Malposition OPP.pptx

8/22/2019 Malposition OPP.pptx

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Malpositions andMalpresentations


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Introduction

Baby presents itself in the mothers pelvis in any

position other than the vertex presentation -

abnormal presentation, ormalpresentation.

Abnormal - because -higher risk of obstruction

and other birth complications than the vertex

presentation. Contd


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The normal way for a baby to deliver -vertex with

the occiput lying anteriorly.

Cephalic presentation-if the occiput is not lateral

in early labour or anterior in advanced labour then

a malposition exists.

Contd


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If the leading pole of the foetus is anything other

than the vertex, a malpresentation exists.

Malpositions and malpresentations present in

labour can proceed to normal during delivery.

More difficult labour is common

Operative delivery & risk is high for both.

Contd


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Left and right occipito-anterior are the only

normal presentations and positions.

Malposition: occipito-posterior.

Malpresentations: anything except vertex.

Contd


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Malpresentations are

Face presentation,

Brow presentation,

Breech presentation,

Shoulder presentation,

Cord presentation and

Complex presentations.


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Malposition: Occipito-

Posterior


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1. Introduction

Most common type of malposition of the occiput.

A persistent occipitoposterior position (POP)

results from a failure of internal rotation prior to

birth.

In Occipito-Posterior - The vertex is presenting,

but the occiput lies in the posterior rather than the

anterior part of the pelvis.


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In a vertex presentation

where the occiput is

placed posteriorly over

the sacro iliac joint or

directly over the sacrum,

it is called an occipito

posterior position

2. Definition


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3. Incidence

- 10% of all vertex presentations

- Expected more during late pregnancy and much less

in late second stage of labour.

- Early in labour(10-20%)

- Late in labour(1-2%)

Contd


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- ROP is 5 times more common than the LOP

- Dextro rotation of the uterus

- Presence of sigmoid colon on the left- Diminished

left oblique diameter -disfavor LOP position.

- The right oblique diameter is slightly longer than

the left one.


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4. Types

ROPLOP

DOP

POP

Primary: It occur late in pregnancy before the

onset of labour. It occur in association with

anthropoid pelvis.Secondary: It develops during labour and in

association with android pelvis


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ROP LOP


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4. Types

Primary: It occur late in pregnancy before the

onset of labour. It occur in association with

anthropoid pelvis.

Secondary: It develops during labour and in

association with android pelvis


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5. Causes

Not clear

The shape of the pelvic inlet: (50-85%)

anthropoid and android pelvises are the most

common cause - due to narrow fore-pelvis &

roomier hind pelvis

Others(15%)

High pelvic inclination Contd


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Abnormal uterine contraction

Maternal kyphosis: The convexity of the fetal

back fits with the concavity of the lumbar

kyphosis.

Anterior insertion of the placenta

Fetal factors: Marked deflection of the fetal

head. Contd


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Reasons for deflexion of head

High pelvic inclination

Attachment of the placenta on the anterior

wall of the uterus

Primary brachy-cephaly

Contd


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Other causes of Malpresentation:

Placenta praevia,

Pelvic tumours,

Pendulous abdomen,

Polyhydramnios,

Multiple pregnancy.

- Idiopathic(10-30%)


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6. Risk factors for OP

position at delivery include

Nulliparity

Maternal age greater than 35 years

Obesity

African-American race

Previous OP delivery

Contd


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6. Risk factors for OP

position at delivery include

Decreased pelvic outlet capacity

Gestational age 41 weeks

Birth weight 4000 g

Prolonged first and/or second stage of labor


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7. Diagnosis

Antenatal diagnosis

Diagnosis during labour

Imaging

Contd


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A. Antenatal diagnosis

i. Listen to the mother

ii. Abdominal examination Inspection

Palpation and Auscultation

iii. Antenatal preparation

Contd


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i. Listen to the mother

Complain of backache

She may feel that her babys bottom is very

high up against her ribs.

Reports - feeling movements across both sides

of her abdomen.

Contd


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ii. Abdominal examination

Inspection Palpation andAuscultation

Inspection

The abdomen looks flat, below the umbilicus.

saucer-shaped depression at or just below the

umbilicus-dip between the head and the lower

limbs of the fetus.

Contd


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a. Inspection

The outline

created by the

high, unengaged

head can looklike a full

bladder.Comparison of abnormal contour in posterior (1) and anterior positions (2) ofthe occiput


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b. Palpation

ON PALPATION:

- The breech is easily palpated at the fundus,

- The back is difficult to palpate as it is out of

maternal side and almost adjacent to the

maternal spine.

