OBSTETRICS II PRELIMS

❑ ABORTION AND ECTOPIC PREGNANCY

❑ GESTATIONAL AND TROPHOBLASTIC DISEASE
❑ INTRAPARTUM ASSESSMENT
❑ ABNORMAL LABOR
❑ LABOR INDUCTION AND AUGMENTATION
❑ MALPRESENTATION AND DELIVERY
❑ FORCEPS DELIVERY AND VACUUM EXTRACTION
❑ CEASARIAN DELIVERY AND HYSTERECTOMY
❑ DISORDERS OF THE AMNIOTIC FLUID
❑ ABNORMALITIES OF PLACENTA,
CORD AND MEMBRANE
 ABORTION
MARLA A. LLANTO, MD, DPOGS
ABORTION

• ABORIRI- latin word – miscarry

• Miscarriage
• Spontaneous or induced termination of pregnancy
before fetal viability
NOMENCLATURE

• VIABILITY- line that separates abortion from preterm

delivery
• NCHS, CDC, WHO
- Pregnancy termination before 20 weeks AOG
and BW< 500g
• SPONTANEOUS ABORTION
- Threatened
- Incomplete
- Complete
- Missed
• RECCURENT ABORTION
• INDUCED ABORTION
 1st TRIMESTER SPONTANEOUS
ABORTION
• PATHOGENESIS
- 80% occur within 1st 12 weeks
- Fetal death, 1st trimester loses ussualy precedes
spontaneous expulsion
- Accompanied by hemorrhage into the decidua
basalis – adjacent tissue necrosis – uterine
contractions - expulsion
RISK FACTORS

• FETAL FACTORS
-chromosomal anomalies
• MATERNAL FACTORS
FETAL RISK FACTORS
• ANEUPLOID ABORTIONS
- occur in early gestation
- 8 weeks
- 95% maternal gametogenesis error
- 5% paternal
• MONOSOMY X (45,X)
- TURNER SYNDROME
- Single most frequent specific chromosomal
abnormality
MATERNAL FACTORS

• Infections
• Medical disorders
• Surgical procedures
• Nutrition
• Social and behavioral factors
• Occupational and environmental factors
• Immunological factors
• Inherited thrombophilias
• Uterine defects
INFECTIONS
• Brucella abortus
• Campylobacter fetus
• Toxoplasma gondii
• Chlamydia trachomatis
• Peridontal infections
• Bacterial vaginosis – 2nd trimester
MEDICAL DISORDERS
• Cancer
• DM
• Thyroid disorders- hypothyroidism
SURGICAL PROCEDURES
• Bariatric surgery
• ONG removal
- corpus luteum- progesterone treatment
• 8-10 weeks AOG- 17-hydroxyprogesterone
caproate, 150mg IM SD at the time of Sx
• 6-8 weeks AOG- 2 additional injection 1-2
weeks after 1st
• Other regimens:
• Micronized progesterone 200-300mg PO OD
• 8% progesterone vaginal gel + 100- 200 oral
micronized progesterone OD until 10 weeks
NUTRITION
• Severe dietary deficiency
• Morbid obesity
SOCIAL AND BEHAVIORAL FACTORS
• Alcohol abuse- chronic and heavy use
• Caffeine- 5 cups/day or 500mg caffeine
• Smoking
OCCUPATIONAL AND ENVIRONMENTAL FACTORS
• Arsenic
• Lead
• Formaldehyde
• Benzene
• Ethylene oxide
• DDT- dichlorodiphenyltrichloroethane
- Mosquito control against malaria
IMMUNOLOGICAL FACTORS
• Antiphospolipid antibody syndrome (APAS)
• Inherited thrombophilias
• Uterine defects
• Paternal factors – increasing paternal age
CLINICAL MANIFESTATION OF
SPONTANEOUS ABORTION
• THREATENED
• INEVITABLE
• COMPLETE
• INCOMPLETE
• MISSED
THREATENED VS ECTOPIC PREGNANCY

• Early gestation with vaginal bleeding + abdominal

pain
• For prompt dx of ectopic pregnancy
• Serial BhCG monitoring, progesterone level, TVS
MISSED ABORTION
▪ Dead products of conception that were retained
for days weeks or months with closed cervix
▪ Gestational age difficult to ascertain
▪ Fetal death – abortion – 6 weeks
• Pseudogestational sac – seen in ectopic pragnancy
• 5-6 weeks
- 1-2mm embryo adjacent to YS
- MSD 16-20mm without embryo- dead fetus
• 6-6.5 weeks
- Embryonic length of 1-5mm
- MSD – 13-18 mm
- (+) fetal cardiac activity

- 5mm embryo without cardiac activity - dead

 MANAGEMENT

• EXPECTANT
• Failure rate 50%
• MEDICAL
• PGE1
• 5-40% failure rate
• SURGICAL
• 95-100% success rate
• invasive
 SEPTIC ABORTION

• Abortion whether spontaneous or induced,

complicated by infection rangig from focal
involvement of the endometrial cavity or its contents
or both, with or without the involvement of uterus
and its appendages
• Can cause
- Parametritis
- Peritonitis
- Septicemia
- Endocarditis
- Severe necrotizing infections
- TSS
(caused by Group A streptococcus and S.
pyogenes)
CLINICAL MANIFESTATIONS

• SYMPTOMS
▪ Fever
▪ Chills
▪ Malaise
▪ Vaginal bleeding
▪ Abdominal pain
▪ Passage of placental tissues
• SIGNS
▪ Fever
▪ Tachycardia
▪ s/s sepsis
▪ Lower abdominal tenderness
▪ Tachypnea
• ABDOMINOPELVIC EXAMINATION
▪ Open cervix with bleeding and foul smelling
discharge
▪ Cervical or vaginal lacerations
▪ Open cervix with or without catheter
▪ Uterine tenderness or bimanual examination
▪ Gas gangrene- crepitation in the pelvis
▪ Generalized peritonitis
▪ Muscle guarding
• TABLE. Refer to pictures o
• INTERPRETATION
MILD <8
MODERATE 8 – 12
SEVERE > 12
RECURRENT MISCARRIAGE

• 3 or more pregnancy losses of less than 20 weeks

AOG or fetus weighing < 500g
• Most are embryonic or early losses and remainder
are unembryonic or those that occur after 14 weeks
AOG
• ETIOLOGY
▪ Parenteral chromosomal abnormalities
▪ Immunological factors, APAS
▪ Uterine abnormalities
▪ Endocrine factors
• Parenteral chromosomal abnormalities
▪ Balanced reciprocal translocations – 50%
▪ Robertsonian translocations – ¼
▪ X- chromosome mosacism- 47 XXY ( Klinefeller
Syndrome)- 12%
• Uterine abnormalities
▪ Acquired
▪ Asherman syndrome – uterine synechiae
▪ follow curettage or ablative procedure
▪ Leiomyoma- submucous type
▪ Congenital
▪ Mullerain duct abnormalities
IMMUNOLOGICAL FACTORS

• AUTOIMMUNE
• SLE
• APAS
• ALLOIMMUNE
• Factors are needed to prevent maternal rejection
of foreign fetal antigens tha are paternally
derived
• HLA, altered NKC, regulatory T cell stimulation,
HLA-G mutations
ENDOCRINE FACTORS

• PCOS
• Luteal phase defect
• Uncontrolled/ overt DM
• Overt hypothyroidism
• Severe iodine deficiency
MIDTRIMESTER ABORTION

• Fetal losses after the 1st trimester or until fetus

weighs > 500g or reaches 20 weeks AOG
CERVICAL INSUFFICIENCY

• Incompetent cervix
• Painless cervical dilatation in the 2nd trimester
• TVS- funneling
• RISK FACTORS
▪ Previous D and C
▪ Conization
▪ 4 fold increase of fetal loss before 24 weeks
▪ Cauterization
▪ Cervical amputation
EVALUATION

• TVS
• Cervical secretions are tested for infections-
gonorrhea and chlamydia
• Trreated for 1 week before and after surgery
TREATMENT

• CERCLAGE
• MCDONALD TECHNIQUE
• SHIRODKAR TECHNIQUE

CONTRAINDICATIONS:
• Bleeding
• Ruptured membranes
• Uterine contractions
• Fetal anomalies incompatible to life
SHIRODKAR
• TIMING OF SURGERY
• Diagnosed based on previous pregnancy
outcome – 12 -14 weeks
• Cervix < 25mm in high risk pregnancy –
immediately
• Not performed beyond 23 weeks
• Complications
• Membrane rupture
• Preterm labor
• Hemorrhage
• Infection
INDUCED ABORTION

• Medical or surgical termination of pregnancy before

the age of viability
• Frequency:
• Abortion ratio
• Number of abortions/ 1000 livebirths
• Abortion rate
• Number of abortions/ 1000 women ages 15-
44 y/o
CLASSIFICATION

• THERAPEUTIC
• INDICATIONS:
• Persistent cardiac decompensation with fixed
pulmonary hypertension
• Malignancy
• Advanced hypertensive vascular disease or
diabetes
• ELECTIVE/ VOLUNTARY
• Per request without medical reasons
CERVICAL PREPARATION

• Soften and slowly dilate the cervix to minimize

trauma
• MECHANICAL DILATORS
• Hygroscopic dilator
• Draws water from the cervix and expand
gradually dilating the cervix
• Laminarua – algae
• Dilapan- S- acrylic- based gel
• Medical dilators
• Misoprostol(Cytotec)
• 400-600ug SL, orally, posterior vaginal fornix
• Mifepristone
• 200-600ug orally
• PGE2 and PGF2A
• 2nd line
• Unpleasant S/E
SURGICAL ABORTION

• Transvaginal approach
• Laparotomy
• Hysterectomy
• hysterotomy
• Transvaginal approach
▪ D and C
▪ D and E
▪ D and X
▪ Menstrual aspiration
▪ Manual vacuum aspiration
DILATATION AND CURRETAGE

• Requires cervical dilatation before sharp curettage

or suction curettage
• Ideal for < 15 weeks AOG
• Complications:
• Perforation
• Hemorrhage
• Incomplete evacuation
• Infections
 DILATATION AND EVACUATION

• For > 16weeks AOG

• Wide cervical dilatation with metal or hygroscopic
dilators – mechanical destruction and avacuation of
fetal parts
• After removal of fetus, large- bore vacuum curette is
used to remove placenta and remaining tissue
• Used with intraop UTZ
 DILATATION AND EXTRACTION

• Similar to D and E
• Suction cannula is used to evacuate the intracranial
contents to minimize uterine and cervical trauma
from fetal bones
MENSTRUAL ASPIRATION

• Done within 1-3 weeks after missed menstruation

period
• it is done with the use of Karman cannula that is
attached to a syringe
MANUAL VACUUM ASPIRATION

• Similar to menstrual aspiration

• Used for early pregnancy failures or elective
termination up to 12 weeks AOG
• Office procedure < 10 weeks
• < 8 weeks- dilatation not necessary
• After 8 weeks, hygroscopic dilators or misoprostol
should be given at least 2-4 hours before procedure
MEDICAL ABORTION

• Alternative to surgical pregnancy termination in

pregnancies < 49 days AOG
• 3 medications used
• Mifepristone
• Methotrexate
• Misoprostol
CONTRAINDICATIONS

• In situ IUD
• Severe anemia
• Coagulopathy
• Anticoagulant use
• Active liver failure
• Cardiovascular dse
• Uncontrolled seizure d/o
• renal insufficiency – methotrexate
COMPLICATIONS

• Bleeding
• Cramping
• 18.10
• Prstaglandin E2
• 20mg suppository placed at posterior vaginal
fornix
• S/E: nausea, vomiting, fever, diarrhea
• Misoprostol
• 600ug/vagina followed by 400 ug q 4 hours
• Mifeprostone
• 200mg PO 1 day prior to misoprostol
CONSEQUENCES

• MORTALITY
• 1/100000 PROCEDURES
• CONTRACEPTION
• Ovulation resumes after 2 weeks of early
pregnancy termination
• IUD insertion after procedure
• Hormonal contraception
ECTOPIC PREGNACY
MARLA A. LLANTO, MD DPOGS
ECTOPIC PREGNANCY

• 1-2% of all pregnancies

• 6% of all pregnancy- related deaths
• Heterotrophic pregnancy
• 1/30000 pregnancies
• 1/7000 following ovulation induction
• D- negative women
• Regardless of location should be given IgG anti-
D immunoglobulin
• 1st trimester- 50ug or 300 ug dose
• Beyond – 300 ug dose
TUBAL PREGNANCY

• 95% of ectopic pregnancy

• Fimbrial
• Ampullary- most common site
• Isthmic – 2nd most common site
• Interstitial
RISK FACTORS

• Tubal surgery
• PID/STI
• Endometriosis
• Salphingitis isthmica nodosa
• Congenital fallopian tube anomalies- sec to DES
exposure
• ART
• Contraception- tubal ligation, IUD, progestin- only
pills
EVOLUTION AND POTENTIAL
OUTCOMES
• Fallopian tubes lack submucosal layer- fertilized
ovum burrows through the epithelium and lie near or
at the muscularis layer
• Embryo is usually absent or stunted
OUTCOMES

• TUBAL RUPTURE
• Early, 1st few weeks- isthmic
• Ampullary area- more distensible
• Interstitium- later rupture
• TUBAL ABORTION
• PREGNANCY FAILURE WITH RESOLUTION
CLINICAL MANIFESTATIONS

• CLASSIC TRIAD
• Delayed menstruation
• Abdominal pain
• Vaginal bleeding/spotting
• If with rupture
• Severe abdominal pain/ tenderness
• Cervical motion tenderness on bimanual exam
• Pain on neck, back or shoulder –
hemoperitonuem, diaphragmatic irritation
• Hypotension and bradycardia
• Tachycardia
• Pallor
DIAGNOSIS
• PROGESTERONE LEVEL
• >25ng/ml- excludes ectopic pregnancy
• <5ng/ml- nonliving IUP or ectopic pregnancy
• 5-25ng/ml- found in most EP
• TVS
• IUP
• GS- 4.5 -5 weeks
• YS- 5-6 weeks
• Fetal pole with cardiac activity – 5.6-6 weeks
• ECTOPIC PREGNANCY
• Trilaminar endometrial pattern
• pseudoGS
• Decidual cyst
• Adnexal findings
• Mass separate from the ovaries
• Extrauterine YS, embryo or fetus is seen – EP
confirmed
• Hyperechoic halo or tubal ring surrounding an
anechoic sac can be seen
• Inhomogenous complex adnexal mass
• Hemoperitonuem
• TVS- anechoic or hypoechoic
• culdocentesis
TX OPTIONS

• Medical
• Use of methotrexate
• Surgical
• Salpingotomy
• Salpingostomy
• Salpingectomy
MEDICAL TX

• 19-2
INDICATIONS

• UNRUPTURED
• No fetal cardiac activity
• Mass is <3.5 cm
• BhCG level < 10000 mIU/ml
• Failure rates:
• <1000mlU/ml – 1.5%
• 1000-2000 mIU/ml- 5.6%
• 2000-5000 mIU/ml- 3.8%
• 5000-10000 mIU/ml- 14.3%
PERSISTENT TROPHOBLAST

• 5-20% of all salpingostomies

• Identified by rising or stable BhCG
• Risk factors:
• Pregnancies <2cm
• <42 menstrual days
• Serum BhCG level > 3000 mIU/ml
• Implantation medial to the salphingostomy site
• Manangement:
• SD methotrexate- 50mg/m2 x BSA
• Prophylaxis- methotrexate- 1mg/m2 BSA
EXPECTANT MANAGEMENT

• For very early tubal pregnancy that are associated

with stable or falling serum BhCG
• INDICATIONS:
• Tubal pregnancy only
• Decreasing BhCG levels
• Ectopic mass <3.5 cm
• Unruptured
INTERSTITIAL PREGNANCY

• Rupture usually occurs after 8-16 weeks of

amenorrhea
• Increased risk of severe hemorrhage
• Criteria to differentiate from pregnancy in a uterus
with Mullerian anomaly
• Empty uterus
• GS separate from the endometrium
• 1cm away from the most lateral edge of the
uterine cavity
• <5mm, myometrial mantle surrounding the sac
• Interstitial line sign- highly sensitive and specific
• Management
• Cornual resection
• For subsequent pregnancies: elective CS
ABDOMINAL PREGNACY

• Implantation in the peritoneal cavity

• Rare: 1 in 1000-25000 livebirths
• DX- difficult
• Absent or vague symptoms
• Alphafetoprotein maybe elevated
• Palpation of abnormal fetal positions
• Oligohydramnios is common but not specific
• Fetus is separate from the uterus
• No myometrium between the fetus and anterior
abdominal wall or bladder
• Extrauterine placental tissues
MANAGEMENT:

• Pregnancy termination upon diagnosis

• Awaits fetal viability with close surveillance
• Multidisciplinary surgical approach
• Placental removal vs placenta – in situ
• Methotrexate post-op
INTRALIGAMENTARY PREGNANCY

• If zygotes are implanted towards the mesosalphinx,

rupture may occur and may be extruded in between
the leaves of the broad ligament
• Rare
• Clinical findings and management mirrors abdominal
pregnancy
• Laparotomy is required in most case
• Laparoscopic excision for early gestation
OVARIAN PREGNANCY

• DX: Spielberg Criteria

• Criteria for diagnosis(Spielberg’s criteria)
1. The fallopian on the affected side must be
intact
2. The fetal sac must occupy the position of the
ovary
3. The ovary must be connected to the uterus
by the ovarian ligament
4. Ovarian tissue must be located in the sac
wall
• Rupture at early AOG
• Management:
• Wedge resection
• Oopherectomy
• Methotrexate – small unruptured
CERVICAL PREGNANCY

• Cervical glands noted histologically opposite to the

placental attachment site
• Part and all of the placenta found below the
entrance of the uterine vessels or below the
peritoneal reflection on the anterior uterus
• 1/8600 to 1/12400 pregnancies
• Dx
• Painless vaginal bleeding
• UTZ
• Spectrum exam
• Palpation
MANAGEMENT

• MEDICAL
• METHOTREXATE: injected into the GS or
systemic
• MTX + uterine artery embolization
• For gestations <12 weeks
• High failure rates in:
• GA> 9 weeks
• BhCG level> 1000 mIU/ml
• CRL of >10mm
• Fetal cardiac activity
• Intracardiac or intrathoracic injection of KCL (2ml, 2
meq/ml)
• MTX- 50-75mg/m2 BSA
• If decrease is <15% after 1 week- 2nd dose of MTX
can be given
• For hemorrhage
• Uterine artery embolization
• Intracervical ballon catheter
• 26F, 30cc, inflated for 24-48 hours
• Hysterectomy
• For uncontrolled bleeding
• Risk of urinary tract injury
• Suction curettage
• Favored in rare cases of heterotropic pregnancy
• Preoperative uterine artery embolization,
ligation of descending branches of uterine
artery, cerclage- lessen bleeding
CESAREAN SCAR PREGNANCY

• Incidence: 1/2000 normal pregnancies

• Pathogenesis is similar to placenta accrete and high
risk for hemorrhage
• Presents early
• Pain and bleeding are common
• 40% are asymptomatic
• DX: routine UTZ
• Management:
• HYSTERECTOMY:
• Desirous of pregnancy:
• MTX
• Conservative surgical procedures
• Suction curettage or transvaginal
aspiration
• Hysteroscopic removal
• Isthmic incision
GESTATIONAL TROPHOBLASTIC
DISEASE
MAE MULLET PANALIGAN
 Used to encompass a group of tumors typified by
abnormal trophoblast proliferation.

Human chorionic gonadotropin(hCG)- produced

by trophoblast
-essential for GTD diagnosis, management and
surveillance.
CLASSIFICATION OF GTD
❑ HYDATIDIFORM MOLE

❑ NON MOLAR TROPHOBLASTIC MALIGNANT

DISEASE
HYDATIDIFORM MOLE

• COMPLETE H. MOLE

• PARTIAL H. MOLE

• MALIGNANT INVASIVE MOLE

NONMOLAR TROPHOBLASTIC
DISEASES

• CHORIOCARCINOMA

• PLACENTAL SITE
TROPHOBLASTIC TUMOR

• EPITHELIOD TROPHOBLASTIC
TUMOR
GESTATIONAL TROPHOBLASTIC NEOPLASIA

Invasive mole choriocarcinoma

Placental site Epitheliod

trophoblastic trophoblastic
tumor tumor
HYDATIDIFORM MOLE
Classic histological findings:
- trophoblast proliferation and villi with stromal
edema
EPIDEMIOLOGY AND RISK FACTORS

Diet

Previous
Race
H. mole

Hydati
Maternal
age diform OCP
mole
PATHOGENESIS
PATHOGENESIS
FEATURES OF COMPLETE AND PARTIAL H. MOLES
FEATURE PARTIAL MOLE COMPLETE MOLE
CLINICAL 69, XXX or 69, XXY 46, XX
PRESENTATION
•preliminary Missed abortion Molar gestation
diagnosis
•uterine size Small for dates Large for dates

•Theca lutein cysts rare 25-30% of cases

•Initial hcg levels <100,000 miU/mL >100,000 miU/mL

•Medical rare uncommon

complications

•Rate of subsequent 1-5% of cases 15-20% of cases

GTN
PATHOLOGY
•Embryo-fetus Often present absent

•Amnion, fetal Often present absent

erythrocytes
•Villous edema focal widespread

•Trophoblastic Focal, slight to Slight to severe

Proliferation moderate
Trophoblastic atypia mild marked

P57 kip2 positive negative

immunostaining
COMPLETE HYDATIDIFORM
MOLE
COMPLETE HYDATIDIFORM
MOLE
THECA LUTEIN CYST
INVASIVE MOLE
 Maternal
chromosome

chromosome duplication
A

_23,Y

Triploid cells
Maternal and paternal
chromosomes
Diandry

B
Twin Pregnancy
-in some twin pregnancies, one chromosomally normal
fetus is paired with a complete diploid molar
pregnancy
- rare
-Dx: amniocentecis and karyotyping
 CLINICAL FINDINGS

