Management of abnormal presentation

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MANAGEMENT OF ABNORMAL PRESENTATIONBYMRS.
GBONJUBOLA OLUDAYO OWOLABIRN. RM., MSc Nursing ,
MSc Sociology, FWACN
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INTRODUCTION

• The normal process of delivery is dependent on
  the physical relationships between the foetus and
  maternal pelvis
• Other factors such as foetal positions, placenta
  and Cord locations, maternal soft tissues are
  contributory to the efficacy and safety of the
  birth process
• The midwife observations, diagnosis and apt
  management of mothers during pregnancy, labour
  and post natal period is crucial in outcome and
  course especially of abnormal positions and
  presentation

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• OUTLINE
• The management of abnormal presentation will
  focus on
• Types
• Causes
• Diagnosis
• Management
• Complications

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OBJECTIVES

• At the end of the presentation participants will
  be able to understand
• Types of malposition and malpresentation
• Causes of malposition and malpresentation
• Diagnosis of malposition and malpresentation
• Management of malposition and malpresentation
• Complications of malposition and malpresentation

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• Types of Abnormal Presentations
• Occipitoposterior position
• Face Presentation
• Brow Presentation
• Breech Presentation
• Shoulder Presentation
• Unstable Lie
• Compound Presentation

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OCCIPITOPOSTERIOR POSITIONS

• These are the most common type of malposition of
  the occiput and occur in approximately 10 of
  labours. Occipitoposterior positions are cephalic
  presentations where the occiput point posteriorly
  towards the left or right sacro-illac joint.
• Causes of Occipitoposterior Positions
• No definite cause of Occipitoposterior positions
  has been established, but it may be associated
  with
• An abnormally shaped pelvis

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• ANTENATAL DIAGNOSIS OF OCCIPITOPOSTERIOR
  POSITIONS
• Abdominal Examination
• Listen to the mothers complains
• On inspection (There is a sauucer shaped
  depression at or just below the umbilicus)
• On palpation (The back is difficult to palpate as
  it is well out to the maternal side)
• On auscultation (Fetal back not well flexed so
  chest thrust forward)

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Diagnosis during Labour

• Continuous backache
• Early spontaneous rupture of membranes
• Slow descent of the foetal head
• The foetal head pressing on the rectum
• Vaginal Examination (locating the anterior
  fontanelle in the anterior part of the pelvis is
  diagnostic)

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• Management of Occipitoposterior positions
• Mother must be kept informed of progress and
  participate in decisions
• A change of position may help to overcome the
  urge to bear down
• The doctor may choose to use forceps to rotate
  the head to occipitoanaterior position before
  delivery

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MACHANISM OF RIGHT OCCIPITOPOSTERIOR POSITION
(LONG ROTATION)

• The lie is longitudinal
• The attitude of the head is deflexed
• The presentation is vertex
• The position is right occipitoposterior
• The denominator is the occiput
• The presenting part is the middle or anterior
  area of the parietal bone
• The occitofrontal diameter, 11.5cm, lies in the
  right oblique diameter of the right sacroiliac
  joint and the sinciput to the left iliopectineal
  eminence

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• Flexion Descent takes place with increasing
  flexion. The occiput becomes the leading
• Internal rotation of the head The occiput
  reaches the pelvic floor fist and rotates
  forwards 3/8 of a circle along the right side of
  the pelvis to lie under the symphysis pubis
• Crowning The occiput escapes under the symphysis
  pubis and the head is crowned
• Extension The sinciput, face and chin sweep the
  perineum and the head is born by a movement of
  extension
• Restitution The occiput turns 1/8 of a circle
  to the right and the head realigns itself with
  the shoulders

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POSSIBLE COURSE AND OUTCOME OF LABOUR

• Long Internal Rotation This is the common
  outcome, with good uterine contractions producing
  flexion and descent of the head so that the
  occiput rotates forward 3/8 of a circle.
• Short Internal Rotation
• Undiagnosed face to pubis
• Deep transverse arrest

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• Complications of Occipitoposterior positions
• Obstructed labour
• Maternal trauma
• Neonatal trauma
• Cord prolapse
• Cerebral Haemorrhage

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FACE PRESENTATION

• When the attitude of the head is one of complete
  extension, the occiput of the foetus will be in
  contact with the spine and the face will present.
  Majority of face presentation develop during
  labour from vertex presentation with the occiput
  posterior. This kind of face presentation is
  known as Secondary Face Presentation.

