Abnormalities of labour and delivery

Artúr Beke MD PhD Semmelweis University Department of and Gynecology

Department of Obstetrics and Gynecology Baross Street Abnormalities of labor and delivery

• 1. Fetal malpositions and malpresentations

• 2. Uterine dystocia • 3. • 4. Premature rupture of the membranes

• 5. • 6. Preterm delivery • 7. Twin delivery

Artur Beke - Abnormalities of Labour and Delivery - 2019 1. Fetal malposition and malpresentations

Artur Beke - Abnormalities of Labour and Delivery - 2019 Fetal malposition and malpresentations

• A./ Abnormal presentation – Breech presentation – Transverse or oblique lie (shoulder presentation) • B./ Abnormal position – High sagittal position – Obliquity • C./ Abnormalities of flexion – Deflexion of the head • D./ Abnormalities of rotation

Artur Beke - Abnormalities of Labour and Delivery - 2019 A./ ABNORMAL PRESENTATION

• 96.5%

• Breech presentation 3.0% • Transverse or oblique lie 0.5%

Artur Beke - Abnormalities of Labour and Delivery - 2019 Breech presentation

• Fetal buttocks or lower extremities present • 3% of all deliveries • At the 30th week 25% of • After 36th week no change in position

Artur Beke - Abnormalities of Labour and Delivery - 2019 Types of breech presentation

• Frank breech - Extended legs (Simple) (65%)

• Complete breech - Flexed legs (25%)

• Incomplete breech - Footling or knee presentation (10%)

Artur Beke - Abnormalities of Labour and Delivery - 2019 Diagnosis of breech presentation

• Leopold examination • Vaginal examination • Sonography

Artur Beke - Abnormalities of Labour and Delivery - 2019 Etiology of breech presentation

• Prematurity • Fetal anomalies • Uterine anomalies • Pelvic anomalies • Umbilical cord complications • Twin • Placenta previa

Artur Beke - Abnormalities of Labour and Delivery - 2019 • must be in frank or complete breech presentation

• • Oxytocine infusion • CTG registration

• Bracht maneuver

• Müller maneuver (freed arms) • Mauriceau-Smellie-Veit maneuver (freed head) • (Forceps) Artur Beke - Abnormalities of Labour and Delivery - 2019 External cephalic version

• External cephalic version – Success rate 75% – Prepared for emergency – Risk of and umbilical cord compression

Artur Beke - Abnormalities of Labour and Delivery - 2019 Indication for Ceasarean Section

• Breech presentation +

• Preterm delivery (fetal head is relatively larger) • 1st delivery (longer 2nd stage) • PROM (dystocia) • Incomplete breech • Twin pregnancy • Large fetus

Artur Beke - Abnormalities of Labour and Delivery - 2019 Transverse or oblique lie (shoulder presentation)

• No fetal pole detected above the symphysis • Vaginal delivery is impossible • High risk of rupture of the

Artur Beke - Abnormalities of Labour and Delivery - 2019 Fetal malposition and malpresentations

• A./ Abnormal presentation – Breech presentation – Transverse or oblique lie (shoulder presentation) • B./ Abnormal position – High sagittal position – Obliquity • C./ Abnormalities of flexion – Deflexion of the head • D./ Abnormalities of rotation

Artur Beke - Abnormalities of Labour and Delivery - 2019 B./ ABNORMAL POSITION

• High sagittal position • Obliquity

Artur Beke - Abnormalities of Labour and Delivery - 2019 High sagittal position

• Normal • / sagittal suture in the transverse/ • Occipito-sacral position

• Occipito-pubical position

If no more rotation

Artur Beke - Abnormalities of Labour passing straight! and Delivery - 2019 Obliquity

Asynclitic • Anterior parietal position = Naegele obliquity

• Posterior parietal position = Litzmann obliquity

Normal Litzmann Naegele

Artur Beke - Abnormalities of Labour and Delivery - 2019 Fetal malposition and malpresentations

• A./ Abnormal presentation – Breech presentation – Transverse or oblique lie (shoulder presentation) • B./ Abnormal position – High sagittal position – Obliquity • C./ Abnormalities of flexion – Deflexion of the head • D./ Abnormalities of rotation

Artur Beke - Abnormalities of Labour and Delivery - 2019 C./ ABNORMALITIES OF FLEXION

