MECHANISM OF LABOUR (NORMAL & ABNORMAL) by 4v91VvF

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									Fetal Malpresentation

       Supervised By
      Prof. Basil Obedat
                    INTRODUCTION


 Fetal Lie.

 Fetal Attitude.

 Fetal Presentation.

 Fetal Position.
                          Fetal Lie
 The relation of the long axis of the fetus to that of the
  mother.

 The normal lie is longitudinal, otherwise abnormal.

 The longitudinal lie is found in 99% of labours at term.

 Risk factors for abnormal lie (transverse or oblique lies):
      - Multiparty
      - Placenta Previa.
      - Polyhydramnious.
      - Uterine Anomalies.
                      Fetal Attitude

 Posture of the fetus  folded on itself to accommodate the
  shape of the uterus.

   Normal Variant:
-   The head is tucked down to the chest,
-   Arms and legs drawn in towards the center of the chest.
-   Flexed thighs, knees & feet.

 Abnormal Variant:
- Head that is extended back or,
- Body parts in extension.
                  Fetal Presentation
 The presenting part is the portion of the body of the fetus
  that is foremost in the birth canal.
 The presenting part can be felt through the vaginal
  examination.



 Longitudinal lie  Cephalic presentation.
                    Breech presentation.

 Transverse lie  shoulder presentation
               Cephalic Presentation
     Depending on the attitude of the PP, is divided into:

 Head is flexed sharply  vertex / occiput presentation.

 Partially flexed  brow presentation (bregma)

 Partially extended  brow presentation (glabella)

 Head is extended sharply  face presentation.
.
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A

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D      (A) vertex             (B) brow          (C) brow          (D) face


    Longitudinal lie. Ce-phalic presentation. Differences in attitude of fetal body,
                 Breech Presentation
     Depending on the attitude of the PP, is divided into:



 Complete breech

 Frank breech

 Footling (incomplete) breech
I
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    Longitudinal    lie.   Frank   breech   Longitudinal lie. Complete breech
    presentation.                           presentation.
Longitudinal lie. Incomplete, or footling,
breech presentation.
                    Fetal Position
The relation of a chosen point (denominator) of the fetal
presenting part to the Rt or Lt side of the maternal birth
canal
The chosen point
     Vertex presentation  occiput
     Face presentation  mentum
     Breech presentation Sacrum
Each presentation has two positions Rt or Lt
Each position has 3 varieties : Ant, transverse, post
                    OA
              ROA        LOA
           ROT                 LOT
              ROP        LOP
                    OP
    LONGITUDINAL LIE VERTEX PRESENTATION

     LOA                        LOP




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    A. Right occiput posterior (ROP)   Right occiput transverse (ROT)




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    Right occiput anterior (ROA).
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Lt mento-ant        Rt mento-ant        Rt mento-post

   Longitudinal lie. Face presentation. Left and right
   anterior and posterior positions.
~




    Longitudinal lie Breech presentation LSP
                    Malpresentation

 Definition.

 Incidence (at term).

 Types.

 Dangers.

 Diagnosis
             Types of Malpresentation


 Transverse Lie.

 Breech.

 Compound.

 Face, Brow.
             Dangers of Malpresentation


 Ill – fitting presenting part.

 PROM.

 Cord Prolapse.

 May proceed quickly in parous women.
          Diagnosis of Malpresentation


 Abdominal Examination.

 Vaginal Examination.

 Ultrasound.
               Breech Malpresentation

 The most common type of malpresentation.
 The buttocks and/or the feet are the presenting parts.
 Prevalence of breech presentation varies with gestational
  age:
      - 33% 21-24 weeks
      - 14% 29-32 weeks
      - 3-4% term
 Perinatal mortality and morbidity higher (3 times cephalic)
 Umbilical cord prolapse - more prevalent.
Maternal Factors Associated With Breech Delivery



   High parity
   Prematurity
   Multiple Gestation
   Polyhydramnios / Oligohydramnios
   Uterine Anomalies
   Prior Breech Delivery
 Fetal Factors Associated With Breech Delivery



 Fetal abnormalities (e.g. hydrocephalus, neck masses,
  anencephaly, neuromuscular condition)
 Macrosomia.
 Intrauterine growth restriction (IUGR)
 Short umbilical cord.
 Intrauterine fetal death (IUFD)
                   Types of Breech
1- Frank Breech (65%)

