MalpresentationMalpresentationpp

Presentation: is the lowest pole of the Presentation: is the lowest pole of the ppfetus that presents to the lower uterine fetus that presents to the lower uterine segment and the cervixsegment and the cervixsegment and the cervix segment and the cervix Normal presentation is vertexNormal presentation is vertex

malpresentationsmalpresentations : Any presentation other than the vertex, that is, breech, brow, face or

A i lA i l

than the vertex, that is, breech, brow, face or shoulder AetiologyAetiology::

contracted pelviscontracted pelvislarge babylarge babyPolyhydramniosPolyhydramniosPolyhydramniosPolyhydramniosmultiple pregnancymultiple pregnancyll l i l tl i l tlowlow--lying placentalying placentapreterm preterm labourlabouranomalies of the fetus (neck anomalies of the fetus (neck tumourstumours))uterus (congenital or acquired e g loweruterus (congenital or acquired e g loweruterus (congenital or acquired, e.g. lower uterus (congenital or acquired, e.g. lower segment fibroids).segment fibroids).

Brow presentationBrow presentationppthe head is half extended and presents to the head is half extended and presents to th l i ith th l t t t ith l i ith th l t t t ithe pelvis with the largest anteroposterior the pelvis with the largest anteroposterior diameter (mentodiameter (mento--vertical vertical -- 13 13 cm). cm).

The presentation may correct itself inThe presentation may correct itself inThe presentation may correct itself in The presentation may correct itself in labour by flexion and present as a vertex labour by flexion and present as a vertex or undergo further extension and presentor undergo further extension and presentor undergo further extension and present or undergo further extension and present as a face and may result in vaginal as a face and may result in vaginal d ld ldelivery delivery Persistence of brow presentation in labourPersistence of brow presentation in labourPersistence of brow presentation in labour Persistence of brow presentation in labour at term, is not compatible with vaginal at term, is not compatible with vaginal delivery and necessitates a CSdelivery and necessitates a CSdelivery and necessitates a CS delivery and necessitates a CS

In early In early labourlabour, preparations should be , preparations should be d k f CS d i ll dd k f CS d i ll dundertaken for CS and time allowed to see undertaken for CS and time allowed to see

whether flexion or extension would take whether flexion or extension would take place. place. Failure to progress in the next few hoursFailure to progress in the next few hoursFailure to progress in the next few hours Failure to progress in the next few hours in in labourlabour with the persistence of brow with the persistence of brow

t ti i i di ti f CS dt ti i i di ti f CS dpresentation is an indication for CS and presentation is an indication for CS and not for augmentation of not for augmentation of labourlabour with with oxytocinoxytocin..Complications inComplications in labourlabour include cordinclude cordComplications in Complications in labourlabour include cord include cord prolapseprolapse with membrane rupture and with membrane rupture and te ine pt e in neglected caseste ine pt e in neglected casesuterine rupture in neglected cases uterine rupture in neglected cases

Face presentation:Face presentation:Face presentation:Face presentation:

Face presentation is confirmed on vaginal Face presentation is confirmed on vaginal examination when the nose, eyes and the examination when the nose, eyes and the , y, yhard gum margins are palpated. hard gum margins are palpated.

The The submentosubmento--bregmaticbregmatic diameter enters diameter enters the pelvis In the vast majority it rotatesthe pelvis In the vast majority it rotatesthe pelvis. In the vast majority it rotates the pelvis. In the vast majority it rotates forwards to be in the forwards to be in the mentomento--anterior anterior position with the chin behind theposition with the chin behind theposition with the chin behind the position with the chin behind the symphysissymphysis pubis. pubis. The presenting lateral (The presenting lateral (biparietalbiparietal 99..5 5 cm) cm) andand anteroposterioranteroposterior ((submentosubmento--bregmaticbregmaticand and anteroposterioranteroposterior ((submentosubmento bregmaticbregmatic99..5 5 cm) diameters are conducive for cm) diameters are conducive for vaginal deliveryvaginal deliveryvaginal delivery. vaginal delivery. Descent is possible when the position is Descent is possible when the position is mentomento--anterior because of large space in anterior because of large space in the lateral sacral area.the lateral sacral area.the lateral sacral area.the lateral sacral area.

If the face rotates to a mento-posterior position, although the diameters are the same as mento-anterior the lateralsame as mento-anterior, the lateral dimensions of the frontal bones are large and do not permit descent behind the narrow retropubic arch and hence a CS isnarrow retropubic arch and hence a CS is advisable.

Transverse Lie & Shoulder Transverse Lie & Shoulder presentation:presentation:

The baby lies with its long axis transverse The baby lies with its long axis transverse in the uterus, when the shoulder is usually in the uterus, when the shoulder is usually , y, ythe presenting part the presenting part Should rupture of membranes take placeShould rupture of membranes take placeShould rupture of membranes take place Should rupture of membranes take place with the fetus in the transverse lie, cord with the fetus in the transverse lie, cord

l h ld dl h ld dprolapse, shoulder presentation and arm prolapse, shoulder presentation and arm prolapse are likely possibilities with prolapse are likely possibilities with p p y pp p y pprogressive cervical dilatation.progressive cervical dilatation.

