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Bukovinian State Medical University




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Bukovinian State Medical University


“Approved”

on methodological meeting

of Department of Obstetrics and Gynecology

with course of Infant and Adolescent Gynecology

“___”______________________ 200_ year

protocol #

The Head of the department

Assistant Professor

________________ S.P.Poliova


Methodological instruction

for practical lesson

“Breech presentation. Malpresentations. Contracted pelvis”



Module 1: Physiology of pregnancy, labor and puerperium

Context module 2: Perinatology. Risk factors of perinatal period.


Subject: Obstetrics and Gynecology

4th year of studying

2nd medical faculty

Number of academic hours – 4

Methodological instruction developed by:

assistant Andriy Berbets


Chernivtsi – 2008


Aim: to learn the biomechanism of labor in breech presentation, recognise the breech presentation and be able to render the manual assistants in labor in the different types of breech presentation. To learn how to make the diagnosis of malpresentations. To show the causes which results in this. To learn the indications, conditions and the techniques for operation of obstetric versions.


^ Professional motivation: The breech presentations occur in about 3-4% of all labors. With breech presentation, compared to cephalic presentation both the mother and the fetus are at greater risk. The prognosis for the fetus in a breech presentation is considerably worse than when in a vertex presentation. The operative delivery rate is higher and may be; higher maternal morbidity and mortality. It is very important to know the biomechanism of labor in breech presentation and the correct management-1 of labor. Students have to be able to render the manual aid to avoid the complication coursed by pathological labor.

Malpresentations are very actual obstetrics problem because it results in increasing of maternal and fetal morbidity and mortality. It is also impossible to manage labors through maternal passages and needs using of obstetrics operation, in most cases cesarean section.

Contracted pelvis: learning the main types and peculiarities of labor in contracted pelvis gives a possibility to prevent the main obstetric complications, perinatal and maternal death.

Basic level:

^ BREECH PRESENTATION

1. Anatomy of fetal head.

2. Anatomy and topography of the uterus, pelvis and pelvic floor.

3. External and internal examination of pregnant women.

4. The structure of the fetal head.

5. Diameters of the fetal body at term.

6. The stages of the labor.

MALPRESENTATIONS

1. Anatomy and topography of the uterus

2. External and internal examination of pregnant women

3. Methods of diagnostic of different fetal positions.

4. Measuring of external pelvis sizes.

5. Kinds of obstetrics operations, indications and contraindincations for cesarean section, craniotomy and embriotomy

6. The preoperative preparing of patients. The deflexed vertex presentation — diagnosis, the cardinal movements of labor, prognosis, the management of labor.

7. The brow presentation — diagnosis, the cardinal movements of labor prognosis, the management of labor.

8. The face presentation - diagnosis, the cardinal movements of labor, prognosis, the management of labor.

9. Prognosis and complications of the labor in deflexed presentation.

10. The deforms of the fetal head in deflexed presentation.

11. The methods of operative delivery in deflexed presentation.


^ CONTRACTED PELVIS

1. Etiology and pathogenesis of abnormal development of pelvis.

2. Sizes of normal pelvis.

3. Principles of dispensary monitoring for the pregnant women with

contracted pelvis.

4. Methods of pregnant and puerpera investigation.

5. Estimation of external and internal pelvic sizes.

6. Clinic and management of physiologic pregnancy and labor.

7. Cardinal moments of labor in flexed and deflexed vertex presentations.


^ STUDENTS' INDEPENDENT STUDY PROGRAM

I. Objectives for Students' Independent Studies

You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:


BREECH PRESENTATION

1. Classification of breech presentations.

2. Diagnosis of breech presentations.

3. The biomechanism of the labor in breech presentations.

4. The cardinal movements of labor in breech presentations.

5. The manual aid by Tsovyanov I on the labor in the frank bree< presentation.

6. The classic manual aid on the labor in the complete and incomplete, breech presentation.

7. The manual aid by Tsovyanov II on the labor in the footling breech presentation.

8. The operative delivery in the breech presentation.

9. The complications to the delivery in a breech presentation.

MALPRESENTATIONS

1. The determination of malpresentations.

2. Types oi malpresentations.

3. The making diagnosis of malpresentations, physical and instrumental

methods of investigations.

4. The determination of obstetrics version. Classification.

5. The indications for external obstetrics version.

6. The contraindications and conditions for the operation of extern*

obstetrics version.

7. The indications, contraindications and requirements for the poda"

internal obstetric version.

8. The technique for the operation of the external obstetrics versio

9. The technique for the operation of the internal podalic version

10. Anesthesia for the operations.

1l. The complications caused by obstetrics versions.

12. Management of postoperative period.

^ CONTRACTED PELVIS

1. Pelvic classification according to form of contractions.

2. Anatomically and clinically contracted pelvis.

3. Diagnosis of contracted pelvis.

4. Pelvic classification according to degree of contraction.

5. Often occurred contracted pelvis: generally contracted pelvis, sial pelvis: simple flat pelvis, flat rachitic pelvis, generally contracted flat pelvis

6. Principles of pregnancy management in contracted pelvis.

7. Principles of labor management in contracted pelvis.

8. Cardinal moments of labor in different types of contracted pelvis-

9. Vasten's and Zangemeister sign.


Key words and phrases: biomechanism, breech presentation, frank

breech presentation, complete and uncompleted breech presentation, descent, flexion, rotation, extension, the manual assistance by Tsovyanov I and by Tsovyanov II, the classic manual assistance, transverse lie, oblique lie, long axis of the fetus, unstable lie, obstetrics versions.


