UNIT 3 FETAL DISTRESS MATERNAL,FETAL MONITORING UMBILICAL CORD ABNORMALITIES MALPRESENATATION AND MALPOSITION SHOULDER DYSTOCIA.pptx

THIS MODULE INTRODUCES STUDENTS TO ABNORMAL CONDITIONS

1. UNIT 3 CONT’ FETAL DISTRESS FETAL MONITORING MATERNAL DISTRESS UMBILICAL CORD ABNORMALITIES MALPRESENTATION AND MALPOSITIONS SHOULDER DYSTOCIA

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29. CORD PRESENTATION AND PROLAPSE OF THE UMBILICAL CORD LEARNING OBJECTIVES At the end of this presentation the student midwife will be able to: Differentiate between presentation and prolapse of the umbilical cord Identify situations when this emengency might occur Discuss the midwife management of cord presentation and prolapse Discuss the possible consequences to the woman and the fetus

30. Definition Cord presentation: presentation of the cord occurs when a loop of cord lies below the presenting part of the fetus and the membranes still intact Cord prolapse: when the membranes rupture it is referred to as cord prolapse and loop may be visible in the vagina or hidden but in front of the presenting part. Occult cord presentation: when a loop of cord lies beside rather than before the presenting part, this will not be felt on vagina examination but may be the cause of unexplained fetal distress in labor characterized by early stages by deep early deceleration of the fetal heart. When confronted with a case of unexplained fetal distress the midwife should consider the possibility of cord compression.

31. Causes Presentation and prolapse of the umbilical cord may occur in any situation which results in a poorly fitting presenting part.some conditions include: An unusually long umbilical cord Malpresentation such as shoulder and breech presentation especially in a footling or flexed breech Preterm fetus more at risk because of higher incidence of malpresentation especially before 34weeks of gestation Malposition such as occipitoposterior Multiple births

32. Causes cont ’ Multiparous women due lax abdominal musculature which favours non-engagement of the fetal head until labor begins External cephalic version Polyhydramnios Low lying placenta previa High presenting part above the pelvic brim Artificial rupture of membranes (ARM)

33. Diagnosis May be diagnosed in pregnancy through ultrasound scanning Vaginal examination mat occasionally reveal a cord presentation with a soft irregular rope like cord being palpated through the fetal membranes, pulsation will be evident and will be synchronous with the fetal heart rate. If the presenting part is very high, the cord may float away from the examining fingers Pulsation causes by the uterine arteries will be felt in the vaginal fornixes and will be synchronous with maternal pulse Aucultation of fetal heart rate to differentiate from maternal pulsation

34. Management of cord prolapse Key points in the management Call medical assistant urgently Relieve pressure on the cord Improve fetal oxygenation Expedite delivery Keep a clear, accurate and contemporaneous record

35. Management of prolapsed umbilical cord : Management: Temporizing measures to relieve cord pressure, Tocolysis with Terbutaline 0.25 mg SC Push cord back into vagina and maintain with gauze pack saturated with normal saline Vaginal retrograde pressure applied to presenting part Hand in vagina elevates presenting part Consider filling Bladder with 500-700 cc Saline Minimize handling of the cord Do not attempt to replace cord back into Uterus Adjust maternal position to reduce cord pressure Raise foot of the bed ( Trendelenburg's Position) Sims' position Mother in left lateral decubitus position Genu-pectoral position Mother in knee-chest position Source: http://www.fpnotebook.com/ob/ld/UmblclCrdPrlps.htm with rationale for each step added by Anne Grove CNM

36. Management cont ’ Adjust maternal position to reduce cord pressure Raise foot of the bed (Trendelenburg's Position) Sims' position Mother in left lateral decubitus position Genu-pectoral position Mother in knee-chest pos Source: http://www.fpnotebook.com/ob/ld/UmblclCrdPrlps.htm with rationale for each step added by Anne Grove CNM

