Malpresentation ( sub :- obstetrics and gynaecology)

Subject:- obstetrics and gynaecology
Topic :- malpresentation
Prepared by :- Joshi Janhavi

1. SUBJECT : OBG topic :- malpresentation Prepared by , Joshi Janhavi Nileshkumar Nursing tutor Ahmedabad

2. WHAT IS LABOR?

3. NORMAL POSITION

4. TERMS POSITION LIE PRESENTATION ATTITUDE DENOMINATOR PRESENTING PART

5. EXPLANATION :- 1. LIE :- RELATIONSHIP BETWEEN THE LONG AXIS OF FETUS AND LONG AXIS OF MOTHER. 2. PRESENTATION :- IS THE POINT OF THE FETUS THAT LIES OVER THE PELVIC INLET AND OCCUPIES THE LOWER POLE OF UTERUS. 3. ATTITUDE :- IT IS THE RELATION OF FETAL PARTS TO OTHERS ORGAN. ( THE MAIN ATTITUDE ARE FLEXION AND EXTENSION)

6. CONTINUE......... 4 . PRESENTING PART :- IS THE MOST DEPENDANT PART OF FETUS WHICH IS FELT FIRST ON VAGINAL EXAMINATION. 5. DENOMINATOR :- IS AN CHOOSEN POINT ON THE PRESENTING PART OF FETUS WHICH IS USED TO DESCRIBE POSITION. 6. POSITION :- IS THE RELATIONSHIP OF THE DENOMINATOR TO THE 4 QUADRANT OF THE MATERNAL PELVIS .

7. IF THE FETUS POSITION IS NOT NORMAL IS CALLED?????

8. MALPRESENTATION

9. WHAT IS MALPRESENTATION ????

10. DEFINITION “ Malpresentation refers to fetal presenting part other than vertex and includes breech, transverse, face, brow, and Sinciput “

11. MALPRESENTATION

12. TYPES OF MALPRESENTATION A. BREECH PRESENTATION 1. COMPLETE OR FLEXED BREECH 2. INCOMPLETE BREECH - FRANK, FOOTLING, KNEE B.FACE PRESENTATION C. BROW PRESENTATION D. SHOULDER PRESENTATION / TRANSVERSE LIE / OBLIQUE LIE E. COMPOUND PRESENTATION / COMPLEX PRESENTATION

13. A. BREECH PRESENTATION Definition :- “ breech Presentation means That either the buttocks Or the feet are The first body part That will contact with cervix “ ∆ it is the Common malpresentation.

14. TYPES OF BREECH PRESENTATION 1. COMPLETE OR FLEXED BREECH :- the baby’s bottom Comes first and the legs are flexed at the hip and extended at the knees ( with feet near the ears) Fetus appear to be sitting “ Crossed – legged”

15. CONTINUE.......... 2. INCOMPLETE BREECH :- Varying degrees of extension of thighs or legs at the podalic pole are seen in an incomplete breech. A. FRANK OR EXTENDED BREECH :- both legs are flexed at the hip and extended at the knee. The presenting part consistent of the two buttocks and external genitalia. It is commonly present in Primigravida.

16. CONTINUE.... B. FOOTLING PRESENTATION :- one or both legs extended at the hip so that the foot is presenting part. C. KNEE PRESENTATION :- thighs are extended but the knees are flexed so that the knee is the presenting part.

17. Position THE SACRUM IS THE DENOMINATOR AND THERE ARE 4 POSITION OF BREECH PRESENTATION :- 1. Left sacro anterior ( most commonest) 2. Right sacro anterior 3. Right sacro posterior 4. Left sacro posterior

18. Factors are responsible for breech presentation PREMATURITY HYDROCEPHALUS PLACENTA PREVIA CONTRACTED PELVIS HYDROAMNIOS CONGENITAL ANOMALIES UTERINE LEIOMYOMA ( non cancerous Growth in the Uterus that can develop during a women’s childbearing year)

19. MECHANISM OF LABOR

20. BURN’S MARSHALL METHOD

21. MALAR FLEXION & SHOULDER TRACTION METHOD

22. B. FACE PRESENTATION DEFINITION :- “ FACE PRESENTATION IS A CEPHALIC PRESENTATION WHERE FACE AS PRESENTING PART, MENTUM AS DENOMINATOR, COMPLETELY FLEXED LIMBS, WITH COMPLETELY EXTENDED HEAD, AND OCCIPUT TOUCHES THE BACK “ .

