1. Obstructed labor occurs when there is failure of progress of labor due to mechanical reasons despite adequate uterine contractions and can lead to maternal and neonatal mortality. (2) It is most common in low-resource settings with inadequate intrapartum care. (3) Cephalopelvic disproportion and malpresentations are the main etiologies of obstructed labor. 2. Prolonged labor in obstructed labor results in pathological changes including thinning of the lower uterine segment which can rupture, edema of bladder and vagina, and fetal distress. Symptoms include abdominal pain, cessation of contractions and bleeding. Management involves relieving obstruction through vaginal or abdominal delivery depending on the situation. (4)

1. 1
December 13, 2023

2. Definition
Obstructed labor - Failure of progress of labor /
decent of fetus in the birth canal for mechanical
reasons in spite of good uterine contraction.
An absolute condition not a relative condition-
should be applied only when further progress is
impossible without assistance.
Major cause of maternal and perinatal mortality and
morbidity in low-resource settings with inadequate or
inaccessible intrapartum care.
2
December 13, 2023

3. Incidence
Related to the incidence of CPD in the
community & to the availability and quality of
antepartum and intra-partum care.
Virtually occurs only in developing countries
Where obstetric care is optimal OL should
never occur.
3
December 13, 2023

4. Etiologies
CPD (commonest cause)
- Faults in the pelvis: small or abnormal in shape
- Faults in the fetus: Macrosomic, Malformation
(eg. Hydrocephalus)
Malpresentations or malpositions of the fetus
- Breech presentation (Impacted large breech,
extended arm, arrest of after coming head)
- Transverse lie (2nd commonest cause)
- Brow - Impacted mentoposterior
4
December 13, 2023

5. Etiologies (ctd.)
Shoulder dystocia
Soft tissue dystocia/ abnormality
- Tight perinium
- Abnormalities of the vagina: Septum, scarring
- Abnormalities of the uterus: Fibroids (Lower
uterine segment Cervical),
- Ovarian tumors
5
December 13, 2023

6. Pathologic changes seen in CPD/OL
A. Uterus – Two patterns
1. Primigravids: A period of strong infrequent
contraction followed by hypotonic contraction
– protective against Ux rupture
2. Multipara: Ux continues to contract strongly »»
progressive thinning and ballooning of the lower Ux
segment while the upper uterine segment thickens »»
Pathologic retraction (Bandle’s) ring between the
two segments »» If not relieved Ux rupture starting
from the thinned lower segment.
6
December 13, 2023

7. Pathologic changes (contd.)
B. Cervix : Two patterns
1 . In primi - slow cervical dilation or no dilation esp.
after rupture of the membranes (2o to poor application of
presenting part » 2o Ux dysfunction » prolonged labor)
- If augmented some increase in dilation (Minimal CPD)
or no dilation (absolute CPD)
- OL usually occurs before full dilation.
- protracted dilation = early warning sign
2. In multi – Normal Cx dilation with arrest as OL
sets in, the only evidence of impending obstruction
being failure of descent.
7
December 13, 2023

8. Pathologic changes (ctd.)
C. Soft tissue
1. Bladder - continued pressure between the fetus & pubic
bone » edematous bladder pulled up into the abdomen
“in multi it forms the 3rd tumor in “the three tumor
abdomen”
Urethra usually difficult to catheterize, may be necessary
to dislodge the presenting part.
 Urine is usually scanty, concentrated and blood stained.
Gross hematuria indicates bladder injury with Ux
rupture.
8
December 13, 2023

9. Pathologic changes (ctd.)
2. Avascular pressure necrosis- Presenting part wedged
with no advance for considerable time »
Sloughing after several days [usually in primi]
i. Vagina alone – heals by scaring » stenosis of the
vagina (Acquired gynatresia) » Dyspareunia.
ii. Proximal urethra + bladder neck » UVF, VVF
iii. Rectum – RVF (occurs in 15% of VVF)
3. Vulva – Usually edematous esp with early pushing
called also “Kannula syndrome” [ Kannulla= to push in zulu ]
9
December 13, 2023

10. Pathologic changes (ctd.)
D. Fetus
i. Caput - which may be considerable (even reaching the
perineum with no engagement) leading to Dxtic error of station
ii. Molding - results in decrease in BPD of 0.5cm
usually not dangerous but if > 0.5cm »» chance IC hemorrhage
(cerebral birth trauma).
iii. Fetal asphyxia – 2o to placental insufficiency from strong
& prolonged contraction
-fetal distress and meconium passage » if severe fetal » death
iv. Increased perinatal (fetal + ENN) morbidity & mortality
[Cerebral birth trauma, aspyxia and infection].
10
December 13, 2023

