HIGH RISK OF PREGNANCY

BLEEDING DURING PREGNANCY

A. First trimester Bleeding

1. SPONTANEOUS ABORTION-also called miscarriage, occurs from natural causes.

 Is a natural termination of pregnancy before the fetus has reached viability.
 A fetus of less than 20 weeks of gestation and weighing less than 500 g is NOT VIABLE.

ABORTION - any interruption of a pregnancy before the fetus is viable.

VIABILITY - ability of the fetus to survive the extra uterine life.
NON-VIABLE FETUS - a fetus of 20-24 weeks gestation or weighing 500 grams.
 Also called premature or immature.

SPONTANEOUS- occurs from natural causes:

Blighted ovum/germ plasma defect implantation or hormonal abnormality following
trauma/infection( rubella or influenza) or emotional problems.

Possible causes:
 Chromosomal or uterine abnormalities.
a. Early abortion – occurs before 16 weeks of pregnancy.
b. 6-12weeks – a moderate degree of attachment to the myometrium.
c. After 12 weeks- attachment is penetrating and deep

A. EARLY ABORTION- if it occurs before weeks 16 of pregnancy.

1. 1st 6 weeks the developing placenta is tentatively attached to the decidua of the uterus
2. 6-12 weeks – a moderate degree of attachment to the myometrium
3. After 12 weeks – attached is penetrating and deep.

ASSESSMENT:
IMMEDIATE ASSESSMENT OF VAGINAL BLEEDING DURING PREGNANCY.
1. Confirmation of pregnancy
2. Pregnancy length
3. Duration
4. Intensity
5. Description
6. Frequency
7. Associated symptom
8. Action
9. Blood type
Threatened abortion

 With bright red vaginal bleeding in moderate amount.

Management:
 CBRx 24- 43, no coitus for 2 weeks
 Save all pads, clots and expelled tissues.

Signs and symptoms:

1. Mild cramps
2. vaginal spotting- beginning as scant bleeding
3. Close cervix

Management:
1. Bed rest
2. Coitus restricted for 2 weeks

B. IMMINENT ( INEVITABLE ABORTION

 With uterine contraction and cervical dilatation.
 Loss of products of conception is inevitable.

Complete abortion – all products of conception ( fetus, placenta and membranes) are
expelled spontaneously without assistance

INCOMPLETE ABORTION
 Part is expelled( fetus) but other products remain in the uterus.
 Dilatation and curettage ( D& C) or Manual Vacuum aspiration( MVA) is indicated.

Signs and symptoms:

1.Uterine contraction
2. Cervix open

Management:
• D&C
• MVA

MISSED ABORTION
 The fetus dies in the uterus but is not expelled.
 Fetus dies in the uterus but is not expelled, induced labor to prevent hypofibrinogemia
or sepsis.
Signs and symptoms
• Vaginal spotting
• Cramping ( slight)
• No apparent loss of pregnancy
Caution: DIC( disseminated intravascular coagulation).a coagulation defect may develop if
the dead fetus remains too long in uterus.
A sonogram can establish that the fetus is dead.
Management:
• If embryo died 4-6 weeks before its detected ( onset of abortion symptoms or failure of
growth ) D & C is done.
• If pregnancy is over 14 weeks, labor may be induced by prostaglandin suppository to
dilate the cervix, followed by oxytocin stimulation.

D. Recurrent ( habitual) abortion

Possible causes:
• Defective spermatozoa or ova.
• Endocrine factors, poor thyroid function, luteal phase defect.
• Deviations of the uterus such as septate or bicormuate uterus
• Infection
• Autoimmune disorders
Complications of abortion
1. Hemorrhage
2. Infection- watch for s/s : fever, abdominal pain or tenderness, foul vaginal discharge
a. E. Coli- the organism responsible for infection in abortion.
3. Septic abortion- an abortion that is complicated by infection

Signs and symptoms:

