2. PRE-REQUISITES
Human anatomy and physiology
especially Female reproductive
system
Normal midwifery
Reproductive health and women’s
health
3. OBJECTIVES
After this course student nurse will be
able to:
Assess and detect woman with vaginal bleeding in late
pregnancy
Detect and manage mal presentation and mal position
Diagnose hypertensive disorders /pregnancy
4. 2. BLEEDING IN LATE PREGNANCY
AND INTRA-PARTUM PERIOD
2.1. PLACENTA PRAEVIA
A. Definition: The placenta embeds itself
in the lower pole of the uterus, partially or
wholly covering the internal os in front of
the presenting part
8. D. Signs and symptoms
Sudden onset of bright red fresh
painless hemorrhage after 22 weeks
of gestation
Unusual irritability and tenderness
Often malpresentation of the fetus
Endo-uterine cavity hemorrhage on
speculum examination
11. G. Management
During pregnancy
- Asymptomatic
Bed rest
Follow up every 2 weeks
- If complete placenta praevia
Admit for fetal lung maturation ≥ 24
weeks
of gestation
Program a Cesarean section at 37-38
weeks
of gestation
Iron supplements
12. Cont…
Symptomatic
Obligatory admission, do FBC and Blood group
crossmatch, blood coagulation tests
Surveillance of fetal heart rate
Ultrasound
Term >34 weeks of gestation
-If minimal hemorrhage and no uterine
contractions: Expectant management
13. Cont….
If Uterine contractions
- Complete placenta praevia or
malpresentation: perfom Cesarean section.
- Partial or marginal placenta preavia:
Carefully perform amniotomy for vaginal delivery if
the head is engaged.
14. Cont…
Term <34 weeks of gestation
Fetal lung maturation with steroids
(Dexamethasone 6 mg IM every 12
hours for 48 hrs)
- If Uterine contractions
Tocolyse with Nifedipine short acting
Tabs 20 mg start, then continue with long
acting nifedipine 20 mg every 8 hrs.
- If premature rupture of membrane:
Ampicilline 2g start dose, then
Amoxycilline tabs 500mg TDS 5/7
15. H. Recommendation
In case of any hemorrhage, the patient
should report to the health facility
immediately.
Avoid vaginal examination
For any risk of premature delivery, the
patient must be managed in a center
with neonatal facilities as nurse you
have to refer the mother at hospital
16. 2. 2. PLACENTAL
ABRUPTION
A. Definition:
It is bleeding from the placental site
due to
premature separation of a normally
situated placenta after 22 weeks of
gestation.
18. B. Cause/risk factors
-Severe pre-eclampsia
- Trauma
- Anatomical causes
• Short umbilical cord
• Uterine anomalies
• Uterine tumors
Dietary cause
Smoking (Cocaine, Tobacco)
Sudden decompression of uterus: rupture of
membranes in
cases of ( Polyhydramios, multiple pregnancy)
Unknown
19. D. Signs and symptoms
Vaginal bleeding: May pass dark blood or
clots. Sometimes bleeding can be concealed
Abdominal pain is moderate to severe but
may be absent in small bleeds
The uterus is often very tender, painful and
some
times hard
Fetal demise or fetal distress may be present
Uterine lower segment bulging and tender on
vaginal examination. The cervix is hard (if the
cervix is opened the membranes are bulging)
21. F. Investigations
Full blood count and cross-match
Ultrasound: Fetal well being, check for
retroplacental hematoma
Renal Function Test and electrolytes
Liver function tests
Proteinuria if pre-eclampsia is
suspected
Fibrinogene tests
Coagulation profile
22. G. Management
Maternal resuscitation
• Insert 2 IV lines with Cristalloids and Colloids
• Transfusion if necessary
• Give O2 6L/min
• Insert a urinary catheter
• If Disseminated Intravascular Coagulation:
Give fresh frozen Plasma 1 Unit/hour, give
Concentrated cells 2-4 units Follow up of the
diuresis and administrate Furosemide 40mg start
dose
Follow up: blood pressure, pulse, bleeding, hourly
dieresis, Complete blood count, clotting profile
23. G. Management cont
Obstetrical management
If the fetus is alive and viable:
Emergency C-section
If the fetus is dead: Normal vaginal
delivery is preferable
- Artificial rupture of membrane, If no
spontaneous labor: induce the labor with
uterotonics (Oxytocin Infusion 5IU in
Dextrose 5% 500 ml beginning with 14
drops/min)
- Active management of third stage of
delivery and uterine revision
24. 2.3 UTERINE RUPTURE
A. Definition:
Uterine rupture refers to a tear or
separation of the uterine wall .
