abnormalities of labor and delivery - semmelweis egyetem€¦ · artur beke - abnormalities of...

Department of Obstetrics and Gynecology

Baross Street

Artúr Beke MD PhDSemmelweis University

Department of Obstetrics and Gynecology

Abnormalities of labour and

delivery

Abnormalities of labor and

delivery

• 1. Fetal malpositions and malpresentations

• 2. Uterine dystocia

• 3. Shoulder dystocia

• 4. Premature rupture of the membranes

• 5. Fetal distress

• 6. Preterm delivery

• 7. Twin delivery

Artur Beke - Abnormalities of Labour

and Delivery - 2019

1. Fetal malposition and

malpresentations


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Fetal malposition and

malpresentations

• A./ Abnormal presentation

– Breech presentation

– Transverse or oblique lie (shoulder presentation)

• B./ Abnormal position

– High sagittal position

– Obliquity

• C./ Abnormalities of flexion

– Deflexion of the head

• D./ Abnormalities of rotation


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A./ ABNORMAL PRESENTATION

• Cephalic presentation 96.5%

• Breech presentation 3.0%

• Transverse or oblique lie 0.5%


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Breech presentation

• Fetal buttocks or lower extremities present

• 3% of all deliveries

• At the 30th week 25% of fetuses

• After 36th week no change in position


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Types of breech presentation

• Frank breech- Extended legs (Simple)

(65%)

• Complete breech- Flexed legs (25%)

• Incomplete breech- Footling or knee presentation (10%)


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Diagnosis of breech presentation

• Leopold examination

• Vaginal examination

• Sonography


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Etiology of breech presentation

• Prematurity

• Fetal anomalies

• Uterine anomalies

• Pelvic anomalies

• Umbilical cord complications

• Twin pregnancy

• Placenta previa


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Vaginal delivery

• Fetus must be in frank or complete breech presentation

• Episiotomy

• Oxytocine infusion

• CTG registration

• Bracht maneuver

• Müller maneuver (freed arms)

• Mauriceau-Smellie-Veit maneuver (freed head)

• (Forceps)Artur Beke - Abnormalities of Labour

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External cephalic version

• External cephalic version

– Success rate 75%

– Prepared for emergency Caesarean section

– Risk of placental abruption and umbilical cord

compression


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Indication for Ceasarean Section

• Breech presentation +

• Preterm delivery (fetal head is relatively larger)

• 1st delivery (longer 2nd stage)

• PROM (dystocia)

• Incomplete breech

• Twin pregnancy

• Large fetus


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Transverse or oblique lie(shoulder presentation)

• No fetal pole detected above the symphysis

• Vaginal delivery is impossible

• High risk of rupture of the uterus


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malpresentations






– Obliquity





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B./ ABNORMAL POSITION

• High sagittal position

• Obliquity


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High sagittal position

• Normal

• / sagittal suture in the transverse/

• Occipito-sacral position

• Occipito-pubical position

If no more rotation

passing straight!Artur Beke - Abnormalities of Labour

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Obliquity

Asynclitic

• Anterior parietal position = Naegele obliquity

• Posterior parietal position = Litzmann obliquity

Normal Litzmann Naegele


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malpresentations






– Obliquity





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C./ ABNORMALITIES OF FLEXION

• Deflexion of the head


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Cephalic presentation

• Vertex presentation

/normal/

• Poorly flexed

• Brow presentation

• Face presentation

Important to examine

the fontanelles and suture lines


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Deflexion of the head

• Brow presentation

– 1/1400 deliveries

– Unstable presentation (convert to face or vertex)

– Persistent brow presentation C/S

• Face presentation

– 1/500 deliveries

– 60% mentoanterior possible vaginal delivery

– 40% mentoposterior C/S


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malpresentations






– Obliquity





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D./ ABNORMALITIES OF ROTATION

• Persisted occipito-posterior position

– (The rotation of the headis opposite)

• Persisted transverse position

– (No rotation)

Longer 2nd stage


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delivery









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2. Uterine dystocia

• Abnormal uterine activity

• Abnormal presentation

• Cephalopelvic disproportion

• Umbilical complication

• Fetal asphyxia


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Management of uterine dystocia

• Oxytocin infusion

• Glucose infusion

• Mobilization

• Cervix dilatation

– Prostaglandins

– Drotaverin + Opiates

– Epidural analgesia

– (Paracervical block)

• Perineal relaxation

– Epidural analgesia

– Pudendal block

– (Spinal analgesia)