       Hips flexed over anterior body.
       Knees extended (with feet near the ears).
                    Types of Breech
2- Complete Breech or Full Breech (25%)
      Both thighs flexed.
      One or both knees flexed.
      So that the baby is sitting cross-legged, with feet
       beside the buttocks (squat position) or feet lying
       below the buttocks.
                  Types of Breech
3- Footling Breech or Incomplete Breech (10%)
       One or both thigh extended .
Complications of the Breech Malpresentation

 Insufficient dilatation of the cervix is the main cause of
  breech complications.
 PROM, cord prolapse and compression, prolonged labor.
 Knee and hip joints.
 Femur fractures.
 Genitalia.
 Abdominal viscera.
 Humerus and clavicular fractures.
 Shoulder dislocation.
 Intracranial Hemorrhage.
 Early separation of the placenta (2nd stage).
   Diagnosis of the Breech Malpresentation

 Abdominal Examination.

      - Longitudinal Lie.
      - Softer irregular mass occupies the lower uterine
        segment above the symphysis pubis.
      - Hard ballottable head at fundus (maybe not
        palpable).
      - Auscultation locates the fetal heart higher than
        expected with a vertex presentation.

                       Leopold Examination
   Diagnosis of the Breech Malpresentation

 Vaginal Examination

      - Frank breech: fetal anus, sacrum, buttocks, ischial
        tuberosity.
      - Complete breech : the feet, ankles and often
        buttocks can be palpated through the dilated cervix.
      - Incomplete breech: one or both feet may be palpated
   Diagnosis of the Breech Malpresentation

 Investigations

  Diagnosis is confirmed by ultrasound and also detect any
  fetal or uterine abnormalities predisposing to breech
  presentation (placental localization, fetal anomalies,
  adequacy of amniotic fluid, head extended or flexed)

  Extended head not delivered vaginally due to fear of head
  entrapment.

  Lateral x-ray pelvimetry :adequacy of inlet and outlet.

  CT and MRI pelvimetry.
End of the 1st Part




Thanx for attention

   Yazeed Hindi



                  Breech Management >>
     BREECH PRESENTATION
    PREGNANCY MANAGEMENT

- Exclude fetal and uterine anomalies:
  If breech presentation is suspected after 34
  weeks, the prenatal records and any prior
  ultrasonic examinations should be reviewed
  for the presence of uterine myomata,
  müllerian anomaly or fetal structural
  abnormality. If suspicious, a thorough
  ultrasonic examination should be ordered.
                                                 36
   BREECH MANAGEMENT

Evaluate for cause in all breech presentation
Consider postural Exercises for patient

    Technique 1: Knee chest
       Knee-chest position for 15 minutes
       Repeat 3 times daily for 5 days



Technique 2: Deep trendelenburg
 position
   Patient supine with hips elevated 9-12
    inches
   Perform 10 minute, once to twice daily
                                                 37
                        BREECH MANEGEMENT

– Footling or Incomplete Breech
    Cesarean Section
– Frank or Complete Breech
    Attempt External Cephalic Version
    If external version fails
        – Cesarean section or
        – Breech Delivery
– Complete Breech with foot protruding
  through cervix
    Dangerous! (Very high risk)
    Emergent Cesarean section
                                            38
     BREECH PRESENTATION
    PREGNANCY MANAGEMENT
- External cephalic version:
  External cephalic version (ECV) is a procedure in
  which the obstetrician manually converts the
  breech fetus to a vertex presentation via external
  uterine manipulation under ultrasonic guidance.
- ECV is a relatively straightorward and safe
  technique and has been shown to reduce the
  number of caesarean sections due to breech
  presentations

                                                       39
          BREECH PRESENTATION
         PREGNANCY MANAGEMENT
- ECV may be considered in a breech presentation at term
  before the onset of labor. Version is not carried out prior to
  36 to 37 weeks' gestation because of the tendency for the
  premature fetus to revert spontaneously to a breech
  presentation.

