Malposition Malpresentation Abnormal Lie
Post on 13-Nov-2014
151 Views
Preview:
Transcript
11
MALPOSITION, MALPOSITION, MALPRESENTATION, MALPRESENTATION,
ABNORMAL LIEABNORMAL LIE
22
PRESENTATIONPRESENTATION
97% : cephalic97% : cephalic 3%: breech3%: breech 0.5% : transverse, oblique,face, brow0.5% : transverse, oblique,face, brow
33
FACE PRESENTATIONFACE PRESENTATION
Head is hyperextended: occiput Head is hyperextended: occiput touches fetal backtouches fetal back
Mento anterior or posteriorMento anterior or posterior Labour progress stalled with MPLabour progress stalled with MP
INCIDENCE:0.17%INCIDENCE:0.17%
44
DIAGNOSISDIAGNOSIS
+V/E: mouth, nose,malar bones and +V/E: mouth, nose,malar bones and orbital ridgesorbital ridges
ETIOLOGY:ETIOLOGY:Factors for extension of neck or Factors for extension of neck or
against flexionagainst flexionCord round neck; rareCord round neck; rareAnencephalyAnencephalyContracted pelvis:-40%, big babyContracted pelvis:-40%, big baby
55
Others Others
Lax pendulous abdomenLax pendulous abdomen High parity High parity
66
Mechanism of labourMechanism of labour
Only in mentoanteriorOnly in mentoanterior Same Same Descent, with chin leading-internal Descent, with chin leading-internal
rotation- chin lies under the rotation- chin lies under the symphysis pubissymphysis pubis
With mento posterior the short neck With mento posterior the short neck unable to span the anterior surface unable to span the anterior surface of sacrum -12cmof sacrum -12cm
77
Mechanism of labMechanism of lab
Chin mouth appears at vulva- birth is Chin mouth appears at vulva- birth is by flexionby flexion
External rotation with chinExternal rotation with chin Cls frequent because of contracted Cls frequent because of contracted
pelvispelvis External continous monitoring –yesExternal continous monitoring –yes Mento posterior—c/sMento posterior—c/s
88
BROW PRESENTATION BROW PRESENTATION
ANTRIOR FONTANELLE AND ORBITAL ANTRIOR FONTANELLE AND ORBITAL RIDGESRIDGES
MIDWAY B/W FLEXION/ EXTENSIONMIDWAY B/W FLEXION/ EXTENSION NO MECHANISM OF LABOUR- NO MECHANISM OF LABOUR-
MENTOVERTICALMENTOVERTICAL UNSTABLE PRESENTATION- CAN UNSTABLE PRESENTATION- CAN
CHANGECHANGE
99
ETIOLOGY: same as in faceETIOLOGY: same as in face Prognosis: small baby ok; term baby Prognosis: small baby ok; term baby
c/sc/s
1010
TRANSVERSE LIETRANSVERSE LIE
Shoulder presentation: dorso Shoulder presentation: dorso anterior; or posterioranterior; or posterior
Incidence:0.3%Incidence:0.3% Etiology : abdominal wall relaxation,Etiology : abdominal wall relaxation,
Preterm Preterm
Placenta previa, uterine anomaly Placenta previa, uterine anomaly excessive liquor,contracted pelvisexcessive liquor,contracted pelvis
1111
Diagnosis and courseDiagnosis and course
Abdominal and V/EAbdominal and V/E MX =C/SMX =C/S
1212
PERSISTENT OCCIPUT PERSISTENT OCCIPUT POSTERIOR POSITIONPOSTERIOR POSITION
MOST: malrotation of ociput anterior MOST: malrotation of ociput anterior positionposition
87% of occiput anterior: rotate 87% of occiput anterior: rotate anterioranterior
LABOUR : monitor as normalLABOUR : monitor as normal
