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1. 1
NON REASURING FETAL STATUS (NRFS)
Introduction
 Fetal compromise is a complex of signs showing response of the fetus to inadequate oxygenation.
 Fetal heart rate (FHR) in labor can be monitored using either continuous electronic monitoring or intermittent auscultation using Pinnard sthetoscope.
 FHR patterns:
1. Normal: Baseline FHR between 110-170 beats per minute (bpm), accelerations with contraction or fetal
movement, early deceleration, normal variability (6-25 bpm).
2. Bradycardia: Baseline FHR ≤ 110 bpm.
3. Tachycardia: Baseline FHR ≥ 170 bpm.
4. Accelerations: Transient increase in FHR associated with contraction or fetal
movement. It is usually favorable sign of fetal wellbeing.
5. Decelerations: Falls from baseline
(i) Early deceleration: Slowing in FHR associated with contractions. Mainly due to head compression.
(ii) Late deceleration: Slowing in FHR which begins at or after the peak of contractions & returns to baseline after the end of contractions. Implies presence of uteroplacental insufficiency.
(iii)Variable deceleration: Variable onset of abrupt slowing of FHR in association with uterine contractions. Signify possible pressence of cord compression.
(iv) Prolonged deceleration: A decrease in FHR below baseline of 15 bpm lasting 2-10 minutes (min) from onset to return to baseline.
6. Beat-to-beat variability: Fluctuations in the baseline FHB. Can be:
a. Absent / undetectable
b. Minimal: < 5 bpm
c. Moderate: 6 - 25 bpm

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d. Marked: > 25 bpm
7. Wandering baseline: Unsteady & wanders between 110 – 170 bpm. Suggests neurologic abnormality.
8. Sinusoidal pattern: Regular variability resembling sin wave with a fixed periodicity of 3 – 5 cycles / min & amplitude of 5 – 40 bpm. It is a response to moderate fetal hypoxemia scondary to fetal anemia.
Diagnosis
 NRFS: Presence of the following signify fetal compromise:
 Repetitive decelerations (variable / late)
 Loss of beat – to –beat variability
 Baseline bradycardia or tachycardia
 Signs of fetal distress:
 Abnormal FHR (above)
 Meconium stained liquor
 Acidic scalp PH
Management
 Digital vaginal examination if there is no contraindication to do so. Done to asses stage of labor, pressence of cord prolapse or cord presentation, and to do artificial rupture of fetal membranes (ARM) to check presence of meconium.
 Intrauterine resuscitation:
 Change position of the mother
 Correct maternal hypotension, dehydration, & hypoglycemia (Intravenous (IV)- fluid)
 Oxygen via tightly fitting face mask (6-8 liters (lit)/min)
 Decrease uterine activity by stopping oxytocin &/or administering tocolytic agents
 Amnioinfusion
 If fetal tachycardia is secondary to chorioamnionitis, treat the chorioamnionitis
 Continue with labor follow up if FHR is normal subsequently

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 If the FHR abnormality doesn’t resolve with the conservative management, immediate delivery is recommended.
 Mode of delivery is dectated by presentation, station, position, cervical dilatation, & status of the fetus;
 Vertex presentation, fully dilated cervix, station at +2 centimeters (cm) or below → Instrumental vaginal delivery(ventouse/forceps).
 Vertex presentation, cervix not fully dilated, or high station with fully dilated cervix → cesarean delivery (C/d).
 Malpresentations → C/d, except face presentation with mentum anterior and station +2 cm or below where obstetric forceps can be used.

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OBSTRUCTED LABOR (OL)
Definition: Obstructed labor is failure of descent of fetal presenting part in maternal birth canal for mechanical reasons despite the presence of adequate uterine contractions.
Causes:
 Cephalo pelvic disproportion (commonest): Contracted pelvis (commonest), pelvic deformities (Rickets, osteomalacia), malposition, big fetus
 Malpresentations: Impacted transverse lie, breech presentation, face presentation (mento posterior), brow presentation, compound presentation, shoulder dystocia
 Soft tissue abnormalities: Cervical stenosis, vaginal stenosis, tumor previa (Myoma)
 Fetal abnormalities: Hydrocephalus, locked twins, conjoined twins
Anticipate OL during antenatal period in presence of:
 Short stature
 Small shoes number
 Previous history of prolonged or difficult labor
 Contracted pelvis on clinical pelvimetry
 Obstetric palpation to pick malpresentations, big fetus, multifetal gestations.
 Unengaged head at term in primigravidas (Head fitting test)
Anticipate OL in labor in presence of:
 Protracted cervical dilatation
 Arrest of cervical dilatation
 Failure/arrest of descent of presenting part
Clinical features:
 Prolonged labor
 Failed instrumental delivery
 Exhausted and anxious mother

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 Dehydration signs present
 Signs of metabolic acidosis
 Birth canal infection (offensive vaginal discharge, fever)
 Bandl’s ring formation (commonly in primigravidas, distended lower uterine segment with a constriction ring separating it from upper uterine segment)
 Ruptured uterus (multigravidas)
 Three - tumor abdomen: distended bladder + ballooned out lower uterine segment + contracted fundus with intervening Bandl’s ring.
 Blood stained urine (edema and echymosis)
 Edema of lower vagina and vulva (Kanula syndrome)
 Moulding and excessive caput
 Fetal death (Alive fetuses usually succumb in first 48 hours after delivery)
Management
 Fluid and electrolyte imbalance correction (IV- crystalloids, N/S and R/L be used)
 Control of infection (use triple antibiotics: Ampicillin 1 gm IV QID/Ceftriaxone 1 gm IV BID + Metronidazole 500 mg IV/PO TID/Chloramphenicol 1 gm IV QID + Gentamycin 80 mg IV TID or 4.0–5.0 mg/kg IV once daily, in an infusion given over a 30-minute period)
 Emptying bladder:
 Avoid metalic and hard plastic catheters (traumatic)
 Relieve compression of the urethra by inserting two fingers, one on either side of the urethra
 Displace presenting part upwards after anesthesia
 During cesarean delivery, after abdomen has been opened the bladder can be emptied with a wide bore needle and syringe
 Emptying the stomach (NGT)
 Administer antiacid suspension orally
 Hematocrit/hemoglobin, blood group and Rh, Cross-match blood

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 Relieve obstruction using any of the following procedures, whichever is appropriate for the situation:
1. Cesarean delivery
 Almost all cases
 Alive fetus, and dead fetus at high station
 Lower uterine segment cesarean delivery is prefered
2. Vaginal operations
 In absence of uterine rupture and imminent uterine rupture
 In the operation theatre especially if uterine rupture or imminent rupture cannot be ruled out (destructive deliveries under direct vision)
 If rupture suspected during procedure (eg. Fresh and excessive vaginal bleeding), abandon the procedure immediately and proceed to laparatomy
 After difficult procedures explore the uterus
 Destructive vaginal deliveries (prerequisites should be fulfilled)
 Craniotomy
 Cleidotomy
 Decapitation
 Evisceration / embryotomy followed by spondylotomy

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UMBILICAL CORD PROLAPSE (UCP)
Introduction
 UCP is obstetric emergrncy that occurs when the umbilical cord(UC) descends alongside or beyond the fetal presenting part.
 Classification:
 Overt UCP: Protrusion of the UC in advance of the fetal presenting part with ruptured fetal membranes.
 Occult UCP: Cord descends alongside, but not past, the presenting part with intact / ruptured fetal membranes.
 Cord presentation: Prolapse of UC below the level of the presenting part before rupture of fetal membranes.
 The incidence of UCP is 0.14 – 0.62 % (varies with fetal presentation: cephalic = 0.5%, frank breech = 0.5%, complete breech = 5%, footling breech = 15%, transverse lie = 20%) & perinatal mortality related to UCP is declining significantly.
 Risk factors:
1. Fetomaternal: Inadequate filling of the maternal pelvis by the fetus. Malpresentations, unengaged presenting part, prematurity, multifetal gestation, PROM, abnormal placentation, multiparity, polyhydramnios, long UC, pelvic deformities, uterine tumors/malformations, congenital anomalies
2. Obstetric interventions: ARM, scalp electrode application, intrauterine pressure monitor catheter insertion, manual rotation of the fetal head, amnioinfusion/amnioreduction, ECV with ROM.
Diagnosis
 Occult UCP: Pressence of severe prolonged fetal bradycardia or moderate to severe variable decelerations after a previous normal tracing.
 Overt UCP: Pressence of palpable cord (pulsatile or non-pulsatile) on pelvic examination or visible cord outside the introitus.

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 Cord presentation: Loops of cord are palpated through the fetal membranes.
Management
 Intrauterine resuscitation and prompt delivery is recommended when fetus is alive.
 Manuevers to reduce fetal presenting part pressure on the cord:
1. Funic decompression: Examiner’s hand is maintained in the vagina to elevate the presenting part off of the UC while preparations for an emergency c/d are being made.
 Client be placed in steep Trendelenberg or knee-chest position.
 Do not manipulate the cord.
 Avoid exposure of the cord to cold environment so as to avoid cord spasm (keep in vagina).
2. Bladder filling: Insert foley catheter into maternal bladder then fill bladder with 500- 700 ml of normal saline with the patient in Trendelenberg position (used during referral).
3. Tocolysis
 Delivery: Mode of delivery depends on:
 Presentation
 Cervical dilatation
 Station of presenting part
 Whether the fetus is alive or dead and GA when alive.
 If fetus is dead (previable/GA<28 weeks), follow labor & attend delivery.
 If fetus is alive with malpresentation or prerequisites for instrumental delivery not fulfilled, immediate c/d.
 Ventouse is preferred over forceps when cervix is dilated ≥ 8 cm and other prerequisites are fulfilled.
 The interval between cord prolapse & delivery is a major determining factor in the immediate neonatal outcome & perinatal mortality.
 In cord presentation with alive fetus, do not rupture fetal membranes at any stage of labor; deliver the fetus by c/d.

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 Prevention:
 ARM should be done when fetal presenting part is well applied to the cervix/engaged.
 Controlled ARM with small gauge needle & simultaneous fundal pressure if fetal presenting part is not well applied.
 Avoid disengaging fetal presenting part when performing procedures.
 Careful pelvic examination immediately after spontaneous rupture of fetal membranes.
 Incidental finding of cord presentation on U/S should be followed to decide mode of delivery.

