FACE PRESENTATION

 

DEFINITION:Cephalic presentation in which the head is completely extended with the face as the PP and the denominator is the chin{Mentum}.

 

POSITIONS:.................

 

INCIDENCE:........

 

AETIOLOGY:........*Don't forget CFMF*

 

TYPES: +Primary face presentation = before the start of labor.

      + + +Secondary face presentation = Extention of O.P in labor

 

DIAGNOSIS:............................

 

MECHANISM OF LABOR

1.Descent

2.Engagement

:Engaging diameter submentobregmatic 9.5cm (or if the head is not well extended submentovertical 11.5cm)

3.Increased extention

4.Internal rotation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MA positions

 

 

 

 

 

 

MP positions

 

 

 

 

 

 

 

 

 

 

 

 

 

chin rotates 1/8 anteriorly

 

 

2/3

 

 

 

1/3

 

 

 

 

 

 

long anterior rotation of the chin3/8

 

Failure of long anterior rotation occurs (due to..?)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DMA

 

 

 

DTA

PMP

DMP

 

 

 

 

 

 

no mechanism for all

 

5.Delivery of the head by flexion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.Restitution --->7.External rotation-->8.Delivery of the shoulders.

 Why perineal tears are common?

- Vulva is distended by Biparietal 9.5cm x submentovertical 11.5cm dtr

- Bones of the face are not compressable.

 MANAGMENT:

 I.Managment during pregnancy: exclude CFMF

 II.Managment during labor:

    1.During the 1st stage:...............

    2.During the 2nd stage:

   -If MA --->Allow Spontaneous vaginal delivery

   -If MP--->Wait for long ant.rotation to occur 2hrs in PG & 1hr inMG

if occurs => spontaneous vaginal delivery.

 

IF FAILURE OF LONG ANTERIOR ROTATION:

May try rotation by:

 a)-->Manual rotation [Disimpaction-Increased extension-Rotation of mentum anteriorly-Rotation of the shoulder] + Forceps extraction

 b)-->Forceps rotation + Forceps extraction

 c)-->C.S

 d)-->Craniotomy if dead fetus

 

INDICATIONS FOR C.S:

1.Head not engaged.[Engagment is late , o if large head better to perform C.S]

2.Failure of rotational technique

3.Recommended by some if long ant.rotation did not occur .

4.Other obstetric indication. 

Old lines of ttt:

1.Conversion to vertex

2.Internal podalic version + breech extraction.

Complications:

I-Maternal:............

  II-Fetal:.............+ Oedema of the face [Tumefication]

                        -CFMF -Injury of the face(esp. eyes) by careless P/V ex

 
BROW PRESENTATION

 

DEFINITION:Cephalic presentation in which the head is midway between flexion & extension , with brow as PP,&frontal bones as denominator.

 

INCIDENCE:........

 

AETIOLOGY:.....

 

TYPES: Persistent brow or Transient brow(changes to face or vertex)

 

POSITIONS:..........

 

DIAGNOSIS:.........

 

MECHANISM OF LABOR

-Primary brow presentation: ----->No mechanism as the engaging diameter is the mentovertical dtr 13.75cm.

           ------->rarely if the mentovertical dtr can enter the pelvis(small head or collapsed head in a wide pelvis) the head descends, engages , iternal rotation of the frontal bones anteriorly , maxilla hinges under the S.P&the head delivers by flexion....etc.

-Secondary brow:changes to face or vertex & delivers accordingly.

 

MANAGMENT:

 

-During pregnancy: exclude CFMF.

 

-During labor:

  1st stage:...............

   + intellegent expectancy :[Memb.intact,Mobile small head,no Maternal  or fetal distress,no Moulding or caput]:

      -If turns Face or vertex---->Manage accordingly

      -If persists----->C.S for living fetus.

               For the dead fetus craniotomy is done in the 2nd stage.

 

Indications for C.S: -Any persistent Brow in a living average fetus.

Old lines of ttt:- Manual conversion to vertex or face.

                      -I.P.V + Breech extraction. 

SHOULDER PRESENTATION

DEFINITION:Malpresentation & lie in which the longitudinal axis of the fetus is transverse(perpendicular)or oblique to that of the mother,the

shoulder is the PP, and the denominator is the scapula.

INCIDENCE:......

AETIOLOGY:.............

POSITIONS:...............

DIAGNOSIS:......

 ** Late in labor P/V ex. reveals:

     -Shoulder: ccc cavity[axilla] + 3 bones (see before)

     -Elbow : Pointed without a patella.{DD:Knee}

     -Hand: No heel , longer curved fingers , easy thumb mobility {DD:foot},Right hand prolapses in R.Sc.P&L.Sc.A positions & shakes with Right hand.Left hand prolapses in......,Shakes with.....,Thumb points to the head,Dorsum same position as back.

 

MECHANISM OF LABOR

I.Full term living fetus:

        -No mechanism

        -Very rarely Spontaneous rectification (becomes cephalic) or spontaneous version(becomes breech) may occur. 

 

II.Premature or small dead fetus the following may occur:

       1.Spontaneous expulsion: Expulsion of V-shaped folded fetus , the vertebrae flex till they are broken. (Coduplicato corpore!!)

       2.Spontaneous evolution: Head retained at the pelvic brim, shoulder descent continues with marked elongation of the neck

--->delivery of the arm-->shoulder-->trunk------>head.

 

MANAGMENT:

 

  -During pregnancy: Exclude CFMF, contraindications of external version.If no contraindication is present it may be tried.

 

 

 -During labor:

  -1st stage:................+

          a)Membranes are intact:

         1.Try ECV or IPV. If failed--> 2. or 3.

         2.Wait for 2nd stage as long as no ROM occurs.

         3.C.S is safest.

      b)Membranes ruptured ---------> C.S

 

  -2nd stage:

      -C.S is safest.

      -If enough liquor ,no contraindication for IPV then it may be tried followed by breech extraction.But C.S is still safer.

      -Dead fetus--------->Decapitation.

 

THE SAFEST & BEST MANAGMENT IS BY C.S

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NEGLECTED SHOULDER.

 

Definition: Cases of transverse lie allowed to continue labor till the picture of obstructed labor is evident with the uterus impending to rupture and the fetus is dead.

Impacted shoulder: Same definition but the fetus is still living.

 

Clinical picture: (= C/P of obstructed labor)

 

General ex: Tachycardia , Tachypnea , Temperature rises

                        Dehydration , Dry tongue

Abdominal ex: -Uterus-->Hard & tender

                                   -->Strong,frequent Ut.contractions

                                  -->Rising pathological retraction ring

                       -Fetal parts:-->difficult to feel

                                         -->Ut.moulded over the fetus.

 P/V ex.:-Vulva------>edematous

              -Vagina----->dry , hot & edematous

              -Cervix----->Thick,&edematous

              -PP--------->Impacted shoulder+/- cyanosed prolapsed arm

 

Complications: as obstructed labor.

 

 

Management:

 

I.Prophylactic managment: Most important.(How?)

 

II.Active management:

        1.Rapid correction of the general condition

        2.Emergency delivery by the fastest , safest way:

             a)If the cervix is not fully dilated-->Rapid C.S

             b)If the cervix is fully dilated--->Ideally decapitation should be         performed,but it needs an experienced obstetrician.

                                                        --->Rapid C.S   

 

*C.S is safest even in dead fetus for fear of rupture of the thin ballooned LUS.( USCS is safer than LSCS.)                  

 

*Line of ttt NEVER to be used or attempted..................?