vasa previa

Vasa previa occurs when fetal blood vessels

unprotected by the umbilical cord or placenta run
through the amniotic membranes and traverse the
cervix.
  vasa previa, is a complication of pregnancy in which
babies' blood vessels cross or run near the 
internal opening of the uterus. These vessels are at risk
of rupture when the supporting membranes rupture,
as they are unsupported by the umbilical cord or 
placental tissue.
Vasa praevia occurs in about 0.6 per 1000 pregnancies.
 The term "vasa previa" is derived from the Latin;
[1]

"vasa" means vessels and "previa" comes from "pre"

meaning "before" and "via" meaning "way". In other
words, vessels lie before the baby in the birth canal
and in the way
 clinical implications of vasa previa
Approximately 1 in 2500 deliveries are complicated by
vasa previa. If membranes rupture, these vessels may
rupture, with resultant fetal hemorrhage,
exsanguination, (severe loss of blood). or even death.
In addition, fetal asphyxia can occur if sufficient
pressure is applied to vessel(s) overlying the cervix and
circulation is compromised.
The 2 major risk factors for vasa previa are
velamentous cord insertion—which accounts for the
majority of reported cases—and
succenturiate placental lobe or bilobed placenta.
Approximately 60% of women with vasa previa at
delivery had a placenta previa or low-lying placenta
identified during second-trimester ultrasound. In
addition, 20% of patients with vasa previa have a low-
lying placenta at delivery.
another risk factor that has been consistently
identified is in vitro fertilization, which may increase
the risk for Type 1 vasa previa to approximately 1 in 250, 
Treatment[
It is recommended that women with vasa previa
should be delivered by elective cesarean before
rupture of the membranes.
 Given that the timing of rupture of membranes is
difficult to predict, elective cesarean delivery at 35–
36 weeks is recommended.
 This gestational age gives a reasonable balance
between the risk of death and that of prematurity.
Several authorities have recommended hospital
admission at about 32 weeks.
This is to give the patient proximity to the
operating room for emergency delivery should the
membranes rupture. Because these patients are at
risk for preterm delivery, it is recommended that
steroids should be given to promote fetal lung
maturation. When bleeding occurs, the patient
goes into labor, or if the membranes rupture,
immediate treatment with an emergency 
caesarean delivery is usually indicated.
Fetal Skull
The fetal skull
Fetal skull is most important part of fetus because it is the
commonest presenting part.
It is the largest and least compressible and once born,
generally ensure smooth delivery of the rest of the body.
The fetal skull
The fetal skull is constituted at its base by large ossified,
firmly united bones which are not easily compressible.
Their function is to protect the vital centers in the brain
stem. The vault is made up of relatively compressible
bone that can override one another at the suture line.
The skull will be described under the following heading:
1) area of the skull
2) Vault of the skull
3) Suture lines
4) Fontanelle
5) Landmarks
6) Diameters
7) miscellaneous
Its importance for midwifes
By knowing the landmarks and measurements of
the fetal skull enable the midwifes to recognize
presentation and position and to facilitate
delivery with the least possible trauma to
mother and child where malpresentation or
disproportion exist, she will be able to identify
it and alert the medical staff.
The fetal skull contains the delicate brain which may be
subjected to great pressure as the head passes through
the birth canal.
It is large in comparison with the true pelvis and some
adaptation between the skull and pelvis must take place
during labor.
The head is the most difficult part to deliver whether it
comes first or last.

1) AREA OF FETAL SKULL

- Vertex, Brow, Face
 Fetal Skull
Vault – Face – Base
The vault is composed
of soft bones separated
by sutures and
fontanelles.
Vault is subdivided into

1. Forehead

2. Vertex

3. Occiput
1) Forehead

From Bregma

to root of the

nose.
 (2) Vertex
It is an area of the vault of skull

Bounded:
 Anteriorly
anterior fontanelle
 Posteriorly
posterior fontanelle
 Laterally
line passing through
parietal eminence
3) Occiput

From posterior

fontanelle to the

external occipital

Protuberance.
Bones of the vault IS (7 bones)
2 frontal bones
2 parietal bones
2 temporal bones
1 occipital bone

• The bones of the vault are not joined thus changes in

the shape of the fetal head during labor can occur due
to moulding
 Sutures
(number = 6)
Spaces between skull bones.

