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Normal puerperium.
Anatomical and
phisiological changes
during puerperium,
condaction of
puerperium. Lactation.

First 6 weeks postpartum to be the
puerperium.
During this time, the reproductive tract
returns anatomically to a normal
nonpregnant state, and in most women
who are not breast feeding, ovulation is
reestablished.
Definition

INVOLUTION OF THE BODY OF THE
UTERUS.
 After placental expulsion, the fundus of the
contracted uterus is slightly below the
umbilicus. After the first 2 days, the uterus
begins to shrink.
 Within 2 weeks, it has descended into the
cavity of the true pelvis.
 It regains its previous nonpregnant size within
about 4 weeks.
 The immediately postpartum uterus weighs
approximately 1 kg. 1 week later it weighs
about 500 g, at the end of the second week to
about 300 g, and soon thereafter to 100 g or
less. The total number of muscle cells does not
decrease appreciably.

REGENERATION OF ENDOMETRIUM
 Within 2 or 3 days after delivery, the remaining
decidua becomes differentiated into two layers.
 The superficial layer becomes necrotic, and it is
sloughed in the lochia.
 The basal layer adjacent to the myometrium,
which contains the fundi of endometrial glands,
remains intact and is the source of new
endometrium.

REGENERATION OF ENDOMETRIUM
 Endometrial regeneration is rapid, except at the
placental site. Within a week or 10 days, the
free surface becomes covered by epithelium, and
the entire endometrium is restored during the
third week.
 The so-called endometritis identified
histologically during the reparative days of the
puerperium is only part of the normal process of
repair.

INVOLUTION OF THE PLACENTAL
SITE.
 Complete extrusion of the placental site takes up
to 6 weeks. This process is of great clinical
importance, for when it is defective, late
puerperal hemorrhage may ensue.
 Immediately after delivery, the placental site is
about the size of the palm of the hand. By the
end of the second week, it is 3 to 4 cm in
diameter.
 Within hours of delivery, the placental site
normally consists of many thrombosed vessels
that ultimately undergo the typical organization
of a thrombus.

CHANGES IN THE UTERINE VESSELS.
 After delivery, the caliber of extra uterine
vessels decreases to equal, or at least
closely approximate, that of the
prepregnant state.
 Within the puerperal uterus, blood vessels
are obliterated by hyaline changes, and
vessels that are smaller replace them.

CHANGES IN THE CERVIX.
 Immediately after the third stage of labor,
the cervix and lower uterine segment are
thin, collapsed, flabby structures.
 The cervical opening contracts slowly, and for
a few days immediately after labor, it readily
admits two fingers.
 By the end of the first week, it has narrowed
to a one-finger diameter. As the cervical
opening narrows the cervix thickens, and a
canal is reformed.

VAGINA AND VAGINAL OUTLET
 Early in the puerperium, the vagina and
vaginal outlet form a capacious, smooth-
walled passage that gradually diminishes in
size but rarely returns to nulliparous
dimensions.
 Rugae reappear by the third week.
 The hymen is represented by several small
tags of tissue, which during cicatrisation.

CHANGES IN THE PERITONEUM AND
ABDOMINAL WALL.
As the myometrium contracts and
retracts after delivery, the peritoneum
covering much of the uterus is formed
into folds and wrinkles. The broad and
round ligaments are much more lax
than in the nonpregnant condition, and
they require considerable time to
recover from the stretching and
loosening that occurred during
pregnancy.

CHANGES IN THE PERITONEUM AND
ABDOMINAL WALL.
 As a result of the rupture of elastic fibers in
the skin and the prolonged distention caused
by the enlarged pregnant uterus, the
abdominal walls remain soft and flabby.
Return to normal for these structures
requires several weeks. There may be a
marked separation, or diastasis, of the rectus
muscles.

CHANGES IN THE URINARY TRACT.
 The puerperal bladder has an increased
capacity and a relative insensitivity to
intravesical fluid pressure.
 Residual urine and bacteriuria in a traumatized
bladder, coupled with the dilated renal pelves
and ureters, create optimal conditions for the
development of urinary tract infection.
 Dilated ureters and renal pelves return to their
prepregnant state from 2 to 8 weeks after
delivery.

Obstetrical factors such as:
1. length of second-stage labor,
2. infant head circumference,
3. birth weight,
4. and episiotomy were associated with the
development of stress incontinence after
delivery.
 Cesarean delivery seemed to protect
against its development. Most women
returned to normal micturition by 3
months postpartum.

 The paralyzing effect of anesthesia, especially
conduction analgesic, and the temporarily
disturbed neural function of the bladder, are
undoubtedly contributory factors
 35% of women who had epidural analgesia had
asymptomatic urinary retention. Careful
attention to all postpartum women, with
prompt catheterization for those who cannot
void, will prevent most urinary problems.

CHANGES IN MAMMARY GLANDS
 Anatomically, each mature mammary gland
is composed of 15 to 25 lobes that arose from
the secondary mammary buds described
above. The lobes are arranged radially and
are separated from one another by varying
amounts of fat. Each lobe consists of several
lobules, which in turn are made up of large
numbers of alveoli. Every alveolus is
provided with a small duct that joins others
to form a single larger duct for each lobe.
These lactiferous ducts open separately upon
the nipple. The alveolar secretory epithelium
synthesizes the various milk constituents.

LACTATION.
 Colostrum is the deep lemon-yellow colored liquid
secreted by the breasts for the first 5 postpartum
days. It usually can be expressed from the nipples
by the second postpartum day.
 Colostrum contains more minerals and protein,
much of which is globulin, but less sugar and fat.
Antibodies are demonstrable in the colostrum, and
its content of immunoglobulin A may offer
protection for the newborn against enteric
pathogens, as describe below.
 Other host resistance factors, as well as
immunoglobulins, are found in human colostrum
and milk. These include complement,
macrophages, lymphocyte, lactoferrin,
lactoperoxidase, and lysozymes.

LACTATION
 Milk. The major components of milk are proteins, lactose,
water, and fat. Major proteins, including α-lactalbumin, β-
lactoglobulin, and casein, are synthesized in the rough
endoplasmic reticulum of the alveolar secretory cell. Most
milk proteins are unique and not found elsewhere. Whey
from human milk has been shown to contain large
amounts of interleukin-6. Additionally, interleukin-6 was
associated closely with local immunoglobulin A production
by the breast.
 Prolactin appears to be actively secreted into breast milk,
and epidermal growth factor (EGF) has been identified in
human milk. Because epidermal growth factor is not
destroyed by gastric proteolytic enzymes, it may be
absorbed and promote growth and maturation of the
infant's intestinal mucosa.

LACTATION
 All vitamins except vitamin К are found
in human milk, but in variable amounts,
and maternal dietary supplementation
increases the secretion of most of these.
Because the mother does not provide the
vitamin К requirements for breast-fed
infants, vitamin К administration to the
infant soon after delivery is required to
prevent hemorrhagic disease of the
newborn.

ENDOCRINOLOGY OF LACTATION.
 Prolactin is essential for lactation; women with
extensive pituitary necrosis, as in Sheehan syndrome, do
not lactate. Although plasma prolactin falls after
delivery to lower levels than during pregnancy, each act
of suckling triggers a rise in prolactin levels. Presumably
a stimulus from the breast curtails the release of
prolactin-inhibiting factor from the hypothalamus; this,
in turn, transiently induces increased prolactin
secretion.
 The neurohypophysis, in pulsatile fashion, secretes
oxytocin, which stimulates milk expression from a
lactating breast by causing contraction of myoepithelial
cells in the alveoli and small milk ducts. In fact, this
mechanism has been utilized to assay oxytocin activity
in biological fluids.

NURSING.
 The ideal food for neonates is mother's milk.
Human lactation has an average efficiency of
95%. Moreover, breast-fed preterm infants
evaluated at 1½ and 7½ years of age
compared with similar preterm infants not
given breast milk had higher intelligence
quotient (IQ) scores.
 Nursing is contraindicated in women with
known:
1. cytomegalovirus,
2. chronic hepatitis B,
3. and human immunodeficiency virus infection.
4. active herpes simplex virus

DRUGS SECRETED IN MILK.
DRUGS AND CHEMICALS CONTRAINDICATED DURING BREAST FEEDING
Drug (Trade Name) Sign or Symptom in Infant and effect on Lactation
Bromocriptine Parlodel Suppresses lactation
Cocaine — Cocaine intoxication
Cyclophosphamide Cytoxan or Neosar Possible immune suppression;
unknown effect on growth or association with
carcinogenesis
Ergotamine Cafergot (ergotamine
tartrate with caffeine)
Vomiting, diarrhea, convulsions (doses used in
migraine medications)
Methotrexate Folex or Mexate Possible immune suppression; unknown effect on
growth or association with carincogenesis;
neutropenia
Phencyclidine
(PCP)
— Patient hallucinogen
Phenidione Hedulin or Eridione Anticoagulant; increased prothrombin and partial
thromboplastin time in one infant

CLINICAL AND PHYSIOLOGICAL ASPECTS OF
THE PUERPERIUM
 Temperature. Engorgement of the breasts with
milk, which is common on the third or fourth
day of the puerperium, was once thought to
cause a rise in temperature. This so-called milk
fever was regarded as physiological. Extreme
vascular and lymphatic engorgement may result
in fever, but it does not last more than 24 hours.
Any fever in the puerperium implies an
infection—most likely somewhere in the
genicourinary tract—until otherwise
proven.

THE PUERPERIUM
 Lochia. Sloughing of decidual tissue results in
a vaginal discharge of variable quantity; this is
termed lochia. Microscopically, lochia consists of
erythrocytes, shreds of decidua, epithelial cells,
and bacteria.
 For the first few days after delivery, blood in the
lochia is sufficient to color it red, or lochia
rubra. After 3 or 4 days, lochia becomes
progressively paler, or lochia serosa. After the
10th day, because of an admixture of leukocytes
and a reduced fluid content, lochia assumes a
white or yellowish-white color, or lochia alba.
 Foul-smelling lochia is suggestive of infection.

THE PUERPERIUM
 Blood. Rather marked leukocytosis occurs during and after
labor. The increase is predominantly granulocytes. There
also is a relative lymphopenia and an absolute eosinopenia.
 Normally, during the first few postpartum days,
hemoglobin, hematocrit, and erythrocyte counts fluctuate
moderately. By 1 week after delivery, the blood volume has
returned to near its nonpregnant level. By 2 weeks, these
changes have returned to normal nonpregnant values.
 Pregnancy-induced changes in blood coagulation factors
persist for variable periods during the puerperium.
Elevation of plasma fibrinogen is maintained at least
through the first week, and as a consequence, the elevated
sedimentation rate normally found during pregnancy
remains high.

CARE OF THE MOTHER DURING THE
PUERPERIUM
 Early Ambulation. Women are now out of bed
within a few hours after delivery.
 Importantly, early ambulation has also reduced
the frequency of puerperal venous thrombosis
and pulmonary embolism. For the first
ambulation at least, an attendant should be
present to help prevent injury if the woman
should become syncopal.

CARE OF THE BREASTS AND NIPPLES
 With irritated nipples, it is necessary to use a
nipple shield for 24 hours or longer. Inverted or
retracted nipples may be troublesome; however,
these can usually be teased out by gently
pulling with the finger and thumb. This is best
done during pregnancy to prepare the nipples
for subsequent nursing.

