Obstructed laborObstructed labor
DefinitionDefinition
►When there is poor or no progress ofWhen there is poor or no progress of
labour in spite of good ute...
Maternal causes (fault in passage)Maternal causes (fault in passage)
1.1. Contracted pelvisContracted pelvis
2.2. Pelvic t...
44
55
Cervix in labor
Fetal causes (fault in the passenger)Fetal causes (fault in the passenger)
1.1. Macrosomic babyMacrosomic baby
2.2. Malpre...
77
99
Shoulder dystocia is called if shoulders
cannot be delivered with gentle traction
04/09/1404/09/14 1010
DiagnosisDiagnosis
►Partograph will recognizePartograph will recognize
impending obstruction earlyimpending obstruction ea...
General examination:-General examination:-
Features of maternal distress i.e.Features of maternal distress i.e.
Exhaustion...
Abdominal examinationAbdominal examination
-The retraction ring (bandl’s ring) is seen and-The retraction ring (bandl’s ri...
04/09/1404/09/14 1515
Vaginal examination:-Vaginal examination:-
- The vulva usually swollen and edematous.The vulva usually swollen and edemato...
ManagementManagement
►Preventive:-Preventive:-
- Proper assessment of pregnant womanProper assessment of pregnant woman
du...
CurativeCurative
A.A. Immediate managementImmediate management
B.B. General managementGeneral management
C.C. Obstetric ma...
Immediate managementImmediate management
1.1. Correct maternal dehydrationCorrect maternal dehydration
2.2. prevent contra...
B. General management :-B. General management :-
1.1. Assessment of mother general condition.Assessment of mother general ...
C. Obstetric managementC. Obstetric management
1-1-Vaginal delivery:-Vaginal delivery:-
(Destructive opt.) dead fetus(Dest...
2. Caesarean section:-2. Caesarean section:-
-A live fetus-A live fetus
-Over distended lower segment with impending ruptu...
Active management of 3Active management of 3rdrd
stage of labor.stage of labor.
AA
CONTROLLED CORD TRACTION
ComplicationComplication
Maternal
-Rupture of uterus
-VVF
-RVF
-PPH
-Puerperal sepsis
-Shock
-Maternal death
Fetal
-intra ...
Shoulder Dystocia
DefinitionDefinition
• impaction of anterior shoulder aboveimpaction of anterior shoulder above
symphysissymphysis
• inabi...
Failure to deliver fetal shoulder without utilizingFailure to deliver fetal shoulder without utilizing
facilitating maneuv...
PathophysiologyPathophysiology
The fetal bisacromial diameterThe fetal bisacromial diameter
normally enters the pelvis at ...
PathophysiologyPathophysiology
In shoulder dystocia there isIn shoulder dystocia there is
– Absence of truncal rotationAbs...
Risk FactorsRisk Factors
• post-term pregnancypost-term pregnancy
• maternal obesitymaternal obesity
• fetal macrosomiafet...
Risk factors are present
in
< 50% of cases
DiagnosisDiagnosis
• head recoils against perineum, ‘turtle’ signhead recoils against perineum, ‘turtle’ sign
• spontaneou...
ComplicationsComplications
• Fetal/neonatalFetal/neonatal
- deathdeath
- asphyxia and sequelaeasphyxia and sequelae
- frac...
ManagementManagement
 Goal: Safe delivery before neontalGoal: Safe delivery before neontal
asphyxia and/or cortical injur...
Prophylactic Cesarean?Prophylactic Cesarean?
Not recommended by ACOGNot recommended by ACOG
Exceptions:Exceptions:
– Consi...
• PPanicanic
• PPullingulling (on the head)(on the head)
• PPushingushing (on the fundus)(on the fundus)
• PPivotingivotin...
Ask for help
Lift - the buttocks
- the legs
Anterior disimpaction of shoulder
- rotate to oblique
- suprapubic pressure
Ro...
• get the mother onget the mother on
your sideyour side
• partner, coachpartner, coach
• nursingnursing
• notify physician...
