16) Mechanism and management of asynclitism, deep cephalic transverse position of the head and high straight cephalic position.

Question 1

what is asynclinitism ?

Answer 1

where the head of of the baby tilted to one of the shoulder

Question 2

what is synclinitism ?

Answer 2

the biparietal diameter is parallel to the pelvic plane and the sagittal sutures lies midway between the posterior and anterior pelvis

Question 3

what is posterior asynclitism ?

Answer 3

the sagittal suture lies closer to symphysis pubis

in vaginal examination the posterior parietal bone presents

Question 4

what is anterior asynclitism ?

Answer 4

the sagittal suture is more closer to the sacrum

in vaginal examination the anterior parietal bone presents

Question 5

what is the clinical management of asynclitism ?

Answer 5

Mild degrees of asynclitism are common but severe degrees indicate cephalopelvic disproportion

most asynclitism corrects spontaneously when it enters the brim - engagement

however persistence of asynclitism

Sidelying Release- ankle , knee , hip and ear all aligned up and
put pressure on the hip while the patient’s leg is lifted up and forward - static stretch” to temporarily, slightly enlarge and soften the pelvis, do the same to the other side

after the baby’s head is engaged and baby is near 0 station do the lunge it opens the midpelvis between the ischial spines
the feet is on a chair to the sid of the body and the and during contraction she rocks towards her knee and then com straight again

ventouse or forceps if obstructed

still obstructed labour- leading to asphyxia - need to do an emergency c section

Question 6

posterior asynclitism is more commonly found in ?

Answer 6

found in primigravidae because of good uterine tone and a tight abdominal wall.

Question 7

anterior asynclitism is more commonly found in ?

Answer 7

found in multipara

Question 8

Asynclitism is beneficial in the mechanism of engagement of head why ?

Answer 8

the two parietal eminences cross the brim one at a time - lesser diameter

This helps lesser diameter (super subparietal: 8.5 cm), to cross the pelvic brim instead of larger biparietal diameter (9.5 cm)

Question 9

when asynclitism is present in vaginal birth what type of forceps do we use to aid the delivery ? and why ?

and describe the methods of that particular forcep?

Answer 9

They are larger than other types of forceps

Kielland’s Forceps
commonly used in deep transverse arrest with asynclitism of the fetal head

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It has got a sliding lock for more appropriate adjustment of the blades

Minimal pelvic curve to facilitate rotation and extraction

Knobs on the handle on the side of the minimal pelvic curve and should be directed toward the foetal occiput during application

> classical method - not used anymore due to birth canal damage

> wandering
direct

Question 10

what is the wandering method in kielland forceps ?

Answer 10

examination through the vagina and palpate the baby’s head sand sagittal suture - find the er - the pinna of the ear - points towards the ocipit

wandering
the anterior blade inserted first . two fingers introduced into the postero-lateral region between the baby’s head and hollow of the sacrum of the pelvis

the blade slips between the head and fingers

then wandered by swinging it around towards the sinciput ( 180 degrees-dta) to fit against the anterior parietal eminence.

posterior blade is inserted the same way as before

The 2 blades are locked

forceps handles are depressed down and handle tips are brought into alignment to correct the asynclitism.

The occiput is rotated anteriorly.

rotation should only be done by three fingers and force never used

Slight upward dislodgement of the head may facilitate rotatio

traction is applied in line of the pelvic axis

one two fingers are used for traction for not excessive force

till we see the occiput behind symphysis the traction is downwards and backwards

and then forward and anteriorly

Question 11

what is the direct method in kielland forceps ?

Answer 11

direct method - ONLY used IN ANTERIOIR ASYNCLITISM AND when the head is at low station

when in this position the tip of the anterior blade can then be inserted behind the symphysis with the obsteteriction kneeling down

the blade is lifted up bringing it into its correct position over the malar bone

If the head is high or the fit too tight this method cannot be used

The posterior blade is applied above the vaginal fingers between the hollow concavity of the sacrum and fetal head

The 2 blades are locked, head is rotated and extracted as occipito-anterior position

Question 12

when is asynclitism normal?

Answer 12

Early in labor, when the baby’s head enters the brim due to the protruding base of the spine (sacral promontory) at 3cm dilation

Question 13

when does asynclitism become abnormal?

Answer 13

5 cm dilation

Question 14

how to diagnose asynclitism?

