ABNORMAL LIE & PRESENTATIONS

1. ABNORMAL LIE & PRESENTATIONS Presenter: Sabina Kangakan

2. Abnormal Fetal Lie • In transverse or oblique lie, the long axis of the fetus is perpendicular, or at an angle, to the maternal longitudinal axis • Abnormalities in axial lie occur in approx 0.33% of all deliveries but may occur 6 times more frequently in premature labors • Causative factors include grand multiparity, prematurity, pelvic contraction, and abnormal placental implantation • When the diagnosis is made in the 3rd trimester prior to labor, external cephalic version enables a number of these patients to undergo vaginal delivery • Abnormal lies have a 20 times greater incidence of cord prolapse than do vertex presentations • Thus prompt cesarean delivery is mandatory with onset of labor or when the membranes rupture

3. Malpresentations Breech presentation • It complicates 3-4% of all pregnancies • Occurs when the fetal pelvis or lower extremities engage the maternal pelvic inlet • Three types of breech are distinguished according to fetal attitude; • Frank breech, the hips are flexed with extended knees bilaterally • Complete breech, both hips and knees are flexed • Footling breech, 1 (single footling) or both (double footling) legs are extended below the level of the buttocks

4. causes • Before 28wks, the fetus is small enough in relation to intrauterine vol to rotate from cephalic to breech and back again with ease • As gestation age & fetal weight increases, the relative decrease in uterine vol makes such changes difficult • In most cases, the fetus spontaneously assumes the cephalic presentation • Breech presentation occurs when spontaneous version to cephalic presentation is prevented as term approaches or if labor & delivery occurs prematurely • Some causes include;

5. cont • Oligohydramnios • Hydramnios • Uterine anomalies such as bicornuate or septate uterus • Pelvic tumors obstructing the birth canal • Abnormal placentation • Advanced multiparity • Contracted maternal pelvis • Multiple gestations • Congenital malformations

6. Diagnosis • Palpation • Performance of Leopold’s maneuvers & ballotment of the uterus may confirm breech presentation • Pelvic examination • During VE, the round, firm, smooth head in the cephalic presentation can easily be distinguished from the soft, irregular breech presentation if the presenting part is palpable • Radiographic studies • Ultrasound scanning • This will document presentation, attitude, & size, multiple gestation, location of the placenta & amniotic fluid vol

7. Management • Antepartum • Following confirmation of breech presentation, the mother must be closely followed to evaluate for spontaneous version • If breech persist beyond 36wks, external cephalic version should be considered • In women considering vaginal breech delivery, radiographic pelvimetry should be performed

8. During Labor • Examination • Patients with singleton breech presentations are admitted to the hospital at the onset of labor or when spontaneous rupture of membranes occurs • Repeat ultrasound to confirm type of breech & ascertain head flexion • A thorough history and examination is done to evaluate status of mother & fetus • Continuous electronic fetal heart rate monitoring is essential • Oxytocin use; • Use in the management of breech labor is controversial • Although some obstetrician condemn its use, others use it with benefit & without complications • Generally, oxytocin should be administered only if uterine contractions are insufficient to sustain normal progress in labor

9. Delivery • Cesarean delivery • The type of incision chosen is extremely important and depends on gestational age • Criteria for CS • Estimated fetal weight of 3500g or more, or less than 1500g • Footling breech • Contracted or borderline maternal pelvic measurements • Deflexed or hyperflexed fetal head • PROM • Unengaged presenting part • Mother with poor obstetric history • Premature fetus (25-34wks) • Fetus with variable heart decelerations

10. Vaginal Delivery • Obstetrician who contemplate a vaginal delivery should be experienced in the maneuver • They should be assisted by 3 physicians; an experienced obstetrician, a pediatrician & an anesthesiologist • Delivery of the buttocks • In most circumstances, full dilatation & descent of the breech will have occurred naturally • When the buttocks become visible & begins to distend the perineum, preparations for the delivery are made • The buttocks will lie in the AP diameter • Once the ant buttock is delivered & the anus is seen over the fourchette, an episiotomy can be cut

11. Delivery of the legs & lower body • If the legs are flexed, they will deliver spontaneously • If extended, they may need to be delivered using Pinard’s maneuver • This entails using a finger to flex the leg at the knee & then extend at the hip, first anterioly then posterioly • With contractions & maternal effort, the lower body will be delivered

12. Delivery of the shoulders • The baby will be lying with the shoulders in the transverse diameter of the pelvic mid-cavity • As the ant shoulder rotates into the ant-post diameter, the spine or scapula will become visible • At this point, a finger gently placed above the shoulder will help to deliver the arm • As the post arm/shoulder reaches the pelvic floor , it too will rotate anteriorly • Once the spine becomes visible, delivery of the second arm will follow

13. Delivery of The Head • The head is delivered using the Mauriceau-Smellie-Veit maneuver • The baby lies on the obstetricians arm with downward traction being levelled on the head via a finger in the mouth & one on each maxilla • Delivery occurs with first downward & upward movement • If this maneuver proves difficult, forceps need to be applied

14. Complications of Breech Delivery • Birth anoxia • Birth injury • Tears in the tentorium cerebellum • Cephalohematoma • Disruption of the spinal cord • Brachial palsy • Fracture of the long bones

15. Version • This is a procedure used to turn the fetal presenting part from breech to cephalic presentation or from cephalic to breech • Cephalic version is performed by manipulating the fetus through the abdominal wall (external cephalic version) • Podalic version is performed by means of internal maneuvers (internal podalic version)

16. External Cephalic Version • Used in the mgt of singleton breech presentation or in a nonvertex 2nd twin • It is safe for both mother & fetus • The goal is to increase the proportion of vertex presentations near term • It is performed in patients who have completed 36wks of gestation • Indications ; • Patients with unengaged singleton breech presentation of at least 36wks • The procedure is more successful in multigravidas & those with a transverse or oblique lie • Use of fetal heart rate monitoring & real-time ultrasonography are essential to document fetal wellbeing during the procedure

17. Cont • Contraindications • Engagement of the presenting part in the pelvis • Marked oligohydramnios • Placenta previa • Uterine anomalies • Presence of nuchal cord • Multiple gestation • PROM • Previous uterine surgery

18. Cont • Complications ;are rare, occurring in 1-2% of all cephalic version • These include; • Placental abruption • Uterine rupture • Rupture of membranes with resultant cord prolapse • Preterm labor • Fetal distress • Fetomarternal hemorrhage • Fetal demise

19. Internal Podalic Version • Now rarely used because of the high fetal & maternal morbidity & mortality associated with the procedure • Occasionally performed as a life-saving procedure or incases of a non-cephalic 2nd twin • Indications • It is the only alternative to cs for rapid delivery of the 2nd twin in a non-cephalic presentation if external cephalic version fails • Thus when cs is not available, it’s required in maternal hemorrhage, fetal distress, prolapsed cord

20. Cont • Contraindications • PROM • Oligohydramnios • Partially dilated cervix • Complications • Traumatic intracerebral hemorrhage • Birth asphyxia • Long bone fractures • Dislocations • Epiphyseal separations

21. Face Presentation • Occurs in approx 0.2% of all deliveries • In face presentation, the fetal head is fully deflexed from the longitudinal axis • Risk factors include; • Grand multiparity, advanced maternal age, pelvic masses, pelvic contraction, multiple gestation, polyhydramnios, prematurity • Diagnosis is most often accomplished by VE by palpating the nose, mouth, & the eyes • Due to complete extension of the fetal head, the presenting diameter is submento-bregmatic(9.5cm) • Progress in labor is slow • In mento-anterior position, vaginal delivery is possible

22. Brow Presentation • It can be considered a midway position between vertex & face • During the normal course of labor, conversion to face or vertex presentation generally occurs • Occurs in approx 0.06% of deliveries • Risk include; pelvic contraction, prematurity, and grand multiparity • Diagnosis is made by VE by palpating the ant fontanelle, supra-orbital ridges & nose • Management is expectant, as spontaneous conversion to vertex presentation occurs in more than 1/3 of all brow presentations • Oxytocin is not recommended, as arrest patterns & uterine inertia are common sequelae • When conversion fails to occur, CS should be done

23. Compound Presentations • This comprises a prolapse of a fetal extremity alongside the presenting part • Prolapse of the hand in cephalic presentation is most common • Compound presentations are uncommon, occurring in 1 in 1000 pregnancies • Because of poor application of the presenting part of the cervix found in cmp presentations, umbilical cord prolapse is common • Causes include prematurity, CPD, multiple gestation, grand multiparity, hydramnios • Diagnosis is made by palpation of a fetal extremity adjacent to the presenting part on VE during labor

24. Cont • Compound presentation may be suspected if poor progress in labor is noted • If diagnosis is suspected, ultrasound can be used to locate the position of the extremities • Management • Depends on the gestational age & type of presentation • Viability of the fetus should be documented prior to delivery as 50% of cmp presentations are associated with prematurity • If the fetus is considered non-viable, labor should be permitted & vaginal delivery anticipated

25. Cont • Labor can be allowed & vaginal delivery anticipated in viable cephalic presentations with a prolapsed hand • Umbilical cord prolapse is a risk in all cases of cmp presentations & continuous fetal heart rate monitoring should be performed • Umbilical cord complication should be managed by immediate cesarean delivery

26. ShoulderPresentation • Frequently reported as occurring in 1:300 deliveries • Occurs as the result of a transverse or oblique lie of the fetus & the causes of this abnormality include placenta praevia, pelvic tumor & uterine abnormality • Occasionally, a woman, usually of high parity present in labor with a shoulder presentation • Delay in making diagnosis risks cord prolapse or uterine rupture • Delivery should be by cesarean section

27. THE END!!!!!!!!!!!!!!!