abnormal presentations

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By
Ahmed Elbohoty MD, MRCOG
Assistant professor of obstetrics and gynecology
Ain Shams University
Breech
2/29/201
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— The incidence of breech presentation decreases from about 20% at 28
weeks of gestation to 3–4% at term, as most babies turn spontaneously
to the cephalic presentation.
2/29/202
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2/29/203
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Longitudinal lie. Frank breech
presentation.
I
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Longitudinal lie. Complete breech
presentation.
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Longitudinal lie. Incomplete, or footling,
breech presentation.
2/29/205
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Causes of breech presentation
— Prematurity
— Uterine abnormality (septum,…
— Multiparity
— Multiple pregnancy
— Pelvic mass
— Placenta previae
— Fetal malformation
— But In most of cases no definitive cause
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Risks
— There is substantial Increased perinatal morbidity and mortality
Due to;
Prematurity
Congenital abnormalities; hydrocephalus
Cord prolapse
Birth asphyxia
Birth trauma
intra-cranial haemorrhage
2/29/207
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TERM BREECH WHAT TO DO???
2/29/20
— Hannah et al., 2000 in Lancet.Term Breech trial: RCT 2083 women
in 121 centers in 16 countries Better neonatal outcome with Elective
CS with no difference in maternal outcome
— Goffinet et al., 2006. PREMODA study inAJOG. Observational cohort
prospective study with strict criteria before and during labour: no
difference. A senior obstetrician was present at 92.3% of all vaginal
deliveries. Pelviometry was employed in 82.5% of planned vaginal births
— Doctors role: explain evidence and ensure understanding and supports
the patients decision to make it as safe as possible
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2/29/20
— The presence of a skilled birth attendant is essential
for safe vaginal breech birth.
— Units with limited access to experienced personnel
should inform women that vaginal breech birth is
likely to be associated with greater risk and offer
antenatal referral to a unit where skill levels and
experience are greater.
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CS benefits and risks
2/29/20
— Women should be informed that planned
caesarean section carries
—a reduced perinatal mortality and early
neonatal morbidity for babies with a breech
presentation at term compared with planned
vaginal birth.
— Women should also be advised that planned
caesarean section for breech presentation carries
—a small increase in serious immediate
complications for them compared with
planned vaginal birth.
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Long term effects
— There is no evidence that the long term health of babies with a breech
presentation delivered at term is influenced by how the baby is born.
— Planned caesarean section for breech presentation does not carry any
additional risk to long-term health outside pregnancy.
— The long-term effects of planned caesarean section for term breech
presentation on future pregnancy outcomes for them and their babies is
uncertain.
2/29/2011
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Management of Breech presentation at term
— Unless contraindicated, ECV should be offered
— Time
— ECV should be offered at term from 37+0 weeks of gestation in multiparous
— In nulliparous women, ECV may be offered from 36+0 weeks of gestation (have a
low chance of spontaneous version)
— Who?
— ECV should only be performed by a trained practitioner or by a trainee working
under direct supervision.
— There is no general consensus on the eligibility for, or contraindications to,
ECV.
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Women's attitude
2/29/20
— Although most women tolerate ECV, they should be informed that
ECV can be a painful procedure.
— The uptake of ECV is best increased by timely identification of the
baby presenting by the breech and provision of evidence-based
information.
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ECV
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Why not done in all breech cases
2/29/20
— The greatest impediment to the use of ECV is the nonidentification of
breech presentation (20.0–32.5% of all breech presentations) and these
have worse outcomes
— The possibility of breech presentation should always be considered at
clinical examination although abdominal palpation has a sensitivity of
only 70%.
— In the absence of routine third trimester ultrasound, particular care
should be taken with high-risk groups, e.g. where a previous baby has
been breech
— Recurrence rate after one breech presentation is 9.9% (RR 3)
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Absolute contraindications for ECV:
— an absolute reason for caesarean section already exists (e.g. placenta praevia major).
— Antepartum haemorrhage within the last 7 days
— Abnormal cardiotocography
— Major uterine anomaly
— Ruptured membranes
— Multiple pregnancy (except delivery of second twin).
— rhesus isoimmunisation
— Abnormal fetal doppler
— where the mother declines or is unable to give informed consent..
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Relative contraindications and needs
additonal precautions if it will be done
— Hypertension
— oligohydramnios
— major fetal anomalies
— scarred uterus
— ECV should be performed with additional caution where there is
oligohydramnios or hypertension
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Previous one CS
2/29/20
— Women should be informed that ECV after one caesarean delivery
appears to have no greater risk than with an unscarred uterus.
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Benefits
— ECV reduces the chance of breech presentation at delivery
and therefore the associated risks, particularly of avoidable
caesarean section.
— With a trained operator, about 50% of ECV attempts will
be successful (60% for MP and 40% for PG) but this rate
can be individualised for them.
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Risks
2/29/20
— Women should be counselled that with appropriate precautions, ECV
has a very low complication rate.
— Nevertheless, a few case reports exist of complications such as placental abruption, uterine
rupture and fetomaternal haemorrhage.
— A 0.5% immediate emergency caesarean section rate and no excess perinatal
morbidity and perinatal mortality.
— The indication in over 90% being vaginal bleeding or an abnormal CTG following the
procedure.
— A small increase in neonatal unit admission OR1.48 after an unsuccessful
attempt
— Labour after ECV is associated with a slightly increased rate of caesarean
section (OR 2) and instrumental delivery (OR 1.5) when compared with
spontaneous cephalic presentation.
— The risk of caesarean delivery may be greater with a shorter ECV to labour
interval.
— Women should be informed that few babies less than 3% revert to breech after
successful ECV
— Fetomaternal haemorrhage was detected in 2.4% of women, a third of which had
more than 1 ml21
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Prediction of success
2/29/20
— ECV success can be predicted to some extent, but the use of models to
predict success should not be used routinely to determine whether ECV
can be attempted.
— Success rates depend on multiple variables. It is likely that case selection
considerably affects success rates.
— multiparity (OR 2.5)
— nonengagement of the breech (OR 9.4)
— use of tocolysis (OR 18)
— a palpable fetal head (OR 6.3)
— a maternal weight of less than 65 kg (OR 1.8)
— posterior placental location (OR 1.9)
— complete breech position (OR 2.3)
— an amniotic fluid index greater than 10 (OR 1.8)
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Failed ECV
—Spontaneous turn to cephalic after an
unsuccessful ECV attempt at 36+0 weeks
of gestation or later occurs only in a few
babies
—Another trial using tocolysis
—Planned CS
—PlannedVD ??
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How to increase the success rate?
2/29/20
— Use of tocolysis with betamimetics improves the success rates of ECV.
— reserved for where the uterus is tense or for where a previous attempt without tocolysis
has been unsuccessful.
— A significant reduction in the incidence of caesarean (RR 0.33) has been demonstrated
with the administration of betamimetic drugs where a previous attempt without
tocolysis has been unsuccessful.
— 250 micrograms of salbutamol in 25 ml of normal saline (10 micrograms/ml) by slow
intravenous injection, or 250 micrograms of terbutaline subcutaneously.
— There are insufficient data to support the use of nifedipine or atosiban compared with
betamimetics and intravenous glyceryl trinitrate was inferior to subcutaneous terbutaline
for tocolysis
— Betamimetics should not be used in women with significant cardiac disease or
hypertension, and will not be effective in those taking beta-blockers. Maternal
palpitations, tachycardia, flushing, tremor and occasional nausea may be experienced.
— Routine use of regional analgesia or neuraxial blockade is not
recommended, but may be considered for a repeat attempt or for
women unable to tolerate ECV without analgesia.
— Regional anaesthesia requires less force and may reduce failure rates, particularly in
conjunction with tocolysis (RR 0.61)
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Safety measures
2/29/20
— ECV should be performed where ultrasound, cardiotocography and theatre facilities
are available.
— Ultrasound should be used during and after the ECV to confirm a normal fetal heart
rate.
— A transient (less than 3 minutes) fetal bradycardia after ECV is common,but should
instigate continuous monitoring in a left lateral position, and if persistent and not
improving after 6 minutes, should prompt preparation for category I caesarean section.
— Urgent delivery should also be advised following the procedure if there is vaginal
bleeding or unexplained abdominal pain, or if an abnormal CTG persists.
— Cardiotocography should be performed after the procedure
— ECV should be performed where facilities for monitoring and surgical delivery are
available.
— The standard preoperative preparations for caesarean section are not recommended
for women undergoing ECV.
— Following ECV, EFM is recommended.
Women undergoing ECV who are D negative should undergo testing for fetomaternal
haemorrhage and be offered anti-D.
— fetomaternal haemorrhage was detected in 2.4% of women, a third of which had more than 1 ml. In one
woman, the estimated fetomaternal haemorrhage was more than 30 ml.
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Technique
2/29/20
— Woman lying on her back with left lateral tilt, legs half bent, bladder
empty.
— Perform when the uterus is relaxed.
— First, push back the breech or shoulder, which is often down in the pelvis
(vertical movement), then attempt rotation slowly, and always in the
direction of foetal flexion: thus bringing either the head or the breech to
the pelvic inlet by the shortest possible route.
— Monitor the foetal heart rate after each attempt, and stop if the rate
slows.
— In most cases, foetal heart rate abnormalities improve within 30
minutes.
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Service provision
2/29/20
— There is no evidence to support any particular service model although
larger institutions may consider a dedicated ECV clinic.
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Other alternatives
2/29/20
— Women may wish to consider the use of moxibustion for breech
presentation at 33–35 weeks of gestation, under the guidance of a
trained practitioner.
— Women should be advised that there is no evidence that postural
management alone promotes spontaneous version to cephalic
presentation.
— Spontaneous version from breech to cephalic is unusual at term and
occurs in only 8% of primigravid women after 36 weeks of gestation.
— Where ECV at term has been unsuccessful, only 3 % of babies will
spontaneously turn to cephalic presentation.
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Breech presentation at term
— Women should be informed that planned caesarean section carries
— a reduced perinatal mortality and early neonatal morbidity for babies with a
breech presentation at term compared with planned vaginal birth.
— Women should be informed of the benefits and risks, both for the
current and for future pregnancies, of planned caesarean section versus
planned vaginal delivery for breech presentation at term.
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The technique of vaginal breech deliveries will
remain integral component of obstetric
practice as:
— caesarean section may be inadvisable or not feasible in
some patients
— many women will opt for vaginal breech delivery
— Intrapartum diagnosis of breech especially at advanced
stage of labour
— there are still unresolved issues regarding the best practice
of delivering preterm breech and breech presentation in
multiple pregnancies.
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—breech presentation at labour or at risk
to be in labour
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How would you confirm the diagnosis?
—An ultrasound scan (USS) is essential to
confirm breech presentation.
—All cases of women with preterm labour and
women with preterm prelabour rupture of
membranes (PPROM) should have an USS to
check for fetal presentation
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Assessment of the risk factors for poor
outcome
2/29/20
— Following the diagnosis of persistent breech
presentation, women should be assessed for risk
factors for a poorer outcome in planned vaginal
breech birth.
— If any risk factor is identified, women should be
counselled that planned vaginal birth is likely to be
associated with increased perinatal risk and that
delivery by caesarean section is recommended.
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Risk factors for poor outcome with VD
2/29/20
— Hyperextended neck on ultrasound.
— High estimated fetal weight (more than 3.8 kg).
— Low estimated weight (less than tenth centile).
— Footling presentation.
— Evidence of antenatal fetal compromise.
The role of pelvimetry is unclear.
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— Diagnosis of breech presentation for the first time during
labour is not a contraindication for vaginal breech birth but
individual cases should be assessed carefully before
selection for vaginal breech birth.
— Many factors can influence the choice of birth including:
—the experience and the competency of the attending
obstetrician
—the wishes of the couple that usually determines the
mode of delivery.
—The presence of risk factors for poor outcome
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Decision
2/29/20
— Any decision to perform a caesarean section needs to be balanced against
the potential adverse consequences that may result from this.
— Clinicians should counsel women in an unbiased way that ensures a