25. B. Cause and risk factors
Previous uterine scar
Malpresentation and Malposition
Misuse of uterotonics
Placenta insertion anomalies
Multiparity
Retracted pelvis
Obstructed labour
Uterine manoeuvers
Instrumental deliveries
Trial of labor after cesarian section
Unkown
26. C. Signs and symptoms
Pre-rupture bandle ring sign
Sudden, severe abdominal pain (may decrease after
rupture)
Bleeding – intra-abdominal and / or vaginal
Cessation of uterine contractions
Tender abdomen
Absent of fetal heart activity
Easily palpable fetal parts on the abdomen
Rapid maternal pulse
Hypovolaemic shock most of the time
Abdominal distension / free fluid
28. D. Complications
Fetal demise
Bladder laceration
Uterine multi-laceration leading to
Hysterectomy
Maternal death
29. E. Investigations
Full blood Count and blood group cross-match
Clotting profile
CTG monitoring
Ultrasound in a stable patient (In cases of uterine
dehiscence suspicion
30. F. Management
Non-Pharmaceutical
Call for assistance – Senior obstetrician, pediatrician
and anaesthetist for assistance
Administer oxygen via face mask 6L/min
Blood Group and cross match, Order 2-4 units of
packed red cells and order complete blood picture
Ensure the woman remains with her legs bent or in
lithotomy to perfuse the brain
Insert 2 large intravenous access using 14-16 gauge
cannulas with appropriate intravenous fluid, e.g. sodium
chloride 0.9 % or Hartmann’s solution and gelatin based
colloid or Haemacel
31. G. Management cont
Assess for clinical signs of shock e.g. cool, clammy,
pale, rapid pulse, decreased blood pressure
Inform the patient and family
Surgical Management
Emergency laparotomy: Conservative or
hysterectomy and repair complications (Bladder or
ureter tear…)
Recommendations
If conservative, contraception for at least 2 years
Elective cesarean section for the next pregnancy at 39
weeks of gestation or if uterine contractions start
Antenatal care for the next pregnancy at a hospital
with surgical facilities
32. 3. MAL-PRESENTATIONS AND
MAL-POSITIONS
A. Definition:
Lie: refers to the relationship of the long axis of
the
fetus to that of the mother. It may be longitudinal,
transverse or oblique
- Presentation: refers to the portion of the fetus
that is
foremost or presenting in the birth canal.
- Malpresentations: all presentations of the fetus
other
than the vertex.
33. Definitions cont..
- Position: reference point on the presenting part, and
how it relates to the maternal pelvis. Normal position
is Occiput anterior position (OA): when the foetal oc
ciput is directed towards the mother’s symphyisis or
anterior
- Mal position: Occipital Posterior (OP). When the
fetal occiput is directed towards the mother’s
sacrum or posteriorl
34. B. TYPES
Mal presentations:
1. Brow
2. Face
3. Breech
4. Transverse
5. Compound
Mal positions:
1. Occiput Posterior Position (OP): when the fetal
occiput is directed towards the mother’s spine or
posteriorly
2. Intermediate positions (Bregma)
35. C. Causes
Defects of the power: Laxity of the abdominal
muscles, exaggerated dextrorotation of the uterus
Defects of passage: Contracted Pelvis, android
pelvis, pelvic tumor, uterine anomaly and placenta
previa.
Defect of passenger: Preterm fetus, macrosomia,
multiple pregnancy, poly hydramnios, anacephaly and
hydrocephaly, Intrauterine fetal death
37. Causes and risk factors
◦ CPD
◦ Thyroid neoplasms
◦ Multiple loops of cord around fetal neck
◦ Fetal anomalies
◦ Polyhydramnios
◦ Prematurity
◦ PROM with unengaged head
◦ Uterine anomalies
◦ Placenta Previa
◦ External Cephalic Version
◦ Idiopathic
◦ More common in nulliparous women
38. Diagnose
◦ Cephalic prominence and back are on same side
◦ FH heard in lower quadrants
◦ On vaginal exam:
◦ Anterior fontanel easily palpated
◦ Frontal suture easily felt, sagittal suture hard to reach
◦ Palpable supra orbital ridges, eyes, root of nose
39. Management and its
complications
Denominator is forehead (frontum – Fr)
Attitude of partial extension
Vertico-mental diameter presents
Incidence 1 in 1000-3000
Descent very slow, molding extreme
Higher fetal mortality, traumatic brain
injury r/t molding
Management: Cannot deliver vaginally
unless converts to face (30%) or vertex
(20%). It is cesarean delivery
41. Types
Incidence <1% (1 in
250-600)
Types
◦ Anterior (LMA, RMA)
Longer labor
90% deliver vaginally
More work for Mom
NB: Facial and
laryngeal edema –
watch for breathing
difficulties for 24
hours, peds at delivery
◦ Transverse (LMT, RMT)
Majority rotate to LMA
→ MA
Remainder either
rotated with forceps or
delivered by c/s
42. Types cont..
◦ Types, cont
Posterior (LMP, RMP)
30% of face
presentations
Most rotate anteriorly
Persistent posterior
cannot be delivered
vaginally
43. Diagnose
On vaginal examination:
The face is palpable and
the point of reference is the
chin. You should feel the
mouth and be careful not to
confuse it with breech
presentation.
