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
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
Artur Beke - Abnormalities of Labour
and Delivery - 2019
A./ ABNORMAL PRESENTATION
• Cephalic presentation 96.5%
• Breech presentation 3.0%
• Transverse or oblique lie 0.5%
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
Artur Beke - Abnormalities of Labour
and Delivery - 2019
Types of breech presentation
• Frank breech- Extended legs (Simple)
(65%)
• Complete breech- Flexed legs (25%)
• Incomplete breech- Footling or knee presentation (10%)
Artur Beke - Abnormalities of Labour
and Delivery - 2019
Diagnosis of breech presentation
• Leopold examination
• Vaginal examination
• Sonography
Artur Beke - Abnormalities of Labour
and Delivery - 2019
Etiology of breech presentation
• Prematurity
• Fetal anomalies
• Uterine anomalies
• Pelvic anomalies
• Umbilical cord complications
• Twin pregnancy
• Placenta previa
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
and Delivery - 2019
External cephalic version
• External cephalic version
– Success rate 75%
– Prepared for emergency Caesarean section
– Risk of placental abruption and umbilical cord
compression
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
Artur Beke - Abnormalities of Labour
and Delivery - 2019
Transverse or oblique lie(shoulder presentation)
• No fetal pole detected above the symphysis
• Vaginal delivery is impossible
• High risk of rupture of the uterus
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
Artur Beke - Abnormalities of Labour
and Delivery - 2019
B./ ABNORMAL POSITION
• High sagittal position
• Obliquity
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
and Delivery - 2019
Obliquity
Asynclitic
• Anterior parietal position = Naegele obliquity
• Posterior parietal position = Litzmann obliquity
Normal Litzmann Naegele
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
Artur Beke - Abnormalities of Labour
and Delivery - 2019
C./ ABNORMALITIES OF FLEXION
• Deflexion of the head
Artur Beke - Abnormalities of Labour
and Delivery - 2019
Cephalic presentation
• Vertex presentation
/normal/
• Poorly flexed
• Brow presentation
• Face presentation
Important to examine
the fontanelles and suture lines
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
Artur Beke - Abnormalities of Labour
and Delivery - 2019
D./ ABNORMALITIES OF ROTATION
• Persisted occipito-posterior position
– (The rotation of the headis opposite)
• Persisted transverse position
– (No rotation)
Longer 2nd stage
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
2. Uterine dystocia
• Abnormal uterine activity
• Abnormal presentation
• Cephalopelvic disproportion
• Umbilical complication
• Fetal asphyxia
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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)
Artur Beke - Abnormalities of Labour
and Delivery - 2019
3. Shoulder dystocia
• Large fetus (more than 4000 g)
• The shoulder is not delivered after the head
during the next contraction
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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)
Artur Beke - Abnormalities of Labour
and Delivery - 2019
4. Premature rupture of the
membranes (PROM)
• Amniorrhexis (spontaneous rupture)
• Before onset of labor (before contractions)
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
Artur Beke - Abnormalities of Labour
and Delivery - 2019
Diagnosis of PROM
• Anamnesis
• Vaginal examination
• Sonography
• Vaginal AFP
• Arborisation
Artur Beke - Abnormalities of Labour
and Delivery - 2019
Management of PROM
• Laboratory examination (WBC, CRP)
• Temperature
• Antibiotic treatment
• Antenatal corticosteroid therapy
• Prostaglandins for cervical ripening
• Induction of the contractions by oxytocin
Artur Beke - Abnormalities of Labour
and Delivery - 2019
Presentation and prolapse of the umbilical cord
• Knee-chest position
• Elevating head
• Emergency Caesarean section
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
5. Fetal distress
Artur Beke - Abnormalities of Labour
and Delivery - 2019
Fetal distress
Fetal hypoxy
• Chronic distress
• Acute distress
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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)
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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)
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
Artur Beke - Abnormalities of Labour
and Delivery - 2019
Pathophysiology of fetal hypoxy
Fetal hypoxy
Fetal hypercapnia
Respiratoric acidosis
Anaerobic processes
Lactate
Metabolic acidosis
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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).
Artur Beke - Abnormalities of Labour
and Delivery - 2019
The consequences of chronic placental
insufficiency
Intrauterine growth restriction (IUGR - nutritive
insufficiency)
Oligohydramnios
Fetal hypoxy (respiratory failure)
Meconium stained amniotic fluid
Intrauterine deaths
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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)
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
Artur Beke - Abnormalities of Labour
and Delivery - 2019
6. Preterm delivery
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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)
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
and Delivery - 2019
7. Twin delivery
Artur Beke - Abnormalities of Labour
and Delivery - 2019
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
Artur Beke - Abnormalities of Labour and
Delivery - 2019
Placentations of monozygotic and dizygotic twins
monozygotic twins
DDD MDD
dizygotic twins
DDD MDD MMD MMM
Ultrasound
Artur Beke - Abnormalities of Labour and
Delivery - 2019
Monochorial or dichorial
Lambda-sign T-sign
MDD MMD
Artur Beke - Abnormalities of Labour and
Delivery - 2019
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%
Artur Beke - Abnormalities of Labour and
Delivery - 2019
Position of fetuses
• „A” vertex – possible vaginal delivery
• „A” breech – Caesarean section• (Higher risk of locked twins!)
• „A” transverse – Caesarean section
Artur Beke - Abnormalities of Labour and
Delivery - 2019
Locked twins
Collisio geminorum - locked twins
Artur Beke - Abnormalities of Labour and
Delivery - 2019
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
Artur Beke - Abnormalities of Labour and
Delivery - 2019
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
Artur Beke - Abnormalities of Labour and
Delivery - 2019
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.
Artur Beke - Abnormalities of Labour
and Delivery - 2019