Amenorrhea
Vaginal bleding
Anemia
Uterine enlargement
Nausea/Vomiting
Acute abdomen
Hypothyroidism
Preeclampsia
 DIAGNOSIS

Serum Beta hCG

“hook effect”- excessive beta hcg hormone levels

oversaturate the assays targetting antibody and create
a false- negative urine pregnancy test results.
 Sonography

COMPLETE MOLE
-echogenic uterine mass
-numerous anechoic cystic spaces but without a
fetus or amnionic sac
-snowstorm appearance
 PARTIAL MOLE

- thickened multicystic placenta along with a fetus or

atleast a fetal tissue.
SNOWSTORM
 MANAGEMENT
Preoperative
CBC
Serum beta hCG
Creatinine
Electrolytes
Hepatic aminotransferase levels
TSH,ft4
Bloodtyping and Rh
Chest Xray
Consider hygroscopic dilators
Intraoperative
Large bore IV catheters
Regional or general
anesthesia
Oxytocin(20 units in 1L)
Other uterotonics
-methylergometrine maleate
-carboprost tromethamine
-Misoprostol
Karman cannula
Consider sonography machine
POST EVACUATION

Anti-D immune globulin (rhogam)if Rh D

negative
Initiate effective contraception
Review pathology report
Serum hcg levels: within 48 hours of evacuation,
weekly until detectable then monthly for 6 months
Molar Pregnancy Termination

Suction curettage
Hysterectomy- for women who finished childbearing
GESTATIONAL TROPHOBLASTIC NEOPLASIA

Invasive mole choriocarcinoma

Placental site Epitheliod

trophoblastic trophoblastic
tumor tumor
 CLINICAL FINDINGS

Agressive invasion into myometrium and

propensity to metastasize

Irregular bleeding with uterine subinvolution

-most common finding
 DIAGNOSIS

1. plateu of serum hcg level(+/- 10 percent) for four

measurements during a period of 3 weeks or longer,
days 1,7,14,21
2. Rise of serum hgc level >10% during 3 weekly
consecutive measurements or longer, during a period of
2 weeks or more, days 1, 7, 14
3. serum b hcg level remains detectable for 6 months
or more
4. histological criteria for choriocarcinoma.
ANATOMICAL STAGING
Stage 1: confined to the uterus
Stage 1l: GTN extends outside the uterus but
is limited to the genital structures (adnexa, vagina,
broad ligament)
Stage lll: GTN extends to the lungs with or without
genital involvement.
Stage lV: all other metastatic sites
SCORING
Low risk: 0-6
High risk: ->/- 7
 HISTOLOGICAL CLASSIFICATION

• Made by persistently elevated serum b hcg

without confirmation by tissue study.
 INVASIVE MOLE

Most common trophoblastic neoplasm that follow

hydatidiform moles
Almost all invasive moles arise from partial or
complete moles
Previously known as chorioadenoma
destruens.
Extensive invasion by trophoblast and whole villi
Although locally invasive, less prone to
metastasis.
 GESTATIONAL CHORIOCARCINOMA
Most common type of trophoblastic neoplasm to
follow a term pregnancy or miscarriage
Only a third of cases follow a molar gestation
Composed of cells reminiscent of early
cytotrophoblast and syncytiotrophoblast.
Contains no villi.
Rapidly growing tumor invades both
myometrium and blood vessels
Metastasis are blood borne
Most common sites (lungs, kidneys, liver, brain, ovaries
and bowel
 PLACENTAL SITE TROPHOBLASTIC TUMOR
Arise from intermediate trophoblast at the placental
site.
Serum b hcg- modestly elevated
Produces variant forms of hcg.
Identification of free hcg- considered diagnostic.

Management: hysterectomy
Chemoresistant
For higher stage and stage 1 and for later stages
- multi drug chemotherapy.
 EPITHELIOD TROPHOBLASTIC TUMOR
Rare
Develops from chorionic- type intermediate
trophoblast.
Uterus –main site of involvement
Bleeding and low hcg- typical findings

Management: hysterectomy
Chemoresistant
Metastatic disease- common- combination
chemotherapy
SUBSEQUENT PREGNANCY

• Delay for 12 months

• No increase congenital anomaly
• Send specimen for histopath
 ABNORMAL LABOR
CARLA L. DELA CRUZ, MD,
Fellow, Philippine Obstetrics and Gynecologic Society
Fellow, Philippine Society of Ultrasound in Obstetrics and Gynecology

Chapter 30, William’s Obstetrics,

TH 23rd Edition
WILLIAMS OBSTETRICS, 25 EDIT’ION
Abnormal labor
(Outline)
• Dystocia
• Abnormalities of expulsive forces
• Prematurely rupture membranes at term
• Precipitous labor and delivery
• Fetopelvic Disproportion
• Pelvic Cavity
• Face Presentation
• Brow Presentation
• Transverse lie
• Compound presentation
• Complications with dystocia
LABOR

• Uterine contractions associated with changes in the

cervical dilatation and effacement

• The patient’s estimated of the start of the

contractions and the obstetrician’s assessment and
monitoring of the cervical changes form the basis for
the diagnosis of labor
 STAGES OF LABOR
First stage Onset of labor to • Latent
full cervical • Active
dilatation
Second Stage Complete cervical dilation until the
delivery of fetus
Third Stage Delivery of the fetus to delivery of
placenta
Fourth Stage Delivery of the placenta until 1 hr
post partum
Gradual cervical effacement
an dilatation
Active phase starts
at the UPSWING 4
cms , full cervical
effacement
Acceleration Predicts the
Phase OUTCOME of
labor
Phase of Reflects the
maximum slope efficacy of the
Machine
Deceleration - Reflective of
phase fetopelvic
relationship
- Cardinal
movements of
labor
 Cardinal movements

Cervix dilates
CONTRACTIONS ARE
COORDINATED,
POLARIZED AND
ORIENTED
PHASES OF LABOR
According to cervical dilatation
CERVICAL DILATATION PHASE OF LABOR
0-3 cms Latent phase
4-8 // 6-8 Active phase
8-9 Deceleration phase
10 cm Second stage
 NORMAL INDICES OF LABOR
LABOR PATTERN DIAGNOSTIC CRITERIA
Nulligravid Multigravid
Latent Phase <20 hrs < 14 hrs
Active Phase 4.9 hrs (11.7 hrs) 2.5 hrs (5.2 hrs)
Duration
Cervical < 1.2 cm/hr <1.5 cm/hr
Dilatation
Fetal descent < 1cm /hr < 2 cms/hr
 DYSTOCIA

• difficult labor characterized by abnormally slow

progress of labor/ prolonged labor
DYSTOCIA

• CAUSES
• Abnormality in expulsive forces
• Abnormality the presentation position and
development of fetus
• Abnormality of maternal bony pelvis
• Abnormality of birth canal
Categories according to the American College
of Obstetricians and Gynecologists
• Abnormalities of the powers—uterine contractility and
maternal expulsive effort.
• Abnormalities involving the passenger—the fetus.
• Abnormalities of the passage—the pelvis and lower
reproductive tract
 COMMON CLINICAL FINDINGS IN WOMEN WITH
INEFFECTIVE LABOR
Inadequate cervical dilation or fetal descent:
Protracted labor—slow progress
Arrested labor—no progress
Inadequate expulsive effort—ineffective pushing
Fetopelvic disproportion:
Excessive fetal size
Inadequate pelvic capacity
Malpresentation or position of the fetus
Abnormal fetal anatomy
Ruptured membranes without labor
MECHANISMS OF DYSTOCIA
At the end of pregnancy:
• Fetal head encounters the following:
• Relatively thick lower uterine segment
• Undilated cervix
• With the onset of labor, factors influencing progress:
• Uterine contractions
• Cervical resistance
• Forward pressure excerted by the leading fetal part
MECHANISMS OF DYSTOCIA

• After complete cervical dilatation (2nd Stage):

the mechanical relationship between the following is
clearer:
• fetal head size and position fetopelvic
• the pelvic capacity proportion
• uterine musculature is much thicker and thus more
powerful
• abnormalities in fetopelvic disproportions
become more apparent
MECHANISMS OF DYSTOCIA

Uterine muscle malfunction can result from

• uterine overdistention or
• obstructed labor or both

• Thus ineffective labor is generally accepted as a

possible warning sign of fetopelvic disproportion

• Uterine dysfunction } labor abnormalities

• Fetopelvic disproportion } so closely interlinked
MECHANISMS OF DYSTOCIA

• Indeed, the bony pelvis rarely limits vaginal delivery

• In the absence of objective means of precisely

distinguising there two causes of labor failure,
clinicians must rely on TRIAL OF LABOR to determine
if labor can be sucessful in effectiving vaginal
delivery
POWERS
UTERINE DYSFUNCTION

• characterized by lack of progress of labor

2 TYPES OF UTERINE DYSFUNCTION
 Hypotonic Uterine Dysfunction
 More common
 No basal hypertonus
 Uterine contractions have a normal gradient pattern
(synchronous)
 Pressure during a contraction is insufficient to dilate the
cervix
 Treatment: Oxytocin
 Hypertonic/Incoordinate Uterine Dysfunction
 Basal tone is elevated
 Pressure gradient is distorted (asynchronism)
 Treatment: sedation
 DIAGNOSTIC CRITERIA
LABOR PATTERN NULLIPARAS MULTIPARAS PREFERRED EXCEPTIONAL
TREATMENT TREATMENT
PROLONGATION DISORDER
Prolonged latent > 20 hours >14 hours Bed rest Oxytocin or
phase cesarean delivery
for urgent problem

PROTRACTION DISORDERS
Protracted active- < 1.2 cm/hr < 1.5 cm/hr Expectant and Cesarean delivery
phase dilatation support for CPD

Protracted descent < 1 cm/ hr < 2 cm/ hr

ARREST DISORDERS
Prolonged > 3 hr > 1 hr Evaluate for CPD; Rest if exhausted;
deceleration phase CPD: CS Cesarean delivery
No CPD: Oxytocin
Secondary arrest > 2 hr > 2 hrs
in dilatation
Arrest in descent > 1 hr > 1 hr
Failure in descent No decent in deceleration phase or
second stage
• Active-phase arrest
• Criteria that should be met:
• Completed latent phase
• Cervix is dilated to > 4 cms
• Uterine contraction pattern of 200 Montevideo
units or more in a 10 minute period has been
present for 2 or more hours without cervical
dilatation
PROLONGED LATENT PHASE
PROTRACTED DILATATION
ARREST IN CERVICAL DILATATION
PROLONGED DECELERATION PHASE
FAILURE IN DESCENT
PROTRACTED DESCENT
ARREST IN DESCENT
(Station +1 and below)
FAILURE IN DESCENT
(Station 0 and above
PROLONGED SECOND STAGE
 RECOMMENDATION OBSTETRIC CARE
CONSENSUS COMMITTEE (2016)
1. Admolishes against cesarean delivery in the latent
phase of labor
A prolonged latent phase is not an indication for
cesarean delivery
 RECOMMENDATION OBSTETRIC CARE
CONSENSUS COMMITTEE (2016)
2. Does not recommend cesarean delivery if labor is
progressive but slow – protraction disorder
Typically managed with
• Observation
• Assessment of uterine activity
• Stimulation of contractions as needed
 RECOMMENDATION OBSTETRIC CARE
CONSENSUS COMMITTEE (2016)
3. A cervical dilatation of 6 cms, not 4 cms is NOW
the recommended threshold to herald active labor
 RECOMMENDATION OBSTETRIC CARE
CONSENSUS COMMITTEE (2016)
4. Cesarean delivery for active phase arrest should be
reserved for women at or beyond 6 cms of cervical
dilatation, with ruptures membranes who fail to
progress despite 4 hours of adequate uterine activity,
or at least 6 hours of oxytocin administration with
inadequate contractions and no cervical change.
 RECOMMENDATION OBSTETRIC CARE
CONSENSUS COMMITTEE (2016)
Second stage of labor

Allow nullipara to push for at least 3 hours and

multipara for at least 2 hours before diagnosing
second stage labor arrest .
One caveat is that the maternal and fetal status are
both reassuring
MATERNAL PUSHING EFFORTS

• Combined force created by contraction of the uterus

and abdominal musculature propels the fetus
downward

• Heavy sedation or regional analgesia may reduce

the reflex urge to push and may impair the ability to
contract abdominal muscles effectively
FETAL STATION AT LABOR ONSET
• Engagement
• Descent of the leading edge of the presenting
part to the level of ischial spines (0 station)

• A higher station at the onset of labor is significantly

linked to subsequent dystocia.