LLifting the legs and buttocksifting the legs and buttocks
-McRobert’s Maneuver-McRobert’s Maneuver
• Flexion of thighs on abdomen
requires assistance
• 70% of cases are resolved
with this maneuver alone
Lifting the legs a...
• suprapubic pressure appliedsuprapubic pressure applied
with heel of clasped hand fromwith heel of clasped hand from
the ...
Suprapubic PressureSuprapubic Pressure
Adduction of the most accessible
shoulder moves the fetus into an
oblique position and decreases the
bisacromial diameter
...
RRotate the posterior shoulder - Woods’otate the posterior shoulder - Woods’
manoeuvermanoeuver
Abduct posterior shoulder ...
MManual removal of the posterior armanual removal of the posterior arm
grasp the posterior arm and
sweep it across the ant...
MMove patient to All-Fours Maneuver(Gaskin Maneuver)ove patient to All-Fours Maneuver(Gaskin Maneuver)
Changes pelvic dime...
EpisiotomyEpisiotomy
• May facilitate Wood’s Manoeuver orMay facilitate Wood’s Manoeuver or
allow room for delivery of the...
As a last resortAs a last resort
• clavicular fractureclavicular fracture
• cephalic replacement (Zavenellicephalic replac...
AfterwardsAfterwards
• be prepared for PPHbe prepared for PPH
• inspect for maternal lacerationsinspect for maternal lacer...
• Anticipate and be prepared (most are
unpredictable)
• Stay calm, don’t panic, pull, push or pivot
• Remember the “ALARM-...
Ask for help
Lift - the buttocks
- the legs
Anterior disimpaction
- suprapubic pressure(abdominal)
- - rotate to oblique (...
A 25 year-old healthy woman has a normal laborA 25 year-old healthy woman has a normal labor
and a spontaneous delivery of...
AnswerAnswer
A) Tell the patient not to pushA) Tell the patient not to push
– The training and experience of clinicianThe ...
Thank you !!!Thank you !!! 
Obstructed labor and shoulder dystocia for undergraduate
Obstructed labor and shoulder dystocia for undergraduate
Obstructed labor and shoulder dystocia for undergraduate
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Obstructed labor and shoulder dystocia for undergraduate

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Undergraduate course lectures in obstetrics&Gynecology Prepared by DR Manal Behery ,Professor of OB&Gyne .Faculty of medicine,Zagazig University

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Obstructed labor and shoulder dystocia for undergraduate

  1. 1. Obstructed laborObstructed labor
  2. 2. DefinitionDefinition ►When there is poor or no progress ofWhen there is poor or no progress of labour in spite of good uterine contraction.labour in spite of good uterine contraction. ►Incidence :Incidence :- 1 -2% of referral cases in- 1 -2% of referral cases in developing country.developing country.
  3. 3. Maternal causes (fault in passage)Maternal causes (fault in passage) 1.1. Contracted pelvisContracted pelvis 2.2. Pelvic tumor:- fibroid, ovarian tumorPelvic tumor:- fibroid, ovarian tumor 3.3. Tumor of rectum, bladder or pelvicTumor of rectum, bladder or pelvic bone.bone. 4.4. Abnormality in uterus & vagina:-stenosisAbnormality in uterus & vagina:-stenosis in Cx. & vagina, contraction ring inin Cx. & vagina, contraction ring in uterus, vaginal septum, rigid perineum.uterus, vaginal septum, rigid perineum.
  4. 4. 44
  5. 5. 55 Cervix in labor
  6. 6. Fetal causes (fault in the passenger)Fetal causes (fault in the passenger) 1.1. Macrosomic babyMacrosomic baby 2.2. MalpresentationMalpresentation 3.3. Malposition:-Malposition:- 4.4. Malformed fetus:- hydrocephalus, fetalMalformed fetus:- hydrocephalus, fetal Ascitis, conjoint twinsAscitis, conjoint twins 5.5. Locked twinsLocked twins
  7. 7. 77
  8. 8. 99 Shoulder dystocia is called if shoulders cannot be delivered with gentle traction
  9. 9. 04/09/1404/09/14 1010
  10. 10. DiagnosisDiagnosis ►Partograph will recognizePartograph will recognize impending obstruction earlyimpending obstruction early .. ►history of-prolonged labour and -the labour painhistory of-prolonged labour and -the labour pain become severe and frequent and -bearing down.become severe and frequent and -bearing down.
