Seminar on Abnormal Labour and Its Management

8/19/2019 Seminar on Abnormal Labour and Its Management

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SEMINAR ON ABNORMAL LABOUR AND ITS

MANAGEMENT

GENERAL OBJECTIVES:

At the end of the seminar the group will be able to gain in depth

knowledge regarding abnormal labour and its management.

SPECIFIC OBJECTIVES

The group will be able to,

1) Dene the terminologies2) Enumerate mal-positions and mal-presentations) Des!ribe "arious mal-positions#) E$plain "arious mal presentations%) Demonstrate the me!hanism of abnormal labour&) E$plain the management of abnormal labour') Dis!uss the nursing management of abnormal labour() E$plain the re!ent modalities in management of abnormal labour

) Dis!uss the nursing diagnosis of abnormal labour and its

management

OUTLINE

1) *ntrodu!tion2) Terminologies

• +abour

• ormal labour

•

Abnormal labour• e!hanism of labour


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• Engagement

• +ie

• resentation

• resenting part

•

Attitude• Denominator

• osition

• al-position

• al-presentation) /arious mal-positions

• al position in "erte$ presentation

• al-position in shoulder presentation

• al-position in fa!e presentation

• al-position in bree!h presentation

#) /arious mal-presentations• 0ree!h presentation

• a!e presentation

• 0row presentation

• houlder presentation

• 3ompound presentation

%) /arious me!hanism of abnormal labour

• 0ree!h presentation

• a!e presentation

• 0row presentation

• houlder presentation

• 3ompound presentation&) anagement of abnormal labour') ursing management of abnormal labour() ursing theor4) ursing diagnosis15) 6e!ent modalities in the management of abnormal labour11) summar412) 3on!lusion1) 6esear!h stud4

1#) 0ibliograph4

*T67D83T*7

8suall4 the fetal head engages in o!!ipito anterior position and then

undergoes a short rotation to be dire!tl4 o!!ipito anterior in the mid


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!a"it4. al positions and malpresentation are the abnormal positions of

the "erte$ of the fetal head relati"e to the maternal pel"is.

DEFINE THE TERMS:

1) LABOUR: A series of events that takes place in a genital organ in efforts to expel

the viable products of conception out of the womb through the vagina into the outer

world is called labour.

2) NORMAL LABOUR (EUTOCIA): A labour is called normal if it fulfils the

following criteria;

• pontaneous in onset and at term• 9ith "erte$ presentation

• 9ithout undue prolongation

• atural termination with minimal aids

• 9ithout ha"ing an4 !ompli!ations a:e!ting the health of the

mother and the bab4.) ABNORMAL LABOUR (DYSTOCIA): An4 de"iation from the

!riteria;s of normal labour is !alled abnormal labour.

#) MECHANISM OF LABOUR: *t is a series of mo"ements that o!!ur

on the fetal head and the trunk in the pro!ess of adaptation, during

its


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15) DENOMINATOR: *t is an arbitrar4 bon4 $ed point on the

presenting part whi!h !omes in relation with the "arious >uadrants

of the maternal pel"is.

11) POSITION: osition refers to the relationship between the

denominator of presenting part and the four >uadrants of the

maternal pel"is.12) MALPOSITION: The relationship between the denominator

?o!!iput) of the presentation ?"erte$) and the point on the pel"is is

other than iliope!teneal eminen!e.1) MALPRESENTATION: The fetus presents in maternal pel"is

other than "erte$, longitudinal lie and @e$ion attitude.

MALPOSITIONS & MALPRESENTATIONS

1) POSITIONS IN VERTEX PRESENTATION

7*T*7 733*8T 7*T

T79A6D

A*TTA+ 8T86E 7

ET8 * 7TBE6

E+/*+eft 7!!ipito +ateral +eft *liope!teneal +ine Trans"erse diameter6ight 7!!ipito +ateral 6ight *liope!teneal +ine Trans"erse diameter+eft 7!!ipito osterior +eft a!ro *lia! ue diameter6ight 7!!ipito osterior 6ight a!ro *lia! Coint 6ight 7bli>ue diameterDire!t 7!!ipito Anterior 4mph4sis ubis Anterio osterior

diameterDire!t 7!!ipito

osterior

a!rum Anterio posterior

diameter

2) POSITIONS IN BREECH PRESENTATION

Pos!o"s S#$%' o !* *!s " %*+#!o"

!o !* 'o!*%s ,*+-s

+eft a!ro +ateral position +eft iliope!teal line6ight sa!ro +ateral position 6ight iliope!teneal line


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+eft a!ro osterior position +eft sa!ro ilia!


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Abdominal e$amination

1. +isten to mother

• 3omplain about ba!k a!he.

• other feels that bab4;s bottom is high up against her ribs.• Fui!kening feels a!ross both sides of her abdomen.

2. 7n inspe!tion

• au!er shaped depression at or ue

diameter of the pel"i! brim.