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3. Shoulder dystocia

• Large fetus (more than 4000 g)

• The shoulder is not delivered after the head

during the next contraction


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Management of shoulder dystocia

• Pressure suprapubic region

• McRoberts maneuver (maternal thigh hyperflexed

against maternal abdomen)

• Woods maneuver (rotate the scapula)

• Free the posterior arm

• Gunn-Zavanelli maneuver (reposition of the head and Caesarean

section)

• (Cleidotomy, cleidorrhexis)

• (Sympisiotomy)


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4. Premature rupture of the

membranes (PROM)

• Amniorrhexis (spontaneous rupture)

• Before onset of labor (before contractions)


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Etiology of the PROM• Mechanical

– Cervix incompetence

– Previous operation on the cervix

– Polyhydramnios

– Transverse lie

– Uterine malformations

– Frequent vaginal examination

– Amnioscopy

• Infection

– Bacterial vaginosis

– Trichomonas

– Cervicitis (Chlamydia)

– Other

• Streptococcus agalactiae

• Streptococcus fecalis

• Listeria monocytogenes


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Diagnosis of PROM

• Anamnesis

• Vaginal examination

• Sonography

• Vaginal AFP

• Arborisation


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Management of PROM

• Laboratory examination (WBC, CRP)

• Temperature

• Antibiotic treatment

• Antenatal corticosteroid therapy

• Prostaglandins for cervical ripening

• Induction of the contractions by oxytocin


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Presentation and prolapse of the umbilical cord

• Knee-chest position

• Elevating head

• Emergency Caesarean section


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delivery









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5. Fetal distress


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Fetal distress

Fetal hypoxy

• Chronic distress

• Acute distress


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Etiology of chronic fetal distress

Maternal causes

Cardiac or pulmonological diseases

Anemia, bleeding

Diabetes, preeclampsia

Immune diseases

Uterine malformation (e.g. Uterus duplex)

Smoking

Infections


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Calcificated placenta

Vascular changes

Chronic hypoxy

Etiology of chronic fetal distress

Fetal causes

Fetal malformations, chromosomal abnormalities

Umbilical cord anomalies (Single umbilical artery)

Rh-sensibilisation

Fetomaternal transfusion

Twin-to-twin transfusion syndrome (TTTS)


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Etiology of acute fetal distress

1. Compressive effect of uterine contractions

- If the placental gas exchange function is close to the critical

level, even normal uterine activity may lead to oxygen

deficiency

- Good placental function + abnormal uterine activity (high

uterine tone, intense, frequent contractions) causes fetal

hypoxia

2. Obstruction of the umbilical cord

- Compression on the umbilical cord (umbilical cord prolapse,

umbilical cord looping, umbilical cord knots)


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Etiology of acute fetal distress

3. Reduction of the working placental surface

- Partial placental abruption

4. Increased vulnerability of the fetus

- Intrauterine infection

- Multiple pregnancy

- Congenital anomaly


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Pathophysiology of fetal hypoxy

Fetal hypoxy

Fetal hypercapnia

Respiratoric acidosis

Anaerobic processes

Lactate

Metabolic acidosis


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Pathophysiology of fetal hypoxy

Centralization of the circulation

Vasoconstriction occurs in the blood vessels of the

periphery (skin, skeletal muscle, lungs, kidneys)

to ensure satisfactory circulation and O2 supply of vital

organs (brain, heart).


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The consequences of chronic placental

insufficiency

Intrauterine growth restriction (IUGR - nutritive

insufficiency)

Oligohydramnios

Fetal hypoxy (respiratory failure)

Meconium stained amniotic fluid

Intrauterine deaths


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Characterization of the fetal circulation -Doppler examination

Normal fetal blood flow values, non-centralized circulation

Onset centralization of circulation (arteria umbilicalis elevated resistance, arteria cerebry media decreased resistance)

Abnormal blood flow, centralized circulation (end-diastolic block, diastolic block)

Cardiac decompensation (reverse flow)


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Characterization of the fetal circulation

- Cardiotocography (CTG)

Bradycardia

Low oscillation (Low < 5bpm, Silent < 2bpm )

