1. 1
NON REASURING FETAL STATUS (NRFS)
Introduction
 Fetal compromise is a complex of signs showing response of the fetus to inadequate oxygenation.
 Fetal heart rate (FHR) in labor can be monitored using either continuous electronic monitoring or intermittent auscultation using Pinnard sthetoscope.
 FHR patterns:
1. Normal: Baseline FHR between 110-170 beats per minute (bpm), accelerations with contraction or fetal
movement, early deceleration, normal variability (6-25 bpm).
2. Bradycardia: Baseline FHR ≤ 110 bpm.
3. Tachycardia: Baseline FHR ≥ 170 bpm.
4. Accelerations: Transient increase in FHR associated with contraction or fetal
movement. It is usually favorable sign of fetal wellbeing.
5. Decelerations: Falls from baseline
(i) Early deceleration: Slowing in FHR associated with contractions. Mainly due to head compression.
(ii) Late deceleration: Slowing in FHR which begins at or after the peak of contractions & returns to baseline after the end of contractions. Implies presence of uteroplacental insufficiency.
(iii)Variable deceleration: Variable onset of abrupt slowing of FHR in association with uterine contractions. Signify possible pressence of cord compression.
(iv) Prolonged deceleration: A decrease in FHR below baseline of 15 bpm lasting 2-10 minutes (min) from onset to return to baseline.
6. Beat-to-beat variability: Fluctuations in the baseline FHB. Can be:
a. Absent / undetectable
b. Minimal: < 5 bpm
c. Moderate: 6 - 25 bpm

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d. Marked: > 25 bpm
7. Wandering baseline: Unsteady & wanders between 110 – 170 bpm. Suggests neurologic abnormality.
8. Sinusoidal pattern: Regular variability resembling sin wave with a fixed periodicity of 3 – 5 cycles / min & amplitude of 5 – 40 bpm. It is a response to moderate fetal hypoxemia scondary to fetal anemia.
Diagnosis
 NRFS: Presence of the following signify fetal compromise:
 Repetitive decelerations (variable / late)
 Loss of beat – to –beat variability
 Baseline bradycardia or tachycardia
 Signs of fetal distress:
 Abnormal FHR (above)
 Meconium stained liquor
 Acidic scalp PH
Management
 Digital vaginal examination if there is no contraindication to do so. Done to asses stage of labor, pressence of cord prolapse or cord presentation, and to do artificial rupture of fetal membranes (ARM) to check presence of meconium.
 Intrauterine resuscitation:
 Change position of the mother
 Correct maternal hypotension, dehydration, & hypoglycemia (Intravenous (IV)- fluid)
 Oxygen via tightly fitting face mask (6-8 liters (lit)/min)
 Decrease uterine activity by stopping oxytocin &/or administering tocolytic agents
 Amnioinfusion
 If fetal tachycardia is secondary to chorioamnionitis, treat the chorioamnionitis
 Continue with labor follow up if FHR is normal subsequently

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 If the FHR abnormality doesn’t resolve with the conservative management, immediate delivery is recommended.
 Mode of delivery is dectated by presentation, station, position, cervical dilatation, & status of the fetus;
 Vertex presentation, fully dilated cervix, station at +2 centimeters (cm) or below → Instrumental vaginal delivery(ventouse/forceps).
 Vertex presentation, cervix not fully dilated, or high station with fully dilated cervix → cesarean delivery (C/d).
 Malpresentations → C/d, except face presentation with mentum anterior and station +2 cm or below where obstetric forceps can be used.

