reproductive health

1. ABNORMAL LABOUR
BY: C. CAROLINE

2. Objectives
By the end of this lesson, you will be able to:
 Describe the management of abnormal uterine
action
 Explain the process of managing trial of labour
 Describe the management of foetal malpositions
 Describe the management of foetal
malpresentations

3. Background
• To define abnormal labor, a definition
of normal labor must be understood
and accepted.
• Normal labor is defined as uterine
contractions that result in
progressive dilation and effacement
of the cervix.

4. Background
• By following thousands of labors resulting
in uncomplicated vaginal deliveries, time
limits and progress milestones have been
identified that define normal labor.
• Failure to meet these milestones defines
abnormal labor, which suggests an
increased risk of an unfavorable outcome

5. Background
• Thus, abnormal labor alerts the
obstetrician to consider alternative
methods for a successful delivery that
minimize risks to both the mother and the
infant.
• Dystocia of labor is defined as difficult
labor or abnormally slow progress of labor.

6. Background
• Other terms that are often used
interchangeably with dystocia are
dysfunctional labor, failure to
progress (lack of progressive cervical
dilatation or lack of descent), and
cephalopelvic disproportion (CPD).

7. Abnormal labour includes;
 Prolonged labour
 Obstructed labour
 Maternal injuries
 In-co-ordinate uterine action
 Precipitate labour
 Mal-positions & mal-presentations
 Maternal and fetal distress

8. PROLONGED LABOR
• Labor is said to be prolonged when
the combined duration of both the
first stage and second stages of
labor is more than 18 hours. It is
more common in a first pregnancy and
in women over the age of 35 years.

9. Prolonged Latent Stage
• The latent phase lasts from the onset of
labour to three centimetre dilatation of
the cervical os. If this phase takes more
than 20 hours in a primigravida and more
than 14 hours in a multigravida, it is
considered prolonged. In practice
diagnosis should be suspected and
treatment instituted many hours before
this time interval has elapsed.

10. Prolonged Latent Stage
• Primary Dysfunctional Labour This is
when active phase of labour is slow and the
cervix dilates at less than one centimetre
per hour.
• Secondary Arrest This is when there is
slow cervical dilatation in the active phase
after normal progress in early labour.

11. Causes
Causes of Prolonged First Stage of Labour
• Poor uterine contractions, leading to the cervix dilating
slowly or not at all
• Pelvic abnormalities (passage), where contracted pelvis and
tumours of the pelvis cause poor progress in labour
• The foetus (passenger) is a large baby, or there is
malposition or malpresentation
• Psychological causes, for instance; tension and fear of the
unknown tend to prolong labour, most commonly in women
who are primigravidae

12. Causes
Causes of Prolonged Second Stage of Labour
• Secondary hypotonic contractions
• Poor maternal effort, which could be due to fear,
exhaustion or lack of sensation due to epidural block, which
may inhibit the woman’s ability to bear down
• A rigid perineum
• Reduced pelvic outlet, as in the android pelvis,
• A large foetus, malposition or malpresentation, leading to a
large presenting diameter, accounting for the delay

13. Causes of Prolonged
Labor
• · Problems with Uterine Contraction:
The uterine muscle may fail to contract
properly when it is grossly distended as in
twin pregnancy and hydramnios (excess
liquor amnii). Presence of tumours like
fibroids in the uterine musculature can
also affect uterine contraction.
• · Use of Sedatives and Anesthesia:
Excessive use of painkillers or anesthesia
can cause inefficient uterine action.

14. Causes of Prolonged
Labor
• They can also decrease the pain of normal labour
and prevent voluntary effort by the mother to
deliver the baby during the second stage of labor.
• · Cervical dystocia or stenosis: The term
cervical dystocia is used when the cervix fails to
dilate properly and remains at the same position
for more than 2 hours. The cervix may fail to
dilate when it is fibrosed due to previous
operations like cone biopsy or due to the presence
of tumors like cervical polyps and fibroids.