• The prognosis of dystocia, was not related in

incrementally higher fetal head station above pelvic
midplane (0 Station)
 REPORTED CAUSES OF UTERINE
DYSFUNCTION
• Various labor factors have been implicated as causes of
uterine dysfunction:
• Neuraxial analgesia
• can slow labor
• associated with lengthening of both first- and second-
stage labor as well as slowing of the rate of fetal
descent
• Chorioamnionitis
• infection in this clinical setting is a consequence of
dysfunctional , prolonged labor rather than a cause
of dystocia
PREMATURE RUPTURE OF MEMBRANES
AT TERM
• Membrane rupture at term without spontaneous
uterine contractions complicates approximately 8%
of pregnancies

• Preferred management: Oxytocin infusion

• Significantly fewer intrapartum and pospartum
infection in women whose labor was induced
PREMATURE RUPTURE OF MEMBRANES
AT TERM
• Labor is induced soon after admission when ruptured
membranes are confirmed at term (At Parkland
Hospital)

• Benefit of prophylactic antibiotics in women with

ruptured membranes before labor at term is
UNCLEAR
• However, in those with membranes ruptured longer
than 18 hours, antibiotics are instituted for group B
streptococcal infection prophylaxis
PRECIPITOUS LABOR AND DELIVERY

• Definition: Extremely rapid labor and delivery

• Precipitous labor terminates in expulsion of the fetus in
less than 3 hours

• May result from:

• an abnormally low resistance of the soft parts of
birth canal
• abnormally strong uterine and abdominal contraction
• rarely from the absence of painful sensation and
thus a lack of awareness of vigorous labor
PRECIPITOUS LABOR AND DELIVERY
Maternal Effects
• uterine rupture
• extensive lacerations of the cervix, vagina, vulva, or perineum
• amnionic fluid embolism
• postpartum hemorrhage from uterine atony (hemorrhage from the placental
implantation site )

Seldom are accompanied by serious maternal complications if:

• the cervix is effaced appreciably and compliant
• the vagina has been stretched previously
• the perineum is relaxed
PRECIPITOUS LABOR AND DELIVERY

Short labors
 rate of cervical dilatation
 5 cm/hr for nulliparas
 10 cm/hr for multiparas
 associated with:
 abruption (20 percent)
 meconium
 postpartum hemorrhage
 cocaine abuse
 low Apgar scores
 multiparity
PRECIPITOUS LABOR AND DELIVERY

Fetal/Neonatal Effects
• Perinatal mortality and morbidity
• Inappropriate uterine blood flow and fetal oxygenation.
• Intracranial trauma(rare)
• Erb or Duchenne brachial palsy
• Injury from fall

Treatment: any oxytocin agents being administered should

be stopped
 BOUNDARIES AP TRANSVERSE
Inlet Sacral promontory to Linea terminalis
lower border of
symphysis pubis

Midplane Lower border of 2 ischial spines

symphysis pubis to S2
S3

Outlet Lowe border of 2 ischial

symphysis to tip of tuberosities
sacrum
FETOPELVIC DISPROPORTION

• arises from diminished pelvic capacity, excessive

fetal size, or more usually, a combination of both.

• Pelvic inlet, midpelvis or pelvic outlet may be

contracted solely or in combination
CONTRACTED PELVIC INLET

• shortest anteroposterior diameter is less than

10 cm or
• greatest transverse diameter is less than 12 cm or
• diagonal conjugate of less than 11.5 cm
CONTRACTED INLET

• Prior to labor, the fetal biparietal diameter averages

from 9.5 to as much as 9.8 cm (Shortest AP Diameter)

• Cervical dilatation aided by hydrostatic action of the

unruptured membranes or, after their rupture, by direct
application of the presenting part against the cervix

• Membrane rupture -> absence of pressure by the head

against the cervix and lower uterine segment ->
less effective contractions -> further dilatation proceeds
very slowly or not at all
CONTRACTED INLET

A contracted inlet plays an important part in the

production of abnormal presentations

In normal nulliparas, the presenting part at term

commonly descends into the pelvic cavity before the
onset of labor. In contracted inlet, descent usually does
not take place until after the onset of labor, if at all.

In women with contracted pelves, face and shoulder

presentations are encountered three times more
frequently, and cord prolapse occurs four to six times
more frequently.
CONTRACTED MIDPELVIS

• more common than inlet contraction

• causes transverse arrest of the fetal head
• Interischial spinous diameter is < 8cm
• Spines are prominent
• Pelvic sidewalls converge
• Narrow sacrosciatic notch
CONTRACTED MIDPELVIS

• Obstetrical plane of the midpelvis

• extends from the inferior margin of the symphysis
pubis through the ischial spines and touches the
sacrum near the junction of the fourth and fifth
vertebrae

• A transverse line theoretically connecting the ischial

spines divides the midpelvis into anterior and
posterior portions.
CONTRACTED MIDPELVIS

• Anterior midpelvis - bounded anteriorly by the lower

border of the symphysis pubis and laterally by the
ischiopubic rami

• Posterior midpelvis - bounded dorsally by the

sacrum and laterally by the sacrospinous ligaments ;
forming the lower limits of the sacrosciatic notch.
 Contracted Midpelvis
• Average midpelvis measurements
• Transverse or interspinous = 10.5 cm
• Anteroposterior (from the lower border of the
symphysis pubis to the junction of S4–S5) = 11.5
cm
• Posterior sagittal (from the midpoint of the
interspinous line to the same point on the sacrum)
= 5 cm
Contracted Pelvic Outlet
Interischial tuberous diameter of 8 cm or less

Pelvic outlet likened to 2 triangles:

Anterior triangle
 base - interischial tuberous diameter
 sides - pubic rami
 apex - inferior posterior surface of the symphysis pubis

Posterior triangle
 base - interischial tuberous diameter
 no bony sides
 apex - tip of the last sacral vertebra (not the tip of the
coccyx).
Estimation of Pelvic Outlet

• X-Ray Pelvimetry
• Computed Tomographic scanning
• Magnetic Resonance

A contracted outlet may cause dystocia through the

often-associated midpelvic contraction
• THE PASSENGER
 ABNORMAL
PRESENTATION,
POSITION AND
DEVELOPMENT
FACE PRESENTATION

• The head is hyperextended , occiput is in contact

with the fetal back and the chin (mentum) is
presenting

• Fetal face may present with the chin (mentum)

anteriorly or posteriorly, relative to the maternal
symphysis pubis
FACE PRESENTATION

The occiput is the

longer end of the
head lever. The chin is
directly posterior.
Vaginal delivery is
impossible unless the
chin rotates anteriorly
FACE PRESENTATION

Diagnosis
• Vaginal examination
• palpation of the distinctive facial features of the
mouth and nose, the malar bones, and
particularly the orbital ridges
• Radiographic examination
• demonstration of the hyperextended head with
the facial bones at or below the pelvic inlet
FACE PRESENTATION

Etiology

• Marked enlargement of the neck or coils of cord

about the neck may cause extension
• Anencephalic fetuses
• Contracted pelvis
• Very large fetus
• Multiparous women
 FACE PRESENTATION
Mechanism of Labor
• Face presentations rarely are observed above the pelvic inlet
• The brow generally presents, converted into a face presentation
after further extension of the head during descent
• Mechanism of labor consists of the following cardinal movements:
• Descent - brought about by the same factors as in cephalic
presentations
• internal rotation - the objective is to bring the chin under the
symphysis pubis
- results from the same factors as in vertex presentations
• flexion
• accessory movements of extension and external rotation -
results from the relation of the fetal body to the deflected
head
FACE PRESENTATION

Management

• In the absence of a contracted pelvis, and with

effective labor, successful vaginal delivery usually
will follow
• Cesarean delivery
• Because face presentations among term-size
fetuses are more common when there is some
degree of pelvic inlet contraction, cesarean
delivery frequently is indicated.
Brow Presentation

• Rarest presentation because it is unstable and often

converts to a face or occiput presentation
• The portion of the fetal head between the orbital
ridge and anterior fontanel presents at the pelvic
inlet
• The fetal head thus occupies a position midway
between full flexion (occiput) and extension (mentum
or face)
• Only transient prognosis depends on the ultimate
presenting part
• Causes are the same as of the face presentation
Brow Presentation

• Causes and etiology are the same as of the face

presentation

• Management is the same as those for a face

presentation
Brow Posterior Presentation
Brow Presentation

Diagnosis

• Abdominal palpation - when both the occiput and

chin can be palpated easily

• Vaginal examination – palpation of the frontal

sutures, large anterior fontanel, orbital ridges, eyes,
and root of the nose
Brow Presentation

Mechanism of Labor

• very small fetus and a large pelvis - labor is

generally easy
• with a larger fetus - usually difficult, because
engagement is impossible until there is marked
molding that shortens the occipitomental diameter or,
more commonly, until there is either flexion to an
occiput presentation or extension to a face
presentation
Transverse Lie

• the long axis of the fetus is approximately

perpendicular to that of the mother

• referred to as shoulder or acromnion presentation

• the shoulder is usually on the pelvic inlet, with the

head lying on one iliac fossa and the breech in
another
Transverse Lie

Diagnosis
Abdominal examination
 abdomen is unusually wide, whereas the uterine
fundus extends to only slightly above the umbilicus.
 no fetal pole is detected in the fundus, ballottable
head is found in one iliac fossa and the breech in the
other
 back up (anterior) - a hard resistance plane extends
across the front of the abdomen
 back down (posterior)- irregular nodulations
representing the small parts are felt through the
abdominal wall.
Transverse Lie

Diagnosis

• Vaginal examination
• early stages of labor: the side of the thorax or
the "gridiron" feel of the ribs
• Advanced labor: the scapula and clavicle are
palpated
 Transverse Lie

Palpation in transverse lie, right acromidorsoanterior position. A. First

maneuver. B. Second maneuver. C. Third maneuver. D. Fourth maneuver.
Transverse Lie