37. Management of umbilical cord prolapse cont’ PREPARE For CAESAREAN DELIVERY Educate the mother and family and reassurance and effective communication Call for helper more helpers

38. Management according to MOH PROTOCOL Treat as an obstetric emergency and arrange for immediate medical assistance (obstetrician, anaesthetist, neonatologist) The mode of delivery will depend on whether a fetal heart is present or absent and the stage of labour Aim to maintain the fetal circulation by preventing / minimising cord compression until birth occurs

39. Management of 1 st stage of labor If Cord pulsating Determine stage of labor by vaginal examination First stage of labor Arrange immediate delivery by caesarean section Administer Oxygen Ensure continuous fetal monitoring until in theatre and commencing caesarean section or until after vaginal birth

40. Management of 1 st stage of labor cont’ The priority is to relieve pressure on the cord while preparations are made for emergency caesarean section. Where possible the bladder can be filled with normal saline where there is delay to carry out the c/section Positioning the woman in the deep knee-chest position (also known as Trendelenburg) so that the pelvis and buttocks are elevated. Elevate the foot of the bed where possible. Using sterile gloves, the midwife / medical officer should insert their fingers into the vagina, identify and carefully elevate the presenting part to reduce the amount of cord compression and keep fingers inside until delivery

41. Management of 1 st stage of labor cont.’ If the cord is protruding outside the vagina, the attending clinician may attempt to push back the cord gently within the vagina Avoid excessive handling of the cord Acute intravenous tocolysis using β2 agonists (Salbutamol or Terbutaline) to relieve pressure on the cord may be an effective adjunct treatment

42. Management of 2 nd stage of labor If cord pulsating If the woman is in the second stage of labor and vaginal birth is imminent and with the presenting part engaged, prepare for vacuum extraction If vaginal delivery is not feasible, do immediately a caesarean section If Cord not pulsating Confirm fetal death with ultrasonography and/or CTG Allow labor to proceed as for vaginal birth of fresh stillbirth

43. Prognosis/ OUTCOMES High perinatal mortality for delayed delivery >40 Prevention Do not perform artificial rupture of membranes if fetal head high above the pelvic brim.

44. Summary The outcome is likely to be poor for the baby if action is not swift and effective The midwife must recognize those who are at higher risk and know what emergency action to take in the event of cord presentation and prolapse Accurate record keeping is vital particularly in regards to times and action taken Psychological care and debriefing after the event are essential for the woman and her family.

45. MALPRESENTATIONS AND MALPOSITIONS LEARNING OBJECTIVES At the end of this session the student midwife will be able to: Have an understanding of the factors which predispose to malposition's and malpresentations Recognize features of malpresentation and malposition and take the appropriate action Consider the management and care that may facilitate normality and ensure a safe and positive experience for the woman and baby

46. B. TYPES Mal presentations : Brow Face Breech Transverse Compound Mal positions: Occiput Posterior Position (OP): when the fetal occiput is directed towards the mother’s spine or posteriorly Intermediate positions ( Bregma )

47. C. Causes Defects of the power : Laxity of the abdominal muscles, exaggerated dextrorotation of the uterus Defects of passage : Contracted Pelvis, android pelvis, pelvic tumor, uterine anomaly and placenta previa . Defect of passenger : Preterm fetus, macrosomia , multiple pregnancy, poly hydramnios , anacephaly and hydrocephaly, Intrauterine fetal death

48. A. MALPOSITION OF THE OCCIPUT Occipitoposterior position occurs in approximately 10% of all labour,most of which end normally. Malposition may also be common with the use of epidural anaesthesia Modern life style with less physical activity and poorer posture has lead to an increase in the number

49. Causes Failure of internal rotation prior to delivery Direct cause is often unknown Associated with an android or anthropoid shaped pelvis

50. Antenatal Diagnosis Abdominal examination: Inspection There is a saucer shaped depression at or just below the umbilicus. Palpation The back is difficult to palpate; it is well out to the side Limbs can be felt on both sides of the midline The head is usually high The occiput and sinciput are on the same level Auscultation The fetal heart can be heard in the midline or in the flank

