BSC – SEM 7 – UNIT 2- OBSTETRICS & GYNECOLOGY NURSING – II
Recognition of deviations from the normal and management during labour
Preterm Labor: Prevention and Management
I. Definition of Preterm Labor
Preterm labor is the onset of regular uterine contractions leading to cervical changes before 37 completed weeks of gestation. It is a leading cause of neonatal morbidity and mortality, and effective prevention and management are essential to improve fetal outcomes.
II. Classification of Preterm Labor
Preterm labor is classified based on gestational age:
Classification
Gestational Age
Outcomes
Extremely Preterm
<28 weeks
High neonatal mortality, severe complications
Very Preterm
28–32 weeks
High risk of respiratory distress, NICU admission
Moderate Preterm
32–34 weeks
Some risks, but better survival rates
Late Preterm
34–37 weeks
Generally good outcomes but risks of feeding and temperature regulation issues
III. Causes and Risk Factors of Preterm Labor
Preterm labor occurs due to maternal, fetal, placental, and environmental factors.
A. Maternal Risk Factors
Previous preterm birth (Strongest risk factor).
Multiple pregnancies (Twins, Triplets).
Short interpregnancy interval (<6 months between pregnancies).
Avoidance of risk factors (Smoking, Alcohol, Illicit Drugs).
Hydration and rest (Dehydration can trigger contractions).
Early detection and treatment of infections (UTI, Bacterial vaginosis).
B. Medical Preventive Interventions
Progesterone Therapy:
Indications: Women with previous preterm birth or short cervix (<25 mm).
Drugs Used:
Intravaginal Micronized Progesterone (200 mg daily) from 16–36 weeks.
17α-Hydroxyprogesterone Caproate (IM injection 250 mg weekly from 16–36 weeks).
Mechanism of Action: Prevents premature cervical ripening and uterine contractions.
Cervical Cerclage (Stitching of the Cervix):
Indications:
History of second-trimester pregnancy loss.
Short cervix (<25 mm) detected on ultrasound.
Procedure: Cervical stitch placed at 12-14 weeks and removed at 36-37 weeks.
VIII. Management of Preterm Labor
A. Hospital Admission & Initial Management
Admit high-risk patients to a well-equipped maternity unit.
Assess contractions, fetal status, and cervix.
Identify and treat underlying causes (Infections, Hypertension, Diabetes).
B. Tocolytic Therapy (Drugs to Delay Labor)
Used to delay preterm labor by 24-48 hours, allowing time for steroid administration.
Drug
Mechanism of Action
Dosage
Side Effects
Nifedipine (First-line)
Calcium channel blocker, relaxes uterus
10-20 mg orally every 6–8 hours
Hypotension, headache
Atosiban
Oxytocin receptor antagonist
IV infusion, loading dose 6.75 mg, then 18 mg/hr
Nausea, dizziness
Terbutaline
Beta-agonist, relaxes uterine muscle
250 mcg SC every 20 minutes (Max 3 doses)
Tachycardia, hyperglycemia
C. Corticosteroids for Fetal Lung Maturity
Given between 24–34 weeks gestation to enhance fetal lung surfactant production.
Betamethasone 12 mg IM every 24 hours for 2 doses.
Dexamethasone 6 mg IM every 12 hours for 4 doses.
D. Magnesium Sulfate for Neuroprotection
Given before 32 weeks to reduce risk of cerebral palsy.
Dosage:4–6 g IV over 15 minutes, then 1–2 g/hr continuous infusion.
E. Antibiotics for Preterm Premature Rupture of Membranes (PPROM)
Ampicillin 2 g IV every 6 hours + Erythromycin 250 mg every 6 hours for 7 days.
IX. Delivery Planning for Preterm Labor
<28 Weeks: Neonatal Intensive Care Unit (NICU) required.
28–34 Weeks: Steroids, delayed delivery if possible.
34–37 Weeks: Delivery considered if fetal lung maturity is confirmed.
Mode of Delivery:
Vaginal preferred unless fetal distress.
Cesarean section if non-reassuring fetal heart rate.
Use of Antenatal Corticosteroids in Preterm Labor
I. Introduction
Antenatal corticosteroids (ACS) are a critical intervention in preterm labor to accelerate fetal lung maturation, reduce neonatal complications, and improve survival rates. The administration of corticosteroids before 34 weeks of gestation significantly lowers the risk of respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), and neonatal mortality.
II. Indications for Antenatal Corticosteroids
Antenatal corticosteroids are recommended in the following cases:
Imminent Preterm Birth (24–34 weeks gestation)
Regular uterine contractions with cervical dilation ≥2 cm.
Positive fetal fibronectin test or short cervix (<25 mm on transvaginal ultrasound).
Preterm premature rupture of membranes (PPROM).
Planned Preterm Delivery (<34 weeks) Due to Maternal or Fetal Conditions
Severe preeclampsia/eclampsia.
Placental abruption.
Intrauterine growth restriction (IUGR).
Multiple pregnancies (If preterm birth risk is high).
Late Preterm Birth (34–36 weeks, Case-Specific)
Some guidelines recommend ACS in late preterm cases (34-36 weeks) if high risk of respiratory distress exists.
III. Mechanism of Action of Antenatal Corticosteroids
Enhances Fetal Lung Maturity:
Stimulates type II pneumocytes in the fetal lungs to produce surfactant, preventing alveolar collapse.
Perform Nitrazine & Fern tests to confirm diagnosis.
Monitor fetal heart rate and uterine contractions.
B. Infection Prevention & Monitoring
Monitor maternal temperature & WBC count for infection.
Administer prescribed antibiotics promptly.
Educate the mother on hygiene to prevent ascending infections.
C. Emotional Support & Patient Education
Reassure the mother and explain the need for hospitalization.
Educate on signs of infection (Fever, foul-smelling discharge).
Encourage adequate hydration and nutrition.
Malpositions and Abnormal Presentations in Labor:
I. Definition
Malpositions and abnormal presentations refer to fetal positions or presentations that deviate from the normal cephalic (vertex) presentation, leading to complications in labor and delivery. These conditions often result in prolonged labor, fetal distress, birth trauma, or the need for assisted delivery (forceps, vacuum, or cesarean section).
II. Classification of Malpositions and Abnormal Presentations
Type
Description
Risk Factors
Breech Presentation
Fetal buttocks or feet present first instead of the head.
Mentum Anterior – Trial of vaginal delivery (If pelvis is adequate).
Mentum Posterior – Cesarean section (Delivery not possible vaginally).
Continuous fetal monitoring for distress.
VI. Shoulder Presentation (Transverse Lie)
A. Definition
Shoulder presentation occurs when the fetus lies horizontally in the uterus (Transverse lie), with the shoulder presenting first.
B. Causes
Multiple pregnancies (Twins, Triplets).
Placenta previa (Placenta covering the cervix).
Polyhydramnios.
C. Diagnosis
Leopold’s maneuvers: No fetal head in the pelvis or fundus.
Ultrasound: Confirms transverse lie position.
D. Complications
Cord prolapse (Common with ruptured membranes).
Uterine rupture (If labor progresses without intervention).
Severe fetal distress (Hypoxia due to obstructed labor).
E. Management
External Cephalic Version (ECV) at 36–37 weeks if membranes intact.
Cesarean Section is required in most cases.
Avoid vaginal delivery (Risk of uterine rupture, fetal asphyxia).
VII. Role of Midwives in Managing Malpositions & Abnormal Presentations
A. Antenatal Period
Early detection of fetal malposition through Leopold’s maneuvers and ultrasound.
Counseling women on risk factors and possible delivery plans.
Monitoring for signs of fetal distress.
B. Intrapartum Period
Ensure continuous fetal heart rate monitoring.
Assist in ECV for breech and transverse lie.
Prepare for emergency C-section if necessary.
Support mother emotionally and provide pain management.
C. Postpartum Period
Monitor for neonatal complications (Birth injuries, facial trauma).
Educate mothers on postnatal care, especially after C-section.
Provide breastfeeding support and neonatal bonding.
Contracted Pelvis:
I. Definition
A contracted pelvis is a condition where the bony pelvis is smaller than normal or has an abnormal shape, preventing the fetal head from passing through the birth canal during labor. This increases the risk of prolonged labor, obstructed labor, fetal distress, and maternal complications.
II. Types of Pelvic Contraction
Pelvic contraction can occur at different levels of the pelvis, leading to labor difficulties.
Type
Affected Pelvic Region
Description & Consequences
Contracted Inlet
Pelvic brim (Entrance to pelvis)
Prevents fetal head engagement, leading to failure of labor progress.
Contracted Midpelvis
Narrow interspinous diameter
Causes prolonged labor and risk of deep transverse arrest.
Contracted Outlet
Pelvic outlet (Lower pelvis)
Leads to obstructed labor and perineal trauma.
Generalized Pelvic Contraction
Entire pelvis is small
Common in rickets, malnutrition, and dwarfism; requires C-section.
III. Causes and Risk Factors of Contracted Pelvis
A. Maternal Factors
Congenital (Present at birth):
Genetic small pelvis.
Müllerian anomalies.
Acquired (Develops later in life):
Malnutrition (Rickets, Vitamin D Deficiency, Calcium Deficiency).
Pelvic fractures (From trauma, accidents, or childhood injuries).
Previous pelvic surgeries or infections (Tuberculosis, Osteomyelitis).
Short stature (<150 cm or 4’11″) associated with a smaller pelvis.
Assess for short stature, malnutrition, previous obstructed labor.
Monitor fetal growth and position using ultrasound.
Nutritional Supplementation:
Calcium, Vitamin D, and protein supplements for bone development.
Birth Planning:
Elective Cesarean Section for severe cases.
Trial of labor for borderline cases with close monitoring.
B. Intrapartum Management (During Labor & Delivery)
Trial of Labor in Borderline Pelvis Cases:
Continuous monitoring of labor progression with partograph.
Assess descent of fetal head (Failure to descend → C-section).
Labor Augmentation if Needed:
Oxytocin infusion for slow labor (Only if fetal distress is absent).
Artificial rupture of membranes (AROM) to facilitate descent.
Early Decision for Cesarean Section:
If labor progress is inadequate.
If fetal distress develops (Non-reassuring FHR on CTG).
C. Postpartum Management
Monitor for Postpartum Hemorrhage (PPH):
Uterotonics (Oxytocin, Misoprostol) to prevent atony.
Pelvic Floor Rehabilitation:
Kegel exercises to strengthen pelvic muscles after birth.
Family Planning Counseling:
Encourage birth spacing and contraceptive use in women with a history of contracted pelvis.
VII. Mode of Delivery Based on Type of Contracted Pelvis
Type of Pelvic Contraction
Delivery Mode
Mild Pelvic Contraction
Trial of vaginal delivery (If fetal head engages).
Moderate Pelvic Contraction
Trial of labor with close monitoring, early C-section if needed.
Severe Pelvic Contraction
Planned Cesarean Section (Safe and preferred).
VIII. Role of Midwives in Managing Contracted Pelvis
A. Antenatal Role
Identify high-risk women early (Short stature, malnutrition, previous obstructed labor).
Educate about the risks of vaginal delivery and the need for C-section.
Monitor fetal growth and pelvic capacity.
B. Intrapartum Role
Use a partograph to monitor labor progress.
Identify signs of labor obstruction early.
Assist in timely decision-making for emergency C-section.
C. Postpartum Role
Ensure proper recovery and monitor for postpartum hemorrhage.
Provide emotional support (Especially after emergency C-section).
Educate on contraceptive methods and family planning.
Cephalopelvic Disproportion (CPD):
I. Definition
Cephalopelvic Disproportion (CPD) is a condition in which the fetal head is too large or the maternal pelvis is too small, preventing the baby from passing through the birth canal during labor. This leads to prolonged labor, obstructed labor, and increased risk of maternal and fetal complications.
II. Types of Cephalopelvic Disproportion (CPD)
Type
Description
True CPD
Absolute mismatch between fetal head size and maternal pelvis, making vaginal delivery impossible.
Relative CPD
Temporary CPD due to factors like poor fetal positioning, malpresentation, or maternal fatigue; vaginal delivery may be possible with intervention.
