1. Non Vertex Presentation
In The Name Of God
Non Vertex Presentation
Dr. Zohreh Lavasani

2. Breech presentation Incidence: %3-%4 Term single fetus
Gestational age:

3. Predisposing factors Previous breech delivery Oligohydramnious
Polyhydramnious
Uterine relaxation due to pariety
Multiple pregnancy
Fetal anomaly(Malformation of C.N.S such as Anencephaly,Hydrocephaly %1.5-%2)
Pelvic mass
Uterine abnormality
Placenta previa
Chromosomal abnormality up to %1

5. No strong correlation between breech and contracted pelvis
Predisposing factors
No strong correlation between breech and contracted pelvis
In more than %50 no causative factor

7. Diagnosis
Abdominal exam
Vaginal exam
(D.D with face presentation)
Imaging techniques (Ultrasound,Pelvimetry, M.R.I and radiography)

8. Frank Breech

9. Complete Breech

10. Incomplete Breech

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 morbidity
Head Trauma
CNS Trauma
Softe Tissue&Muscle Trauma
Decelaration Of FHR CP

13. Prognosis 1
Both 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 2
Perinatal mortality and morbidity: prognosis of the fetus is considerably worse than the vertex presentation
Major Contributers: preterm delivery, congenital anomaly and birth trauma
Outcomes: 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 score
Hyperextension of fetal head
(%5),Stargaser fetus or flying fetus
Induction of labor

16. Breech Radiography

17. RECOMMENDATION FOR DELIVRERY
Up to %87 cesarean
Frank breech term with E.F.W= Grams and adequate pelvis and flexed head is good candida for vaginal delivery

18. Recommendation for cesarean
Large fetus
Any degree of contraction or unfavarable shape of the pelvis
Hyperextension of fetal head
Indicated delivery
Uterine dysfunction
Incomplete or footling breech
An apparently healthy and viable fetus in mother with indicated delivery or in active labor
Sever I.U.G.R
Previous prenatal death or children suffering from birth trauma
Request of T.L
Lack of experienced operator

19. Methods of vaginal delivery
Spontaneous breech delivery
Partial breech extraction
Total breech extraction

20. Labor management 1
During 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 condition
A venous catheter is inserted and infusion begun as soon as possible

21. Labor management 2
Route 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 personnel
An individual trained to resuscitate infant

24. Vaginal Delivery

25. Vaginal Delivery

26. Vaginal Delivery

27. Vaginal Delivery

28. Vaginal Delivery

29. Vaginal Delivery

30. Delivery of the aftercoming Head
Mauriceau Maneuver
Prague Maneuver
Piper Forceps
Gentel traction on the fetal body with cervix manually slipped over the occiput
Duhrssen incision
I.V nitroglycerin is recommended by some
Symphysiotomy

31. Mauriceau Maneuver

32. Duhrssen Incision
Prag Maneuver

33. ANALGESIA AND ANESTHESIA
The second stage is significantly prolong
Pudendal block for episiotomy and intravaginal manipulation, Nitrous oxide plus oxygen provide further relief pain
If 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.

36. Fracture of femur

37. VERSION
A procedure in which the fetal presentation is altered by physical manipulation
External cephalic version with %35-%80 success rate
Internal podalic version for delivery second twin

38. External cephalic version

39. Indications for external cephalic version 1
Breech presentation with 36 weeks of gestation and not in labor
Version 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.F
Factors 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 1
Should be done in an area that has ready access to perform emergency cesarean
Sonography (A.F,previa,fetal anomalies)
Fetal monitoring
Tocolysis and epidural analgesia
RH immunization
Forward roll /backwardroll

42. TECHNIQUE OF VERSION 2
Version is discontinued if exessive discomfort, persistant abnormal F.H.R or after multiple attempts
The 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 fetus
Placenta previa
Excessive amnionic fluid
Contracted pelvis

45. NEGLECTED TRANSVERSE LIE
MANUVER OF LEOPOLD
NEGLECTED 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)

48. Vertex sinciput brow face

49. FACE PRESENTATION 1
The 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 %0.17
Labor usually impeded in term fetus with M.P

50. FACE PRESENTATION 2
Flexion of the head and vaginal delivery is typical in M.A
Presenting diameter is trachelobregmatic
(7 mm longer than subocciputobrematic)
قطر تِراکِلُو بِرِگماتیک یعنی فاصله بین فونتانل قدامی و محل اتصال کف دهان بر گردن
Diagnose: Vaginal Exam
D.D: Frank Breech

51. Etiology of face presentation
Any factor that favors extension or prevent head flexion
Marked enlargement of the neck
Coils of cord about the neck
Anencephal fetus
Contraction of pelvis (%40 inlet contraction)
Large fetus
Multiparous women

52. Management of labor
In 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 longer
Oxytocin is not a cotraindication

53. FACE PRESENTATION

54. MENTUM POSTERIOR-MENTUM ANTERIOR

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 presentation
LABOR:
Brow presentation is unstable and often converts to face (%30) or occiput (%20) and prognosis for delivery depends on the ultimate presentation

57. POSTERIOR BROW

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 birth
Prognosis: perinatal loss is increased due to preterm delivery, cord prolapse and traumatic obstetrical prodcedure
Management: In most cases, the prolapsed part will not interfere with labor

60. COMPOUND PRESENTATION

61. PERSISTANT OCCIPUT POSTERIOR 1
Most often undergo spontaneous anterior rotation
Incidence: %15 early in labor and %5 at delivery
Etiology: unknown, but transverse narrowing of the midpelvis is a contributing factor

62. PERSISTANT OCCIPUT POSTERIOR 2
Vaginal delivery:
Spontaneous delivery
Forceps delivery
Forceps rotation and delivery
Manual rotation and delivery
Outcome: 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 contraction
Delivery: 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 breech
There is no correlation between cord length and either fetal or placental weight.

66. CORD PROLAPSE 1
Incidence: %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 cases
L.B.W in %30-%50 of cases
Grand multiparity (<5 pregnancies) in %10
Multiple gestation in %10 of cases
Rupture of membrane in %10-%15 of cases

68. CORD PROLAPSE 3
Diagnose: should be suspected in any F.H.R abnormalities after rupture of the membranes and confirmed by palpation the cord alongside the presenting part
Management: Trendelenburg or knee chest position and presenting part manually elevated through vaginal exam and cesarean as soon as possible
Perinatal mortality is almost %15

70. TRUE KNOTS
Incidence: %1(%0.3-%2.1), in longer cord is more common (%3 in cord longer than 80cm)
Diagnose: Only after delivery
Tight knot will demonstrate variable deceleration and must be manage
No 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 cords
No evidence that nuchal cord cause fetal death or significant fetal distress
No increase in the incidence of depressed 5- minute Apgar score, perinatal mortality or abnormal neonatal development.