51. Diagnosis during labor The woman may complain of continuous and severe backache worsening with contractions Spontaneous rupture of membranes may occur at an early stage of labor Contractions may be incoordinate There is slow decent of the head even with good contraction

52. Labor diagnosis cont ’ The woman may have a strong desire to push at the early stage of labor Vaginal examination finding will depend upon the degree of decent of the fetal head; locating the anterior fontanelle in the anterior part of the pelvis is diagnostic The direction of the sagittal suture and location of the posterior fontanelle will help to confirm the diagnosis

53. Management of labor First stage: Labour with a fetus in occipitoposterior can be long and painful. Assist with pain management techniques such as massage,change of position and posture, Give pharmacological pain relief Prevent dehydration and ketosis Correct any incoordinate uterine contractions with an oxytocin The urge to push before the cervix has become fully dilated may be eased by a change in position and the use of breathing techniques

54. Management cont ’ Second stage: Full dilatation of cervix may be confirmed by a vaginal examination Encourage the woman to remain in upright position If contraction are weak and inefficient an oxytocin infusion may be commenced The length of the second stage of labor is increased when the occiput is posterior,with an increased risk of operative delivery.

55. COMPLICATIONS Early rupture of membranes Cord prolapse Prolonged labor Retention of urine Premature expulsive phase Infections Trauma to the mother’soft tissue Post traumatic stress disorders or postnatal depression Maternal exhaustion Fetal intracranial injury and hemorrhage Increased perinatal mortality and morbidity

56. Malpresentation Malpresentation refers to the orientation of the fetus and may be diagnosed during pregnancy or labor. Any presentation other than vertex is termed a malpresentation and therefore includes: Breech,face,shoulder , and brow As in malposition there is commonly an ill fitting presenting part which is associated with early rupture of membranes.

57. BROW PRESENTATION The fetal head is partially extended with the frontal bones lying at the pelvic brim.the presenting diameter is the mento -vertical (13.5cm)

58. B.BROW PRESENTATION

59. Causes and risk factors CPD Thyroid neoplasms Multiple loops of cord around fetal neck Fetal anomalies Polyhydramnios Prematurity PROM with unengaged head Uterine anomalies Placenta Previa External Cephalic Version Idiopathic More common in nulliparous women

60. Diagnosis Cephalic prominence and back are on same side FH heard in lower quadrants On vaginal exam: Anterior fontanel easily palpated Frontal suture easily felt, sagittal suture hard to reach Palpable supra orbital ridges, eyes, root of nose

61. Management and its complications Denominator is forehead Attitude of partial extension Mento vertical 13.5cm diameter presents Incidence 1 in 1000-3000 Descent very slow, molding extreme Higher fetal mortality, traumatic brain injury r/t molding Management : Cannot deliver vaginally unless converts to face (30%) or vertex (20%). It is cesarean delivery

62. Management cont ’ On vaginal examination Presenting part is high The anterior fontanelle may be felt on one side of the pelvis and orbital ridge,root of the nose at the other A large caput succedenum may mask these land marks if the woman has been in labor for some time.

63. C.FACE PRESENTATION Face presentation: Hyperextension of the fetal head

64. Types Anterior (LMA, RMA) Longer labor 90% deliver vaginally More work for Mom NB: Facial and laryngeal edema – watch for breathing difficulties for 24 hours, peds at delivery Transverse (LMT, RMT) Majority rotate to LMA → MA Remainder either rotated with forceps or delivered by c/s           

65. Types cont.. Posterior (LMP, RMP) 30% of face presentations Most rotate anteriorly Persistent posterior cannot be delivered vaginally

66. Diagnose On vaginal examination: The face is palpable and the point of reference is the chin. You should feel the mouth and be careful not to confuse it with breech presentation. It is necessary to distinguish the chin-anterior position from chin- posterior position

