Midwives Revision

Day 6: Abnormal Labour Patterns - Nurses Revision Uganda
DAY 6
📅 Nov 15 (Fri)

🌀 ABNORMAL LABOUR PATTERNS

DME 121: Malpresentation & Malposition

  • Malpresentations (Breech types, Face, Brow, Shoulder)
  • Malpositions (Occipito-posterior, Occipito-transverse)
  • Abnormal Uterine Action (Incoordinate, Hypertonic)
  • Fetal Distress (Causes, Diagnosis with FHR)
  • Cord Prolapse (EMERGENCY Management!)
  • Deep Transverse Arrest & Cephalopelvic Disproportion
🌀 BREECH REMEMBER: Frank (hips flexed, knees extended), Complete (hips & knees flexed), Incomplete/Footling (one/both feet below buttocks). External cephalic version at 37 weeks!
🚨 CORD PROLAPSE = EMERGENCY! Knee-chest position, elevate presenting part with vaginal hand, emergency CS. TIME IS LIFE! Every second counts!
🧠 MNEMONIC: FETAL = Fetal heart, Elevate presenting part, Tocolytics, Assess, Labour ward prepare
💪 "Abnormal labour tests your skills. Stay calm and act fast! Your quick actions save two lives!"
🙏 "God is our refuge and strength, a very present help in trouble." - Psalm 46:1

📖 1. MALPRESENTATIONS - OVERVIEW

MALPRESENTATION: Any presentation other than vertex (occiput) presentation. The fetus presents with a part other than the head. Incidence: 3-4% of all pregnancies at term.
⚠️ WHY IT MATTERS: Malpresentations increase risk of obstructed labour, uterine rupture, fetal distress, birth injuries, and perinatal mortality. Requires early recognition and proper management!
📊 INCIDENCE IN UGANDA:

Malpresentations are more common in:
• Grand multipara (5+ deliveries)
• Polyhydramnios (excess liquor)
• Multiple pregnancies
• Preterm labour
• Uterine anomalies
• Placenta previa

🌀 2. BREECH PRESENTATION (Most Common Malpresentation)

BREECH PRESENTATION: Buttocks or lower limbs present first instead of the head. Buttocks are the presenting part. Occurs in 3-4% of term pregnancies.

📋 TYPES OF BREECH (MEMORIZE THESE!)

🧠 MNEMONIC: FCI = Frank, Complete, Incomplete
1. FRANK BREECH (50-70% of breeches):
  • Thighs flexed at hips, knees extended
  • Feet near head
  • "Pike position"
  • BEST TYPE FOR VAGINAL DELIVERY
2. COMPLETE BREECH (5-10%):
  • Thighs flexed at hips, knees flexed
  • Legs crossed in front of abdomen
  • "Tucked position"
3. INCOMPLETE (FOOTLING) BREECH (10-30%):
  • One or both hips not flexed
  • One or both feet/knees present below buttocks
  • HIGHEST RISK - DO NOT DELIVER VAGINALLY!

🔍 DIAGNOSIS:

  • Abdominal palpation (Leopold's maneuvers): Head in fundus, irregular mass in pelvis
  • Fetal heart heard above umbilicus (instead of below)
  • Vaginal exam: Feel buttocks, feet, or membranes with meconium
  • Ultrasound: confirms type and excludes hydrocephalus

⚠️ RISKS & COMPLICATIONS:

RISKS TO BABY: Cord prolapse, head entrapment, birth asphyxia, intracranial hemorrhage, fractures, brachial plexus injury, organ damage

RISKS TO MOTHER: Obstructed labour, uterine rupture, genital trauma, postpartum hemorrhage
📌 RISK FACTORS FOR BREECH:
  • Prematurity (common before 34 weeks)
  • Uterine anomalies (bicornuate uterus)
  • Fibroids
  • Polyhydramnios or oligohydramnios
  • Placenta previa
  • Previous breech delivery
  • Pelvic tumor blocking head engagement
  • Fetal abnormalities (hydrocephalus, anencephaly)

🏥 MANAGEMENT:

ANTENATAL (Before Labour):
• EXTERNAL CEPHALIC VERSION (ECV) at 37 weeks
• Done by skilled doctor in hospital with surgical facilities
• Contraindications: APH, placenta previa, hypertension, fetal compromise
INTRAPARTUM MANAGEMENT:

OPTION 1: EMERGENCY CAESAREAN SECTION (Preferred for most breeches in Uganda!)
  • Most breech deliveries in Uganda are by CS due to lack of skilled providers
  • Indications: Footling breech, large baby, fetal distress, CPD, previous CS

OPTION 2: VAGINAL BREECH DELIVERY (Only if ALL criteria met!)
  • ✅ Frank or complete breech
  • ✅ Estimated fetal weight 2.5-3.5 kg
  • ✅ Adequate pelvis (clinical assessment)
  • ✅ Flexed fetal head
  • ✅ No other complications
  • ✅ EXPERIENCED PROVIDER AVAILABLE!
🎯 VAGINAL BREECH DELIVERY TECHNIQUE (If certified to perform!):
  1. Allow spontaneous descent to umbilicus
  2. Keep hands OFF until buttocks appear (Hands-off technique)
  3. Rotate baby to sacro-anterior position
  4. Deliver legs if extended
  5. Wrap body in towel for traction
  6. Deliver shoulders using Lovset's manoeuvre
  7. Deliver head using Mauriceau-Smellie-Veit manoeuvre
  8. NEVER PULL ON THE BABY!
🚨 IN UGANDA: Due to limited skilled providers, most breech deliveries are by CS. As certificate nurse, your role is early recognition, stabilization, and urgent referral!

😮 3. FACE & BROW PRESENTATIONS

FACE PRESENTATION: Head hyperextended, face is presenting part. Mentum (chin) is denominator.
INCIDENCE: 1 in 500-600 deliveries (0.2%)

📊 TYPES OF FACE PRESENTATION:

🧠 MNEMONIC: MAP = Mentum Anterior, Posterior

1. MENTUM ANTERIOR (MA): Chin towards front of mother
  • Can deliver vaginally if MA persists
  • Labour is often prolonged
2. MENTUM POSTERIOR (MP): Chin towards mother's back
  • CANNOT deliver vaginally - head cannot extend further!
  • Requires emergency CS

🔍 DIAGNOSIS:

  • Abdominal exam: Head not engaged, high head
  • Vaginal exam: Feel nose, mouth, eyes, malar prominences
  • Must differentiate from breech! (Mouth vs anus rule: mouth has hard gums!)
  • DON'T rupture membranes too early - cord prolapse risk!
⚠️ BROW PRESENTATION: Head midway between flexion and extension (forehead presents). RARE! (1 in 2000 deliveries)

UNSTABLE - usually converts to vertex or face during labour

MANAGEMENT: Watch for 1-2 hours in early labour. If persists or arrests → CS! Do NOT deliver vaginally!

💀 4. SHOULDER PRESENTATION (TRANSVERSE LIE)

SHOULDER PRESENTATION: Fetus lies horizontally across uterus. Shoulder, arm, or trunk is presenting part. Acardia presents first.
INCIDENCE: 1 in 300 deliveries (0.3%)
CANNOT DELIVER VAGINALLY!
🚨 THIS IS AN OBSTETRIC EMERGENCY!
• Cannot deliver vaginally - fetal axis doesn't match birth canal
• Risk of cord prolapse, uterine rupture, fetal death
• MUST DELIVER BY CS!

🔍 DIAGNOSIS:

  • Abdominal palpation: Head on one side, breech on opposite side
  • Head not engaged, not in pelvis
  • FHR heard near umbilicus or flanks
  • Vaginal exam: May feel arm, ribs, shoulder
  • Ultrasound confirms diagnosis

⚠️ RISK FACTORS:

  • Grand multiparity (common in Uganda!)
  • Placenta previa
  • Preterm labour
  • Polyhydramnios
  • Uterine anomalies
  • Multiple pregnancy
  • Pelvic tumor blocking head engagement
MANAGEMENT:

ANTENATAL:
• Try external cephalic version at 37 weeks (often fails)
• Admit at 38 weeks for elective CS

INTRAPARTUM:
1. DO NOT LET LABOUR PROGRESS!
2. Emergency CS immediately
3. If membranes rupture and cord prolapses → even more urgent!
4. Stabilize mother and prepare for surgery
5. Monitor fetal heart continuously
🎯 CERTIFICATE NURSE ROLE:

At health centre level, you will likely see this in latent phase. Your job is:
• RECOGNIZE immediately
• Start IV line
• Keep mother nil by mouth (prepare for surgery)
• Monitor FHR
• URGENT REFERRAL to hospital with surgical facilities
• Document everything

🔄 5. MALPOSITIONS (OCCIPITO-POSTERIOR & OCCIPITO-TRANSVERSE)

MALPOSITION: Head is presenting but occiput is not anterior (not facing mother's front). Common in early labour, most rotate to OA during descent.
OCCIPITO-POSTERIOR (OP): Occiput towards mother's back
OCCIPITO-TRANSVERSE (OT): Occiput towards mother's side

📊 INCIDENCE:

  • OP: 10-20% in early labour, 5-10% at delivery
  • OT: Common in early labour, usually rotates
  • More common in primigravida, android pelvis

⚠️ DIAGNOSIS:

  • Abdominal exam: Head not engaged, limbs palpable anteriorly
  • Vaginal exam: Fontanelles in unusual positions:
    • OP: Anterior fontanelle easily felt anteriorly
    • OT: Fontanelles on sides
  • FHR heard clearly on maternal back!

💢 CLINICAL FEATURES:

OP POSITION CAUSES:
  • Early rupture of membranes
  • Inadequate uterine contractions
  • Pelvic contraction
  • Deflexed head
  • Android or anthropoid pelvis
⚠️ COMPLICATIONS OF PERSISTENT OP:
• "BACKACHES" - severe back pain during labour
• Prolonged labour (failure of rotation)
• Deep transverse arrest
• Fetal distress
• Obstructed labour
• Increased need for CS or assisted delivery

🏥 MANAGEMENT:

🧠 MANAGEMENT: WAIT & WATCH, ASSIST, OR SURGERY

1. CONSERVATIVE MANAGEMENT (Wait & Watch):
  • Most OP positions rotate to OA during descent
  • Encourage mobility, hands-and-knees position
  • Adequate hydration and rest
  • Monitor progress with partogram
2. ACTIVE MANAGEMENT (Assist Rotation):
  • Artificial rupture of membranes (AROM) if head engaged
  • Oxytocin augmentation if poor contractions
  • Manual rotation (by skilled doctor)
3. SURGERY:
  • CS if persistent OP with arrested progress
  • CS if fetal distress
  • Kielland's forceps (rarely used, need expertise)
💡 PRACTICAL TIP: In Uganda's health centres, most OP positions that don't resolve are referred for CS. Your role is monitoring, identifying arrest, and timely referral!

💪 6. ABNORMAL UTERINE ACTION

ABNORMAL UTERINE ACTION: Contractions that are ineffective, uncoordinated, or excessive, leading to poor cervical dilatation and descent of fetus.

📋 TYPES:

🧠 TYPES: H I P = Hypertonic, Incoordinate, Precipitate
1. HYPERTONIC UTERINE ACTION (Primary Uterine Inertia):
  • FEATURES: Painful, frequent contractions but POOR cervical dilatation
  • OCCURS: In latent phase of labour
  • CAUSES: Anxiety, exhaustion, dehydration, full bladder/rectum
  • MANAGEMENT: Rest, sedation, hydration, empty bladder/rectum, emotional support
2. INCOORDINATE UTERINE ACTION (Secondary Uterine Inertia):
  • FEATURES: Irregular, weak contractions. Good contractions then stop. Arrest of progress.
  • OCCURS: In active phase, after good progress
  • CAUSES: CPD, malposition, cephalopelvic disproportion, exhaustion
  • MANAGEMENT: Correct cause, oxytocin augmentation if no obstruction, CS if CPD
3. PRECIPITATE LABOUR (Excessive Uterine Action):
  • FEATURES: Labour < 3 hours from onset to delivery. Violent, frequent contractions.
  • RISKS: Uterine rupture, maternal lacerations, PPH, amniotic fluid embolism, fetal hypoxia, intracranial hemorrhage
  • MANAGEMENT: Left lateral position, Tocolytics (salbutamol), prepare for rapid delivery, manage PPH risk
⚠️ HOW TO RECOGNIZE:
• Partogram shows poor cervical dilatation despite strong contractions
• Mother exhausted, dehydrated
• Fetal distress may develop
• Progress slows or stops
💡 CERTIFICATE NURSE ROLE: Plot contractions on partogram every 30 minutes. If >3 contractions/10 minutes but slow progress → suspect abnormal uterine action. Report to doctor/midwife immediately!

💓 7. FETAL DISTRESS

FETAL DISTRESS: Compromise of fetus during labour due to lack of oxygen (hypoxia) or other problems. Indicates impending fetal death if not promptly managed.
🚨 RECOGNITION IS CRITICAL! Fetal distress is THE major indication for emergency intervention. Every certificate nurse must master fetal heart rate (FHR) monitoring!

❓ CAUSES OF FETAL DISTRESS:

🧠 CAUSES: PROMAF
  • Prolonged labour (uterine exhaustion)
  • Rupture of uterus/scar
  • Oligohydramnios (reduced liquor)
  • Meconium aspiration
  • Abruptio placentae
  • Fever/maternal infection
  • Prolapsed cord
  • Hypotension (maternal)
  • CPD/obstructed labour
  • Anaemia (severe maternal)

🔍 DIAGNOSIS - HOW TO RECOGNIZE:

1. FETAL HEART RATE CHANGES (Most Important!):
  • TACHYCARDIA: >160 beats/min for >10 minutes
  • BRADYCARDIA: <110 beats/min for >10 minutes
  • DECREASED VARIABILITY: <5 beats/min variation
  • LATE DECELERATIONS: FHR drops after contraction (pathological)
  • SEVERE VARIABLE DECELERATIONS: >60 beats drop, lasts >60 seconds
2. OTHER SIGNS:
  • Meconium-stained liquor (green/black fluid)
  • Decreased fetal movements (mother reports)
  • Abnormal fetal growth (IUGR)
  • Maternal fever, infection
⚠️ CATEGORIES OF FETAL HEART RATE (WHO Guidelines):
• NORMAL: 120-160 bpm with good variability
• SUSPICIOUS: One non-reassuring feature (e.g., mild bradycardia 100-110)
• PATHOLOGICAL: Two or more non-reassuring features OR one abnormal feature (e.g., bradycardia <100)

🏥 MANAGEMENT OF FETAL DISTRESS:

IMMEDIATE ACTIONS:

A. INTRAPARTUM (During Labour):
  1. LEFT LATERAL POSITION: Improves uteroplacental blood flow
  2. STOP OXYTOCIN: If running (reduces uterine contraction stress)
  3. GIVE OXYGEN: 4-6 L/min via mask to mother
  4. IV FLUIDS: Increase rate (improves perfusion)
  5. CHECK VITALS: BP, pulse, temperature
  6. VAGINAL EXAM: Check for cord prolapse, cervical dilatation, progress
  7. FHR MONITORING: Continuous if pathological
  8. URGENT ACTION: Prepare for emergency delivery (CS if no progress)
🎯 CERTIFICATE NURSE ACTIONS:
  1. Take FHR every 15-30 minutes in active labour
  2. Plot on partogram immediately
  3. Report SUSPICIOUS or PATHOLOGICAL FHR immediately to midwife/doctor
  4. Prepare for emergency interventions
  5. Do not leave mother alone if FHR abnormal
  6. Assist with position changes, oxygen administration
🧠 EMERGENCY MANAGEMENT: SOOOO = Stop Oxytocin, Oxygen, On left side, Open IV, Observe, Operate if needed

🆘 8. CORD PROLAPSE (THE ULTIMATE EMERGENCY!)

CORD PROLAPSE: Umbilical cord passes through cervix ahead of presenting part. Cord is compressed between baby and pelvis → cuts off blood supply → fetal asphyxia and death within MINUTES!
🚨 THIS IS THE MOST CRITICAL OBSTETRIC EMERGENCY!
• Fetal mortality: 50% if not managed immediately!
• Every second counts - you have 5-10 minutes to save baby!
• REQUIRES IMMEDIATE EMERGENCY CS!

📊 TYPES:

🧠 TYPES: OPC = Occult, Partial, Complete
  • OCCULT PROLAPSE: Cord trapped alongside head but not visible
  • PARTIAL PROLAPSE: Cord in vagina but not out of introitus
  • COMPLETE PROLAPSE: Cord visible outside vagina

⚠️ RISK FACTORS:

  • Malpresentations (breech, transverse lie)
  • High head before rupture of membranes
  • Polyhydramnios (sudden gush of fluid)
  • Unstable lie
  • Multiple pregnancy (2nd twin)
  • Low-lying placenta
  • Small baby
  • Artificial rupture when head high

🔍 DIAGNOSIS:

  • Sudden fetal bradycardia after membrane rupture
  • Variable decelerations
  • See/feel cord during vaginal exam
  • Mother reports "something coming out"
🚨 IMMEDIATE EMERGENCY MANAGEMENT - DO NOT DELAY!

STEP 1: RECOGNIZE & CALL FOR HELP (30 seconds!)
  • Shout for help immediately
  • Call senior midwife/doctor
  • Alert theatre for emergency CS

STEP 2: RELIEVE CORD COMPRESSION (FIRST PRIORITY!)
  1. POSITION: Put mother in knee-chest or exaggerated Sims position (left lateral) - uses gravity to move baby off cord
  2. ELEVATE PRESENTING PART: Insert sterile gloved hand into vagina. Push presenting part up into uterus to relieve pressure on cord. KEEP HAND IN PLACE until CS starts!
  3. GIVE TOCOLYTICS: Salbutamol 0.5mg SC to relax uterus
  4. FILL BLADDER: 500-750ml saline via catheter - pushes baby up

STEP 3: PREPARE FOR EMERGENCY CS
  1. OXYGEN: Give mother 100% oxygen via tight-fitting mask
  2. IV FLUIDS: Start large-bore IV (16G), run fast
  3. MONITOR FHR: Continuous if possible
  4. CONSENT: Explain urgency, get consent for CS
  5. PRE-OP PREP: Blood for HB, grouping, crossmatch
  6. URGENT CS: Aim for delivery within 10-15 minutes!

STEP 4: IF BABDY IS COMING NOW (Too late for CS!)
  • Quick vaginal delivery if cervix fully dilated
  • Push cord back gently during contraction
  • Clamp and cut cord immediately after delivery
  • Resuscitate baby aggressively
🧠 EMERGENCY PROTOCOL: HELP-PECS
Help, Elevate, Left lateral, Position, Oxygen, Emergency CS, C-circulation, Stabilize
🎯 CERTIFICATE NURSE ROLE IN CORD PROLAPSE:
  1. RECOGNIZE IMMEDIATELY: Sudden fetal bradycardia after ROM = suspect cord prolapse!
  2. CALL FOR HELP: Don't wait - shout for senior immediately
  3. POSITION MOTHER: Knee-chest or left lateral position
  4. GIVE OXYGEN: Start oxygen at 6L/min
  5. START IV: Large bore, run fluids fast
  6. URGENT REFERRAL: If at health centre, transfer immediately with nurse's hand in vagina if needed to keep pressure off cord!
  7. DOCUMENT: Time of ROM, time cord seen, actions taken, FHR
🌍 IN RURAL UGANDA: If at HC II/III without CS, your job is to keep pressure off cord (hand in vagina if trained) and REFER IMMEDIATELY. Never leave the patient - go with her to hospital!
⏱️ TIMING IS EVERYTHING:
• Cord occlusion for >5 minutes → severe brain damage
• Cord occlusion for >10 minutes → fetal death likely
• Target: Delivery within 10-15 minutes of diagnosis
• Your speed in recognition and action saves lives!

🚫 9. DEEP TRANSVERSE ARREST & CPD

DEEP TRANSVERSE ARREST: Head is deeply engaged in mid-pelvis but stuck in transverse position (OT). Cannot rotate or descend further.
CEPHALOPELVIC DISPROPORTION (CPD): Baby's head is too large to pass through mother's pelvis.
⚠️ These conditions often coexist and are major causes of obstructed labour in Uganda!
• Must be recognized early to prevent uterine rupture
• REQUIRES CS!

🔍 SIGNS OF DEEP TRANSVERSE ARREST:

  • Strong contractions but no descent for >2 hours
  • Cervix fully or nearly fully dilated
  • Head at 0 to +1 station, transverse position
  • Mother exhausted, distressed
  • Caput and moulding present
  • Bandl's ring may appear (sign of obstructed labour!)

🔍 SIGNS OF CPD:

  • Large baby (fundal height >40cm, ultrasound >4kg)
  • Small mother, android pelvis
  • Failure to engage at term
  • Prolonged labour with poor progress
  • Excessive caput and moulding
MANAGEMENT:

1. DEEP TRANSVERSE ARREST:
  • Attempt manual rotation (by senior obstetrician)
  • If fails or fetal distress → EMERGENCY CS!

2. CPD:
  • ELECTIVE CS BEFORE LABOUR if diagnosed antenatally
  • If in labour → CS (do not attempt vaginal delivery)
  • Never use oxytocin if CPD suspected!
🎯 CERTIFICATE NURSE: Plot progress on partogram. If no progress for >2 hours despite good contractions → suspect arrest/CPD. Report immediately!

📝 LIKELY EXAM QUESTIONS FOR DAY 6 📝

1. FILL-IN-THE-BLANK (2 marks)

The three types of breech presentation are Frank, Complete, and Incomplete/Footling.

2. FILL-IN-THE-BLANK (2 marks)

Cord prolapse is an emergency because it can cause fetal death within 5-10 minutes due to cord compression.

3. MULTIPLE CHOICE (2 marks)

Which type of breech has the HIGHEST risk and should never deliver vaginally?

4. MULTIPLE CHOICE (2 marks)

The most appropriate immediate action for cord prolapse is:

5. MULTIPLE CHOICE (2 marks)

Fetal distress is BEST diagnosed by:

6. FILL-IN-THE-BLANK (2 marks)

The ideal position for a mother with cord prolapse while awaiting CS is knee-chest or exaggerated left lateral position.

7. SHORT ANSWER (5 marks)

Describe the steps you would take as a certificate nurse when you diagnose cord prolapse during vaginal examination.

ANSWER GUIDE:
• Call for help immediately
• Position mother knee-chest
• Insert hand to elevate presenting part
• Administer oxygen
• Start IV fluids
• Prepare for urgent CS
• Monitor FHR
• Document all actions

8. SHORT ANSWER (5 marks)

What are the three main features of hypertonic uterine action?

ANSWER GUIDE: Painful frequent contractions, poor cervical dilatation, occurs in latent phase. Mother exhausted but cervix not opening.

9. LIST QUESTION (10 marks)

List five (5) risk factors for breech presentation and explain why each increases the risk.

ANSWER GUIDE: Prematurity, uterine anomalies, polyhydramnios, placenta previa, multiple pregnancy, fibroids. Explain how each prevents head from engaging.

10. MULTIPLE CHOICE (2 marks)

Which of the following is a sign of cephalopelvic disproportion (CPD)?

11. PRACTICAL SCENARIO (10 marks)

You are a certificate nurse at a rural health centre. A 28-year-old G5P4 at 40 weeks comes in labour. Abdominal exam shows breech presentation. Membranes rupture and you see the umbilical cord at the introitus. What do you do? (Consider your level, available resources, and referral system).

ANSWER GUIDE:
• Recognize cord prolapse emergency
• Call for help immediately
• Position mother knee-chest
• Insert hand to elevate presenting part if trained
• Give oxygen, start IV
• Call ambulance for urgent referral
• Accompany patient if possible
• Document everything
• Call ahead to referral hospital

12. ESSAY QUESTION (15 marks)

Discuss the management of a patient with persistent occipito-posterior position in active labour. Include both conservative and surgical options.

ANSWER GUIDE: Discuss conservative (wait, mobility, hands-knees), augmentation (AROM, oxytocin), manual rotation, and CS indications. Emphasize monitoring and when to intervene.
📊 EXAM STATISTICS: Cord prolapse and breech management appear in 90% of UNMEB midwifery exams. Master the emergency protocols!
⏱️ Study Time: 7-8 hours
Difficulty Level: ★ ★ ★ ★ ★ (Very Difficult - Critical Skills)

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