Answer 14

The baby’s head will seem a little lower and closer to the bones on the thin side of cervix.

The baby’s head will seem to angle away, deeper into the pelvis and less close to the mother’s bones on the thick side of the cervix

Labor is often longer

Sometimes the labor pattern is a fast dilation to about 8 cm and then slow to get to 10 cm

may have significant pain in one hip.

Question 15

what causes asynclitism?

Answer 15

water release suddenly with a strong contraction, there is a possibility that the baby’s head comes down to the mid-pelvis while still asynclitim

hand near face

imbalance of muscles in the body

the pelvic floor is asymmetrical

Question 16

when using kielland force in deep transverse arrest situations what are the important things to remember?

Answer 16

in anterior parietal presentation - posterior blade introduced very deep into the pelvic cavity so on locking the handles are not in the same level

the opposite for posterioir parietal presentation

ROTATion done only in between uterine contractions , so when uterine contraction happen unlock the blade

traction takes place DURING uterine contractions

the knobs pointed towards the occiput - so that during rotation these knobs go to the pubic symphysis

Question 17

what is mandatory using kielland forceps ?

Answer 17

Deep mediolateral episiotomy is mandatory

Question 18

complications of using kielland forceps ?

Answer 18

Facial bruising, laceration,
facial nerve palsy, skull fractures, intracranial hemorrhage.

Maternal: Perineal sulcus tear,
complete perineal tear.

Question 19

what is deep transverse arrest

Answer 19

The head is deep into the cavity;

the sagittal suture is placed in the transverse bispinous diameter and there is no progress in descent of the head even after 1⁄2–1 hour following full dilatation of the cervix

failure of both· rotation and descent of the head from a transverse position at or just above the level of the ischial spines, provid- ed that the cervix is fully dilated and the uterine contractions are adequate.

Question 20

causes of deep transverse arrest ?

Answer 20

deflexion of head occipitoposterior position and android pelvis

> prominent ischial spines,

> flat sacrum

> convergent side walls
= android pelvis

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or

nonrotation of occipitotransverse position of normal mechanism of labor
>Weak uterine contraction

> Laxity of the pelvic floor muscles.

Question 21

diagnosis of deep traverse arrest ?

Answer 21

The head is engaged,
The sagittal suture lies in the transverse bispinous diameter,
Anterior fontanel is palpable,
Faulty pelvic architecture may be detected.

Question 22

scheme of management in persistent ocipitoposterioir / or DTA position

Answer 22

we do assisted delivery :

1) if pelvis adequate
and BABY BELOW or at ischial spines

• ventouse - ideal
• manual rotation and mid forcep delivery application
• head rotation with kielland and forceps extraction

2) if not adequate / or above ischial spine
- C section

Question 23

describe manual rotation for deep transverse postion arrest ?

Answer 23

whole hand method

in ROP or ROT = left hand
vice versa

in occipito transverse
our fingers are pushed in the sacral hollow to be placed over the posterior parietal bone and the thumb is placed over the anterior parietal bone

in oblique posterior position, the four fingers of partially supinated hand are placed over the occiput and the thumb is placed over the sinciput

pronation of the hand, causes the head to be rotated and bring the occiput anteriorly along the shortest route. Simultaneously, the back of the fetus is rotated by the external hand from the flank to the midline

A little over rotation is desirable anticipating slight recurrence of malposition before the application of mid forceps

When the left hand is used, it is placed on the right side of the pelvis after rotation, as such the right blade is to be introduced first and the left blade is then to be introduced underneath the right blade vice versa

While introducing the blades, it is preferable that an assistant fixes the head by suprapubic pressure in a manner of first pelvic grip

Question 24

what is the manual half hand method in DTA and ocipitoposterioir arrest

Answer 24

rotation is done only by using the right hand.

four fingers are introduced into the vagina using right hand no thumb

the pressure is applied on the side and the parietal eminence of the head.

In ROP or ROT positions, the fingers are placed anterior to the head and the pressure is applied by the ulnar border of the hand

. In LOP or LOT positions, the fingers are placed posteriorly and the pressure is applied by the radial border of the hand. The force is applied intermittently till the occiput is placed behind the symphysis pubis

Question 25

how do you use the kielland forceps in DTA ?

Answer 25

same with asynclitism - wandering method and direct method