- Limbs can be felt on both side of midline

Contd


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b. Palpation

- High head reason for non engagement in Primi

gravida - large presenting diameter, the

occipitofrontal (11.5cm) The occiput and sinciput

are on the same level. Flexion allows the

engagement of the suboccipitofrontal diameter

(10cm).

Contd


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Engaging diameter of a deflexed head, OF 13.5cm Flexion with Descent of the head


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b. Palpation

Umbilical grip:The findings are:

1.The fetal limbs are more easily felt near the

midline on either side.

2.The fetal back is felt away from the midline on

the flank and often difficult to outline clearly.

3.The anterior shoulder lies far away from the

midline. Contd


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b. Palpation

Umbilical grip:The findings are:

1.The fetal limbs are more easily felt near the

midline on either side.

2.The fetal back is felt away from the midline on

the flank and often difficult to outline clearly.

3.The anterior shoulder lies far away from the

midline. Contd


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b. Palpation

Pelvic grips: The findings are:

1. The head is not encaged.

2. The cephalic prominence (Sinciput) is not felt as

prominent as found in well flexed occipito-

anterior. In direct occipito-posterior, the small

sinciput is confused with breech.

Contd


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b. Palpation

The cause of the deflexion

Is a straightening of the fetal spine against the

lumbar curve of the maternal spine.

This makes the fetus straighten its neck and

adopt a more erect attitude.

ON AUSCULTATION:


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ON AUSCULTATION:

- F.H.S can be heard at

midline.

- Sometime f.H.S can be

heard more easily at theflank on the same side of

the back.

- Difficult to locatespecially in lop


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i i i . Antenatal preparation

Active changes of maternal posture.

Mother adopting a kneechest position several

times a day - temporary rotation of the fetus to an

anterior position - short-term effect upon fetal

presentation.


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B. Diagnosis during labour

Head is high

Non engagement of head

May complain of continuous and severe

backache worsening with contractions


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Large and irregularly shaped presenting

circumference - membranes tend to rupture

spontaneously at an early stage of labour

Contractions may be incoordinate.


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Good contractions but slow descending of the

head.

Strong desire to push early in labour because the

occiput is pressing on the rectum.


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Presenting dimensions of a

deflexed head


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Vaginal examination

The findings will depend upon the degree of

flexion of the head.

Anterior fontanelle in the anterior part of the

pelvis - difficult if caput succedaneum is present.

The direction of the sagittal suture and location

of the posterior fontanelle confirms the

diagnosis. Contd


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The findings in early labour are:

Elongated bag of membranes - rupture during

examination.

The sagittal suture occupies any of the oblique

diameters of the pelvis.


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Posterior fontanelle is felt near the sacro iliac

joint.

The anterior fontanelle is felt more easily

because of the deflexion of the head and at

times, is felt at a lower level than the posterior

one.


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In late labour

diagnosis is often difficult - caput formation

which obliterates the sutures and fontanelles.

In such cases, the ear is to be located and the

unfolded pinna points towards the occiput.

Simultaneous assessment of the pelvis should be

done.


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c. Imaging

Ultrasonagraphy is rarely done.

It is helpful to know the descent, attitude of

the head and its relation to the pelvic walls

(position).

8 Mechanism of (labour)


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8. Mechanism of (labour)

Right occipitoposterior

position (long rotation)The head encages through the

right oblique diameter in ROP and

left oblique in LOP.

The encaging transverse diameter of the head is

biparietal (9.5cm)

Contd

8 Mechanism of (labour)


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8. Mechanism of (labour)

Right occipitoposterior

position (long rotation)Antero-posterior diameter is either

Suboccipito-frontal (10cm) or

Occipito-frontal (11.5cm) (deflexion

engagement is delayed).

In favorable circumstances of OPP - mechanism

is possible. Contd


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Fetal Description/Criteria:The lie is longitudinal

The attitude of the head is deflexed

The presentation is vertex

The position is right occipitoposterior

The denominator is the occiput

Contd


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Fetal Description/Criteria:The presenting part is the middle or anterior area

of the left parietal bone

The occipitofrontal diameter, 11.5cm, lies in the

right oblique diameter of the pelvic brim.