PUERPERIUM
 Care of the Vulva. The patient should be
taught to cleanse the vulva from anterior to
posterior (vulva toward anus). An ice bag
applied to the perineum help reduce edema and
discomfort during the first several hours after
episiotomy repair. Beginning about 2 hours
after delivery, moist heat as provided with
warm sits baths can be used to reduce local
discomfort.

PUERPERIUM
Bladder Function.
 If the woman has not voided within 4 hours
after delivery, it is likely she cannot.
Ambulation to a toilet usually should be tried
before resorting to catheterization.
 The likelihood of hematomas of the genital tract
must be considered when the woman cannot
void postpartum.
 40% of such women will develop bacteriuria;
thus, a short course of antimicrobial therapy
seems reasonable after catheter removal.

PUERPERIUM
 Bowel Function. At times, the lack of a bowel
movement is no more than the expected
consequence of an efficient cleansing enema
administered before delivery. With both early
ambulation and early feeding of a general diet,
constipation has become much less of a problem
in the puerperium.
Subsequent Discomfort. During the first few
days after vaginal delivery, the mother may be
uncomfortable for a variety of reasons, including
afterpains, episiotomy and lacerations, breast
engorgement, and at times, postspinal puncture
headache. It is prudent to provide codeine, 60
mg; aspirin, 600 mg; at intervals as frequent as
every 3 hours during the first few days after
delivery.

 Mild Depression. There is strong tradition in the psychiatric
literature to consider postpartum depression a distinct diagnosis.
Symptomatically, postpartum “depression” seems to involve a milder
disturbance suggesting that it is best seen as an adjustment disorder.
Approximately 10% of the women met diagnostic criteria for
depression during pregnancy and 7% were depressed postpartum.
 The transient depression, or postpartum blues, most likely is the
consequence of a number of factors. Prominent in its genesis are
(1) the emotional letdown that follows the excitement and fears that
most women experience during pregnancy and delivery,
(2) the discomforts of the early puerperium that have been described
above,
(3) fatigue from loss of sleep during labor and postpartum in most
hospital settings,
(4) anxiety over her capabilities for caring for her infant after leaving
the hospital,
(5) fears that she has become less attractive to her husband. In the great
majority of cases, effective treatment need be nothing more than
anticipation, recognition, and reassurance.

PUERPERIUM
 Diet. An appetizing general diet is
recommended. Two hours after a normal vaginal
delivery, if there are no complications likely to
anesthetic, the woman should be given
something to drink and eat if she desires.
 The diet of lactating women, compared with that
consumed during pregnancy, should be increased
in calories and protein. If the mother does not
breast feed her infant, her dietary requirements
are the same as for a normal nonpregnant
woman.

PUERPERIUM
Immunizations. The D-negative woman who
is not isoimmunized and whose baby is D-
positive is given 300 μg of anti-D
immunoglobulin. Women who are not already
immune to rubella are excellent candidates for
vaccination before discharge.

PUERPERIUM
 Time of Discharge. Following vaginal delivery,
if there are no puerperal complications,
hospitalization is seldom warranted for more
than 48 hours, excluding the day of delivery.
Following an uncomplicated postoperative
cesarean delivery, women usually are ready for
discharge on the third or fourth day.
 Before discharge, the woman should receive
instructions concerning the anticipated normal
physiological changes of the puerperium,
including changes in lochia patterns, weight loss
due to diuresis, and when to expect milk let
down. She also should receive instructions
concerning what to do if she becomes febrile, has
excessive vaginal bleeding, or develops leg pain,
swelling, or tenderness.

CONTRACEPTION.
 Coitus. There is no definite time after delivery
when coitus should be resumed; however,
hemorrhage and infection are less likely 14 to 21
days postpartum. Resumption of intercourse this
soon may prove to be unpleasant, if not frankly
painful, due to incomplete uterine involution and
incomplete healing of the episiotomy and
lacerations.
 The best rule to follow is one of common sense.
Specifically, coitus should not be resumed prior to 2
weeks postpartum for the reasons listed above.
After 2 weeks, coitus may be resumed based upon
the patient’s desire and comfort.

CONTRACEPTION.
 This has proven quite satisfactory both to
identify any abnormalities of the later
puerperium as well as to initiate
contraceptive practices (estrogen plus
progestin oral contraceptives).
Intrauterine devices were inserted during
the third week postpartum were no
greater than when the devices were
inserted 3 months or more postpartum.

PUERPERIUM
 Infant Follow-up. Special arrangements must
be made to insure that the neonate receives
appropriate follow-up care. The neonate
discharged early should be term, normal, and
have stable vital signs.
 All laboratory studies should be normal
including direct Coombs test bilirubin,
hemoglobin and hematocrit, and blood glucose.
The maternal serological test for syphilis and
hepatitis В surface antigen should be
nonreactive. Initial hepatitis В vaccine should
be administered, and all screening tests
required by law should be performed. These
always include testing for phenylketonuria
(PKU) and hypothyroidism.

RETURN OF MENSTRUATION AND
OVULATION.
 If the woman does not nurse her child, menses usually return
within 6 to 8 weeks. In lactating women the first period may
occur as early as the second or as late as the 18th month
after delivery.
 Ovulation is much less frequent in women who breast feed
compared to those who do not. Onset of menses increased
from 8% the first month after delivery to 61% by 12 months.

PUERPERIUM
 Follow-up Care. By the time of discharge, women
who had a normal delivery and puerperium can
resume most activities, including bathing, driving,
and household functions.
 Puerperal women should have been given
appointments for follow-up examination during the
third postpartum week.

PRESENTATION -
ABNORMAL LABOR
2017

DYSTOCIA
Dystocia literally means difficult labor and is characterized by abnormally
slow labor progress. It arises from four distinct abnormalities that may exist
singly or in combination.They are abnormalities of :
1) Power -Uterine contractility and maternal expulsive forces
2) Passenger – fetus abnormalities including the presentation , position, lie
and station.
3) Passage- pelvis ( contracted pelvis)

ABNORMALITIES OF EXPULSIVE FORCES
NORMAL PHYSIOLOGY –
Cervical dilatation and propulsion and expulsion of the fetus are brought
about by contractions of the uterus, which are reinforced during the
second stage by voluntary or involuntary muscular action of the
abdominal wall—“pushing.” Uterine contractions of normal labor are
characterized by a gradient of myometrial activity. These forces are
greatest and last longest at the fundus—considered fundal dominance—
and they diminish toward the cervix.

TYPES OF UTERINE DYSFUNCTION
• Hypotonic uterine dysfunction :
There is no basal hypertonus and uterine contractions have a normal
gradient pattern (synchronous), but pressure during a contraction is insufficient to dilate
the cervix.
• Hypertonic or incoordinate uterine dysfunction:
Either basal tone is elevated appreciably or the pressure gradient is
distorted. Gradient distortion may result from more forceful contraction of the uterine
midsegment than the fundus or from complete asynchrony of the impulses originating in
each cornu or a combination of these two.

•P rotraction disorder : protraction is defined as
less than 1 cm/hr cervical dilatation for a
minimum of 4 hours. ( slow progress)
•Arrest disorder: complete cessation of progress.

INVESTIGATIONS
Uterine activity (contraction) is measured by noting
(i) basal tone (ii) active (peak) pressure and (iii) frequency.
Assessment is usually done by—
(i) Clinical palpation—(inaccurate),
(ii) Tocodynamometer with external transducer,
(iii) Intrauterine pressure catheter (IUPC) is used to measure intrauterine pressure during uterine contractions.
Normal baseline tonus is between 5 mm Hg and 20 mm Hg. Minimum uterine pressure required to dilate the
cervix is 15 mm Hg over the baseline. Normal uterine contractions in labor create an intrauterine pressure up to
60 mm Hg. Oxytocin is to be used when uterine contractions are inadequate. Oxytocin dose is to be escalated till
the optimum uterine contractions (3–4 per 10 minutes) with a peak intrauterine pressure of 50–60 mm Hg and a
resting tone of 10–15 mm Hg is obtained.

Normal labor usually divided into:
1. Latent phase: usually little cervical dilatation but considerable changes taken
place in the connective tissue components of the cervix.
2. Active phase: Friedman subdivided the active phase into acceleration phase,
phase of maximum slope and the deceleration phase.
Latent phase :
Friedman defined it as the point at which the mother perceives
regular uterine contraction along with cervical softening and
effacement and ends at 3 cm dilatation.

P R OLONG E D LATE NT P HAS E
Defined (1963) by Friedman and Sachtleben to be greater than 20 hours in the
nullipara and 14 hours in the paras women.These are the 95th percentage.
• Factors that affect the duration of the latent phase include :
1. Excessive sedation: conduction analgesia.
2. Poor cervical conduction: (eg.Thick, uneffaced or undilated)
3. False labor.
• Rest is preferable for correcting prolonged latent labor because unrecognized false
labor was common, with strong sedation 85 % of females begin active labor and 10 %
cease contraction (false labor) and 5 % develop recurrent abnormal latent labor and
require oxytocin stimulation.

Active labor
It begins when the cervix is 3 cm dilated. Active phase abnormalities are
the most common abnormalities of labor about 25% of nullipara and 15% of
multipara.
Friedman subdivided active phase problems into protraction and arrest
disorders.
• Protraction defined as a slow rate of cervical dilatation or descent. i.e < 1.2
cm dilatation / hour or < 1 cm / hour
for nullipara or < 1.5 cm / hour or < 2 cm / hour for multipara. (minimum of 4
hours according to WHO).
• Arrest of dilatation defined as 2 hr with no cervical change or arrest of
descent as 1 hour without fetal descent

Factors contributing to both protraction and arrest
disorders were:
1. Excessive sedation.
2. Conduction analgesia.
3. Fetal malposition eg. Persistant occipito – posterior.
In both protraction and arrest disorders, fetopelvic
examination done to diagnose CPD.

“2 HOUR RULE” FOR ARREST LABOUR
Accordingly,the American College of Obstetricians and
Gynecologists (2013) has suggested that
before the diagnosis of first-stage labor arrest is
made, specific criteria should be met. First, the latent phase has
been completed, and the cervix is dilated 4 cm or more.Also, a
uterine contraction pattern of 200 Montevideo units or more in
a 10-minute period has been present for 2 hours without
cervical change.

SECOND STAGE OF LABOR
The second stage of labor begins when cervical dilatation is complete and
ends with fetal expulsion.
• The length of the second stage of labor in nullipara was limited to 2 hours
and extended to 3 hours when regional analgesia was used. For multipara 1
hour was the limit extended to 2 hours with regional analgesia.The causes
can be classified also as abnormalities of the powers, the passenger and the
passages.
• Three options to treat :
o Continued observation.
o Attempt at operative vaginal delivery
o Cesarean delivery

PASSENGER ABNORMALITIES
•Fetal Weight EFW > 4000-4500 grams →
increased risk of dystocia
•Fetal Attitude, Presentation, Position, and Lie

PRESENTATION
Refers to the fetal part presenting at the pelvic outlet
1. Breech (complete, frank, footling)
2. Cephalic – head first
3. Vertex – everything is flexed
4. Brow – usually converts to face or vertex
5. Face – usually requires a C-Section, although mentum anterior may
deliver vaginally
6. Compound – limb presents with vertex
7. Shoulder (arm, shoulder, trunk)
All Except vertex are considered malpresentation

FACE
PRESENTATION
BREECH PRESENTATION

PELVIS - PASSAGE
• Dystocia can result from several distinct abnormalities involving
the cervix, uterus, the fetus, other obstruction in the birth canal
or in the maternal bony pelvis. Quit often combination of these
interactions to produce dysfunction labor. Recently term such
as cephalopelvic disproportion and failure to progress are often
used to describe these dysfunctional labors when cesarean
section delivery is necessary.

