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AP Exam 4 (UPenn) > Malpresentations > Flashcards

Malpresentations Flashcards

1
Q

Fetal lie

A

Orientation of fetal spine relative to spine of mother (longitudinal, oblique, transverse)

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2
Q

Presentation

A

Presenting part which is the first portion of fetus to enter into pelvic inlet (cephalic, breech, shoulder)

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3
Q

Position

A

Presenting parts in relation to mom’s pelvis.

Determined by dividing mom’s pelvis into quadrants (anterior-posterior-transverse / right-left) , and determining reference point for fetal presenting part:
Cephalic – occiput (O), brow/fronto (F), face/chin (M)
Breech/sacrum/coccyx (S)
Shoulder– scapula (Sc), acromion (A)

Each presenting part has 6 possible positions. Right vs Left, O/F/M/S/Sc/A, and Anterior vs Posterior vs Transverse.

For occiput - LOA, LOP, LOT, ROA, ROP, ROT

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4
Q

Attitude

A

Position of fetal head in relation to neck (full flexion = normal, chin against upper chest). Various degrees of deflection or even extension which can lead to face or brow presentation.

a. complete flexion (normal)
b. moderate flexion (military)
c. poor flexion/marked extension
d. hyperextension (face)

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5
Q

Station

A

Depth of that the presenting part has descended into the pelvis in relation to ischial spines of mother’s pelvis.

Degree of advancement is measured in cm.

0 station = ischial spines
Above ischial spines = -1 to -5 (-1 lowest, -5 highest above pelvis)
Below ischial spines = +1 to +5 (+5 lowest descent of presenting part)

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6
Q

Variety

A

Relationship of the presenting part to the anterior, posterior, or transverse portion of the pelvis (part of flexion)

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7
Q

Malpresentation

A
  • Not cephalic presentation (breech or shoulder)
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8
Q

Breech presentations

A
  1. Complete breech (feet tucked position, flexed at hips and one/both knees flexed)
  2. Footling/Incomplete breech (one or both feet or knees lie below the breech)
  3. Frank breech (pike position, hips flexed knees extended, feet toward head)
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9
Q

Characteristics of transverse/Oblique lies

A

Fetal spine or long axis crosses mothers’, may cause arm, foot or shoulder as presenting part. Shoulder is typically over pelvic inlet

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10
Q

Characteristics of shoulder presentation

A

Presentation is further based on which maternal side the fetal acromion rests, as well as by position of fetal back (i.e. dorsoanterior or dorsoposterior).
*at risk for cord prolapse

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11
Q

Characteristics of fundic presentation

A

Cord presentation

Umbilical cord is presenting part before fetus (bad news bears). Often happens with transverse /oblique lie

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12
Q

Characteristics of compound presentation

A

Extremity is prolapsed between main presenting fetal part (ie. hand over head) and both parts present simultaneously

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13
Q

Characteristics of face and brow presentation

A

Often presents with various degrees of fetal neck/chin deflection and extension (“attitude”).

Face presentation: longitudinal lie w/ full extension of fetal neck and head, and occiput against back.

Brow presentation: longitudinal lie with partially deflexed cephalic attitude midway between full flexion and full extension.

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14
Q

Landmarks of malpresentation/malpositions detectable by leopolds

A
  • Face presentation: fetal cephalic prominence found on same side as maternal abdomen as fetal back with leopolds. More often discovered by vaginal exam
  • Brow presentation: detection by leopolds unusual, more likely detected on vag exam during labor (different from face presentation b/c chin and mouth cannot be palpated on vag exam)
  • Compound presentation: On vag exam, discovery of irregular mobile tissue mass adjacent to larger presenting part
  • Shoulder presentation: weird feeling on leopolds, on vag exam feels bony, like small knob (vs round, smooth head)
  • Funic presentation: feel pulsation on vag exam
  • Breech presentation: dx may be made by leopolds or vag exam and c/w US
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15
Q

Risk factors for malpresentation & malpositions

A

Maternal:

  • contracted pelvis
  • high parity
  • abnormal placentation, placentation high in fundus or low in pelvis
  • uterine anomalies
  • prior c/s
  • sedentary lifestyle
  • prior malposition/presentation (if d/t recurrent factor)
  • obstructed pelvic outlet
  • uterine fibroids
  • cephalopelvic disproportion (associated with contracted maternal pelvis and severe fetal hydrocephalus)

Fetal:

  • prematurity
  • macrosomia
  • fetal malformations
  • multiples
  • polyhydramnios
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16
Q

Potential complications of ALL malpresentation and malpositions

A
  • fistulae

- lacerations

17
Q

Face presentation complications

A
  • 10x increase in fetal compromise
  • Prolonged labor
  • Associated with increased number of intrapartum death
  • Fetal laryngeal and tracheal edema

Contraindications for vaginal delivery w/ face presentation:

  • macrosomia
  • NRFHT
  • inadequate maternal pelvis
18
Q

Brow presentation complications

A
  • prolonged labor, secondary arrest
  • C/S recommended if found ?
  • Contraindicated – forced conversion of brow to more favorable position with forceps and attempts at manual conversion
19
Q

Transverse lie/shoulder presentation complications

A
  • cord prolapse
  • arm prolapse in labor
  • shoulder entrapment
  • uterine rupture
  • C/S delivery with persistent transverse lie
20
Q

Compound presentation complications

A
  • elevated perinatal mortality
  • C/S
  • birth trauma
  • cord prolapse
  • labor dystocia
  • neuro/musculoskeletal damage to involved extremity
  • labor dystocia
  • C/S delivery
  • maternal soft tissue damage
21
Q

Funic presentation complications

A
  • cord compression
  • NRFHT
  • stillbirth
  • operative delivery
22
Q

Breech presentation complications

A
  • asphyxia and neuro damage from head entrapment, especially in PTB (head is bigger than abdomen and gets stuck)
  • premature or aggressive intervention may adversely affect delivery d/t cervical retraction or deflexion of fetal neck –> larger occipitofrontal fetal cranial profile to pelvic inlet. Could be catastrophic and increase risk of nuchal arm
23
Q

Vertex postural management (baby is vertex, but not occiput anterior)

A

-spinning babies exercise, walking, keeping knees below hips/leaning forward when sitting, keeping pelvis in neutral/engaged position.

24
Q

Face, brow & compound presentation prevention

A

manage expectantly

  • 50% of brows will convert to face or occiput by extending or flexing
  • w/ compound, prolapsed part often retracts as labor progresses
25
Q

transverse/should prevention

A

If dx before onset of labor, ECV recommended at 36-37 wks.

If still transverse, C/S

26
Q

Preterm malpresentation delivery mode

A

C/S (usually classical)

27
Q

Malposition

A
  • Cephalic presentation with change in extension of fetal neck (median vertex/military, brow, face)
  • Abnormal lie
  • Flexed attitude

*often associated w/ increased risk to mother and fetus

AP Exam 4 (UPenn) (5 decks)

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