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STEPS OF MECHANISM

1. E"/#/*'*"!H Engagement o!!urs in right obli>ue diameter of the

pel"is.2. F+*6o"H De!ent o!!urs with in!reasing @e$ion. The o!!iput is the

leading part.. I"!*%"#+ %o!#!o" o !* *#7H The o!!iput rea!hes the pel"i!

@oor rst and rotates forwards I( of the !ir!le along the right sides

of the pel"is to lie under the s4mph4sis pubis. The shoulders follow,

turning 2I( of a !ir!le from the left to right obli>ue diameter.

#. C%o8""/: The o!!iput es!apes under the s4mph4sis pubis and

!rowning o!!urs.%. E6!*"so" o *#7H The sin!iput, fa!e and !hin sweeps the

perineum and head is born b4 a mo"ement of e$tension.&. R*s!!!o": 7!!iput turns 1I(th of a !ir!le to the right and the

head realigns itself with the shoulders.'. I"!*%"#+ %o!#!o" o !* so+7*%sH The shoulder enters in the

pel"is in right obli>ue diameter, the anterior shoulder rea!hes the

pel"i! @oor rst and rotates forwards 1I(th of a !ir!le and lie under

s4mph4sis pubis.(. E6!*%"#+ %o!#!o" o !* *#7H At the same time the o!!iput turns

a further 1I(th of a !ir!le to lie under s4mph4sis pubis.. L#!*%#+ 9*6o"H the anterior shoulder es!apes under the s4mph4sis

pubis, posterior shoulder sweeps the perineum and the bod4 is born

b4 a mo"ement of lateral @e$ion.

THE POSSIBLE COURSE AND OUTCOME OF LABOUR

1. +ong internal rotation2. hort internal rotation. 8ndiagnosed fa!e to pubis

#. Deep trans"erse arrest%. 3on"ersion to fa!e or brow presentation


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COMPLICATIONS

1. 7bstru!ted labour2. aternal trauma. eonatal trauma#. 3ord prolapsed%. 3erebral haemorrhage&. 6isk of infe!tion'. rolonged labour

MANANGEMENT OF LABOUR

P%"$,+*s:

• Earl4 diagnosis

• tri!t "igilan!e with wat!hful e$pe!tan!4

• Cudi!ious and timel4 interferen!e

S!*,s o '#"#/*'*"!

1) Diagnosis and e"aluation2) Earl4 !aesarean se!tion

D%"/ %s! s!#/*:

• *f there is no !ompli!ation labour is allowed to pro!eed similar

to normal labour.

• Anti!ipating prolonged labour- start intra"enous 6+.

• 3he!k the progress of labour.

• 9eak pain, persisten!e of de@e$ion and non rotation of the

o!!iput are too often !oe$istent start o$4to!in infusion for

augmentation of labour.

• 3he!k the indi!ations for !aesarean se!tion. ?Arrest of labour,

in!oordinate uterine a!tions, fetal distress).


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D%"/ s*$o"7 s!#/*:

• *n ma


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1) /entouse or "a!uum e$tra!tion2) Alternati"e methods

• anual rotation followed b4 for!eps e$tra!tion

• or!eps rotation and e$tra!tion

• 3aesarean se!tion

• 3raniotom4

OCCIPITO SACRAL ARREST

• *f the o!!iput below the *s!hial spine - or!eps appli!ation in

unrotated fetal head followed b4 e$tra!tion as fa!e to pubis.

• *f the o!!iput remains at or abo"e the le"el of is!hial spine

!aesarean se!tion.

DEEP TRANSVERSE ARREST

D*"!o":

The head is deep in to the !a"it4J the sagital suture is pla!ed in the

trans"erse bispinous diameter and there is no progress in the des!ent of

the head e"en after K to 1 hour following full dilatation of the !er"i$.

C#s*s:

• ault4 pel"i! ar!hite!ture

• De@e$ion of the head

• 9eak uterine !ontra!tion

• +a$it4 of the pel"i! @oor mus!les

D#/"oss:

• The head is engaged

• The sagital suture lies in the trans"erse bispinous diameter

• Anterior fontanelle is palpable

• ault4 pel"i! ar!hite!ture ma4 be dete!ted.


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M#"#/*'*"!:

0ased upon fetal !ondition and ndings of pel"i! assessment.

1) *n !ase of big bab4 and inade>uate pel"is- 3aesarean se!tion.2) *f there is no !ontraindi!ations for "aginal deli"er4

• /entouse.

• anual rotation and appli!ation of for!eps.

• or!eps rotation and deli"er4 with kielland.

NURSING MANAGEMENT OF MALPOSITIONS

anagement during *st

stage of labour• 3ontinuous support from midwife ?massage, posture and positions)

• 7$4to!in infusion to !orre!t in !oordinated uterine !ontra!tion.

• ro"ide rela$ation to a"oid earl4 urge to push ?!hange in position,

breathing te!hni>ues, inhalational analgesia)anagement during **nd stage of labour

• /aginal e$amination to !onrm the full dilatation of !er"i$,

moulding, and formation of !aput su!!edaneum.