15. Signs and Symptoms of
Prolonged Labour
 Labor extends for more than 18 hours.
 Patient looks exhausted and distressed. Dehydration may be
present. Mouth may be dry due to prolonged mouth
breathing.
 Pain may be more on the back radiating to the thighs rather
than inside the abdomen. This is due to pressure over the
muscles and ligaments.
 Labor pains may initially be severe, frequent and prolonged
but later decrease and become very mild as the muscles
become fatigued.
 Pulse rate is often high.

16. Signs and Symptoms of
Prolonged Labour
 The large intestines are dilated and can be palpated along
both sides of the uterus as large, thick structures filled
with air. They give off the hollow sound of drums on tapping.
 The uterus is tender on palpation and does not relax fully
between contractions.
 Ketosis may develop due to prolonged starvation.
 Fetal distress may develop.
 Membranes may or may not rupture early. In early rupture,
there is a risk of infection of the uterine contents if proper
antibiotics are not prescribed.

17. Diagnosis of Prolonged
Labour
• Proper history of labour including type, duration and
frequency of uterine contractions
• Examination of the mother, checking for general
appearance, whether distressed or
exhausted
• Check the temperature and pulse as an increase of either of
them would be significant
• Urinalysis, where concentrated urine suggests fluid
imbalance and dehydration. Check for ketones in the urine,
the presence of this must be corrected at once
• It is important to identify the cause in order to decide the
course of action.

18. Risks of Prolonged
Labour
• Fetal Risks:
– Fetal Distress due to decreased oxygen reaching the fetus.
– Intracranial hemorrhage or bleeding inside the fetal head.
– Increased chances of operative delivery like Cesarian sections.
– Longterm risks of the baby developing cerebral palsy.
• Maternal Risks:
– Intrauterine infections
– Trauma and injuries in the maternal birth passage (See
Maternal Injuries.)
– Postpartum hemorrhage.
– Postpartum infection.

19. Management / Treatment
of Prolonged Labour
• With the discovery of various drugs capable of
accelerating labour, prolonged labour is a rarity
nowadays.
• After 3cms of dilation, the cervix should dilate at
the rate of 1cm per hour. If there is lack of
dilation for a reasonable period of time, then an
oxytocin drip is started. Drugs like epidosin
causes softening of tissues in the cervix.

20. Management / Treatment
of Prolonged Labour
• If the cervix fails to dilate in spite of adequate uterine
contraction, epidosin or buscopan can be safely given to
cause softening of the cervix.
• Intensive clinical monitoring should be done, recording the
pulse, BP, fetal heart sound (FHS) and dilation of the cervix
at intervals of two hours. FHS should be checked even more
frequently if necessary.
• If, in spite of the above procedures, labour fails to get
accelerated or if foetal distress develops, Cesarian Section
should be done.

21. MATERNAL INJURIES
• Most maternal injuries occur during
the second stage of labour but the
diagnosis is made in the third stage
after the delivery of the baby. Some
of the commoner ones are described
below.

22. PERINEAL TEARS
• The perineum is the region between the
vaginal opening and the anus. The perineum
may get injured when there is
overstretching or rapid stretching during
the delivery of the baby. An inelastic
perineum due to the presence of a scar can
also lead to a perineal tear.

23. PERINEAL TEARS
• causes of overstretching of the perineum leading to
perineal tear are:
 A big baby - usually babies more than 4000 kgs or 9 ounces
are considered big.
 Malpresentation of the baby like occipitoposterior position
or face presentation.
 Average sized baby with a narrow maternal vaginal outlet
 Forceps delivery or other instrumental deliveries
 Shoulder Dystocia

24. Degrees of perineal
tear:
• There are three degrees of perineal tear.
• First Degree perineal tear: This is only a mild degree of
laceration or tear of the skin at the edge of the vaginal opening.
The lower part of the vagina as well as the perineal skin may be
torn but the major muscles of this region are not affected.
• Second degree perineal tear: This involves rupture of the
muscles of the perineum with deep tears in the vaginal wall. The
tear may extend right up to the anus, but does not involve the anal
sphincter.
• Third degree perineal tear: In a complete perineal tear, the tear
extends from the vaginal opening through the posterior vaginal
wall and the perineal muscles upto the anus with injuries to the
external anal sphincter. The anal or the rectal canal may or may
not be involved.