Decelerations

Early decelerations - Head compression /normal/

Late decelerations - Uteroplacental insufficiency

Variable decelerations - Cord compression

Prolonged decelerations


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6. Preterm delivery


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Preterm delivery

• Delivery between 24 weeks 0 days and 36 weeks 6

days

• Preterm birth rate: 6-10%

• WHO's 1961 definition: delivery before 37th week


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PHYSIOLOGICAL RISK FACTORS

FOR PREMATURE BABIES• Weakly calcified skull

• Vascular structures in vulnerable

• Vulnerable dura mater

• Lower levels of clotting factor

• Hgb lower level

• Cerebral dysfunction of autoregulation (consequtive hypertension)

• Sensitivity to hypoxia (cerebral hemorrhagia due to hypoxia)

• Relatively larger skullIncidence of breech is higher• → PERIVENTRICULAR HAEMORRHAGE, INJURIES

• Lung immaturity• → RESPIRATORY DISTRESS SYNDROME

• Immaturity of the immune system• → INFECTIONS (PNEUMONIA, SEPSIS, NEC)


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ETIOLOGY

INFECTION

• Premature contractions

• Early cervical ripening

• Premature rupture of membranes

• Bacterial enzymes, inflammatory reaction

ANATOMICAL, MECHANICAL FACTORS

• Damaged cervical locking function

• Uterine malformations

• Polyhydramnios, multiple pregnancy, transverse lie

• Cervical stretch – reflective contractions

BLEEDING

• Placental abruption, placenta praevia

INDUCED PRETERM DELIVERY


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STEROID-PROPHYLAXIS

PREVENTON OF RESPIRATORY DISTRESS SYNDROME

• Surfactant production in Type II pneumocytes (from 22 weeks)

• Up to 34th weeks is recommended for prophylaxis of steroid

• In cases of premature rupture of membranes can also be used

• 24 hours later develops optimum effect

• After 2 week, repeatable

• Dexamethasone

• Betamethasone


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DELIVERY

• In cases of preterm delivery is important the

route of delivery

• In vertex presentation the vaginal delivery

will not elevate morbidity, mortality

indicators

• In breech presentation (under 2000 g and

before the 34th week) the Caesarean section

favorably affect the life expectancy of

newborn Artur Beke - Abnormalities of Labour

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7. Twin delivery


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Prevalence of twin pregnancy

Hellin's rule / classic /Gemini - 1/85

• Trigemini - 1/852

• Qadrigemin - 1/853

At present the rates are higher, because of assisted reproductive methods

Spontaneous reduction – fetus papyraceus

or fetus compressus

Artur Beke - Abnormalities of Labour and

Delivery - 2019

Monozygotic and dizygotic twins

• Monozygotic

• Dizygotic

– 25% of same-sex

– 75% of the opposite sex


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Placentations of monozygotic and dizygotic twins

monozygotic twins

DDD MDD

dizygotic twins

DDD MDD MMD MMM

Ultrasound


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Monochorial or dichorial

Lambda-sign T-sign

MDD MMD


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Position of fetuses

• vertex-vertex 45,4%

• vertex-breech 38,6%

• breech-breech 9,2%

• vertex-transverse 5,3%

• breech-transverse 1,7%

• transverse-transverse 0,2%


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Position of fetuses

• „A” vertex – possible vaginal delivery

• „A” breech – Caesarean section• (Higher risk of locked twins!)

• „A” transverse – Caesarean section


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Locked twins

Collisio geminorum - locked twins


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Risk of twin pregnancy

• During delivery

– Uterine distocia

– Overstrain of uterus

– Locked twins

– "B" fetus – placental abruption

– "B" fetus - turns to transverse

– Caesarean section because of "B„

– Atony after delivery / Caesarean section


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Vaginal delivery of twin

pregnancy

• Delivery of „A” fetus – episiotomy is recommended.

• Necessary tools for two fetuses

• Two obstetricians or more

• Presence of neonatologist

• After delivery of „A” fetus - an internal examination

check the position of the „B”

• If the „B” is in vertex position, the assistant fixes the skull, and the

obsterician rupture the membrane, and start pushing

• If the „B” fetus is in breech presentation, the same like in delivery of breech

• If the „B” fetus turns to transverse, hold the leg and turning and extraction


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Monochorial monoamniotic twin

pregnancies• Rare (0.2%)

• Hospitalisation is advocated as soon as the fetuses are

viable

• Fetal heart trace monitoring twice a day

• Fetal heart trace monitoring

– uterine contractions or

– sharp fetal movements felt by the mother

• Planned, prophylactic Caesarean at 32 weeks*

*Beasley E, Megerian G, Gerson A, Roberts N. Monoamniotic twins caseseries

and proposal for antenatal management. Obstet Gynecol1999;93:130–4.


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