By Dr Sonali and Dr Preeti
Abnormal
Delivery
You are said to have a normal delivery if
you deliver your child vaginally at full term, with the baby’s head coming first,
without any instrumentation. Episiotomy is considered
to be normal.Even twins are considered to be abnormal-medically speaking .Though in
layman's term a normal delivery is
Baby in normal position
 Not
every woman experiences a text book pattern of delivery. You may have variations in the
course of labour. Inspite of these variations you may have safe delivery and a healthy
baby.
The variations are:
Variations in the time of
labour.
Variations in the positions
of the baby.
Variations in conducting
the vaginal delivery (operative vaginal delivery).
Prolonged Labour:
The word ‘difficult labour’ or
‘dystocia’ suggests that labour has failed to progress normally. Link to progress of labour in Delivery and is causing
difficulties for you and your baby. Delayed progress of labour can be due to various
causes. If the labour doesn’t complete within-18 hours in case of the first time pregnant woman and 12 hours in case of those who have had a prior delivery,it is
considered prolongued.
Causes of prolonged labour:
Factors causing delayed progress of
labour are:
·
Inadequate
intensity and frequency of uterine contractions.
·
Overdistention
of the uterus (in cases like twins or large baby).
·
The
position of the baby in your uterus is not favorable. Link to
malpresentations in abnormal delivery.
·
Pelvis is
not adequate for the passage of the baby’s head. Link to
Cephalo-pelvic disproportion in abnormal delivery. Then Caesarean section is a best
option.
Ceasarean Section in Abnormal Pregnancies
.
·
Some
medications have been given to you for pain relief or to decrease the perception of contractions (epidural anaesthesia) Link to epidural anaesthesia in Delivery. These sometimes
have an effect of prolonging labour, particularly the second stage.
·
If
you have not completely evacuated your urinary bladder / bowels, they may rarely cause
failure of progress of labour. In most hospital enema is given during the 1st
stage of labour. Link to preparation in 1st stage of labour in Delivery.
Effects of prolonged labour:
This difficulty in progress of labour may lead to:
On admission in the hospital
Your doctor will do the following things.
Try and rule out the different causes of prolonged labour.
Assess your condition by checking your pulse,
blood pressure, uterine activity and cervical dilatation.
Assess your baby’s condition.Investigations and tests.
To hasten the process of
labour your doctor might adopt various measures.
Start intravenous drip of oxytocin
if needed after ruling out inadequacy of pelvis.
Mode of
delivery:
Your doctor may consider operative vaginal
delivery by the forceps or vacuum. Link to forceps and vacuum delivery in abnormal delivery. OR
May consider caesarean section, if no
satisfactory progress in cervical dilatation / descent of the head of the baby/ any
irregularities in your baby’s heart rate suggestive of foetal condition being
compromised.
Malpresentations:
Your baby is said to be in a normal position if it is facing toward
the mother’s back with the face angled toward the right or left, and upside down with
the head coming first (vertex presentation), with the neck bent forward, chin tucked in
and arms folded across the chest. Any variation from this position makes your baby’s
journey through the birth canal difficult, sometimes hazardous and occasionally
impossible. Hence known as ‘malpresentations’.
Causes of Malpresentations:
Many factors lead to malpresentations such as:
The malpresentations include:
Breech presentation:
 When the buttocks of your baby is the presenting
part (i.e. the 1st part of your baby to be delivered) your baby is in a breech
presentation.
Spontaneous
change in position
In most cases, the breech detected
earlier in the pregnancy spontaneously turns to the head down position as the pregnancy
progresses.
Your doctor can confirm the position of the baby by an abdominal examination / USG.Link to Ultra Sonography and Investigation and Tests
This spontaneous change of position of
breech does not occur in and may persist as breech in:
Breech baby with extended legs.
Twins.
Less amount of amniotic fluid.
Any abnormality of the uterus.
Risks in vaginal deliveries
Trauma to your genital tract.
If the umbilical cord gets compressed after the delivery of the
buttocks, but before the head delivers out, then there may be decreased supply of oxygen
to your baby.
There may be some injuries to baby while delivering despite
best care by your doctor.
Excessive pull on the neck while the head is being delivered out.
During vaginal delivery, the buttock
comes out early as they are easily compressible. But the after coming head being hard and
less compressible may (occasionally) get stuck at the
outlet of the birth canal such head can be removed by using forceps. Link to forceps in abnormal delivery in delivery.
Correction
of breech position:
IF near full term, the position of the baby is breech, your doctor can change the
position of the baby to head down by the maneuver called ‘external cephalic
version'
The procedure is not done if:
You are having marked increased in blood pressure.
Hypertension in Pregnancy
Previous births by caesarean section. Link
to caesarean section.
Your pelvis is not adequate for the passage of your baby’s
head.
Your baby’s head is hyper-extended, i.e. the back of head
touches the back of the baby.
