Problems of The Passenger
Problems of The Passenger
Problems of The Passenger
ABNORMAL LIE
Where the long axis of the fetus is not lying along the long axis of the mother’s uterus
o Transverse
o Oblique
o Unstable
Longitudinal (may either be cephalic or breech) is normal
FETAL MALPOSITION
Where the fetus is lying longitudinally and the vertex is presenting, but not in occiput anterior (OA) position.
Arrested labor may occur when head does not rotate and/or descend
Delivery maybe complicated by perineal tears or extension of an episiotomy
Is the incomplete rotation of occiput posterior to occiput anterior, which results in a horizontal or transverse
position of the fetal head
DIAGNOSIS:
Course of labor is usually normal, except for prolonged second stage (>2 hours)
1. Abdominal Examination
a. Lower part of the abdomen is flattened
b. Difficult to palpate fetal back
c. Fetal small parts are palpable anteriorly
d. Fetal heart tone may be heard in the flanks
2. Vaginal Examination
a. Posterior fontanel is towards the Sacral-iliac joint (difficult)
b. Anterior fontanel is easily felt, if head is deflexed
c. Fetal head may be markedly molded with extensive caput, making it more difficult to diagnose the correct
station and position.
MANAGEMENT:
FETAL MALPRESENTATION
A. VERTEX MALPRESENTATION
ASSESSMENT:
ABDOMINAL EXAMINATION—half of fetal head is above symphysis pubis & occiput is palpable higher than
sinciput
VAGINAL EXAMINATION—anterior fontanel & orbits are felt
MANAGEMENT:
CAUSES:
MATERNAL FETAL
Lax uterus due to multiparity Large fetus
Contracted pelvis/ CPD Congenital malformation (Anencephaly)
Placenta previa Multiple cord coil
Multiple pregnancy Musculoskeletal abnormality
Occiput posterior due to tendency of fetus of (spasm/shortening of extensor muscle of
extending head instead of flexing it neck)
Tumors around the neck (congenital goiter)
SIGNS AND SYMPTOMS:
MANAGEMENT:
If chin is in anterior position (LMA or RMA), uterine contractions are strong, head is small, shoulders have
already entered the pelvis and there is no pelvic contraction, vaginal delivery is possible but longer than usual
forceps may be used to hasten 2nd stage
If chin is in posterior position (RMP, LMP), vaginal delivery may be impossible and dangerous if attempted
because it can lead to transverse arrest. CS
3. Sincipal Presentation
B. BREECH PRSENTATION
Most common fetal malpresentation
1. Frank Breech
2. Complete Breech
4. Kneeling Breech
ASSESSMENT:
1. Abdominal Examination
Leopold’s maneuver number 1
Head is felt on the fundus
2. Auscultation
Leopold’s maneuver number 2
FHT on upper quadrant of the abdomen
3. Vaginal Examination
Buttocks and/or feet are felt
Thick dark meconium is normal
ETIOLOGY:
COMPLICATIONS:
Prolapse Cord
Presenting part does not fit well enough into the pelvic brim
Birth Trauma
That includes:
o Fracture of the skull, clavicle, humerus
o Intracranial hemorrhage
o Rupture of abdominal organs
Meconium Aspiration
Pressure on abdomen and buttocks can force passage of meconium into the amniotic fluid before birth
Intrauterine Anoxia
Fetal Death
MANAGEMENT:
RISK OF ECV:
Placental abruption
PROM
Cord accident
Transplacental hemorrhage
Fetal bradycardia
Principle, Masterly inactivity (hand- off). Important points for safe conduct are:
Do not be in a hurry
Never pull from below, let the mother expel the fetus by her own effort with uterine contractions
Always keep the fetus with its back anterior
Keep a pair of obstructive forceps ready if necessary to assist the after coming head.
Anesthetist and pediatrician should attend the delivery
Inform operating room if CS is needed.
4. Caesarian Section
6. Assessment of fetal condition: ultrasound to determine anomalies such as hydrocephaly, microcephaly and
anencephaly
DIFFERENT MANEUVERS:
1. Pinard’S Maneuver
Done in breech with extended leg, anterior leg is always delivered
first
Once the groin is visible, gentle pressure can be applied to abduct
the thigh and reach the knee
The knee can be flexed with pressure in the popliteal fossa & the leg
delivered.