Summary

^ BREECH PRESENTATION

There is a fundamental difference between delivery in cephalic and breech presentation. With a cephalic presentation, once the head is delivered, typically the rest of the body follows without difficulty. With a breech, however, successively larger or, in case of the head, very much less compressible parts of the fetus are born.

Spontaneous complete expulsion of the fetus that presents as a breech, as described below, is seldom successfully accomplished. As the rule, either cesarean section of vaginal delivery that requires skilled participation by the obstetrician is essential for a favorable outcome.

Etiology. Breeches are much more common at the end of the second trimester of pregnancy than at or near term. Factors other than prematurity that arrear to predispose to breech presentation include uterine relaxation association with great parity,multiple fetuses,hydramnion.hydrocephalus, anencephalus, previous breech delivery, uterine anomalies, and tumors.

Classification. The varying relations between the lower extremities and buttocks of the fetus in breech presentation form the categories of frank breech, complete breech, incomplete breech presentation, footling and kneeling presentation.

In frank breech presentation the lower extremities are flexed at the hips and extended at the knees and thus the feet lie in close proximity to the head.

In complete breech presentation the lower extremities are flexed at hips and at the knees.

In incomplete breech presentation the lower extremities are flexed at nips and at the knees and the one or both feet lie below the breech. »n footling presentation the feet lies lower than breech. 1 tie kneeling presentation is the especial form of the breech, when the fetal knees are lower than the breech.

Diagnosis. The diagnosis of the breech presentation may be making 'he help of external and internal obstetrics investigation. With the first maneuver of the external examination we identify the hard, round ballottable fetal head to occupy he fundus of the uterus. The second maneuver indicates the back to be on one side of the abdomen and the small parts in other. On the third maneuver the breech is movable above the pelvic inlet. The heart sounds of the fetus are usually heard loudest slightly above the umbilicus.

Vaginal examination. In frank breech presentation only buttocks and its characteristics components (both ischial tuberosities, the sacrum, the anus, the external genitalia) are usually palpable. In incomplete breech presentation the buttocks and the feet may be palpated. In footling the fetal feet are lower than buttocks.

Biomechanism of labor in breech presentation,

I moment - the internal breech rotation. The breech rotates and fetal intertrochanteric diameter from one of oblique size of the pelvic inlet to anteteroposterior size of the pelvic outlet.

II moment - the lateral flexion of the body. The anterior hip is stemmed against the pubic arc. By lateral flexion of the fetal body the posterior hip is forced over the anterior margin of the perineum. Then anterior hip is born.

III moment - the internal shoulders rotation. Alter the birth of the breech, there is the slight external rotation as a result of the descends and rotations of the shoulders. The shoulders rotates on the pelvic floor and. diameter biacromialis occupies anteroposterior diameter of the pelvic outlet.

IV moment - the lateral flexion the body in the thoraco-brachial part. The shoulders are born.

V moment - the internal rotation of the head. The rotation begins when the fetal head descends from the plane of greatest pelvic dimensions, to the least pelvic dimensions (midpelvis). The rotation is complete when the head reaches the pelvic floor, the sagittal suture is in the anteroposterior diameter of the pelvic outlet and the small fontanel is under the symphysis

VI moment - the flexion of the fetal head. The head fixes with its, fossa suboccipitalis to the inferior margin of symphysis pubis and flexes. The face,forehead,vertex,and occiput are born.


^ The manual aids in breech presentations.

The manual aid by Tsovyanov I in frank breech presentations.

The aim of the manual aid: to prepare the maternal ways to the delivery of the head and shoulders and to keep the normal attitude of the fetus.

in the frank breech presentation the fetus extremities are flexed the hips and extended at the knees and thus the feet lie in close proximity to the head. The circumference of the thorax with the crossing on it arms so their circumference is larger than circumference of the head and the after-coming; which deliveries easily.

^ The technique. The aid begins after the delivery of the buttocks. The physician’s hands are applied over the buttocks, the thumbs placed on fetus sacrum and other fingers on the legs. The doctor gently supports legs to avoid its flexion. If the normal attitude of the fetus is keeping head deliveries easy.


The classic manual aid on the labor in complete and incomplete breech presentation.

The aim of the classic manual aid: to help of the shoulders and the head delivery.

The classic manual aid begins when the lower angular of the anterior scapula became visible. There are 4 moments of the classic manual aid.

I moment - the delivery of the posterior arm. The posterior shoulder must be delivered first. The feet are grasped in one hand and drawn upward over the groin of the mother toward which the ventral surface of the fetus is directed; in this manner, leverage is exerted upon the posterior shoulder, which slides out over the perineal margin, usually followed by the arm and hand.

II .and III moment - the external trunk rotation and removal of the posterior arm The aim of this moment is the reverse of the anterior shoulder to the sacrum and the delivery of second arm. The obstetrician applies his hand on the lateral sides of the fetus trunk and rotates it. The direction of the movement must be in this way: the occiput must go under the symphysis pubis. When the posterior shoulder and arm appears at the vulva the doctor put two fingers into the vagina, the fingers passed along the humorous until the elbow is reached. The fingers are now used to splint the arm, which is swept downward and delivered through the vulva.

IV moment - delivery of the head. After the shoulder' are born, th head usually occupies an oblique diameter of the pelvic with the occiput directed anteriorly. The fetal head may then be extracted by the method of Mauriceau-Levret. Employing the Mauriceau-Levre maneuver to help flex head, the doctor's middle finger of one hand are applied into the fetal mouth, while the fetal body rests upon the palm of the hand and fore arm, which is straddled the fetal legs. Two fingers of the operator's other hand are then hooked over the fetal neck and grasping the shoulders, downward

traction is applied until the suboccipital region appears under the symphysis.

