(4 M) Diagnosis of Presentation, Position & Lie (2nd hour)

OBSTETRICS
Dr. Salvador | October 2015

2nd PART OF LECTURE: or hyperextension. So if it is in hyperextended

*RED: AUDIO position, definitely you can not deliver that. We call it
GREEN: OT STAR GAZING FETUS.
BLACK: SLIDE - *if and only if you are very sure of the position of the
head which is flexed, then you can opt in doing this
but not in primigravid. You can do this in
FREQUENCY OF VARIOUS PRESENTATION & POSITION
multipara/multigravida because the pelvic canal and
- 96% at or near term the vagina has been tested already. There is some
• 2/3= Left Occiput Position (LOP) sort of relaxation.
• 1/3= Right occiput Position (ROP) - Increase incidence of cord prolapse
- Upon internal examination: Poke your fingers in to
*at term, the fetus assumes cephalic presentation and once determine the breech position - if there is resistance
the fetal head descends down in the pelvis, 2/3s of them usually it’s the anus because sphincter is present and
descends in the LEFT OCCIPUT POSITION and only 1/3 will when you withdraw your finger usually there is a
be on the RIGHT OCCIPUT POSITION. meconium staining while mouth has no resistance.

*and, of course you do know that the fetus will assume its - And the ischial tuberosity is in line with that of the
characteristic posture or attitude at 32 weeks AOG. anus