It is necessary to
distinguish the chin-
anterior position from chin-
posterior position
44. Management
If Chin-anterior position
If the cervix is fully dilated: vaginal
delivery
If there is slow progress and no sign
of
obstruction, augment labor
If descent is unsatisfactory, perform a
C/S
If Chin-posterior position
Deliver by C/S
45. Implications for practice
◦ Notify consulting MD
◦ Reevaluate adequacy of
pelvis
◦ Closely monitor
mechanisms of labor and
identify if rotates to MP
position
◦ No FSE
◦ Careful VEs so as not to
damage eyes
◦ Gentle pressure on fetal
brow to maintain
extension until chin is
born
◦ Control head delivery,
gradual flexion and birth
of remainder of head
◦ Peds at delivery
◦ Reassurance to parents
about extensive edema
46. MECHANISMS OF LABOR
◦ Extension
◦ Engagement – when the
submentalbregmatic diameter
passes through pelvic inlet
◦ Descent occurs throughout
◦ Internal rotation
RMA and LMA to MA (45°)
RMT and LMT to MA (90°)
RMP and LMP t0 MA (135°)
RMP and LMP to MP (45°)
◦ Birth of the head by extension followed by flexion
Extension until chin is born under the symphysis pubis
Chin impinges beneath symphysis pubis and rest of head is
born by flexion
◦ Restitution
◦ External rotation
◦ Birth of shoulders and body by lateral flexion via the curve of
Carus
49. Breech
Types
• Complete – flexion at
thighs and knees (5-10%)
• Frank – flexion at thighs,
extension at knees (50-
70%)
• Footling – extension at
thighs and knees, single or
double (10-30%)
• Kneeling – extension at
thighs, flexion at knees,
single or double
50. Diagnosis
Pt reports FM in lower abdomen/rectum
Ballotable head felt in fundus
Non-ballotable breech felt in lower
abdomen
FH heard at or above umbilicus
On VE, high presenting part, negative
findings
Presenting part soft and irregular
The buttocks and/or feet are felt, thick
dark
52. Management
Criteria for vaginal breech delivery
◦ No Contraindications to vaginal birth
◦ No fetal anomaly that may interfere with vaginal birth
◦ EFW 2000-4000g
◦ GA 36+ weeks
◦ Flexed fetal head – NO hyperextension
◦ Frank breech
◦ Normal progress of labor
◦ Continuous EFM
◦ Skilled provider and c/s immediately available
53. Management cont
Varney’s 9 Steps/Criteria before Delivery of a Breech
1. Abdominal exam or sono/x-ray to r/o hyperextension
of fetal head, hydrocephalus, footling/kneeling
breech
2. Complete cervical dilation
3. Completely assured of adequacy of pelvis
4. Empty bladder
5. Determine need for episiotomy and perform
6. Ensure effective maternal pushing
7. Prepare for full-scale NB resuscitation
8. Position woman in lithotomy, at edge of bed
9. Consulting physician at bedside or immediately
available
54. Management cont..
Types of vaginal breech delivery
◦ Spontaneous – no traction, no manipulation
◦ Assisted – infant delivers spontaneously to umbilicus,
maneuvers are used to facilitate rest of delivery
◦ Total breech extraction – feet are grasped, entire fetus
is extracted
55. In breech presentations, three segments of the fetus go through the
mechanism of labor:
1. The buttocks and lower limbs
2. The shoulders and arms
3. The head
Mechanism of labor for Right Sacrum Anterior, R.S.A.:
Descent occurs throughout for all three segments due to the force of
uterine contractions.
I. The Buttocks:
◦ Engagement: has been achieved when the bitrochanteric
diameter has passed through the inlet of the pelvis with the
sacrum in the left anterior quadrant of the mother's pelvis and the
bitrochanteric diameter in the left oblique diameter of the
mother's pelvis. Lateral flexion occurs at the waist.
56. ◦ Internal Rotation: When the
anterior hip meets the
resistance of the pelvic floor, it
rotates forward 45 degrees so
that the bitrochanteric diameter
becomes anteroposterior. (RSA
to RST)
◦ Birth of the Buttocks: by
Lateral Flexion:
The anterior hip impinges
under the pubic symphysis;
lateral flexion at the waist is
increased; the posterior hip is
born over the perineum. Then
the anterior hip slips out from
under the symphysis and is
born. The legs and feet
usually follow spontaneously
57. Management of Breech
Presentation
◦ Restitution occurs as
the buttocks rotate
45 degrees (RST to
RSA) in response to
internal rotation of
the shoulders.
As the buttocks are born:
58. II. Shoulders and Arms:
◦ Engagement of the shoulders occurs with
the bisacromial diameter passing through
the pelvic inlet in the right oblique
diameter of the maternal pelvis.
◦ Internal Rotation occurs as the anterior
shoulder strikes one or both pelvic
sidewalls and rotates 45 degrees from the
right oblique diameter to the
anteroposterior diameter of the maternal
pelvis.
◦ Birth of the Shoulders by Lateral
Flexion:
The anterior shoulder impinges under
the symphysis and the posterior
shoulder and arm are born over the
perineum as the baby's body is lifted
upward. Then the anterior shoulder and
arms pass out under the symphysi
59. III. The Head: When the shoulders are at
the outlet, the head is entering the pelvis.
