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MALPRESENTATION

MALPRESENTATION. &MALPOSITION. LECTURE OVERVIEW. Abnormal lie, malpresentation and malposition Malpresentation and its management breech face brow shoulder compound. DEFINITIONS. Abnormal lie where the long axis of the fetus is not lying along the long axis of the mother

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MALPRESENTATION

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  1. MALPRESENTATION &MALPOSITION

  2. LECTURE OVERVIEW • Abnormal lie, malpresentation and malposition • Malpresentation and its management • breech • face • brow • shoulder • compound

  3. DEFINITIONS • Abnormal lie • where the long axis of the fetus is not lying along the long axis of the mother • LONGITUDINAL (MAY BE EITHER CEPHALIC OR BREECH) • TRANSVERSE • OBLIQUE • UNSTABLE

  4. DEFINITIONS • Malpresentation • where the fetus is lying longitudinally, but presents in any manner other than vertex • BREECH • FACE • BROW • SHOULDER • COMPOUND • CORD

  5. DEFINITIONS • Malposition • where the fetus is lying longitudinally and the vertex is presenting, but it is not in the OA position • OT (LOT, ROT) • OP

  6. DEFINITIONS • Malpresentation • where the fetus is lying longitudinally, but presents in any manner other than vertex • BREECH • FACE • BROW • SHOULDER • COMPOUND • CORD

  7. MANAGEMENT OF BREECH PRESENTATION AT TERM Management options (1) external cephalic version (2) elective caesarean section (3) trial of vaginal delivery

  8. EXTERNAL CEPHALIC VERSION • CONTRAINDICTAIONS: • 3rd trimester bleeding • uterine anomalies • ROM, oligohydramnios • need for CS for other reasons (placenta praevia, contracted pelvis, hyperextended head) • indicated vaginal delivery (fetal death, anomaly best delivered as breech)

  9. EXTERNAL CEPHALIC VERSION • SUCCESS • 60-70% • TECHNIQUE • after 36W • CTG prior • attempt to perform forward somersault • tocolytic • CTG after (8% bradycardia; 5% fetomaternal haemorrhage) • anti D (if Rh negative)

  10. ELECTIVE CAESAREAN SECTION • EFW <2500g; >3500g • preterm breech • hyperextended fetal head • palcenta praevia • concerns re. fetal well being, including oligohydramnios • footling breech • 10% risk of cord prolapse • ?complete breech • 5% risk of cord prolapse (c.f. 1% with frank breech) • ?all PG breech

  11. CRITERIA FOR VAGINAL DELIVERY • Frank or complete breech • EFW 2500-3500g • gestational age >36 weeks • fetal head must be flexed • maternal pelvis must be adequate • judged clinically or by pelvimetry • no other maternal or fetal indiaction for CS • experienced obstetrician, anaesthetist and paediatrician present at delivery

  12. FACE PRESENTATION • Incidence: 0.2% • Mechanics of presentation: • Characterized by extreme extension of the fetal head so the face (rather than the skull) presents to the birth canal • Aetiology • any factor that favours extension such as fetal goitre, anencephaly • high maternal parity • At diagnosis: • 60% mentoanterior • 15% mentotransverse • 25% mentoposterior

  13. BROW PRESENTATION • Incidence: 1:1400 • Mechanics of presentation: • head is extended such that attitude is halfway between flexion (vertex) and hyperextension (face) • usually transitional- when the head is in the process of converting from a vertex to a face or vice versa • presenting part is between the facial orbits and anterior fontanelle • supraoccipitomental diameter is presenting 13.5cm; cf 9.5cm for suboccipitobregmatic (vertex) or submentobregmatic (face)

  14. AETIOLOGY • Fetal • prematurity, multiple • Liquor • polyhydramnios • Uterine • anomaly • Placenta • praevia • Pelvis • contraction, tumour • Parity • high maternal parity (80% of cases occur in women who are para3 or more)

  15. MANGEMENT • Exclude cord prolapse • occurs in up to 20% of cases • Otherwise expectant • mostly doesn’t interfere with normal delivery • vertex-foot: try to gently reposition the lower extremity • if arm prolapses in vertex-hand, wait and see if it moves as head descends; if it converts to shoulder presentation, deliver by CS

  16. SUMMARY • Abnormal lie, malpresentation, malposition • Incidence, mechanics, aetiology, diagnosis, management of • BREECH PRESENTATION • FACE PRESENTATION • BROW PRESENTATION • SHOULDER PRESENTATION • COMPOUND PRESENTATION

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