1313
OPTIONSOPTIONS
Await spont. DeliveryAwait spont. Delivery Forceps delivery with occiput posteriorForceps delivery with occiput posterior Forceps rotation to anterior B/4 Forceps rotation to anterior B/4
deliverydelivery Manual rotation to anterior B/4 Manual rotation to anterior B/4
spontaneous or forceps deliveryspontaneous or forceps delivery clscls
1414
OutcomeOutcome
Increase duration of labourIncrease duration of labour More interventionMore intervention
1515
Persistent occiput transverse Persistent occiput transverse positionposition
Transitory positionTransitory position Options:Options:
Oxytocin augmentationOxytocin augmentation
Manual rotationManual rotation
Forcep rotationForcep rotation
clscls
1616
BREECH PRESENTATION BREECH PRESENTATION
Buttocks presentButtocks present Incidence: 3-4% at term deliveryIncidence: 3-4% at term delivery ETIOLOGY:ETIOLOGY:
Abdomen, uterus, liquor, baby Abdomen, uterus, liquor, baby placenta, cord, contracted pelvis , placenta, cord, contracted pelvis , cornuo-fundal placentacornuo-fundal placenta
1717
COMPLICATIONSCOMPLICATIONS
Perinatal morbidity and mortalityPerinatal morbidity and mortality Low birth weight: preterm; IUGRLow birth weight: preterm; IUGR Prolapsed cordProlapsed cord Placenta preaviaPlacenta preavia Fetal, neonatal, infant mortalityFetal, neonatal, infant mortality Uterine anomaly and tumorsUterine anomaly and tumors Multiple fetusesMultiple fetuses Operative interventionsOperative interventions
1818
DIAGNOSISDIAGNOSIS
ABDOMINAL / V/EABDOMINAL / V/E
FrankFrank
Flexed Flexed
Footling breechFootling breech
IMAGING: IMAGING:
USSUSS
X-ray : controversialX-ray : controversial
1919
PrognosisPrognosis
Maternal morbidity/mortalityMaternal morbidity/mortality Breech prognosis : irrespective of Breech prognosis : irrespective of
mode of deliverymode of delivery
2020
Pronosis Pronosis
Maternal : increased interventionsMaternal : increased interventions Fetus infant morbidity/mortality:Fetus infant morbidity/mortality:
Preterm delivery,congenital anomaly, birth Preterm delivery,congenital anomaly, birth traumatrauma
injuries in order of frequency at autopsyinjuries in order of frequency at autopsy
Brain, spinal cord, liver, adrenal gland,and Brain, spinal cord, liver, adrenal gland,and spleenspleen
Others: brachial plexus,pharynx, Others: brachial plexus,pharynx, sternocleidomastoidsternocleidomastoid
2121
Complications with vagina Complications with vagina deliverydelivery
Delay/rushedDelay/rushed Preterm baby: cervical head Preterm baby: cervical head
entrapment; use duhrssen incisionentrapment; use duhrssen incision Cord prolapse: frank breech : 0.5%Cord prolapse: frank breech : 0.5%
Flexed breech: 5%. Foootling: 15%Flexed breech: 5%. Foootling: 15%
Cord length is short and true knots Cord length is short and true knots commoncommon
2222
Factors to considerFactors to consider
X –ray pelvimentry : no consensusX –ray pelvimentry : no consensus Hperextension of fetal head:5%; Hperextension of fetal head:5%;
delivery causes cervical spine injury.delivery causes cervical spine injury.