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• Causes of Face Presentation
• Anterior Obliquity of the uterus
• Contracted Pelvis
• Polyhydramnios
• Congenital abnormality
• Diagnosis of Face Presentation
• Antenatal diagnosis is rare since face
  presentation develop during labour in the
  majority case.
• Intrapartum Diagnosis
• On abnormal Palpation
• On vaginal Examination

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Management of Face Presentation

• Upon diagnosis, midwife should inform the doctor
  of this deviation from normal
• Routine observations of maternal and foetal
  conditions
• Vaginal examination should be performed to
  exclude cord prolapse
• Descent of head should be observed abdominally,
  and careful vaginal examination performed
• If necessary prescribed oral ranitidine, 150mg
  every six(6) hours throughout labour

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Complications of Face Presentation

• Obstructed labour
• Cord prolapse
• Facial bruising
• Cerebral Haemorrhage
• Mental Trauma

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• BROW PRESENTATION
• In brow presentation the foetal head is partially
  extended with the frontal bone, which is bounded
  by the anterior fontanelle and the orbital ridges
  lying at the pelvic brim. This presentation is
  rare, with an incidence of 1 in 1000 deliveries
  at full term.
• Causes of Brow Presentation
• Lax uterus due to repeated full term pregnancy
• Multiple pregnancy
• Polyhydramnios
• Abnormal shape of mothers pelvis

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• Diagnosis of Brow Presentation
• It is usually detected before the onset of labour
• On abdominal Examination
• On vaginal Examination
• Management of Brow Presentation
• The doctor must be informed immediately this
  presentation is suspected
• If head fails to descend and the brow
  presentation persists, a caesarean section should
  be carried out.

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Complications of Brow Presentation

• Obstructed labour
• Cord prolapse
• Facial bruising
• Cerebral Haemorrhage
• Mental Trauma

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• Breech Presentation
• A breech presentation is an unusual presentation
  but it should not be considered abnormal as the
  foetus lies longitudinally with the buttocks in
  the lower pole of the uterus. This presentation
  occurs in approximately 3 of pregnancies at
  term.
• Hannah et al 2000 reports that vaginal birth is
  more hazardous than caesarean birth.
• Types of Breech Presentation
• Frank breech Footling breech
• Knee breech Complete breech

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Causes of Breech Presentation

• Extended legs
• Intrapartum labour
• Multiple pregnancy
• Polyhydramnios
• Hydrocephaly
• Uterine abnormalities
• Placenta praevia

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Diagnosis of Breech Presentation

• Antenatal
• Abdominal Examination
• Palpation
• Auscultation
• Ultrasound Examination
• X-ray examination
• During Labour
• Abdominal Examination
• Vaginal Examination

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• Management of Breech Presentation
• If midwife detects a breech presentation at 37
  weeks gestation or later, she should refer the
  woman to a doctor
• External Cephalic Version (ECV) can be offered by
  skilled and experienced practitioners.

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MECHANISM OF LEFT SACROANTERIOR POSITION

• The lie is longitudinal
• The attitude is one of the complete flexion
• The presentation is breech
• The position is left sacroanterior
• The denominator is the sacrum
• The presenting anterior buttock
• The bitrochsnteric dismeter, 10cm, enters the
  pelvis in the left oblique diameter of the brim
• The sacrum points to the left iliopectineal
  eminence

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• Compaction Descent takes place with increasing
  compaction owing to increased flexion on the
  limbs
• Internal Rotation of the buttocks The anterior
  buttock reaches the pelvic floor first and
  rotates forwards 1/8 of a circle along the right
  side of the pelvis to lie undernath the symphysis
  pubis
• Lateral Flexion of the body The anterior
  buttocks escape under the symphysis pubis, the
  posterior buttock sweeps the perineum and the
  buttocks are born by a movement of lateral
  flexion
• Restitution The anterior buttock turns slightly
  to the mothers right side

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• Internal Rotation of the shoulders The
  shoulders enter the pelvis in the same oblique
  diameter as the buttocks, the left oblique.
• Internal Rotation of the head The head enters
  the pelvis with the sagittal suture in transverse
  diameter to the brim
• External Rotation of the body At the same time
  the body turns so that the back is uppermost
• Birth of the head The chin, face and sinciput
  sweep the perineum and the head is born in a
  flexion attitude

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PARTIAL BREECH EXTRACTION OR ASSISTED BREECH
DELIVERY

• Delivery of the aftercoming head
• Burns Marshall Method
• Mauriceau-Smellie-veit maneuver
• Prague maneuver
• Piper forceps

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Complication of Breech Presentation

• Knotting of the umbilical cord
• Separation of the placenta
• Rupture of the membrane
• Relative contraindications
• Contraindications include
• Pre-eclampsia or hypertension
• Oligohydramnios
• Rupture of membranes
• Any condition that would require delivery by
  caesarean section.