Etiology
• Abdominal wall relaxation from high parity.
• Preterm fetus.
• Placenta previa.
• Abnormal uterine anatomy.
• Excessive amnionic fluid.
• Contracted pelvis.
Transverse Lie

Mechanism of Labor
• Spontaneous delivery of a fully developed newborn
is impossible with a persistent transverse lie
• rupture of the membranes -> the fetal
shoulder is forced into the pelvis corresponding
arm frequently prolapses shoulder is arrested
by the margins of the pelvic inlet ( head in one iliac
fossa and the breech in the other) -> impacted
shoulder -> neglected transverse lie ->
uterine rupture
Neglected shoulder presentation. A thick muscular band forming a pathological
retraction ring has developed just above the thin lower uterine segment. The force
generated during a uterine contraction is directed centripetally at and above the level
of the pathological retraction ring. This serves to stretch further and possibly to rupture
the thin lower segment below the retraction ring. (P.R.R. = pathological retraction ring.)
Transverse Lie

• If the fetus is small—usually less than 800 g—and

the pelvis is large, spontaneous delivery is possible
despite persistence of the abnormal lie
Transverse Lie

Management
• In general, the onset of active labor in a woman with
a transverse lie is an indication for cesarean
delivery
• Because neither the feet nor the head of the fetus
occupies the lower uterine segment, a low transverse
incision into the uterus may lead to difficulty in
extraction of a fetus entrapped in the body of the
uterus above the level of incision. Therefore, a
vertical incision is likely to be indicated
OBLIQUE LIE

• called an unstable lie

• when the long axis forms an acute angle
• usually only transitory, because either a longitudinal
or transverse lie commonly results when labor
supervenes
Compound Presentation

• an extremity prolapses alongside the presenting

part, with both presenting in the pelvis
simultaneously
 COMPOUND PRESENTATION

The left hand is lying in front of the vertex. With further labor, the
hand and arm may retract from the birth canal and the head may
then descend normally.
COMPOUND PRESENTATION

Causes

• conditions that prevent complete occlusion of the

pelvic inlet by the fetal head, including preterm birth
COMPOUND PRESENTATION
Prognosis and Management
Perinatal loss is increased as a result of concomitant
preterm delivery, prolapsed cord, and traumatic
obstetrical procedures
In most cases, the prolapsed part should be left alone,
because most often it will not interfere with labor
Prolapsed arm alongside the head close observation
to ascertain whether the arm retracts out of the way
with descent of the presenting part, if it fails to retract
and if it appears to prevent descent of the head, the
prolapsed arm should be pushed gently upward and
the head simultaneously downward by fundal pressure
-> vaginal delivery
EFFECTS OF DYSTOCIA
Maternal Complications
Intrapartum Infection
Uterine Rupture
Pathological Retraction Ring
 Pathological retraction ring of Bandl, an
exaggeration of the normal retraction ring
 often the result of obstructed labor
 marked stretching and thinning of the lower
uterine segment
 may be seen clearly as a uterine indentation and
signifies impending rupture of the lower uterine
segment
EFFECTS OF DYSTOCIA
Maternal Effects
Fistula Formation
 vesicovaginal, vesicocervical, or rectovaginal fistulas
 develops from impaired circulation, necrosis becoming
evident several days after delivery
Pelvic Floor Injury
Postpartum Lower Extremity Nerve Injury
 Footdrop - secondary to injury at the level of the
lumbosacral root, lumbosacral plexus, sciatic nerve, or
common peroneal nerve
 most common mechanism of injury, however, is external
compression of the peroneal nerves usually caused by
inappropriate leg positioning in stirrups especially during
a prolonged second stage of labor
 symptoms resolve within 6 months of delivery in most
women.
EFFECTS OF DYSTOCIA

Fetal Effects
• Caput Succedaneum
• Fetal Head Molding
associated with: nulliparity
oxytocin labor stimulation
delivery with a vacuum extractor
• Skull fractures
 LABOR INDUCTION AND
AUGMENTATION
Daisy Jara-Dulnuan, MD, FPOGS, FPSMFM, PSUCMI
DEFINITION

• INDUCTION OF LABOR:
stimulating the uterus to begin labor

• AUGMENTATION OF LABOR
Stimulating the uterus during labor to increase the
frequency, duration and strength of contractions
INDUCTION

• Implies stimulation of contractions before the

spontaneous onset of labor, with or without ruptured
membranes.
• When the cervix is closed and uneffaced, labor
induction will commence with cervical ripeding, a
process that generally employs prostaglandins or
any other agent to soften and open the cervix.
INDICATIONS
Indicated when the benefits to either the mother or
fetus outweigh those of pregnancy continuation.

• Membrane rupture without • Postterm preganancy

labor
• Various maternal medical
• Gestational Hypertension conditions
• Oligohydramnios • Chronic Hypertension
• Nonreassuring fetal status • Diabetes
 CONTRAINDICATIONS TO LABOR
INDUCTION
CONDITIONS THAT PRECLUDE SPONTANEOUS LABOR OR
DELIVERY

• Prior uterine incision type

• Macrosomia
• Contracted or distorted pelvic
anatomy • Severe hydrocephalus
• Abnormally implanted • Malpresentation
placentas • Nonreassuring fetal status
• Uncommon conditions
• Genital herpes infection
• Cervical cancer
TECHNIQUES

• OXYTOCIN • MECHANICAL METHODS

• Stripping of
membranes
• PROSTAGLANDINS
• Artificial rupture of
Misoprostol, membranes
Dinoprostone
• Extraamnionic Saline
Infusion
• Transcervical Balloons
• Hygroscopic Cervical
Dilators
RISKS

• Cesarean delivery
• Chorioamnionitis
• Uterine scar rupture
• Postpartum hemorrhage
• Uterine atony
ASSESSMENT OF THE CERVIX

• The success of induction of labor is related to the

condition of the cervix at the start of induction.
• A cervical exam is performed and Bishop scoring is
applied
• If the cervix is favorable (has a score of 6 or
more) labor is usually succeessfully induced with
oxytocin alone.
• If the cervix is unfavorable, (has a score of 5 or
less), ripen the cervi before induction.
BISHOP SCORE
OXYTOCIN
• Carefully observe women receiving oxytocin.
• When oxytocin infusion results in a good labor
pattern, maintain the same rate until delivery.
• Be sure induction is indicated, as failed induction is
usually followed by cesarean section.
• Women receiving oxytocin should not be left alone.
• Do not use oxytocin 10 units in 500ml (i.e. 20 mIU/ml)
in multigravida and women with previous cesarean
section.
• Increase the rate of oxytocin infusion only to the point
where good labor is established and then maintain
infusion at that rate.
PROSTAGLANDINS
• Check the woman’s pulse, blood pressure and contractions and
check the fetal heart rate. Record findings.
• It is placed high in the vagina in the posterior fornix of the
vagina and may be repeated after 6 hours if required.
• Monitor uterine contractions and fetal heart rate of all women
undergoing induction of labor with prostaglandins.
• Do not use oxytocin within 8 hours of using prostaglandins.
Monitor uterine contractions and fetal heart rate
• Discontinue use and begin oxytocin infusion if:
• Membranes rupture;
Cervical ripening has been achieved;
• Good labor has been established;
• OR 12 hours have passed
FOLEY CATHETER

• Avoided in women with obvious cervicitis or vaginitis.

• History of bleeding or ruptured membranes or
obvious vaginal infection,
AUGMENTATION

• Refers to enhancement of spontaneous contractions

that are considered inadequate because of failed
cervical dilation and fetal descent.

• A good labor pattern is established when there are

three contractions in 10 minutes, each lasting more
than 40 seconds
AUGMENTATION

• Active labor has started, but contractions are weak

or irregular or have stopped entirely.
• You have gone into active labor, but amniotic sac has
not ruptured on its own. AROM needs to be done in
this case. If labor still does not progress, oxytocin
maybe given to make the uterus contract.
• Active labor has started and the amniotic sac has
ruptured on its own, but labor still is not progressing.
Oxytocin may be given to make the uterus contract.
 ARTIFICIAL RUPTURE OF MEMBRANES
• Review indications
• NOTE: In areas of high HIV prevalence, it is prudent
to leave the membranes intact for as long as possible
to reduce perinatal transmission of HIV

• Listen to and note the fetal heart rate

• Ask the woman to lie on her back with her legs bent, feet
together and knees apart
• Wearing high-level disinfected gloves, use one hand to
examine the cervix and note the consistency, position,
effacement and dilatation.
• Use the other hand to insert an amniotic hook, needle or
stick into the vagina.
ARTIFICIAL RUPTURE OF MEMBRANES
• Guide the clamp or hook towards the membranes along the
fingers in the vagina.
• Place two fingers against the membranes with the
instrument in the other hand.
• Allow the amniotic fluid to drain slowly around the fingers.
• Note the color of the amniotic fluid (clear, greenish,
bloody).
• If meconium is thick( greenish), suspect fetal distress.
• After AROM, listen to the fetal heart rate during and after
a contraction.
• If the fetal heart rate is abnormal ( < 100 or > 180
bpm), suspect fetal distress
AFTER AROM
• If delivery is not anticipated within 18 hours, give
prophylactic antibiotics in order to help reduce Group B
straptococcus infection in the neonate.
• Penicillin G 2 MU IV
• Ampicillin 2 grams IV, every 6 hours until delivery
• If good labor is not established 1 hour after AROM,
begin oxytocin infusion
• If labor is induced because of severe maternal disease
(e.g. sepsis or eclampsia), begin oxytocin infusion at the
same time as AROM
 NEVER FORCE ANTHING IN YOUR LIFE.
JUST LET IT BE.
• IF LABOR FAILS TO PROGRESS IF ITS MEANT TO BE, IT WILL BE.

