DR. IQBAL TURKISTANI

ASST. PROF. & CONSULTANT

Malpositions & Malpresentations carry an increased risk for both mother and fetus

Maternal risks:- Prolonged labour infection- Obstructed labour- General anaesthesia at short notice, when the mother is in poor condition- Difficult vaginal delivery or C.S.

trauma leading to haemorrhage- Damage to pelvic veins resulting

to venous thrombosis and fatal pulmonary embolism in the puerperium

- In developing countries obstructed labour may cause tissue necrosis vesico- vaginal and recto-vaginal fistula.

Perinatal mortality and morbidity: due to fetal malformation intrauterine death extreme prematurity cord prolapse +

malpresentation Potent abnormal uterine action causes and prolonged or obstructed of fetal labour hypoxia Fetus at risk of infection (: prolonged ROM)

and also meconium aspiration

Significant proportion of ruptured uterus still result into maternal deaths from unwise management of malpresentation or malposition

Therefore, for optimal result/safe labour and delivery: Early diagnosis by skilled assessment Plan delivery by experienced staff Working in proper surrounding Experienced anaesthesia must be available for

these most difficult cases Close supervision and full use of available

monitoring methods ..if vaginal delivery is planned

Facilities to perform immediate operative delivery or caesarean section are mandatory

Review of progress and necessary intervention by senior staff members is the rule

LIE, PRESENTATION POSITION

LIE:The relationship of the long axis of the foetus to

that of the mother

A. LONGITUDINALB. TRANSVERESE & OBLIQUE (Shoulder

present.)

CAUSES: High multip. Hydramnious Pre-term lab Obstructing tum. Or Multiple Preg. Plac. previa Ut. Anomaly Severe pelvic

contraction

MANAGEMENT: Antenatal Intrapartum

PRESENTATIONThat part of the foetus that is

foremost in the birth canal, or closes to it.

A. Cephalic

B. Breech

C. Shoulder

D. Compound

CEPHALIC PRESENTATION1. Vertex 96% (suboccipito – bregmatic= 9.5 cm)2. SINCIPUT (occipito – frontal = 11.5 cm) OP3. BROW 1:1050 (mento- vertical = 13 CM)

CAUSES:- Chance- Neck swelling e.g. goiter or cystic hygroma- Spasm of sternomastoid muscle

DX:- Ant. fontanell & supraorbital ridge (pv)- XR (lat)

4. FACE 0.3% (Submentobregmatic = 9.5 cm) DX:

- Palpation of supraorbital ridges & aveolar margins (confusion with breech)

BREECH PRESENTATION1. Frank Breech 65%2. Complete Breech 25%3. Footling Breech 10%

CAUSES:- Extended legs preventing spont. version- Those conditions preventing fetal presenting

parts entering pelvic cavity.- Uterine anomaly- Chance

ASSOCIATED FACTORS:- Fetal anomaly- Preterm delivery- Multiple pregnancy

ANTENATAL MANAGEMENT

ECV: Hazards:

Preterm Labour

Abruption

Cord accident

Ut. Rupture (prev. C.S.)

CONTRAINDICATIONS:a. Absolute:

Multiple preg. APH Rupt. Membrane Oligohydramnios Significant fetal anomaly C.S. indicated for other reasons

b. Relative: Prev. C.S IUGR H.T Rh. Isoimmunization Grand multip Ant. Placenta Obesity

MANAGEMENT OF DELIVERY

Pre-delivery assessment: Pelvic dimension (clinical & XR

~37wks)

USS of BPD, fetal mass, attitude & flex/ ext. of head)

Major fetal anomalies to be excluded

VAGINAL DELIVERY:

Term (fetal wt. 2.5-3.5 kg) Frank breech Normal pelvis No other complic. of preg. (e.g. PET) Normal FHR & BPP Epidural

C.S.

FREQUENCY:

VERTEX 96%

BREECH 3.5%

FACE 0.3%

SHOULDER 0.2%

POSITION:

Refers to the relation of an arbitrarily chosen portion of the presenting part of the fetus, to the right or left side of the mother :

VERTEX …... OCCIPUT-- LO., RO

FACE ……CHIN (mentum)-- LM., RM

BREECH ….. SACRUM -- LS., RS

SHOULDER … ACROMION OR SCAPULA

OP POSITION:

If baby’s head is partially extended it does not fit into the lower ut. pole well with the following consequences in labour:

1. Early ROM & Cx. not well opposed to head.2. Sinciput reaches pelvic floor first & therefore

rotates to front i.e. occiput is post.3. Large occipito frontal diam. of head presents

(10 cm) more difficult to pass.4. 1st stage of labour is prolonged.5. Movements of forces pushes head

posteriorly causing backache & inducing bearing down efforts before full dilatation

6. 2nd stage of labour may be prolonged.

THE OCCIPUT may rotate anteriorly & deliver relatively easily (75%)

Or Persists posteriorly (POP) (5%)

spontaneous delivery if pelvis is capacious (face to pubis)

or requires assisted delivery

Or Begins to rotate ant. but undergoes deep transverse arrest at level of ischial spines instrumental

delivery may be required (20%)

PREDISPOSING FACTORS:

- Slight reduction in pelvic inlet

- Large baby

DIAGNOSIS:

- Antenatally

- During labour (both fontanells easily palpable)

MANAGEMENT:

♣ Epidural/ adeq. analgesia

♣ Prevent maternal ketosis & dehydration

♣ Monitor fetal well being

♣ R/O relative CPD