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DR. IQBAL TURKISTANI
ASST. PROF. & CONSULTANT
Malpositions & Malpresentations carry an increased risk for both mother and fetus
Maternal risks:- Prolonged labour infection- Obstructed labour- General anaesthesia at short notice, when the mother is in poor condition- Difficult vaginal delivery or C.S.
trauma leading to haemorrhage- Damage to pelvic veins resulting
to venous thrombosis and fatal pulmonary embolism in the puerperium
- In developing countries obstructed labour may cause tissue necrosis vesico- vaginal and recto-vaginal fistula.
Perinatal mortality and morbidity: due to fetal malformation intrauterine death extreme prematurity cord prolapse +
malpresentation Potent abnormal uterine action causes and prolonged or obstructed of fetal labour hypoxia Fetus at risk of infection (: prolonged ROM)
and also meconium aspiration
Significant proportion of ruptured uterus still result into maternal deaths from unwise management of malpresentation or malposition
Therefore, for optimal result/safe labour and delivery: Early diagnosis by skilled assessment Plan delivery by experienced staff Working in proper surrounding Experienced anaesthesia must be available for
these most difficult cases Close supervision and full use of available
monitoring methods ..if vaginal delivery is planned
Facilities to perform immediate operative delivery or caesarean section are mandatory
Review of progress and necessary intervention by senior staff members is the rule
LIE, PRESENTATION POSITION
LIE:The relationship of the long axis of the foetus to
that of the mother
A. LONGITUDINALB. TRANSVERESE & OBLIQUE (Shoulder
present.)
CAUSES: High multip. Hydramnious Pre-term lab Obstructing tum. Or Multiple Preg. Plac. previa Ut. Anomaly Severe pelvic
contraction
MANAGEMENT: Antenatal Intrapartum
PRESENTATIONThat part of the foetus that is
foremost in the birth canal, or closes to it.
A. Cephalic
B. Breech
C. Shoulder
D. Compound
CEPHALIC PRESENTATION1. Vertex 96% (suboccipito – bregmatic= 9.5 cm)2. SINCIPUT (occipito – frontal = 11.5 cm) OP3. BROW 1:1050 (mento- vertical = 13 CM)
CAUSES:- Chance- Neck swelling e.g. goiter or cystic hygroma- Spasm of sternomastoid muscle
DX:- Ant. fontanell & supraorbital ridge (pv)- XR (lat)
4. FACE 0.3% (Submentobregmatic = 9.5 cm) DX:
- Palpation of supraorbital ridges & aveolar margins (confusion with breech)
BREECH PRESENTATION1. Frank Breech 65%2. Complete Breech 25%3. Footling Breech 10%
CAUSES:- Extended legs preventing spont. version- Those conditions preventing fetal presenting
parts entering pelvic cavity.- Uterine anomaly- Chance
ASSOCIATED FACTORS:- Fetal anomaly- Preterm delivery- Multiple pregnancy
ANTENATAL MANAGEMENT
ECV: Hazards:
Preterm Labour
Abruption
Cord accident
Ut. Rupture (prev. C.S.)
CONTRAINDICATIONS:a. Absolute:
Multiple preg. APH Rupt. Membrane Oligohydramnios Significant fetal anomaly C.S. indicated for other reasons
b. Relative: Prev. C.S IUGR H.T Rh. Isoimmunization Grand multip Ant. Placenta Obesity
MANAGEMENT OF DELIVERY
Pre-delivery assessment: Pelvic dimension (clinical & XR
~37wks)
USS of BPD, fetal mass, attitude & flex/ ext. of head)
Major fetal anomalies to be excluded
VAGINAL DELIVERY:
Term (fetal wt. 2.5-3.5 kg) Frank breech Normal pelvis No other complic. of preg. (e.g. PET) Normal FHR & BPP Epidural
C.S.
FREQUENCY:
VERTEX 96%
BREECH 3.5%
FACE 0.3%
SHOULDER 0.2%
POSITION:
Refers to the relation of an arbitrarily chosen portion of the presenting part of the fetus, to the right or left side of the mother :
VERTEX …... OCCIPUT-- LO., RO
FACE ……CHIN (mentum)-- LM., RM
BREECH ….. SACRUM -- LS., RS
SHOULDER … ACROMION OR SCAPULA
OP POSITION:
If baby’s head is partially extended it does not fit into the lower ut. pole well with the following consequences in labour:
1. Early ROM & Cx. not well opposed to head.2. Sinciput reaches pelvic floor first & therefore
rotates to front i.e. occiput is post.3. Large occipito frontal diam. of head presents
(10 cm) more difficult to pass.4. 1st stage of labour is prolonged.5. Movements of forces pushes head
posteriorly causing backache & inducing bearing down efforts before full dilatation
6. 2nd stage of labour may be prolonged.
THE OCCIPUT may rotate anteriorly & deliver relatively easily (75%)
Or Persists posteriorly (POP) (5%)
spontaneous delivery if pelvis is capacious (face to pubis)
or requires assisted delivery
Or Begins to rotate ant. but undergoes deep transverse arrest at level of ischial spines instrumental
delivery may be required (20%)
PREDISPOSING FACTORS:
- Slight reduction in pelvic inlet
- Large baby
DIAGNOSIS:
- Antenatally
- During labour (both fontanells easily palpable)
MANAGEMENT:
♣ Epidural/ adeq. analgesia
♣ Prevent maternal ketosis & dehydration
♣ Monitor fetal well being
♣ R/O relative CPD