Malpresentaton and Malpresentaton and Breech presentationBreech presentation

DefinitionsDefinitions

• Position

• The relationship of a defined area on the presenting part to the mother’s pelvis (Denominator)

• Presentation• The part of the fetus occupying the lower segment• The part of fetus felt on vaginal examination

Normal PresentationNormal Presentation

• Normal Presentation;• Bony Pelvis

– Pelvic Brim– Pelvic cavity– Pelvic outlet

• Vertex The area of the skull between the anterior and

posterior fontanelles, and the parietal eminence Top of the skull

• Occiput Back of the fetal head behind the posterior

fontanelle• Sinciput That part of the fetal head in front of the anterior

fontanelle.-forehead or brow

MalpresentationMalpresentation

BreechFaceBrow ShoulderCordCompound

ConsequencesConsequences

• Presnting part, ill-fitting

• Uterine Contractions, poor

• Membranes, rupture early- cord prolapse

• Labour, difficult, long, obstructed

• Birth trauma

• Operative intervention

Mother, Fetus and neonateMother, Fetus and neonate

• Increased perinatal mortality and morbidity

Fetal malformation Intrauterine fetal deathCord proplase Birth trauma,Birth asphysixa Infection, fetus, neonate and motherUterine ruptureThromboembolism in the mother

For Optimal ResultFor Optimal Result

• Early diagnosis,• Planned delivery• Experienced staff• Well equipped hospital• Cross match 2 unit• Adequate hydration• Monitor in Labour• Pain relief

Face PresentaionFace Presentaion

• 1:300• Full extension of the head• Presenting part: Face• Denominator: Omentum/Chin• Diameter; Subomento bregmatic 9.5cm• Presentation, Mento anterior– Vaginal delivery

Mento posterior- Ceasaeran section

CausesCauses

• Anenecephaly

• Prematurity

• Multifetal pregnancy

• Polyhydramnious

• Neck tumours

• Sternomastoid spasm

• Multiparty

DiagnosisDiagnosis

• Abdominal

• Vaginal

Brow PresentationBrow Presentation

• 1:800, 1:2000 deliveries

• The area between the orbital ridge and the anterior fontenalle

• Most unfavourable of all presentation

• Transient presentation;

Full flexion—Occiput

Full extension---Face

Dignosis and managementDignosis and management

• Delivery??

Shoulder presentationShoulder presentation

Causes• Multiparty• Prematurity• Multiple pregnancy• Polyhydrmanious congenital uterine

anomly• Contacted pelvis• Pelvic tumour, placenta previae

Compound presentationCompound presentation

• Limb, limbs, umbilical cord alongside the presenting part; cephalic or breech

Umbilical cord presentationUmbilical cord presentation

• Umbilical cord, alongside or below the presenting part , membranes intact.

• Cord prolapse, the memebranes have ruptures

Breech presentationBreech presentation

-Fetus presenting by the buttock/ feet/foot

Types

30% at 30 weeks, 3% of all deliveries at termFlexed Fetal buttock as well as fetal feet present to the pelvic inlet

Extended The buttock alone present to the pelvic inlet (Frank)

Fooling

one or both feet presenting

Causes of breech presentationCauses of breech presentation

• Prematurity

• Multiparity

• Multiple pregnancy

• Pelvic mass

• Placenta previae

• Fetal malformation

RisksRisks

• Increased perinatal morbidity and mortality

Due to;

Prematurity

Congenital abnormalities; hydrocephalus

Cord prolapse

Birth asphyxia

Birth trauma ; intra-cranial haemorrhage

DiagnosisDiagnosis

• Abdominally,

Palpation:Soft irregular presenting partFirm, round, ballottable head in the uterine

fundus

ManagementManagement

• No action until 37-38 weeks of gestationReason???

Exclude fetal anomaliesPlacenta previaeMultiple pregnancyOffer external cephalic version (ECV)Should not be attempted if there are risksRisks???Prerequisites??Drawbacks of ECV

DeliveryDelivery

• Assisted Vaginal Breech delivery• Elective Caesarean Section (CS)• Emergency CS• Selection for vaginal deliveryAverage fetal weight not more than 3.5kgNormal pregnancyNo growth restrictionWilling parentsExperienced staff, Midwife, Obstet,

neonatologist, anesthetist

Assisted vaginal breech deliveryAssisted vaginal breech delivery

• Close supervision• Epidural analgesia• Progress of labourSecond stage of labour, can be dangerousObserve for delivery of the breech,Hands offo Help is needed if the arms are extended above the head Lovset’s manoevour to deliver the shouldero Delivery of head, forceps or head traction jaw flexion

• SuturesThe term applied to the junction between the bones of the fetal skull,

the chief sutures are between the frontal bones( frontal) parietal bone( sagittal), parietal and frontal (coronal), parietal and occiput (Lmbdoid).

• Caput succedaneumOedema from obliterated venous return and lymphatic drainage in the

fetal scalp caused by pressure of the head against the rim of the cervix or birth canal not limited by suture. Collection between appenerouses and periostium.

• CephalhaematomaA collection of blood beneath the periostium of a skull bone. Limited by

sutures, appear after few hours of birth.

Definitions related to fetusDefinitions related to fetus• Bregma;The large diamond shaped anterior fontanelle

• Fontanelles; Space at the junction of three or skull bones, covered by a

membrane and skin.Can be felt by running a finger through 360 degrees to feel

the sutures.Anterior FontenallePosterior FontenalleSmall and triangular space in the fetal skull situated in the

posterior end of the sagittal sutures.

• Attitude of fetusRelationship of fetal head and limbs to fetal trunk,

usually flexion

• Lie of the fetusRelationship of the long axis of fetus to the long

axis of the uterus, usually longitudinal lie, ( Transverse, oblique). Usually to the long axis of the mother.

• Position of the fetusThe relationship of a defined area on the

presenting part, called the denominator to the mother’s pelvis

Further readingsFurther readings

• www.patient.co.uk

The following statements about The following statements about breech delivery are correctbreech delivery are correct

1. Lovset’s manouver is employed to deliver the head.

2. Breech extraction is less hazardous than assisted beech delivery