The body of the fetus is then elevated toward the mother abdomen, and mouth, nose, brow and the occiput emerge over the perineum. Gentle traction should be exerted by the fingers over the shoulders.


^ The manual aid by Tsovyanov II in footling presentation

The aim of the manual aid: To perform the footling presentation the incomplete breech and to prepare the maternal ways to the deliver the head and shoulders.

The doctor covers the area of the vulva with the sterile napkin and puts up resistance to the delivery of the feet. The feet are flexing and the footling presentation becomes incomplete breech presentation. Than the delivery manage as in incomplete breech presentation.

Favorable factors for breech delivery:

1. Gestation age of more than 36 but less than 38 weeks. If the baby small, the head will be lager than the breech and may be trapped i cervix; if too large, the difficulty is obvious.

2. Estimated fetal weight of more than 2500 but less than 3175g

3. The presenting part at or below station -1 at the onset of labor

4. The cervix soft, effaced, and dilated more than 3 cm.

5. Ample gynecoid or anthropoid pelvis (the head will enter th pelvis in the anterior position).

6. A history of a previous breech delivery of a baby weighing more than 3175g or a previous vertex delivery of baby weighing more than 3600g.

Unfavorable factors:

1. Gestation age of more than 38 weeks.

2. Estimated fetal weight of more than 3500 - 3600g.

3. The presenting part is at pelvic inlet.

4- The cervix firm, incompletely effaced, and less than 3 cm dilated

5. No history of prior vaginal delivery, or history of difficult vaginal delivery

6. Android or flat pelvis.

7. Footling or full breech presentations.

8. Extension of the fetus head is extremely unfavorable and is indication for cesarean section.

The presence of any one of the aforementioned unfavorable factors should strongly suggest the desirability of delivery by cesarean. section.

The predelivery examination: its chief purpose is to confirm the conditions for the operation.

Indications for breech extraction:

• The requirement for instant vaginal delivery;

• Cases in which one is already committed to vaginal delivery and cesarean section is not appropriate or feasible (maternal indications -preeclarnpsia, hard heart and puimonal diseases, cord prolapse; fetus indications - acute hypoxia);

• The breech extraction is committed after the operation.


^ The conditions for breech extraction:

• The cervix must be completely dilated and retracted high in the pelvis (although the breech - especially in footling presentation - may pass the cervix without incident, the shoulders or head will surely be trapped by incompletely dilated cervix);

• The uterus must be relaxed;

• The normal fetopelvic proportion;

• The rupture of membranes.

^ The techniques for breech extraction.

The techniques for the operation of extraction fetus on the two legs.

Dy\uring total breech extraction, the obstetrician's entire hand should be inserted through the vagina and both feet of the fetus grasped. The breech are held with the second finger lying between them. The feet are brought down the vagina, and gentle traction applied until they appear from the vulva. Now both feet are grasped and pulled through the vulva. As the legs commence to emerge through the vulva, they should be wrapped in sterile towel to obtain a firmer grasp, for the vernix caseosa renders them difficult to hold. Downward gentle traction is then continued.

As the legs emerge, successively higher portion are grasped, first the legs (shins) and later the thighs. When the breech appears at the vulva, gentle traction is applied until the hips are delivered. As the buttocks emerge, the hack of the infant usually rotates to the anterior. The thumbs of the operator are then placed over the sacrum and gentle downward traction is continued until the costal margins, and then, the scapulas become visible. The back of the infant tends to turn spontaneously toward the side of the mother to which it originally directed. If turning does not occur, slight rotation should he added to the traction, with the object of bringing the bisacrorrsial diameter of the fetus in the antero-posterior diameter of the pelvic outlet.

There are two methods of delivery of the shoulders: with the scapulas visible, the trunk is rotated in such a way that the anterior shoulder and the arm appear at the vulva and can easily be released and delivered first. The operator is shown rotating the trunk of the fetus counterclockwise to deliver

the right shoulder and arm. The body of the fetus is then rotated in the reverse direction to deliver the other shoulder and arm. If trunk rotation is unsuccessful, the posterior shoulder must be delivered first. The feet are grasped in one hand and drawn upward over the groin of the mother

toward which the ventral surface of the fetus is directed; in this manner, leverage is exerted upon the posterior shoulder, which slides out over the perineal margin, usually followed by the arm and hand. Then, by depressing the body of the fetus, the anterior shoulders emerges beneath the pubic arch, the arm and hand usually follow spontaneously. Thereafter, the back ends to rotate spontaneously in the direction of the mother's symphysis. If upward rotation fails to occur, it is effected by manual rotation of the body.

Delivery of the head may then be accomplished.

After the shoulders are born,the head usually occupies an oblique diameter of the pelvis with the chin directed posteriorly. The fetal head then be extracted either with forceps, which is the method preferred by many obstetricians, or by so-calted Mauriceau maneuver. Employing the Mauriceau maneuver to help flex the head, the operator'smiddle finger of the hand are applied over the maxilla, while the body rests upon the palm of the hand and forearm, which is straddled by the fetal legs. Two fingers of the operator's other hand are then hooked over the fetal neck, and grasping the shoulders, downward traction is needed until the suboccipital region appears under the symphysis. The body of the fetus is then elevated toward the mother's abdomen, and the mouth, nose brow and eventually the occiput emerge successively over the perineum Gentle traction should be exerted by the fingers over the shoulders. At the same time, suprapubic pressure, appropriately applied by an assistant.


^ The management of the breech delivery.

