Ob-Malpresentation

Front 1

**Prevalence of breech presentation?

Back 1

3-4% of singleton deliveries

Front 2

**MC type of breech?

Back 2

Frank breech

Front 3

How is fetal position in breech presentation determined?

Back 3

Using sacrum as fetal point of reference to maternal pelvis.

Front 4

How is station determined in breech presentation?

Back 4

Location of fetal sacrum with regard to maternal ischial spines.

Front 5

**3 types of breech?

Back 5

Frank: thighs flexed on abdomen and both legs extended at knee. Best chance of vaginal delivery.

Complete: Both thighs flexed on abdomen and both legs flexed at knee.

Footling: One or both legs extended below level of buttocks. Single footling aka incomplete breech.

Front 6

**7 causes of breech?

Back 6

Oligohydraminos (prevents ease of movement to turn into cephalic position).
Uterine abnomalies (bicornuate, septate, mass).
Pelvic tumors obstructing birth canal.
Multiple gestation.
Fetal congen malformation.
Prematurity.
Macrosomia.

Front 7

7 congenital malformation assoc w/ breech?

Back 7

Congenital hip dislocation.
Hydrocephalus.
Anencephalus.
Familial dysautonomia (hered defective lacrimation, skin blotching, emotional instability, hyporeflexia).
Spina bifida,
Meningomyelocele.
Trisomies 18 and 21.

Front 8

What might hearing the loudest fetal heart tones above the umbilicus in an at term pregnancy suggest?

Back 8

Breech

Front 9

Antepartum management of breech?

Back 9

Follow closely - watch for spontaneous version.

If breech persists >36 weeks, external version considered.

Xray pelvimetry, CT or MRI to r/o inadequate pelvis.

Front 10

Management of breech during labor (4)?

Back 10

Examination. (admit when labor starts or ROM to watch for cord complications, Repeat US, take detailed hx and pe).

Electronic fetal monitoring: fetal HR and uterine contractions. Watch for distress or dysfunctional labor, often req c-section.

Oxytocin: use is controversial. Only if contractions are insuff. At that point you may just want to do US tho.

Delivery: *Not all breech req c-section. weigh risks/ benefits.

Front 11

2 main types of complications in breech delivery?

Back 11

Birth anoxia: d/t cord compression and prolapse. May occur during contractions causing decels in fetal hr. Anoxia or death can occur. Do c-section.

Birth injury: 6.7% (13x more than cephalic)

Front 12

**7 types of injuries from breech delivery?

Back 12

Tears in tentorum cerebellum.
Cepalohematomas. (blood behind periosteum).
Disruption of spinal cord.
Brachial palsy (erbs).
Fracture long bones.
Rupture of SCM.
Injuries to fetal adrenals, liver, anus, genitalia, spine, hip joint, sciatic nerve and arm/ leg/ back muscles.

Front 13

2 types of version?

Back 13

External cephalic (MC)

Internal podalic

Front 14

Why is external cephalic version becoming more popular again?

Back 14

Because of safe tocolytic agents that suppress uterine activity during procedure.

**note: frank prsetnation w/ both extremities flexed = difficult to turn because lower extremeties act as splint and prevent necessary flexion.

Front 15

Success rate of external cephalic version?

Back 15

67%

Front 16

At what age gestation should you consider external cephalic version?

Back 16

37-42 if singleton and unengaged.

Front 17

6 contraindications of cephalic version?

Back 17

Engagement,
Marked oligohydrmainos,
Placenta previa,
PROM,
Previous uterine surgery,
Suspected or known IUGR

Front 18

Maternal/ fetal complications of cephalci version?

Back 18

IU fetal demise d/t cord entaglement,
abruptio placentae,
PROM,
Premature labor,
Cord prolapse,
Transplacental fetomaternal hemorrhage (do Kleihaur betke acid elution).
Uterine rupture,
Fetal cardiac abnormalities

Front 19

When is internal podalic version used?

Back 19

Rarely! Risky to mom and fetus.

Occasionally done as lifesaving procedure (second twin in fetal distress, prolapsed cord, maternal major hemorrhage w/ premature separation of placenta)

Cervix must be completely dilated and membranes intact

Front 20

Contraindications of podalic version?