•

ro"ide upright position. This ma4 shorten the length of se!ond

stage of labour and redu!e the need for operati"e deli"er4.

• 7$4to!in infusion to stimulate ade>uate uterine !ontra!tions and

a!hie"e ad"an!e of the presenting part.

• 3lose obser"ation of maternal and fetal !ondition.

BREECH PRESENTATION

*n bree!h presentation fetus lies longitudinall4 with butto!ks in the lower

pole of the uterus. The presenting diameter is bitro!hanteri!- 15 !m and

the denominator is sa!rum.

INCIDENCE

7!!urs in appro$imatel4, 1% at 5 weeks and at term.


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CAUSES

1) F*!#+

• rematurit4

• ultiple pregnan!4• alformations

• 3ongenital dislo!ation of hip2) L"/ 7*/%**s o

*6!*"so" o !/s o% +*/s #! !* ,o7#+$ ,o+*?T>,*s:

• F%#"@ =%**$: *t is bree!h with e$tended legs. etal thighs of

both limbs are @e$ed and both lower limbs are e$tended at

the knee. *n!iden!e is &% of bree!h presentation.• Foo!+"/ =%**$: This is in!omplete bree!h o!!urs in 15 of

bree!h presentation. 7ne or both fetal thighs are e$tended

and one or both knees or feet lie below the butto!ks.

• "** ,%*s*"!#!o": Thighs are e$tended but the knees are

@e$ed, bringing the knees down to present at the brim.

C+"$#+ !>,*s:


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1) U"$o',+$#!*7: 0ree!h presentation is not asso!iated with an4

obstetri!al !ompli!ations.2) Co',+$#!*7: 0ree!h presentation asso!iated with obstetri!al

!ompli!ations and whi!h ad"ersel4 a:e!t the prognosis.

POSITIONS IN BREECH PRESENTATION

Pos!o"s S#$%' o !* *!s " %*+#!o"

!o !* 'o!*%s ,*+-s+eft a!ro +ateral position +eft iliope!teal line6ight sa!ro +ateral position 6ight iliope!teneal line

+eft a!ro osterior position +eft sa!ro ilia!


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• oft irregular mass without sutures

• Anus ma4 be felt

• e!onium stained ngers

• E$ternal genitalia is "er4 e"ident in !ase of e$tended legs.

•

*f a foot is felt di:erentiate it from the hands.- Toes are all the same length, shorter than the

ngers and the big toe !annot oppose to ea!h

other. The foot is at right angles to the leg and heel has

not e>ui"alent in the hand.

• 3onrmator4 diagnosis b4 8 and L-ra4

ANTENATAL MANAGEMENT

At & weeks gestation or later

1) E$ternal !ephali! "ersion.2) Assessment for "aginal birth.) etal si=e.0) el"i! !apa!it4.

MECHANISM OF LABOUR

• The lie is longitudinal.

• Attitude is one of !omplete @e$ion.

• The presentation is bree!h.

• The position is left sa!ro anterior.

• The denominator is the sa!rum.

• The presenting part is the left butto!ks.

• The presenting diameter is bitro!hanteri!, 15 !m. Enters the

pel"is in left obli>ue diameter of the brim.the sa!rum points to

the left iliope!teneal eminen!e.

STEPS OF MECHANISM

1) Co',#$!o"H De!ent takes pla!e with in!reasing !ompa!tion,

owing to in!reased @e$ion of the limbs.


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2) E"/#/*'*"!: Engagement of hips takes pla!e in an +A

position with sa!rum in the left anterior portion on the

mothers pel"is, and the bitro!hanteri! diameter is in the left

obli>ue diameter of the mothers pel"is.) I"!*%"#+ %o!#!o" o !* #"!*%o% =!!o$@s: The anterior

butto!ks rea!hes the pel"i! @oor rst and rotates forwards 1I(

of a !ir!le along the right side of the pel"is to lie underneath

the s4mph4sis pubis. The bitro!hanteri! diameter is now in the

antero posterior diameter of the pel"is.#) L#!*%#+ 9*6o" o !* =o7>: The anterior butto!ks es!apes

under the s4mph4sis pubis, the posterior butto!ks sweeps the

perineum and the butto!ks are born b4 a mo"ement of lateral

@e$ion.%) R*s!!!o" o !* =!!o$@s: The anterior butto!k turns

slightl4 to the maternal right side.

&) I"!*%"#+ %o!#!o" o !* so+7*%s: The shoulder enters

the pel"is in the left obli>ue diameter. The anterior shoulder

rotates forwards 1I( of a !ir!le along the right side of the

pel"is and es!apes under the s4mph4sis pubis, the shoulder

sweeps the perineum and the shoulders are born.') I"!*%"#+ %o!#!o" o !* *#7: the head enters the pel"is

with the sagittal sutures are in trans"erse diameter of the

brim. The o!!iput rotates forwards along the left side and the

subo!!ipital region?nape of the ne!k)impinges on the

underneath of the s4mph4sis pubis.() E6!*%"#+ %o!#!o" o !* =o7>: At the same time the bod4

turns so that the ba!k is uppermost.


