets, osteomalacia, tuberculosis of

the pelvis joints or spines, poliomyelitis is to be enquired.
Obstetrical: a history of prolonged and a tedious labor followed by either
spontaneous or difficult instrumental delivery is suggestive of pelvic
contraction. Difficult vaginal delivery is ending in still born or early
neonatal death. Weight of the baby, evidences of maternal I juries such as is
complete perineal tear, vesico vaginal or recto vaginal fistula, if, available,
are of useful guide.

Physical examination:

Stature: A small woman of less than 5 ft is likely to have a small pelvis.

Stigma: deformities (congenital or acquired) of pelvic bones, hip joint, spine.

Abdominal examination:

Inspection: pendulous abdomen specially in primigravidae.

Obstetrical: in primigravidae usually there is engagement of the head before
the onset of the labor. Presence of malpresentation in primigravidae, gives
rise to a suspicion of pelvis of pelvic contraction.

Assessment of the pelvis (Pelvimetrty):

 Assessment of the pelvis can be done by bimanual examination: clinical
pevimetry or by imaging studies- radiopelvimetry, computed tomography
(CT) and Magnetioc resonance image (MRI).
Clinical Pelvimetry: this is done manually.
Time: in vertex presentation, the assessment is done at any time beyond 37
weeks but better at beginning of the labor. Because of softening of the
tissues, assessment can be done effectively during this time.
Procedures:
The patient has to empty the bladder. The pelvic examination is done with
the patient in dorsal position taking aseptic preparations. The following
features are to be noted simultaneously:
(1) State of the cervix;
(2) To note the station of the presenting part in relation to ischial spines;
(3) To test for cephalopelvic disproportion in nonengaged head (described
later);
(4) To note the resilience and elasticity of the perineal muscles.

Steps:

The internal examination should be gentle, thorough, medical and

purposeful.

Sacrum: the sacrum is smooth, well curved and usually inaccessible beyond lower
three pieces.

Sacrosciatic notch: the configuration of the notch denotes the capacity of the
posterior segment of the pelvis and the side walls of the lower pelvis.

Ischial spines: spines are usually smooth and difficult to palpate.

Iliopectenial lines: to note for any breaking suggestive of narrow pelvis fore
pelvis.

Posterior surface of the symphysis pubis: it normally forms a smooth rounded

curve.

Sacro coccygeal joint: its mobility and presence of hooked occurs, if any are
noted.
Pubic arch: normally the pubic arch is rounded and should accommodate the
palmer aspect of the two fingers.

Pubic angle: the inferior pubic rami are defined in female, the angle roughly
corresponds to the fully abducted thumb and index fingers. In narrow angle, it
roughly corresponds to the fully abducted middle and index fingers.

Transverse diameter of the outlet: it is measured by placing the knuckles of the

first inter phalengeal joints or knuckles of the clenched fist between the ischial
tuberositie.

Anterio posterior diameter of the outlet: the distance between the inferior
margin of the symphysis pubis and the skin over the sacro coccygeal joint can be
measured with the metjod employed for diagonal conjugate.

X-ray pelvimetry: is of limited value in the diagnosis of pelvic contraction or

cephalopelvic disproportion. Apart from pelvic capacity there are several other
factors involved in successful vaginal delivery. These are the fetal size,
presentation, position and the force of uterine contractions. X-ray pelvimetry
cannot assess the other factors. It cannot reliably predict the likelihood of vaginal
delivery neither in breech presentation nor in cases with previous cesarean section.
X-ray pelvimetry is a poor predictor of pelvic adequacy and success of vaginal
delivery. However, X-ray pelvimetry is useful in cases with fractured pelvis and
for the important diameters which are inaccessible to clinical examination.

Computed tomography :(CT) involves less radiation exposure (44–425 millirad)

and is easier to perform. Accuracy is greater than that of conventional X-ray
pelvimetry (Fig. 24.8). Three images (lateral, AP and axial slice) are taken.

Magnetic resonance imaging (MRI) :is more accurate to assess the bony pelvis.
It is also helpful to assess the fetal size and maternal soft tissues which are
involved in dystocia. It has got no radiation risk, hence biologically safe. It is
expensive, requires more time and availability is limited.

Ultrasonography: is useful to measure the fetal head dimensions in the

intrapartum phase
 CEPHALOPELVIC DISPROPORTION

INTRODUCTION:

The disparity in relation between the head and the pelvis is called cephalo
pelvic disproportion. Disproportion may be either due to an average size of the
baby with a small pelvis or due to big baby with normal size pelvis or due to
combination of both the factors.

Pelvic inlet contraction: is considered when the obstetric conjugate is < 10 cm or

the greatest transverse diameter is < 12 cm or diagonal conjugate is < 11 cm.
Contracted

Midpelvis: Midpelvis is considered contracted when the sum of the interischial

spinous and posterior sagittal diameters of the midpelvis (normal: 10.0 + 5 = 15.0
cm) is 13.0 cm or below.

Contracted outlet: is suspected when the interischial tuberous diameter is 8 cm or

less. A contracted outlet is often associated with midpelvic contraction. Isolated
outlet contraction is a rarity. Disproportion at the outlet may not give rise to severe
dystocia, but may cause perineal tears. The head is pushed backwards as it cannot
be accommodated beneath the symphysis pubis. As the head is the largest part of
the fetus, it is more important to know whether the greatest diameter of the head
passes through the different planes of the pelvis. Thus, from the clinical point of
view, identification of the cephalopelvic disproportion is more logical than to
concentrate entirely on the measurements of a given pelvis, as the fetal head is the
best pelvimeter. Thus, disproportion may be limited to one or more planes.
Absence of cephalopelvic disproportion at the brim usually, but not always,
negates its presence at the midpelvic plane. On the other hand, isolated outlet
contraction without midpelvic contraction is a rarity. Thus, a thorough assessment
of the pelvis and identification of the presence and degree of cephalopelvic
disproportion are to be noted while evaluating a case of contracted pelvis.

DEFINITION:
The disparity in the relation between the head and the pelvis is called
cephalopelvic disproportion.

- D.C DUTTA

Diagnosis of the cephalo pelvic disproportion at the brim:

The presence and degree of cephalo pelvic disproportion at the bri can be
ascertained by the following:

 Clinical abdominal method

 Imaging Pelvimetry
 Cephalometry
 Ultrasound
 Magnetic resonance Imaging (MRI).
 X-ray.

Clinical:

In multigravidae, a previous history of spontaneous delivery of an avarege size

baby, resonble rules out contracted pelvis. But in a primigravida with noon
engagement of the head even at labour, one should rule out disproportion.