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Pathway of care in UCP
Lateral position
100% oxygen by tightly fitting face mask (6-8 l/min)
Replace cord in vagina but avoid handling cord as much as possible
Discontinue oxytocin if present
↓
Assess fetal viability
FH on Pinnard/Doppler/CTG
/
Yes – baby is alive No – FHT
↓ ↓
Is cervix fully dilated? Await spontaneous delivery
Is baby cephalic?
/
No – not fully dilated or Yes – fully dilated/ ≥ 8 cm
Vaginal delivery deemed inappropriate ↓
Or unsuccessul Consider ventouse if easy delivery
↓
Is FHR normal?
↓
No – FHR is abnormal Yes – FHR is ok
↓ ↓
Relieve pressure on the cord: Make arrangements for emergency c/d
 Knee-elbow/lateral position with
Trendelenberg → Does FHR improve?
 Manual elevation of presenting part No – FHR stays abnormal
 Cetheterize & fill the bladder with ↓
500 ml N/S then clamp catheter Prepare for emergency c/d as fast as possible

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ANTEPARTUM HEMORRHAGE (APH)
 Definition: Genital tract bleeding from 28th week of gestation till delivery of the fetus.
 Incidence: 2 – 3 % of all pregnancies.
 Causes:
A. Placental and fetal membranes: Placenta previa, abruptio placenta, vasa previa, placenta membranacea, circumvalate placenta
B. Non – placental: Heavy show, ruptured uterus, bleeding diathesis
C. Local causes: Cervicitis, cervical Ca, cervical polyp, leech infestation, vaginal & vulvar pathologies
D. Unknown cause
NB: The cause of any APH should be taken to be placenta previa unless ruled out otherwise. Hence, vaginal & rectal examinations are contraindicated in women with APH until placenta previa is ruled out.
Placenta previa
 It is implatation of placenta at the lower uterine segment within zone of cervical dilatation & effacement.
 Incidence : 4 per 1000 pregnancies.
 Risk factors: High parity, advanced age, multifetal gestation, erythroblastosis, previous c/d, other uterine scars, smoking, high altitude, male fetus, early GA.
NB: In placenta previas diagnosed at early GA there is placental “migration” which results from formation of lower uterine segment & unidirectional trophoblast growth.
Diagnosis:
 Clinical features (supportive): Painless & recurrent vaginal bleeding (70-80%), uterine contraction (10-20%), assymptomatic (Incidental finding) in < 10%.
 Mainly by U/S: -Transvaginal (Gold standard)
-Trans abdominal: -Accuracy is > 95 %

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- Anterior placenta---with empty bladder
- Posterior placenta---Trendelenberg position
- Central complete---placenta seen anterior & posterior
 Classification: 1. Low lying (I): Within 6cm from internal OS of the cervix.
2. Marginal (II): Placenta edge reaching the internal OS of the cervix.
3. Partialis (III): Placenta covering internal OS of the cervix partly.
4. Totalis (IV): Placenta covering the internal OS of the cervix completely.
 Management:
 Admit all ladies with APH secondary to placenta previa at time of diagnosis.
 Resuscitation based on clinical condition.
 Vaginal & rectal examinations are absolutely contraindicated.
 Monitor closely maternal & fetal conditions.
 HCT, BG & Rh, cross-match at least two units of blood
 Decide on conservative management versus immediate delivery
 Indications for immediate delivery:Term pregnancy, IUFD, fetal growth restriction, NRFS, excessive bleeding, gross fetal congenital malformation which may not be compatible with life, lady in labor.
 In absence of any of the above indications to deliver the fetus, conservative management is instituted till an indication comes to picture.
 Conservative management in preterms includes:
-Bed rest (in hospital)-----No place for out patient management
-Dexamethasone 6mg IM Q 12 hours for a total of 4 doses
-Follow: Maternal V/S, vaginal bleeding, uterine contractions, fundal height, FHB, kick count, BPP, serial HCT.
- Deliver at 37 completed weeks of gestation after maturity is confirmed

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 Route of delivery depends on the type of placenta previa and presence of other obstetric indications:
 Low lying & anterior marginal → vaginal delivery
 Partialis, totalis, & posterior marginal → c/d
 Excessive bleeding, NRFS, other obstetric indications → c/d
 Double setup examination: Used in areas where U/S is not widely available/not done by experienced people. The procedure:
 Client taken to operation room
 Everything must be ready for delivery
 Speculum examination is done gently to rule out local causes & see the cervical status → Then gentle digital vaginal examination is done to check for pressence of placenta between fornices & presenting part, cervical dilatation & effacement, pressence of placenta through open cervix.
 Used to decide on mode of delivery
Placental abruption
 It is the premature separation of a normally implanted placenta.
 Immediate cause is rupture of defective maternal vesseles in the decidua basalis, where it interfaces with the anchoring villi.
Incidence: 1 in 75 – 225 deliveries, severe enough to cause still birth (SB) occurs 1 in 830 deliveries. Accounts for 1/3rd of APH.
Risk factors: Trauma, hypertension, rapid uterine decompression, high parity, multifetal gestation, previous history of abruption (most predictor, increases 10×), uterine leiomyoma & anomalies, cigarette smoking, cocaine abuse, placental anomalies, inherited thrombophilia.
Recurrence: 5 – 15 % after an episode, 25 % after two consecutive episodes
Diagnosis:
 Primarily clinical: Vaginal bleeding ( > 80 %), abdominal pain ( > 50 %), contractions ( Tachysystole), uterine tenderness, NRFHR, rigid (woody hard) uterus, amount of bleeding doesn’t correlate well with the extent of maternal hemorrhage, DIC ( 10 – 20 % of severe abruptions).

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NB: Bleeding in placental abruption can be:
 Revealed (Vaginal) in 80 %
 Concealed
 To amniotic fluid giving it “Port wine” discoloration
 Into myometrium------“Couvelaire uterus”
 Clinical diagnosis is supported by:
 Radiologic findings: High resolution U/S with experienced hand can reveal retroplacental clot.
 Laboratory findings: Hypofibrinogenemia
 Pathologic findings: Retroplacental clot after delivery, depression on maternal surface of placenta (long standing abruption), bluish uterus at c/d (Couvelaire).
 Grading of abruptio placentae: Sher, 1978
 Grade 0: Retrospective diagnosis of abruption
 Grade 1: Vaginal bleeding
 Grade 2: Vaginal bleeding, concealed hemorrhage, uterine tenderness, NRFHR
 Grade 3: Vaginal bleeding, shock, extensive concealed hemorrhage, uterine tenderness, IUFD
Grade 3 A: With no coagulopathy
Grade 3 B: With coagulopathy
 Management:
 All cases: Asses hemodynamic status, then
 IV line to be opened
 Fetal well being monitoring
 HCT, BGP & Rh, platelets, fibrinogen, PT, aPTT
 Grade 2 – 3: Asses maternal hemodynamic status, then stabilize the mother
 Maintain U.O.P > 30 ml/hr & HCT > 30%
 Platelets (6U) transfusion if thrombocytopenia
 FFP if fibrinogen < 100mg/dl
 Delivery: -Vaginal----Amniotomy & induction with oxytocin
-C/d for uncontroled hemorrhage & other obstetric indications

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 Hysterectomy---Uncontrolled hemorrhage
 Couvelaire uterus---Uterotonic agents, hysterectomy if unresponsive
 Grade 1: Conservative management
 Steroid in < 34 weeks of gestation
 Keep in ward till bleeding subsides
 Tocolysis in < 33 weeks of gestation
 Follow maternal V/S, bleeding, uterine contraction & tenderness, FHB, kick count, BPP, fetal growth
 Indications for delivery: Term, IUFD, malformed fetus, NRFHR, advanced labor, excessive bleeding
NB:
 All cases of APH be admitted at initial diagnosis & stabilized.
 Placenta previa must be considered unless ruled out in all cases of APH.
 Local causes be ruled out 48 hrs after last episode of bleeding with speculum examination in those with no placenta previa.
 In APH secondary to local causes, the primary cause be treated.
 Pregnancies with APH of unknown cause be induced at 37 copmleted weeks after confirmation of maturity.
 In vasa previa, bleeding is mainly fetal. Emergency c/d is indicated if fetus is alive.

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MULTIFETAL GESTATION
Etiology
 Etiology of MZ twining is unknown
 DZ twining appears to result from ovulation of multiple follicles (Elevated FSH, ovarian stimulation, in vitro fertilization).
Placentation
 DZ twins have dichorionic-diamniotic placentas
 In MZ twins the timing of egg division determines placentation:
-Division within 3 days of fertilization: DADC
-Division between days 4 & 8: DAMC
-Between days 8 & 12 : MAMC
-Division at or after day 13 results in conjoined twins
Diagnosis
 Persistent hyperemesis gravidarum
 Pregnancy heavier than previous pregnancies
 Personal or family history of twins
 Early onset preeclampsia
 Pregnancy following assisted reproductive technology
 Big for date uterus
 Excessive weight gain
 Obstetric palpation revealing more than two poles
 FHR heared by two people at different areas with rate difference of at least 10 bpm (with different rate to the maternal pulse).
 U/S: Presence of two or more GS/fetuses, dividing membranes
Management
 Increase energy consumption (increase 300 Kcal more)

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 Supplements ( Iron, Folic acid)
 Frequent ANC visits, rest and antepartum fetal surveillance as indicated
 U/S:- Placentation, number of fetuses, AF, placental abnormalities, fetal growth, presence of congenital anomalies
 Preterm labor: Tocolysis, steroids before 34 weeks of GA
 VBAC is contraindicated
 Timing of delivery: - Elective delivery before 38 weeks should be after lung maturity is ascertained.
- No twin pregnancy should be allowed to go beyond 40 weeks of GA.
 Induction and augmentation: Contraindicated
 Route of delivery: Depends on presentation & GA (rarely)
 Both twins vertex: Deliver vaginally, c/d reserved for indications similar to singleton.
 Twin 1 non-vertex: C/d
 Twin 1 vertex & twin 2 non-vertex: deliver 1st twin vaginally, then options for 2nd twin are: ECV, internal podalic version followed by total breech extraction, vaginal breech delivery
 C/d in cases of: Conjoined twins, monoamniotic twins, locked twins.
 Intrapartum both twins should be monitored using continuous monitoring methods (One- to-one Pinnard sthetoscope auscultation if continuous monitoring is not feasible).
Complications
 Interval between delivery of the two twins:
- There doesn’t have to be finite intervel between delivery of 1st & 2nd twin as long as FHR tracing is reasuring.
- Continuous fetal monitoring & real-time U/S help to identify those second twins who would benefit from expedited delivery allowing most cases to be managed expectantly.
 Conjoined twins:

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 Incidence: 1 in 50,000 to 1 in 100,000 live births with female to male ratio = 3:1.
 Classification based on site of most prominent union:
- Cephalopagus: Head
- Thoracopagus: Chest
- Omphalopagus: Abdomen
- Parapagus: Pelvis & variable trunk
- Rachiopagus: Vertebral column
- Pygopagus: Sacrum
 Diagnosis: U/S typical features include:
- Fixed position of the fetal heads (both at same level)
- Parallel lie / persistently similar lie
- Inability to detect separate bodies or skin contours
- Lack of separating membranes
 Management:
- Elective termination at time of diagnosis when there is a cardiac or cerebral fusion, as separation is rarely successful, & if severe deformities are anticipated after separation.
- If pregnancy is continued, elective c/d after lung maturation.
- Destructive delivery may be considered in dead and partly delivered fetuses.
- After birth, elective separation is indicated (survival rate is 80%).
- Emergency separation is indicated if:
One of the twins is dead
One of the twins threatens survival of the other twin
Life threatening condition exists in one of the twins
 Twin-twin transfusion syndrome: Almost always due to artery-to-vein anastomoses
 Diagnostic criteria antenatally:
- Same sex
- Monochorionic with vascular anastomoses
- Weight difference > 20%

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- Polyhydramnios in the larger fetus
- Oligohydramnios (stuck) in the smaller fetus
- Hgb defference > 5 gm/dl
 Management: Amnioreduction, septostomy, laser ablation of vascular anastomoses, selective feticide.
 Death of one fetus: Prognosis of the surviving fetus depends on:
- GA at time of death
- Chorionicity
- Length of time between death & delivery of the surviving fetus
 Management depends on cause of death & risk to surviving fetus
 Generally conservative management is recommended with close follow up of maternal clotting profiles & fetal surveillance.
 Discordant twins: EFW difference of > 20% between the smaller twin as compared to the larger twin; fetal surveillance is recommended till delivery which is at term or when the surveillance shows compromise.
 Locked twins: Can be chin to chin interlocking, collision, impaction, compaction.
 Chin to chin locking: 1st breech & 2nd cephalic
- Avoid traction on 1st twin
- If both alive, c/d
- If 1st twin is dead, decapitate & deliver 2nd twin then deliver the decapitated head of the 1st twin.
NB: - Higher order multifetal gestations should be suspected whenever twin pegnancy is considered.
-All higher order pregnancies be delivered by c/d unless c/d is contraindicated or the fetuses are extemely premature.

