Managing Malposition and Malpresentations During Labour

and Delivery

Cont…

Definitions

• Malpresentation:- A presentation other than vertex. Eg. Shoulder face brow and breech.

• Malposition:- This is the malposition of the normal vertex presentation that when the occiput occupies the posterior area of the pelvis (Right or left sacroiliac joint).

Cont…General causes of malpresnetation and

malposition.

• Increased ratio of fluid to fetus.

Eg. - Polyhydramnious Prematurity

• Something preventing the engagement of the head in to the pelvis.

Eg. - CPD , Placenta praevia

• Abnormal shape of uterus and pelvis

• Laxity of uterine muscles (GMP)

• Multiple pregnancies.

Cont…NB. Malpresentaition and mal position have ill-fitting

presenting part. An ill-fitting presenting part associated with

• Slow erratic short lived contraction

• Early rupture of membrane with risk of cord prolapsed

• Pause in labour after rupture of membrane leading to in coordinate and excessive painful labour.

• Premature labour

• Prolonged and obstructed labour

• Rupture of uterus

• PPH

• Fetal and maternal distress

• Increase fetal and maternal mortality and morbidity.

Cont…

A. Malpositions

• 1. Occipito Posterior position (OPP)

• Defn - This is when the occiput lies in the posterior segment of the pelvis. ( Right or left sacroiliac joints)

Cont…• It is a malposition of vertex presentation.

• OPP occur in approximately 10% of labors.

• A persistent OPP results from a failure of internal rotation prior to delivery this occurs in 5% of deliveries.

• It is the commonest cause of high head (non –engagement) in primigravida mother during the later weeks of pregnancy.

• As a consequence of OPP the fetal head is deflexed and larger diameters of the fetal skull present (occipito frontal 11.5 cm)

Cont…Causes The direct cause is often unknown but it may be

associated with 1. An abnormally shaped pelvis. • In an android pelvis the fore pelvis is narrow and the

occiput tends to occupy the roomiest hind pelvis. • The anthropoid (oval) pelvis with its narrow transverse

diameter results a failure of internal rotation of the head.

2. Multiparity• Lax uterine and abdominal muscles allow more room

so there is risk of both malposition and malpresentaiton.

• 3. Placenta praevia • 4. Multiple pregnancy • 5. Premature baby

Cont…

Diagnosis of OPP

A. Abdominal examination.

1. On inspection

• There is a saucer – shaped depression at or just below the umbilicus. This dip is created by the “ dip” between the head and the lower limbs of the fetus.

• The high unengaged head with the depression above it look like a full bladder which is a deflexed head.

Cont…

2. on palpation

• The head is high and feels unduly large.

• The back is difficult to palpate as it is well out to the maternal side sometimes almost adjacent to the maternal spine.

• Limbs are felt on both sides of the midline

• Occiput and sinciput are felt on the same level.

Cont…

3. on auscultation

• The fetal back is not well flexed so the chest is thrust forward therefore the fetal heart can be heard in the midline.

Cont…During labour

1. The woman may complain of continuous and severe backache worsening with contraction.

2. Due to an ill-fitting of the presenting part on the cervix the membranes tend to rupture early and contraction may be in coordinate.

3. Descent of the head can be slow even with good contraction.

4. The woman may have a strong desire to push early because the occiput is pressing on the rectum

Cont…

5. On vaginal examination.

– The finding will depend up on the degree of flexion of the head.

– Locating anterior fontanelle anteriorlly and posterior fontanel posteriorlly confirms the diagnosis of OPP.

Cont…

Management of OPP in first stage of labour

• Labour in OPP can be long and painful the woman may experience severe and unremitting backache.

• Also the deflexed head does not fit well on to the cervix and therefore does not produce optimum stimulation for uterine contraction.

Cont…

1. Warm bath if possible

2. Back rub (massaging)

3. Encourage to remain mobile

4. Allow to adapt what ever position that she feels comfortable.

5. Adequate antipain

6. Prevent dehydration

7. Keep accurate observation

8. Reduce vaginal examination to the minimum.

9. Alleviate fear and stress

Cont…

10 . Estimate the progress of labour by descent, flexion and dilatation of cervix.

