Prolonged labour – cpd, fetal malposition and

1. Prolonged Labour – CPD, Fetal
Malposition and Malpresentation
Tanan G.

2. Prolonged Labour
The onset of labor is defined as the period
when the uterine contraction activity is
regular and cervical dilatation is present.
The progress of labor can be divided into
three stages which are preceded by the latent
phase.
The labour is considered to be prolonged if it
exceeds the combined duration of 18 hrs of
the 1st and 2nd stage.

3. The Friedman Curve for normal labour

4. Latent Phase
Preparatory stage of uterus and cervix before the
onset of labour.
8 hrs in primi
4 hrs in multi
If it exceeds 20 hrs in primi, 14 hrs in multi it is
abnormal and is considered to be prolonged
latent phase.
Labour should be considered prolonged once it
lags behind the normal partogram by 2-3 hrs.

5. Partogram
Managerial tool used to record all
observations made on a woman and fetus in
labour in one chart.
Partogram helps to identify at an early stage
those women whose labour is slow.
A managerial tool for prevention of prolonged
labour.

6. Partograph
ALERT LINE – represent the mean rate of slowest progress of labour
ACTION LINE – appropriate action should be taken

7. DYSTOCIA
Labor abnormalities that may interfere with
the orderly progression to spontaneous
delivery
Abnormalities:
• Powers (abnormal contractility, maternal
expulsive effort)
• Passenger (abnormal descent of the
presenting part of the fetus)
• Passage (delayed cervical dilatation, CPD)

8. Cephalopelvic Disproportion (CPD)
Obstructed labor resulting from disparity
between the fetal head size and maternal
pelvis.

9. Absolute CPD (true mechanical
obstruction)
Permanent (maternal):
• Contracted pelvis
• Pelvic exostoses
• Spondylolisthesis
• Anterior sacrococcygeal
tumors
Temporary (fetal):
• Hydrocephalus
• Large infant
Relative CPD
• Brow presentation
• Face presentation –
mentoposterior
• Occipitoposterior
positions
• Deflexed head

10. Contracted Pelvis
It is a pelvis in which one or more of its
diameters is reduced below the normal
ranges by 1-2 cm, so that it interferes
with the normal mechanism of labour.

11. Pelvis Diameter ( cm)
Anteroposterior Transverse Oblique
Pelvic Inlet 11 13 12
Pelvic Cavity 12 12 12
Pelvic Outlet 13 11 -

13. Influencing Factors
• Developmental (hereditary, congenital
disorders)
• Racial
• Nutritional
• Sexual (excessive production of androgen may
result in android pelvis)
• Metabolic (rickets, osteomalacia)
• Trauma, diseases or tumours

14. Developmental
• Small gynaecoid pelvis
• Small android pelvis
• Small anthropoid pelvis
• Small platypelloid pelvis
• Naegele’s pelvis: absence of one sacral ala
• Robert’s pelvis: absence of both sacral alae
• High assimilation pelvis: The sacrum is composed of 6
vertebrae
• Low assimilation pelvis: The sacrum is composed of 4
vertebrae
• Split pelvis: splitted symphysis pubis

15. Classification by Pelvic Architecture
a. Pelvis aequabiliter justo minor
• Characterized by general reduction of all
diameters; equally shortened usually by 1-
2cm
• Occurs in short women, also in women with
massive skeletal bones and developed
muscles, the pelvis has masculine features
such as narrow sacrum, narrow pubic outlet

16. b. Flat pelvis
Reduced AP diameters with normal transverse
and oblique diameters. Has 2 types:
Simple flat (or platypellic) pelvis
Entire sacral platform is dislocated toward the
symphysis hence all AP diameters of all pelvic
planes are reduced
Flat rachitic
Only AP diameter of the pelvic inlet is reduced

17. c. Generally Contracted Pelvis
• All diameters reduced, but the AP
diameters are shortened greater than
the others
• Usually connected with the childhood
history of rickets

18. Rare Forms
• Otto’s pelvis – develop as result of inflammatory
process in the hip or knee
• Beaked (rostrate) pelvis – under development of
both sacral wings
• Spondylolisthetic pelvis – formed due to partial
dislocation of last lumbar vertebra in front of 1st
sacral vertebra
• Osteomalacic pelvis
• Scoliotic pelvis – only the lumber region cause
deformity of the pelvis. The acetabulum is
pushed inwards on the weight bearing side.

23. Classification by Degree of
Contracture
I First degree: true conjugate <11cm but not
<9cm, spontaneous delivery is possible
II Second degree: true conjugate equal to 9-
7.5cm, spontaneous delivery possible but
complications may arise
III Third degree: true conjugate 7.5-6cm
spontaneous delivery impossible, use C-section
IV Fourth degree: true conjugate <6cm, impossible
delivery, only way is C-section; also known as
absolutely contracted pelvis

24. Diagnosis
History
• Rickets (if there is a history of delayed walking
and dentition)
• Trauma or diseases (previous tuberculosis of
bones and joints)
• Infantilism
• Bad obstetric history (prolonged labour ended by:
difficult forceps, caesarean section or still birth, evidence
of maternal injuries: complete perineal tear,
vesicovaginal fistula, rectovaginal fistula)

25. Examination
General examination:
• Gait (suggestive of abnormalities in the pelvis,
spine or lower limbs)
• Stature (women with less than 140-150 cm
height usually have contracted pelvis)
• Spine and lower limbs (may have a disease or
lesion)

26. • Rickets manifestations (square shaped head,
rosary beads in the costal ridges, pigeon chest,
Harrison’s sulcus, bow legs)
• Dystocia dystrophia syndrome (the person is
short, stocky, subfertile, has android pelvis and
masculine hair distribution, with history of
delayed menarche. Possibly may be more
exposed to occipito-posterior position and
dystocia)
• Solovjov’ index (estimated by the circumference
of radiocarpal joint, if it exceeds 14-16 cm it
indicates the thickness of the pelvic bones)

27. 2 shapes of abdomen
• Acuminate (pointed) abdomen in primigravida
with a resilient abdominal wall
• Pendulous abdomen in multiparous women

28. Abdominal Examination
• Pendulous abdomen in primigravida
• Positive Vasten’ sign (if disproportion between
fetal head and symphisis pubis is prominent -
Vasten’ sign is positive, if disproportion
between fetal head and symphisis pubis is
absent - Vasten’ sign is negative)
• Non engagement in last 3-4 wks in
primigravida

29. Degrees of Contracted Pelvis
1. Minor degree: The true conjugate is 9-10 cm. It
corresponds to minor disproportion.
2.Moderate degree: The true conjugate is 8-9 cm. It
corresponds to moderate disproportion.
3.Severe degree: The true conjugate is 6-8 cm. It
corresponds to marked disproportion.
4.Extreme degree: The true conjugate is less than 6
cm. Vaginal delivery is impossible even after
craniotomy as the bimastoid diameter (7.5 cm) is
not crushed.

30. Pelvimetry
Assessment of the pelvic diameters and capacity done at 38-39
weeks.
• Clinical pelvimetry:
▫ Internal pelvimetry for:
 inlet,
 cavity, and
 outlet.
▫ External pelvimetry for:
 inlet and
 outlet
• Imaging pelvimetry:
▫ X-ray
▫ CT
▫ MRI

31. Cephalometry
Ultrasonography is safe, accurate and easy.
Can detect:
The biparietal diameter (BPD)
 The occipito-frontal diameter.
The circumference of the head.

32. Mechanism of Labour in Contracted
Pelvis
The process passes flat rachitic pelvis till
the mid cavity, where internal rotation
and further descent cannot occur due to
persistence of flattening of the pelvis and
contracted outlet. So, deep transverse
arrest is common and vaginal delivery is
obstructed.

33. Management
It depends mainly on the degree of
disproportion.
• Minor disproportion: vaginal delivery
• Moderate disproportion: trial labour, if failed
C-section
• Marked disproportion: C-section

34. Indications of Caesarean Section
• Elective cesarean section:
• Major degree of contraction
• Major disproportion
• Absolute contraction
• Dead fetus
• Patient not fit for trial labor
• During last week of pregnancy.
• When trial labour has failed

35. Trial Labour
Conduction of spontaneous labour in a
moderate degree of disproportion, in an
institution under supervision with watchful
expectancy for a vaginal delivery.

36. Suitable cases
• Young primigravida in good health
• Moderate disproportion
• Vertex presentation
• No outlet contractions
• Average sized baby

37. Termination
• Vaginal delivery (spontaneously or by
forceps if the head was engaged)
• Caesarean section (failed trial of labour i.e.
the head did not engage)
• Complications (foetal distress or prolapsed
pulsating cord)

38. Careful fetal and maternal monitoring by
electronic fetal monitoring and non stress test
• Oral feeding remain suspended and hydration is
maintained by intravenous drip
• Adequate analgesic is administered
• Augmentation of labor by pitocin

39. Successful trial - a healthy baby was born
vaginally, spontaneously or by forcep, with the
mother in good condition
Failure - delivery by cesarean section or
delivery of a dead baby spontaneously or by
craniotomy

40. • The progress of labor is mapped with
partograph
• After the membrane rupture, pelvic
examination is to be done:
– to exclude cord prolapse
– to note the color of liquor
– to assess the pelvis once or more
– to note the condition of the cervix

41. Complications
Maternal
During pregnancy:
• Incarcerated retroverted gravid uterus
• Malpresentations
• Pendulous abdomen
• Nonengagement
• Pyelonephritis (due to the compression of the
ureter)

42. During Labour:
• Inertia, slow cervical dilatation and prolonged
labour
• Premature rupture of membranes and cord
prolapse
• Obstructed labour and ruptured uterus
• Necrotic genito-urinary fistula
• Injury to pelvic joints or nerves from difficult
forceps delivery
• Postpartum haemorrhage

43. Foetal
• Intracranial haemorrhage
• Asphyxia
• Fractured skull
• Nerve injuries
• Intra-amniotic infection

44. 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.

45. Occipitoposterior positions
• Most common type
• The vertex is presenting, but the occiput lies in
the posterior rather than the anterior part of
the pelvis.
• As a consequence, the fetal head is deflexed
and larger diameters of the fetal skull present.

46. There are three positions:
• Right occipito-posterior position ROP (the
occiput directed to the right sacro-iliac joint)
• Left occipito-posterior position LOP ( the
occiput directed to the left sacro-iliac joint)
• Direct occipitoposterior

47. Causes
• Anteriorly situated placenta
• Anthropoid pelvis
• Flat Sacrum
• Pundulous abdomen
• Chance
• R.O.P. three times as common as L.O.P.

48. Diagnosis
• Listen to the mother’s complaints (backaches,
she may feel that her baby’s bottom is very
high up against her ribs, feeling movements
across both sides of her abdomen and etc.)
• Inspection (saucer-shaped depression at or
just below the umbilicus, outline of the high,
unengaged head can look like a full bladder)

49. • Palpation (the back is difficult to palpate as it
is well out to the maternal side, limbs can be
felt on both sides of the midline)
• Auscultation (the fetal back is not well flexed
so the chest is thrust forward, therefore the
fetal heart can be heard in the midline, the
heart may be heard more easily at the flank
on the same side as the back)

50. Management
• 12% will deliver spontaneously O.P.
• Transverse arrest may require operative
intervention
• Lack of progress may warrant c-section
• Vacuum may be preferable to Forceps

51. FACE PRESENTATION
• Cephalic presentation where the attitude is
one of complete extension, presenting part is
face and denominator is the chin or mentum
• Engaging diameter is submentobregmatic-
9.4cm
• Primary face presentation are present before
onset of labour and are rare
• Secondary caused by extension during labour
and is most common

52. Positions
• Left mentoanterior(LMA)
• Right mentoanterior(RMA)
• Right mentoposterior(RMP)
• Left mentoposterior(LMP)
70% are mentoanterior and 30% posterior.

53. Causes
Maternal
• contracted pelvis
• obliquity of uterus
• multiparity or
pendulous abdomen
Fetal
• anencephaly and
iniencephaly
• cord around the neck
• tumours of neck, like
congenital goiter
• spasm of
sternocleidomatoid muscle

54. Diagnosis
• In mentoanterior, back is felt with difficulty as
it is posterior and limbs anteriorly
• Head remains high
• Cephalic prominence is the occiput and on the
same side as the back
• Groove b/w the head and back is prominent
• Fetal heart sounds are transmitted through
the chest and heard well anteriorly in
mentoanterior

55. Management
• Mentoanterior, forward rotation in
mentoposterior- labour allowed
• CPD, anencephaly, other anomalies, persistent
mentoposterior, obstructed labour- C-section
• Dead baby- C-section or craniotomy

56. Brow Presentation
• Most unfavourable
• Attitude is one of partial extension, presenting
part being the area between the ant.
Fontanelle above and glabella and orbital
ridges below and denominator is forehead or
frontum
• Presenting diameter is verticomental- 13.5cm
• Transitory presentation- flex or extend

57. Diagnosis
• High mobile head, which feels large from side
to side
• Cephalic prominence is the occiput and is on
same side as back and groove between
cephalic prominence and back is less
prominent than in face presentation

58. Management
• If membrane not ruptured wait for correction
• After membrane ruptures, brow presentation
diagnosed and in persistent brow presentation
–C-section
• Prologed labour with head high.. Brow
presentation must be suspected

59. Shoulder Presentation
• Long axes of fetal and maternal ovoid are
approximately at right angles to each other
and shoulder is presenting in the pelvic inlet.
• Denominator- acromion
POSITIONS
• Right acromial
• Left acromial

60. Depending on the direstion of the back:
• Dorsoanterior
• Dorsoposterior
• Dorsosuperior
• Dorsoinferior

61. Causes
• Incidence- 1 in 500
Maternal Factors
• Multiparity
• Contracted pelvis
• Uterine anomalies like septate,bicornuate and
arcuate uterus
• Placenta praevia
• Fibroid in the lower segment

62. Fetal Factors
• Prematurity
• Multiple pregnancy
• Polyhydraminos
• IUD

63. Diagnosis
• Transversely stretched
• Fundal height less than period of gestation
• No Fetal pole at fundus
• Ballotable head in one flank & breech in the
other
• In dorsoanterior, back is felt a uniform reistance
acros the front of abdomen
• In dorsoposterior, limbs are felt anteriorly
• Empty pelvic grip

64. Vaginal Examination
• Hand/shoulder/elbow may be felt as a
uniform resistance across the front of
abdomen
• Shoulder can be identified by ribs running
parallel to each other
• Late in labour, shoulder may be wedged in the
pelvis and hand freequently prolapse into the
vagina

65. Complications
Maternal
• Increased chance of C-section
• Obstructed labour or ruptured uterus
Fetal
• Birth asphyxia due to cord prolapse and in
obstructed labour

66. Management
• External Cephalic Version
• C-section best option
• When ECV fails and CI
• Transverse incision
• If the fetus is dead – C-section or craniotomy

67. Breech Presentation
It is a polar alignment of the fetus in which the
fetal buttocks present at the maternal pelvic
inlet.
• 3 types:
– Frank
– Incomplete
– Complete

68. Causes
• Polyhydramnios
• Oligohydramnios
• Uterine abnormalies
(bicornuate, uterus)
• Pelvic tumour
• Uterine surgery
• Prematurity
• Multiple pregnancy
• Fetal anomalies
(hydrocephalus,
anencephaly

69. Frank/Extended
The fetal hips are flexed
and the knees extended
so that the thighs are
apposed to the abdomen
and the lower legs to the
chest The buttocks are
the most dependent part
of the fetus.

70. Incomplete/Footling
In incomplete breech
presentation, the fetus has
one or both hips
incompletely flexed so that
some part of the fetal
lower extremity, rather
than the buttocks, is the
most dependent part
(hence the terms single
footling or double
footling).

71. Complete/Flexed
The fetal hips and
knees are both flexed
so that the thighs are
opposed to the
abdomen and the legs
lie on thighs.

72. Diagnosis
• A transverse groove may be seen above the
umbilicus in sacro-anterior position.
Corresponds to the neck.
• If the patient is thin, the head may be seen as
a localised bulge in one hypochondrium.

73. Diagnosis
• Fundal grip. The head is felt as a smooth, hard,
round ballottable mass which is often tender.
• Umbilical grip. The back is identified and a
depression corresponds to the neck may be
felt.
• First pelvic grip. The breech is felt as a smooth,
soft mass continuous with the back. Trial to do
ballottement to the breech shows that the
movement is transmitted to the whole trunk.

74. Diagnosis
Fetal Heart Sound may be heard above the
level of the umbilicus.

75. Diagnosis
Ultrasonography:
• Diagnosis
• Type of breech
• Gestational age and foetal weight
• Congenital anomalies

76. Management
• Vaginal breech delivery
• External Cephalic Version (ECV)
• Caesarian Section

77. ECV
• External cephalic version (ECV) is a third
alternative to vaginal delivery or cesarean
delivery for the breech fetus
• Success rate 60-75%
• The mechanical goal is to squeeze the fetal
vertex gently out of the fundal area to the
transverse and finally into the lower segment
of the uterus.

78. ECV

79. Risks
• Placental abruption
• Premature rupture of the membranes
• Cord accident
• Transplacental haemorrhage(remember anti-D
aministration in Rhesus-negative women)
• Fetal bradycardia

80. Vaginal Delivery
Three types:
• A spontaneous breech delivery is one in which
the entire infant delivers vaginally without
manual aid.
• The assisted breech delivery( partial breech
extraction.) In this delivery, the fetus is allowed to
deliver by the forces of uterine contractions and
maternal bearing-down efforts until the fetal
umbilicus has passed over the mother's
perineum. After this, delivery of the legs, trunk,
and arms are assisted manually; the head may be
delivered manually or with forceps.

81. • A complete breech extraction, in which
manual assistance is applied by traction in the
groins or on the lower extremities before
delivery of the buttocks.

82. Pinard’s manoeuvre
• In breech with extended legs
• once the groin is visible gentle pressure can be
applied to abduct the thigh and reach the
knee.
• The knee can be flexed with pressure in the
popliteal fossa and the leg delivered.
• Anterior leg is always delivered first.

83. Loveset’s manoeuvre
• This procedure automatically corrects any upward
displacement of arms.
• In Lovset’s maneuver baby’s trunk is made to rotate with
downward traction holding the baby at the iliac crest so
that posterior shoulder comes below symphysis pubis
and the arm is delivered by flexing the shoulder followed
by hooking at the elbow and flexing it followed by
bringing down the forearm ‘like a hand shake’.
• The same procedure is repeated by reverse rotation of
180 degree so that anterior shoulder comes below the
symphysis pubis.

84. Mariceau-Smellie-Veit
manoeuvre
• Here the baby is allowed to rest on the left supinated
forearm of the obstetritian, with the limbs hanging on
either side.
• Left index and middle finger is placed on the malar bones,
while the right index and ring fingers are placed on the
respective shoulders and the middle finger on the sub-
occipital region.
• To achieve flexion, traction is now given in downward and
backward direction and simultaneous suprapubic pressure
is maintained by the assitant until the nape of the neck is
visible.
• Thereafter, the baby is pulled in upward and forward
direction so that the face is born and by depressing the
trunk the head is born.