III. Causes and Risk Factors of CPD
A. Maternal Factors (Pelvic Abnormalities)
Contracted Pelvis
Small or abnormal pelvic shape due to genetic factors, rickets, malnutrition.
Pelvic Trauma or Fractures
Previous accidents or surgeries affecting the pelvis.
Previous Pelvic Surgeries
Previous C-section, pelvic tumors, or congenital anomalies.
Short Maternal Stature (<150 cm or 4’11″)
Associated with smaller pelvic capacity.
B. Fetal Factors (Large Baby – Macrosomia)
Fetal Macrosomia (>4 kg birth weight)
Common in gestational diabetes, post-term pregnancy, genetic factors.
Hydrocephalus (Large Head Size Due to Fluid Accumulation)
Abnormal Fetal Presentations
Breech, Brow, Face, or Shoulder presentations increase risk of CPD.
C. Other Risk Factors
Multiparity (Repeated Pregnancies Leading to Pelvic Weakness).
Prolonged pregnancy (>42 weeks, leading to fetal overgrowth).
Maternal obesity (Excess weight gain affecting pelvic soft tissues).
IV. Pathophysiology of CPD
Mismatch Between Fetal Head and Pelvic Size
Leads to failure of fetal descent and engagement in the birth canal.
Prolonged Labor & Uterine Overstretching
Increases risk of maternal exhaustion and uterine rupture.
Educate about the risks of CPD and the need for birth planning.
B. Intrapartum Role
Monitor labor progress using partograph.
Detect signs of obstructed labor early (Arrest of dilation, fetal distress).
Assist in safe labor induction or prepare for emergency C-section if needed.
C. Postpartum Role
Monitor for postpartum hemorrhage and complications.
Counsel on contraception and family planning (Elective C-section for next pregnancy).
Disorders of Uterine Action – Prolonged Labor:
I. Definition
Prolonged labor, also known as dysfunctional labor or failure to progress, occurs when labor lasts longer than normal due to inefficient uterine contractions, cephalopelvic disproportion (CPD), fetal malposition, or maternal exhaustion.
A. Criteria for Prolonged Labor
First Stage of Labor (Dilatation Phase)
Nulliparous women: >20 hours
Multiparous women: >14 hours
Second Stage of Labor (Pushing Phase)
Nulliparous women: >2 hours (or >3 hours with epidural anesthesia)
Multiparous women: >1 hour (or >2 hours with epidural anesthesia)
II. Causes of Prolonged Labor
Prolonged labor is usually caused by one or more of the following factors:
A. Uterine Factors (Disorders of Uterine Action)
Primary Uterine Inertia
Weak and ineffective contractions from the onset of labor.
Common in first-time mothers, maternal exhaustion, and sedation use.
Secondary Uterine Inertia
Initially strong contractions weaken over time due to prolonged labor and uterine fatigue.
Common in prolonged rupture of membranes, maternal dehydration, and infections.
Hypertonic Uterine Dysfunction
Frequent but uncoordinated and ineffective contractions that fail to dilate the cervix.
Causes fetal distress due to inadequate oxygen supply.
Hypotonic Uterine Dysfunction
Weak, infrequent contractions that fail to progress labor.
Associated with overdistended uterus (polyhydramnios, multiple pregnancies, grand multiparity).
B. Fetal Factors
Cephalopelvic Disproportion (CPD)
The fetal head is too large for the maternal pelvis, preventing descent.
Fetal Malpresentation and Malposition
Occiput posterior position (baby facing mother’s front instead of back).
Breech, transverse, or brow presentation.
Fetal Macrosomia (Large Baby >4 kg)
Results in obstructed labor and shoulder dystocia.
C. Maternal Factors
Inadequate Cervical Dilatation (Failure of the Cervix to Open)
Rigid or scarred cervix (Previous surgeries, infections, or cervical stenosis).
Emotional stress leading to hormonal imbalance and delayed labor progression.
Pelvic Abnormalities
Contracted pelvis or deformed pelvis due to rickets, fractures, or congenital anomalies.
Maternal Exhaustion & Dehydration
Prolonged labor leads to fatigue, dehydration, and inefficient contractions.
Use of Anesthesia or Sedation
Excessive epidural anesthesia slows contractions and fetal descent.
III. Complications of Prolonged Labor
A. Maternal Complications
Uterine rupture (Increased risk with CPD, grand multiparity).
B. Medical Management (Labor Augmentation & Induction)
Oxytocin (To Strengthen Uterine Contractions)
IV Oxytocin infusion given in low doses if contractions are weak.
Monitor fetal heart rate (Risk of hyperstimulation and fetal distress).
Amniotomy (Artificial Rupture of Membranes – AROM)
Performed if membranes are intact and labor progress is slow.
Contraindicated if CPD or fetal distress is present.
C. Obstetric Interventions for Prolonged Labor
Instrumental Delivery (Forceps or Vacuum Extraction)
Indicated in prolonged second stage of labor with fetal distress.
Prerequisites:
Fully dilated cervix.
Fetal head at low station (Below ischial spines).
No CPD present.
Cesarean Section (C-Section Indications in Prolonged Labor)
Failure of labor to progress despite augmentation.
Fetal distress on CTG.
Cephalopelvic disproportion (CPD).
Malpresentation (Transverse lie, Brow presentation, Persistent OP position).
VI. Role of Midwives in Managing Prolonged Labor
A. Antenatal Role
Identify high-risk mothers (Short stature, history of prolonged labor, CPD).
Encourage optimal maternal nutrition and hydration.
Educate women about signs of prolonged labor and when to seek care.
B. Intrapartum Role
Monitor labor progress using a partograph.
Encourage proper positioning (Upright, squatting, lateral positions to aid descent).
Provide emotional and psychological support.
Detect early signs of obstructed labor (Fetal distress, maternal exhaustion).
C. Postpartum Role
Monitor for postpartum hemorrhage (PPH).
Ensure adequate maternal hydration and pain relief.
Educate mother on postpartum recovery and family planning.
Precipitate Labor:
I. Definition
Precipitate labor is an abnormally rapid labor and delivery, completed within less than 3 hours from the onset of regular contractions. It involves intense uterine contractions leading to a very fast delivery, which increases the risk of maternal and neonatal complications.
A. Criteria for Precipitate Labor
Total labor duration: <3 hours.
Rapid cervical dilation (>5 cm per hour in primigravida, >10 cm per hour in multipara).
Strong, frequent, and painful contractions.
II. Causes and Risk Factors of Precipitate Labor
A. Maternal Factors
Multiparity (Multiple previous births)
The uterus responds more strongly to oxytocin, leading to rapid contractions.
History of Precipitate Labor
If a woman has had a previous rapid labor, she is more likely to experience it again.
Hypertonic Uterine Contractions
Overactive uterus causes excessive frequency and intensity of contractions.
Uterine Overdistension
Common in polyhydramnios, multiple pregnancies, grand multiparity.
Small Baby (Low Birth Weight <2.5 kg)
The fetus descends more quickly through the birth canal.
B. Fetal and Placental Factors
Preterm Birth
Smaller fetus can pass through the birth canal faster.
Low Resistance of Soft Tissues in the Birth Canal
More common in women with previous multiple vaginal deliveries.
Fetal distress leads to early passage of meconium, which the baby may inhale.
Respiratory Depression
Short labor may result in inadequate fetal lung preparation for breathing.
Umbilical Cord Complications
Cord prolapse or cord compression may occur due to rapid descent.
VI. Diagnosis of Precipitate Labor
A. History and Clinical Examination
Rapid cervical dilation on repeated vaginal examinations.
Very frequent, strong contractions lasting >60 seconds.
B. Fetal Monitoring (CTG – Cardiotocography)
Shows signs of fetal distress due to hyperstimulation.
Decelerations in fetal heart rate may indicate umbilical cord compression.
VII. Management of Precipitate Labor
A. Immediate Management (During Labor)
Provide Emotional Support to the Mother
Reassure the mother to stay calm and guide her through breathing exercises.
Slow Down Delivery (If Possible)
Encourage the mother to pant instead of pushing to slow fetal descent.
Apply gentle pressure on the fetal head to prevent perineal tears.
Prevent Maternal Tears and Trauma
Perineal support with warm compresses and controlled delivery techniques.
Monitor for Fetal Distress
Continuous fetal heart monitoring is essential to detect signs of distress.
B. Postpartum Management (After Delivery)
Prevent Postpartum Hemorrhage (PPH)
Administer Oxytocin 10 IU IM after delivery to ensure effective uterine contraction.
Massage the uterus (Fundal massage) to prevent atony.
Inspect for Perineal Tears & Repair Immediately
Suture vaginal and cervical tears to prevent excessive bleeding.
Monitor Newborn for Birth Injuries
Assess for signs of hypoxia, birth trauma, and respiratory distress.
Immediate resuscitation if required (Oxygen, Suctioning for meconium aspiration).
VIII. Prevention of Precipitate Labor
A. Antenatal Prevention for High-Risk Women
Identify Women with a History of Precipitate Labor
Closely monitor during the last weeks of pregnancy.
Scheduled Early Hospital Admission
Women with previous rapid labor should be admitted before labor begins.
Cervical Assessment at Term
Ultrasound and vaginal examination to check cervical ripening.
B. Intrapartum Prevention
Avoid Overuse of Labor Induction Drugs (Oxytocin, Prostaglandins)
Monitor contractions closely if labor is induced.
Slow the Progress of Labor (If Needed)
If contractions are too strong and frequent, a tocolytic (e.g., Terbutaline 250 mcg SC) may be used to slow contractions.
IX. Role of Midwives in Managing Precipitate Labor
A. Antenatal Role
Educate women about signs of precipitate labor.
Ensure proper birth planning for women with a history of rapid labor.
B. Intrapartum Role
Ensure the mother is in a safe environment for delivery.
Guide controlled breathing to slow the delivery process.
Assist in immediate postpartum care to prevent PPH and neonatal distress.
C. Postpartum Role
Monitor mother and baby for complications.
Provide emotional support and psychological counseling if needed.
Dysfunctional Labor:
I. Definition
Dysfunctional labor, also known as dystocia, refers to abnormal labor progression due to ineffective uterine contractions, fetal malposition, or pelvic abnormalities, leading to prolonged or obstructed labor. Dysfunctional labor increases the risk of maternal exhaustion, fetal distress, postpartum hemorrhage, and operative deliveries (Cesarean section, forceps, or vacuum extraction).
II. Types of Dysfunctional Labor
A. Disorders of Uterine Contractions (Primary Cause of Dysfunctional Labor)
Type
Description
Complications
Hypertonic Uterine Dysfunction
Excessively strong, frequent, and painful contractions but uncoordinated, leading to ineffective cervical dilation.
Prevents maternal malnutrition, fetal macrosomia, and weak uterine contractions.
Exercise & Pelvic Floor Strengthening
Encourages effective labor contractions and fetal descent.
B. Intrapartum Preventive Measures
Early Monitoring with Partograph
Detects slow labor progression early.
Avoid Excessive Epidural or Oxytocin Use
Prevents uterine dysfunction.
Proper Positioning During Labor
Upright positions (Squatting, sitting) help fetal descent.
VIII. Role of Midwives in Managing Dysfunctional Labor
A. Antenatal Role
Identify high-risk pregnancies early.
Educate about proper nutrition and labor exercises.
Encourage regular antenatal check-ups.
B. Intrapartum Role
Monitor labor progression using partograph.
Encourage effective labor positions and breathing techniques.
Detect early signs of dystocia and refer for obstetric intervention.
C. Postpartum Role
Monitor for postpartum hemorrhage (PPH).
Provide emotional support after prolonged or operative labor.
Educate about future pregnancy planning.
Complications of the Third Stage of Labor: Retained Placenta
I. Definition
The third stage of labor refers to the period from the delivery of the baby to the expulsion of the placenta and membranes. A retained placenta is a failure of the placenta to be delivered within 30 minutes after the birth of the baby, leading to increased risks of postpartum hemorrhage (PPH), infection, and uterine inversion.