The occiput points to the right sacroiliac joint

and the sinciput to the left iliopectineal eminence.Contd

Mechanism of labour


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Mechanism of labourThe main movements are:

Flexion

I nternal rotation of the head

Crowning

Extension

Restitution

I nternal rotation of the shoulders

External rotation of the head

Lateral f lexion

C i


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Crowning: Occiput escape under the pubicarch and the head is said to be crown

Alternative mechanism in


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Alternative mechanism in

favorable situation

(uncommon)If the shoulders fail to follow the anterior rotation

of the occiput,

The neck sustains a torsion and the shoulders

remain static in the left oblique diameter in ROP

and in the right oblique diameter in LOP.


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In such cases

Restitution occurs 3/8th of a circle and

External rotation occurs through 1/8th of a circle

in the opposite direction of restitution.

However the mechanism is quite unlikely.


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In OP Presentation

Favorable circumstances 90%

Unfavorable circumstances 10%


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I f bl


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In unfavorable

circumstances of OPP

In Certain circumstances

The occiput fails to rotate as described

previously.

Th f f lt t ti


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The causes of faulty rotation

Deflexion of the head,

Weak uterine contraction,

Faulty shape of the pelvis - flat sacrum,

prominent ischial spines or convergent

side walls and weak pelvic floor muscles.

Big baby and immobility of the fetaltrunk

The drainage of liquor amnii.


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Results in Deep

transverse arrest

Incomplete

forward rotation

Sinciput & occiput touch the

pelvic floor simultaneously

Malrotation - Sinciput anterior rotation

- occiput to the sacral hollow -

Occipito- sacral position

Oblique

posterior arrest

Face to pubis Occipito-sacral arrest

Favorable

circumstances

Unfavorable

circumstances

M h i f F t P bi


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Mechanism of Face to Pubis

delivery

Further descent occurs

Flexion occurs

Restitution

External rotation


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Persistent occipito-posterior

Abnormal mechanism of the occipitoposterior

position.

Delivery - spontaneously as face to-pubis or

occipito- sacral arrest.


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Deflexed head, Faulty shape of pelvis, Weak

pelvic floor muscles, Big baby, Immobility of

fetal trunk, Drainage of AF

Incomplete

forward rotation

Sinciput & occiput touch the

pelvic floor simultaneouslyMalrotation - Sinciput anterior

rotation - occiput to the sacral

hollow

COURSE OF LABOUR/


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COURSE OF LABOUR/

CARE IN LABOUR

Course of events in labour are modified

Longer first and second stage

Painful labour

The deflexed head not fit well onto the cervix -

does not produce optimal stimulation for uterine

contractions


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First stage

Tendency to delay means longer time of first

stage.

Causes are Persistence of deflexion of the head

1. Delay in engagement Driving force fetal axis not inalignment

2. Membrane status - Deflexed head - cannot fit well in sphericallower segment - loss of ball valve action - uterine contraction - EROM anddrainage of liquor.

3. Uterine contraction- ill fitting in the LUS -lack of stimulus foruterine contraction- results slow dilatation of the cervix. Pressure on the rectum

by wide occiput - premature desire of bearing down effort in 1st stage. Exhaustion

of client.


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The woman may experience

Severe and unremitting backache, causes tiring -

very demoralizing because of slow progress.

Midwife support essential for mother and her

partner to cope with the labour.The all-fours position may relieve some

discomfort.


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Prolonged labour - prevent the mothersdehydration or ketosis.

Incoordinate uterine action or ineffectivecontractions correct an oxytocin infusion.

The woman may experience a strong urge topush before full dilation causes cervix edema

delay onset of 2nd stage.


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The urge to push eased by - change in position,use of breathing techniques or inhalational

analgesia - enhances relaxation.

Partner/midwife can assist throughout labour

with massage, physical support and suggestions

for alternative methods of pain relief.

Pain control methods.


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Second stage

Delayed 2nd stage - long internal rotation or

malrotation / arrest of the head.

This may happen in android pelvis or in mid

pelvic or in mid pelvic contraction.

If felt uncared - arrest of the head may lead to

obstructed labour.


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Confirm full dilatation of the cervix -

moulding and caput succedaneum may

bring the vertex into view.

Onset of 2

nd

stage no visible head -encourage the woman to remain upright-

shorten the length of the second stage and

may reduce the need for operative delivery.


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Third stage

Increased incidence of

Postpartum hemorrhage and

Trauma of the genital tract


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MODE OF DELIVERY

Long anterior rotation of the occiput - SVD or

AVD.

