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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" !* $#-!>
C#s*s:
D*9*6*7 *#7
• 3ontra!ted pel"is
M#"#/*'*"!:
• Deli"er4 of the head b4 for!eps A! !* o!+*!:
C#s*s:
• 6igid perineum
• De@e$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
• 3ontra!ted pel"is
• 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$tension. The presenting part is
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2) anual !orre!tion) !raniotom4
TRANSVERSE LIE
DEFINITION:
1) 9hen the long a$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$illa.2) 3hara!teristi! landmarks are, feeling of ribs and inter!ostals spa!es.) 6arel4 the arm or leg ma4 be prolapsed, loop of !ord ma4 found
alongside of the prolapsed arms.
COMPLICATION:
1) remature rupture of membrane.
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2) 7bstru!ted labour) egle!ted labour#) Deh4dration%) Netoa!idosis&) ho!k and sepsis
FAVOURABLE EVENTS
1) pontaneous re!ti!ation or "ersion2) pontaneous e"olution) pontaneous e$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%
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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 $ed in the lower pole of the uterus.
1) rand multipara with la!k of uterine tone and pendulus abdomen2) B4dramnios) 3ontra!ted pel"is#) la!enta prae"ia
%) el"i! tumour
COMPLICATIONS:
1) 3ord entanglement2) 3ord prolapsed.) erinatal death
MANAGEMENT
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♦ *n 1'# got retired O was re!ogni=ed all o"er as a nurse.
♦ ursing !an be "iewed as an interpersonal pro!ess as it in"ol"es
intera!tion between two or more indi"idual with a !ommon goal.
♦ or de"eloping intera!tion between nurse and patient the nurse has to
!hoose se>uential pattern and di:erent skills and assume "arious roles
et!.
♦ *n 1'# got retired O was re!ogni=ed all o"er as a nurse.
♦ ursing !an be "iewed as an interpersonal pro!ess as it in"ol"es
intera!tion between two or more indi"idual with a !ommon goal.
♦ or de"eloping intera!tion between nurse and patient the nurse has to
!hoose se>uential pattern and di:erent skills and assume "arious roles
et!.
NURSING DIAGNOSIS:
1) Bigh risk of infe!tion related to disease !ondition2) Bigh risk of a!>uiring an opportunisti! infe!tion related to poor
nutritional status) *mpaired famil4 !oping related to aternal out !ome
#) An$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$ia() Anti!ipator4 grie"ing related to disease !ondition
RECENT MODALITIES IN MANAGEMENT OF ABNORMAL LABOUR
TreatmentH
*ndu!tion of labour
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Amniotom4
el"imetr4
8
L-ra4
Diet
A!ti"it4
edi!ation
SUMMARY:
Toda4 we ha"e dis!ussed about !ertain terminologies related to abnormal
labour, mal-positions and mal-presentations, demonstrated the
me!hanism of abnormal labour, management of abnormal labour, nursing
management of abnormal labour, re!ent modalities in management of
abnormal labour and nursing diagnosis of abnormal labor.
CONCLUSION:
8suall4 the fetal head engages in o!!ipito anterior position and then
undergoes a short rotation to be dire!tl4 o!!ipito anterior in the mid
!a"it4. al positions and malpresentation are the abnormal positions of
the "erte$ 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$es one;s !lini!al skills
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under the best of !ir!umstan!es. u!h !ases are !ompli!ated b4 patients
who demand and e$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- #%'- #'.