◦ Engagement: occurs with the sagittal
suture in the left oblique diameter of the
pelvis. The occiput is in the right
anterior quadrant of the pelvis.
◦ Flexion: of the head will take place but
must be maintained.
◦ Internal Rotation: The occiput strikes
the pelvic sidewalls and rotates 45
degrees anteriorly so that the sacrum
becomes position S.A. resulting in the
sagittal suture being in the
anteroposterior diameter of the pelvis.
◦ Birth of the Head: The nape of the neck
pivots under the symphysis and the
chin, mouth, nose, forehead, bregma
and occiput are born over the perineum
by flexion
60. APPENDIX D
PROCEDURE FOR MANAGEMENT OF A BREECH DELIVERY
The involvement of midwives with breech
deliveries differs in different practice settings. But
regardless of the birth site, the midwife must
know how to manage and deliver a baby in a
breech presentation. At times the midwife may
confront an unplanned or emergency breech
delivery. Medical help should be summoned,
and the following procedure used until a
consultant physician arrives.
On other occasions, midwifery delivery of a
breech presentation may be expected and
planned for. This situation should always involve
close collaboration with, and immediate
availability of, a physician, in case of potential
problems, i.e. difficulty in delivery of the after-
coming head.
In any case, preparation should be made for
possible extensive newborn resuscitation and
infant transfer to a high-risk nursery
61. A. GUIDELINES FOR SAFE DELIVERY OF A BREECH
1. Cervix fully dilated before pushing is allowed.
2. Bladder empty.
3. Episiotomy performed, unless perineum is very
lax.
4. Delivery accomplished by maternal pushing —
rather than traction from below.
5. Intervention consists of aiding the steps of the
mechanism of labor to happen within safe time
limits.
62. 6. Safe traction is made by
downward pull on the baby's
pelvis (by fingers on the iliac
crests and thumbs over the
sacro-iliac regions) or later after
the trunk has been delivered by
a finger hooked over each
shoulder.
7. Delivery of the shoulders
should be attempted only after
the scapulae can be seen.
From Williams 22nd Ed figure
24-8
63. 8. Safe rotation of the trunk is
made by using the same
grasp on the baby's pelvis
and turning.
9. Delivery of the head
should be attempted only
after the hairline at the
sub-occipital region can
be seen.
From Williams 22nd Ed figure 24-9
64. B. PROCEDURE FOR DELIVERY OFA FLEXED
BREECH
All steps as in procedure for normal delivery apply except where
the following special points replace them:
1. There should be no intervention ("hands off the breech")
until the body is born as far as the umbilicus.
2. When the umbilical cord can be seen, gently draw down a
loop of cord, placing this to the side or near the perineum, to
avoid a pull on the cord or unnecessary pressure. If the cord
does not slip down with gentle traction, omit this step.
3. With the next contraction, have the mother bear down
strongly to deliver chest and arms. Meanwhile, grasp the baby
by its pelvis (see # 6 above), and when the body is delivered
as far as the axilla, guide it downward to release the anterior
shoulder and arm, then upward for the posterior shoulder and
arm
65. 4. As soon as the body and shoulders
are fully born, rotate the back
uppermost to ensure that the
occiput rotates anteriorly. Have an
assistant apply suprapubic
pressure to maintain flexion of the
infant's head until the head is born.
Rest the baby's body on your non-
dominant hand and forearm,
hooking the index and ring fingers of
this hand on each malar eminences.
Place your other hand on the
baby's upper back, with the index
finger hooked over one shoulder, and
the middle finger hooked over the
other shoulder. Place the hooking
fingers as far away from the neck as
possible to avoid pressure on the
cervical or brachial nerve plexuses.
As the mother bears down, make
downward and outward traction
on the shoulders until the hairline
66. Procedure for Delivery of a
Flexed Breech
Alternative: if no assistant is available to
apply suprapublic pressure, use the upper
hand to apply suprapubic pressure to the
head until the hairline appears under the
pubic arch
67. 5. Apply upward traction while elevating the infant's
body, following the curve of Carus. When the
suboccipital region of the head pivots under the
symphysis pubis, lift the body 45°, until the
infant's nose and mouth are visible at the introitus.
Complete delivery of the head by gradually easing
the vault out through continuing the upward lift of the
body.
Alternative: The upper hand grasps the baby by the
ankles, maintaining slight traction to ensure that the
suboccipital region pivots under the symphysis pubis.
Lift the body about 45o until the nose and mouth are
visible at the introitus. With the lower hand , wipe
off the nose and mouth. Complete delivery of the
head by gradually easing the vault out through
continuing the upward lift of the body.
68. C. MANAGEMENT OF
DIFFICULTIES IN A BREECH
DELIVERY
▫ Lower part of trunk
1. In the rare cases where extended
legs splint the trunk to such a
degree that delivery is
obstructed, be sure that the body
is turned so that the
bitrochanteric diameter is
directly A-P. This allows the
maximum amount of lateral
flexion of the trunk. Remember
that there is no rush with this
part of the delivery.
