11.. Malpresentation and malpositio.pptx

Malpresentation

1. Malpresentations

2. Learning objectives Introduction Definition of mal presentation Diagnosis of mal presentation Management of mal presentation Complication of mal presentation 2

3. Introduction Presentation is defined as: Part of the fetus that directly overlies the pelvic inlet , or foremost within the birth canal or in closest proximity to it. Any presentation other than vertex are called Malpresentation . Malpresentations include: Face , brow , breech , shoulder , or compound . Malpresentation is often associated with increased risk to both the mother and the fetus

4. Definition of terms Fetal Lie :- is the relation of the long axis of the fetus to the long axis of the mother Attitude :- refers to the position of the fetal head in relation to the neck . Presentation :- refers to the fetal part that directly overlies the pelvic inlet . Position :- refers to the relationship of the fetal presenting part to the maternal pelvis . Station :- is a measure of descent of the bony presenting part of the fetus through the birth canal

5. Predisposing Factors Maternal Contracted pelvis Pendulous abdomen, High parity Pelvic tumors:- fibromyomas, ovarian tumor etc. Uterine anomalies:- bicornuate uterus, uterine septum etc… Placental and Membranes Placenta previa Fetal Prematurity Fetal attitude Fetal anomaly (e.g. hydrocephalus, anencephalus) Polyhydramnious / oligohydramnious Multiple pregnancy

6. Complications of malpresentations Maternal Genital trauma Post partum hemorrhage Intrapartum infections Puerperal sepsis Complications of operative delivery Fetal/Neonatal Birth trauma- IVH; Nerve injury (palsy) Perinatal asphyxia Cord prolapse Neonatal infections Increased risk of meconium aspiration syndrome

7. Complications of malpresentations … Labor and Delivery Prolonged labor Obstructed labor PROM Increased operative vaginal delivery Increased caesarean delivery Inefficient uterine action

8. Breech presentation It is a longitudinal lie in which the buttocks is the presenting part with or without the lower limbs. Diagnosis can be made through abdominal palpation, vaginal examination and confirmed by ultrasound Types Frank : hip flexed and knee extended commonest Complete : hip and knee are flexed, in multipara Footling : hip and leg are extended, one /both feet present, Knee : the hips are extended with knees flexed

9. Prematurity, fetal malformation, Uterine anomalies, and polar placentation are commonly observed causative factors

10. Etiologic factors Prematurity : due to small foetal size, relatively excess amniotic fluid, and more globular shape of the uterus. Multiple pregnancy : Poly-and oligohydramnios. Hydrocephalus, anencephalus. Bicornuate and septate uterus. Uterine & pelvic tumors. Placenta praevia

11. Recurrence Risk of breech presentation in a 2nd pregnancy: 2% if the first infant was non breech 9% if the first infant was breech and After two consecutive breech deliveries, 21 to 28% After 3 consecutive breech deliveries the risk is 38%. Men or women who were delivered at term from breech presentation were twice as likely to have firstborn offspring in breech presentation. 15

12. Diagnosis Abdominal Examination after 34 weeks Leopold maneuver: The hard, round, readily ballotable fetal head occupy the fundus. FHB will be heard more easily at or above the umbilicus Vaginal Examination Frank breech presentation: Ischial tuberosities, sacrum, and the anus ..palpable After further fetal descent, the external genitalia may be distinguished. The sacrum are palpated to establish the position and presentation 16

13. May confuse with Face presentation Breech : Finger encounter muscular resistance by the anus Stained with meconium on removal Ischial tuberosity and anus are in straight line While mouth and malar eminence form triangular shape in face.

14. Cont… Sonography The best confirmation of a suspected breech presentation is with U/S. It also can provide information regarding the breech type and EFW. Management of Breech Presentation 1.Vaginal delivery 2.Cesarean delivery 3. External cephalic version (ECV) …Antenatally if spontaneous version is not occurred 19

15. Management Indications for C/S large fetus ( EFW ≥3500gm) or < 1.5kg Any degree of pelvic contracture Footling breech Ux dysfunction Severe IUGR Breech with poor obstetric performance (previous perinatal death) Elderly primigravida Others: Request for sterilization Zatuchini – Andros score <4

16. If the score is 0-4, cesarean delivery is recommended decision regarding mode of delivery should depend on the experience of the health care provider Zatuchni-Andros Breech Scoring 1 2 Parity 1 2 Gestational age (wk) 39+ 38 <37 EFW (lb) 8lb (3.6kg) 7-8 lb(3.2-3.6kg) <7 lb(<3.2kg) Previous breech 1 2 Dilatation 2 3 4 Station -3 -2 -1