11. The woman may experience a strong urge to push long before the cervix is fully dilated at this time the cervix become edematous so that show how to relax and breath in between contraction.

Cont…

Mechanism of long rotation (OPP)

• The lie is longitudinal

• The attitude of the head is deflexed

• The presentation is vertex

• The position is ROP

• The denominator is the occiput

• The engaging diameter SOB (9.5 cm) which is changed from OF (11.5 cm)

Cont…A. Flexion - descent takes place with increasing

flexion. The occiput becomes the leading part.

B. Internal rotation of the head – The occiput reaches the pelvic floor first and rotates forwards 3/8 of the circle (1350) along the right side of the pelvis.

C. Crowning – The occiput escapes under the S.pubis and the head is crowned.

D. Extension – The sinciput, face, and chin sweep the perineum and the head is born by a movement of extension.

Cont…E. Restitution – Takes place and the occiput turns

1/8 of a circle to the right F. Internal rotation of the shoulder – The shoulders

enter the pelvis in the right oblique diameter, the anterior shoulder reaches the pelvic floor first and rotates forwards 1/8 circle to lie under syp.

G. External rotation of the head – at the same time the occiput turns a further 1/8th of the circle to the right.

H. Lateral flexion – The anterior shoulder escapes under the syp the posterior shoulder sweeps the perineum and the body is born movement of lateral flexion.

Cont…The outcomes of OPP (The probable course of

labour)

There are three possible out comes

1. Long rotation to occipito anterior

• This is the commonest out come – 65 – 90%

• With good uterine contractions producing flexion and descent of the head and rotates 1350 for wards (3/8th of the circle)

• The engaging diameter of the head in long rotation is SOB (9.5 cm) which is changed from OF (11.5 cm) due to good uterine contraction..

Cont…2. Short internal rotation • Also known as persistent occipito posterior, or

face to pubis or unreduced occipito posterior • It happens in 20% of cases • The engaging diameter is occipito frontal (11.5

cm) • Indicates that the occiput fails to rotate fore

wards instead it rotates 1/8 of the circle (450) to the opposite of long rotation.

• In other words instead of the occiput the sinciput reaches the pelvic floor first and rotates forwards. Then the occiput goes in to the hollow of the sacrum. The baby is born facing the pubic bone (face to pubis).

Cont…Cause:- Failure of flexion. That is

• The head descends with out increased flexion and the bi partial diameter of the head (9.5 cm) get caught in the sacrocotyloid (9 cm) diameter of the pelvis and the sinciput becomes the leading part.

• It reaches the pelvic floor first and rotates forwards and then this makes the occiput to rotates 1/8 (450) of the circle to the opposite direction of the long rotation bringing the face under symphysis pubis.

Cont…

3. Deep transverse arrest (Incomplete rotation)

• It happens in 15% of cases

• The head descends with moderately flexed

• The engaging diameter is Suboccipito frontal (10 cm)

Cont…

• Cause:- Moderately flexed head. That is the occiput descends and reaches pelvic floor first and tries to rotate for ward but gets caught at the bispinous diameter in the ischial spines and can not rotate any further and this is know as deep transverse arrest.

• Arrest may be due to weak uterine contraction, a straight sacrum or a narrowed out let

Cont…

Management of OPP in second stage of labour

• A. Long rotation

• Rotation usually occur in 2nd stage

• Delivery is normal as occipito anterior position

• If delay is occur by forceps or vacuum

Cont…B. Face to pubis

Diagnosis

• Delay in second stage of labour

• Vaginal examination reveals that Anterior fontanelle under symphysis pubis it is a diagnostic.

• Sagittal suture in the anterior posterior diameter

• There is an upward Moulding (sugar loaf Moulding)

• Excessive bulging of the perineum and gaping of the anus are evident.

Cont…

• In face to pubis the delivery is by further flexion that is = holding the sinciput back under the symphysis pubis to allow the occiput to escape over the perineum and this is followed by extension of head so that the forehead, eyes, nose, mouth and chin are successively born under SYP.(First by flexion then extension)

• An episiotomy is usually necessary to facilitate delivery and avoid serious perineal tear.

Cont…C. Deep transverse arrest Diagnosis• Prolonged 2nd stage with no advices of descent in

spite of good uterine contractions • Excessive caput • Sagittal suture felt in transverse diameter with

the fontanelle on either sides as the level of ischial spines

• Delivery management if possible it is corrected with use of Kiellands rotation forceps or manually pushing the head above the spines and completing the rotation manually.

• Rarely a LSCS may be necessary

Cont…

Complication of OPP

• Prolonged labour

• Hypotonic uterine action

• PROM

• Prolapse of the cord

• PPH

• Cerebral hemorrhage

• Perineal laceration

B. Malpresnetations

1. Face presentation

• Defn :- When the attitude of the head is one of complete extension the occiput of the fetus will be in contact with its spine and the face will present.

Cont…• The engaging diameter is sub mento

bregmatic 9.5 cm

• The denominator is mentum or chin

• It occurs 1 in 500 deliveries

• The majority develop during labour from vertex presentation with the occiput posterior this is termed as secondary face presentation.

• Less commonly the face presents before labour this is termed primary face presentation.

Cont…• There are eight positions in face presentation

this are1. Right mentoanterior (RMA) • This is when the mentum points to the right

iliopectineal eminence. 2. Left mento anterior. (LMA) • When the mentum points to the left iliopectineal

eminence 3. Right mento lateral (RML) • When the mentum points mid way between the

right iliopectineal eminence and the right sacroiliac joints.

Cont…4. Left mento lateral (LML)

• When the mentum points mid way between the left iliopectineal eminence and the left sacro iliac joints.

5. Right mento posterior (RMP)

• When the mentum points to the right sacro iliac joints

6. Left mento posterior (LMP)

• When the mentum points to the left sacro iliac joints.

Cont…

7 Direct mento anterior (DMA)

• When the mentum points directly to the symphysis pubis

8. Direct mento posterior (DMP)

• When the mentum points directly to the promontory of the sacrum

Cont…

Causes

1. Anterior obliquity of the uterus

• The uterus of a multiparous woman with slack abdominal muscles and a pendulous abdomen will lean for ward and alter the direction of the uterine axis.

• This causes the fetal buttocks to lean forwards and the force of the contractions to be directed in a line towards the chin rather than the occiput resulting in extension of the head.

Cont…2. Abnormal pelvis • In this pelvis the head enters in the transverse diameter of

the brim and the parietal eminence may be held up in the obstetrical conjugate.

• The head becomes extended and a face presentation develops.

3. Polyhydramnious If the vertex is presenting and the membranes rupture spontaneously the resulting gush of fluid may cause the head to extend as it sinks in to the lower uterine segment.

4. Congenital abnormality • Anencephaly can be a fetal cause of a face presentation.

Because the vertex is absent the face is thrust forward and presents.

Cont…

Diagnosis

A. On abdominal examination

• Inspection:- irregular abdomen the shape of the fetal spine is that of an S shape.

• Palpation – Prominent occiput is felt on supra pubic area and a deep groove is felt between fetal head and back.

• Auscultation – The fetal heart is heard clearly at midline.

Cont…B. On vaginal examination

• Presenting part feels soft, high and irregular it may be defined orbital ridges mouth, gums and mentum. Sometimes there is sucking reflex.

• Feeling of gums and sucking reflex are diagnostic for face presentation.

• NB - As labour progresses the face becomes edematous making it more difficult to distinguish from a breech presentation.

Cont..

Mechanism of a left mento anterior position

• The lie is longitudinal

• The attitude is one of extension of head

• The presentation of face

• The position is LMA

• The denominator is the mentum

Cont…

A. Extension – Descent takes place with increasing extension. The mentum becomes a leading part.

B. Internal rotation of the head

• Occurs when the chin reaches the pelvic floor and rotates forwards 1/8 of the circle. The chin escapes under the SYP.

C. Flexion – Takes place and the sinciput, vertex and occiput sweep the perineum the head is born.

Cont…

D. Restitution:- Occurs when the chin turns 1/8 of a circle to the woman’s left.

E. Internal rotation of the shoulder.

F. External rotation of the head

G. Lateral flexion

• The baby born by a lateral flexion of the body

Cont…NB:- The mechanism of face is the same as in

vertex presentation except that.

• Instead of an increase in flexion it is an increase in extension.

• the chin instead of the occiput rotates

• The head is born by extension until the chin is delivered and then the head is delivered by flexion.

• The engaging diameter is SMB.

Cont…Out comes of face presentation

1. Prolonged labour

• Labour is often prolonged because the face is an ill fitting presenting part and does not there fore stimulate effective uterine contraction

• In addition the facial bones do not mould in order to reduce the engaging diameter.

• Mentoanterior positions.

• With good uterine contractions, descent and rotation of the head occurs and labour progresses to a spontaneous delivery.

Cont…2. Mento posterior positions

• If the head is completely extended, so that the mentum reaches the pelvic floor first and the contraction are effective the mentum will rotate forwards and the position become anterior.

3. Persistent mento posterior position

• In this case the head is incompletely extended and the sinciput reaches the pelvic floor first and rotates forwards 1/8 of the circle which brings the chin in to the hollow of the sacrum.

• There is no further mechanism

• The face becomes impacted because both head and chest accommodated in the pelvis.

• This can not be born normally so caesarean section will be necessary

Cont…

5. Reversal of face presentation.

• A face presentation in a PMPP may in some cases be manipulated to an occipito anterior position using bimanual pressure.

Cont…Management in labour

A. If the chin is anterior let labour continue.

• If transverse watch that rotates to anterior. And then when the face distends the perineum perform an episiotomy then hold back the sinciput and allow the chin to be born. Now when the chin is born flex the head and allow the occiput to be born (First extension then flexion).

Cont…

B. If the head does not descend in the second stage with mento anterior position inform to doctor he may apply forceps.

C. If the head is impacted this may be PMPP so that you may do reversal of face presentation to occipito anterior position manually.

If this is impossible inform to doctor because a caesarean section will be necessary.

Complications of face presentation

1. Obstructed labour – due to PMPP

2. Cord prolapse – due to an ill – fitting presenting part

3. Facial bruising

– The baby’s face is always bruised and swollen at birth with edematous eyelids and lips.

– The midwife must reassure the parents that the edema will disappear with in 1 or 2 days.

4. Cerebral hemorrhage

• The lack of Moulding of the facial bones can lead to intracranial hemorrhage caused by excessive compression.

5. Maternal trauma

• Extensive perineal laceration may occur at delivery due to the large SMV (11.5) diameter distending the vagina and perineum.

6. Injury to the eye – always be careful not to damage the babies eyes with fingers or antiseptic lotion.

2. Brow presentation

Defn - Is when the sinciput or the area between the orbital ridged and the anterior fontanel presents in the lower pole of the uterus.

• Attitude – midway between flexion and extension (partially extended)

• Denominator – sinciput

• Engaging diameter – mento vertical (13.5 cm)

• It occurs 1:1000 deliveries

Causes

• Lax uterus

• Multiple pregnancy

• Hydramnios

• Abnormal shape of pelvis

• Due to extension of vertex presentation

Diagnosis of brow • Brow presentation is not usually detected before

the onset of labour • On abdominal palpation • The head is high appears unduly large and does

not descend into the pelvis despite good uterine contractions.

• On vaginal examination – The presenting part is high it is difficult to reach the

presenting part it is above the brim and will not enter it.

– A smooth hairless area is felt with part of the bregmaat one side

– The orbital ridges may be felt (diagnostic)

Management of brow presentation • If brow presentation is diagnosed early in labour

in rare case it may convert to a face presentation by becoming fully extended or it may flex to a vertex presentation.

• Brow presentation undiscovered and untreated will lead to obstructed labour. The engaging diameter is too big to enter the average pelvis so delivery will not takes place 13.5 cm of head can not enter 13 cm of pelvis unless the head is premature.

• Caesarean section is the management for a live baby

• Craniotomy if baby is dead.

Complications

• Obstructed labour

• Rupture of the uterus

• Injury to the eye of the fetus

• Intera cranial hemorrhage

3. Breech presentation

• Defn When the fetus lies with it’s buttocks in the lower pole of the uterus.

• Lie is longitudinal

• The presenting diameter is bitrochantric (10 cm)

• The denominator is sacrum

• In mid trimester the frequency is much higher because the greater proportion of amniotic fluid facilitates free movement of the fetus.

