11

MALPOSITION, MALPOSITION, MALPRESENTATION, MALPRESENTATION,

ABNORMAL LIEABNORMAL LIE

22

PRESENTATIONPRESENTATION

97% : cephalic97% : cephalic 3%: breech3%: breech 0.5% : transverse, oblique,face, brow0.5% : transverse, oblique,face, brow

33

FACE PRESENTATIONFACE PRESENTATION

Head is hyperextended: occiput Head is hyperextended: occiput touches fetal backtouches fetal back

Mento anterior or posteriorMento anterior or posterior Labour progress stalled with MPLabour progress stalled with MP

INCIDENCE:0.17%INCIDENCE:0.17%

44

DIAGNOSISDIAGNOSIS

+V/E: mouth, nose,malar bones and +V/E: mouth, nose,malar bones and orbital ridgesorbital ridges

ETIOLOGY:ETIOLOGY:Factors for extension of neck or Factors for extension of neck or

against flexionagainst flexionCord round neck; rareCord round neck; rareAnencephalyAnencephalyContracted pelvis:-40%, big babyContracted pelvis:-40%, big baby

55

Others Others

Lax pendulous abdomenLax pendulous abdomen High parity High parity

66

Mechanism of labourMechanism of labour

Only in mentoanteriorOnly in mentoanterior Same Same Descent, with chin leading-internal Descent, with chin leading-internal

rotation- chin lies under the rotation- chin lies under the symphysis pubissymphysis pubis

With mento posterior the short neck With mento posterior the short neck unable to span the anterior surface unable to span the anterior surface of sacrum -12cmof sacrum -12cm

77

Mechanism of labMechanism of lab

Chin mouth appears at vulva- birth is Chin mouth appears at vulva- birth is by flexionby flexion

External rotation with chinExternal rotation with chin Cls frequent because of contracted Cls frequent because of contracted

pelvispelvis External continous monitoring –yesExternal continous monitoring –yes Mento posterior—c/sMento posterior—c/s

88

BROW PRESENTATION BROW PRESENTATION

ANTRIOR FONTANELLE AND ORBITAL ANTRIOR FONTANELLE AND ORBITAL RIDGESRIDGES

MIDWAY B/W FLEXION/ EXTENSIONMIDWAY B/W FLEXION/ EXTENSION NO MECHANISM OF LABOUR- NO MECHANISM OF LABOUR-

MENTOVERTICALMENTOVERTICAL UNSTABLE PRESENTATION- CAN UNSTABLE PRESENTATION- CAN

CHANGECHANGE

99

ETIOLOGY: same as in faceETIOLOGY: same as in face Prognosis: small baby ok; term baby Prognosis: small baby ok; term baby

c/sc/s

1010

TRANSVERSE LIETRANSVERSE LIE

Shoulder presentation: dorso Shoulder presentation: dorso anterior; or posterioranterior; or posterior

Incidence:0.3%Incidence:0.3% Etiology : abdominal wall relaxation,Etiology : abdominal wall relaxation,

Preterm Preterm

Placenta previa, uterine anomaly Placenta previa, uterine anomaly excessive liquor,contracted pelvisexcessive liquor,contracted pelvis

1111

Diagnosis and courseDiagnosis and course

Abdominal and V/EAbdominal and V/E MX =C/SMX =C/S

1212

PERSISTENT OCCIPUT PERSISTENT OCCIPUT POSTERIOR POSITIONPOSTERIOR POSITION

MOST: malrotation of ociput anterior MOST: malrotation of ociput anterior positionposition

87% of occiput anterior: rotate 87% of occiput anterior: rotate anterioranterior

LABOUR : monitor as normalLABOUR : monitor as normal

1313

OPTIONSOPTIONS

Await spont. DeliveryAwait spont. Delivery Forceps delivery with occiput posteriorForceps delivery with occiput posterior Forceps rotation to anterior B/4 Forceps rotation to anterior B/4

deliverydelivery Manual rotation to anterior B/4 Manual rotation to anterior B/4

spontaneous or forceps deliveryspontaneous or forceps delivery clscls

1414

OutcomeOutcome

Increase duration of labourIncrease duration of labour More interventionMore intervention

