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8/22/2019 Malposition OPP.pptx
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Malpositions andMalpresentations
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Introduction
Baby presents itself in the mothers pelvis in any
position other than the vertex presentation -
abnormal presentation, ormalpresentation.
Abnormal - because -higher risk of obstruction
and other birth complications than the vertex
presentation. Contd
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The normal way for a baby to deliver -vertex with
the occiput lying anteriorly.
Cephalic presentation-if the occiput is not lateral
in early labour or anterior in advanced labour then
a malposition exists.
Contd
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If the leading pole of the foetus is anything other
than the vertex, a malpresentation exists.
Malpositions and malpresentations present in
labour can proceed to normal during delivery.
More difficult labour is common
Operative delivery & risk is high for both.
Contd
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Left and right occipito-anterior are the only
normal presentations and positions.
Malposition: occipito-posterior.
Malpresentations: anything except vertex.
Contd
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Malpresentations are
Face presentation,
Brow presentation,
Breech presentation,
Shoulder presentation,
Cord presentation and
Complex presentations.
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Malposition: Occipito-
Posterior
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1. Introduction
Most common type of malposition of the occiput.
A persistent occipitoposterior position (POP)
results from a failure of internal rotation prior to
birth.
In Occipito-Posterior - The vertex is presenting,
but the occiput lies in the posterior rather than the
anterior part of the pelvis.
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In a vertex presentation
where the occiput is
placed posteriorly over
the sacro iliac joint or
directly over the sacrum,
it is called an occipito
posterior position
2. Definition
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3. Incidence
- 10% of all vertex presentations
- Expected more during late pregnancy and much less
in late second stage of labour.
- Early in labour(10-20%)
- Late in labour(1-2%)
Contd
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- ROP is 5 times more common than the LOP
- Dextro rotation of the uterus
- Presence of sigmoid colon on the left- Diminished
left oblique diameter -disfavor LOP position.
- The right oblique diameter is slightly longer than
the left one.
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4. Types
ROPLOP
DOP
POP
Primary: It occur late in pregnancy before the
onset of labour. It occur in association with
anthropoid pelvis.Secondary: It develops during labour and in
association with android pelvis
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ROP LOP
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4. Types
Primary: It occur late in pregnancy before the
onset of labour. It occur in association with
anthropoid pelvis.
Secondary: It develops during labour and in
association with android pelvis
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5. Causes
Not clear
The shape of the pelvic inlet: (50-85%)
anthropoid and android pelvises are the most
common cause - due to narrow fore-pelvis &
roomier hind pelvis
Others(15%)
High pelvic inclination Contd
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Abnormal uterine contraction
Maternal kyphosis: The convexity of the fetal
back fits with the concavity of the lumbar
kyphosis.
Anterior insertion of the placenta
Fetal factors: Marked deflection of the fetal
head. Contd
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Reasons for deflexion of head
High pelvic inclination
Attachment of the placenta on the anterior
wall of the uterus
Primary brachy-cephaly
Contd
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Other causes of Malpresentation:
Placenta praevia,
Pelvic tumours,
Pendulous abdomen,
Polyhydramnios,
Multiple pregnancy.
- Idiopathic(10-30%)
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6. Risk factors for OP
position at delivery include
Nulliparity
Maternal age greater than 35 years
Obesity
African-American race
Previous OP delivery
Contd
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6. Risk factors for OP
position at delivery include
Decreased pelvic outlet capacity
Gestational age 41 weeks
Birth weight 4000 g
Prolonged first and/or second stage of labor
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7. Diagnosis
Antenatal diagnosis
Diagnosis during labour
Imaging
Contd
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A. Antenatal diagnosis
i. Listen to the mother
ii. Abdominal examination Inspection
Palpation and Auscultation
iii. Antenatal preparation
Contd
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i. Listen to the mother
Complain of backache
She may feel that her babys bottom is very
high up against her ribs.
Reports - feeling movements across both sides
of her abdomen.
Contd
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ii. Abdominal examination
Inspection Palpation andAuscultation
Inspection
The abdomen looks flat, below the umbilicus.
saucer-shaped depression at or just below the
umbilicus-dip between the head and the lower
limbs of the fetus.
Contd
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a. Inspection
The outline
created by the
high, unengaged
head can looklike a full
bladder.Comparison of abnormal contour in posterior (1) and anterior positions (2) ofthe occiput
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b. Palpation
ON PALPATION:
- The breech is easily palpated at the fundus,
- The back is difficult to palpate as it is out of
maternal side and almost adjacent to the
maternal spine.
- Limbs can be felt on both side of midline
Contd
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b. Palpation
- High head reason for non engagement in Primi
gravida - large presenting diameter, the
occipitofrontal (11.5cm) The occiput and sinciput
are on the same level. Flexion allows the
engagement of the suboccipitofrontal diameter
(10cm).
Contd
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Engaging diameter of a deflexed head, OF 13.5cm Flexion with Descent of the head
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b. Palpation
Umbilical grip:The findings are:
1.The fetal limbs are more easily felt near the
midline on either side.
2.The fetal back is felt away from the midline on
the flank and often difficult to outline clearly.
3.The anterior shoulder lies far away from the
midline. Contd
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b. Palpation
Umbilical grip:The findings are:
1.The fetal limbs are more easily felt near the
midline on either side.
2.The fetal back is felt away from the midline on
the flank and often difficult to outline clearly.
3.The anterior shoulder lies far away from the
midline. Contd
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b. Palpation
Pelvic grips: The findings are:
1. The head is not encaged.
2. The cephalic prominence (Sinciput) is not felt as
prominent as found in well flexed occipito-
anterior. In direct occipito-posterior, the small
sinciput is confused with breech.
Contd
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b. Palpation
The cause of the deflexion
Is a straightening of the fetal spine against the
lumbar curve of the maternal spine.
This makes the fetus straighten its neck and
adopt a more erect attitude.
ON AUSCULTATION:
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ON AUSCULTATION:
- F.H.S can be heard at
midline.
- Sometime f.H.S can be
heard more easily at theflank on the same side of
the back.
- Difficult to locatespecially in lop
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i i i . Antenatal preparation
Active changes of maternal posture.
Mother adopting a kneechest position several
times a day - temporary rotation of the fetus to an
anterior position - short-term effect upon fetal
presentation.
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B. Diagnosis during labour
Head is high
Non engagement of head
May complain of continuous and severe
backache worsening with contractions
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B. Diagnosis during labour
Large and irregularly shaped presenting
circumference - membranes tend to rupture
spontaneously at an early stage of labour
Contractions may be incoordinate.
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B. Diagnosis during labour
Good contractions but slow descending of the
head.
Strong desire to push early in labour because the
occiput is pressing on the rectum.
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Presenting dimensions of a
deflexed head
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Vaginal examination
The findings will depend upon the degree of
flexion of the head.
Anterior fontanelle in the anterior part of the
pelvis - difficult if caput succedaneum is present.
The direction of the sagittal suture and location
of the posterior fontanelle confirms the
diagnosis. Contd
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The findings in early labour are:
Elongated bag of membranes - rupture during
examination.
The sagittal suture occupies any of the oblique
diameters of the pelvis.
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Posterior fontanelle is felt near the sacro iliac
joint.
The anterior fontanelle is felt more easily
because of the deflexion of the head and at
times, is felt at a lower level than the posterior
one.
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In late labour
diagnosis is often difficult - caput formation
which obliterates the sutures and fontanelles.
In such cases, the ear is to be located and the
unfolded pinna points towards the occiput.
Simultaneous assessment of the pelvis should be
done.
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c. Imaging
Ultrasonagraphy is rarely done.
It is helpful to know the descent, attitude of
the head and its relation to the pelvic walls
(position).
8 Mechanism of (labour)
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8. Mechanism of (labour)
Right occipitoposterior
position (long rotation)The head encages through the
right oblique diameter in ROP and
left oblique in LOP.
The encaging transverse diameter of the head is
biparietal (9.5cm)
Contd
8 Mechanism of (labour)
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8. Mechanism of (labour)
Right occipitoposterior
position (long rotation)Antero-posterior diameter is either
Suboccipito-frontal (10cm) or
Occipito-frontal (11.5cm) (deflexion
engagement is delayed).
In favorable circumstances of OPP - mechanism
is possible. Contd
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Fetal Description/Criteria:The lie is longitudinal
The attitude of the head is deflexed
The presentation is vertex
The position is right occipitoposterior
The denominator is the occiput
Contd
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Fetal Description/Criteria:The presenting part is the middle or anterior area
of the left parietal bone
The occipitofrontal diameter, 11.5cm, lies in the
right oblique diameter of the pelvic brim.
The occiput points to the right sacroiliac joint
and the sinciput to the left iliopectineal eminence.Contd
Mechanism of labour
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Mechanism of labourThe main movements are:
Flexion
I nternal rotation of the head
Crowning
Extension
Restitution
I nternal rotation of the shoulders
External rotation of the head
Lateral f lexion
C i
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Crowning: Occiput escape under the pubicarch and the head is said to be crown
Alternative mechanism in
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Alternative mechanism in
favorable situation
(uncommon)If the shoulders fail to follow the anterior rotation
of the occiput,
The neck sustains a torsion and the shoulders
remain static in the left oblique diameter in ROP
and in the right oblique diameter in LOP.
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In such cases
Restitution occurs 3/8th of a circle and
External rotation occurs through 1/8th of a circle
in the opposite direction of restitution.
However the mechanism is quite unlikely.
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In OP Presentation
Favorable circumstances 90%
Unfavorable circumstances 10%
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I f bl
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In unfavorable
circumstances of OPP
In Certain circumstances
The occiput fails to rotate as described
previously.
Th f f lt t ti
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The causes of faulty rotation
Deflexion of the head,
Weak uterine contraction,
Faulty shape of the pelvis - flat sacrum,
prominent ischial spines or convergent
side walls and weak pelvic floor muscles.
Big baby and immobility of the fetaltrunk
The drainage of liquor amnii.
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Results in Deep
transverse arrest
Incomplete
forward rotation
Sinciput & occiput touch the
pelvic floor simultaneously
Malrotation - Sinciput anterior rotation
- occiput to the sacral hollow -
Occipito- sacral position
Oblique
posterior arrest
Face to pubis Occipito-sacral arrest
Favorable
circumstances
Unfavorable
circumstances
M h i f F t P bi
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Mechanism of Face to Pubis
delivery
Further descent occurs
Flexion occurs
Restitution
External rotation
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Persistent occipito-posterior
Abnormal mechanism of the occipito- posterior
position.
Delivery - spontaneously as face to-pubis or
occipito- sacral arrest.
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Deflexed head, Faulty shape of pelvis, Weak
pelvic floor muscles, Big baby, Immobility of
fetal trunk, Drainage of AF
Incomplete
forward rotation
Sinciput & occiput touch the
pelvic floor simultaneouslyMalrotation - Sinciput anterior
rotation - occiput to the sacral
hollow
COURSE OF LABOUR/
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COURSE OF LABOUR/
CARE IN LABOUR
Course of events in labour are modified
Longer first and second stage
Painful labour
The deflexed head not fit well onto the cervix -
does not produce optimal stimulation for uterine
contractions
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First stage
Tendency to delay means longer time of first
stage.
Causes are Persistence of deflexion of the head
1. Delay in engagement Driving force fetal axis not inalignment
2. Membrane status - Deflexed head - cannot fit well in sphericallower segment - loss of ball valve action - uterine contraction - EROM anddrainage of liquor.
3. Uterine contraction- ill fitting in the LUS -lack of stimulus foruterine contraction- results slow dilatation of the cervix. Pressure on the rectum
by wide occiput - premature desire of bearing down effort in 1st stage. Exhaustion
of client.
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The woman may experience
Severe and unremitting backache, causes tiring -
very demoralizing because of slow progress.
Midwife support essential for mother and her
partner to cope with the labour.The all-fours position may relieve some
discomfort.
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Prolonged labour - prevent the mothersdehydration or ketosis.
Incoordinate uterine action or ineffectivecontractions correct an oxytocin infusion.
The woman may experience a strong urge topush before full dilation causes cervix edema
delay onset of 2nd stage.
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The urge to push eased by - change in position,use of breathing techniques or inhalational
analgesia - enhances relaxation.
Partner/midwife can assist throughout labour
with massage, physical support and suggestions
for alternative methods of pain relief.
Pain control methods.
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Second stage
Delayed 2nd stage - long internal rotation or
malrotation / arrest of the head.
This may happen in android pelvis or in mid
pelvic or in mid pelvic contraction.
If felt uncared - arrest of the head may lead to
obstructed labour.
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Confirm full dilatation of the cervix -
moulding and caput succedaneum may
bring the vertex into view.
Onset of 2
nd
stage no visible head -encourage the woman to remain upright-
shorten the length of the second stage and
may reduce the need for operative delivery.
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Third stage
Increased incidence of
Postpartum hemorrhage and
Trauma of the genital tract
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MODE OF DELIVERY
Long anterior rotation of the occiput - SVD or
AVD.
Short posterior rotation - SVD or AVD and
perineal injuries
Non- rotation or short anterior rotation SVD.
Uncared - prolonged and obstructed labour.