proper understanding of the absolute as well as relative risks of their
different options.
— individualised assessment of the long-term risks of caesarean section based on
their individual risk profile and reproductive intentions, and counselled
accordingly.
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Benefits of CS
2/29/20
— Planned caesarean section leads to a small reduction in perinatal
mortality compared with planned vaginal breech delivery.
— Planning delivery for a breech baby, the risk of perinatal mortality is
approximately 0.5/1000 with caesarean section after 39+0 weeks of
gestation; and approximately 2.0/1000 with planned vaginal breech
birth.This compares to approximately 1.0/1000 with planned cephalic
birth.
— Perinatal death is reduced due to three factors:
— the avoidance of stillbirth after 39 weeks of gestation
— the avoidance of intrapartum risks and the risks of vaginal breech birth
— and that only the last is unique to a breech baby.
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Risks of CS
2/29/20
— Planned caesarean section for breech presentation at term carries a small
increase in immediate complications for the mother compared with
planned vaginal birth
— Caesarean section increases the risk of complications in future
pregnancy, including the risks of opting for vaginal birth after caesarean
section, the increased risk of complications at repeat caesarean section
and the risk of an abnormally invasive placenta.The risk of abnormally
invasive placentation increases from 0.31% with one prior caesarean
section to 2.33% with four30 and the incidence is rising.
— caesarean section has been associated with a small increase in the risk of
stillbirth (OR 1.47) for subsequent babies although this may not be causal.
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Vaginal
2/29/20
— Vaginal breech birth increases the risk of low Apgar scores
and serious short-term complications, but has not been
shown to increase the risk of long-term morbidity.
— Selection of appropriate pregnancies and skilled
intrapartum care may allow planned vaginal breech birth
to be nearly as safe as planned vaginal cephalic birth.
— Maternal complications are least with successful vaginal
birth; planned caesarean section carries a higher risk, but
the risk is highest with emergency caesarean section which
is needed in approximately 40% of women planning a
vaginal breech birth.
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Intrapartum ECV
2/29/20
— It may be considered if informed consent is possible, providing the
membranes are intact and no contraindications exist
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Intrapartum care
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2/29/20
In breech: The presenting fetal diameter is bitrochanteric diameter (the distance between the
outer points of the hips) and it is the same as the biparietal diameter
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— Labour should be allowed to continue as long as there is evidence of
progressive cervical dilatation and descent of the presenting part
without any evidence of maternal or fetal compromise.
— Women should have a choice of analgesia in labour, including
epidural analgesia.
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Induction and augmentation
— Women should be informed that induction of labour is not usually
recommended.
— Augmentation of slow progress with oxytocin should only be
considered if the contraction frequency is low in the presence of
epidural analgesia.
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However these Criteria should be fulfilled to
allow the trial of vaginal delivery
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2/29/20
— Where a woman presents with an unplanned vaginal breech labour,
management should depend on the stage of labour, whether factors
associated with increased complications are found, availability of
appropriate clinical expertise and informed consent.
— Women near or in active second stage of labour should not be routinely
offered caesarean section.
— Where time and circumstances permit, the position of the fetal neck
and legs, and the fetal weight should be estimated using ultrasound, and
the woman counselled as with planned vaginal breech birth
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Risks versus benefits
2/29/20
CS in advanced labour for breech presentation
may be complex due to increased risks of:
• GA with non fasted mother
• Technical difficulties delivering the breech low
in the pelvis
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Vaginal breech delivery
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Breech delivery
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Setting
2/29/20
— Birth in a hospital with facilities for immediate
caesarean section should be recommended with
planned vaginal breech birth, but birth in an
operating theatre is not routinely recommended.
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Senior experienced obstetrician Help is
essential so communicate (ISBAR)
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Team and care
— Senior midwifery, obstetric, anaesthetic and paediatric staff should be
alerted to the possibility of a vaginal breech delivery.An experienced
obstetrician should be available to supervise labour and delivery.
— One-to-one midwifery care should also be available.
— If the membranes rupture spontaneously, vaginal examination is required
immediately to exclude umbilical cord prolapse.
— If the membranes do not rupture spontaneously, then amniotomy should
only be performed for standard obstetric indications.
— Continuous electronic fetal monitoring is the mainstay for monitoring
the fetus during labour.
— The presence of meconium is an unreliable sign of fetal distress in breech
presentation.
— Fetal blood sampling from the fetal buttock is technically possible but
generally not advised. 2/29/2057
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Position
2/29/20
— Either a semirecumbent or an all-fours position may be
adopted for delivery and should depend on maternal
preference and the experience of the attendant.
— If the latter position is used, women should be advised that
recourse to the semirecumbent position may become
necessary.
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epidural analgesia
2/29/20
— Women should be informed that the effect of epidural analgesia on the
success of vaginal breech birth is unclear, but that it is likely to increase
the risk of intervention.
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Fetal monitoring
2/29/20
—Women should be informed that while
evidence is lacking, continuous electronic fetal
monitoring may lead to improved neonatal
outcomes.
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Intrapartum care
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management
2/29/20
— The first stage of labour should be managed according to the same
principles as with a cephalic presentation.
— To reduce the risk of cord compression, amniotomy is reserved for
definite clinical indications.
— Where the progress is slow, caesarean section should be considered. In
the presence of epidural analgesia and a contraction frequency of fewer
than four in ten, however, oxytocin may be considered.
— A passive second stage to allow the descent of the breech to the
perineum prior to active pushing is recommended
— If the breech is not visible within 2 hours of the passive second stage,
caesarean section should normally be recommended.
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Basic principles during the 2nd stage:
— Adequate descent of the breech in the passive second stage is a prerequisite for
encouragement of the active second stage.
— avoid handling the breech (hands off)
— Many breeches will deliver without assistance
— Tactile stimulation of the fetus may result in reflex extension of the arms or head,
and should be minimised..
— avoid handling the umbilical cord
— Art is to know when you interfer
— keep the sacrum anterior
— delay active pushing until the breech has descended to the pelvic floor
— delay placing the mother in the lithotomy position until the fetal anus is visible
over the posterior fourchette
— avoid traction at all times.
— Care must be taken in all manoeuvres to avoid fetal trauma: the fetus should be
grasped around the pelvic girdle (not soft tissues) and the neck should never be
hyperextended.
— Selective rather than routine episiotomy is recommended 2/29/2064
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Signs that delivery should be assisted include
2/29/20
— lack of tone or colour, or delay, commonly due to extended arms or
an extended neck.
— there is evidence of poor fetal condition
— if there is a delay of more than 5 minutes from delivery of the
buttocks to the head, or of more than 3 minutes from the umbilicus to
the head.
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2/29/20
— Assistance, without traction, is required if there is
delay or evidence of poor fetal condition.
— All obstetricians and midwives should be familiar
with the techniques that can be used to assist vaginal
breech birth.
— The choice of manoeuvres used, if required to assist
with delivery of the breech, should depend on the
individual experience/preference of the attending
doctor or midwife.67
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When to intervene
— Prolonged 2nd stage
— Pathological CTG
— Back is posterior
— Stopped progression at umbilicus level:
— If perineum is rigid: Episiotomy
— If arms are extended or Nuchal arm: : Lovset manouvre, deliver posterior arm
— Arms delivered but head doesn’t follow with the next contactions:Asses
where is the head
— if it is outside the pelvis: flex, rotate with suprapubic pressure
— if inside the pelvis assist its delivery
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The Burns-Marshall method
— The baby should be allowed to hang
until the nape of the neck is visible so
that its weight exerts gentle
downwards and backwards traction to
promote flexion of the fetal head.