  11. 11. General examination:-General examination:- Features of maternal distress i.e.Features of maternal distress i.e. Exhaustion & keto acidosisExhaustion & keto acidosis DehydrationDehydration Tachycardia >100/mTachycardia >100/m Raise temperatureRaise temperature Scanty urineScanty urine
  12. 12. Abdominal examinationAbdominal examination -The retraction ring (bandl’s ring) is seen and-The retraction ring (bandl’s ring) is seen and felt between the tonically contracted upperfelt between the tonically contracted upper segment of the uterus and the distended ,segment of the uterus and the distended , tender and stretched lower segment.tender and stretched lower segment. - Distended urinary bladder.Distended urinary bladder. - FHS shows evidence of fetal distress orFHS shows evidence of fetal distress or even absent.even absent.
  13. 13. 04/09/1404/09/14 1515
  14. 14. Vaginal examination:-Vaginal examination:- - The vulva usually swollen and edematous.The vulva usually swollen and edematous. - The vaginal is dry, hot ,balloned.The vaginal is dry, hot ,balloned. - The cervix is almost fully dilated or hangingThe cervix is almost fully dilated or hanging - .. - The presenting part is extremely moulded andThe presenting part is extremely moulded and jammed in the pelvis.jammed in the pelvis. - With large caput formation.With large caput formation.
  15. 15. ManagementManagement ►Preventive:-Preventive:- - Proper assessment of pregnant womanProper assessment of pregnant woman during ANC.during ANC. - Proper assessment in early labour to detectProper assessment in early labour to detect the cause if any.the cause if any. - Partograph have to strictly follow.Partograph have to strictly follow.
  16. 16. CurativeCurative A.A. Immediate managementImmediate management B.B. General managementGeneral management C.C. Obstetric managementObstetric management
  17. 17. Immediate managementImmediate management 1.1. Correct maternal dehydrationCorrect maternal dehydration 2.2. prevent contraction by tocolytic drugsprevent contraction by tocolytic drugs 3.3. Blood sample for grouping and crossBlood sample for grouping and cross matching.matching.
  18. 18. B. General management :-B. General management :- 1.1. Assessment of mother general condition.Assessment of mother general condition. 2.2. Broad spectrum antibiotics.Broad spectrum antibiotics. 3.3. Catheterization.Catheterization. 4.4. Sodium bicarbonate infusion to correctSodium bicarbonate infusion to correct acidosis.acidosis.
  19. 19. C. Obstetric managementC. Obstetric management 1-1-Vaginal delivery:-Vaginal delivery:- (Destructive opt.) dead fetus(Destructive opt.) dead fetus -if head is low and vaginal delivery is not risky, forceps-if head is low and vaginal delivery is not risky, forceps extraction may be done in alive foetus also.extraction may be done in alive foetus also.
  20. 20. 2. Caesarean section:-2. Caesarean section:- -A live fetus-A live fetus -Over distended lower segment with impending rupture even-Over distended lower segment with impending rupture even the foetus is dead.the foetus is dead.
  21. 21. Active management of 3Active management of 3rdrd stage of labor.stage of labor. AA CONTROLLED CORD TRACTION
  22. 22. ComplicationComplication Maternal -Rupture of uterus -VVF -RVF -PPH -Puerperal sepsis -Shock -Maternal death Fetal -intra uterine asphyxia -Intracranial haemorrhage -Neonatal infection -Acidosis -Foetal death
  23. 23. Shoulder Dystocia
  24. 24. DefinitionDefinition • impaction of anterior shoulder aboveimpaction of anterior shoulder above symphysissymphysis • inability to delivery shoulders by usualinability to delivery shoulders by usual methodsmethods IncidenceIncidence • 1 to 2 per 1000 deliveries1 to 2 per 1000 deliveries • 16 per 1000 deliveries of babies >16 per 1000 deliveries of babies > 4000 g4000 g
  25. 25. Failure to deliver fetal shoulder without utilizingFailure to deliver fetal shoulder without utilizing facilitating maneuversfacilitating maneuvers Normal DystociaNormal Dystocia
  26. 26. PathophysiologyPathophysiology The fetal bisacromial diameterThe fetal bisacromial diameter normally enters the pelvis at annormally enters the pelvis at an oblique angle with the posterioroblique angle with the posterior shoulder ahead of the anteriorshoulder ahead of the anterior one,one, Then Rotation to the anterior-Then Rotation to the anterior- posterior position at the pelvicposterior position at the pelvic outlet with external rotation ofoutlet with external rotation of the fetal head.the fetal head.
  27. 27. PathophysiologyPathophysiology In shoulder dystocia there isIn shoulder dystocia there is – Absence of truncal rotationAbsence of truncal rotation Fetal shoulders remain A-P or descent simultaneouslyFetal shoulders remain A-P or descent simultaneously
  28. 28. Risk FactorsRisk Factors • post-term pregnancypost-term pregnancy • maternal obesitymaternal obesity • fetal macrosomiafetal macrosomia • previous shoulder dystociaprevious shoulder dystocia • operative vaginal deliveryoperative vaginal delivery • prolonged labourprolonged labour • poorly controlled diabetespoorly controlled diabetes
  29. 29. Risk factors are present in < 50% of cases
  30. 30. DiagnosisDiagnosis • head recoils against perineum, ‘turtle’ signhead recoils against perineum, ‘turtle’ sign • spontaneous restitution does not occurspontaneous restitution does not occur • failure to deliver with expulsive effort andfailure to deliver with expulsive effort and usual gentle directionusual gentle direction
  31. 31. ComplicationsComplications • Fetal/neonatalFetal/neonatal - deathdeath - asphyxia and sequelaeasphyxia and sequelae - fractures - clavicle, humerusfractures - clavicle, humerus - brachial plexus palsybrachial plexus palsy • MaternalMaternal - postpartum hemorrhagepostpartum hemorrhage - uterine ruptureuterine rupture
  32. 32. ManagementManagement  Goal: Safe delivery before neontalGoal: Safe delivery before neontal asphyxia and/or cortical injuryasphyxia and/or cortical injury  7 minutes!!!7 minutes!!!
  33. 33. Prophylactic Cesarean?Prophylactic Cesarean? Not recommended by ACOGNot recommended by ACOG Exceptions:Exceptions: – Consider if…Consider if… >5000g in mother without DM>5000g in mother without DM >4500g in mother with DM>4500g in mother with DM
  34. 34. • PPanicanic • PPullingulling (on the head)(on the head) • PPushingushing (on the fundus)(on the fundus) • PPivotingivoting (sharply angulating the(sharply angulating the head, using the coccyx as a fulcrum)head, using the coccyx as a fulcrum) Avoid the P’s
  35. 35. Ask for help Lift - the buttocks - the legs Anterior disimpaction of shoulder - rotate to oblique - suprapubic pressure Rotation of the posterior shoulder - Woods’ manoeuver Manual removal of posterior arm Move patient toALL four position } McRobert’s manoeuver Remember Alarm
  36. 36. • get the mother onget the mother on your sideyour side • partner, coachpartner, coach • nursingnursing • notify physician backnotify physician back up or otherup or other appropriate personnelappropriate personnel Ask for HELP
  37. 37. LLifting the legs and buttocksifting the legs and buttocks -McRobert’s Maneuver-McRobert’s Maneuver