Made of un-ossified membranes which

allows movements of cranial bones to
decrease the skull diameters.
 Sutures = 6 in number

- Sagittal suture

- Frontal suture

- Coronal suture

- Lambdoidal sutures

- 2 Temporal sutures
Fontanelles is the space created by the joining of
.two or more sutures
It is covered by thick membranes and the skin on the
baby’s head, protecting the brain underneath the
fontanel from contact with the outside world.
Identification of the two large fontanels on the top of
the fetal skull helps you to locate the angle at which
the baby’s head is presenting during labor and
deliver suture line
gfdgfgfgfdg
Landmark of Fetal skull
Bregma  Ant fontanelle
Brow  lies between Bregma &root of the
nose
Face  lies between root of the nose &
subra orbital ridges and chin
Occiput boney prominence behind post
fontanelle
Vertex Diamond shaped area between ant & post
fontanelles & parietal eminences
Sinciput : area bounded by the glabella and
orbital ridges inferiorly and bregma and
coronal sutures superiorly.

Nation: the root of the rose

Parietal eminences: the base area of the

parietal bone. The distance between the two
eminences is called biparital diameter
Moulding :
Moulding is the ability of the fetal head to change its
shape and there by adopt to the rigid maternal
pelvis.
The suture lines permit the skull bone to slide over
each other. The posterior parietal bone is subjected
to great pressure by the sacral promontory, hence it
passes underneath the anterior parietal bone,
permitting overlapping of the parietal bone in the
midline. The occipital bone and the frontal bone
slide under the parietal bone .
Moulding helps to reduce the presenting diameters,
however the skull undergoes a corresponding increase
in the diameter at the right angle to its so that the
volume of the cranium is not decrease and brain not
damage.
Excessive moulding in vertex can lead to elongation of
the mento vertical diameter resulting in tearing of the
tantorium cerebelli (is an extension of the dura mater
that separates the cerebellum from the inferior
portion of the occipital lobes) and rupture of the vein
of the galen (great cerebral vein) causing grave
intracranial haemorrhage.
-Grading of moulding : there are four grading
0- no moulding -
1- the bones touching but not overlapping
2- overlapping but easily seperated
3 – fixed overlapping
Diameters of Fetal
Skull
Diameter of the skull: the measurement
of the skull are important because the
midwife needs a practical understanding
of the relation between the fetal head and
mother’s pelvis. It will become clear that
some diameters are more favorable for
easy passage through the pelvic canal and
this will depend on the attitude of the
head.
Important Definitions
Fetal Attitude
 It is the relations of the fetal parts to each other,
it is in a general flexion attitude i.e. all joints are
flexed.
Complete Flexion
Most common ( in Vertex presentation)
Deflexion: In O.P position.

Military attitude: Midway between flexion &

extension (brow).
Complete extension In face presentation.
Lie
The relation between the longitudinal axis of the fetus to that of the
mother.

Types:
1) Longitudinal (99.5 %). 2-Oblique or transverse (0.5 %).
Presentation
It is the lowermost part the fetus & the part related to the pelvic brim and first felt by vaginal examination.

Presentation

C eph alic
) 96%(

Breech Transverse
Vertex Brow )3.5%( Face )0.5%(
N.B:
In term pregnancy cephalic presentation is more common than breech

Because of:
1. The head is heavier so it occupies the LUS
2. The buttocks are larger so it occupies the fundus
Position
The relation of the back of the fetus to the
right or to the left sides of the mother and
whether it is directed anteriorly or posteriorly.

• 1 st position: The back is left and anterior.

• 2 nd position: The back is right and anterior.

• 3 rd position: The back is right and posterior.

• 4 th position: The back is left and posterior

The denominator
A landmark on the presenting part denoting
the position

Occiput ------------------- in vertex.

Frontal bone------------- in brow .
 Chin ----------------------- in Face.
Scapula ------------------- in shoulder

Sacrum -------------------- in Breech

Vertex ---------------- occiput
In vertex presentation
(the commonest),
There are 8 positions
- Right and left
occipito-anterior

- Right and left

occipito- posterior

- Right and left

occipito-transverse

- Direct occipito
anterior and posterior
8 positions
Fetal Position
The fetal compass rose
 Engagement

Passage of the widest

transverse diameter
of the presenting part
through the plane of

the pelvic inlet.

