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. |
|||||||||||||||||||||||||||||
- Vulva is distended by Biparietal 9.5cm x submentovertical 11.5cm dtr
- Bones of the face are not compressable.
-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
---------------------------------------------------------------------------------------
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..................?