• It occurs in 3% pregnancies at term.

Types of breech presentation

1. Frank breech (Breech with extended legs)

• The most common types of breech (70%)

• The breech presents with the thighs (hips) flexed and legs extended on the abdomen

• It is particularly common in primigravidawhose good uterine muscle tone

• inhibits flexion of the legs and free turning of the fetus.

2. Complete breech (Breech with flexed legs)

• The fetal attitude is one of complete flexion hips and knees both flexed and the feet tucked in beside the buttocks. The presenting part therefore bulky and consists of buttocks the external genitalia, and both feets.

3. Footling breech

• This is rare one or both feet present because neither hips nor knees are fully flexed. The feet are lower than the buttocks which distinguishes it from the complete breech.

4. Knee presentation

• This is very rare only or both hips are extended with the knees flexed

Positions for a breech presentation 1. Right sacro anterior (RSA) • This is when the sacrum points to the right

iliopectineal eminence.2. Left sacro anterior (LSA) • When the sacrum points to the left iliopectineal

eminence. 3. Right sacrolateral (RSL) • When the sacrum points mid way between the

right iliopectineal eminence and the right sacroiliac joints.

4. Left sacro lateral (LSL)

• When the sacrum points mid way between the left iliopectineal eminence and the left sacroiliac joints.

5. Right sacroposterior (RSP)

• When the sacrum points to the right sacroiliac joints

6. Left sacro posterior (LSP)

• When the sacrum points to the left sacroiliac joints

7. Direct sacro anterior (DSA)

• When the sacrum points directly to the symphysis pubis

8. Direct sacro posterior (DSP)

• when the sacrum points directly to the promontory of the sacrum

Causes

• Often no cause is identified but the following circumstances favors breech presentation.

• Defluxion attitudes of the fetus are the main causes in late pregnancy and accounts for the greater number of extended legs.

3. Extended legs • Spontaneous cephalic version may be inhibited if

the fetus lies with the legs extended “Splinting” the back

4. Too much room or too little room. • Here the fetus is either held tightly and can not

move easily or has so much room to move that there is a significant risk of mal presentation such as – Primigravida – tight abdominal muscle – Multiparas – lax muscles – Polyhydramnious – Pre – term labour – Oligohydraminous

Cont…4. Abnormality

• Here abnormality of either the fetus or the uterus can result in a mal presentation such as – Hydrocephaly (big fetal head accommodate more in

the fundus)

– Septum or fibroid in the uterus

5. Law of accommodation. Such as – Placenta praevia

– Multiple pregnancy

• Here if a placenta is filling the lower segment or another fetus is present the fetus will have to occupy alternative space with in the uterus.

Cont…Diagnosis 1. Palpation A. On pelvic palpation on head can be detected. • The pelvic area is occupied by an irregular soft

mass B. Lie is longitudinal C. The fundus contains a firm smooth, rounded

mass which ballots between the examining hands2. Auscultation • In most causes the fetal heart is heard with

greater clarity above the umbilicus except when a breech with extended legs engages in the pelvis.

Cont…3. Vaginal examination

A. The breech is felt high, soft, irregular in shape (and not smooth and round with palpable sutures as in the head)

B. During labour when membranes are ruptured the anal sphincter will grip the examining finger in male fetus we may feels scrotum.

• Meconium on the examining finger is diagnostic for breech presentation or meconium stained amniotic fluid.

Cont…

4. X – ray or ultrasound

• May confirm diagnosis.

5. Symptoms

• Frequently the pregnant woman whose fetus presents by the breech complains of discomfort under the ribs especially when the fetus moves. This is due to pressure of the fetal head on the ribs.

Cont…

Cont…Mechanism of breech delivery (LSA)

• The lie is longitudinal

• The attitude is one of complete flexion

• The presentation is breech

• The position is left sacroanterior

• The denominator is the sacrum

• The presenting part is the anterior (left) buttock

• Engaging diameter – bitrochantric (10 cm)

• The sacrum points to the left iliopectineal eminence

Cont…1. Compaction

• Descent takes place with increasing compaction owing to increased flexion of the limbs

2. Internal rotation of the buttocks

• The anterior buttock reaches the pelvic floor first and rotates for wards 1/8 of the circle along the right side of the pelvis to lie underneath the symphysis pubis. The bitrochanteric diameter is now in the anteroposterior diameter of the out let.

