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Abnormal lie & presentation


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Abnormal lie & presentation

  1. 1. ABNORMAL LIE & PRESENTATION Associate Professor Dr Hanifullah Khan
  2. 2. 2 Objectives Understand fetal skull & pelvic anatomy Basic definitions in obs Identify types of abnormal lie and presentation Identify causes of each abnormal lie and presentation Making a diagnosis which includes history taking, physical examination and investigation
  3. 3. Pelvis • Space or compartment surrounded by the pelvic girdle (bony pelvis) • Subdivided into greater and lesser pelvis – greater pelvis affords protection to inferior abdominal viscera – lesser pelvis provides the skeletal framework for both the pelvic cavity and the perineum
  4. 4. Normal pelvis - anatomy • The bony pelvis is formed by 4 bones:- a. Right and left hip bones (fusion of Ilium, Ischium and Pubis) b. Sacrum (fusion of 5 sacral vertebrae) c. Coccyx • Joints :- – 2 Sacroilliac joints – Pubic Symphysis and – Sacrococcygeal joint Clinically Oriented Anatomy, 5th Edition, Moore, Keith L.; Dalley, Arthur F. page 357
  5. 5. Pelvic inlet • Bounded: – anterior by Pubic symphysis – laterally by upper margin of pubic bones, the ileopectineal line & ala of the sacrum – Posteriorly by the sacral promontory. • Normal Transverse diameter = 13.5 cm • Anterior-Posterior diameter = 11.0 cm
  6. 6. Inlet – side view • The angle of the inlet: – -normally 60° to the horizontal in the erect position. – Increase in angle may delay the head entering the pelvis in labour
  7. 7. Pelvic mid cavity • area bounded: – anteriorly by middle of Symphysis Pubis – -laterally by pubic bones and inner aspect of the ischial spine and bone – posteriorly by junction of 2nd and 3rd sacral section. • Cavity almost rounded. Transverse &AP diameter are similar at 12cm. • The ischial spines are palpable vaginally and used as landmarks to assess the station and pudendal anaesthetic block.
  8. 8. Pelvic outlet • Bounded: -anteriorly by the lower margin of the of SP -laterally by the descending ramus of the pubic bone, ischial tuberosity and sacrotuberous ligament -posteriorly bounded to last segment of sacrum
  9. 9. Pelvic outlet diameters  Transverse diameter = 11 cm  AP diameter = 13.5 cm
  10. 10. Types of pelves • 4 common pelvic shapes in female -Gynaecoid pelvis(most favourable for labour) -Android pelvis(predispose to deep transverse arrest) -Anthropoid pelvis (encourage occipito-posterior position) -Platypelloid pelvis(increase risk of obstructed labour)
  11. 11. Pelvic shapes
  12. 12. Fetal skull Made up of: • Vault (formed by the parietal bones, part of the occipital, frontal and temporal bones), Face and Base. • Sutures-sagittal, coronal, frontal, temporal • Fontanelles(anterior and posterior)
  13. 13. Skull diameters • The fetal head is ovoid in shape. • The attitude of the fetal head refers to the degree of the extension or flexion at the upper cervical spine.
  14. 14. Attitudes & diameters
  15. 15. Basic Definition • Lie – Relationship between long axis of fetus and long axis of uterus • Presentation- Part of the fetus that presents to the maternal pelvis
  16. 16. Types Abnormal lie Abnormal presentation Transverse Breech Oblique Face Unstable Brow Shoulder
  17. 17. Abnormal lie
  18. 18. Abnormal presentation
  19. 19. Causes & associations Unknown Cephalopelvic disproportion Risk factors: Preterm delivery Small for dates Fetal anomalies Polyhydramnios Multiparous /high parity • Others Placenta praevia fetal thyroid enlargement Uterine & abd wall laxity Uterine abnormality Abnormal fetal position 19
  20. 20. BREECH PRESENTATION Definition: Baby presents with the buttocks or feet rather than the head first (cephalic presentation) 20
  21. 21. 21 Classification of Breech Presentations
  22. 22. 22 Face Presentation Face: presenting part is the face, denominator is mentum
  23. 23. Brow Presentation Brow: when the portion of the fetal skull just above the orbital ridge presents Should be suspected in unexpectedly prolonged labour with failure to progress 23
  24. 24. Transverse Lie
  25. 25. Shoulder presentation
  27. 27. Important • Dates must always be determined – By history ● Regularity of periods ● Dates of onset of pregnancy symptoms ● Date of quickening – Examination ● Uterine size & fundal assesment – Ix ● Ultrasound scanning (esp. 1st trimester)
  28. 28. Discrepancy in dates • This can lead to a wrong diagnosis of abnormal lie • Preterm fetuses are prone to abnormal lie • Confirmation of dates can rule out macrosomia (a cause of abn lie & presentation)
  29. 29. History taking • Assess pregnancy for risk factors • Previous or current history of vaginal bleeding includes onset, duration, amount, character and aggravating factor (to rule out placenta praevia) • Ask for any history of decreased fetal movement • Any previous or current history of multiple pregnancy
  30. 30. Past History • Previous history of abnormal lie and presentation. • Previous history of preterm delivery • History of fetal anomalies (eg:hydrocephalus) • History of tumour (thyroid, pelvis)
  31. 31. Physical examination • Inspection (asymmetrical or fullness at certain areas of abdomen) • Palpation – – measure the SF height (whether it corresponds to date) – assess number of fetal poles – grip palpation to assess fetal lie and presentation – leopold maneuvers – palpation of pelvic brim might reveal an empty pelvis – assess adequacy of liqour – Estimate fetal weight • Vaginal examination- can be empty or other parts besides fetal head.
  32. 32. Leopold’s maneuver
  33. 33. Investigations • Ultrasound scan - to rule out any fetal anomalies and assess amount of liqour) - to check for the presentation and lie of the fetus • MOGTT – for gestational diabetes
  34. 34. Management • Caesarean section is the form of delivery • Well planned vaginal delivery may be attempted – in cases of abnormal cephalic presentations e.g. face • External cephalic version: maneuvering infant to a vertex position (only if breech is diagnosed before onset of labour).