Diagnosis:Diagnosis:Th b l h f th t (thTh b l h f th t (thThe abnormal shape of the uterus (the The abnormal shape of the uterus (the fundusfundus being lower than expected), no being lower than expected), no fetal pole at the fetal pole at the fundusfundus or inor in the pelvic the pelvic inletinletinlet inlet

In early In early labourlabour an elongated bag of an elongated bag of forewatersforewaters may be felt vaginally which may be felt vaginally which y g yy g ycould contain a limb or a loop of cord.could contain a limb or a loop of cord.Neglected transverse lie will almostNeglected transverse lie will almostNeglected transverse lie will, almost Neglected transverse lie will, almost inevitably lead to uterine rupture. inevitably lead to uterine rupture.

Management:Management:f bl l d df bl l d dIf transverse or oblique lie discovered If transverse or oblique lie discovered

early in early in labourlabour it can be corrected by it can be corrected by yy yyexternal cephalic version if the external cephalic version if the membranes are intact.membranes are intact.membranes are intact.membranes are intact.Once the lie is corrected the membranes Once the lie is corrected the membranes h ld b t d & t i t tih ld b t d & t i t tishould be ruptured & uterine contractions should be ruptured & uterine contractions

will maintain the longitudinal lie.will maintain the longitudinal lie.

If the membranes rupture and the fetus is If the membranes rupture and the fetus is ppstill in the transverse lie, CS should be still in the transverse lie, CS should be performed to avoid injury to the fetus orperformed to avoid injury to the fetus orperformed to avoid injury to the fetus or performed to avoid injury to the fetus or the uterus. the uterus. I h th di i i d l tI h th di i i d l tIn cases where the diagnosis is made late In cases where the diagnosis is made late the fetus may be impacted in the the fetus may be impacted in the transverse lie and safe delivery may be transverse lie and safe delivery may be only possible by a CS with a midlineonly possible by a CS with a midlineonly possible by a CS with a midline only possible by a CS with a midline vertical incision. vertical incision. Labo and spontaneo s aginal deli eLabo and spontaneo s aginal deli eLabour and spontaneous vaginal delivery Labour and spontaneous vaginal delivery is possible in extreme preterm and is possible in extreme preterm and macerated fetuses. macerated fetuses.

Cord prolapseCord prolapse

Cord prolapse defined as the descent of the umbilical cord through the cervixthe umbilical cord through the cervix alongside (occult) or past the presenting part (overt) in the presence of rupturedpart (overt) in the presence of ruptured membranes.Cord presentation is the presence of theCord presentation is the presence of the umbilical cord between the fetal presenting part and the cervixpresenting part and the cervix.

The overall incidence of cord prolapseThe overall incidence of cord prolapse ranges from 0.1% to 0.6%.I d i t l t lit d tIncreased perinatal mortality due to prematurity, congenital malformations & birth asphyxia.The principal causes of asphyxia areThe principal causes of asphyxia are thought to be cord compression and

bili l t i lumbilical arterial vasospasm

Clinicians need to be aware of the risk factors associated with umbilical cordfactors associated with umbilical cord prolapse.

Risk factors for cord prolapseMultiparity :Artificial rupture of membranesp y pLow birth weight, less than 2.5 kg PrematurityyFetal congenital anomaliesBreech presentationpTransverse, oblique and unstable lie Second twinPolyhydramniosUnengaged presenting partg g p g pLow-lying placenta, other abnormal placentation

Can cord prolapse or its effects be avoided?avoided?

C d l h ld b t d hCord prolapse should be suspected where there is an abnormal fetal heart rate pattern (bradycardia,variable decelerations etc), particularly if such changes commence soon p y gafter membrane rupture, spontaneously or with amniotomywith amniotomy.

What is the optimal initial management of cord prolapse in hospital settings?p p p gWhen cord prolapse is diagnosed before full dilatation assistancebefore full dilatation, assistance should be immediately called and preparations made for immediatepreparations made for immediate delivery in theatre.T t th h ldTo prevent vasospasm, there should be minimal handling of loops of cord l i t id th ilying outside the vagina.To prevent cord compression, it is p p ,recommended that the presenting part be elevated either manually or p yby filling the urinary bladder.

Bladder filling can be achieved quickly by inserting the end of a blood giving set into g g ga Foley’s catheter. The catheter should be clamped once 500–750 ml has beenclamped once 500 750 ml has been instilled.

l h bl ddIt is essential to empty the bladder again just before any delivery attempt, be it j y y p ,vaginal or caesarean section.

Cord compression can be further reduced by the mother adopting the knee–chest position or head-down tilt (preferably in left-lateral position).

Tocolysis can be considered while ypreparing for caesarean section if there are persistent fetal heart rate abnormalities after attempts to preventabnormalities after attempts to prevent compression mechanically and when the delivery is likely to be delayed.

What is the optimal mode of delivery with cord prolapse?

i i h d dA caesarean section is the recommended mode of delivery in cases of cord prolapse when vaginal delivery is not imminent towhen vaginal delivery is not imminent, to prevent hypoxia–acidosis of the baby .

If babay is dead vaginal delivery is the route if no babay s d ad ag a d y s ou ocontraindications