CEPHALOPELVIC DISPROPORTION (CPD)
Abnormal labor due to disparity between the dimensions of the fetal head and maternal
pelvis, as to preclude vaginal delivery. It can be due to a large head, small pelvis or a
combination of the two. Originally describe for overt pelvic contracture due to rickets,
however now such true CPD is rare and most disproportions are due to malpositions of the
fetal head- asynchtisim or extension of the bony diameters of the fetal head, or to
ineffective uterine contraction.
Women of small stature (< 1.60 m) with a big baby in their first pregnancy are candidate
to develop this abnormality. Sometimes the pelvis is unusually small due to previous
fractures or metabolic bone disease. Rarely a fetal anomaly may contribute to CPD as
hydrocephaly, fetal thyroid and neck tumor.

CPD is suspected if there is:
1. Progress is slow or arrest despite
efficient uterine contraction.
2. The fetal head is not engaged.
3. Vaginal examination shows severe
moulding and caput formation.
4. The head is poorly applied to the
cervix.
Risk factors for poor progress in labor
• 1. Small women.
• 2. Big baby.
• 3. Malpresentation.
• 4. Malposition.
• 5. Early rupture of membrane.
• 6. Soft tissue / pelvic malformation.
• 7. Dysfunctional uterine activity.

DYSTOCIA DUETO PELVIC CONTRACTION
Any contraction of the pelvic diameters that diminishes the capacity of the
pelvic can create dystocia during
labor. Pelvic contractions may be classified as follows:
1. Contraction of the pelvic inlet.
2. Contraction of the mid pelvis.
3. Contraction of the pelvic outlet.
4. Generally contracted pelvis (combination of the above).

PELVIMETRY
1. Contracted Pelvic Inlet
• Shortest AP Diameter <10 cm
• Diagonal conjugate <11.5cm
• Average BPD 9.5-9.8cm
2. Contracted Midpelvis
• Interspinous Diameter
3. Contracted Pelvic Outlet
• Interischial tuberous diameter is common base for 2 triangles
• Posterior – sacral tip, sacralsciatic ligaments, ischial tuberousities (8cm)
• Anterior – area under pubic arch

ETIOLOGY OF CONRACTED PELVIS
1) Nutritional and environmental defects —
Minor variation: Common
Major: Rachitic and osteomalacic — rare
(2) Diseases or injuries affecting the bones of the pelvis — fracture, tumors,
tubercular arthritis;
spine — kyphosis, scoliosis, spondylolisthesis, coccygeal deformity; lower
limbs — poliomyelitis, hip joint disease.
(3) Development defects — Naegele’s pelvis, Robert’s pelvis; high or low
assimilation pelvis.
Naegele’s pelvis

OTHER PELVIS CAUSES
Abnormalties in the uterus and cervix can also delay labor. Unsuspected
fibroid in the lower uterine segment can prevent the descent of the fetal
head.
Delay can also be caused by “cervical dystocia”, a term used to describe a
non- compliant cervix which effaces but fail to dilate because of severe
scarring usually as a result of a previous cone biopsy.
 It is rare for soft tissues of the pelvic floor to cause significant delay in
labor.

MECHANISM OF LABOR IN CONTRACTED PELVIS
WITHVERTEX PRESENTATION
In the flat pelvis, the head finds difficulty in negotiating the brim and once it passes through the brim, there is no
difficulty in the cavity or outlet. The head negotiates the brim by the following mechanism:
1.The head engages with the sagittal suture in the transverse diameter.
2.Head remains deflexed and engagement is delayed.
3. If the anteroposterior diameter is too short, the occiput is mobilized to the same side to occupy the sacral
bay.The biparietal diameter is thus placed in the sacrocotyloid diameter (9.5 cm or 8.5 cm) and the narrow
bitemporal diameter is placed in the narrow conjugate. If lateral mobilization is not possible, there is a chance of
extension of the head leading to brow or face presentation.
4. Engagement occurs by exaggerated parietal presentation so that the super-subparietal diameter (8.5 cm),
instead of the biparietal diameter (9.5 cm), passes through the pelvic brim.
5. Molding may be extreme and often there is an indentation or even a fracture of one parietal bone. However,
the caput that forms is not big.
6. Once the head negotiates the brim, there is no difficulty in the cavity and outlet and normal
mechanism follows

MECHANISM OF LABOR IN FLAT PELVIS: (A) LATERALIZATI
ON OF OCCIPUT TO THE SACRAL BAY;
(B AND C) ENGAGEMENT OF THE HEAD BY
EXAGGERATED PARIETAL PRESENTATION

MANAGEMENT
Minor degrees of inlet contraction does not give rise to much problem and the cases
are left to have a spontaneous vaginal delivery at term.
The moderate and the severe degrees are to be dealt by any one of the following:
• Induction of labor
• Elective cesarean section at term
• Trial labor

ABNORMALITIES OF
UTERUS CONTRACTILITY

INTRODUCTION
NORMAL LABOUR IS CHARACTERIZED BY
COORDINATED UTERINE CONTRACTIONS ASSOC. WITH
PROGRESSIVE DILATATION OF CERVIX AND DESCENT OF
THE FETAL HEAD.
NORMAL LABOUR IS ASSOC. WITH CERVICAL
DILATATION >1 CM/HOUR IN A NULLIPAROUS WOMAN
AND LIKELY TO END WITH A SUCCESSFUL VAGINAL
DELIVERY.
LABOR ABNORMALITIES OCCUR IN ABOUT 25% OF
NULLIPAROUS WOMEN AND 10% OF MULTIPAROUS
WOMEN.

ANY DEVIATION OF THE NORMAL
PATTERN OF UTERINE
CONTRACTIONS AFFECTING THE
COURSE OF LABOUR IS
DESIGNATED AS DISORDERED OR
ABNORMAL UTERINE ACTION.

ABNORMAL UTERINE ACTION
NORMAL POLARITY ABNORMAL POLARITY
EXCESSIVE CONTRACTION UTERINE INERTIA
OBSTRUCTION OBSTRUCTION
(-) (+)
SPASTIC ASMMETRY GENERALISED
LOWER UTERINE TONIC
PRECIPIT ATE TONIC SEGMENT CONTRACTION cONTRACTION
LABOUR UTERINE
CONTRACTION
& RETRACTION
(Bandl’s ring) COLICKY CONSTRICTION CERVICAL
UTERUS RING DYSTOCIA
hypertonic uterus ineffective uterine contraction

NORMAL AND ABNORMAL PATTERNS OF
UTERINE CONTRACTIONS
(A)Normal uterine contractions with single dominant pacemaker focus
(B)Uterus with 3 separate pacemakers firing sequentially
(C)Normal uterine contraction
(D)Uterine inertia
(E)Colicky uterus
(F)Spastic lower segment
(G)Asymmetrical contraction
(H)Cervical dystocia

ETIOLOGY
CLINICAL CONDITIONS OFTEN ASSOCIATED WITH ABNORMAL
UtERINE CONTRACTIONS:
PREVALENCE IN 1ST BIRTH (ESP.ADVANCED AGED MOTHERS)
PROLONGED PREGNANCY
OVER DISTENSION DUE TO POLYHYDRAMNION & MULTIPLE
GESTATION
PSYCHOLOGICAL FACTORS
CONTRACTED PELVIS,MALPRESENTATION,DEFLEXED
HEAD,FULL BLADDER(RESULT IN INHIBITION OF LOCAL
REFLEX WHICH NEEDED TO PRODUCE EFFECTIVE
CONTRACTION OF UPPER SEGMENT)
INJUDICIOUS ADMINISTRATION OF
SEDATIVES,ANALGESICS&OXYTOCINS
PREMATURE ATTEMPT AT VAGINAL DELIVERY OR ATTEMPTED
INSTRUMENTAL VAGINAL DELIVERY UNDER INSUFFICEINT
ANESTHESIA

UTERINE ACTIVITY
MEASURED BY NOTING:
1.basal tone
2.active (peak) pressure
3.frequency
ASSESSMENT DONE BY:
1.clinical palpation-inaccurate
2.tocodynamometer with external transducer
3.using intrauterine pressure catheter-accurate
*normal baseline tonus=5-20mmhg
*peak pressure=><60 mmhg

UTERINE INERTIA(HYPOTONIC
ACTIVITY)
Common type of disordered uterine contraction but less serious
Uterine contraction:
1.diminished intensity
2.shortened duration
3.intervals increased
4.general pattern maintain ,intrauterine pressure hardly rises above 25
mmhg
Diagnosis:
1.patient feel less pain during uterine contraction
2.less hardening of uterus during contraction
3.uterine wall easily indentable
4.uterus become relaxed after contraction
5.poor dilation of cervix
It’ll lead to maternal exhaustion

UTERINE INERTIA(HYPOTONIC
ACTIVITY)
MANAGEMENT :
CAESEREAN SECTION:
INDICATIONS: presence of contracted pelvis
malpresentation
evidence of fetal distress
VAGINAL DELIVERY
-uterine contraction is accelerated by low rupture of membrane
followed by oxytocin drip.

INCOORDINATED UTERINE
ACTION
1.spastic lower uterine segment
2.colicky uterus
3.asymmetrical uterine contraction
4.constriction ring
5.generalised tonic contraction of the uterus
*ALL THIS CONDITION COLLECTIVELY MAKES UP
INCOORDINATED UTERINE ACTION.

ACTION
INCREASED FREQUENCY& OR DURATION OF
UTERINE CONTRACTIONS
RISE IN BASELINE TONE
DIMINISH CIRCULATION IN PLACENTAL VILLUS SPACE
FETAL HYPOXIA IN LABOUR

ACTION
placental abruption often assoc with high baseline
tone(>25mmhg)
On CTG ,FHR shows reduced variability and late
decelerations
Uterine hyperstimulation by oxytocin often assoc
withfetal tachycardia due to fetal stress

ACTION
a)Normal uterine contractions showing peak pressure,contraction
interval,pain treshold,and rise of basal tone.
b)Hypertonic contractions with prolonged duration
c)Hypertonic contractions with increase frequency-both showing
changes in heart rate(deceleartions)on CTG

SPASTIC LOWER SEGMENT
UTERINE CONTRACTION:
1.fundal dominance is lacking, reversed polarity
2.inadequate relaxation in betw contractions
3.basal tone raised above 20mmhg
DIAGNOSIS:
1.pain reffred to the back
2.dehydration and ketoacidosis
3.bladder is distended and retention of urine
4.distension of stomach and bowels are visible
5.premature attempts to bear down
6.palpation reveals:
-uterus is tender
-uterus remain tense and tender even after contraction passes off
-difficult palpation of fetus
-early appearance of fetal distress
7.cervix is thick,edematous;hang like curtain
8.inappropriate dilatation of the cervix
9.absence of membranes
10.arying degree of caput
11.meconium stained liquor amnii
Fetal distress appears early due to placental insufficiency caused by inadequate
relaxation of the uterus

SPASTIC LOWER SEGMENT
MANAGEMENT:
-cesarean section is done in majority of
cases.
CONSERVATIVE APPROACH:
-adequate pain relief
-corection of dehydration in hope of
spontaneous delivery
*no place of oxytocin augmentation in such
abnormality.