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PREMATURE RUPTURE OF FETAL MEMBRANES (PROM)
PROM: is rupture of fetal membranes at least an hour before onset of labor.
Prolonged PROM: is rupture of fetal membranes for more than 8 hours.
Latency period: is the period between the rupture of fetal membranes and onset of labor.
Types of PROM
1. Preterm PROM: is the rupture of fetal membranes between the GA of 28 and 37 completed weeks.
2. Term PROM: is the rupture of fetal membranes after GA of 37 completed weeks.
Incidence:
PROM occurs in approximately 8-10% of pregnancies.
Preterm PROM complicates 3% of pregnancies.
Etiology:
Predisposing factors: Cervical insufficiency, polyhydramnios, multiple pregnancies, mal presentations, intra amnionic infection (chorioamnionitis), low tensile strength of the fetal membranes, lower socioeconomic status, cigarette smoking, sexually transmitted infections, fetal malformations, amniocentesis, and previous conization.
Symptoms:
 Over 90% of women with PROM report a history of ‘gush of fluid’ per vaginum.
DIAGNOSIS OF PROM
 PROM is diagnosed by the presence of the following findings:
1. History of gush of fluid per vaginum followed by continuous trickling that moists vulval pads.
NB: Vulval pads can be moistened with urine or other vaginal discharge.

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2. Sterile speculum examination: Visualization of a pool of fluid in the posterior vaginal fornix with evidence of clear fluid passing from the cervical canal.
NB: Digital cervical examinations should not be performed in patients with PROM who are not in labor and in whom immediate delivery is not planned.
3. Nitrazine paper test: the color turns from yellow to deep blue, due to alkalinity of the amniotic fluid.
NB: Blood, semen or presence of vaginal infections make the environment alkaline, giving the same result.
4. Fern test: - Visualization of fern-like pattern of dried amniotic fluid on a glass slide under microscopy due to presence of protein.
NB: Protein may be present in urine.
5. Ultrasound: is an ideal non-invasive technique for the detection of the residual amount of amniotic fluid. Oligohydramnios is diagnosed if the measurements of the largest pocket of the amniotic fluid are less than 2cm. The largest pocket is usually present between the anterior shoulder and the neck.
6. Dye injection: - through abdominal needle under ultrasonic guidance into the amniotic sac and observation of its passage through the external os or even in the vulval pad.
Eg. Ultrasonographically guided transabdominal instillation of indigo carmine dye (1 mL in 9 mL sterile normal saline), followed by observation for passage of blue fluid from the vagina within 30 minutes of amniocentesis.
Complications:
1. Preterm labor: with the risk of prematurity like respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, sepsis, hypoglycemia, and hypothermia.
2. Infection: chorio-amnionitis, septicaemia and fetal Pneumonia.
3. Fetal skeletal deformities and distress: due to oligohydramnios.

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4. Postpartum endometritis.
Signs of infection (chorioamnionitis):
1. Maternal Temperature ≥ 38°c
2. Uterine tenderness
3. Foul smelling amniotic fluid through the vagina
4. Maternal or fetal tachycardia
5. Increased WBC count
Management of PROM
Management depends on: Gestational age, duration of rupture of fetal membranes, fetal condition (dead, fetal distress, congenital malformations), presence of infection, labor and previous cesarean scar, and other obstetric indications.
1. Gestational age greater than 34 weeks
I. Rupture of fetal membranes greater than 8hours and no previous c/s:
- Start Ampicillin 2gm IV QID until delivery
- Start induction with oxytocin if no labor
- Caesarean delivery is indicated in malpresentations
II. Rupture of fetal membranes greater than 8hours and previous c/s:
- Prophylactic antibiotics (eg. Ampicillin 2gm iv stat)
- Immediate cesarean delivery
III. Rupture of fetal membranes less than 8 hours and no previous c/s:
- Follow fetal and maternal condition for spontaneous onset of labor for total of 8 hours duration and then start induction if labor does not start
- Caesarean delivery is indicated immediately in mal presentations
IV. Rupture of fetal membrane less than 8hours and previous c/s:
-Depends on mother’s preference whether she wants observation for spontaneous onset of labor for 8 hours or immediate delivery by cesarean.
-Caesarean section is indicated immediately in mal presentations

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2. Gestational age between 28- 34 weeks and alive fetus:
I. Rupture of fetal membranes in absence of infection:
 Ampicillin 2gm IV QID for 48 hours then amoxicillin 500 mg PO TID for 7-10 days.
 Erythromycin 500 mg IV QID for 48 hours then 500 mg PO QID for 7-10 days.
 Start dexamethasone 6 mg IM BID for four doses or Betamethasone 12 mg IM daily for two doses.
 Follow till 34-37 weeks of GA or till an indication for delivery comes into picture during follow up.
II. Rupture of fetal membranes in presence of infection and no previous c/s:
- Start Ampicillin 2gm iv QID + Gentamycin 80 mg IV TID (Ceftriaxone 1 gm IV BID alone)
- Start induction with oxytocin if no labor
- Caesarean delivery is indicated in malpresentations
III. Rupture of membrane with fetal death or severely malformed fetus:
- Deliver immediately with induction if there is no previous c/s or by cesarean if there is previous c/s.
NB: Tocolysis may be utilized in patients with preterm PROM to permit administration of antenatal corticosteroids and antibiotics.
Immediate delivery of the fetus may be indicated in the following circumstances: Malformed fetus, chorioamnionitis (maternal fever, uterine tenderness, maternal or fetal tachycardia, offensive vaginal discharge), non-reassuring fetal testing, fetal death, evidence of placental abruption with significant vaginal bleeding, active labor with advanced cervical dilation and/or fetal mal presentation with increased concern for umbilical cord prolapse.
Components of conservative management:

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1. Bed rest as long as there is leakage of liquor with restriction of efforts that increase intra-abdominal pressure.
2. Temperature is recorded every 4- 6 hours.
3. Observation for malaise, abdominal pain, uterine tenderness and smell of liquor on sterile vulval pads.
4. Leucocyte count and C-reactive protein may be done every other day.
5. Prophylactic antibiotics be given as in the above.
6. Tocolytic drugs are given if uterine activity starts.
7. Corticosteroid therapy is given for gestations before 34 weeks.
Treatment with antibiotics along with conservative management can potentially treat or prevent ascending infection, prevent chorioamnionitis, reduce neonatal sepsis, and prolong the latency period.
Management of PROM with viral infection (Herpes genitalis and HIV)
Route of delivery is abdominal by c/d if duration of rupture of fetal membranes is less than 4 hours and active herpes genitalis is present.

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INTRAUTERINE FETAL DEATH (IUFD)
Intrauterine fetal death (IUFD) is fetal death after 28 weeks of gestation but before the onset of labor.
It complicates about 1% of pregnancies. ETIOLOGY  In more than 50% of cases, the etiology of antepartum fetal death is not known or cannot be determined.  Associated causes: hypertensive diseases of pregnancy, diabetes mellitus, erythroblastosis fetalis, umbilical cord accidents, fetal congenital anomalies, fetal or maternal infections, fetomaternal hemorrhage, antiphospholipid antibodies and hereditary thrombophilias. DIAGNOSIS  Clinically, fetal death should be suspected when the patient reports the absence of fetal movements (the usual reason for consultation), if the uterus is small for date or if the fetal heart tones are not detected.  Confirm the lack of fetal movement and absence of fetal cardiac activity with real-time ultrasonography.  Because the placenta may continue to produce hCG, a positive pregnancy test does not exclude an IUFD.
Management
Management includes: 1. Watchful expectancy
2. Immediate induction of labor
The mother must be involved in the decision.
1. Watchful expectancy:

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 About 80% of patients experience the spontaneous onset of labor within 2 to 3 weeks of fetal demise.  Weekly determination of fibrinogen levels, hematocrit and platelet count should be done and monitored during the period of expectant management.  If the fibrinogen level is decreasing, even a "normal" fibrinogen level of 300 mg/dL may be an early sign of consumptive coagulopathy in cases of fetal demise.  An elevated prothrombin and partial thromboplastin time, the presence of fibrinogen- fibrin degradation products, and a decreased platelet count may clarify the diagnosis.  If laboratory evidence of mild disseminated intravascular coagulation is noted in the absence of bleeding, delivery by the most appropriate means is recommended.  If the clotting defect is more severe or if there is evidence of bleeding, blood volume support or use of component therapy (fresh-frozen plasma) should be given prior to intervention.  However, conservative approach may prove unacceptable when mother’s feelings of personal loss and guilt create anxiety.  Expectant management is also not possible in the phase of obstetric complications like PROM, chrioamnionitis , Rh isoimmunization, severe maternal disease (eg congestive heart disease). 2. Induction of labor
 Justifications for early intervention include the emotional burden on the patient associated with carrying a dead fetus, the slight possibility of chorioamnionitis, and the 10% risk of disseminated intravascular coagulation when a dead fetus is retained for more than 5 weeks in the 2nd or 3rd trimester.
 If the cervix is favourable, then start induction with Oxytocin drip.

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 For unfavourable cervix, priming cervix with misoprostol vaginally 25 - 50 microgram every 4 - 6 hours (2 to 3 doses are usually enough ) followed by Oxytocin drip after 4 hours of the last dose of misoprostol.
 Induction should always be on elective basis, unless emergency conditions arise like chorioamnionitis.
 In case of malpresentations or fetopelvic disproportions during labor, try everything possible to avoid Cesarean sections.
 Perform destructive delivery when pre-requisites are fulfilled. Care should be taken to prevent maternal injury.
 Cesarean section is done only as last resort, or if a clear cut indication for cesarean section is present. Follow-up  It is important to determine the cause of a fetal death so that the parents can be counseled, that will help to describe risk of recurrence and help to develop the plan for care of subsequent pregnancy.  The obstetrician should write a detailed note describing the stillborn (sex, birth weight, grade of the maceration, look for malformations, growth restriction or hydropic features ), amniotic fluid ( amount, meconium staining), umbilical cord (malformations, number of vessels), placenta (weight, malformations, degree of calcification), and membranes. Investigations:  Testing for syphilis (VDRL), maternal diabetes (fasting blood sugar) and Rh-isoimmunization (Rh type) should be done.  Because significant fetal-maternal hemorrhage has been observed in approximately 5 percent of all fetal deaths, a Kleihauer-Betke test should be obtained.

