Ob And Gyn - Fetal Lie Abnormalities

Front 1

Define lie

Back 1

The relationship of the long axis of the foetus to that of the maternal spine.

In early pregnancy, the foetal lie keeps changing because of relative large volume of amniotic fluid and enough space but at term about 99% of the foetus takes a permanent longitudinal lie.

Front 2

In early pregnancy, the foetal lie keeps ....... ? Because of?

but

at term about ...... of the foetus takes a

....... lie.

Back 2

1. In early pregnancy, the foetal lie keeps changing because of relative large volume of amniotic fluid and enough space but

2. at term about 99% of the foetus takes a permanent longitudinal lie.

Front 3

1. common types of lie are ?

2. ...... is the normal lie

Back 3

1. longitudinal,

oblique and

transverse .

2. Longitudinal is the normal lie , in which the both are parrallel to each other

Front 4

What is unstable lie?

How is it managed?

Back 4

1. foetus continues to change lie at term, it is termed unstable lie.

2. Unstable lie is managed by stabilizing induction if there is no contraindication to vaginal delivery.

Front 5

Presenting part Vs presentation?

Define

Back 5

1. The presenting part is that part of the foetus that is in contact with the maternal pelvis.

2. Presentation is that part of the presenting part felt during V.E.

Front 6

Transverse lie presents ? And

and difficult to deliver vaginally ?

Back 6

1. Transverse lie presents the shoulder and difficult to deliver vaginally

2. unless in dead babies or

very small preterm foetuses where the baby may be delivered by double folding.

In viable foetuses, the best option of delivery for a transverse lie is c/s.

Front 7

List the presenting part in

1. Longitudinal lie ?

2. Transverse lie ?

3. The normal presentation is?

Back 7

1. In longitudinal lie, the presenting part can either be cephalic or breech.

2. In transverse lie, the presenting part is shoulder..

3. The normal presentation is vertex while the abnormal ones are breech, brow, face, cord & compound.

Front 8

At term more than ..... of presentations are vertex, .... are breech, .... are face and shoulder.

Back 8

At term more than

1. 96% of presentations are vertex

2. 3% are breech,

3. 0.5% are face and shoulder.

Front 9

About vertex presentation.

1. Head is?

2. Presenting diameters?

3. Delivery?

Back 9

In vertex presentation

1. the head is normally well flexed with chin on the chest.

2. In such a situation the presenting diameters are SOF diameter (10cm) & Biparietal diameter (9.5cm).

3. Delivery occurs normally.

Front 10

Brow presentation

1. What gives it?

2. Presenting diameters? 3. Delivery?

Back 10

1. little extension of the head from vertex presentation gives ‘Brow’ presentation.

2. The presenting diameters in this situation are Mentovertical (13.5cm) and biparietal diameters (9.5cm).

3. In this case, with normal fetus and pelvis delivery from the vagina cannot occur because the biggest diameter of the pelvis is 12.5cm but if the foetus is small with a large pelvis, engagement and descent may be possible.

Front 11

About face presentation

1. How does it come about?

2. Presenting diameters?

3. Delivery?

Back 11

1. With further extension of the head (full extension), the face presents.

2. The diameters then become submento-bregmatic (9.5cm) and biparietal (9.5cm).

3. Engagement and descent continues & if the mentum leads, it hits the pelvic floor and rotates anteriorly under the pubic symphysis with eventual delivery by SVD .

But if the sinciput leads, it is carried anteriorly and the mentum is carried posteriosly. The mechanism becomes difficult because further extension is not possible hence the face and shoulder try to engage together giving a diameter of 18cm leading to obstruction with a normal foetus and pelvis. Small baby with roomy pelvis may allow passage of foetus.

Front 12

Define breech presentation

Cause of worry when and why ?

Requires?

Back 12

1. This is when either the buttocks or the foot/feet of the foetus occupy the lower uterine segment. It is a malpresentation..

2. It is a cause of worry when it occurs at term because of the associated poorer perinatal and neonatal outcomes compared with cephalic presentation.

3. Requires proper investigation and determination of the mode of delivery.

Front 13

About breech presentation

1. Incidence?

2. Types ?

Back 13

1. Incidence: varies with G.A being higher at lower G.A

i. 20-25 weeks (30-40%),

ii. 28 weeks (25%),

iii. 32 weeks (15%),

iv. term (3-4%).

2. Types

i. Frank (Extended) breech

ii. Complete/flexed breech/full breech

iii. Footling or incomplete breech

Front 14

Incidence of breech presentation varies with?

Back 14

Gestational age , being higher at lower gestational age

Front 15

Type of breech presentation is based on

Back 15

Based on the

1. attitude of the foetal lower limbs and

2. the breech in the lower segment.

Front 16

List the types of breech presentation and explain

Back 16

1. i. Frank (Extended) breechii. Complete/flexed breech/full breech iii. Footling or incomplete breech

2. i. Frank (Extended) breech:

Both limbs extend at the knee and flexed at the hip joints.

65% of cases and commoner in primigravidae.

ii. Complete/flexed breech/full breech: Both lower limbs are flexed at the hip and knee joints. Buttock and both feet occupy the lower segment. (10% of cases). Multiparous pts.

iii. . Footling or incomplete breech: One or both lower limbs are extended at the hip and knee joints such that the baby appears to be standing on the lower segment.