2. Loveset Maneuver
Automatically corrects any upward displacement of arms
Baby’s trunk is rotated with downward traction, holding at the iliac crest so that posterior shoulder comes
below the symphysis pubis
Arm is delivered by flexing the shoulder followed by hooking at the elbow and flexing it,
Followed by bringing down the forearm like a “hand shake”
Same procedure is repeated by reverse rotation of 180 ° so that the anterior shoulder comes below the
symphysis pubis
4. Prague Maneuver
Used when the back of the fetus fails to rotate to the anterior
The operator delivers the shoulders with one hand, while
making pressure above the symphysis pubis with the other
hand
5. Bracht Maneuver
Achieved by force of uterine contraction and moderate suprapubic
pressure.
Delivery by extension of the legs and trunk of the fetus over the
symphysis pubis and abdomen of the mother.
6. Abdominal Rescue
Fetus is replaced when fully deflexed head is entrapped and cannot be delivered vaginally. CS follows
7. Cleidotomy
Involves cutting of shoulder to facilitate delivery. Also used in shoulder dystocia
C. SHOULDER PRESENTATION
Occurs when fetus assumes transverse or oblique lie
Fetus does not engage in this presentation so there is great danger of cord prolapsed after membranes have
ruptured
CAUSES:
MANAGEMENT:
D. COMPOUND PRESENTATION
When an arm prolapsed alongside presenting part
A fetal presentation in which an extremity presents alongside the part of the fetus
closest to the birth canal the majority of compound presentations consist of a
fetal hand or arm presenting with the vertex.
MANAGEMENT:
Observed closely to ascertain whether the arm retracts out of the way with
descent of the presenting part.
If it fails and appears to prevent descent of the head, prolapsed arm should be pushed gently upward and the
head simultaneously downward by fundal pressure.
SUMMARY
PRESENTATION MANAGEMENT
Breech Vaginal delivery ±ECV / CS
Face Vaginal delivery (chin anterior), CS (chin posterior)
Brow Cesarean Section (CS)
Shoulder Cesarean Section (CS)
Compound Replacement of prolapsed arm— Vaginal delivery/
Cesarean Section
FETAL DISTRESS
Refers to the presence of signs in a pregnant woman before or during childbirth, that suggest that the fetus may
not be well
Generally, it is preferable to describe specific signs in LIEU of declaring fetal distress that include:
CAUSES:
TREATMENT:
Instead of referring to “fetal distress”, current recommendations hold to look for more specific signs and
symptoms, assess them, and take the appropriate steps to remedy the situation through the implementation of
intrauterine resuscitation
Traditionally, the diagnosis of “fetal distress” led the obstetrician to recommend rapid delivery by instrumental
delivery or by Caesarian Section if vaginal delivery is not advised
Occurs when the cord passes out the uterus ahead of the presenting part
Occurs after membranes have ruptured when the fetus is not yet engaged, or does not completely cover the
pelvic inlet
Always lead to cord compression as the presenting part descends in the birth canal
CAUSES:
Polyhydramnios Prematurity
Long cord Placenta previa
Malposition and malpresentation (shoulder and Premature rupture of membranes
foot)
RISK FACTORS:
1. Spontaneous Factors:
Fetal Malpresentation—abnormal fetal lie tends to result in space below the fetus in the maternal pelvis,
which can then be occupied by the cord
Polyhydramnios—or an abnormally high amount of amniotic fluid
Prematurity—likely related to increased chance of malpresentation and relative polyhydramnios
Low Birth Weight—usually described as <2500g at birth, though some studies will use <1500g, cause is likely
similar to those for prematurity
Multiple Gestation—or being pregnant with more than one fetus at a given time: more likely to occur in the
fetus that is not born first
Spontaneous Rupture of Membranes—about half of prolapses occur within 5minutes of membrane
rupture, 2/3 within 1hour, 95% within 24hrs
2. Treatment Associated Factors:
Artificial rupture of membranes
Placement of internal monitors (for example: internal scalp electrode or intrauterine pressure catheter)
Manual rotation of fetal head
CLASSIFICATION:
MANAGEMENT: