1. Mariechen Puchert 2010
NOTE/Disclaimer: These are notes I made for myself during my second year. I cannot
guarantee that there aren’t mistakes. I do know that studying them were great help to me. I
used notes and powerpoints given to my class by lecturers (University of Stellenbosch,
Tygerberg Campus, South Africa) as well as the following textbooks:
Clinical Gynaecology : TF Kruger, MH Botha
Ostetrics in South Africa: Cronje
Abnormal Labour
Failure to progress in active phase of first stage of labour
Aetiology
1. Patient – excessive pain, full bladder, exhaustion
2. Power – inadequate contractions, dysfunctional contractions
3. Passenger – cephalopelvic distortion, malposition
4. Passage – small pelvis, increased perineal resistance, pelvic tumours
Maternal complications
a. Infection
b. Trauma and haemorrhage
c. Atonic uterus leading to PPH
d. Uterine rupture
e. Fistulae – uterovaginal, rectovaginal
Foetal complications
a. Infection
b. Hypoxia
c. Birth trauma
Caesarean Section
Maternal Indications Foetal Indications
Life threatening uterine haemorrhage
Eclampsia
Placenta praevia
Space occupying pelvic lesion
Urinary incontinence surgery
Cervical carcinoma
Previous C/S
Serious medical illness
Foetal distress
Umbilical cord prolapse or presentation
Malpresentation
Prematurity
Multiple pregnancy
Macrosomia
Risk of foetal infection
Complications
o Acute bleeding
o Inability to deliver foetal head
o Rupture of lower uterine segment
o Urinary tract injuries
o Intra-uterine sepsis
o Haematoma/abscess
o UTI
o Thromboemboli

2. Mariechen Puchert 2010
Genital Injuries
Grade I Laceration of superficial skin and subcutaneous tissues
Grade II Laceration involving skin, perineal body and muscles
Grade III Laceration involving skin, perineal body, muscles and anal
sphincter with or without laceration of atonal mucosa
Grade III management
General anaesthesia
Prophylaxis
Anatomic repair:
i. Anal/rectal mucosa
ii. Anal sphincter
iii. Perineal muscles
iv. Vaginal epithelium
v. Perineal skin
Strict diet – low residue, 2 weeks
Local hygiene
Episiotomy indications
o Foetal distress
o Maternal exhaustion
o Quick and easy second stage needed
o Prolonged labour
o Delivery of preterm infant
o Risk of 3°tear
o Breech or forceps delivery
Repair of Episiotomy
1. Vaginal epithelium
2. Muscular layer
3. Perineal skin
Aetiology of Uterine Rupture
a. Uterine stretch in previously operated uterus
b. Obstructive labour
c. Obstetric intervention e.g. in breech
d. Trauma – MVA, GSW

3. Mariechen Puchert 2010
Induction of labour
Artificial initiation of uterine contractions before the spontaneous onset of labour to
achieve vaginal delivery as the preferred route
Prerequisites
1. Effective method
2. No foetal distress
3. Longitudinal lie
4. Maternal condition
5. Adequate birth canal
Maternal Indications Foetal Indications
Hypertension Post-dates
Deteriorating health APH
IUD Red cell iso-immunisation
Prolonged labour Placental insufficiency
Contra-indications
o Previous Caesarean Section
o Previous hysterotomy
o Contracted pelvis
o Malpresentation
o Major placenta praevia
Methods of IOL
I. Surgical – amniotomy
II. Mechanical – Foley’s catheter
III. Medical
Medical compounds
1. Oxytocin
2. Prostaglandins – misoprostol

4. Mariechen Puchert 2010
Instrumental Delivery
Forceps Foetal Indications Forceps Maternal Indications
Foetal distress Disease aggravated by bearing down
Prematurity Exhaustion
Breech birth
Prolonged second stage
Forceps Prerequisites
1. Fully engaged
2. Fully dilated
3. Normal uterine contractions
4. Ruptured membranes
5. Empty bladder and rectum
6. Minimal analgesia
7. Episiotomy
Forceps Contraindications
• Inexperienced doctor
• Obstructive labour
• Not engaged
• Incomplete dilation
• Unknown position
• Uterine atony
Forceps Maternal Complications Forceps Foetal Complications
Trauma Death
Haemorrhage Skull fracture
Infection Neurological injuries
Bladder atony Trauma
Neurological injuries
Ventouse Contraindications
• Prematurity
• Breech or face presentation
• Possible bleeding tendency
• Uterine atony
• Slipped twice
• Not fully engaged
• Foetal distress
Advantages of Ventouse over Forceps
Facilitates flexion and traction
Head rotates naturally
Occupies no space between head and pelvis
Some trauma only
Guides only – more natural birth
Decreased maternal trauma

5. Mariechen Puchert 2010
Preterm Labour
Labour with cervical effacement and/or dilation before 37 weeks of gestation
Dangers of preterm labour
• Death
• Respiratory disease
• Hypothermia
• Hypoglycaemia
• Jaundice
• Infection, necrotising enterocolitis
• Chronic impairment
Aetiology of preterm labour
1. Local infection
2. Placental abruption
3. Overdistension of uterus
4. Premature rupture of membranes
5. Cervical incompetence
6. Iatrogenic
7. IUD or foetal anomalies
8. Uterine anomalies
Risk factors
o Previous preterm labour
o Poor socio-economic status
o Young women
o Underweight
o Cigarette smoking
o Strenuous work
o Pregnancy complications
o Short cervix
Tocolysis Postpone delivery
1. Prostaglandin synthase inhibitors
2. Calcium channel blockers
3. Oxytocin agonist
4. Corticosteroids
5. Antibiotics
6. β-sympathomimetics
7. Nifedipine
Contraindications to tocolysis
i. Foetal distress
ii. Chorio-amnnionitis
iii. Severe pre-eclampsia
iv. Foetal maturity
v. Foetal death
vi. Maternal haemodynamic instability