1. Fever
2. Crampy abdominal pain
3. Uterine tenderness

COMPLICATIONS:
1. Toxic shock syndrome
2. Septicemia
3. Kidney failure
4. Death

Management: immediate, intensive assessment and treatment

1) Obtain CBC, serum electrolytes, serum creatinine, blood types and cross matching,
cervical, vaginal, urine cultures.
2) Insertion of indwelling catheter ( IC) to monitor I & O hourly.
3) IV fluid administration to restore fluid and provide a route for high dose, broad
spectrum antibiotic therapy.
4) Insertion of CVP or pulmonary artery catheter to monitor left atrial filling pressure
and hemodynamic status.
5) D and C to remove necrotic tissues
6) Administration of tetanus toxoid SQ or tetanus immune globulin IM for prophylaxis
against tetanus.
2. Ectopic pregnancy
 Implantation which occurs outside the uterine cavity.
 Any gestation located outside uterine cavity.
 Ruptures about 12 weeks
 With rigid abdomen,(+) Cullen’s sign-bluish umbilicus, excruciating pain when cervix
is moved during IE, signs of shock

MANAGEMENT: Salpingotomy,Salpingectomy,+ blood transfusion, combat shock

Causes:
1) Endometriosis
2) Salpingitis
3) Pelvic inflammatory disease ( PID)
4) Congenital anomalies of the uterus
5) Scars from tubal surgery
6) Uterine tumor, FP methods
Sites of implantation: types of ectopic
1) TUBAL –site of implantation is the fallopian tube
a. Most common site ( 95%)
i. Ampullar portion- 60%
ii. Isthmus – 25%
iii. Interstitial- 5%
iv. Fimbria
2) CERVIX
3) 3.OVARY
4) 4.ABDOMEN

SIGNS AND SYMPTOMS:

1. AMENORRHEA
2. NAUSEA AND VOMITING
3. (+) PREGNANCY TEST
4. SHARP STABBING PAININ EITHER RLQ OR LLQ
5. LITTLE VAGINAL SPOTTING
6. SIGNS OF SHOCK
7. LEUKOCYTOSIS-WBC BECAUSE OF TRAUMA
8. RIGIDITY OF THE ABDOMEN FROM PERITONIAL IRRITATION
CULLEN’S SIGN- BLUISH TINGE UMBILICUS
9. EXCRUCIATING PAIN UPON MOVEMENT OF THE CERVIX
10. PALPABLE MASS AT CUL- DE SAC OF DOUGLAS UPON VAGINAL
EXAMINATION

DIAGNOSTIC EXAM:
1. CULDOCENTESIS
2. CULDOSCOPY OR LAPAROSCOPY
3. ULTRASOUND
THERAPEUTIC MANAGEMENT:
1. INTRAVENOUS FLUID THERAPY
2. SURGERY- TO REMOVE THE RUPTURED TUBE ( LAPAROTOMY)
3. Rho ( D) immune globulin ( RHIG)administration to women with Rh ( -) blood
4. Methotrexate therapy to cause sloughing of the tubal implantation site.

Methotrexate – a chemotherapeutic agent that attacks and destroys fast- growing cells.
Conditions associated with second trimester bleeding
• HYDATIDIFORM MOLE ( H-MOLE)/GESTATIONAL TROPHOBLASTIC
DISEASE
 Proliferative and degeneration of the trophoblastic villi as the cells degenerate, they
became fluid filled grape sized vesicles.
 A precedent of choriocarcinoma
 Incidence – 1 in every 2000 pregnancies
 Proliferation and degeneration of chorionic villi , most common lesion anteceding
CHORIOCARCINOMA

H-MOLE
 DECREASE SOCIO ECONOMIC BACKGROUNDS WHICH DECREASE CHON
INTAKE, ABOVE 35 YEARS OLD AND BELOW 18 YEARS OLD.
 SIGNS AND SYMPTOMS:
 Increase level of HCG
 Marked nausea and vomiting
 Rapid increase in fundic height
 Toxemia sign and symptoms appears before 24th weeks of gestation
 No fetal heart tones
 Vaginal bleeding seen clear fluid-filled graped sized vesicles.
Management:

1. D & C, METHOTREXATE , MONITOR URINALYSIS FOR 1 YEAR.

PREDISPOSING FACTORS:

1) LOW SOCIO ECONOMIC STATUS- protein intake

2) Below 18 years and above 35 years old
3) Women of ASIAN heritage

Signs and symptoms

1) UTERUS IS LARGER THAN NORMAL
2) NO FHT
3) HIGHLY ( +) PREGNANCY TEST
4) MARKED NAUSEA AND VOMITING
5) SIGNS OF PIH ( PROTEINURIA,EDEMA & HYPERTENSION ) BEFORE 20TH
WEEKS OF PREGNANCY
MANAGEMENT:
1) D & C OR MVA TO EVACUATE THE MOLE
2) MONITOR OF HCG LEVEL
3) PROPHYLACTIC TREATMENT OF METHOTREXATE ( DRUG OF CHOICE
FOR CHORIOCARCINOMA)

1. Incompetent cervix
 a cervix that dilates prematurely and therefore cannot hold a fetus until term.
 Cervix dilates prematurely, chief cause of habitual abortion( 3 or more consecutive
abortions)
CAUSES: Congenital devt’ factors, endocrine factors, trauma to the cervix .
Sign and symptoms: show and uterine contractions , rupture of BOW, painless cervical
dilatation.

Signs and symptoms:

 Dilatation is usually painless
1) Show is often the first symptoms
a. SHOW – pink stained vaginal discharge
2) Increased pelvic pressure
3) Rupture of membrane and discharge of AF
4) Labor contraction and birth of fetus

PREDISPOSING FACTORS: Associated with

1) Increased maternal age
2) Trauma

Management:
Cervical cerclage- purse string sutures are placed in the cervix by a vaginal route

McDonald or Shirodkar procedure.

Conditions associated with third trimester bleeding

1. PLACENTA PREVIA- low implantation of the placenta
 Diagnostic exam: symptoms and USG or ultrasonic echo sounding or SONAR-uses
intermittent waves of frequency.
Preparation for USG: painless, no known ill effects, empty bladder but ask patient to take 6
glasses of H2O afterwards
Clinical Uses of USG:
 Diagnosis pregnancy as early 5-6 weeks AOG
 Predict EDC

Clinical uses of usg

 Determine AOG
 Diagnose polyhydramnious and oligohydramnios
 Diagnose placenta previa & H- mole multiple pregnancy, ascites, polycystic kidneys,
ovarian cysts, baby and sex.
Management: CBR, V/S & FHR, O2 and blood, NO IE, double set-up
COMPLICATIONS: hemorrhage, infection, prematurity

Four degrees ( classification)

1) LOW-LYING= Implantation occurs in the lower rather than in the upper portion of the
uterus.
2) MARGINAL IMPLANTATION- the placenta edge approaches that of the cervical Os
marginalis
3) PARTIAL PLACENTA PREVIA- implantation that occludes a portion of the cervical
Os partialis.
4) TOTAL PLACENTA PREVIA- implantation that totally obstructs the cervical Os.

Risks factors
1) ADVANCED MATERNAL AGE
2) INCREASED PARITY
3) RAPID SUCCESSION OF PREGNANCY
4) POST CS
5) POST D & C
6) MULTIPLE GESTATION

Painless, bright red vaginal bleeding –most important sign ( due to tearing of placental
attachment)

Management:
1) Inspect perineum for bleeding
2) Pad count- weight before and after and subtracting the difference is a good method
to determine blood loss

b. Abruptio placenta
 Premature separation of the placenta
 Direct trauma, hypofibrinogemia

Sign and symptoms:

 Severe sharp knife like stabbing pain high in the fundus
 Hard board like uterus
 Rigid abdomen
 Signs of shock
 Copper-colored uterus ( COUVELAIRE)
Mgmt. HYSTERECTOMY