• Deflexion of the head

Artur Beke - Abnormalities of Labour and Delivery - 2019 Cephalic presentation

• Vertex presentation /normal/ • Poorly flexed • Brow presentation • Face presentation

Important to examine the fontanelles and suture lines Artur Beke - Abnormalities of Labour and Delivery - 2019 Deflexion of the head

• Brow presentation – 1/1400 deliveries – Unstable presentation (convert to face or vertex) – Persistent brow presentation C/S • Face presentation – 1/500 deliveries – 60% mentoanterior possible vaginal delivery

– 40% mentoposterior C/S

Artur Beke - Abnormalities of Labour and Delivery - 2019 Fetal malposition and malpresentations

• A./ Abnormal presentation – Breech presentation – Transverse or oblique lie (shoulder presentation) • B./ Abnormal position – High sagittal position – Obliquity • C./ Abnormalities of flexion – Deflexion of the head • D./ Abnormalities of rotation

Artur Beke - Abnormalities of Labour and Delivery - 2019 D./ ABNORMALITIES OF ROTATION

• Persisted occipito- posterior position – (The rotation of the head is opposite)

• Persisted transverse position – (No rotation) Longer 2nd stage

Artur Beke - Abnormalities of Labour and Delivery - 2019 Abnormalities of labor and delivery

• 1. Fetal malpositions and malpresentations

• 2. Uterine dystocia • 3. Shoulder dystocia • 4. Premature rupture of the membranes

• 5. Fetal distress • 6. Preterm delivery • 7. Twin delivery

Artur Beke - Abnormalities of Labour and Delivery - 2019 2. Uterine dystocia

• Abnormal uterine activity • Abnormal presentation • Cephalopelvic disproportion • Umbilical complication • Fetal asphyxia

Artur Beke - Abnormalities of Labour and Delivery - 2019 Management of uterine dystocia

• Oxytocin infusion • Glucose infusion • Mobilization • Cervix dilatation – Prostaglandins – Drotaverin + Opiates – Epidural analgesia – (Paracervical block) • Perineal relaxation – Epidural analgesia – Pudendal block – (Spinal analgesia)

Artur Beke - Abnormalities of Labour and Delivery - 2019 3. Shoulder dystocia

• Large fetus (more than 4000 g) • The shoulder is not delivered after the head during the next contraction

Artur Beke - Abnormalities of Labour and Delivery - 2019 Management of shoulder dystocia

• Pressure suprapubic region • McRoberts maneuver (maternal thigh hyperflexed against maternal abdomen) • Woods maneuver (rotate the scapula) • Free the posterior arm

• Gunn- (reposition of the head and Caesarean section) • (Cleidotomy, cleidorrhexis) • (Sympisiotomy) Artur Beke - Abnormalities of Labour and Delivery - 2019 4. Premature rupture of the membranes (PROM)

• Amniorrhexis (spontaneous rupture) • Before onset of labor (before contractions)

Artur Beke - Abnormalities of Labour and Delivery - 2019 Etiology of the PROM • Mechanical – Cervix incompetence – Previous operation on the cervix – – Transverse lie – Uterine malformations – Frequent vaginal examination – Amnioscopy • Infection – Bacterial vaginosis – Trichomonas – Cervicitis (Chlamydia) – Other • Streptococcus agalactiae • Streptococcus fecalis • Listeria monocytogenes Artur Beke - Abnormalities of Labour and Delivery - 2019 Diagnosis of PROM

• Anamnesis • Vaginal examination • Sonography • Vaginal AFP • Arborisation

Artur Beke - Abnormalities of Labour and Delivery - 2019 Management of PROM

• Laboratory examination (WBC, CRP) • Temperature • Antibiotic treatment • Antenatal corticosteroid therapy

• Prostaglandins for cervical ripening • Induction of the contractions by oxytocin

Artur Beke - Abnormalities of Labour and Delivery - 2019 Presentation and prolapse of the umbilical cord

• Knee-chest position • Elevating head • Emergency Caesarean section

Artur Beke - Abnormalities of Labour and Delivery - 2019 Abnormalities of labor and delivery

• 1. Fetal malpositions and malpresentations

• 2. Uterine dystocia • 3. Shoulder dystocia • 4. Premature rupture of the membranes

