IMLE Preparatory Course

Lecture 55
Obstetrics and Gynecology

Abnormal Labor and Delivery

Puerperium
Abnormal Labor and Delivery
Shoulder dystocia
Failure to progress
Rupture of membranes
Preterm labor
Fetal Malpresentation
Cesarean Section
Episiotomy
 Shoulder Dystocia
 Affects 0.6–1.4% of
all deliveries
 Risk factors include

 Obesity
 Diabetes
 A history of a
macrosomic infant
 A history of prior
shoulder dystocia
 Shoulder Dystocia Diagnosis
 By a prolonged second stage of labor, recoil of the
perineum (“turtle sign”), and lack of spontaneous
restitution.
 Shoulder Dystocia Treatment
In the event of dystocia, be the mother’s HELPER:

 Help reposition.
 Episiotomy.
 Leg elevated (McRoberts’ maneuver).
 Pressure (suprapubic).
 Enter the vagina and attempt rotation (Wood’s
screw).
 Reach for the fetal arm.
23 year old G2P1 delivering 42 weeks gestational, is noted to
be in second stage when fetus head is retracted back to the
introitus. The shoulder is not deliver with the push of the
mother. Which of the following maneuvered is best?

a. Internal podalic version

b. Suprabubic pressure
c. Fundal pressure
d. Intentional fracture of the humerus
e. Delivery of the anterior scalp
23 year old G2P1 delivering 42 weeks gestational, is noted to
be in second stage when fetus head is retracted back to the
introitus. The shoulder is not deliver with the push of the
mother. Which of the following maneuvered is best?

a. Internal podalic version

b. Suprabubic pressure
c. Fundal pressure
d. Intentional fracture of the humerus
e. Delivery of the anterior scalp
Failure to Progress
 Associated with chorioamnionitis, occiput
posterior position, nulliparity, and elevated birth
weight.
 Failure to Progress Diagnosis
 First-stage protraction or arrest: Labor that fails
to produce adequate rates of progressive cervical
change.
 Prolonged second-stage arrest:
 Nulliparous: Inadequate cervical dilation after
> 3 hours with regional anesthesia, > 2 hours
without.
 Multiparous: Inadequate cervical dilation after
> 2 hours with regional anesthesia, > 1 hour
without.
Failure to Progress Treatment
 Complications
 Chorioamnionitis leads to fetal infection,
pneumonia, and bacteremia.

 Some 10% of those affected have permanent

injury, 11% have a risk of postpartum
hemorrhage, and 3.8% are at risk of fourth-
degree laceration.
Rupture of membranes
 Premature rupture of membranes (PROM)
 Rupture of the chorioamnionic membrane
(amniorrhexis) prior to the onset of labor at
any stage of gestation

 Preterm premature rupture of membranes

(PPROM)
 PROM prior to 37-wk. gestation
 PROM/PPROM: History & Physical Exam
 History
 “Gush” of fluid
 Steady leakage of small amounts of fluid

 Physical
 Sterile vaginal speculum exam
 Minimize digital examination of cervix, regardless of gestational age, to
avoid risk of ascending infection/amnionitis
 Assess cervical dilation and length
 Obtain cervical cultures (Gonorrhea, Chlamydia)
 Obtain amniotic fluid samples
 Findings
 Pooling of amniotic fluid in posterior vaginal fornix
 Fluid per cervical os
 PROM/PPROM: Diagnosis
 Test
 Nitrazine test
 Fluid from vaginal exam placed on strip
of nitrazine paper
 Paper turns blue in presence of alkaline
(pH > 7.1) amniotic fluid

 Fern test
 Fluid from vaginal exam placed on slide
and allowed to dry
 Amniotic fluid narrow fern vs. cervical
mucus broad fern
PROM/PPROM: Diagnosis
 False positive Nitrazine test
 Alkaline urine
 Semen (recent coitus)
 Cervical mucus
 Blood contamination
 Vaginitis (e.g. Trichomonas)

 False-Negative Nitrazine test

 Remote PROM with no residual fluid
 Minimal amniotic leakage
PROM/PPROM: Diagnosis
 Test
 Ultrasound
 Assess amniotic fluid level and compatibility
with PROM
 Indigo-carmine Amnioinfusion
 Ultrasound guided indigo carmine dye
amnioinfusion (“Blue tap”)
 Observe for passage of blue fluid from vagina
PROM/PPROM: Risk Factors
 Prior PROM or PPROM
 Prior preterm delivery
 Multiple gestation
 Polyhydramnios
 Incompetent cervix
 Vaginal/Cervical Infection
 Gonorrhea, Chlamydia, GBS, S. Aureus
 Antepartum bleeding (threatened abortion)
 Smoking
 Poor nutrition
Management: PPROM
(< 24 wk gestation – “previable”)