25. Management/Treatment
of Perineal Tears
• Prevention is the best management. The second stage of labour
should be properly conducted. An episiotomy should be performed
wherever deemed necessary to prevent tear of the perineum.
• Immediate Repair: A first degree or second degree tear should
be immediately repaired, preferably within the first 24 hours.
• Delayed Repair: If the tear is diagnosed after 24 hours, then the
woman is given antibiotics and the wound dressed so that infection
, if any, is controlled. Then the tear is repaired.
• Third Degree tear: A third degree tear is always repaired after 3
months of the delivery of the baby to allow the tissues to regain
the pre-pregnant state.

26. VAGINAL TEARS
• Vaginal Tears can occur at any part of the vaginal wall, but are
seen mostly at the junction between the lateral and posterior
walls. These tears may be superficial with only minor lacerations of
the vaginal mucosa. But, sometimes the tears may be deep enough
to expose the inner muscles.
• Vaginal tears can also occur at the region around the urethra - the
opening through which urine comes out. These are then called '
Paraurethral tears'. The problem with these type of tears is that
there may be profuse bleeding from even a small tear since the
region has a large blood supply.
• Treatment / Management of vaginal Tears
• The vagina should always be examined under proper light
immediately after the delivery of the baby for any such tears. All
tears should be repaired immediately.

27. CERVICAL TEARS
• Minor tears of the cervix are very common during
delivery, especially in a woman who is delivering
her first child. But sometimes, major lacerations
which can cause severe bleeding may also occur .
In fact, cervical tears are the commonest form of
traumatic post partum hemorrhage. Cervical tears
are commonest at the lateral angle, between the
anterior and posterior lips of the cervix.

28. Causes of Cervical tear:
 Delivery through an undilated cervix
whether spontaneously, or by forceps.
 Precipitate labour.
 Rigid cervix due to previous operations like
the LEEP procedure, conisation, or cervical
amputation.
 Very vascular cervix as can occur in low
level placenta previa

29. Treatment / Management
of Cervical Tears
• The aim of treatment is to control bleeding as
early as possible by repairing the tear. Minor
lacerations without active bleeding does not
require to be repaired - they heal spontaneously
with no ill effects.
• Major cervical lacerations or tears need to be
repaired in the Operating theater under
anesthesia, good light and proper exposure of the
tear.

30. VULVAL HEMATOMA
• Collection of blood anywhere in the vulval region is
called vulval hematoma. Although vulval
haematomas can also occur after an injury due to
any cause, it is commonly seen after the vaginal
delivery of a baby.
• A Vulval hematoma can occur either spontaneously
or after improper repair of an episiotomy wound.
Blood from a rupture of the deep veins of this
region collects in a closed space with no opening
for it to drain out.

31. Symptoms of Vulval
Hematoma:
 A steadily increasing swelling to one side of the
vagina.
 The swelling is tense and tender to the touch.
 The woman complains of severe pain, more so on
sitting down.
 There may be difficulty in passing urine if the
swelling presses on the urethra.
 The bleeding can be severe enough to cause the
patient to go into shock.

32. Treatment / Management
of Vulval Hematoma
• The aim of treatment is to ligate the bleeding
blood vessels as early as possible and support the
patient with IV drips and medicines so that she
does not go into shock.
• An incision is made at the most distended point of
the hematoma.
• The incision is then deepened and the blood clots
scooped out.
• The bleeding vessels are identified and tied up.

