malposition.pptx midifery obsgynae consultancy

malposition.

1.   MALPRESENTATION AND MALPOSITION

2. Summary : Definitions Risks on mother and fetus Predisposing factors Breech. occipito posterior. face. brow. shoulder, compound .

3. Definitions : 1- Presentation :- leading part of the fetus that presents to the lower uterine segment. 2- Malpresentation : any other presentation other than vertex 3- Position : relationship of presenting part to the pelvic brim.

4. Definitions (cont): 4- Denominator : Most definable peripheral point in the presenting part - Vertex- occiput - Face- mentum - Breech- sacrum 5- Position at start of labour - 90 %:LOA,ROA,OA

5. Risks on mother and fetus: 1- Prolonged and obstructed labour 2- Ruptured uterus 3- Difficult C/S, forceps, ventouse -traumatic delivery 4- Complications of puperperium 5- Vesico vaginal fistula 6- Increased maternal and perinatal mortality

6. Prevention of Risks: 1- Early diagnosis 2- Monitoring 3- Trained attendant 4- Facilities

7. Predisposing factors 1-Pre-maturity 2- Contracted pelvis- malformation 3- Multiple pregnancy 4- Polyhydramnios 5- Big baby 6- Congenital malformation of fetus

8. Predisposing factors (cont): 7- Congenital malformation of uterus 8- Fibroids 9- Placenta Previa 10 Oligohydramnios 11- Pendulous abdomen, grandmultipara

9. BREECH PRESENTATION: 1- Incidence 3-4% at term 2- Denominator sacrum 3- Diagnosis Head occupies the fundus (hard, rounded, ballotable , tender) Breech above pelvic brim (broad, soft, irregular) Longitudinal lie Fetal heart above umbilicus

10. Breech (cont ) : U/S: confirm diagnosis.Diagnose , maturity, placenta previa , fibroids, fetal malformation, twins, uterine malformation, liquor. Vaginal examination Incomplete breech: ischial tuberosities sacrum, anus Complete: feet beside buttocks Footling:foot Knee: knee

11. Breech (cont ): 4- Types of breech: Group assignment

12. Breech (cont ): 5- Risks to mother: - Dystocia, sepsis, lacerations, C/S

13. Breech (cont ): 6- Risks to the fetus: 6.1 Stillbirth - Intracranial haemorrhage Rapid moulding and rapid correction of moulding Rapid uncontrolled delivery - Asphyxia Slow delivery. Pressure of cord between fetal body and pelvic wall - Medullary coning through foramen magnum - Spinal cord injury. 6.2 Other injuries ( brachial plexus - femur- liver) 6.3 Intraprtum asphyxia ( dystocia , cord prolapse )

14. Breech (cont) Management Ante partum: 1- Identify cause by U/S 2- External Cephalic Version (ECV) 3- If ECV fail: Decide C/S or assisted vaginal delivery

15. Breech (cont) ECV: In hospital where C/S can be done immediately 37 weeks. <37 = per-term. > 37 = difficult Success= 60% in multipara 40% in primigravida

16. Preparation (ECV): U/S: confirm, back IUGR, liquor CTG: 20 min before Procedure . well Nothing by mouth Empty bladder I.V line 0.25 mg turbutaline subcutaneous 15 min before start ( tocolytic Trendelenberg position

17. Procedure (ECV): Elevate breech from pelvis Flex fetus and rotate in direction of nose Transverse Guide head in pelvis CTG for 30 min (reactive- no contraction )

18. Procedure (ECV): If no success after 15 min stop Stop if severe pain or bradycardia If bradycardia persists revert ECV If still bradycardia C/S

19. Breech (cont) Contraindications for ECV: Vaginal delivery not possible Multiple pregnancy IUGR Previous C/S APH

20. Contraindications for ECV: Pre-eclampsia Ruptured membranes Cardiac disease Uterine abnormality Rhesus negative

21. Breech (cont) Complications of ECV: Premature labour Cord accident Abruptio placenta IUFD Feto -maternal transfusion Bradycardia

22. Breech (cont) Difficult ECV: Primigravida Obese Decrease liquor Anterior placenta Early labour Big baby Irritable uterus