 Patient counseling
 Expectant management vs. induction of labor
 GBS prophylaxis NOT recommended
 Antibiotics
 Incomplete data
 Corticosteriods NOT recommended
 Management: PPROM
(< 24 wk gestation – “previable”)
 Patient counseling
Outcomes at 18 to 22 Months Corrected Age*
Gestational Age
Death Before Death/ Profound
(In Completed Death/Moderate to Severe Neuro-
NICU Discharge Death Neurodevelopmental
Weeks) developmental Impairment
Impairment

22 Weeks 95% 95% 98% 99%

23 Weeks 74% 74% 84% 91%
 Fetal complications
24 Weeks 44% of prolonged
44%PPROM 57% 72%
25 Weeks 24% 25% 38% 54%
Pulmonary hypoplasia

Skeletal malformations

Fetal growth restriction

IUFD
 Maternal complications of prolonged PPROM
 Chorioamnionitis
Management: PPROM
(24 – 31 wk gestation)
 Expectant management
 Deliver at 34 wks
 Unless documented fetal lung maturity
 GBS prophylaxis
 Antibiotics
 Single course corticosteroids
 Tocolytics
 No consensus
Management: PPROM
(32 – 33 wk gestation)

 Expectant management
 Deliver at 34 wks
 Unless documented fetal lung maturity
 GBS prophylaxis
 Antibiotics
 Corticosteroids
 No consensus, some experts recommend
Management: PROM
(> 34 wk gestation)
 Proceed to delivery
 Induction of labor
 GBS prophylaxis
 Management: Amniocentesis
 Typically performed after 32 wks
 Tests for fetal lung maturity (FLM)
 Lecethin/Sphingomyelin ratio (not
commonly used, more for historic interest)
 L/S ratio > 2 indicates pulmonary maturity
 Phosphatidylglycerol
 > 0.5 associated with minimal respiratory
distress
 Flouresecence polarization (FLM-TDx II)
 > 55 mg/g of albumin
 Lamellar body count
 30,000-40,000
 If negative, proceed with expectant
management until 34 wks
 Preterm Labor

 Defined as onset of labor between 20 and 37

weeks’ gestation.

 Risk factors include multiple gestation, infection,

PROM, uterine anomalies, previous preterm
labor or delivery, polyhydramnios, placental
abruption, poor maternal nutrition, and low SES.

 Most patients have no identifiable risk factors.

Preterm Labor Diagnosis

 Patients may have menstrual-like cramps, onset of

low back pain, pelvic pressure, and new vaginal
discharge or bleeding.

 Requires regular uterine contractions (≥ 3

contractions of 30 seconds each over a 30-minute
period) and concurrent cervical change at < 37
weeks’ gestation
 Preterm Labor Diagnosis
 Assess for contraindications to tocolysis
(infection, nonreassuring fetal testing, placental
abruption).
 Perform a sterile speculum exam to rule out
PROM.
 Obtain an ultrasound to rule out fetal or uterine
anomalies, verify GA, and assess fetal
presentation and amniotic fluid volume.
 Obtain cultures for chlamydia, gonorrhea, and
GBS.
Preterm Labor Treatment
 Hydration and bed rest.
 Unless contraindicated, begin tocolytic therapy (β-mimetics,
MgSO4, CCBs, PGIs) and give steroids to accelerate fetal
lung maturation.
 Give penicillin or ampicillin for GBS prophylaxis if preterm
delivery is likely.

 RDS, intraventricular hemorrhage, PDA, necrotizing

enterocolitis, retinopa-
 thy of prematurity, bronchopulmonary dysplasia, death.
Preterm Labor Complications
 RDS
 Intraventricular hemorrhage
 PDA
 Necrotizing enterocolitis
 Retinopathy of prematurity
 Bronchopulmonary dysplasia
 Death.
 Fetal Malpresentation
 Defined as any presentation other than vertex
(head closest to birth canal, chin to chest, occiput
anterior).

