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Normal Presentation
The normal situation in primiparae is confirmed by the
presence of a longitudinal foetal lie, a flexed foetal attitude,
and a.cephalic presentation as a vertex. The foetus forms
an ovoid with the larger breech and flexed lower limbs
occupying the roomier upper pole of the uterus, and the
heavier head lying over the pelvic brim.
This situation
should be present at 34 weeks, and should continue unchanged
until term. The head should become engaged at about 36
weeks' gestation, and should remain engaged until the onset
of labour.
In multiparae the longitudinal lie, attitude of flexion, and
vertex presentation should be present, as in the case of primiparae, and indeed the head should engage about the same
time. However, it is accepted that the head in multiparous
cases frequently remains free until the onset of labour through
laxity of the abdominal muscles altering the relationship
between the uterine and pelvic axes. Prior to its engagement,
however, it should be possible to push the head into the pelvic
cavity, either by posturing the patient by placing her in a
sitting position, or by pushing the head into the brim by
manual pressure as advocated in the external Muller test.
Occipito-posterior Presentation
This malpresentation often causes trouble because it is
difficult to diagnose and is relatively frequent (about 7%) in
occurrence. It tends to be associated with an android type
of pelvis, in which the capacity of the fore-pelvis is reduced
by convergent bony contours, leaving more room in the
posterior segment for accommodation of the foetal occiput.
However, in some cases it probably has some connexion with
the attitude of the foetal head, which is held slightly extended.
In cases of occipito-posterior presentation engagement of
the head is typically delayed until labour is established. Postmaturity is commonplace owing to absence of the presenting
part in the lower segment. The onset of labour is frequently
preceded by rupture of the membranes. This is followed by
a gradual onset of uncoordinated uterine contractions,
irregular in rhythm, amplitude, and contraction pattern as
*
Master, Rotunda Hospital, Dublin.
t General Practitioner, Dublin.
Face Presentation
Where the foetus is in an extended attitude, the normal
relationship of the foetal presenting part to the maternal pelvis
is upset. A fully extended attitude of the foetal head constitutes a face presentation, and the foetal body is in an
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Brow Presentation
In this situation the foetal head is held erect midway
between flexion and extension. The foetus appears to be, as
it were, too proud to permit easy delivery by mere application
of forceps and suchlike methods, and it either has to be fetched
out by caesarean section, or by being converted by flexion to
the more submissive attitude of vertex presentation, provided
that the cervix is sufficiently dilated to admit the whole hand
to effect this manceuvre. If conversion to a vertex presentation fails, it is sometimes possible to extend the head from
the " military attitude " of brow, into the flamenco-like attitude
of extreme extension resembling face presentation. Basically
these are complex manceuvres which must be carried out under
deep anaesthesia with a considerable degree of uterine relaxation. The names of Schatz and Thorn are associated with
methods in which the foetal occiput is cupped in the obstetrician's hand and flexion is then produced. The difficulty always
lies in maintaining the head in its new attitude. In recent years
the vacuum extractor has proved to be a very useful method of
maintaining the attitude of flexion following correction of brow
presentation by one of the manceuvres outlined above.
When it is realized that brow presentation is often foetal in
origin, and is generally to be regarded as only a single
episode in what will otherwise be a normal obstetrical career,
it will be appreciated that it is worth while dealing with the
situation by correction of the brow presentation and subsequent vaginal delivery. This is done by assessment of the
pelvic capacity by clinical examination supplemented if
necessary by x-ray pelvimetry. If disproportion can be
excluded (and this is the general rule), then the obstetrician
should lean towards achieving correction of the malpresentation and subsequent vaginal delivery.
Unstable Lie
Unstable lie may be usefully defined as " instability of the
longitudinal axis of the foetus in relation to that of the uterus
after the 36th week of gestation." This is a situation fraught
with dangers. To appreciate these it is well to consider the
associated causative factors first:
1.
2.
3.
4.
Disproportion
Placenta praevia
Hydramnios
Hydrocephalus
5. Pelvic tumours
6. Congenital abnormalities of the uterus
7. Pendulous abdomen, with abnormal relationship
between the axis of the uterus and the pelvis.
Analysis of a series of unstable lies at the Rotunda
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MEDICAL
JOURNAL
grand multiparity and lax abdominal muscles alone. However 30% had association with serious factors, such as
placenta praevia and contracted pelvis. The latter was some-
times due to acquired spondylolisthesis, with forwarddislocation of the lumbosacral articulation, and consequent
reduction in the conjugate vera as described by Feeney.:'
Thus it becomes a matter of great importance to assess the
situation with the utmost care before the possible time of
onset of labour, bearing in mind the following unpleasant list
of dangers which may complicate unstable lie.
(a) Ante-partum haemorrhage from placenta praevia
(b) Obstructed labour due to disproportion, pelvic tumour,
or
hydrocephalus
(c) Premature rupture of membranes with consequent
risk of:
i Cord prolapse
ii Shoulder presentation
iii Neglected shoulder presentation, prolapsed arm,
and moulding of the uterus round the foetal body,
leading to intrauterine death and threatened rupture
of the uterus
In the face of this formidable situation many obstetricians
feel that there is little justification for withholding caesarean
section, and they would be right in most cases, although it is
sometimes difficult to embark on such a course with a patient
who has already had numerous normal deliveries and then
had a pregnancy complicated by unstable lie for no obvious
reason.
Nevertheless facts show that foetal salvage is
improved in this condition by using caesarean section more
freely, and this is the tendency at the present time. It is
obvious that this situation is quite unsuitable for management
as a domiciliary problem, and the sooner it is referred to a
maternity unit the better.