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OBSTRUCTED LABOR (OL)
Definition: Obstructed labor is failure of descent of fetal presenting part in maternal birth canal for mechanical reasons despite the presence of adequate uterine contractions.
Causes:
 Cephalo pelvic disproportion (commonest): Contracted pelvis (commonest), pelvic deformities (Rickets, osteomalacia), malposition, big fetus
 Malpresentations: Impacted transverse lie, breech presentation, face presentation (mento posterior), brow presentation, compound presentation, shoulder dystocia
 Soft tissue abnormalities: Cervical stenosis, vaginal stenosis, tumor previa (Myoma)
 Fetal abnormalities: Hydrocephalus, locked twins, conjoined twins
Anticipate OL during antenatal period in presence of:
 Short stature
 Small shoes number
 Previous history of prolonged or difficult labor
 Contracted pelvis on clinical pelvimetry
 Obstetric palpation to pick malpresentations, big fetus, multifetal gestations.
 Unengaged head at term in primigravidas (Head fitting test)
Anticipate OL in labor in presence of:
 Protracted cervical dilatation
 Arrest of cervical dilatation
 Failure/arrest of descent of presenting part
Clinical features:
 Prolonged labor
 Failed instrumental delivery
 Exhausted and anxious mother

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 Dehydration signs present
 Signs of metabolic acidosis
 Birth canal infection (offensive vaginal discharge, fever)
 Bandl’s ring formation (commonly in primigravidas, distended lower uterine segment with a constriction ring separating it from upper uterine segment)
 Ruptured uterus (multigravidas)
 Three - tumor abdomen: distended bladder + ballooned out lower uterine segment + contracted fundus with intervening Bandl’s ring.
 Blood stained urine (edema and echymosis)
 Edema of lower vagina and vulva (Kanula syndrome)
 Moulding and excessive caput
 Fetal death (Alive fetuses usually succumb in first 48 hours after delivery)
Management
 Fluid and electrolyte imbalance correction (IV- crystalloids, N/S and R/L be used)
 Control of infection (use triple antibiotics: Ampicillin 1 gm IV QID/Ceftriaxone 1 gm IV BID + Metronidazole 500 mg IV/PO TID/Chloramphenicol 1 gm IV QID + Gentamycin 80 mg IV TID or 4.0–5.0 mg/kg IV once daily, in an infusion given over a 30-minute period)
 Emptying bladder:
 Avoid metalic and hard plastic catheters (traumatic)
 Relieve compression of the urethra by inserting two fingers, one on either side of the urethra
 Displace presenting part upwards after anesthesia
 During cesarean delivery, after abdomen has been opened the bladder can be emptied with a wide bore needle and syringe
 Emptying the stomach (NGT)
 Administer antiacid suspension orally
 Hematocrit/hemoglobin, blood group and Rh, Cross-match blood

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 Relieve obstruction using any of the following procedures, whichever is appropriate for the situation:
1. Cesarean delivery
 Almost all cases
 Alive fetus, and dead fetus at high station
 Lower uterine segment cesarean delivery is prefered
2. Vaginal operations
 In absence of uterine rupture and imminent uterine rupture
 In the operation theatre especially if uterine rupture or imminent rupture cannot be ruled out (destructive deliveries under direct vision)
 If rupture suspected during procedure (eg. Fresh and excessive vaginal bleeding), abandon the procedure immediately and proceed to laparatomy
 After difficult procedures explore the uterus
 Destructive vaginal deliveries (prerequisites should be fulfilled)
 Craniotomy
 Cleidotomy
 Decapitation
 Evisceration / embryotomy followed by spondylotomy

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UMBILICAL CORD PROLAPSE (UCP)
Introduction
 UCP is obstetric emergrncy that occurs when the umbilical cord(UC) descends alongside or beyond the fetal presenting part.
 Classification:
 Overt UCP: Protrusion of the UC in advance of the fetal presenting part with ruptured fetal membranes.
 Occult UCP: Cord descends alongside, but not past, the presenting part with intact / ruptured fetal membranes.
 Cord presentation: Prolapse of UC below the level of the presenting part before rupture of fetal membranes.
 The incidence of UCP is 0.14 – 0.62 % (varies with fetal presentation: cephalic = 0.5%, frank breech = 0.5%, complete breech = 5%, footling breech = 15%, transverse lie = 20%) & perinatal mortality related to UCP is declining significantly.
 Risk factors:
1. Fetomaternal: Inadequate filling of the maternal pelvis by the fetus. Malpresentations, unengaged presenting part, prematurity, multifetal gestation, PROM, abnormal placentation, multiparity, polyhydramnios, long UC, pelvic deformities, uterine tumors/malformations, congenital anomalies
2. Obstetric interventions: ARM, scalp electrode application, intrauterine pressure monitor catheter insertion, manual rotation of the fetal head, amnioinfusion/amnioreduction, ECV with ROM.
Diagnosis
 Occult UCP: Pressence of severe prolonged fetal bradycardia or moderate to severe variable decelerations after a previous normal tracing.
 Overt UCP: Pressence of palpable cord (pulsatile or non-pulsatile) on pelvic examination or visible cord outside the introitus.