Abdominal method:

The patient is placed in dorsal position with the thighs slightle flexed and
separated. The head is grasped by the left hand. Two fingers ( index and
middle) of the right hand are placed above symphysis pubis keeping the inner
surface of the fingers in line with the anterior surface of the symphysis pubis to
note the degree of the overlapping if, any, when the head is pushed down wards
and backwards.

Inferences:

 The head can be pushed down in the pelvis without overlapping of the
parietal bone on the symphysis pubis — no disproportion.
 Head can be pushed down a little but there is slight overlapping of the
parietal bone evidenced by touch on the under surface of the fingers
 (overlapping by 0.5 cm or 1/4" which is the thickness of the symphysis
pubis) — moderate disproportion.
 Head cannot be pushed down and instead the parietal bone overhangs the
symphysis pubis displacing the fingers — severe disproportion.

The abdominal method can be used as a screening procedure:

At times, it is difficult to elicit due to deflexed head, thick abdominal wall,

irritable uterus and high-floating head.

Abdominovaginal method (Muller-Munro Kerr):

This bimanual method is superior to the abdominal method as the pelvic

assessment can be done simultaneously. Muller introduced the method by
placing the vaginal finger tips at the level of ischial spines to note the descent of
the head. Munro Kerr added placement of the thumb over the symphysis pubis
to note the degree of overlapping.

Lower bowel is emptied, preferably by enema. The patient is asked to empty the
bladder. The patient is placed in lithotomy position and the internal examination
is done taking all aseptic precautions. Two fingers of the right hand are
introduced into the vagina with the finger tips placed at the level of ischial
spines and thumb is placed over the symphysis pubis. The head is grasped by
the left hand and is pushed in a downward and backward direction into the
pelvis.

Inferences:

(1) The head can be pushed down up to the level of ischial spines and there is no
overlapping of the parietal bone over the symphysis pubis — no disproportion;

(2) The head can be pushed down a little but not up to the level of ischial
spines and there is slight overlapping of the parietal bone — slight or moderate
disproportion;

(3) The head cannot be pushed down and instead the parietal bone overhangs
the symphysis pubis displacing the thumb — severe disproportion.

Limitations of clinical assessment:

 (1) The method is only applicable to note the presence or absence of
disproportion at the brim and not at all applicable to elicit midpelvic or outlet
contraction;

(2) The fetal head can be used as a pelvimeter to elicit only the contraction in
the anteroposterior plane of the inlet but when the contraction affects the
transverse diameter of the inlet, it is of less use.

X-ray pelvimetry: Lateral X-ray view with the patient in standing position is
helpful in assessing cephalopelvic proportion in all planes of the pelvis — inlet,
midpelvic and outlet.

Cephalometry: While a rough estimation of the size of the head can be

assessed clinically, accurate measurement of the biparietal diameter would have
been ideal to elicit its relation with the diameters of the planes of a given pelvis
through which it has to pass. In this respect, ultrasonographic measurement of
the biparietal diameter or Magnetic Resonance Imaging (MRI) gives superior
information. The average biparietal diameter measures 9.4–9.8 cm at term.

Magnetic Resonance Imaging (MRI): MRI is useful to assess the pelvic

capacity at different planes. It is equally informative to assess the fetal size,
fetal head volume and pelvic soft tissues which are also important for
successful vaginal delivery

Degree of disproportion and contracted pelvis:

Based on the clinical and supplemented by imaging pelvimetry, the following

degrees of disproportion at the brim are evaluated:

(1) Severe disproportion: Where obstetric conjugate is < 7.5 cm (3"). Such type is
rare to see.

(2) Borderline: Where obstetric conjugate is between 9.5 cm and 10 cm. When
both the anteroposterior diameter (< 10 cm) and the transverse diameter (< 12 cm)
of the inlet are reduced, the risk of dystocia is high than when only one diameter is
contracted.

EFFECTS OF CONTRACTED PELVIS ON PREGNANCY AND LABOR:

Pregnancy: The general course of pregnancy is not much affected. However, the
following may occur:

(1) There is more chance of incarceration of the retroverted gravid uterus in flat
pelvis

(2) Abdomen becomes pendulous especially in multigravida with lax abdominal

wall

(3) Malpresentations are increased three to four times and so also increased
frequency of unstable lie.

Labor: The course of events in labor is greatly modified depending upon the
degree of pelvic contraction and presentation of the fetus:

(1) There is increased incidence of early rupture of the membranes

(2) Incidence of cord prolapse is increased

(3) Cervical dilatation is slowed

(4) There is increased tendency of prolonged labor and in neglected cases,

obstructed labor with features of exhaustion, dehydration, ketoacidosis and sepsis

(5) There is increased incidence of operative interference, shock, postpartum; and

hemorrhage and sepsis.

Maternal injuries: The injuries of the genital tract may occur spontaneously or
following operative delivery There is increased maternal morbidity and mortality

Fetal hazards: Fetal risks are due to trauma and asphyxia The net effect leads to
increased perinatal mortality and morbidity.

MANAGEMENT OF CONTRACTED PELVIS (INLET CONTRACTION)

The prerequisite in the formulation of the line of management of contracted inlet is

to ascertain the degree of disproportion by clinical examination and supplemented
by imaging pelvimetry. Due consideration is given to the associated complicating
factor, if any.
Minor degrees of inlet contraction does not give rise to much problem and the
cases are left to have a spontaneous vaginal delivery at term. The moderate and the
severe degrees are to be dealt by any one of the following:

 Induction of labor
 Elective cesarean section at term
 Trial labor

Induction of labor prior EDC:

Induction 2–3 weeks prior to the EDC may be considered only in cases with minor
to moderate degrees of pelvic contraction. It is not favored nowadays. However, in
a selected multigravida with previous history of difficult vaginal delivery, this
method may be considered 2–3 weeks before the date. In any case, one should be
certain about the fetal gestational age.

Elective cesarean section at term:

This is commonly done. Elective cesarean section at term is indicated in—

(1) major degree of inlet contraction and also in

(2) moderate degree of inlet contraction associated with outlet contraction or

complicating factors like elderly primigravida, malpresentation, post-cesarean
pregnancy, etc. If there is no doubt about the maturity of the fetus, the operation is
done in planned way any time during last week of pregnancy. In doubtful maturity,
investigations are done to ascertain maturity otherwise the operation is withheld till
the pains start or the membranes rupture, whichever occurs early.

TRIAL LABOR

Definition:

It is the conduction of spontaneous labor in a moderate degree of cephalopelvic

disproportion, in an institution under supervision with watchful expectancy, hoping
for a vaginal delivery.
Every arrangement should be made available for operative delivery, either vaginal
or abdominal, if the condition so arises.