- Version is sometimes used during labor before the
  amniotic sac has ruptured. This can be a good time to use
  version, when labor is constantly monitored and a
  cesarean delivery (C-section) can be done right away if
  necessary. But, the chance to do the version can be lost if
  labor speeds up or the amniotic sac ruptures.
             EXTERNAL CEPHALIC VERSION

To avoid harm to the fetus, a version procedure
 is closely monitored.
Fetal ultrasound is first used to confirm the
 fetus' position, where the placenta is, and the
 amount of amniotic fluid. Fetal ultrasound is
 often used during the version attempt to
 monitor the fetal position.
Electronic fetal heart monitoring is used before,
 possibly during, and after a version attempt. An
 active fetus whose heart rate increases
 normally with movement is usually considered
 to be healthy. If the fetus' heart rate becomes
 abnormal, the version procedure may be
 stopped.                                            41
     EXTERNAL CEPHALIC VERSION

The procedure must be carried out in a hospital
 that is equipped to perform an emergency
 cesarean section because of the small risk of
 placental abruption or cord compression.
 The patient should have nothing by mouth for
 8 hours prior to the version attempt in case
 emergency delivery is necessary.
Anti –D should be given if the patient is Rh
 negative
 Before the version attempt, an injection of
 tocolytic medication may be given to relax the
 uterus and prevent uterine contractions. The
 most commonly used tocolytic medication is
 terbutaline.                                      42
     EXTERNAL CEPHALIC VERSION

The procedure:

-While the uterus is relaxed the doctor places
  his or her hands on the abdomen, moving the
  baby up out of the pelvis bones (pic A)
- The baby turned either forward or backward
  until it is in the vertex position .


                                                 43
EXTERNAL CEPHALIC VERSION




                            44
    EXTERNAL CEPHALIC VERSION

Absolute contraindications :
1- multiple gestations with a breech presenting
  fetus,
2- contraindications to vaginal delivery (eg,
  herpes simplex virus infection, placenta
  previa),
3- nonreassuring fetal heart rate tracing.
4-PET
5-prior uterine surgery (eg.caesarean section)
6-utero-palcental insuffeciency                   45
   EXTERNAL CEPHALIC VERSION

 Relative contraindication:
   1-polyhydramnios
   2-oligohydramnios
   3-fetal growth restriction
   4- uterine malformation
   5- fetal anomaly



                                46
     EXTERNAL CEPHALIC VERSION
Complications:
 Uncommon risks of ECV include fractured fetal
 bones, precipitation of labor or premature
 rupture of membranes, abruptio placentae,
 fetomaternal hemorrhage (0-5%), and cord
 entanglement ( <1.5%). A more common risk of
 ECV is transient slowing of the fetal heart rate
 (in as many as 40% of cases). This risk is
 believed to be a vagal response to head
 compression with ECV. It usually resolves
 within a few minutes after cessation of the ECV
 attempt and is not usually associated with
 adverse sequelae for the fetus.
                                                    47
        EXTERNAL CEPHALIC VERSION

 The success rate of external version is about
 60% regardless of whether systemic tocolytics
 or regional anesthesia is used. Only 2% of
 successful term versions revert to breech.




                                                  48
           BREECH PRESENTATION
            LABOR MANAGEMENT

The standard of care now in most practices
 is to deliver all breeches by cesarean
 section to avoid the potential morbidities of
 umbilical cord prolapse, head entrapment,
 birth asphyxia, and birth trauma.
             BREECH PRESENTATION
              LABOR MANAGEMENT
    Vaginal Delivery:
    Performed in selected centers in patients who meet strict criteria.
    When cesarean section is impossible or unsafe.

•    Fetus must be in a frank or complete breech presentation.
•    Gestational age should be at least 36 weeks.
•    Estimated fetal weight should be between 2500 and 3800 g.
•    Fetal head must be flexed.
•    Maternal pelvis must be adequately large, as assessed by x-
     ray pelvimetry or tested by prior delivery of a reasonably large
     baby.
•    There must be no other maternal or fetal indication for
     cesarean section.
•    Anesthesiologist must be in attendance.
•    Obstetrician must be experienced.                            50
•    Assistant must be scrubbed and prepared to guide the fetal
     head into the pelvis.
               BREECH PRESENTATION
               LABOR MANAGEMENT

Types of vaginal breech delivery:

1.Spontaneous breech Delivery
2.Assisted breech delivery (Partial breech extraction)
3.Total breech extraction
PARTIAL BREECH EXTRACTION
  Assisted Breech Delivery



             After spontaneous delivery to the
             umbilicus, traction is applied to the
             infant's pelvis. When the scapulae
             are visible, rotation of the trunk
             allows delivery of the anterior
             shoulder.




                                                     52
PARTIAL BREECH EXTRACTION
  ASSISTED BREECH DELIVERY




          Delivery of the anterior shoulder
          by downward traction




                                              53
PARTIAL BREECH EXTRACTION
  ASSISTED BREECH DELIVERY



                Delivery of the posterior
                shoulder by upward traction. The
                posterior arm is freed digitally by
                splinting the fetal humerus
                (inset).