To try the minimize infant mortality and morbidity, cesarean section is now commonly used. The indications to the cesarean section:

1. Breech presentation and a large fetus (the weight of the fetus estimated 3500 g and more).

2. Breech presentation and any degree of contraction or unfavorable shape of the pelvis.

3. Breech presentation and deflexed head.

4. Breech presentation and uterine dysfunction.

5. Breech presentation and previous perinatal death of children, suffering from birth trauma.

6. Breech presentation and fetal hypoxia.


MALPRESENTATIONS

The transverse lie is the condition when the long axis of the fetus is approximately perpendicular to that of the uterus. When it forms an acute angle, an oblique lie results. An oblique lie is usually only transitory, however, for either a longitudinal or transverse lie commonly results when labor supervenes. For this reason, the oblique lie is termed unstable lie.

An unstable lie is one in which the presenting part alters from week to week. It may be either a transverse or oblique lie or possibly a breech presentation. These are relatively uncommon events but are found in association with the following conditions:

1. Grand muitipara. This is by far the commonest factor, due to the lax uterine and abdominal walls, which prevent the splinting effect found in women with lesser parity.

2. Poiyhydramnios. The volume of fluid distends the uterus and allows the fetus to swim like a goldfish in a bowi — often taking up an oblique or transverse lie.

3. Prematurity. Here there is a relative excess of fluid to the fetus. If preterm labour occurs, the fetus may be found to have a transverse lie.

4. Subseptate uterus. The septum prevents the fetus from turning in utero.

5. Pelvic tumors such as fibroids and ovarian cysts may not only prevent the lower pole from engaging, but cause it to take up a transverse lie.

6. Placenta praevia. This usually prevents engagement of the present­ing part. Because of this it may present with the fetus in an oblique or transverse lie.

7. Multiple pregnancies may present with a transverse lie. If this occur, it is more common in the second twin.

^ Diagnosis of the transverse and oblique lies: 1- The external inspection shows than the abdomen is unusually wide from side to side, whereas the fundus of the uterus extends scarcely above the umbilicus. On palpation, with the first maneuver no fetal pole is detected. On the second maneuver, a ballottable head is found in one side and the breech in other. The third and fourth maneuvers are negative unless labor is vvoii advanced and the shoulder has become impacted in the pelvis. When the fetal head is situated in the left side of the uterus th first position of the fetus is identified. When the fetal head is situated h the right side of the uterus the second position is recognized. On vaginal examination, in the early stages of labor, the side of the thorax, if it can be reached, may be recognized above the pelvic inlet. When the dilatation is further advanced, the scapula and the clavicle are distinguished on opposite sides of the thorax. Later in the labor, the shoulder becomes tightly wedged in the pelvic canal, and a hand and arm frequently prolapse into the vagina and through the vulva.

Management of transverse and oblique lie. It is not uncommon for the fetus to have a transverse lie until about the 32nd week of pregnancy If the transverse lie persists after this time a cause should be determined. An ultrasound examination should be done to exclude placenta praevia, ovarian tumor or fibroid and if either of these conditions are present an elective cesarean section should be performed at 38-39 weeks of gestation. The ultrasound is also used for identifying twins and a subseptate uterus, whilst a vaginal examination will confirm a pelvic tumor.

The main risk of a transverse or oblique lie is in association with preterrn rupture of the membranes and cord prolapse. When diagnosed the state of the cervix should be checked. If the cervix is dilated, the patient should be admitted to hospital. If, however, the cervix is closed and the membranes are intact the patient may be reviewed on a regular basis. If no easily identifiable cause is found, attempted external cephalic version can be made after 34 weeks. In grand multipara patients,the fetus will usually turn easily but will often swing back to an abnormal lie. If the abnormal lie persists or constantly reoccurs, the woman should be admitted to hospital by the 38th week. If external version is successful at this stage and the patient's cervix is favorable then artificial rupture of the membrane can be performed with the head held over the pelvic brim and an oxytocin drip commenced to augment uterine activity. If the cephalic presentation is maintained, labor may be allowed to continue. If the transverse or oblique lie reoccurs in labor then a cesarean section must be performed. Complications of a transverse lie. If a mother goes into labor with a transverse or oblique lie,several catastrophes may occur. Because this occurs more commonly in multiparous women and their uterine activity is often much stronger, rupture of the uterus is more likely. When the membranes rupture there is a greatly increased danger of cord prolapse-

^ Obstetrics versions

Operations for correction of abnormal lie or presentation of fetus as obstetrics versions. There are two types of obstetrics versions: external and internal podalic version. Indications for obstetrics versions: fetal malpresentations (breech, transverse and oblique lie).

Contraindications. Complicated pregnancy, multifetal pregnancy, ngenital uterine anomalies, placenta previa, feto-pelvic disproportion.

^ Conditions: for the external version - 32-36 weeks, intact merribranes, normal movement of the fetus in the uterus, satisfactory fetal and mother condition; for the internal podalic version - cervix must be fully dilated, intact or just rupture membranes, normal movement of the fetus in the uterus, satisfactory mother condition, absence of fetopelvic disproportion.

The internal podalic version consists of such moments:

1. Inserting a hand into uterine cavity.

2. Finding a foot.

3. Grasping one foot.

4. Drawing foot through the cervix while exerting pressure transabdominally in the opposite direction on the upper portion of the body.

The version is finished when fossa poplitea of the grasping foot in presented in the pudendal cleft.

^ DEFLEXED PRESENTATIONS

There are 3 types of deflexed presentation — deflexed vertex, brow and

face presentation.

Etiology. The causes of deflexed presentation are manifold, there are the factors that Savors extension or prevents flexion the head. Extended position of the head occur more frequently when the pelvis is contracted or fetus is very large. In multiparous women the pendulous abdomen predisposes to deflexed presentation. In exceptional instances, marked tumors of the fetal neck or coils of cord about the neck may cause extension. Anencephalic fetus present by the brow or face because of faulty development of the cranium.