Aims:

A trial labor aims at avoiding an unnecessary cesarean section and at delivering a

healthy baby. The phrase “trial” was used originally to test for pelvic adequacy but
subsequently its use has been extended to test numerous factors other than the
pelvic capacity. For example, the trial is conducted to test the integrity of the scar
in a woman with prior cesarean delivery when she goes into labor.

Contraindications:

(1) Associated midpelvic and outlet contraction

(2) Presence of complicating factors like elderly primigravida, malpresentation,

postmaturity, post-cesarean pregnancy, pre-eclampsia, medical disorders like heart
disease, diabetes, tuberculosis, etc.

(3) Where facilities for cesarean section is not available round the clock.

Conduction of trial labor:

The management of a trial labor requires careful supervision and consideration.

The following guidelines are prescribed.

The labor should ideally be spontaneous in onset. But in cases where the labor fails
to start even on due date, induction of labor may be done.

Oral feeding remains suspended and hydration is maintained by intravenous drip.

Adequate analgesic is administered.

The progress of the labor is mapped with a partograph

(a) progressive descent of the head and

(b) progressive dilatation of the cervix.

To monitor the maternal health . Fetal monitoring is done clinically and/or using
EFM .
If there is failure to progress due to inadequate uterine contraction, augmentation
of labor may be done by amniotomy along with oxytocin infusion. On no account
should the procedure be employed before the cervix is at least 3 cm (2 fingers)
dilated.

After the membranes rupture, pelvic examination is to be done:

(a) To exclude cord prolapse

(b) To note the color of liquor;

(c) To assess the pelvis once more and

(d) To note the condition of the cervix including pressure of the presenting part on
the cervix.

Successful outcome depends on:

(1) Degree of pelvic contraction

(2) Shape of the pelvis—flat pelvis is better than android or generally contracted
pelvis

(3) Favorable vertex presentation—anterior parietal presentation with less parietal

obliquity is favorable

(4) Intact membranes till full dilatation of cervix

(5) Effective uterine contractions and

(6) Emotional stability of the woman.

 Unfavorable features:
 Appearance of abnormal uterine contraction
 Cervical dilatation less than 1 cm per hour in the active phase (protracted
active phase)
 Descent of fetal head less than 1 cm per hour (protracted active phase)
inspite of regular uterine contractions;
 Arrest of cervical dilatation and nondescent of fetal head in spite of oxytocin
therapy
  Early rupture of the membranes
 Formation of caput and evidence of excessive molding
 Fetal distress.

How long the trial to be continued? It is indeed difficult to set an arbitrary time
limit which is applicable to all cases. One should individualize the case. So long as
the progress is satisfactory (evidenced by descent of the head and progressive
cervical dilatation) and the maternal and fetal condition remain good, trial may be
continued safely. However, if any ominous feature appears, trial is to be terminated
forthwith. Nowadays, there is a tendency to shorten the duration of trial. In spite of
adequate uterine contractions, if there is arrest of descent or dilatation of the cervix
for a reasonable period (3-4 hours) in the active phase, labor is terminated by
cesarean section.

Termination of trial labor:

The methods of termination are any one of the following:

Spontaneous delivery with or without episiotomy (30%).

Forceps or ventouse (30%)—Difficult forceps delivery is to be avoided.

Cesarean section (40%)—Judicious and timely decision for cesarean delivery is to

be taken. However, in significant cases, the section is done even before full
dilatation of the cervix, the indication being uterine inertia or fetal distress.

Successful trial:

A trial is called successful, if a healthy baby is born vaginally, spontaneously or

by forceps or ventouse with the mother in good condition. Delivery by cesarean
section or delivery of a dead baby, spontaneously or by craniotomy, is called
failure of trial labor.

Advantages of trial labor:

(1) It eliminates unnecessary cesarean section electively decided upon

(2) It eliminates injudicious use of premature induction of labor with its

antecedent hazards
(3) A successful trial ensures the woman a good future obstetrics.

Disadvantages of trial labor:

(1) Test of disproportion remains unproven when cesarean delivery is done due to
fetal distress or uterine dysfunction

(2) Increased perinatal morbidity or mortality due to asphyxia or intracranial

hemorrhage when the trial is prolonged and/or ends in difficult delivery

(3) Increased maternal morbidity due to the effects of prolonged labor and/or
operative delivery

(4) Increased psychological morbidity when trial ends with a traumatic vaginal
delivery or in cesarean delivery.

MIDPELVIC AND OUTLET DISPROPORTION:

In clinical assessment, it is difficult to determine where the midpelvis ends and

outlet begins. Moreover, isolated outlet contraction without midpelvic contraction
is a rarity. As such, in practice the two problems are jointly considered as outlet
contraction. Cephalopelvic disproportion at the outlet is defined as one where the
biparietal-suboccipitobregmatic plane fails to pass through the bispinous and
anteroposterior planes of the outlet.

Management:

Unlike inlet disproportion, clinical diagnosis of midpelvic and outlet disproportion

can only be made after the head sufficiently comes down into the pelvis.

(1) Elective cesarean section: Contraction of both the transverse and

anteroposterior diameters of the midpelvic plane or minor contraction associated
with other complicating factors is dealt by elective cesarean section.

(2) To allow vaginal delivery: In otherwise uncomplicated cases with minor

contraction, vaginal delivery is allowed under supervision with watchful
expectancy. Molding and adaptation of the head and “give” of the pelvis may
allow the head to pass through the contracted zone. Delivery is accomplished by
forceps or ventouse with deep episiotomy to prevent perineal injuries, especially
with narrow pubic arch. Labor progress should be mapped with a partograph to
make an early diagnosis of dysfunctional labor due to disproportion. Oxytocin may
be used to augment labor for adequate uterine contractions. If there is no dilatation
of cervix or descent of the fetal head after a period of 2 hours in the active phase of
labor, arrest of labor is considered. Once arrest disorder is diagnosed, cesarean
delivery is the option.

The principles of management rest on:

(i) Cesarean section to avoid difficult forceps

(ii) Forceps with deep episiotomy
(iii) Symphysiotomy followed by ventouse or (iv) Craniotomy if the fetus is
dead.

COMPLICATIONS OF CONTRACTED PELVIS

During pregnancy:

 Incarcerated retroverted gravid uterus.

 Malpresentations.
 Pendulous abdomen.
 Nonengagement.
 Pyelonephritis especially in high assimilation pelvis due to more
compression of the ureter.