CONSTRICTION RING
A form of incoordinated uterine action where there is localised
spastic contraction of a ring of circular muscle fibers of the
uterus
Usually situated at junction of upper and lower segment around
a constricted part of the fetus usually around the neck in
cephalic presentation
May appear in all stages of labour
Usually reversible and complete

CONSTRICTION RING
CAUSES IS NOT CLEAR
OCCURRENCE IS ASSOC WITH:
1.injudicious administration of oxytocins
2.premature rupture of membranes
3.premature attempts at instrumental delivery esp. under light
anesthesia
DIAGNOSIS:
1.revealed during c-sec in 1st stage
2.revealed during forceps delivery in 2nd stage
3.revealed during manual removal in 3rd stage(hour glass
contraction)
4.ring is not felt at abdomen
FETUS IS IN JEOPARDY BECAUSE OF
HYPERTONIC STAGE

CONSTRICTION RING
TREATMENT:
1ST stage:
diagnosis made during c-sec after opening uterine cavity
ring may have to be cut vertically to deliver baby
2nd stage:
failure to deliver head raises the suspicion of constriction ring
confirm by palpation after removal of forceps blade
cesarean section should be performed in this stage
forceps delivery is possible by deepening the plane of general
anesthesia
3rd stage:
diagnosis is made during attempted manual removal
deepening the plane of anesthesia is usually effective

ABNORMAL UTERINE CONTRACTION(NORMAL UTERINE
POLARITY)
TYPES CHARACTERIS
TICS
CAUSES MANAGEMENT
PROLONGED
LATENT
PHASE
-BEGIN WITH ONSET OF
REGULAR CONTRACTION
TO BEGINNING OF
CERVICAL DILATATION
-ANORMALLY >20 HRS IN
NULLIPAROUS,>14 HRS IN
MULTIPAROUS
-EXCESSIVE SEDATION
-GIVE GENERAL
ANESTHSIA BEFORE
LABOUR EXTENDS TO
ACTIVE PHASE
-LABOUR BEGIN WITH
UNFAVOURABLE CERVIX
WEAK,IRREGULAR,INCOOR
DINATION&INEFFECTIVE
UTERINE CONTRACTION
-FETOPELVIC
DISPOPORTION
-THERAPEUTIC
REST
REGIME/ACTIVE
MANAGEMENT
WITH OXYTOXIN
INFUSION
ABSENT OF
EXPULSIVE
FORCE OF 2ND
STAGE
-INADEQUATE
PUSHING
-FULL
DILATATION,UTE
RINE
CONTRACTION
BECOMES WEAK
AND
INEFFECTIVE
1.FAULT IN POWER
-UTERINE INERTIA
-EPIDURAL ANALGESIA
2.FAULT IN PASSAGE
-CEPHALOPELVIC
DISPORPOTION
-CONTRACTED
PELVIS/ANDROID
-SOFT TISSUE TUMOR
3.FAULT IN PASSENGER
-MALPOSITION
-MAL PRESENTATION
-MACROSOMATIC BABY
-WEAKNESS OF
ABDOMINAL
WALL,HERNIATION OF
RECTUS MUSCLE
-IV OXYTOXIN
-
INSTRUMENTAL
DELIVERY OR
FORCEPS
DELIVERY

ABNORMAL UTERINE CONTRACTION(NORMAL
UTERINE POLARITY)
Primary
inertia
-regular contraction
-interval betw contraction
is longer
-duration is short
-does not increase with
time
-decrease intensity
-result in insufficiency
of cervical dilatation
-congenital weak
uterus
-infusionof
oxytocin
Secondary
inertia
-begin with regular good
contraction and intensity
-normal duration
-normal intensity
-normal forced
-after that decrease
duration,increase interval
-decrease intensity result
in arrest of cervical
dilatation(does not dilate
because constriction
stops)
-obstruction
-cephalopelvic
disproprotion
*rule out
cephalopelvic
disproportion by
hillus-muller
method
*if cephalopelvic
disproportion,c-
section is indicated
-infusion of
oxytocin

HILLUS MULLER METHOD OF
DETERMINING CEPHALOPELVIC
DISPROPORTION
Lower bowel is emptied preferably by enema
Patient in lithotomy position
Internal examination is done by aseptic precautions
2 right hand fingers introduced into vagina
Finger tips placed at level of ischial spine
Thumb is placed over symphysis pubis
Head of fetus is grasped at left hand and pushed in downward
and backward direction into pelvis

HILLUS MULLER METHOD OF
DETERMINING CEPHALOPELVIC
DISPROPORTION
What are the expected results?
1.No disproportion
-head can be pushed down upto the level of ischial spines
-no overlapping of the parietal bone over symphysis pubis
2.Slight and moderate disproportion
-the head can be pushed down a little but not up to the level of
ischial spine
-there’s slight overlapping of parietal bones
3.Severe disproportion
-the head cannot be pushed down
-parietal bones overhangs the symphysis pubis displacing the
thumb

ABNORMAL UTERINE CONTRACTION(ABNORMAL UTERINE POLARITY)
TYPE CHARACTERISTICS CAUSES MANAGEMENT
REVERSED
UTERINE
POLARITY
-CONTRACTION BEGIN FROM
LOWER SEGMENT
-FUNDAL DOMINANCE IS
LACKING
-INADEQUATE RELAXATION
BETW CONTRACTIONS
-BASAL TONE >20 MMHG
-LACK OF FUNDAL
DOMINANCE
-C-SECTION
-CONSERVATIVE
APPROACH,PAIN
RELIEF,CORRECT
DEHYDRATION
-HOPE FOR
SPONTANEOUS
DELIVERY
TETANY
UTERINE
POLARITY
-PRONOUNCED
CONTTRACTION INVOLVE
WHOLE UTERUS UP TO INT.
OS LEVEL
-NO PHYSIOLOGIAL
DIFFERENTIATION OF ACTIVE
UPPER SEGMENT AND
PASSIVE LOWER SEGMENT
-UTERINE CONTRACTION
CEASES AND WHOLE
UTERUS UNDERGOES TONIC
MUSCULAR SPASM
HOLDING FETUS IN SIDE
-FAILURE TO
OVERCOME
OBSTRUCTION BY
POWERFUL UTERUS
CONTRACTION
-INAPPROPRIATE
ADMINISTRATION OF
OXYTOCIN
-CORRRECT
DEHYDRATION AND
KETOACIDOSIS
BY RINGER’S
SOLUTION
-ANTIBIOTIC
CONTROL INFECTION
-PAIN RELIEF
-TOCOLYTICS
(TERBUTALINE)TO
MANAGE OXYTOCIN
-C-SEC IN MAJOR
CASE ESP.IN
SUSPECTED
OBSTRUCTION

ABNORMAL UTERINE CONTRACTION(ABNORMAL
UTERINE POLARITY)
TYPE CHARACTERISTICS CAUSES MANAGEMENT
CONSTRICT
ION RING
-CONTRACTION AT
MIDDLE SEGMENT
-”HOUR GLASS”
UTERUS
-INCOORDINATED
UTERINE ACTION
LOCALIZED SPASTIC
CONTRACTION
OF CIRCULAR ,USCLE
FIBERS
-SITUATED AT
JUNCTION OF UPPER
SEGMENT AND
LOWER SEGMENT
AROUND NECK OF
FETUS IN CEPHALIC
PRESENTATION
-REVERSIBLE AAND
COMPLETE
-UNCLEAR
-OCCURRENCE
ASSOC WITH:
1.INJUDICIOUS
ADMIN OF
OXYTOCIN
2.PREMATURE
MEMBRANE
RUPTURE
3.PREMATURE
ATTEMPTS OF
INSTRUMENTAL
DELIVERY
UNDER LIGHT
ANESTHESIA
MANAGEMENT
FOLLOWS STAGES
IN VARIOUS
DELIVERY
1.IN C-SEC:RING IS
CUT VERTICALLY
TO DELIVER BABY
2.IN FORCEPS
DELIVERY:REMOVE
FORCEPS BLADE
AND PERFORM C-
SEC
3.IN MANUAL
DELIVERY:INCREA
SE ANESTHESIA
AND CONTINUE
DELIVERY

CERVICAL DYSTOCIA
Progressive dilatation needs an effective
stretching force by presenting part
Failure of dilatation is due to:
1.inefficient uterine contractions
2.malpresentations,malposition
3.spasm of cervix

CERVICAL DYSTOCIA
CLASSIFICATION:
1.PRIMARY
-commonly observed during 1st birth where external os fails to
dilate
-uterine contractions are ineffective
-edema of ant. Lip may occur and delivery is accomplished with
avulsion of ant. Lip or by annular detachment of cervix
2.SECONDARY
-result due to excess scarring or rigidity of the cervix from affect
of previous operation or disease

CERVICAL DYSTOCIA
TREATMENT:
in presence of complications ,c-sec is prefered
if head is sufficiently low down with only
thin rim of cervix left behind, the rim may be
pushed up manually during contraction or
traction given by venthouse
If cervix is very much thinned but only half
dilated, Duhrssen’s incision at 2 & 10 o’clock
positions followed by forceps or venthouse
extraction

GENERALISED TONIC
CONTRACTION
Pronounced retraction occurs involving whole
of uterus up to level of internal os
No physiological differentiation of active
upper segment and passive lower segment of
the uterus
No thining of lower segment,there is no
chance of rupture of uterus
Uterine contraction ceases and whole uterus
undergoes tonic muscular spasm holding the
fetus inside

GENERALISED TONIC
CONTRACTION
CAUSES:
1.failure to overcome the
obstruction by powerful
contractions of uterus
2.injudicious administration
of oxytocins

GENERALISED TONIC
CONTRACTION
CLINICAL FEATURES:
1.prolonged labour having severe and
continous pain
2.upon palpation,uterus is smaller in
size, tense and tender
3.fetal parts are neither well
defined,nor is fetal heart sound
audible
4.vaginal examinatin reveals jammed
head with big caput;dry and edematous
edema

GENERALISED TONIC
CONTRACTION
TREATMENT:
1.correction of dehydration and
ketoacidosis by infusion of Ringer’s
solution
2.antibiotic to control infection
3.pain relief
4.tocolytics(terbutaline 0.25mg s.c)
to manage oxytocins induced
hypercontractility.stop oxytoxin
5.cesarean delivery is done in majority of
cases esp. when obstructio is suspected.