- Even if the leg\feet is presenting, still you have to feel

- Almost always, baby is at the cephalic presentation
for the sacrum, where is it in relationship to maternal
outlet.
Reason: Piriform shape of uterus- 32 weeks AOG. The
podalic pole (breech and extremities of fetus) will fit at
FACE PRESENTATION = 0.3% where the head is
the upper part of the uterus better than the cephalic
hyperextended so much so that the occiput is in close
pole.
contact to the back of the baby
- PREDISPOSING FACTORS:
- In hydrocephalus, fetus present as breech because
 High parity due to lax abdominal cavity
head\cephalic pole is bigger than podalic pole.
 Contracted pelvis –especially the inlet
BREECH PRESENTATION= 3.5%  Anencephalic fetus
- FRANK BREECH= most common where in the thighs  Marked enlargement of neck
are flexed to the abdomen and the legs are as well  Nuchal Cord coils preventing the head to
extended to the thorax. And the number 1 flex
complication of breech is CORD PROLAPSE most
commonly seen in Kneeling breech or footling breech SHOULDER PRESENTATION= 0.4%
presentation - PREDISPOSING FACTORS:
- COMPLETE BREECH where in the thighs are flexed  High parity
towards the abdomen but the legs are flexed towards  Preterm fetus where it is still small
the thighs just like a Budha position  Placenta previa
- FOOTLING/ INCOMPLETE is called as such because the  Abnormal uterus like septal uterus
one that presents foremost in the birth canal is  Excessive amniotic fluid
actually either the legs or the foot or sometimes they  Contracted pelvis
call it the Kneeling breech is the knees are the ones
presenting into the birth canal. So in this case, you
expect an increased incidence of cord prolapse.
- KNEELING BREECH
- *you know, the problem with breech presentation so
the manner of delivery is always caesarean section is
mainly because of the aftercoming(??) head so you
don’t know if ever the aftercoming head is in flexion
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 DIAGNOSIS OF FETAL PRESENTATION & POSITION - Define which fetal
pole is present in
the fundus
1. ABDOMINAL PALPATION= LEOPOLD’S MANEUVER,
 Head=
AUSCULTATION done after doing LM first to locate
(cephalic),
the fetal back
hard, round,
2. VAGINAL EXAMINATION to determine the
movable
POSITION. Cervix must be open (3-4) to appreciate
 Breech=
the sagittal suture. BoW must also be ruptured.
(podalic) large, nodular body
3. IMAGING STUDIES= *not necessarily done, only in
cases of obese patients, presence of tumors like
ovarian cyst or myoma. Ultrasound, Computerized LEOPOLD’S MANEUVER 2: Where is the fetal back in relation
tomographic scan (CT), Magnetic Resonance to the maternal side?
Imaging studies(MRI) *We call this UMBILICAL GRIP kasi ang reference point is the
umbilicus
LEOPOLD’S MANEUVER: *use the PALMS of the hand
*if you want to determine the part of the fetus in the right
*done to determine the fetal position, presentation and lie maternal side, use your right palm and apply pressure on the
which means you have to appreciate the fetus, you have to LEFT maternal side of the abdomen towards your left palm
be able to feel the fetus if you perform it. which is on the right maternal abdominal side
*if you feel irregular nodules, you are dealing with fetal small
*And again, I love to ask this one, is Leopold’s Maneuver a parts. If it is the fetal back, it will be felt as a smooth, firm,
special procedure of pregnant patient? Do you need to ask hard mass.
for a consent before you do it? NOOO!! *REPORT as: LM2, FETAL BACK ON THE RIGHT MATERNAL
SIDE (example) or LM2, FETAL SMALL PARTS ON THE LEFT
*Leopold’s maneuver is part and parcel of your abdominal MATERNAL SIDE
examination. IAPePa. - Determines what part
of the fetus occupies
*WHEN is the best time to do a LM? You can not do it before the right &
28 weeks AOG at the most. They said you can do it at 26 wks left maternal side
AOG. Okay, in a LEAN patient. Payat. To be able to palpate  Fetal small
the baby. Because at 26 weeks, the fetus is still so small. So parts=
the BEST is still 28 weeks. numerous,
small, irregular
LEOPOLD’S MANEUVER I: What part of the fetus occupies the nodularities
fundus?  Fetal back=
*we call it FUNDIC GRIP because you are applying pressure in hard, resistant structure
the fundal area of the abdomen
*confine your examination in the fundic area, use tips/pads of LEOPOLD’S MANEUVER 3: How deep is the presenting part?
fingers of both hands - PAWLICK’S GRIP done by using the pads of your
*so we are dealing here with a baby in a longitudinal lie, thumb and the tips of your fingers. YOU DON’T
cephalic presentation and the reference point is the vertex PINCH the lower abdomen!! Grasp the presenting
*if BREECH, how is it felt? Soft and irregular and nodular kasi part by resting hand at the top of symphysis pubis
buttocksor you can go and say “PODALIC POLE OCCUPIES THE and try to tap it. If it is ballottable, it bounces back
FUNDUS” to your fingers if you tap it.
*if it is the head that is presenting there, it is felt as a hard *mention whether it is ballotable or not
ballotable mass. So report it with “CEPHALIC PRESENT ON *mind you, Ballottement is different from Engagement
THE FUNDUS” *ENGAGEMENT: the biparietal diameter passed through the
pelvic inlet while BALLOTTEMENT, if the head is engage of
course you can’t ballotte it
*FIXATION: the head is just down there but not necessarily
engaged. Just the same, it is not ballotable
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*STATION: reference point is the lower most part of the LM4, NONE (no head so no cephalic prominence. Do not
fetus that lies along the ischial spines which is the midplane report it as NOT APPRECIATED kasi it means na meron kaso
(OUTLET is the bituberous diameter) hindi lang ma-appreciate. SO NONE. )
*Report: LM3, CEPHALIC BALLOTTABLE or LM3, CEPHALIC
NON-BALLOTTABLE
 Determines the
presenting part
 Determine whether
presenting part is
ballotable or not
ballotable