II. Types of Retained Placenta
Type
Description
Cause
Placenta Adherent (Failure of Separation)
Placenta remains attached to the uterine wall due to weak contractions.
Uterine atony, incomplete placental detachment.
Placenta Trapped (Mechanical Retention)
Placenta detaches but remains inside due to cervical spasm or a closed cervix.
Oxytocin 20-40 IU in IV drip (First-line treatment).
Misoprostol 800 mcg rectally (If oxytocin is unavailable).
Ergometrine 0.2 mg IM (Contraindicated in hypertension and heart disease).
Nitroglycerin (If Placenta is Trapped Due to Cervical Spasm)
IV nitroglycerin relaxes the cervix, allowing placental passage.
C. Manual Removal of Placenta (MRP) (If Medical Methods Fail)
Performed under sterile conditions with anesthesia to remove the placenta manually.
Indications:
Failure of placenta to separate within 30-60 minutes.
Excessive bleeding or maternal distress.
Steps for Manual Placenta Removal
Insert one hand into the uterus while applying gentle traction on the cord.
Detach the placenta from the uterine wall using a sweeping motion.
Inspect the uterus for completeness and prevent retained fragments.
Administer antibiotics to prevent infection.
D. Surgical Management (For Placenta Accreta Cases)
Surgical Removal (Dilation and Curettage – D&C)
Performed if small placental fragments remain inside.
Hysterectomy (Last Resort in Severe Placenta Accreta or Uncontrolled Bleeding)
Total removal of the uterus to save the mother’s life.
VII. Prevention of Retained Placenta
A. Antenatal Preventive Measures
Identify high-risk women (Previous C-section, placenta previa, history of retained placenta).
Ensure proper maternal nutrition (Prevent uterine atony and malnutrition-related complications).
Perform antenatal ultrasounds to detect abnormal placental attachment early.
B. Intrapartum Preventive Measures
Active Management of the Third Stage of Labor (AMTSL)
Oxytocin administration after delivery to contract the uterus.
Controlled cord traction to aid placental expulsion.
Uterine massage to prevent atony.
Avoid Premature Cord Clamping
Allows for natural placental separation and reduces complications.
VIII. Role of Midwives in Managing Retained Placenta
A. Antenatal Role
Identify women at risk and educate them on possible complications.
Ensure proper follow-up with obstetricians in high-risk cases.
B. Intrapartum Role
Monitor the third stage closely and ensure active management.
Detect early signs of retained placenta and intervene promptly.
Assist in manual placenta removal if indicated.
C. Postpartum Role
Monitor for excessive bleeding and signs of infection.
Provide postpartum care and educate women on future pregnancy risks.
Injuries to the Birth Canal:
I. Definition
Birth canal injuries refer to trauma to the cervix, vagina, perineum, or uterus occurring during labor and delivery. These injuries may result from prolonged labor, operative deliveries, fetal malposition, or rapid labor, leading to postpartum hemorrhage (PPH), infection, and long-term complications like urinary or fecal incontinence.
II. Types of Birth Canal Injuries
Type
Description
Causes
Complications
Perineal Tears
Tears in the skin and muscles between the vagina and anus.
Large baby, forceps delivery, episiotomy extension.
Pain, bleeding, fecal/urinary incontinence.
Vaginal Tears
Tears in the vaginal wall or fornices.
Prolonged labor, large baby, rough instrumental delivery.
Encourage pelvic floor exercises (Kegels) for tissue elasticity.
Provide proper nutrition (Calcium, Vitamin C, Protein) to improve tissue strength.
B. Intrapartum Prevention
Controlled Delivery Techniques
Encourage slow crowning of the fetal head to allow perineal stretching.
Use warm compresses on perineum to prevent tearing.
Proper Episiotomy Use
Performed only when necessary (Rigid perineum, large baby).
Mediolateral episiotomy preferred over midline to prevent anal sphincter injury.
Judicious Use of Instrumental Delivery
Ensure proper technique to avoid trauma.
IX. Role of Midwives in Managing Birth Canal Injuries
A. Antenatal Role
Educate women on perineal care and pelvic exercises.
Identify risk factors early and plan appropriate birth strategies.
B. Intrapartum Role
Ensure gentle delivery techniques and controlled cord traction.
Monitor for signs of perineal or vaginal trauma during labor.
C. Postpartum Role
Provide pain relief and wound care.
Educate on perineal hygiene and infection prevention.
Monitor for PPH, shock, and complications like incontinence.
Postpartum Hemorrhage (PPH):
I. Definition
Postpartum hemorrhage (PPH) is excessive bleeding following childbirth, which can lead to shock, organ failure, or even maternal death if not managed promptly. It is one of the leading causes of maternal mortality worldwide.
PPH is classified into:
Primary PPH – Blood loss of ≥500 mL after vaginal delivery or ≥1000 mL after cesarean section within the first 24 hours postpartum.
Secondary PPH – Excessive bleeding between 24 hours and 12 weeks postpartum, usually due to retained placental tissue, infection, or uterine subinvolution.
II. Causes and Risk Factors of PPH
PPH is commonly caused by the “Four Ts”:
Tone (Uterine Atony) – The most common cause, accounting for 70-80% of PPH cases. It occurs when the uterus fails to contract after delivery, leading to uncontrolled bleeding from placental blood vessels. Risk factors include:
Prolonged labor or rapid labor (Uterus becomes exhausted).
Use of tocolytic drugs (Nifedipine, Atosiban) delaying uterine contractions.
General anesthesia (Relaxing uterine muscles excessively).
Tissue (Retained Placenta or Membranes) – If placental fragments remain inside the uterus, they prevent proper uterine contraction and cause continuous bleeding. Causes include:
Placenta accreta (Placenta deeply attached to uterine wall).
Previous C-section or uterine surgery (Leading to abnormal placenta attachment).
Failure to properly examine and remove placental fragments after birth.
Trauma (Birth Canal Injuries) – Excessive bleeding due to tears or lacerations in the vagina, cervix, uterus, or perineum. Causes include:
Uterine massage immediately after placenta expulsion.
C. Postpartum Monitoring
Monitor blood loss, uterine contraction, and maternal vitals every 15 minutes for the first hour.
Encourage early breastfeeding (Releases oxytocin to promote uterine contraction).
Educate mothers on danger signs of PPH before discharge.
VII. Role of Midwives in Managing PPH
A. Immediate Response in Emergency Situations
Recognize early signs of excessive bleeding.
Ensure rapid administration of uterotonic drugs.
Assist in bimanual uterine massage and tamponade procedures.
B. Postpartum Care
Monitor uterine involution and signs of secondary PPH.
Encourage maternal hydration and proper nutrition.
Provide psychological support for mothers experiencing severe bleeding.
Bimanual Compression of the Uterus: A Life-Saving Technique for Postpartum Hemorrhage (PPH)
I. Definition
Bimanual compression of the uterus is an emergency obstetric procedure used to control severe postpartum hemorrhage (PPH) due to uterine atony. It involves applying firm pressure to the uterus using both hands (one internally and one externally) to compress bleeding vessels, promote uterine contraction, and reduce blood loss.
This technique is life-saving in cases where uterotonics (Oxytocin, Misoprostol, Ergometrine) fail to stop bleeding, and it provides temporary control while preparing for advanced interventions such as uterine balloon tamponade or surgery.
Uterine Artery Ligation or B-Lynch Suture in Severe Cases.
Hysterectomy (If all measures fail and bleeding is life-threatening).
VIII. Role of Midwives in Bimanual Compression
A. Early Recognition of PPH
Identify excessive bleeding immediately and assess uterine tone.
Ensure proper active management of the third stage of labor (AMTSL).
B. Assisting with the Procedure
Perform bimanual compression when needed.
Monitor maternal vitals during and after the procedure.
Prepare for further interventions if bleeding continues.
C. Postpartum Care and Education
Monitor for delayed hemorrhage or anemia.
Educate the mother on symptoms of secondary PPH (Persistent bleeding, fever, foul-smelling discharge).
Aortic Compression: A Life-Saving Technique in Postpartum Hemorrhage (PPH)
I. Definition
Aortic compression is an emergency maneuver used to control severe postpartum hemorrhage (PPH) by manually compressing the abdominal aorta against the spine. This reduces blood flow to the uterus while maintaining perfusion to the brain and heart, buying time for resuscitation and definitive treatment such as uterotonics, surgical intervention, or blood transfusion.
Aortic compression is particularly useful in hypovolemic shock when uterotonics and bimanual compression fail to control bleeding and when surgical intervention is delayed or unavailable.
II. Indications for Aortic Compression
Aortic compression is performed when:
Severe postpartum hemorrhage (PPH) is not controlled by uterotonics (Oxytocin, Misoprostol, Ergometrine).
Bimanual uterine compression fails to stop bleeding.
The patient is in hypovolemic shock due to massive blood loss (>1500 mL).
There is a delay in definitive treatment (Surgery, Blood transfusion, Balloon tamponade).
There is no immediate access to an operating theater or advanced care.
III. Contraindications of Aortic Compression
Severe abdominal trauma or internal organ injury (Compression may worsen damage).
Advanced pregnancy (Gestation above 20 weeks, unless used in rare cases of antepartum hemorrhage).
Known aortic aneurysm or vascular disease (Risk of aortic rupture).
IV. Procedure for Aortic Compression
A. Preparation
Ensure the Mother is in Supine Position
Lay the patient flat on her back with legs slightly elevated to improve circulation.
Ensure an IV line is established for resuscitation with fluids and blood transfusion.
Locate the Abdominal Aorta
The abdominal aorta runs along the midline, just above the umbilicus (At the level of the umbilicus or slightly above, around the L2 vertebral level).
Feel for the pulsation of the aorta just above the navel.
B. Performing Aortic Compression
Step 1: Apply Direct Pressure Over the Aorta
Use a closed fist or the palm of your hand to press firmly over the aorta.
Push downward towards the spine to compress the aorta effectively.
Compression should be firm enough to stop the femoral pulses, indicating reduced blood flow to the lower body.
Step 2: Maintain Compression and Monitor Response
Hold compression for at least 10-15 minutes while resuscitation is ongoing.
Check if bleeding slows down, confirming successful compression.
If the bleeding persists, increase the pressure slightly.
Step 3: Transition to Definitive Treatment
Continue aortic compression until:
Surgical intervention (Hysterectomy or uterine artery ligation) is available.
Balloon tamponade (Bakri balloon, condom catheter) is inserted.
Recognize severe PPH and initiate immediate interventions.
Perform aortic compression while preparing for definitive management.
Monitor maternal vitals and ensure resuscitation measures are ongoing.
B. Assisting with Advanced Interventions
Coordinate with obstetric teams for blood transfusion and surgical preparation.
Ensure correct administration of uterotonics and IV fluids.
C. Postpartum Care and Monitoring
Monitor for signs of delayed hemorrhage after releasing compression.
Educate the mother on postpartum recovery and warning signs of secondary PPH.
Uterine Balloon Tamponade: A Life-Saving Intervention for Postpartum Hemorrhage (PPH)
I. Definition
Uterine balloon tamponade (UBT) is an emergency obstetric procedure used to control severe postpartum hemorrhage (PPH) due to uterine atony, placenta previa, or retained placental fragments. It involves inserting a sterile balloon catheter into the uterus and inflating it with sterile fluid to apply direct pressure on bleeding vessels and promote clot formation.
UBT is effective in 80-90% of cases and can help avoid surgical interventions such as hysterectomy.
Start IV Fluids and Blood Transfusion (If needed).
Administer uterotonics (Oxytocin 20 IU IV, Misoprostol 800 mcg PR) before inserting the balloon.
Confirm That the Uterus is Empty
Manually remove any retained placenta before inserting the balloon.
Perform gentle uterine massage to help contractions.
B. Insertion of the Uterine Balloon
Step 1: Insert the Balloon into the Uterus
Lubricate the balloon catheter with sterile gel.
Insert the balloon through the cervix into the uterine cavity using sterile technique.
Ensure correct positioning in the fundus of the uterus before inflation.
Step 2: Inflate the Balloon with Sterile Fluid
Slowly inflate the balloon with 300–500 mL of sterile saline or Ringer’s lactate.
