PROBLEMS WITH THE PASSENGER

ABNORMAL LIE

Where the long axis of the fetus is not lying along the long axis of the mother’s uterus.

• Transverse

• Oblique

• Unstable

MALPOSITION

Where the fetus is lying longitudinally and the vertex is presenting, but not in Occiput Anterior (OA) position.

Occiput Posterior (OP)

– A malposition of vertex presentation

– Arrested labor may occur when head does not rotate and/or descend.

– Delivery maybe complicated by perineal tears or extension of an episiotomy.

Occiput Transverse (OT)

Is the incomplete rotation of Occiput Posterior to Occiput Anterior, which results in a horizontal or transverse position of the fetal head.

MALPRESENTATION

Where the fetus is lying longitudinally, but presents in any manner other than vertex.

• Breech

• Brow

• Face

• Shoulder

• Compound

Brow Presentation

− most uncommon of all presentation

− babies born vaginally experience extreme facial edema

Face Presentation

Occurs when head is hyper-extended, the face is the presenting part, the chin (mentum) is the denominator

chin is in anterior position

uterine contractions are strong, head is small, shoulders have already entered the pelvis and there is no pelvic contraction, vaginal delivery is possible but longer than usual. Forceps may be used to hasten 2nd stage

chin is in posterior position (RMP, LMP)

vaginal delivery may be impossible and dangerous if attempted because it can lead to transverse arrest. CS

Sincipal Presentation

Occurs when the larger diameter of the fetal head is presented.

− Labor progress is slowed with slower descent of the fetal head.

Breech Presentation

– Most common cause of fetal malpresentation.

Frank Breech

Buttocks comes first

– Hips are flexed, knees are extended

Complete Breech

Buttocks comes first

– Hips and knees are flexed

Footling (Double or Single)

– 1 or both feet come first

– Rare in term, common in premature

Kneeling Breech

– 1 or both legs extended at the hips & flexed at the knees

– Extremely rare

External Cephalic Version (ECV)

breech presentation is present at or after 37 weeks

• vaginal delivery is possible

there are no contraindications (fetal abnormality, placenta previa, uterine bleeding, previous uterine surgery, hypertension, multiple gestation, Oli or Polyhydramnios)

Risk of ECV

Placental abruption

- PROM

- Cord accident

- Transplacental Hemorrhage

- Fetal bradycardia

Vaginal Breech Delivery

may be attempted if:

• there is no pelvic contraction

• fetal weight is not more than 3,500 grams

• there is experienced/skilled personnel in breech delivery

• spontaneous labor occurs with progressive cervical dilatation

• no evidence of feto-pelvic disproportion

Spontaneous Breech Delivery

born without traction or manipulation from OB

Partial Breech Extraction

born up to the umbilicus; rest of the body is extracted

Total Breech Extraction

entire body is extracted by OB

Pinard’s

– done in breech with extended leg

once the groin is visible, gentle pressure can be applied to abduct the thigh and reach the knee

The knee can be flexed with pressure in the popliteal fossa & the leg delivered.

– anterior leg is always delivered first

Loveset Maneuver

automatically corrects any upward displacement of arms

− Baby’s trunk is rotated with downward traction, holding at the iliac crest so that posterior shoulder comes below the symphysis pubis, arm is delivered by flexing the shoulder followed by hooking at the elbow and flexing it, followed by bringing down the forearm like a “hand shake”.

Same procedure is repeated by reverse rotation of 180° so that anterior shoulder comes below the symphysis pubis.

Mauriceau-Smellie-Veit Maneuver

used to extract the head after delivery of infant’s body

− Baby is rested on obstetrician’s supinated non-dominant hand, with limbs hanging on either side.

− Non-dominant Index & middle fingers are placed on malar bones, dominant index & ring fingers are placed on shoulders with middle finger on sub-occipital region.

Prague Maneuver

used when the back of the fetus fails to rotate to the anterior.

− The operator delivers the shoulders with one hand, while making pressure above the symphysis pubis with the other hand.

Bracht Maneuver

– Delivery by extension of the legs and trunk of the fetus over the symphysis pubis and abdomen of the mother

The fetal head is born spontaneously as the legs and trunk are lifted above the maternal pelvis, and as the body of the infant is extended by the operator.

Abdominal Rescue

– fetus is replaced when fully deflexed head is entrapped and cannot be delivered vaginally. CS follows

Cleidotomy

– involves cutting of shoulder to facilitate delivery. Also used in shoulder dystocia

Shoulder Presentation

Occurs when fetus assumes a transverse or oblique lie

− The fetus does not engage in this presentation so there is a great danger of cord prolapsed after membranes have ruptured

Compound Presentation

A fetal presentation in which an extremity presents alongside the part of the fetus closest to the birth canal. The majority of compound presentations consist of a fetal hand or arm presenting with the vertex.

Breech

Vaginal delivery +- ECV / CS

Face

Vaginal delivery (chin anterior), CS (chin posterior)

Brow

Cesarean Section (CS)

Shoulder

Cesarean Section (CS)

Compound

Replacement of prolapsed arm →vaginal delivery / Cesarean Section

FETAL DISTRESS

Refers to the presence of signs in a pregnant woman before or during childbirth that suggest that the fetus may not be well.

PROLAPSE UMBILICAL CORD

Occurs when the cord passes out the uterus ahead of the presenting part.

− Occurs after membranes have ruptured when the fetus is not yet engaged or does not completely cover the pelvic inlet.

PROLAPSE UMBILICAL CORD

ALWAYS lead to cord compression as the presenting part descends in the birth canal.

Polyhydramnios

An abnormally high amount of amniotic fluid

Overt Umbilical Cord Prolapse

Descent of the umbilical cord past the presenting fetal part.

- Cord is through the cervix and into or beyond the vagina.

- Requires rupture of membranes.

- This is the most common type of cord prolapse.

Occult Umbilical Prolapse

Descent of the umbilical cord alongside the presenting fetal part, but has not advanced past the presenting fetal part.

- Can occur in intact or ruptured membranes.

Funic (Cord) Presentation

Presence of the umbilical cord between the presenting fetal part and fetal membranes.

- The cord has not passed the opening of the cervix.

- The membranes are not yet ruptured.