The only normal presentation is the complete flexed cephalic presentation of the vertex.
Malpositions and Malpresentations Carry increased risk for both 1. Mother and Fetus Must be managed by 2. experienced personnel.
Maternal Risks: Prolonged labour 1. Infection/ Pueperal sepsis 2. Obstructed labour 3. Injury to bladder, vagina and 4. rectum Maternal Haemorrhage 5. Thrombo-embolism 6. Ruptured Uterus 7.
Fetal Risks: Perinatal Mortality and 1. Morbility Cord Prolapse 2. Perinatal infection and 3. Meconium Aspiration Traumatic injury 4.
The Position The relationship of the presenting part to the mothers pelvis
The Denominator An arbitrary part of the presentation used to denote the position of the presenting part with regard to the pelvis
The Denominator Occiput in vertex Sacrum in breech Mentum in face presentation Scapula in shoulder presentation
The vertex The area bounded by the anterior and posterior fontanelles and the parietal eminences
• Malposition – The fetus is lying longitudinally and the vertex is presenting, but it is not in the OA position • OP
Aetiology Narrow fore pelvis (android &anthropoid pelvis) Anterior insertion of the placenta Maternal kyphosis Placenta praevia ,tumor ,fibroid (anteriorly) Idiopathic Faults in passanger : Dead fetus , twins, oligohydrominos Faults in power : Pendelous abdomen Idiopathic ( 10-20%)
Occipto Posterior Position OP Diagnosis During Labour vaginal examination during labour : High presenting part Anterior fontanel felt near to the symphysis Posterior fontanel felt near to the sacral promontory
○ Mechanism of labour in OP 75 % of the vertex rotate from the posterior position to anterior position and deliver as Occipito anterior 5 % of the vertex continue labour in Posterior position and deliver as Face to Pubis 20% will end as deep transfers arrest and need to be delivered by vacuum rotation by rotational forceps by Cesarean Section
Nursing care Assessment • Backache. • Prolonged first stage. • Poor progress of labor Nursing Diagnosis Pain related to uterine contractions and prolonged first stage. Ineffective individual coping related to backache. Discomfort and slow progress of labor.
Encourage side lying position: The woman should lie on the right side in case of left occipito posterior. The woman should lie on the left side in case of right occipito posterior. Knee chest position relives backache and assists fetal rotation. Apply sacral pressure, or warm back and give back massage.
Encourage ambulation if not contraindicated Monitor maternal and fetal conditions and progress of labor regularly. Administer analgesics as prescribed to relieve pain. Maintain adequate hydration. Help the woman to resist the urge to bear down to prevent cervical edema. Explain the cause of prolonged labor to relieve anxiety and encourage relaxation.
Offer support and reassurance to alleviate feelings of frustration and exhaustion. Use aseptic technique to prevent infection due to prolonged labor. No food is permitted because general anesthesia may be used. Assist with the delivery.
The fetus is lying longitudinally, but presents in any manner other than vertex • BREECH • FACE • BROW • SHOULDER • CORD
BREECH PRESENTATION Definition The fetal buttocks or lower extremeties present into the maternal pelvis Incidence 15% (30W) 3% at term
AETIOLOGY Fetal Prematurity Multiple Anomalies: often those that restrict the ability of the fetus to assume a vertex presentation (Hydrocephaly, anencephaly ,and congenital dislocation of the hip). IUFD
Maternal Liquor oligohydramnios/polyhydramnios Uterine anomalies (bicornuate, fibroid) Placenta praevia Pelvis contraction, pelvic tumours obstructing birth canal Laxity of uterus in multipara Idiopathic (20%)
TYPES OF BREECH Frank (breech with extended legs): 65% More common in primigravida Both fetal thighs flexed Both lower limbs extended at the knee Complete (fully flexed): 25% When both fetal thighs and knees are flexed Incomplete: 10% Footling (rare) :one or both fetal thighs are extended, and one or both feet lie below the buttocks Knee presentation ( very rare): one or both fetal thighs are extended, and one or both knee lie below the buttocks
Complications Maternal Prolonged labor Cervical , vaginal , perineal laceration and even ruptured uterus Trauma Sepsis PPH Anesthetic complications. ,
Fetal: Cord prolapse. Birth injuries: Fracture humerus, clavicle or femur Dislocation of hip joint. Erb's palsy. Trauma to internal organs such as spleen, liver, kidneys, lungs, supra renal, etc. Intra-cranial hemorrhage due to rapid delivery of head Asphyxia due to: Cord compression. Retraction of placental site. Premature attempt of respiration. Delayed delivery of the head.