^ The deflexed vertex presentation. The deflexed vertex presentation is a I degree of head extension.

Diagnosis. The diagnosis of the deflexed vertex presentation bases on the results of the vaginal palpation: the sagittal suture, the large and the small iontanels on the same level. The fetal head presents with a ironto-occipital diameter,a leader point is the large fontanei.

The cardinal movements of labor in deflexed vertex presentation arc:

• deflexion;

• internal rotation;

• flexion;

• extension;

• internal rotation of the fetal body and external rotation of the fetal head. Deflexion. The sagittal suture is in the transverse or oblique

size of the pelvic inlet. The head fixes to the inlet and some deflexed. The large fontanel becomes the leader point.

^ 2. Internal rotation. This movement is a manner that the occiput gradually moves from its original position posteriorly towards the sacrum os. The rotation is complete when the head reaches the pelvic floor; the sagittal suture is in the anteroposterior diameter.

3. Flexion of the head. Flexion begins when the head fixes by its root of the nose (the first fixing point) to the inferior margin of symphysis pubis. The flexion finishes when the occiput comes to the tip of sacrum and the second fixing point forms.

^ 4. Extension of the head. After internal rotation and flexion the fetal head closely touched with the area of the occiput to the tip of the sacrum. The head extends and deliveries.


Internal rotation of the fetal trunk and external rotation of fetal head. This moment realizes as in anterior occiput presentation. The brow presentation is a II degree of extension. With the brow presentation, that portion of the fetal head between the bital ridge and the frontal suture presents at the pelvic inlet. The fetal 0 d thus occupies a position midway between full flexion (ociput) and e II extension (mentum or face). Except when the fetal head is very small the pelvis is unusually large, engagement of the fetal head and subsequent cannot take place as long as the brow presentation persists.


Diagnosis. The diagnosis of the brow presentation bases on the results of the external obstetrics examination and vaginal palpation. The brow presentation may be recognized by abdominal palpation when both the occi put and chin can be easily palpated. The reliable information can be felt by the vaginal examination: the frontal suture, the large fontanel, orbital ridges, eyes, and root of the nose. The nose and mouth can not be palpable.

The fetal head presents with a mento-occipital diameter, a leader point is the middle of the frontal suture.

The delivery at term in brow presentation is impossible. The preterm delivery, when the fetus is small is possible and the characteristically deforms of the head occurred. The caput succedaneum is over the fore head and may be so extensive that identification of the brow by palpation is impossible.

If the labor is possible the cardinal movements in brow presentation are:

1. Deflexion. The frontal suture is in the transverse size of the pelvic inlet. The head fixes to the inlet and deflexed. The middle of the irontal suture becomes the leading point.

2. Internal rotation.

3. Flexion of the head.

4. Extension of the head.

5. Internal rotation of the fetal trunk and external rotation °f the fetal head

Face presentation.

In the face presentation.the head is hyperextended so that the occiput is in contact with the fetal back and the chin (mentum) is presenting part.

Diagnosis. By abdominal palpation the occiput, the chin and the angle between the fetal back and the occiput can be easily palpated. The 'e'al heart sound are the loudest from the side of the fetal thorax. On palpation, the distinctive features of the face presentation are the nose, the malar bones, and the orbital ridges. Face presentation is rarely observed above the pelvic inlet. The brow ;.Ue y presents and is converted to a face presentation after further extension of the head during descent through the pelvis.


^ The cardinal movements of labor in face presentation are:

1. Deflexion. The face linea is in the transverse size of the p%\v inlet. Descent is brought about by the same factors as vertex presentation The head presented its vertical diameter. The chin is the leading point

2. Internal rotation The object of internal rotation of the face i to bring the chin under the symphysis. Only in this way the neck subtend the posterior surface of the symphysis pubis. If the chin rotates directlv posteriorly, the birth oi the head is impossible.

3. Extension of the head. After the rotation and descent, the chin and mouth appear at the vulva, the undersurface of the chin presses against the symphysis, and the head is delivered by flexion. The nose, eyes, brow and occiput then appeared in succession over the anterior margin of the perineum

4. Internal rotation of the fetal trunk and external rotation of the fetal head. The shoulders are born as in vertex presentations.


^ CONTRACTED PELVIS

Anatomically contracted pelvis is characterized by shortening of

one diameters of the true pelvis into 1,5 - 2 cm and more. Clinically or functional contracted pelvis is usually defined as jviS with normal dimensions, but vaginally delivery is impossible due to "fetopelvic disproportion".

The main causes of "cephalopelvic disproportion" are fetal macrosomia, postdate pregnancy, uterine inertia, fetal malpresentation, especially fetal head extension — sinciput vertex,brow,face anterior position, ninic signs of clinically contracted pelvis:

1. Head is arrested in the pelvic inlet (absence of fetal descending in complete cervical dilation and adequate uterine contractions).

2. Uterine contractions abnormality.

3. Positive Vasten' sign (if disproportion between fetal head and symphisis pubis is prominent — Vasten' sign is positive, if disproportion between fetal head and symphisis pubis is absent - Vasten' sign is negative).

4. Signs of urinary bladder compression.

5. Edema of the cervix, and vaginal walls, productions of fistulas. When the presenting part is firmly wedged into the pelvic inlet but

does not advance for a considerable time, portions of the birth canal lying between it and the pelvic wall may be subjected to excessive pressure. As a circulation is impaired, the resulting necrosis may become manifest several days after delivery by the appearance of vesicovaginal, vesicocervical, or rectovaginal fistulas.