67. Management If Chin-anterior position If the cervix is fully dilated: vaginal delivery If there is slow progress and no sign of obstruction, augment labor If descent is unsatisfactory, perform a C/S If Chin-posterior position Deliver by C/S

68. MIDWIFERY MANAGEMENT Call for help Reevaluate adequacy of pelvis Closely monitor mechanisms of labor and identify if rotates to MP position Careful VEs so as not to damage eyes Gentle pressure on fetal brow to maintain extension until chin is born Control head delivery, gradual flexion and birth of remainder of head Neonatology inform incase of resuscitation Reassurance to parents about extensive edema Effective communication with team,mother and partner. Give iv fluid

69. D.BREECH PRESENTATION A breech presentation occurs when the fetal buttocks lie lowermost in the maternal uterus and the fetal head occupies the fundus The lie is longitudinal,the denominator is the sacrum,presenting diameter is the bitrochanteric which measures 10cm.

70. t TYPES OF BRRECH Complete – flexion at thighs and knees (5-10%) Frank – flexion at thighs, extension at knees (50-70%) Footling – extension at thighs and knees, single or double (10-30%) Kneeling – extension at thighs, flexion at knees, single or double

71. Causes/ Risk factors Prematurity High parity Polyhydramnios Oligohydramnios Uterine anomalies, uterine neoplasms , contracted pelvis Placenta previa Multiple gestation Hydrocephaly, anencephaly, other fetal anomalies IUFD

72. Diagnosis Pt reports FM in lower abdomen/rectum Ballotable head felt in fundus Non- ballotable breech felt in lower abdomen FH heard at or above umbilicus On VE, high presenting part, negative findings Presenting part soft and irregular The buttocks and/or feet are felt, thick dark meconium is normal

73. Criteria for vaginal breech delivery No Contraindications to vaginal birth No fetal anomaly that may interfere with vaginal birth EFW 2000-4000g GA 36+ weeks Flexed fetal head – NO hyperextension Frank breech Normal progress of labor Continuous EFM Skilled provider and c/s immediately available

74. Management cont Varney ’ s 9 Steps/Criteria before Delivery of a Breech Abdominal exam or sono /x-ray to r/o hyperextension of fetal head, hydrocephalus, footling/kneeling breech Complete cervical dilation  Completely assured of adequacy of pelvis Empty bladder Determine need for episiotomy and perform Ensure effective maternal pushing Prepare for full-scale NB resuscitation Position woman in lithotomy , at edge of bed Consulting physician at bedside or immediately available

75. Management cont.. Types of vaginal breech delivery Spontaneous – no traction, no manipulation Assisted – infant delivers spontaneously to umbilicus, maneuvers are used to facilitate rest of delivery Total breech extraction – feet are grasped, entire fetus is extracted

76. Mechanism of labor In breech presentations, three segments of the fetus go through the mechanism of labor: 1. The buttocks and lower limbs 2. The shoulders and arms 3. The head Mechanism of labor for Right Sacrum Anterior, R.S.A.:   Descent  occurs throughout for all three segments due to the force of uterine contractions.   I. The Buttocks :   Engagement :  has been achieved when the bitrochanteric diameter has passed through the inlet of the pelvis with the sacrum in the left anterior quadrant of the mother's pelvis and the bitrochanteric diameter in the left oblique diameter of the mother's pelvis. Lateral flexion occurs at the waist.

77. Mechanism cont ’ Internal Rotation : When the anterior hip meets the resistance of the pelvic floor, it rotates forward 45 degrees so that the bitrochanteric diameter becomes anteroposterior. (RSA to RST) Birth of the Buttocks : by Lateral Flexion: The anterior hip impinges under the pubic symphysis; lateral flexion at the waist is increased; the posterior hip is born over the perineum. Then the anterior hip slips out from under the symphysis and is born. The legs and feet usually follow spontaneously

78. Mechanism cont ’ Restitution occurs as the buttocks rotate 45 degrees (RST to RSA) in response to internal rotation of the shoulders.