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 Postmortem autopsy should be requested if available and parents consent. Managing perinatal grieving:  Keep parents informed; be honest and forthright.  Encourage the mother to make as many choices about her care as possible.  Support parents in seeing, touching, or holding the still born.  Describe the still born in detail, especially for couples who choose not to see the still born.  Allow photographs of the still born.  Discuss subsequent pregnancy.  Avoid the traditional advice of encouraging the family to embark soon on another pregnancy as a “replacement” for the still born.  Relaxation of many of the traditional hospital routines may be necessary to provide the type of support these families need. For example, allowing a loved one to remain past visiting hours, providing a couple a private setting to be with their deceased infant, or allowing unusually early discharge with provisions for follow-up visits which facilitates the resolution of grief.  Keeping the mother away from rooms where there are mothers with newborns.

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INTRAUTERINE GROWTH RESTRICTION (IUGR) Definition: EFW less than or equal to 10th percentile for gestational age.  Definition is not accurate; some consider 5% as a cutoff point.  10% in any population  70% are constitutionally small  Is second to prematurity as a cause of perinatal mortality Classification and pathogenesis: Compared with AGA fetuses, IUGR infants have :  decreased body fat, total protein, DNA/RNA mass,  decreased body glycogen and free fatty acids  altered distribution of weight among organs 1. Asymmetric IUGR  Brain sparing than abdominal organs especially liver  80% of all IUGR  Primarily from decreased cell size than number  Usually due to nutritional deprivation during later half of pregnancy. 2. Symmetric IUGR  Proportionally affects brain and other organs  Primarily from decreased cell numbers  From nutritional deprivation during early pregnancy, genetic disorders, infections.

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 Accounts for 20% of IUGR cases Causes: A) Non pathological causes: Maternal/paternal height, primigravidity, fetal sex (females <males: 5% in weight and 2% in height), ethnicity. B) Pathological causes 1. Maternal - Chronic illnesses including hypertension, cardiac disease, anemia, renal disease, chronic obstructive pulmonary disease, chronic liver disease, pancreatitis.  Drug use like alcohol, smoking, heroin/cocaine, anticonvalsants, cytotoxic drugs  Severe malnutrition 2. Fetal factors a) Genetic abnormalities are most common causes;30-50%  autosomal trisomies : trisomy 21, 18 and 13  sex chromosome abnormalities: 45xo, xxx, xxy b) Fetal malformations including NTDs, skeletal dysplasia, abdominal wall defects, renal agenesis osteogenesis imperfecta. c) Congenital infections  Viral: CMV, HSV, VZV, Rubella,  Bacterial: Listeria monocytogens, TB, syphilis  Protozoa: malaria, toxoplasmosis d) Multiple pregnancy

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3. Placental and cord factors  Abnormal implantation eg . placenta previa, circummvalate/ battledor  Chronic abruption  Infections, tumors, infarctions  Single umbilical artery Diagnosis Known GA:  Clinical screening by symphysis fundal height with a discordance of at least 3cms  Diagnosis by fetal weight estimation using ultrasound Unknown GA:  Suspected asymmetric IUGR . Using body proportions  HC/AC > 2SD is abnormal and suggestive  FL/AC > 23.5% IS 50 – 60 % sensitive  Fetal pondral index  Transverse cerebellar diameter, TCD/ AC > 2SD Investigations Maternal - Hct, CBC, RFT, LFT, echocardiography, CXR - Infectious workup for common viral diseases - Serum alfa fetoprotein

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Fetal - Karyotyping for those < 32wks, < 3 percentile, polyhydraminos as is associated with trisomy 18 - U/S for congenital anomaly, oligohydraminos, placentation, gestation, abruption - 3D U/S increases the yield Treatment: depends on etiology  Control or correction of maternal chronic illness  Correct maternal nutrition  Treat fetal infection  Stop drug use  Treat placental infections  Bed rest doesn’t seem to improve birth weight Obstetric management Serial follow up helps to identify those at high risk for demise 1) Serial weight assessment every 3 - 4 wks 2) Biophysical profile every 1 – 2 wks 3) Doppler velocimetry: Umbilical artery, middle cerebral artery 4) Fetal blood sampling, but not routinely recommended for it is invasive 5) Growth velocity: to identify those which are constitutionally small 6) Medical interventions: Nutritional supplementation, plasma volume expansion, low dose aspirin, bed rest, oxygen therapy, and beta mimetic or calcium channel blockers to increase placental blood flow.

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Timing of delivery Depends on gestational age and severity:  Remote from term (≤34wks)  Conservative in majority  Immediate delivery in those with absent or reversed diastolic flow on Doppler velocimetry  The effect of IUGR on accelerating pulmonary maturity is controversial and corticosteroid administration is recommended.  Term or near term (>34wks)  Delivery if: IUGR from maternal hypertension, arrest of growth over 3-4wks, low BPP (<6), and absent or reversed flow on doppler velocity * Expectant management till 37wks if no indication for delivery  In general, pregnancy suspected for IUGR should not extend beyond 40wks of GA. Intrapartum management: Emphasizes the need for continuous intrapartum monitoring; labor and vaginal delivery unless rapid delivery is indicated. Complications Maternal: Related to chronic illness than IUGR; cesarean related complications. Fetal: Hypoxia, acidosis, malformation, stillbirth Neonatal: Hypoglycemia, hypothermia, hypocalcemia, hyperbilirubinemia, meconium aspiration, sudden infant death syndrome. Adults: Lower intelligent quotient, increased seizure disorder, cerebral palsy, mental retardation, and hypertension.

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Prevention  Cessation of smoking at 16wks has no risk and at 28wks improves birth weight  Protein and energy supplementation  Antimalarial chemoprophylaxis  Screening for CMV, HSV, Rubella, toxoplasmosis  Avoid drugs  Control maternal chronic illnesses

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ANTEPARTUM FETAL SURVEILLANCE
Definition: Assessment of the wellbeing of fetus/fetuses during pregnancy especially after the fetus is considered viable.
Goals:
1. To prevent fetal death.
2. To avoid fetal neurologic injury.
Indications:
All pregnancies require fetal well being evaluation, however due attention and frequent evaluation is needed for complicated pregnancies with increased risk of perinatal morbidity and mortality.
These conditions include: Prolonged pregnancy, diabetes mellitus, hypertensive disorders of pregnancy (HDP), intra uterine growth restriction (IUGR), Rh-isoimmunization, unexplained previous perinatal loss, ante partum hemorrhage (APH), preterm premature rupture of fetal membranes (PPROM), maternal diseases like cardiac, lung and renal illnesses.
Techniques:
Techniques include: fetal movement assessment, NST, contraction stress test (CST), BPP, modified BPP, and umbilical artery Doppler velocimetry.
Maternal fetal movement assessment
 Is ideal for routine antepartum fetal surveillance.
 A decrease in maternal perception of fetal movement can precede fetal death, sometimes by several days.
 Perception of 10 distinct movements in a period of up to 2 hours is considered reassuring
 Once 10 movements have been perceived, the count may be discontinued.

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 There should be a minimum of 10 movements in 12 hours.
 More than 12 hours to achieve 10 movements alarms further evaluation.
Non- stress test (NST)
 Is usually performed in an outpatient setting.
 In most cases, 20 minutes are required to complete the test.
 It has virtually no contraindications.
 The mother can sit or tilt to the left (left lateral position)
 Fetal heart rate is monitored using the Doppler, ultrasound transducer, or tocodynamometer.
Interpretations:
Reactive (Normal): 2 or more FHR accelerations, at least 15 bpm above the baseline and lasting at least 15 seconds within a 20-minute period.
Non reactive: If the criteria for reactivity are not met.
A nonreactive NST is one that lacks sufficient fetal heart rate accelerations over a 40-minute period.
If the test has been extended for 40 minutes and reactivity has not been seen a BPP or CST should be performed.
Other unusual FHB patterns that indicate fetal jeopardy during NST include: Persistent late or variable decelerations, bradycardia.
Consider delivery if this abnormal pattern persist for more than one minute.
Contraction stress test (CST):
 Also known as the oxytocin challenge test (OCT)

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 Uterine contractions produced a reduction in blood flow to the intervillous space.
 The CST is based on the response of the fetal heart rate to uterine contractions.
 Conducted in the labor and delivery suite or in an adjacent area.
 With the patient in the lateral recumbent position, the fetal heart rate and uterine contractions are simultaneously recorded with an external fetal monitor.
 If at least three spontaneous contractions of 40 seconds’ duration each or longer are present in a 10-minute period, no uterine stimulation is necessary.
 If fewer than three contractions of at least 40 seconds’ duration occur in10minutes, contractions are induced with either nipple stimulation or intravenous administration of dilute oxytocin.
Interpretation: Negative: no late or significant variable decelerations Positive: late decelerations following 50% or more of contractions—even if the contraction frequency is fewer than three in 10 min Equivocal-suspicious: intermittent late decelerations or significant variable decelerations; should be repeated in 24 hours. Most of these tests will become negative. Equivocal-hyperstimulatory: fetal heart rate decelerations that occur in the presence of contractions more frequent than every 2 min or lasting longer than 90 seconds; should be repeated in 24 hours. Unsatisfactory: fewer than three contractions in 10 min or an uninterpretable tracing; should be repeated in 24 hours.
* Because of high false positive rate of CST Positive results should be supplemented with standard BPP

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Contraindications: Premature rupture of fetal membranes, cervical insufficiency, multiple pregnancy, uterine scar, placenta previa, history of previous preterm birth.
Bio physical profile (BPP):
The BPP consists of an NST combined with four observations made by real-time ultrasonography
1. Non stress test (which, if all four ultrasound components are normal, may be omitted without compromising the validity of the test results)
2. Fetal breathing movements (one or more episodes of rhythmic fetal breathing movements of 30 seconds or more within 30 minutes)
3. Fetal movement (three or more discrete body or limb movements within 30 minutes)
4. Fetal tone (one or more episodes of extension of a fetal extremity with return to flexion, or opening or closing of a hand)
5. Determination of the amniotic fluid volume (a single vertical pocket of amniotic fluid exceeding 2 cm is considered evidence of adequate amniotic fluid)
 Each of the five components is assigned a score of either 2 (normal or present as defined previously) or 0 (abnormal, absent, or insufficient).
 A composite score of 8or 10 is normal, a score of 6 is considered equivocal, and a score of 4 or less is abnormal.
 Regardless of the composite score, in the presence of oligohydramnios (largest vertical pocket of amniotic fluid volume ≤ 2 cm), further evaluation is warranted.
Biophysical Profile Score
Interpretation
Recommended Management
10
Normal, non- asphyxiated
No fetal indication for intervention; repeat test weekly except in diabetic patient and prolonged

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pregnancy (twice weekly)
8 Normal fluid
Normal, non- asphyxiated fetus
No fetal indication for intervention; repeat testing per protocol
8 Oligohydramnios
Chronic fetal asphyxia suspected
Deliver if > 37 weeks, otherwise repeat testing
6
Possible fetal asphyxia
If amniotic fluid volume is abnormal, deliver
If normal fluid at > 36 wk with favorable cervix, deliver
If repeat test < 6, deliver
If repeat test > 6, observe and repeat per protocol
4
Probable fetal asphyxia
Repeat testing same day; if biophysical profile score < 6, deliver
0–2
Almost certain fetal asphyxia
Deliver
 The modified BPP combines the NST with the amniotic fluid index (AFI)
 The modified BPP is considered normal if the NST is reactive and the AFI is more than 5, and abnormal if either the NST is nonreactive or the AFI is 5 or less.
 Abnormal modified BPP should be supported by standard BPP and CST.
When to start evaluation?
 Initiating testing at 32–34 weeks of gestation is appropriate for most at-risk patients.
 However, in pregnancies with multiple or particularly worrisome high-risk conditions (eg, chronic hypertension, with suspected intrauterine growth restriction), testing might begin as early as 28 weeks of gestation.