2. If the above fails to relieve the
obstruction, intervene by
rotating the thighs laterally, then
pressing in the popliteal space
to cause the leg to flex at the
knee. Grasp the ankle and
deliver the lower extremity by
bringing it down across the
baby's abdomen in the
physiological range of motion.
If necessary, do the same to the
other leg.
Pinard Maneuver:Williams Fig 24-12
69. ◦ At Umbilicus
◦ Note: When the umbilicus appears, the fetal
head is entering the pelvis, and compression of
the cord to some degree is inevitable from then
on. Cord pulsations can be felt, but usually will
be slow because of the interference with feto-
placental circulation. The time generally
mentioned that fetal anoxia can be endured
without causing brain damage is five minutes.
From this point on, there is a time limit for safe
delivery, but anoxia from cord compression is
probably a less important cause of fetal damage
than anoxia from delay or intracranial trauma and
fractures of cervical vertebrae caused by frantic
but unskilled efforts to deliver the baby quickly
70. Upper Trunk
1. When intervention is necessary to
assist delivery of the chest and upper
extremities, make outward traction on
the pelvis until the scapula or axilla
comes into view. Then use
downward traction to release the
anterior shoulder, and follow with
upward traction to deliver the
posterior shoulder.
2. If this is not effective, use a technique
similar to the Screw Maneuver of
Woods, which for breech delivery is
called the Lovset Maneuver. This
consists of rotating the posterior
shoulder, keeping the back anterior,
and using the grip on the pelvis to do
the rotation while maintaining
moderate traction. When the posterior
shoulder has become anterior, repeat
the maneuver again keeping the back
anterior.
71. 3. If the arms do not deliver spontaneously with the
shoulders, reach in along the upper arm, use your
fingers to splint the humerus, and draw it across the
chest and out. Repeat for the other arm.
◦ After-coming Head
If there is a delay in descent of the head, reach in
and try to determine the cause. The most important
causes which can be remedied quickly enough to
save the baby are:
1. Transverse arrest of the head in the mid pelvis.
2. Partial extension of the head, causing a large diameter to
present.
3. Trapping of the head by an incompletely dilated cervix
72. Mauriceau-Smeillie-Veit
Maneuver
Transverse Arrest of the Head
A finger on each of the malar eminences of the face
(ring and index finger) is used to rotate the head to
bring the chin directly posterior. The middle finger
in the mouth does not press downward on the
jaw, but is on the superior maxillary bone
73. ◦ Partial Extension of the Head
The same grip may be used to flex the head. It is very important to cause
flexion by pressure on the malar eminences, not by pressing on the tongue
and mandible. The latter is both ineffective and apt to injure the baby. Once
the head is in the A.P., and flexed, the grip is maintained while downward
traction on the shoulders and suprapubic pressure by an assistant causes
descent. Then the head is delivered by upward traction, as previously
described. (This is called the Mauriceau-Smellie-Veit Maneuver
Williams 22nd ed figure 24-19
74. Incompletely Dilated Cervix Gripping Head
The first maneuver to be tried is to slip
the cervix up over the occiput,
above the symphysis pubis. If this is
not successful, the cervix should be
incised at the 10:00 and 2:00
positions, making a cut with the
scissors through the cervix to its
juncture with the vaginal wall. If
these two incisions do not provide
sufficient room for the head to slip
through, a third is made at 6:00
(Duhrssen's incisions). Cutting the
cervix is less traumatic for the
mother than having it torn by
forcibly dragging the baby out. Not
only does force traumatize the baby,
but the cervical tears caused may
extend into the lower segment and
these uterine tears (ruptures) can be
a grave hazard to the life of the
mother
Williams 22nd ed figure 24-4
75. Difficult delivery of Breech Presentation
Note: The consulting physician may apply forceps to the
after-coming head when its delivery is delayed. If the
midwifery measures described above have been tried
unsuccessfully, the midwife will have to wait until
medical assistance arrives. Meanwhile, s/he can insert a
vaginal retractor and, by pressure on the posterior
vaginal wall, provide a means for air to reach the baby's
nose and mouth (Oxorn
76. The dangers to the baby in a breech delivery, and
the corresponding means to avoid these are as
follows
1. Damage to internal organs of the
trunk.
◦ Proper grip on pelvis as described in A, #6
2. Fracture of bones of extremities.
◦ If intervention necessary to deliver extremities, splinting
with fingers during maneuvers, and movement only in the
normal range for the joint.
3. Injury to brachial plexus
◦ Avoid overstretching of the plexus and neck in attempts to
deliver the head
77. The dangers to the baby in a breech delivery, and
the corresponding means to avoid these are as
follows
4. Fracture of cervical vertebrae
◦ Avoid hyper extending neck vertebrae by
lifting body in attempt to deliver the head:
until the sub-occipital region (hairline)
comes under the pubic arch.
5. Intracranial damage.
◦ Avoid anoxia caused by delayed delivery
or prolonged cord compression and avoid
rapid delivery ("popping") of the vault of
the head.