If using a condom catheter method, tie a sterile condom to a Foley catheter and inflate it with 250–300 mL of sterile saline.
The pressure compresses the uterine walls against bleeding vessels, stopping hemorrhage.
Step 3: Secure the Balloon and Monitor for Effectiveness
Gently pull the catheter until resistance is felt (Ensures tamponade effect).
Secure the catheter to the mother’s thigh to prevent dislodgment.
Monitor for continued bleeding through the drainage port.
If bleeding persists, add 100 mL increments up to 800 mL total capacity.
C. Post-Insertion Care and Monitoring
Monitor for Effectiveness
If vaginal bleeding stops or significantly reduces within 15 minutes, the tamponade is working.
If heavy bleeding continues, additional interventions (Surgery) are needed.
Monitor Maternal Vital Signs and Blood Loss
Every 15 minutes for the first hour, then hourly.
Continue IV fluids, blood transfusion if needed.
Duration of Balloon Retention
The balloon is left in place for 12–24 hours to ensure clot formation.
Slowly deflate the balloon over 2–3 hours while monitoring for bleeding recurrence.
Balloon Removal
If no active bleeding is observed, deflate gradually and remove.
Continue close monitoring for secondary PPH.
VI. Complications of Uterine Balloon Tamponade
Failure to stop bleeding (May require surgical intervention).
Uterine perforation (Rare but possible with incorrect placement).
Infection (If the balloon is left too long without proper monitoring).
Cervical trauma (If excessive traction is applied on the catheter).
VII. Alternative Measures if UBT Fails
B-Lynch Compression Suture (Surgical suturing to compress the uterus).
Uterine Artery Ligation (Tying off arteries to reduce blood flow).
Hysterectomy (Last resort for life-threatening hemorrhage).
VIII. Role of Midwives in Uterine Balloon Tamponade
A. Immediate Response in Emergency Situations
Identify severe PPH and prepare for UBT insertion.
Ensure proper sterile technique during the procedure.
Monitor vital signs and manage fluid resuscitation.
B. Assisting with Advanced Interventions
Coordinate with the obstetric team for surgical backup if UBT fails.
Assist in blood transfusion and pain management.
C. Postpartum Care and Education
Monitor for secondary hemorrhage after balloon removal.
Educate the mother on warning signs of late PPH and when to seek help.
IX. Effectiveness and Outcomes
UBT stops PPH in 80-90% of cases, reducing the need for hysterectomy.
It is widely used in both high-resource and low-resource settings as an effective and life-saving technique.
Midwives and obstetricians must be trained in UBT insertion to manage severe PPH efficiently.
Obstetric Emergency: Ruptured Uterus – A Life-Threatening Condition
I. Definition
Uterine rupture is a life-threatening obstetric emergency where the uterine wall tears, leading to hemorrhage, fetal distress, and potential maternal and fetal death. It can be complete (full-thickness tear) or incomplete (partial tear with the peritoneum intact).
It most commonly occurs in:
Women with a previous cesarean section or uterine surgery.
Obstructed labor or prolonged labor with excessive contractions.
Grand multiparity (Five or more previous deliveries).
Without immediate surgical intervention, maternal mortality can reach 10-20%, and fetal mortality can be as high as 50-75%.
II. Types of Uterine Rupture
Complete Uterine Rupture
All layers of the uterus (endometrium, myometrium, serosa) tear, leading to severe hemorrhage and fetal expulsion into the peritoneal cavity.
Incomplete Uterine Rupture
The myometrium is disrupted, but the peritoneal covering remains intact, leading to concealed bleeding.
III. Causes and Risk Factors of Uterine Rupture
A. Maternal Factors
Previous Uterine Surgery (Cesarean section, Myomectomy, Hysterotomy).
Grand Multiparity (Weakening of uterine muscles due to multiple deliveries).
Cross-Matching – Prepares for emergency blood transfusion.
VI. Management of Uterine Rupture
A. Immediate Emergency Management
Call for Immediate Obstetric and Surgical Team Assistance.
Resuscitate the Mother
IV Fluids – Start 2 large-bore IV lines (18G) with Ringer’s Lactate or Normal Saline.
Blood Transfusion – If severe hemorrhage, transfuse Packed RBCs immediately.
Administer Oxygen (10-15 L/min via face mask).
Monitor Vital Signs every 5 minutes.
Urgent Laparotomy (Surgical Exploration)
Immediate surgical repair or hysterectomy is performed based on the severity of rupture.
B. Surgical Management
Uterine Repair (For Small, Clean Ruptures in Women Who Want Future Pregnancy).
Performed in women with previous scar rupture but minimal damage.
Subtotal or Total Hysterectomy (For Extensive Rupture with Uncontrollable Bleeding).
If the uterus cannot be repaired, a hysterectomy is required to save the mother’s life.
C. Post-Surgical Monitoring and Recovery
Monitor for Postpartum Hemorrhage (PPH) and Hypovolemic Shock.
Broad-Spectrum Antibiotics to Prevent Infection.
Psychological Support for Emotional Distress.
VII. Prevention of Uterine Rupture
A. Antenatal Preventive Measures
Identify High-Risk Women Early (Previous C-section, Multiple Pregnancies, CPD).
Antenatal Ultrasound to Check for Placental Attachment (Avoid Placenta Accreta in Scar Tissue).
Advise Elective Cesarean Section if High Risk for Uterine Rupture.
B. Intrapartum Preventive Measures
Avoid Excessive Uterine Stimulation with Oxytocin or Prostaglandins.
Perform Cesarean Section in Cases of Obstructed Labor.
Continuous Fetal Monitoring (CTG) to Detect Early Fetal Distress.
Educate Women on Risks of Vaginal Birth After Cesarean (VBAC).
VIII. Role of Midwives in Managing Uterine Rupture
A. Early Detection and Monitoring
Recognize high-risk cases during antenatal care.
Monitor for warning signs of obstructed labor and fetal distress.
B. Emergency Response in Labor
Immediately alert the obstetric team if rupture is suspected.
Start IV fluids, oxygen therapy, and prepare for surgery.
Monitor maternal vital signs and fetal heart rate continuously.
C. Postpartum Care and Emotional Support
Ensure wound care and monitor for infection after surgery.
Provide psychological support for women who undergo hysterectomy.
Educate on future pregnancy risks and family planning options.
IX. Prognosis and Maternal Outcomes
If managed early, maternal survival is high, but fetal survival depends on rapid intervention.
Women with previous uterine rupture must be counseled for elective C-section in future pregnancies.
Midwives and obstetricians play a critical role in preventing, recognizing, and managing uterine rupture to reduce maternal and neonatal mortality.
Obstetrical Shock: A Life-Threatening Emergency
I. Definition
Obstetrical shock is a life-threatening condition that occurs when there is a sudden and severe drop in blood circulation, leading to inadequate oxygen supply to vital organs. It is a major cause of maternal mortality if not managed promptly.
It results from massive blood loss (Hemorrhagic shock), severe infection (Septic shock), or other pregnancy-related complications (Cardiogenic or Neurogenic shock).
II. Types of Obstetrical Shock
1. Hemorrhagic Shock (Most Common in Obstetrics)
Caused by excessive blood loss due to:
Postpartum hemorrhage (PPH)
Uterine rupture
Placental abruption
Ectopic pregnancy rupture
2. Septic Shock
Occurs due to severe infection, leading to systemic inflammatory response and low blood pressure.
Causes:
Chorioamnionitis (Uterine infection)
Puerperal sepsis
Infected abortion
3. Cardiogenic Shock
Results from heart failure in pregnancy (Peripartum cardiomyopathy, cardiac disease).
4. Neurogenic Shock
Occurs due to spinal cord injury during labor or epidural anesthesia complications.
III. Causes and Risk Factors of Obstetrical Shock
A. Hemorrhagic Causes
Postpartum Hemorrhage (PPH) – The most common cause
Uterine rupture or inversion
Placental Abruption or Placenta Previa
Ectopic Pregnancy Rupture
Severe trauma during labor (Tears, Cesarean complications)
Perform uterine massage and administer uterotonics (Oxytocin, Misoprostol, Carboprost)
If PPH continues, proceed with Uterine Balloon Tamponade or B-Lynch Suture
Emergency Surgery (Laparotomy or Hysterectomy if bleeding is uncontrolled)
2. Septic Shock Management
Start Broad-Spectrum IV Antibiotics (Ceftriaxone + Metronidazole)
Drain infected tissue if needed (Evacuate retained placenta, remove infected uterus if necessary)
Fluid resuscitation to prevent organ failure
3. Cardiogenic Shock Management
Give diuretics (Furosemide) if pulmonary edema is present
Administer vasopressors (Dopamine, Dobutamine) if blood pressure is critically low
Consult cardiology for specialized management
4. Neurogenic Shock Management
Maintain spine stabilization if trauma is suspected
Avoid excessive epidural anesthesia dosage
Give IV fluids and vasopressors (Epinephrine or Norepinephrine) if BP is very low
C. Surgical and Advanced Management (If Medical Treatment Fails)
Uterine Artery Ligation (If Severe Hemorrhage Continues)
Hysterectomy (If Uterine Atony or Rupture is Uncontrollable)
ICU Admission for Organ Failure and Shock Monitoring
VII. Prevention of Obstetrical Shock
A. Antenatal Preventive Measures
Identify High-Risk Mothers Early (Previous PPH, Placenta Previa, Sepsis History)
Optimize Hemoglobin Levels (Iron and Folic Acid Supplementation)
Screen for Infections During Pregnancy (Urinary Tract Infections, Chorioamnionitis)
B. Intrapartum Preventive Measures
Active Management of the Third Stage of Labor (AMTSL) to Prevent PPH
Avoid Unnecessary Induction with Excessive Oxytocin or Prostaglandins
Monitor High-Risk Women Closely in Labor for Early Intervention
VIII. Role of Midwives in Obstetrical Shock Management
A. Early Recognition and Response
Monitor for sudden blood loss, low BP, and abnormal fetal heart rate
Start IV fluids and prepare for blood transfusion immediately
Alert the obstetric emergency team and assist with resuscitation
B. Assisting in Advanced Interventions
Prepare for uterine balloon tamponade, B-Lynch suture, or hysterectomy
Assist in oxygen therapy and patient stabilization
C. Postpartum Monitoring and Education
Monitor for secondary hemorrhage and sepsis
Educate mothers on postpartum warning signs (Heavy bleeding, fever, dizziness)
Amniotic Fluid Embolism (AFE): A Rare but Fatal Obstetric Emergency
I. Definition
Amniotic fluid embolism (AFE) is a catastrophic obstetric emergency that occurs when amniotic fluid, fetal cells, or other debris enter the maternal circulation, leading to sudden cardiovascular collapse, respiratory failure, and disseminated intravascular coagulation (DIC).
It is one of the leading causes of maternal mortality with a high fatality rate (Up to 80% if untreated). It can happen during labor, delivery, or the immediate postpartum period.
II. Pathophysiology of Amniotic Fluid Embolism
AFE occurs in two phases:
Phase 1: Pulmonary and Cardiovascular Collapse
Amniotic fluid enters the maternal bloodstream and triggers a severe anaphylactic reaction.
Leads to pulmonary vasoconstriction, severe hypoxia, and heart failure.
Results in sudden cardiac arrest, hypotension, and cyanosis.
Prepare for intubation and mechanical ventilation.
Start IV Fluid Resuscitation
2 large-bore IV lines (18G) with rapid infusion of Normal Saline or Ringer’s Lactate.
Monitor urine output (Catheterization to detect kidney failure).
Administer Vasopressors (To Maintain Blood Pressure).
Epinephrine, Dopamine, or Norepinephrine for hypotension.
B. Specific Treatment Based on Symptoms
1. Management of Cardiac Arrest and Shock
If cardiac arrest occurs, perform immediate CPR and defibrillation.
Administer adrenaline (1 mg IV every 3-5 minutes).
2. Management of Coagulopathy (DIC and PPH)
Blood Transfusion:
Packed RBCs to restore oxygen supply.