1515

Persistent occiput transverse Persistent occiput transverse positionposition

Transitory positionTransitory position Options:Options:

Oxytocin augmentationOxytocin augmentation

Manual rotationManual rotation

Forcep rotationForcep rotation

clscls

1616

BREECH PRESENTATION BREECH PRESENTATION

Buttocks presentButtocks present Incidence: 3-4% at term deliveryIncidence: 3-4% at term delivery ETIOLOGY:ETIOLOGY:

Abdomen, uterus, liquor, baby Abdomen, uterus, liquor, baby placenta, cord, contracted pelvis , placenta, cord, contracted pelvis , cornuo-fundal placentacornuo-fundal placenta

1717

COMPLICATIONSCOMPLICATIONS

Perinatal morbidity and mortalityPerinatal morbidity and mortality Low birth weight: preterm; IUGRLow birth weight: preterm; IUGR Prolapsed cordProlapsed cord Placenta preaviaPlacenta preavia Fetal, neonatal, infant mortalityFetal, neonatal, infant mortality Uterine anomaly and tumorsUterine anomaly and tumors Multiple fetusesMultiple fetuses Operative interventionsOperative interventions

1818

DIAGNOSISDIAGNOSIS

ABDOMINAL / V/EABDOMINAL / V/E

FrankFrank

Flexed Flexed

Footling breechFootling breech

IMAGING: IMAGING:

USSUSS

X-ray : controversialX-ray : controversial

1919

PrognosisPrognosis

Maternal morbidity/mortalityMaternal morbidity/mortality Breech prognosis : irrespective of Breech prognosis : irrespective of

mode of deliverymode of delivery

2020

Pronosis Pronosis

Maternal : increased interventionsMaternal : increased interventions Fetus infant morbidity/mortality:Fetus infant morbidity/mortality:

Preterm delivery,congenital anomaly, birth Preterm delivery,congenital anomaly, birth traumatrauma

injuries in order of frequency at autopsyinjuries in order of frequency at autopsy

Brain, spinal cord, liver, adrenal gland,and Brain, spinal cord, liver, adrenal gland,and spleenspleen

Others: brachial plexus,pharynx, Others: brachial plexus,pharynx, sternocleidomastoidsternocleidomastoid

2121

Complications with vagina Complications with vagina deliverydelivery

Delay/rushedDelay/rushed Preterm baby: cervical head Preterm baby: cervical head

entrapment; use duhrssen incisionentrapment; use duhrssen incision Cord prolapse: frank breech : 0.5%Cord prolapse: frank breech : 0.5%

Flexed breech: 5%. Foootling: 15%Flexed breech: 5%. Foootling: 15%

Cord length is short and true knots Cord length is short and true knots commoncommon

2222

Factors to considerFactors to consider

X –ray pelvimentry : no consensusX –ray pelvimentry : no consensus Hperextension of fetal head:5%; Hperextension of fetal head:5%;

delivery causes cervical spine injury.delivery causes cervical spine injury.

In labour=C/SIn labour=C/S

INDUCTION/ AUGMENTATION:INDUCTION/ AUGMENTATION:

Difffering reports on fetal prognosisDifffering reports on fetal prognosis

2323

MODE OF DELIVERYMODE OF DELIVERY

DISCRETION: PRETERM/TERMDISCRETION: PRETERM/TERM PRETERM: birth weightPRETERM: birth weight Ceaserean sectionCeaserean section

Large babyLarge baby

Contracted pelvisContracted pelvis

Hyperextended headHyperextended head

Coexistent problemsCoexistent problems

Footling breechFootling breech

2424

Others Others

IUGRIUGR BOHBOH

2525

LABOUR AND DELIVERYLABOUR AND DELIVERY

Descent : bis trochanteric diameter with Descent : bis trochanteric diameter with ant hip leadingant hip leading