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) B%! o !* *#7: The !hin, fa!e and sin!iput sweeps the

perineum and head is born in a @e$ed attitude.

COMPLICATION

Rs@s !o !* 'o!*%

1. 6isks of operati"e pro!edure2. 6isks of general anaesthesia. erineal and !er"i!al la!eration#. 0leeding due to la!eration%. infe!tion

Rs@s !o !* =#=>

1) Mo%!#+!> 7* !o

• *ntra!ranial haemorrhage

• 3ord !ompression

• Asph4$ia

• Damage to li"er, suprarenal gland and kidne4

• ra!ture of !er"i!al spine2) Mo%=7!> 7* !o

• ra!ture femur, humerous and !la"i!le.

• Damage to the bra!hialple$us.

• Baematoma.

• h4si!al and mental handi!ap.

• 6isks of e$ternal !ephali! "ersion.

MANAGEMENT

A"!*"#!#+ '#"#/*'*"!:

• *denti!ation of the !ompli!ating fa!tors

• E$ternal !ephali! "ersion

• ormulation of the line of management

D%"/ -#/"#+ 7*+-*%>:


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P%*+'"#%*s:

1. 3onrm the !omplete dilatation of the !er"i$2. 3he!k the ade>ua!4 of the pel"is

. Empt4ing of the bladder#. Ade>uate e$planation to mother for e:e!ti"e pushing e:ort.%. 6eadiness for a full- s!ale new born resus!itation e:ort.&. roper positioning of the arti!les.'. oti!ation and presen!e or immediate a"ailabilit4 of the

!onsulting ph4si!ian, anaesthesiologist and paediatri!ian.

F%s! s!#/*:

• la!e the women in lithotom4 position.

• erform "aginal e$amination to e$!lude !ompli!ations.

• ited intra"enous line with 6+, a"oid oral intake.

• ro"ide ade>uate analgesia.

• onitor fetal !ondition and progress of labour.

• 7$4to!in infusion for the augmentation of the labour.

• En!ourage the women to push with !ontra!tions.

• 3he!k the indi!ations for !aesarean se!tion.

S*$o"7 s!#/*: T*%* #%* !%** '*!o7s o% -#/"#+ =%**$

7*+-*%>

1) S,o"!#"*os =%**$ 7*+-*%>: Deli"er4 o!!urs with little

assistan!e from the attendant.2) Asss!*7 =%**$ 7*+-*%>: The butto!ks are born

spontaneousl4, but some assistan!e pro"ided for the deli"er4

of e$tended legs or arms and the head.) B%**$ *6!%#$!o": anipulati"e deli"er4 performed b4 an

obstetri!ian to hasten the deli"er4 in an emergen!4.

ASSISTED BREECH DELIVERY

PRINCIPLES:


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1) e"er to rush.2) e"er pull from below but push from abo"e.) Alwa4s keep the fetus with the ba!k anteriorl4.

P%*+'"#%*s:

1) Anaesthetist2) An assistant) *nstruments and suture materials for episiotom4#) A pair for obstetri! for!eps%) Applian!es for resus!itation of the bab4&) eonatologist

STEPS:

1) atient brought to the table when the anterior butto!ks and fetal

anus are "isible.2) la!e the woman in lithotom4 position when the posterior butto!k

distends the perineum.) Tilt the woman 1%o laterall4 using a wedge under the ba!k to a"oid

aorto!a"al !ompression.#) udendal blo!k anaesthesia done along with perineal inltration.%) Episiotom4H should be done in all !ases of primigra"ide and sele!ted

multigra"ide. 0est time for episiotom4 is when the perineum is

distended and thinned b4 the bree!h as it is !limbing the perineum.A7-#"!#/*s:

• To straighten the birth !anal.

• To fa!ilitates intra"aginal manipulation for for!eps deli"er4.

• To minimise the !ompression of the after !oming head.&) atient is en!ouraged to bear down as the e$pulsi"e for!es from

abo"e ensure @e$ion of the fetal head and safe de!ent') oon after the trunk up to the umbili!us is born,

• The e$tended legs are to be de!omposed b4 pressure on the

knees ? poplitial fossa) in a manner of abdu!tion and @e$ion of

thighs.


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• The umbili!al !ord is to be pulled down and to be mobilised to

be one side of the sa!ral ba4 to minimise !ompression.