TOXEMIA OR PREGNANCY INDUCED HPN( PIH)

-vascular disease of unknown cause which occurs anytime after the 24th week of gestation –
2 weeks post partum
TRIAD Symptoms: HPN, Edema and Proteinuria
PREDISPOSING FACTORS:
AGE : PRIMI IS UNDER 20 AND 30, MULTIPARITY,MULTIPLE
PREGNANCY,HEART DISEASE,HPN OR DM.
PATHOGENESIS: BLOOD SUPPLY ‘O2 PERFUSION TO VITAL ORGANS
( KIDNEY,LIVER & PLACENTA.
TYPES:
MILD : SUDDEN WEIGHT GAIN 1 – 5 LBS. / WEEK( EARLISTS ) EDEMA FOUND IN
UPPER HALF OF THE BODY,SYSTOLIC BP OF 140 MmHg or diastolic of 90 or
abt. 15 or more, proteinuria.
DYSTOCIA- ABNORMAL OR DIFFICULT LABOR AND DELIVERY.
A. VIERINE INERTIA- sluggish of contractions.

Causes:
• Inappropriate use of analgesic
• Pelvic bone contraction
• Poor fetal position
• Over distention- due to multiple pregnancy.polyhydramious or excessive large fetus.

• PRIMARY ( Hypertonic ) – uterine dysfunction

-relaxation are inadequate and mild thus are inactive
Tx: sedate patient ( latent phase is prolonged)
HYPERTENSIVE DISORDERS OF PREGNANCY
CLASSIFICATION OF HYPERTENSIVE STATES OF PREGNANCY

 GESTATIONAL HYPERTENSION-development of mild hypertension during

pregnancy in previously non- hypertensive clients without proteinuria and with
normal laboratory test
ECLAMPSIA- Development of seizures in the preeclamptic client hypertension occurring
before pregnancy or a blood pressure of 140/90 or higher before 20 weeks of gestation
on two occasion, 6 hours apart.
 PREECLAMPSIA- DEVELOPMENT OF HYPERTENSION AND PROTEINURIA
IN PREVIOUSLY NON HYPOTENSIVE CLIENTS AFTER 20 WEEKS OF
GESTATION OR EARLY POST PARTUM PERIOD; IT CAN DEVELOP BEFORE
20 WEEKS OF GESTATION.
Preeclampsia superimposed on chronic hypertension- development of preeclampsia or
eclampsia in patient with chronic hypertension.
b. Precipitate delivery
 Labor and delivery that is complete in less than3hours after the onset of true labor
pains due to multiparity,following oxytocin administration or amniotomy.

DANGERS: extensive lacerations, abruption placenta or hemorrhage due to sudden release

of pressure leading to SHOCK.
Prolonged labor
 In primis,labor for more than 18hours, and in multis more than 12HOURS

DANGERS: maternal exhaustion, uterine atony or caput succedaneum.

Uterine rupture
Occurs when the uterus undergoes more strain that is capable of sustaining.

CAUSES:

d. SCAR FROM PREVIOUS CS

e. UNWISE USE OF OXYTOCICS
f. OVER DISTENTION
g. FAULTY PRESENTATION OR PROLONGED LABOR
SIGNS AND SYMPTOMS
h. SUDDEN SEVERE PAIN
i. HEMORRHAGE CLINICAL SIGNS OF SHOCK ( RESTLESSNESS,
PALLOR,BP,RR,PR)
j. CHANGE IN ABDOMINAL CONTOUR WITH 2 SWELLING ON THE ABDOMIN.

MANAGEMENT: HYSTERECTOMY

UTERINE INVERSION
 FUNDUS IS FORCED THROUGH THE CERVIX SO THAT THE UTERUS IS
TURNED INSIDE OUT.

Causes:
Insertion of placenta at the fundus, strong fundal push, attempts to delivery. The placenta
before signs of placental separation appear.

