Post on 30-Dec-2015
MAL PRESENTATION,MAL POSITION & CORD
PROLAPSE
TRISHA KELLY & SARAH McLEOD TRAINING &
PRACTICE DEVELOPMENT CO-ORDINATORS, MATERNITY
SERVICES, NHS HIGHLAND
AIMS & OBJECTIVES
LOOK AT TYPES OF MAL PRESENTATION & POSITION (MAIN FOCUS ON BREECH)
HOW TO MANAGE IN DIFFERENT PRACTICE ENVIRONMENTS
LOOK AT SOME ALTERNATIVE THERAPIES
CONSOLIDATE WITH ‘HANDS ON’ PRACTICE
OCCIPITOPOSTERIOR POSITION (OP) INCIDENCE IS AROUND 10% 5% DELIVER IN OP POSITION PREVIOUS OP LABOUR – MORE LIKELY TO HAVE A
REPEAT ADVISE MUM OF OPTIMAL FETAL POSITIONING MOBILISATION IN LABOUR IMPORTANT LEAVE MEMBRANES INTACT HOPEFULLY ROTATION WILL HAPPEN IN LABOUR
FOLLOWED BY SPONTANEOUS DELIVERY. IF NOT……….
OP CONTINUED…
MANUAL ROTATION ROTATION USING VENTOUSE CUP ROTATIONAL FORCEPS CAESAREAN SECTION
MANUAL ROTATION OF LOP
COMPLETE ROTATION
FACE PRESENTATION
INCIDENCE IS ABOUT 1:600 CAN BE CONFUSED WITH BREECH ON
VAGINAL EXAM – FEEL FOR MOUTH & MALAR PROMINANCES (TRIANGULAR SHAPE)
CHIN MUST BE ANTERIOR TO ALLOW VAGINAL DELIVERY
HEAD DELIVERS BY FLEXION FACE CAN BE VERY DISTORTED
FACE PRESENTATION
BROW PRESENTATION INCIDENCE IS ABOUT 1:700 ASSOCIATED WITH CONTRACTED PELVIS AND
OP POSITION BIGGEST PRESENTING DIAMETER
MENTOVERTICAL (13.5CM) & EXCEEDS ALL DIAMETERS IN THE MATERNAL PELVIS
PRESENTING PART USUALLY HIGH ON VE (CARE NOT TO RUPTURE MEMBRANES)
MAY CONVERT TO A FACE WILL DELIVER VAGINALLY, NEEDS TO ROTATE TO OP
USUALLY CAESAREAN SECTION IS INDICATED
BROW PRESENTATION
TRANSVERSE OR OBLIQUE LIE
INCIDENCE IS ABOUT 1:500 ASSOCIATED WITH LAX UTERINE MUSCLES
OR UTERINE ANOMALIES PRESENTING PART USUALLY SHOULDER &
THERE IS NO MECHANISM FOR VAGINAL DELIVERY
RISK OF CORD PROLAPSE HIGH TRANSFER PRIOR TO LABOUR, IF IN LABOUR
EMERGENCY TRANSFER GOOD RISK MANAGEMENT VITAL HERE
NOT GOOD!
BREECH PRESENTATION
3-4% AT TERM LOOK FOR TUBEROSITIES & ANUS IN A
STRAIGHT LINE ON VE (LABOUR) USUALLY FRANK BUT CAN BE COMPLETE,
FOOTLING OR KNEELING CAESAREAN SECTION NORM FOR ‘SAFE’
DELIVERY TERM BREECH TRIAL (HANNAH ET AL 2000) ‘3
TIMES LESS LIKELY TO DIE OR SUFFER SERIOUS MORBIDITY THAN MEDICALLY MANAGED VAGINAL DELIVERIES’
TYPES OF BREECHES:EXTENDED, COMPLETE & FOOTLING
BREECH – EXTERNAL CEPHALIC VERSION
SHOULD BE OFFERED TO ALL WOMEN WITH AN UNCOMPLICATED BREECH AT TERM
MUST BE DONE IN A CONTROLLED ENVIRONMENT
EFFECTIVE TOCOLYTIC DRUG MUST BE USED
OPERATOR EXPERIENCED & COMPETENT
BREECH – ALTERNATIVE THERAPIES
POSITIONING - MATERNAL ACUPUNCTURE USING MOXIBUSTION CHINESE HERBAL MEDICINE – HERB USED
ARTEMISIA VULGARIS MADE INTO A STICK (MOXA) BURNT AT THE LATERAL SIDE OF THE LITTLE TOE ACUPUNCTURE POINT ‘BLADDER 67’
CAN BE DONE TWICE PER DAY UNTIL BABE TURNS USUALLY WHEN THE UTERUS HAS MAXIMUM LIQUOR AROUND 34 WEEKS
BREECH – VAGINAL DELIVERY
LOST SKILLS ‘HANDS OFF’! ‘LITHOTOMY’ POSTION ADAPT IF AT HOME OR
STANDING, SQUATTING, KNEELING SHOULD ALLOW 5 MINS FOR LEGS, BODY,
ARMS & HEAD – PATIENCE!! MAY NEED TO ASSIST LIMBS ESP. ARMS CONTROLLED DELIVERY OF HEAD – MODIFIED
MAURICEAU-SMELLIE-VIET (MSV)
BREECH – EXTENDED LEG
BREECH – EXTENED ARM (LOVSET MANEOUVRE)
BREECH – MAURICEAU-SMELLIE-VEIT
BREECH MSV - CONT
BREECH MSV - CONT
BREECH – MSV CONTINUED
SUMMARY…
GOOD RISK MANAGEMENT ADVISE MUM ON OPTIMAL FETAL
POSITIONING (OP) HOME/CMU BIRTH – ULTRA SOUND TO
CONFIRM PRESENTATION ‘FIRE DRILLS’ FOR VAGINAL BREECH
ESPECIALLY
Cord Prolapse
Associated Risk Factors
Multiparity Malpresentation Multiple pregnancy Prematurity Polyhydramnios High presenting part Artificial rupture of membranes when presenting part
is high
Objectives
Identify risk factors for cord prolapse Diagnosis of cord prolapse Identify management options
Definition and Incidence
Cord Presentation
The umbilical cord lies below or alongside the presenting part with membranes intact
Cord Prolapse
The cord lies below or alongside the presenting part in the presence of ruptured membranes
Incidence: 0.2 – 0.5% of all births
CORD PROLAPSE
Diagnosis
Cord visible at vulva Cord felt on vaginal examination Abnormal fetal heart rate – variable
decelerations or bradycardia
Management
Get help - if cord pulsating, fetus is alive Explain to woman and partner emergency measures
that are required Diagnose stage of labour by vaginal examination
(keep cord handling to a minimum) Relieve pressure on cord by elevating the
presenting part Alter maternal position – ‘Knee-chest’ or
‘Exaggerated Sim’s’ to elevate buttocks Emergency transfer if in community – consider
safety
MANAGEMENT CON’T
FILL URINARY BLADDER 500 MLS NORMAL SALINE – CLAMP BUYS TIME MAY INHIBIT UTERINE CONTRACTIONS
SUMMARY
Call for help – team work vital Explanation of emergency situation to woman
and partner Elevate presenting part off cord Knee-chest position or elevate buttocks Keep cord in vagina (minimal handling) Expedite delivery ‘Fire Drills’