11. Pathologic changes (ctd.)
E. General condition
i. Intrapartum infection - occurs almost always and
may lead to septic shock, peritonitis or abscess
formation.
-Prolonged ROM, repeated PV, manipulation and
application of local medicine »» Chorio-amnionitis
»» puerperal sepsis + congenital pneumonia/sepsis
in the fetus.
ii. Fluid balance - DEHYDRATION due to muscular
activity + hyperventilation in the absence of
adequate fluid intake.
11
December 13, 2023

12. Pathologic changes (ctd.)
iii. Acid - base balance
METABOLIC ACIDOSIS
a. lactic acid from Ux muscle
b. Ketone from inadequate calorie intake & fat break
down.
c. DHN- induced oliguria decreased excretion of anion
® Rapid shallow respiration, rapid pulse.
12
December 13, 2023

13. Clinical presentation
A. Primigravid
Hx - usually a young teenage
- Hx of prolonged labor at home (days).
- Usually no ANC follow up
P/E – Tired, exhausted and anxious.
- Dehydrated + Acidotic [^PR, ^RR, ^T], BP
usually normal unless septicemic.
- Distended atonic bowl.
- Bladder distended with difficult catheterization.
13
December 13, 2023

14. Clinical presentation (ctd.)
- Ux either hypotonic or has strong painful contraction
with poor relaxation in b/n.
- P/V- edematous vulva and Cx
- Dry vagina with scanty foul smelling meconium
stained liquor
- Cx usually not fully dilated, high head with
excessive caput and molding + contracted pelvis.
14
December 13, 2023

15. Clinical presentation(ctd.)
B. Multigravid - finding vary if the patient is seen prior to
or after Ux rupture.
i. Before rupture – generally findings are as primi +
- often three tumor abdomen [edematous enlarged
bladder, distended tender lower ux segment & tonically
contracted upper segment] - P/V- Cx is fully dilated.
ii. After rupture – two presentation
a. if presenting part is impacted, temponade effect on torn
Ux vessels, minimal or no hemorrhage with no
hypovolumic shock »» clinical presn. is as above (i)
b. if it is not impacted and major vessels involved profound
shock often mixed (hypovolumic +septic)
15
December 13, 2023

16. Management of Obstructed Labor
Obstruction should be relieved without delay.
Before that try to correct/rectify the effects
of prolonged labor.
General (nonspecific) measures & definitive
(specific) measures
16
December 13, 2023

17. Management (ctd.)
A. General measures
i. Resuscitation- should be as rapid as possible as
operative delivery is usually urgent; in the OR if
actively bleeding:
- open IV line with wide bore cannula
- 5% D/W or 5% D in ½ strength N/S
- 50 ml of 50% dextrose in the bag
- *** Determine Hgb, BG & Rh & X- match.
17
December 13, 2023

18. Management (ctd.)
ii. Control infection
In all cases infection should be assumed and broad
spectrum antibiotics should be commenced IV.
iii. Empty the bladder
- by plastic (Not metallic) catheter
- if difficult dislodge the presenting part vaginally
- if impossible catheterize after GA
- Keep catheter 48hrs – 10 days
18
December 13, 2023

19. Management (ctd.)
B. Definitive management
- some sort of operative delivery is needed [Vaginal or Abd.]
- No wait and see policy and non-operative methods has no
place.
Abdominal delivery (Indication)
- Alive child with incomplete dilation or high station (criteria
for instrumental delivery not met)
- Ruptured Ux
- Eminent Ux rupture even if fetus is dead
- Dead fetus – when the criteria for destructive or
instrumental delivery not met.
19
December 13, 2023

20. Management (ctd.)
Vaginal delivery
Options include-Forceps/ vacuum delivery : limited place
in OL due to minor mal-positions.
-Destructive delivery(Indication, Prerequisite,
contraindication.)
- Symphisiotomy
20
December 13, 2023

21. Prevention of OL
Optimal antenatal care
Detection of risk factors
Midwife run satellite clinics and
simple mother waiting areas
Avoidance of teenage pregnancies
Skilled birth attendance and use of partograph
in labor.
21
December 13, 2023

22. Complications of OL
Uterine rupture
PPH, Sepsis
Neurologic-Complication (Foot drop)
Anesthetic complication
Avascular necrosis (Vaginal stenosis/ atresia,
VVF, UVF, RVF)
Psychological trauma, Infertility, cerebral palsy.
Fetal and Maternal death.
22
December 13, 2023

23. 23
December 13, 2023

24. INTRODUCTION
Tear of uterine wall which could be any where
in the body or lower segment which can be life
threatening for the mother and fetus.
Previous uterine surgery is the most common
risk factor.
Rupture of the unscarred uterus is rare, but
appears to account for an increasing proportion
of all uterine ruptures.
24
December 13, 2023

25. Definition
Uterine rupture- is rupture of the gravid uterus
through the entire/partial thickness of the
myometrium during pregnancy.
It is however still prevalent in low-resource
settings where skilled pregnancy care is mostly
unavailable, e.g. sub-Saharan Africa.
Increasing rates of caesarean deliveries also
increase the possibility of a rise in rates of scar
dehiscence in the future.
25
December 13, 2023

26. PREVALENCE
The incidence of rupture in unscarred and
scarred uteruses are 0.7 and 5 per 10,000
deliveries, respectively.
Rupture of the unscarred uterus appears to occur
more frequently in less developed countries,
possibly related to higher parity, longer labors,
and a higher frequency of contracted pelvises
and lack of access to emergency obstetrical
services.
26
December 13, 2023

27. .
Classification
Extent Complete uterine rupture-extends through the whole
thickness of the uterus (myometrium and serosa)
Incomplete- rent of myometrium but with intact serosal
cover(so bleeding forms hematoma extra-peritoneally)
Etiology Spontaneous- uterine rupture without any external trauma
Traumatic- uterine rupture following iatrogenic or
accidental trauma
Timing Antepartum- uterine rupture before the onset of labor –
usually scar dehiscence
Intra-partum- uterine rupture during labor
Anatomic Fundal uterine rupture
Lower segment uterine rupture – transverse; vertical
Posterior uterine rupture
Uterine rupture with vaginal extension
Presence of
scar
Rupture of an unscarred uterus
Rupture of a scarred uterus – “Uterine Scar Dehiscence”
December 13, 2023 27

28. Etiology of Uterine Rupture
Etiology Examples
Abnormal labor •Obstructed labor, Precipitate labor
•Uterine hypertonus (oxytocin induction/augmn
Trauma •Car accident; Seat belt injury
•Fall accident with abdominal trauma
•Domestic violence
Iatrogenic •External or internal versions
•Total breech extractions
•Difficult forceps ( mid) deliveries
•Difficult embryotomy procedures
•Abdominal massage by a traditional labor attendant
Uterine scar Caesarean; myomectomy; previous repaired rupture;
previous uterine perforation
Spontaneous Certain antepartum or intrapartum ruptures occur
without any obvious explanations; extremely rare
occurrence 28
December 13, 2023

29. Mechanism of rupture
During labor & before the upper segment of the
uterus become thicker & the lower segment become
thinner which they form physiological retraction
ring.
Abnormal thinning of the lower uterine segment
create a serious danger during prolonged labor,
particularly in women of high parity & in those
with prior CS .
Also in obstructed labor it forms a pathological
retraction ring band may develop which the lower
segment to markedly stretch & rupture.
December 13, 2023 29

30. Mechanism
Progressive thickning of the upper uterine segment
at the expense of the thinning lower uterine
segment
In primigravidas contraction ceases at some point
when OL sets in before Ux rupture [“Primis Ux is
wise”]
spontaneous rupture in primigravidas is rare;
rupture usually associated with use of oxytocin,
operative vaginal deliveries.
In multigravidas Ux contraction continues until
finally the progressively thinning lower Ux
segment ruptures.
30
December 13, 2023

31. Manifestations
Prior to the onset of labor, a beginning rupture may produce
locale pain & tenderness associated with increased uterine
irritability & vaginal bleeding.
78% have fetal distress prior to pain so disappearance of
fetal heart tones.
Cessation of uterine contraction
Recession of the fetal presenting part
Sign of shock
Chest pain
Hematuria
Ultrasound may confirm abnormal fetal position or hemo-
peritonium
December 13, 2023 31

32. Manifestation
A. Symptoms
1. Impending (Imminent) rupture
- Anxiety, restlessness, weakness
- Worsening of abdominal pain especially suprapubically.
- Strange feeling that fetus is moving up with each contraction.
2. Ruptured Ux
a. Sudden cessation of contraction and fetal movement
b. Pain - often little or none
- severe continuous pain
- sharp shearing pain followed by either continuous pain or
relieved commonly
- late – sub-diaphragmatic + shoulder pain.
c. Vaginal bleeding – often little or none
d. Hematuria
32
December 13, 2023

33. Manifestation (ctd.)
B. Signs
a. Vital sign – vary from normal BP + PR to profound shock
(No BP +PR)
[Factors: +Temponade effect, Time elapsed, +involvement of
major vessels]
b. Variable pallor
c. Abdomen
- Soft to diffuse tenderness with Ux difficult to feel
- Variable abdominal + bowl distension
- Ux contraction is often absent & defect may be felt if tear is
anterion
- FHB usually absent unless a recent rupture.
- Fetal part may be easily appreciated only if extruded (Difficult if
abdomen is tense) + Shifting dullness
33
December 13, 2023

34. Manifestation (ctd.)
d. PV
- Jammed presenting part or may have receded to the brim
[“ loss of station”]
- variable bleeding
- catheterization – frank blood (only if there
is associated bladder rupture)
- Rarely : delivery of placenta before fetus or loop of bowl felt
Dxtic Investigations
- of limited value + no time to do them
34
December 13, 2023

35. Diagnosis of Uterine Rupture
Symptoms Signs Diagnostics
•Severe abd pain
•Symptoms of hypovolemia
and shock – dizziness,
weakness, sweating,
delirium, coma, etc
•In labor- cessation of
typical labor pains and
replacement with diffuse
generalized abdominal pain
•Vaginal bleeding
•Cessation of fetal
movement
•Respiratory difficulty
•Fever, chills, rigors
•History of previous uterine
surgery in some mothers
•Hypovolemia and shock
•Acute cardio respiratory
distress
•Pallor
•Dry mucosal surfaces
•Tender abdomen
•Easily palpable fetal parts
•Fetal distress or death
•Evidence of fluid in abdomen
•Features of obstructed labor
on vaginal exam
•Bloody vaginal discharge
•Bloody urine on bladder
catheterization
•Offensive vaginal discharge
•Postpartum uterine exploration
in cases of PPH
•CTG-
abnormal fetal
heart patterns
•Hematocrit
•Blood group
and typing
•Cross match of
blood
35
December 13, 2023

36. Management
Hysterectomy is the preferred treatment in complete
uterine rupture.
If lateral rupture involving the lower segment the uterine
artery with hemorrhage can obscure the operation by
forming hematoma so ipislateral legation is important
Occult rupture of lower uterine segment encountered at
repeat section may be treated by freshening the wound
edges & secondary reaper.
A Pfannenstiel incision provides good exposure to the
lower uterine segment and pelvis, but a midline incision
provides better exposure for comprehensive abdominal
exploration, including the uterine fundus, which extends
above the umbilicus by the late second trimester.
December 13, 2023 36

37. Management
A. Life of the patient depends on the speed and efficacy with
which hypo-volumia is corrected, hemorrhage controlled
and infection is treated.
B. Supportive Mx (Resuscitation)
Short period of intense resuscitation preferably in OR
which is continued intra-operatively.
1. Rx Shock or impending shock
- Open IV line with wide bore canulla(if in shock
two IV line), infuse crystalloids (N/S, R/L)
- Urgent Hgb, BG & RH
- Prepare at least two units of blood, preferable fresh
37
December 13, 2023

38. Management (ctd.)
2. Treat infection- Broad spectrum antibiotics
3. Others
- catheterize her
- Insert NG tube, aspirate and non
particulate anti-acid.
B. Definitive management
- laparatomy – any Rx other than immediate
surgery is to be condemned
- Do midline vertical incision
Type of surgery depends on type, extent, location of
tear, condition of patient and future fertility
Do the shortest possible procedure that gets the in
best possible condition. 38
December 13, 2023

39. Management (ctd.)
Repair
- Easier, faster, less blood loss
- Risk of infection & future rupture (if BTL not done and
became pregnant)
- Done for clean, anterior, lower segment tear
- For critical patient- BTL
- For a woman with no alive child (with out BTL), done
only if pt is likely to return before onset of labor - NOT
RECOMENEDED!
39
December 13, 2023

40. Management (ctd.)
Hysterectomy
- TAH if the pt is stable – standard Mx
- Subtotal HE if pt is critical [Decrease
anesthesia time, bleeding and ureteral injury]
Post op care
- Equally important especially in the first 24 hours
- Continue resuscitation + antibiotics
- Watch for 20 hemorrhage
- Monitor VS, UOP
Prognosis
Depends on early Dx, adequate resuscitation and early
intervention
Significant morbidity expected
MMR = 15 -25%
40
December 13, 2023

41. Management (ctd.)
Prognosis
Depends on early Dx, adequate resuscitation and early
intervention
Significant morbidity expected
MMR = 15 -25%
The goals of conservative surgery are to repair the uterine
defect, control hemorrhage, identify damage to other organs
(eg, urinary tract), minimize early post-surgical morbidity,
and reduce the risk of complications in future pregnancies.
41
December 13, 2023

42. Management of Uterine Rupture
Resuscitation Surgical Management
•Administer oxygen by face mask
•Open wide bore IV access
•Fluid resuscitation with crystalloids
•Administration of broad spectrum
antibiotics
•Type and cross match blood for possible
transfusion
•Catheterize bladder and monitor input-
output
•Insert NG tube if food ingested recently
or labor prolonged for days to avoid
aspiration
•Administer antacids
•Prepare for emergency surgery or refer
Immediate Laparotomy
Type of surgery
performed depends on:
•Parity and future
fertility needs
•Hemodynamic status
and ability to withstand
prolonged anesthesia
•Site and extent of
rupture
•Presence or absence of
overt uterine and intra
abdominal infection.
42
December 13, 2023

43. Types and Circumstances of Surgery in Uterine Rupture
Surgery for
uterine rupture
Circumstances in which performed
Total abdominal
hysterectomy
High parity with no future fertility needs; grossly infected
uterus; gross intra abdominal infection; posterior uterine
rupture; Ragged rupture impossible to repair; extensive
tear difficult to repair
Subtotal
abdominal
hysterectomy
All the above indications for total hysterectomy but the
overall status of the client does not warrant prolonged
anesthesia time and the experience of the surgeon makes
him/her feel that he can perform subtotal hysterectomy
faster than total hysterectomy
Repair of rupture
with tubal ligation
All the indications for total hysterectomy present except
that the tear is simple and repairable and no gross infection
is evident plus the status of the patient makes her unable to
withstand long anesthesia
Repair without
tubal ligation
Very low parity with future fertility needs; no gross
infection; anterior repairable tear; client informed upon
discharge on future delivery care 43
December 13, 2023

44. Complication
Hemorrhage, shock, post operative infection, urethral
damage, DIC, pituitary failure, Stillbirth and early neonatal
death.
Hysterectomy and loss of fertility
Post partum anemia and maternal death.
Pregnancy after uterine rupture
 If the site of the rupture scar is confined to the lower
segment the rate of repeat rupture is 6%.in contrast upper
segment is 32%.
 Therefore women with prior uterine rupture are should
delivered by CS as soon as the fetus is matured or at 36-
37 week of gestation before the onset of labor.
December 13, 2023 44

45. Prevention
Most of the cause of uterine rupture can be avoided by
good obstetric assessment & technique
Supervised administration of oxytocin during labor.
Estimation of fetal weight
Fundal pressure in the 2nd stage of labor should be avoided.
Similarly, procedures that involve uterine manipulation
should be performed gently or not at all when there is an
increased risk of rupture, such as external cephalic version
for malpresentation.
C/S on recognition of protraction disorders, should reduce
the risk of rupture of the unscarred normal uterus.
December 13, 2023 45

46. December 13, 2023 46

47. Definitions
Premature rupture of the membranes (PROM) – is
rupture of fetal membrane at any time before the onset of
contractions regardless of gestation of age (Pre-labor rupture
of membrane ).
Term PROM - rupture of membranes after 37wks & before
onset of labor.
Pre term PROM is rupture of membranes before 37wks of GA.
Prolonged PROM is rupture of membranes for >24hrs.
Mid-trimester preterm PROM - rupture of membranes at
16-26 wks.
December 13, 2023 47

48. Incidence
 PROM – occurs in 5-10% of all deliveries.
 PPROM occurs in approximately 1% of all pregnancies and
associated with 30 to 40% of preterm deliveries.
 PROM is the clinically recognized precipitating cause of about
one third of all preterm births.
 After premature rupture of the membranes at term, 70 % of
women begin to labor within 24 hours, and 95 % within 72
hours.
December 13, 2023 48

49. STRUCTURE OF THE FETAL
MEMBRANES
The membranes surrounding the amniotic cavity are
composed of the amnion and the chorion
Consist of several cell types, including epithelial cells,
mesenchymal cells, and trophoblast cells, embedded in a
collagenous matrix.
They retain amniotic fluid, secrete substances both into the
amniotic fluid and toward the uterus, and
Guard the fetus against infection ascending the
reproductive tract.
December 13, 2023 49

50. The human amnion is composed of five distinct layers.
It contains no blood vessels or nerves; the nutrients it
requires are supplied by the amniotic fluid.
The innermost layer, nearest the fetus, is the amniotic
epithelium. Amniotic epithelial cells secrete collagen types
III and IV and non-collagenous glycoproteins (laminin,
nidogen, and fibronectin) that form the basement
membrane, the next layer of the amnion.
STRUCTURE OF THE FETAL
MEMBRANES…….
December 13, 2023 50

51. Fetal membranes
Made of thin inner layer that covers amniotic cavity called amnion.
Outer layer ,thicker that apposes the decidua called chorion.
Both fuse together at 14weeks.
Pathogenesis
 Membrane rupture is related to biochemical processes, including
disruption of collagen within the extracellular matrix of the amnion
and the chorion and programmed death of cells in the fetal
membranes.
 The response to membrane stretching and infection of the
reproductive tract produce mediators, such as prostaglandins,
cytokines, and protein hormones, that govern the activities of
matrix-degrading enzymes.
December 13, 2023 51

52. Etiology
•Connective tissue disorders
•Urogenital tract infection,
•Low socioeconomic status,
•Uterine over-distention,
•Second- and third-trimester bleeding,
•Low body mass index
•Prior PROM – recurrence
•Nutritional deficiencies
•Maternal cigarette smoking,
•Cervical incompetence
•Cervical conization or cerclage,
•Pulmonary disease in pregnancy
December 13, 2023 52

53. Clinical manifestation & Dx
 Hx: The classic clinical presentation of PPROM is a sudden
"gush" of clear or pale yellow fluid from the vagina.
 Many women describe intermittent or constant leaking of
small amounts of fluid or just a sensation of wetness within the
vagina or on the perineum.
 Should be confirmed by visual inspection or laboratory tests to
exclude other causes of vaginal/perineal wetness, such as
urinary incontinence, vaginal discharge.
 Digital examination should be avoided because it may
decrease the latency period (ie, time from rupture of
membranes to delivery) and increase the risk of intrauterine
infection.
December 13, 2023 53

54. Diagnosis
Physical examination
Sterile speculum exam - is the best method of confirming
the diagnosis of PPROM is direct observation of amniotic fluid
coming out of the cervical canal or pooling in the vaginal
fornix.
If amniotic fluid is not immediately visible, the woman can be
asked to push on her fundus, Valsalva, or cough to provoke
leakage of amniotic fluid from the cervical os.
December 13, 2023 54

55. Diagnosis…
Nitrazine test — the diagnosis can be confirmed by testing
the pH of the vaginal fluid, which is easily accomplished with
nitrazine paper. Amniotic fluid usually has a pH range of 7.0 to
7.3 compared to the normally acidic vaginal pH of 3.8 to 4.2.
Dye injection:
Through abdominal needle under ultrasonic guide into the
amniotic sac and observation of its passage through the
external os or even in the vulvar pad. Instillation of indigo
carmine-injected trans-abdominally into the amniotic fluid and
a tampon is placed in the vagina.
December 13, 2023 55

56. Diagnosis….
AmniSure - is a rapid slide test that uses immune-
chromatographic methods to detect trace amounts of placental
alpha microglobulin-1 protein in vaginal fluid.
An advantage of this test is that it is not affected by semen or
trace amounts of blood.
The test is done by the provider at the point of care using a
commercially available kit. (one line - negative result and two
lines - positive result, no visible lines is an invalid result).
December 13, 2023 56

57. Ferning
Fluid from the posterior vaginal fornix is swabbed onto a glass
slide and allowed to dry for at least 10 minutes.
Amniotic fluid produces a delicate ferning pattern, in contrast to
the thick and wide arborization pattern of dried cervical mucus.
Well-estrogenized cervical mucus or a fingerprint on the
microscope slide may cause a false-positive fern test .
Ultrasonography —50-70%of women with PPROM have low
amniotic fluid volume on initial sonography (oligohydramnios).
December 13, 2023 57

58. Complications
Maternal
Endomyometritis
Sepsis
PPH
APH
Wound infection
Cesarean delivery
Fetal
Chorioamnionitis
Neonatal sepsis
Pulmonaryhypoplasia
Cord prolapse
Limb deformity
December 13, 2023 58

59. MANAGEMENT
The management depends upon:
 Gestational age
 Availability of neonatal intensive care
 Presence or absence of maternal/fetal infection
 Presence or absence of labor
 Fetal presentation (breech and transverse lies are unstable
and may increase the risk for cord prolapse)
 Fetal heart rate (FHR) tracing pattern
 Likelihood of fetal lung maturity
 Cervical status (by visual, not digital, inspection unless
induction is planned or the woman is in labor)
December 13, 2023 59

60. Management….
Hospitalization
Hospitalize women with PPROM who have a viable fetus from
the time of diagnosis until delivery, with few exceptions.
Women are typically kept at modified bedrest and frequently
assessed for evidence of infection or labor.
Resealing: Up to 14 percent of gravidas with spontaneous
midtrimester PPROM eventually stop leaking amniotic fluid,
presumably due to "resealing" of the fetal membrane.
Cessation of leakage is probably not due to actual repair and
regeneration of the membranes, but rather to changes in the
decidua and myometrium that block further leakage .
December 13, 2023 60

61. Mx of TERM PROM
Labor is induced, unless there are contraindications to labor or
vaginal delivery, in which case cesarean delivery is performed.
Most women with term PROM who are followed expectantly will
go into spontaneous labor and deliver within 24, 48, and 72
hours of PROM in 70, 85, and 95 percent of women,
respectively.
Expectant management
if:
No contraindications to labor and vaginal delivery
no evidence of clinical chorioamnionitis or
Medical or obstetrical complications, and reassuring fetal
testing.
December 13, 2023 61

62. Surveillance
Maternal surveillance
Monitor for signs of infection(Chorioamnionitis)(Fever, Abdominal
tenderness, Offensive Vx discharge, Fetal tachycardia, maternal
tachycardia
Leukocytosis).
Fetal surveillance
Kick counts
Non stress tests
Biophysical profile [BPP]
Antenatal steroids
Dexamethasone 6mg bid ;04 doses
Betamethasone 12mg daily;02doses
Hydrocortisone 2 g IM x 1 dose
December 13, 2023 62

