DYSTOCIA: PASSENGER

Review Fetal Lie Longitudinal Transverse

Review Fetal Presentation Cephalic Breech Compound Shoulder

Review Fetal Presentation Cephalic Breech Compound Shoulder

Review Fetal Presentation Cephalic Breech Compound Shoulder

Review Fetal Presentation Cephalic Breech Compound Shoulder

OA ROA LOA ROT LOT ROP LOP OP

Diagnosis: by vaginal exam Cephalic Presentation AP Diameter (cm) Head Feel for… Vertex/ Occiput SOB 9.5 Full flexion Posterior fontanel Sinciput OF 12.5 Partially flexed Anterior fontanel (bregma) Brow OM 13.5 Partially extended Orbital ridge/ frontal bone Face SMB 9.5 Hyperextended Chin/mentum

Diagnosis: Leopold’s maneuver

Cardinal movements Mechanism of labor Engagement Descent Flexion Internal Rotation Extension External Rotation Expulsion

DYSTOCIA DUE TO ABNORMALITIES OF THE FETUS Malpresentation Cephalic Presentation Face Brow Persistent OP, OT Transverse Lie Compound Presentation Breech Presentation Shoulder Dystocia 2. Due to development Hydrocephalus Large Fetal Abd Fetal Macrosomia Conjoined Twins

Face Head is hyperextended Chin (mentum) is presenting In term-size fetuses, If Mentum Posterior, Labor progression usually impeded because fetal brow/ bregma pressed against the maternal symphysis pubis If Mentum Anterior Flexion of the head and vaginal delivery are typical Many MP converts spontaneously to MA

Face Diagnosis: Vaginal examination and palpation of Distinctive facial features of mouth and nose, malar bones, and particularly the orbital ridges Radiographic demonstration of hyperextended head

Face Etiology Any factor that favors extension or prevents head flexion Marked enlargement of the neck or coils of cord about the neck  extension Anencephalic fetuses Large fetus; Contracted pelvis Pendulous abdomen Permits the back of the fetus to sag forward or laterally High parity

Face Mechanism of labor Brow presentation  face presentation after further extension of head during descent Descent, internal rotation, and flexion And the accessory movements of extension and external rotation Internal flexion: to bring the chin under the symphysis pubis so that neck can traverse the posterior surface of the symphysis pubis (anterior flexion) Flexion: (chin and mouth appear at the vulva) head is delivered by flexion

Face

Face Management Vaginal Delivery (MA) Absence of contracted pelvis With effective labor Cesarean delivery (MP)

Brow Rarest Midway between full flexion (occiput) and extension(face) Diagnosis: Abdominal palpation, vaginal examination Feel for frontal sutures, large anterior fontanel, orbital ridges, eyes and root of the nose (neither mouth nor chin is within reach)

Brow Etiology Same as for face Brow presentation is commonly unstable and often converts to a face or occiput presentation

Brow Mechanism of labor Prognosis If very small fetus and large pelvis – easy labor Large fetus Engagement is impossible until there is marked molding that shortens the occipitomental diameter (molding deforms the head) or Until there is either flexion to an occiput persentation or extension to a face presentation Prognosis Depends on ultimate presentation If brow persists – poor for vaginal delivery unless small or birth canal is huge

Persistent Occiput Posterior Often – spontaneous anterior rotation followed by uncomplicated delivery Contributing factor for failure: transverse narrowing of the midpelvis

Persistent Occiput Posterior Labor and delivery need not differ remarkably from OA Progress may be determind by assessing cervical dilatation and descen tof the head Possibilities for vaginal delivery Spontaneous delivery Forceps delivery with occiput directly posterior Manual rotation to the anterior position followed by spontaneous forceps delivery Forceps rotation of the occiput to the anterior position and delivery

