I N T HE N AME O F G OD Dr. Zohreh Lavasani N ON V ERTEX P RESENTATION.

IN THE NAME OF GOD

Dr. Zohreh Dr. Zohreh LavasaniLavasani

NON VERTEX NON VERTEX PRESENTATIPRESENTATI

ONON

BREECH PRESENTATION

Incidence: %3-%4 Term single fetus

Gestational age:

PREDISPOSING FACTORS

1. Previous breech delivery2. Oligohydramnious3. Polyhydramnious4. Uterine relaxation due to pariety5. Multiple pregnancy 6. Fetal anomaly(Malformation of C.N.S

such as Anencephaly,Hydrocephaly %1.5-%2)

7. Pelvic mass8. Uterine abnormality9. Placenta previa10. Chromosomal abnormality up to %1

PREDISPOSING FACTORS

No strong correlation between breech and contracted pelvis

In more than %50 no

causative factor

DIAGNOSISAbdominal exam

Vaginal exam (D.D with face presentation)

Imaging techniques (Ultrasound,Pelvimetry, M.R.I and radiography)

FRANK BREECH

COMPLETE BREECH

INCOMPLETE BREECH

TYPES OF BREECH PRESENTATION

FRANK INCOMPLETE COMPLETE

COMPLICATIONS1. L.B.W (Preterm and I.U.G.R)2. Perinatal mortality (4 fold in

term fetus and 2-3 fold in preterm,1/3

are preventable) and morbidity3. Head Trauma4. CNS Trauma5. Softe Tissue&Muscle Trauma6. Decelaration Of FHR7. CP

PROGNOSIS 1Both mother and fetus are at higher risk compared with cephalic presentation.

Maternal morbidity and mortality is increased because of greater frequency of operative delivery especially in emergency cesarean deliveries.

PROGNOSIS 2Perinatal mortality and morbidity: prognosis of the fetus is considerably worse than the vertex presentation

Major Contributers: preterm delivery, congenital anomaly and birth trauma

Outcomes: Due to careful assesment before vaginal delivery and increased cesarean, bad outcomes are decreased from %9 to %3 from 1967-1976 to 1984-1994.

VAGINAL DELIVERY

Pelvic exam and breech typeTime for molding (Head Trauma, Hypoxia and acidosis)

Preterm delivery (Head entrapment)Nuchal arm (%6)Cord prolapse (espicially in small fetus and footling

breech)

Apgar scoreHyperextension of fetal head

(%5),Stargaser fetus or flying fetus

Induction of labor

Breech Breech RadiographyRadiography

RECOMMENDATION FOR DELIVRERY

Up to %87 cesarean

Frank breech term with E.F.W=2000-3500 Grams and adequate pelvis and flexed head is good candida for vaginal delivery

RECOMMENDATION FOR CESAREAN

Large fetus Any degree of contraction or unfavarable

shape of the pelvis Hyperextension of fetal head Indicated delivery Uterine dysfunction Incomplete or footling breech An apparently healthy and viable fetus in

mother with indicated delivery or in active labor

Sever I.U.G.R Previous prenatal death or children suffering

from birth trauma Request of T.L Lack of experienced operator

METHODS OF VAGINAL DELIVERY

Spontaneous breech

delivery

Partial breech extraction

Total breech extraction

LABOR MANAGEMENT 1

During labor both mother and fetus are at considerably increased risk compared with cephalic presntation so rapid evaluation should be made to establish the status of membranes,F.H.R,uterine contractions, and cervical condition

A venous catheter is inserted and infusion begun as soon as possible

Route of delivery may have taken place before admission based on the type of breech,flexion or extention of head,fetal size,quality of contractions,type and size of maternal pelvis and preferences of the informed parents.

Sonography for fetal anomaly

LABOR MANAGEMENT 2

Radiography is necessary for vaginal delivery

Guidelines for monitoring the high risk fetus are applied (one-on – one nursing,fetal monitoring and physician must readily available)

Risk of cord prolapse must be considered with R.O.M,so immidiate vaginal exam and F.H.R monitoring for 5-10 minutes is recommended

