Transcript Occipitoposterior Position, Face Presentation and

Occipitoposterior Position, Face
Presentation and Transverse Lie
Definitions
Malposition: when the head, coming first does
not rotate to occipitoanterior(OA) but is persitent
to the occipitotransverse(OT)
/occipitoposterior(OP) position.
Malpresentation: describes and non-vertex
presentation.
Occipitoposterior position
Aetiology
1)Fetal back on right side: 25-30% (ROP)
2)Anterior insertion of placenta
3)Pelvic brim:
-anthropoid pelvis: AP > transverse
diameter
-android pelvis: Flat sacrumprevents
posterior rotation  arrest of labor
Occipitoposterior position
Diagnosis
Abdominal Examination
Vaginal Examination
1)Subumbilical flattening due to
absence of back
1)Early rupture of conical bag of
membranes
2)Back cannot be felt, limbs
anteriorly
2) Both fontanelle’s palpated when
head is deflexed.
3)Shoulder felt on flanks
3) Anterior fontanelle felt with
ease. See fig 1:1
4)Head in deflexion: sinciput +
occiput felt
5)Fetal heart sounds
indistinct/heard on flanks
Pubic symphysis
Frontal suture
Coronal suture
Anterior Fontanelle
Sagittal Suture
Posterior Fontanelle
Lamboid Suture
Normal Delivery:
Direct
Occipitoanterior
(DOA)
Direct
Occipitoposterior
(DOP)
Fig 1:1 : Anterior fontanelle
easily palapated in
occipitoposterior position
Left
Occipitoposterior
(LOP)
Right
Occipitoposterior
(ROP)
Occipitoposterior position
Mechanism of Labor
Why is labor prolonged in occipitoposterior
position?
Deflexed headoccipitofrontal
diameter(11.5cm) longer internal
rotation
Occipitoposterior position
Course of
Labor
Long Rotation to
Occipitoanterior
Persistent Right
Occipitoposterior
Deep Transverse
arrest
Right
Occipitoposterior
(ROP)
Short posterior
rotation and face
to pubis
Occipitoposterior position
Management
1) Epsiotomy
2) Fluids+ analgesia
3) Epidural Analgesia
4) Partogram
Management for poor progress
1) Exclude Cephalopelvic
Disproportion(CPD) oxytocin
augmentation in achieving
rotation and delivery
2) C-section: in CPD and when
oxytocin not working
Management of deep transverse
arrest and persistent
occipitoposterior
1) C-section: for android pelvis.
Avoid interacranial hemorrhage.
2) Vaccum extraction: Done in
absence of CPD. Adv: promotes
flexion and autorotation of head,
no need for GA, less traumatic.
3) Manual rotation: General
Anesthesia(GA) given.
4) Forceps rotation: Keillands
forceps. General anesthesia(GA)
given.
Face presentation
Presentation: Cephalic
Attitude: Complete Extension
Presenting part: Face
Denominator: Chin/ Mentum
Positions: Prefix- mento
1)Left mentoanterior (LMA)
2)Right mentoanterior (RMA)
3)Right mentoposterior (RMP)
4)Left mentoposterior (LMP)
Face presentation
Incidence & Aetiology: 1 in 500.
Maternal Factors
Fetal Factors
1) Contracted Pelvis
1) Anencephaly
2) Obliquity of uterus
2) Cord around neck
3) Multiparity and pendulous
abdomen
3) Tumors around neck like
congenital goitre
4) Spasm of sternocleidomastoid
muscle
Face presentation
Diagnosis
Abdominal Examination
Vaginal Examination
1) Mentoanterior: Back is felt
posteriorly with difficulty and limbs
anterior
1) Conical bag of membranes
2) High Head
2) Chin, mouth, nose felt
3) Cephalic prominence: occiput felt
3) Vaginal examination done gently
without cream to avoid injury to
eyes.
4) Groove between head and neck
prominent
5) Fetal heart sounds heard well in
mentoanterior
Face presentation
Mechanism of Labor: Mentoanterior
External Rotation
Engagement
Descent with
increasing extension
Internal Rotation:
Chin reaches pelvic
floor and rotates 45°
towards symphysis
Restitution
Flexion: Head born
by flexion
Face presentation
Complications
Maternal
Fetal
• Prolonged labor
• Increased risk
of operative
delivery
• Obstructed
labor:
mentoposterior
• Face edematous
and swollen
• Larygneal
edema
• Anencephaly
• Birth asphyxia
due to cord
prolapse.
Face presentation
Management
1) CPD present then go in for C- Section
2) CPD and other anomalies ruled out and
position is mentoanterior allow for normal
vaginal delivery.
3) Persistent mentoposterior perform C-section
Transverse Lie
Fetus in horizontal lie
Denominator: Shoulder
Positions
Depend on Acromion:
1)Right acromial
2)Left acromial
Depend on direction of back:
1)Dorsoanterior
2)Dorsoposterior
3)Dorsosuperior
4)Dorsoinferior
Transverse lie
Incidence and Aetiology: 1 in 500
Maternal Factors
Fetal Factors
1) Multiparous Women
1) Prematurity
2) Uterine anomalies
2) Multiple pregnancy
3) Placenta previa
3) Polyhydramnios
4) Fibroids in lower segment
4) Intrauterine death
Transverse lie
Diagnosis
Ultrasonography: rule out placenta previa, anomalies and lie.
Abdominal Examination
Vaginal Examination
1) Abdomen transversely stretched
1) Conical membranes with
2) Fundal height less than period of
gestation (POG)
2) Head/shoulder/elbow may be felt
3) No fetal pole
3)Late in labor: hand prolapse
4) Ballotable head in one flank and
breech at other
5) Empty pelvic grip
6) Dorsoposterior: limbs anteriorly
Transverse lie
Neglected shoulder presentation
Ill-fitting presenting part ruptures membrane and
results in cord prolapse, hand prolapse. In nulli
para they might go for uterine inertia. In Multipara
the upper part of uterus contracts and lower part of
uterus stretches and a junction between the two is
called Bandl’s ring.
Transverse lie
Complications
Maternal
• Increased
chance of Csection
• Obstruction
of labor and
rupture of
uterus.
Fetal
• Birth
asphyxia due
to cord
prolapse and
in obstructed
labor.
Transverse lie
Management
1) External Cephalic Version: more successful in
multipara. ECV successful can be followed by
stabilising induction; oxytocin infusion started.
2) C-section: if ECV fails or is contraindicated.
3) Neglected shoulder presentation: Perform a Csection and remove baby if dead.
Bibliography
• Sheila: Textbook of Obstetrics
• Clinical Ob/gyn: Saunders
• Williams