Persistent Occiput Posterior Spontaneous delivery If the pelvic outlet is roomy and vaginal outlet and perineum are somewhat relaxed from previous vaginal deliveries Forceps delivery If vaginal outlet is resistant to stretch and perineum is firm… During each expulsive effort the head is driven aginst the perineum to a much greater degree than when anterior. Generous episiotomy usually needed. (on careful palpation – if head above the pelvic inlet  prompt cesarean delivery)

Persistent Occiput Posterior 3. Manual rotation to anterior Hand introduced to locate posterior ear – confirms posterior position Then occiput often spontaneously rotates toward anterior position. If not, head may be grasped with fingers over one ear and the thumb over the other and rotation of the occiput to the anterior position attempted 4. Forceps rotation Attempted if head is engaged, cervix fully dilated, and pelvis adequate Most likely when ineffective expulsive efforts of the mother during 2nd stage of labor

Persistent Occiput Transverse Most likely a transitory one because tends toward OA Delivery: If rotation ceases because of poor expulsive forces and pelvic contractions are absent  vaginal delivery Occiput may be manually rotated anteriorly or posteriorly and forceps delivery performed If failure of spontaneous rotation is caused by hypotonic uterine contractions without cephalopelvic disproportion, oxytocin may be infused and closely monitored Difficulties Platypelloid (AP flattened) pelvis Android (heart shaped) pelvis

Transverse Lie Long axis of the fetus is perpendicular to that of the mother Shoulder usually over the pelvic inlet Diagnosis: Abdomen unusually wide Uterine fundus extends to only slightly above the umbilicus No fetal pole is detected in the fundus and the ballottable head is found in one iliac fossa and breech in the other When the back is anterior, hard resistance plane extends across the front of the abdomen, if posterior – irregular nodulations felt through the abdominal wall

Transverse Lie

Transverse Lie Etiology: Abdominal wall relaxation from high parity Women with 4 or more deliveries have 10x incidence Relaxation of the abdominal wall with a pendulous abdomen allows the uterus to fall forward, deflecting the long axis of the fetus away Preterm fetus Placenta previa Abnormal uterine anatomy Excessive amniotic fluid Contracted pelvis

Transverse Lie Mechanism of labor Spontaneous delivery impossible After rupture of membranes, if labor continues, fetal shoulder is forced into the pelvis  arm prolapses

Transverse Lie Mechanism of labor Uterus contracts vigorously in an unsuccessful attempt to overcome the obstacle. With time retraction ring rises increasingly higher and becomes more marked. Neglected transverse lie If not promptly managed  uterine rupture

Transverse Lie Mechanism of labor Morbidity increased because of frequent association with Placenta previa Increased likelihood of cord prolapse Necessity for major operative efforts Small fetus (less than 800 g) + large pelvis  spontaneous delivery is possible. Head and thorax pass through the pelvic cavity at the same time and fetus which is doubled upon itself is expelled (conduplicato corpore)

Transverse Lie Management Cesarean delivery Vertical incision Because a low transverse incision into the uterus may lead to difficulty in extraction of a fetus entrapped in the body of the uterus above the level of incision since neither feet nor head occupies the lower uterine segment Attempts at conversion to a longitudinal lie by abdominal manipulation will likely not be successful. ? Attempts at external version

Breech Predisposing factors uterine relaxation Great parity Multiple fetuses Hydramnios Oligohydramnios hydrocephalus, Anencephaly Previous breech delivery Uterine anomalies Tumors of the pelvis

Breech Complications Cord prolapse Increased perinatal morbidity and mortality due to difficult delivery LBW or growth restriction Fetal anomalies and developmental abnormalities that occur after newborn period Uterine anomalies Multiple fractures Increased operative intervention

Breech Mechanism of labor Delivery of the breech draws the umbilicus and attached cord into the pelvis, which compresses the cord. Once the breech has passed beyond the vaginal introitus, the abdomen, thorax, arms and head must be delivered promptly.  delivery of successively less readily compressible parts