79. II. Shoulders and Arms : Engagement of the shoulders occurs with the bisacromial diameter passing through the pelvic inlet in the right oblique diameter of the maternal pelvis.   Internal Rotation occurs as the anterior shoulder strikes one or both pelvic sidewalls and rotates 45 degrees from the right oblique diameter to the anteroposterior diameter of the maternal pelvis. Birth of the Shoulders by Lateral Flexion : The anterior shoulder impinges under the symphysis and the posterior shoulder and arm are born over the perineum as the baby's body is lifted upward. Then the anterior shoulder and arms pass out under the symphysi

80. III. The Head : When the shoulders are at the outlet, the head is entering the pelvis. Engagement :  occurs with the sagittal suture in the left oblique diameter of the pelvis. The occiput is in the right anterior quadrant of the pelvis. Flexion : of the head will take place but must be maintained. Internal Rotation : The occiput strikes the pelvic sidewalls and rotates 45 degrees anteriorly so that the sacrum becomes position S.A. resulting in the sagittal suture being in the anteroposterior diameter of the pelvis. Birth of the Head : The nape of the neck pivots under the symphysis and the chin, mouth, nose, forehead, bregma and occiput are born over the perineum by flexion

81. A. GUIDELINES FOR SAFE DELIVERY OF A BREECH 1. Cervix fully dilated before pushing is allowed. 2. Bladder empty. 3. Episiotomy performed, unless perineum is very lax. 4. Delivery accomplished by maternal pushing — rather than traction from below. 5. Intervention consists of aiding the steps of the mechanism of labor to happen within safe time limits. 6. Administration of iv fluid 7. Regular strong contractions

82. LOVESET MANOEVER(CLOCKWISE AND ANTI CLOCWISE ROTATION) 6. Safe traction is made by downward pull on the baby's pelvis (by fingers on the iliac crests and thumbs over the sacro -iliac regions) or later after the trunk has been delivered by a finger hooked over each shoulder. 7. Delivery of the shoulders should be attempted only after the scapulae can be seen. From Williams 22 nd Ed figure 24-8

83. LOVESET CONT’ 8. Safe rotation of the trunk is made by using the same grasp on the baby's pelvis and turning. 9. Delivery of the head should be attempted only after the hairline at the sub-occipital region can be seen. From Williams 22 nd Ed figure 24-9

84. PROCEDURE FOR DELIVERY OF A FLEXED BREECH MAURICEAU-SMELLIE-VEIT MANOEUVRE All steps as in procedure for normal delivery apply except where the following special points replace them: 1. There should be no intervention (" hands off the breech ") until the body is born as far as the umbilicus . 2. When the umbilical cord can be seen, gently draw down a loop of cord , placing this to the side or near the perineum, to avoid a pull on the cord or unnecessary pressure. If the cord does not slip down with gentle traction, omit this step. 3. With the next contraction, have the mother bear down strongly to deliver chest and arms. Meanwhile, grasp the baby by its pelvis (see # 6 above), and when the body is delivered as far as the axilla , guide it downward to release the anterior shoulder and arm, then upward for the posterior shoulder and arm

85. MAURICEAU-SMELLIE VEIT CONT’ 4. As soon as the body and shoulders are fully born, rotate the back uppermost to ensure that the occiput rotates anteriorly . Have an assistant apply suprapubic pressure to maintain flexion of the infant's head until the head is born. Rest the baby's body on your non-dominant hand and forearm , hooking the index and ring fingers of this hand on each malar eminences. Place your other hand on the baby's upper back , with the index finger hooked over one shoulder, and the middle finger hooked over the other shoulder. Place the hooking fingers as far away from the neck as possible to avoid pressure on the cervical or brachial nerve plexuses. As the mother bears down, make downward and outward traction on the shoulders until the hairline appears under the pubic arch.