• *f the ba!k remains posteriorl4, rotate the trunk to bring the

ba!k anteriorl4.• The bab4 is wrapped with a sterile towel to pre"ent slipping

when held b4 the hands and fa!ilitates manipulation.() D*+-*%> o !* #%'sH The assistant is to pla!e the hands o"er the

fundus and keep a stead4 pressure during !ontra!tions to pre"ent

e$tension of the hands. The arms are deli"ered one after the other

onl4 when one a$illa is "isible, b4 simpl4 hooking down ea!h elbow

with a nger. 0ab4 should be held b4 the feet o"er the sterile towel

while the arms are deli"ered.) D*+-*%> o !* #!*% $o'"/ *#7: ost !ru!ial stage of

deli"er4. The time between the deli"er4 of umbili!us to deli"er4 of

mouth should be preferabl4 %- 15 minutes.M*!o7s:

B%"s M#%s#++ M*!o7: The bab4 is allowed to hang b4 its own weight. The

assistant is asked to gi"e suprapubi! pressure with the @at

of hand in a downward and ba!kward dire!tion, the

pressure is to be e$erted more towards the sin!iput. 9hen the nape of the ne!k is "isible under the pubi! ar!h,

the bab4 is grasped b4 ankles with a nger in between the

two. aintaining a stead4 tra!tion and forming a wide ar! of a

!ir!le, the trunk swung in upward and forward dire!tion. eanwhile, the left hand to guard the perineum, fa!e and

brow su!!essi"el4 slipped o: from the perineum.


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9hen the mouth should be !leared o: the "ul"a, there

should be no hurr4. u!us of the mouth and phar4n$ is

!leared b4 mu!us su!ker.

Depress the trunk to deli"er the rest of the bod4.Fo%$*,s 7*+-*%>

or!eps !an be used as a routine. The head must be in the

!a"it4. 9hen the o!!iput lies against the ba!k of the s4mph4sis

pubis an assistant raises the legs of the bab4 to fa!ilitate the

introdu!tion of the blade from below.

Bead should be deli"ered slowl4 to redu!e !ompression

de!ompression for!es as that ma4 !ause intra!ranial

bleeding.

M#+#% 9*6o" #"7 so+7*% !%#$!o" (Mo7*7

M#%$*# S'*++* V*! !*$"


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3arried the fetus in upward and forward dire!tion towards the

mother;s abdomen releasing the fa!e, brow, and depress the

trunk to release the o!!iput and "erte$.

1) R*ss$!#!o" o !* =#=>:11) D%"/ !%7 s!#/* o +#=o%H roph4la!ti! ergometrine 5.2

mg with the !rowning of head.

MANAGEMENT OF COMPLICATED BREECH DELIVERY

D*+#> " 7*s$*"7 o !* =%**$:

C#s*s:

• 0ig bab4 with e$tended legs

• weak uterine !ontra!tion

• 6igid perineum

outlet !ontra!tion A%%*s!*7 #! !* o!+*!:

M#"#/*'*"!:

• !aesarean se!tion

I" !* #=s*"$* o o!+*! $o"!%#$!o" #"7 *!o,*+-$

7s,%o,o%!o"M#"#/*'*"!:

• +iberal episiotom4 with or without groin tra!tion. A%%*s! o !* =%**$ #! o% #=o-* !* +*-*+ o s$#+ s,"*

M#"#/*'*"!:

• 3aesarean se!tionF%#"@ =%**$ *6!%#$!o"? ( P"#%7s '#"*-*%*)

• *s done b4 intrauterine manipulation to !on"ert frank

bree!h to a footling bree!h.


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• The middle and inde$ ngers !arried up to the popliteal

fossa. *t is then pressed and abdu!ted so that the fetal leg

is @e$ed.

• rasp the fetal foot at the ankle and e$tra!t the bree!h.

EXTENDED ARMS

7ne or both arms ma4 be full4 stret!hed along the sides of the head or lie

behind the ne!k.

C#s*: ault4 te!hni>ues in deli"er4?

D#/"oss:

• 9inging of the s!apula

• Absen!e of @e$ed limbs in front of the !hest.

M#"#/*'*"!:

8rgent deli"er4 of the e$tended arms.

P%"$,+*s o '#"#/*'*"!:

• 0e!ause of the !ur"ed birth !anal, when the anterior shoulder

remains abo"e the s4mph4sis pubis, the posterior shoulder will be

below the le"el of sa!ral promontor4.

• *f the fetal trunk is rotated keeping the ba!k anterior and

maintaining downward tra!tion, the posterior shoulder will appear

below the s4mph4sis pubis.

M*!o7s o 7*+-*%>

C+#ss$#+ '*!o7:


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• irst the posterior forearm is deli"ered followed b4 anterior

forearm.

• *ntrodu!e left arm along the !ur"e of sa!rum while the bab4 is

pulled slightl4 upward.• Appl4 rm pressure on humerus, the posterior arm is pushed

o"er the bab4;s fa!e.

• The e$tended anterior arm is deli"ered from the anterior

aspe!t b4 introdu!ing the right hand in the same manner,

while the bab4;s trunk is depressed towards the perineum.Lo-s*!s '#"*-*%:

• 0ab4 is wrapped in warm towel and grasped, using both hands

b4 femoro pel"i! grip keeping the thumbs parallel to the

"ertebral !oloumn. The maneu"er should start onl4 when the

inferior angle of the anterior s!apula is "isible underneath the

pubi! ar!h.

S!*, 1: The bab4 is lifted slightl4 to !ause lateral @e$ion. The

trunk is rotated through 1(55 keeping the ba!k anterior and

maintaining down ward tra!tion. This will bring the posterior arm

to emerge under the pubi! ar!h whi!h is then hooked out.