Management: HYSTERECTOMY
AMNIOTIC FLUID EMBOLISM
 OCCURS WHEN AMNIOTIC FLUID IS FORCED INTO AN OPEN MATERNAL
UTERINE BLOOD SINUS THROUGH SOME DEFECTS IN THE MEMBRANE
OR AFTER PARTIAL PREMATURE SEPARATION OF THE PLACENTA.SOLID
PARTICLES IN THE A.F ENTER THE MATERNAL CIRCULATION AND REACH
THE LUNGS AS EMBOLI.

SIGNS & SYMPTOMS: woman in labor suddenly sits up and grasp her chest because of
inability to breath and sharp pains, turns pain and then typical bluish gray color associated
with pulmonary embolism. Death may occur in few minutes.
Trial labor
If the woman has borderline ( just adequate ) pelvic measurements but fetal position and
presentation are good.

Management:
Monitor FHR, uterine contractions, keep bladder empty, emotional support.
Premature labor and delivery
 If uterine contractions occur before the 37th weeks of gestation.
• If there is no bleeding and cervical dilatation and fetal heart sounds are good,
premature uterine constructions can be stopped by:
• Ethyl alcohol ( Ethanol) IV – blocks the release of oxytocin
• Vasodilation IV – a vasodilator S.E- hypotension and tachycardia
• Ritodrine- a relaxant p.o
• Bricanyl- brochodilator
2. If premature uterine contraction are accompanied by progressive fetal descent and
cervical dilatation
 Not necessarily shorter than FT babies
 Pain meds. Are kept at minimum because analgesics are known to cause respiratory
depression
 Steroids ( glucocorticoids) are given to mother to help lung maturation by hastening
production of surfactant
 Episiotomy may not be necessary
 Cord is cut immediately or after 3 mins.
Labor management using partograph
PARTOGRAPH – Greek word that means labor curve.
 Is an inexpensive, effective and pragmative tool which presents a graphical depiction
of a labor” curve” and can be used to assess labor and its progress.
 It evaluates the progress of labor primary in terms of cervical dilatation in
centimeters against duration of labor in hours, and to identify when management or
intervention is necessary
 Has been used since 1970 and after extensively testing, the World Health organization
( WHO) advocates its use in all health settings-primary,secondary and tertiary by the
medical practitioner, nurse Midwife and Midwife.
Values of the partograph
• Prevention of prolonged Labor or augmented labor
 Reduced risk of postpartum hemorrhage and sepsis, eliminated obstruction labor and
uterine rupture, thereby improving maternal outcomes and reducing maternal
mortality.
2. Improvement in maternal outcomes
3. Improvement in neonatal outcomes
 reduced intra partum fetal death and neonatal morbidity
Note: the partograph must be in the active phase of labor.
Principle in the use of partograph
• The active phase of labor commence at 4cm cervical dilatation
• The latent phase of labor should last not longer than 8 hours
• During the active labor, the rate of cervical dilatation should be not slower than 1 cm/
hour.
• Vaginal examination should be done as infrequently as is compatible with safe
practice ( once every 4 hours is recommended )
• The partograph shows graphically the rate of progress of labor:
k. The rate of cervical dilatation
l. The rate of fetal head descent
m. The duration and frequency of uterine contraction
n. Monitoring vital signs
7. The partograph must be started only when the woman is in the active phase labor with
cervical dilatation of more than 4 cm and uterine contractions of two or more in 10 minutes
each lasting 20 seconds or more.
Three components of the partograph
o. Progress of labor – to monitor and evaluate the progress of labor, the parameters used
are:
p. Cervical dilatation
 Active management of labor using the partograph recognizes only two phases of the
first stage of labor:
q. Latent – shows period of the cervical dilatation ( 0-2cm)
r. Active- faster period of cervical dilatation (3-10cm)

