NCM 109 4P's

• Abnormal lie


  Where the long axis of the fetus is not lying along the long axis of the mother's uterus
• Types of abnormal lie

  • Transverse
  • Oblique
  • Unstable
• Fetal malposition


  Where the fetus is lying longitudinally and the vertex is presenting, but not in occiput anterior (OA) position

  
• Persistent occiput posterior


  Directed diagonally and posteriorly, right, ROP or LOP
• Conditions that tend to cause persistent occiput posterior

  • Android pelvis- "male" pelvis
  • Anthropoid pelvis- "ape-like"
  • Contracted pelvis
• Occiput posterior (OP)


  Posteriorly presenting head does not fit the cervix as snugly as one in anterior position

  
• Occiput posterior (OP)


  Arrested labor may occur when head does not rotate and/or descend
• Occiput posterior (OP)

  Delivery maybe complicated by perineal tears or extension of an episiotomy
• Occiput transverse (OT)


  Incomplete rotation of occiput posterior to occiput anterior, which results in a horizontal or transverse position of the fetal head

  
• Occiput transverse (OT)


  • Course of labor is usually normal, except for prolonged second stage (>2 hours)
• Diagnosis of occiput transverse

  1. Abdominal examination: Lower part of the abdomen is flattened, Difficult to palpate fetal back, Fetal small parts are palpable anteriorly, Fetal heart tone may be heard in the flanks

  2. Vaginal examination: Posterior fontanel is towards the Sacral-iliac joint (difficult), Anterior fontanel is easily felt if head is deflexed, Fetal head may be markedly molded with extensive caput, making it more difficult to diagnose the correct station and position

  
• Occiput transverse (OT)


  Spontaneous rotation to occiput anterior occurs in 90% of cases
• Occiput transverse (OT) with arrested labor in 2nd stage

  Emergency CS
• Types of vertex malpresentation

  • Suboccipitobregmatic (9.5cm)- flexed vertex presentation
  • Suboccipitofrontal (10.5cm)- partially deflexed vertex
  • Occipitofrontal (11.5cm)- deflexed vertex
  • Mentovertical (13cm)- brow
  • Submentobregmatic (9.5cm)- face
• Babies born after face presentation

  • Facial edema- ecchymotic bruising, Lip edema- infant unable to suck
• Brow presentation (Mentovertical)


  Fetal head is partly extended (poor flexion-extension)
• Diagnosis of brow presentation

  1. Abdominal examination: Half of fetal head is above symphysis pubis & occiput is palpable higher than sinciput

  2. Vaginal examination: Anterior fontanel & orbits are felt

  
• Brow presentation


  Can be delivered by CS only
• Face presentation (Submentobregmatic)


  Occurs when head is hyper-extended, the face is the presenting part, the chin (mentum) is the denominator
• Mechanism of labor in face presentation

  1. Descent

  2. Internal Rotation

  3. Flexion

  4. Extension

  5. External Rotation

  6. Expulsion
• Causes of face presentation

  • Maternal: Lax uterus due to multiparity, Contracted pelvis/ CPD, Placenta previa, Multiple pregnancy
  • Fetal: Occiput posterior due to tendency of fetus of extending head instead of flexing it, Large fetus, Congenital malformation (Anencephaly), Multiple cord coil, Musculoskeletal abnormality (spasm/shortening of extensor muscle of neck), Tumors around the neck (congenital goiter)

  
• Diagnosis of face presentation

  Absence of engagement occurs, On IE, the examining fingers feel the mouth, nose, malar bones, and orbital ridges, UTZ confirms the diagnosis
• Management of face presentation

  1. If chin is in anterior position (LMA or RMA), uterine contractions are strong, head is small, shoulders have already entered the pelvis and there is no pelvic contraction, vaginal delivery is possible but longer than usual forceps may be used to hasten 2nd stage

  2. If chin is in posterior position (RMP, LMP), vaginal delivery may be impossible and dangerous if attempted because it can lead to transverse arrest. CS
• Sincipal presentation "Military position"


  Occurs when the larger diameter of the fetal head is presented, Labor progress is slowed with slower descent of the fetal head
• Presenting part diameters


  • Suboccipitobregmatic (Flexed vertex) 9.5cm
  • Suboccipitofrontal (Partially deflexed vertex) 10.5cm
  • Occipitofrontal (Sinciput-deflexed vertex) 11.5cm
  • Mentovertical (Brow) 13cm
  • Submentobregmatic (Face) 9.5cm

  
• Breech presentation

  Most common fetal malpresentation, Majority of fetuses are in breech presentation early in pregnancy by week 38 AOG fetuses normally turn to cephalic presentation and "retain most comfortable position"

  
• Uterus


  Fundus- largest part of uterus, 97% of all pregnancies, fetuses turns so that the buttocks and lower extremities are in the fundus those who failed to turn are breech
• Prevention of breech presentation

  Woman to assume 15 minutes knee-chest position for 3x a day during pregnancy so breech presentation will be less likely to occur
• Types of breech presentation

  • Frank Breech
  • Complete Breech
  • Footling (Double or Single)
  • Kneeling Breech
• Assessment of breech presentation

  1. Abdominal examination: Leopold's maneuver number 1, Head is felt on the fundus

  2. Auscultation: Leopold's maneuver number 2, FHT on upper quadrant of the abdomen

  3. Vaginal examination: Buttocks and/or feet are felt, Thick dark meconium is normal

  
• Etiology of breech presentation

  • Maternal: Polyhydramnios, Oligohydramnios, Uterine abnormalities, Pelvic tumor, Uterine surgery, Contracted pelvis, Previous breech delivery, Pendulous abdomen- lax abdominal muscle
  • Fetal: Prematurity, Multiple pregnancy, Fetal anomalies (Hydrocephalus, Anencephaly, Meningocele)
  • Placental: Placenta Previa

  
• Complications of breech presentation

  • Prolapse Cord, Birth Trauma (Fracture of the skull, clavicle, humerus, Intracranial hemorrhage, Rupture of abdominal organs), Dysfunctional & Prolonged Labor, Meconium Aspiration, Intrauterine Anoxia, Fetal Death
• Management of breech presentation

  1. Confirmatory by Ultrasound at or after 36 weeks

  2. External Cephalic Version (ECV) attempt if breech at or after 37 weeks, vaginal delivery possible, no contraindications

  3. Vaginal Breech Delivery may be attempted if no pelvic contraction, fetal weight not more than 3,500 grams, experienced/skilled personnel, spontaneous labor with progressive cervical dilatation, no evidence of feto-pelvic disproportion

  4. Caesarian Section

  
• General techniques of vaginal breech delivery

  • Spontaneous Breech Delivery
  • Partial Breech Extraction
  • Total Breech Extraction
• Nursing care of client with malpresentation

  Screen for abnormal fetal presentation, Perform abdominal plapation on all patients in labor, Palpate presenting part when performing vaginal exams, Report abnormal findings to the physician, Assist with diagnostic procedures, Avoid rupturing membranes, Encourage to empty bladder q2h, Be prepared for CS, forceps delivery, neonatal resuscitation or postpartum hemorrhage
• Compound presentation


  A fetal hand is coming out with fetal head, Prolapsed or concurrent presentation of an extremity with the presenting part

  
• Compound presentation


  Increased risk of mechanical injury to the arm and shoulder, including fractures, nerve injuries and soft tissue injury
• Management of compound presentation

  The fetus can be encouraged to withdraw the hand, If the fetus and arm are relatively small, vaginal delivery may still be possible but with some risk of injury to the arm, If the fetus and arm are relatively large, obstructed labor will occur and a cesarean will be needed
• Macrosomia


  Oversized fetus, Weighs >4000 to 4500g (9-10 lbs), Large babies associated with: DM, multiparity, Oversized infant may cause uterine dysfunction during labor or at birth because to the overstretching of the fiber of the myometrium

  
• Different maneuvers for breech delivery

  • Pinard's Maneuver
  • Loveset Maneuver
  • Mauriceau-Smellie-Veit Maneuver (Jaw flexion & Shoulder traction)