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Malposition & Malpresentation: Ahmad Makhlouf
Malposition & Malpresentation: Ahmad Makhlouf
Malposition & Malpresentation: Ahmad Makhlouf
MALPRESENTATION
By
Ahmad Makhlouf
Contents
Breech Presentation
Complex Presentation
INCIDENCE
POSITION
ETIOLOGY
MECHANISM OF LABOR
DIAGNOSIS & INVESTIGATIONS
MANAGEMENT DURING PREGNANCY, LABOR
COMPLICATIONS
COMPLICATIONS
MATERNAL • FETAL
1) PROM 1) Asphyxia
2) Cord prolapse 2) Operative birth injuries
3) Prolonged labor 3) Intracranial hemorrhage
4) Obstructed labor
5) Uterine inertia
6) PPH
7) Perineal lacerations
8) Puerperal sepsis
Breech Presentation
Breech presentation
Definition:
It is a malpresentation in which the
presenting part is breech, the denominator is
the sacrum and the head is extended or
flexed.
Complete
breech(left Frank breech
sacroposterior)
Three types of breech
Frank or extended Complete or flexed Footling breech:
breech: 65 to 70% breech: 30% 10%
lumbar spine
Breech presentation
Etiology: (fetal causes)
1. Prematurity (50%) the most common cause due to:
5. Multiple pregnancy
Breech presentation
Etiology: (maternal causes)
• Polyhydramnios allow free fetal movement
• Oligohydramnios interfere with spontaneous version
• Septate, bicornuate uterus decrease the capacity of the fundus
• Fundal myoma decrease the capacity of the fundus
• Multiparity due to laxity of abdominal & uterine walls allow free fetal
movement
• Idiopathic
• Contracted pelvis doesn’t lead to breech
Risk factors for persistent
breech presentation
Fetal conditions
Maternal conditions
• Multiparity • Preterm delivery
• Congenital uterine anomalies • Polyhydramnios
• Uterine fibroids • Oligohydramnios
• Previous breech presentation • Fetal macrosomia
• Placenta previa or cornual placenta • Multiple pregnancy
• Cephalo-pelvic disproportion • Fetal anomalies
Breech presentation
Diagnosis: (during pregnancy)
2. Inspection:
buttock.
Accurate documentation
1. CS delivery
4. Breech extraction
1- CS delivery when?
Absolute Indications of CS in Breech presentation:
1- Breech with primigravida
2- Breech with Contracted pelvis
2- Breech with Preterm delivery <2000 g
3- Breech with Fetal size > 3800 g.
4- Breech with Hyperextended head.
5- Footling breech
1. Once the breech appears at the vulva, a sterile pad is applied over
the buttocks &push it upwards during contractions to ensure full
cervical dilatation , increase head flexion and prevent arrest of
head .
Assisted breech delivery
1. Burns-Marshal method
2. Jaw flexion and shoulder traction (Mauriceau-
Smellie-Veit method).
3. Piper Forceps Delivery of the aftercoming
head
Burns –Marshall technique
1. The body of the fetus is left hanging down from the mother (but
supported to avoid slipping).
2. This leads to help engagement, increase flexion.
3. After the suboccipital region appears below SP ( to avoid fracture
dislocation of cervical spine) the head is delivered by lifting the
fetal body towards the mother abdomen (not more than 90).
4. The head is delivered by flexion.
Mauriceau- Smellie- Veit technique
Jaw Flexion – Shoulder Traction
1. The fetus is put on the left arm with
the index, middle fingers introduced
into its mouth to increase head
flexion.
2. The index, middle fingers of the
right arm are applied over the
shoulders from behind.
3. Traction is applied downwards and
backwards until the suboccipital
region appears below SP.
4. Then the fetus is moved upward
towards the mother abdomen to
deliver the head in flexion.
Piper forceps delivery
1. The forceps is applied from the
abdominal aspect of the fetus.
2. Traction is applied downward and
backward till the suboccipital region
appears below SP.
3. Then elevated upward to deliver the
head in flexion.
4. Aesthesia is necessary for forceps
application.
5. Advantages: promotes head flexion,
prevent traction on the neck, protects
the head from compression –
decompression, intracranial hge.
Complications of breech delivery
A- Maternal : as scheme.
B - Fetal mortality
1- Intracranial hemorrhage: (the commonest cause of death (50%)
1.Rapid compression-decompression as there is no sufficient time for
moulding to occur.
INDICATIONS:
Breech diagnosed at 36 – 38 weeks.
Transverse lie from 36 – 38 weeks.
EXTERNAL CEPHALIC VERSION
CONTRAINDICATIONS:
Elderly PGDA
Contracted pelvis
Antepartum hemorrhage
Hypertensive disorders
Multiple pregnancy
Uterine scar or anomalies
Poly or oligohydramnios
PROM
Hydrocephalus, macrosomic baby
EXTERNAL CEPHALIC VERSION
TECHNIQUE:
Before 1. Abdominal US to confirm diagnosis
ECV 2. No anesthesia
3. Tocolytic as ritodrine can be given IV drip to
relax the uterus
4. Empty bladder, rectum
EXTERNAL CEPHALIC VERSION
TECHNIQUE:
ECV Stop manipulations immediately if there is:
•Pain
•FHR changes
•Vaginal bleeding occurs
EXTERNAL CEPHALIC VERSION
TECHNIQUE:
After 1. FHS is heared again, if there is fetal distress
ECV for more than 5 minutes, the fetus is returned
back to its position as the cord may be coiled
2. Give anti –D if RH negative
EXTERNAL CEPHALIC VERSION
COMPLICATIONS:
PROM
Placental separation
Preterm labor
Cord prolapse, true knots, coiling around fetus
Fetal shock, distress, death
Rupture uterus
Rh isoimmunization
Amniotic fluid embolism
Failure or recurrence
Shoulder presentation
Shoulder presentation
Definition:
2. Palpation:
- FL < amenorrhea
- FG: empty
- - UG: head to one side, lower & breech on other side, higher
( because it is heavier)
- -1st PG: empty
3. Auscultation:
- FHS heared on the side of the umbilicus (head)
Shoulder presentation
Diagnosis: (during labor)
1. Abdominal examination: ( as before)
Definition:
It is a shoulder presentation, the patient allowed in labor
(neglected) for a long time , so the shoulder become impacted
with the full picture of obstructed labor, impendeing rupture uterus
and dead fetus
C/P: Full picture of obstructed labour : refer to this lecture and
Farouk Haseeb book
Neglected Shoulder
NEGLECTED SHOULDER
Management:
1- correction of general condition by proper IV rehydration and
correction of acidosis
2- Urgent CS regardless of the fetal state
3- A tocolytic may be administered to allow for uterine relaxation
during fetus extraction.
4- A vertical LUS will be performed
5- Guard againt PPH
6- Antibiotics to guard againt GBS infection
7- Examine the genital tract for lacerations after CS
Cord presentation
Cord presentation
Definition: