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Labor and Delivery

Complications

Reproductive Medicine and Urology -2004

November 16, 2004 13h00 -14h00Dr. Roger W. Turnell

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Malpresentations

n Maternal and uterine factors

1. Contracted pelvis

2. Pendulous maternal abdomen

3. Neoplasms of uterus and ovaries

4. Uterine cavity abnormalities

5. Abnormalities of placental location

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Malpresentations

n Fetal Factors

1. Large baby

2. Errors in fetal polarity such as breech

presentation or transverse lie3. Abnormal internal rotation, ie occiput

posterior

4. Fetal attitude: extension in place ofnormal flexion

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Malpresentations

n Fetal Factors

5. Multiple pregnancy

6. Fetal anomalies including hydrocephaly7. Polyhydramnios.

8. Prematurity

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Malpresentations

n Placenta and Membranes

1. Placenta Praevia

2. Premature Rupture of themembranes

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Effects of Malpresentations on

Labor

1. The incidence of feto-pelvicdisproportion is higher

2. Inefficient uterine action is common

3. Prolonged labor

4. Pathologic retraction rings candevelop, and rupture of the loweruterine segment can result

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Effects of Malpresentations on

Labor

5. The cervix often dilates slowly andincompletely

6. The presenting part stays high

7. Premature rupture of the membranescan occur

8. The need for operative delivery is

increased8

Effects of Malpresentations on

the Mother

1. Maternal exhaustion

2. Increased risk for maternal traumasecondary to operative delivery

3. Increased risk for bleeding andinfection

4. Long-term issues of pelvic floordamage, especially with prolongedsecond stage or vaginal operativedelivery

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Effects of Malpresentation on

the Fetus

1. The fetus fits the pelvis less perfectly,making its passage through the pelvis more

difficult

2. Longer labor may have a higher association

with fetal hypoxia3. Operative delivery can increase the risk of

trauma to the fetus

4. Prolapse of the umbilical cord is more

common, leading to possible fetal asphyxiaand death

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Breech Presentation

nAt term, makes up to 3 to 4% ofpatients

nAt 28 weeks, seen in almost 25% ofpatients

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Breech Presentations

Risk Factors

n Maternal

1. High parity (uterine relaxation)

2. Polyhydramnios

3. Oligohydramnios

4. Uterine anomalies

5. Neoplasms ( Fibroids )

6. Contracted Pelvis

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Breech Presentation

Risk Factors

n Fetal

1. Multiple pregnancy

2. Hydrocephaly

3. Anencephaly

4. Any fetal anomaly

5. Intrauterine death

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Breech Presentations

Risk Factors

n Placental

There is a positive association of placentapraevial and breech presentation.

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Breech Presentations

Management

n Attempt external cephalic version to cephalicpresentation after 37 weeks

n A recent multicentre international trial

suggests that there is a 3 to 5 x increase infetal mortality and morbidity with vaginaldelivery at term in well selected candidates

patients previously thought to be ideal forvaginal breech delivery

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Breech Presentations

Management

n It appears that the current standard ofcare will be to recommend C-section to

all patients that are a Breechpresentation in labor at viability ( > 24to 25 weeks).

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Transverse Lie

n When the long axes of mother andfetus are at right angles to one another,a transverse lie is present.

n Because the shoulder is placed sofrequently in the brim of the inlet, themalposition is often referred to as theshoulder presentation

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Transverse Lie

n The incidence is 1:500

n This is a serious malpresentation whose

management must not be left to nature.

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Transverse Lie

Etiology

n High Multiparity

n Placenta Praevia

n Obstructing Neoplasm

n Multiple Pregnancies

n Fetal Anomalies

n Polyhydramnios

n Feto-pelvic disproportion

n Uterine abnormalities

n Contracted pelvis

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Transverse Lie

Management

nAttempt external cephalic version

n C-section if transverse lie in labor

especially after viability after 24 weeks

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Shoulder Dystocia

nA shoulder dystocia is defined as thefollowing situation:

n Presentation is cephalic; the head has been

born, but he shoulders cannot be deliveredby the usual methods. There is no othercause for this difficulty.

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Shoulder Dystocia

n The incidence is less than 1%.

n In babies weighing over 4000 gm, the

incidence is 1.6%.

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Shoulder Dystocia

Risk Factors

1. Maternal Obesity

2. Excessive Weight Gain

3. Oversized Infants ( > 4500 gm)

4. History of Large Infants5. Maternal Diabetes

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Shoulder DystociaManagement

n Anaesthesia on stand-by or administered

n Vaginal exam

n Episiotomy

n Hyperabduction of maternal hips

n Suprapubic pressure

n Rotation of anterior shoulder under the symphysis pubis

n Extraction of posterior arm and shoulder

n Screw Principle of Woods ( deliver posterior shoulder and rotatebaby 180 degrees)

n Zavonelli ( Reduce baby back into vagina and C-section

n Modified Zavonelli ( Start C-section and push baby from abovethrough vagina)