Fresh Frozen Plasma (FFP) and Cryoprecipitate for clotting factors.
Platelets if thrombocytopenia is severe.
Administer Tranexamic Acid (TXA) to reduce bleeding.
3. Management of Pulmonary Edema (Respiratory Failure)
Diuretics (Furosemide 40 mg IV) to remove excess lung fluid.
Mechanical ventilation for respiratory support.
C. Advanced Interventions for Severe Cases
Extracorporeal Membrane Oxygenation (ECMO): Used for severe heart and lung failure.
Uterine Balloon Tamponade or Hysterectomy (If Uncontrollable PPH).
VII. Prognosis and Maternal Outcomes
Mortality Rate: 20-80% (If untreated).
Neonatal Outcomes:
50% of infants develop brain injury due to maternal hypoxia.
Early delivery improves fetal survival.
VIII. Prevention of Amniotic Fluid Embolism
While AFE is unpredictable, certain measures can reduce risk:
A. Antenatal Preventive Measures
Identify high-risk pregnancies (Previous AFE, placenta previa, grand multiparity).
Optimize maternal health (Avoid unnecessary induction of labor).
Avoid excessive uterotonic stimulation with oxytocin or prostaglandins.
B. Intrapartum Preventive Measures
Monitor high-risk women continuously during labor.
Perform cesarean section if severe risk factors (Placenta previa, uterine rupture).
Ensure aseptic conditions to prevent infections.
IX. Role of Midwives in AFE Management
A. Early Detection and Emergency Response
Monitor for sudden hypoxia, hypotension, or cardiac arrest in labor.
Alert the obstetric emergency team immediately.
Assist in oxygen therapy and IV fluid administration.
B. Assisting in Advanced Interventions
Prepare for intubation, mechanical ventilation, and vasopressor administration.
Monitor urine output and vital signs continuously.
C. Postpartum Monitoring and Psychological Support
Monitor for late complications like secondary PPH or sepsis.
Provide emotional support to families if maternal or neonatal loss occurs.
Fetal Distress: A Critical Obstetric Emergency
I. Definition
Fetal distress refers to a compromised condition of the fetus during labor or late pregnancy, characterized by hypoxia (oxygen deprivation) and acidosis, which may lead to permanent brain damage, stillbirth, or neonatal death if not managed promptly.
Fetal distress is most commonly identified by abnormal fetal heart rate patterns, decreased fetal movements, and meconium-stained amniotic fluid.
Consider early delivery (Induction or C-section if needed).
Severe Fetal Distress (Persistent bradycardia, absent variability, recurrent late decelerations)
Immediate emergency C-section (Fetal survival at risk).
VI. Prevention of Fetal Distress
A. Antenatal Preventive Measures
Regular Antenatal Checkups:
Monitor fetal growth (Ultrasound and Doppler scans).
Identify high-risk pregnancies early (Preeclampsia, Diabetes, IUGR).
Maternal Nutrition and Hydration:
Encourage a well-balanced diet, iron, and folic acid supplementation.
Avoid Excessive Uterine Stimulation:
Judicious use of oxytocin and prostaglandins.
B. Intrapartum Preventive Measures
Continuous Fetal Monitoring in High-Risk Mothers:
CTG every 30 minutes in normal labor, every 15 minutes in high-risk labor.
Avoid Prolonged Labor or Obstructed Labor:
Early recognition and intervention (Augmentation or C-section if needed).
Ensure Proper Fluid Management to Maintain Uteroplacental Perfusion.
VII. Role of Midwives in Managing Fetal Distress
A. Early Detection and Monitoring
Recognize early warning signs (Abnormal FHR, decreased fetal movements).
Ensure continuous CTG monitoring for high-risk pregnancies.
Assist in fetal scalp blood sampling if required.
B. Emergency Response and Decision-Making
Perform immediate resuscitation (Oxygen, IV fluids, maternal repositioning).
Stop uterotonics and alert obstetricians if fetal distress persists.
Prepare for emergency cesarean section if fetal distress worsens.
C. Postpartum Care and Neonatal Follow-Up
Ensure immediate neonatal resuscitation if the baby is born with birth asphyxia.
Monitor for hypoxic-ischemic encephalopathy (HIE) in newborns.
Cord Prolapse: A Life-Threatening Obstetric Emergency
I. Definition
Cord prolapse is a critical obstetric emergency where the umbilical cord descends through the cervix before or alongside the fetal presenting part, leading to cord compression, reduced blood flow, and severe fetal hypoxia.
Cord prolapse requires immediate intervention to prevent fetal asphyxia and stillbirth.
II. Types of Cord Prolapse
1. Overt Cord Prolapse (Most Severe Type)
The umbilical cord descends through the cervix and is visible outside the vagina.
High risk of fetal hypoxia due to cord compression.
2. Occult Cord Prolapse
The cord is trapped alongside the fetal presenting part but is not visible externally.
Detected by fetal heart rate abnormalities (Variable decelerations on CTG).
3. Funic Presentation (Cord Presentation Without Prolapse)
The umbilical cord is positioned between the fetal head and cervix but has not yet prolapsed.
If membranes rupture, it can lead to overt prolapse.
III. Causes and Risk Factors of Cord Prolapse
A. Maternal Factors
Multiparity (Weak uterine tone allowing cord descent before the baby).
Multiple pregnancies (Increased risk of malposition and excess cord length).
Low birth weight or Small for Gestational Age (SGA) babies (Poor engagement in pelvis).
C. Obstetric Factors
Artificial rupture of membranes (ARM) before engagement of the fetal head.
Unengaged fetal head in labor (Head should normally act as a plug to prevent prolapse).
Long umbilical cord (More likely to prolapse into the vagina).
IV. Clinical Features of Cord Prolapse
A. Symptoms and Signs
Maternal Observation
Sudden feeling of a loop of cord in the vagina.
Visible cord at the vaginal opening (In overt prolapse).
Fetal Distress Indicators
Variable decelerations or prolonged bradycardia (<110 bpm) on CTG.
Absent fetal movements if severe hypoxia occurs.
V. Diagnosis of Cord Prolapse
A. Clinical Examination
Visual Inspection
Overt prolapse: Cord visible outside the vagina, bluish and swollen.
Occult prolapse: Cord not visible but suspected from FHR abnormalities.
Vaginal Examination (Sterile Digital Exam)
Cord palpable in front of the fetal presenting part.
Cord pulsations may be present or absent (Absence indicates fetal compromise).
B. Fetal Heart Rate Monitoring
Variable decelerations or prolonged fetal bradycardia (Signs of cord compression).
C. Ultrasound (If Diagnosis is Unclear)
Detects cord position relative to fetal parts before ARM.
VI. Emergency Management of Cord Prolapse
A. Immediate First Aid Measures
Call for an Obstetric Emergency Team (Cord Prolapse is an Absolute Emergency).
Reposition the Mother to Relieve Cord Pressure
Knee-Chest Position (Preferred Position)
Mother is placed on hands and knees with her chest down and buttocks elevated.
Reduces pressure on the cord and improves blood flow.
Trendelenburg Position (If Knee-Chest is Not Possible)
Mother lies on her back with legs elevated higher than the head.
Uses gravity to reduce cord compression.
Manually Elevate the Presenting Part (Sterile Technique)
Using a sterile gloved hand, push the fetal head away from the cord.
Maintain pressure until cesarean section is performed.
Prevent Cord Drying and Vasospasm
If the cord is outside the vagina, cover it with warm saline-soaked gauze (Prevents constriction).
Administer Oxygen (10-15 L/min via Face Mask)
Increases fetal oxygen supply.
Reduce Uterine Contractions (If Labor is Active)
Stop Oxytocin infusion immediately.
Administer Tocolytics (Terbutaline 250 mcg SC or Nifedipine 10 mg PO) to relax the uterus.
B. Definitive Management – Immediate Delivery Decision
Emergency Cesarean Section (Preferred Method of Delivery)
Indicated in all cases of overt cord prolapse with fetal distress.
The fastest route for fetal delivery to prevent hypoxia and stillbirth.
Assisted Vaginal Delivery (Only if Fully Dilated & Immediate)
Forceps or vacuum-assisted delivery may be performed if the cervix is fully dilated and the head is low.
Only considered if C-section is delayed and fetal heart rate is stable.
VII. Prognosis and Outcomes
If managed within 10-15 minutes, neonatal survival rate is >90%.
Prolonged cord compression (>30 minutes) significantly increases the risk of hypoxic-ischemic encephalopathy (HIE) or stillbirth.
VIII. Prevention of Cord Prolapse
A. Antenatal Preventive Measures
Identify High-Risk Pregnancies
Monitor women with polyhydramnios, breech presentations, multiple pregnancies, and preterm labor.
Avoid Artificial Rupture of Membranes (ARM) Before Head Engagement
Always check fetal head station before performing ARM.
Elective Cesarean Section for High-Risk Women
Breech, unengaged fetal head, placenta previa cases should be managed with planned C-section.
IX. Role of Midwives in Cord Prolapse Management
A. Early Recognition and Diagnosis
Immediate assessment of fetal heart rate abnormalities.
Perform vaginal examination if cord prolapse is suspected.
B. Emergency Response and Management
Reposition the mother (Knee-chest or Trendelenburg position).
Manually lift the presenting part to relieve cord compression.
Administer oxygen and tocolytics to improve fetal survival.
Ensure rapid referral for emergency cesarean section.
C. Postpartum Monitoring and Neonatal Care
Monitor the newborn for hypoxia-related complications.
Early neonatal resuscitation if Apgar scores are low.
Shoulder Dystocia: A Life-Threatening Obstetric Emergency
I. Definition
Shoulder dystocia is an obstetric emergency that occurs when the fetal head has delivered, but the anterior shoulder gets stuck behind the maternal pubic symphysis, preventing complete delivery. This can lead to fetal hypoxia, brachial plexus injuries, or maternal complications such as postpartum hemorrhage and perineal trauma.
It requires urgent obstetric maneuvers to safely deliver the baby without causing injury.
II. Causes and Risk Factors of Shoulder Dystocia
A. Maternal Risk Factors
Obesity (BMI >30) – Increased risk due to excessive maternal tissue.
Diabetes Mellitus – Leads to fetal macrosomia (Large baby).
Short maternal stature or a small pelvis (Cephalopelvic Disproportion – CPD).
Prolonged second stage of labor (Delayed descent and difficulty delivering shoulders).
B. Fetal Risk Factors
Fetal macrosomia (>4 kg or 8.8 lbs).
Large chest-to-head ratio (Seen in diabetic mothers’ babies).
Post-term pregnancy (Increased fetal size and less flexibility).
C. Obstetric Risk Factors
Instrumental Delivery (Forceps or Vacuum) – Increased risk due to forceful traction.
Previous Shoulder Dystocia – Recurrence rate of up to 25%.
Rapid Precipitate Labor – Does not allow time for proper shoulder rotation.
Delayed Labor Induction (Failure to progress in labor).
III. Clinical Features of Shoulder Dystocia
A. Warning Signs Before Delivery (Antenatal & Intrapartum)
Turtle Sign: The fetal head delivers but then retracts back against the perineum due to trapped shoulders.
Failure of shoulders to deliver within 60 seconds after the head.
Prolonged second stage of labor.
Difficult or failed instrumental delivery.
B. Complications of Shoulder Dystocia
1. Fetal Complications
Brachial Plexus Injury (Erb’s Palsy or Klumpke’s Palsy).
Fracture of the Clavicle or Humerus (Due to excessive traction).
Hypoxia leading to Neonatal Encephalopathy or Stillbirth (If delivery is delayed >5 minutes).
2. Maternal Complications
Postpartum Hemorrhage (PPH) due to uterine atony.
Severe perineal or vaginal tears (3rd or 4th degree).
Uterine rupture (In extreme cases).
IV. Diagnosis of Shoulder Dystocia
Failure of Shoulder Delivery After the Head Has Emerged
Turtle Sign – The fetal head retracts against the perineum.
Detect Turtle Sign immediately and initiate HELPERR maneuvers.
B. Emergency Response and Maneuver Assistance
Position the mother correctly (McRoberts Maneuver first).