TONIC UTERINE CONTRACTION
AND RETRACTION
This type of uterine contraction is predominantly due
to obstructed labour
There’s a gradual increase in inensity,duration and
frequency of uterine contraction
Relaxation phase becomes lesser and state of tonic
chronic contraction develops,retraction continues
Lower segments elongates and becomes progressively
thinner to accommodate the fetus driven from upper
sement
*A circular groove encircling the uterus is formed
betw the active upper segment and the distended lower
segmentation,called-PATHOLOGICAL
RETRACTION RING(BANDL’S RING)

AND RETRACTION
CLINICAL FEATURES:
1.patient is in agony,from continuos pain and discomfort and becomes restless
2.features of exhaustion and ketocdosis
3.abdominal palpation reveals:
-upper segment is hard and tender
-lower segment is distended and tender
-pathological retraction ring is placed obliquely betw umbilicus and
symphysis pubis and rises upwards in course of time
-taut tender round ligaments may be felt(due to uterine
attacments being raised by round ligament raised by
shortening of upper segment and distension of lower segment)
4.internal examinaton reveals:
-vagina dry and hot with offesive discharge
-cervix fully dilated
-membranes are absent
-cause of obstructed labour revealed

AND RETRACTION
PREVENTION:
it’s a preventable condition
abnormality can be detected during
antenatal or early intranatal
period,Cesarean section is done
It is rarely seen nowadays due to
early detection and intevention of
prolonged labour

AND RETRACTION
TREATMENT:
rupture of uterus is to be excluded
Correction of dehydration and ketoacidosis
Adequate pain relief
Parenteral antibiotic
Cesarean delivery is done in majority of cases

AND RETRACTION
(a)Normal labour (b)late obstruction
*note the circumferential dilatation and progressive stretching of the lower segment
with corresponding thickening of the upper segment and rise in the level of
retraction ring following obstruction

AND RETRACTION
DIFFERENCE BETW CONSTRICTION RING AND
RETRACTION RING

MANAGEMENT OF
DYSFUNCTIONAL LABOUR
MANAGEMENT OF DYSFUNCTIONAL LABOUR
NON PROGRESS OF LABOUR
REASSESSMENT
MOTHER FETUS
-UTERINE CONTRACTIONS -FHR PATERN
-PAIN ADEQUACY BY CLINICAL PELVIMETRY -ESTIMATED FETAL WEIGHT
-PAIN TOLERANCE -FETAL PRESENTATION
-EVIDENCE OF ANY INFECTION POSTION,STATION
-LIQUOR COLOUR
EVIDENCE OF INADEQUATE UTERINE CONTRACTION
1.CPD 2.FETAL DISTRESS 3.BIG BABY
CESAEREAN DELIVERY 1.START OXYTOXIN
2.AMNIOTOMY
3.PAIN RELIEF-EPIDURAL ANALGESIA
WHEN CERVICAL DILATATION
>3CM
PROGRESS SATISFACTORY NO PROGRESS OF LABOUR
VAGINAL DELIVERY 1ST STAGE 2ND STAGE
C.S C.S
OPERATIVE VAGINAL DELIVERY
BY FORCEPS OR VENTHOUSE
1.Arrest of cervical dilatation
2.Arrest in descent of fetal head

THANK YOU
“THE END IS THE BEGINNING IS THE
END …”

Abortion spontaneous and
induced.
Contraception.
Foreign students faculty
Department of obstetrics and gynecology

ABORTION
Abortion is the expulsion or extraction from
its mother of an embryo or fetus weighing
less 500g, when it is not capable of
independent survival, regardless of whether
it’s spontaneous or intentionally induced

I) SPONTANEOUS ABORTION
(MISCARRIAGE)
Miscarriage or spontaneous abortion is the
natural or spontaneous end of a pregnancy
at a stage where the embryo or fetus is
incapable of surviving, generally defined in
humans at prior to 20 weeks of gestation.
Miscarriage is the most common
complication of early pregnancy

 TERMS USED TO DESCRIBE
PREGNANCIES THAT DO NOT
CONTINUE
An empty sac
- is a condition where the gestational sac
develops normally, while the embryonic
part of the pregnancy is either absent or
stops growing very early. Other terms for
this condition are blighted ovum and
anembryonic pregnancy.

CONTINUE
A threatened abortion
- it is a clinical entity where the process of
abortion has started but has not
progressed to a state from which recovery
is impossible

CONTINUE
An inevitable abortion
- describes where the fetal heart beat is
shown to have stopped and the cervix has
already dilated open, but the fetus has yet
to be expelled. This usually will progress
to a complete abortion.

CONTINUE
- Gestational sac with fetus having become
detached from the implantation site,
leading to spontaneous abortion within
the next few hours. Clinical findings:
* Severe pain.
* Uterine contractions.
* Dilated cervix.

CONTINUE
- through US, possible findings:
* Sac situated low within the uterus.
* Sac surrounded by perigestational
hemorrhage.
* Dilated cervix.
* Uterine contractions originating in the
uterine fundus may be observed
sonographically

Severe oligohydramnios, fluid in cervix

 Poor decidual reaction
 Sac within uterine cavity (white lines) and not within decidua.
 Spontaneous abortion two days later.

 Gestational sac low within the uterine cavity.
 Low implantation versus inevitable abortion.
 Spontaneous abortion same day

CONTINUE
A complete abortion
- when all products of conception have
been expelled. Products of conception
may include the trophoblast, chorionic
villi, gestational sac, yolk sac, and fetal
pole (embryo); or later in pregnancy the
fetus, umbilical cord, placenta, amniotic
fluid, and amniotic membrane.

CONTINUE
An incomplete abortion
- occurs when tissue has been passed, but
some remains in utero.
A missed abortion
- when the embryo or fetus has died, but a
miscarriage has not yet occurred. It is also
referred to as delayed miscarriage.

(a)Threatened abortion (b) Inevitable abortion
(c) Incomplete abortion

CONTINUE
A septic abortion
- occurs when the tissue from a missed or
incomplete abortion becomes infected.
The infection of the womb carries risk of
spreading infection (septicaemia) and is a
grave risk to the life of the woman.

CONTINUE
Recurrent pregnancy loss (RPL) or recurrent
miscarriage (medically termed habitual
abortion)
- occurrence of three consecutive
miscarriages. The occurrence of recurrent
pregnancy loss is 1%. A large majority
(85%) of women who have had two
miscarriages will conceive and carry
normally afterwards.

 ETIOLOGY
First trimester
i) Chromosomal abnormalities (50%)
e.g. autosomal trisomy, polyploidy,
monosomy
ii) Endocrine disorders (10 – 15%)
e.g. Luteal Phase Defect (LPD), Diabetes
Mellitus, Thyroid abnormalities,
deficient progesterone

 ETIOLOGY
First trimester
iii) Immunological disorders (5 – 10%)
* Autoimmune disease – formation of
antibodies against their own tissue and
placenta
* Alloimmune disease – paternal antigens
which are foreign to the mother invoke a
protective blocking antibody response

 ETIOLOGY
First trimester
iv) Infections (5%)
* Viral e.g. Rubella, CMV, HIV
* Bacterial e.g. Chlamydia, Brucella,
Ureaplasma
* Parasitic e.g. Candida albicans,
Toxoplasma gondii

 ETIOLOGY
First trimester
v) Maternal medical illness
e.g. SLE, cyanotic heart disease,
hemoglobinopathies, renal disease
vi) Blood group incompatibility
e.g. Rh incompatibility

 ETIOLOGY
First trimester
vii) Radiation, drugs and environmental
pollutants
* Radiation e.g. X-irradiation, serious
nuclear accidents
* Drugs and other substances e.g. alcohol
consumption, arsenic, formaldehyde,
psychotropic drugs
* Environmental pollution e.g. lead,
anaesthetic gases

 ETIOLOGY
Second trimester
i) Anatomic abnormalities
* Cervical incompetance (congenital or
acquired)
* Mullerian Fusion Defects e.g. bicornuate
uterus, septate uterus
* Uterine fibroids/uterine myomata –
subserosal, intramural or submucosal
* Intrauterine adhesions

 ETIOLOGY
Second trimester
ii) Maternal medical illness
iii) Unexplained

 MECHANISM OF ABORTION
i) Before 8 weeks
- the ovum, surrounded by villi with
decidual coverings, is expelled out intact
ii) 8 – 14 weeks
- expulsion of the fetus commonly occurs
leaving behind the placenta and the
membranes
iii) Beyond 14th week - similar to “mini
labour”; fetus is expelled first followed by
expulsion of the placenta after a varying
interval

II) INDUCED ABORTION
Induced abortion is the intentional
termination of a pregnancy before the fetus
can live independently. An abortion may be
elective (based on a woman's personal
choice) or therapeutic (to preserve the health
or save the life of a pregnant woman).

 PURPOSE
An abortion is considered to be elective if a
woman chooses to end her pregnancy, and it is
not for maternal or fetal health reasons. Some
reasons a woman might choose to have an elective
abortion are:
Continuation of the pregnancy may cause
emotional or financial hardship.
The woman is not ready to become a parent.
The pregnancy was unintended.
The woman is pressured into having one by her
partner, parents, or others.
The pregnancy was the result of rape or incest.

 PURPOSE
A therapeutic abortion is performed in order to
preserve the health or save the life of a pregnant
woman. A therapeutic abortion may be indicated
if a woman has a pregnancy-related health
condition that endangers her life, example:
severe hypertension (high blood pressure)
cardiac disease
severe depression or other psychiatric conditions
serious kidney or liver disease
certain types of infection
malignancy (cancer)
multifetal pregnancy

 MEDICAL ABORTION
Medical abortions are brought about by taking
medications that end the pregnancy.
The advantages of a first trimester medical
abortion are:
The procedure is non-invasive; no surgical
instruments are used.
Anesthesia is not required.
Drugs are administered either orally or by
injection e.g. Methotrexate, Mifepristone
The outcome resembles a normal

 MEDICAL ABORTION
The disadvantages of medical abortion are:
The effectiveness decreases after the 7th
week
The procedure may require multiple visits to
the doctor
Bleeding after the abortion lasts longer than
after a surgical abortion
The woman may see the contents of her
womb as it is expelled

 SURGICAL ABORTION
a) MANUAL VACUUM ASPIRATION.
Up to 10 weeks gestation, a pregnancy can be
ended by a procedure called manual vacuum
aspiration (MVA). This procedure is also called
menstrual extraction, mini-suction, or early
abortion. The contents of the uterus are
suctioned out through a thin plastic tube that is
inserted through the cervix; suction is applied
by a syringe. The procedure generally lasts
about 15 minutes.

b) DILATATION AND SUCTION CURETTAGE
(D & C)
This method may also be called suction
dilation, vacuum curettage, or suction
curettage. The procedure involves gentle
stretching of the cervix with a series of dilators
or specific medications. The contents of the
uterus are then removed with a tube attached
to a suction machine, and walls of the uterus
are cleaned using a narrow loop called a
curette.

(D & C)

Advantages of this method:
• It is usually done as a one-day outpatient
procedure
• The procedure takes only 10-15mins
• Bleeding after the abortion lasts 5 days or
less
• The woman does not see the products of her
womb removed

Disadvantages of this method:
• The procedure is invasive, surgical instruments
are used
• Infection may occur

c) DILATATION AND EVACUATION (D & E)
Some second trimester abortions are performed
as a dilatation and evacuation (D & E). The
procedures are similar to those used in a D & C,
but a larger suction tube must be used because
more material must be removed. This increases
the amount of cervical dilation necessary and
increases the risk and discomfort of the
procedure. A combination of suction and manual
extraction using medical instruments is used to
remove the contents of the uterus.

c) DILATATION AND EVACUATION (D & E)

d) DILATATION AND EXTRACTION (D & X)

e) Other surgical options
• Induction of labor
• Hysterotomy

MANAGEMENT
No treatment is necessary for a diagnosis of complete abortion
(as long as ectopic pregnancy is ruled out). In cases of an
incomplete abortion, empty sac, or missed abortion there are
two treatment options:
1) Medical management usually consists of using misoprostol (a
prostaglandin, brand name Cytotec) to encourage completion of
the miscarriage. About 95% of cases treated with misoprostol will
complete within a few days
2) Surgical treatment (D&C or D&E) is the fastest way to complete
the miscarriage. It also shortens the duration and heaviness of
bleeding, and is the best treatment for physical pain associated
with the miscarriage. In cases of repeated miscarriage or later-
term pregnancy loss, D&C is also the best way to obtain tissue
samples for pathology examination.