Trauma to the genital tract
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MODE OF DELIVERY
Moulding - compression of the OF diameter with
elongation of the vault. Frontal bones
displacement beneath the parietal bones -tentorial tear.
MODE OF DELIVERY
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MODE OF DELIVERY
PrognosisMaternal morbidity (4 out of 5 cases no
trouble),
Incidental to prolonged labour and operative
delivery.
Increased perinatal morbidity and mortality -
asphyxia or trauma during vaginal operative
delivery.
MANAGEMENT OF
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MANAGEMENT OF
LABOUR
Principle in the management of the OPP are
1)Early diagnosis,
2) Strict vigilance with watchful expectancy
3) Judicious and timely interference, if necessary.
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Diagnosis and evaluation:
Fetal back on the flank - F.H.S not easily
located,
Early ROM should arouse suspicion.
Internal examination is confirmatory.
Overall assessment of the client and
The pelvic assessment is mandatory.
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Early Caesarean Section
OPP is not an indication of caesarean section.
CS for Pelvic inadequacy or its unfavorable
configuration,
Obstetric complications - pre-eclampsia, post
caesarean pregnancy, big baby usually needcaesarean section.
First stage
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g
Allow for normal labour in uncomplicated cases.
The following are the special instructions:
Anticipating prolonged labour- IV RL.
Judge progress of labour
Observe for a triad - Weak pain, persistence of
deflexion and non-rotation of the occiput
Indication of caesarean section
J d P f L b
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Judge Progress of Labour
(a) Progressive descent of the head
(b) Rotation of the back and the anterior shoulder
towards the midline
(c) Increasing flexion of the head
(d) Position of the sagittal suture on vaginalexamination and
(e) Cervical dilatation.
Weak pain persistence of deflexion and non
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Weak pain, persistence of deflexion and non-
rotation of the occiput are the triad
coexistent - oxytocin infusion for augmentation
of labour.
Indication of caesarean section
(a) Arrest of labour (failure of rotation)
(b) Incoordinated uterine action
(c) Fetal distress.
Second Stage
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Second Stage
In majority anterior rotation of the occiput is
completed and
The delivery is either spontaneous or
By low forceps or ventouse.
Second stage:In minority
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g y
(Unrotated & Malrotated)
Good fetal and maternal conditions - a watchful
expectancy.
In occipito-sacral position, spontaneous delivery
as face- to pubis may occur. In such cases,
Proper conduction of delivery and
Liberal episiotomy- to prevent complete
perineal tear.
Third Stage
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Third Stage
Prolongation of labour - Tendency of PPH
Prophylactic IV ergometrine 0.25 mg - delivery
of anterior shoulder.
Meticulous inspection of the cervix and lower
genital tract to detect any injury.
Arrested Occipito-posterior
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Arrested Occipito-posterior
PositionGood uterine contractions for about 1/2-1 hour +
full dilatation of the cervix = if no progress -
interference is indicated.
Once more to be assessed - abdominal and
vaginal before suitable method of interference.
Types of arrested OPP transverse, oblique,
sacral
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Per abdomen: Assess:
(1) Size of the baby
(2) Engagement of the head
(3) Amount of liquor
(4) F.H.S.
Vaginal examination: Note
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Vaginal examination: Note
(1)Station of the head
(2) Position of the sagittal suture and the occiput
(3) Degree of deflexion of the head
(4) Degree of moulding and caput formation
(5) Assessment of the pelvis at and below the levelof obstruction.
ARREST IN OCCIPITO-
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TRNSVERSE OR OBLIQUE O. P.
POSITION
Ventouse (Vacuum extraction)
Alternative methods:
Manual rotation followed by forceps
extraction.
Forceps rotation and extractionCaesarean section
Craniotomy
OCCIPITO-SACRAL
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ARRESTHead engaged
Occiput descends below the ischial spines,
Forceps application in unrotated head followed
by extraction as face-to-pubis - effective
procedure.
Liberal mediolateral episiotomy.
If occiput remains at or above the level of ischial
spines - caesarean section.
DEEP TRANSVERSE
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DEEP TRANSVERSE
ARREST (DTA)
The head is deep into the cavity
Sagittal suture - transverse bispinous diameter
No progress in descent of the head even after 1/2-
1 hour following full dilation of the cervix.
A t i i it t iti d lt
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Arrest in occipito-transverse position - end result
of incomplete anterior rotation (1/8
th
of circle) ofoblique occipito-posterior position.
or it may be due to
Non-rotation of the commonly primary occipito-
transverse position of normal mechanism of
labour.
