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’