Short posterior rotation - SVD or AVD and

perineal injuries

Non- rotation or short anterior rotation SVD.

Uncared - prolonged and obstructed labour.

Trauma to the genital tract


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MODE OF DELIVERY

Moulding - compression of the OF diameter with

elongation of the vault. Frontal bones

displacement beneath the parietal bones -tentorial tear.

MODE OF DELIVERY


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MODE OF DELIVERY

PrognosisMaternal morbidity (4 out of 5 cases no

trouble),

Incidental to prolonged labour and operative

delivery.

Increased perinatal morbidity and mortality -

asphyxia or trauma during vaginal operative

delivery.

MANAGEMENT OF


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MANAGEMENT OF

LABOUR

Principle in the management of the OPP are

1)Early diagnosis,

2) Strict vigilance with watchful expectancy

3) Judicious and timely interference, if necessary.


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Diagnosis and evaluation:

Fetal back on the flank - F.H.S not easily

located,

Early ROM should arouse suspicion.

Internal examination is confirmatory.

Overall assessment of the client and

The pelvic assessment is mandatory.


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Early Caesarean Section

OPP is not an indication of caesarean section.

CS for Pelvic inadequacy or its unfavorable

configuration,

Obstetric complications - pre-eclampsia, post

caesarean pregnancy, big baby usually needcaesarean section.

First stage


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g

Allow for normal labour in uncomplicated cases.

The following are the special instructions:

Anticipating prolonged labour- IV RL.

Judge progress of labour

Observe for a triad - Weak pain, persistence of

deflexion and non-rotation of the occiput

Indication of caesarean section

J d P f L b


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Judge Progress of Labour

(a) Progressive descent of the head

(b) Rotation of the back and the anterior shoulder

towards the midline

(c) Increasing flexion of the head

(d) Position of the sagittal suture on vaginalexamination and

(e) Cervical dilatation.

Weak pain persistence of deflexion and non


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Weak pain, persistence of deflexion and non-

rotation of the occiput are the triad

coexistent - oxytocin infusion for augmentation

of labour.

Indication of caesarean section

(a) Arrest of labour (failure of rotation)

(b) Incoordinated uterine action

(c) Fetal distress.

Second Stage


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Second Stage

In majority anterior rotation of the occiput is

completed and

The delivery is either spontaneous or

By low forceps or ventouse.

Second stage:In minority


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g y

(Unrotated & Malrotated)

Good fetal and maternal conditions - a watchful

expectancy.

In occipito-sacral position, spontaneous delivery

as face- to pubis may occur. In such cases,

Proper conduction of delivery and

Liberal episiotomy- to prevent complete

perineal tear.

Third Stage


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Third Stage

Prolongation of labour - Tendency of PPH

Prophylactic IV ergometrine 0.25 mg - delivery

of anterior shoulder.

Meticulous inspection of the cervix and lower

genital tract to detect any injury.

Arrested Occipito-posterior


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Arrested Occipito-posterior

PositionGood uterine contractions for about 1/2-1 hour +

full dilatation of the cervix = if no progress -

interference is indicated.

Once more to be assessed - abdominal and

vaginal before suitable method of interference.

Types of arrested OPP transverse, oblique,

sacral


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Per abdomen: Assess:

(1) Size of the baby

(2) Engagement of the head

(3) Amount of liquor

(4) F.H.S.

Vaginal examination: Note


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Vaginal examination: Note

(1)Station of the head

(2) Position of the sagittal suture and the occiput

(3) Degree of deflexion of the head

(4) Degree of moulding and caput formation

(5) Assessment of the pelvis at and below the levelof obstruction.

ARREST IN OCCIPITO-


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TRNSVERSE OR OBLIQUE O. P.

POSITION

Ventouse (Vacuum extraction)

Alternative methods:

Manual rotation followed by forceps

extraction.

Forceps rotation and extractionCaesarean section

Craniotomy

OCCIPITO-SACRAL


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ARRESTHead engaged

Occiput descends below the ischial spines,

Forceps application in unrotated head followed

by extraction as face-to-pubis - effective

procedure.

Liberal mediolateral episiotomy.

If occiput remains at or above the level of ischial

spines - caesarean section.

DEEP TRANSVERSE


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DEEP TRANSVERSE

ARREST (DTA)

The head is deep into the cavity

Sagittal suture - transverse bispinous diameter

No progress in descent of the head even after 1/2-

1 hour following full dilation of the cervix.