6. Injury to pharynx.
◦ Avoid placing finger in baby's mouth.
80. Management of BREECH according to MOH
guideline and protocol, 2012
Consider external cephalic version at 37 weeks if all
requirements are met (Adequate amniotic fluid, placenta
in fundal position, No uterine anomalies, no previous
uterine scar, availability of theatre)
Ideally, every breech delivery should take place in a
hospital with surgical capability.
Determine most favorable mode of delivery
81. Cont…
Contraindications to vaginal delivery
are
Unfavorable pelvis, primigravida, macrosomia,
severe prematurity, IUGR, placental insufficiency,
footling breech, hyperextension of fetal head, fetal
anomalies, nuchal arm, PROM or non-progressive labor
Note: Vaginal breech delivery is safe
and feasible by a skilled health
provider
82. Complications and
recommendation
Complications
Entrapment of the after coming head
Nuchal arm
Recommendation:
As health care provider if we diagnose a case of breech at
HC refer her at hospital.
If she came at expulsion legs out you can try to conduct
delivery in order to save life.
84. Diagnosis and management
On Vaginal Examination
Fingers/Arm is felt with the presenting
part
Management
Replace the arm and if sucessful
continue with vaginal delivery
If Contracted pelvis and/or cord
prolapsed: Do a C – section
86. Cont…
◦ Incidence 1 in 500
◦ Denominator –
scapula
◦ Becomes impacted if
not corrected
◦ May turn
spontaneously, can
be turned manually
◦ Clearly document,
do not neglect
◦ Risks
Uterine rupture, fetal
death if neglected
Prolapsed arm or cord
87. Diagnosis
During pregnancy:
Inspection:
abdomen is
broader from side
to side
Palpation: the
fundus feels empty
and the fundal level
is lower than
expected
Ultrasound
confirms the
During labor:
On vaginal
examination the
scapular is felt as
point of reference
Ultrasound
confirms the
diagnosis
88. Diagnosis
◦ Abdomen appears asymmetrical
◦ Fundus lower than expected
◦ Head palpable in one maternal flank
◦ FH heard below umbilicus
◦ Negative findings on VE
92. OCCIPUT POSTERIOR POSITION
(OP)
The fetus lies with its occiput towards
the
mother’s spine and its face towards the
mother’s symphysis and abdomen
93. Diagnosis
On vaginal examination:
The anterior fontanelle is palpated
Identify the sagittal suture which is
mostly asymmetric
Dilation is often asymmetric, you can
feel the fetal ear and a persistent
anterior cervical lip is common
94. Management
Spontaneous delivery is possible:
Make sure
uterine contractions are adequate and
no fetal distress
Manual Rotation
Vacuum extraction delivery
Cesarean delivery should always be
the backup method of delivery for any
Occiput posterior presentation that
cannot be safely delivered vaginally
95. 5. MULTIPLE PREGNANCY
More than one foetus
in the uterus.
Mostly twin
pregnancy but
others may be
encountered,
triplets or plus
97. 1.Causes/Risk
factors
Use of fertility
reproduction (in vitro
fertilization, ovulation
induction)
Hereditary factors
Previous multiple
pregnancy
2.Signs and
Symptoms
Fundal height larger
the gestational age
Two audible fetal
heart beats
-Multiple fetal parts
or more than two
fetal poles
Exaggerated
symptoms of
Pregnancy
100. Management
Antenatal:
• Routine antenatal care
• Hb check
• Monitor for associated obstetric
complications to determine:
presentation of first twin, detect
anomalies, mode of delivery
• Bed rest
• Increase nutrition
101. Management cont
Mode of delivery:
• Elective Cesarean section
if Previous Uterine scar
The first Twin is not cephalic
More than two fetuses
• Vaginal Delivery
If the first Twin is cephalic
Otherwise do a Caesarean section
if Retained second twin
102. Management cont…
For Vaginal Delivery
Perform abdominal and vaginal
examination and assess: membranes; if
intact perform amniotomy
Look for evidence of fetal and maternal
distress and manage accordingly
If assessment favorable then oxytocin
and
delivery or C/S if the evolution is poor
Third Stage
Look for and anticipate post partum
hemorrhage.