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Frequency of testing
 If the indication for testing is not persistent (eg, a single episode of decreased fetal movement followed by reassuring testing in an otherwise uncomplicated pregnancy), it need not be repeated.
 When the clinical condition that prompted testing persists, the test should be repeated periodically until delivery to monitor for continued fetal well-being
 If the maternal medical condition is stable and CST results are negative, the CST is typically repeated in 1 week
 NST, BPP, or modified BPP are typically repeated at weekly intervals, but in the presence of certain high-risk conditions, such as prolonged pregnancy, type 1 diabetes, intrauterine growth restriction, or pregnancy-induced hypertension, twice-weekly NST, BPP, or modified BPP testing is necessary.
 Deterioration in maternal condition or diminution in fetal activity demand reevaluation regardless of the time elapsed since the last evaluation.
 In the absence of obstetric contraindications, delivery of the fetus with an abnormal test result often may be attempted by induction of labor with continuous monitoring of the fetal heart rate and contractions. If repetitive late decelerations are observed, cesarean delivery generally is indicated.
 Recent, normal antepartum fetal test results should not preclude the use of intrapartum fetal monitoring.
 Generally feto-maternal condition should dictate mode and route of delivery.

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INDUCTION AND AUGMENTATION OF LABOR
Induction of labor: refers to the iatrogenic stimulation of uterine contractions before the spontaneous onset of labor, with the goal of achieving delivery.
 Induction of labor should be undertaken when the benefits of expeditious delivery to either mother or fetus outweigh the risk of continuing the pregnancy. Induction could be planned or emergency
Augmentation of labor: is the stimulation of uterine contractions that began spontaneously but are either too infrequent or too weak, or both.
Indications: Hypertensive disorders of pregnancy, chorioamnionitis, Rh-isoimmunization, congenital anomalies not compatible with life (eg. Anencephaly), diabetes at term, placental abruption, PROM, IUGR, non-reassuring antepartum fetal testing, oligohydramnios, IUFD, prolonged pregnancy, chronic renal diseases, chronic pulmonary diseases.
Contraindications: Prior classic uterine incision or transfundal uterine surgery or metroplasty, active genital herpes infection, placenta previa (major degree) or vasa previa, umbilical cord prolapse, transverse or oblique fetal lie, gross cephalopelvic-disproportion, footling breech, pelvic tumor obstructing the birth canal (tumor previa), acute fetal distress, two or more previous lower uterine cesarean scar, invasive cervical cancer.
Complications of induction: Hyperstimulation (Hypersystole and tachysystole), failed induction, sepsis, hyponatremia, rupture of a vasa previa, umbilical cord prolapsed, placental abruption, postpartum hemorrhage, uterine rupture, iatrogenic prematurity, fetal asphyxia.
Preconditions for induction Parameter Criteria

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Parameter Criteria
Maternal
Confirm indication for induction and review contraindications to labor and/or vaginal delivery
Perform clinical pelvimetry to assess pelvic shape and adequacy of bony pelvis
Assess cervical condition (assign Bishop score)
Review risks, benefits and alternatives of induction of labor with patient
Fetal/neonatal
Confirm gestational age
Assess need to document fetal lung maturity status
Estimate fetal weight (either by clinical or ultrasound examination)
Determine fetal presentation and lie
Confirm fetal well-being
Staff
Ascertain availability of labor ward staff and capability to perform cesarean section
Bishop’s pelvic scoring system
Modified Bishop Score Score Parameter 0 1 2 3
Dilatation (cm)
Closed
1–2
3–4
5 or more
Effacement (%)
0–30
40–50
60–70
80 or more

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Score Parameter 0 1 2 3
Length * (cm)
>4
2–4
1–2
1–2
Station
-3
-2
-1 or 0
+1 or +2
Consistency
Firm
Medium
Soft
Cervical Position
Posterior
Midposition
Anterior
*
This modification replaces percent effacement as one of the parameters of the Bishop score.
 Score ≤ 4 is unfavorable or unripened
 Score 5 – 8 is intermediate
 Score ≥ 9 is favorable
MODES OF INDUCTION
Preinduction cervical ripening indicated when the Bishop’s score is ≤ 4.
1. Prostaglandins
PGE2 (Dinoprostone)
 0.5 mg dinoprostone (prepidil) in 2.5 mL gel for intacervical every 6-12 hours for maximum of 1.5 mg in 24 hours till the cervix becomes favorable. Oxytocin induction will be initiated after 6-12 hours of the last dose.
 10 mg dinoprostone vaginal insert (Cervidil), in a timed release (0.3 mg/hour) left in place for 12 hours. Oxytocin administration can be started after 30-60 minutes of removal.

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PGE1 (Misoprostol)
 25 mcg intra vaginal into posterior fornix is as effective as 100 mcg po administered every 3-6 hours till cervix become favorable. Oxytocin can be initiated after 4 hours of the last dose.
 Patient should remain recumbent for at least 30 minutes after insertion and observed.
The fetal heart rate and uterine activity should be monitored continuously for a period of 30 minutes to 2 hours after administration of the PGE2 gel.
2. Transcervical balloon catheter
 Said to be as effective as prostaglandins and superior to oxytocin in preinduction cervical ripening.
 A deflated Foley catheter, a 16 French 30 mL balloon (25-50 ml ballon), can be passed through an undilated cervix into the extra-amniotic space and then inflated with 30mL of sterile normal saline.
 The balloon is then retracted to rest against the internal os.
 One can just attach the catheter to the thigh.
 The catheter can be left in place until it is extruded typically within 12 hours (should induce cervical ripening within 8-12 hours).
 The cervix will be dilated 2-3 cm when the balloon falls out, which will make amniotomy possible, but effacement may be unchanged.
 Remove non extruded catheters after 24 hours.
3. Hygroscopic dilators
 Laminaria tents are made from desiccated stems of the cold-water seaweed Laminaria digitata or L.japonica.
 When placed in the endocervix for 6-12 hours, the laminaria increases in diameter 3-4 fold by extracting water from cervical tissues, gradually swelling and expanding the cervical canal.

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 Synthetic dilators like lamicel, a polyvinyl alcohol polymer sponge impregnated with 450 mg of MgSO4, and dilapan, which is made from a stable nontoxic hydrophilic polymer of polyacrylonitrile, are also noted to be highly effective in mechanical cervical dilatation.
4. Oxytocin induction:
 Start early in the morning (at 8 A.M) except for emergency indications.
 Encourage the mother to empty her rectum on the day of induction
 Light fluid diet only in the morning.
 Follow fetomaternal conditions
 Check recent Hematocrit
 Oxytocin infusion:
o Secure intravenous line with number 18 cannula
o Dosage is the same for primigravida and multigravida
o Increase the drop rate every 20 minutes until 3-5 contractions are achieved in 10 minutes each lasting for 40-60 seconds.
*Add 6 IU oxytocin to 1000mL of N/S or R/L and start at 6 mu/min. increasing every 20 min. by 6 mU/min.
Drops /min mU /min
20 6
40 12
60 18
80 24
If no adequate contraction, add 6 IU in the same bag and start with,
40 27
60 40
80 54

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If no adequate contraction, add 6 IU in the same bag and start with,
60 69
80 92
After initiation of oxytocin infusion:
 Follow maternal v/s and input/output
 Don’t increase the dose of oxytocin once adequate contractions are achieved.
 In the presence of hyperstimulation, stop infusion and restart when indicated at half the stopping dosage. Thereafter, the dosage is increased at 3 mU/min when appropriate and 1mU/min when hyperstimulation persists.
 Continue the oxytocin for 1 – 2 hours post partum.
*Failed induction is diagnosed when there has been no cervical change or descent of the presenting part after 6-8 hours of labor, or contraction of 3 in 10 min. has not been achieved.
AUGMENTATION OF LABOR
The dosage and protocol is the same to that of induction for both primigravida and multigravida.

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Prolonged pregnancy
Definition: refers to a pregnancy that has extended to or beyond a gestational age of 42 weeks or 294 days from the first day of the last normal menstrual period or 40 weeks gestation from the time of conception.
Incidence: Prolonged pregnancy complicates 3-12% of pregnancies.
Clinical Significance of Prolonged Pregnancy
Fetal risks:
1. Perinatal mortality at ≥ 42 weeks of gestation is twice that at term (4 to 7 versus 2 to 3 per 1,000 deliveries) and increases fourfold at 43 weeks and five to seven-fold at 44 weeks which is associated with: Fetoplacental insufficiency, asphyxia (with and without meconium), intrauterine infection, and anencephaly.
2. Higher incidence of macrosomia (4500 g) (2.5 to 10 versus 0.8 to 1 %) leading to complications including prolonged labor, fetopelvic disproportion, and shoulder dystocia with resultant risks of orthopedic or neurologic injury.
3. Fetal dysmaturity (postmaturity) syndrome (20 %), which describes infants with characteristics of chronic intrauterine growth restriction from uteroplacental insufficiency.
Maternal risks:
 Increase in labor dystocia (9 to 12 percent postterm versus 2 to 7 percent at term),
 Increase in severe perineal injury related to macrosomia (3.3 versus 2.6 percent at term)
 Doubling in the rate of cesarean delivery which is associated with higher risks of complications such as endometritis, hemorrhage, and thromboembolic disease.
Determining Gestational Age:
 Accurate pregnancy dating is critical to the diagnosis

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 There are two categories of pregnancies that reach 42 completed weeks:
1. Those truly 40 weeks past conception.
2. Those of less advanced gestation due to inaccurate estimate of gestational age.
Because there is no method to identify pregnancies that are truly prolonged, all pregnancies judged to be 42 completed weeks should be managed as if abnormally prolonged.
The diagnosis of prolonged pregnancy is made by confirmation of the gestational age by referring to:
 The first day of the LNMP to calculate the estimated date of confinement (EDC).
 Date of quickening (maternal perception of fetal movement) and begins around 16 weeks of gestation in multigravidas and 18 weeks in primigravidas.
 Uterine size that increases with gestational age.
 The uterus is a pelvic organ until 12 weeks, at which time the fundus can be palpated at the level of the symphysis pubis.
 The uterine fundus is palpable at the umbilicus around 20 weeks.
 Between 20 and 36 weeks, the measurement of the uterus in centimeters from the symphysis pubis to the fundus approximates the gestational age within 2 weeks.
 Fetal heart tones
 Pinnard sthetoscope at 18-20 weeks
 Electronic Doppler ultrasound may detect fetal heart tones as early as 10 to 11 weeks' gestation.
 Positive pregnancy test in urine by 6 weeks from LNMP
 Ultrasound examination
 First trimester measurement of the crown-rump length (CRL) is accurate to within 5 to 7 days of the actual gestational age.

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 Second- and third-trimester ultrasound parameters for determining gestational age include biparietal diameter (BPD), femur length (FL), and abdominal circumference (AC).
 In the second trimester, BPD is the most accurate but only to within 14 days of the actual gestational age.
 Measurements in the third trimester may have an error up to ±21 days of the actual gestational age.
Management
The goal of management of prolonged pregnancy is to decrease the risk of an adverse perinatal outcome.
Antenatal testing and induction of labor are the two most widely used strategies for management.
1. Antenatal testing: Generally started twice weekly between 41 and 42 weeks' gestation. It can include nonstress test (NST), contraction stress test (CST), or biophysical profile (BPP)
 Weekly NST with CST for nonreactive NST.
 Twice weekly NST with BPP for nonreactive NST with induction for a 4/10 BPP.
 Twice weekly NST with BPP for nonreactive NST and a weekly determination of the amniotic fluid volume.
N.B: At each visit determining the bishop’s score should be done
2. Induction of labor:
 Induction of labor may be performed at 41 weeks if the cervix is favorable.
 If the cervix is unfavorable, then expectant management with antepartum fetal surveillance should be continued.
 Generally, at 42 weeks of gestation, if the cervix remains unfavorable, prostaglandins are administered to ripen the cervix for induction.
 A cervix is determined to be favorable by its Bishop score. Induction is usually successful with a score of 9 or greater.

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 Intrapartum management includes a one-to-one Pinnard sthetoscope follow up, continuous electronic fetal heart rate monitoring.

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OPERATIVE VAGINAL DELIVERY
DEFINITION: Operative vaginal delivery refers to a delivery in which the operator uses forceps or a vacuum device to assist the mother in delivering the fetus.
INDICATIONS: ACOG outlined the following indications for operative vaginal delivery (forceps or vacuum).
Indications for Operative Vaginal Delivery
Type
Indication
Fetal
 Presumed fetal compromise (e.g., non-reassuring fetal heart rate pattern)
Maternal
 Medical indications to avoid Valsalva (e.g., cardiac disease Class III or IV hypertensive crises, cerebral vascular disease, particularly uncorrected cerebral vascular malformations, myasthenia gravis, spinal cord injury)
Prolonged second stage of labor (inadequate progress)
 Nulliparous women: lack of continuing progress for three hours with regional anaesthesia, or two hours without regional anaesthesia
 Multiparous women: lack of continuing progress for two hours with regional anaesthesia, or one hour without regional anaesthesia
 Maternal fatigue/exhaustion
Prerequisites for Operative Vaginal Delivery
Preparation
Essential
Full abdominal and vaginal examination
 Head is < 1/5 palpable per abdomen
 Vertex presentation
 Cervix is fully dilated (≥8 cm for ventouse) and the membranes

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ruptured
 Exact position of the head can be determined*
 Fetal size has been estimated**
 Pelvis is deemed adequate
Mother
 Informed consent be obtained and clear explanation given***
 A pudendal block may be appropriate, particularly in the context of urgent delivery
 Maternal bladder has been emptied recently
 Indwelling catheter should be removed or balloon deflated
 Aseptic techniques
Staff
 Operator must have the knowledge, experience, and skills necessary to use the instruments
 Adequate facilities and back-up personnel are available
 Back-up plan in place in case of failure to deliver
 Anticipation of complications that may arise (e.g., shoulder dystocia, postpartum hemorrhage)
 Personnel present who are trained in neonatal resuscitation
*Fetal presentation, position, lie, and any asynclitism are known. The fetus must be in a vertex presentation (unless the purpose is to use forceps to assist in delivery of face presentation in mentum anterior position and an after-coming head in breech presentation).

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**Minimum and maximum estimated fetal weight: Instrumental delivery of the macrosomic infant (birth weight >4000 g) may be associated with an increased risk of injury. Vacuum devices should not be used to assist delivery prior to 34 weeks of gestation (mean birth weight 2500 g) because of increased risks of fetal intraventricular hemorrhage in premature infants.
***The risks of the procedure should be explained to the woman & the informed consent discussion (with specific risks, benefits, and alternatives delineated) should be documented.
NB: The prerequisites for application of forceps or vacuum extractor are identical.
Mnemonic checklist:
Think “FORCEPS” before operative vaginal delivery:
F: The fetus is in a favorable head position, and an assessment of fetal weight and status done.
O: The patient has a completely dilated cervical OS, and the operating room is ready if needed.
R: Membranes are ruptured, and the patient qualifies for operative vaginal delivery under the rule of threes, defined as: "In an OA [occiput anterior] presentation, if the sum of the number of fifths of the fetal head palpated above the pelvic inlet abdominally and the degree of molding of the fetal head palpated vaginally equals or exceeds three, then attempted operative vaginal delivery is likely to be unsuccessful and should be avoided."
C: Contractions are present, and the patient has given consent for operative vaginal delivery.
E: The fetal head is engaged, the maternal bladder is empty, and the mother has an epidural or other anesthesia on board.
P: The maternal pelvis is adequate for operative vaginal delivery, team is prepared for cesarean delivery, and a pediatrician is available.
S: This stands for stirrups, a reminder to check that the patient is in the lithotomy position with her buttocks over the end of the bed.
Contraindications:

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Most contraindications to instrumental delivery are related to the potential for unacceptable fetal risks.
 Some other contraindications include: known fetal demineralizing diseases (eg. osteogenesis imperfecta), fetal bleeding diatheses (e.g., hemophilia, alloimmune thrombocytopenia), unengaged head, unknown fetal position, malpresentation (e.g., brow), and suspected feto-pelvic disproportion (FPD).
 Vacuum devices should not be used to assist delivery prior to 34 weeks of gestation because of the risk of fetal intraventricular hemorrhage, cephalhematoma, and neonatal jaundice. Prior scalp sampling or multiple attempts at fetal scalp electrode placement are also relative contraindications to vacuum extraction since these procedures may increase the risk of cephalhematoma or external bleeding from the scalp wound.
 Vacuum is also not recommended to perform a rotation.
 The vacuum extractor is contraindicated with mal presentations.
Trial of instrumental delivery:
An operative vaginal delivery should only be considered when the likelihood of success is high.
Variables associated with an increased risk of failed operative delivery:
 Two common causes are occiput posterior position and macrosomia.
 Other factors: more than one fifth of the head palpable abdominally, the presenting part only as far as the ischial spines, excessive molding of the fetal head, protracted labor, and maternal obesity.
Classification of forceps deliveries:
 With respect to operative vaginal delivery of the vertex, station is defined as the relationship of the estimated distance, in centimeters, between the leading bony portion of the fetal head and the level of the maternal ischial spines.

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Classification for Operative Vaginal Delivery
Term
Definition
Outlet
 Fetal scalp visible without separating the labia
 Fetal skull has reached the pelvic floor
 Sagittal suture is in the antero-posterior diameter or right or left occiput anterior or posterior position (rotation does not exceed 45 degrees)
 Fetal head is at or on the perineum
Low
 Leading point of the skull (not caput) is at station + 2 cm or more and not on the pelvic floor
 Two subdivisions:
A. Rotation of 45 degrees or less
B. Rotation more than 45 degrees
Mid
High
 Better not be done in our setup
 Not included in the classification
Choice of instrument:
 The choice of instrument is determined by level of training with the various forceps and vacuum equipment.
 In general, vacuum devices are easier to apply, place less force on the fetal head, require less maternal anesthesia, result in less maternal soft tissue trauma, and do not affect the diameter of the fetal head compared to forceps.

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 By comparison, the advantages of forceps are that they are unlikely to detach from the head, can be sized to a premature cranium, may be used for a rotation, result in less cephalhematoma and retinal hemorrhage, and do not aggravate bleeding from scalp lacerations.
 Vacuum delivery is probably safer than forceps for the mother, while forceps are probably safer than vacuum for the fetus.
Vacuum:
 Soft vacuum extractor cups (silicone, plastic, rubber) are more likely to fail in achieving vaginal delivery than rigid (metal, plastic).
 Soft cups are associated with fewer scalp injuries & no differences between groups in regard to maternal injury.
 Metal or rigid cups are more suitable for occiput posterior, transverse, and difficult occiput anterior deliveries, whereas the soft cups are appropriate for uncomplicated deliveries.
Forceps:
 In general, the instrument selected should have cephalic and pelvic curves appropriate to the size and shape of the fetal head, maternal pelvis, and planned procedure.
 Simpson type forceps tend to fit a long molded head, Elliott or Tucker-McLane type forceps are better suited to a round unmolded head, Kielland forceps are useful for rotations because of their minimal pelvic curve and sliding lock, and Piper forceps is used for after coming head in breech presentation.
APPLICATION:
Forceps: Appropriately applied forceps grasp the occiput anterior (OA) fetal head such that:
 The long axis of the blades corresponds to the occipitomental diameter

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 The tips of the blades lie over the cheeks
 The blades are equidistant from the sagittal suture, which should bisect a horizontal plane through the shanks
 The posterior fontanelle should be one finger breadth anterior to this plane
 Fenestrated blades should admit no more than one finger breadth between the heel of the fenestration and the fetal head
 No maternal tissue has been grasped.
To reduce the risk of laceration, forceps are disarticulated and removed when expulsion is certain but before the widest diameter of the fetal head passes through the introitus.
Vacuum:
 Successful use of the vacuum extractor is determined by proper application on the fetal head and traction within the pelvic axis.
 The leading point of the fetal head is the ideal position for vacuum cup placement. It is labeled the flexion point or pivot point and is located on the sagittal suture 2 to 3 cm anterior to the posterior fontanele. Placement of the vacuum cup over the pivot point maintains the attitude of flexion for a well-flexed head and creates flexion in a deflexed head if traction is applied correctly.
Traction:
 Traction with forceps (or vacuum) should be steady (not rocking) and in the line of the birth canal.
 Traction should be exerted with each contraction and in conjunction with maternal expulsive efforts; the forceps can be relaxed between contractions to reduce fetal cranial compression.