— The fetal trunk is then swept in a wide
arc over the maternal abdomen by
grasping both the feet and maintaining
gentle traction; the aftercoming head is
slowly born in this process.
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The Mauriceau-Smellie-Viet manoeuvre
— The Mauriceau-Smellie-Viet (MSV) manoeuvre encourages flexion of the fetal head. One hand
should be placed above the fetus with one finger on the fetal occiput and one finger on each of
the fetal shoulders.
— The other hand should be placed below the fetus and two fingers should be placed adjacent to
the fetal nose on the maxillae. Fingers should not be placed in the fetal mouth as this may be
associated with jaw traction and subsequent dislocation.
— Both hands are used to promote flexion of the head.The fetal body is raised upward in an arc
completing delivery.
— An assistant may apply suprapubic pressure to further promote flexion.
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In up to 20% of vaginal breech deliveries, obstetric Killand forceps
may be required to deliver the fetal head
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Management of fetal head
entrapment:
— Call for help – inform anaesthetist, paediatric staff, senior midwife and
maternity operating theatre staff
— Perform McRobert's manoeuvre as per shoulder dystocia
— Apply suprapubic pressure as per shoulder dystocia
— MSV manoeuvre should be reattempted in conjunction with suprapubic
pressure
— Rotate baby to sacro–transverse position
— Administer tocolysis; consider 100 micrograms intravenous glyceryl
trinitrate (GTN)
— Attempt forceps delivery
— Surgical management.
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Emergency surgical management of fetal head
entrapment includes:
— cervical incisions
— symphysiotomy
— Caesarean section
— If the baby is still alive, an alternative to cervical incision and symphysiotmy
is delivery by caesarean section.
— The baby will need to be supported and pushed up from below.
— Bracht manouver
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Duhrssen's incisions
— If the head fails to deliver despite additional manoeuvres, then
consideration should be made for performing cervical incisions.These
are known as Duhrssen's incisions.
— Ring forceps should be applied to the cervix in pairs, parallel to each
other at 2, 6 and 10 o'clock.An incision should be made between each
pair of forceps.
— The main difficulties when performing cervical incisions for head
entrapment at breech delivery are achieving adequate analgesia and
exposure.
— There is a significant risk of haemorrhage; the cervical incision may
extend upwards within the broad ligament causing broad ligament
haematoma.
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Preterm breech
2/29/20
— Consider caesarean section for women presenting in suspected,
diagnosed or established preterm labour between 26+0 and 36+6 weeks
of pregnancy with breech presentation. NICE 2015
— The mode of delivery should be individualised based on the stage of
labour, type of breech presentation, fetal wellbeing and availability of an
operator skilled in vaginal breech delivery.
— Women should be informed that caesarean section for breech
presentation in spontaneous preterm labour at the threshold of viability
(22–25+6 weeks of gestation) is not routinely recommended.
— Women should be informed that planned caesarean section is
recommended for preterm breech presentation where delivery is
planned due to maternal and/or fetal compromise.
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Intrapartum
2/29/20
— Labour with a preterm breech should be managed as with a term
breech.
Where there is head entrapment, incisions in the cervix (vaginal
birth) or vertical uterine incision extension (caesarean section) may
be used, with or without tocolysis.
— Specific problem encountered during preterm breech delivery is
delivery of the trunk through an incompletely dilated cervix; this
occurs in up to 14% of vaginal deliveries.
— In this situation, lateral cervical incisions have been used to release the
after-coming head.
— Incisions at 2, 6 and 10 o’clock. Similar rates of head entrapment have
been described for vaginal and abdominal delivery.
— For head entrapment at caesarean delivery, it may be necessary to
extend the uterine incision to a J shape or invertedT100
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Twins
2/29/20
— Women should be informed that the evidence is limited, but that
planned caesarean section for a twin pregnancy where the presenting
twin is breech is recommended.
— Routine emergency caesarean section for a breech first twin in
spontaneous labour, however, is not recommended.
— The mode of delivery should be individualised based on cervical
dilatation, station of the presenting part, type of breech presentation,
fetal wellbeing and availability of an operator skilled in vaginal breech
delivery.
101
101
2nd twin
2/29/20
— Routine caesarean section for breech presentation of the
second twin is not recommended in either term or preterm
deliveries.
102
102