Prolapse of Cord
Cord Complications
Cord complications may occur in association with translie, hydramnios, or breech presentation. They may also
appear for no apparent reason. Prolapse of the cord spells
drama and danger in midwifery practice, and constitutes a
very grave emergency.
Management is divided into two
main phases : (a) first aid; and (b) replacement of the cord
and delivery.
First-aid management consists in endeavouring to relieve
pressure upon the cord, and thus to allow the continued survival of the foetus. This can be achieved in several bizarre
ways, such as the knee-chest position or the Trendelenburg
position, or simply by inserting a hand into the vagina and
preventing the presenting part from pressing on the cord.
None of these methods is of much use for more than a short
time while preparations for active and decisive delivery are
being made. However, one or other of them must be carried
out, and probably the knee-chest position is the most effective
of the three.
Immediate delivery by forceps application may be possible
where the cervix is fully dilated. Replacement of the cord
followed by application of the vacuum extractor to bring the
presenting part firmly on to the cervix is a satisfactory form
of management where the patient is advancing well in labour
with the cervix three to four fingers dilated.
Caesarean
section is the only choice where the cervix is less than three
fingers dilated, and indeed it might with justification be. used
for every case where immediate vaginal delivery is not considered possible.
Prolapse of the cord in the course of home confinement
often spells disaster for the foetus. Improvisation with the
first-aid methods described above is all that can be done in
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16 May 1964
the patient's home unless immediate vaginal delivery following cord replacement is considered possible. It is important
not to attempt over-heroic measures such as internal version,
which places the mother in considerable danger without at
the same time doing anything significant to improve the
situation for the foetus.
Cord Presentation
Cord presentation implies that the cord presents within the
intact sac of membranes. All the horrors of cord prolapse
are impending. The cervix is usually only about two fingers
dilated at the time of diagnosis, and there is little choice apart
from caesarean section.
Breech Presentation
In primiparae the foetus generally assumes an attitude of
extension when a breech presentation occurs and it seems
probable that the malpresentation is due mainly to the
abnormal attitude of the foetus. This also makes external
version difficult at any time, especially after 34 weeks' gestation. Other factors associated with breech presentation in
the primipara include contracted pelvis, placenta praevia,
pelvic tumours, and congenital abnormalities of the uterus.
In the multipara, however, breech presentation is usually
transient, and in these cases the baby is generally in an attitude
of flexion. One good kick with the legs will cause a forward
somersault which restores a normal presentation. This
happens spontaneously in many cases and it is recognized as
such by the patient herself. External version is generally
quite easy at 34 weeks, and up to 37 or 38 weeks it may still
be worth attempting. It is more likely that a breech presentation in a multipara is associated with some significant factor
such as placenta praevia than in the case of a primipara.
Management
The main point of management in the primiparous breech
patient is the meticulous assessment of her pelvic capacity by
all available means, including clinical assessment using the
Muller-Munro Kerr technique, and x-ray pelvimetry in
selected cases. The general practitioner should avail himself
of the services of his specialist colleague for this purpose. In
vertex presentation, the head acts as the pelvimeter par
excellence, and reliance can be placed on the fact that if the
head engages in the pelvic brim it will pass through the pelvic
cavity in nearly every case. Where the breech presents in a
primipara this valuable sign is not available, and her medical
adviser has to exercise all available science and art in order
to assure himself that the pelvis is of adequate capacity to
transmit the average-sized baby, bearing in mind the penalty
of being stuck at the time of delivery with a baby whose legs
and trunk are delivered but whose head is immovably jammed
in a contracted pelvis. Such a situation should be impossible
in modern times, and indeed would be impossible were it not
for the negligence of patients who fail to attend their doctors,
or of doctors who fail to attend adequately to their patients.
Where the pelvic capacity is in doubt, caesarean section may
well be the method of choice for delivery, consideration also
being given to the patient's age and years of marriage before
conception, and other such relevant factors.
Trial labour in a breech case has little to recommend it.
The progress of the breech through the pelvic cavity is not
a reliable index of the capacity of the pelvis to transmit the
after-coming head. Symphysiotomy performed in order to
enlarge the pelvic cavity during delivery of a breech case is
theoretically attractive, coupled with a trial of labour. In
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Conclusion
The recognition of abnormalities such as those described
above constitutes the most important initial step in their
eventual management. In this sphere the general practitioner
bears heavy responsibility towards his patient. The decision
as to the mode of delivery tends to be more in the sphere of
the specialist obstetrician. There is abundant opportunity
for improved levels of consultation between the two types of
medical practitioner on such occasions. There is no place at
all for mutual criticism, condemnation, or lack of communication in the conduct of an abnormal case, and no one stands
to suffer more in these circumstances than the patient and
her unborn baby.
REFERENCES
TO-DAY'S DRUGS
Treatment of Allergy
A panel discussion on this subject was held on 18 March. The members of the panel were Dr. R. S. BRUCE PEARSON
(Physician, King's College Hospital, London), Dr. F. RAY BETTLEY (Dermatologist, Middlesex Hospital), and Dr. JOHN
HUNT (General Practitioner, London). The chair was taken by a member of the B.M.7. editorial staff.
Definition
Chairman: I think we ought to begin with a short definition
of allergy. Dr. Pearson ?
Pearson: One might say that it now generally refers to
sensitivity reactions dependent on antigen/antibody mechanisms
that give rise to stereotyped groups of symptoms. But I
wouldn't claim this was a complete definition.
Principles of Treatment