63. Antibiotics Prophylaxis
Goal:
 Decrease maternal infection
 >> fetal infection
 Prolong latency(onset of labor)
Administering a seven-day course of antibiotic prophylaxis to all
women with PPROM who are being managed expectantly.
The preference antibiotics are:
 Ampicillin 2 gIV every QID for 48 hours, followed by
 Amoxicillin 500 mg PO TID or 875 mg PO BID for an
additional five days. Or Erythromycin QID IV for 48hrs,Eryth
IV 7d.
December 13, 2023 63

64. Tocolysis
The principal indication for tocolysis in the setting of PPROM is to
delay delivery for 48 hours to allow administration of
corticosteroids.
They also should not be administered:
 For advanced labor (>4 cm dilation)
 Chorioamnionitis
 Not for more than 48 hours.
Termination Of pregnancy
If chorioamnionitis develop any time.
At 34wks
At 32-34wks if lung maturity confirmed
Mode of delivery based on obstetric indications.
December 13, 2023 64

65. PREDICTING PRETERM PREMATURE RUPTURE OF THE
MEMBRANES
Markers of degradation of the extracellular matrix of fetal
membranes could be used to identify women who are at risk
for PROM and preterm delivery.
Fetal fibronectin is marker which present in the extracellular
matrix of fetal membranes.
Produced by human amniotic cells is stimulated by
inflammatory mediators (including interleukin-1 ).
December 13, 2023 65