A t i i it t iti d lt


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Arrest in occipito-transverse position - end result

of incomplete anterior rotation (1/8

th

of circle) ofoblique occipito-posterior position.

or it may be due to

Non-rotation of the commonly primary occipito-

transverse position of normal mechanism of

labour.

C f DTA


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Causes of DTA

(a) Faulty pelvic architecture

(b) Deflexion of the head

(c) Weak uterine contraction

(d) Laxity of the pelvic floor muscles.


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Diagnosis of DTA

(a) The head is engaged

(b) The sagittal suture lies in the transverse

bispinous diameter

(c) Anterior fontanelle is palpable

(d) Faulty pelvic architecture


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Management

The fetal condition and pelvic assessment -

guide as to the line of management

Vaginal delivery is found safe

(1) Ventouse- ideal

(2) Manual rotation and application of forceps


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Management

(3) Forceps rotation and delivery - Kielland / expert

(4) Vaginal delivery is not safe - with big baby and

or inadequate pelvis - Caesarean Section

(5) Craniotomy in dead baby.


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MANUAL ROTATIONWhole hand method or With half hand method

Patient - in lithotomy position and GA

Strict aseptic technique

Catheterize the bladder

Vaginal examination and detect the direction of

occiput if caput seek help of unfolded pinna

MANUAL ROTATION -


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Whole hand method

Step- I: Gripping of the head

Step-II: Rotation of the head

Step-III: Application of the forceps

S I G i i f h h d


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R.O.P. or R.O.T. - Left hand and

L.O.P. or L.O.T. - Right hand

Separate the labia by two fingers

Introduce the corresponding hand into the vagina

in a cone shaped manner.




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Step : G pp g o t e ead

Occipito-transverse

position - the four 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.



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p pp g

In oblique posterior

position - the four fingers

of partially supinated hand

are placed over the occiput

and the thumb is placed

over the sinciput.



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Step II: Rotation of the headSlight dis-impaction

needed for good grip.

By a movement of

pronation of the hand,

rotate the head to bring

the occiput anterior

along the shortest

route.



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Step II: Rotation of the head

Simultaneously, the back of the fetus is rotated

by the external hand from the flank to the

midline - essential prerequisite.

A little over rotation is desirable anticipating

slight recurrence of malposition before the

application of forceps.

Step-III: Application of the


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p pp

forcepsIf right hand is placed on the left side of the

pelvis introduce left blade.

In left hand use - place right side of the pelvis.

While introducing the blades, - assistant fixes the

head by suprapubic pressure - first pelvic grip.

As it is a mid forceps application, axis traction

device should be used.


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Difficulties and dangers


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g

1) Failure to grip the head

2) Failure to dislodge the head from the impacted

position

3) Inadequate anesthesia

4) Wrong case selection.

Dangers- accidental slipping of the head above the

pelvic brim and prolapsed of the cord.

HALF HAND METHOD


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HALF HAND METHOD

Four fingers are only introduced in to the vagina.

Advantages

i) Less space is required and

ii) Less chance to displacement of the head

Steps


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Steps

The rotation is done only by using the right hand.

With four fingers tangential pressure is applied

on the head at the level of diameter of

engagement.

Pressure is applied on the side and the parietal

eminence of the head.

Steps


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In R.O.P. or R.O.T. position the fingers areplaced anterior to the head and the pressure is

applied by the ulnar border of the hand.

In L.O.P. or L.O.T. position, the fingers are

placed posteriorly and the pressure is applied

intermittently till the occiput is placed behind the

symphysis pubis.

Complications


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p

PROM in early labour.

Cord presentation and prolapse

Prolonged & obstructed labour

Maternal, neonatal trauma rupture of uterus, PPH,

Puerperal sepsis & Cerebral hemorrhage

Increased incidence of perinatal mortality.

Increased incidence of instrumental and operative

delivery.


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Possible Nursing Diagnosis


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Possible Nursing Diagnosis

Acute pain related toprogress of labor.

Anxiety RT slow

progress of labour

Alteration in fetal

tissue perfusion

related to maternal

position, epidural,oxytocin, rupture of

membranes

Potential for infection

related to rupture of

membranes

Bibli h


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Bibliography

- Fraser and Cooper. Myles textbook of

midwives.14th edition.churchill livingstone

publication.philadelphia2007. page no 551-557- Dutta D.C. Text book of obstetrics.6th edition.

New central book publication. kolkata 2006.

page no 365-374


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Malposition OPP.pptx

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