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MALPRESENTATION,
ABNORMAL LIE
1
PRESENTATION
97% : cephalic
3%: breech
0.5% : transverse, oblique,face, brow
2
FACE PRESENTATION
Head is hyperextended: occiput
touches fetal back
Mento anterior or posterior
Labour progress stalled with MP
INCIDENCE:0.17%
3
DIAGNOSIS
+V/E: mouth, nose,malar bones and
orbital ridges
ETIOLOGY:
5
Mechanism of labour
Only in mentoanterior
Same
Descent, with chin leading-internal
rotation- chin lies under the
symphysis pubis
With mento posterior the short neck
unable to span the anterior surface
of sacrum -12cm
6
Mechanism of lab
Chin mouth appears at vulva- birth is
by flexion
External rotation with chin
Cls frequent because of contracted
pelvis
External continous monitoring –yes
Mento posterior—c/s
7
BROW PRESENTATION
ANTRIOR FONTANELLE AND ORBITAL
RIDGES
MIDWAY B/W FLEXION/ EXTENSION
NO MECHANISM OF LABOUR-
MENTOVERTICAL
UNSTABLE PRESENTATION- CAN
CHANGE
8
ETIOLOGY: same as in face
Prognosis: small baby ok; term baby
c/s
9
TRANSVERSE LIE
Shoulder presentation: dorso
anterior; or posterior
Incidence:0.3%
Preterm
Placenta previa, uterine anomaly
excessive liquor,contracted pelvis
10
Diagnosis and course
Abdominal and V/E
MX =C/S
11
PERSISTENT OCCIPUT
POSTERIOR POSITION
MOST: malrotation of ociput anterior
position
87% of occiput anterior: rotate
anterior
LABOUR : monitor as normal
12
OPTIONS
Await spont. Delivery
Forceps delivery with occiput
posterior
Forceps rotation to anterior B/4
delivery
Manual rotation to anterior B/4
spontaneous or forceps delivery
cls
13
Outcome
14
Persistent occiput transverse
position
Transitory position
Options:
Oxytocin augmentation
Manual rotation
Forcep rotation
cls
15
BREECH PRESENTATION
Buttocks present
Incidence: 3-4% at term delivery
ETIOLOGY:
16
COMPLICATIONS
Perinatal morbidity and mortality
Low birth weight: preterm; IUGR
Prolapsed cord
Placenta preavia
Fetal, neonatal, infant mortality
Uterine anomaly and tumors
Multiple fetuses
Operative interventions
17
DIAGNOSIS
ABDOMINAL / V/E
Frank
Flexed
Footling breech
IMAGING:
USS
X-ray : controversial
18
Prognosis
Maternal morbidity/mortality
Breech prognosis : irrespective of
mode of delivery
19
Pronosis
Maternal : increased interventions
Fetus infant morbidity/mortality:
21
Factors to consider
X –ray pelvimentry : no consensus
Hperextension of fetal head:5%;
22
MODE OF DELIVERY
DISCRETION: PRETERM/TERM
PRETERM: birth weight
Ceaserean section
Large baby
Contracted pelvis
Hyperextended head
Coexistent problems
Footling breech
23
Others
IUGR
BOH
24
LABOUR AND DELIVERY
Descent : bis trochanteric diameter
with ant hip leading
Internal rotation,birth is by lateral
flexion
External rotation=back anterior as
shoulders enter inlet
Shoulders : internal rotation at outlet
Head : rotate with occiput under
symphsis 25
METHODS OF VAGINA
DELIVERY
SPONTANEOUS
ABD
BREECH EXTRACTION
26
MANAGEMENT OF LABOUR
IV ACCESS
CLOSE MONITORING
UNBOOKED : NOT INDICATION FOR
C/S
LABOUR : ULTIMATE ARBITER
SKILLED MEDICAL PERSONNEL
27
DELIVERY
PROGNOSIS BEST IF SPONTANEOUS
DEL UP TO UMBILICUS
MODE OF ABD
28
MANUEVERS
MSV
PRAGUE MANUEVER:
29
Entrapment of after coming
head
Small preterm baby
Manual manipulation of cervix
Duhrssen incision
Cephalic replacement then c/s
30
Analgesia and anaesthesia
Epidural : prolongs 2nd stage: weigh
agaist risk
31
Morbidity/mortality
Maternal and fetal
32
VERSION
ALTERATION OF PRESENTATION
ARTIFICIALLY
One pole for another in logitudinal
Transverse to longitudinal
EXTERNAL/INTERNAL VERSION
33
ECV
Safe
Cost effective
Successful
34
ECV
35-37WKS
ECV succeeds in 65% of cases
If version succeeds,almost all fetuses
stay cephalic and vice-versa
Ultimately and despite version
attempts,37% of women identified to
have a late pregnancy breech will
requireC/S
35
ECV SUCCESS
Presenting part has not descended
into pelvis
Normal amount of liquor
Fetal back is not posterior
Woman is not obese
36
Technique
In labour ward close to theatre
USS
Continous external monitoring
Forward role if fails back flip
Tocolysis
37
Interesting concept
Moxibuston; burning herbs to
stimulate acupuncture point
BL67==promotes spontaneous
breech version possibly by increasing
fetal activity=proven in studies
38
Complications of ECV
ABRUPTIO
UTERINE RUPTURE
AFE
FM haemorrhage
PRETERM LABOUR
FETAL DISTRESS,DEMISE
39
INTERNAL PUDALIC
VERSION
DISTRESS IN TWIN 2
40
CONCLUSION
HIGH RISK OBSTETRICS
41