Example: B.P.D. in cephalic presentation

 Timing of engagement
In PG: (last 3 – 4 weeks)
In MP: it usually occurs in the 1st
stage or with onset of 2nd stage

Detection of engagement
•Abdominally: by 1st pelvic grip (Rule of fifths).

•Vaginally: (Rule of station).

 Station
The level of the head in the pelvis.
 Detection of engagement

Abdominally (Rule of fifths).

Rule of fifths
0 station: 2/5 of the head are felt abdominally
above symphysis pubis

+1 station: 1/5 of the head is felt

+2 station: none of the fetal head is felt

-1 station: 3/5 head is felt

-2 stations: 4/5 head is felt

-3 station : the whole head (5/5) is felt

Vaginally(Station of the head)
The level of the vertex is assessed in relation to the level of ischeal spines
At this level it is called station (0) above this level is by minus every 1 cm
and below by pulse every 1 cm
Assessing the Descent of the Fetal Head
by Vaginal Examination
Station of the head
0 = The lowest part of the head is felt vaginally at
the level of the ischial spine.

+ 1= If 1 cm. below the level of ischial spines.

+2 = If 2 cm below the level of ischial spines.

+3= If 3 cm. below the level of ischial spines

-1 = If 1 cm above the level of ischial spines.

-2 = If 2 cm above the level of ischial spines.

-3 = If 3 cm above the level of ischial spines.

 Causes of Non-engagement of fetal head
Fetal causes Maternal causes
• Large sized head • Pelvic contraction
• Hydrocephalic head • Pelvic tumors
• Malposition • Placenta previa
• Malpresentation • Hypertonic LUS
• Multiple pregnancy • Atony of abdominal or
• Short umbilical cord uterine muscles
• Polyhydraminos

In 20% of cases no cause is found.

MCQ
(1) The greatest diameters of the
normal fetal head is which of the
following?
A. Occipito – frontal
B. Suboccpito bregmatic
C. Bitemporal
D. Biparital
E. Mento – vertical

(E)
(2) The relation of the fetal parts to each
other determines which of the following?
A. Presentation of the fetus
B. Lie of the fetus
C. Attitude of the fetus
D. Position of the fetus
E. Intention of the fetus

(c)
(3) In vertex presentation, what
fetal part determined the fetal
position?
A. Mentum
B. Sacrum
C. Acromion
D. Occiput
E. Sinciput

(D)
(4) The relationship of the long axis of
the fetus to that of the mother called IS:

a) Lie
b) Presentation
c) Attitude
d) Posture
e) Position
(A)
(5) Regarding the fetal skull fontanelles, one
of the following is true:

A. There are 3 fontanelles

B. The posterior fontanelle is closed at 28 weeks of
gestation
C. The anterior fontanelle is closed at birth
D. The anterior fontanelle is irregular in shape
E. The posterior fontanelle is triangular in shape

(E)
(7) The correct statement for
anterior fontanelle (Bregma) is:

a) Triangular in shape
b) Smaller than the posterior
fontanelle
c) Has bony floor
d) Becomes obliterated 18 months
after birth

(D)
(8) The correct statement for
biparietal diameter of fetal head
a) Extend from a point below one parietal bone
to a point above the opposite eminence
b) It is the engaging diameter in brow
presentation
c) It is 9.5 cm in length
d) All of the above

(c)
(9) Concerning the occipto frontal
diameter, all of the following are true
EXCEPT:
a) It extends from occipital protuberance to
root of the nose
b) It is 9.5 cm I length
c) It is the diameter of engagement in after
coming head of breech.
d) It is the diameter distending
() the vulva in
face to pubis delivery

(B)
Short questions

Short
Gives

?Account on
What are the various types of
fetal presentations?

What are the different cephalic

presentations?

How is position determined?

What is the definition of
mal presentation?

What is the Rule of fifths?

Causes of non engagement ?

Definition of
1. Lie
2. Vertex
3. Attitude
4. Engagement
5. Pelvic brim
6. Synclitism
7. Asynclitism
8. Station of the head