Cont…3. Lateral flexion of the body

• The anterior buttock escapes under the symphysis pubis the posterior buttock sweeps the perineum and the buttocks are born by a movement of lateral flexion.

4. Restitution of the buttocks

• The anterior buttock turns slightly to the mother’s right side

5. Internal rotation of the shoulders

• The shoulders enter the pelvis in the same oblique diameter as the buttocks the left oblique. The anterior shoulder rotates forwards 1/8 of the circle. A long the symphysis pubis the posterior shoulder sweeps the perineum and the shoulders are born

Cont…6. Internal rotation of the head • The head enters the pelvis with the sagittal

suture in the transverse diameter of the brim. The occiput rotates forwards a long the left side and the suboccipital region (the nape of the neck) impinges on the undersurface of the symphysis pubis.

7. External rotation of the body • At the same time the body turns, so that the

back is uppermost • 8. Birth of the head • The chin, face and sinciput sweep the perineum

and the head is born in a flexed attitude

Cont…Management of uncomplicated breech

presentation in labour

• NB - Before conducting breech presentation always be sure full dilatation of the cervix because may be the presenting part escape out with undilated cervix and then the head may be delayed and held up at an un dilated cervix.

• If vaginal delivery is selected the chance of successes is 50%.

Cont…A. Management of breech presentation in first stage of

labour • The basic care is the same as normal labour • The chance of rupture of membrane is high in

complete breech due to an ill-fitting the presenting part. So that the risk of cord prolapse should be excluded by vaginal examination.

• If the membrane is not rupture spontaneously at an early stage it is safer to leave them intact until labour is well established and the breech at the level of ischial spines.

• Meconium – stained liquor is some times found due to compression of the fetal abdomen and is not always a sign of fetal distress.

Cont…B. Management of breech presentation in second stage of

labour• Full dilatation of cervix should always be confirmed by

vaginal examination before the woman commences active pushing.

• Active pushing is commenced when the buttocks distending the vulva.

Types of breech delivery A. Spontaneous breech delivery • When delivery occurs with little assistance B. Assisted breech delivery• The buttocks are born spontaneously but some assistance

is necessary for delivery of extended legs or arms and the head

C. Breech extraction • This is a manipulative delivery carried out usually by an

obstetrician.

Cont…

C. Footling breech

Cont…Steps of delivery 1. Delivery of the buttocks • When the buttocks are distending the perineum

the woman is placed in the lithotomy position. • Then the vulva is swabbed and draped with

sterile towels • The bladder must be empty • Perineum is infiltrated with up to 10ml of 0.5%

plain lignocaine prior to an episiotomy. • The woman is encouraged to push with the

contraction and the buttocks are delivered spontaneously.

Cont…• If the legs are flexed the feet disengage at the

vulva and the baby is born as far as the umbilicus.

• The loop of cord is gently pulled down to avoid traction on the umbilicus after checking its pulsation.

• Then feel the elbows which are usually on the chest. If so the arms will escape with the next contraction. If the arms are not felt they are extended.

Cont…2. Delivery of the shoulder

• The uterine contractions and the weight of the baby will bring the shoulders down on to the pelvic floor.

• Wrap a small sterile towel around the baby’s hips which preserves warmth and improves the grip on the slippery skin.

• The midwife now grasps the baby by the iliac crests with her thumbs held parallel over his sacrum and tilts the baby towards the maternal sacrum in order to free the anterior shoulder.

Cont…• When the anterior shoulder has escaped the

buttocks are lifted towards the mother’s abdomen to enable the posterior shoulder and arms to pass over the perineum.

• As the shoulders are born the head enters the pelvic brim with the sagittal suture in the transverse diameter.

• The back must remain lateral until this has happened but will after wards be turned uppermost.

• If the back is turned upwards too soon the anteroposterior diameter of the head will enter the antero posterior diameter of the brim (instead of transverse diameter) and may become extended.