Apply suprapubic pressure if needed.
Assist in internal rotation maneuvers if delivery does not progress.
C. Postpartum and Neonatal Follow-Up
Monitor the baby for brachial plexus injury or fractures.
Educate the mother about the risks in future pregnancies.
Counsel on the possibility of a cesarean section for subsequent pregnancies.
IX. Prognosis and Maternal-Neonatal Outcomes
If managed within 5 minutes, fetal survival is >90%.
Delay beyond 10 minutes increases the risk of brain damage due to hypoxia.
Recurrence rate in future pregnancies: 10-25%.
Uterine Inversion: A Life-Threatening Obstetric Emergency
I. Definition
Uterine inversion is a rare but life-threatening obstetric emergency where the uterus turns inside out, partially or completely protruding through the cervix or even outside the vagina. This results in severe postpartum hemorrhage (PPH), hypovolemic shock, and maternal mortality if not managed immediately.
It occurs in approximately 1 in 2,000 to 1 in 20,000 deliveries and requires immediate recognition and correction to prevent maternal complications.
II. Types of Uterine Inversion
Incomplete Uterine Inversion:
The fundus is depressed but remains inside the uterus.
Complete Uterine Inversion:
The fundus protrudes through the cervix into the vagina.
Prolapsed Uterine Inversion:
The fundus is completely outside the vagina.
Total Uterine Inversion:
The uterus, including the cervix, is completely inside out and outside the vaginal opening.
III. Causes and Risk Factors of Uterine Inversion
A. Maternal Risk Factors
Uterine atony (Failure of the uterus to contract after delivery).
Multiparity (Weakened uterine tone due to multiple deliveries).
Optimize maternal nutrition (Iron and calcium for better uterine strength).
B. Intrapartum Preventive Measures
Controlled Cord Traction (CCT) with Caution
Always ensure the uterus is well-contracted before applying traction.
Avoid Excessive Fundal Pressure During Placental Delivery
Ensure Proper Management of Placenta Accreta Cases
Manual removal should be done gently to avoid sudden inversion.
Encourage Active Management of the Third Stage of Labor (AMTSL)
Use Oxytocin immediately after delivery to promote uterine contraction.
IX. Role of Midwives in Uterine Inversion Management
A. Early Detection and Emergency Response
Identify risk factors and monitor for signs of uterine inversion.
Recognize PPH and shock symptoms early.
Ensure rapid transfer to an emergency obstetric unit.
B. Assisting in Uterine Repositioning
Prepare the mother for manual reduction or surgery.
Administer IV fluids, uterotonics, and oxygen therapy.
Support obstetricians in hydrostatic or surgical reduction procedures.
C. Postpartum Monitoring and Counseling
Monitor for infection, uterine atony, and re-inversion risks.
Educate women on future pregnancy risks and family planning.
Vasa Previa: A Life-Threatening Obstetric Emergency
I. Definition
Vasa previa is a rare but serious obstetric emergency where fetal blood vessels cross or run near the internal cervical os, unprotected by the placenta or umbilical cord, making them vulnerable to rupture during labor or membrane rupture.
Without early diagnosis and emergency intervention, vasa previa can lead to rapid fetal exsanguination (severe blood loss) and stillbirth.
It occurs in approximately 1 in 2,500 pregnancies, with fetal mortality exceeding 50% if undiagnosed before delivery.
II. Pathophysiology of Vasa Previa
Normally, fetal blood vessels are safely protected within the umbilical cord.
In vasa previa, unprotected fetal vessels lie between the baby and the cervix, making them highly vulnerable to rupture.
During labor, when the membranes rupture, these fetal vessels can tear, leading to sudden and severe fetal hemorrhage.
III. Causes and Risk Factors of Vasa Previa
A. Maternal Risk Factors
Advanced maternal age (>35 years).
Multiparity (Multiple pregnancies increase risk of abnormal placental attachment).
History of infertility treatment (IVF pregnancies have a higher incidence).
B. Placental and Umbilical Cord Factors
Velamentous cord insertion (Umbilical cord inserts into the membranes instead of the placenta, leaving fetal vessels unprotected).
Placenta previa (Placenta partially or completely covers the cervix).
Bilobed or succenturiate-lobed placenta (Accessory placental lobes increase risk).
No maternal distress – Unlike placental abruption, the mother is stable, but the fetus is in critical danger.
C. Fetal Complications
Severe fetal anemia and hypoxia (Due to rapid blood loss).
Stillbirth (If intervention is delayed).
V. Diagnosis of Vasa Previa
A. Antenatal Screening (Best Method for Early Detection)
Transvaginal Ultrasound with Color Doppler (Gold standard for diagnosis).
Confirms fetal vessels crossing the cervix.
B. Apt Test (If Bleeding Occurs in Labor)
Determines whether the blood is fetal or maternal.
Fetal blood remains pink after adding sodium hydroxide, while maternal blood turns brown.
C. Fetal Heart Rate Monitoring (Signs of Distress)
Sudden, severe fetal bradycardia or late decelerations.
VI. Management of Vasa Previa
A. Antenatal Management (Before Labor Begins)
Hospitalization at 30-32 Weeks (For Close Monitoring).
Antenatal Corticosteroids (Betamethasone 12 mg IM x 2 doses)
Promotes fetal lung maturity in case of preterm delivery.
Early Elective Cesarean Section (Ideal at 34-36 Weeks).
Prevents rupture of fetal vessels during labor.
B. Emergency Management in Labor (If Vasa Previa is Undiagnosed and Ruptures)
Call for Immediate Emergency Cesarean Section (C-Section Required Immediately).
Delivery must occur within minutes to prevent fetal exsanguination.
Administer Oxygen to the Mother (10-15 L/min via Face Mask).
Maximizes oxygen delivery to the fetus.
Volume Resuscitation for the Fetus (If Needed).
If the baby is born with severe anemia, an emergency blood transfusion may be required.
VII. Prognosis and Neonatal Outcomes
If diagnosed early and delivered by elective C-section, neonatal survival is >97%.
If undiagnosed and vessels rupture, fetal mortality exceeds 50% within minutes.
VIII. Prevention of Vasa Previa
A. Antenatal Preventive Measures
Routine Screening for High-Risk Pregnancies (Multiple Gestation, IVF, Placenta Previa).
Perform Transvaginal Color Doppler Ultrasound at 18-20 Weeks for Early Detection.
Plan Early Cesarean Section at 34-36 Weeks If Diagnosed.
IX. Role of Midwives in Vasa Previa Management
A. Early Detection and Monitoring
Identify high-risk pregnancies and ensure Doppler screening.
Educate mothers about signs of vasa previa and the need for early delivery.
B. Emergency Response in Labor
Recognize sudden painless vaginal bleeding with fetal distress.
Prepare for emergency C-section immediately.
Assist in neonatal resuscitation if the baby is born with anemia or shock.
C. Postpartum and Neonatal Follow-Up
Monitor neonates for anemia, hypoxia, and potential transfusion needs.
Educate mothers about future pregnancy risks and management.
Episiotomy and Suturing: A Comprehensive Guide
I. Definition
An episiotomy is a surgical incision made in the perineum (the area between the vagina and the anus) during the second stage of labor to enlarge the vaginal opening for easier delivery of the baby. It helps prevent severe perineal tears, reduces labor complications, and facilitates a controlled birth.
Suturing is the process of repairing the episiotomy incision or any spontaneous perineal tears using absorbable stitches to promote healing and prevent complications.
Educate women about episiotomy indications and preventive perineal exercises.
Encourage controlled pushing techniques to avoid unnecessary episiotomies.
B. Proper Sterile Technique and Suturing Skills
Ensure correct suture technique to prevent complications.
Teach proper postpartum wound care to reduce infection risk.
C. Postpartum Monitoring and Follow-Up
Assess healing progress during postnatal visits (After 1 week and at 6 weeks postpartum).
Identify and treat complications early to improve maternal recovery.
Forceps Delivery:
I. Definition
Forceps delivery is an operative vaginal delivery technique where obstetric forceps are used to assist in the delivery of the fetal head when the mother is unable to push effectively, or when fetal distress requires immediate delivery.
It is a lifesaving intervention in certain cases but must be performed only by a skilled obstetrician due to the potential risk of maternal and fetal complications.
II. Indications for Forceps Delivery
A. Maternal Indications
Prolonged Second Stage of Labor
Primigravida: No progress after >2 hours with epidural, or >1 hour without epidural.
Multigravida: No progress after >1 hour with epidural, or >30 minutes without epidural.
Example: Kjelland’s Forceps for rotation in OP position.
4. Piper’s Forceps
Used for aftercoming head in breech deliveries.
V. Procedure for Forceps Delivery
A. Preparation
Informed Consent: Explain risks, benefits, and alternatives to the mother.
Ensure Full Cervical Dilatation (10 cm) and Ruptured Membranes.
Empty the Bladder: Insert a Foley catheter to prevent obstruction.
Maternal Positioning:
Lithotomy position (Legs in stirrups for best visibility).
Anesthesia:
Regional anesthesia (Epidural or Pudendal block preferred).
If urgent, local infiltration with Lidocaine may be used.
B. Steps of Forceps Application
1. Choosing the Right Forceps and Holding the Blades
Left blade inserted first (Held in the left hand).
Right blade inserted second (Held in the right hand).
Blades should lock smoothly if properly placed.
2. Applying the Forceps to the Fetal Head
Ensure correct placement over the fetal cheeks and parietal bones.
Blades should not cross or press on the fetal fontanelles.
3. Traction (Pulling to Assist Delivery)
Pulling is done only during contractions.
Traction is directed downward (With perineum) at first, then upward once the head crowns.
Avoid excessive force to prevent fetal skull fractures.
4. Delivery of the Head
As soon as the head emerges, release the forceps to avoid maternal perineal trauma.
5. Delivery of the Body
Allow the shoulders and body to deliver spontaneously or with gentle assistance.
VI. Post-Procedure Care
A. Immediate Neonatal Assessment
Check for Birth Trauma:
Facial bruising or forceps marks.
Facial nerve palsy (Resolves in 2-3 weeks).
Cephalohematoma (Localized scalp bleeding).
Monitor for Respiratory Distress (Due to Intracranial Hemorrhage).
Perform APGAR Score at 1 and 5 Minutes.
B. Maternal Care
Inspect the Perineum for Lacerations
Suture any episiotomy or perineal tears.
Monitor for Postpartum Hemorrhage (PPH)
Due to uterine atony or trauma.
Pain Management
NSAIDs (Ibuprofen, Diclofenac) for pain relief.
Cold packs for perineal swelling.
Prevent Infection
Maintain perineal hygiene.
VII. Complications of Forceps Delivery
A. Neonatal Complications
Facial Bruising and Swelling
Cephalohematoma (Blood collection between the skull and periosteum).
Facial Nerve Injury (Temporary facial asymmetry).
Skull Fracture (Rare, but serious if excessive force is applied).
Intracranial Hemorrhage (Risk in preterm or bleeding disorder cases).
B. Maternal Complications
Severe Perineal Tears (3rd and 4th degree, extending to the anus).
Postpartum Hemorrhage (PPH) due to uterine trauma.
Bladder or Urethral Injury (Leading to urinary retention).
Pelvic Floor Dysfunction (Risk of urinary incontinence later).
VIII. Comparison: Forceps vs. Vacuum Extraction
Feature
Forceps
Vacuum Extraction
Application
Applied to fetal head
Applied to fetal scalp
Traction
Higher force
Gentle suction
Risk of Neonatal Injury
Higher (Bruising, Nerve Palsy)
Lower (Scalp Hematoma)
Maternal Trauma Risk
Higher (Perineal tears)
Lower
Preferred for Rotations
Yes
No
IX. Role of Midwives in Forceps-Assisted Deliveries
A. Pre-Delivery Care
Identify high-risk cases early and prepare for forceps delivery.
Ensure bladder is emptied and cervix is fully dilated.
Provide psychological support to the mother.
B. Assisting in the Procedure
Assist with positioning and anesthesia administration.
Monitor fetal heart rate continuously.
Hand the correct type of forceps to the obstetrician.
