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    O&G - Abnormal Presentation

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    AnironOrion
    This presentation was oversee by Obstetrics Specialist of HRPZII Hospital, Kota Bharu, Kelantan, Malaysia. Reference and pictures are taken from Obstetrics by Ten Teachers, Obstetrics Illustrated, Oxford Handbook of Obstetrics & Gynaecology and several credible websites. Feel free to use them as reference. Credit must be given to the author and reference on which the material was made from.

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    O&G - Abnormal Presentation

    Uploaded by

    AnironOrion
    917 views32 pages
    This presentation was oversee by Obstetrics Specialist of HRPZII Hospital, Kota Bharu, Kelantan, Malaysia. Reference and pictures are taken from Obstetrics by Ten Teachers, Obstetrics Illustrated, Oxford Handbook of Obstetrics & Gynaecology and several credible websites. Feel free to use them as reference. Credit must be given to the author and reference on which the material was made from.

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    This presentation was oversee by Obstetrics Specialist of HRPZII Hospital, Kota Bharu, Kelantan, Malaysia. Reference and pictures are taken from Obstetrics by Ten Teachers, Obstetrics Illustrated, Oxford Handbook of Obstetrics & Gynaecology and several credible websites. Feel free to use them as reference. Credit must be given to the author and reference on which the material was made from.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    917 views32 pages

    O&G - Abnormal Presentation

    Uploaded by

    AnironOrion
    This presentation was oversee by Obstetrics Specialist of HRPZII Hospital, Kota Bharu, Kelantan, Malaysia. Reference and pictures are taken from Obstetrics by Ten Teachers, Obstetrics Illustrated, Oxford Handbook of Obstetrics & Gynaecology and several credible websites. Feel free to use them as reference. Credit must be given to the author and reference on which the material was made from.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 32