Internal rotation,birth is by lateral flexionInternal rotation,birth is by lateral flexion External rotation=back anterior as External rotation=back anterior as

shoulders enter inletshoulders enter inlet Shoulders : internal rotation at outletShoulders : internal rotation at outlet Head : rotate with occiput under Head : rotate with occiput under

symphsissymphsis

2626

METHODS OF VAGINA METHODS OF VAGINA DELIVERYDELIVERY

SPONTANEOUSSPONTANEOUS ABDABD BREECH EXTRACTIONBREECH EXTRACTION

2727

MANAGEMENT OF LABOURMANAGEMENT OF LABOUR

IV ACCESSIV ACCESS CLOSE MONITORINGCLOSE MONITORING UNBOOKED : NOT INDICATION FOR UNBOOKED : NOT INDICATION FOR

C/SC/S LABOUR : ULTIMATE ARBITERLABOUR : ULTIMATE ARBITER SKILLED MEDICAL PERSONNELSKILLED MEDICAL PERSONNEL

2828

DELIVERY DELIVERY

PROGNOSIS BEST IF SPONTANEOUS PROGNOSIS BEST IF SPONTANEOUS DEL UP TO UMBILICUSDEL UP TO UMBILICUS

MODE OF ABDMODE OF ABD

2929

MANUEVERSMANUEVERS

MSVMSV PRAGUE MANUEVER:PRAGUE MANUEVER:

Occiput remain posterior: manual Occiput remain posterior: manual rotation msv, rotation msv,

Prague:hands on back down fetal Prague:hands on back down fetal shoulders, other hand draws feet shoulders, other hand draws feet over abdomen of motherover abdomen of mother

3030

Entrapment of after coming Entrapment of after coming headhead

Small preterm babySmall preterm baby Manual manipulation of cervixManual manipulation of cervix Duhrssen incisionDuhrssen incision Cephalic replacement then c/sCephalic replacement then c/s

3131

Analgesia and anaesthesiaAnalgesia and anaesthesia

Epidural : prolongs 2Epidural : prolongs 2ndnd stage: weigh stage: weigh agaist riskagaist risk

3232

Morbidity/mortalityMorbidity/mortality

Maternal and fetalMaternal and fetal

3333

VERSIONVERSION

ALTERATION OF PRESENTATION ALTERATION OF PRESENTATION ARTIFICIALLYARTIFICIALLY

One pole for another in logitudinalOne pole for another in logitudinal

Transverse to longitudinalTransverse to longitudinal

EXTERNAL/INTERNAL VERSIONEXTERNAL/INTERNAL VERSION

3434

ECVECV

Safe Safe Cost effective Cost effective SuccessfulSuccessful

USS, electronic monitoring and USS, electronic monitoring and tocolytics increase safetytocolytics increase safety

3535

ECVECV

35-37WKS35-37WKS ECV succeeds in 65% of casesECV succeeds in 65% of cases If version succeeds,almost all fetuses If version succeeds,almost all fetuses

stay cephalic and vice-versastay cephalic and vice-versa Ultimately and despite version Ultimately and despite version

attempts,37% of women identified to attempts,37% of women identified to have a late pregnancy breech will have a late pregnancy breech will requireC/SrequireC/S

3636

ECV SUCCESSECV SUCCESS

Presenting part has not descended Presenting part has not descended into pelvisinto pelvis

Normal amount of liquorNormal amount of liquor Fetal back is not posteriorFetal back is not posterior Woman is not obeseWoman is not obese

3737

TechniqueTechnique

In labour ward close to theatreIn labour ward close to theatre USSUSS Continous external monitoringContinous external monitoring Forward role if fails back flipForward role if fails back flip TocolysisTocolysis

3838

Interesting conceptInteresting concept

Moxibuston; burning herbs to Moxibuston; burning herbs to stimulate acupuncture point stimulate acupuncture point BL67==promotes spontaneous BL67==promotes spontaneous breech version possibly by increasing breech version possibly by increasing fetal activity=proven in studiesfetal activity=proven in studies

3939

Complications of ECVComplications of ECV

ABRUPTIOABRUPTIO UTERINE RUPTUREUTERINE RUPTURE AFEAFE FM haemorrhageFM haemorrhage PRETERM LABOURPRETERM LABOUR FETAL DISTRESS,DEMISEFETAL DISTRESS,DEMISE

4040

INTERNAL PUDALIC INTERNAL PUDALIC VERSIONVERSION

DISTRESS IN TWIN 2DISTRESS IN TWIN 2

4141

CONCLUSIONCONCLUSION

HIGH RISK OBSTETRICSHIGH RISK OBSTETRICS