17. Vaginal delivery Indications No fetal indication for c/s Wt < 3500gm Franck breech Adequate pelvis Zatuchini – Andros score > 4 Documented lethal fetal congenital anomalies Presentation of mother in advanced labor with no maternal or fetal distress 22

18. Methods of Vaginal Delivery General methods of vaginal breech delivery: Spontaneous breech delivery : without any traction or manipulation other than support of the newborn. Partial breech extraction . The fetus is delivered spontaneously as far as the umbilicus , but the remainder of the body is extracted will be assisted by maneuvers. Total breech extraction . The entire body of the fetus is extracted by the obstetrician. Replaced by C/S 23

19. Mechanism of labor in breech Engagement and descent: Takes place with the Bitrochanteric Ø 10 cm in one of the oblique Ø of the Pelvis Internal rotation Ant. hip toward the pubic arch Bitrochanteric Ø in Antero-posterior Lateral flexion External rotation : After birth of the breech Back turning anteriorly (SA) Shoulder brought into one of the oblique Ø of the pelvis (biacromial diameter 12 cm) 24

20. Assisted vaginal breech delivery Instruct the mother to bear down with every contraction (2nd stage). Episiotomy – when fetal anus is visible and perineum distended unless perineum is well relaxed . Allow the breech to be delivered and wait without intervention till body born up to the level of umbilicus . The golden rule is to "Keep your hands off“ to deliver the fetal buttock and The body is allowed to deliver spontaneously up to the level of the umbilicus 25

21. After the umbilicus has been reached, wait spontaneous delivery of the legs . If not delivered spontaneously, deliver one leg at a time: Flexion and abduction of thigh, subsequent delivery of the lower leg. Do not pull the baby while the legs are being delivered 27

22. Pinard maneuver If no spontaneous delivery of the legs two fingers are carried up along one extremity to the knee to push it away from the midline. Spontaneous flexion usually follows, Exerting pressure laterally to sweep the legs away from the mid line . 2/23/2016 28

23. 31 Following delivery of the legs, the fetal bony pelvis is grasped with both hands, using a cloth towel moistened with warm water. The fingers should rest on the anterior superior iliac crests and the thumbs on the sacrum, minimizing the chance of fetal abdominal soft tissue injury

24. 32 Lovset’s Maneuver Arms are stretched above the head or folded around the neck: Gentle downward traction is combined with an initial 90 rotation of the fetal pelvis through one arc and Then a 180 rotation to the other, to effect delivery of the scapulas and arms

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26. Deliver head by: Mauriceau Smellie Veit maneuver: 35 Lay the baby face down with the length of its body over your hand and arm. Place the first and third fingers of this hand on the baby’s cheekbones and place the second finger on the baby’s chin. Use the other hand to grasp the baby’s shoulders and to push the occiput

27. Delivery of the head…. Bern's Marshal maneuver - The baby is allowed to hang by its own weight with suprapubic pressure & Up ward movement of the baby while the other hand supporting the perineum 37

28. Piper forceps can be used to deliver the after coming head, when MSV maneuver cannot be accomplished easily. Suspension of the body of the fetus in a towel effectively holds the fetus and helps keep the arms out of the way 38 Forceps to After coming Head

29. Complications of Breech Delivery Maternal: Prolonged labor with maternal distress. OL Laceration especially perineal. PPH due to prolonged labor and lacerations. Puerperal sepsis B. Fetal: Intracranial haemorrhage (IVH) Fracture, dislocation of the cervical spines Asphyxia due to: Cord prolapse or compression Rupture of an abdominal organ. Brachial plexus injury. 39

30. External Cephalic Version(ECV) When a breech presentation is recognized prior to labor in a woman who has reached 36 weeks' gestation, ECV should be considered. Before this time, there is a relatively high incidence of recurrence.(unstable) After 36 weeks, however, the likelihood of spontaneous version is low. Version is C/I if vaginal delivery is not an option Anti-D immune globulin is given if indicated. 40

31. Factors Associated with Successful Version 11/4/2017 41

32. Technique of ECV ECV should be carried out in an area that has ready access to a facility equipped to perform emergency cesarean deliveries. U/S examination is performed to confirm non vertex presentation and adequacy of AFV, to exclude obvious fetal anomalies if not done previously and to identify placental location. External monitoring is performed to assess fetal heart rate reactivity. Version attempts are discontinued for excessive discomfort, persistently abnormal fetal heart rate, or after multiple failed attempts. 42

33. Technique… A forward roll of the fetus usually is attempted first. Each hand grasps one of the fetal poles, and The buttocks are elevated from the maternal pelvis and displaced laterally. 43