b. In the primi gravida the latent phase lasts for 8 hours during which the cervix dilates at
a rate of 1 cm / hour
c. In the multigravida, the latent phase last for about 4 hours during which the cervix
dilates at the rate of 1.5 cm/ hour. In multigravida, effacement and dilatation occur
simultaneously.
d. Cervical dilatation is assessed during every vaginal examination. Vaginal examination is
made every 4 hours, unless contraindicated.
Plot cervical dilatation with an X . Begin plotting on the partograph at 4 cm.
• In the section labeled active phase, there is an alert line a straight line from 3-10cm.
• When the woman is admitted in the active phase, cervical dilatation is plotted on the
alert line and clock time written directly under the X in the space of time.
The rate of progress is plotted against the expected rate of progress. If progress is
satisfactory, the plotting of cervical dilatation will remain on or to left of the alert line and
should not move.
Preterm labor
 Labor is the occurrence of regular ,frequent, uterine contractions, associated with
progressive cervical dilatation and effacement.
 Most labor occurs within 2 weeks of the due date.
 Labor occurring prior to the 38th week of pregnancy is preterm labor, although
definitions vary depending on the clinical circumstances. Some use the 37th week as
the lower limit for term labor
 Delivering a little bit early usually poses no particular problem for the mother or the
baby.
 More significant amounts of prematurity pose more significant risks for the infant.
 Of these, immaturity of the lungs is among the most hazardous, but other organs,
including the brain, GI tract , and liver can be affected.
 The cause of preterm labor is often unknown, but in about half the cases, it is
associated with detectable intrauterine infection.
 Other cases are associated with placental abruption , uterine over distention( such as
with twins).
Management
 Our instincts are to try to prevent preterm delivery to avoid the morbidity associated
with it.
 This instinct is based on the premise that the problem is primarily one of prematurity.
 But in some patients, preterm labor is either a symptom of an underlying problem
( infection, fetal stress, etc.) or part of the body’s attempts to resolve a threat.
 In such cases, vigorous attempts to prevent delivery, even when sucessful,may only
delay treatment of the underlying problem.
 Further , the medications commonly used to prevent premature delivery have
significant side effects and risks.
 Third, the risk of premature, while significant, decrease rapidly with advancing
gestational age.
The following table shows approximate survival and handicap rates for premature infants
born at various gestational ages in the United states.
 Between 32 and 34 weeks both the survival rate and long term term major handicap
rates become nearly indistinguishable from the baseline rates of these adverse
outcomes for full- term infants. ( learning disabilities are still somewhat increased in
comparison to the 10% rate at full – term).
 For these reasons judgement is used to decide who should be treated for preterm
labor and who should be allowed to deliver in many hospitals, no attempt is made to
arrest labor after the 34th week, unless it is to facilitate transfer to a high risk center
Manifestations :
 Threatened preterm labor consists of regular, frequent contractions ( every
10minutes)
 If these contraction lead to progressive cervical change, then it is no longer threatened
preterm labor.
 In many hospitals, it is customary to withhold any labor- stopping medication until
cervical change is noted.
 These hospitals often have abundant resources to treat preterm labor and premature
infants should labor unexpectedly progress rapidly.
 In hospital without these advanced resources, earlier treatment may be indicated .