6. Danger of uterine rupture.

When the disproportion between the head and the pelvis is so pronounced that engagement and descent do not occur, the lower uterine segment becomes increasingly stretched, and the danger of its rupture ecornes imminent. In such cases, a pathologic contractile ring may form and can be felt as a transverse or oblique ridge extending across

e uterus somewhere between the symphysis and the umbilicus. Whenever condition is noted, prompt cesarean delivery must be employed to prevent rupture of the uterus.

'- Pushing occurs if fetal head is situated in the plane of inlet. In the case of clinically contracted pelvis - only cesarean section.

Pelvic classification according to form of contractions:

^ 1. Often occurred

• generally contracted pelvis;

• flat pelvis: simple flat pelvis, flat rachitic pelvis, generally contracted.

Generally contracted pelvis is characterized by diminution of true pelvic diameters (anteroposterior, transverse, and oblique) into 2 cm. Subpubic arch is narrow. Average sizes of the pelvis are: D. spinarum - 23cm, D. cristarum - 26 cm. D. trochanterica - 29 cm, C. externa - ig cm, C. diagonalis — 11 cm, C. vera — 9 cm. Course of labor:

• prolongation of labor;

• considerable fetal head flexion thanks to which it is elongated in the ocipitofrontal diameter (dolichocepaly);

• posterior fontanel is situated into the axis of pelvis;

• considerable molding of the fetal head. Caput succedaneum is formed in the area of posterior fontanel;

• with increasing narrowing of the pubic arch, the occiput cannot emerge directly beneath the symphysis pubis but is forced increasingly farther down upon the ishiopubic rarni. It may play an important part in the production of perineal tears.

Management of labor. Vaginaliy delivery is possible.

^ Flat pelvis - is usually defined as diminution of anteroposterior diameters of true pelvis,transverse and oblique diameters are normal.

Simple flat pelvis is defined as shortening of anteroposterior diameters at all levels of true pelvis, as a result of this sacrum is inclined anteriorly to pubis.

Average sizes of the pelvis are: D. spinarum - 26cm, D. cristarum ~ 29 cm. D. trochanterica - 31 cm, C. externa - 18 cm, C. diagonalis - H cm, C. vera - 9 cm.

^ Course of labor:

• prolongation of labor;

• sagittal suture of the fetal head arresting in the transverse diarnetei

of the plane of inlet;

• fetal head extension until bitemporal fetal head diameter would W situated in the anteroposterior diameter of the plane of inlet;

• anterior fontanel is the leading point of the fetal head (lowermost situate"'1

• asynclitism should be presented (anterior or posterior);

• considerable molding of the fetal head. Caput succedaneum is iorme in the area of anterior fontanel.


Flat rachitic pelvis — is characterized by some peculiarities:

1. True conjugate is shortened.

2. Sidewalls tend to converge, as result of this D. spinarum and D. cristarum are equal.

3. Additional promontoriurn may be presented between 1 and 2 vertebrae of sacrum

4. Subpubic arch is shallow and wide.

5. Top of the sacrum is situated posteriorly that's why dimensions of the pelvic outlet are normal or even increased.

Average sizes of the pelvis are: D. spinarum - 26cm, D. cristarum -26 cm.- D. trochanterica — 31 cm, C. externa — 17 cm, C. diagonalis — 10 cm, C. vera - 8 cm.


^ Course of labor is the same as in the simple flat pelvis. But thanks to normal or even increased anteroposterior size of pelvic outlet perineal tears as result of quick second stage labor may be presented.

Management of labor. Vaginal delivery is possible.

Generally contracted flat pelvis is characterized by combination of the signs of generally contracted and flat pelvis.

Average sizes of the pelvis are: D. spinarum — 24cm, D. cristarum — 25 cm., D. trochanterica - 28 cm, C. externa - 16 cm, C. diagonalis - 9 cm, C. vera — 7 cm.

^ Course of labor depends from predominance of kind of pelvis contraction.

Management of labor. Cesarean section is the method of choice.


Rare occurred contracted pelvis: obliquely contracted pelvis, obliquely dislocated pelvis,.transverse contracted pelvis.osteomalacic pelvis, lunnel-shaped pelvis, spondylolisthetic pelvis, contracted pelvis as a result °' exostosis and bone tumors. Management of labor. Cesarean section should be performed in all of these types of pelvis.

^ Pelvic classification according to degree of contraction: Four degrees of pelvic contractions should be distinguished: I degree - True conjugate is 11-9 cm. Vaginal delivery is possible. II degree - True conjugate is 9-7,5 cm. Vaginal delivery is possible. III degree - True conjugate is 7,5 - 5.5 cm Cesarean section is Performed. IV - degree — True conjugate is 5.5 cm. Cesarean section is performed.


^ BREECH PRESENTATION

II. Tests and Assignments for Self-assessment.

Multiple Choice.

Choose the correct answer / statement:

1. What the type of presentation is if the buttocks and feet are palpable:

A - Frank breech presentation;

B - Complete breech;

C - Incomplete breech presentation;

D - Footling ;

E - Kneeling presentation.


2. What the type of presentation is if the feet are palpable than the buttocks:

A - Frank breech presentation;

B - Complete breech;

C - Incomplete breech presentation;

D - Footling;

E - Kneeling presentation.


3. What the estimated weight of the fetus is the indication | cesarean section?

A - 2500 g; B - 3000 g; C- 36OO g; D - 4000 g


4 What type of the manual aids need the patients with a footling?

A- Manual aid by Tsovyanov 1; B - Manual aid by Tsovyanov II; C - Classic manual aid; D - Breech extraction.


5. What type of the manual aids need the patients with a frank breech presentation?

A- Manual aid by Tsovyanov I.

B- Manual aid by Tsovyanov II;

C - Classic manual aid;

D - Breech extraction.


