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![]() If all above maneuvers fail, attempt the all fours position.Move to another maneuver if delivery is not accomplished within 20–30 seconds.Any of the internal maneuvers below may be attempted next.The patient should stop bearing down and lie supine with the buttocks on the edge of the bed.Turtle sign: the fetal head is partially delivered but retracts against the perineum.Features of arrested active phase of labor.Definition: an obstetric emergency in which the anterior shoulder of the fetus becomes impacted behind the maternal pubic symphysis during vaginal delivery.Vesicovaginal fistula and ureterovaginal fistula.Shoulder dystocia : various obstetrical maneuvers may be tried (e.g., McRoberts, Zavanelli) to deliver the infant and avoid fetal demise from umbilical cord compression.For a low-risk pregnancy, if the patient wishes to avoid surgery.In emergency cases where cesarean delivery was not possible.Cesarean delivery: if external cephalic version is unsuccessful or contraindicated (e.g., in active labor, fetal distress ).Contraindications for external cephalic version.Involves manual adjustment of fetal position by applying pressure on the mother's abdomen.Should be offered in all cases ≥ 37 weeks who would like to attempt a vaginal delivery, unless there are contraindications.No interventi on necessary before 37 weeks' gestation, as most fetuses spontaneously convert to cephalic presentation as they get closer to term.Use of forceps or a vacuum to rotate the fetal head if arrested labor ≥ 60 min.Stimulate uterine contractions (e.g., with oxytocin ).Lateral positioning of the mother to achieve 90° rotation of the fetal head.In the case of arrested labor: cesarean delivery.Lateral positioning of the mother to achieve a 90° rotation of the fetal head, stimulate uterine contractions (e.g., with oxytocin).Cesarean delivery is recommended if fetus is still in transverse lie at the time of labor.Neglected transverse lie: additional impaction of the fetus (prolapsed arm, wedged-in shoulder).No intervention is necessary before 37 weeks of gestation since the majority of fetuses will eventually rotate naturally to a cephalic or breech presentation before labor.If head is not engaged: cesarean delivery. ![]() ![]() If the head is engaged: forceps delivery with/without repositioning of the arm.More accurate than digital cervical examination.Fetal head position is an important factor in determining the mode of delivery.Uncertain fetal presentation/position: Perform intrapartum transabdominal ultrasound if fetal head position is uncertain during delivery.General: cesarean delivery for any maternal etiologies or congenital anomalies.Head molding (excessive during obstructed labor).High presenting part not engaged ruptured membranes.Uterine abnormalities, e.g., due to tumor (e.g., uterine leiomyoma), deformities of maternal pelvis, bicornuate uterus, multiparity.Excessive fetal size ( macrosomia may be physiological or pathological, e.g., due to hydrocephalus ).Arrest of vaginal delivery because of a mechanical obstruction (see “ Arrested active phase ” for comparison).If the placenta is incomplete or if an accessory placenta is suspected, manual palpation should be performed and any remaining tissue should be removed by curettage. Hysterectomy if the above approach failsĬomplications of a prolonged second stage are postpartum hemorrhage and a poor neonatal outcome.Inadequate contractions or retained placenta (e.g., abnormal placental implantation such as placenta increta, placenta percreta, placenta accreta).Placenta has not been delivered 30 minutes after the birth.Cesarean delivery if the fetal head is not engaged.Trial of forceps or vacuum delivery if the fetal head is engaged and maternal contractions are adequate.Augmentation with oxytocin if uterine contractions are inadequate and progress is > 2 hour ( > 3 hours in patients who received an epidural).> 3 hours ( > 4 hours in patients who received an epidural).Arrest of fetal descent occurring after complete cervical dilation ( > 10 cm ) and effacement (100%).Usually due to abnormalities of the 3 P's of labor.≥ 6 cm cervical dilation without adequate dilation ( 6 hours of inadequate contractions.Oxytocin may be considered in well-rested mothers if the previous measures have been implemented.Rest, hydration, and adequate analgesia.Slow progression (contraction frequency) with a cervical dilation ≤ 6 cm. |
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