During labour:

 Inertia, slow cervical dilatation and prolonged labour.

 Premature rupture of membranes and cord prolapse.
 Obstructed labour and rupture uterus.
 Necrotic genito-urinary fistula
 Injury to pelvic joints or nerves from difficult forceps delivery.
 Postpartum haemorrhage

Foetal:

 Intracranial haemorrhage.
 Asphyxia. Fracture skull. Nerve injuries.
 Intra-amniotic infection.
OBSTETRICAL EMERGENCIES:

Obstetrical emergencies are life threatening medical conditions that occur in

pregnancy or during labor or after delivery.

1.VASA PREVIA

This term is used when a fetal blood vessel lies over the os infront of the
presenting part. This usually occurs when fetal vessels from a velamentous
insertion of the cord cross the area of the internal os to the placenta. However, vasa
previa may also occur when there is a succenteriate placenta since the vascular
connections to the succenteriate lobe are also unprotected vessels coursing between
the chorion and amnion. With fetal descend and rupture of the membranes, the
vessels are subject to compression and rupture with resulting exsanguinations and
anoxia of the fetus.
Vasa previa occurs in less than 0.2 percent of pregnancies. While extremely
rare it should be thought of as a possibility, any time the midwife is not positive of
what she feels presenting at the cervical os.

DEFINITION:

It is an abnormality of the cord that occurs when one or more blood vessels from
the umbilical cord or placenta cross the cervix but it is not covered by Wharton’s
jelly. This condition can cause hypoxia to the baby due to pressure on the blood
vessels. It is a life threatening condition.
- D.C.DUTTA

ETIOLOGY:
These vessels may be from either
 Velamentous insertion of umbilical cord
 placental lobe joined to the main disk of the placenta.
 Low-lying placenta
 Previous delivery by C-section.
SYMPTOMS:
 The baby’s blood is a darker red color due to lower oxygen levels of a fetus
 Sudden onset of painless vaginal bleeding, especially in their second and
third trimesters
 If very dark burgundy blood is seen when the water breaks, this may be an
indication of vasa previa

DIAGNOSIS:
 Vasaprevia may sometimes be palpated on vaginal examination when the
membranes are still intact. Pulsations felt my be synchronous with the fetal
heart rate.
 A speculum examination may be done to visualize the blood vessel.
 It may also be visualized on ultrasound.
 Fresh vaginal bleeding, which commences at the time of rupture of
membranes, may be due to ruptured vasa previa.

MANAGEMENT:

Immediate consultation with the physician is mandatory when the midwife

believes the presenting part to the abnormal. The fetal heart rate should be
monitored. If in the first stage of labor and the fetus is alive, an emergency
cesarean section is carried out. If the mother is in the second stage of labor,
delivery should be expedited and a vaginal birth may be achieved. The mode of
delivery will be dependent on parity and fetal condition.
A pediatrician should be present at delivery and if the baby is alive,
hemoglobin estimation is necessary after resuscitation. The baby will require a
blood transfusion, but the mortality rate is high with this emergency.

NURSING MANAGEMENT:

 Assess bleeding, color, amount

 Administer IV fluids.
 Administer oxygen.
  Strict vitals and FHS monitoring.
 Prepare patient for caesarean section.
 Reserve blood if (Hct >30%).

2.PRESENTATION AND PROLAPSE OF THE UMBILICAL CORD

There are three clinical types of abnormal descend of the umbilical cord by the
side of the presenting part. All these are included under the heading cord
prolapsed.
 Occult prolapsed: The cord lies alongside but not in front of the presenting
part and is not felt by the fingers on internal examination.
 Cord presentation: The cord is slipped down below the presenting part and
lies in front of it in the intact bag of membranes.
 Cord prolapsed: The cord lies in front of the presenting part inside the
vagina or outside the vulva following rupture of the membranes.

INCIDENCE:
Cord prolapse is about 1 in 300 deliveries. It occurs mostly in parous women
especially in higher parities.

PREDISPOSING FACTORS:
These are same for both presentation and prolapsed of the cord. Any
situation where the presenting part is neither well applied to the lower uterine
segment nor well down in the pelvis may make it possible for a loop of cord to slip
down in front of the presenting part.
Such situations include:
 Malpresentations
 Prematurity
 Multiple pregnancy
 Polyhydromnios
 High head
 High parity

Malpresentations:
 The commonest malpresentation associated with cord prolapse is transverse
followed by breech, especially complete or footling. This relates to the ill fitting
nature of the presenting part and the proximity of the umbilicus to the buttocks. In
this situation the degree of compression will be less than with a cephlic
presentation, but there is still a danger of asphyxia. Face and brow presentations
are less common causes of cord prolapse.

Prematurity:
The size of the fetus in relation to the pelvis and the uterus allows the cord to
prolapse. Babies of very low birth weight, less than 1,500 gm are particularly
vulnerable.

Multiple pregnancy:
Malpresentation of the second twin is common in multiple pregnancy.

Polyhydramnios:
The cord is liable to be swept down in the gush of liquor if the membranes
rupture spontaneously. Controlled release of liquor with artificial rupture of
membranes is sometimes performed to prevent this.

High head:
If the membranes rupture spontaneously when the fetal head is high, a loop
of cord may pass between the uterine wall and the fetus resulting it lying in front of
the presenting part.

Multiparity:
The presenting part may not be engaged when the membranes rupture and
malpresenttion is more common.

DIAGNOSIS

Occult prolapsed:
This is difficult to diagnose. the possibility should be suspected if
there is :
 1) Persistence of variable deceleration of fetal heart rate pattern detected of
fetal heart rate pattern detected on continuous fetal monitoring in an
otherwise normal delivery or
2) Persistent fetal soufflé with irregular heart sounds.

Cord presentation:

The diagnosis of cord presentation is made by feeling the

pulsation of the cord through the intact membranes . it is however , rarely detected
but many also be associated with aberrations in fetal heart monitoring , such as
decelerations.

Cord prolapsed:

The cord id felt below or beside the presenting part on vaginal

examination . a loop of cord may be visible t the vulva. The cord is more
commonly felt in the vagina or in cases where the presenting part is high ; it may
be felt at the cervical os. Pulsation can be felt between contractions if the fetus is
alive
Risks to mother and fetus

Maternal

The maternal risks are incidental due to emergency operative

delivery, which involves the risk of anesthesia , blood loss and infection.
Fetal

The fetus is at risk of anoxia due to acute placental insufficiency

moment cord is prolapsed . the blood flow is occluded either due to mechanical
compression by the presenting part against the incompletely dilated cervix or
pelvic wall , or due to vasospsm of the umbilical vessels due to exposure to cold or
irritation when exposed outside the vulva or as a result of handling . the danger is
more in vertex presentation , especially when the prolapsed is through the anterior
segment of the pelvis or when the cervix is partially dilated.