104. 6. HYPERTENSIVE
DISORDERS IN
PREGNANCY
6.1. PRE-ECLAMPSIA
a. Definition:
Blood pressure of ≥ 140/90 mm Hg after 20 weeks
of gestation plus proteinuria of 300 mg per 24
hours or >2+ on urine dipstick
105. Risk factors
Nulliparity
Maternal age < 20 years and > 40 years
Multiple gestation
Pre-eclampsia in previous pregnancy
Chronic hypertension
Chronic renal disease
Diabetes mellitus
Elevated BMI
Antiphospholipid syndrome
Family history
106. Signs and symptoms
Blood pressure of ≥ 140/90 mm Hg
Headaches, dizziness, ecophene,
blurred vision, Epigastric pain
Proteinuria (≥ 300mg per 24 hours)
Generalized oedema
110. Non-pharmaceutical management
Pregnancy < 37 weeks of gestation
Hospitalisation and close monitoring
Bed rest
Monitoring BP, diuresis, proteinuria, fetal
movement and fetal heart beats (every day)
Advise the patient or the family on the
eventual
signs of complications
Pregnancy >37 weeks of gestation
Admission
Consider delivery
111. Management cont…
Severe preeclampsia (Critical care) : BP
≥ 160/110 mm Hg (especially diastolic
≥110 mmHg) Proteinuria ≥+++or ≥
1g/24h
- Severe Preeclampsia (is treated like
eclampsia)
• Hospitalisation and close monitoring
• Order bed rest
• Monitor BP, pulse, deep tendon reflexes,
breathing every 4 hours
• Maintain input and output balance sheet
112. Pharmaceutical management
The ideal drug for this clinical scenario
is one that reduces the BP in a
controlled manner, avoiding
precipitous reduction that may
compromise placental perfusion.
The goal is to lower the BP to a mildly
hypertensive level (diastolic BP
between 90-100mmHg).
113. First choice treatment
Anti- convulsion Treatment
Magnesium sulphate:
Dosage
Loading Dose: 4 to 6 g IV bolus (20ml) over 5 to 15
minutes
Maintenance dose: 1to 2 gr infusions of 200-300 ml of
Ringer’s lactate per hour, or 5 g undiluted 50% of
magnesium sulphate injection (add 1 ml of lidocaine
2%) by deep intramuscular (IM) injection into each but
tock every 4hrs for about 24 hrs after delivery or the last
fit/seizure.
Contra-Indications: Myasthenia, Respiratory
insuffisancy, cardiomyopathy, oligoanuria.
114. Management…
Note: Monitor respiratory rate (> 16
breaths/min), urine output,
consciousness, deep tendon reflexes
and Magnesium sulphate serum levels
(where possible)
■ S/E: hypermagnesium: colic,
decreased respiratory rate, heart rate,
oliguria, & depressed deep tendon
reflexes (DTR)
■ Calcium gluconate: Should be ready (1
g
Slow IV bolus in 2 to 3 minutes as an
115. Management cont
Anti- Hypertensive treatment
Hydralazine IV Initial dose 5 mg IV in
10 mls sterile water over 4 minutes. If
necessary repeat 30minutes after
■ S/E: nausea, headache, weakness,
palpitation, flushing, aggravation of
angina, anxiety, restlessness,
hyperreflexia.
■ C/I: porphyria, aortic stenosis, lupus
erythematosis renal failure
116. Management cont…
OR
Nifedipine: 20 mg orally TDS until stabilized
blood pressure
Nifedipine: 10 mg short acting if diastolic blood
pressure is ≥ 110mmhg
■ S/E: difficult breathing, hives, hypotension
OR
Labetalol if hypertension is refractory to hydralazine.
■ Dosage: 20-50mg intravenously, infusion
200mg in 200ml Ringers lactate at 5 drops
per minute.
■ S/E: severe fetal and neonatal bradycardia
117. Management cont…
Obstetrical Management
If at term deliver immediately
preferably vaginal delivery.
If preterm (24 to 34 weeks), give
Dexamethasone 6mg every 12 hrs for
48 hours and deliver by induction (if
not contraindicated) after 48 hrs.
118. Recommendation
Imminent delivery with severe
prematurity must be done in a center
with neonatology facilities
Contraception for at least one year
Closely follow up next pregnancy
Low dose Acetyl salicylic Acid
(aspirine) 75 mg PO once daily and
calcium supplementation 1g daily can
be considered for the next pregnancy
119. 6.2. ECLAMPSIA
Definition
Onset of convulsion/generalized
seizures in a woman with pre-
eclampsia that can not be attributed to
other causes
121. Signs and symptoms
Signs of severe pre-eclampsia (Refer
above)
- Hypertension of Usually > 160/110mm
Hg)
- Loss of consciousness
- Tonic-clonic seizures
- Coma
123. Investigations
Full blood count and cross-match
Ultrasound
Urea and createnine + electrolytes
Liver function tests
24h urine collection for Proteinuria
Uric acid
Clotting profile
124. Management (Critical care)
Maternal resuscitation
Prevent aspiration and trauma during
convulsions
Insert 2 IV lines (One for Magnesium
sulphate and the other for Anti-
Hypertensives)
Fluids should be restricted to avoid
pulmonary oedema (80 mls per hour is
recommended)
Give O2 6L/min by face mask
Insert a urinary catheter
Prevent and stop convulsions
Same treatment as severe pre-eclampsia
125. Management
Obstetrical management
• If pregnancy 34 weeks or more
Immediate delivery after stabilization should
be considered
If stable, no fetal distress, no labor, vaginal
delivery
should be considered
- Misosprostol, 50mcg PO or 25mcg vaginally
to repeat 4 hrs after, up to a total of six doses
maximum
If failure of stabilization immediate Cesarean
section
126. Management cont…
If the pregnancy is 32-34 weeks and no
labor
Stabilize and administer
Dexamethazone IM
should be considered and vaginal delivery
is preferred after 24-48 hrs,
■ 6 mg IM every 12 hrs for 48 hrs
■ S/E: increase intrauterine growth
retardation
If the pregnancy is less than 32 weeks
Cesarean Section is preferred as the
success of induction is reduced
127. Recommendations
Obligatory postpartum follow up
If pregnancy is <32 weeks, delivery should be done in
a
center with the necessary facilities
Neonatal rescuscitation should be done in delivery
room.
