MALPRESENTATON (Br, Brow, and Shoulder)

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					 MALPRESENTATON (Br,
Brow, Face, and Shoulder)

   PRESENTED BY

PROF. O.B FASUBAA
INTRODUCTION
* Presentation is the part of the fetus
  occupying     the     lower     uterine
  segment. Thus we can have cephalic,
  breach and shoulder presentation in
  the real sense of the definition.
* The part of the presentation that lies
  closest to the internal cervical OS or
  that which can be felt on vaginal
  examination is regarded as the
  presenting part.
   Thus we can have vertex, face
    brow presenting part as these
    areas are easily felt on vaginal
    examination.
   Thus by definition: Brow and
    face are presenting parts and not
    true presentation
   Any presentation other than
    cephalic presentation in the
    lower    uterine   segment     is
    described as malpresentation.
BREECH PRESENTATION
 This occurs when the caudal pole of
  the fetus occupy the lower uterine
  segment.
 The incidence ranges between 2-4%
  of pregnancies at term.
AETIOLOGY
 Prematurity is the commonest cause
  of Br. Presentation. It accounts for
  30-40% of singletons between 20-
  25wks, 15% at 32wks and by 34 wks
  most have undergone spontaneous
  version to a cephalic presentation
   Multiple pregnancy
   Oligohydramnios
   Abnormalities of uterine shape
   Cornual attachment of the placenta
   Previous breech delivery
   Extended legs which hinders
    spontaneous version
   Primgravidity

   Hydrocephaly

   Polyhydramnios

   Intra uterine fetal death

   Pelvic tumours e.g. fibroids,
    ovariancyst

   Contracted pelvis
Diagnosis
 High    index of suspicion is
  required bearing in mind the
  notable aetiological factors
 No characteristics symptoms are
  given by the patients except for
  occasional mild discomfort in
  either of the hypochondrium
 No   characteristic findings on
  abdominal inspection
   Palpation reveals the hard,
    round, ballotable head occupying
    the fundus uteri with the back on
    one side and limbs on the other
   The rather narrow and softer
    breach may be mobile above the
    pelvic brim or may dip through
    it.
   The fetal heart will be heard best
    above the umbulicus
   On vaginal examination prior to
    labour the presenting part is
    usually high of softer consistency
    than the head and may be
    irregular in outline
   Confirmation of the diagnosis
    can be obtained by sonar
    (ultrasound), which will exclude
    placenta      praevia,    multiple
    pregnancy, structural defects in
    the uterus and fetus, fetal ascitis
    and abdominal tumours.
   In labour, apart from a high
    presenting part, the tuber ischi,
    sacrum and anus are palpable
    and the external genitalia may
    be identified. The feet may be
    felt along side the buttocks in
    complete Breech
   Early diagnosis allows time for
    adequate      assessment      and
    delivery under optimal conditions
Types of Breech
1. Extended or Fran Breech
  The lower limbs are fully flexed at
   the hip and fully extended at the
   knee
  The feet are high in the uterus
   leaving a smooth, well fitting
   presenting part which tends to
   engage early.
  The snug fit results in a low
   incidence of cord prolapse
  Frank Br occurs in 60-70% of all
   cases and more frequent in
   primigravida
  Has good prognosis for vaginal
   delivery
2.   Flexed or complete breech
    The hips and knees are flexed.
     The feel being closely applied to
     the dorsal aspect of the thighs
    The presenting part is more
     irregular
    Early engagement is less likely
     and prolapse of the cord is
     4times as common as in Frank
     Br
3.   Footling or Knee presentation
     (In complete Breech)
    Presentation of one or both feet
     being more common than knee
     presentation
    There is a high risk of
     presentation or prolapse of the
     cord
Management:
 Antenatal    care and visits when the
  diagnosis is made very early at booking.
 How ever consideration may be given for
  external cephalic version in some selected
  cases
 External cephalic version attempts to turn

  the fetus to cephalic presentation by
  manipulation     through    the   mother’s
  anterior      abdominal      wall    under
  analgesia/anaesthesia or sedation
    For this procedure to succeed, there
     must be enough liquor and anterior
     abdominal wall must be thin
* ECV is contraindicated in
1.   Rhesus negative mother
2.   Moderate or severe hypertension
4.    APH/placenta praevia
5.    Uterine scars
6.    Ruptured membranes
7.    IUGR
8.    Twin pregnancy
9.    Major fetal deformity
10.   Where elective c/s is planned
   The success rate of ECV varies
    from center to center
   The procedure of ECV is not
    generally     favoured     among
    obstetricians because:
   Many believe that incidence of Br
    at term is similar in centers that
    do it and in those that do not do
    it.
   That many of the Br wound
    undergo spontaneous version
    naturally
   Associated complications of
    ECV are considerate e.g.
    • Premature labour / PPROM
    • Cord prolapse
    • Abruptio placenta
    • Ruptured uterus
    • Fetal bradycardia necessitating EMLSCS
   Expertise is drying out
   Routine c/s is being embarked upon
    as a policy of managing Br.
   There is no doubt that ECV has a
    place in Sub-Saharan African
    where there is aversion to surgery
    and rising cost of c/s
   It is best to plan the mode of
    delivery antenataly if associated
    perinatal mortality is to fall.
      Elective c/s in Br presentation
   c/s indicated in the presence of another
    obstetric problem (A + B = C)
   Associated conditions such as DM
    moderate – severe hypertension, PP and
    fulminating pre-eclampsia may justify
    elective c/s.