  38. 38. • Flexion of thighs on abdomen requires assistance • 70% of cases are resolved with this maneuver alone Lifting the legs and buttocks -McRobert’s Maneuver
  39. 39. • suprapubic pressure appliedsuprapubic pressure applied with heel of clasped hand fromwith heel of clasped hand from the posterior aspect of thethe posterior aspect of the anterior shoulder to dislodgeanterior shoulder to dislodge itit Anterior Disimpaction - 1) Suprapubic Pressure Abdominal approach
  40. 40. Suprapubic PressureSuprapubic Pressure
  41. 41. Adduction of the most accessible shoulder moves the fetus into an oblique position and decreases the bisacromial diameter Anterior Disimpaction - 2) Rubin Manoeuver • vaginal approach
  42. 42. RRotate the posterior shoulder - Woods’otate the posterior shoulder - Woods’ manoeuvermanoeuver Abduct posterior shoulder exerting pressure onAbduct posterior shoulder exerting pressure on anterior surface of posterior shoulderanterior surface of posterior shoulder
  43. 43. MManual removal of the posterior armanual removal of the posterior arm grasp the posterior arm and sweep it across the anterior chest to deliver
  44. 44. MMove patient to All-Fours Maneuver(Gaskin Maneuver)ove patient to All-Fours Maneuver(Gaskin Maneuver) Changes pelvic dimensions in a similar way toChanges pelvic dimensions in a similar way to Mc Roberts maneuverMc Roberts maneuver Apply downward traction to disimpact theApply downward traction to disimpact the posterior shoulderposterior shoulder
  45. 45. EpisiotomyEpisiotomy • May facilitate Wood’s Manoeuver orMay facilitate Wood’s Manoeuver or allow room for delivery of the posteriorallow room for delivery of the posterior armarm
  46. 46. As a last resortAs a last resort • clavicular fractureclavicular fracture • cephalic replacement (Zavenellicephalic replacement (Zavenelli manoeuvre)manoeuvre) • symphysiotomysymphysiotomy
  47. 47. AfterwardsAfterwards • be prepared for PPHbe prepared for PPH • inspect for maternal lacerationsinspect for maternal lacerations and traumaand trauma • examine the baby for evidence ofexamine the baby for evidence of injuryinjury • explain the delivery andexplain the delivery and manoeuversmanoeuvers • chart what was donechart what was done
  48. 48. • Anticipate and be prepared (most are unpredictable) • Stay calm, don’t panic, pull, push or pivot • Remember the “ALARM-E” Finally
  49. 49. Ask for help Lift - the buttocks - the legs Anterior disimpaction - suprapubic pressure(abdominal) - - rotate to oblique (vaginal) Rotate the posterior shoulder - Woods’ manoeuver Manual removal of the posterior arm,OR Move patient to ALL four position Episiotomy - consider } McRobert’s Manoeuver ALARM-E”
  50. 50. A 25 year-old healthy woman has a normal laborA 25 year-old healthy woman has a normal labor and a spontaneous delivery of the fetal head. Onand a spontaneous delivery of the fetal head. On expulsion of the head, a shoulder dystocia isexpulsion of the head, a shoulder dystocia is recognized. Before instituting maneuvers the nextrecognized. Before instituting maneuvers the next step is to:step is to: – A) Tell the patient not to pushA) Tell the patient not to push – B) Apply fundal pressureB) Apply fundal pressure – C) Increase or initiate Oxytocin administrationC) Increase or initiate Oxytocin administration – D) Cut a large episiotomyD) Cut a large episiotomy
  51. 51. AnswerAnswer A) Tell the patient not to pushA) Tell the patient not to push – The training and experience of clinicianThe training and experience of clinician should dictate sequence of maneuvers thatshould dictate sequence of maneuvers that will be used; however, initially it is best to dowill be used; however, initially it is best to do nothing that will further impact the anteriornothing that will further impact the anterior shoulder above the pubic symphysis. Theshoulder above the pubic symphysis. The simplest way to avoid further impaction is tosimplest way to avoid further impaction is to ask the patient to stop pushing.ask the patient to stop pushing.
  52. 52. Thank you !!!Thank you !!! 
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