86. Procedure for Delivery of a Flexed Breech Alternative: if no assistant is available to apply suprapublic pressure, use the upper hand to apply suprapubic pressure to the head until the hairline appears under the pubic arch

87. 5. Apply upward traction while elevating the infant's body, following the curve of Carus . When the suboccipital region of the head pivots under the symphysis pubis, lift the body 45°, until the infant's nose and mouth are visible at the introitus . Complete delivery of the head by gradually easing the vault out through continuing the upward lift of the body. Alternative : The upper hand grasps the baby by the ankles, maintaining slight traction to ensure that the suboccipital region pivots under the symphysis pubis. Lift the body about 45o until the nose and mouth are visible at the introitus . With the lower hand , wipe off the nose and mouth . Complete delivery of the head by gradually easing the vault out through continuing the upward lift of the body.

88. COMPLICATIONS Extended arms Extended head Entrapment of the fetal head Damage to internal organs of the trunk. Fracture of bones of extremities. Injury to brachial plexus Entrapment of the after coming head Nuchal arm

89. Management of BREECH according to MOH guideline and protocol, 2012 Consider external cephalic version at 37 weeks if all requirements are met (Adequate amniotic fluid, placenta in fundal position, No uterine anomalies, no previous uterine scar, availability of theatre) Ideally, every breech delivery should take place in a hospital with surgical capability. Determine most favorable mode of delivery(WHO advises c/ section,vaginal delivery in emergency cases to minimize complications

90. Contra-indications Unfavorable pelvis, primigravida , macrosomia , severe prematurity, IUGR, placental insufficiency, footling breech, hyperextension of fetal head, fetal anomalies, nuchal arm, PROM or non-progressive labor Note: Vaginal breech delivery is safe and feasible by a skilled health provider

91. COMPOUND PRESENTATION Definition: Occurs when an arm prolapses alongside with the presenting part

92. Diagnosis and management On Vaginal Examination Fingers/Arm is felt with the presenting part Management Replace the arm and if successful continue with vaginal delivery If Contracted pelvis and/or cord prolapsed: Do a C – section

93. Oblique and transverse lie leading to shoulder presentation A shoulder presentation occurs as a result of a transverse or oblique lie. Shoulder presentation is not uncommon and is only probmatic if the fetus is not cephalic by 36 weeks of gestation If uncorrected shoulder presentation will result in obstructed labor and must be readily identified The most commonest cause of an unstable lie and shoulder presentation is laxity of the uterine and abdominal muscles Seen most frequently on women of high parity

94. Causes Placenta previa is the most commonest cause Persistent oblique lie Multiple pregnancy Polyhydramnios Uterine abnormality Contracted pelvis Large uterine fibroid Over distended bladder

95. Diagnosis Abdominal examination: the shape of the uterus appears too broad with fetal pools felt on either side of the abdomen while the fundus is usually low Palpation will reveal the fetal head on one side and the breech on the other and no presenting part within the pelvis In obliques lie the fetal head or breech is found in one or other iliac fossa Ultrasound may be used to confirm the diagnosis

96. Management After 36 weeks the doctor may attempt to correct the lie by external cephalic version to a longitudinal lie and cephalic presentation Ultrasound examination to exclude placenta previa,fetal and uterine abnormalities Vaginal examination to detect any abnormalitiessuch as contracted pelvis If the lie continues to be tranverse or obliques then c/section should be performed Effective communication Psychological support Adequate fluid intake Monitor contraction,fetal heart rate and act accordingly.

97. Complications Arm prolapse Infection Umbilical cord prolapse Uterine rupture Fetal and maternal death

98. Summary Malpresentation and malposition of the fetus may increase the risk of fetal and neonatal morbidity and mortality The midwife should ensure that the woman and her partner feel prepared and supported for birth Effective communication and team work are crucial in the provision of safe and appropriate care to women and their babies Manoeuvres and other skills based on physiological and evidence –based principles should be practiced by those providing care to women and their babies on a regular bases.

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