COMPLICATIONS
• Uncontrolled bleeding
• Infection
• Blood clots accumulating in the uterus
• A tear in the cervix or uterus
• Perforation of the uterus
• Missed abortion (the pregnancy is not
terminated)
• Incomplete abortion where some material
from pregnancy remains in the uterus
• Sterility
• Death – due to anesthetic complications,
severe bleeding or uncontrolled infection

COMPLICATIONS
Symptoms of post-abortion complications
(should see the doctor who performed the
abortion immediately):
• Severe pain
• Fever over 38.20C
• Heavy bleeding that soaks through more than
1 sanitary pad per hour
• Foul-smelling discharge from the vagina
• Continuing symptoms of pregnancy

CONTRACEPTION
Definition
Contraception means a sensitive decision
employed by an individual or both couples to
terminate fertility or conception. Contraception
is also defined as the prevention of fertilization
of an egg by a sperm (conception).

Classification
1) Physiological Contraception:
 Periodic abstinence
 Coitus interruptus
 Prediction of ovulation
 Prolongation of lactation
2) Chemical:
 Spermicidal
3) Barrier:
 Male and female condom
 Vaginal diaphragm
 Vaginal contraceptive sponge
 Cervical cap

4) Intrauterine Contraception:
 Progestasert
 Paragard (Copper bearing)
 Mirena (Levonorgestrel releasing system)
5) Hormonal Contraception:
 Oral contraceptives
 Depot Progesterone
 Implants (Norplant I & II)
 Progesterone intra uterine system
6) Surgical Contraception:
 Laparotomy
 Minilaparotomy
 Vaginal Sterilization
 Endoscopic Techniques
 Hysterectomy
 Tubal Ligation

i) Periodic Abstinence:
Absolute abstinence from sexual intercourse is
the sure-fire way to prevent conception.
ii) Coitus Interruptus:
Act of withdrawing the penis from the vagina
before ejaculation. Very unreliable method.
Requires discipline. No STD protection

iii) Prediction Of Ovulation (Rhythm
Method):
1) BBT (Basal Body Temperature)
Measuring:
Body temperature rises slightly during ovulation.
2) Calendar Method:
Length of menstrual cycle is recorded.
3) Cervical Mucus Method:
Consistency of cervical mucus changes depending
on state of fertility.

Advantages
 No
dependence of
hormones,
chemical or
devices.
 Satisfactory
for those who
cannot use
other methods.
 Inexpensive.
Disadvantages
 Needs high degree of
discipline.
 Not good if cycles are
irregular.
 No STD protection.
 Low effectiveness rate.
 Possibility of variable
cycles.
 Hyperthermia arising
from non-ovulatory
causes.

Cervical Mucus Or Billings
A = Intermediate type mucous B = Infertile type mucous
C = Fertile type mucous

iv) Prolongation of lactation (Lactation
Amenorrhea):
 Delay in ovulation during breast
feeding caused by increased prolactin
levels.
 Mother must provide breast feeding as
the only form of infant nutrition.
 Amenorrhea must be maintained
 Should be maintained for period of 6
months.

Advantages
 STD protection.
 Female has
control of use.
Disadvantages
 Insertion difficulty.
 High failure rate.
 Dislodges during
intercourse.
 Vaginal irritation.

Male condom
 When placed correctly over the penis,
the condom acts as a mechanical barrier
that prevents contact between
semen and the sexual partner.

Advantages
 Easy to use
 Cheap
 Very reliable if used
properly
 STD protection
Disadvantages
 Risk of dislodging
 Decreased sensation
 Tear,breakage risk
 Disintegrates when left
unpackaged
 Not everyone knows
how to use it(though they
think they do)

Advantages
 Non hormonal
 Placement may
occur up to 2
hours before
ejaculation
 Some STD
protection
 Reusable
Disadvantages
 Dislodges during sex
 Allergy to rubber
 Risk of bladder infection
 Requires individual fitting
 Reapplication of spermicide
for repeated intercourse
 Vaginal wall irritation

iii) Cervical cap:
 It is a small cup like
diaphragm placed
tightly over the
cervix and is held in
place by suction.
 Its is smeared with
spermicidal cream
for additional
protection.

Advantages
 Non hormonal.
 Insertion may occur
from 30 minutes to 48
hours before
intercourse.
 May be left in place
for prolonged period
of time (1 or 2 days).
 STD protection.
 Reusable.
 Female controlled.
Disadvantages
 Dislodges during sex.
 Allergy to rubber.
 Requires fitting by
professional.
 Impossible to use if
cervix is short.
 Difficult insertion and
removal.

Foam, Jelly, Cream, Pessaries,
Gels, Aerosols.
 It consists of deposition
of spermicidal substance
in the vagina before
coitus.
 This spermicidal
substance destroys the
sperm, so that no viable
sperm can reach the
ovum.

Advantages
 Easy insertion.
 Lubricating
properties.
 Possible to use
with barrier
methods.
 Use along or with
condom.
Disadvantages
• Allergic reaction.
• Short duration of
action.
• Short time to wait
for dispersion.
• Inability to
correctly place.

Types
 Chemical inert.
 Chemically active:-
a) hormone contained (with progesterone)
which must be replaced every year.
b) Non hormonal (copper, silver, gold
containing) which need to be replaced every
3-5 years.

 Different types of
IUD(top) with their
Introducers(bottom)
From left to right-
1.Usual(physically
prevents implantation
2. Nova-T
3. Multiload -375

Mechanism of action:
 Altered implantation.
 Altered tubal motility.
 Create local endometrial sterile inflammatory
reaction in response to the presence of foreign
body.
 Hormonal effects of progesterone in
progesterone IUD, causes atrophy of
endometrial and thickening of cervical mucus.
 Spermicidal activity with copper devices.

Advantages
 Highly effective, failure
rate only 2%.
 Long duration of action
(1,3-5 years).
 No systemic side effects.
 Does not interrupt sexual
activity.
 Suitable for breast
feeding women.
 Progesterone containing
devices decrease
menstrual flow.
Disadvantages
 Possibility of increased
menstrual flow and
cramps.
 Risk of pelvis infections.
 Increase ectopic
pregnancy.
 Uterine perforation.
 No STD protection.
 Insertion requires
involvement of trained
personal.
 Initial expense of
insertion is high.

Classification:
i) Oral contraceptives:
 Combines estrogen/progesterone.
 Progesterone only.
ii) Depot progesterone:
 Injections.
 Subcutaneous silicon implants.
 Skin patches
iii) Vaginal:
 Silicone rings releasing estrogen and progesterone.

Mechanism of action:
 It suppresses ovulation, both estrogen and
progesterone act on the hypothalamus
affecting negative feedback mechanism to
prevent production of FSH and LH.
 It prevents estrogen surge and progesterone
component keeps the mucus scanty and
viscous. This type of cervical mucous
prevents sperm penetration and migration.

i) Oral contraceptives:
There formulations may be:
 Monophasic (each tablet contains a fixed amount of
estrogen and progestin);
 Biphasic (each tablet contains a fixed amount of
estrogen, while the amount of progestin increases in
the second half of the cycle); or
 Triphasic (the amount of estrogen may be fixed or
variable, while the amount of progestin increases in
3 equal phases).

Side effects:
 Breakthrough Bleeding (≤ 25%)
 Amenorrhea
 Breast Tenderness, Nausea
 H/A (+/–)
 HTN
 Weight Gain

ii) Depot progesterone:
 Depo-Provera:
 Inhibits Ovulation
 150 mg q3months (14 day grace period)
 Delayed Ovulation After Discontinuation
 Main Side-Effects:
 Amenorrhea
 AUB
 Weight Gain
 Hair Loss

 Norplant:
 Implantable for ≤ 5 Years
 Similar Side Effects as Depo-Provera
 Avg. Yearly Failure Rate: 0.8/100
(Increases : > 2/100 after 5 years)
 Occasionally Difficult to Remove

 Skin patches
 The R W Johnson Pharmaceutical Research Institute submitted a new drug
application for a seven day contraceptive patch last month. The Ortho Evra
weekly patch can be worn on a woman’s lower abdomen or buttocks

definition
 It is the termination of fertility or conception
by operative procedure.
 The patient can’t conceive after the operation
but the patient is not castrated.
Classification
 Male- vasectomy.
 Female- tubal ligation.

INDICATIONS
 It is indicated for married women over 30 years who
want a permanent method of contraception and are
free of any gynecological pathology that would
otherwise dictate an alternate procedure.
 Women in premenopause age.
 It is also indicated for women with disease in whom a
pregnancy could represent a significant clinical and
medical risk or life threatening to the mother.

CONTRAINDICATIONS
 Obesity.
 Cardiovascular arrhythmias,
thromphlebitis,embolic predisposition.
 Poor anesthesia risk.
 Asthma.
 Coagulative complications cause by heparin
or inherited diseases like hemophilia.
 Metabolic immunosuppression.
 History of previous abdominal or pelvic
infection.

 Thank you so much for your
peaceful and
kind attention.

DEFINITION:
 Bleeding from or into the genital
tract after the 22 eek of pregnancy
but before the birth of the baby
(the first and second stage of labour
are thus included).
 The incidence is about 3% among
hospital deliveries.

More serious causes of late-
term bleeding may include:
 Placenta previa. The placenta moves down
the side of the uterus and covers the cervix
 Placenta abruption. The placenta becomes
detached, either partially or fully, from the
uterine wall.
 Late miscarriage.
 Preterm labor. Dilatation of the cervix in
preterm labor that occurs between 20 and 37
weeks of pregnancy.

PLACENTA PRAEVIA
 DEFINITON: When the placenta is
implanted partially or completely over
the lower uterine segment it is called
placenta praevia.
 INCIDENCE: The incidence of placenta
praevia ranges from 0,5-1% amongst hospital
deliveries. The incidence is increased beyond
the age of 35, with high birth order
pregnancies and in multiple pregnancy. In
80%, it is related to multiparous women.

AETIOLOGY
 The following theories are postulated.
 Dropping down theory: The fertilized ovum drops down and is
implanted in the lower segment. Poor decidual reaction in the
upper uterine segment may be the cause. Failure of zona
pellucida to disappear in time can be a hypothetical possibility.
This explains the formation of central placenta praevia.
 Persistence of chorionic activity in the decidua and its
subsequent development into capsular placenta which comes in
contact with decidua vera of the lower segment can explain the
formation of lesser degrees of placenta praevia.
 Defective decidua, results in spreading of the chorionic villi
over a wide area in the uterine wall to get nourishment. During
this process, not only the placenta becomes membranous but
encroaches onto the lower segment.
 Big surface area of the placenta as in twins may encroach
onto the lower segment.

What causes placenta
praevia?
The cause of placenta praevia is unknown, but it is associated with
certain conditions including the following:
 women who have scarring of the uterine wall from previous
pregnancies
 women who have fibroids or other abnormalities of the uterus
 women who have had previous uterine surgeries or cesarean
deliveries
 older mothers (over age 35)
 African-American or other minority race mothers
 cigarette smoking
 placenta previa in a previous pregnancy

TYPES OF DEGREES: There are four types of placenta praevia
depending on the degrees of extension of placenta to the lower
segment.

SYMPTOMS:
The most common symptom of placenta previa is
vaginal bleeding that is bright red and not associated
with abdominal tenderness or pain, especially in the
third trimester of pregnancy. However, each woman
may exhibit different symptoms of the condition or
symptoms may resemble other conditions or medical
problems. Always consult your physician for a
diagnosis.
Signs: General condition and anemia are proportionate
to the visible blood loss. But in the tropics, the
picture is often confusing due to pre-existing anemia.

