Presentation on theme: "Non Vertex Presentation"— Presentation transcript:
1 Non Vertex Presentation In The Name Of GodNon Vertex PresentationDr. Zohreh Lavasani
2 Breech presentation Incidence: %3-%4 Term single fetus Gestational age:
3 Predisposing factors Previous breech delivery Oligohydramnious PolyhydramniousUterine relaxation due to parietyMultiple pregnancyFetal anomaly(Malformation of C.N.S such as Anencephaly,Hydrocephaly %1.5-%2)Pelvic massUterine abnormalityPlacenta previaChromosomal abnormality up to %1
11 Types Of Breech Presentation Frank Incomplete Complete
12 Complications L.B.W (Preterm and I.U.G.R) Perinatal mortality (4 fold in term fetus and 2-3 fold in preterm,1/3 are preventable) and morbidityHead TraumaCNS TraumaSofte Tissue&Muscle TraumaDecelaration Of FHRCP
13 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.
14 Prognosis 2Perinatal mortality and morbidity: prognosis of the fetus is considerably worse than the vertex presentationMajor Contributers: preterm delivery, congenital anomaly and birth traumaOutcomes: Due to careful assesment before vaginal delivery and increased cesarean, bad outcomes are decreased from %9 to %3 from to
15 Vaginal Delivery Pelvic exam and breech type Time 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 fetusInduction of labor
17 RECOMMENDATION FOR DELIVRERY Up to %87 cesareanFrank breech term with E.F.W= Grams and adequate pelvis and flexed head is good candida for vaginal delivery
18 Recommendation for cesarean Large fetusAny degree of contraction or unfavarable shape of the pelvisHyperextension of fetal headIndicated deliveryUterine dysfunctionIncomplete or footling breechAn apparently healthy and viable fetus in mother with indicated delivery or in active laborSever I.U.G.RPrevious prenatal death or children suffering from birth traumaRequest of T.LLack of experienced operator
20 Labor management 1During 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 conditionA venous catheter is inserted and infusion begun as soon as possible
21 Labor management 2Route 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
22 Labor management 3 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
23 Delivery team Skilled obstetrician An associate to assist delivery An anesthesia personnelAn individual trained to resuscitate infant
30 Delivery of the aftercoming Head Mauriceau ManeuverPrague ManeuverPiper ForcepsGentel traction on the fetal body with cervix manually slipped over the occiputDuhrssen incisionI.V nitroglycerin is recommended by someSymphysiotomy
33 ANALGESIA AND ANESTHESIA The second stage is significantly prolongPudendal block for episiotomy and intravaginal manipulation, Nitrous oxide plus oxygen provide further relief painIf general anesthesia is required,it can be induced with thiopental plus a muscle relaxant
34 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.
35 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.
39 Indications for external cephalic version 1 Breech presentation with 36 weeks of gestation and not in laborVersion should not be done if N.V.D is contraindicated(previa, nonreassuring fetal status or uterine incision)
40 Indications for external cephalic version 2 Version is succesful in multiparous women with non engaged fetus and normal A.FFactors 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
41 TECHNIQUE OF VERSION 1Should be done in an area that has ready access to perform emergency cesareanSonography (A.F,previa,fetal anomalies)Fetal monitoringTocolysis and epidural analgesiaRH immunizationForward roll /backwardroll
42 TECHNIQUE OF VERSION 2Version is discontinued if exessive discomfort, persistant abnormal F.H.R or after multiple attemptsThe 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.
43 TRANSVERSE LIE Incidence: %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)
44 TRANSVERSE LIE (Etiology) Abdominal wall relaxation due to parity (10 fold in p4)Preterm fetusPlacenta previaExcessive amnionic fluidContracted pelvis
45 NEGLECTED TRANSVERSE LIE MANUVER OF LEOPOLDNEGLECTED TRANSVERSE LIE
46 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)
47 MECHANISM OF LABOR 2 Version 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)
49 FACE PRESENTATION 1The 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 %0.17Labor usually impeded in term fetus with M.P
50 FACE PRESENTATION 2Flexion of the head and vaginal delivery is typical in M.APresenting diameter is trachelobregmatic(7 mm longer than subocciputobrematic)قطر تِراکِلُو بِرِگماتیک یعنی فاصله بین فونتانل قدامی و محل اتصال کف دهان بر گردنDiagnose: Vaginal ExamD.D: Frank Breech
51 Etiology of face presentation Any factor that favors extension or prevent head flexionMarked enlargement of the neckCoils of cord about the neckAnencephal fetusContraction of pelvis (%40 inlet contraction)Large fetusMultiparous women
52 Management of laborIn 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 longerOxytocin is not a cotraindication
55 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
56 BROW PRESENTATION 2 Etiology: The causes are same as for the face presentationLABOR:Brow presentation is unstable and often converts to face (%30) or occiput (%20) and prognosis for delivery depends on the ultimate presentation
58 COMPOUND PRESENTATION In 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)
59 COMPOUND PRESENTATION Etiology: causes are conditions that prevent complete occlusion of the pelvic inlet by the fetal head like preterm birthPrognosis: perinatal loss is increased due to preterm delivery, cord prolapse and traumatic obstetrical prodcedureManagement: In most cases, the prolapsed part will not interfere with labor
61 PERSISTANT OCCIPUT POSTERIOR 1 Most often undergo spontaneous anterior rotationIncidence: %15 early in labor and %5 at deliveryEtiology: unknown, but transverse narrowing of the midpelvis is a contributing factor
62 PERSISTANT OCCIPUT POSTERIOR 2 Vaginal delivery:Spontaneous deliveryForceps deliveryForceps rotation and deliveryManual rotation and deliveryOutcome: Only %40 delivered spontaneously and cesarean for O.P accounted for %12 of all cesarean for dystocia.
63 PERSISTANT OCCIPUT TRANSVERSE Etiology: Android or platypelloid pelvis and hypotonic uterine contractionDelivery: If rotation ceases because of poor expulsive forces and pelvic contractures are absent, oxytocin, manual or forceps rotation is recommended.
65 UMBLICAL CORD COMPLICATION The mean length of umbilical cord at term 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 breechThere is no correlation between cord length and either fetal or placental weight.
66 CORD PROLAPSE 1Incidence: %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)
67 CORD PROLAPSE 2 Causative factors: Excessive cord length Mal presentation in %50 casesL.B.W in %30-%50 of casesGrand multiparity (<5 pregnancies) in %10Multiple gestation in %10 of casesRupture of membrane in %10-%15 of cases
68 CORD PROLAPSE 3Diagnose: should be suspected in any F.H.R abnormalities after rupture of the membranes and confirmed by palpation the cord alongside the presenting partManagement: Trendelenburg or knee chest position and presenting part manually elevated through vaginal exam and cesarean as soon as possiblePerinatal mortality is almost %15
70 TRUE KNOTSIncidence: %1(%0.3-%2.1), in longer cord is more common (%3 in cord longer than 80cm)Diagnose: Only after deliveryTight knot will demonstrate variable deceleration and must be manageNo differnce in 5-minute Apgar scores or neurologic abnormalities at 1 year%4-%5 stillborns have through knots compared with %1 live-born infants
71 NUCHAL CORD Incidence: %25 One loop %21 and two or more loops %4 %0.1 four or more loops%14 with short cords and %53 in long cordsNo evidence that nuchal cord cause fetal death or significant fetal distressNo increase in the incidence of depressed 5- minute Apgar score, perinatal mortality or abnormal neonatal development.