34. Technique… The buttocks are then gently guided toward the fundus, while the head is directed toward the pelvis. If the forward roll is unsuccessful, then a backward flip is attempted. 44

35. Complications Placental abruption, Uterine rupture, Fetomaternal hemorrhage, Isoimmunization, PROM Preterm labor, fetal compromise, and even death. Amniotic fluid embolism. 45

36. Brow Presentation It is a cephalic presentation in which the head is midway between flexion and extension . Diagnosed when the portion of the fetal head between the orbital ridge and the anterior fontanel presents at the pelvic inlet. Presenting diameters in brow presentation: Biparietal diameter – 9.5 cms Mentovertical diameter- 13.5 cms Most brow presentations at term are transitory presentations in early labor .

37. Diagnosis of Brow Presentation During pregnancy: It is difficult. Ultra sonography may be helpful. During labor: Frontal bones, Supra-orbital ridges, and Root of the nose but not the chin. 48

38. Mechanisms of Labor… Persistent brow: The engagement diameter is the mento -vertical 13.5 cm which is longer than any diameter of the inlet So there is no mechanism of labor and labor is obstructed . Transient brow: May occur during conversion of vertex into face presentation. So if brow is flexed to become vertex or extended to become face it may be delivered. 49

39. Management: Early in the first stage: Observe carefully and given a chance for spontaneous conversion into either face or vertex. Exclude contracted pelvis, if present do S/C In the second stage: If considered as persistent brow so: 1. Caesarean section is done if the foetus is living. 2. Craniotomy if the foetus is dead. 50

40. Face presentation It is a cephalic presentation in which the head is completely extended , allowing the occiput to touch the back Boundaries: Superiorly; supra orbital ridges and the root of the nose. Inferiorly; the mentum. Sub-mento bregmatic: 9.5 Denominator : mentum

41. Face presentation… Possible positions 8 (e.g. MA, left mento transverse..) It is presumed to occur because of factors that: Favor extension: goiter and excessive nuchal cords Prevent flexion of the fetal neck. Other factors includes: CPD, Contracted maternal pelvis & platypelloid pelvis Prematurity/low birth weight, polyhydramnios Macrosomia Multiparity Extreme laxity of the anterior abdominal wall

42. Mechanism of action In mento anterior positions, delivery follows by flexion of the head towards the symphysis pubis (face to pubis) In MA vertex fit into the hollow of the sacrum and the chin fits under the symphysis. Persistent MP positions cannot be delivered vaginally as the fetal brow pressing over the symphysis precludes flexion Presenting diameter sterno-bregmatic(18cm) An open fetal mouth may act as a fulcrum against the sacrum preventing further descent .

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44. Diagnosis In prolonged labor with facial edema , can be DDx breech presentation on vaginal exam The distinguishing features from frank breech The mouth and the malar eminences are not in a line ; but the anus and the ischial tuberosities are in one line, Sucking effect of mouth, Absence of meconium staining on the examination fingers. Antenatal diagnosis is rarely made .

45. Management Vaginal delivery can be tried in MA and rotated MP Augmentation is controversial C/S if persistent MP

46. Shoulder Presentation 11/5/2017 62 Shoulder presentation occurs with the fetus is in the transverse lie . May accompanied by a hand prolapse. Diameter attempting to be delivered in shoulder presentations is the crown-rump length Possible positions of shoulder presentation include: dorso anterior; dorso posterior; dorso superior and dorso inferior

47. Diagnosis of Shoulder Presentation Leopold’s palpations Transverse lie diagnosed. Abnormal after the 34 th week of pregnancy. Vaginal examination In delayed and neglected cases the hand and arm may prolapse. Cord prolapse rate is the highest among the malpresentations (20%). Sonography In addition to confirming the diagnosis, presence of congenital anomalies, placenta previa, uterine anomalies and fetal size assessment should be made . 63

48. Management In rare circumstances when the fetus is very small and the pelvis is capacious, a shoulder presenting fetus can be delivered doubled up “Conduplicato corpore”- doubled upon itself Cesarean delivery

49. Compound presentation 66 It is the presence of a limb alongside the presenting part(head) It can be vertex with a single or double hand or feet A breech with a single or double hand felt alongside the breech. If the hand is felt alone, not alongside with presenting part, then it is a “hand prolapse”

50. Mechanism of labor The usual progress in a compound presentation diagnosed in early labor is the gradual regression of the extremity upward as the vertex is pushed downwards by uterine action. In cases of CPD, the brow may persist and requires follow up with labor progress and appropriate management. Induction and augmentation and instrumental deliveries are contraindicated in compound presentations 69

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