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MALPRESENTATION &MALPOSITION. LECTURE OVERVIEW Abnormal lie, malpresentation and malposition Abnormal lie, malpresentation and malposition Malpresentation.

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Presentation on theme: "MALPRESENTATION &MALPOSITION. LECTURE OVERVIEW Abnormal lie, malpresentation and malposition Abnormal lie, malpresentation and malposition Malpresentation."— Presentation transcript:

1 MALPRESENTATION &MALPOSITION

2 LECTURE OVERVIEW Abnormal lie, malpresentation and malposition Abnormal lie, malpresentation and malposition Malpresentation and its management Malpresentation and its management  breech  face  brow  shoulder  compound

3 DEFINITIONS Abnormal lie Abnormal lie  where the long axis of the fetus is not lying along the long axis of the mother  LONGITUDINAL (MAY BE EITHER CEPHALIC OR BREECH)  TRANSVERSE  OBLIQUE  UNSTABLE

4 DEFINITIONS Malpresentation Malpresentation  where the fetus is lying longitudinally, but presents in any manner other than vertex  BREECH  FACE  BROW  SHOULDER  COMPOUND  CORD

5 DEFINITIONS Malposition Malposition  where the fetus is lying longitudinally and the vertex is presenting, but it is not in the OA position  OT (LOT, ROT)  OP

6 DEFINITIONS Malpresentation Malpresentation  where the fetus is lying longitudinally, but presents in any manner other than vertex  BREECH  FACE  BROW  SHOULDER  COMPOUND  CORD

7 MANAGEMENT OF BREECH PRESENTATION AT TERM Management options (1) external cephalic version (2) elective caesarean section (3) trial of vaginal delivery

8 EXTERNAL CEPHALIC VERSION CONTRAINDICTAIONS: CONTRAINDICTAIONS:  3rd trimester bleeding  uterine anomalies  ROM, oligohydramnios  need for CS for other reasons (placenta praevia, contracted pelvis, hyperextended head)  indicated vaginal delivery (fetal death, anomaly best delivered as breech)

9 EXTERNAL CEPHALIC VERSION SUCCESS SUCCESS  60-70% TECHNIQUE TECHNIQUE  after 36W  CTG prior  attempt to perform forward somersault  tocolytic  CTG after (8% bradycardia; 5% fetomaternal haemorrhage)  anti D (if Rh negative)

10 ELECTIVE CAESAREAN SECTION EFW 3500g EFW 3500g preterm breech preterm breech hyperextended fetal head hyperextended fetal head palcenta praevia palcenta praevia concerns re. fetal well being, including oligohydramnios concerns re. fetal well being, including oligohydramnios footling breech footling breech  10% risk of cord prolapse ?complete breech ?complete breech  5% risk of cord prolapse (c.f. 1% with frank breech) ?all PG breech ?all PG breech

11 CRITERIA FOR VAGINAL DELIVERY Frank or complete breech Frank or complete breech EFW g EFW g gestational age >36 weeks gestational age >36 weeks fetal head must be flexed fetal head must be flexed maternal pelvis must be adequate maternal pelvis must be adequate  judged clinically or by pelvimetry no other maternal or fetal indiaction for CS no other maternal or fetal indiaction for CS experienced obstetrician, anaesthetist and paediatrician present at delivery experienced obstetrician, anaesthetist and paediatrician present at delivery

12 FACE PRESENTATION Incidence: 0.2% Incidence: 0.2% Mechanics of presentation: Mechanics of presentation:  Characterized by extreme extension of the fetal head so the face (rather than the skull) presents to the birth canal Aetiology Aetiology  any factor that favours extension such as fetal goitre, anencephaly  high maternal parity At diagnosis: At diagnosis:  60% mentoanterior  15% mentotransverse  25% mentoposterior

13 BROW PRESENTATION Incidence: 1:1400 Incidence: 1:1400 Mechanics of presentation: Mechanics of presentation:  head is extended such that attitude is halfway between flexion (vertex) and hyperextension (face)  usually transitional- when the head is in the process of converting from a vertex to a face or vice versa  presenting part is between the facial orbits and anterior fontanelle  supraoccipitomental diameter is presenting 13.5cm; cf 9.5cm for suboccipitobregmatic (vertex) or submentobregmatic (face)

14 AETIOLOGY Fetal Fetal  prematurity, multiple Liquor Liquor  polyhydramnios Uterine Uterine  anomaly Placenta Placenta  praevia Pelvis Pelvis  contraction, tumour Parity Parity  high maternal parity (80% of cases occur in women who are para3 or more)

15 MANGEMENT Exclude cord prolapse Exclude cord prolapse  occurs in up to 20% of cases Otherwise expectant Otherwise expectant  mostly doesn’t interfere with normal delivery  vertex-foot: try to gently reposition the lower extremity  if arm prolapses in vertex-hand, wait and see if it moves as head descends; if it converts to shoulder presentation, deliver by CS

16 SUMMARY Abnormal lie, malpresentation, malposition Abnormal lie, malpresentation, malposition Incidence, mechanics, aetiology, diagnosis, management of Incidence, mechanics, aetiology, diagnosis, management of  BREECH PRESENTATION  FACE PRESENTATION  BROW PRESENTATION  SHOULDER PRESENTATION  COMPOUND PRESENTATION


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