Midwife responsibility
 It is often helpful to postpone delivery long enough to set the patient to a definite care
setting, even if the patient is more than 34 weeks gestation.
 It is best to coordinate the use of these medications with the receiving facility.
 Any of the following treatment may effectively disrupt the labor process for 24-48
hours, and this is usually long enough to move the patient to an area of greater
resource.
1. Magnesium sulfate ,4 gm loading dose over at least 5 minutes. Followed by 2 gm/hour in
steady IV drip
 Watch for magnesium toxicity with diminished reflexes and respiratory depression.
 If magnesium toxicity develops, it is treated with calcium gluconate.
 Common side effects include flushing, palpitations, headache and muscle weakness.
 Serum magnesium levels can be monitored ( target level 6-8mg/dL)
 Contraindicated with myasthemia gravis recent myocardial infarction, or impaired
renal function.
2.Ritodrine ( Yutobal) 100 mg/minute IV, increased every 15minutes by 50ug to a maximum
of 350mg. Min.
3. Terbutaline 0.25 mg SQ, every 1-4 hours x 24 hours,total dose not to exceed 5 mg in 24
hours.
 May also be given P.O in 2.5-7.5 mgdoses, every2-4 hours
 Target maternal pulse rateisnot less than 100 and not more than 120BPM.
 Contraindicated with hemorrhage ,hyperthyroidism, uncontrolled diabetes,& heart
disease.
Essential intrapartum and newborn care ( EINC) who
ADMINISTRATION OF STEROIDS
 Many fetuses less than 34 weeks gestation will benefit from administering steroids to
the mother.
 The effect of the steroids on the fetus is to accelerate fetal pulmonary maturity,
lessening the risk of respiratory distress syndrome of the newborn. Appropriate doses
include:
 Betamethasone 12 mg IM and repeated in 24 hours
 Dexamethasone 6mg IM every 12 hours x 4 doses
 When transporting the mother to definite care setting have her remain way over on her
left or right side with a pillow between her and an IV securely in place.
Premature rupture of membrane
Most women will rupture their membranes during labor. If the membranes rupture prior
to the onset of labor, this is called premature rupture of the membranes, or PROM.
The obstetrical significance of PROM is that:
• Labor needs to begin promptly or infection will develop with bacteria ascending
through the birth canal and
• In some cases of PROM , the reason the membranes rupture prematurely is because
there is an established infection which has weakened the membranes.
 Confirmation of PROM is optimally made via a sterile speculum examination,
although at full term, with obvious leakage of amniotic fluid from the vagina, a simple
pelvic exam will be expeditious; look for
 Gross leakage of clear fluid from the cervical Os.
 Pooled amniotic fluid in the vagina
 Nitrazine positive fluid
 if the pregnancy is at full term and there is no evidence of infection , no treatment is
necessary initially, because most women will go into spontaneous labor within the next
6 hours.
 After 6 hours of rupture or in the face of infection or other pressing clinical
circumstances, labor can be induced
 Unless infection is evident antibiotics are not helpful, until the patient is in labor and
membranes have been ruptured more than 12 hours. In this case Group B strep
prophylaxis is a wise course.
When PROM occurs two basic approaches can be taken:
1. induce labor or
2. Wait for the fetus to mature further.
 There are pros and cons to each of these approaches
 The best decision will frequently hinge on individual clinical circumstances.
 This decision is best made in consultation with definite care facility.

 If chorioamnionitis is not present, antibiotics are not helpful and are generally
withheld.
 Following the mothers WBC and temperature, and the fetal baseline heart rate are
useful in detecting the earliest signs of chorioamnionitis.
 The WBC , normally slightly elevated during pregnancy , may show a steady increase.
 The combination of an elevation of an elevated WBC elevated maternal temperature
and fetal tachycardia suggest the presence of chorioamnionitis.
Abnormalities in Fetal presentation
Fetal presentation means the part of the fetus that is “ presenting” at the cervix:
 CEPHALIC presentation- means head first. This is the normal presentation
 BREECH presentation- means the fetal butt is coming out first.
 Transverse Lie means the fetus is oriented from one side of the mother to the other
and neither the head nor the butt is coming out first.

 COMPOUND presentation- means that a fetal hand is coming out with the fetal head.
 SHOULDER presentation means that the fetal shoulder is trying to come out first.
Breech presentation
FRANK BREECH – means the buttocks are presenting and the legs are up long the fetal
chest. The fetal feet are next to the fetal face. This is the safest arrangement for breech
delivery.