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 Cord presentation: Loops of cord are palpated through the fetal membranes.
Management
 Intrauterine resuscitation and prompt delivery is recommended when fetus is alive.
 Manuevers to reduce fetal presenting part pressure on the cord:
1. Funic decompression: Examiner’s hand is maintained in the vagina to elevate the presenting part off of the UC while preparations for an emergency c/d are being made.
 Client be placed in steep Trendelenberg or knee-chest position.
 Do not manipulate the cord.
 Avoid exposure of the cord to cold environment so as to avoid cord spasm (keep in vagina).
2. Bladder filling: Insert foley catheter into maternal bladder then fill bladder with 500- 700 ml of normal saline with the patient in Trendelenberg position (used during referral).
3. Tocolysis
 Delivery: Mode of delivery depends on:
 Presentation
 Cervical dilatation
 Station of presenting part
 Whether the fetus is alive or dead and GA when alive.
 If fetus is dead (previable/GA<28 weeks), follow labor & attend delivery.
 If fetus is alive with malpresentation or prerequisites for instrumental delivery not fulfilled, immediate c/d.
 Ventouse is preferred over forceps when cervix is dilated ≥ 8 cm and other prerequisites are fulfilled.
 The interval between cord prolapse & delivery is a major determining factor in the immediate neonatal outcome & perinatal mortality.
 In cord presentation with alive fetus, do not rupture fetal membranes at any stage of labor; deliver the fetus by c/d.

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 Prevention:
 ARM should be done when fetal presenting part is well applied to the cervix/engaged.
 Controlled ARM with small gauge needle & simultaneous fundal pressure if fetal presenting part is not well applied.
 Avoid disengaging fetal presenting part when performing procedures.
 Careful pelvic examination immediately after spontaneous rupture of fetal membranes.
 Incidental finding of cord presentation on U/S should be followed to decide mode of delivery.

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Pathway of care in UCP
Lateral position
100% oxygen by tightly fitting face mask (6-8 l/min)
Replace cord in vagina but avoid handling cord as much as possible
Discontinue oxytocin if present
↓
Assess fetal viability
FH on Pinnard/Doppler/CTG
/
Yes – baby is alive No – FHT
↓ ↓
Is cervix fully dilated? Await spontaneous delivery
Is baby cephalic?
/
No – not fully dilated or Yes – fully dilated/ ≥ 8 cm
Vaginal delivery deemed inappropriate ↓
Or unsuccessul Consider ventouse if easy delivery
↓
Is FHR normal?
↓
No – FHR is abnormal Yes – FHR is ok
↓ ↓
Relieve pressure on the cord: Make arrangements for emergency c/d
 Knee-elbow/lateral position with
Trendelenberg → Does FHR improve?
 Manual elevation of presenting part No – FHR stays abnormal
 Cetheterize & fill the bladder with ↓
500 ml N/S then clamp catheter Prepare for emergency c/d as fast as possible

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ANTEPARTUM HEMORRHAGE (APH)
 Definition: Genital tract bleeding from 28th week of gestation till delivery of the fetus.
 Incidence: 2 – 3 % of all pregnancies.
 Causes:
A. Placental and fetal membranes: Placenta previa, abruptio placenta, vasa previa, placenta membranacea, circumvalate placenta
B. Non – placental: Heavy show, ruptured uterus, bleeding diathesis
C. Local causes: Cervicitis, cervical Ca, cervical polyp, leech infestation, vaginal & vulvar pathologies
D. Unknown cause
NB: The cause of any APH should be taken to be placenta previa unless ruled out otherwise. Hence, vaginal & rectal examinations are contraindicated in women with APH until placenta previa is ruled out.
Placenta previa
 It is implatation of placenta at the lower uterine segment within zone of cervical dilatation & effacement.
 Incidence : 4 per 1000 pregnancies.
 Risk factors: High parity, advanced age, multifetal gestation, erythroblastosis, previous c/d, other uterine scars, smoking, high altitude, male fetus, early GA.
NB: In placenta previas diagnosed at early GA there is placental “migration” which results from formation of lower uterine segment & unidirectional trophoblast growth.
Diagnosis:
 Clinical features (supportive): Painless & recurrent vaginal bleeding (70-80%), uterine contraction (10-20%), assymptomatic (Incidental finding) in < 10%.
 Mainly by U/S: -Transvaginal (Gold standard)
-Trans abdominal: -Accuracy is > 95 %

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- Anterior placenta---with empty bladder
- Posterior placenta---Trendelenberg position
- Central complete---placenta seen anterior & posterior
 Classification: 1. Low lying (I): Within 6cm from internal OS of the cervix.
2. Marginal (II): Placenta edge reaching the internal OS of the cervix.
3. Partialis (III): Placenta covering internal OS of the cervix partly.
4. Totalis (IV): Placenta covering the internal OS of the cervix completely.
 Management:
 Admit all ladies with APH secondary to placenta previa at time of diagnosis.
 Resuscitation based on clinical condition.
 Vaginal & rectal examinations are absolutely contraindicated.
 Monitor closely maternal & fetal conditions.
 HCT, BG & Rh, cross-match at least two units of blood
 Decide on conservative management versus immediate delivery
 Indications for immediate delivery:Term pregnancy, IUFD, fetal growth restriction, NRFS, excessive bleeding, gross fetal congenital malformation which may not be compatible with life, lady in labor.
 In absence of any of the above indications to deliver the fetus, conservative management is instituted till an indication comes to picture.
 Conservative management in preterms includes:
-Bed rest (in hospital)-----No place for out patient management
-Dexamethasone 6mg IM Q 12 hours for a total of 4 doses
-Follow: Maternal V/S, vaginal bleeding, uterine contractions, fundal height, FHB, kick count, BPP, serial HCT.
- Deliver at 37 completed weeks of gestation after maturity is confirmed

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 Route of delivery depends on the type of placenta previa and presence of other obstetric indications:
 Low lying & anterior marginal → vaginal delivery
 Partialis, totalis, & posterior marginal → c/d
 Excessive bleeding, NRFS, other obstetric indications → c/d
 Double setup examination: Used in areas where U/S is not widely available/not done by experienced people. The procedure:
 Client taken to operation room
 Everything must be ready for delivery
 Speculum examination is done gently to rule out local causes & see the cervical status → Then gentle digital vaginal examination is done to check for pressence of placenta between fornices & presenting part, cervical dilatation & effacement, pressence of placenta through open cervix.
 Used to decide on mode of delivery
Placental abruption
 It is the premature separation of a normally implanted placenta.
 Immediate cause is rupture of defective maternal vesseles in the decidua basalis, where it interfaces with the anchoring villi.
Incidence: 1 in 75 – 225 deliveries, severe enough to cause still birth (SB) occurs 1 in 830 deliveries. Accounts for 1/3rd of APH.
Risk factors: Trauma, hypertension, rapid uterine decompression, high parity, multifetal gestation, previous history of abruption (most predictor, increases 10×), uterine leiomyoma & anomalies, cigarette smoking, cocaine abuse, placental anomalies, inherited thrombophilia.
Recurrence: 5 – 15 % after an episode, 25 % after two consecutive episodes
Diagnosis:
 Primarily clinical: Vaginal bleeding ( > 80 %), abdominal pain ( > 50 %), contractions ( Tachysystole), uterine tenderness, NRFHR, rigid (woody hard) uterus, amount of bleeding doesn’t correlate well with the extent of maternal hemorrhage, DIC ( 10 – 20 % of severe abruptions).