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• UNSTABLE LIE
• The lie is defined as unstable when after 36
  weeks gestation, instead of remaining
  longitudinal, it varies from one examination to
  another between longitudinal and oblique or
  transverse.
• Causes of Unstable Lie
• Maternal
• Lax uterine muscles in multigravides
• Contracted pelvis
• Foetal
• Polyhydramnios
• Placenta Praevia

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Management of Unstable Lie

• Antenatal
• Woman should be admitted to hospital to avoid
  unsupervised onset of labour with transverse lie
• Ultrasonography should be done to rule out
  placenta praevia
• Attempt should be made to correct the abnormal
  presentation by ECV, if unsuccessful then
  caesarean section should be considered.

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• Intrapartum
• A controlled rupture of the membrane can be
  performed so that the head enters the pelvic brim
• Induction may be performed after 38 weeks
  gestation by administering of IV oxytocin to
  stimulate contraction.
• Midwife should ensure that the woman has an empty
  rectum and bladder before necessary procedure.
• Complications of Unstable Lie
• Complications are same as the transverse lie.

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• SHOULDER PRESENTATION
• When the foetus lies with its long axis across
  the long axis of the uterus (transverse lie) the
  shoulder is most likely to present. This occurs
  in approximately 1300 pregnancies near term.
• Causes of Shoulder Presentation
• Maternal
• Lax abdominal and Uterine muscles
• Uterine abnormality
• Contracted pelvis

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Foetal

• Pre-term pregnancy
• Multiple pregnancy
• Polyhydramnios
• Macerated Foetus
• Placenta praevia
• Diagnosis of Shoulder Presentation
• Antenatal Intrapartum
• On abdominal Palpation On abnormal Palpation
• Ultrasound On vaginal
  Examination

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• Management of Shoulder Presentation
• Antenatal
• An ultrasound examination should be done to
  detect placenta praevia or uterine abnormalities,
  while X-ray pelvimetry will demonstrate a
  contracted pelvis.
• Any of these causes requires elective caesarean
  section.
• Admit the woman to hospital for further
  investigation
• She may remain on admission until labour because
  of the risk of cord prolapse if membrane rapture

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• Intrapartum
• If a transverse lie is detected in early labour
  while the membranes are still intact, the doctor
  may attempt an ECV.
• If the membranes have already ruptured
  spontaneously, a vaginal examination must be
  performed immediately to detect possible cord
  prolapse
• Immediate caesarean section must be performed if
• The cord prolapse
• the membranes are already ruptured
• ECV is unsuccessful
• Labour has been in progress for some hours

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• Complication of Shoulder Presentation
• Prolapsed Cord
• Trauma to prolapsed arm
• Obstructed labour and ruptured uterus
• Foetal hypoxia and death

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• COMPOUND PRESENTATION
• When a hand, or occasionally a foot, lies
  alongside the head, the presentation is said to
  be compound.
• This tends to occur with a small fetus or roomy
  pelvis and seldom is difficulty encountered
  except on cases where it is associated with a
  flat pelvis
• If diagnosed during first stage of labour,
  medical aid must be sought
• If during second stage, the midwife sees a hand
  presenting alongside the vertex, she could try to
  hold the hand back

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References

• Fraser D. M., Cooper M. A.(2009) Myles Textbook
  for Midwife, pp578 602. Edinburgh Churchill
  Livingstone
• Gimovsky, M, Global Library of Womens Medicine.
  (ISSN 1756-2228) 2016DOI 10.3843/GLOWM.10135
• http//www.slideshare.net/mobile/aymanshehata2010/
  breech-presentation-47436046
• Weingold A. B. (1984) The management of breech
  presentation. In Iffy L, Charles C (ed)
  Operative Perinatology, pp537 553. New York,
  Macmillan

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Thank you