Shoulder,face ,braw,,compound presention for undergraduate
Definition DefintionFetal presenting part other than vertex includes breech, face, brow, transverse, and compound presention.
Related Factors More than one pregnancy(e.g. Multipara,Grand multipara )More than one fetus (e.g. Twins)Too much or too little amniotic fluid (e.g. Poly hydramnious, oligohydramnios)Abnormal uterine shape (e.g. Arcuate ,septate, supseptate) or abnormal growth (e.g Fibroid)Placenta previaThe baby is preterm
Incidence of malpresentation Defintion• Breech 3 in 100 (3%)• Face 1 in 500 (0.5%)• Brow 1 in 2000 (0.02%)• Shoulder 1 in 300 (0.3%)• Compound 1 in 5000 ( 0.05%)
Shoulder presentationIt is a Transverse liein which the long axis of the fetus is perpendicular( 900) to long axis of mother.Shoulder of baby comes in– the lower segment of uterus(0.5%)
4 position in Shoulder presentation Acrimon- anterior(60%) Left Right Acrimo- posterior(40%) Right Left Acrimo anterior position is more common as the concavity of front of fetus fix in convexity of maternal spine Placenta is posterior in 60% of cases
DiagnosisAbdominal examination, the head is usually felt in one iliac fossa or in the flank. The breech in the other iliac fossa but at a higher level Fundal level just above umbilicus FH sound heard below the umbilicus
On vaginal examinationEarly in labor the cervix is elevated lower uterine segment is imperfectly filledLate in labor The cervix is sufficiently dilated: We can feel: scapula, acromion, clavicle, axilla and ribsConfirm position: If the arm is prolapsed and supinated the dorsum points to the back and the thumb points to the head.
Neglected shoulder Prolonged laborMembrane rupturedliquor drainedArm may be prolapsedFetus dead or dyingLower segment overstretchedSigns and symptoms of obstructed labor
ManagementDuring pregnancy A-External cephalic version Can be tried up to full term, Even early in labour before ROM * Laxity of the abdominal & uterine walls makes the procedure easier than in breech * The fetus will be rotated only 90 degrees. B. If fails, do external podalic version. head.
During labor External cephalic version (ECV) is tried with intact membranes : - If succeeded: Rupture of membranes and application of abdominal binder. - If failed: C.S. is the safest for the mother & fetus. If the membranes are ruptured before full cervical dilatations do C.S.
ManagementIn modern practice, persistenttransverse lie in labor is delivered bycaesarean section whether the fetus isalive or dead
Face Presentationhead is hyper extendedpresenting part is face- denominator is chin(mentum)between glabella & chinpresenting diameter issubmentobregmatic (9.5cm)
Types of Face Presentation2ry face (during labor) commenThe majority of cases of face are secondary to occipto-posterior which transformed to mento anteriorCauses are maternal1ry face (during pregnancy )rareCauses are fetal
Diagnosis The chin serves as thereferenc point in describingthe position of the head. It is necessary to distinguishchin-anterior positions inwhich the chin is anterior inrelation to the maternal pelvis from chin-posterior positions.
Diagnosis On abdominal examination,a groove may be felt betweenthe occiput and the back. On vaginal examination Neither the occiput nor the sinciput are palpable supra-orbital ridges, chin,alveolar margin ± ala nasiConfirm presention
Mechanism of labor in MA The head descends with the submento-bregmatic diameter (9.5 cm). Descent, engagement, increased extension of the head the chin meets the pelvic floor first and rotates forwards 1/8 of a circle. With further descent the submental-region hinges below the symphysis pubis the head is delivered by flexion , followed by restitution and external rotation of the chin as in vertex presentation.
Mechanism of labor in MP Normal mechanism: In 2/3 of cases the chin rotates forwards 3/8 of a circle and delivered as MA Abnormal mechanism (In 1/3 of cases): The chin may rotate forwards 1/8 circle (deep transverse arrest of the face). no rotation(persistent oblique MP). The chin rotate backwards 1/8 circle (direct MP)
Management of Chin-anterior Management of Chin-anterior Cervix fully dilated Cervix not fully dilated Allow normal child Allow normal child birth Augmentation of Augmentation of birthSlowSlow labour labourprogressprogress Descent Descentwith nowith no unsatisfactory unsatisfactorysigns ofsigns ofobstruction Augmentationobstruction Augmentation Forceps delivery of labour of labour
It is a cephalic presentation with the head midway between flexion and extension.Incidence: 1 /2000The frontal bone isthe denominator.
There are 4 main positions• - Left fronto-anterior.• - Right fronto-anterior.• - Right fronto-posterior.• - Left fronto-posterior.
Types &Etiology of browTransient brow(2RY)• During conversion of vertex to face.Persistent brow(1RY)• Extremely rareEtiology: same as face
Mechanism of labourTransient brow(2RY)brow may be converted spontaneously into face (by extension) or vertex (by flexion) and this followed by spontaneous delivery
Persistent brow:There is no mechanism for delivery because thehead descends by the mento-vertical diameter (13.5 cm) which is longer than anyof the diameters of the pelvic inlet. So, the head become arrested at the pelvic inlet ,and labour is obstructed.
DiagnosisAbdominal examination:the occiput & sinciputare felt at the same level PV examinationfrontal bone, supra-orbital ridges and the root of thenose are felt.
Compound PresentationOccurs when an extremity (usually an arm less commonly lower limb) prolepses alongside the presenting part.• Both the prolapsed arm and the fetal head present in the pelvis simultaneously.
DiagnosisSuspect compound presentation when1.Active labor is arrested2.The fetus fail to engage3.The prolapsed extremity is palpated directly
ManagementDon’t manipulate the prolapsed extremity In many cases the extremity will spontaneously be pulled back and away from the presenting part. Spontaneous delivery in 75% of vertex /upper extremity presentation Do continuous FHR monitoring because of associated occult cord prolapse
Reduce the extremity if Prolapsed extremity prevent descent of fetus gently reduce by pushing it upward above the pelvic brim and hold it until a contraction pushes the head into the pelvis.Do CS if Non reassuring FHR trace Cord prolapsed Failure of labor to progress