Cont…3. Delivery of the flexed head by Burns Marshal

method. Steps A. After the shoulder are born the baby allowed to

hang unsupported with in one minute until the nape of the neck (hairline) appears.

B. Then with the left hand the baby is grasped on the ankles.

C. Right hand guards the perineum D. Then the baby kept straight towards the mother

abdomen with sufficient traction and lifted in a circular movement to allow chin and face to sweep the perineum.

Cont…Common complications of breech delivery and it’s

management 1. Delivery of extended legs Diagnosis • On vaginal examination no feet felt and buttock

firm to touch, round, smooth and external genitalia evident.

• The frank breech descends more rapidly during labour due to well fitting presenting part and also the cervix dilates more quickly.

• Delay may occur at the out let because the legs splint the body and impede lateral flexion of the spine.

Cont…Technique to deliver extended legs (By pinard

maneuver) • If the buttocks are not expelled slight groin

traction can applied by inserting the finger in the fold of the groins during uterine contraction

• When the popliteal fossa appear at the vulva two fingers are placed along the length of one thigh with the fingertips in the fossa.

• The leg is swept to the side of the abdomen (abducting the hip) and the knee is flexed by the pressure on it’s under surface.

• This makes the lower part of the leg will emerge in to the vagina

Cont…2. Delivery of extended arms

Diagnosis

• When the elbow are not felt on the chest after the umbilicus is born.

• This may be deal with by using the lovset maneuver.

• This is a combination of rotation and downward traction which may be employed to deliver the arms what ever position they are in the direction of rotation must always bring the back upper most and the arms are delivered from under the pubic arch

Cont…

Technique to deliver extended arms (Lovset maneuver)

A. When the umbilicus is born and the shoulders are in the anteroposterior diameter the baby is grasped by the iliac crests with the thumbs over the sacrum. Down ward traction is applied until the axilla is visible.

Cont…

B. By maintaining gentle down ward traction rotate half a circle (1800) starting by turning the back uppermost.

C. Assist delivery of the first arm under syp by inserting two fingers of the hand and draw it down over the chest as the elbow of the baby is flexed.

D. Then turn the back upper most and rotate 1800 in the opposite direction of the first rotation by applying gentle down ward traction.

E. Assist delivery of the second are under syp in the same way of the first arm.

Lovsets manuver

Cont…3. Delivery of the extended head (Arrest of the

after coming head)• Delivery by maurceau – smellie veit maneuver.

This is jaw flexion and shoulder traction • Also arrest of the after coming head assisted by

forceps delivery (piper forceps) Technique of maurceau – smellie – veit maneuver

(MSV)A. The baby is laid a astride the right arm with the

palm supporting the chest. B. Two fingers of the right hand inserted on to the

baby’s maxilla to pull the jaw down wards and flex the head.

Cont…

C. Two fingers of the left had are hooked over the shoulders with the middle finger pushing up the occiput to aid flexion.

D. Then traction is applied to draw the head out of the vagina.

E. At the same time appropriate suprapubicpressure applied by an assistant is helpful in delivery of the head

Msv manuver

Cont…Prague maneuver

• Delivery of the after coming head using the modified Prague maneuver necessitated by failure of the fetal trunk to rotate anterior.

• The modified maneuver as practiced today consists of two fingers of one hand grasping the shoulders of the back down fetus from below while the other hand draws the feet up over the maternal abdomen.

Cont…Recommendation for C/S

• Cesarean delivery is commonly but not exclusively used in the following circumstance

1. A large fetus

2. Any degree of contracted pelvis

• 3. A hyper extended head

4. No labor in PIH and ruptured membranes for 12 hours or more

5. Uterine dysfunction

6. Footling presentation

7. PTL

Cont…8. Sever IUGR9. Previous prenatal death10. A request for sterilization Complication of breech presentation 1. Impacted breech • Labour becomes obstructed when the fetus is

disproportionately large for the size of the maternal pelvis. 2. Cord prolapse • This is more common in a flexed or footling breech as these

have ill fitting presenting parts. 3. Superficial tissue damage • Edema and bruising of the baby’s genitalia • Discolored and edematous of the footling breech

Cont…4. Fractures of humerus, clavicle, femur, dislocation

of shoulder or hip – caused during delivery of extended arms or legs.