S!*, 2: The trunk is then rotated into re"erse dire!tion keeping

the ba!k anterior to deli"er the posterior shoulder while anterior

shoulder under the s4mph4sis pubis.

ARREST OF THE AFTER COMING HEAD

A! !* =%':

C#s*s:


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• De@e$ed head

• 3ontra!ted pel"is

M#"#/*'*"!:

• Deli"er4 of the head b4 for!eps

• *n de@e$ed head- malar @e$ion and shoulder tra!tion I" !* $#-!>

C#s*s:

D*9*6*7 *#7


M#"#/*'*"!:

• Deli"er4 of the head b4 for!eps A! !* o!+*!:

C#s*s:

• 6igid perineum

• De@e$ed head

M#"#/*'*"!:

• Episiotom4 followed b4 for!eps appli!ation

• alar @e$ion and shoulder tra!tion

1? D*+-*%> o !* *#7 !%o/ #" "$o',+*!* 7+#!*7 $*%-6:C#s*s:

• remature bab4

• a!erated bab4

• ootling presentation

• Bast4 deli"er4 of the bree!h before the !er"i$ is full4 dilated2? O$$,!o ,os!*%o% ,os!o" o !* *#7: 8suall4 o!!urs in

spontaneous "aginal deli"er4.

• 6otation of the fetus.


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FACE PRESENTATION

INCIDENCE : 1 in %55 deli"eries.

• &5 mento anterior

• 1% mento trans"erse

• 2% mento posterior

MECHANICS OF PRESENTATION

3hara!teri=ed b4 e$treme e$tension of the fetal head so the fa!e presents

to the birth !anal. The o!!iput of the fetus will be in !onta!t with its spine.

TYPES OF FACE PRESENTATION

P%'#%> #$* ,%*s*"!#!o"H a!e presentation before the labour.

S*$o"7#%> #$* ,%*s*"!#!o"H a!e presentation de"elops during

labour from "erte$ presentation with the o!!iput posterior.

ossible positionsH

1) +eft ento Anterior2) +eft ento osterior) +eft ento Trans"erse#) 6ight ento Anterior%) 6ight ento osterior&) 6ight ento Trans"erse

CAUSES

#) M#!*%"#+:

• ultiparit4 with pendulus abdomen

• +ateral obli>uit4 of the uterus


• el"i! tumours=) F*!#+:

• 3ongenital malformations


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• Twist of the !ord around the ne!k

• *n!reased tone of the e$tensor group of ne!k mus!le.

DIAGNOSIS

enerall4 diagnosed on "aginal e$amination in labour.

ABDOMINAL FINDINGS:

I"s,*$!o": M; shaped spine, no "isible bulging on @anks.

P#+,#!o":

rips ento- Anterior ento- posterior+ateral grip 1) etal limbs are

felt anteriorl42) 0a!k is on the

@ank and is

diG!ult to

palpate.) The !hest is

thrown anteriorl4

against uterine

wall and is often

mistatken for

ba!k.

1) 0a!k is felt to the

front and better

to palpated onl4

towards the

podali! pole

be!ause of

e$tension of

spine.

el"i! grip 1) Bead seems

good and is not

engaged.2) 3ephali!

prominent is to

the side towards

1) ame

2) ame

) The groo"e is


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whi!h ba!k lies.) roo"e between

head and ne!k is

not so prominent.

prominent.

Aus!ultation B is distin!tl4

audible anteriorl4

through the !hest wall

of the fetus towards

the side of the limb.

B is not so distin!t

and is audible on the

@ank towards the side

of the limb.

V#/"#+ *6#'"#!o": Diagnosti! features are,

alpating the mouth with hard al"eolar margins, nose, malar eminen!e,

supraorbital ridges and mentum. The e$amination should be !ondu!ted

gentl4 to a"oid in


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1) E"/#/*'*"!: The engaging diameter of the pel"is is obli>ue

diameter. 6ight in +A and left in 6A, with the mentum related to one

iliopubi! eminen!e and the glabella to the opposite sa!ro ilia! ue diameter and the anterior shoulder rea!hes the pel"i! @oor

rst and rotates forwards 1I(th of a !ir!le along the left side of the

pel"is in the 6A position and along the right side in +A position.') B%! o !* so+7*% #"7 =o7> => +#!*%#+ 9*6o": The anterior

shoulder es!apes under the s4mph4sis pubis, the posterior shoulder

sweeps the perineum and the bod4 is born b4 a mo"ement of lateral

@e$ion.

POSSIBLE COMPLICATIONS


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• 7bstru!ted labour.

• 3ord prolapse.

• a!ial bruising.

• 3erebral haemorrhage.

•

aternal trauma.

MANAGEMENT: 7"erall assessment of-

• el"i! ade>ua!4

• i=e of the bab4

• 7f the !ompli!ating fa!tors

• 3ongenital malformation

• osition of the mentum

• 3he!k the indi!ations of earl4 or ele!ti"e !aesarean se!tion

VAGINAL DELIVERY:

MENTOANTERIOR:

P%"$,+*:

9ait and wat!h poli!4.