Back 20

Ruptured membranes,

Oligohydraminos,

Paritally dilated cervix

Front 21

Complications of podalic version?

Back 21

Traumatic injury to fetus and mother (long bone fractures, dislocations, epiphyseal separation, CNS deficits).

Front 22

**Definition of compound presentation?

Back 22

Prolapse of fetal extremity into lower uterine segment along side presenting part.

Uncommon 1/200 pregs

Front 23

**5 causes of compound presentation?

Back 23

Prematurity.
CPD.
Multiple gestation.
Grand multiparity (>6).
Hydramnios (excessive amniotic fluid).

Front 24

**Management of compound presentation?

Back 24

Depends on gest age, type of presentation and whether it is a hand or foot.
Freq occur in premature preg.
Maybe c-section. (can have vag delivery w/ viable cephalic presentation & prolapsed hand).
Cord prolapse is risk, must do internal electronic monitor and do c-section if fetal distress occurs.

Front 25

8 causes of shoulder dystocia?

Back 25

Macrosomia,
Abnormal pelvic anatomy,
Obese women >180lbs,
Gestational or over DM (larger babies).
Post dates preg,
Previous shoulder dystocia,
Short stature,
Multiparas w/ prev large infant.

Front 26

5 maternal complications to shoulder dystocia?

Back 26

Lacs of cervix, vagina, perineum.
Excessive blood loss/ postpartum hem.
Rectovaginal fistula.
Symphyseal separation.
Uterine rupture.

Front 27

3 fetal complications of shoulder dystocia?

Back 27

Asphyxia/ hypoxia,

Trauma injuries (fracture humerus, clavicle, erbs).

Fetal death

Front 28

Managment of shoulder dystocia? HELPERR

Back 28

1. call for help.
2. Evaluate for episiotomy. Alone, will not release shoulder but will give more room for maneuvers. Usually not needed.
3. Legs (McRoberts Maneuver).
4. suprapubic Pressure (Rubin I)
5. Enter Maneuvers (internal rotation)
- Rubin II,
- Woods Corkscrew
- Reverse woods corkscrew
6. Remove posterior arm
7. Roll patient

Front 29

What is the McRoberts maneuver?

Back 29

Full flexion of maternal legs and hips and abduction of hips. Flattens sacral promontory. Cephalad rotation of pubic symph.

Front 30

What is Rubin I maneuver?

Back 30

Suprapubic pressure. CPR sytpe downward and lat motion on posterior aspect of fetal shoulder.
Keep downward traction on fetal head.

Front 31

What is Rubin II maneuver?

Back 31

Insert fingers vaginally behind posterior aspect of anterior shoulder of fetus and rotate shoulder toward fetal chest.

This adducts the fetal shoulder girdle, reducing diameter and freeing impacted anterior shoulder.

Front 32

What is Woods Corkscrew maneuver?

Back 32

Place two fingers on anterior aspect of fetal posterior shoulder, applying gentle upward pressure around circumference of arc in same direction as Rubin II.
Creates rotation.

Rubin II and woods corkscrew may be combined to increase torque.
Downward traction should be continued during these maneuvers, simulating rotation of a screw being removed.

Front 33

What is the reverse woods corkscrew maneuver?

Back 33

If traditional woods corkscrew doesnt' work, slide fingers down to back of posterior shoulder and attempt 180 degree rotation in opposite direction.

Front 34

Maneuvers of last resort for shoulder dystocia?

Back 34

Deliverate fracture of clavicle.
Zavanelli maneuver: cephalic replacement into pelvis then c-section.
General anesthesia to relax uterus or oral or IV nitro.
Abdominal surgery w/ hysterectomy - infant rotated through incision and delivered vaginally.
Symphysiotomy. Not done in US unelss all other options have failed.

Front 35

How does the Zavanelli Maneuver work?

Back 35

Cephalic replacement into pelvis, then c-section.

Head is rotated into a direct occiput anterior position, then vertex is flexed and pushed back into birth canal while holding continuous upward pressure until c-secion complete.

Front 36

What is it called when the umbilical cord prolapses and is lying adjacent to presenting part?

Back 36

Occult

Front 37

What is it called when the cord prolapses and is below presenting part?

Back 37

Overt

Front 38

What is it called when the cord is below presenting part before rupture of membranes?