^ Real - life situations to be solved:

6. N., 21 eyars old, primapara. Full term of pregnancy. The labor started 8 hours ago. The membranes ruptured 15 minutes later. Pelvic sizes: 25,28,31,20 cm. Fetal head rate 140 per minute with satisfactory characteristics. Per vaginum: the cervix is completely dilated. The amniotic sac is absent. Fetal buttocks are palpated in outlet plane of pelvic. Bitrochanter diameter is in the direct size of pelvic outlet. Diagnosis? What type of the manual aids need the patient?


7. Prirnipara F.,25 years old. Pregnancy at term. The labor started 6 hours later. The membranes ruptured 1 hour ago. Pelvic sizes: 23,25,29,18 cm. Fetal head rate 140 per minute with satisfactory characteristics. Uterine contractions are occurring every 7-8 minutes. Per vaginum: the uterine cervix dilatation is 5 sm. The amniotisac is absent. One fetal foot is palpated in the vagina. Buttocks are in the pelvic inlet. Diagnosis? How the delivery must be managed?


III. Answers to the Self- Assessment.

I- C. 2. D. 3. C. 4. B. 5. A. 6. First at term labor. Second stage of

labor. The frank breech presentation. Management: Vaginal delivery. The

manual aid by Tsovyanov I. 7.First at term labour I, first stage of labor.

footling presentation. Contracted pelvis I-II degree. Cesarean section should be performed.


Students must know:

1. Classification of breech presentations.

2. Diagnosis of breech presentations.

3. The biomechanism of the labor in breech presentations.

4. The cardinal movements of labor in breech presentations.

5. The classification of the manual aids lo breech presentations, indications to cesarean section.


Students should be able:

1. To show the cardinal movements of labor in breech presentation on phantom.

2. To determine the movements of the labor.

3. To determine the complications in labor.

4. To show the technique of the manual aids in breech presentat on phantom.


^ BREECH EXTRACTION

II. Tests and Assignments for Self - assessment. Multiple Choice.

Choose the correct answer / statement:

1. The breech hydrocephalus is best managed by: A — Cesarean section;

B — Destructive procedure;

C - Decompression of the head transvaginally;

D - Decompression of the head transabdominally.


2. If there has been no descent of the presenting breech for over 1 hour during the second stage of labor, and fetal heart rate is l00, the doctor should perform:

A - Breech extraction;

B - Cesarean section;

C - Any active procedure;

D - Destructive procedure.


3. Vaginal delivery of the term breech is generally avoided when the fetus weight is more of how many grams?

A - 2500 - 3000;

B - 3000 - 3500;

C - 3500 - 4000;

D - 4000 - 4500.

Real-life situation to be solved:

4. 38-years-old women at term arrives in active labor, full dilated with a presenting part at the pelvic floor. She has had no prenatal care and four previous vaginal deliveries of four boys all weighing 3000 to 3200 g. Because there are variable decelerations and a questionable loss of long term variability, artificial rupture of membranes is performed, at which time the patient is found to have a frank breech presentation. The FHR is now reassuring. Contractions are strong, occurring every 3 minutes. The fetal heart rate is 110 beat in minute. Which would be the best management?


III. Answers to the Self- Assessment.

1. B. 2. A. 3. CD. 4. Labor V, at term, II stage of the labor. The franc breech presentation. Fetal hypoxia. The best management is the operation of extraction fetus on the groin.


Students must know:

The determination of the operation of breech extraction.

The indications for breech extraction.

The conditions for the operation of breech extraction.

The techniques for breech extraction.

Anesthesia for breech extraction.

The techniques for the operation of extraction fetus on the one on the two legs, on the groin.

The complications caused by breech extraction

Students should be able:

1. To make the external obstetric physical examination.

2. To make the internal obstetric physical examination.

3. To make the diagnosis of type of breech presentation.

4. To choose the methods of delivery.

5. To evaluate of investigation.

6. To perform an operation of extraction on the phantom.

7. To choose the method of treatment.


MALPRESENTATIONS

^ II. Tests and Assignments for Self - assessment.

Multiple Choice.

Choose the correct answer / statement:

1. Which is the most appropriate treatment for the woman on 34 week of gestation having an oblique lie of the fetus? A - The classic version of the fetus; B - To stimulate delivery: C — Cesarean delivery; D - External version of the fetus.

2- A 17-year-old patient at 39 weeks gestation presents to the hospital av'nga transverse lie of the fetus. Which is the most appropriate treatment? A - External version of the fetus;

B - Rupture of the fetal membranes to stimulate delivery; C - Immediate cesarean delivery; D - An immediate vaginal delivery.

3- What are the requirements for internal podalic version of the fetus? A - Normal temperature of the body

B - Cervix must be fully dilated;

C - Membranes must be ruptured;

D - All of the above.

^ Real — life situations to be solved:

4. A multipara at 38 weeks of gestation entered the obstetrical department with normal labor activity. Complaints of the cough, headache The temperature of the body is 38,7 °C. Pelvic sizes: 25-28-31-20. Expected weight of fetus is 3000 g. Fetal heart tones are normal. The presenting part is not palpated upon the pelvic inlet. The head is situated in the left part of the uterus. Vaginal examination shows: the cervix is completely dilated. The membranes are intact. Shoulder of the fetus is palpated as a presenting part. Which is the most appropriate treatment?

III. Answers to the Self- Assessment.

1. D. 2. C. 3. D. 4. Labor, at term, second stage. Acute respiratory disease. Transverse fetal lie. The most appropriate management is internal podalic version.

Students must know:

l. The determination of the operation of obstetrics versions.