IN SPITE OF ALL THE TECHNIQUES

MENTIONED,
DELIVERY BY CESAREAN SECTION
MAYBE CONSIDERED.
MALPRESENTATION
AND DELIVERY
R.A. 30 years old, G3P1(1011), 37 weeks AOG,
consulted at the ER for watery vaginal discharge 1
hour prior. Her 1st baby was delivered 5 years ago
via NSD in cephalic presentation with a BW of 3,000
grams. She only had 2 PNCU at the local health
center. LM1=fetal head at fundus; LM2=fetal back, R
with FHT of 150. R; LM3=breech; LM4=breech
beneath the symphysis. EFW=2,600. IE: +gross
pooling of amniotic fluid, fully dilated, station +4
WHAT IS THE COMPLETE DIAGNOSIS?
CATEGORIES OF BREECH PRESENTATION
COMPLETE FRANK INCOMPLETE
FOOTLING

The thighs are flexed at the the knees are extended while the hips and joints extended on
hips and the legs at knees. hips are flexed. one or both sides
CATEGORIES OF BREECH PRESENTATION
COMPLETE FRANK INCOMPLETE
FOOTLING

The thighs are flexed at the the knees are extended while the hips and joints extended on
hips and the legs at knees. hips are flexed. one or both sides
ABDOMINAL EXAMINATION-LEOPOLD’S MANEUVER
What is the plan of management for this
patient? Give justifications for your
answer
☞ Multiple factors aid determination of the
best delivery route for a mother-fetus pair:
• ☞fetal characteristics
• ☞pelvic dimensions
• ☞coexistent pregnancy complications
• ☞operator experience
• ☞patient preference
• ☞ hospital capabilities
Rapid ☞ membranes, labor, and fetal condition.
assessment ☞ Close surveillance : FHT, UC
☞ an OB skilled in the art of breech extraction
☞ Anesthesia/ skilled OB assist/pedia
Plan for the ☞ assess the cervix, station & type of
route of delivery presentation.
☞ Satisfactory progress in labor is the best
indicator of pelvic adequacy
☞ Sonographic assessment of fetal biometry,
head flexion & fetal anatomy
Choice of ☞ is based on the factors favoring CS
abdominal or
vaginal
delivery
☞Lack of operator experience
☞Patient request for CS delivery: Prior CS
☞Large fetus > 3800 to 4000 g
☞Apparently healthy & viable preterm fetus
☞Severe fetal growth restriction
☞Fetal anomaly incompatible w/vaginal delivery
☞Prior perinatal death or neonatal birth trauma
☞Incomplete or footling breech presentation
☞ Hyperextended head
☞Pelvic contraction
 3 METHODS OF BREECH DELIVERY
Spontaneous ☞ The fetus is expelled entirely
breech delivery spontaneously without any traction or
manipulation other than support of the
newborn
Partial breech ☞ The fetus is delivered spontaneously as
extraction far as the umbilicus
☞ remainder of the body is extracted or
delivered with operator traction and
assisted maneuvers, with or without
maternal expulsive efforts.
Total breech ☞ The entire body of the infant is extracted
extraction by the obstetrician
MECHANISM OF LABOUR

•Delivery of the buttocks

•Shoulders

Head
☞Anesthesia for breech decomposition and extraction
☛must provide sufficient relaxation to allow intrauterine
manipulations

☞EPIDURAL ANALGESIA
☛may provide sufficient relaxation to allow intrauterine
manipulations but increased uterine tone may render the
operation more difficult.

☞GENERAL ANESTHESIA
☛may be required to relax the uterus as well as to provide
analgesia
 BREECH PRESENTATION AND DELIVERY
Hurry Up & Wait!

• DON’ T PU LL !
• Traction deflexes the
fetal head
• May cause nuchal arm

Obstetrics - Normal and Problem Pregnancies, 2nd Edition Edited

by SG Gabbe, JR Niebyl, JL Simpson. (1991)

14
BREECH PRESENTATION AND
DELIVERY

Deliver Legs by
PINARD’S MANEUVER

• insert 2 fingers along

one leg to the knee,
then pushed away from
midline (abducted)
while flexing leg at hip
 BREECH PRESENTATION AND DELIVERY
DELIVERY OF ARMS
• Good maternal pushing
• Deliver when scapulae
visible
• Rotate to shoulder anterior
• Sweep humerus across the
chest and deliver(LOVESET
MANEUVER)
• Rotate to other shoulder
anterior and sweep second
arm to deliver

16
BREECH PRESENTATION AND DELIVERY
AVOID OVER-EXTENSION

Obstetrics - Normal and Problem Pregnancies,2nd Edition Edited by SG Gabbe, JR Niebyl, JL Simpson. (1991) 38
 BREECH PRESENTATION AND DELIVERY

Delivery of the Head

• Mauriceau-Smellie-Veit
Maneuver

• Flexion maintained with

suprapubic pressure
• Pressure on maxilla

287
BREECH PRESENTATION AND DELIVERY
Delivery of the Head
with Forceps

• Assistant supporting baby

• Direct pelvic
application

288
 MANEUVER DESCRIPTION
CONSENT/HELP
ANESTHESIA
EPISIOTOMY
SPONTANEOUS EXPULSION TO UMBILICUS. WAIT, DON’T PULL!
PINARD’S DELIVER LEGS LATERAL ROTATION OF THIGHS AND
FLEXION OF KNEES – KEEP SACRUM
ANTERIOR
DELIVER ARMS DELIVER WHEN WINGING OF SCAPULAE
SEEN ROTATE ARM TO ANTERIOR

LOVESET SWEEP HUMERUS ACROSS THE CHEST

AND DELIVER
ROTATE OTHER ARM ANTERIOR AND REPEAT
TO DELIVER
NAPE OF NECK SUPRAPUBIC PRESSURE
AVOID OVER EXTENSION
MAURICEAU- DELIVERY OF THE AFTERCOMING HEAD
SMELLIE-VEIT
PIPERS FORCEPS
INSPECT FOR INJURIES/LACERATIONS
DOCUMENTATION
DELIVERY OF THE AFTERCOMING HEAD
The back of the fetus
fails to rotate to the
anterior

PRAGUE
MANEUVER
What are the possible
complications that may arise
from a vaginal breech
delivery?
 Common injuries
Fractures of the humerus, Spinal cord injury or vertebral
clavicle, & femur fracture
• Traction may separate
scapular, humeral or
femoral epiphysis
Upper extremity paralysis, Erb Testicular injury
or Duchenne
Spoon shaped depression or Umbilical cord prolapse; hip
actual fractures of the skull dysplasia
 BREECH CESAREAN

@
BREECH DELIVERY

Rowena M. Auxillos, MD, FPOGS, MBA-H

 CESAREAN DELIVERY
&
PERIPARTUM HYSTERECTOMY
MARITES MIGUEL-BUTARAN MD
FELLOW PHILIPPINE OBSTETRICAL & GYNECOLOGICAL SOCIETY
INTERNATIONAL FELLOW IN PEDIATRIC & ADOLESCENT GYNECOLOGY
FREQUENCY

• From 1970 to 2007:

• CS rate in the US rose from 4.5% of all deliveries to
31.8 % (Hamilton and colleagues, 2009;
MacDorman and associates, 2008).

• VBAC rates dropped to 8.5 % (Hamilton and

associates, 2009)
FREQUENCY

 ACOG Task Force on Cesarean Delivery Rates

(2000) recommended two benchmarks for the US
for the year 2010:
 1. CS rate of 15.5 % for nulliparous women at 37
weeks, singleton, cephalic .

 2. VBAC rate of 37%

 CVMC : 25% CS rate and should be lower.

FREQUENCY

Increase in CS rates could be due to :

•1. Nulliparas
•2. Maternal age is rising – increased older women
that are nulliparas
•3. Use of electronic fetal monitoring
•4. Breech are now CS
•5. Use of forceps and vacuum deliveries has
decreased
•6. Labor induction continue to rise
•7. Obesity
FREQUENCY

• 8. Preeclampsia have increased

• 9. Vaginal birth after cesarean—VBAC—has
decreased
• 10. Pelvic floor injury associated with vaginal birth,
medically indicated preterm birth, to reduce the risk
of fetal injury, and for patient request
• 11. Malpractice litigation continues to contribute
significantly to the present cesarean rate
 INDICATIONS
• MATERNAL AND OR FETAL
1. Dystocia
2. Prior CS delivery
3.Fetal distress
4. breech presentation or transverse lie
5. Placental abruption
6. Placenta previa
7. Cord prolapse
8. Respiratory Disease
9. Conditions with increased ICP
10. Obstruction of the lower uterine segment and vulva
11. Cardiac disease
METHODS TO DECREASE CESAREAN
DELIVERY RATES
1. Educating physicians
2. Peer reviewing
3. Encouraging a trial of labor after prior transverse
cesarean delivery
4. Restricting cesarean deliveries for dystocia only to
women who meet strictly defined criteria
MATERNAL MORTALITY AND
MORBIDITY
• MMR of 2.2 per 100,000 cesarean deliveries (Clark
and colleagues, 2008)
• Emergency CS was associated with an almost
ninefold risk of maternal death.
• Elective CS was associated with threefold risk (Hall and
Bewley, 1999)
• Maternal morbidity rate: twofold increase with
cesarean delivery compared with vaginal delivery
(Villar and associates, 2007).
MATERNAL MORTALITY AND MORBIDITY

• Principal sources :
• Puerperal infection, hemorrhage, and
thromboembolism (Burrows and associates, 2004)

• Bladder laceration (1.4 per 1000 procedures)

Ureteral injury (0.3 per 1000) (Rajasekar and Hall, 1997)
• Uterine infection
• Uterine rupture in subsequent pregnancy
• 0.3 percent (Spong and colleagues, 2007)
CESAREAN DELIVERY ON MATERNAL
REQUEST (CDMR)
 Reasons for mothers to request cesarean delivery:
avoidance of pelvic floor injury during vaginal
birth
reduced risk of fetal injury
avoidance of the uncertainty and pain of labor
convenience
 ISSUES on: medical rationale from both a maternal and
fetal-neonatal standpoint, the concept of informed free
choice by the woman, and the autonomy of the
physicians in offering this choice.
TECHNIQUE FOR CESAREAN
DELIVERY
ABDOMINAL INCISION
 VERTICAL INCISION
 Infra umbilical midline vertical incision from skin to
the level of the anterior rectus sheath.
 Freed of subcutaneous fat to expose a 2-cm-wide
strip of fascia in the midline
 Fascia can be incised using scalpel and extending it
using a scissors
 The rectus and the pyramidalis muscles are
separated in the midline by sharp and blunt
dissection to expose transversalis fascia and
peritoneum.
ABDOMINAL INCISION
 The transversalis fascia and preperitoneal fat are
dissected carefully .
 The peritoneum near the upper end of the incision
is opened carefully, either bluntly, or by elevating it
with two hemostats placed about 2 cm apart.
 The tented fold of peritoneum is then examined
and palpated to be sure that omentum, bowel, or
bladder is not adjacent
 The peritoneum is incised superiorly to the upper
pole of the incision and downward to just above
the peritoneal reflection over the bladder
ADVANTAGE AND DISADVANTAGES

 Advantages
- speed of abdominal entry
- Less bleeding
- Space for extension upwards

- Disadvantages
- - greater risk of postoperative wound dehiscence
- - devt of incisional hernia
- - cosmetically less pleasing
ABDOMINAL INCISION

• TRANSVERSE INCISION (Pfannenstiel incision)

• Skin and subcutaneous tissue are incised using a
lower, transverse, slightly curvilinear incision
• Incised at the level of the pubic hairline .and
Extended beyond the lateral borders of the rectus
muscles
• Identify superficial epigastric vessels, suture ligated
or coagulated if lacerated
ABDOMINAL INCISION
 Subcutaneous tissue is separated from the
underlying fascia for 1 cm.
 Fascia is incised at the midline and extended
laterally using scalpel or scissors
 Two layers of anterior abdominal fascia:
the aponeuroses from the external oblique muscle
a fused layer containing aponeuroses of the
internal oblique and transverse abdominis
muscles.
 The inferior epigastric vessels typically lie outside
the lateral border of the rectus abdominis muscle
and beneath the fused aponeuroses of the internal
oblique and transverse abdominis muscles
ABDOMINAL INCISION
 The superior and then the inferior edge of the
fascia is grasped with suitable clamps and
elevated by the assistant as the operator separates
the fascial sheath from the underlying rectus
muscles either bluntly or sharply
 Blood vessels coursing between the muscles and
fascia are clamped, cut, and ligated, or they are
fulgurated with electrocautery
 The fascial separation is carried near enough to the
umbilicus to permit an adequate midline
longitudinal incision of the peritoneum.
 The rectus muscles are then separated in the
midline to expose the underlying peritoneum
• Advantage
- cosmetically pleasing
- less prone to dehiscense and insitional hernia
- less postoperative pain
- for obese individual
• Disadvantage
- more blood loss
- risk for suprafascial hematoma
- prolonged numbness of the skin around insision site
UTERINE INCISIONS