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NB: Bleeding in placental abruption can be:
 Revealed (Vaginal) in 80 %
 Concealed
 To amniotic fluid giving it “Port wine” discoloration
 Into myometrium------“Couvelaire uterus”
 Clinical diagnosis is supported by:
 Radiologic findings: High resolution U/S with experienced hand can reveal retroplacental clot.
 Laboratory findings: Hypofibrinogenemia
 Pathologic findings: Retroplacental clot after delivery, depression on maternal surface of placenta (long standing abruption), bluish uterus at c/d (Couvelaire).
 Grading of abruptio placentae: Sher, 1978
 Grade 0: Retrospective diagnosis of abruption
 Grade 1: Vaginal bleeding
 Grade 2: Vaginal bleeding, concealed hemorrhage, uterine tenderness, NRFHR
 Grade 3: Vaginal bleeding, shock, extensive concealed hemorrhage, uterine tenderness, IUFD
Grade 3 A: With no coagulopathy
Grade 3 B: With coagulopathy
 Management:
 All cases: Asses hemodynamic status, then
 IV line to be opened
 Fetal well being monitoring
 HCT, BGP & Rh, platelets, fibrinogen, PT, aPTT
 Grade 2 – 3: Asses maternal hemodynamic status, then stabilize the mother
 Maintain U.O.P > 30 ml/hr & HCT > 30%
 Platelets (6U) transfusion if thrombocytopenia
 FFP if fibrinogen < 100mg/dl
 Delivery: -Vaginal----Amniotomy & induction with oxytocin
-C/d for uncontroled hemorrhage & other obstetric indications

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 Hysterectomy---Uncontrolled hemorrhage
 Couvelaire uterus---Uterotonic agents, hysterectomy if unresponsive
 Grade 1: Conservative management
 Steroid in < 34 weeks of gestation
 Keep in ward till bleeding subsides
 Tocolysis in < 33 weeks of gestation
 Follow maternal V/S, bleeding, uterine contraction & tenderness, FHB, kick count, BPP, fetal growth
 Indications for delivery: Term, IUFD, malformed fetus, NRFHR, advanced labor, excessive bleeding
NB:
 All cases of APH be admitted at initial diagnosis & stabilized.
 Placenta previa must be considered unless ruled out in all cases of APH.
 Local causes be ruled out 48 hrs after last episode of bleeding with speculum examination in those with no placenta previa.
 In APH secondary to local causes, the primary cause be treated.
 Pregnancies with APH of unknown cause be induced at 37 copmleted weeks after confirmation of maturity.
 In vasa previa, bleeding is mainly fetal. Emergency c/d is indicated if fetus is alive.

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MULTIFETAL GESTATION
Etiology
 Etiology of MZ twining is unknown
 DZ twining appears to result from ovulation of multiple follicles (Elevated FSH, ovarian stimulation, in vitro fertilization).
Placentation
 DZ twins have dichorionic-diamniotic placentas
 In MZ twins the timing of egg division determines placentation:
-Division within 3 days of fertilization: DADC
-Division between days 4 & 8: DAMC
-Between days 8 & 12 : MAMC
-Division at or after day 13 results in conjoined twins
Diagnosis
 Persistent hyperemesis gravidarum
 Pregnancy heavier than previous pregnancies
 Personal or family history of twins
 Early onset preeclampsia
 Pregnancy following assisted reproductive technology
 Big for date uterus
 Excessive weight gain
 Obstetric palpation revealing more than two poles
 FHR heared by two people at different areas with rate difference of at least 10 bpm (with different rate to the maternal pulse).
 U/S: Presence of two or more GS/fetuses, dividing membranes
Management
 Increase energy consumption (increase 300 Kcal more)

