PASSENGER.docx

7/27/2019 PASSENGER.docx

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PASSENGER

FACE PRESENTATION

the head is hyperextended , occiput is in contact with the fetal back and the chin (mentum)

is presenting

fetal face may present with the chin (mentum) anteriorly or posteriorly, relative to the

maternal symphysis pubis

The occiput is the longer end of the head lever. The chin is directly

posterior. Vaginal delivery is impossible unless the chin rotates

anteriorly

Diagnosis

Vaginal examination

palpation of the distinctive facial features of the

mouth and nose, the malar bones, and particularly the orbital

ridges

Radiographic examination

demonstration of the hyperextended head with the

facial bones at or below the pelvic inlet

Etiology

Marked enlargement of the neck or coils of cord about the neck may cause extension

Anencephalic fetuses

Contracted pelvis

Very large fetus

Multiparous women

Mechanism of Labor

Face presentations rarely are observed above the pelvic inlet

The brow generally presents, converted into a face presentation after further extension of

the head during descent

Mechanism of labor consists of the following cardinal movements:

Descent - brought about by the same factors as in cephalic presentations

internal rotation - the objective is to bring the chin under the symphysis pubis



- results from the same factors as in vertex presentations

flexion

accessory movements of extension and external rotation - results from the relation

of the fetal body to the deflected head

Mechanism of labor for right mentoposterior position with subsequent rotation of the mentum

anteriorly and delivery

Management

In the absence of a contracted pelvis, and with effective labor, successful vaginal delivery

usually will follow

Cesarean delivery

Because face presentations among term-size fetuses are more common when there

is some degree of pelvic inlet contraction, cesarean delivery frequently is indicated.

BROW PRESENTATION

Rarest presentation because it is unstable and often converts to a face or occiput

presentation

The portion of the fetal head between the orbital ridge and anterior fontanel presents at the

pelvic inlet

The fetal head thus occupies a position midway between full flexion (occiput) and extension

(mentum or face)

Only transient prognosis depends on the ultimate presenting part

Causes are the same as of the face presentation

Management is the same as those for a face presentation

Diagnosis



Abdominal palpation - when both the occiput and chin can be palpated easily

Vaginal examination – palpation of the frontal sutures, large anterior fontanel, orbital ridges,

eyes, and root of the nose

Mechanism of Labor

very small fetus and a large pelvis - labor is generally easy

with a larger fetus - usually difficult, because engagement is impossible until there is

marked molding that shortens the occipitomental diameter or, more commonly, until there

is either flexion to an occiput presentation or extension to a face presentation

TRANSVERSE LIE

the long axis of the fetus is approximately perpendicular to that of the mother

referred to as shoulder or acromnion presentation

the shoulder is usually on the pelvic inlet, with the head lying on one iliac fossa and the

breech in another

Diagnosis

Abdominal examination

abdomen is unusually wide, whereas the uterine fundus extends to only slightly

above the umbilicus.

no fetal pole is detected in the fundus, ballottable head is found in one iliac fossa

and the breech in the other

back up (anterior) - a hard resistance plane extends across the front of the abdomen

back down (posterior)- irregular nodulations representing the small parts are felt

through the abdominal wall.

Diagnosis

Vaginal examination

early stages of labor: the side of the thorax or the "gridiron" feel of the ribs

Advanced labor: the scapula and clavicle are palpated



Palpation in transverse lie, right acromidorsoanterior position. A. First maneuver. B. Second

maneuver. C. Third maneuver. D. Fourth maneuver.

Etiology

Abdominal wall relaxation from high parity.

Preterm fetus.

Placenta previa.

Abnormal uterine anatomy.

Excessive amnionic fluid.

Contracted pelvis.

Mechanism of Labor

Spontaneous delivery of a fully developed newborn is impossible with a persistent

transverse lie

rupture of the membranes the fetal shoulder is forced into the pelvis

corresponding arm frequently prolapses shoulder is arrested by the margins of the

pelvic inlet ( head in one iliac fossa and the breech in the other) impacted shoulder

neglected transverse lie uterine rupture

Neglected shoulder presentation. A thick muscular band forming a pathological retraction

ring has developed just above the thin lower uterine segment. The force generated during a



uterine contraction is directed centripetally at and above the level of the pathological

retraction ring. This serves to stretch further and possibly to rupture the thin lower segment

below the retraction ring. (P.R.R. = pathological retraction ring.)

If the fetus is small—usually less than 800 g—and the pelvis is large, spontaneous delivery is

possible despite persistence of the abnormal lie

Management

In general, the onset of active labor in a woman with a transverse lie is an indication for

cesarean delivery

Because neither the feet nor the head of the fetus occupies the lower uterine segment, a

low transverse incision into the uterus may lead to difficulty in extraction of a fetus

entrapped in the body of the uterus above the level of incision. Therefore, a vertical incision

is likely to be indicated

OBLIQUE LIE

called an unstable lie

when the long axis forms an acute angle

usually only transitory, because either a longitudinal or transverse lie commonly results

when labor supervenes

COMPOUND PRESENTATION

an extremity prolapses alongside the presenting part, with both

presenting in the pelvis simultaneously

The left hand is lying in front of the vertex. With further labor, the hand and

arm may retract from the birth canal and the head may then descend

normally.

Causes

conditions that prevent complete occlusion of the pelvic inlet by the

fetal head, including preterm birth

Prognosis and Management

Perinatal loss is increased as a result of concomitant preterm delivery, prolapsed cord, and

traumatic obstetrical procedures

In most cases, the prolapsed part should be left alone, because most often it will not

interfere with labor

Prolapsed arm alongside the head close observation to ascertain whether the arm retracts

out of the way with descent of the presenting part, if it fails to retract and if it appears to



prevent descent of the head, the prolapsed arm should be pushed gently upward and the

head simultaneously downward by fundal pressure vaginal delivery

PERSISTENT OCCIPUT POSTERIOR POSITION

Transverse narrowing of the midpelvis is undoubtedly a contributing factor

Usually undergo spontaneous anterior rotation followed by uncomplicated delivery

The possibilities for vaginal delivery are:

Spontaneous delivery

Forceps delivery with the occiput directly posterior

Manual rotation to the anterior position followed by spontaneous or forceps

delivery

Forceps rotation of the occiput to the anterior position and delivery

PERSISTENT OCCIPUT TRANSVERSE POSITION

Most likely a transitory one because the occiput tends toward the anterior position in the

absence of a pelvic architecture abnormality

Spontaneous anterior rotation usually is completed rapidly, thus allowing the choice of

spontaneous delivery or delivery with outlet forceps.

If rotation ceases because of poor expulsive forces and pelvic contractures are absent,vaginal delivery usually can be accomplished

The occiput may be manually rotated anteriorly or posteriorly and forceps delivery

performed from either the anterior or posterior position

Delivery

Application of Kielland forceps to the fetal head to rotate the occiput to the anterior

position, and then deliver the head either with the same forceps or with Simpson or Tucker –

McLane forceps

Oxytocin may be infused and closely monitored

With the platypelloid (anteroposteriorly flattened) and the android (heart-shaped) pelves,

there may not be adequate room for rotation of the occiput to either the anterior or the

posterior position.

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