5. Erb’s palsy • - Caused by the brachial plexus being damaged

by twisting the neck.6. Trauma to internal organs• - Especially a ruptured liver or spleen or adrenals

caused due to grasping of the abdomen. 7. Fracture of the spinal cord • Caused by bending the body backwards over the

syp while delivering the head.

Cont…8. Intra cranial hemorrhage • Caused by rapid delivery of the head which has had no

opportunity to mould.9. Fetal hypoxia • This may caused due to intra cranial hemorrhage,

compression of the cord and or premature separation of the placenta.

10. Premature separation of the placenta 11. Aspiration – because baby stimulated to birth before the

head is born. 12. Maternal trauma 13. Prolonged labour 14. More interference 15. Operative delivery 16. Infection

Cont…4. Shoulder presentation

Defn When the fetus lies with its long axis across the long axis of the uterus (transverse lie) the shoulder is most likely to present.

• It occurs 1 in 300 pregnancies near term.

• The head lies on one side of the abdomen with the breech at a slightly higher level on the other

• The fetal back may be anterior or posterior

• The denominator is the acromion process.

Cont…Causes

1. Lax abdominal and uterine muscles

• This is the most common cause and is found in multigravida mother.

2. Uterine abnormality

A bicornute or subseptate uterus may result in a transverse lie

3. Contracted pelvis

• This may prevent the head from entering the pelvic brim

4. Preterm pregnancy

Cont…

• The amount of amniotic fluid in relation to the fetus is greater allowing the fetus more mobility than at term.

5. Multiple pregnancies

• It is the second twin which more commonly adopts this lie after delivery of the first fetus.

6. Polyhydramnios

Cont…• The distended uterus is globular and the fetus

can move freely in the excessive liquor.

7. Macerated fetus

• Lack of muscle tone causes the fetus to slump down in to the lower pole of the uterus.

8. Placenta praevia

• This may prevent the head from entering the pelvic brim

Cont…

Diagnosis

A. On abdominal palpation

• The uterus appears broad and the fundalheight is less than expected for the period of gestation.

• On pelvic and fundal palpation neither head nor breech is felt.

• The mobile head is found on one side of the abdomen and the breech at a slightly higher level on the other.

Cont…

B. On vaginal examination

• If the labour has been in progress for sometime the shoulder may be felt as a soft irregular mass. It is sometimes possible to palpate the ribs.

• When the shoulder enters the pelvic brim an arm may prolapse this is diagnostic.

Cont…Possible out come

• There is no mechanism for delivery of a shoulder presentation. If this persists in labour delivery must by c/s to avoid obstructed labour and subsequent uterine rupture.

• If the fetus is quite small (< 800gm) and the pelvis is large spontaneous delivery is possible despite persistence of the abnormal lie.

• The fetus is compressed with the head forced against the abdomen.

• A portion of the thoracic wall below the shoulder thus becomes the most dependent part appearing at the vulva.

• The head thorax then pass through the pelvic cavity at the same time and the fetus which is doubled up on itself ( conduplicato corpore) is expelled

Cont…Management

• External version may be attempted by Dr when transverse lie is diagnosed at 36 weeks of gestation during antenatal visits. (not recommended currently)

• If external version fails requires elective c/s

Cont…

• If a transverse lie detected in early labor while the membrane is intact doctor may attempt an external version if this is successful by a controlled rupture of the membranes to prevent card prolapse.

• If the membranes have already ruptured c/s is necessary.

Cont…Immediate caesarean section must be

performed if

• The cord prolapses

• When the membranes are already ruptured

• When external version is unsuccessful

• When labour has already been in progress for some hours.

• Arm is prolapse even with dead fetus because of danger of rupture uterus.

Cont…Complications

1. Prolapsed cord

• .This may occur when the membranes rupture.

2. Prolapsed arm

• This may occur when the membranes have ruptured ahs the shoulder has become impacted

• delivery should be by immediate c/s. Whether the fetus is alive or dead as attempts at manipulative procedures or destructive operations can be dangerous for the mother and may result in uterine rupture.

Cont…

3. Obstructed labour

4. Rupture of the uterus

5. IUFD