presentation of the vertex. Malpositions and Malpresentations - - PowerPoint PPT Presentation

The only normal presentation is the complete flexed cephalic presentation of the vertex.

Malpositions and Malpresentations

1.

Carry increased risk for both Mother and Fetus

2.

Must be managed by experienced personnel.

Maternal Risks:

1.

Prolonged labour

2.

Infection/ Pueperal sepsis

3.

Obstructed labour

4.

Injury to bladder, vagina and rectum

5.

Maternal Haemorrhage

6.

Thrombo-embolism

7.

Ruptured Uterus

Fetal Risks:

1.

Perinatal Mortality and Morbility

2.

Cord Prolapse

3.

Perinatal infection and Meconium Aspiration

4.

Traumatic injury

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,

• ligohydrominos

 Faults in power : Pendelous abdomen  Idiopathic ( 10-20%)

vaginal examination during labour :

 High presenting part  Anterior fontanel felt near to the symphysis Posterior fontanel felt near to the sacral promontory

Diagnosis During Labour Occipto Posterior Position OP

○ 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

• bstructing 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 :

1.

Elderly primigravida

2.

Premature fetus (gestional age of 25-34 weeks

3.

Contracted pelvis

4.

Deflexed fetal head

5.

Estimated fetal weight ≥ 3800 gm or more ( a large fetus)

6.

Incomplete breech presentation

7.

Unengaged presenting part

8.

Bad obstetric history

9.

Prolonged rupture of membranes

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 .

The anterior arm is followed to the elbow, and the arm is swept out of the vagina.

The fetus is rotated 180°, and the contralateral arm is delivered in a similar manner as the first. The infant is then rotated 90° to the back-up position in preparation for delivery of the head .

The after coming head is delivered by one of the following methods

Jaw flexion –shoulder traction

MAURICEAU – SMELLIE – VEIT maneuver

Forceps for the after coming head

Definition

Cord Presentation : Descent of the umbilical cord below the presenting part with an intact bag of membranes. Cord Prolapse: Where the umbilical cord lies in front of or beside the presenting part in the presence of ruptured membranes.

Contributing factors

 Transverse and oblique lie  Breech presentation  Disproportion  Multiple pregnancy  Polyhydramnios  Pelvic tumours  Pre-term rupture of membranes  Placenta praevia

Pathophysiology

 When the presenting part does not fit

into the lower uterine segment, as in polyhydrominous or when the membranes rupture, a sudden gush of amniotic fluid may cause the cord to be displaced downward

• Cord presentation is seldom discovered
• Diagnosis of cord prolapse is made by visual inspection or

palpation on vaginal examination where the umbilical cord is felt below or beside the presenting part.

• CTG abnormality (bradycardia, severe variable

decelerations) suggestive of cord prolapse Where predisposing risk factors exist a vaginal examination should be performed after the membranes rupture or of fetal bradycardia occurs after rupture of membranes.

Prevention



Identify risk factors or identify a cord presentation

• n ultrasound.



Artificial rupture of membranes (ARM) should not be done when the station is high.



If ARM is essential to manage a difficult obstetric situation and the head is not engaged and high; controlled ARM by senior medical staff



Ensure emergency theatre is available prior to ARM.



The same procedure should take place in the situation of polyhydraminos.

Management of cord presentation

 Positioning the woman such that

gravity tends to keep the presenting part off the cord, i.e. knee-elbow position

 Infusion of fluid, e.g. 500 ml saline, into

the bladder, via a size 16 catheter

 Keeping the cord in the vagina and

avoiding handling in order to prevent spasm

Management of cord prolapse

 The aim of the management in the few

minutes it takes to perform a caesarian section is to prevent the compression of the cord by the presenting part. Thus: Determine if the cord is still pulsating If the cord is pulsating then push any exposed loop back into the vagina so to keep it warm and moist

Management of cord prolapse

 Displacement of the presenting part, in particular

during a contraction, by putting a hand in the vagina, so that the presenting part does not compress the cord

 Note: If the presenting part is sufficiently low in

the pelvis and the cervix is fully dilated then an experienced obstetrician might undertake a vaginal delivery (forceps if cephalic presentation

• r breech extraction). Otherwise an immediate

caesarian section is indicated.

Cord Presentation

 Check fetal heart sound.  Place the woman in knee chest, trendlenburg or

exaggerated Sim’s or left lateral position to alleviate pressure on the cord and avoid fetal suffocation from lack of oxygen .

 The doctor or midwife may insert a sterile gloved

hand into the vagina to remove pressure from the umbilical cord.

 Ask the mother to avoid bearing down efforts.  Supply oxygen to the mother as it ultimately reaches

the fetusApply an abdominal binder to maintain the presenting pad in place and avoid crushing of the cord.

 To reduce anxiety, speak to the woman calmly and

quietly, explain procedures and answer her questions.

Cord Prolapse

In case of’ cord prolapse:



If the cord is pulsating, the type of delivery will depend upon maternal and fetal condition, cervical dilatation, presentation and position.



If the cord is not pulsating in case of fetal death, the women will be left to deliver spontaneously.

Cord prolapse is an obstetric emergency and delivery must be as quick as possible C/S is necessarily except if :

The cervix is fully dilated and the presenting part is engaged forceps or vacuum can be performed by experienced obstetrician. Death fetus with no other indication for C/S allow vaginal delivery.

Cord Prolapse, cont.

Cord Prolapse, cont.

 Summons medical assistance; Obstetrician, Anesthetist,

Pediatrician.

 Immediate assessment of clinical circumstances;

gestation, presentation, cervical dilatation, fetal wellbeing.

 Woman placed in knee to chest position, alternatively

exaggerated Simms position - Left lateral supported with 2 pillows.

 The presenting part is pushed out of the pelvis upward

by fingers in the vagina to relieve pressure on the cord by the presenting part. This is to continue until delivery is commenced.

 If the cord is protruding replace it into the vagina. Avoid

• ver handling as it can cause spasm.

Cord Prolapse, cont.



Administer oxygen to the woman via a mask, discontinue oxytocics if present.



Provide reassurance and explanation to the woman.



Delivery must be expedited to reduce morbidity and mortality to the fetus.



If vaginal birth not imminent. Continue efforts to hold the presenting part off the

• cord. Deep trendelenburg position is also

useful to add gravity to other efforts to elevate the fetus off the cord.



Monitor fetal heart rate.