• 5. Fetal distress • 6. Preterm delivery • 7. Twin delivery

Artur Beke - Abnormalities of Labour and Delivery - 2019 5. Fetal distress

Artur Beke - Abnormalities of Labour and Delivery - 2019 Fetal distress

Fetal hypoxy

• Chronic distress • Acute distress

Artur Beke - Abnormalities of Labour and Delivery - 2019 Etiology of chronic fetal distress

Maternal causes Cardiac or pulmonological diseases Chronic hypoxy Anemia, bleeding

Diabetes, preeclampsia Vascular changes Immune diseases Uterine malformation (e.g. Uterus duplex)

Smoking Calcificated placenta Infections

Artur Beke - Abnormalities of Labour and Delivery - 2019 Etiology of chronic fetal distress

Fetal causes Fetal malformations, chromosomal abnormalities Umbilical cord anomalies (Single umbilical artery) Rh-sensibilisation Fetomaternal transfusion Twin-to-twin transfusion syndrome (TTTS)

Artur Beke - Abnormalities of Labour and Delivery - 2019 Etiology of acute fetal distress

1. Compressive effect of uterine contractions - If the placental gas exchange function is close to the critical level, even normal uterine activity may lead to oxygen deficiency - Good placental function + abnormal uterine activity (high uterine tone, intense, frequent contractions) causes fetal hypoxia 2. Obstruction of the umbilical cord - Compression on the umbilical cord (, umbilical cord looping, umbilical cord knots)

Artur Beke - Abnormalities of Labour and Delivery - 2019 Etiology of acute fetal distress

3. Reduction of the working placental surface - Partial placental abruption

4. Increased vulnerability of the fetus - Intrauterine infection - Multiple pregnancy - Congenital anomaly

Artur Beke - Abnormalities of Labour and Delivery - 2019 Pathophysiology of fetal hypoxy

 Fetal hypoxy  Fetal hypercapnia  Respiratoric acidosis  Anaerobic processes  Lactate  Metabolic acidosis

Artur Beke - Abnormalities of Labour and Delivery - 2019 Pathophysiology of fetal hypoxy

Centralization of the circulation  Vasoconstriction occurs in the blood vessels of the periphery (skin, skeletal muscle, lungs, kidneys) to ensure satisfactory circulation and O2 supply of vital organs (brain, heart).

Artur Beke - Abnormalities of Labour and Delivery - 2019 The consequences of chronic placental insufficiency

Intrauterine growth restriction (IUGR - nutritive insufficiency) Fetal hypoxy (respiratory failure) Meconium stained Intrauterine deaths

Artur Beke - Abnormalities of Labour and Delivery - 2019 Characterization of the fetal circulation - Doppler examination

Normal fetal blood flow values, non-centralized circulation

Onset centralization of circulation (arteria umbilicalis elevated resistance, arteria cerebry media decreased resistance)

Abnormal blood flow, centralized circulation (end-diastolic block, diastolic block)

Cardiac decompensation (reverse flow)

Artur Beke - Abnormalities of Labour and Delivery - 2019 Characterization of the fetal circulation - (CTG) Bradycardia Low oscillation (Low < 5bpm, Silent < 2bpm ) Decelerations Early decelerations - Head compression /normal/ Late decelerations - Uteroplacental insufficiency Variable decelerations - Cord compression Prolonged decelerations

Artur Beke - Abnormalities of Labour and Delivery - 2019 6. Preterm delivery

Artur Beke - Abnormalities of Labour and Delivery - 2019 Preterm delivery

• Delivery between 24 weeks 0 days and 36 weeks 6 days • rate: 6-10% • WHO's 1961 definition: delivery before 37th week

Artur Beke - Abnormalities of Labour and Delivery - 2019 PHYSIOLOGICAL RISK FACTORS FOR PREMATURE BABIES

• Weakly calcified skull • Vascular structures in vulnerable • Vulnerable dura mater • Lower levels of clotting factor • Hgb lower level • Cerebral dysfunction of autoregulation (consequtive hypertension) • Sensitivity to hypoxia (cerebral hemorrhagia due to hypoxia) • Relatively larger skull Incidence of breech is higher • → PERIVENTRICULAR HAEMORRHAGE, INJURIES • Lung immaturity • → RESPIRATORY DISTRESS SYNDROME • Immaturity of the immune system • → INFECTIONS (PNEUMONIA, SEPSIS, NEC)

