ABNORMAL PRESENTATION & BREECH DR. IQBAL TURKISTANI ASST. PROF. & CONSULTANT

Malpositions & Malpresentations  carry an increased risk for both mother and fetus Maternal risks: - Prolonged labour infection - Obstructed labour - General anaesthesia at short notice, when the mother is in poor condition - Difficult vaginal delivery or C.S. trauma leading to haemorrhage - Damage to pelvic veins resulting to venous thrombosis and fatal pulmonary embolism in the puerperium

In developing countries  obstructed labour may cause tissue necrosis vesico- vaginal and recto-vaginal fistula.  Perinatal mortality and morbidity:  due to fetal malformation  intrauterine death  extreme prematurity  cord prolapse + malpresentation Potent  abnormal uterine action causes and prolonged or obstructed of fetal labour hypoxia  Fetus at risk of infection (: prolonged ROM) and also meconium aspiration

Significant proportion of ruptured uterus still result into maternal deaths from unwise management of malpresentation or malposition Therefore, for optimal result/safe labour and delivery:  Early diagnosis by skilled assessment  Plan delivery by experienced staff  Working in proper surrounding  Experienced anaesthesia must be available for these most difficult cases  Close supervision and full use of available monitoring methods ..if vaginal delivery is planned  Facilities to perform immediate operative delivery or caesarean section are mandatory  Review of progress and necessary intervention by senior staff members is the rule

LIE, PRESENTATION POSITION The relationship of the long axis of the foetus to that of the mother LONGITUDINAL TRANSVERESE & OBLIQUE (Shoulder present.) CAUSES:  High multip.  Hydramnious  Pre-term lab  Obstructing tum. Or  Multiple Preg. Plac. previa  Ut. Anomaly  Severe pelvic contraction MANAGEMENT:  Antenatal  Intrapartum

PRESENTATION That part of the foetus that is foremost in the birth canal, or closes to it. A. Cephalic B. Breech C. Shoulder D. Compound

CEPHALIC PRESENTATION Vertex 96% (suboccipito – bregmatic= 9.5 cm) SINCIPUT (occipito – frontal = 11.5 cm)  OP BROW 1:1050 (mento- vertical = 13 CM) CAUSES: - Chance - Neck swelling e.g. goiter or cystic hygroma - Spasm of sternomastoid muscle DX: - Ant. fontanell & supraorbital ridge (pv) - XR (lat) FACE 0.3% (Submentobregmatic = 9.5 cm) - Palpation of supraorbital ridges & aveolar margins (confusion with breech)

BREECH PRESENTATION CAUSES: ASSOCIATED FACTORS: Frank Breech 65% Complete Breech 25% Footling Breech 10% CAUSES: Extended legs preventing spont. version Those conditions preventing fetal presenting parts entering pelvic cavity. Uterine anomaly Chance ASSOCIATED FACTORS: Fetal anomaly Preterm delivery Multiple pregnancy

ANTENATAL MANAGEMENT ECV: Hazards: Preterm Labour Abruption Cord accident Ut. Rupture (prev. C.S.)

CONTRAINDICATIONS: Absolute: Relative:  Multiple preg.  APH  Rupt. Membrane  Oligohydramnios  Significant fetal anomaly  C.S. indicated for other reasons Relative:  Prev. C.S  IUGR  H.T  Rh. Isoimmunization  Grand multip  Ant. Placenta  Obesity

MANAGEMENT OF DELIVERY Pre-delivery assessment:  Pelvic dimension (clinical & XR ~37wks)  USS of BPD, fetal mass, attitude & flex/ ext. of head)  Major fetal anomalies to be excluded

VAGINAL DELIVERY:  Term (fetal wt. 2.5-3.5 kg)  Frank breech  Normal pelvis  No other complic. of preg. (e.g. PET)  Normal FHR & BPP  Epidural C.S.

FREQUENCY: VERTEX 96% BREECH 3.5% FACE 0.3% SHOULDER 0.2%

POSITION: Refers to the relation of an arbitrarily chosen portion of the presenting part of the fetus, to the right or left side of the mother : VERTEX …... OCCIPUT-- LO., RO FACE ……CHIN (mentum)-- LM., RM BREECH ….. SACRUM -- LS., RS SHOULDER … ACROMION OR SCAPULA

OP POSITION: If baby’s head is partially extended it does not fit into the lower ut. pole well with the following consequences in labour: Early ROM & Cx. not well opposed to head. Sinciput reaches pelvic floor first & therefore rotates to front i.e. occiput is post. Large occipito frontal diam. of head presents (10 cm)  more difficult to pass. 1st stage of labour is prolonged. Movements of forces pushes head posteriorly causing backache & inducing bearing down efforts before full dilatation 2nd stage of labour may be prolonged.

Or Persists posteriorly (POP) (5%) THE OCCIPUT may rotate anteriorly & deliver relatively easily (75%) Or Persists posteriorly (POP) (5%)  spontaneous delivery if pelvis is capacious (face to pubis)  or requires assisted delivery Or Begins to rotate ant. but undergoes deep transverse arrest at level of ischial spines  instrumental delivery may be required (20%)

PREDISPOSING FACTORS: - Slight reduction in pelvic inlet - Large baby DIAGNOSIS: - Antenatally - During labour (both fontanells easily palpable)

MANAGEMENT: ♣ Epidural/ adeq. analgesia ♣ Prevent maternal ketosis & dehydration ♣ Monitor fetal well being ♣ R/O relative CPD