C f DTA
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Causes of DTA
(a) Faulty pelvic architecture
(b) Deflexion of the head
(c) Weak uterine contraction
(d) Laxity of the pelvic floor muscles.
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Diagnosis of DTA
(a) The head is engaged
(b) The sagittal suture lies in the transverse
bispinous diameter
(c) Anterior fontanelle is palpable
(d) Faulty pelvic architecture
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Management
The fetal condition and pelvic assessment -
guide as to the line of management
Vaginal delivery is found safe
(1) Ventouse- ideal
(2) Manual rotation and application of forceps
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Management
(3) Forceps rotation and delivery - Kielland / expert
(4) Vaginal delivery is not safe - with big baby and
or inadequate pelvis - Caesarean Section
(5) Craniotomy in dead baby.
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MANUAL ROTATIONWhole hand method or With half hand method
Patient - in lithotomy position and GA
Strict aseptic technique
Catheterize the bladder
Vaginal examination and detect the direction of
occiput if caput seek help of unfolded pinna
MANUAL ROTATION -
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Whole hand method
Step- I: Gripping of the head
Step-II: Rotation of the head
Step-III: Application of the forceps
S I G i i f h h d
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R.O.P. or R.O.T. - Left hand and
L.O.P. or L.O.T. - Right hand
Separate the labia by two fingers
Introduce the corresponding hand into the vagina
in a cone shaped manner.
Step- I: Gripping of the head
Step- I: Gripping of the head
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Step : G pp g o t e ead
Occipito-transverse
position - the four fingers
are pushed in the sacral
hollow to be placed over the
posterior parietal bone and
the thumb is placed over the
anterior parietal bone.
Step- I: Gripping of the head
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p pp g
In oblique posterior
position - the four fingers
of partially supinated hand
are placed over the occiput
and the thumb is placed
over the sinciput.
Step-II: Rotation of the head
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Step II: Rotation of the headSlight dis-impaction
needed for good grip.
By a movement of
pronation of the hand,
rotate the head to bring
the occiput anterior
along the shortest
route.
Step-II: Rotation of the head
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Step II: Rotation of the head
Simultaneously, the back of the fetus is rotated
by the external hand from the flank to the
midline - essential prerequisite.
A little over rotation is desirable anticipating
slight recurrence of malposition before the
application of forceps.
Step-III: Application of the
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p pp
forcepsIf right hand is placed on the left side of the
pelvis introduce left blade.
In left hand use - place right side of the pelvis.
While introducing the blades, - assistant fixes the
head by suprapubic pressure - first pelvic grip.
As it is a mid forceps application, axis traction
device should be used.
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Difficulties and dangers
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g
1) Failure to grip the head
2) Failure to dislodge the head from the impacted
position
3) Inadequate anesthesia
4) Wrong case selection.
Dangers- accidental slipping of the head above the
pelvic brim and prolapsed of the cord.
HALF HAND METHOD
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HALF HAND METHOD
Four fingers are only introduced in to the vagina.
Advantages
i) Less space is required and
ii) Less chance to displacement of the head
Steps
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Steps
The rotation is done only by using the right hand.
With four fingers tangential pressure is applied
on the head at the level of diameter of
engagement.
Pressure is applied on the side and the parietal
eminence of the head.
Steps
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In R.O.P. or R.O.T. position the fingers areplaced anterior to the head and the pressure is
applied by the ulnar border of the hand.
In L.O.P. or L.O.T. position, the fingers are
placed posteriorly and the pressure is applied
intermittently till the occiput is placed behind the
symphysis pubis.
Complications
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p
PROM in early labour.
Cord presentation and prolapse
Prolonged & obstructed labour
Maternal, neonatal trauma rupture of uterus, PPH,
Puerperal sepsis & Cerebral hemorrhage
Increased incidence of perinatal mortality.
Increased incidence of instrumental and operative
delivery.
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Possible Nursing Diagnosis
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Possible Nursing Diagnosis
Acute pain related toprogress of labor.
Anxiety RT slow
progress of labour
Alteration in fetal
tissue perfusion
related to maternal
position, epidural,oxytocin, rupture of
membranes
Potential for infection
related to rupture of
membranes
Bibli h
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Bibliography
- Fraser and Cooper. Myles textbook of
midwives.14th edition.churchill livingstone
publication.philadelphia2007. page no 551-557- Dutta D.C. Text book of obstetrics.6th edition.
New central book publication. kolkata 2006.
page no 365-374
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