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Unergraduate course lectuers in Obstetrics&Gynecology,Faculty of medicine,Zagazig University Prepared by Dr Manal Behery
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Defintion
Fetal presenting part other than vertex includes breech, face, brow, transverse, and compound presention.
Definition
More than one pregnancy (e.g. Multipara,Grand multipara )More than one fetus (e.g. Twins)Too much or too little amniotic fluid (e.g.
Poly hydramnious, oligohydramnios) Abnormal uterine shape (e.g.
Arcuate ,septate, supseptate) or abnormal growth (e.g Fibroid)
Placenta previa The baby is preterm
Related Factors
Defintion• Breech 3 in 100 (3%)• Face 1 in 500 (0.5%)• Brow 1 in 2000 (0.02%)• Shoulder 1 in 300 (0.3%)• Compound 1 in 5000 ( 0.05%)
Incidence of malpresentation
Shoulder presentation
It is a Transverse lie
in which the long axis of the
fetus is perpendicular( 900)
to long axis of mother.Shoulder of baby comes in– the lower segment of uterus(0.5%)
4 position in Shoulder presentation Acrimon- anterior(60%) Left Right Acrimo- posterior(40%) Right Left Acrimo anterior position is more common as the
concavity of front of fetus fix in convexity of maternal spine
Placenta is posterior in 60% of cases
Lt Acrimoanterior Rt Acrimoanterior
Rt Acrimoposterior Lt Acrimoposterior
Diagnosis
Abdominal examination,the head is usually felt in one
iliac fossa or in the flank.
The breech in the other iliac fossa but at a higher level
Fundal level just above umbilicus
FH sound heard below the umbilicus
On vaginal examination
Early in laborthe cervix is elevatedlower uterine segment is imperfectly filledLate in labor The cervix is sufficiently dilated: We can feel:
scapula, acromion, clavicle, axilla and ribsConfirm position: If the arm is prolapsed
and supinated the dorsum points to the back and the thumb points to the head.
Neglected shoulder
Prolonged laborMembrane ruptured liquor drained Arm may be prolapsedFetus dead or dyingLower segment overstretchedSigns and symptoms of obstructed labor
Management
During pregnancyA-External cephalic version Can be tried up to full term,Even early in labour before ROM
* Laxity of the abdominal & uterine walls makes the procedure easier than in breech
* The fetus will be rotated only 90 degrees. B. If fails, do external podalic version.
head.
During labor
External cephalic version (ECV) is tried with intact membranes :
- If succeeded: Rupture of membranes and application of
abdominal binder. - If failed: C.S. is the safest for the mother & fetus.
If the membranes are ruptured before full cervical dilatations do C.S.
Management
In modern practice, persistent transverse lie in labor is delivered by caesarean section whether the fetus is alive or dead
Face Presentation
head is hyper extended
presenting part is face
- denominator is chin(mentum) between glabella & chin
presenting diameter is submentobregmatic (9.5cm)
Types of Face Presentation
2ry face (during labor) commen
The majority of cases of face are secondary to occipto-posterior which transformed to mento anterior
Causes are maternal
1ry face (during pregnancy )rare Causes are fetal
AETIOLOGY
In Face presentation- 6 position
Lt mento-ant Rt mento-ant Rt mento-post
Diagnosis
The chin serves as the referenc point in describing the position of the head. It is necessary to distinguish chin-anterior positions in which the chin is anterior in relation to the maternal pelvis from chin-posterior positions.
Diagnosis
On abdominal examination, a groove may be felt between the occiput and the back.On vaginal examination Neither the occiput nor the sinciput are palpable
supra-orbital ridges, chin, alveolar margin ± ala nasi Confirm presention
Mechanism of labor in MA
The head descends with the submento-bregmatic diameter (9.5 cm).
Descent, engagement, increased extension of the head
the chin meets the pelvic floor first and rotates forwards 1/8 of a circle.
With further descent the submental-region hinges below the symphysis pubis
the head is delivered by flexion , followed by restitution and external rotation of the chin as in vertex presentation.
Mechanism of labor in MP
Normal mechanism: In 2/3 of cases the chin rotates forwards 3/8 of a circle and delivered as MA
Abnormal mechanism (In 1/3 of cases): The chin may rotate forwards 1/8 circle (deep transverse arrest of the face).
no rotation(persistent oblique MP). The chin rotate backwards 1/8 circle (direct MP)
Cervix fully dilated Cervix not fully
dilated
Allow normal child birthAllow normal child birth
Slow progress with no signs of obstruction
Slow progress with no signs of obstruction
Descent unsatisfactoryDescent unsatisfactory
Augmentation of labour
Augmentation of labour
Forceps delivery
Augmentation of labourAugmentation of labour
Management of Chin-anterior Management of Chin-anterior
It is a cephalic presentation with the head midway between flexion and extension.
Incidence: 1 /2000
The frontal bone is
the denominator.
There are 4 main positions
• - Left fronto-anterior. • - Right fronto-anterior.
• - Right fronto-posterior. • - Left fronto-posterior.
Types &Etiology of brow
Transient brow(2RY)• During conversion of vertex to face.Persistent brow(1RY) • Extremely rareEtiology: same as face
Mechanism of labour
Transient brow(2RY)
brow may be converted spontaneously into face (by extension) or vertex (by flexion) and this followed by spontaneous delivery
Persistent brow:
There is no mechanism
for delivery because the
head descends by the mento
-vertical diameter (13.5 cm)
which is longer than any
of the diameters of the pelvic inlet. So, the head become arrested at the
pelvic inlet ,and labour is obstructed.
Diagnosis
Abdominal examination: the occiput & sinciput are felt at the same level PV examinationfrontal bone, supra-orbital ridges and the root of the nose are felt.
Compound Presentation
Occurs when an extremity (usually an arm less commonly lower limb) prolepses alongside the presenting part.
• Both the prolapsed arm and the fetal head present in the pelvis simultaneously.
Diagnosis
Suspect compound presentation when
1.Active labor is arrested
2.The fetus fail to engage
3.The prolapsed extremity is palpated directly
ManagementDon’t manipulate the prolapsed extremityIn many cases the extremity will spontaneously
be pulled back and away from the presenting part.
Spontaneous delivery in 75% of vertex /upper extremity presentation
Do continuous FHR monitoring because of associated occult cord prolapse
Reduce the extremity if Prolapsed extremity prevent descent of
fetus gently reduce by pushing it upward above the pelvic brim and hold it until a contraction pushes the head into the pelvis.
Do CS if Non reassuring FHR traceCord prolapsedFailure of labor to progress
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