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Abnormal lie & presentation
1) Abnormal lie and presentation occur when the fetus is positioned in the uterus with something other than its head facing downward toward the birth canal. 2) The document defines abnormal lie and presentation and identifies types such as transverse, oblique, breech, face, brow, and shoulder. 3) Causes of abnormal lie and presentation include cephalopelvic disproportion, preterm delivery, small baby size, fetal anomalies, and uterine or abdominal wall issues. Diagnosis involves assessing dates, history, physical exam including palpation and ultrasound, and may require caesarean section or external cephalic version for breech presentations.
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Abnormal lie & presentation
- 1. ABNORMAL LIE &PRESENTATION Associate Professor Dr Hanifullah Khan
- 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. Pelvis • Space orcompartment 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. 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. 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. Inlet – sideview • 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. 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. Pelvic outlet • Bounded: -anteriorlyby 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. Pelvic outlet diameters Transverse diameter = 11 cm AP diameter = 13.5 cm
- 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)
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- 12. Fetal skull Made upof: • 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. Skull diameters • Thefetal 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.
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- 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. Types Abnormal lie Abnormalpresentation Transverse Breech Oblique Face Unstable Brow Shoulder
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- 19. Causes & associations Unknown Cephalopelvicdisproportion 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. BREECH PRESENTATION Definition: Babypresents with the buttocks or feet rather than the head first (cephalic presentation) 20
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- 22. 22 Face Presentation Face: presentingpart is the face, denominator is mentum
- 23. Brow Presentation Brow: whenthe portion of the fetal skull just above the orbital ridge presents Should be suspected in unexpectedly prolonged labour with failure to progress 23
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- 27. Important • Dates mustalways 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. 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. History taking • Assesspregnancy 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. Past History • Previoushistory of abnormal lie and presentation. • Previous history of preterm delivery • History of fetal anomalies (eg:hydrocephalus) • History of tumour (thyroid, pelvis)
- 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.
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- 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. Management • Caesarean sectionis 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).