Management of cord prolapsed

The aim is to preserve the membranes and to expedite the delivery.

 The midwife should discontinue vaginal examination in order to reduce the
risk of rupturing the membranes
 Medical help should be summoned immediately
 Fetal heart should be auscultated as possible or obtained through continuous
electronic monitoring.
 Cesarean section is the most likely method of delivery.
 During the time of preparing the woman for operative delivery , she is kept
in exaggerated Sims position to minimize cord compression.
Immediate action

 When the diagnosis of cord prolapsed is made, the midwife calls for
urgent assistance.
 The mother and her family must be given explanation about the
findings and the emergency measures that will be needed.
  If oxytocin infusion in progress ;it should be stopped.
 If the baby id alive , the aim of immediate management is to minimize
pressure on the cord until such time when the woman is prepared for
assisted delivery or is transferred to an equipped hospital . for this ,
the gloved fingers are to be introduced into the vagina to lift the
presenting part inside the vagina until definitive is instituted.
 Postural treatment is given until the delivery of the delivery of the
baby , either vaginally or by cesarean section . the woman is placed in
exaggerated elevated Sims position with pillow under the hip . the
foot end of the bed may be elevated . high tendlenberg or knee chest
position , which has been traditionally mentioned , is very tiring and
distressing to the woman.
 If the cord lies outside the vagina, it should be replaced into the
vagina to minimize vasospasm due to irritation and to maintain the
temperature.
 If much of the cord is outside the vulva, it should be covered with
sterile wet guaze, to prevent spasm of the umbilical blood vessels due
to draughts.

Definitive management

 Caesarean section is the ideal management when the baby is sufficiently

mature enough to survive. Where the fetus is confirmed alive and delivery is
not imminent, the birth and delivery is not imminent, the birth must be
expedited with the greatest possible speed to reduce the mortality and
morbidity associated with this condition.
 If immediate cesarean section is not possible or the baby is too premature,
reposition of the cord may be alternative. The cervix must be expedited with
the greatest possible speed to reduce the mortality and morbidity associated
with this condition.
 If immediate cesarean section is not possible or the baby is too premature,
reposition of the cord may be alternative. The cervix must be at least half
dilated and the cord wrapped in a large piece of sterile roller guaze, is
manually pushed above the presenting part under general anaesthesia. This is
 followed by stimulation of uterine contraction with oxytocin drip, if
necessary . when the cervix is about three –fourths dilated, ventouse traction
may be applied to deliver the baby. This is possible only with vertex
presentation and carries high fetal risks.
 If the head is engaged, delivery is completed by forceps. With a breech
engaged, a breech extraction is done.
 If the fetus is confirmed dead, labor is allowed to proceed, awaiting
spontaneous termination.

3.SHOCK

Shock is defined as a state of circulatory inadequacy with poor tissue

perfusion resulting in generalized cellular hypoxia leading to dysfunction of organs
and cells.
Shock can be acute but prompt treatment results in recovery with little
detrimental effect on the mother. However, inadequate treatment can result in
chronic multisystem organ failure, which may be fatal.

CLASSIFICATION OF SHOCK:
Based on the basic pathophysiology of shock and its clinical correlation,
shock may be classified as follows:

HYPOVOLEMIC SHOCK
The result of a reduction in intravascular volume.
 Hemorrhagic shock: associated with postpartum or post abortal hemorrhage,
ectopic pregnancy , placenta previa, abruption placenta, rupture of uterus
and obstetric surgery.
 Fluid loss shock: associated with excessive diarrhoea, vomiting, dieresis or
too rapid removal of amniotic fluid.
 Supine hypotensive syndrome: associated with compression of inferior vena
cava by pregnant uterus.
 Shock associated with disseminated intravascular coagulation: intrauterine
dead fetus syndrome and amniotic fluid embolism.
CARDIOGENIC SHOCK
Impaired ability of the heart to pump blood.
 Failure of the left ventricular ejection in cardiac arrest and myocardial
infarction.
 Failure of left ventricular filling associated with cardiac tamponade and
pulmonary embolism.

NEUROGENIC SHOCK
 Chemical injury : A ssociated with aspiration of gastrointestinal contents
during general anesthesia, especially in caesarean section (Mendelson’s
syndrome)
 Drug induced: Associated with spinal anesthesia.

SEPTIC SHOCK (ENDOTOXIC SHOCK)

Associated typically with septic abortion , chorioamnionitis, pyelonephritis

and rarely postpartum endometritis. This type of shock may be hypovolemic but
has primary cardiogenic and cellular components also. In this section, hypovolemic
shock and septic shock are discussed as either of which may occur because of child
bearing.

1. HYPOVOLEMIC SHOCK:
The body reacts to the loss of circulating fluid in stages as follows:

 INTIAL STAGE:
The reduction in fluid or blood decreases the venous return to the heart. The
ventricles of the heart are inadequately filled, causing a reduction in stroke
volume and cardiac output. As cardiac output and venous return fall, the
blood pressure is reduced. The drop in blood pressure decreases the supply
of oxygen to the tissues and cell function is affected.

 COMPENSATORY STAGE:
 The drop in cardiac output produces a response from the sympathetic
nervous system through the activation of receptors in the aorta an carotid
arteries. Blood is redistributed to the vital organs. Vessels in the
gastrointestinal tract, kidneys, skin and lungs constrict. The response is seen
by the skin becoming pale and cool peristalsis shows, urinary output is
reduced and exchange of gas in the lungs is impaired. The heart rate
increases in an attempt to improve cardiac output and blood pressure. Pupils
of the eyes dilate.
Adrenaline and aldosterone from adrenal glands and antidiuretic
hormone from posterior pituitary gland are secreted causing
vasoconstriction, an increased cardiac output and a decrease in urinary
output. Venous return to the heart will increase but, unless the fluid loss is
replaced, this will not be sustained.

 PROGRESSIVE STAGE:
This stage leads to multisystem failure. Compensatory mechanisms begin to
fail, with vital organs lacking adequate perfusion. Volume depletion causes further
fall in blood pressure and cardiac output. The coronary arteries suffer lack of
supply. Peripheral circulation is poor, with weak or absent pulses.