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 Supplements ( Iron, Folic acid)
 Frequent ANC visits, rest and antepartum fetal surveillance as indicated
 U/S:- Placentation, number of fetuses, AF, placental abnormalities, fetal growth, presence of congenital anomalies
 Preterm labor: Tocolysis, steroids before 34 weeks of GA
 VBAC is contraindicated
 Timing of delivery: - Elective delivery before 38 weeks should be after lung maturity is ascertained.
- No twin pregnancy should be allowed to go beyond 40 weeks of GA.
 Induction and augmentation: Contraindicated
 Route of delivery: Depends on presentation & GA (rarely)
 Both twins vertex: Deliver vaginally, c/d reserved for indications similar to singleton.
 Twin 1 non-vertex: C/d
 Twin 1 vertex & twin 2 non-vertex: deliver 1st twin vaginally, then options for 2nd twin are: ECV, internal podalic version followed by total breech extraction, vaginal breech delivery
 C/d in cases of: Conjoined twins, monoamniotic twins, locked twins.
 Intrapartum both twins should be monitored using continuous monitoring methods (One- to-one Pinnard sthetoscope auscultation if continuous monitoring is not feasible).
Complications
 Interval between delivery of the two twins:
- There doesn’t have to be finite intervel between delivery of 1st & 2nd twin as long as FHR tracing is reasuring.
- Continuous fetal monitoring & real-time U/S help to identify those second twins who would benefit from expedited delivery allowing most cases to be managed expectantly.
 Conjoined twins:

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 Incidence: 1 in 50,000 to 1 in 100,000 live births with female to male ratio = 3:1.
 Classification based on site of most prominent union:
- Cephalopagus: Head
- Thoracopagus: Chest
- Omphalopagus: Abdomen
- Parapagus: Pelvis & variable trunk
- Rachiopagus: Vertebral column
- Pygopagus: Sacrum
 Diagnosis: U/S typical features include:
- Fixed position of the fetal heads (both at same level)
- Parallel lie / persistently similar lie
- Inability to detect separate bodies or skin contours
- Lack of separating membranes
 Management:
- Elective termination at time of diagnosis when there is a cardiac or cerebral fusion, as separation is rarely successful, & if severe deformities are anticipated after separation.
- If pregnancy is continued, elective c/d after lung maturation.
- Destructive delivery may be considered in dead and partly delivered fetuses.
- After birth, elective separation is indicated (survival rate is 80%).
- Emergency separation is indicated if:
One of the twins is dead
One of the twins threatens survival of the other twin
Life threatening condition exists in one of the twins
 Twin-twin transfusion syndrome: Almost always due to artery-to-vein anastomoses
 Diagnostic criteria antenatally:
- Same sex
- Monochorionic with vascular anastomoses
- Weight difference > 20%

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- Polyhydramnios in the larger fetus
- Oligohydramnios (stuck) in the smaller fetus
- Hgb defference > 5 gm/dl
 Management: Amnioreduction, septostomy, laser ablation of vascular anastomoses, selective feticide.
 Death of one fetus: Prognosis of the surviving fetus depends on:
- GA at time of death
- Chorionicity
- Length of time between death & delivery of the surviving fetus
 Management depends on cause of death & risk to surviving fetus
 Generally conservative management is recommended with close follow up of maternal clotting profiles & fetal surveillance.
 Discordant twins: EFW difference of > 20% between the smaller twin as compared to the larger twin; fetal surveillance is recommended till delivery which is at term or when the surveillance shows compromise.
 Locked twins: Can be chin to chin interlocking, collision, impaction, compaction.
 Chin to chin locking: 1st breech & 2nd cephalic
- Avoid traction on 1st twin
- If both alive, c/d
- If 1st twin is dead, decapitate & deliver 2nd twin then deliver the decapitated head of the 1st twin.
NB: - Higher order multifetal gestations should be suspected whenever twin pegnancy is considered.
-All higher order pregnancies be delivered by c/d unless c/d is contraindicated or the fetuses are extemely premature.

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PREMATURE RUPTURE OF FETAL MEMBRANES (PROM)
PROM: is rupture of fetal membranes at least an hour before onset of labor.
Prolonged PROM: is