 Low transverse (low segment, Kerr incision)

 Described by Kerr (1921)
 the lower uterine segment is incised transversely

 low-segment vertical incision

 described by Krönig in 1912

 classical incision
 a vertical incision into the body of the uterus above
the lower uterine segment and reaches the uterine
fundus
TECHNIQUE FOR TRANSVERSE
CESAREAN INCISION
The reflection of peritoneum above the upper margin of the bladder
and overlying the anterior lower uterine segment—the bladder flap—
is grasped in the midline with forceps and incised transversely with
scissors.
Scissors are inserted between the vesicouterine serosa and
myometrium of the lower uterine segment.
The scissors are pushed laterally from the midline, and then withdrawn
while partially opening the blades intermittently which separates a 2-
cm–wide strip of serosa, which is then incised.
the scissors are directed more cephalad at the lateral margin on
each side.
The lower flap of peritoneum is elevated, and the bladder is gently
separated by blunt or sharp dissection from the underlying
myometrium.
the separation of bladder should not exceed 5 cm in depth and
usually should be less.
The uterus is entered through the lower uterine segment approximately
1 cm below the upper margin of the peritoneal reflection
TECHNIQUE FOR TRANSVERSE
CESAREAN INCISION
• The reflection of peritoneum above the upper margin of
the bladder and overlying the anterior lower uterine
segment—the bladder flap—is grasped in the midline
with forceps and incised transversely with scissors
• Scissors are inserted between the vesicouterine serosa
and myometrium of the lower uterine segment
• The scissors are pushed laterally from the midline, and
then withdrawn while partially opening the blades
intermittently which separates a 2-cm–wide strip of
serosa, which is then incised
• the scissors are directed more cephalad at the lateral
margin on each side
Technique for Transverse Cesarean
Incision
• The lower flap of peritoneum is elevated, and the bladder is
gently separated by blunt or sharp dissection from the
underlying myometrium
• the separation of bladder should not exceed 5 cm in depth
and usually should be less

• The uterus is entered through the lower uterine segment

approximately 1 cm below the upper margin of the
peritoneal reflection

• The uterine incision must be relatively higher in women with

advanced or complete cervical dilatation to minimize both
lateral extension of the incision into the uterine arteries and
unintended entry into the vagina
Incision to the uterus may be initiated by using a scalpel to transversely
incise the exposed lower uterine segment for 1 to 2 cm in the midline

This must be done carefully to ovoid injury to the fetus

Laceration is the most common fetal injury
Careful blunt entry using hemostats or fingertip to split the
muscle may be helpful Once the uterus is opened, the incision
can be extended by cutting laterally and then slightly upward
with bandage scissors
Technique for Transverse Cesarean
Incision
• The uterine incision should be made large enough to
allow delivery of the head and trunk of the fetus
without either tearing into or having to cut into the
uterine vessels that course through the lateral margins
of the uterus
In a cephalic presentation, a hand is
slipped into the uterine cavity between the
symphysis and fetal head
The head is elevated gently with the
fingers and palm through the incision,
aided by modest transabdominal fundal
pressure
The shoulders then are delivered using gentle traction plus fundal
pressure
The rest of the body readily follows
DELIVERY OF THE INFANT

• After the shoulders are delivered, an intravenous

infusion containing two ampules or 20 units of
oxytocin per liter of crystalloid is infused at 10
mL/min until the uterus contracts satisfactorily
• The umbilical cord is doubly clamped and cut in
between the clamps
• Bleeding area in the uterine incision is clamped with
Pennington or ring forceps or similar instruments
DELIVERY OF THE PLACENTA

The placenta is then

delivered by manual
removal, but spontaneous
delivery along with some
cord traction can be done
Fundal massage, begun as
soon as the fetus is
delivered, reduces
bleeding and hastens
placental delivery.
TECHNIQUE FOR TRANSVERSE
CESAREAN INCISION
• The Joel-Cohen and Misgav-Ladach methods
• use an abdominal incision placed higher than the
Pfannenstiel and use blunt dissection of all
encountered layers following sharp skin incision
• associated with lower rates of intraoperative
blood loss, puerperal fever, and postoperative
pain and with shorter operative times
UTERINE REPAIR

• The uterus may be lifted through the incision onto the

draped abdominal wall, and the fundus covered
with a moistened laparotomy pack
• Advantages of uterine exterioration
• relaxed, atonic uterus can be recognized quickly
• incision and bleeding points are more easily
visualized and repaired
• Adnexal exposure is superior
UTERINE REPAIR

• The uterine cavity is inspected, suctioned or wiped

out with a gauze pack to remove avulsed
membranes, vernix, clots, and other debris.

• The upper and lower cut edges and each lateral

angle of the uterine incision are examined carefully
for bleeding
The uterine incision is then
closed with one or two layers
of continuous 0- or #1
absorbable suture.
Chromic suture or synthetic
delayed-absorbable
sutures
The initial suture is placed just
beyond one angle of the
uterine incision in running-lock
fashion (hemostatic closure)
It is performed with each
suture penetrating the full
thickness of the
myometrium
The running-lock suture is
continued just beyond the
opposite incision angle
UTERINE REPAIR
• Another layer of sutures may be placed to achieve
approximation and hemostasis, or individual
bleeding sites can be secured with figure-of-eight
or mattress sutures.

• Serosal edges overlying the uterus and bladder

have been approximated with a continuous 2-0
chromic catgut suture.
UTERINE REPAIR

• The type of uterine closure did not significantly

affect several maternal and fetal complications in
the next pregnancy (Chapman and associates, 1997)
• Single-layer closure was associated with a fourfold
increased risk of uterine rupture during a subsequent
trial of labor (Bujold and associates, 2002)
Abdominal Closure

 All packs are removed, and the paracolic gutters

and cul-de-sac are emptied of blood and amnionic
fluid using gentle suction
 Sponge and instrument are counted
 The abdominal incision is closed in layers
 Many surgeons omit parietal peritoneal closure but
closure may help to protect the bowel when fascial
sutures are placed
 Bleeding sites are located, clamped, and ligated or
coagulated with an electrosurgical blade
ABDOMINAL CLOSURE

 Rectus muscles are allowed to fall into place, and

the subfascial space is meticulously checked for
hemostasis
◦ may be approximated with one or two figure-of-
eight sutures of 0 or #1 chromic gut suture
 The overlying rectus fascia is closed either with
interrupted 0-gauge delayed-absorbable sutures
that are placed lateral to the fascial edges and no
more than 1 cm apart, or by a continuous,
nonlocking technique with a delay-absorbable
suture
ABDOMINAL CLOSURE

• The subcutaneous tissue usually need not be closed if

it is less than 2 cm thick
• The skin is closed with vertical mattress sutures of 3-
0 or 4-0 silk or equivalent suture; with a running 4-0
subcuticular stitch using delayed-absorbable suture;
or with skin clips.
• If the subcutaneous tissue is at least 2 cm thick, it
should be closed
CLASSICAL CESAREAN DELIVERY
CLASSICAL CESAREAN INCISION
INDICATIONS:
 densely adhered bladder from previous surgery
 a leiomyoma occupies the lower uterine segment
 the cervix has been invaded by cancer
 massive maternal obesity precludes safe access to
the lower uterine segment
 some cases of placenta previa with anterior
implantation, placenta increta or percreta
 Transverse lie of a large fetus
 multiple fetuses
UTERINE INCISION

• A vertical uterine incision is initiated with a scalpel

beginning as low as possible and is made above the
level of the bladder
• Once the uterus is entered with a scalpel, the incision
is extended cephalad with bandage scissors until it is
sufficiently long to permit delivery of the fetus
UTERINE REPAIR

• 1st layer – continuous 0- or #1 chromic catgut to

approximate the deeper halves of the incision
• 2nd layer – closed with similar suture, using either a
continuous stitch or figure-of-eight sutures
• It is helpful to have an assistant compress the uterus
on each side of the wound toward the midline as
each suture is placed and tied
POSTMORTEM CESAREAN DELIVERY

• Cesarean delivery is performed in a woman who

has just died, or who is expected to do so
momentarily
PERIPARTUM HYSTERECTOMY
Indications

 To control hemorrhage from intractable uterine

atony, lower-segment bleeding associated with the
uterine incision or placental implantation, uterine
rupture, or uterine vessel laceration
 Elective indications for peripartum hysterectomy
include large or symptomatic leiomyomas and
severe cervical dysplasia or carcinoma in situ.
 Major complications of peripartum hysterectomy are
increased blood loss and greater risk of urinary
tract damage
TECHNIQUE FOR PERIPARTUM
HYSTERECTOMY
• Placement of a self-retaining retractor such as a
Balfour is not necessary
• Satisfactory exposure is best obtained with
cephalad traction on the uterus by an assistant,
along with handheld retractors such as a Richardson
or Deaver
• The bladder flap is deflected downward to the level
of the cervix
• Closure of uterine incision is optional
The round ligaments close to
the uterus are divided
between Heaney or Kocher
clamps and doubly ligated
using 0- or #1 suture
The incision in the
vesicouterine serosa that was
made to mobilize the bladder
is extended laterally and
upward through the anterior
leaf of the broad ligament to
reach the incised round
ligaments
The posterior leaf of the broad ligament adjacent to the uterus is perforated just
beneath the fallopian tubes, utero-ovarian ligaments, and ovarian vessels
These vessels then are doubly clamped close to the uterus and divided, and the
lateral pedicle is doubly ligated
The posterior leaf of the
broad ligament is divided
inferiorly toward the
uterosacral ligaments
Next, the bladder and
attached peritoneal flap are
again deflected and dissected
from the lower uterine segment
and retracted out of the
operative field
A. The uterine artery and
veins on either side are
triply clamped
immediately adjacent to
the uterus and divided. B,
C. The vascular pedicle is
doubly suture ligated.
The cardinal ligaments, the
uterosacral ligaments, and the many
large vessels these ligaments
contain are clamped systematically
with Heaney-type curved clamps,
Ochsner-type straight clamps, or
similar instruments.
The tissue between the pair of
clamps is incised and the distal
pedicle suture ligated.
These steps are repeated until the
level of the lateral vaginal fornix is
reached.
In this way, the descending branches
of the uterine vessels are clamped,
cut, and ligated as the cervix is
dissected from the cardinal
ligaments
A curved clamp is placed
across the lateral vaginal
fornix below the level of the
cervix, and the tissue incised
medially to the point of the
clamp
The excised lateral vaginal
fornix can be simultaneously
doubly ligated and sutured to
the stump of the cardinal
ligament
Close the vagina using figure-
of-eight chromic catgut sutures
or achieve hemostasis by using
a running-lock stitch of chromic
catgut suture placed through
the mucosa and adjacent
endopelvic fascia around the
circumference of the vaginal
cuff
SUPRACERVICAL HYSTERECTOMY