Back 38

funic

Front 39

8 causes of umbilical cord prolapse?

Back 39

Prematurity (<34 wks),
Abnormal presentations,
Pelvic tumors,
Placenta previa,
CPD,
Hydramnios,
Multiple gestation,
PROM

Front 40

Maternal comps of cord prolapse?

Back 40

C-section and its risks.

Lac of cervix, vagina, perineum

Front 41

Neonate comps of cord prolapse?

Back 41

Hypoxia,

Acidosis,

Death

Front 42

**Prevention of umbilical prolapse?

Back 42

Pts at risk, should be considered high risk. Monitor to detect abnormalities in fetal HR.

Front 43

Managment of cord prolapse?

Back 43

Put pt in lateral sims or trendelenburg position to alleviate cord compression.
Give O2 and monitor fetal HR.
C-section for mod-severe decels or brady.
Monitor w/ US.

Front 44

*Prefered route of delivery in occult cord prolapse usually?

Back 44

C-section

*vaginal delivery is route of choice for immature or dead fetus.

Front 45

5 essentials to diagnose multiple gestation?

Back 45

2 or more fetuses on US, fetal heart beats, fetal parts.
Disproprtionately large uterus for dates.
Increased fetal activity.
Greater than expected maternal wt gain.
Maternal hypochromic- normocytic andema.

Front 46

Mean duration of gestation for multiples?

Back 46

37 wks

Front 47

Causes for increased maternal morbidity and mortality in multiple gestations?

Back 47

Preterm labor,
Hemorrhage,
UTI,
Preg induced hypertension

Front 48

*Definition of monozygotic gestation?

Back 48

Identical twins from division of single fertilized ovum by single sperm.

**Always same sex.
Usually have same phys characteristics and genetic features mirror image of each other.
*Fingerprints different.

Front 49

*Definition of dizygotic gestation?

Back 49

Two ova and two sperms --> fraternal.
May be same or diff sex.
Resemble each other, but not same genetics.

MC blacks. Least common in Asians.
Polyovulation.
Clomid (estrogen analog - fertility) use.
MC in pregnancies soon after cessation of long term oral contraception (?rebound gonadotropin secretion).

Front 50

How do conjoined twins result?

Back 50

From incomplete segmentation of single fertilized ovum between 8th and 14th day.

Usually female.

Front 51

**What is the most serious prob w/ monochorionic placentas?

Back 51

Local shunting of blood -
TWIN TO TWIN TRANSFUSION SYNDROME!!

Front 52

**In twin to twin transfusion syndrome, characteristics of the recipient twin?

Back 52

Plethoric, edematous, hypertensive.
Ascites and kernicterus often.
Enlarged heart, liver, kidneys.

Hypervolemic and may die of HF during first 24 hrs.

Front 53

**In twin to twin transfusion syndrome, chracteristics of donor twin?

Back 53

Small, pale, dehydrates (Growth retardation, malnutirion, hypovolemia).
Oligohydramnios.
Severe anema. May lead to HF.

Front 54

*Signs of multiple pregnancy?

Back 54

Uterus larger (>4 cm) for dates,
Excressive wt gain not otherwise explained,
Polyhydramnios, manifested by uterine size out of proportion to calculated duration of gestation.
Outline of more than one fetus.
Multiplicity of small parts.
Uterus containing 3 or more large parts.
Diff fetal HRs.
Palpation of one or more fetuses in fundus after delivery of one infant.

Front 55

Expected lab findings in multiple gestation?

Back 55

Decreased CBC values.
Higher rate of gestational DM and hypoglycemia found w/ GTT.
Elevated AFP.

Front 56

**Common US findings in multiple gestation?

Back 56

Both twins vertex presentation: 50%.

One vertex, one breech in 33%.

Both breech in 10%.

Any combo of transverse 10%

Front 57

*5 things on differential w/ multiple gestation?

Back 57

Singleton - innacurate date.
Polyhydramnios determined by US.
HYdatidiform mole.
Abd tumors: uterine fibroids, ovarian tumors.
Complicated twin preg - one twin dies.

Front 58

Delivery of twins?

Back 58

If both cephalic presentation, vaginal delivery. Otherwise C section.

If second twin is NOT cephalic, C-section, external cephalic version, internal podalic version.
*watch for prolapsed cord!