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Pathologic Obstetrics
CPD- in Rickets

Abnormalities of Expulsive Forces

Dystocia 1st stage of labor: contractions of the uterus will lead to cervical
Dr. Sylvia Carnero dilatation, propulsion and expulsion of the fetus
Dystocia 2nd stage of labor: there will be additional voluntary or involuntary
- difficult labor characterized by abnormally slow progress of muscular action of abdominal wall – this is when the mother is
labor “Pushing” or “bearing down”
Four Distinct Abnormalities
1. Abnormalities of the expulsive forces – uterine contractions Three significant advances in the treatment of uterine dysfunction:
which may be insufficiently strong or inappropriately 1. Prolongation of labor – may lead to perinatal morbidity and
coordinated to efface and dilate the cervix and it is also known mortality
as uterine dysfunction 2. Dilute intravenous infusion of oxytocin in the treatment of
2. Abnormalities of presentation, position, or development of the hypotonic uterine dysfunction
fetus 3. Use of cesarean delivery rather than difficult mid-forceps delivery
3. Abnormalities of the maternal bony pelvis when oxytocin fails, or its use is inappropriate
4. Abnormalities of soft tissues of the reproductive tract
Two types of Uterine Dysfunction
Categories According to the American College of Obstetricians I. Hypotonic uterine dysfunction
and Gynecologists - More common
- we can group this into 3 Ps - Occurs during active phase of labor
- No basal hypertonus
1. Abnormalities of the Powers – uterine contractility and
maternal expulsive effort may be insufficient - Uterine contractions have a normal gradient pattern
2. Abnormalities involving the Passenger – which is the fetus; any (synchronous)
abnormalities in the development and presentation of the - The problem here is that there is only a slight raise in pressure
fetus may cause dystocia position size malformation
, ,
during a contraction which is insufficient to dilate the cervix
3. Abnormalities of the Passage – the pelvis - Treatment: oxytocin (if there is no CPD)to augment labor
II. Hypertonic/incoordinate uterine dysfunction
According to the Canadians, the RCOT, there is a fourth P which - Basal tone is elevated in bet. contraction there is no relaxation
; ,

is Psyche. Because stress-related hormones are secreted - Occurs during latent phase of labor more pain
during labor when woman is under stress and is anxious. These - Pressure gradient is distorted (asynchronism)
stress-related hormones are the beta-endorphins, cortisol,
- There is usually a fundal dominance in the pressure gradient
ACTH, and epinephrine
(pressure is highest at the fundus); diminishing towards the
midportion of the uterus, and lowest at the lower uterine
Common clinical findings in women with ineffective labor
segment
I. Inadequate dilatation or fetal descent
 Protracted labor – slow progress - Treatment: sedation (because the contractions are
 Arrested labor – no progress incoordinate and with hypertonus, this will be painful and will
 Inadequate expulsive effort – ineffective pushing during not help in the dilatation, and because there is frequent
2nd stage of labor contractions without complete relaxation in between
II. Fetopelvic disproportion contractions, making the possibility of having fetal hypoxia is
 Excessive fetal size – even when pelvis is adequate higher because the blood vessels are compressed having lesser
 Inadequate pelvic capacity – pelvis is contracted blood supply to the fetus)
 Malpresentation or position of the fetus – the presenting
part is the bigger diameters of the fetal head ABNORMAL LABOR PATTERNS, DIAGNOSTIC CRITERIA, AND METHODS
III. Ruptured membranes without labor OF TREATMENT

Mechanism of Dystocia
At the end of pregnancy: only give
if
there's rupture Bow
&
Obstacles for the fetal head as it traverses the birth canal:
 Thicker lower uterine segment
 Undilated cervix
 Less developed and less powerful fundal muscles / pelvic
Factors influencing the progress of the 1st stage of labor
 Uterine contractions
 Cervical resistance
 Forward pressure exerted by the leading fetal part
Second stage of labor (fully dilated cervix):
 Fetopelvic proportion is observed – relationship of the fetal
head size position with pelvic capacity is observed
 Uterine muscle malfunction results from uterine
overdistension or obstructed labor or both *study this table*

Therefore, ineffective labor is a possible warning sign of Follow the table.

fetopelvic disproportion Prolongation Disorder like prolonged latent phase which is >20hrs in
- When ineffective labor is diagnosed, it should not be Nulliparas and >14 hrs in Multiparas and the preferred treatment is
managed immediately by giving oxytocin or stimulation bed rest. The exceptional treatment such as administration of
of uterine contractions as there might be fetopelvic oxytocin or cesarean section is only for urgent problems such as
disproportion and might lead to uterine rupture
Sources: 2021 lecture video part 1, Chelseashell Trans, *F : UD

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Pathologic Obstetrics

prelabor rupture of memebranes (PROM) to prevent Functional Division of Labor

chorioamnionitis we should stimulate labor.
Protraction Disorders, protracted active phase dilatation
meaning that the rate of dilatation is <1.2cm/hr in Nulliparas
and 1.5cm/hr in Multiparas. Expectant and supportive
treatment. You only do cesarean if there is cephalopelvic
disproportion (CPD). The same with protracted descend.
Arrest Disorders. Prolonged deceleration phase which is >3hrs in
Nulliparas and >1hr in Multiparas. If we have ruled out CPD we
can administer Oxytocin and advise rest if the mother is
exhausted.
Secondary arrest of dilatation – there is no progress or after
the start of active labor it stops before full cervical is reached
Arrest of descent – lack of progress of descent after it has
gone down beyond station 0 after more than 1 hour for both
nulliparas and multiparas. Treatment is CS if there is CPD.
Failure of descent – no descent or lack of expected descent
during the deceleration phase and 2nd stage of labor which is Preparatory - Includes the latent and acceleration
the pelvic division of labor. Treatment is CS if there is CPD if none Division phase; little is happening by way of dilatation and
give oxytocin. descent. It is during this interval that the cervix is
being prepared for later active dilatation, so the
FRIEDMANS CURVE changes here are found subcellular alteration of
the ground substance, collagen, reticulum, and
other connective tissues resulting in softening and
effacement of the cervix.
- Effacement of the cervix is important because
even if the cervix is 6cm dilated, if the cervix is 1 ½
cm long, the progress of delivery is slow
- Contractions become coordinated, polarized,
and oriented
In nulliparas: by the time they enter into the
process of labor, most of the patients, will have
their presenting part already engaged, and have
passed Station 0.
Dilatation - corresponds to phase of maximal slope, a time
Division when there is very rapid progression and
cervical dilatation. Again, abnormalities in cervical
dilatation will be diagnosed during this phase, no
Violet line - Descent curve A W b .
C .

problems yet when it comes to descent

Pink line - Dilatation of cervix curve Pelvic - includes both the deceleration and the 2nd
Sigmoid Shaped Curve Division stage of labor; progressive linear descent of the
fetal head until it goes down to the outlet and
Dilatation Pattern delivery is accomplished
- follow the pink line
Latent Phase From the start of the uterine contractions until Normal Descent Pattern
before the cervix reaches 4 cms
3 division:
1. Acceleration Phase - there is an upswing
of progress of cervical dilatation as
compared to latent phase wherein dilatation
doesn’t really progress much. The dilatation
from 4cm to 8cm is the entry to the phase of
maximum slope. This is the time when you
diagnose abnormalities in cervical dilatation
because the rate of dilatation is <1.2cm/hr
Active Phase for nulliparas and <1.5cm/hr for multiparas.
2. Phase of maximum slope
3. Deceleration Phase - not much of
dilatation, but rather, retraction of the cervix
which is around the presenting part (head of
the fetus). So, it is pushed/retracted upwards,
cephalad, and by the time the cervix is no
longer palpable, that is the time you reach
the 2nd stage of labor. Preparatory - during the early part of labor there is
As long as the cervix is still palpable, and you Division/Latent not much descent going on
think the dilatation has reached 10cm, you Phase
have not reached 2nd stage of labor unless Dilatation Division/ - Where the acceleration of descent
the cervix has been fully retracted above the Phase of Maximum starts
head of the baby. Slope
Sources: 2021 lecture video part 1, Chelseashell Trans,
25th Edition Williams Obstetrics Chapter 23 2
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Pathologic Obstetrics

Pelvic Division/ - Where liner progression of descent Rouse and Owen (1999)
Deceleration
⑧
occurs when the cervix is 9cm dilated
and going to full dilatation
Challenged the “2-hour rule” on the grounds that a longer time, that
is, at least 4 hours, is necessary before concluding that the active
* rapid progression
- descend will be rapid phase of labor has failed.
of descent fetal head - During this time, abnormalities in 2014 ACOG AND SMFM CONSENSUS
-
-

descent is diagnosed. Due to the increasing rate of cesarean section. This consensus was
made in order to prevent primary cesarean delivery. In order to
-
-

Abnormal Descent Pattern decrease incidence CS, you have to prevent the first CS as that
usually leads to subsequent CS

& engagement
-

Protracted - There is descent of the head, but very slow in

Descent progress
(RED) - Does not follow the 2cm/hr for multiparas and
1cm/hr in nulliparas
- Can still lead to delivery, but labor will be
prolonged
Failure of - There is descent of the head, but does not
Descent progress beyond station 0
(BLUE) - Because the definition of failure of descent is
lack of expected descent during the pelvic RECOMMENDATIONS OF OBSTETRIC CARE CONSENSUS COMMITTEE
division (deceleration phase and 2nd stage of (2016)
labor). Remember that it is during the pelvic - the same as the 2014 recommendation, this is just to reaffirm the
division that the mechanism of labor takes place, previous ones
and the cardinal movements of labor occur. 1. Admonishes against CS delivery in the latent phase of labor.
Review: Cardinal movement of labor starts with - A prolonged latent phase is not an indication for cesarean delivery
engagement (station 0), descent, flexion, internal 2. Does not recommend cesarean delivery if labor is progressive but
rotation, extension, external rotation and slow – protraction disorder
expulsion. Typically managed with:
- If the station of the head does not go beyond  Observation
station 0, and your cervix is already 9-10cm  Assessment of uterine activity
dilated, then the other cardinal movements don’t  Stimulation of contractions as needed
happen (ONLY ENGAGEMENT). 3. A cervical dilatation of 6cm –j not 4cm – is now the recommended
Arrest of - If the head descents beyond station 0 but it does threshold to herald active labor
Descent not progress any further 4. Cesarean delivery for active phase arrest should be reserved for
(YELLOW) - Lack of progress of descent after it has gone women at or beyond 6cm of cervical dilatation, with ruptured
did not
progress beyond station 0 after more than 1 hour membranes who fail to progress despite 4 hours of adequate uterine
activity, or at least 6 hours of oxytocin administration with inadequate
Point of reference between arrest of descent and failure of contractions and no cervical change
descent is Station 0
 Failure of Descent – does not go beyond Station 0 Friedman and Zhang
 Arrest of Descent – goes beyond Station 0 then stop

*Cases is at page 6-8*

Active Phase Disorders

Classification:
 Protraction disorder (slower than normal)
 Arrest disorder (complete cessation of progress)
BEFORE THE DIAGNOSIS OF ARREST DURING FIRST STAGE OF
LABOR IS MADE, THESE CRITERIA SHOULD BE MET (ACOG 1989)
1. The latent phase has been completed and the cervix is Comparison of study populations analyzed to define normal labor
dilated 4cm or more curves: Basically, Zhang had more patients, and more patients had
2. A uterine contraction pattern of 200 MVU or more in a 10- epidural analgesia and oxytocin augmentation as compared to
minute period has been present for 2 hours without cervical Friedman.
change

Sources: 2021 lecture video part 1, Chelseashell Trans,

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Rate of change at each stage of cervical dilatation: - This was challenged since some wanted to allow a longer 2nd stage
of labor to decrease operative vaginal delivery rate, and thus
prevent grave neonatal deliveries. However, adverse maternal
outcomes happen with prolonged 2nd stage of labor duration,
although neonatal mortality and morbidity rates are not related with
the length of the 2nd stage. They observed that after the 3rd hour of
the 2nd stage, delivery by CS or delivery by other operative methods
increase progressively. But by 5 hours, the prospect for spontaneous
delivery in the subsequent hours were only 10-15%. Doc believes that
3 hours with regional analgesia is enough to make diagnosis of
prolonged 2nd stage of labor.

This is the 2014 ACOG/SMFM Consensus and was reaffirmed in 2016

The data shows that from 2-5cm, cervical dilatation is slow, but
once 6 cm dilatation is reached, the rate of dilatation becomes
more rapid until the 2nd stage of labor. This is why they use 6cms
as the threshold for active phase of labor.

The finding in Zhang’s study, for the cervix to progress from 4 to 5

cms, it may take as long as 6 hours. For dilatation from 5 to 6cm,
it may take 3 hours, and yet the patient could also deliver
vaginally. After 6cm, it was found there is a rapid progression of
cervical dilatation, prompting the suggestion of making 6cm as
the start of active phase of labor as compared to the previous
4cm. This will prevent unnecessary CS in latent phase of labor.

Cervical dilation curves: Deceleration

Phase

..
RECOMMENDATIONS OF OBSTETRIC CASE CONSENSUS COMMITTEE
(2016) SECOND STAGE OF LABOR
1. Allow nullipara to push for at least 2 hours before diagnosing
second stage of labor arrest
- One caveat is that the maternal and fetal status are both
- -

reassuring *
- The goal to lower CS rates is best balanced by ensuring the
neonatal safety, there is no robust data on neonatal outcomes to
support the safety of allowing the prolonged 2nd stage labor. Data
from many evaluations, review the many serious newborn
Comparison of Friedman and Zhang’s curves. The sigmoid
complications at prolonged 2nd stage labor longer than 3 hours.
shape is Friedman’s (blue line), there is deceleration phase while
with Zhang’s (red line) there's no deceleration, because his
Ruptured Membrane at term
study is retrospective and there’s so many people who took the
- Management: stimulation of contractions when labor did not begin
IE. The deceleration is the time where the cervix is retracted
after 6 to 12 hours (Calkins, 1952)
upwards, and the time when its 2nd stage already you’ll not be
- Induction with oxytocin immediately is better than expected due to
able to palpate the cervical lip. This is very important because if
lower incidence of intrapartum and postpartum infections (Hanna
you diagnosed the patient as fully dilated and you’ll need
and Associates, 2000)
forceps extraction but it’s not really fully dilated, the cervical lip
- Induction is done after admission (Parkland Hosp)
may get caught between the blade of the forceps and head of
the baby and you may cause avulsion of the cervix.
Precipitous Labor and Delivery
- Definition: Extremely rapid labor and delivery (less thanI3 hours)
Second Stage Disorders
Causes
- Incorporates many of the cardinal movements necessary for
 Abnormally low resistance of the soft parts of the birth canal
the fetus to negotiate the birth canal.
 Abnormally strong uterine and abdominal contractions
- Disproportion of the·
fetus and pelvis frequently becomes
- Rarely, absence of painful sensations and thus a lack of awareness
apparent
of vigorous labor – some women have lowthreshold or high threshold
for pain
Duration of 2nd stage of labor
Nulliparas Multiparas
Short Labors
Without regional 2 hrs 1 hr Rate of cervical dilatation:
analgesia lepidural  >5 cm/hr for nulliparas
With regional analgesia 3 hrs 2 hrs  >10 cm/hr for multiparas
- There will be “Bearing down” or “pushing” – contraction of the Associated with:
abdominal musculature to generate increased intra-abdominal  Abruption (20 percent)
pressure together with uterine contractions and this will result in  Meconium
propulsion of the fetus downward  Postpartum hemorrhage

Sources: 2021 lecture video part 1, Chelseashell Trans,

25th Edition Williams Obstetrics Chapter 23 4
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 Low Apgar scores Contracted - Shortest anteroposterior diameter (AP) – less

 Multiparity Pelvic Inlet than 10 cm
 Cocaine abuse
~

- Greatest transverse diameter – less than 12 cm

MUST REMEMBER: Uterus that contracts with unusual vigor before - Diagonal conjugate – less than 11.5 cm - can be
delivery, is likely be hypotonic after delivery, so there is possibility measured directly by the fingers reaching for the
of postpartum hemorrhage because of uterine atony. sacral promontory (which is why you need to
know the measurement of your fingers)
Maternal  Uterine rupture - Fetal biparietal diameter – average – 9.5-9.8 cm
effects  Extensive lacerations of the cervix, vagina, vulva, - Cervical dilatation is facilitated by:
or perineum  Hydrostatic action of the unruptured
 Amniotic fluid embolism /AXE membranes
 Postpartum hemorrhage from uterine atony  Direct application of the presenting part
(hemorrhage from the placental implantation - there is no direct pressure on the cervix and the
site) lower uterine segment, so most of the time, there
is early rupture of membranes and less effective
SERIOUS MATERNAL COMPLICATIONS ARE RARE IF: uterine contractions because in contracted
 The cervix is effaced and compliant pelvis, the head is in a high station, so the head
 The vagina has been stretched previously will not be applying directly to the cervix, it will be
 The perineum is relaxed at the amniotic sac which will be in contact with
Fetal/  Perinatal mortality and morbidity due to the cervix, and with increased uterine
Neonatal decreased uterine blood flow and fetal contraction, the membranes will rupture early
Effects oxygenation - Related to abnormal presentations/asynclitism
 Intracranial trauma (rare) and descent does not take place until after labor
 Erb or Duchene brachial palsy onset
 Injury from fall - no one attending to the mother above the &
- Fetal head floats over pelvic inlet or in one iliac
and the labor is rapid, the baby might fall pelvic
inlet fossa –floating head is when the most dependent
Treatment: any oxytocin agents being administered portion of the head is above the pelvic inlet,
should be Stopped doing the Leopold maneuver, the head will be
freely movable, station is still - 5, the head has not
Fetopelvic Disproportions entered the pelvic inlet.
- Diminished pelvic capacity – measurements of the pelvic - Face and shoulder presentations are three times
diameters are diminished, the pelvic is contracted more frequent
- Excessive fetal size or presentation – macrosomia, extended - Cord prolapse – four to six times more frequent –
head # passenger passage
,
because there is early rupture of the membranes
- More commonly – combination of both without the head firmly applied, so there will be
space, causing the prolapse of the umbilical cord
Different types of Pelvis Obstetrical plane of the midpelvis:
- AP diameter is the Inferior margin of the symphysis pubis
through the ischial spines and touches the sacrum near the
junction of the fourth and fifth vertebrae (S4-S5)
- A transverse line connecting the ischial spines divides the
midpelvis into anterior and posterior portions
- Anterior midpelvis – bounded anteriorly by the lower border of
the symphysis pubis and laterally by the ischiopubic rami
- Posterior midpelvis – bounded dorsally by the sacrum and
laterally by the sacrospinous ligaments

AVERAGE MIDPELVIS MEASUREMENTS (Normal)

- Transverse (interspinous, between the 2 spinous process) =
10.5cm (IS)
- Anteroposterior (lower border of the symphysis pubis to the
&
junction of S4-S5 = 11.5 cm (APM)
- Posterior sagittal (from the midpoint of the interspinous line to
the same point to the sacrum) =O 5 cm (PSM)
Contracted - More common than inlet contraction
Midpelvis - Causes transverse arrest of the fetal head
- IS + PSM IS less than*13.5 cm (normal is around
15.5 cm)
- Interspinous diameter is <8cm
Clinical pelvimetry:
 Spines are prominent
 Pelvic sidewalls converge
 Narrow sacrosciatic notch
Contracted - Interischial tuberous diameter of 8cm or less –
Pelvic can be measured directly by a tape measure or
Outlet ruler, patient in litothomy position
Pelvic outlet likened to 2 triangles:
I. Anterior triangle
 Base – interischial tuberous diameter
Sources: 2021 lecture video part 1, Chelseashell Trans,
25th Edition Williams Obstetrics Chapter 23 5
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Pathologic Obstetrics

 Sides – pubic rami PROBLEM: During the early part of labor the progress of cervical
 Apex – inferior posterior surface of the dilatation is slow, the rate of dilatation is 1cms in 2hrs.
symphysis pubis Answer: The diagnosis at this time is Protracted Cervical Dilatation –
II. Posterior triangle there is just slow progression of dilatation, and was resolved
 Base – interischial tuberous diameter
 No bony sides CASE 2: (Follow the red line)The patient was admitted at 2cms, after
 Apex – tip of the last sacral vertebra (not the 2hrs at 3-4cm dilatation, another 2hrs at 5cms and another 2hrs at
tip of the coccyx) 6cms dilated. Amniotomy and Oxytocin was given to improve
- Often associated with midplane contraction contractions. The patient stayed at 6cms dilatation for 4hrs without
- Pure outlet contraction is rare – no trial of labor any progress.(Follow the blue line) The station of the head started at -
for outlet contraction 1 to station 0 and does not go beyond station 0 for 4hrs hours.
- Related to perineal tears*

Pelvic Fractures
- Trauma from automobile collisions – most common cause
- Fracture pattern, minor malalignment, retained hardware –are
not absolute indication for cesarean section
- Fracture healing requires 8 to 12 weeks, thus recent fracture
(<8 weeks) merits CS
X

- Review of previous radiograph and x-ray pelvimetry later in

pregnancy

Estimation of Pelvic Capacity

 Clinical estimation
 X-ray pelvimetry- not used anymore, not reliable and
possible exposure of the baby to radiation
dO
 Computed tomographic scanning (250-1500 mrad) – I

reduced radiation exposure, greater accuracy and easier CS

performance as compared to conventional x-ray -

 Magnetic resonance – lack of radiation, accurate

measurements, complete fetal imaging, evaluate soft Answer: Arrest of Cervical Dilatation
tissue dystocia Rationale: The character of uterine contractions was good (bec
oxytocin was given) so the problem is not the powers. Any arrest
Fetal Dimensions in fetopelvic disproportion would be most likely due to CPD. Since Station is at 0, then problem is
- Estimation of fetal head size: at midplane. Since the cervix only 6cm dilated, you are still not in the
1. Clinical (Mueller Hillis Maneuver) pelvic division (since in the deceleration phase, you need to
- Fetal brow and suboccipital region are grasped be >8cm dilated)you can’t diagnose any abnormalities on descent.
through the abdominal wall with the fingers and firm Kaya cervical dilatation arrest lang pwede.
pressure is directed downward in the axis of the inlet
2. Sonogram – fetopelvic index CASE 3: (Follow the red line)Patient admitted at 7cms dilatation of
- No satisfactory method for prediction of fetopelvic cervix at 6 hour of labor and amniotomy was done and oxytocin
disproportion were administered. After 2hrs at 8cms, another 2hrs at 9cm and
stayed at 9cm for 4hrs. (Follow the blue line) Station of the head
Example Cases started at -1 to 0 when the cervix is at 9cm dilated for 4hrs and did
CASE 1: (Follow the red line)Admitted at the 4th hour of labor at not progress.
2cms dilatation, and the after two hours the cervix became
3cms, after another two hours became 4cms, another 2 hours at
5cms, another more than 2 hours at 6cms. When there is
spontaneous rupture of membranes, and administration of
oxytocin there was progression up to full cervical dilatation.
(Follow the blue line) The station of the head started at -1,
descended to 0 and then +1, once it reached the pelvic
division it is already 8cm and the descend rapidly and the baby
was delivered spontaneously.

Answer: Prolonged Deceleration Phase with Failure of Descent

Rationale: Since 9cm dilated, the pelvic division is reached,
then diagnosis on descent abnormalities can be used. More
than >3hrs (for primi) or >1 hr (for multi) of deceleration phase
is already prolonged.
Sources: 2021 lecture video part 1, Chelseashell Trans,
25th Edition Williams Obstetrics Chapter 23 6
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Pathologic Obstetrics

CASE 4:(Follow the red line)Admitted at 6cm dilatation at the This is just for prolonged latent phase with aog not more than 41
6hr of labor. Amniotomy and oxytocin were administered. After weeks and no proble with the mother and the baby.
2hrs at 7cms, after another 2hrs at 8cm and another 2hrs
became fully dilated. (Follow the blue line)Started at Station 0 CASE 2: G1P0 39 weeks AOG with good progression of cervical
the went down to +1 when the cervix is fully dilated. dilatation from 4 to 7 cm and descent from station -1 to 0.
Amniotomy was done and oxytocin augmentation started.
Findings remained the same for 4 hours with uterine contraction
intensity of 230 Montevideo units. good
1. What is the diagnosis?
a. Protracted cervical dilatation
b. Arrest in cervical dilatation
c. Prolonged deceleration phase
d. Arrest in descent
Answer: Arrest in cervical dilatation - there is no problem in descent
because the patient is only 7 cm dilated. She is not yet fully dilated.
Only diagnose an abnormality in descent if the pelvic division
(beyond 8 cm) is reached.

Level of station 0:
Midpelvis/Midplane
Answer: Prolonged 2nd stage of Labor and Arrest of Descent
Rationale: Patient is at full cervical dilatation so no dilatation
problem. The problem is now on descent as it was stuck at +1
for more than 3 hours. Since the patient also stayed fully
dilated for 3 hours, there is also prolonged 2nd stage of labor. Complete diagnosis: G1P0 39 weeks, pregnancy uterine, Arrest in
cervical dilatation
Remember:
Dilatational Division/Phase of maximum slope - diagnosis of 2. What is the appropriate management?
abnormalities in dilatation a. Continue to observe for another 2 hours
Pelvic Division/Deceleration - diagnosis of abnormalities in b. Increase the dose of oxytocin
descent. c. Operative vaginal delivery
d. Cesarean delivery
Answer: Cesarean delivery
Cases from synchronous lecture CS because contractions are good at 230 Montevideo units thus
CASE 1: A 25 year old G1P0 39 weeks AOG has been having there is no need to increase the dose of oxytocin.
mild contractions every 10 to 30 minutes lasting for 20 to 30 *It should fulfill the criteria go back to page 3 on Active Labor
seconds, for more than 20 hours. On IE, cervix 2 cm dilated, 1 disorders*
cm long, soft, cephalic presentation, station -2, intact BOW. Vital
signs are normal, FHR reassuring CASE 3: G1P0 39 weeks AOG admitted with 5 cm dilated cervix 60%
effaced intact BOW LOA station -1. Two hours later, cervix 7 cm
1. What is the labor pattern? dilated 80% effaced intact BOW station -1. Contractions every 3 to 4
a. False labor minutes, 40 to 50 seconds duration, moderate. Amniotomy was done
b. Prolonged latent phase and oxytocin augmentation started. Two hours later, cervix 9 cm
c. Protracted cervical dilatation dilated 90% effaced station 0. Findings remained the same for 4 hours.
d. Arrest in cervical dilatation 1. What is the diagnosis?
Answer: Prolonged latent phase because labor is already more a. Arrest in cervical dilataion
than 20 hours and the cervix is dilated to 2 cm. If this is a false b. Arrest in cervical dilation with failure of descent
labor, the cervix will not dilate. c. Prolonged deceleration phase with failure of descent
d. Prolonged deceleration phase with arrest of descent
Answer: Prolonged deceleration phase with failure of descent
Normally, when pelvic division is reached, the descent will be fast.
However with the patient, the baby is not descending hence there
might be a problem (i.e. CPD

2. What is the appropriate management? Complete diagnosis: G1P0, 39 weeks aog, pregnancy uterine,
a. Rest and sedation prolonged deceleration phase with failure of descent probably due
b. Amniotomy to cerphalopelvic disproportion (CPD) at midplane (station 0).
c. Oxytocin augmentation
d. Cesarean section 2. What is the management?
Answer: Rest and sedation a. Observe for another 2 hours
This is the preferred treatment for prolonged latent phase. Do b. Forceps delivery
not do any intervention if the baby and mother is okay. c. Vacuum extraction
IF you do amniotomy (letter b), you are committed to deliver d. Cesarean delivery
that baby, and you do not to oxytocin augmentation (c) or Answer: Cesarean delivery -
cesarean section (d) because there is no indication. Not forceps - because at station 0 (mas preferred ang outlet), the
cervix is not yet fully dilated it may cause the cervical lip be caught
Sources: 2021 lecture video part 1, Chelseashell Trans,
25th Edition Williams Obstetrics Chapter 23 7
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 FAR EASTERN UNIVERSITY - NICANOR REYES MEDICAL FOUNDATION
Pathologic Obstetrics

between the head of the baby and the forceps blade. Already
9 cm dilated for 4 hours at station 0. )

CASE 4: G1P0 40 weeks AOG admitted with a fully dilated cervix,

ruptured BOW, LOA, station +1, with good uterine contractions.
She has been bearing down for 3 hours with no change in the
station of the head.
1. What is the diagnosis?
a. Prolonged deceleration phase with failure of descent
b. Prolonged deceleration phase with arrest of descent
c. Prolonged second stage with failure of descent
d. Prolonged second stage with arrest of descent
Answer: Prolonged second stage with arrest of descent

Complete diagnosis: G1P0 40 weeks, pregnancy uterine,

prolonged second stage with arrest of descent probably due to
cephalopelvic disproportion (CPD) at the level of midplane.

2. What is the management?

a. Observe for another hour
b. Forceps delivery
c. Vacuum extraction
d. Cesarean delivery
Answer: Cesarean delivery
Explanation: Forceps delivery is not advisable because the baby
is only at station +1.

CASE 5: Clinical pelvimetry of a G1P0 at 37 weeks revealed

sacral promontory reached at 11 cm, convergent sidewalls,
prominent ischial spines, narrow sacrosciatic notches, subpubic
angle 45 degrees.
1. What is your interpretation?
a. Contracted inlet
b. Contracted midplane
c. Contracted outlet
d. Universally contracted pelvis
Answer: Universally contracted pelvis -means all levels are
affected
 Sacral promontory is reached at 11 cm (contracted inlet).
 Prominent ischial spines, narrow sacrosciatic notches,
convergence sidewalls (contracted mid-plane).
 Subpubic angle 45 degrees - narrowed (contracted outlet)
*go back to page 5*

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Sources: 2021 lecture video part 1, Chelseashell Trans,

25th Edition Williams Obstetrics Chapter 23 8
NO-FACE x seaslug
DR CARNERO, SOURCE: MOODLE VIDEO LECTURE 2021, SEACHELSEASHELL X MTEVF TRANS Left Mertum
.

Aut
FACE PRESENTATION delivery to be successful in face presentation. As long as it
persists as face-mentum posterior, vaginal delivery will not
 Head is hyperextended, occiput is in contact with the be possible.
fetal back and the chin (mentum) is presenting - In the absence of contracted pelvis, and with effective
 Fetal face may present with

MANAGEMENT
labor, successful vaginal delivery usually will follow
the chin (mentum) anteriorly (Mentum Anterior)
DESCRIPTION

or posteriorly, relative to the - Cesarean delivery (Mentum posterior)

maternal symphysis pubis o Pelvic inlet contraction
 The occiput is in the longer Do not attempt to manually rotate to vertex, or rotate
end of the head lever. The mentum posterior to anterior or do internal podalic version.
chin is directly posterior.
Vaginal delivery is impossible
unless the chin rotates BROW PRESENTATION
anteriorly. - Rarest presentation because it often converts to face
(when the head extends) or occiput presentation (when
 Prematurity  Anencephalic the head flexes)
 Marked fetuses - Fetal head between the orbital ridge and anterior
ETIOLOGY

enlargement of the  Contracted pelvis fontanel presents at the pelvic inlet

neck or coils of cord  Very large fetus - Fetal head occupies a position midway between full
about the neck may  Multiparous*women flexion (occiput) and extension (mentum or face)
- Engagement of fetal head

DESCRIPTION
cause extension  Hydramnios
and delivery will not occur
Vaginal examination unless the head is small or
 palpation of the distinctive facial features of the mouth pelvis is unusually large.
and nose, the malar bones, and particularly the orbital - Causes and etiology are
ridges (differentiate it from breech) the same as of the face
presentation
How to differentiate face presentation from breech? - Unstable – may convert to
Face presentation as mentioned, the point of reference will occiput or face
DIAGNOSIS

be the malar bones, and the mouth. So when you draw a line - Management is the same
connecting this, you will have a triangle. But with frank as those for a face
breech presentation where your points of reference will be presentation
the ischial tuberosities and the anus. It will form a straight
line. So kung straight ung line, that would be your - Abdominal palpation - When both the occiput and chin
DIAGNOSIS

differentiating point. can be palpated easily

- Vaginal examination - Palpation of the frontal sutures,
Radiographic examination large anterior fontanel, orbital ridges, eyes and root of
- demonstration of the hyperextended head with the the nose
facial bones at or below the pelvic inlet - Very small fetus and a large pelvis – labor is generally
- Face presentations rarely are observed above the pelvic
LABOR MECHANISM

easy
inlet - Usually it has descended beyond the pelvic inlet - Larger fetus – usually difficult, because engagement is
 The brow generally presents, converted into a face impossible until there is marked molding that shortens
presentation after further extension of the head during the occipitomental diameter, or more commonly, until
.. descent there is either flexion to an occiput presentation or
 Mechanism of labor consists of the following cardinal extension to a face presentation. Persistent brow –
movements: vaginal delivery is difficult and management is same as
o Descent – brought about by the same factors as in face
cephalic presentations
o Internal rotation – the objective is to bring the chin
MECHANISM OF LABOR

TRANSVERSE LIE
under the symphysis pubis – in order to have a vaginal
delivery. Results from the same factors as in vertex - The long axis of the fetus is approximately
presentations perpendicular to that of the mother
DESCRIPTION

o Flexion -face - Long axis forms an acute angle – Oblique lie (unstable)
o Accessory movements of extension and external - Referred to as shoulder or acromion presentation (point
rotation – results of reference is the acromion or AC)
from the relation of - The shoulder is usually over the pelvic inlet, with the
the fetal body to head lying on one iliac fossa and the breech in the
the deflected head. other.
 Abdominal wall  Abnormal uterine
Mechanism of labor for relaxation from high anatomy
ETIOLOGY

right mentoposterior parity  Excessive amniotic

position with subsequent  Preterm fetus fluid
The chin will be rotating  Placenta previa**  Contracted pelvis
towards the anterior ** presence of placenta in the lowest segment will prevent
beneath the symphysis the head of the baby from entering the pelvis
pubis in order for vaginal

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Occipot extension
-
 Abdominal examination/Leopold’s maneuver - In general, the onset of active labor in transverse lie is
- Transverse lie - Abdomen is unusually wide, whereas an indication for cesarean delivery
the uterine fundus extends to only slightly above the - Because neither the feet nor the head of the fetus

MANAGEMENT
umbilicus occupies the lower uterine segment, a low transverse
- In L1, no fetal pole is detected in the fundus, in L2, incision into the uterus may lead to difficulty in
ballotable head is found in one iliac fossa and the extraction of a fetus entrapped in the body of the uterus
breech in the other above the level of incision. Therefore, a vertical incision
- Back up (anterior)/Shoulder presentation – a hard is recommended especially for acromiodorsoanterior
resistance plane extends across the front of the presentation
abdomen (fetal back)
- Back down (posterior)- irregular nodulations OBLIQUE LIE
representing the small parts are felt through the
abdominal wall - Called an unstable lie
- When the long axis forms an acute angle
- Usually only transitory, because either a longitudinal or
transverse lie commonly results when labor supervenes

COMPOUND PRESENTATION
- An extremity prolapses alongside the presenting part
DIAGNOSIS

or with both presenting in the pelvis simultaneously

- The left hand is lying in front of

the vertex. With further labor, the
hand and ram may retract from
the birth canal and the head may

DESCRIPTION
then descend normal

Palpation in transverse lie, right acromidorsoanterior position A. first

maneuver B. second maneuver. C. third maneuver. D fourth maneuver
In L1 there is no fetal pole in the upper portion of the fundus
(-), L2 you will feel the fetal head in one iliac fossa and the
breech in the other, L3 is negative, in L4 you will just feel
the breech in the portion of the iliac fossa and nothing in the
CAUSES

lower portion. Conditions that prevent complete occlusion of the pelvic

Vaginal examination inlet by the fetal head, including preterm birth
- Early stages of labor: the side of the thorax or the
“gridiron” feel of the ribs would be appreciated
- Advanced labor: the scapula and clavicle are palpated - Perinatal loss is increased as a result of preterm
&

delivery, prolapsed cord, and traumatic obstetrical

- Spontaneous delivery of a fully developed newborn is procedures
impossible with a persistent transverse lie - In most cases, the prolapsed part should be left alone,
Rupture of membranes → fetal shoulder is forced into because most often it will not interfere with labor
MANAGEMENT

the pelvis → corresponding arm frequently prolapses - Prolapsed arm alongside the head → ascertain
PROGNOSIS

→ shoulder is arrested by the margins of the pelvic whether the arm retracts out of the way with descent
inlet (head in one iliac fossa and breech in the other) of the presenting part, if it fails to retract and if it
→ impacted shoulder in the upper pelvis → pathologic appears to prevent descent of the head, the prolapsed
retraction ⑧
ring formation → rupture of the uterus arm should be pushed upward and the had
simultaneously downward by fundal pressure
Neglected transverse lie
MECHANISM OF LABOR

Pathologic retraction ring (upper PERSISTENT OCCIPUT POSTERIOR POSITION

arrows), prolapsed arm out of the
introitus, the head is compressed - 2-10% of deliveries
DESCRIPTION

on one side, while the thorax is on - Transverse narrowing of the midpelvis is undoubtedly
the other, so it is impossible to a contributing factor (so when there is narrowing of
delivery the baby vaginally. the interspinous diameter
- Usually undergo spontaneous anterior rotation
followed by uncomplicated delivery
- Epidural analgesic
FACTOR

- If the fetus is small – usually less than 800g – and the - Nulliparity
RISK

pelvis is large, spontaneous delivery is possible despite - Greater fetal weight

persistence of the abnormal lie. - Prior occiput posterior position delivery
- The fetus is compressed with the head forced against - Prolonged 2nd stage of labor
its abdomen – conduplicato corpore
MORBIDITY

- Increased CS delivery and operative vaginal delivery

- Head and thorax pass through the pelvic cavity at the - Increased blood loss (vaginal delivery)
same time - Higher order vaginal lacerations (3rd and 4th degree
lacerations)
- Neonatal outcomes: academic umbilical cord gases,
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 Birth trauma, APGAR scores <7, NICU admission SHOULDER DYSTOCIA
 6-1.4% incidence (ACOG 2012)
 Head to body delivery time
o Normal birth – 24 seconds
o Shoulder dystocia – >60 seconds
 Fetal shoulder becomes wedged behind symphysis pubis
and fails to deliver with downward traction and pushing
 Emergency – because the umbilical cord is compressed
within the birth canal
 Neonates experiencing shoulder dystocia had significant
greater shoulder-to-head and chest-to-head
disproportions compared with those of equally
macrosomic newborns delivered without dystocia

MATERNAL Postpartum hemorrhage – usually

This shows that in cases of term pregnancies, who
presented as occiput anterior (OA) in early labor, there is a from uterine

CONSEQUENCES
4% of cases which could convert to occiput posterior (OP) atony, vaginal and cervical lacerations
during delivery. Those with OP in early labor, which FETAL Fetal morbidity and Mortality
persisted at OP at delivery are about 13%. The rest will (neuromusculoskeletal injuries)
convert to OA at delivery, and the total OP at delivery will Brachial plexus injury
be around 5%. Clavicular fracture/ humeral fracture/rib
fracture
 Spontaneous delivery – because the pelvis is wide
Hypoxia (HIE – hypoxic ischemic
VAGINAL DELIVERY
POSSIBILITIES FOR

and baby is not large

encephalopathy)
 Forceps delivery with the occiput directly posterior
Increasing fetal Obesity, multiparity, DM and GDM, and
 Manual rotation to the anterior position followed by Weight risk post-term pregnancy
 spontaneous or forceps delivery factors
 Forceps rotation of the occiput to the anterior position 75% SD cases → birthweight > 4000g
and delivery Intrapartum Prolonged second stage
PREDICTORS

factors Operative vaginal delivery

Spontaneous Roomy pelvic outlet or relaxed Prior shoulder dystocia
vaginal delivery perineum
Manual rotation to Resistant vaginal outlet or firm Newborns of DM mothers were shown to have larger shoulder
occiput anterior perineum and extremities circumferences, decreased head to shoulder
and spontaneous
DELIVERY

ratio, higher body fat and thicker upper extremity skin folds
delivery compared with non-diabetic controls.
Forceps or Ineffective expulsive efforts
Vacuum delivery Must meet criteria for forceps ACOG 2012 Conclusion on Studies about Shoulder Dystocia
or vacuum delivery  Most cases of shoulder dystocia cannot be accurately
Cesarean section Elongation of fetal head predicted or prevented
(molding/caput)
ACOG

 Elective induction of labor or elective CS for all women

Head not engaged suspected of having macrosomic fetus is not appropriate
 Planned CS maybe considered for non-diabetics with
PERSISTENT OCCIPUT TRANSVERSE POSITION fetus whose estimated weight is >5000 grams or for
- Transitory because the occiput tends to rotate to diabetics >4500 grams
DESCRIPTION

anterior position in the absence of a pelvic  Reduction in the interval of time from delivery of the
architecture abnormality or asynclitism head to delivery of the body is of great importance to
MANAGEMENT

- Spontaneous anterior rotation usually is completed survival, the neonates should be delivered within 4
rapidly, thus allowing the choice of spontaneous minutes, the incidence of pressed neonates increases
delivery or delivery with outlet forceps after 3 minutes
 If rotation ceases because of poor expulsive forces  An initial gentle attempt at traction, assisted by maternal
and pelvic contractures are absent, vaginal delivery expulsive efforts, is recommended
usually can be accomplished with oxytocin infusion to  Large episiotomy is necessary
improve uterine contractions  Adequate analgesic
 The occiput may be manually rotated anteriorly or
posteriorly, and forceps delivery performed from either MANUEVERS FOR DYSTOCIA
the anterior or posterior position
DELIVERY

Techniques to free the anterior shoulder from its impacted

 Application of Kielland forceps (used in cases of position beneath the symphysis pubis:
occiput transverse to rotation of the head to OA) to the
MODERATE  Can be applied by an assistant while
fetal head to rotate the occiput to the anterior
SUPRAPUBIC downward traction is applied to the fetal
position, and then deliver the head either with the
PRESSURE head
same forceps or with Simpson or Tucker-McLane
forceps
 Difficult rotation is expected on platypelloid and
android(heart-shaped) pelvis – might not be
successful and may be delivered CS

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  Pressure is applied with the heel of the hand The hand Is placed behind the posterior shoulder
on the anterior shoulder WOOD of the fetus and progressively rotating the
CORKSCREW posterior shoulder 180° degrees in a corkscrew
MANEUVER fashion so the impacted anterior shoulder could
be released

RUBIN’S  The fetal shoulders are rocked from side to

MCROBERTS  Consists of removing the legs from the MANEUVER side by applying force to the maternal
MANEUVER stirrups and sharply flexing them up onto the abdomen
abdomen  The pelvic hand reaches the most easily
 Causes straightening of the sacrum relative accessible fetal shoulder, which is then
to the lumbar vertebrae, rotation of the pushed toward the anterior surface of the
symphysis pubis toward the maternal head, chest; the direction is always towards the
and a decrease in the angle of the pelvic chest of the baby
inclination Deliberate Pressing the anterior clavicle against the ramus of
 Pelvic rotation cephalad tends to free the fracture of the pubis to free the shoulder impaction
impacted anterior shoulder the clavicle
 Reduces the forces needed to free the fetal Hibbard Pressure is applied to the fetal jaw and neck in
shoulder maneuver the direction of the maternal rectum, with strong
 The suprapubic pressure of the heel of the fundal pressure applied by an
clasped hands from the posterior aspect of assistant as the anterior shoulder s freed
the anterior shoulder to dislodge this is also Gaskin all-fours maneuver; parturient is rolled onto her
known as the Mazzanti maneuver maneuver knees and hands, and downward traction against
the head and neck attempts to free
the posterior shoulder
Zavanelli the reversing the cardinal movements of labor
maneuver Rotate the head to OA, then rotate and flex the
head and push it up and to the pelvis, then it is
followed by CS
Cephalic replacement into the pelvis and then
cesarean delivery
Cleidotomy Cutting the clavicle with scissors or other sharp
instruments
Usually used for a dead fetus
Symphysioto symphysis pubis is cut, that will widen the area
my and the shoulder of the fetus will be released and
be delivered easily. After the procedure, wiring is
put in order to approximate the symphysis pubis
again

Delivery of the posterior shoulder consists of

carefully sweeping the posterior arm of the fetus
across the chest, followed by delivery of the arm. SHOULDER DYSTOCIA DRILL
The shoulder girdle is then rotated into one of the  Call for help – mobilize assistants, an anesthesiologist,
oblique diameters of the pelvis with subsequent and a pediatrician. Initially, a gentle attempt at traction
delivery of anterior shoulder is
made. Drain the bladder if it is distended
 A generous episiotomy (mediolateral or
Shoulder dystocia with impacted episioproctotomy) may afford room posteriorly
anterior shoulder of the fetus.  Suprapubic pressure is used initially by most
A. The operator’s hand is practitioners because it has the advantage of simplicity.
introduced into the vagina along Only one assistant is needed to provide suprapubic
the fetal posterior humerus, downward traction is applied to the fetal head
which is splinted as the arm is  The McRoberts maneuver requires two assistants
swept across the chest, keeping Both suprapubic pressure and McRoberts maneuver together will
the arm flexed at the elbow. resolve most cases of shoulder dystocia.
B. The fetal hand is grasped and
the arm is extended along the If the above maneuvers fail:
side of the face  Delivery of posterior arm
C. The posterior arm is delivered  Woodscrew
from the vagina  Rubin’s maneuver
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IF IT FAILS… b. Vacuum extraction
 Cleidotomy c. Forceps delivery
 Zavanelli d. Cesarean delivery
 symphysiotomy
“No one maneuver is superior to another releasing an impacted Explanation: Because the pelvis is not contracted and is adequate.
shoulder or reducing an impacted shoulder or reducing the chance Proof of this is that a 3500 g baby was able to pass thru. 2nd
of injury but McRobert’s maneuver was deemed a reasonable choice: Forceps delivery
initial approach.”
– American College of OB-GYN (2012) CASE 2
COMPLICATIONS WITH DYSTOCIA G5P4 (4004) 36 weeks in active labor with the following
 Uterine rupture findings: L1 no fetal pole, L2 hard round ballotable mass on the

E
 Pathological retraction ring – associated with marked right iliac fossa, nodular mass on the left, hard resistance plane
stretching and thinning of the lower uterine segment, across the abdomen, L3 negative.
and the ring signifies the impending rupture of the
lower uterine segment 1. What is the position?
a. Right Acromio-Dorsoanterior (RAcDA)
 Fistula formation – the tissues of the birth canal lying
b. Left Acromio-Dorsoanterior (LAcDA)
between the leading part and the pelvic wall may be
MATERNAL

c. Right Acromio-Dorsoposterior (RacDP)

subjected to excessive pressure and necrosis may
d. Left Acromio-Dorsoposterior (LAcDP)
result, and become evident several days after delivery
as vesico-vaginal or vesico-cervical or recto-vaginal
Answer: Right Acromio-Dorsoanterior (RAcDA)
fistulas
Explanation: The point of reference for the transverse lie is the
 Pelvic floor injury - the direct compression from the
acromion process. The acromion process is near the head. The
fetal head and the downward pressure from maternal
hard round ballotable mass on the right iliac fossa is the head. So,
expulsive efforts will stretch and distend the pelvic floor
the position is on the right acromion. The hard resistance plane is
leading in functional and anatomical alterations in
across the abdomen meaning that the back of the baby is facing
muscles, nerves, connective tissues. Lead to urinary
anteriorly. So the position is on the dorsoanterior
incontinence and pelvic organ prolapse
o Incidence of OASI or obstetric anal sphincter injury
– reduce if mediolateral episiotomy is done; do it at 2. What is the management?
60º from the midline at a time when there is a. External cephalic version (abdominal manipulation)
crowning, in cases of cephalic presentation. But the b. Internal cephalic version
mere relaxation from the pressure of the maternal c. Cesarean section
expulsive efforts, distention that could result to
pelvic floor injury and later on pelvic organ prolapse Explanation: External cephalic version is when a breech or
 Infection transverse lie presentation is changed into a cephalic
 Postpartum Hemorrhage presentation by abdominal manipulation. This could not be done
Fetal sepsis because the mother is already in active labor.
PERINATAL

Caput succedaneum
Molding CASE 3
Nerve injury/fractures G3P2 (2002), with gestational diabetes at 38 weeks with EFW
Cephalhematoma of 4000 g. After 10 hours of labor, the head was delivered. After
1 minute, there was difficulty in delivering the shoulder. Which
of the following maneuvers should be performed initially?
CASES FOR DYSTOCIA PART 2
a. Mc Roberts maneuver
CASE 1 b. Rubin’s maneuver
Abdominal exam of G7P6 (6006) whose largest baby weighed c. Woods corkscrew maneuver
3500 g revealed L1 nodular mass, L2 fetal back on the right,fetal d. Zavanelli maneuver
small parts on the left, L3 round hard mass, L4 cephalic
prominence on the right. IE cervix 7 cm dilated 60% effaced with Explanation: The best initial is suprapubic pressure however it is
ruptued BOW, palpable mouth, nose, malar bones. Chin directed not in the choices. Amongst the choices, McRoberts is the
towards the symphysis pubis. simplest and is usually successful. Most shoulder dystocia
resolves with Moderate Suprapubic Pressure and McRoberts.
1. What is the presentation and position?
a. LMA * end
b. LMP
c. RMA
d. RMP

Answer: Face presentation, RMA

Explanation: Cephalic prominence on the right and the fetal back
on right means that the head of the baby is extended. If vertex, the
cephalic prominence should be at the same side of the fetal small
parts. The IE confirms the presentation

2. What is the management?

a. Await vaginal delivery

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