Abnormal Lie, Malpresentations, Mal Flashcards
What are abnormal presentations?
Breech
Brow (partially deflexed cephalic)
Face (fully deflexed cephalic)
Cord
What is an abnormal position?
Occipito posterior
What are causes of abnormal lies/malpresentation and malposition
Maternal factors:
- abnormalities of pelvic size or shape
- pelvic tumors eg fibroids or ovarian masses
- congenital abnormalities of the uterus
- placenta Praevia
- multiparity
- pre term labour
Fetal factors - fetal macrosomia - multiple pregnancy - polyhydramnios Congenital abnormalities -intrauterine fetal death -intrauterine growth restriction
What are the clinical consequences of abnormal lie etc?
Effects on labour
- presenting part remains high
- membranes rupture early
- less efficient labour due to poor application and uncoordinated uterine contractions
- dilatation is often slow and incomplete
- CPD occurs more commonly
- pathological retraction ring and uterine rupture may occur
- increase in incidence of operative deliveries
Effects on mother
- maternal exhaustion
- trauma to birth canal
- Caesarian section
- PPH- trauma and atony
- infection: due to prolonged rupture of membranes and labor
- urine retention
- paralytic uterus
- psychological
Effects on the fetus
- excessive caput and moulding
- fetal asphyxia
- fetal trauma
- cord prolapse
Why is a transverse lie an obstetric emergency?
Risk of cord prolapse and insurmountable obstruction leading to uterine rupture
What is the management of transverse lie?
- find the cause
- if no contraindications: offer external cephalic version
- ECV successful: allow labour to commence or offer stabilizing induction
- ECV unsuccessful: csection
- csection: especially is fetal back is lying inferiorly
What is the mento- vertical diameter (brow presentation)
13.5 cm
What is management of brow presentation?
- early labour: spontaneous correction via either flexion or extension of the fetal head may occur
- manual rotation to occipito anterior or face presentation is possible but seldomly done
- csection is the safest way to deliver if there is doubt about safety of interference
Destructive procedures if baby is dead or several abnormal
What are the two types of fave presentations?
Mento anterior ( can deliver vaginally) Mento posterior ( forehead impacted behind symphysis)
What is a compound presentation?
More than one fetal part presents. Prolapse of fetal extremity into the lower uterine segment alongside the presenting part
What are the dangers of an occipito-posterior position?
Prolonged labour
Painful labour
Complicated delivery
What are the clinical signs of an occipito posterior position?
- Head is not engaged
- Abdomen may have a scaphoid shape
- Often difficult to identify
- Anterior shoulder is displaced laterally
- Limbs and fetal movement may be palates on both sides of the midline
- Head is often deflexed with the occiput and sinciput are at the same level
- fetal heart is heard more literally
- vaginal exam: posterior fonatanelle in posterior half of pelvis
- poor cervical effacement, dilatation and application can be anticipated
What are the two types of occipito posterior presentations
Direct position: Sagital suture in midline
Lateral; head attempts to find a larger area in the android pelvis- associate with more problems
What are the three things the head may do during labour when it presents in the OP position?
- remain and deliver in the occipito posterior position
- rotate completely to the anterior position with delivery in this position and restitution to the posterior
- descent and rotate to posterior position where it becomes arrested on the Ischial spines
What instrument would you use to deliver a fetus in the occipito posterior position?
Vacuum extraction- can be used with the head in any position
Use forceps when head has rotated to he direct AP position
What is the management of a cord presentation?
- avoid rupture of the membranes
- as for cord prolapse: elevate the presenting part , knee chest position, fill bladder
- Caesarian section
- vaginal delivery of baby is dead, grossly abnormal or rarely, assisted delivery is patient is fully dilated
What are the types of breech presentation?
Complete
Incomplete/ frank breech
Footling breech
Kneeling breech
Which type of breech presentation can be delivered vaginally?
Complete and incomplete
What are the dangers of s breech presentation?
1 abnormal labour
2 intracranial haemorrhage
3 asphyxia (due to delay in the delivery of the head, bearing down through a partially dilated cervix, difficulty of the delivery with displaced arms, cord prolapse or compression)
4 trauma ( fractures, damage to intrabdoninal organs or maternal injury from manipulation)
5 fetal death
When is an external cephalic version performed?
37 weeks
What are complications of an ECV?
Abruptio placenta
Feto maternal bleed
Rupture of membranes
Ruptured uterus (rare)
Contraindications to ECV
- ruptured membranes
- APH
- multiple pregnancy
- HIV
- less than 37 weeks gestation
- indications for a csection
- previous csection
- hypertensive conditions
- growth restrictions
- fetal anomaly
- RH negative (use rhogam)
When would vaginal delivery be strongly contraindicated for a breech presentation?
Footling breech Kneeling breech Extended fetal head Estimated fetal weight > 3.5 kg Estimated fetal weight 1-1.5 kg Contracted pelvis
What do you look for on ultrasound with breech presentation?
Presentation, attitude, placental site
Fetal malformations
Multiple pregnancy
Biometry and estimation of weight and gestational age
What are the three main methods of delivering the after coming of the head for breech?
- Wigand Martin
- mauriceau- smellie- veit
- burns- marchall’s
What is the management of compound presentation?
- confirm diagnosis by ultrasound or X-ray
- wstablish fetal viability
Allow vaginal delivery in pre viable fetus
In viable fetus- csection is better
What are the dangers associated with compound presentation ?
Prematurity
Cord prolapse
Traumatic vaginal delivery
What are the various type of fetal lies?
Normal: longitudinal
Abnormal: transverse/ oblique