   Some cases of Rhesus isoimmunzation

   Growth retarded fetus
   Suspected contracted pelvic
   Footling Breech
   Poor obstetric history with difficulty
    with fertility
   Previous uterine scar
   Pre term infants
*c/s rate for Br in our center
  approaches65% and is much
  lower when compared to the
  developed world.
SELECTION OF CASES FOR
  VAGINAL Br DELIVERY
 Pelvic shape and capacity must
  be judged adequate by past
  obstetric history through clinical
  and radiological assessment x-
  ray or CT pelvimetry
   X-ray many also reveal skeletal
    abnormality, hydrocephalus
   In labour ZATURCHNI– ANDRO’S
    score is desirable and a score of
    6 and above will give satisfactory
    prognosis of vaginal delivery
MECHANISM OF LABOUR IN
 BREECH        (Describe  and
 demonstrate if possible)
Conduct of vaginal breech delivery
   This should always be in a unit
    equipped for c/s and should be
    attended by an experienced
    obstetrician anaesthetist and
    neonatologist and all present at
    delivery.
   Routine     fetal   well      being
    monitoring in labour is ideal
First stage
 Require I.V. line as they may
  require anaesthesia urgently and
  also to give adequate fluid and
  to avoid ketosis
 Attention paid to presence of
  cord prolapse each time after
  vaginal examination which is
  done every 2-4 hourly
 Epidural analgesia may be
  desirable to reduce pain but may
  prolong second stage
Second stage
Delivery may occur
  spontaneously, by assisted
  breech delivery or by breech
  extraction
Spontaneous Br delivery
 Occurs rarely

 Carries a high perinatal mortality

Assisted Br delivery
 Describe the procedure

 Lithotomy position
 Drapping
 If not on epidural – pudendal
  block + perineal infiltration
 Start   delivery when Br is
  climbing the perineum and
  the Anus visible
 Give episiotomy
 Bring down the extended legs
  by Pinnard’s manoeuvre
 Allow the fetus to hang until
  scapula and one axilla of the
  fetus is seen.
   Then bring out the flexed arms
    from the anterior wall of the
    chest
   Use Louvset manoeuvre to
    deliver extended arms if possible
   Allow the fetus to hang until the
    Nape of the scalp of seen
   Then begin delivery of the fetal
    head by forceps, or Burns
    Marshal procedure or mauriceau
    – smellie – veit technique
   Hand over baby to neonatologist
    for adequate resuscitation
Breech extraction
Not much indicated in modern obstetrics
 except for the delivery of the second twin
 fetus at risk
Dangers of Br delivery
Maternal
 Sepsis

 Tears of vagina, cervix perineum and
  uterus
 PPH

 Dangers of emergency anaesthesia
  and those of c/s
Fetal
• PNMR
• Still birth from intracranial
  haemorrhage
• Birth Asphyxia
• Medullary conning through the
  foramen magnum
• Severance of the cord
• Brachial plexus injury with Erb’s
  palsy
• Fractured skull
  •Stenocleidomastoid
    heamatoma
  •Tearing of lower lumbar muscle
  •Crush     syndromes     on    the
    kidneys + liver
  •Injury to abdominal organs
  •Breathing difficulties
All    these     fetal    morbidities
 jusctifies advocacy for routine
 c/s or at best ECV to prevent
 occurrence          of      Breech
 presentation.
OTHER MALPRESENTATION
Face presentation
 Incidence 1:500

 15% - due to congenital abnormality

  such as anencephaly, tumour
 Most occur by chance as the head

  extends rather than flexes as it
  engages
 Diagnosis may be difficult antenatally
  and may not be recognized until
  labour has ensured.
   On vaginal examination, the nose
    and eyes may be felt but may not be
    possible because of oedema which
    may mimick breech presentation.
   Most engage in the transverse
    mento-bregmatic diameter – 9.5cm
   90% rotate so that the chin lies
    behind the symphysis and the head
    can be born by flexion
   If the chin rotates to the sacrum
    (Mento posterior). Caeseran section
    is indicated
BROW: Occur in 1:2000 deliveries
  often     associated      with   a
  contracted pelvis or a very large
  fetus
 Antenataly: The head does not
  engage (Mentovertical diameter
  = 13cm) and a sulcus may be
  felt between the occiput and the
  back
 On    vaginal examination, the
  anterior       fontanelle      and
  supraorbital ridges may be felt
 Delivery by c/s
Shoulder presentation
Occurs in 1 in 400 deliveries and
 is usually in multiparous women
   Other predisposing factors include
    multiple pregnancy, polyhydramnios,
    uterine anomalies (arcuate or
    septate uteurs), placenta preavia,
    contracted pelvic
   Antenatal diagnosis: Ovoid uterus
    wider at the sides
 Lower pole is empty, the head lies in
  one flank, the fetal heart is heard in
  variable positions
 On     vaginal examination – ribs,
  shoulder or prolapsed hand may be
  felt if membranes have ruptured
 If     malpresentation   persists    –
  ceaseran section is the appropriate
  mode of treamtnet.
If detected at about 32-34 wks ECV
  may be done

				
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