33. Treatment / Management
of Vulval Hematoma
• The incision is closed by applying different
layers of stitches.
• A drain may be put in the wound for 24
hours to allow any oozing blood to flow out.
• Proper antibiotics are prescribed and the
patient kept under close observation.
• Blood transfusion is given if necessary.

34. Abnormal Uterine
Action
• Abnormal uterine action is a dysfunction of
uterine muscles due to neuromuscular disharmony.
Some types of abnormal uterine action include:
 Hypotonic uterine action
 In-co-ordinate uterine action, including
hypertonic lower uterine segment, constriction
ring dystocia, colicky uterus and spurious labour
 Cervical dystocia
 Precipitate labour

35. Hypotonic Uterine
Action
• This is poor tone in the uterine muscle fibres which results from
weak/short contractions. The contractions are infrequent and cause less
pain. The uterus may be indented at the height of a contraction. Both
mother and baby are affected by the contractions. The effects of weak
contractions bring about very slow or no cervical dilatation. This results in
prolonged labour. There are two types of hypotonia; primary and secondary
uterine inertia also respectively known as primary and secondary hypotonia.
Primary hypotonia starts at the onset of labour. The cause is unknown and
it is common in primigravida. Secondary hypotonia occurs when labour has
already been established. The uterus is exhausted and contractions slow
down, due to:
• Retained second twin
• Cephalopelvic disproportion
• Malpresentation or malposition
• Effect after epidural anaesthesia

36. Incoordinate Uterine
Action
• In cases of incoordinate uterine action, there is alteration in the
polarity of the uterus with an increase in the resting tone. The
uterus is very irritable. The contractions are strong, painful and
erratic but in spite of strong contractions, the cervix dilates
slowly. Clinically, the patient experiences a lot of pain both before
and after contraction. She is exhausted and bears down early due
to severe backache. This may lead to retention of urine. Foetal
hypoxia occurs due to the hypertonic state of uterus, which
interferes with the placental circulation. On Vaginal Examination
(VE) the cervix is noted to dilate slowly despite frequent painful
contractions. The cervix is tight, unyielding and oedematous since
the mother bears down with each contraction. There are four
varieties of Incoordinate uterine action, which will be explored on
the next page.

37. Incoordinate Uterine
Action
There are four types of incoordinate
uterine action
Hypertonic Lower Uterine Segment
Colicky Uterus
Constriction Ring Dystocia
Spurious Labour

38. Hypertonic Lower
Uterine Segment
• In this case, the lower uterine
segment is hypertonic. There is loss
of polarity and intermittent
abdominal pains. The pains occur
before and persist long after a
uterine contraction. The cervix fails
to dilate.

39. Colicky Uterus
• The upper uterine segment contracts strongly and
spasmodically. As a result of the different parts
of the uterus contracting differently the cervical
dilatation is ineffective. There may be reduced
placental blood flow leading to
foetal distress.
There is intense clump-like pain, contractions are
not effective and the uterus is tender. The
mother may not experience severe backache.

40. Constriction Ring
Dystocia
• This condition happens one in every thousand labours (Myles,
1999). It is a localised spasm of a ring of muscle fibres. This is a
result of disorganised uterine action. It is commonly found near
the junction of both the upper and lower uterine segment. It
usually embraces a narrow part of the neck of the foetus. It may
happen at any stage of labour but if it occurs in the third stage, it
is known as an hourglass constriction.
• The spasm may be triggered by an early rupture of membranes.
The hypertonic uterus is irritated by being moulded round the
foetus or by interuterine manipulation.
• The condition can be diagnosed vaginally when there is a delay in
labour. There is no advance of the presenting part and the upper
segment feels tender to the touch. Inhalation of amylnitrate or
10ml of 2% IV magnesium sulphate solution may relieve spasms.

41. Spurious Labour
• Spurious labour is a condition where
contractions occur before the onset
of labour, which are painful and are
accompanied by backache. Giving
pethidine or morphine 1ml to relax
the uterine contractions can abolish
them. This differentiates it with
true labour.