23. POSITIONS 1. RIGHT MENTO POSTERIOR 2. RIGHT MENTO ANTERIOR 3. LEFT MENTO POSTERIOR 4. LEFT MENTO ANTERIOR 5. RIGHT MENTO LATERAL 6. LEFT MENTO LATERAL

24. CONTINUE....

25. CAUSES CAUSES ARE NOT CLEAR BUT SOME FACTORS ARE ASSOCIATED WITH FACE PRESENTATION A.. MOTHER:- B.. FETUS - GRAND MULTIPAROUS - ANENCEPHALY - CONTACTED PELVIS - CONGENITAL GOITER - PELVIC TUMOR - CYSTIC HYGROMA ( fluid full fill sac - POLYHYDRAMNIOS that results from A blockage in the - PLACENTA PREVIA Lymphatic system ) mostly in neck.

26. COMPLICATIONS :- FETAL :- * CORD PROLAPSE * CEREBRAL CONGESTION ( Increased volume of Intravascular compartment of the brain :, Often associated with Brain sweeling) METERNAL :- INCREASED MORBIDITY DUE TO OPERATIVE DELIVERY AND VAGINAL MANIPULATION IN MENTOANTERIOR.

27. MANAGEMENT OF LABOR Overall assessment of the case is to be done and exclude fetal anomalies and contracted pelvis. Indication of elective cesarean section :- contracted pelvis, big baby, and other complication. VAGINAL DELIVERY :---- 1) MENTO ANTERIOR :- in uncomplicated cases, manage first stage as in Occipito posterior. Forceps delivery may be indicated in prolonged 2 nd stage and liberal Mediolateral Episiotomy is necessary to protect the perineum.

28. CONTINUE...... 2) MENTO POSTERIOR :- In uncomplicated cases, vaginal delivery is allowed with strict vigilance for spontaneous anterior rotation of the chin. During second stage , if anterior rotation of the mentum occurs, spontaneous or forceps delivery with Episiotomy should be done. In incomplete or Malrotation, Cesarean section is the safest and the current alternative in modern obstetrics. The face of the fetus is Edematous after delivery so the mother is assured that this will be spontaneously relieved within few days.

29. C. BROW PRESENTATION DEFINITION :- “it is a cephalic presentation In which the head is midway between full felxion and full extension and presenting part is the brow “. ETIOLOGY :- * prematurity * Multiparity * Tumor of neck * Polyhydroamnios * spasm of Neck

30. COURSES IN LABOR DENOMINATOR :- FRONTUM ATTITUDE :- PARTIAL EXTENSION ENGAGING DIAMETER :- VERTICO MENTUM => VAGINAL DELIVERY IS NOT POSSIBLE WHEN THE FETUS IS SMALL OR PREMATURE.

31. MANAGEMENT OF LABOR 1) ANTEPARTUM MANAGEMENT:- if the brow presentation is confirmed during the pregnancy and there are no other complications for vaginal delivery, nothing is to be done. Exclude contacted pelvis and congenital anomalies. 2) INTRAPARTUM MANAGEMENT :- in uncomplicated cases, if spontaneous correction to either vertex or face fails to occur early in labor, cesarean section is the best choice => Craniotomy is done if the fetus is dead.

32. CRANIOTOMY

33. D. SHOULDER PRESENTATION ( transverse lie / oblique lie) DEFINITION :- “ A SHOULDER PRESENTATION REFERS TO THE LONGITUDINAL AXIS OF THE FETUS LIES PERPENDICULARLY TO THE MATERNAL SPINE. “

34. POSITION The scapula is the denominator. Shoulder presentation are classified into 4 types, based on the location of the scapula. 1) left scapulo anterior 2) left scapulo posterior 3) right scapulo anterior 4) right scapulo posterior

35. Left scapulo posterior Or Right scapulo anterior

36. CAUSES * MULTIPARITY * PREMATURITY * TWINS * PLACENTA PRAEVIA * PELVIC TUMOURS * IUD

37. DIAGNOSTIC TESTS * FUNDAL PALPATION * ULTRASONOGRAPHY * VAGINAL EXAMINATION * X RAY

38. MECHANISM OF LABOR AND MANAGEMENT As a rule no mechanism of labor should be anticipated in transverse lie and labor is obstructed. MANAGEMENT OF LABOR :- 1) external cephalic version :- it should be done in all cases beyond 35 weeks provided there is no contraindication. 2) internal podalic version :- it is mainly indicated in 2 nd twin of transverse lie. 3) cs :- if version fails Or contraindicated that time perform cs is safe for both.

39. CONTINUE.... Vaginal delivery :- allowed in a dead or congenital malformed fetus. The labor may be allowed to continue under vigilance till full Dilatation of the cervix, when the baby should be delivered by internal version.