    ABNORMAL

    PRESENTATION
    (a.k.a Malpresentation)
    MOHD HAFIS ZUL ARIF BIN AWANG
    MBBS 2010 – IMS – MSU
    Definition
    • Presentation = fetal part in the lower part of the
    uterus over the pelvic brim, that in close proximity to
    the internal os of the cervix.
     e.g. Cephalic (head), Breech (buttocks) & Shoulder
    • Presenting Part = the part of the presentation which
    lies immediately inside the internal os.
     Determined by vaginal examination in labour
     Vertex, Brow or Face
    • Malpresentation = any presentation other than a
    vertex lying in close proximity to the internal os of
    the cervix.
    • Vertex = the area of fetal skull bounded by the two
    parietal eminence and the anterior and posterior
    fontanelles.
     This is the presenting part of 95% normal term
    labour.
    Overview
    • Normal Presentation is CEPHALIC and WELL-
    FLEXED VERTEX
    Causes
    a) Idiopathic (most common) • Multiple preganancy
    b) Maternal • Intrauterine death
    • Multiparity Macrosomia
    • Pelvic tumors • Fetal abnormality (eg:
    hydrocephalus,
    • Congenital uterine
    anencephaly, cystic
    anomalies
    hygroma)
    • Contracted pelvis
    d) Placental
    c) Fetal
    • Placenta praevia
    • Prematurity
    • Polyhydromnios
    • Amniotic bands
    Types
    A. Cephalic: Face & Brow
    B. Breech (3-4%): Extended, Flexed & Footling
    C. Transverse
    D. Compound
    E. Shoulder
    A) Cephalic
    1. Normal Presentation: Vertex
    • Normal Attitude: Fetus is in full flexion
    • Every fetal joint is flexed
    • Smallest fetal head diameter:
    Suboccipitobregmatic (9.5cm)
    2) Abnormal Presentations: Extended Attitude
    a) General
    – Abnormal Attitude: Fetal head is extended
    – Results in largest head diameter: Occipitomental
    (11.5 cm)
    – Increases diameter 3 cm (24%) over flexed head
    – May results in Failure to Progress
    b) Face Presentation
    c) Brow Presentation
    d) Shoulder Presentation
    3. Abnormal Presentation: Asynclitism
    • Definition
    – Lateral flexion of head
    – Sagittal Suture not in midline of vaginal canal
    • Interpretation
    – Mild asynclitism is normal
    – Extreme asynclitism interferes with delivery
    » May result in failure to progress
    » Interferes with forceps application
    B) Breech
    • Definition = baby’s buttocks lie over maternal pelvis.
     Lie is longitudinal
     Head is found in the fundus
    • Breech delivery is the single most common abnormal
    presentation.
    • The incidence is highly dependent on the gestational age.
    More common in preterm.
    • Not important before 34-36 unless woman in labour.
    • At 20 weeks, about one in four pregnancies are breech
    presentation. By full term, the incidence is about 4%.
    • Types of Breech
     Flexed / Complete / Full breeches (15%): legs
    flexed at the knees so that both buttocks and feet
    are presenting.
     Extended / Frank breeches (70%): both legs
    extended with feet by head; presenting part is the
    buttocks.
     Footling / Incomplete breeches (15%): one leg
    flexed and one extended. Can be ‘single’ or ‘double’
    footling
    • Consequences
     Fetal: increased risk of hypoxia, trauma in labor.
     Maternal: delivered by CS
    • Diagnosis
     History: breech in early pregnancy and previous
    delivery, uterine fibroids and malformation
     Examination: longitudinal lie, head palpated at fundus,
    presenting part not hard, fetal heart best heard high up
    on uterus.
     Investigation: Confirmed with USG; should asses
    growth anomaly, neck hyperextension, liquor, EFW,
    placental site
    • Management of Breech
    a) External Cephalic Version (ECV)
     May be undertaken from 34th week gestation
     Containdication:
    i. Absolute – multiple pregnancy, APH, placenta
    previa, ROM, fetal abnormality.
    ii. Relative – previous CS, IUGR, Rh-isoimmunization
    b) Vaginal Breech Delivery
    • Favorable vs. Unfavorable for Vagina Delivery
     Previous delivery of normal-sized infant / Nulliparity,
    other indication for CS
     EFW: 2-3.8kg / EFW >3.8kg
     Extended breech / Footling breech, hyperextended
    neck
     Normal liquor / oligo- or polyhydromnios
     Maternal desire for vaginal delivery / CS
     Gestation > 33 weeks / Previous CS
     Grossly contracted pelvis
    OR
    1. Lateral flexion of trunk required to allow progress
    2. Deliver one leg at a time
    3. Deliver anterior shoulder blade and arm
    4. Grasped ankles and swung upwards  permits
    posterior arm freed.
    5. Body allowed to hang till head descends into
    pelvis and hair line shows.
    6. Head my be delivered using forceps OR
    7. The Mauriceau-Smellie-Viet manoeuvre: Traction
    by index, middle and ring finger to promote head
    flexion. Other hand support fetal back OR
    8. The Burns-Marshall method: feet are grasped with
    gentle traction arc over maternal abdomen 
    mouth freed  delivery completed by further
    swinging over maternal abdomen.
    N.B:
     Delivery of head as slow as possible to decrease damage to
    skull membrane by sudden compression and release
     Air passage should be cleared as quickly as possible by
    aspirating nose and mouth
    c) Breech Extraction
    • Obstetrician places hand inside the uterus and
    grasps the foot.
    • Baby delivered by traction of the foot
    • Procedure now restricted to delivery of second
    twin (lying transverse and membrane ruptured)
    • If membrane intact, ECV possible.
    d) Caesarean Section
    C) Transverse
    • Transverse lie occurs frequently in early pregnancy, when it is
    of no consequence. At 16 weeks gestation, about half of all
    pregnancies will be transverse lie. This number steadily falls
    as pregnancy advances and the incidence of transverse lie by
    the 28th week is well below 10%. It falls steadily thereafter.
    • If the fetus remains in a transverse lie, it cannot be delivered
    vaginally as the diameter of the fetal presenting part (the
    whole body, in this case) cannot descend through the birth
    canal.
    • Complication: ruptured uterus, prolapse umbilical cord.
     For these reasons, women found to have a transverse lie in
    labor will usually have a CESAREAN SECTION.
    • Exceptions to this indication for cesarean section:
     If labor is occurring during the middle trimester and fetus is
    not considered viable, it may be possible for this very small
    and fragile fetus to compress enough to squeeze through the
    pelvis. In this case, fetal survival would not be an issue.
     It may be possible to perform an external version,
     In the case of twins, it would be acceptable to allow labor,
    even though the second twin is in transverse lie, anticipating
    that after delivery of the first twin, you would reach in and
    perform an internal version, converting the transverse lie to
    cephalic or breech presentation prior to delivery.
    • Management:
     Evaluate the patient carefully with ultrasound to

    determine if there are any predisposing factors,


    such as a placenta previa or pelvic kidney that
    could modify your management of the patient.
     So long as a placenta previa is not present, many

    obstetricians will check the patient's cervix at


    frequent intervals to detect early cervical dilatation
    and the consequential increased risk of cord
    prolapse.
     Sometimes, these patients are delivered early by

    scheduled cesarean section to avoid that risk.


    D) Compound
    • Compound presentation means that a fetal hand is
    coming out with the fetal head. This is a problem
    because:
     The amount of baby that must come through the
    birth canal at one time is increased.
     There is increased risk of mechanical injury to the
    arm and shoulder, including fractures, nerve injuries
    and soft tissue injury.
    • A compound presentation may be resolvable if the
    fetus can be encouraged to withdraw the hand, for
    example.
    • If the fetus and arm are relatively small in
    comparison to the maternal pelvis, vaginal delivery
    may still be possible, but with some risk of injury to
    the arm.
    • If the fetus and arm are relatively large in
    comparison to the maternal pelvis, obstructed labor
    will occur and a cesarean will be needed.
    E) Shoulder
    • Shoulder presentation means that the fetal shoulder
    is trying to come out first. This is a more advanced
    form of transverse lie and is undeliverable vaginally.
    THANK YOU

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