Abnormalities of labour and delivery Artúr Beke MD PhD Semmelweis University Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology Baross Street 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 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 • Cephalic 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 fetuses • 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 pregnancy • Placenta previa Artur Beke - Abnormalities of Labour and Delivery - 2019 Vaginal delivery • Fetus must be in frank or complete breech presentation • Episiotomy • 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 Caesarean section – Risk of placental abruption 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 uterus 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-Zavanelli maneuver (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 – Polyhydramnios – 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 prolapse, umbilical cord looping, umbilical cord knots) Artur Beke - Abnormalities of Labour and Delivery - 2019 Etiology of acute fetal distress 3. Reduction of the