Complicated labor refers to abnormalities during labor due to improper fetal position, fetal lie, or umbilical cord issues.
1. Malpresentation & Malposition
Definition:
- Malpresentation: Any presentation other than vertex (head-first).
- Malposition: Vertex presentation but with abnormal rotation (e.g., occiput posterior).
A. Malpresentations
1. Breech Presentation
- Definition: Fetal buttocks or legs present first.
- Types:
- Frank Breech: Hips flexed, knees extended.
- Complete Breech: Hips and knees flexed.
- Footling Breech: One or both feet present first.
- Risk Factors:
o Prematurity, multiple pregnancy, polyhydramnios, uterine anomalies.
Diagnosis:
o Leopold’s maneuvers, ultrasound, vaginal examination.
Management:
o External Cephalic Version (ECV) at 36–37 weeks (if no contraindications).
o C-section preferred for large babies or footling breech.
2. Face Presentation
- Definition: The fetal head is hyperextended.
- Management:
- Vaginal delivery possible if mentum anterior.
- C-section for mentum posterior (obstruction risk).
3. Brow Presentation
- Definition: The fetal head is partially extended.
- Management:
- C-section if persistent.
4. Shoulder Presentation (Transverse Lie)
- Definition: Fetal shoulder presents at the cervical os.
- Risk Factors:
- Prematurity, placenta previa, uterine anomalies.
- Management:
- C-section mandatory.
B. Malpositions
1. Occiput Posterior (OP) Position
- Definition: The fetal occiput (back of the head) is facing the maternal sacrum.
- Risk Factors:
- Pelvic contraction, android pelvis, inadequate uterine contractions.
- Management:
- Manual rotation or operative vaginal delivery (Forceps, Vacuum).
- C-section if labor fails to progress.
2. Occiput Transverse (OT) Position
- Definition: The fetal head is transverse at the pelvic inlet.
- Management:
- Manual rotation.
- C-section if persistent.
2. Cord Prolapse
Definition:
Cord prolapse occurs when the umbilical cord descends below the fetal presenting part before delivery, leading to fetal hypoxia due to cord compression.
Types:
- Occult Cord Prolapse: Cord lies beside the presenting part, not visible.
- Overt Cord Prolapse: Cord is visible outside the cervix.
Risk Factors:
- Breech presentation.
- Polyhydramnios.
- Premature rupture of membranes (PROM).
- Multiple pregnancy.
Clinical Features:
- Sudden fetal bradycardia (<110 bpm).
- Palpable umbilical cord in the vagina.
Management:
- Emergency C-section (Definitive treatment).
- Position the mother in Trendelenburg or knee-chest position.
- Manually elevate the presenting part to relieve pressure on the cord.
- Avoid handling the cord (prevents vasospasm).
Summary of Complicated Labor
|
Condition |
Definition |
Management |
|
Breech Presentation |
Buttocks or feet present first |
ECV, C-section for footling/large baby |
|
Face Presentation |
Hyperextended head |
Vaginal delivery if mentum anterior, C-section if
mentum posterior |
|
Brow Presentation |
Partially extended head |
C-section if persistent |
|
Shoulder Presentation |
Transverse lie |
C-section |
|
Occiput Posterior |
Fetal head facing maternal sacrum |
Manual rotation, Forceps, C-section if failure to
progress |
|
Cord Prolapse |
Cord below presenting part |
Emergency C-section |
Key Takeaways
- Breech presentation is the most common malpresentation.
- Face & brow presentations require careful assessment for vaginal delivery.
- Cord prolapse is a medical emergency requiring immediate C-section.
