Malposition Malpresentation Abnormal Lie

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MALPOSITION, 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%

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DIAGNOSIS+V/E: mouth, nose,malar bones and orbital ridges ETIOLOGY: Factors for extension of neck or against flexion Cord round neck; rare Anencephaly Contracted pelvis:-40%, big baby4

Others

Lax pendulous abdomen High parity

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 -12cm6

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 posteriorc/s7

BROW PRESENTATION

ANTRIOR FONTANELLE AND ORBITAL RIDGES MIDWAY B/W FLEXION/ EXTENSION NO MECHANISM OF LABOURMENTOVERTICAL UNSTABLE PRESENTATION- CAN CHANGE8

ETIOLOGY: same as in face Prognosis: small baby ok; term baby c/s

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TRANSVERSE LIEShoulder presentation: dorso anterior; or posterior Incidence:0.3% Etiology : abdominal wall relaxation, Preterm Placenta previa, uterine anomaly excessive liquor,contracted pelvis10

Diagnosis and course

Abdominal and V/E MX =C/S

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PERSISTENT OCCIPUT POSTERIOR POSITION

MOST: malrotation of ociput anterior position 87% of occiput anterior: rotate anterior LABOUR : monitor as normal

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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 cls13

Outcome

Increase duration of labour More intervention

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Persistent occiput transverse positionTransitory position Options: Oxytocin augmentation Manual rotation Forcep rotation cls15

BREECH PRESENTATIONButtocks present Incidence: 3-4% at term delivery ETIOLOGY: Abdomen, uterus, liquor, baby placenta, cord, contracted pelvis , cornuo-fundal placenta

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 interventions17

DIAGNOSISABDOMINAL / V/E Frank Flexed Footling breech IMAGING: USS X-ray : controversial18

Prognosis

Maternal morbidity/mortality Breech prognosis : irrespective of mode of delivery

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PronosisMaternal : increased interventions Fetus infant morbidity/mortality: Preterm delivery,congenital anomaly, birth trauma injuries in order of frequency at autopsy Brain, spinal cord, liver, adrenal gland,and spleen Others: brachial plexus,pharynx, sternocleidomastoid20

Complications with vagina deliveryDelay/rushed Preterm baby: cervical head entrapment; use duhrssen incision Cord prolapse: frank breech : 0.5% Flexed breech: 5%. Foootling: 15% Cord length is short and true knots common21

Factors to considerX ray pelvimentry : no consensus Hperextension of fetal head:5%; delivery causes cervical spine injury. In labour=C/S INDUCTION/ AUGMENTATION: Difffering reports on fetal prognosis

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MODE OF DELIVERYDISCRETION: PRETERM/TERM PRETERM: birth weight Ceaserean section Large baby Contracted pelvis Hyperextended head Coexistent problems Footling breech23

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 25 symphsis

METHODS OF VAGINA DELIVERY

SPONTANEOUS ABD BREECH EXTRACTION

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MANAGEMENT OF LABOUR

IV ACCESS CLOSE MONITORING UNBOOKED : NOT INDICATION FOR C/S LABOUR : ULTIMATE ARBITER SKILLED MEDICAL PERSONNEL

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DELIVERY

PROGNOSIS BEST IF SPONTANEOUS DEL UP TO UMBILICUS MODE OF ABD

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MANUEVERSMSV PRAGUE MANUEVER: Occiput remain posterior: manual rotation msv, Prague:hands on back down fetal shoulders, other hand draws feet over abdomen of mother29

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

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Morbidity/mortality

Maternal and fetal

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VERSIONALTERATION OF PRESENTATION ARTIFICIALLY One pole for another in logitudinal Transverse to longitudinal EXTERNAL/INTERNAL VERSION

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ECVSafe Cost effective Successful USS, electronic monitoring and tocolytics increase safety

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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/S35

ECV SUCCESS

Presenting part has not descended into pelvis Normal amount of liquor Fetal back is not posterior Woman is not obese

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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

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INTERNAL PUDALIC VERSION

DISTRESS IN TWIN 2

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CONCLUSION

HIGH RISK OBSTETRICS

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