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10/11/10

MALPOSITION, MALPRESENTATION

97% 3%:

: cephalic breech 0.5% : transverse, oblique,face, brow

Dr Raed Sayed Ahmed

Head

is hyperextended: occiput fetal back Mento anterior or posterior Labour progress stalled with MP INCIDENCE:0.17%
touches

Exam: 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

Lax

High

pendulous abdomen parity

Only

in mentoanterior chin leading-internal rotation- chin lies under the symphysis pubis With mento posterior the short neck unable to span the anterior surface of sacrum
Descent, with

10/11/10

Chin

mouth appears at vulvais by flexion External rotation with chin Cls frequent because of contracted pelvis External continous monitoring yes Mento posterior C/S
birth

ANTRIOR

FONTANELLE AND ORBITAL RIDGES MIDWAY B/W FLEXION/ EXTENSION NO MECHANISM OF LABOURMENTOVERTICAL UNSTABLE PRESENTATION- CAN CHANGE ETIOLOGY: same as in face Prognosis: small baby ok; term baby c/s

Shoulder

presentation: dorso anterior; or posterior Incidence:0.3% Etiology : abdominal wall relaxation, Preterm Placenta previa, uterine anomaly excessive liquor,contracted pelvis

MOST: malrotation Abdominal MX

of ociput anterior

and V/E

position 87%

=C/S

of occiput anterior: rotate : monitor as normal

anterior LABOUR

10/11/10

Incidence:
> 28 weeks25%

Breech Presentation
Term 2-3% 1/3 are undiagnosed in labour

A 26 years old primigravida was referred to the antenatal clinic at 36 weeks gestation with a history of persistent breech presentation since the 28th week. Your abdominal examination confirms the finding with fundal height of 38 weeks size. How would you manage the patient and what advice would you give the patient regarding the mode of delivery.

Classification:
1. Frank (65%): The foetal hips are flexed and the knees are extended. 2. Complete (25%): The foetal hips and knees are flexed. 3. Incomplete (10%): The foetal feet or knees are the lowermost presenting part

Etiology:

Diagnosis :
Clinical examination:
abdominal vaginal

1. Prematurity 2. Congenital anomalies, 6% {2-3%}>>> anencephaly,hydrocephalus 3. Uterine anomalies, septate. 4. Multiple gestation 5. Placenta praevia 6. Ployhydramnios 7. Pelvic tumours, fibroids ovarian..

i.

ii. Radiological examination:


x-ray ultrasound scan

External Cephalic Version


Management During Pregnancy: If persisted till 34 weeks. Then ultrasound scan to exclude; abnormality, Ployhydramnios, placenta praevia. By completed 37 weeks External Cephalic Version: 45-80% success rate 5% revert back to breech Protocol to avoid complications In delivery room NPO and ready for c/s CTG & USS Tocolytic Head down position Dislodge breech then gently turn around US and CTG after procedure.

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Mode

of delivery:

Types of vaginal breech delivery:

Criteria:

1. Spontaneous breech delivery 2. Assisted breech delivery 3. Breech extraction


Mechanism

a) Frank or complete breech presentation b) Gestational age > 36 weeks c) Estimated foetal weight b/n 2.5-3.5 kg d) Foetal head must be flexed e) Adequate maternal pelvis, x-ray or ct pelvimetry ??? f) No other obstetric complications, prev.c/s, pet etc g) Preferably epidural analgesia

of delivery:

SOME OBSTETRIC COMPLICATIONS OF BREECH PRESENTATION COMPLICATION FETAL/NEONATAL Intrapartum foetal death Intrapartum foetal asphyxia Intrapartum foetal distress Umbilical cord prolapse Birth trauma 16 times (x) non-breech 3 to 8 x non-breech ~60% (of all breech presentations 2.5 % overall (18 x non-breech) = < 13 x non-breech INCIDENCE

Entrapment of aftercoming head ~9% (of babies > 2500 g) Perinatal/neonatal mortality 3 to 5 x non-breech[25/1000 vs (mainly intracranial hemorrhage) 1-2/1000] MATERNAL (Largely due to cesarean section) Variable

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2. Caesarean Section:
# Indications
1. Any abnormality of the bony pelvis 2. Foetal weight > 3.5 kg 3. Hyperextension of foetal head 4. Previous difficult labour 5. IUGR 6. Bad obstetric history 7. Diabetes 8. Severe pre-eclampsia 9. Failure to progress in first stage or descent in second stage 10. Footling breech 11.Preterm labour 12. Previous c/s 13. PRIMIGRAVIDA
Multi-centric

International trial to determine the safer way to deliver babies in the breech presentation had to be stopped because analysis of preliminary results showed

trial

25% of < 28 weeks in breech presentation in Preterm labour of which 18% are congenitally abnormal Has a higher antepartum stillbirth and neonatal death rate than babies presenting by the head irrespective of the mode of delivery

High perinatal mortality in the breech baby irrespective of the mode of delivery Reducing morbidity for vaginal breech delivery is by careful selection, clear intrapartum guide lines and expertise Despite recent evidence, difficulty in favoring a mode of delivery due to social consideration External Cephalic Version should be tried unless contra-indication Preterm breech is safer to be delivered by c/s if normal