                                                  54
PARTIAL BREECH EXTRACTION
  ASSISTED BREECH DELIVERY




                        Delivery of the
                        aftercoming
                        head using Piper
                        forceps.




                                       55
    PARTIAL BREECH EXTRACTION
      ASSISTED BREECH DELIVERY




Delivery of the aftercoming head using the Mauriceau-Smellie-
Veit maneuver. Abdominal pressure is applied to maintain
flexion of the fetal head.                                      56
         BREECH PRESENTATION
          LABOR MANAGEMENT
Assisted Breech Delivery:
1)The fetus is allowed to spontaneously deliver up to
  the umbilicus.
2) Gentle downward traction is exerted until the
  scapulae appear at the introitus.
3) After delivery of the scapulae, the shoulders are
  delivered by sweeping each arm in turn across the
  fetal chest until only the fetal head remains
  undelivered.
4)The head is delivered by manual flexion of the fetal
  head with the operator's fingers applied to the fetal
  maxilla or with Piper forceps. Some obstetricians use
  Piper forceps routinely because this method has been
  shown to result in delivery of the head with the least
  amount of trauma to the fetus.
                                                           57
           BREECH PRESENTATION
        COMPLICATIONS AND OUTCOME
Even with optimal management, the perinatal mortality of breech
  fetuses is approximately 25 per 1000 live births, vs. 12 to 16 per
  1000 for nonbreech fetuses. When prematurity and multiple
  gestations are excluded, the perinatal mortality for breech
  fetuses is still significantly higher than for vertex fetuses.

Factors that contribute to increased perinatal morbidity and
 mortality include :
 1)lethal congenital anomalies 2)prematurity
 3)birth trauma 4)asphyxia.

- Asphyxia typically results from umbilical cord prolapse during labor or
   entrapment of the aftercoming head.
                                                                            59
- Birth trauma can occur whenever forceful traction is exerted on the fetus
   and can involve the brachial plexus (Erb's palsy), pharynx, and liver.
End of the 2nd Part




Thanx for attention
                   Umbilical cord prolapse

 Epidemiology
   – Incidence
          Vertex presentation: 0.4%
          Frank Breech: 0.5%
          Complete Breech: 4-6%
          Footling Breech: 15-18%
 Pathophysiology:
  It occurs when the umbilical cord presents itself outside of
  the uterus while the fetus is still inside
   – Umbilical Cord prolapses
        Frank cord presentation:
           Cord prolapsed through cervix
        Occult cord presentation:
           Cord trapped alongside presenting part
   – Follows Rupture of Membranes

                                                                 61
             Umbilical cord prolapse

Pathophysiology (cont.)
  Occurs when presenting part is ill fitting
     Footling Breech Presentation
     Cephalopelvic Disproportion
     Fetal abnormality
   Fetal blood supply obstructed when cord out of
    uterus
     Drop in temperature of prolapsed cord
     Vasospasm of umbilical vessels
     Compression between pelvic brim and presenting part




                                                            62
                   Umbilical cord prolapse

 Risk factors
   Multiparity
   Prematurity
   Macrosomia (excessive birth weight)
   Breech Presentation
   Polyhydramnios
 Signs
   Ill-fitting or non-engaged presenting part
   Prolapsed Umbilical Cord
      Umbilical Cord visualized in vagina or at vulva
      Umbilical Cord palpated on pelvic exam
   Fetal Distress on Fetal Heart Tracing
      May follow Rupture of Membranes


                                                         63
               Umbilical cord prolapse

 Management: General
   Emergent Cesarean Section
     Vaginal delivery only if imminent
  Deliver as Intrauterine Fetal Demise if fetus has
   died
     Check for cord pulsations
     Check for fetal heart sounds
     Obstetric Ultrasound to assess heart activity
  Pre-hospital cord prolapse noted at home by patient
     Patient assumes deep knee-chest position
     Emergent transport to hospital



                                                         64
                   Umbilical cord prolapse

 Management: Temporizing measures to relieve cord
  pressure
 – Tocolysis with Terbutaline 0.25 mg SC
 – Push cord back into vagina.
 – Minimize handling of the cord
     Do not attempt to replace cord back into uterus

 – Vaginal retrograde pressure applied to presenting part
     Hand in vagina elevates presenting part

 – Consider filling bladder with 500-700 cc Saline
 – 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

                                                            65
                  Umbilical cord prolapse

 Prognosis
   – High perinatal mortality for delayed delivery >40
     min
 Prevention
   – Do not Artificial Rupture Of Membrane if fetal head
     at high station .