 LATE STAGE (IRREVERSIBLE):

Hypotension continues and cannot be reversed by replacement of fluid because
of stagnation of blood at the micro vascular level. Color of skin becomes ashen
gray. Metabolic acidosis starts and for elimination of accumulated carbon dioxide,
the respiratory rate becomes rapid. Imperceptible low volume pulse, oliguria and
mental confusion occur. Multisystem failure and cell destruction are irreparable.
Treatment of any kind is practically useless in this phase. Death ensues.

ETIOLOGY:
Antenatal – Ruptured ectopic pregancy , Incomplete abortion ,Placenta previa –
Placental abruption , Uterine rupture
Post partum – Uterine atony ,Laceration to genital tract ,Chorioamnionitis –
Coagulopathy , Retained placental tissue

SIGN AND SYMPTOMS:

 Mild symptoms can include:
headache , fatigue , nausea, profuse sweating , dizziness
Severe symptoms, include:-
cold or clammy skin, pale skin, rapid, shallow breathing , rapid heart rate, little
or no urine output , confusion , weakness , weak pulse , blue lips and fingernails
,Lightheadedness , loss of consciousness

MANAGEMENT:

Urgent resuscitation is needed to prevent the mother’s condition from

deteriorating and causing irreversible damage. The priorities are to:
1. Maintain the airway: if the mother is severely collapsed, she should be
turned on to her side and oxygen administered at a rate of 6-8 liters per
minute. If she is unconscious, endotracheal intubation may be necessary.
2. Replace fluids: (infusion and transfusion) : Blood should be taken for cross
matching prior to commencing intravenous fluids. A plasma expander or
fresh frozen plasma is given until whole blood is available.
3. Avoid warmth: constriction of the peripheral blood supply occurs in
response to the shock and keeping the mother warm may interfere with this
response, causing further detoriation in her condition.
4. Control of hemorrhage: Specific surgical and medical treatment for control
of hemorrhage should start along with the general management of shock.

2. SEPTIC SHOCK
There is an overwhelming infection, commonly from gram-negative
organisms such as Escherichia coli, Proteus etc.
The body’s primary response to infection is alteration in the peripheral
circulation. Cells damaged by the infecting organisms release histamine and
enzymes that contribute to vasodilatation and increased permeability of the
capillaries. Mediators are also reduced that have the opposite action of
vasoconstriction. The overall response, however, is one of vasodilatation , which
reduces the systemic vascular resistance.
ETIOLOGY:
 Post cesarean delivery
 Prolonged rupture of membranes
 Retained products of conception
 rupture membrane
 Intra-amniotic infusion
 Water birth
 Retained product of conception
 Urinary tract infection
 Toxic shock syndrome
 Necrotizing Fasciitis

CLINICAL SIGNS OF SEPTIC SHOCK

 In the initial phase, there is marked flushing of the face and the skin feels
warm.
 Temperature rise varies between 1010 F to 1050 F.
 Tachycardia, tachypnea and rigors occur.
 Hemorrhage may be present which either could be due to the events of
childbearing or because of disseminated intravascular coagulation.
 As vasodilatation continues, hypotension leads to kidney damage with
reduced glomerular filtration and acute tabular necrosis and oliguria.
 If the shock condition does not improve, the patient passes clinically to the
stage of “irreversible shock”. She remains cold and clammy with ashen-gray
cyanotic appearance.
 Anuria, cardiac or respiratory distress and coma may supervene.
 Disseminated intravascular coagulation is also a feature of septic shock.
 Multisystem organ failure will result as an effect of the continued
hypotension and myocardial depression. Failure of the liver, brain and
respiratory systems follows and death results.

MANAGEMENT OF SEPTIC SHOCK

 Management is based on further deterioration by restoring circulatory
volume and eradication of the infection. A full infection screening should be
carried out including a high vaginal swab, midstream urine and blood cultures.
Retained products of conception if detected on ultrasound should be removed.
Measures of management include intravenous administration of antibiotics,
intravenous fluids, adjustment of acid base balance, steroids, prevention and
treatment of intravascular coagulation and toxic myocarditis, administration of
oxygen and elimination of the source of infection.
 Antibiotics broad spectrum
 Intravenous fluids and electrolyes
 Correction of acidosis
 Maintenance of blood pressure.
 Corticosteroids
The mother may require care and management in a critical or intensive care
unit. The family should be kept informed of progress.

3.CARDIOGENIC SHOCK:
Cardiogenic shock in pregnancy is a life- threatening medical condition resulting
from an inadequate circulation of blood. Pregnancy puts progressive strain on the
heart as progresses. Preexisting cardiac disease places the parturient at particular
risk. Cardiac related death in pregnancy is the second most common cause of death
in pregnancy.

SIGN AND SYMPTOMS:

 Chest pain
 Nausea and vomiting
 Dyspnoea
 Profuse sweating
 Confusion/disorientation
 Palpitations
 Faintness/syncope
 Pale, mottled, cold skin with slow capillary refill and poor peripheral pulses.
Hypotension (remember to check BP in both arms in case of aortic
dissection). Tachycardia/bradycardia.
  Peripheral oedema. Quiet heart sounds or presence of third and fourth heart
sounds.
 Heaves, thrills or murmurs may be present and may indicate the cause, such
as valve dysfunction.
 Bilateral basal pulmonary crackles or wheeze may occur.
 Oliguria

.
MANAGEMENT:
Re-establishment of circulation to the myocardium,
Minimising heart muscle damage and improving the heart’s effectiveness as
a pump.
Administer Oxygen (O2) therapy to reduces the workload of the heart by
reducing tissue demands for blood flow.
Administration of cardiac drugs such as Dopamine, dobutamine,
epinephrine, norepinephrine,

4.RUPTURE OF THE UTERUS

Rupture of the uterus is an uncommon injury and when it happens, it can be a
catastrophic event, as it places the mother and fetus at high risk for morbidity and
mortality.

DEFINITION:
A rupture is defined as an abrupt tearing of the uterus and can be complete or
incomplete.

CLASSIFICATION OF RUPTURE
Scar Rupture and Dehiscence
 In scar rupture disruption of the entire length of the scar occurs. With
classical scars, rupture occurs late in pregnancy or early labor. Bleeding is
slight unless the placenta is lying underneath. Rupture lower segment scars
occur with obstructed labor. It is accompanied by a “tearing pain”. Bleeding
may not be heavy.
  Dehiscence is disruption of part of the scar and not the entire length. It tends
not to cause any bleeding and is without clinical significance.

complete and incomplete rupture

 Complete uterine rupture extends through the entire wall and peritoneum
with the entire contents spilling into the abdominal cavity.
 An incomplete uterine rupture extends through the endometrium and
myometrium without involving the peritoneum.

spontaneous and traumatic rupture

 A spontaneous rupture is one that occurs during labor owing to a
myometrium weakened by a previous scar.
 A traumatic uterine rupture may be caused by trauma resulting from
obstetric instruments, obstetric interventions or accidents such as fall or
blow on the abdomen.

