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 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.  
  
  
• Pelvis is not adequate for the passage of the baby’s head.
  Then Caesarean section is a best option   .
  
  
• Some medications have been given to you for pain relief or to decrease the perception of contractions (epidural anaesthesia) 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 1^st stage of labour.  

  Effects of prolonged labour:

This difficulty in progress of labour may lead to:

•  Exhaustion of the mother.

• Increased post partum bleeding.

• Increased chances of trauma to the genital tract.

• Increased chances of operative deliveries – like, forceps, vacuum.       
  
  
• Decreased supply of oxygen to your baby.
  
  
• Increased chances of infection in the uterus.

  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.

  To hasten the process of labour your doctor might adopt various measures.

• Rupture the membrane.
  
  
• To augment the labour.
  
  
• To see the colour of the amniotic fluid.

  Start intravenous drip of oxytocin if needed after ruling out inadequacy of pelvis.

• Give antibiotics to prevent infections.

Mode of delivery:

• Your doctor may consider operative vaginal delivery by the forceps or vacuum .
  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:

Causes of Malpresentations:

Many factors lead to malpresentations such as:

• Pre-Trem Labour   

• Multiple pregnancy.i.e twins,triplets etc.

• Excessive / less amount of amniotic fluid in the uterine.

• Some congenital abnormalities in the baby.

• Any abnormality of the uterus.

  The malpresentations include:

• Breech presentation.

• Face presentation.

• Brow presentation.

• Occipito posterior position.(Back labour)

• Transverse lie.

• Shoulder presentation.

Breech Presentation:

When the buttocks of your baby is the presenting part (i.e. the 1^st 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.      

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   .

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.
• Previous births by 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 (1^st 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       
• Suspicion of an inadequacy of the pelvis.
• Prolonged labour .
• Baby with intrauterine growth retardation.    
• Previous caesarean section.
• Oligohydramnios (less aminiotic fluid)
• Pre-term labour.
• Other associated complications like placenta praevia, hypertension in pregnancy.

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.
• Congetial  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:

• To exclude bony congenital malformation of the baby.
• To note the size of the baby.

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:

• Inadequacy of your pelvis.
• Big baby.    .
• Associated complicating factors.

 The risks includes:

• A chance of umbilical cord coming out first at delivery.
• Prolonged labour    
• 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:

• Confirm the brow presentation.
• Check for the adequacy of your pelvis.

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 2^nd 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

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:

• Pregnancy induced hypertension.  

• Post maturity.

• Post caesarean pregnancy       .

• Big baby.    

  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. There may be a slight delay. In most cases delivery is spontaneous. In other few cases forceps / vacuum may be required.  

A Caesarean section is opted in cases of:

• Presence of any risk factors.

• Foetal distress.

• Improper uterine action.

• Maternal distress (exhaustion) in case of prolongation of labour.

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.      

  Diagnosis:

• H/O ovulation inducing drugs for infertility.

• Family h/o twinning.

• The symptoms of normal pregnancy are exaggerated.   

1. Increase nausea and vomiting in early months of pregnancy.

2. Increase chances of swelling of the legs varicose veins.

3. Unusual enlargement of abdomen

4. Excessive foetal movements.

5. Increased weight gain as there are 2 babies growing in the uterus.

• Your doctor can also locate two separate spots with two distinct heart sounds.

• Sonography is the best investigation to show about the twin pregnancy.

  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.

• 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 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 experinced person's hands, the risks are minimum.