LABOR MANAGEMENT 3

DELIVERY TEAM

1. Skilled obstetrician

2. An associate to assist delivery

3. An anesthesia personnel

4. An individual trained to

resuscitate infant

VAGINAL DELIVERY

VAGINAL DELIVERY

VAGINAL DELIVERY

VAGINAL DELIVERY

VAGINAL DELIVERY

VAGINAL DELIVERY

DELIVERY OF THE AFTERCOMING HEAD

Mauriceau Maneuver

Prague Maneuver

Piper Forceps

Gentel traction on the fetal body with

cervix manually slipped over the occiput

Duhrssen incision

I.V nitroglycerin is recommended by some

Symphysiotomy

Mauriceau Maneuver

Prag ManeuverDuhrssen Incision

ANALGESIA AND ANESTHESIAThe second stage is significantly prolong

Pudendal block for episiotomy and intravaginal manipulation, Nitrous oxide plus oxygen provide further relief pain

If general anesthesia is required,it can be induced with thiopental plus a muscle relaxant

MORBIDITY AND MORTALITY 1

Maternal injuries :Manual manipulations increase the risk of infection, intrauterine maneuvers may cause rupture of uterus, laceration of cervix and anesthesia for uterine relaxation may cause uterine atony and hemorrhage.

MORBIDITY AND MORTALITY 2

Fetal injuries: Fracture of humerus and clavicle, hematomas of s.c.m, separation of the epiphyses of scapula, femur or humerus. paralysis of arm (due to pressure on the brachial plexus or overstretching the neck), spoon shape or actual fracture skull, testicular injury.

Fracture of femur

VERSIONA procedure in which the fetal presentation is altered by physical manipulation

External cephalic version with %35-%80 success rate

Internal podalic version for delivery second twin

EXTERNAL CEPHALIC VERSION

INDICATIONS FOR EXTERNAL CEPHALIC

VERSION 1Breech presentation with 36 weeks of gestation and not in labor

Version should not be done if N.V.D is contraindicated

(previa, nonreassuring fetal status or uterine incision)

INDICATIONS FOR EXTERNAL CEPHALIC

VERSION 2

Version is succesful in multiparous women with non engaged fetus and normal A.F

Factors associated with failed version are diminished A.F, maternal obesity, anterior placenta, cervical dilatation, ant. or post. fetal spine and descent breech in to the pelvis

TECHNIQUE OF VERSION 1 Should be done in an area that has

ready access to perform emergency cesarean

Sonography (A.F,previa,fetal anomalies)

Fetal monitoring Tocolysis and epidural analgesia RH immunization Forward roll /backwardroll

TECHNIQUE OF VERSION 2 Version is discontinued if exessive

discomfort, persistant abnormal F.H.R or after multiple attempts

The N.S.T is repeated after version until a normal test is obtained.

Complications: abruption, fetal distress, fetal demise, uterine rupture, fetomaternal hemorrhage, amniotic fluid embolism, isoimmunization, preterm labor.

TRANSVERSE LIE Incidence: %0.3%0.3 Diagnosis Inspection (abdomen is wide and

fundus slightly above the umbilicus)

leopold exam, vaginal exam (ribs, scapula and clavicle and even in neglected cases arm or hand prolapse into vagina and through vulva)

TRANSVERSE LIE (ETIOLOGY)

1.Abdominal wall relaxation due to parity (10 fold in p4)

2.Preterm fetus3.Placenta previa4.Excessive amnionic fluid5.Contracted pelvis

MANUVER OF LEOPOLD

NEGLECTED TRANSVERSE LIE

MECHANISM OF LABOR 1

Spontaneous delivery is impossible

Neglected transverse lie (pathologic ring)

Morbidity is increased even with best care (due to previa and cord prolapse)

MECHANISM OF LABOR 2Version may be attempted before labor

Management of labor (cesarean with classic incision)

If the fetus is small (below 800 gr) and the pelvis is large spontaneous labor is possible (conduplicato corpore)

VERTEX SINCIPUT BROW FACE

FACE PRESENTATION 1

The head is hyperextend so that occiput is in contact with the fetal back and mentum is presenting

(Mentum ant. %60 Or Mentum post %25)

Incidence:1/600 or %0.17

Labor usually impeded in term fetus with M.P

FACE PRESENTATION 2

Flexion of the head and vaginal delivery is typical in M.A

Presenting diameter is trachelobregmatic

(7 mm longer than subocciputobrematic)یعنی فاصُله ِبین فونتانل قدامی و محل تTراِکTُلWو ِبTرTگماتیک قطر

اتصال ِکف دهان ِبر گردن

Diagnose: Vaginal Exam

D.D: Frank Breech

ETIOLOGY OF FACE PRESENTATION

Any factor that favors extension or prevent head flexion

1. Marked enlargement of the neck

2. Coils of cord about the neck

3. Anencephal fetus

4. Contraction of pelvis (%40 inlet contraction)

5. Large fetus

6. Multiparous women

MANAGEMENT OF LABOR

In the absence of a contracted pelvis and with effective labor Mentum Ant. succesful vaginal delivery usually will follow.

First stage is similar to vertex. second stage is similar or slightly

longer Oxytocin is not a cotraindication

FACE PRESENTATION

MENTUM POSTERIOR-MENTUM ANTERIOR

BROW PRESENTATION 1

The rarest presentation

The engaging diameter is mentoparietal

(1.5 cm longer than vertex)

Dianose: The frontal suture, large anterior fontanel, orbital ridge, eyes and the root of the nose can be felt on vaginal exam

BROW PRESENTATION 2Etiology:The causes are same as for the face presentation

LABOR:Brow presentation is unstable and often converts to face (%30) or occiput (%20) and prognosis for delivery depends on the ultimate presentation

POSTERIOR BROW

COMPOUND PRESENTATIONIn compound presentation, an exteremity prolapses alongside the presenting part, with both presenting in the pelvis simultaneously.

Incidence:1/700 (hand or arm prolapsed alongside the head)

COMPOUND PRESENTATIONEtiology: causes are conditions that prevent complete occlusion of the pelvic inlet by the fetal head like preterm birth

Prognosis: perinatal loss is increased due to preterm delivery, cord prolapse and traumatic obstetrical prodcedure

Management: In most cases, the prolapsed part will not interfere with labor

COMPOUND PRESENTATION

PERSISTANT OCCIPUT POSTERIOR 1

Most often undergo spontaneous anterior rotation

Incidence: %15 early in labor and %5 at delivery

Etiology: unknown, but transverse narrowing of the midpelvis is a contributing factor

PERSISTANT OCCIPUT POSTERIOR 2

Vaginal delivery:1. Spontaneous delivery2. Forceps delivery3. Forceps rotation and delivery4. Manual rotation and delivery5. Outcome: Only %40 delivered

spontaneously and cesarean for O.P accounted for %12 of all cesarean for dystocia.

PERSISTANT OCCIPUT TRANSVERSE

Etiology:Etiology: Android or platypelloid pelvis and hypotonic uterine contraction

Delivery:Delivery: If rotation ceases because of poor expulsive forces and pelvic contractures are absent, oxytocin, manual or forceps rotation is recommended.

UMBLICAL CORD COMPLICATIONUMBLICAL CORD COMPLICATIONThe mean length of umbilical cord at

term 55-60 cm (35-80cm)

The longest umbilical cord reported (129cm)

Male fetus have larger cord (1.6cm at term)

Vertex fetuses have cord 4.5cm longer than breech

There is no correlation between cord length and either fetal or placental weight.

CORD PROLAPSE CORD PROLAPSE 11 Incidence: %0.2-%0.6

(%0.4 in normal cord and never occurs with cords shorter than 35 cm and %4-%6 with cords longer than 80cm)

CORD PROLAPSE CORD PROLAPSE 22 Causative factors:1. Excessive cord length2. Mal presentation in %50 cases3. L.B.W in %30-%50 of cases4. Grand multiparity (<5 pregnancies) in

%105. Multiple gestation in %10 of cases6. Rupture of membrane in %10-%15

of cases

CORD PROLAPSE CORD PROLAPSE 33Diagnose: should be suspected in any F.H.R abnormalities after rupture of the membranes and confirmed by palpation the cord alongside the presenting part

Management: Trendelenburg or knee chest position and presenting part manually elevated through vaginal exam and cesarean as soon as possible

Perinatal mortality is almost %15

TRUE KNOTSTRUE KNOTSIncidence: %1(%0.3-%2.1), in longer cord is more common (%3 in cord longer than 80cm)

Diagnose: Only after delivery

Tight knot will demonstrate variable deceleration and must be manage

No differnce in 5-minute Apgar scores or neurologic abnormalities at 1 year

%4-%5 stillborns have through knots compared with %1 live-born infants

NUCHAL CORDNUCHAL CORDIncidence: %25One loop %21 and two or more loops %4

%0.1 four or more loops%14 with short cords and %53 in long cords

No evidence that nuchal cord cause fetal death or significant fetal distress

No increase in the incidence of depressed 5- minute Apgar score, perinatal mortality or abnormal neonatal development.