C. Postpartum Monitoring
Inspect the perineum and assist in episiotomy suturing.
Monitor the baby for signs of birth trauma.
Educate the mother on post-delivery care.
Vacuum-Assisted Delivery:
I. Definition
A vacuum-assisted delivery (also called ventouse delivery) is an operative vaginal delivery technique in which a vacuum cup is applied to the fetal head to aid in extraction when the mother is unable to push effectively, or when fetal distress necessitates an immediate delivery.
Vacuum delivery is less traumatic than forceps delivery and is commonly used for mild to moderate cases of prolonged second-stage labor.
II. Indications for Vacuum Delivery
A. Maternal Indications
Prolonged Second Stage of Labor
Primigravida: No progress after >2 hours with epidural, or >1 hour without epidural.
Multigravida: No progress after >1 hour with epidural, or >30 minutes without epidural.
Meconium-stained amniotic fluid (Sign of fetal hypoxia).
Malposition of the Fetal Head
Occiput posterior (OP) or transverse positions (Vacuum helps rotation).
III. Contraindications of Vacuum Delivery
Gestational age <34 weeks (Risk of intracranial hemorrhage due to weak skull bones).
Fetal macrosomia (>4.5 kg, Increased risk of scalp trauma).
Unengaged fetal head (High station, Risk of cephalopelvic disproportion – CPD).
Incomplete cervical dilatation (Cervix must be fully dilated to avoid trauma).
Fetal bleeding disorders (Hemophilia, Thrombocytopenia – Risk of intracranial hemorrhage).
Severe fetal scalp abnormalities (Caput succedaneum, Cephalohematoma).
IV. Types of Vacuum Cups
A. Soft Cups (Silicone or Rubber Cups)
Less traumatic to the fetal scalp.
Less effective in rotation.
More likely to detach if traction is excessive.
Used in low-station deliveries.
B. Rigid Cups (Metal or Hard Plastic Cups)
More effective for deep station deliveries.
Better traction and rotational control.
Higher risk of fetal scalp injury.
C. Hand-Held vs. Electric Vacuum Pumps
Hand-held vacuum pumps allow controlled suction.
Electric vacuum pumps generate faster, stronger suction but require experience.
V. Procedure for Vacuum Delivery
A. Preparation
Obtain Informed Consent:
Explain risks, benefits, and alternatives to the mother.
Ensure Full Cervical Dilatation (10 cm) and Ruptured Membranes.
Empty the Bladder:
Insert a Foley catheter if needed.
Maternal Positioning:
Lithotomy position (Legs in stirrups for best access).
Anesthesia:
Regional anesthesia (Epidural or Pudendal block preferred).
If urgent, local infiltration with Lidocaine may be used.
B. Steps of Vacuum Application and Delivery
1. Choosing the Correct Cup Size
A cup size of 40-60 mm is generally used.
2. Applying the Vacuum Cup
Cup should be placed 3 cm anterior to the posterior fontanelle (Flexion point).
Ensure proper suction before applying traction.
3. Creating the Vacuum Seal
Suction pressure is increased gradually to 600 mmHg (Maximum).
Ensure no air leaks and cup is well-attached before traction.
4. Traction (Pulling to Assist Delivery)
Apply gentle downward traction with maternal contractions.
Traction should be in line with the birth canal.
Once the head crowns, stop traction and allow normal delivery of shoulders and body.
5. Releasing the Vacuum and Removing the Cup
Gradually release suction before removing the vacuum cup.
Inspect the fetal scalp for bruising or hematomas.
VI. Post-Procedure Care
A. Immediate Neonatal Assessment
Check for Birth Trauma:
Scalp bruising or swelling (Caput succedaneum, Cephalohematoma).
Skull fractures (Rare but possible with excessive force).
Monitor for Intracranial Hemorrhage (Rare but life-threatening).
Perform APGAR Score at 1 and 5 Minutes.
B. Maternal Care
Inspect the Perineum for Lacerations
Suture any episiotomy or perineal tears.
Monitor for Postpartum Hemorrhage (PPH)
Due to uterine atony or trauma.
Pain Management
NSAIDs (Ibuprofen, Diclofenac) for pain relief.
Cold packs for perineal swelling.
Prevent Infection
Maintain perineal hygiene.
VII. Complications of Vacuum Delivery
A. Neonatal Complications
Caput Succedaneum (Soft tissue swelling on the scalp, resolves in 24-48 hours).
Cephalohematoma (Blood collection under the periosteum, may take weeks to resolve).
Subgaleal Hemorrhage (Life-threatening bleeding under the scalp, requires emergency care).
Retinal Hemorrhage (Small bleeding in the eyes, resolves spontaneously).
Intracranial Hemorrhage (Rare but can lead to long-term complications).
B. Maternal Complications
Perineal Tears (If excessive downward traction is applied).
Postpartum Hemorrhage (Due to uterine atony).
Urinary Retention (Due to perineal swelling).
Pelvic Floor Dysfunction (Long-term risk of incontinence).
VIII. Comparison: Vacuum vs. Forceps Delivery
Feature
Vacuum Delivery
Forceps Delivery
Application
Applied to fetal scalp
Applied to fetal head
Traction
Gentler
Stronger
Risk of Neonatal Injury
Lower (Scalp hematoma)
Higher (Facial nerve injury, skull fractures)
Maternal Trauma Risk
Lower
Higher (Perineal tears)
Preferred for Rotations
No
Yes
IX. Role of Midwives in Vacuum-Assisted Deliveries
A. Pre-Delivery Care
Identify high-risk cases early and prepare for vacuum delivery.
Ensure bladder is emptied and cervix is fully dilated.
Provide psychological support to the mother.
B. Assisting in the Procedure
Assist with positioning and anesthesia administration.
Monitor fetal heart rate continuously.
Hand the correct vacuum cup to the obstetrician.
C. Postpartum Monitoring
Inspect the perineum and assist in episiotomy suturing.
Monitor the baby for signs of birth trauma.
Educate the mother on post-delivery care.
Version (Fetal Version):
I. Definition
Version is an obstetric procedure used to change the fetal position inside the uterus to improve the chances of a safe vaginal delivery. It is commonly performed when the fetus is in an abnormal position, such as breech or transverse lie, and the goal is to rotate the fetus into a cephalic (head-down) presentation before labor begins.
II. Types of Version
1. External Cephalic Version (ECV) – Most Common Type
A manual procedure performed after 36-37 weeks of gestation to rotate a breech or transverse fetus into a cephalic presentation using external pressure on the mother’s abdomen.
Success Rate: 50-70%.
Performed in a hospital setting with ultrasound guidance.
2. Internal Podalic Version (IPV) – Rarely Used
Used only in twin pregnancies when the second twin is in a breech or transverse position after the first twin is delivered.
The obstetrician inserts their hand into the uterus, grasps the second twin’s feet, and rotates the baby to a head-down or footling breech position for delivery.
Now rarely used due to the high risk of complications.
3. Spontaneous Version
Occurs naturally when the fetus changes position on its own before labor.
III. Indications for Version
A. External Cephalic Version (ECV)
Breech presentation at ≥36 weeks (Primigravida) or ≥37 weeks (Multipara).
Transverse or oblique fetal lie (When there are no contraindications for vaginal delivery).
Mother desires a vaginal birth and wants to avoid a cesarean section.
B. Internal Podalic Version (IPV)
For the delivery of the second twin who is in a non-cephalic presentation.
IV. Contraindications for Version
A. Absolute Contraindications
Multiple gestation (Except for IPV in second twin).
Engaged fetal head (Less likely to be successfully rotated).
V. Procedure for External Cephalic Version (ECV)
A. Pre-Procedure Preparation
Obtain Informed Consent:
Explain benefits, risks, and alternatives (C-section vs. vaginal breech delivery).
Confirm Fetal Position:
Ultrasound scan to confirm breech or transverse lie.
Ensure Fetal Well-being:
Perform a non-stress test (NST) to check fetal heart rate (FHR).
Administer Tocolytics (To Relax the Uterus):
Injection of Terbutaline 250 mcg SC or Nifedipine 10 mg PO to reduce uterine contractions.
Monitor Maternal Vital Signs:
Check blood pressure, pulse, and oxygen saturation.
B. Steps of External Cephalic Version (ECV)
Maternal Positioning:
The mother lies in a semi-Fowler’s or supine position with a slight tilt.
Locate the Fetus and Apply Gentle Pressure:
One hand placed on the fetal buttocks, the other on the fetal head.
Begin Rotation in a Forward or Backward Somersault Movement:
Forward Roll (Most common): Fetal head is gently pushed down while the breech is lifted upward.
Backward Flip: The fetus is rotated in the opposite direction if the forward roll fails.
Monitor Fetal Heart Rate (FHR) Continuously:
Stop the procedure immediately if fetal distress occurs.
Confirm Success with Ultrasound:
Check that the fetal head is now in a cephalic position.
C. Post-Procedure Monitoring
Repeat Fetal Heart Rate Monitoring for 30-60 Minutes.
Monitor for Complications (Vaginal Bleeding, Uterine Rupture, or Preterm Labor).
Advise the Mother to Report Any Decreased Fetal Movements.
VI. Success Rates and Outcomes of External Cephalic Version
Factor
Success Rate
First-time pregnancy (Primigravida)
50-60%
Multiparous women
60-75%
Breech presentation at 36-37 weeks
50-60%
Use of tocolytics (Terbutaline)
Increases success rate
Engaged fetal head
Decreases success rate
If ECV is successful, 90% of women deliver vaginally.
If unsuccessful, a cesarean section is planned.
VII. Complications of Version
A. Maternal Complications
Pain and Discomfort (Most Common).
Vaginal Bleeding (Rare, but may indicate placental abruption).
Preterm Labor (ECV can sometimes trigger contractions).
Uterine Rupture (Rare, but can occur in scarred uterus).
B. Fetal Complications
Fetal Heart Rate Abnormalities (Transient bradycardia in 5-10% of cases, usually recovers).
Cord Accidents (Cord entanglement or prolapse, though rare).
Placental Abruption (Can cause fetal distress and require emergency delivery).
VIII. Comparison: External Cephalic Version vs. Internal Podalic Version
Feature
ECV
IPV
Indication
Breech or transverse at term
Second twin in breech or transverse
Method
External manipulation
Internal hand rotation
Success Rate
50-70%
Unpredictable
Complications
Mild (Bradycardia, Discomfort)
Higher risk (Cord prolapse, Uterine rupture)
Preferred Delivery
Vaginal
Vaginal or C-section
ECV is preferred for singleton breech presentations before labor.
IPV is rarely used and mostly for the second twin in a breech or transverse position.
IX. Role of Midwives in Version Procedures
A. Pre-Procedure Care
Identify high-risk pregnancies requiring version.
Ensure informed consent and emotional support for the mother.
Assist in fetal monitoring and positioning.
B. Assisting in the Procedure
Monitor maternal and fetal status during ECV.
Provide pain relief if needed.
C. Post-Procedure Monitoring
Assess for fetal distress or uterine contractions.
Educate the mother on signs of complications.
Manual Removal of the Placenta:
I. Definition
Manual removal of the placenta is an obstetric procedure performed when the placenta fails to deliver spontaneously within 30 minutes after childbirth or when there is retained placental tissue leading to postpartum hemorrhage (PPH).
This procedure is a life-saving intervention that prevents complications like severe bleeding, infection, and uterine atony.
II. Indications for Manual Removal of the Placenta
A. Retained Placenta (Placenta Not Delivered Within 30 Minutes Postpartum)
Failure of the placenta to separate and expel naturally.
Common in cases of uterine atony or abnormal placental attachment.
B. Postpartum Hemorrhage (PPH)
Heavy vaginal bleeding due to retained placental fragments.
If fundal massage and uterotonics fail to control bleeding.
C. Abnormal Placental Attachment
Partial placenta accreta (Placenta attached too deeply into the uterine wall).
Placenta adherens (Placenta loosely attached but not separating).
D. Incomplete Placental Delivery
Fragments of the placenta remain inside the uterus, causing ongoing bleeding.
III. Contraindications
Placenta percreta (Deepest form of abnormal placental attachment, requiring surgical management).