42. Precipitate Labour
• Def:
 strong and frequent contractions from
the onset of labour, resulting in an
abnormally rapid progress of labour and
delivery may occur within an hour from the
onset of labour. There are several types
of complications, which can occur.

43. Precipitate Labour
 Over-Stimulation of the Uterus
• This may occur as a result of excessive use of syntocinon or
prostaglandin, which may cause tetanic contractions with
inadequate periods of relaxation.
• Complications of over-stimulation of the uterus include
 foetal hypoxia.
 If uterine spasms that reduce the transfer from the
placenta of foetal oxygen are not treated, foetal death may
occur.
 precipitate labour and
 rupture of uterus in cases of disproportion.

44. Precipitate Labour
• Methods of management should include the
following:
 Stop the administration of syntocinon or
prostaglandin
at once
 In case of tonic contractions, the patient should
be given
two puffs of ventolin inhaler
 If there is foetal distress, give dextrose IV and
oxygen by mask

45. Precipitate Labour
 Tonic Contractions
• This is where the contractions are excessively longer,
stronger and more frequent. This results in almost
continuous contractions with short periods of relaxation.
Tonic contractions are caused by cephalopelvic
disproportion. The uterus attempts to overcome the
obstruction and so it increases its strength and frequency.
The condition is common in primigravida.
• Possible complications of tonic contractions include
 rupture of the uterus and
 foetal death due to prolonged labour.

46. Precipitate Labour
• Management of Tonic contractions
If the patient is on syntocinon drip, it
should be discontinued and the
doctor informed.
The vital signs, including observations
of pulse & blood pressure, should be
monitored carefully.

47. Precipitate Labour
There are several factors, which predispose to
abnormal uterine action, these include:
 elderly primigravida
 Primigravida
 Cephalopelvic disproportion or malpresentation
 Post maturity
 Multiple pregnancy
 Early rupture of membranes
 Emotional tension of the patient

48. Precipitate Labour
• Maternal complications include
 cervical and perennial lacerations.
 The uterus may fail to contract during the
third stage of labour, leading to a retained
placenta.
 Post partum haemorrhage, uterine
inversion, shock and collapse may occur
due to sudden relief of pressure.

49. Precipitate Labour
• Foetal complications include
 foetal hypoxia, which may occur as a result
of frequent and strong contractions.
 Rapid moulding may result in intracranial
pressure and, during delivery, this may
lead to intracranial haemorrhage.
 Asphyxia may occur due to rapid expulsion
of the baby’s unmoulded head.

50. Precipitate Labour
• Remember: Precipitate labour tends
to recur. Therefore, with future
pregnancies the mother needs to be
admitted early into hospital for
safe delivery.

51. Cervical Dystocia
Cervical dystocia can be divided into two classes; primary and
secondary.
• Primary
• Secondary
• Primary Cervical Dystocia In primary cervical dystocia, the
uterine contractions are normal. The presenting part is low
down in the pelvis but the cervix fails to dilate. The delay is
due to the formation of a cartilaginous ring round the
cervix.
• This condition occurs mainly in primagravida whereby the
first stage is prolonged and there is severe and persistent
backache. On vaginal examination the cervix feels thin,
tight and unyielding.

52. Secondary Cervical
Dystocia
• This type occurs due to previous trauma to the cervix, for
example, tears which were repaired, scarring or from
infection. The cervix fails to dilate in spite of good uterine
contractions.
• The management of cervical dystocia is by encouraging the
mother to lie on her back, elevation of the bed foot to ease
pressure on the cervix and care must be taken to avoid
lacerations. Caesarean section should be done to hasten
delivery of the baby.