 Risk factors include prematurity, prior breech

delivery, uterine anomalies, poly or
oligohydramnios, multiple gestations, PPROM,
hydrocephalus, anencephaly, and placenta previa.
 Fetal Malpresentation
 Breech presentations are the most common form (affect
3% of all deliveries) and involve presentation of the fetal
lower extremities or buttocks into the maternal pelvis.

 Frank breech (50–75%): The thighs are fl exed and the

knees are extended.
 Footling breech (20%): One or both legs are extended
below the buttocks.
 Complete breech (5–10%): The thighs and knees are
flexed.
Fetal Malpresentation Treatment
 Follow: 75% spontaneously change to vertex by week 38.

 External version

 Trial of breech vaginal delivery: Attempt only if delivery is

imminent. Complications include cord prolapse and/or head
entrapment.

 Elective C-section: Recommended given the lower risk of

fetal morbidity.
Caesarean section
 Types of C-sections
 The classical Caesarean
section involves a
midline longitudinal
incision which allows a
larger space to deliver the
baby. However, it is rarely
performed today, as it is
more prone to
complications.
 Types of C-sections
 The lower uterine
segment section is the
procedure most
commonly used today. It
involves a transverse
cut just above the edge of
the bladder and results in
less blood loss and is
easier to repair.
Maternal Indications for Cesarean Section

 Prior classical C-section (vertical incision

predisposes to uterine rupture with vaginal
delivery)
 Active genital herpes infection
 Cervical carcinoma
 Maternal trauma/demise
 HIV infection
 Prior transverse C-section (relative indication)
Fetal and Maternal Indications for
Cesarean Section

 Cephalopelvic disproportion (most

common cause of 1° C-section)
 Placenta previa/placental abruption
 Failed operative vaginal delivery
 Post-term pregnancy (relative indication)
 Fetal Indications for Cesarean Section
 Fetal malposition (e.g., posterior chin, transverse lie,
shoulder presentation)
 Fetal distress
 Cord compression/prolapse
 Erythroblastosis fetalis (Rh incompatibility)

 For both elective and indicated cesarean delivery,

sodium citrate should be used to ↓ gastric acidity
and prevent acid aspiration syndrome.
The best pregnancy management of a 40 years old
nullipara, prior myomectomy during which the
endometrial cavity was anterior:

a. Labor allowed
b. Labor allow, low forceps/vacuum to shorten the 2nd
stage
c. Caesarian section near prior term of labor
d. Oxitoxin at 38 weeks
e. Caesarian section at 40-41 week
The best pregnancy management of a 40 years old
nullipara, prior myomectomy during which the
endometrial cavity was anterior:

a. Labor allowed
b. Labor allow, low forceps/vacuum to shorten the 2nd
stage
c. Caesarian section near prior term of labor
d. Oxitoxin at 38 weeks
e. Caesarian section at 40-41 week
Complications
 INTRAOPERATIVE
 Bleeding & the need for transfusion
 Hysterectomy
 Complications of anesthesia
 Damage to the bladder, ureter, colon , retained placental tissue
 Fetal injury

 POSTOPERATIVE
 Gaseous distension
 Paralytic ileus
 Wound dehiscence & infection
 DVT & pulmonary embolism
 Vesico uterine fistula
A 32 year old woman gravid 3 para 3 just delivered a viable female
infant weighting 4000 grams via cesarian section for nonreassuring
fetal heart rate pattern, she received intrathecal spinal anesthetic
and nacratic for pain relief during the procedure, her foley
catheter is left in place for several hours after the cesarian section
this will prevent?

a.stress incontinence
b.urge incontinence
c.overflow incontinence
d.mixed incontinence
e.preoperative urinary tract infection
A 32 year old woman gravid 3 para 3 just delivered a viable female
infant weighting 4000 grams via cesarian section for nonreassuring
fetal heart rate pattern, she received intrathecal spinal anesthetic
and nacratic for pain relief during the procedure, her foley
catheter is left in place for several hours after the cesarian section
this will prevent?

a.stress incontinence
b.urge incontinence
c.overflow incontinence
d.mixed incontinence
e.preoperative urinary tract infection
Post natal care
 Blood loss must be monitored
 Uterine fundus palpated
 Effective parenteral analgesics
 Deep breathing & coughing encouraged
 Early mobilization
 Fluid therapy &diet
 Bladder & bowel function
 Wound care
 Breast care
 Prophylaxis for thromboembolism
Mode of delivery in next pregnancy
Criteria for VBAC
 Patient must agree to the procedure
 A low transverse uterine incision
 Non recurrent cause of the previous CS
 No macrosomia, malposition, multiple gestation, breech

Contraindications for VBAC

 Previous classical CS
 2 or more previous CS
 Previous other uterine surgery
 History of scar rupture
 Placenta previa or transverse lie
 Episiotomy
 Surgical extension of the vaginal opening into the
perineum.
 There are two types: median (midline) and mediolateral.
 Episiotomy Complications
 Extension to the anal sphincter (third degree) or
rectum (fourth degree), which is more common
with midline episiotomy.
 Bleeding
 Infection
 Dyspareunia
 Rectovaginal fistula
 Maternal death.