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SBA
2/29/20103
103
— When performing vaginal breech delivery you...
— Always have the patient in the lithotomy position
Attempt to deliver flexed legs by pulling the heels
Attempt to keep the sacrum posterior
May use suprapubic pressure to deliver the fetal head
Pull the umbilical cord to ensure it remains loose
2/29/20104
104

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— For assisted vaginal delivery...
— The Burn Marshall method involves delivering the baby by
extension
The Mauriceau-Smellie-Veit method involves delivering the
baby by flexion by placing one finger in the baby's mouth and
two fingers alongside the nose
The pelvic grasp in Lovsett’s manoeuvre is a routine part of
delivery for delivering the babies arms
Upwards traction should only commence when the fetal chin
has reached the perineum
Wrigleys forceps should always be used to deliver the fetal
head
2/29/20105
105
SBA
— Fetal head entrapment during vaginal breech
delivery...
a. Consider rotating the body to sacro-transverse position
b. Is more likely in term infants compared to pre-term infants
c. Often requires cephalocentesis
d. Should be managed with Duhrssens incisions at 3, 6 and 9
o’clock
e. Wrigleys forceps should be used to achieve delivery
2/29/20106
106

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— The correct answer is consider rotating the body to sacro-
transverse position, then flexing the head via supra pubic
pressure, apply traction and rotate to scaro anterior and
deliver with forceps.
2/29/20107
107
Breech extraction is allowed only in 2nd
twin delivery
2/29/20108
108

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2/29/20109
109
2/29/20110
110

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2/29/20111
111
Malpresentation
Ø Breech
Ø Face
Ø Brow
Ø Shoulder
Ø Cord
Ø Compound
2/29/20112
112

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2/29/20113
113
2/29/20114
114

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Transverse lie. Right acromiodorsoposterior position (RADP). The
shoulder of the fetus is to the mother's right, and the back is posterior.
2/29/20115
115
Consequences
— Presnting part, ill-fitting
— Uterine Contractions, poor
— Membranes, rupture early- cord prolapse
— Labour, difficult, long, obstructed
— Birth trauma
— Operative intervention
2/29/20116
116

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Mother, Fetus and neonate
— Increased perinatal mortality and morbidity
ü Fetal malformation
üIntrauterine fetal death
üCord proplase
üBirth trauma,
üBirth asphysixa
üInfection, fetus, neonate and mother
üUterine rupture
üThromboembolism in the mother
2/29/20117
117
For Optimal Result
— Early diagnosis,
— Planned delivery
— Experienced staff
— Well equipped hospital
— Cross match 2 unit
— Adequate hydration
— Monitor in Labour
— Pain relief
2/29/20118
118

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Face Presentaion
— 1:300
— Full extension of the head
— Presenting part: Face
— Denominator: Omentum/Chin
— Diameter; Subomento bregmatic 9.5cm
— Presentation, Mento anterior–Vaginal delivery
Mento posterior- Ceasaeran section
2/29/20119
119
2/29/20120
120

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Causes
— Anenecephaly
— Prematurity
— Multifetal pregnancy
— Polyhydramnious
— Neck tumours
— Sternomastoid spasm
— Multiparty
2/29/20121
121
Diagnosis
— Abdominal
— Vaginal
2/29/20122
122

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Brow Presentation
— 1:800, 1:2000 deliveries
— The area between the orbital ridge and the anterior
fontenalle
— Most unfavourable of all presentation
— Transient presentation;
Full flexion—Occiput
Full extension---Face
2/29/20123
123
Dignosis and management
— Delivery??
2/29/20124
124

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Shoulder presentation
qCauses
— Multiparty
— Prematurity
— Multiple pregnancy
— Polyhydrmanious congenital uterine anomly
— Contacted pelvis
— Pelvic tumour, placenta previae
2/29/20125
125
Compound presentation
— Limb, limbs, umbilical cord alongside the presenting part;
cephalic or breech
2/29/20126
126

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2/29/20127
127
2/29/20128
128

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2/29/20129
129
2/29/20130
130