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 In most cases, progress is noted with the first or second pull and delivery occurs by the third pull.
When to abandon operative delivery:
 The decision to proceed with operative vaginal delivery is ongoing, decided moment by moment based on assessment of the success of the various steps in the procedure.
 Operative vaginal delivery should be abandoned where there is no evidence of progressive descent with each pull or where delivery is not imminent following three pulls of a correctly applied instrument by an experienced operator.
 Operative vaginal delivery should be abandoned if it is difficult to apply the instrument, descent does not easily proceed with traction, or the baby has not been delivered within a reasonable time (15 to 20 minutes).
 If descent has occurred and delivery is clearly imminent, then proceeding with instrumental delivery after three pulls may be appropriate and less morbid than a cesarean delivery of an infant with its head on the perineum.
 The operator should not be fixated on effecting a vaginal delivery.
Sequential attempts at instrumental delivery:
 ACOG has suggested that multiple attempts at operative vaginal delivery using different instruments (vacuum, different types of forceps) be avoided due to the greater potential for maternal and/or fetal injury.
 It should not be considered as sequential delivery in situations where proper placement of forceps cannot be achieved or a vacuum device fails to achieve suction and no traction has been applied and then a second instrument is used.
Should prophylactic antibiotics be given?
 No sufficient data to make recommendations on prophylactic antibiotics in operative vaginal delivery.

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Risks of operative vaginal deliveries:
Maternal complications
Short-term: pain at delivery, lower genital tract lacerations and hematomas (periurethral/labial laceration, vaginal laceration, 3rd or 4th degree perineal laceration, vulvar or vaginal hematomas, or cervical lacerations), urinary retention and incontinence, anemia, anal incontinence.
Severe maternal trauma is primarily associated with rotational and midforceps operations; direct bladder injury, ureteral lacerations/transections, and uterine rupture have been reported in such cases.
Fetal position also has an impact on the risk of maternal trauma during delivery. The rate of rectal injury is higher for instrumental delivery from the occiput posterior (OP) compared with the occiput anterior (OA) position.
Long-term: Long-term maternal sequelae from operative delivery are primarily related to potential disturbances in urinary and anal function, such as urinary incontinence, fecal incontinence, pelvic organ prolapse, and, occasionally, fistula formation.
Neonatal complications
Short-term: are usually caused by head compression and traction on the fetal intracranial structures, face, and scalp. The most serious complication is intracranial hemorrhage. Others: bruises and lacerations, facial nerve palsy, cephalhematoma, retinal hemorrhage, subgaleal hemorrhage, and skull fracture.
Long-term: intracranial hemorrhage (subdural, subarachnoid, intraventricular and/or intraparenchymal hemorrhage) and neuromuscular injury.
Developmental outcome appears to be equivalent for both forceps and vacuum assisted births.

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MALPRESENTATIONS
Etiologies: High parity, pelvic tumors, pelvic contracture, uterine malformation, prematurity, multiple gestations, polyhydramnios, macrosomia, hydrocephaly, trisomies, anencephaly, myotonic dystrophy, placenta previa.
Deflection attitudes
 “Attitude” refers to the position of the fetal head in relation to the trunk.
 The normal attitude of the fetal vertex during labor is one of full flexion on the neck, with the fetal chin against the upper chest.
 Deflexed attitudes include various degrees of deflection or even extension of the fetal head on the neck.
 Spontaneous conversion to a more normal flexed attitude or further extension of an intermediate deflection to a fully extended position commonly occurs as labor progresses owing to resistance exerted by the bony pelvis and soft tissues.
 Although safe vaginal delivery is possible in many cases, experience indicates that cesarean delivery is the only appropriate alternative when arrest of progress is observed.
Face presentation
 Face presentation is characterized by a longitudinal lie and full extension of the fetal head on the neck, with the occiput against the upper back.
 The fetal chin (mentum) is chosen as the point of designation during vaginal examination.
 The reported incidence of face presentation is about 0.2 percent, or 1 in 500 live births overall.
 The diagnosis can be suspected anytime abdominal palpation finds the fetal cephalic prominence on the same side of the fetal back; however, face presentation is more often discovered by vaginal examination.
 Less than 1 in 20 infants with face presentation are diagnosed by abdominal examination.

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 At diagnosis, 60 to 80 percent of infants with a face presentation are mentum anterior, 10 to 12 percent are mentum transverse, and 20 to 25 percent are mentum posterior.
 Most mentum transverse and 25 to 33 percent of mentum posterior fetuses will rotate and deliver vaginally in the mentum anterior position.
 Prolonged labor is a common feature of face presentation. Therefore, prompt attention to an arrested labor pattern is recommended.
 In the case of an average or small fetus, adequate pelvis, and hypotonic labor, in mentum anterior position oxytocin may be considered with strict follow up, but an arrest of progress despite adequate labor should call for cesarean delivery.
 Continuous intrapartum electronic (one-to-one Pinnard stethoscope) fetal heart rate monitoring of a fetus with face presentation is considered mandatory.
 Cesarean delivery is warranted if a non-reassuring heart rate pattern is identified, even if sufficient progress in labor is occurring.
 Safe vaginal delivery may be accomplished in many cases of face presentation, and a trial of labor with careful monitoring of fetal condition and labor progress is not contraindicated unless macrosomia or a small maternal pelvis is identified.
Brow presentation
 The reported incidence of brow presentation is about 1 in 1,500 deliveries
Diagnosis:
 Diagnosed when portion of the fetal head between the orbital ridge and the anterior fontanel presents at the pelvic inlet.
 Fetal head occupies a position midway between full flexion (occiput) and extension (mentum or face).
 Except when the fetal head is small or the pelvis is unusually large, engagement of the fetal head and subsequent delivery cannot take place as long as the brow presentation persists.
 The frontal bones (frontum) are the point of designation.

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 Brow presentation is detected more often in early labor before flexion occurs to a normal attitude. Less frequently, further extension results in a face presentation.
 In general, factors that delay engagement are associated with persistent brow presentation. Cephalopelvic disproportion, prematurity, and great parity are found in more than 2/3 of cases with persistent brow presentation.
 Brow presentation is detected on vaginal examination.
 A persistent brow presentation requires engagement and descent of the largest (mento- occipital) diameter or profile of the fetal head.
 One cause of persistent brow presentation may be an open fetal mouth pressed against the vaginal wall, splinting the head and preventing either flexion or extension.
 Expectant management may be justified only with a large pelvis, a small fetus, and adequate progress of labor.
 Consideration of a trial of labor with careful monitoring of maternal and fetal conditions over 4 – 6 hours may be appropriate.
 If a brow presentation persists with a large baby, successful vaginal delivery is unlikely, and cesarean delivery may be most prudent.
Compound presentation
 An extremity prolapses alongside the presenting part, with both presenting in the pelvis simultaneously.
 Its incidence is about 1 in 1000.
 Causes of compound presentations are conditions that prevent complete occlusion of the pelvic inlet by the fetal head, including preterm birth.
 The combination of an upper extremity and the vertex is the most common.
 This diagnosis should be suspected with any arrest of labor in the active phase or failure to engage during active labor.
 Diagnosis is made by vaginal examination by discovery of an irregular mobile tissue mass adjacent to the larger presenting part.
 The very small premature fetus is at great risk of persistent compound presentation.

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 In late pregnancy, external cephalic version of a fetus in breech position increases the risk of a compound presentation.
 Fetal risk in compound presentation is specifically associated with birth trauma, cord prolapse (11 – 20%), neurologic and musculoskeletal damage to the involved extremity.
 Maternal risks include soft tissue damage and obstetric laceration.
 Labor is not necessarily contraindicated with a compound presentation; however, the prolapsed extremity should not be manipulated. The accompanying extremity may retract as the major presenting part descends.
 Seventy-five percent of vertex/upper extremity combinations deliver spontaneously.
 Occult or undetected cord prolapse is possible, and therefore, continuous electronic (one- to-one Pinnard stethoscope) fetal heart rate monitoring is recommended.
 The primary indications for surgical intervention are cord prolapse, non-reassuring fetal heart rate patterns, and arrest of labor.
Breech presentation
 The infant presenting as a breech occupies a longitudinal axis with the cephalic pole in the uterine fundus.
 Occurs in 3 - 4 % of labors overall.
 The three types of breech presentations are: Frank breech (flexed at the hips with extended knees), complete breech (flexed at both hip and knee joints), and footling breech (one or both hips partially or fully extended).
Diagnosis: abdominal palpation or vaginal examination and ultrasound to confirm the diagnosis
 The hard, round, readily ballotable fetal head is found to occupy the fundus.
 If engagement has not occurred, the breech is movable above the pelvic inlet.
 Fetal heart sounds usually are heard loudest slightly above the umbilicus.
Vaginal examination

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 With the frank breech presentation, ischial tuberosities, the sacrum, and the anus usually are palpable, and after further descent, the external genitalia may be distinguished. The most accurate information, however, is based on the location of the sacrum and its spinous processes, which establishes the diagnosis of position and variety.
 In complete breech presentations, the feet may be felt alongside the buttocks, and
 In footling presentations, one or both feet are inferior to the buttocks. In footling presentations, the foot can readily be identified as right or left on the basis of the relation to the great toe. When the breech has descended further into the pelvic cavity, the genitalia may be felt.
Ultrasonography:
 It confirms the clinical diagnosis
 It can detect fetal congenital abnormality, congenital anomalies of the uterus, & placenta location.
 It measures GA & approximate weight of the fetus
 Attitude of the fetus
Positions: The sacrum is the denominator of breech; L.S.A (the commonest), R.S.A, R.S.P, and L.S.P
Antenatal management:
 Identification of complicating factors associated with breech
 External cephalic version, if not contraindicated
 Formulation of the line of management, if version fails or is contraindicated
1. ECV: To minimize the high perinatal mortality associated with vaginal breech delivery and to reduce the risk of cesarean section.
 The success rate of version is about 60%.

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 It can be considered at 35 - 37 weeks but can be attempted at any time there after up to early labor.
 Hypertonus or irritable uterus can be overcome with the use of tocolytic drugs.
 Successful version is likely in cases of: Complete breech, non-engaged breech, sacroanterior position (fetal back anterior), adequate liquor, non obese patient.
 Contraindications to ECV: APH, major congenital abnormalities of the fetus, IUFD, hyperextension of the head, IUGR, multiple pregnancy, ruptured membranes, known congenital malformation of the uterus, contracted pelvis, previous C/S, severe pre- eclampsia, obesity, elderly primigravida, bad obstetric history
 Dangers of version: Preterm labor and PROM, placental abruption, cord entanglement, cord knotting and fetal death, increased chance of fetomaternal bleeding (immunoprophylaxis with anti-D gamma globulin for RH-negative mothers), amniotic fluid embolism
3. Management of breech presentation if version fails or is contraindicated:
 Pregnancy is to be continued with usual check up, and spontaneous version may occur.
 If breech persists, do elective C/S or allow spontaneous labor to start and vaginal breech delivery to occur.
 Indications for cesarean delivery:
 Big baby ( EFW > 3500 gms)
 Hyper extension of the head
 Footling breech presentation
 Suspected pelvic contraction
 Any associated obstetric complication
 Delivery of preterm breech (weight < 1500 gms)
 Vaginal breech delivery is considered in those with:
 Adequate pelvis

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 Average fetal weight(1500 - 3500 gms)
 Flexed head and without any other complication ( frank breech is preferred)
 A woman with a fetus presenting as a breech should not be allowed to labor unless:
 Anesthesia coverage is immediately available
 Cesarean delivery can be undertaken promptly
 Continuous fetal heart rate monitoring or one-to-one pinnard sthetoscope follow up is used
 The delivery is attended by someone who is experienced with vaginal breech delivery.
Management of vaginal breech delivery
First stage:
 Spontaneous onset of labor increases the chance of successful vaginal delivery
 Vaginal examination is indicated at the onset of labor for pelvic assessment and soon after rupture of fetal membranes to exclude cord prolapse.
 Secure I.V- line with crystalloid, avoid oral intake and determine Hct & blood group.
 Monitor fetal status and progress of labor.
Second stage:
 Methods of vaginal breech delivery:
 Spontaneous (10%): this is not preferred
 Assisted breech delivery: delivery is assisted from the beginning to the end. This method should be employed in all cases
 Breech extraction: when the entire body of the fetus is extracted by the obstetrician. Indication is only in the delivery of the second twin after internal podalic version as a life saving procedure when c/d is not possible.