F%s! s!#/*: +abour is !ondu!ted in the usual pro!edure.

S*$o"7 s!#/*: erineum should be prote!ted with liberal mediolateral

episiotom4.

MENTO POSTERIOR:

F%s! s!#/*: *n un!ompli!ated !ases, "aginal deli"er4 is allowed with

stri!t "igilan!e hoping for spontaneous anterior rotation of the !hin.

S*$o"7 s!#/*:


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1) *f anterior rotation of the !hin o!!urs, pontaneous or for!eps

deli"er4 with episiotom4 is needed.2) *n in!omplete or malrotation- hould take earl4 de!isions for method

of deli"er4 soon after the full dilatation of the !er"i$.• 3aesarean se!tion

• anual rotation of !hin anteriorl4 followed b4 immediate

for!eps e$tra!tion.

NURSING MANAGEMENT

1) 6e!ognition of the fa!e presentation and noti!ation of the

ph4si!ian about the mal presentation.2) hould not appl4 fetal s!alp ele!trode. 3are should be taken not to

infe!t or inuest the paediatri!ian to assist the

deli"er4.') 6eassuring the parents, famil4 and signi!ant others that the

position of head and ne!k of the bab4 and e$tensi"e swelling of the

features normall4 disappear in a few da4s. BRO

PRESENTATION

6arest "ariet4 of !ephali! presentation, where the presenting part is the

brow and the attitude of head is e$tension. The presenting part is


31/40


32/40

2) anual !orre!tion) !raniotom4

TRANSVERSE LIE

DEFINITION:

1) 9hen the long a$is of the fetus lies perpendi!ularl4 to the maternal

spine or !entralised uterine a$is, it is !alled trans"erse lie.2) 9hen the fetal a$is pla!ed obli>ue to the maternal spine and is then

!alled obli>ue lie.

POSITIONS:

D*!*%'"*7 => !* 7%*$!o" o !* =#$@?1) Dorso anterior2) Dorso -posteror) Dorso superior#) Dorso inferior

I"$7*"$*H 1 in 255 births.

C#s*s:

1) ultiparit42) rematurit4) Twins#) B4dramnios%) 3ontra!ted pel"is

&) la!enta prae"ia') el"i! tumours() 3ongenital malformations of the uterus) *ntra uterine death

DIAGNOSIS:

A=7o'"#+ *6#'"#!o":


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I"s,*$!o": 8terus looks broader and often as4mmetri! and not

maintaining the p4riform shape.

P#+,#!o":

• F"7#+ */!: +ess than the period of amenorrhoea.

F"7#+ /%,H etal pole ?0ree!h I Bead) is not palpable.

L#!*%#+ /%,:

a) oft, broad and irregular bree!h is felt to one side of the midline

and smooth, hard globular head is felt on the other side.b) 0a!k is felt anteriorl4 a!ross the long a$is in dorso anterior or the

irregular small parts are felt anteriorl4 in dorso posterior.• P*+-$ /%,: The lower pole of the uterus is found empt4.

As$+!#!o":

• *n dorso anterior positionH B is heard below the umbili!us.

• *n dorso posterior position B heard in high le"el.

U+!%#so"o/%#,>: To !onrm the diagnosis.

V#/"#+ *6#'"#!o":

D%"/ ,%*/"#"$>: The fetal part is so high and is diG!ult toidentif4.

D%"/ +#=o%:

1) Distinguishing features are, a!romion pro!ess, s!apula, !la"i!le and

a$illa.2) 3hara!teristi! landmarks are, feeling of ribs and inter!ostals spa!es.) 6arel4 the arm or leg ma4 be prolapsed, loop of !ord ma4 found

alongside of the prolapsed arms.

COMPLICATION:

1) remature rupture of membrane.


34/40

2) 7bstru!ted labour) egle!ted labour#) Deh4dration%) Netoa!idosis&) ho!k and sepsis

FAVOURABLE EVENTS

1) pontaneous re!ti!ation or "ersion2) pontaneous e"olution) pontaneous e$pulsion

MANAGEMENT OF SHOULDER PRESENTATION:

ANTENATAL

E$ternal !ephali! "ersion, should be pro"ided in all !ases be4ond%

weeks pro"ided if there is no !ontraindi!ations.

I -*%so" #+s o% s $o"!%#"7$#!*7

• The patient is to be admitted at 'th weekethod of deli"er4- ele!ti"e !aesarean se!tion.

• /aginal deli"er4 ma4 be allowed to !ontinue in a dead or

!ongenitall4 malformed fetus. +abour allowed to !ontinue under

super"ision till the full dilatation of the !er"i$. Deli"er4 !ompleted

b4 internal "ersion.

PATIENT SEEN IN LABOUR

E#%+> " +#=o%:

• E$ternal !ephali! "ersion.

• 3aesarean se!tion.