FOOTLING BREECH – means either one foot ( “ single footling”) or both ( double
footling”) is presenting. This is also known as an INCOMPLETE BREECH
COMPLETE BREECH- means fetal thighs are flexed along the fetal abdomen, but the
fetal shins and feet are tucked under the legs. The buttocks are presenting first , but
the feet are very close.
While many breech fetuses deliver vaginally without incident, this presentation is
associated with an increased risk of:
 Fetal mechanical injury( fractures, nerve damage and soft tissue injuries
 Fetal asphyxia due to umbilical cord prolapse and obstruction, and fetal head
entrapment.
 For these reasons, many breech babies are delivered by CS and some OB feel that all
breech babies should be delivered in this way.
Abnormalities in fetal position
 Fetal “ presentation” is different from fetal “ position”.
 Fetal position refers to orientation of the fetus within the birth canal( eg, looking
towards the mother’s pubic bone( OP), or look toward the mother’s coccyx ( OA) etc.
TRANSVERSE LIE
 If the fetus remains in a transverse lie, it cannot deliver vaginally as the diameter of
the fetal presenting part ( the whole body, in this case) cannot descend through the
birth canal.
 If labor is allowed to continue for enough time with the fetus in transverse lie, the
uterus will rupture
 Even before the uterus ruptures, there is an increased risk in this presentation for
prolapsed umbilical cord. For these reasons, women found to have a transverse lie in
labor will usually have CS

There are some reasons exceptions to this indication for cs

• If labor is occurring during the middle trimester and fetus is not considered viable,
it may be possible for this very small and fragile fetus to compress enough to
squeeze through the pelvis. In this case, fetal survival would not be an issue.
2.It may be possible to perform an external version, during which you manipulate the fetus,
converting it to either breech or cephalic presentation. This is often more difficult that
it sounds, particularly during labor, and carries some risk of injury to the fetus,
placenta, umbilical cord or uterus.

3. In the case of twins, it would be accepted to allow labor even though the second twin is in
transverse lie, anticipating that after delivery of the first twin you would reach in and
perform an internal version, converting the transverse lie to cephalic or breech
presentation prior to delivery.
Predisposing factors for a transverse lie include:

 Grand multi parity- more than 5 term pregnancies

 Placenta previa
 Bony abnormalities of the pelvis
 Pelvic kidney
 Other pelvic mass
 Transverse lie occurs frequently in early pregnancy, when it is of no consequence. At
16 weeks gestation, about half of all pregnancies will be transverse lie. This number
steadily falls as pregnancy advances and incidence of transverse lie by 28th week is
well below 10%. It falls steadily thereafter.
 Whenever a fetal transverse lie is an encountered near term or in labor, evaluate the
patient carefully with ultrasound to determine if there are any predisposition factors,
such as a placenta previa or pelvic kidney that could modify your management of the
patient

So long as a placenta previa is not present many Obstetricians will check the patient’s
cervix at frequent intervals to detect early cervical dilatation and the consequential
increased risk of cord prolapse. Sometimes, these patients are delivered early by
scheduled CS to avoid that risk.
Compound presentation
Compound presentation means that fetal hand is coming out with the fetal head.
This is a problem because:
 The amount of baby that must come through the birth canal at one time is increased.
 There is increased risk of mechanical injury to the arm and shoulder, including
fractures, nerve injuries and soft tissue injury.
A compound presentation may be resolved if the fetus can be encouraged to withdraw the
hand, for example.
If the fetus and arm are relatively small in comparison to the maternal pelvis , vaginal
delivery may still be possible, but with some risk of injury to the arm.
If the fetus and arm are relatively large in comparison to the maternal pelvis, obstructed
labor will occur and CS will be needed.
Impending breech delivery
Delivery of a fetus when the breech ( the buttocks or feet) appear first in the birth canal

TYPES OF BREECH
• COMPLETE BREECH
 Thigh flexed on the abdomen and legs upon the thighs
2. FRANK BREECH
 Thighs of the fetus are flexed and the legs are extended over the anterior surface of
the body
 Most favorable type for vaginal delivery
3. Incomplete breech
Single footling-one foot or one knee presenting.
Double footling-two feet or two knees presenting

Etiology:
• Uterine relaxation
• Multiple pregnancy
• Polyhydramnious
• Oligohydramnios
• Hydrocephalus
• Anencephaly
• Prematurity
• Previous breech
• Placenta previa
• Tumors in the pelvis