• Amputate the body of the uterus immediately below

the level of uterine artery ligation
• The cervical stump may be closed with continuous or
interrupted chromic catgut sutures
PERIPARTUM MANAGEMENT
PREOPERATIVE CARE

• A sedative may be given at bedtime the night

before the operation
• Oral intake is stopped at least 8 hours before
surgery
• An indwelling bladder catheter is placed
• CBC
INTRAVENOUS FLUIDS

• Lactated Ringer solution or a similar crystalloid

solution with 5-percent dextrose
Prevention of Postoperative Infection

• For women in labor or with ruptured membranes,

most clinicians recommend a single 2-g dose of a ß-
lactam drug—either a cephalosporin or extended-
spectrum penicillin—after delivery of the newborn
SUBSEQUENT CARE

• Analgesia
• Vital Signs
• Fluid Therapy and Diet
• Bladder and Bowel Function
• Ambulation
• Wound Care
DISORDERS OF THE
AMNIOTIC FLUID
MARLA LLANTO, MD DPOGS
 AMNIOTIC FLUID
• ROLES
– Creates physical space for fetal movement
– Permit fetal swallowing and breathing
– Guard against umbilical cord compression
– Protects the fetus from trauma
– Bacteriostatic
– Reflects fetal or placental pathology
 NORMAL AMNIOTIC FLUID
• 30ml by 10 weeks
• 200ml by 16 weeks
• 800ml by mid 3rd trimester
• 98% water
• FT fetus- contains about 2800ml of water
• Palcenta- 400ml of water
• term uterus holds nearly 4L of water
• OLIGOHYDRAMNIOS
– Abnormally decreased AF volume
• POLYHYDRAMNIOS
– Abnormally increased AF volume
 PHYSIOLOGY
• EARLY PREGNANCY
• Amniotic cavity is filled with fluid that is similar in
composition to extracellular fluid
• 1st half of pregnancy
– Transfer of water and other small molecules takes
place
– Across the amnion- transmembranous flow
– Across the fetal vessels on the placental surface-
intramembranous flow
– Across fetal skin
• Fetal urine production
– Starts at 8-11 weeks
– Becomes major component of AF at 2nd trimester
– Fetus with lethal renal abnormalities only manifests
ith severe oligohydramnios after 18 weeks
• Water transport across fetal skin continues until
keratinization occurs at 22-25 weeks
• Extremely preterm infants- experience significant fluid
loss across their skin
• AMNIOTIC FLUID REGULATION
– 4 MAJOR PATHWAYS
• Fetal urination
• Intramembranous fluid transfer
• Respiratory tract
• Fetal swallowing
• 1. FETAL URINATION
– Primary amniotic source by 2nd half of pregnancy
– Term- urine production may exceed 1L/day
• 2. INTRAMEMBRANOUS FLUID TRANSFER
– URINE OSMOLALITY
• Hypotonic to that of maternal and fetal plasma
• Similar to amniotic fluid
• Maternal and fetal plasma osmolality- 280
m)sm/ml
• Amniotic fluid osmolality – 260 mOsm/ml
• This hypotonicity accounts for significant
intramembranous fluid transfer into fetal vessels
on the placental surface and thus the fetus
• 400ml/day
• 2nd regulator
• 3. RESPIRATORY TRACT
– 3rd source
– 350ml of lung fluid produced daily in late
pregnancy
– Half is immediately swallowed
• 4. FETAL SWALLOWING
– Primary mechanism for AF resorption
– 500- 1000ml/ day
– Impaired swallowing- CNS or GI obstruction-
polyhydramnios
• 11.1
 MEASUREMENT
• DIRECT MEASUREMENT
• DYE- DILLUTION METHOD
– Injection of small quantity of a dye-
amniohippurate- into the amniotic cavity thru UTZ-
guided and sampled to determine the dye
concentration
– 2 studies
Brace and Wolf(1989)
Maggan et al
• BRACE AND WOLF
– Amniotic fluid increase across gestation
– Mean value did not change significantly between
22-39 weeks
– 750 ml
– Mid 3rd trimester- 5th percentile: 300ml and 95th
percentile 2L
• MAGANN ET AL
– Amniotic fluid volume continues to increase with
advancing gestation
– 400ml at 22-30 weeks then doubles there after-
800ml
– Volume remains until 40 weeks
– Declines thereafter- 8%weekly
 SONOGRAPHIC ASSESSMENT
• Component of every standard 2nd and 3rd trimester
UTZ
• Measured by:
– Single vertical pocket
– Amniotic fluid index (AFI)
• SINGLE DEEPEST POCKET
– Maximum vertical pocket
– Transducer withheld perpendicular to the floor and
parallel to the long axis of the pregnant women
– May contain fetal parts or umbilical cord but not
part in the measurement
– Normal value: 2-8cm
• SDP
– Twin or multifetal gestation
• AF should be assessed in each gestational sac
• Range: 2-8cm
• AFI
– Most commonly used method in AF assessment
– Done as single vertical pocket
– The uterus is divided into 4 equal quadrants and
the AFI is the sum of all quadrants
– May contain fetal aprts and umbilical cord but are
included in the measurement
– NV: 5-24cm
 HYDRAMNIOS
• Poluhydramnios
• Abnormally increased AF volume
• Complicates 1-2% of pregnancies
• Suspected if uterine size exceeds AOG
• Fetal parts and heart tones are difficult to
palpate and auscultate
• CATEGORY (AFI)
– Primarily used in research
– MILD – 25- 29.9cm
• Most common, 2/3 of cases
– MODERATE – 30-34.9 cm
• 20%
– SEVERE- >35 cm
• 15%
• CATEGORY I ( SINGLE VERTICAL POCKET)
– MILD- 8- 9.9 cm
– MODERATE -10- 11.9cm
– SEVERE - >12
• 11.2
• DM
– AF glucose concentration is higher in diabetic
women
– AFI correlates with AF glucose concentration
– Supports the hypothesis that maternal
hyperglycemia causes fetal hyperglycemia which
results in fetal osmotic diuresis into the AF
compartment
• CNS ABNORMALITIES
– Anencephaly
– Hydranencephaly
– Holoprecencephaly
– Impaired fetal swallowing
• UPPER OBSTRUCTION
– Esophageal atresia
– Duodenal atresia
• FETAL NEUROMUSCULAR DISORDERS
– Myotonic dystrophy
• OBSTRUCTIVE DISORDERS
– Clefts
– Micronagthia
– Conenital high- airway obstruction sequence
– Fetal neck masses
• THORACIC ABNORMALITIES
– Diaphragmatic hernia
– Cystic adenomatoid malformation
– Pulmonary sequestration

– Mediastinal shift and impaired swallowing

• UTEROPELVIC JUNCTION OBSTRUCTION
– Fetal renal anomaly that may cause paradoxical
hydramnios
• TUMORS
– Fetal sacrococcygeal teratoma
– Fetal mesoblastic nephroma
– Large placental chrioangiomas
• MULTIFETAL GESTATION
– Hydramnios is defined as single vertical pocket of
> 8 cms
– Hydramnios in one amniotic sac – twin – twin
transfusion syndrome
 IDIOPATHIC HYDRAMNIOS
• When there is no obvious cause
• Accounts for almost 70% of cases
• Have atleast 2x likelihood of infant BW exceeding
4kg
• Larger infants have higher UO
 COMPLICATIONS
– PRETERM LABOR
– DYSPNEA AND ORTHOPNEA
– EDEMA
– OLIGURIA
– MATERNAL COMPLICATIONS
• PLACENTAL ABRUPTION
• UTERINE DYSFUNCTION
• POSTPARTUM HEMORRHAGE
 PREGNANCY OUTCOMES
• CS rate (3 fold)
• BW > 4kg
• Preterm delivery
• Perinatal mortality rate (4 fold)
– +IUGR (20fold)
 MANAGEMENT
• AMNIOREDUCTION
– Large volume amniocentesis
– 1000ml- 1500ml is withdrawn in 30 mins
– Goal: restore AFI to upper normal range
 OLIGOHYDRAMNIOS
• Abnormally increased AF
• Cause for concern
• AFI < 5 cm or single vertical pocket , < 2cm
• Complicates 1-2 % of pregnancies
 ETIOLOGY
• EARLY ONSET
– 2ND trimester
– Fetal abnormality that precludes normal urination
or placental abnormality severe enough to impair
perfusion
– Poor prognosis
– Membrane rupture
• After MIDPREGNANCY
– 2ND OR 3RD TRIMESTER
– MOSTLY ASSOCIATED
• FETAL GROWTH RESTRICTION
• PLACENTAL ABNOMALITY
• MATERNAL COMPLICATION – PREECLAMPSIA
OR VASCULAR DISEASE

UTEROPLACENTAL INSUFFICIENCY
• POSTTERM PREGNANCIES
– Oligohydramnios is common
– Decrease in amniotic fluid volume of 8%/ week
beyond 40 weeks
– Associated with non- reassuring fetal status and
adverse pregnancy outcome
• CONGENITAL ANOMALIES
– 18weeks- fetal kidneys are the main contribuitor to
AF volume
– Early gestation →associated with GUT anomalies
– Anomalies with other organ system, aneuploidy and
genetic syndromes
• Indirect cause
• Fetal decompensation
• IUGR
• Placental abnormality
• CONGENITAL ANOMALIES
– Renal Agenesis
• Limb contractures, compressed face and
pulmonary hypoplasia (Potter syndrome, Potter
sequence)
– Bilateral multicystic dysplastic syndrome
– Unilateral renal agenesis with multicystic
dysplastic syndrome
– Infantile form of AR polycystic kidney disease
• Bladde outlet obstruction
– Posterior urethral valves
– Urethral atresia/ stenosis
– Megacystis microcolon intestinal hypoperistalsis
syndrome
• Complex fetal GU abnormalities
– Persistent cloaca
– sirenomalia
• MEDICATIONS
– ACE- inhibitors
• Fetal hypotension
• Renal hypoperfusion
• Renal ischemia
– NSAIDS
• Constriction of ductus arteriosus
• Decrease urine production
• PREGNANCY OUTCOMES
– Increased risk od adverse pregnancy outcomes
– More likely to have malformation
– Increased rate of stillbirths
– growth restriction
– NRFS
– Meconium- aspiration syndrome
• AFI < between 24-34 weeks AOG
– Stillbirth
– Spontaneous or medially indicated preterm birth
– NRFS
– IUGR
• Increase labor induction rate
• CS rate increase by 50% due to NFRS
• Between 20-22 weeks
– Pulmonary hypoplasia- prognosis depends on the
underlying cause
– Secondary to renal abnormalities- poor prognosis
– Chronic abruption- oligohydramnios sequence-
cause IUGR
• Poor prognosis
 MANAGEMENT
• Targets underlying cause
• Initial evaluation of fetal anomalies and growth
• Close fetal surveillance
• Amniotransfusion- used to intrapartum for FHR
decelerations
BORDERLINE OLIGOHYDRAMNIOS
• AFI between 5-8cm
• Higher rates of preterm delivery, CS and IUGR
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