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Assisted breech delivery:
 Episiotomy is done when required as the bitrochanteric diameter of the fetus crowns
 Don’t touch the fetus until the buttocks are delivered along with the legs in flexed breech and the trunk slips up to the umbilicus.
 The Pinnard maneuver may be needed to facilitate delivery of the legs in a frank breech presentation, pressure is applied to the medial aspect of the knee, which causes flexion and subsequent delivery of the lower leg.
 A cardinal rule in successful breech delivery is to employ steady, gentle, downward rotational traction until the lower halves of the scapulae are delivered outside the vulva, making no attempt at delivery of the shoulders and arms until one axilla becomes visible.
 Deliver the anterior shoulder first, but if rotation is difficult deliver the posterior shoulder first.
 Louvset’s maneuver can be used when one or both arms may be fully stretched along the side of the head or lie behind the neck (nuchal displacement) resulting in arrest with delivery of the trunk up to the costal margins.
 Then the baby is wrapped with sterile towel.
Delivery of the after coming head:
 The fetal head may be extracted with Piper forceps or by one of the following maneuvers:
1. Mauriceau – Smellie - Veit (MSV) Maneuver (Malar flexion and shoulder traction):
 The index and middle fingers of one hand are applied over the maxilla, to flex the head, while the fetal body rests on the palm of the hand and forearm.
 Gentle suprapubic pressure simultaneously applied by an assistant helps keep the head flexed.
 The body then is elevated toward the maternal abdomen.

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2. Prague Maneuver
 Rarely, the back of the fetus fails to rotate to the anterior.
 Posteriorly, extraction may be accomplished using the MSV maneuver and delivering the fetus back down. If this is impossible,
 Modified Prague maneuver: two fingers of one hand grasping the shoulders of the back-down fetus from below while the other hand draws the feet up over the maternal abdomen.
3. Forceps for after-coming head
 Specialized forceps can be used to deliver the after-coming head.
 Piper forceps may be applied electively or when the MSV maneuver cannot be accomplished easily.
4. Burn Marshal Method: down ward traction of the fetus till the fetal occiput, then rotating the fetal back towards the maternal abdomen with gentle traction and an assistant applying suprapubic pressure to facilitate flexion.
Entrapment of the After-coming Head:
 With gentle traction on the fetal body, the cervix, at times, may be manually slipped over the occiput. If this is not successful, then
 Dührssen incision is usually necessary, which is usually done at 2 and 10 O’clock positions on the cervix.
 Zavanelli maneuver: Replacement of the fetus higher into the vagina and uterus, followed by cesarean delivery, but these days it is obsolete.
 Symphysiotomy is used to widen the anterior pelvis.
Habitual / recurrent breech: When it recurs in three or more consecutive pregnancies. The probable causes are uterine malformation & repeated cornu-fundal attachment of the placenta.

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ANTENATAL CARE (ANC)
 ANC is the health care given to a pregnant woman so as to ensure the birth of healthy baby with minimal health risk to the mother.
 Thus it is a goal oriented with interventions to achieve the medical and psychological needs of pregnant women, which have proven values.
 Its strategies target pregnant women to help them maintain normal pregnancies & delivery through:
 Identification of pre-existing health conditions
 Early detection of complications arising during pregnancy
 Health promotion & disease prevention
 Birth preparedness and complication readiness planning
I) Identification of pre-existing health conditions; current health & pregnancy status of the women
 Can be identified during initial assessment (1st visit); regardless of trimesters through; detailed history, examinations, and laboratory investigations during subsequent visits.
Detailed History:
Includes:
 Identification: age, address, religion, educational status…
 HPP: gravidity, parity, abortions…
 LNMP date (if known), assess reliability of menses, calculate GA & EDD
 Is the current pregnancy planned/unplanned, wanted/ unwanted, supported / unsupported?
 Symptoms & signs of pregnancy (if early)
 Date of quickening
 Vaginal bleeding, discharge, leakage of liquor

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 Any complaint or concerns.
 Past obstetric History:
 All previous pregnancies in detail
 Complications which can recur or have an impact on current pregnancy
 Complications / health problems during:
 Antepartum: Preterm labour, APH, Preeclampsia/ eclampsia, PROM
 Intrapartum: Prolonged labor, mode of delivery (SVD, C/D, instrumental vaginal delivery, repaired uterine rupture), place of delivery, birth outcome (Preterm/term/post-term, Alive/dead, birth weight, congenital anomaly)
 Postpartum: PPH, infections, ENND
 Past Gynaecologic History:
 History of: Female genital mutilation, ectopic pregnancy, STIs & HIV (personal & of the partner), gynecologic operations; myomectomy, removal of septum, fistula repair, cone biopsy, cervical cerclage.
 Past medical & surgical History:
 History of: Malaria infection, heart disease, renal disease, anemia, DM, tuberculosis, chronic HTN.
 Personal, Social & Family History:
 Family history of: DM, HTN, multiple pregnancies, congenital anomaly.
 Personal habits of: Smoking, alcohol drinking, illicit drug use.
Physical Examination focusing on:
 G/A
 V/S: BP, PR, RR, Temperature, weight including pre-pregnancy weight, height, BMI.
 HEENT:- Clinical signs of anemia, icterus, edema
 Glands: - breasts, thyroid gland, Lymph nodes
 Abdomen:
 As in general medical examination of the abdomen
 Obstetric examination:
- Uterine size in Weeks (symphysis - fundal height in cm)
- Fetal presentation, lie, attitude, descent, multiple fetal parts & FHB

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 GUS: CVA tenderness, vulvar ulcer, discharge, speculum examination: Evaluation of the vagina & cervix
- Digital pelvic examination (when indicated); pelvic mass.
 Signs of violence
 MSS: edema (site/type, grade)
 CNS: consciousness, orientation.
Laboratory Investigation:
Basic investigations/initial screening should include the following studies:
 Hct/Hgb level
 Blood group & Rh
 U/A for : protienuria, glucose, ketone, infection
 Serologic examination for syphilis, HBSAg
 PICT
 Other investigations as indicated
II) Early detection of Complications arising during pregnancy
 Timing: during initial evaluation & during subsequent visits
 Talk with her & examine her for problems of pregnancy that might need treatment & closer monitoring: Anemia, infection, vaginal bleeding, HDP, abnormal fetal growth & presentations (after 36 weeks)
History: - Revise history for pre-existing conditions previously identified
- Ask for: Complaints & concerns, danger signs and symptoms of pregnancy, fetal movements, social support/physical abuse
Physical Examination: As in initial examination emphasize on:
 G/A
 V/S: BP with notation of any change, weight gain (both excessive or under weight gain is dangerous)
 HEENT: Clinical signs of anemia & edema, icterus

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 Systemic examination
 Abdominal Examination: Obstetric examinations: Uterine fundal height measurement (Weeks/ Cms), fetal presentation, Lie, FHB & fetal well being assessments
 Signs of physical abuse
 GUS: CVA tenderness, pelvic examination if indicated
Laboratory Investigations:
 Basic laboratory investigations if not done previously
 Repeat these during 3rd trimester: Hgb/Hct level, DM screening with 1 hr GTT, repeat antibody test in un-sensitized patient who are Rh –ve at 28- 30 Wks.
 Other investigations based on indications.
III) Health promotion, Disease prevention & Provision of care
 Should be provided at each visits
 Includes counseling, early recognition/detection of complications of pregnancy, provision of care for disease prevention & treatment of identified health problems
 Counsel about important issues affecting health of the mother & the new born:
 Danger symptoms & signs of pregnancy: Complication during pregnancy & labor, how to recognize the problems, what to do if encountered, and where to get help.
 Nutrition: The importance of good nutrition, how to get enough calories & essential nutrients for a healthy pregnancy, micronutrient supplements.
 Risk of: Tobacco smoking, alcohol drinking, chat chewing, medications & local drugs
 Rest, activities, avoidance of heavy physical work & sexuality
 Transportation
 Personal hygiene, prevention of infections
 Family planning: Benefit of child spacing, options of family planning services
 BF: Health & practical benefits, exclusive breast-feeding, importance of breast- feeding immediately after delivery

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 HIV & other STIs: Condom’s dual protection, other measures of protection, availability & benefits of testing (including her partner), specific issues related to MTCT & living with AIDS (after positive test result)
 Provide: Treatment for identified problems, immunization for tetanus HBV, PMTCT, Fe &Folic acid supplementations (folate supplementation prior to conception & throughout first trimester), malaria prophylaxis, and intestinal parasites treatment.
 Next appointment/visit: Importance of next visits, timing should be individualized according to the risk identified, for pregnancies in which no risk identified follow the countries schedule recommendations
NB: In addition to the above, at each visits look for and manage risk factors & complications of pregnancy
IV) Birth preparedness & complication Readiness
 Discuss and help her in:
 Preparation for child birth
 Making arrangements for her new born
 Need for safe & clean delivery
 Plan for: Skilled provider to be at birth, place for birth & how to get there
 Items needed for the birth like money
 Support from family, neighbors, & community who accompany her
Frequency of Visits
 The current available evidence based studies showed that decreasing the number of visits need not compromise maternal & fetal out come. Thus;
 Reduced number of visits can be safely applied to apparently low risk pregnancies in resource limited setting.
 WHO recommends a minimum of 4 visits for pregnancies in which risks not identified.
 Our country has adopted this recommendation and MOH has established this system in health institutions giving ANC.

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 Remark: pre-existing maternal health conditions, disease status developing during pregnancy and complications of pregnancy could dictate more frequent visits and
 They should visit health institution if any complaints or problems encountered.
Schedules/visits for pregnancies in which risks not identified:
No. of Visit
Timing
1st visit
Missed period to Better before 16 wks
2nd visit
Better 24-28 wks
3rd visit
Better 30-32 wks
4th visit
Better 36-40 wks
Minimum services and health care needed to be given during follow- up for current pregnancy recommended by FMOH:
Activities
Visits
1st visit
2nd visit
3rd visit
4th visit
Date of visit
GA in completed Wks ( from LNMP)
BP( mm Hg)
Weight (Kg)
Pallor
Uterine heights(wks)
Fetal heart beat
Presentation
U/A-infection
U/A-protein
VDRL
Hgb/Hct level

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Blood Group & Rh
TT dose
Iron/folic acid
Mebendazole
Use of ITN
ARV Px (type)
Danger sign identified & investigation:
Action, advice and counseling given
Appointment for next follow-up
Remark
Name & signature of care provider
* Shaded = Not to be done / given.