Artur Beke - Abnormalities of Labour and Delivery - 2019 ETIOLOGY

INFECTION • Premature contractions • Early cervical ripening • Premature • Bacterial enzymes, inflammatory reaction

ANATOMICAL, MECHANICAL FACTORS • Damaged cervical locking function • Uterine malformations • Polyhydramnios, multiple pregnancy, transverse lie • Cervical stretch – reflective contractions

BLEEDING • Placental abruption,

INDUCED PRETERM DELIVERY

Artur Beke - Abnormalities of Labour and Delivery - 2019 STEROID-PROPHYLAXIS

PREVENTON OF RESPIRATORY DISTRESS SYNDROME

• Surfactant production in Type II pneumocytes (from 22 weeks) • Up to 34th weeks is recommended for prophylaxis of steroid • In cases of premature rupture of membranes can also be used • 24 hours later develops optimum effect • After 2 week, repeatable

• Dexamethasone • Betamethasone

Artur Beke - Abnormalities of Labour and Delivery - 2019 DELIVERY

• In cases of preterm delivery is important the route of delivery • In vertex presentation the vaginal delivery will not elevate morbidity, mortality indicators • In breech presentation (under 2000 g and before the 34th week) the Caesarean section favorably affect the life expectancy of newborn Artur Beke - Abnormalities of Labour and Delivery - 2019 7. Twin delivery

Artur Beke - Abnormalities of Labour and Delivery - 2019 Prevalence of twin pregnancy

Hellin's rule / classic / Gemini - 1/85 • Trigemini - 1/852 • Qadrigemin - 1/853 At present the rates are higher, because of assisted reproductive methods Spontaneous reduction – fetus papyraceus or fetus compressus

Artur Beke - Abnormalities of Labour and Delivery - 2019 Monozygotic and dizygotic twins

• Monozygotic • Dizygotic – 25% of same-sex – 75% of the opposite sex

Artur Beke - Abnormalities of Labour and Delivery - 2019 Placentations of monozygotic and dizygotic twins monozygotic twins

DDD MDD MMD MMM

dizygotic twins

Ultrasound

Artur Beke - Abnormalities of Labour and DDD MDD Delivery - 2019 Monochorial or dichorial

MDD MMD

Artur Beke - Abnormalities of Labour and Lambda-sign Delivery - 2019 T-sign Position of fetuses

• vertex-vertex 45,4% • vertex-breech 38,6% • breech-breech 9,2% • vertex-transverse 5,3% • breech-transverse 1,7% • transverse-transverse 0,2%

Artur Beke - Abnormalities of Labour and Delivery - 2019 Position of fetuses

• „A” vertex – possible vaginal delivery • „A” breech – Caesarean section • (Higher risk of !) • „A” transverse – Caesarean section

Artur Beke - Abnormalities of Labour and Delivery - 2019 Locked twins

Collisio geminorum - locked twins

Artur Beke - Abnormalities of Labour and Delivery - 2019 Risk of twin pregnancy

• During delivery – Uterine distocia – Overstrain of uterus – Locked twins – "B" fetus – placental abruption – "B" fetus - turns to transverse – Caesarean section because of "B„ – Atony after delivery / Caesarean section

Artur Beke - Abnormalities of Labour and Delivery - 2019 Vaginal delivery of twin pregnancy

• Delivery of „A” fetus – episiotomy is recommended. • Necessary tools for two fetuses • Two obstetricians or more • Presence of neonatologist • After delivery of „A” fetus - an internal examination check the position of the „B” • If the „B” is in vertex position, the assistant fixes the skull, and the obsterician rupture the membrane, and start pushing • If the „B” fetus is in breech presentation, the same like in delivery of breech • If the „B” fetus turns to transverse, hold the leg and turning and extraction

Artur Beke - Abnormalities of Labour and Delivery - 2019 Monochorial monoamniotic twin • Rare (0.2%) • Hospitalisation is advocated as soon as the fetuses are viable • Fetal heart trace monitoring twice a day • Fetal heart trace monitoring – uterine contractions or – sharp fetal movements felt by the mother • Planned, prophylactic Caesarean at 32 weeks* *Beasley E, Megerian G, Gerson A, Roberts N. caseseries and proposal for antenatal management. Obstet Gynecol1999;93:130–4.

Artur Beke - Abnormalities of Labour and Delivery - 2019