 Routine use of episiotomy is not recommended.

Puerperium
Postpartum Hemorrhage
Postpartum infections
Sheehan’s syndrome
Postpartum Hemorrhage
 Defined as a loss of > 500 mL of blood for vaginal delivery or > 1000
mL for C-section occurring before, during, or after delivery of the
placenta.

 Uterine Atony
 Genital tract trauma
 Retained placental tissue

 Complications include acute blood loss (potentially

fatal), anemia due to chronic blood loss (predisposes to
puerperal infection), and Sheehan’s syndrome.
 Uterine Atony
 Risks:
 Uterine overdistention.
 Exhausted myometrium.
 Uterine infection.
 Conditions interfering with contractions (anesthesia, myomas, MgSO4).

 Diagnosis:
 Palpation of a soft, enlarged, “boggy” uterus.
 The most common cause of postpartum hemorrhage (90%).

 Treatment:
 Bimanual uterine massage (usually successful).
 Oxytocin infusion.
 Methergine (methylergonovine) if not hypertensive.
 Prostaglandin (PGF2a).
 Genital Tract Trauma
 Risks:
 Precipitous labor.
 Operative vaginal delivery (forceps, vacuum extraction).
 Large infant.
 Inadequate episiotomy repair.

 Diagnosis:
 Manual and visual inspection of the lower genital tract for
any laceration > 2 cm long.

 Treatment:
 Surgical repair of the physical defect.
Retained Placental Tissue
 Risks:
 Placenta accreta/increta/percreta.
 Placenta previa.
 Uterine leiomyomas.
 Preterm delivery.
 Previous C-section/curettage.

 Diagnosis:
 Manual and visual inspection of the placenta and uterine cavity for
missing cotyledons.
 Ultrasound.

 Treatment:
 Manual removal of remaining placental tissue.
 Curettage with suctioning.
 Postpartum Infections
 Characterized by a temperature ≥ 38°C for at least two
of the first ten postpartum days (not including the first
24 hours).
Postpartum Infections Risk Factors
 Emergent C-section
 PROM
 Prolonged labor
 Multiple intrapartum vaginal exams
 Intrauterine manipulations
 Young age
 Prolonged ruptured membranes
 Bacterial colonization
 Corticosteroid use
 Postpartum Infections

 For endometritis, hospitalize and give broad

spectrum empiric IV antibiotics (clindamycin
and gentamicin) until patients have been
afebrile for 48 hours.

 Add ampicillin for complicated cases.

 Postpartum Infections

 For persistent postpartum fever that is not

responsive to broad-spectrum antibiotics, think
septic pelvic thrombophlebitis.

 The clot is then invaded by microorganisms.

Suppuration follows, with liquefaction,
fragmentation, and, finally, septic embolization.
 Postpartum Infections
 Presents with abdominal and back pain and a
picket-fence fever curve (“hectic” fevers) with
wide swings from normal to as high as 41°C.

 Diagnose with blood cultures and CT looking for

a pelvic abscess.

 Treat with broad-spectrum antibiotics and

anticoagulation with heparin × 10 days.
 Sheehan’s Syndrome
 Defined as pituitary ischemia and necrosis that leads to
anterior pituitary insufficiency 2° to massive obstetric
hemorrhage and shock.

 The 1° cause of anterior pituitary insufficiency in adult

females.
 The most common presenting syndrome is failure to
lactate (due to ↓prolactin levels).
 Other symptoms include weakness, lethargy, cold
insensitivity, genital atrophy, and menstrual disorders.
 Sheehan’s Syndrome
 The diagnosis is established with provocative
hormonal testing and MRI of the pituitary and
hypothalamus to rule out tumor or other
pathology.

 Treatment consists of the replacement of all

deficient hormones. However, some patients may
recover TSH and even gonadotropin function
after cortisol replacement alone.