Inform ICU on immediate transfer of Mother
Inform neonatal ICU on immediate transfer of Neonate
Contraception for at least one year
Closely follow up next pregnancy
Low dose Acetyl salicylic Acid (aspirine) and Calcium
sup
plementation can be considered for the next pregnancy
Rescuscitation of the mother should be done in the
delivery room
128. 7. POST PARTUM
HEMORRHAGE
Definition
Loss of more than 500 ml of blood from the
genital tract in the first 24 hours after vaginal
delivery and more than 1000 ml after
cesarean section.
Excessive vaginal bleeding resulting in signs
of hyovolemia (Hypotension, Tachycardia,
oliguria, light headedness)
A 10% decline in post partum hemoglobin
concentration from antepartum levels
129. Types of PPH
Primary: Occurs within first 24 hrs
Secondary: After 24hrs to the end of
puerperium (42days after delivery)
130. Risk factors
Overdistension of the uterus(Polyhydramnios,
Multiple pregnancies, Macrosomia…)
Grand multiparity
Previous history of PPH
Ante-partum hemorrhage
Myomatous uterus
Hypertensive disorders
Drug use (Mgso4, Salbutamol…)
135. Management
Uterine massage
Inspect for lacerations
Medications( iv fluid, oytocin, cytotec,….)
Surgical intervention
136. Management cont..
APPLY ACTIVE MANAGEMENT OF 3RD STAGE OF LABOR:
Administration of 10 IU of oxytocin IM within first minute after
delivery of fetus
Apply controlled cord traction
Uterine massage after delivery of placenta
137. Management
Resuscitative Measures :
Call for help
Airway, Breathing, Circulation
Two large bore IVs
Oxygen
Stat labs: type & cross, hgb, coags
Consider transfusion
138. Management..
Stage 0:normal treated
with massage and oxytocin
Stage 1: more than normal
bleeding : Establish large-
bore intravenous access,
assemble personnel,
increase oxytocin, consider
use of methergin, and
perform massage,
Stage 2: Bleeding continues ,
check coagulation status,
assemble response team, move
to operating room,administer
additional uterotonics,
misoprostol, curettage, and
laparotomy with uterine
compression or hysterectomy.
Stage 3: Bleeding
continues , activate
massive transfusion
protocol, mobilize
additional personnel,
recheck laboratory tests,
perform laparotomy,
consider hysterectomy
139. Management cont…
Uterine atony
-Bimanual uterine
massage
-Oxytocin 20 iu/ 1000ml
of ns in 20 minute
If uterus is soft “ boggy”
Misoprostol 1000 mcg
per os/ intra anal
Methylergonovine 0.2
mgIM
143. Management cont…
Blood not clotting Thrombin
Replace coagulating factors
Fresh frozen plasma
Recombinant factors villa platelet
transfusion
144. Management cont…
If Blood loss> 1000ml and massive
hemorrhage
Transfuse RBCs, platelet, clotting
factors, support BP with vasopressors
ICU- anesthesia, hematology, surgery,
uterine packing/tamponade procedure
Vessel embolization/ ligation/ suture
HYSTERECTOMY
145. Recommendations
Methotrexate is only used in abnormal
adherence of the placenta (Increta, percreta)
Hemostatic drugs like tranexamic Acid IV
500mg every 6 hrs (with a maximum single dose
of 2.5g) and Etamsylate (dicynone) 500mg IV
infusion every 8 hrs are usually beneficial in the
management of PPH
146. References
Ministry of health, 2020, obstetrics Care protocol: Kigali Rwanda
Managing Postpartum hemorrhage hhp://reprolineplus.org/learning
opportunities/course/managing-postpartum-hemorrhage
Managing Pre-eclampsia and Eclampsia
http://reprolineplus.org/learning opportunities/course/managing-pre-
eclampsia and-eclampsia
Managing Prolonged and obstructed labor
http://reprolineplus.org/learning opportunities/course/managing-
prolonged-and-obstructed-labor
Managing Post-abortion care http://reprolineplus.org/learning
opportunities/course/managing-post abortion-care/take-the-course
147. Assignments
1. Diabetes during pregnancy and Rhesus
isoimmunization
2. Anaemia during pregnancy
3. Urinary tract infection during pregnancy
4. Cervical incompetence
5. Malaria during pregnancy
6. Post term pregnancy and induction
Editor's Notes
Incidence? Perhaps included in Footling, since 10-30% includes “footling or incomplete”
Oxorn 222-4, UTD, Emedicine