                                                           66
                        shoulder presentation

 Definition
   Transverse lie is perpendicular to mother's long axis
   Shoulder presentation
   The shoulder, arm, or trunk may exit first if the fetus is in a
    transverse lie. This type of birth occurs less than 1% of the
    time. Transverse lie is more common with premature delivery
    or multiple gestations.
      Occurs when fetus is transverse with back down
      Shoulder sits over pelvic inlet


 Causes
   Prematurity
   Placenta Previa
   Abnormal uterus
   Multiple gestation
   Polyhydramnios



                                                                      67
                       shoulder presentation


 Diagnosis
   Leopold's Maneuvers
     Transverse lie should be easy to identify
   Digital cervical exam
     No presenting part
 Management
   Ceserean section required in most cases
   Indications to consider External Cephalic Version
     Intact membranes and no labor
     Back-up transverse lie with cervix fully dilated
 Complications
   Uterine Rupture

                                                         68
End of the 3rd Part




Thanx for attention
                face presentation

Definition
Face presentation occurs when the fetal head is
 hyperextended such that the fetal face, between the
 chin and orbits, is the presenting part.
Pathophysiology
   Normal Attitude: Fetus is in full flexion
       Smallest fetal head diameter: Suboccipitobregmatic (vertex)
    Face presentation is an extended attitude
    Submentobregmatic which is about 9.5 cm

 Epidemiology
    Incidence: 0.1 to 0.2% of singleton deliveries 1 to 500 labors



                                                                      70
                 Face Presentation




Spontaneous delivery of a mentum anterior face presentation.
Note the flexion of the head under the symphysis pubis. The
chin appears first, followed by the nose, brow, vertex, and
occiput.                                                       71
                    face presentation

 Causes
   – Grand multiparous patients
   – Large fetus and contracted pelvis
   – Neck swelling (e.g. Cystic Hygroma, Thyroid
      Goiter)
   – Anencephaly
 Signs
   – Digital cervical exam
          Facial features palpable (mouth, nose)
 Differential Diagnosis
- Breech Presentation (much more common than face)
  The diagnosis of face presentation is usually made at
  the time of vaginal examination during labor, when the
  soft tissues of the fetal mouth and nose are noted
  adjacent to the malar bones and orbital ridges.
- Face presentation is then confirmed by sonography or
  by radiography. Because anencephalic fetuses
  uniformly present face first, anencephaly should be
  ruled out when face presentation is suspected.

                                                           72
             Face Presentation


 Management
  – Do not attempt to convert face presentation to
    vertex
  – Never apply vacuum extractor to face presentation
  – Avoid Oxytocin in most cases
  – Consider large episiotomy if fetus delivers
    vaginally



                                                        73
              Brow presentation

• It occurs when the presenting part of the fetus is between the
  facial orbits and anterior fontanelle. This type of presentation
  arises as the result of extension of the fetal head such that it is
  midway between flexion (vertex presentation) and
  hyperextension (face presentation).
• The incidence is about 1 in 1400 deliveries.
• With a brow presentation, the presenting diameter is the
  supraoccipitomental diameter, which is much longer than
  the presenting diameter for a face or a vertex presentation.
• The intrapartum management is expectant, because the brow
  presentation is an unstable one. Fifty percent to 75% will
  convert to either a face presentation, through extension, or a
  vertex presentation, through flexion, and will subsequently
  deliver vaginally.

                                                                        74
                 Brow presentation

• With a persistent brow presentation, the large
  presenting diameter makes vaginal delivery impossible,
  unless the fetus is very small or the maternal pelvis is
  very large, and delivery must be accomplished by
  cesarean section.
• There is an increased incidence of both prolonged labor
  (30% to 50%) and dysfunctional labor (30%).
• As with face presentations, midpelvic delivery and methods
  to convert the brow presentation to a vertex presentation are
  contraindicated.
• Perinatal morbidity and mortality are similar to those for
  vertex presentations.



                                                                  75
 Brow presentation




    Brow presentation. Note the large
presenting diameter (occipitomental).
                                        76
End of the Seminar

   Prepared By

   Yazeed Hindi
 Yazeed Al Olayan
   Ahmad Al Ali
 Mohammad Batta
 Mohammad Fares
  Qais Shatnawi
  Luai Al Healeh

								
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