Breech With term fetus, some degree of head molding may be essential thus in ceratin cases: 1. delivery may be delayed many minutes  hypoxia,acidemia 2. delivery may be forced, causing trauma from compression, traction, or both With preterm fetus, at times, buttocks and lower extremities will pass through the cervix but head cannot escape without trauma. (Duhrssen incision or cesarean delivery)

Breech Fetal outcome - Higher perinatal mortality Term fetus: risk of fracture of the humerus and clavicle, fracture of the femur during breech extractions, paralysis of the arm following pressure on brachial plexus spoon shaped depressions or fractures of the skull, Term fetus: causes of death – head entrapment, cerebral injury, Intracranial hemorrhage, cord asphyxia Maternal outcome – higher morbidity

Breech Management Vaginal delivery by essentially skilled obstetricians Cesarean delivery commonly done if Large fetus contraction or unfavorable pelvic shape (platypelloid, android) Hyperextended head Delivery indicated in the absence of spontaneous labor (some use oxytocin) Uterine dysfunction Incomplete or footling breech presentation Viable preterm fetus, mother in active labor Severe fetal growth restriction Previous perinatal death or children suffering from birth trauma Request for sterilization Lack of experienced operator

Breech Management Vaginal delivery by essentially skilled obstetricians External cephalic version Cesarean delivery commonly done if Large fetus contraction or unfavorable pelvic shape (platypelloid, android) Hyperextended head Delivery indicated in the absence of spontaneous labor (some use oxytocin) Uterine dysfunction Incomplete or footling breech presentation Viable preterm fetus, mother in active labor Severe fetal growth restriction Previous perinatal death or children suffering from birth trauma Request for sterilization Lack of experienced operator

Compound Presentation Extremity prolapses alongside the presenting part with both presenting in the pelvis simultaneously

Compound Presentation Etiology: Conditions that prevent complete occlusion of the pelvis inlet by the fetal head including preterm birth Prognosis Perinatal loss increased Concomitant preterm delivery Prolapsed cord Traumatic obstetrical procedures

Compound Presentation Management: Observed closely to ascertain whether the arm retracts out of the way with descent of the presenting part If it fails, and appears to prevent descent of the head, prolapsed arm should be pushed gently upward and the head simultaneously downward by fundal pressure Vaginal delivery

Shoulder Dystocia

Hydrocephalus Excessive accumulation of CSF with consequent cranial enlargement Uncommon with births at term Associated defects: especially neural tube defects Fetal head circumference: Often exceeds 50 cm, may reach 80 (N: 32-38) Fluid volume As much as 5 L (N: 500-1500 mL)

Hydrocephalus Gross cephalopelvic disproportion is the rule Dystocia usual consequence

Hydrocephalus Breech – difficult to diagnose radiographically because outline of normal fetal head often appears enlarged to a degree suggestive of hydrocephalus Difficulties inherent in radiological diagnosis obviated by: Use of ultrasonography to measure the diameter of the lateral ventricles and thickness of cerebral cortex and to compare size of the head with that of the thorax and abdomen

Hydrocephalus Management Cesarean delivery Cephalocentesis (?) With cephalic presentation transvaginally With breech presentation Breech nad trunk delivered, needle inserted transvaginally just below the anterior vaginal wall (sterile plastic tubing to protect birth canal) Transabdominal approach

Large Fetal Abdomen Usually result of greatly distended bladder, ascites, or enlargement of kidnes or liver. Diagnosis: Ultrasound Management Reduction transabdominally depending on cause Fluid in fetal bladder and peritoneum can be emptied, however decompression may not be successful with severe hydrops fetalis. Ascites may be accompanied by severe abdominal edema and liver enlargement and render delivery difficult

Macrosomia Prognosis Fetal weigh more than 4000 g Factors Multiparity Large parents especially mother Maternal obesity Maternal diabetes Postdatism Previous delivery of infants weighing more than 4kg Prognosis Mother and fetus at risk: increased perinatal loss, severely depressed at birth, neurologic complications, high infant mortality before age of 7 years

Conjoined Twins

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