LEOPOLD’S MANEUVER 4: Where is the Cephalic

Prominence? LEOPOLD’S MANEUVER-SHOULDER PRESENTATION
*What is the fetal attitude by feeling the fetal prominence LM1, NONE/ EMPTY
called PELVIC GRIP LM2, CEPHALIC ON THE RIGHT MATERNAL SIDE AND
*from the midpoint of the abdomen, simultaneously move BREEACH ON THE LEFT MATERNAL SIDE
the pads/balls of your fingers towards the symphysis pubis to LM3, NONE/EMPTY
determine the cephalic prominence. Where your hand is LM4, NONE
arrested first, that is the cephalic prominence.
*Basing from the picture, the RIGHT hand is arrested on the
RIGHT maternal side, on the BROW while the left hand goes
straight to the symphysis pubis. The attitude of the baby then
is in FLEXION. (The Brow felt is on the same side of the small
fetal parts, so pwedeng sabihin po na nakaflex ang baby.
Basing po sa description ng Attitude which is the relationship
of one fetal part to the other. Para po, example, if the
CEPHALIC PROMINENCE is on the same side as the fetal back,
then what you will feel there is the OCCIPUT kaya EXTENSION
po. )
*Attitude: is the relationship of LM2 to LM4
(SORRY, MAGULO AUDIO KO SA LM4 kaya di ko na nilagay
iba)
- Determines fetal
cephalic
prominence= AUSCULTATION
fetal attitude: - Reinforce results obtained by palpation
 Flexion - Fetal heart sounds are transmitted through the
 extension convex portion of the fetus that lies in intimate
contact with the uterine wall
 Vertex & breech presentation= FHT heard on the
fetal back
 Face presentation= fetal thorax
LEOPOLD’S MANEUVER- BREECH
*LM1, CEPHALIC OCCUPIES THE FUNDUS
- The region of the abdomen in which the fetal heart
LM2, FETAL BACK IS ON THE LEFT/RIGHT MATERNAL SIDE
sounds are heard most depends on the
LM3, BREECH BALLOTTABLE
presentation & the extent to which the fetal
presenting part has descended:
 Cephalic= midway between maternal umbilicus
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 & the ASIS
 Breech= slightly above the umbilicus
 OA position= short distance from the midline
 Transverse position= lateral
 Posterior varieties(fetus is same as the mother
who is lying down)= flanks
VAGINAL EXAMINATION - VERTEX
- OUTLINE the SAGITTAL SUTURE
- ANTERIOR FONTANEL = lozenge-shaped space at
the junction of sagittal & coronal sutures , bigger so
aka GREATER FONTANEL
- POSTERIOR FONTANEL = triangular area at the
intersection of sagittal &lambdoid suture
- LOCATING FOR THE SAGITTAL SUTURE
*feel for the sagittal suture and swipe your fingers to and
fro to look for the fontanel.
*in cases of CAPUT baby, it will be hard to locate the
fontanel
- DIFFERENTIATING THE FONTANELS
ASYNCLITISM
*Synclitism: term used when the sagittal suture lies parallel to
the transverse diameter of the maternal pelvis which means
in IE, the sagittal suture is straight or parallel to the pelvic
brim. If it goes anteriorly or posteriorly, we call it
ASYNCLITISM.
 MODERATE ASYNCLITISM = rule in normal labor in
order for the baby to be accommodated inside the birth
canal
Anterior Asynclitism is when the sagittal
suture goes posteriorly and it is the
anterior parietal boss?? that lies in
contact(below) with the symphysis pubis;
aka nihilist obliquity???
Posterior Asynclitism is when the sagittal
suture goes anteriorly and the posterior
parietal boss that lies in contact(below)
with the symphysis pubis; posterior ear
felt in IE; AKA …. obliquity
*if asynclitism is too severe, it can lead to dystocia or
abnormal labor. Usually, patient undergoes CS
VAGINAL EXAMINATION = BREECH PRESENTATION
- Ischial tuberosities & anus are in straight line so in
IE, you feel for the two ischial tuberosity and then
at the middle would be the anus(with resistance
when palpated due to sphincter)
- Muscular resistance encountered with the anus
- Presence of meconium on the examining finger
- Foot can be identified as right or left basing on the
great toe
VAGINAL EXAMINATION=SHOULDER PRES
- The position of the axilla indicates the side of the
mother toward which the shoulder is directed
- “Gridiron” feel of the ribs on the side of the thorax
VAGINAL EXAMINATION = FACE PRESENTATION
- Differentiate with breech:
 Mouth & malar prominences form a triangular
shape
 Less yielding jaws are felt through the mouth
 Examining finger not stained with meconium
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ULTRASOUND

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