Malpresentations (Q-A)

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    What are the causes of malpresentations ?
      Contracted pelvis
      Uterine fibroids
      Placenta praevia
      Multiple pregnancy
      Hydramnios
      Extereme uterine obliquity including lax abdominal wall.

    Face presentation

    What is the frequency of face presentation ?

      1 in 200 labours

    What are the commonest causes of face presentation ?

      An increase in the tone of extensor muscles of the baby’s neck.

    What is the denominator in face presentation ?

      Chin

    Name the different positions of face presentation ?

      Right mento-posterior , Left mento posterior , Left mento anterior

    Which is the most common position ?

      Mento anterior

    How these positions are produced ?

      Right mento posterior—-From LOA by complete flexion
      Left mento -posterior—From second vertex by complete extension
      Left mento -anterior—-From full extension of ROP vertex

    What is felt on PV examination ?

      Bridge of fetal nose , supraorbital ridges , mobile frontal suture

    What is the presenting diameter ?

      Submento-bregmatic which is 9.4 cm

    What are the events during delivery ?

      The leading point is chin
      Internal rotation brings chin to the front
      Birth of head by flexion when chin passes through subpubic arch
      successive birth of forehead , vertex and occiput
      Restitution
      External rotation

    What is persistent mento posterior position ?

      Failure of the internal rotation of the head leading to obstructed labour leading to caesarean section

      What are the causes of brow presentation ?

        Same as those of face presentation

      What is the presenting diameter ?

        Mento vertex 13.8 cm

      What is primary brow ?

        It denotes the brow presentation when foetus is above brim

      What is secondary brow ?

        Which results during the course of labour

      How do you manage cases of brow presentation ?

        By doing caesarean section

            Name the types of breech presntation ?

              Frank breech , complete breech , footling breech .

            What is frank breech ?

              Legs extended at the knee and fully flexed at hip , buttocks is the presenting part.

            What is complete breech ?

              Legs flexed at both knee and the hip.

            What is footling breech ?

              Partial extension of the hip results in footling breech , there is high risk of cord prolapse and expulsion of trunk before full dilatation.

            What is the denominator in breech ?

              The sacrum

            What are the positions of breech ?

              Left sacro-anterior
              Right sacro-anterior
              Right sacro-posterior
              Left sacro-posterior

            When in pregnancy the foetus does presents as breech ?

              Upto 28-30 weeks.

            What are the complications which prevent the spontaneous correction of breech ?

              Fibroids , septate , bicornuate uterus , premature onset of labour , multiple pregnancy , hydramnios, breech with extended legs

            What do you see on per abdominal examination ?

              Pelvic grip feels large , soft and irregular.
              Fundal grip shows hard round , ballotable head
              Lateral palpation reveals prominent fetal spine in one or the other flank .

            Where do you hear the best FHS ?

              Usually above and one or other side of umbilicus

            What are the risks of breech delivery ?

              Maternal trauma like extensive tear of perineum , cervix and even lower uterine segment
              Foetal anoxia and death
              Foetal trauma like intracranial haemorrhage , lacerations of liver , dislocation or fractures of lims , jaw , clavicle, brachial plexus and sternomastoid.

            How is the buttock delivered in LSA position ?

              Engagement of breech in LSA in oblique diameter of pelvis
              Anterior rotation of the buttock through 1/8 of the circle
              Birth of the buttocks by lateral flexion of trunk towards mother’s abdomen
              Restitution brings the buttock in front

            Describe the delivery of shoulders ?

              Engagement of bisacromial diameter in the left oblique
              Internal rotation of anterior shoulder through 1/8 of circle
              Birth of posterior shoulder first and then of anterior shoulder

            Describe the events in the delivery of head ?

              Engagement of sub-occipito bregmatic diameter in the right oblique diameter inlet.
              Internal rotation of occiput as it touches the pelvic floor.
              Birth of head by flexion in the order : chin , face and forehead.

            What complications can occur during the course of breech delivery ?

              Delayed dilatation of cervix
              Uterine inertia
              Premature rupture of membranes
              Cord prolapse
              Prolong labour causing foetal distress
              Chances of PPH and puerperal pyrexia.

            How will you manage a case of breech delivery ?

              See for the associated anomalies like placenta praevia, contracted pelvis , multiple pregnancy , anencephaly , monsters etc by USG
              External cephalic version is not done now a days because of the risk of antepartum haemorrhge , cord prolapse , PROM, foetal hypoxia , previous scar rupture.
              If it is full term primi breech then LSCS is done.
              If second gravia , previous history of normal delivery and baby is not post mature , pelvis is roomy one can go for the vaginal delivery.

            How will you deliver a breech baby ?

              Episiotomy under local is given , some give it at the time of delivery of head and some obstetricians give it before , at the time of breech coming out.I give it at the time of delivery of head but give local anesthesia in advance.
              Gentle release of legs ( anterior first )
              Drawing aside a loop of cord , when trunk born upto the level of umbilicus.
              Note the pulsation in the cord.
              Cover the baby with warm towel ( discourages aspiration of liquor amnii )
              Releasing the arms gently by making slight traction upon the elbow , posterior arm delivered first.
              Delivering the posterior shoulder by moving the baby towards mother’s abdomen.
              Delivering the anterior shoulder by turning the baby backwards.
              Allowing the baby to hang on its weight for sometime.( It helps in flexion of the head )
              Applying the little suprapubic pressure
              Delivering the head by gently drawing toward’s mother’s abdomen , when subocciput free under symphisis pubis.

            How will you manage arrested breech in the cavity ?

              By : Pinnard’s manoeuvre ( if due to extended legs )
              Lovset’s manoeuvre ( If due to extended arms )

            What is Pinnard’s manoeuvre ?

              With two fingers the thigh is forced out and a sharp tap is given in the popliteal fossa , this causes flexion in the legs and with gentle traction each leg is taken out with ease.

            What is Lovset’s manoeuvre ?

              The baby is rotated 180 degrees , keeping the back anterior to bring the posterior arm under symphisis pubis then the posterior arm is delivered.For the delivery of other arm , baby is rotated in apposite direction.

            What are the causes of arrest of breech at pelvic outlet ?

              Breech with extended legs , uterine inertia , rigid perineum , outlet contraction.

            What is done to assist the delivery of head ?

              Jaw-shoulder traction
              forceps for after coming head.

            What is jaw-shoulder traction ?

              Middle finger of left hand is inserted into the baby’s mouth and first and third fingers of right hand are hooked over the baby’s shoulder , one on either side of neck and then traction is applied to maintain the flexion of the head till hair line appears under pubic arch.Now the foetus is grasped by feet and pulled downwards and upwards toward’s the mother’s abdomen.

            How do you apply forceps on after coming head ?

              With the bay held upwards toward’s mother’s abdomen , first the left then right blades of outlet forceps are applied after giving episiotomy.
              [2]

                What is transverse lie ?

                  It is a position of the foetus in which long axis lies transverse to the long axis of mother.

                What are the causes ?

                  Contracted pelvis, multiparity , uterine deformities , placenta praevia etc.

                What will you get on palpation ?

                  Fundal and pelvic grips feel empty , hard ballotable head is felt in one or other iliac fossa and soft irregular breech in the other iliac fossa.

                How will you manage a case of full term transverse lie ?

                  Confirm by doing USG and LSCS is the only choice.
                  Assess the dilatation , weight of the baby and it depends upon the expertise of the person who is handling the case.One can try for internal podalic version but availability of paediatrician , anaaesthtist is must and prepare the OT for LSCS if required.

                References

                • Viva in Obstetrics , 1979

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