L#!* +#=o%


35/40

B#=> #+-*

*f the bab4 is mature and fetal !ondition is good !aesarean se!tion

is preferable.

-*nternal "ersion

B#=> 7*#7

3aesarean se!tion

-Destru!ti"e operation

UNSTABLE LIE

DEFINITION: This is the !ondition where the presentation of the fetus is

!onstantl4 !hanged e"en be4ond &th week of pregnan!4 when it should

ha"e been stabilised.

CAUSES: The !auses are the !onditions those pre"enting the presenting

part to remain $ed in the lower pole of the uterus.

1) rand multipara with la!k of uterine tone and pendulus abdomen2) B4dramnios) 3ontra!ted pel"is#) la!enta prae"ia

%) el"i! tumour

COMPLICATIONS:

1) 3ord entanglement2) 3ord prolapsed.) erinatal death

MANAGEMENT


36/40


37/40


38/40

♦ *n 1'# got retired O was re!ogni=ed all o"er as a nurse.

♦ ursing !an be "iewed as an interpersonal pro!ess as it in"ol"es

intera!tion between two or more indi"idual with a !ommon goal.

♦ or de"eloping intera!tion between nurse and patient the nurse has to

!hoose se>uential pattern and di:erent skills and assume "arious roles

et!.

♦ *n 1'# got retired O was re!ogni=ed all o"er as a nurse.

♦ ursing !an be "iewed as an interpersonal pro!ess as it in"ol"es

intera!tion between two or more indi"idual with a !ommon goal.

♦ or de"eloping intera!tion between nurse and patient the nurse has to

!hoose se>uential pattern and di:erent skills and assume "arious roles

et!.

NURSING DIAGNOSIS:

1) Bigh risk of infe!tion related to disease !ondition2) Bigh risk of a!>uiring an opportunisti! infe!tion related to poor

nutritional status) *mpaired famil4 !oping related to aternal out !ome

#) An$iet4 related to disease !ondition%) Nnowledge de!it related to disease !ondition.&) atigue related to la!k of food intake') Altered nutrition less than bod4 re>uirement related to anore$ia() Anti!ipator4 grie"ing related to disease !ondition

RECENT MODALITIES IN MANAGEMENT OF ABNORMAL LABOUR

TreatmentH

*ndu!tion of labour


39/40

Amniotom4

el"imetr4

8

L-ra4

Diet

A!ti"it4

edi!ation

SUMMARY:

Toda4 we ha"e dis!ussed about !ertain terminologies related to abnormal

labour, mal-positions and mal-presentations, demonstrated the

me!hanism of abnormal labour, management of abnormal labour, nursing

management of abnormal labour, re!ent modalities in management of

abnormal labour and nursing diagnosis of abnormal labor.

CONCLUSION:

8suall4 the fetal head engages in o!!ipito anterior position and then

undergoes a short rotation to be dire!tl4 o!!ipito anterior in the mid

!a"it4. al positions and malpresentation are the abnormal positions of

the "erte$ of the fetal head relati"e to the maternal pel"is. There is no

known test that !an di:erentiate normal from abnormal labor. The

diagnosis and optimal management of abnormal labor !ombine s!ien!e

and art. The management of abnormal labor ta$es one;s !lini!al skills


40/40

under the best of !ir!umstan!es. u!h !ases are !ompli!ated b4 patients

who demand and e$pe!t a painless and fast deli"er4 resulting in a perfe!t

infant. The possibilit4 of malpra!ti!e litigation further !ompli!ates the

issuesPa thorough do!umentation of e"ents, espe!iall4 in the fa!e of

malo!!urren!e, !annot be stressed enough. A ke4 to the optimal

management of abnormal labor remains intensi"e obser"ation with

!onser"ati"e, well-!hosen, and !arefull4 e$e!uted inter"entions.

Appropriate management during antenatal and intranatal period helps to

ta!kle the !ompli!ations during the time of labour.

REFERENCES:

1) Dian raser, argret A 3ooper , 4les Te$t book for idwi"es, 1%th

edition, p-%'#-&5%.2) Annamma Ca!ob, 3omprehensi"e Te$t book of midwifer4 and

4nae!ologi!al ursing, rd edition, Ca4pee ubli!ations, p-&-(%.) 0ahar A, 6isk fa!tors and fetal out!ome in !ases of shoulder

d4sto!ia !ompared with normal deli"eries of a similar birth weight,

0ritish Counal of 7bstetri!s and4nae!olog4, 1&J 15H (&(- '2.#) Dutta D3, Te$t book of 7bstetri!s &th edition, 3ul!utta, ew 3entral

0ook 3ompan4, 2551H p-'#-#55.%) 6ubin A. anagement of shoulder d4sto!ia. Cournal of the Ameri!an

edi!al Asso!iation. 1J 1(H(%.&) Namini 6ao, Te$t book of midwifer4 O 7bstetri!s for urses,

Else"eir ubli!ation 2511H p- #%'- #'.

Documents

Seminar on Abnormal Labour and Its Management