RISK FACTORS:
 A tumultuous labor resulting from oxytocin induction when not controlled
carefully .
 Multiparity combined with use of oxytocin.
 Obstructed labor such as with absolute.
 Accidents such as falling face downwards.
 Trauma due to forceps, breech extraction or internal version late in labor.
 Excessive fundal pressure.
 Shoulder dystocia.

SIGNS AND SYMPTOMS

 Exquisite abdominal pain . when the rupture is complete, the woman

experiences a transient relief from pain followed by cessation of
contractions.
 Vaginal bleeding
  Intra abdominal bleeding, which may be lead to rapid collapse. Blood may
be confined retroperitoneal as a broad ligament hematoma.
 Lack of progress in labor.
 Shock from hemorrhage
 Alteration in shape of abdominal swelling. The uterus contracts and may be
mistaken for a fetal head in the suprapubic region.
 Palpation of fetal parts outside the uterine wall. the fetus is wholly or partly
extruded into the abdominal cavity and quickly dies whether or not the tear
is complete or incomplete.
 Rapid onset of fetal distress progressing to absence of fetal heart sounds.
 Restlessness and anxiety.
 An empty pelvis on vaginal examination.

MANAGEMENT:

-Emergency cesarean delivery with repair of the rupture., if the woman is

undelivered and the symptoms are not severe.
-cesarean hysterectomy , if the tear is severe and cannot be repaired.

NURSING MANAGEMENT
 Continous assessment of the woman who is predisposed to develop a
rupture. In those with classical cesarean scar, the rupture is likely to occur
even before labour begins.
 Monitor the progress of labor carefully in order to facilitate early
identification or abnormal symptoms.itmaternal and fetal vitals and fluid
status.
 Administer oxygen saturation.
 Cautions use of oxytocin in women with uterine scar.
 Monitor maternal and fetal vitals and fluid status.
 Support to woman and family regarding the situation.
5.AMNIOTIC FLUID EMBOLISM

This condition occurs when amniotic fluid enters the maternal circulation
through the membranes or placenta. The body responds in two phases- the initial
phase is one of vasospasm causing hypoxia, hypotension and cardiovascular
collapse. The second phase is the development of left ventricular failure, with
hemorrhage and coagulation disorder followed by pulmonary edema. Mortality and
morbidity are very high.
The presence of thromboplastin rich liquor amnii in the maternal circulation
blocks the pulmonary arteries and triggers the complex coagulation mechanism
leading to DIC. There will be severe clotting defect with profuse bleeding per
vagina or through the venepuncture sites due to consumption of coagulation
factors.

PREDISPOSING FACTORS:

Amniotic fluid embolism can occur at any stage in gestation. It is mostly

associated with labor, through cases in early pregnancy and postpartum have been
reported.
 Transfer of amniotic fluid from the uterus to the maternal circulation can be
insidiously associated with a tear in the membranes.
 Amniotic fluid under pressure may enter maternal circulation in the first
phase of hypoxia during hypertonic uterine activity.
 Procedures such as insertion of intrauterine catheter and artificial rupture of
membranes are associated with the condition.
 In cases of placenta abruption the placental bed is disrupted, and the barrier
between maternal circulation and amniotic sac may be breached.
 It can occur during a caesarean section or termination of pregnancy or in
association with ruptured uterus.
 Trauma may occur during intrauterine manipulation such internal podalic
version.
The condition is difficult to predict and equally difficult to prevent.

CLINICAL FEATURES
  Sudden onset of maternal respiratory distress: the woman becomes severely
dyspnic and cyanosed
 There is maternal hypotension and uterine hypotonia.
 Fetal distress in response to hypoxia caused by hypertonia.
 Cardiopulmonary arrest follows quickly in minutes.
 Many mothers present with convulsion immediately preceding the collapse.

EMERGENCY MANAGEMENT

Any one of the above symptoms is indicative of an acute emergency. The

mother may be in a state of collapse and resuscitation must be started at once.
Specific management of the condition is life support and high levels of oxygen are
required. Mothers who survive may suffer neurological impairment.

COMPLICATIONS
 DIC (Disseminated intravascular coagulation)
 Acute renal failure
 Prolonged hypovolemic hypotension.

EFFECT ON THE FETUS

Perinatal mortality and morbidity are high, where amniotic fluid embolism occurs
before the birth of the baby. Maternal collapse to delivery need to be minimal if
fetal death is to be avoided.

NURSING MANAGEMENT:

Give immediate and vigorous treatment.

Give oxygen by face mask.
Maintain normal blood volume through administration of plasma and
intravenous fluids.
Prevent development of disseminated intravascular coagulation (DIC).
Serious complications can occur.
 Administer whole blood and fibrinogen.
Monitor the patient’s vital signs.
Deliver the fetus as soon as possible

6.INVERSION OF THE UTERUS

It is rare but potentially a life threatening situation in which the uterus is

turn inside out partially or completely the incidence is about 1:20,000 deliveries.
The obstetric inversion is usually an acute one and usually complete.

Classification of inversion:

I degree: there is dimpling of the fundus which remains above the level of internal
os.
II degree: the uterus is inverted and the fundus passes through the cervix but lies
inside the vagina.
III degree: the endometrium with or without the attached the placenta is visible
outside the vulva. The uterus, cervix and the part of vagina are inverted and visible.

Causes:

The inversion may be spontaneous or more commonly induced.

Spontaneous( 40%):

this is brought about by local atony of the placental site over the fundus associated
with sharp rise of intra abdominal pressure as in coughing, sneezing or bearing
down effort. Fundal attachment of the placenta, short cord, and placenta accrete
are often associated.

Induced(60%):
This is due to mismanagement of third stage of labor
  pulling the cord when the uterus is atonic specially when combined with
fundal pressure
 crede’s method of placental expression while the uterus is relaxed.
 Faulty technique in manual removal: pulling the partially separated
placenta, or firmly pressing on the atonic uterus by the external hand or
rapidly withdrawing the internal hand there by creating negative pressure.