Active maternal infection (Chorioamnionitis, HIV without prophylactic treatment).
Severe uterine rupture (May require hysterectomy instead of manual removal).
IV. Procedure for Manual Removal of the Placenta
A. Pre-Procedure Preparation
Obtain Informed Consent
Explain the need for the procedure, risks, and benefits.
Reassure the mother about pain control and the necessity of the intervention.
Prepare for Anesthesia and Pain Management
Regional anesthesia (Epidural or spinal block) preferred if time allows.
IV analgesia or sedation if anesthesia is unavailable.
Ensure Proper Infection Control Measures
Sterile gloves and antiseptic cleansing of the perineum.
Use of prophylactic antibiotics (IV cefazolin or ampicillin).
Assess Maternal Stability
Monitor blood pressure, pulse, and oxygen levels.
Ensure IV access for possible fluid or blood transfusion.
B. Steps of Manual Placental Removal
1. Positioning the Mother
Lithotomy position (Legs in stirrups) to ensure proper access.
Empty the bladder with a Foley catheter to prevent obstruction.
2. Uterine Relaxation
Administer Nitroglycerin 50 mcg IV or Terbutaline 250 mcg SC if the uterus is tightly contracted.
3. Inserting the Hand into the Uterus
The dominant hand is inserted into the uterus through the vagina, following the umbilical cord.
Fingers are spread to locate the placental edge.
4. Gentle Separation of the Placenta
Using the edge of the hand, the placenta is carefully peeled away from the uterine wall.
A smooth, sweeping motion is used to detach the placenta completely.
5. Removal and Inspection
The placenta is slowly withdrawn and checked for completeness.
Any remaining placental fragments are carefully removed.
6. Uterine Massage and Administration of Uterotonics
Immediate fundal massage to encourage uterine contraction.
Oxytocin infusion (20-40 IU in 1L Normal Saline) is started to prevent bleeding.
V. Post-Procedure Monitoring and Care
A. Monitor for Postpartum Hemorrhage (PPH)
Check for continuous vaginal bleeding and signs of uterine atony.
Administer additional uterotonics (Misoprostol 800 mcg rectally or Carboprost 250 mcg IM if needed).
B. Monitor for Infection
Observe for fever, foul-smelling vaginal discharge, and uterine tenderness.
Continue IV antibiotics for 24-48 hours if needed.
C. Monitor for Uterine Rupture or Trauma
Check for signs of severe pain, peritonitis, or excessive bleeding.
Perform ultrasound if retained products of conception are suspected.
VI. Complications of Manual Placental Removal
A. Immediate Complications
Postpartum Hemorrhage (PPH)
If the uterus fails to contract after removal of the placenta.
Uterine Inversion (Rare but Life-Threatening)
Occurs if excessive force is used during placental separation.
Uterine Perforation or Rupture
Risk increases if excessive pressure is applied.
Vaginal and Cervical Trauma
Minor tears may occur, leading to additional bleeding.
B. Delayed Complications
Endometritis (Uterine Infection)
Occurs if sterile precautions are not maintained.
Presents with fever, foul-smelling lochia, and lower abdominal pain.
Retained Placental Fragments
Leads to prolonged bleeding and subinvolution of the uterus.
May require further uterine evacuation or curettage.
Scar tissue formation inside the uterus leading to menstrual irregularities and infertility.
VII. Prevention of Retained Placenta and the Need for Manual Removal
A. Active Management of the Third Stage of Labor (AMTSL)
Early Administration of Oxytocin (Within 1 Minute of Birth).
Controlled Cord Traction (CCT) to Assist Placental Delivery.
Fundal Massage After Placental Delivery.
B. Early Identification of High-Risk Pregnancies
Screen for placenta accreta, previa, and uterine abnormalities via ultrasound.
Manage known risk factors such as prolonged labor or prior cesarean sections.
VIII. Role of Midwives in Manual Placental Removal
A. Early Detection and Preparation
Identify signs of retained placenta early (Failure to deliver within 30 minutes).
Prepare the mother for the procedure by explaining the steps and ensuring pain relief.
B. Assisting in the Procedure
Monitor maternal vital signs and fetal well-being if undelivered twin remains.
Ensure sterile technique and assist in administering uterotonics.
C. Post-Procedure Monitoring
Watch for postpartum hemorrhage and infection.
Provide postpartum counseling and emotional support.
Induction of Labor: Medical and Surgical Methods –
I. Definition
Induction of labor is an obstetric procedure performed to artificially initiate uterine contractions before spontaneous onset to achieve vaginal delivery. It is indicated when continuing the pregnancy poses a greater risk to the mother or fetus than delivering the baby.
Labor can be induced using medical (pharmacological) methods or surgical (mechanical) methods depending on the maternal and fetal condition.
II. Indications for Induction of Labor
A. Maternal Indications
Prolonged pregnancy (Post-term pregnancy >42 weeks) to reduce stillbirth risk.
Pre-eclampsia, Eclampsia, or Gestational Hypertension (To prevent maternal complications).
Diabetes Mellitus (Risk of macrosomia and fetal distress if pregnancy continues).
Premature rupture of membranes (PROM) without labor onset within 24 hours.
Cord prolapse (In cases of artificial rupture with high presenting part).
VII. Role of Midwives in Induction of Labor
A. Before Induction
Assess maternal and fetal condition before recommending induction.
Ensure informed consent and explain risks/benefits to the mother.
Prepare for emergency intervention if needed.
B. During Induction
Monitor maternal contractions and fetal well-being closely.
Adjust oxytocin dosage as needed to prevent hyperstimulation.
Provide pain relief and emotional support.
C. After Induction
Assess for complications like postpartum hemorrhage or fetal distress.
Encourage maternal mobility and hydration.
Ensure immediate neonatal care after delivery.
Caesarean Section:
I. Definition
A Caesarean section (C-section) is a surgical procedure in which the fetus is delivered through an incision made in the abdomen and uterus when a vaginal delivery is not safe for the mother or baby.
C-sections can be elective (planned in advance) or emergency (performed due to complications in labor).
II. Indications for Caesarean Section
A. Maternal Indications
Cephalopelvic Disproportion (CPD) – Fetal head too large or maternal pelvis too small.
Previous classical C-section or multiple previous C-sections (Risk of uterine rupture).
Placenta previa (Placenta covering the cervix, preventing vaginal delivery).
Uterine rupture or previous uterine surgery (Risk of severe hemorrhage).
Obstructed labor (Due to pelvic tumor, fibroids, or severe fetal malposition).
Maternal infections (Active genital herpes or untreated HIV).
Severe maternal conditions (Heart disease, severe pre-eclampsia, or eclampsia).
Infections (Endometritis, Wound Infection, or Sepsis).
Deep Vein Thrombosis (DVT) Due to Immobility.
Uterine Rupture in Future Pregnancies (If Classical C-Section was Performed).
B. Neonatal Complications
Respiratory Distress Syndrome (RDS) Due to Delayed Lung Fluid Clearance.
Birth Trauma (Rare, But Can Include Accidental Lacerations).
VIII. Role of Midwives in Caesarean Section
A. Preoperative Care
Provide emotional support and explain the procedure to the mother.
Assist in preoperative preparation, including IV line placement and catheterization.
B. Intraoperative Care
Assist the surgical team in monitoring maternal and fetal status.
C. Postoperative Care
Monitor for complications such as bleeding and infection.
Encourage early breastfeeding and maternal bonding.
Common Nursing Management of Women Undergoing Obstetric Operations and Procedures
Women undergoing obstetric operations and procedures, such as Caesarean section, forceps/vacuum delivery, manual removal of placenta, induction of labor, episiotomy, and other obstetric interventions, require comprehensive nursing care to ensure maternal and fetal safety, prevent complications, and promote recovery.
Nurses and midwives play a crucial role in preoperative, intraoperative, and postoperative care, ensuring that the patient receives adequate monitoring, pain management, emotional support, and education.
I. General Preoperative Nursing Care (Before Surgery or Procedure)
1. Obtain Informed Consent
Ensure the mother understands the procedure, risks, benefits, and alternatives.
Verify signed consent before proceeding.
2. Conduct a Thorough Maternal and Fetal Assessment
Strengthens pelvic muscles after vaginal delivery, episiotomy, or instrumental delivery.
Helps prevent urinary incontinence.
V. Emergency Nursing Management for Obstetric Complications
1. Management of Postpartum Hemorrhage (PPH)
Massage the uterine fundus to encourage contraction.
Administer IV Oxytocin, Misoprostol, or Carboprost as needed.
Start IV fluids and transfuse blood if required.
Prepare for emergency uterine balloon tamponade or hysterectomy in severe cases.
2. Management of Uterine Rupture
Recognize signs: Sudden severe abdominal pain, fetal distress, vaginal bleeding.
Prepare for emergency laparotomy and possible hysterectomy.
3. Management of Fetal Distress in Labor
Change maternal position (Left lateral).
Stop oxytocin infusion if hyperstimulation occurs.
Administer oxygen (10-15 L/min).
Prepare for emergency C-section if needed.
Drugs Used in the Management of Abnormal Labour
Abnormal labor, also known as dystocia, includes conditions such as prolonged labor, uterine inertia, precipitate labor, dysfunctional labor, fetal distress, induction of labor, postpartum hemorrhage, and obstetric emergencies. The management of these conditions involves the judicious use of medications to regulate uterine contractions, control hemorrhage, relieve pain, prevent infection, and stabilize the mother and fetus.
Below is a detailed guide to the drugs used in managing abnormal labor, categorized by their function and usage.
I. Drugs Used for Induction and Augmentation of Labor
These drugs are used to induce labor (initiate contractions) or augment labor (increase contraction strength and frequency in weak labor).
1. Oxytocin (Pitocin, Syntocinon)
Mechanism: Stimulates uterine contractions by acting on oxytocin receptors in the myometrium.
Indications:
Induction of labor (When the cervix is favorable).
Augmentation of labor (If contractions are weak or slow).
Prevention and treatment of postpartum hemorrhage.
Dosage:
Induction/Augmentation: IV infusion starting at 1-2 mU/min, increased every 30-60 minutes as needed.
PPH: IV infusion 10-40 IU in 1L Normal Saline or Ringer’s lactate.
Side Effects:
Hyperstimulation of uterus → Fetal distress, uterine rupture.
Water intoxication (When used in high doses due to antidiuretic effect).
2. Tranexamic Acid (TXA) – Antifibrinolytic Used in PPH and Shock
Dose:1 g IV over 10 minutes, can be repeated in 30 minutes.
Action: Reduces bleeding by stabilizing clots.
3. Broad-Spectrum Antibiotics – Used in Infections After Obstetric Procedures
Ampicillin + Gentamicin + Metronidazole for postpartum sepsis.
Ceftriaxone + Metronidazole for chorioamnionitis.
VI. Summary of Key Drugs Used in Abnormal Labor
Condition
First-Line Drug
Alternative/Second-Line
Induction of labor
Oxytocin
Misoprostol, Dinoprostone
Cervical ripening
Misoprostol
Dinoprostone
Hyperstimulation
Terbutaline
Nifedipine, Nitroglycerin
Preterm labor
Nifedipine
Magnesium sulfate, Terbutaline
PPH management
Oxytocin
Misoprostol, Carboprost, Tranexamic Acid
Eclampsia
Magnesium Sulfate
Diazepam (If MgSO₄ not available)
Severe bleeding/shock
Tranexamic Acid
Blood transfusion, IV fluids
Anesthesia and Analgesia in Obstetrics
I. Introduction
Pain relief and anesthesia are essential components of obstetric care, ensuring a safe and comfortable childbirth experience for the mother while maintaining maternal and fetal well-being. Anesthesia and analgesia are used in labor, cesarean section, and obstetric emergencies. The choice depends on maternal condition, fetal status, and the urgency of the procedure.
II. Types of Analgesia in Obstetrics
Analgesia is used primarily for pain relief during labor and delivery. It does not cause complete loss of sensation or consciousness.
A. Non-Pharmacological Pain Relief Methods
These methods enhance comfort and relaxation during labor without medications.