53. Cervical Dystocia
• Cervical dystocia can be further divided into one of three
types, any of which can occur as primary or secondary
cervical dystocia.
• Rigid cervix
• Annular detachment of the cervix
• Oedematous anterior lip of cervix
• Rigid cervix Rigid cervix is a rare condition in which the
cervix fails to dilate despite normal uterine contractions. It
is characterised by severe persistent backache. On vaginal
examination the cervix feels thin, tight and unyielding.

54. Annular detachment of
the cervix
• Annular detachment of the cervix is
characterised by persistent and
prolonged pressure on the rigid
cervix, which causes ischemia. The
necrosed ring of the cervix is
detached and expelled and
contributes to a uterine rupture.

55. Oedematous anterior lip
of cervix
• Oedematous anterior lip of the cervix involves the
anterior lip being nipped between the foetal head
and the pelvic brim. It becomes swollen due to
pressure. On vaginal examination the oedematous
cervix feels like a firm ridge as thick as a finger.
It may also be seen at the vulva as a bluish
glistering cervix. It delays the first stage of
labour, as the cervix does not dilate quickly.

56. Trial of Labour
Trial of labour is a test of labour
conducted where there is a minor or
moderate degree of Cephalopelvic
Disproportion (CPD) in which it is
difficult to decide whether delivery
per vagina is possible.

57. factors influencing good
prognosis
 Strength of the uterine contractions
 Flexion of the head
 Degree of moulding of the foetal head,
that is, reduced engaging diameters
 The giving of pelvic joints. In pregnancy,
the joints of the pelvis are relaxed and
separate by half to one centimetre
 Maternal courage

58. factors influencing poor
prognosis
 Early rupture of membrane which may be
accompanied by prolapsed cord
 Poor moulding of the head
 Maternal or foetal distress which will
necessitate intervention on trial of vaginal
delivery
• Remember: Do not hesitate to terminate
the trial of labour when there is foetal
or maternal distress.

59. contraindications for
trial of labour
 Grossly contracted pelvis
 Medical or obstetrical complications
 Mal-presentations, for example, breech
 Elderly primigravida
 Cases where trial of labour failed before
 Cases of two previous caesarean sections
• Remember: Your encouragement and friendly
attitude will boost the mother’s morale.

60. Management of Trial of
Labour
• Explain the situation to the mother and
prepare her for possible operative
intervention. Assess patient carefully on
admission to ascertain the following:
• Whether the mother is in established
labour
• Presentation of foetus
• Check for flexion of the head

61. Management of Trial of
Labour
• State of foetal heart, that is, rate, rhythm and
volume
• General condition of mother physically and
emotionally
• Confine the mother to bed to prevent early
rupture of membranes
• Close observations of temperature and blood
pressure every four hours
• Observe foetal heart rate and maternal pulse
quarterly to half hourly

62. Management of Trial of
Labour
• You should always observe for signs of foetal and
maternal distress. Accurately observe and record
for onset, strength, frequency and duration of
the contractions. Closely observe the descent of
the head every one to two hours per abdominal
palpation by the same midwife if possible.
Encourage the mother to pass urine every two
hours and test for acetone to exclude acidosis.

63. Management of Trial of
Labour
• A vaginal examination should be done every four
hours to assess the level of the presenting part,
the degree moulding and flexion, the dilation of
the cervix (whether progressive or not), the
consistency of the cervix and the presence or
absence of caput.
• You should also check whether the membranes are
intact or ruptured. Encourage adequate hydration
by giving intravenous 5% dextrose. Sedate the
mother with pethidine or morphia in early labour
to promote rest, and reduce anxiety.

64. Trial of Scar
• Trial of scar is a test of labour for a woman with
a previous caesarean section scar, where no
recurrent indication is present. Studies have
shown that some 60 – 65% of previous caesarean
section mothers (Reedes/Martin, 1987) deliver
per vagina, involving same or fewer risks than a
repeated section. The trial should be in a facility
where, if there is a need for a caesarean section,
this can be performed immediately. The midwife
should be vigilant in making the necessary
observations.

