Obstetrics - Prolonged pregnancy, Malpresentation and Malposition Flashcards
Prolonged pregnancy
- Definition
- Risk factors
Prolonged pregnancy
Risks and consequences
Prolonged pregnancy
Management
Malpresentation
Types
Cephalic:
* Vertex (normal)
* Face
* Brow
* Shoulder
Breech:
* Frank breech/ extended breech
* Complete breech (flexed breech)
* Incomplete breech
Compound
Face presentation
- Causes
- Cause of poor progress
- Management
Brow presentation
Causes
Diagnosis in labor
Management
Shoulder presentation
- Causes
- Types
- Risks
- Management
Management
Before labor:
- Elective admission from 37w and advice to present urgently if S/S of labor or suspicion of membrane rupture (risk of cord prolapse)
- Offer ECV at 37w ± repeat ECV 38-39w as there is ↑chance of spontaneous reversion in case of non-longitudinal lies
Alternative:
- stabilizing induction at 39w: a/w ↑risk of failure but ↓risk of reversion
- expectant Mx: keep admission after 39w due to risk of SROM → cord prolapse
- elective C/S at term
In labor:
- Membranes ruptured → ECV C/I → perform caesarean delivery
- In active labor → ECV difficult unless early → perform caesarean delivery
Caesarean delivery:
- dorsosuperior (back up): lower segment curvillinear incision appropriate
- dorsoinferior (back down): fetal feet difficult to grasp - intra-abdominal version with vertical uterine incision
Compound presentation
- Diagnosis in labor
- Management
Diagnosis:
- Palpation of an extremity along with the major presenting part
Management:
- Expectant management
- Push extremity gently upward if persistently prolapsed
- Close monitoring of cord prolapse
Breech presentation
Types
Clinical sequalae of breech presentation
Risks a/w vaginal breech delivery:
- Cord prolapse and cord compression
- Head entrapment and hypoxia
- Visceral trauma: esp rupture of spleen or gut if the fetal abdomen is handled
Other birth injuries
- damaged brachial plexus with traction
- tentorial tear, ICH: in rapid delivery of head as the fetal skull does not have time to mould
Risk factors of breech presentation
Management of preterm breech presentation
Management of term breech
External cephalic version
Indications
Contraindications
External cephalic version
Preparation
Procedure
External cephalic version
Outcome
Complications
Vaginal breech delivery
Risks
Indication
Reasons for avoidance
Predictors of high risk of vaginal breech delivery
Predictors of ↑risk of vaginal breech delivery → prefer C/S
- Hyperextended neck on US
- ↑EFW (>3.8kg) or ↓EFW (<10th centile)
- Footling presentation
- Evidence of AN fetal compromise
Stages of delivery for malpresentation
Unstable lie
Definition
Causes
Management
Unstable lie: constantly changing fetal lie after 37w
Causes: similar to other causes of malpresentation
Management:
- Elective admission after 37w for risk of cord prolapse due to ROM
- Daily observation of fetal lie and presentation
- Stabilizing induction at term: perform ECV to convert to cephalic presentation, AROM as head approach pelvic prim assisted by gentle suprapubic pressure, oxytocin induction after successful amniotomy
- Elective LSCS at term when ECV/vaginal delivery C/I or ECV failed
Types of positions in labor
Types of malposition
Cause of difficult delivery
Position: relationship of denominator to fixed points of maternal pelvis
Occiput anterior (OA) position is the case in 90% → normal position
Malposition = any other position of head
- occiput transverse (OT): sagittal suture directed along transverse diameter of pelvis
- occiput posterior (OP): occiput present in posterior half of pelvis (face-up)
Difficult delivery: frequently a/w larger presenting diameters leading to difficult delivery due to
- deflexion of head: no longer present in suboccipito-bregmatic diameter (best)
- asynclitism: one parietal bone (usu anterior) being lower in pelvis with parietal eminences at different levels
Occiput posterior position
Risk factors
Diagnosis
Occiput posterior position
Clinical presentation
Complications
Occiput-Posterior position
Management
Occiput transverse position
Cause
Consequence
Occiput transverse position
Management