Abdominal examination :
 The size of the uterus is proportionate to the period of
gestation.
 The uterus feels relaxed, soft and elastic without any localised
area of tenderness.
 Persistence of malpresentation like breech or transverse or
unstable lie is more frequent. There is also increased frequency
of twin pregnancy.
 The head is high floating in contrast to the period of gestation
or persistent displacement of the fetal head is very suggestive.
The head cannot be pushed down into the pelvis.
 Fetal heart sound is usually present, unless there is major
separation of the placenta with the patient in exsanguinated
condition. Slowing of the fetal heart rate on-pressing the head
down into the pelvis which soon recovers promptly when the
pressure is released is suggestive of the presence of low lying
placenta specially of posterior type (Stallworthy's sign).

 Vulval inspection : Only inspection is to be done to
note whether the bleeding is still active or ceased,
character of the blood — bright red or dark colored and
the amount of blood loss — to be assessed from the
blood stained clothing's. In placenta praevia, the
blood is bright red as the bleeding occurs from the
separated utero-placental sinuses close to the cervical
opening and escapes out immediately.
 Vaginal examination must not be done outside the
hospital or outside the operation theatre in the hospital,
as it can provoke further separation of placenta with
torrential bleeding and may be fatal. Vaginal
examination should only be done prior to
termination of pregnancy in the operation theatre under
anesthesia, keeping everything ready for Caesarean
section.

COMPLICATIONS
MATERNAL:
 During pregnancy:
1. Antepartum haemorrhage.
2. Malpresentation.
3. Premature labour either spontaneous or induced is quite
common.
 During labour :
1. Early rupture of the membranes
2. Cord prolapse
3. Slow dilatation of the cervix
4. Intrapartum haemorrhage
5. Increased incidence of operative interference
 Puerperium
1. Sepsis
2. Subinvolution
3. Embolism.

COMPLICATIONS
 FOETAL:
1. Low birth weight babies
2. Asphyxia is common and which may be the effect
of — (a) early separation of placenta, (b)
compression of the placenta or (c) compression of
the cord.
3. Intrauterine death is more related with severe
degree of separation of placenta, with maternal
hypovolaemia and shock.
4. Birth injuries are more common due to increased
operative interference.
5. Congenital malformation is three times more
common in placenta praevia.

PREVENTION:
 Adequate antenatal care to improve the health
status of the patient, specially correction of anaemia,
so that the patient can withstand blood loss.
 Antenatal vigilance to detect the suspected cases
of placenta praevia and their confirmation by
sonography where available before the bleeding
starts, is indeed a great achievement.
 Significance of "warning haemorrhage" should
not be ignored or under-estimated.
 Family planning and limitation of births have
been proved to lower the incidence of placenta
praevia in the hospital statistics.

ADMISSION TO HOSPITAL :
 All cases of APH, even if the bleeding is
slight or absent by the time the patient
reaches the hospital, should be admitted.
 The reasons are:
(1) All the cases of APH should be regarded as
due to placenta praevia unless proved
otherwise.
(2) As such, the bleeding may recur sooner or
later and none can predict when it recurs and
how much she will bleed.

TREATMENT ON ADMISSION
Overall assessment of the case is quickly made as
regards:
1. Assessment of the blood loss — by noting the
general condition, pallor, pulse rate and blood
pressure.
2. An infusion of 5% dextrose is started, if
required and compatible cross matched blood
transfusion should be arranged, whenever
necessary.
3. Gentle abdominal palpation to ascertain any
uterine tenderness and auscultation to note the
foetal heart rate.
4. Inspection of the vulva to note the presence of
any active bleeding. Increasing darkness of the
blood reassures that no fresh bleeding is occurring.

The cases suitable for
expectant treatment are:
 Mother is in good condition with a wide
margin of safety to withstand further
bouts of haemorrhage, if occurs.
 Duration of pregnancy is less than 38
weeks.
 Active vaginal bleeding is absent.
 F.H.S. is good.

Conduct of expectant
treatment:
Absolute bed rest is imposed for at least 5-7 days
after the vaginal bleeding ceases.
Investigations —hemoglobin estimation, blood
grouping and Rh- typing and urine for protein are
done.
Periodic inspection of the vulval pads and
auscultation of the fetal heart rate are done. When
the patient is allowed out of the bed (5-7 days after
the bleeding stops), a gentle speculum
examination is made using Sims' speculum to
exclude local cervical and vaginal lesions for
bleeding.
Localization of the placenta is to be done by the
available methods.

Termination of the expectant
treatment:
 The expectant treatment is carried up to 38
weeks of pregnancy. By this time, the baby
becomes sufficiently mature.
 However, premature termination may
have to be done in conditions, such as:
(1) Recurrence of brisk haemorrhage and which
is continuing.
(2) The foetus is dead.
(3) The foetus is found congenitally malformed
on investigation. Repeated small bouts of
haemorrhage is not an indication for
termination of expectant treatment.

Active treatment:
 The indications of active treatment are:
(1) Bleeding occurs at or beyond 38 weeks of
pregnancy.
(2) Patient is in labor.
(3) Patient is in exsanguinated state on
admission.
(4) Bleeding is continuing and of moderate
degree.
(5) Baby is dead or known to be congenitally
deformed.

DEFINITIVE TREATMENT
I. Vaginal examination in operation theatre followed
by:
(a) Low rupture of the membranes or
(b) Caesarean section
 II. Caesarean section without internal
examination
 Contra-indications of vaginal examination are:
(1) Patient in exsanguinated state
(2) Diagnosed cases of major degree of placenta praevia
(3) Associated complicating factors such as:
malpresentation, elderly primigravidae, pregnancy with
previous history of Caesarean section, contracted pelvis.

Caesarean section
 The indications of Caesarean section
are:
 Severe degree of placenta praevia (Type-II
post, Type-III and Type-IV). This is
indicated even where the baby is dead.
 Lesser degree of placenta praevia where
amniotomy fails to stop bleeding or fetal
distress appears.
 Complicating factors associated with lesser
degrees of placenta praevia where vaginal
delivery is found unsafe.

ABRUPTIO PLACENTAE
 DEFINITION : It is one form of
antepartum haemorrhage where
the bleeding occurs due to
premature separation of normally
situated placenta.

VARIETIES:
 Revealed: Following separation of the
placenta, the blood insinuates downwards
between the membranes and the decidua.
Ultimately, the blood comes out of the
cervical canal to be visible externally. This is
the commonest type.
 Concealed: The blood is collected behind the
separated placenta or collected in between
the membranes and decidua. At times, the
blood may percolate into the amniotic sac
after rupturing the membranes. This type is
rare.

AETIOLOGY
1. high birth order pregnancies with gravida 5 and
above – three times more common than in first
birth
2. advancing age of the mother
3. poor socio-economic conditions
4. malnutrition
5. a tendency of recurrence in subsequent pregnancy
6. Relation with toxaemia
7. Trauma
8. Sudden uterine decompression
9. Short cord
10. Supine hypotension syndrome
11. Folic acid deficiency
12. Torsion of the uterus

CLINICAL CLASSIFICATION:
 Grade – 0: Clinical feature suggestive of placental
separation may be absent.
 Grade – 1: External bleeding is present. Tenderness
on the uterus may or may not be present. Shock is
absent. FHS is good.
 Grade – 2: External bleeding may or may not be
present. Uterine tenderness is always present. Shock
is absent. Fetal distress or even fetal death occurs.
 Grade – 3: External bleeding may or may not be
present. Uterine tenderness is marked. Shock is
pronounced. Fetal death is the rule. Associated
coagulation defect or anuria may complicate.

PROGNOSIS
 The prognosis of the mother and the baby depends on the
clinical types (revealed, mixed or purely concealed), degree of
placental separation, the interval between the separation of the
placenta and delivery of the baby and the efficacy of treatment.
 MATERNAL:
 In revealed type – maternal risk is proportionate to the visible
blood loss and maternal death is rare.
 In concealed variety – the prognosis is very uncertain. The
following complications may occur either singly or in combination.
(1) Haemorrhage.
(2) Shock.
(3) Blood coagulation disorders.
(4) Oliguria and anuria due to — (a) hypovolaemia, (b) uterorenal
reflex, (c) serotonin liberated from the damaged uterine muscle
producing renal ischaemia and (d) DIC.
(5) Postpartum haemorrhage.
(6) Puerperal sepsis.

FOETAL:
 In revealed type, the fetal death is to
the extent of 25-30%. In concealed
type, however, the fetal death is
appreciably high, ranging from 50-
100%. The deaths are due to
prematurity and anoxia due to
placental separation.

PREVENTION
 Prevention, early detection and
effective therapy of pre-eclampsia and
other hypertensive disorders of pregnancy.
 Avoidance of trauma
 To avoid sudden decompression of the
uterus
 Routine administration of folic acid
supplement
 To avoid supine hypotension syndrome

TREATMENT
 IN THE HOSPITAL:
 REVEALED TYPE :
 Assessment of the case is to be done as regards:
(a) amount of blood loss,
(b) maturity of the foetus and
(c) whether the patient is in labor or not (usually labor starts).
 Preliminaries:
(i) Blood is sent for hemoglobin estimation, ABO grouping and Rh
typing and urine for detection of protein.
(ii) A 5% dextrose drip is started and arrangement for blood
transfusion is to be made, if necessary.
 Definitive treatment:
 The patient is in labor: low rupture of the membranes.
Oxytocin drip may be started to accelerate labor.

The patient is not in labor:
 Pregnancy 38 weeks or more:
Induction of labor is to be done by low rupture of the
membranes with or without oxytocin.
 Indications of Caesarean section are —
(a) appearance of fetal distress,
(b) amniotomy fails to control bleeding and
(c) associated complicating factors.
 Pregnancy less than 38 weeks:
(1) Bleeding, moderate to severe and continuing
— low rupture of the membranes is quite effective.
Oxytocin drip may be added. Labor usually starts
soon. Caesarean section is rarely indicated.
(2) Bleeding slight or stopped — the patient is put on
conservative treatment as outlined in placenta praevia.

MIXED OR CONCEALED TYPE:
 Principles in the management of
concealed type are:
(1) To correct hypovolaemia.
(2) Initiation of uterine contraction is the
only effective means to control
haemorrhage in abruptio placentae.
(3) To observe blood coagulation profiles
two hourly by bed side methods.

Definitive treatment:
 Sedation
 To correct hypovolaemic shock.
 Artificial rupture of the
membranes. Oxytocin drip should be
started, if not contraindicated.
 Vaginal delivery
 Caesarean section (early or late ).

Disseminated intravascular
coagulation
 Disseminated intravascular coagulation (DIC) is a
complex systemic thrombohemorrhagic disorder
involving the generation of intravascular fibrin and
the consumption of
 procoagulants and platelets.
 DIC is define as an acquired syndrome characterized
by the intravascular activation
 of coagulation with loss of localization arising from
different causes. It can originate from and cause
damage to the microvasculature, which if sufficiently
severe, can produce organ dysfunction.

Pathophysiology of DIC
The pathophysiology of DIC involves the
initiation of coagulation via endothelial injury
or tissue injury and the subsequent release of
procoagulant material in the form of
cytokines and tissue factors. Interleukin-6
and tumor necrosis factor may be the most
influential cytokines involved in coagulation
activation (via tissue factor) and may be
responsible for the end-organ damage that
occurs. Further, in the setting of sepsis,
neutrophils and their secretory products may
promote platelet-mediated fibrin formation.

