Professional Documents
Culture Documents
FETUS
PRESENTATIONS
• Longitudinal orientation:
- fetus and the mother are in the same verical axis
- is the most common lie
• Transverse orientation:
- fetus at right angles to mother
• Oblique orientation:
- fetus at 45⁰ angle to mother
1. Transverse fetal lie
• In logitudinal lies, the presenting part is either the fetal head or breech,
creating cephalic and breech presentations;
• When the fetus lies with the long axis transversely, the shoulder is the
presenting part and is felt through the cervix on vaginal examination;
* In most normal pregnancies, the fetus settles into the mother’s pelvic
cavity from week 36 onwards, ready for labour and birth.
About 8 in 10 fetuses settle head downwards, facing the mother’s back,
with the chin resting on the chest. In this presentation, the fetus is in the
optimum position for birth, and a normal vaginal delivery is usually possible
Cephalic presentation Breech presentation Shoulder
* ATTITUDE
• According with each presentation there may be two positions: Right or Left
• For still more acurate orientation the relationship of a given portion of the
presenting part to the anterior, transverse or posterior portion of the
maternal pelvis is considered
• Ordinarily, the head is flexed sharply so that the chin is in contact with the
torax
a. b. c.
SINCIPUT PRESENTATION
DEFINITION:
- Also known as “military position”, occurs when the head is
neither flexed nor extended. The anterior fontanel is felt as the
presenting part.
EPIDEMIOLOGY:
- Sinciput presentation occurs in 1 of every 1000- 2000 live births
POSITION:
- The anterior fontanel (bregma) is the point of designation and can
present in any position relative to the maternal pelvis.
DIAMETER:
- presenting diameter is occipito-frontal (12,5 cm)
ETIOLOGY:
MATERNAL
OVULAR
FACTORS:
- uterine FACTORS:
malformations - Small head
- abdominal
tumors - Placenta
- cephalopelvic
praevia
disproportion
DIAGNOSIS:
MECHANISM OF LABOUR:
• The engagement is done with difficulty due to the large size of the fronto-
occipital diameter (12,5 cm) for small fetuses or it is not done at all for large
fetuses.
• When the circumference gets on the pelvic-perineal floor, there are
possible three situations:
For all the other pregnant a birth prove will be performed (2-4
hours); if the engagement was not produced: cesarean surgery will be
perform
EPIDEMIOLOGY:
- Brow presentation is the least common of all fetal presentations and the
incidence varies from 1 in 500 deliveries to 1 in 1400 deliveries.
POSITION:
- The frontal bones are the point of designation and can present (as with the
occiput during a vertex delivery) in any position relative to the maternal pelvis.
- When the sagittal suture is transverse to the pelvic axis and the anterior fontanel
is on the right maternal side, the fetus would be in the right fronto-transverse position
(RFT).
- Most frequent positions are: right fronto-posterior position and left fronto-
anterior position
DIAMETER:
- presenting diameter is occipito-mental (13,5 cm)
ETIOLOGY:
OVULAR FACTORS:
- fetal malformations
- short neck
MATERNAL FACTORS: - small fetal thyroid
- cephalopelvic enlargement
disproportion or pelvic - musculoskeletal
contracture abnormality
- uterine
malformations - placenta praevia
- uterin fibroma - polyhydramnios
- premature rupture
of membranes
(27%)
DIAGNOSIS:
- Diagnosis of a brow presentation can occasionally be made with
abdominal palpation by Leopold maneuvers:
a prominent occipital prominence is encountered along the fetal
back, and the fetal chin is also palpable;
however, the diagnosis of a brow presentation is usually
confirmed by examination of a dilated cervix
MECHANISM OF LABOUR:
Three labor courses are possible when the fetal head engages in a brow
presentation:
I. The brow may convert to a vertex presentation
II. The brow may convert to a face presentation
III. Or remain as a persistent brow presentation
* More than 50% of brow presentations will convert to vertex or face presentation and
labor courses are managed accordingly when spontaneous conversion occurs.
In the brow presentation, the occipito-mental diameter, which is the
largest diameter of the fetal head, is the presenting portion.
• Descent and internal rotation occur only with an adequate pelvis and if
the face can fit under the pubic arch
• While the head descends, it becomes wedged into the hollow of the
sacrum. Downward pressure from uterine contractions and maternal
expulsive forces may cause the mentum to extend anteriorly and low to
present at the perineum as a mentum anterior face presentation.
• If the mentum is anterior and the forces of labor are directed toward the
fetal occiput, flexing the head and pivoting the face under the pubic arch,
there is conversion to a vertex occiput posterior position. If the occiput lies
against the sacrum and the forces of labor are directed against the fetal
mentum, the neck may extend further, leading to a face presentation.
Most experts would agree that there is no mechanism of successful labor for a
termsized persistent brow under most circumstances, and therefore vaginal delivery is
impossible. However, vaginal delivery can occur if the fetus is quite small or if the pelvis is
very large
MANAGEMENT :
EPIDEMIOLOGY:
- Face presentation occurs in 1 of every 600-800 live births, averaging about
0.2% of live births
POSITION:
- The fetal chin (mentum) is the point designated for reference during an
internal examination through the cervix. The occiput of a vertex is usually hard
and has a smooth contour, while the face and brow tend to be more irregular
and soft.
- Like the occiput, the mentum can present in any position relative to the
maternal pelvis. For example, if the mentum presents in the left anterior
quadrant of the maternal pelvis, it is designated as left mentum anterior
(LMA).
Positions in face presentation
DIAMETER:
- presenting diameter is submento- bregmatic (9.5 cm)
OVULATORY FACTORS:
ETIOLOGY:
- Prematurity
- fetal anomalies
(hydrocephalus,
anencephaly)
MATERNAL FACTORS: - neck masses
- grand multiparity - large infants
- multiple gestations - musculoskeletal
- cephalopelvic
abnormality
disproportion
- uterine
malformations - several coils of
- abdominal tumors
ombilical cord
- uterine fibroma
around the neck
- placenta praevia
- polyhydramnios
DIAGNOSIS:
- Face presentation is diagnosed late in the first or second stage of
labor by examination of a dilated cervix
MECHANISM OF LABOUR:
* The above mechanisms of labor in the term infant can occur only if the
mentum is anterior and at term, only the mentum anterior face
presentation is likely to deliver vaginally
* If the mentum is posterior or transverse, the fetal neck is too short to span
the length of the maternal sacrum and is already at the point of maximal
extension. The head cannot deliver as it cannot extend any further through
the symphysis and cesarean delivery is the safest route of delivery.
- Fortunately, the mentum is anterior in over 60% of cases of face
presentation, transverse in 10-12% of cases, and posterior only 20-25% of
the time
- When the mentum is posterior, the neck, head and shoulders must
enter the pelvis simultaneously, resulting in a diameter too large for the
maternal pelvis to accommodate unless in the very preterm or small infant
*Little knowledge is
dangerous