23. Breech (cont) If ECV fails decide: C/S, Vagianl :

24. Elective C/S Hypertension, diabetes, APH Big baby ≥ 3.8 kg Contracted pelvis < 4.5"AP IUGR Previous SB Relative infertility

25. Elective C/S Primigravida Previous C/S Footling Hydrocephalus Hyperextended head

26. Breech (cont) Vaginal delivery: - Adequate pelvis - Wt: < 3.8 kg - No complication - Multipara - Malformed baby

27.   Breech (cont) Mechanism of labour: 1- Engagement- bitrochantric diameter transverse and sacrum ventral 2- Anterior hip rotates anteriorly under the pubic arch 3- Post hip deliver by lateral flexion 4- Baby straightens and anterior hip delivers 5- Legs and feet

28. Mechanism of labour: 6- Ext rotation- shoulders antero posterior 7- Head Fixed under pubic arch Deliver by flextion (chin-mouth-nose-brow-vertex- occiput ) 8- Keep back anterior 9- Second stage not more than 30 min

29. Breech (cont) Management during labour: 1- First stage: Assess mother-fetus Look for cord prolapse Monitor mother+fetus C/S:fetal distress, maternal distress, failure of progress (no syntocinon )

30. Management during labour (cont): 2- Second stage: - The larges part of baby delivers last - Spontanous - Extraction(only second twin)

31. Breech (cont): Assisted vaginal delivery: 1- Empty bladder 2- Cervix fully dilated 3- L ook for cord 4- Sacrum anterior 5- Prineum distended and breech climbs perineum

32. Breech (cont): Assisted vaginal delivery: 6- Pudendal block 7- Episitomy 8- Delvier buttocks and legs 9- Frank breech: abduct thigh and flex knee deliver 10- Hold baby back anterior

33. Assisted vaginal delivery (cont): 11- WAIT DO NOT PULL

34. Assisted vaginal delivery (cont): 12- Deliver arms when scapula appears 13- Extended arms due to pulling (LOVSET) - Rotation of body so that the posterior shoulder becomes anterior and below pubic symphysis 14- Leave baby hang by gravity (supported) flexed and engaged 15- Nape of neck under symphysis pubis

35. Deliver Head: A- Mauriceau smellie veit Two fingers press over maxilla to flex the head, suprapubic pressure. Shoulder traction B- Swing the trunk towards the maternal abdomen until the mouth and nose are visible C- Forceps Piper-Neville Barnes Forceps Long Forceps when MSV fails

36. OCCIPITOPOSTERIOR (OP) AND DEEP TRANSEVERSE ARREST: 1- Normally head engages with occiput lateral (LOL,ROL) Usually rotates anterior (OA). 80% well flexed. Presenting diameters: suboccipito bregmatic + biparietal 9.5 × 9.5 cm Rarely delivers occipito lateral (small baby) 2- In 1/5 labour starts with occipitposterior.Usually ROP Good contractions: 80% flexion and rotates anterior OA Rarely rotates to deep transverse arrest - C/S.

37. OP (cont) 3- Head engages as OP Small baby and anthropoid pelvis No rotation. Deliver face to pubis 4- Persistent occipito posterior Defelxed head Occipito frontal diameter 4 1/2 11.5 cm Large diameter-difficult labour

38. OP (cont) Associate with: Android and anthropoid pelvis Epidural analgesia Most unknown

39. OP (cont): Diagnosis : Flat abdomen Fetal parts anterior Difficult to feel the back Fetal heart at flanks

40. OP (cont) Vaginal Examination: 1- Early in labour Head is high and anterior fontanelle occupies the center. Posterior fontanelle high and sagital suture anteropsterior 2-Late in labour Moulding +caput Parietal bones overlap on each other and on the occiput Diagnosis difficult, feel ears Asymetrical dilatation of Cervix oedema of anterior Lip

41. OP (cont) Features of labour: Back pain Prolonged and Obstructed Early rupture of membranes Cord prolapse Lacerations-vagina perineum

42. OP (cont) Management: 1-Similar to occipito anterior 2- Monitoring Fetal distress Maternal distress Failure of progress 3- In primigravida syntocinon may correct position