Management of breech presentation at term I. Breech associated with complcations C.S. II. Not associated complication: 3 options need to be explained to the mother: 1.ECV 2.Elective C. S (planned) 3.Trial of planned vaginal breech delivery
External cephalic version(ECV) to avoid breech presentation
EXTERNAL CEPHALIC VERSION SUCCESS 60-70% TECHNIQUE Between 32- 36 weeks CTG prior tocolytic CTG after (8% bradycardia; 5% fetomaternal haemorrhage) anti D (if Rh negative)
Complications of (ECV) – Accidental hemorrhage – Premature labor – Cord presentation – Fetal shock Contraindications of (ECV) – Pre-eclampsia or hypertension – because of the increased risk of placental abruption – Multiple pregnancy – Oligohydramnios – because too much force has to be applied directly to the fetus and the version is likely to be unsuccessful – Ruptured membranes – Any condition that would require delivery by caesarean section.
Elective C. S (planned) Some obstetricians believe that the risks to the fetus of a breech delivery are such that all cases of breech presentation should be delivered by C.S and some would not attempt an external version . Others will be resorted to C.S for : Elderly primigravida 1. Premature fetus (gestional age of 25-34 weeks 2. Contracted pelvis 3. Deflexed fetal head 4. Estimated fetal weight ≥ 3800 gm or more ( a large fetus) 5. Incomplete breech presentation 6. Unengaged presenting part 7. Bad obstetric history 8. Prolonged rupture of membranes 9.
Planned Vaginal Breech Delivery Requirements: -Frank breech - Young multipara - roomy pelvis - Flexed fetus - Engaged breech - Intact membranes - Good uterine contraction - Without any complication or abnormalities - In hospital & with specialist & assistant - Gestational age ≥ 34 weeks
Planned Vaginal Breech Delivery 1. Spontaneous breech delivery (without any traction or manipulation), This occurs only in precipitate labor when the uterine contractions are strong , multipara , pelvis is roomy and premature baby . 2. Assisted breech delivery 3. Total breech extraction: the fetal feet are grasped, and the entire fetus is extracted, it is associated with a birth injury rate of 25% and a mortality rate of approximately 10%.
Assisted Vaginal Breech Delivery Roles However, before considering a normal breech delivery you must ensure that all conditions for a safe vaginal breech delivery are met key is waiting to allow the delivery to occur spontaneously Refrain from touching the fetus until the umbilicus is visible {premature assistance will result in: incomplete cervical dilatation & deflection of the head} Avoid PROM to avoid cord prolapse Partogram Continuous fetal monitoring Analgesia Inform neonatologest Keep theater staff and the anesthetist informed Episitomy
Nursing management Vigilant monitoring of maternal and fetal conditions and the progress of labor. At first stage: -Keep mother in bed if breech is not engaged to prevent early rupture of membrane . -If membrane rupture ,PV to detect cord prolapse -Careful & continuous monitoring for fetal, maternal & uterine action. -Oxytocic drug if uterine hypotonic present.
Nursing management At second stage: -Prepare the instrument needed for episitomy & forceps - Don’t allow women to push until cervix is fully dilated, then encourage her to push with contraction after full dilatation.
Assist in delivery by preparing warm towel to cover the infant's trunk before expulsion of the head. This will maintain the infant's temperature and prevent inhalation of amniotic fluid as a reaction to cold environment outside the uterus. Resuscitate the baby if needed.
No downward or outward traction is applied to the fetus until the umbilicus has been reached .
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