66. Preterm Labour(PTL)
Definition: PTL is defined as labour occurring after 28
weeks but before 37 completed weeks of gestation.
Complicates 5 – 15 % of all pregnancies.
The single most important complication of PTL is
prematurity and the care of premature infant is costly
compared with term infants.
Those born prematurely suffer greatly from increased
morbidity and mortality.
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67. PTL Cont….
Thus every effort should be made to prevent or
inhibit preterm labor.
If it can not be inhibited or is best allowed
continuing, it should be conducted with the least
possible trauma to the mother and infant.
67
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68. PTL Cont…
Risk Factors:
Race (Black > non black)
Low socio economic status
Poor nutrition and low pre pregnancy weight
History of previous PTL.
Second trimester abortion
Negative attitude towards pregnancy??
Current pregnancy complications including placenta
previa, abruptio placenta, polyhydramnious,
Oligohydramnious, and multiple pregnancies.
68
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69. PTL Cont…
Cervical conization
Age <18y or >40 y
Uterine anomaly or fibroids( Tumors)
Maternal stress
Anemia
Cigarette smoking
Genital infection or colonization
Medical diseases(anemia, DM, HTN, pyelonephritis, and
febrile illness)
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70. PTL Cont…
Diagnosis of PTL:
1.Signs and symptoms:
Uterine contraction 2/10/30”
Cervical dilation and effacement.
 Progressive change in the cervix
 Cervical dilatation of 2 cm or more
 Cervical effacement of 80% or more
B. Visual estimates:
During speculum exam, if fetal parts or membranes
are visible, cervix is 2 cm or more dilated.
C. Trans vaginal ultrasound showing:
Cervical length (normally 2.5 – 3 cm)
70
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71. PTL Cont…
Laboratory Studies:
CBC with differentials
U/A and sensitivity
U/S for fetal size
Amniocentesis for
 Maturity assessment
 Bacteriological study
71
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72. PTL Cont…
Management:
The pt should be observed for ½ - 1 hr to determine
appropriate management
1.If Benefit of continuing px outweigh----attempts
to postpone labour…tocolytics!!!
2.If risk of continuing px outweigh ---allow to be
continued!!!
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73. PTL Cont…
Criteria to use tocolysis:
1.The fetus is apparently healthy
2.GA is b/n 28 & 37 weeks)
3.Cervical dilation is < 4 cm & effacement <
80%
4.The membranes are intact
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74. PTL Cont…
Drugs used for tocolysis:
1.First line agents:
 - drenergics(ritodrine, terbutaline, fenoterol)
 Magnisum sulphate
2. Second line drugs
 Antiprostaglandines( Indomethacin, Naperoxen)
 Calcium channel blokers ( Nifedipine)
74
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75. PTL Cont…
Delivery:
Vaginal delivery:
 Wide episiotomy
 “Prophylactic” forceps)
C/S: for LBW and non vertex presentation.
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76. PTL Cont…
Identification and prevention of pre term labour:
1.Identification:
Prior pre term birth
Cervical dilatation
S/S including:
 Uterine contractions - Blood stained discharge
 Pelvic pressure - Pain in the lower back
 Menstural like cramps
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77. PTL Cont…
Prevention of PTL:
Educate woman at high risk about s/s of preterm
labor
Follow closely with weekly or biweekly examination
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78. Prolonged/Postterm/ Pregnancy
Definition:
Postterm pregnancy is defined as the one that
exceeds 294 days/42 weeks from the first date of the
last menstrual period.
Postdatism is pregnancy lasting beyond the
estimated due date at 40 weeks.
Incidence: 10% of all pregnancies. High in primigravidae.
Diagnosis:
1.EDD calculation: do not forget to ask history of
hormonal method of contraception.
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79. Postterm Cont…
2. Quickening: can be heard from 16 – 20 weeks
(pregnant women should be asked to note the date they
felt fetal movement first time).
3. Ultrasound: Better if done before 20 weeks of
gestation: accuracy with in 5 days n 95 % of cases.
4. FHB: heard from 20 weeks onwards
5. X-ray
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80. Postterm Cont…
S/S of Postterm:
Diminished liquor
Reduced fetal movements
Abnormal fetal heart rate
Maternal wt loss
Decreased uterine size
Meconium stained liquor
Advanced bone maturation- hard fetal skull
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81. Postterm Cont…
Note: pregnancy can not be said Postterm without
accurate dating.
Effects of Postterm:
1.On the mother:
Anxiety
CPD
Prolonged labour
Risks related to C/S
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82. Postterm Cont…
B. On the fetus:
Placental insufficiency  fetal hypoxia
fetal distress meconium aspiration 
IUFD
Mental Retardation
Macrosomia- b/s the fetus has longer time
to grow in the uterus  Birth trauma
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83. Postterm Cont…
Appearance of post mature baby:
Hard skull bones
Small fontanelles with narrow suture
Long finger nails
Absence of vernix casiosa
Dry, peeling and cracked skin
83
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84. Post-maturity syndrome
Representing 20 % cases of prolonged pregnancy and
is associated with :
1. Meconium -stained amniotic fluid,
2. Oligohydramnios
3. Fetal distress
4. Evidence of loss of subcutaneous fat and
5. Dry, cracked skin
Reflecting placental insufficiency
84
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85. Etiologic Factors
The most frequent cause is an error in dating.
When truly exists, the cause usually is unknown.
Primiparity and prior postterm pregnancy are the
most common identifiable risk factors.
85
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86. Etiologic Factors…
Rarely, it may be associated with placental
sulfatase deficiency or fetal anencephaly.
Male sex also has been associated.
Genetic predisposition may play a role .
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87. Postterm Cont…
Factors increasing Risk:
Congenital anomalies:
 Hydrocephaly
 Anencephaly
Older primigravidae
Poor obstetric history
Pre-eclampsia
DM
Previous history of big baby
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88. Management
Two management options
1.Direct termination
Induce at
 42 completed weeks with favorable bishop
 42 completed week with unfavorable bishop by ripening
 43 completed week irrespective of the cervical status
 C/S for whom vaginal delivery is contraindicated
88
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89. Management cont…
2.Expectant management
 42-43 weeks of gestation with unripe cervix
with reassuring fetal condition
 Women with uncertain date and appear late
in pregnancy
89
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90. Expectant Management…
Patients are followed at OPD level with appropriate fetal
wellbeing testing :
 Begin at 41wks
 kick count -if decreased further testing
 BPP if <8 consider termination
 NST 2x/wk, if non reactive CST
 CST wkly, if positive terminate
 a single abnormal test is satisfactory to consider
termination of the pregnancy
90
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91. Management cont…
Expectant management
Bishop score is assessed during follow up
Termination of the pregnancy if
 Fetal jeopardy
 Cervix is ripe
 > 43weeks
91
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92. Cervical Ripening
Most parturient with documented post-term pregnancy have a
low Bishop score.
Cervical ripening techniques may help to attain a safe vaginal
delivery.
Method used includes membrane stripping, PG E2,
?misoprostol and Foley catheter traction.
Once the cervical priming is complete, amniotomy or oxytocin
administration may be used to stimulate labor.
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93. Management cont…
Management during labour and delivery
Induction is per protocol, elective vs emergency
Decision to perform amniotomy;
 Problematic b/c further reduction in AFV, enhance the
possibility of UC compression
 aids identification of thick meconium
 Scalp electrode and IUx pressure catheter can be
placed
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94. Management cont…
If meconium is present then consider risk of meconium
aspiration, continuous fetal assessment with Electronic
Fetal Monitoring is recommended.
1. Early labor with thick, Meconium -stained amniotic
fluid,( MSAF)
 Strong consideration should be given for c/s delivery
especially when CPD is suspected/dysfunctional labor
is evident .
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95. Management cont…
First stage monitor continuously by CTG or
intermittent auscultation Q15 min
Second stage – anticipate complications
Third stage – manage actively
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96. PREVENTION
GA assessment using the LMP tends to overestimate GA,
Early routine US significantly reduced the rate of
intervention for postterm pregnancy
 not been recommended as a standard of prenatal care
Nipple stimulation (manual/electrical)
Sweeping of membrane at /near term
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97. THANK YOU!
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December 13, 2023