43. OP (cont) Management: 4- Mode of delivery: Spontaneous delivery face to pubis Fetal distress or maternal distress or cord prolapse in first stage=CS Failure of progress (after syntocinon ) in first stage=C/S Fetal distress or maternal distress in second stage and head not engaged = C/S

44. OP (cont) Management: 4- Mode of delivery: Head not engaged, no FD or MD, second stage = syntocinon Fetal distress or maternal distress or failure of progress in second stage and head engaged= Vacuum: enhance rotation and delivery OA. Forceps: Deliver face to pubis Manual rotation- flex head+rotate

45. FACE PRESENTATION: 1- Incidence 1:300 2- Aetiology Hyperextended head +face presenting Submentobregmatic diameter 9.5 cm Usually secondary in labour i - Big baby ii-Contracted pelvis i ii-Pendulous abdomen of grandmultipara i v-Premature v - Goitre , anencephaly

46. Face presentation (cont): 3- Diagnosis : Vaginal examination Frontal bones, supraorbital ridges, eycs , nose, mouth, chin. Mouth(suckling reflex, alveolar margin, mouth and maxilla form triangle) Anus: Straight line with ischial tuberosities .

47. Face presentation (cont): 4- Labour : Face bones not comperssable Submento bregmatic diameter 9.5 cm Prolonged labour, early rupture of membranes Strats mento -lateral and rotates to mentoanterior Neck fixed under pubic arch and head delivers by flexion Mento posterior rotates to mentoanterior Persistent nentoposterior - impossible vaginal .

48. Face presentation (cont): 5- Management : Evaluate condition carefully after diagnosis Vaginal delivery – Mento anterior and mento lateral: Monitor (FD,MD, Failure progress) Large episiotomy

49. Face presentation (cont): 5- Management: Contra- indicated Syntocinon . Vacuum Scalp electrode - Forceps may be used

50. Face presentation (cont): 5- Management: Caesarean section Contracted pelvis Big bay Previou C/S Hypertension, APH, diabetes Presistent mento posterior

51. Face presentation (cont): Dead fetus Craniotomy C/S

52.     BROW PRESENTATION:   Incidence 1:600 Aetiology similar toface Deflexed head. Mentovertical diameter 13.5 cm - Diagnosed by vaginal exam Frontal sutures, anterior fontanelle , supra orbital ridges, eyes, nasion (mouth and chin not felt) - Management:C /S

53. TRANSVERSE LIE OR SHOULDER PRESENTATION: Incidence 1:300 Aetiology Multiparous Pendulous abdomen Pre-term Placenta previa Abnormal uterus Contracted pelvis Polyhydramios Malformed baby

54. Transverse lie or shoulder presentation (cont): Diagnosis: Asymmetrical abdomen Fundus less than dates Head usually to the left In back down transeverse lie the shoulder is over the pelvic inlet (shoulder presentation) In back up transever lie (second twin) Oblique lie Unstable lie Empty pelvis

55. Transverse lie or shoulder presentation (cont): Vaginal examination: Early labour: bag of water with fetal parts Late labour: membranes ruptured Shoulder presents in back down transevers lie ( ribe in medial side of axilla , clavicle, acromion ) Arm proplapse .

56. Transverse lie or shoulder presentation (cont): Features of labour: Ruptured membranes+cord proplapse Obstructed labour ruptured uterus Neglected shoulder presentation

57. Transverse lie or shoulder presentation (cont): Management Antepartum: 1- U/S (Placenta previa etc) 2- Attempt ECV 3- C/S Management in labour : C/S

58. PROPLAPSE AND PRESENTATION OF CORD: Aetiology : 1- Malpresentaion malposition 2- Multiparous -high head at start of labour 3- Polyhydramnios 4- ARM-high head 5- ECV 6- Forceps-vacuum 7- Long cord 8- Pre-term .

59. Prolapse and presentation of the cord (cont): 1- Proplapse : Membranes ruptured - Diagnosed : visual, vag examination Bradycardia : Cord spasm. Compressed. Asphyxia 2- Presentation : membranes not ruptured (C/S)

60. Management of Prolapsed cord : 1- Keep cord in vgina 2- Elevate foot of bed.fill bladder 3- Never attempt to reposition in uterus 4- Forceps:alive +fully dilated cervix 5- C/S:alive 6- Vaginal : dead.

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