You are having any malformation of uterus or fibroids or other
problems in the birth passage.
Twins
If you have previous pre-term delivery or the placenta is low lying
.
On
admission to the hospital :
Your doctor will examine you and will monitor your uterine contractions, your progress of
labour and your baby’s condition and decide about the mode of delivery.
Mode of
delivery:
In primigravidas (1st
time pregnant woman) the vaginal delivery of breech is difficult
because the mother’s birth canal has not been stretched by a previous delivery. In
such cases, caesarean section gives the option of well-planned delivery, under controlled
conditions. Although, the delivery maneuver is the same, it is done under anaesthesia as
an ‘open’ procedure. Hence, it is easier to handle any difficulties in the
delivery of your baby.
In multigravidas (
women who have delivered a child before ) vaginal delivery can be considered as a
good option before going for a caesarean section.
Caesarean section is a must in
cases like;
Large baby
Diabetes Mellitus in Complications in Pregnancy
Suspicion of an inadequacy of the pelvis.
Prolonged labour. Link to prolonged
labour.
Baby with intrauterine growth retardation. Link to IUGR in complication of pregnancy.
Previous caesarean section.
Oligohydramnios (less aminiotic fluid)
Pre-term labour.
Other associated complications like placenta praevia, hypertension
in pregnancy.
However it is a question of personal choice as risks of vaginal
breech delivery cannot be completely ruled out. So the doctor will be the right person to
guide you. The aim is to have a safe birth for you and your baby, regardless of the route
chosen. Link to Breech delivery by caesarean section in
Caesarean section
Face presentation:
 This
is a rare variety of presentations of your baby in which there is complete extension of
your baby’s head almost touching to the back. In this case, the baby's face is
delivered first rather than the top of the head.
Causes of face
presentations:
Lax and pendulous abdomen due to multiple births.
Pelvis is inadequate or flat.
Congenital
malformations of the baby such as cysts in the neck, thyroid problem.
Increased tone of the baby's muscles present at the back of its
neck.
Loops of cord around the neck.
On admission to
the hospital:
Diagnosis of the face presentation is
usually made at the time of labour. It can only be suspected on abdominal examination.
Your doctor will do your internal examination to:
Feel the mouth, nose, cheekbone and
chin of your baby thus confirming if your baby is in a face presentation.
Check for the adequacy of the pelvis.
He will also rule out associated complicating factors like increased blood
pressure, post caesarean pregnancy, post caesarean pregnancy, post maturity etc.
 To
confirm the diagnosis USG can be done if available. In case of emergency an X-ray of your
abdomen may be required.
This can also help:
Mode of
delivery:
Your doctor is the best person to decide the mode of delivery. i.e. either by vaginal
delivery or by a caesarean section
Early caesarean section is done in
cases of:
The risks includes:
A chance of umbilical cord coming out first at delivery.
Prolonged labour. Link to Prolonged
Labour in Abnormal Delivery.
Injury to the birth canal.
Excessive post partum bleeding.
Brow presentation:
 When your baby’s neck is moderately arched
so that the brow presents first i.e. the head lies in between the normal position and the
face presentation. This is a very rare type of presentation, commonly unstable and
converts to either the normal position or the face presentation.
On
admission to the hospital:
Similar to the face presentation, the diagnosis of the brow presentation is made at
the time of the delivery.This position is confirmed by your internal examination and USG.
Your doctor will do an internal examination to:
Your doctor will rule out any
associated complicating factors.
Mode
of delivery:
For a while your doctor may observe the
progress of labour. If your baby spontaneously converts to the face presentation or the
normal position, vaginal delivery is possible. Caesarean section is the best option for
the persistent brow presentation associated with complicating factors.
Transverse Lie:
 When baby’s spine lies perpendicular to your spine, it is
called as transverse lie.
When the baby’s spine is placed
oblique to the maternal spine. This is known as ‘oblique lie’. 
uterus with
transverse lie.
In oblique lie, if the head of the baby
is above the navel of the baby then during labour this position is mostly changed to the
breech position.
uterus
with oblique lie
Causes of transverse and oblique lies are:
Lax and pendulous abdomen.
Twins – more common for the 2nd baby.
Excessive amniotic fluid.
Inadequate pelvis.
Pelvic tumours like fibroids, ovarian cysts.
Congenital malformation of the uterus like a septum.
In both the transverse and
oblique lie, commonly during the delivery the shoulder comes first and is known as
shoulder presentation Link to shoulder presentation in
abnormal delivery.
Back labour (Occipito Posterior Position):
Normally the baby lies facing the
mother’s spine in an upside down position.In occipito posterior type of
malpresentation, the baby faces infront, with its back towards the mother’s side
(right / left)
Diagnosis:
Your doctor will do an internal
examination to confirm the occipito posterior position and to check for the adequacy of
pelvis.
