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MALPOSITION,

MALPRESENTATION,
ABNORMAL LIE

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PRESENTATION
 97% : cephalic
 3%: breech
 0.5% : transverse, oblique,face, brow

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FACE PRESENTATION
 Head is hyperextended: occiput
touches fetal back
 Mento anterior or posterior
 Labour progress stalled with MP

 INCIDENCE:0.17%

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DIAGNOSIS
 +V/E: mouth, nose,malar bones and
orbital ridges
 ETIOLOGY:

Factors for extension of neck or


against flexion
Cord round neck; rare
Anencephaly
Contracted pelvis:-40%, big baby
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Others
 Lax pendulous abdomen
 High parity

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Mechanism of labour
 Only in mentoanterior
 Same
 Descent, with chin leading-internal
rotation- chin lies under the
symphysis pubis
 With mento posterior the short neck
unable to span the anterior surface
of sacrum -12cm

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Mechanism of lab
 Chin mouth appears at vulva- birth is
by flexion
 External rotation with chin
 Cls frequent because of contracted
pelvis
 External continous monitoring –yes
 Mento posterior—c/s

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BROW PRESENTATION
 ANTRIOR FONTANELLE AND ORBITAL
RIDGES
 MIDWAY B/W FLEXION/ EXTENSION
 NO MECHANISM OF LABOUR-
MENTOVERTICAL
 UNSTABLE PRESENTATION- CAN
CHANGE

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 ETIOLOGY: same as in face
 Prognosis: small baby ok; term baby
c/s

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TRANSVERSE LIE
 Shoulder presentation: dorso
anterior; or posterior
 Incidence:0.3%

 Etiology : abdominal wall relaxation,

Preterm
Placenta previa, uterine anomaly
excessive liquor,contracted pelvis

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Diagnosis and course
 Abdominal and V/E
 MX =C/S

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PERSISTENT OCCIPUT
POSTERIOR POSITION
 MOST: malrotation of ociput anterior
position
 87% of occiput anterior: rotate
anterior
 LABOUR : monitor as normal

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OPTIONS
 Await spont. Delivery
 Forceps delivery with occiput
posterior
 Forceps rotation to anterior B/4
delivery
 Manual rotation to anterior B/4
spontaneous or forceps delivery
 cls
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Outcome

 Increase duration of labour


 More intervention

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Persistent occiput transverse
position
 Transitory position
 Options:

Oxytocin augmentation
Manual rotation
Forcep rotation
cls

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BREECH PRESENTATION
 Buttocks present
 Incidence: 3-4% at term delivery

 ETIOLOGY:

Abdomen, uterus, liquor, baby


placenta, cord, contracted pelvis ,
cornuo-fundal placenta

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COMPLICATIONS
 Perinatal morbidity and mortality
 Low birth weight: preterm; IUGR
 Prolapsed cord
 Placenta preavia
 Fetal, neonatal, infant mortality
 Uterine anomaly and tumors
 Multiple fetuses
 Operative interventions
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DIAGNOSIS
 ABDOMINAL / V/E
Frank
Flexed
Footling breech
IMAGING:
USS
X-ray : controversial
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Prognosis
 Maternal morbidity/mortality
 Breech prognosis : irrespective of
mode of delivery

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Pronosis
 Maternal : increased interventions
 Fetus infant morbidity/mortality:

Preterm delivery,congenital anomaly, birth


trauma
injuries in order of frequency at autopsy
Brain, spinal cord, liver, adrenal gland,and
spleen
Others: brachial plexus,pharynx,
sternocleidomastoid
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Complications with vagina
delivery
 Delay/rushed
 Preterm baby: cervical head

entrapment; use duhrssen incision


 Cord prolapse: frank breech : 0.5%

Flexed breech: 5%. Foootling: 15%


Cord length is short and true knots
common

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Factors to consider
 X –ray pelvimentry : no consensus
 Hperextension of fetal head:5%;

delivery causes cervical spine injury.


In labour=C/S
INDUCTION/ AUGMENTATION:
Difffering reports on fetal prognosis

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MODE OF DELIVERY
 DISCRETION: PRETERM/TERM
 PRETERM: birth weight

 Ceaserean section

Large baby
Contracted pelvis
Hyperextended head
Coexistent problems
Footling breech
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Others
 IUGR
 BOH

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LABOUR AND DELIVERY
 Descent : bis trochanteric diameter
with ant hip leading
 Internal rotation,birth is by lateral
flexion
 External rotation=back anterior as
shoulders enter inlet
 Shoulders : internal rotation at outlet
 Head : rotate with occiput under
symphsis 25
METHODS OF VAGINA
DELIVERY
 SPONTANEOUS
 ABD
 BREECH EXTRACTION

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MANAGEMENT OF LABOUR
 IV ACCESS
 CLOSE MONITORING
 UNBOOKED : NOT INDICATION FOR
C/S
 LABOUR : ULTIMATE ARBITER
 SKILLED MEDICAL PERSONNEL

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DELIVERY
 PROGNOSIS BEST IF SPONTANEOUS
DEL UP TO UMBILICUS
 MODE OF ABD

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MANUEVERS
 MSV
 PRAGUE MANUEVER:

Occiput remain posterior: manual


rotation msv,
Prague:hands on back down fetal
shoulders, other hand draws feet
over abdomen of mother

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Entrapment of after coming
head
 Small preterm baby
 Manual manipulation of cervix
 Duhrssen incision
 Cephalic replacement then c/s

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Analgesia and anaesthesia
 Epidural : prolongs 2nd stage: weigh
agaist risk

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Morbidity/mortality
 Maternal and fetal

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VERSION
 ALTERATION OF PRESENTATION
ARTIFICIALLY
One pole for another in logitudinal
Transverse to longitudinal
EXTERNAL/INTERNAL VERSION

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ECV
 Safe
 Cost effective

 Successful

USS, electronic monitoring and


tocolytics increase safety

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ECV
 35-37WKS
 ECV succeeds in 65% of cases
 If version succeeds,almost all fetuses
stay cephalic and vice-versa
 Ultimately and despite version
attempts,37% of women identified to
have a late pregnancy breech will
requireC/S

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ECV SUCCESS
 Presenting part has not descended
into pelvis
 Normal amount of liquor
 Fetal back is not posterior
 Woman is not obese

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Technique
 In labour ward close to theatre
 USS
 Continous external monitoring
 Forward role if fails back flip
 Tocolysis

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Interesting concept
 Moxibuston; burning herbs to
stimulate acupuncture point
BL67==promotes spontaneous
breech version possibly by increasing
fetal activity=proven in studies

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Complications of ECV
 ABRUPTIO
 UTERINE RUPTURE
 AFE
 FM haemorrhage
 PRETERM LABOUR
 FETAL DISTRESS,DEMISE

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INTERNAL PUDALIC
VERSION
 DISTRESS IN TWIN 2

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CONCLUSION
 HIGH RISK OBSTETRICS

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