2. The indications for obstetrics versions.

3. The conditions for the operation of obstetrics versions.

4. The techniques for the external and internal obstetrics versions.

5. Anesthesia for the operation.

6. The complications caused by obstetrics versions.

Students should be able to:

1. To make the external obstetric physical examination.

2. To make the internal obstetric physical examination;

3. To evaluate the indications and contraindications to obstetric versions.

4. To do the operations of the internal and external version on phantom.


^ DEFLEXED PRESENTATIONS

II. Tests and Assignments for Self - assessment.

Multiple Choice.

Choose the correct answer / statement:

1. What is the first movement of labor in face presentation? A — Internal rotation;

B — External rotation: C — Flexion: D - Extension.

2. What is the first degree of the head extension? A — Deflexed vertex presentation;

B — Breech presentation; C - Brow presentation; D - Face presentation.

3. What is the fixing point in the face presentation?

A - Occiput;

B - Sinciput;

C — Fossa suboccipitalis;

D - The area of the border of the hair part.

4. What is the leader point in the face presentation? A - Anterior fontanel;

B - Posterior fontanel; C — Chin.

D — Area of the border of the hair part. Real ~ life situations to be solved:

5. M., 28 years old, para 2. Full term of pregnancy. Initiation ot labQl was 8 hours ago. The membranes ruptured 20 minutes ago. Fetal heart rate is 132 per minute with satisfactory

cter'istics. Per vaginum: the cervix is completely dilated. The amniotic is absent. Fetal head is in outlet plane of pelvic. The chin is palpated under the symphysis.

Diagnosis? What is the moment of labor biomechanism ?

6. Primipara N.,25 years old. Delivery at term. The labor started 6 ago. The membranes ruptured 1 hour ago. Pelvic sizes: 25,28,31,20. Fetal head rate 140 per minute with satisfactory characteristics. Uterine ntractions are occurring every 7-8 minutes. Per vaginum: the uterine cervix dilatation is 6 cm. The amniotic sac is absent. Fetal head fixed to the inlet of pelvis. Sagittal suture is in the right oblique size. Small and large fontanels are palpated. The large fontanel is lower. Diagnosis?

III. Answers to the Self- Assessment,

1. D. 2. A. 3. C. 4. C. 5. Labor 2, at term, 2 period of labor. Face presentation. Third moment of the labor biomechanism: flexion of the fetal head. Management: normal vaginal delivery. 6. Labour 1, at term. 1 period of labor. The defiexed vertex presentation. Visual Aids and Material Tools:

LMi Students must know:

1. The cardinal movements of labor in deflexed cephalic presentation.

2. The definition of deflexed vertex, brow and face presentation.

3. The mechanism of the head's flexion, rotation, extension, internal body's rotation and external head's rotation.

4. The definition of the leader point and the fixing point. Students should be able to:

1. To make the external obstetric physical examination.

2. To make the internal obstetric physical examination.

3. To show the cardinal movements of labor in deflexed cephalic presentation on phantom.

4. To determine normal and pathological course of the labor.


^ CONTRACTED PELVIS

II. Tests and Assignments for Self - assessment.

Multiple Choice.

Choose the correct answer / statement:

1. What is the first movement of labor in face presentation? A — Internal rotation;

B — External rotation: C — Flexion: D - Extension.

2. What is the first degree of the head extension? A — Deflexed vertex presentation;

B — Breech presentation; C - Brow presentation; D - Face presentation.

3. What is the fixing point in the face presentation?

A - Occiput;

B - Sinciput;

C — Fossa suboccipitalis;

D - The area of the border of the hair part.

4. What is the leader point in the face presentation? A - Anterior fontanel;

B - Posterior fontanel; C — Chin.

D — Area of the border of the hair part. Real ~ life situations to be solved:

5. M., 28 years old, para 2. Full term of pregnancy. Initiation ot labQl was 8 hours ago. The membranes ruptured 20 minutes ago. Fetal heart rate is 132 per minute with satisfactory

cter'istics. Per vaginum: the cervix is completely dilated. The amniotic is absent. Fetal head is in outlet plane of pelvic. The chin is palpated under the symphysis.

Diagnosis? What is the moment of labor biomechanism ?

6. Primipara N.,25 years old. Delivery at term. The labor started 6 ago. The membranes ruptured 1 hour ago. Pelvic sizes: 25,28,31,20. Fetal head rate 140 per minute with satisfactory characteristics. Uterine ntractions are occurring every 7-8 minutes. Per vaginum: the uterine cervix dilatation is 6 cm. The amniotic sac is absent. Fetal head fixed to the inlet of pelvis. Sagittal suture is in the right oblique size. Small and large fontanels are palpated. The large fontanel is lower. Diagnosis?

III. Answers to the Self- Assessment,

1. D. 2. A. 3. C. 4. C. 5. Labor 2, at term, 2 period of labor. Face presentation. Third moment of the labor biomechanism: flexion of the fetal head. Management: normal vaginal delivery. 6. Labour 1, at term. 1 period of labor. The defiexed vertex presentation.

Students must know:

1. The cardinal movements of labor in deflexed cephalic presentation.

2. The definition of deflexed vertex, brow and face presentation.

3. The mechanism of the head's flexion, rotation, extension, internal body's rotation and external head's rotation.

4. The definition of the leader point and the fixing point. Students should be able to:

1. To make the external obstetric physical examination.

2. To make the internal obstetric physical examination.

3. To show the cardinal movements of labor in deflexed cephalic presentation on phantom.

4. To determine normal and pathological course of the labor.


References:

1. Danforth's Obstetrics and gynaecology. - Seventh edition.- 1994, ~ P. 113-114,501-528.

2. Obstetrics and gynaecology. Williams & Wilkins Waverly Company. - Third Edition.- 1998. - P." 112-113."

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