ABNORMAL LIE AND PRESENTATION.
Foetal lie:
it refers to the relationship between the longaxis of the foetus and the
longaxis of the uterus. If the two long ares are one same plane, it is regarded
as a longitudinal lie (x this is the normal lie). Any lie apart from the
longitudinal lie is an abnormal lie are e.g. Oblique and transverse lie.
Transverse:
The long axis of the foetal spine is at right angle to the long axis of the
uterus.
Oblique:
the long axis of the foetal spine is at an angle < 90 to that of the uterine
axis
Unstable
lie: The foetus changes its lie in each Obstetric examination.
It is only in longitudinal lie that ther is
mechanism of labour and the women can deliever vaginally. In every other lie,
there is no mechanism. Of labour and delivery is by C/S.
Presentation:
refers 2days part of the foetus datis overlying the pelvic brim when the
prossenting part is not engaged or is the in the pelvic cavity when it is
engaged. The commonest presentation is the cephalic. Any other presentation
outside this is known as abnormal.
Fully
flered head-vertex presentation
Slight
deflection –brew presentation
Straight
deflection – face presentation
Full
defection- chin presentation
Others
deliver by cs
Another
abnormal presentation of labour is the breach
Presentation
(commonest malpresentation)
It
is only in vertx and monto-anterior presentation that are the there is only
ones that ther’s a mechanism of labour and vagina delivery.
BREECH PRESENTATION.
Introduction:
Breech Presentation is a form of malpresentation in these foetal buttocks or
lower extremities occupy is in direct relationship the maternal pelvic in let.
It is incidence is the advancing age from
25% at via 15% of 32doses to 2% at term.
It accounts fro 3-4% of infants born at term
or atleast 20,00 babies per yr in UK
Depending
on the attitude of the foetus, breach presentation has been.
Classified as:
Frank or Extended breech presentation when
the foetal imps are flexed and knees extended. Also called
“pike”--------------- thus accts for
50-70% of breach presentation and is commoner in primi grauda.
Complete or flexed breach presentation: when
both hips and knees are flexed. Also referred to as cannon ball (account for
5-10% of breach presentation) Commoner in multi-parous women.
Footing or incomplete breach presentation:
When one or both hips are extended. Here the feet(foot) lie below the foetal
buttocks and either it or the knee may be presenting.
Clinically,
2 varieties of breach presentation exists
Complicated
and Uncomplicated.
Uncomplicated:-
one in is no other associated obstetric complication is. Apart from the
presentation exist.
Complicated:-
occur when associated the factors which adversely influence the prognosis e.g.
multiple pregnancy, contracted pelvis, placenta praevia e.tc.
It
should be noted that extended legs or arms cord prolepses, and other
difficulties encountered during delivery are also designated abnormal or
complicated breach deliveries.
Complications /
problems of breech presentation(BP)
Complication associated the BP may be
maternal or foetal.
Maternal risks are both related to operative
and vagina deliveries and include genital tract trauma, sepsis and anesthetic
complication. The prenatal mortality is 2-4folds by breach presentation
compared to cephalic presentation regardless of delivery mode.
This is associated the malformation,
prematurely and IUD. Foetal complications associated the vaginal delivery, falx
arebricerebellar and fentional tears,
sub-arachunid hemorrhage, cephaihaematomas, spinal cord, disrupting, bracluial
plexus stretch (erb’s and klumle’s palsy), fractures of long bones (femur and
hermous) eruptive of 5cm mz.
Injury to the foetal adrenal glands, liver,
arms, ext. gervitalia , hip joint and sciatic nerve, could also occur in vagina
breach presentation delivery. Asphyxia could result from cord prolapsed and compression,
placental site, retractor, delayed delivery of out coming foetal head,
premature attempt at respiration the incompletely delivered head.
The
resort to abnormal delivery is associated the some anesthetic risks, hemorrhage
and the risk for blood transfusion and the morbidity
Delivery of outstand foetal lead, premature
attempt at respiration with incompletely delivered head.
The represent resort to able delivery is
associated with some rita, homology to increased mobility
ETIOLOGICAL
ASSOCIATION
Breach presentation is multifactor in origin.
It may however, occur in the absence of any known Predisposing Factor(s):
Advancing material age, null parity, female foetus, caffeine and a variably of
foetal anomalies have been implicated. The commonest cause, however, is per
maturity as a higher incidence of beach presentation has been found in early
weeks of pregnancy. This is due to a smaller foetal size of a comparatively
larger amniotic fluid volume, which allows the foetus to undergo spontaneous
version by kicking provident units 36 weeks when the position becomes
stabilized as liquor volume ratio decreases
Certain factors which prevent spontaneous
version, such as extended breach multiple pregnancy, oligohydramnios,
congenital uterine malformations (sepate, bicornate of unicornuate uterus). A
relatively short umbilical cord of IUFD may predispose to breach pre. Other
factors may also cause it by encouraging favourable adaptation of the foetus to
the unterine anatomy. Such factors included hydrocepholus placenta precria,
contracted pelvis, leiomyometa uteri (fibroid) other peliv fumours as well as
cornua-fundal uterine attachment Excessive foetal mobility as may occur in
polyhydraminios of multipara with lax abdomen as well as foetal anomalies like
anencephaly and hydrocephalus to may also predisp to breach present
Recurrent
or habitual breach is said to occur when breach presentation occurs in the
three or more consecutive pregnancies. Cause includes:
–– Pelvic malformation
–– Congenital uterine malformations
–– Repeated conva-fundal placental attachment
DIAGNOSIS
This
can be much clinically and confirmed by ancillary or radiographic
investigations. There may be complaints of epigastric or sebcostal discomfort,
due to the pressure of the foetal head
on the ribs, while some patient may experience foetal kick more in the pelvic
region. Inspection of the abdomen usually shows nothing specific whereas
palpation may rounded and ballot able mass in the pelvic. Demonstrate an
irregular, firm (but not bony hard) less rounded mass. Difficulties may arise
in the presence of obesity, plyhydramics to in extended bread where ballotment
of the head may be obscured by the foetal legs. On auscut of the maternal
umbilicus. However in a frank breach, early engagement may make the foetal what
tones to be heard at levels lower than this on VE, make the foetal buttock,
which is less rounded sotter than the head will be feet. When the cervix is
dilated of membranes ruptured the metal clefts may be felt with the felt close
to the buttock
Confirmatory investigations include:
USS- which will show a foetus in a
longitudinal lie with the buttock or fect in the lower uterine segment.
A and plan Abd X-ray can also be used in the
absence of the USS machine late in pregnancy to this will show the foetal skull
in relation to the maternal ribs and the foetal pelvic bones in relation to the
maternal pelvis a CT scan can also be used if available
The USS is pattered as it is more common
(cheaper) and more able to show the foetal attitude, estimating the foetal
weight, assessing the biophysical profile and excluding predisposing factors of
placenta praevia, pelvic tumours, polyhydramnios foetal congenital anomalies
e.t.c.
In
addition, there is a lower risk of irradiation to the foetus unlike CT scan
Despite
the above many studies have demonstrated that over 25-30% of breach
presentation of the term are not diagnosed until labour either after abdominal
palpation, or mor commonly following vaginal examination. This Unfortunately,
represents a missed opportunity for external cephalic version in the extenuate
period
MANGEMENT
The management breach presentation begins in
the ante-natal period. The aims of antenatal care are: for the identification
of complicating factors related to breach presentation .
Formation of a management plan
Performance of external cephalic version if
not contraindicated.
Fairly broking of regular checkups are
encouraged intervention are usually unnecessary when detected before 30weeks
because of the likelihood of spontaneous version. After 32weeks gestation
follow up at 36weeks is important because o9f the relatively lower rates of
spontaneous version thereafter. At 36weeks, the patient is re-evaluated
clinically to a USS is then performed for placental site, associated anomalies,
liquor volume, and, if appropriate, Doppler measurement. If foetus remains
breach with no associated complications, then there are three options of management (i.e at 36weeks)
a.
External
cephalic version
b.
Trial
of vaginal breach delivery (assisted breach delivery)
c.
Elective
CS
The findings from the physical examination,
investigation of clinically pelveimetry ,as well as the maternal choice are considered and a decision on mode of
delivery arrived at
External
Cephalic Version: This is trans-abdominal of the foetus into a aphalic
presentation. It helps in a reduction in non-cephalic birth as well as CS rate
due to them. It is discussed with the pt at 36weeks (in mulliparous women) and
after 37weeks ( in multiparcus women).
Absolute
Contraindication to EVC includes:
i.
Multiple
gestation
ii.
Plan-reassuring
foetal heir rate tracing
iii.
Previous
ante partum hemorrhage in the index pregnancy
iv.
Two
pervious caesario9n section
v.
Any
other contradiction to vaginal delivery
Relative
Contraindications
i.
Oligohydramnios
ii.
Polyhydramnios
iii.
IUGR
iv.
HTN
v.
One
pervious CS
Complications
i.
Fracture
of the long bones
ii.
Abruption
placenta
iii.
Ruptured
visera
iv.
Premature
rupture of membranes
v.
Cord
entanglement
vi.
Foeto-maternal
haemorrhage
Others maneuvers belived to ecourage version
includes:
i.
Elkin’s
manoeuivre
ii.
Moxibustion
manoeuvre
b. VAGINAL
BREACH DELIVERY(VBD): This is best conducted in a unit equipped for CS by
an obstetrician experienced in the procedure in the presence of an obstetric
anaesthetist and a necnatologist. The problems of predicting the chance of a
success of VBD, the implications of introduce serceral selection criteria or
conditions for attempting vaginal breach birth. The most popular of these is
these is the Zatuchini-Andros scoring
system. It is based on six parameter scored 0-2.
i. Parity
ii.
Gestational age
iii.
Estimated
foetal weight
iv.
Pervious
vaginal breach delivery
v.
Cervical
dilatation
vi.
Station
With scores of 0-4 CS is recommended
c. CAESARIAN
SECTION: CS has clear advantages over VBds even in uncomplicated breach
presentation as it is associated with lower prenatal and neonatal mortality.
Despite the occasional averson sown, especially in developing nations to CS,
the presence of other obstetric problems in association with breach
presentation renders CS almost inevitable.
TYPES
OF FORCEPS
1.
Kiellard’s
forceps
2.
Simpson’s
forceps
3.
Wingleys
forceps
4.
Neville-Barnes
forceps
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July 06, 2015
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