 Diagram of structure felt on internal exam:
He’ll also rule out other risk
factors, which will need a caesarean section like:
Mode
of Delivery:
Occipito posterior per say does not
require a caesarean section.Vaginal delivery may be opted but a careful watch has to be
kept.A liberal episiotomy may be required.
in Delivery. There may be a slight delay. In most cases delivery is
spontaneous. In other few cases forceps / vacuum may be required. Link to Operative vaginal Delivery in Abnormal Delivery.
A Caesarean section is opted in cases
of:
Multiple Pregnancies:
When more than one foetus
simultaneously develops in the uterus, it is called multiple pregnancy. The most commonly
seen type of multiple pregnancy is the twin pregnancy. I.e. two babies in the uterus.
Rarely, development of three foetuses (triplets) four foetuses (quadruplets) may also
occur.
Twins:
Identical
Twins:
Identical (maternal) twins are the result of a single ovum
fertilised by a single sperm, which later divides in 2 separate cells. These form 2
different foetus. Both foetuses have same placenta, same sex and look similar.
Non Identical Twins:
Non Identical (fraternal) twins are the
result of 2 eggs being fertilized by 2 different sperms at the same time. Each foetus has
its own placenta. The sex of the babies may differ / may be same, depending on the sperm.
Causes:
The factors related to twin pregnancy
are:
Advancing age of mother, between 30 – 35 years
Family history of twins from the maternal side.
Drugs used for induction of ovulation in infertility cases e.g.
Gonadotriophin therapy clomiphene citrate. Link to treatment
of infertility.
Diagnosis:
Increase nausea and vomiting in early months of pregnancy.
Increase chances of swelling of the legs varicose veins.
Unusual enlargement of abdomen
Excessive foetal movements.
Increased weight gain as there are 2 babies growing in the uterus.
Antenatal
management of twins:
Diet:
Increased dietary intake of 300 Calories more than in a normal pregnancy (600 Calories
more than pre-pregnancy diet
Supplementation
of Iron, folic acid other vitamins, Calcium etc.
Avoid excessive physical strains.
Antenatal visits should be more frequent.
Mode
of Delivery:
This depends on the position of the
foetuses in the uterus.
If both the babies are lifting vertically in the uterus a vaginal
delivery may be possible.
If both are in a transverse / oblique lie, a caesarean section is a
must. Link to transverse / oblique lie in Abnormal delivery.
If one is vertical and other is transverse than your doctor will be
a better person to judge and decide the mode of delivery.
Operative vaginal Deliveries:
Forceps and Vacuum extraction:
Forceps and vacuum extractors are used to
assist the mother to deliver her baby in certain cases when spontaneous birth is not
possible.
Common indications include:
Prolonged second stage.
Maternal exhaustion (pulse, respiratory, temperature elevated, too
tired to push).
Foetal distress (irregular heart beat, meconium in amniotic fluid).
Mother unable to push (e.g. under epidural
anaesthesia, suffering from respiratory or cardiac disease).
Forceps:
 Forceps are twin steel
blades that are placed in the vagina and secured on either side of the baby's head. The
blades are locked and the doctor pulls until the head is delivered.
The forceps that is in use in modern day obstetrics is the low or outlet forceps. There
are certain pre-requisites required before the use of forceps, the main being that the
head of the baby is almost fully rotated, the scalp is easily visible, the cervix is fully
dilated, and the mother’s urinary bladder is empty.
Vacuum:
 Vacuum extractor (or ventouse) is a cup made of steel or a soft
flexible plastic cup. It is attached to a suction device to help pull out the baby. The
vacuum extractor is placed on the top of the baby's head and the suction is
activated.
With activation of the suction, the scalp of the baby is sucked into the cup helping in
creating traction. The doctor then pulls and during pulling if the head is not rotated, it
will spontaneously rotate till the head is born. The vacuum extractor can also be applied
to an un-rotated head, which is more commonly done.
With
both of these instruments, mothers may very well need an episiotomy Link to Episitomy in Delivery to facilitate insertion of the
instrument.
Risks:
In the
past ‘forceps’ was thought to be a fairly dangerous or risky procedure.In
today’s obstetric practice, the forceps is used to facilitate easy delivery of the
head of the baby.
Risks of the vacuum extractor to the baby are less than forceps. Complications
occur much less often with the vacuum extractor than with forceps.
Forceps and Vacuum for epidural anaesthesia:
Epidural anaesthesia may interfere with your
ability to push your baby out. So in case you have been given an epidural anaesthesia
there are chances of application of forceps or vacuum even though you do not have any
medical indications.
Another rare occasion where instrument delivery is required is when the mother has an
established heart disease and the exertion of pushing and exhaustion may lead to a further
reduction of the efficiency of the heart.
Your doctor will discuss the procedure with you if it is required. In
experienced person`s hands, the risks are minimum.
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Prolonged Labour
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