Front 17

List risk factors for breech presentation

Back 17

RISK FACTORS

1. Uterine anomalies (septate, bicornuate)

2. placenta praevia,

3. uterine fibroids,

4. pelvic tumours,

5. multiple pregnancy,

6. oligohydramnios,

7. polyhydrammios,

8. foetal malformations,

9. contracted pelvis,

10. prematurity,

11. multiparity etc.

Front 18

Management of breech presentation

Back 18

1. Preterm

i. if no labour-Expectant.

ii. If in labour- consider salvage rate in the locality. If the G.A. is capable of surviving do a c/s but if not allow vaginal delivery. The mode of delivery should be a balance between the opinions of the Obstetrician, neonatologist and the pregnant woman..

2. Term ; 3 options are available:

if there is no associated complications.

1. External cephalic version (ECV)

2 . Vaginal breech delivery. if there is h/v associated complications.

3. Elective caesarean section

Front 19

About ECV

1. meaning / definition

2. Done when?

3. Advantages

4. Requirements

5. Factors favoring

6. Contraindications

7. Complications

Back 19

1. Definition: external cephalic version.

This is the trans-abdominal manipulation of a breech presenting foetus to a cephalic presentation.

2. Done at term (37 weeks).

3. In well-selected cases;

i. Reduces incidence of c/s

ii. Reduces the foetal mortality associated with vaginal breech delivery.

iii. Reduces foetal complications associated with vaginal breech delivery.

4. i. Facilities for emergency c/s

ii. Skilled personnel

iii. Availability of USS

iv. Availability of CTG..

5. Factors that favour ECV ; Multiparity, adequate liquor volume, Station of breech above the pelvic brim, relaxed uterus (Tocolytics)

6. Relative: IUGR, HBP, D.M, Obesity, grandmultiparity, anterior placenta, rhesus iso-immunisation

Absolute: multiple pregnancy, APH, previous c/s, ROM oligohydramnios, major foetal anomaly, contracted pelvis.

7. Abruptio placentae, membrane rupture, cord accidents, premature contraction; uterine rupture, foetal distress.

Front 20

List the types of vaginal breech delivery . How many types?

Back 20

1. Assisted vaginal breech delivery

2. Breech extraction.

2 types

Front 21

About vaginal breech delivery

1. List types

2. Conditions where you can do it

Back 21

1. Assisted vaginal breech delivery , Breech extraction..

2. i . Adequate pelvis (Do P.A at 36 weeks),.

ii. normal-sized foetus (≤3.5kg, do USS at 36 weeks),

iii. skilled personnel,

iv. healthy patient that does not have diseases that will not allow her push during 2nd stage labour,

v. absence of footling breech. Why?

ENTRAPMENT OF AFTER-COMING FETAL HEAD

Front 22

Why is absence of footling breech a condition for vaginal breech delivery

Back 22

ENTRAPMENT OF AFTER-COMING FETAL HEAD.

This occurs mainly where there is incomplete dilatation of the cervix as in footling breech .

Front 23

A. FAVOURABLE CONDITIONS FOR SUCCESSFUL VBD

B. Breech extraction Conditions

Back 23

A. 1. Skilful personnel;

2. fetal weight <3.5kg,

3. multiparity,

4. previous successful vaginal breech delivery,

5. previous large babies delivered vaginally,

6. frank breech,

7. good labour progress.

The favoured vaginal breech method is assisted vaginal breech delivery.

B. Rarely indicated these days.

Few indications for that include

1. retained second twin in breech or transverse lie,

2. IUFD in breech,

3. cord prolapse with fully dilated cervix in breech presentation. Complete takeover of delivery (pushing by mother not needed)

Front 24

About assisted vaginal breech delivery

1. Aim

2. Requirements

3. List the stages where assistance is needed

Back 24

1. The aim here is to assist the mother at certain stages of delivery of a breech presenting foetus without completely taking over the delivery process as in breech extraction..

2. Requirements

i. Experienced personnel,

ii. lithotomy position;

iii. Analgesia especially epidural block (where available) helps to prevent premature bearing down and allows controlled delivery of the after coming head.

3. Delivery of the

a. buttocks,

b. delivery of the legs,

c. at the level of the cord,

d. delivery of the arms;

e. delivery of the after coming head (most important).

Front 25

Which type of anaesthetic is used in assisted vaginal breech delivery and why?

Back 25

Epidural block

where available) helps to prevent premature bearing down and allows controlled delivery of the after coming head.

Front 26

Parts of assistance and maneuver used

Back 26

1. Delivery of the buttocks-

2. delivery of the legs-

3. at the level of the cord-

4. delivery of the arms-

5. delivery of the after coming head -

Front 27

Define

1. Altitude

2. Denominator

3. Position

4. Engagement

Back 27

1. Altitude refers to the relationship between one fetal part and another

2. Denominator refers to that part of the presenting part or presentation that denotes the position..

The denominator for

a. Cephalic - occiput

b. Breech- sarcum

c. Shoulder- acronium

3. Position - refers to the relationship of a denominator in the presenting part to the maternal pelvis .

4. Engagement - refers to the passage of the widest diameter tru the pelvic brim.

For cephalic - biparietal

For breech - bitrochanteric diameter

Front 28

Normal altitude is?

Back 28

That of flexion

Front 29

The denominator for

a. Cephalic - b. Breech- c. Shoulder-

Back 29

The denominator for a. Cephalic - occiput b. Breech- sarcum c. Shoulder- acronium