65. management
• The management of this mother is as for trial of
labour with the addition of these few points
below:
• Palpate abdomen gently
• Check for any tenderness over the scar
• Observe for any signs of impending rupture of the
uterus
• Report any constant pain in abdomen
• Educating the Patient on Avoiding Unnecessary
Caesarean Birth

66. Contraindications
 Where the reason for the first scar is likely to be repeated
e.g. in CPD
 Classical type of C/S
 Malpresentation
 Two previous scars, regardless of the causes
 Where the previous scar wound did not heal with the first
intension
 Where pregnancy occurs within 6months of a C/S
 Where there is over-distension due to multiple pregnancy or
hydromnious
 Multiparity

67. Maternal Distress
• This is a serious and life threatening condition,
which should not occur in this era. It happens
when the metabolism and the electrolyte balance
of the woman in labour is disturbed and this can
result into keto-acidosis hypotonic uterine inertia.
Maternal and foetal distresses usually occur
together after prolonged labour.
• Often maternal and foetal distress present
together in women who have been in labour for a
long time at home and are brought to a health
centre or hospital in poor condition.

68. main symptoms
• mother is exhausted by severe pain and
lack of sleep and she might have severe
abdominal pain because of the prolonged
and obstructed labour.
• She displays signs of anxiety
• She has a dry and furred tongue
• Her pulse rate is over 120 beats per
minute

69. main symptoms
• Rapid and deep respiration because of acidosis
• She has hot, dry and inelastic skin
• She has a distended abdomen
• There is a reduced output of highly concentrated
urine
• Her temperature is 38°C
• She might already have a purulent discharge from
an intrauterine infection due to early rupture of
the membranes

70. management
• The main investigation is testing for the
presence of acetone in the urine.
• The management of Maternal Distress
involves giving an infusion of 10% glucose
to correct dehydration. A caesarean
section is performed when in the first
stage of labour. In the second stage, an
episiotomy is given and delivery is assisted
with vacuum extraction.

71. Foetal Distress
• Foetal distress occurs when the foetus is
deprived of oxygen and, as a result, develops
hypoxia. The baby may be born as a still birth or
develop asphyxia and suffer brain damage. Click
here to see some of the causes of foetal distress.
• Foetal tachycardia of more than 160 per minute is
an early sign while foetal bradycardia or pulse less
than 120 beats per minute is a late sign of foetal
distress. Foetal heart acceleration related with
uterine contraction is another sign of foetal
distress.

72. Causes of Fetal Distress
Congenital malformation
Problems with the cord e.g. prolapse,
true knot, twisted round the neck
Obstetric complications
Mother’s condition of preeclampsia/
eclampsia
Sever anaemia, APH

73. Intra- partum causes
include:
Prolonged labour
Malpresentation
Malposition
Shoulder dystocia

74. Management
 When foetal distress is anticipated, a blood
sample is taken, the normal pH being 7.35
 If this falls to 7.2, labour has to be terminated
 Below ph 7, the brain cells perish
 When there are signs of FD, call the doctor
 If the mother is on an oxytocin drip, stop it
immediately
 Change the mother’s position and give oxygen by
facemask

75. Management
If the mother is in the 1st stage of
labour, a c/s should be performed
If she is in the 2nd stage, an
episiotomy should be given
Forceps or vacuum hastens the birth
A pediatrician should always be
present, if possible

76. Malpositions and
malpresentations
• Malpositions are abnormal positions of the vertex
of the fetal head (with the occiput as the
reference point) relative to the maternal pelvis.
Malpresentations are all presentations of the
fetus other than vertex.
• The fetus is in an abnormal position or
presentation that may result in prolonged or
obstructed labour.

77. GENERAL
MANAGEMENT
• Make a rapid evaluation of the general condition
of the woman including vital signs (pulse, blood
pressure, respiration, temperature).
• Assess fetal condition:
• - Listen to the fetal heart rate immediately
after a contraction:
• - Count the fetal heart rate for a full minute at
least once every 30 minutes during the active
phase and every 5 minutes during the second
stage;

78. GENERAL
MANAGEMENT
• - If there are fetal heart rate abnormalities
(less than 100 or more than 180 beats per
minute), suspect fetal distress.
• - If the membranes have ruptured, note the
colour of the draining amniotic fluid:
• - Presence of thick meconium indicates the need
for close monitoring and possible intervention for
management of fetal distress;

79. GENERAL
MANAGEMENT
• - Absence of fluid draining after rupture of the
membranes is an indication of reduced volume of
amniotic fluid, which may be associated with fetal
distress.
• Provide encouragement and supportive care.
• Review progress of labour using a partograph.
• Note: Observe the woman closely.
Malpresentations increase the risk for uterine
rupture because of the potential for obstructed
labour.

80. DIAGNOSIS
• DETERMINE THE PRESENTING PART
• The most common presentation is the
vertex of the fetal head.
• If the vertex is the presenting part, use
landmarks of the fetal skull to determine
the position of the fetal head

81. Landmarks of the fetal
skull

82. • DETERMINE THE POSITION OF
THE FETAL HEAD
• The fetal head normally engages in
the maternal pelvis in an occiput
transverse position, with the fetal
occiput transverse in the maternal
pelvis

83. Occiput transverse
positions

84. Occiput transverse
positions

85. • With descent, the fetal head rotates
so that the fetal occiput is anterior
in the maternal pelvis Failure of an
occiput transverse position to rotate
to an occiput anterior position should
be managed as an occiput posterior
position.

86. Occiput anterior
positions

87. Occiput anterior
positions

88. Occiput anterior
positions

89. • An additional feature of a normal
presentation is a well-flexed vertex
(Fig S-12), with the fetal occiput
lower in the vagina than the sinciput.

90. Well-flexed vertex

91. • If the fetal head is well-flexed with
occiput anterior or occiput transverse (in
early labour), proceed with delivery.
• If the fetal head is not occiput anterior,
identify and manage the malposition.
• If the fetal head is not the presenting
part or the fetal head is not well-flexed,
identify and manage the malpresentation.

92. MANAGEMENT
• OCCIPUT POSTERIOR POSITIONS
• Spontaneous rotation to the anterior position occurs in 90%
of cases. Arrested labour may occur when the head does
not rotate and/or descend. Delivery may be complicated by
perineal tears or extension of an episiotomy.
• If there are signs of obstruction or the fetal heart rate
is abnormal (less than 100 or more than 180 beats per
minute) at any stage, deliver by caesarean section.
• If the membranes are intact, rupture the membranes with
an amniotic hook or a Kocher clamp.

93. MANAGEMENT
• If the cervix is not fully dilated and there are no signs of
obstruction, augment labour with oxytocin.
• If the cervix is fully dilated but there is no descent in
the expulsive phase, assess for signs of obstruction - If
there are no signs of obstruction, augment labour with
oxytocin.
• If the cervix is fully dilated and if:
• - the fetal head is more than 3/5 palpable above the
symphysis pubis or the leading bony edge of the head is
above -2 station, perform caesarean section;

94. MANAGEMENT
• OCCIPUT POSTERIOR POSITIONS
• - the fetal head is between 1/5 and 3/5 above the
symphysis pubis or the leading bony edge of the head is
between 0 station and -2 station:
• - Delivery by vacuum extraction and symphysiotomy;
• - If the operator is not proficient in symphysiotomy,
perform caesarean section;
• - the head is not more than 1/5 above the symphysis
pubis or the leading bony edge of the fetal head is at 0
station, deliver by vacuum extraction or forceps.

95. Malpresentation
• Predisposing factors to malpresentation
include:
• Prematurity
• Multiple pregnancy
• Abnormalities of the uterus, e.g. fibroids
• Partial septate uterus
• Abnormal fetus
• Placenta praevia