In labour=C/SIn labour=C/S
INDUCTION/ AUGMENTATION:INDUCTION/ AUGMENTATION:
Difffering reports on fetal prognosisDifffering reports on fetal prognosis
2323
MODE OF DELIVERYMODE OF DELIVERY
DISCRETION: PRETERM/TERMDISCRETION: PRETERM/TERM PRETERM: birth weightPRETERM: birth weight Ceaserean sectionCeaserean section
Large babyLarge baby
Contracted pelvisContracted pelvis
Hyperextended headHyperextended head
Coexistent problemsCoexistent problems
Footling breechFootling breech
2424
Others Others
IUGRIUGR BOHBOH
2525
LABOUR AND DELIVERYLABOUR AND DELIVERY
Descent : bis trochanteric diameter with Descent : bis trochanteric diameter with ant hip leadingant hip leading
Internal rotation,birth is by lateral flexionInternal rotation,birth is by lateral flexion External rotation=back anterior as External rotation=back anterior as
shoulders enter inletshoulders enter inlet Shoulders : internal rotation at outletShoulders : internal rotation at outlet Head : rotate with occiput under Head : rotate with occiput under
symphsissymphsis
2626
METHODS OF VAGINA METHODS OF VAGINA DELIVERYDELIVERY
SPONTANEOUSSPONTANEOUS ABDABD BREECH EXTRACTIONBREECH EXTRACTION
2727
MANAGEMENT OF LABOURMANAGEMENT OF LABOUR
IV ACCESSIV ACCESS CLOSE MONITORINGCLOSE MONITORING UNBOOKED : NOT INDICATION FOR UNBOOKED : NOT INDICATION FOR
C/SC/S LABOUR : ULTIMATE ARBITERLABOUR : ULTIMATE ARBITER SKILLED MEDICAL PERSONNELSKILLED MEDICAL PERSONNEL
2828
DELIVERY DELIVERY
PROGNOSIS BEST IF SPONTANEOUS PROGNOSIS BEST IF SPONTANEOUS DEL UP TO UMBILICUSDEL UP TO UMBILICUS
MODE OF ABDMODE OF ABD
2929
MANUEVERSMANUEVERS
MSVMSV PRAGUE MANUEVER:PRAGUE MANUEVER:
Occiput remain posterior: manual Occiput remain posterior: manual rotation msv, rotation msv,
Prague:hands on back down fetal Prague:hands on back down fetal shoulders, other hand draws feet shoulders, other hand draws feet over abdomen of motherover abdomen of mother
3030
Entrapment of after coming Entrapment of after coming headhead
Small preterm babySmall preterm baby Manual manipulation of cervixManual manipulation of cervix Duhrssen incisionDuhrssen incision Cephalic replacement then c/sCephalic replacement then c/s
3131
Analgesia and anaesthesiaAnalgesia and anaesthesia
Epidural : prolongs 2Epidural : prolongs 2ndnd stage: weigh stage: weigh agaist riskagaist risk
3232
Morbidity/mortalityMorbidity/mortality
Maternal and fetalMaternal and fetal
3333
VERSIONVERSION
ALTERATION OF PRESENTATION ALTERATION OF PRESENTATION ARTIFICIALLYARTIFICIALLY
One pole for another in logitudinalOne pole for another in logitudinal
Transverse to longitudinalTransverse to longitudinal
EXTERNAL/INTERNAL VERSIONEXTERNAL/INTERNAL VERSION
3434
ECVECV
Safe Safe Cost effective Cost effective SuccessfulSuccessful
USS, electronic monitoring and USS, electronic monitoring and tocolytics increase safetytocolytics increase safety
3535
ECVECV
35-37WKS35-37WKS ECV succeeds in 65% of casesECV succeeds in 65% of cases If version succeeds,almost all fetuses If version succeeds,almost all fetuses
stay cephalic and vice-versastay cephalic and vice-versa Ultimately and despite version Ultimately and despite version
attempts,37% of women identified to attempts,37% of women identified to have a late pregnancy breech will have a late pregnancy breech will requireC/SrequireC/S
3636
ECV SUCCESSECV SUCCESS
Presenting part has not descended Presenting part has not descended into pelvisinto pelvis
Normal amount of liquorNormal amount of liquor Fetal back is not posteriorFetal back is not posterior Woman is not obeseWoman is not obese
3737
TechniqueTechnique
In labour ward close to theatreIn labour ward close to theatre USSUSS Continous external monitoringContinous external monitoring Forward role if fails back flipForward role if fails back flip TocolysisTocolysis
3838
Interesting conceptInteresting concept
Moxibuston; burning herbs to Moxibuston; burning herbs to stimulate acupuncture point stimulate acupuncture point BL67==promotes spontaneous BL67==promotes spontaneous breech version possibly by increasing breech version possibly by increasing fetal activity=proven in studiesfetal activity=proven in studies
3939
Complications of ECVComplications of ECV
ABRUPTIOABRUPTIO UTERINE RUPTUREUTERINE RUPTURE AFEAFE FM haemorrhageFM haemorrhage PRETERM LABOURPRETERM LABOUR FETAL DISTRESS,DEMISEFETAL DISTRESS,DEMISE
4040
INTERNAL PUDALIC INTERNAL PUDALIC VERSIONVERSION
DISTRESS IN TWIN 2DISTRESS IN TWIN 2
4141
CONCLUSIONCONCLUSION
HIGH RISK OBSTETRICSHIGH RISK OBSTETRICS
top related