Malpresentations Labor and Delivery

Complications
Reproductive Medicine and Urology -2004 November 16, 2004 13h00 -14h00 Dr. Roger W. Turnell
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Maternal and uterine factors

1. 2. 3. 4. 5.

Contracted pelvis Pendulous maternal abdomen Neoplasms of uterus and ovaries Uterine cavity abnormalities Abnormalities of placental location
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Malpresentations
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Malpresentations
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Fetal Factors
1. 2.

Fetal Factors
5. Multiple pregnancy 6. Fetal anomalies including hydrocephaly 7. Polyhydramnios. 8. Prematurity

3.

4.

Large baby Errors in fetal polarity such as breech presentation or transverse lie Abnormal internal rotation, ie occiput posterior Fetal attitude: extension in place of normal flexion
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Malpresentations
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Effects of Malpresentations on Labor

1.

Placenta and Membranes 1. Placenta Praevia 2. Premature Rupture of the membranes The incidence of feto-pelvic disproportion is higher Inefficient uterine action is common Prolonged labor Pathologic retraction rings can develop, and rupture of the lower uterine segment can result
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2. 3. 4.

Effects of Malpresentations on Labor

5. The cervix often dilates slowly and incompletely 6. The presenting part stays high 7. Premature rupture of the membranes can occur 8. The need for operative delivery is increased
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Effects of Malpresentations on the Mother

1. 2.

3.

4.

Maternal exhaustion Increased risk for maternal trauma secondary to operative delivery Increased risk for bleeding and infection Long-term issues of pelvic floor damage, especially with prolonged second stage or vaginal operative delivery

Effects of Malpresentation on the Fetus

1.

Breech Presentation
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2.

3.

4.

The fetus fits the pelvis less perfectly, making its passage through the pelvis more difficult Longer labor may have a higher association with fetal hypoxia Operative delivery can increase the risk of trauma to the fetus Prolapse of the umbilical cord is more common, leading to possible fetal asphyxia and death 9

At term, makes up to 3 to 4% of patients At 28 weeks, seen in almost 25% of patients

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Breech Presentations Risk Factors

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Breech Presentation Risk Factors

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Maternal
1. 2. 3. 4. 5. 6.

Fetal
1. 2. 3. 4. 5.

High parity (uterine relaxation) Polyhydramnios Oligohydramnios Uterine anomalies Neoplasms ( Fibroids ) Contracted Pelvis
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Multiple pregnancy Hydrocephaly Anencephaly Any fetal anomaly Intrauterine death

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Breech Presentations Risk Factors

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Breech Presentations Management

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Placental
There is a positive association of placenta praevial and breech presentation.

Attempt external cephalic version to cephalic presentation after 37 weeks A recent multicentre international trial suggests that there is a 3 to 5 x increase in fetal mortality and morbidity with vaginal delivery at term in well selected candidates patients previously thought to be ideal for vaginal breech delivery
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Breech Presentations Management

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Transverse Lie
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It appears that the current standard of care will be to recommend C-section to all patients that are a Breech presentation in labor at viability ( > 24 to 25 weeks).

When the long axes of mother and fetus are at right angles to one another, a transverse lie is present. Because the shoulder is placed so frequently in the brim of the inlet, the malposition is often referred to as the shoulder presentation
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Transverse Lie
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Transverse Lie Etiology

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The incidence is 1:500 This is a serious malpresentation whose management must not be left to nature.

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High Multiparity Placenta Praevia Obstructing Neoplasm Multiple Pregnancies Fetal Anomalies Polyhydramnios Feto-pelvic disproportion Uterine abnormalities Contracted pelvis
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Transverse Lie Management

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Shoulder Dystocia
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Attempt external cephalic version C-section if transverse lie in labor especially after viability after 24 weeks

A shoulder dystocia is defined as the following situation:

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Presentation is cephalic; the head has been born, but he shoulders cannot be delivered by the usual methods. There is no other cause for this difficulty.

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Shoulder Dystocia
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Shoulder Dystocia Risk Factors

1. 2.

The incidence is less than 1%. In babies weighing over 4000 gm, the incidence is 1.6%.

3. 4. 5.

Maternal Obesity Excessive Weight Gain Oversized Infants ( > 4500 gm) History of Large Infants Maternal Diabetes

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Shoulder Dystocia Management

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Anaesthesia on stand-by or administered Vaginal exam Episiotomy Hyperabduction of maternal hips Suprapubic pressure Rotation of anterior shoulder under the symphysis pubis Extraction of posterior arm and shoulder Screw Principle of Woods ( deliver posterior shoulder and rotate baby 180 degrees) Zavonelli ( Reduce baby back into vagina and C-section Modified Zavonelli ( Start C-section and push baby from above through vagina)
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