Acute DIC is characterized by generalized bleeding,
which ranges from petechiae to exsanguinating
hemorrhage or microcirculatory and macrocirculatory
thrombosis. This leads to hypoperfusion, infarction, and
end-organ damage. In severe cases, patients may
develop fever and a shocklike picture with tachycardia,
tachypnea, and hypotension. Chronic DIC is
characterized by subacute bleeding and diffuse
thrombosis. Localized DIC is characterized by bleeding
or thrombosis confined to a specific anatomic location.
It has been associated with aortic aneurysms, giant
hemangiomas, and hyperacute renal allograft rejection

Causes of DIC in pregnancy
 Causes: Causes of DIC can be classified as acute or
chronic
 Acute DIC
1. Placental abruption
2. Amniotic fluid embolism
3. Acute fatty liver of pregnancy
4. Eclampsia
 Chronic DIC
1. Retained dead fetus syndrome
2. Retained products of conception

Medication
 Anticoagulant agents -- These agents are
used in the treatment of clinically evident
intravascular thrombosis when the patient
continues to bleed or clot 4-6 h after initiation
of primary and supportive therapy.
Thrombosis can present as purpura fulminans
or acral ischemia. Take special precaution in
obstetric emergencies or massive liver failure.
The anti-inflammatory properties of
antithrombin III may be particularly useful in
DIC secondary to sepsis.

Medication
 Recombinant Human Activated Protein C -- These
agents inhibit factors Va and VIIIa of the coagulation
cascade. They may also inhibit plasminogen activator
inhibitor-1 (PAI-1).
 Antifibrinolytic agents -- These agents are used only
after all other therapeutic modalities have been tried
and deemed unsuccessful. Increase in circulating
plasmin and laboratory evidence of decreased
plasminogen should be documented. Antifibrinolytics
may be useful in cases of DIC secondary to
hyperfibrinolysis associated with acute promyelocytic
leukemia and other forms of cancer

Complications
 Acute renal failure
 Life-threatening thrombosis and hemorrhage
(in patients with moderately severe to severe
DIC)
 Cardiac tamponade
 Hemothorax
 Intracerebral hematoma
 Gangrene and loss of digits
 Death

DEFINITION:
 Bleeding from or into the genital tract after
the 28th week of pregnancy but before the
birth of the baby (the first and second stage of
labour are thus included).
 The incidence is about 3% among hospital
deliveries.

MORE SERIOUS CAUSES OF LATE-
TERM BLEEDING MAY INCLUDE:
 Placenta previa. The placenta moves down
the side of the uterus and covers the cervix
 Placenta abruption. The placenta becomes
detached, either partially or fully, from the
uterine wall.
 Late miscarriage.
 Preterm labor. Dilatation of the cervix in
preterm labor that occurs between 20 and
37 weeks of pregnancy.

PLACENTA PRAEVIA
 DEFINITON: When the placenta is
implanted partially or completely
over the lower uterine segment it is
called placenta praevia.
 INCIDENCE: The incidence of placenta
praevia ranges from 0,5-1% amongst
hospital deliveries. The incidence is
increased beyond the age of 35, with high
birth order pregnancies and in multiple
pregnancy. In 80%, it is related to
multiparous women.

AETIOLOGY
 The following theories are postulated.
 Dropping down theory: The fertilized ovum drops down and
is implanted in the lower segment. Poor decidual reaction in
the upper uterine segment may be the cause. Failure of zona
pellucida to disappear in time can be a hypothetical possibility.
This explains the formation of central placenta praevia.
 Persistence of chorionic activity in the decidua and its
subsequent development into capsular placenta which comes in
contact with decidua vera of the lower segment can explain the
formation of lesser degrees of placenta praevia.
 Defective decidua, results in spreading of the chorionic villi
over a wide area in the uterine wall to get nourishment.
During this process, not only the placenta becomes
membranous but encroaches onto the lower segment.
 Big surface area of the placenta as in twins may encroach
onto the lower segment.

WHAT CAUSES PLACENTA PRAEVIA?
The cause of placenta praevia is unknown, but it is
associated with certain conditions including the
following:
 women who have scarring of the uterine wall from
previous pregnancies
 women who have fibroids or other abnormalities of the
uterus
 women who have had previous uterine surgeries or
cesarean deliveries
 older mothers (over age 35)
 African-American or other minority race mothers
 cigarette smoking
 placenta previa in a previous pregnancy

TYPES OF DEGREES: THERE ARE FOUR TYPES OF PLACENTA PRAEVIA
DEPENDING ON THE DEGREES OF EXTENSION OF PLACENTA TO THE
LOWER SEGMENT.

PLACENTA ACCRETA
 – Accreta = adherent to endometrial cavity
 – Increta = placental tissue invades myometrium
 – Percreta = placental tissue grows through
uterine wall

SYMPTOMS:
The most common symptom of placenta previa
is vaginal bleeding that is bright red and not
associated with abdominal tenderness or pain,
especially in the third trimester of pregnancy.
Signs: General condition and anemia are
proportionate to the visible blood loss. But in the
tropics, the picture is often confusing due to pre-
existing anemia.

ABDOMINAL EXAMINATION :
 The size of the uterus is proportionate to the period of gestation.
 The uterus feels relaxed, soft and elastic without any localised area
of tenderness.
 Persistence of malpresentation like breech or transverse or
unstable lie is more frequent. There is also increased frequency of
twin pregnancy.
 The head is high floating in contrast to the period of gestation or
persistent displacement of the fetal head is very suggestive. The head
cannot be pushed down into the pelvis.
 Fetal heart sound is usually present, unless there is major
separation of the placenta with the patient in exsanguinated
condition. Slowing of the fetal heart rate on-pressing the head down
into the pelvis which soon recovers promptly when the pressure is
released is suggestive of the presence of low lying placenta specially of
posterior type (Stallworthy's sign).

 Vulval inspection : Only inspection is to be done
to note whether the bleeding is still active or ceased,
character of the blood — bright red or dark colored and
the amount of blood loss — to be assessed from the
blood stained clothing's. In placenta praevia, the
blood is bright red as the bleeding occurs from the
separated utero-placental sinuses close to the cervical
opening and escapes out immediately.
 Vaginal examination must not be done outside the
hospital or outside the operation theatre in the
hospital, as it can provoke further separation of
placenta with torrential bleeding and may be fatal.
 Vaginal examination should only be done prior to
termination of pregnancy in the operation theatre
under anesthesia, keeping everything ready for
Caesarean section.

COMPLICATIONS
MATERNAL:
 During pregnancy:
1. Antepartum haemorrhage.
2. Malpresentation.
3. Premature labour either spontaneous or induced is
quite common.
 During labour :
1. Early rupture of the membranes
2. Cord prolapse
3. Slow dilatation of the cervix
4. Intrapartum haemorrhage
5. Increased incidence of operative interference
 Puerperium
1. Sepsis
2. Subinvolution
3. Embolism.

COMPLICATIONS
 FOETAL:
1. Low birth weight babies
2. Asphyxia is common and which may be the
effect of — (a) early separation of placenta, (b)
compression of the placenta or (c) compression of
the cord.
3. Intrauterine death is more related with severe
degree of separation of placenta, with maternal
hypovolaemia and shock.
4. Birth injuries are more common due to
increased operative interference.
5. Congenital malformation is three times more
common in placenta praevia.

PREVENTION:
 Adequate antenatal care to improve the health
status of the patient, specially correction of
anaemia, so that the patient can withstand blood
loss.
 Antenatal vigilance to detect the suspected cases
of placenta praevia and their confirmation by
sonography where available before the bleeding
starts, is indeed a great achievement.
 Significance of "warning haemorrhage" should
not be ignored or under-estimated.
 Family planning and limitation of births have
been proved to lower the incidence of placenta
praevia in the hospital statistics.

ADMISSION TO HOSPITAL :
 All cases of APH, even if the bleeding is
slight or absent by the time the patient
reaches the hospital, should be admitted.
 The reasons are:
(1) All the cases of APH should be regarded
as due to placenta praevia unless proved
otherwise.
(2) As such, the bleeding may recur sooner or
later and none can predict when it recurs
and how much she will bleed.

TREATMENT ON ADMISSION
Overall assessment of the case is quickly made as
regards:
1. Assessment of the blood loss — by noting the
general condition, pallor, pulse rate and blood
pressure.
2. An infusion of 5% dextrose is started, if
required and compatible cross matched blood
transfusion should be arranged, whenever
necessary.
3. Gentle abdominal palpation to ascertain any
uterine tenderness and auscultation to note the
fetal heart rate.
4. Inspection of the vulva to note the presence of
any active bleeding. Increasing darkness of the
blood reassures that no fresh bleeding is
occurring.

THE CASES SUITABLE FOR
EXPECTANT TREATMENT ARE:
 Mother is in good condition with a wide margin of
safety to withstand further bouts of haemorrhage,
if occurs.
 Duration of pregnancy is less than 38 weeks.
 Active vaginal bleeding is absent.
 F.H.S. is good.

CONDUCT OF EXPECTANT
TREATMENT:
Absolute bed rest is imposed for at least 5-7 days
after the vaginal bleeding ceases.
Investigations —hemoglobin estimation, blood
grouping and Rh- typing and urine for protein
are done.
Periodic inspection of the vulval pads and
auscultation of the fetal heart rate are done.
When the patient is allowed out of the bed (5-7
days after the bleeding stops), a gentle
speculum examination is made using Sims'
speculum to exclude local cervical and vaginal
lesions for bleeding.
Localization of the placenta is to be done by the
available methods.

TERMINATION OF THE
EXPECTANT TREATMENT:
 The expectant treatment is carried up to
38 weeks of pregnancy. By this time, the
baby becomes sufficiently mature.
 However, premature termination may
have to be done in conditions, such as:
(1) Recurrence of brisk haemorrhage and
which is continuing.
(2) The foetus is dead.
(3) The foetus is found congenitally
malformed on investigation. Repeated small
bouts of haemorrhage is not an indication
for termination of expectant treatment.

ACTIVE TREATMENT:
 The indications of active treatment
are:
(1) Bleeding occurs at or beyond 38 weeks of
pregnancy.
(2) Patient is in labor.
(3) Patient is in exsanguinated state on
admission.
(4) Bleeding is continuing and of moderate
degree.
(5) Baby is dead or known to be congenitally
deformed.

DEFINITIVE TREATMENT
I. Vaginal examination in operation theatre
followed by:
(a) Low rupture of the membranes or
(b) Caesarean section
 II. Caesarean section without internal
examination
 Contra-indications of vaginal examination
are:
(1) Patient in exsanguinated state
(2) Diagnosed cases of major degree of placenta praevia
(3) Associated complicating factors such as:
malpresentation, elderly primigravidae, pregnancy
with previous history of Caesarean section, contracted
pelvis.

CAESAREAN SECTION
 The indications of Caesarean section
are:
 Severe degree of placenta praevia (Type-II
post, Type-III and Type-IV). This is
indicated even where the baby is dead.
 Lesser degree of placenta praevia where
amniotomy fails to stop bleeding or fetal
distress appears.
 Complicating factors associated with
lesser degrees of placenta praevia where
vaginal delivery is found unsafe.

VASA PREVIA
 • Associated with velamentous insertion of the
 umbilical cord (1% of deliveries)
 • Bleeding occurs with rupture of the amniotic
 membranes (the umbilical vessels are only
 supported by amnion)
 • Bleeding is FETAL (not maternal as with
 placenta previa)
 • Fetal death may occur with trivial symptoms

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