Flashcards in MALPRESENTATION IN LABOUR Deck (43)
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1
What do we mean by malpresentation towards the end of pregnancy?
Any presentation other than a vertex presentation.
2
What is the vertex in terms of presentation of the fetus?
The vertex is the area between parietal eminences and the anterior and posterior fontanelles. The fetus will have its neck flexed with its chin tucked into its chest.
3
What are the different types of malpresentation?
Breech
Shoulder
Face
Brow
Transverse
4
What are the maternal causes and risk factors of malpresentation?
Contraction of the pelvis
Pelvic tumour eg fibroid
Mullerian abnormality
Multiparity
5
What are the fetoplacental causes and risk factors of malpresentation?
Prematurity
Placenta praevia
Polyhydramnios
Multiple pregnancy
Fetal abnormality
Fetal anomaly:
Hydrocephalus
Extension of fetal head by neck tumours
Anencephaly
Decreased fetal tone
6
What is the most common type of malpresentation?
Breech
7
What is the most important risk factor for breech presentation?
Prematurity
8
What is the incidence of breech presentation in term babies?
3%
9
What is the incidence of breech presentation in babies who are born at 32 weeks?
15%
10
What is the incidence of breech presentation in babies who are born at 28 weeks?
25%
11
What are the three main types of breech presentation? Describe each one.
Extended or frank breech presentation - hips are flexed and the knees are extended with feet situated adjacent to the head.
Flexed or complete breech presentation - flexion at both the hips and knees with feet at same level as breech
Footline breech presentation - flexion at both hips and knees but with feet present to the maternal pelvis not the breech
12
What is the most common type of breech presentation?
Extended or frank breech - 50%
13
If there is doubt about malpresentation from palpation what should be done for the patient?
Ultrasound to confirm
14
What are the complications associated with breech presentations at labour?
Increased perinatal mortality and morbidity - usually associated with delivering the head once the rest has delivered.
Intracranial injury - no time for head moulding as head will compress cord
Hypoxic-ischemic encephalopathy
Cord prolapse
Spinal cord injury
Adrenal haemorrhage
Fractures of clavicle or humerus
15
What is a nuchal arms delivery?
This is when the arms get trapped up along with the head and allows for even less space through the pelvis.
16
What are the three management options for a breech presentation?
External cephalic version (ECV)
Elective caesarian section
Planned vaginal breech delivery
17
What is external cephalic version?
This is an attempt to turn the baby inside the womb to cephalic presentation, by massaging the fetus first into transverse lie and then rolling over into the cephalic presentation.
18
When should external cephalic version be attempted?
At 37 weeks.
19
What are the contraindications to external cephalic version.
Pelvic masses
Antepartum haemorrhage
Placenta praevia
Previous caesarian section or hysterotomy
Multiple pregnancy
Ruptured membrane
20
What medications should be given if external cephalic version is to be attempted?
Tocolytics can be used to reduce uterine activity
Anti-D should be given if mother is rhesus negative
21
What measures should be taken if the mother decides to proceed with a vaginal breech delivery?
Check estimated fetal weight - above 4kg should indicate caesarian section
Continuous fetal heart measurement
Must exclude cord prolapse when membranes rupture or if fetal heart rate becomes abnormal
Epidural anaesthesia is recommended because of increased manipulation required.
Routine episiotomy
22
What is the success rate of vaginal breech delivery?
About 50% as there is such a low threshold for doing caesarian section that most will never get far enough.
23
What is Lovset's manoeuvre?
This is a manoeuvre performed to keep the spine anterior and aims to reduce the incidence of nuchal arms.
24
What is the Mauriceau-Smellie-Veit manoeuvre?
Improves flexion of head to allow easier delivery.
25
What is the definition of unstable lie?
This is when, after 37 weeks, the fetal lie is found to be in a different orientation at each palpation.
26
What is the incidence of transverse lie in labour?
1 in 500
27
What should you check before doing a vaginal examination of a patient with a fetus in transverse lie?
Placenta praevia should be excluded
28
What risk factors particularly increase the likelihood of the fetus being in transverse lie at labour?
Multiparity - reduced tone of uterus
Premature labour
The second twin is more likely to be in transverse lie
29
What is the most serious complication of transverse lie?
Cord prolapse
30