Complication:

 Shock which is profound and mainly neurogenic in origin due to:

- Tension on the nerves from stretching of the infundibulopelvic
ligament.
- Pressure on the ovaries as they are dragged with the fundus.
- Peritoneal irritation.
 Hemorrhage after detachment of placenta
 Pulmonary embolism
 Infection
 Uterine sloughing

Diagnosis:
 Acute lower abdominal pain with bearing down sensation
 varying degrees of shock
 on abdominal examination:
- dimpling and cupping of the fundal surface
- fundus cannot be palpated
- incomplete variety, a pear shaped mass protrudes outside the vulva
with the broad end and pointing down wards and looking reddish
purple in color

MANAGEMENT:

Before shock develops:

Immediate medical support must be summoned. Urgent manual replacement
must be done as
 to push the fundus with the palm of the hand, along the direction of the
vagina towards the posterior fornix.
To apply counter support with the other hand palced on the abdomen
After replacement the hand should remain inside the uterus until the uterus
becomes contracted by parenteral oxytocics.
The placenta is to be removed manually only after the Uterus becomes
contracted. A partially separated placenta may be removed prior to
replacement to reduce the bulk which facilitates replacement.
Usual treatment of shock including blood transfusion should be arranged as
and when required.

After shock develops:

The treatment of shock should be instituted vigorously. Morphine 15mg IM,
dextrose saline drip and arrangements for blood transfusion to be made.
To push the uterus inside the vagina if possible, and to pack the vagina with
antiseptic roller gauze.
Foot end of the bed is to be raised
Replacement of the uterus under general anesthesia to be done along with
resuscitative measures.

If manual replacement fails the method of hydrostatic

replacement is instituted. This involves the instillation of warm saline through a
douche nozzle. The pressure of the fluid builds up as several liters are run into the
vagina and restores the uterus to the normal position while the operator seals off
the introitus by one hand inserted into the vagina.

If the inversion cannot be manually replaced it may be due to

development of cervical constriction ring drugs can be utilized to relax the
constriction ring and facilitate the return of the uterus to its normal position.
Throughout the procedure, the women and her husband or family
should be kept informed of what is happening. Assessment of vital signs and level
of consciousness is of great importance.
NURSING MANAGEMENT:

 Monitor for signs of hemorrhage and shock and treat shock

 Prepare patient to reposition the uterus to the correct position via the vagina
or lapr0tomy if unsuccessful.

NURSING DIAGNOSIS:

 Ineffective tissue perfusion related to excessive blood loss causing decreased

placental circulation to the fetus.
 Deficit fluid volume in relation to excessive blood loss
 Anxiety related to unexpected occurrences because of the sudden
development of complications.
 Ineffective individual or family coping related to the transfer of the woman
to a tertiary center for more intensive management.
 Powerlessness related to inability to prevent or control condition and
outcomes.
 Risk for impaired physical mobility related to restriction of movement with
monitoring devices.

SUMMARY:
Till now we have discussed about definition of contracted pelvis, causes
,diagnosis, management ,obstetrical emergencies its definition, classification,
etiology, clinical manifestation, management and nursing diagnosis in detail.

CONCLUSION:
The management of emergencies is usually the responsibility of hospital
obstetricians. As more maternity care is now given in the community, however,
midwives, general practitioners, and paramedics may be involved and must know
the outlines of management of emergencies and the possible side effects.

RESEARCH ARTICLE::Scenario of obstetrical emergencies at a tertiary care

hospital Indian Journal of Obstetrics and Gynecology Research YEAR- 2016
ISSN NO-397-399The present study was conducted on a prospective basis for
one year, from 1st Feb 2011 to 31st Jan 2012 in the department of Obstetrics
and Gynecology Govt. Medical College and Rajindra Hospital, Patiala.
All the cases referred as critical emergency from nearby areas during their
antenatal period or within 42 days of delivery were included in the study. A
detailed history including age, parity, gestational age, antenatal care during
pregnancy, socioeconomic status, obstetrical history, medical or surgical disorders
was taken into account. Attention was paid on the management received by each
case including blood transfusion, surgical interventions, ICU
80. Total deliveries during this period were 2223. Total obstetric emergencies
came out to be 252. Thus the incidence of obstetric emergencies came out to be
11.3%. Various obstetric emergencies that were encountered – Hemorrhage
(47.97%), Hypertensive disorders of pregnancy (35.32%), obstructed labor
(12.3%), P. sepsis (3.18%), Rupture uterus (2.78%). Maternal mortality came out
to be 8.8% Hemorrhage was leading cause of death in 36.36% cases followed by
P. sepsis (13.64%), Hypertensive disorders of pregnancy (13.64%), Rupture uterus
(9.09%). There were 70.2% Live births and 29.8% still births.
81. Conclusions: It was concluded that obstetric emergencies are more common
in unbooked cases and women with low socioeconomic status with poor access to
antenatal care.

BIBLIOGRAPHY:
• Ajit virkud Modern Obstetrics, APC Publishers Mumbai, 3rd edition 2017.
• D.c Dutta Textbook of Obstetrics7th edition, New central book agency private
limited London. Pg 233-340
• Anamma Jacob Midwifery and Gynaecological nursing 4th edition, Jaypee
brothers and medical publishers, New Delhi. Pg 290-315
•https://www.jstor.org/stable/3401872
•www.ucdenver.edu/.../20a%20Hawkins%20OB%20Emergencies%20C
RASH%20201
• https://www.ncbi.nlm.nih.gov › NCBI › Literature › PubMed Central (PMC)
 RISK APPROACH,
SCREENING OF HIGH
RISK PREGNANCY AND
NEWER MODALITIES OF
DIAGNOSIS

SUBMITTED TO SUBMITTED BY

MRS .DR.S.SUJATHA MADAM J.KALPANA

ASST.PROFF MSC (N) II YR

GCON GCON

HYDERABAD HYDERABAD
NAME OF THE STUDENT : MS. J.KALPANA

COURSE : MSC (N) II YEAR

SUBJECT : OBG

TOPIC : RISK APPRAOCH IN PREGNANCY AND NEWER MODALITIES

GROUP : MSC (N)IIYEAR

PLACE : MSC CLASS ROOM

DATE : 29/01/2019

DURATION : 2HRS

METHOD OF TEACHING : LECTURER CUM DISCUSSION

SUPERVISED BY :MRS .RUTH JOSHILA ,LECTURER

OBJECTIVES:

General objectives:

By the end of seminar group will be able to gain in depth knowledge in risk
approach in pregnancy and newer modalities of diagnosis.

Specific objectives:

 group will be able to;

 Define risk approach
 Describe its strategies and purpose of risk approach
 Ennumerate the gaols of risk approach
 Explain the concept of risk approach
 Enlist the identification of high risk pregnancy
 Explain screening of high risk cases
 Describe the management of risk approach
 Discuss role of nurse of risk approach
 Explain in detail about newer modalities if diagnosis of risk approach