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This refers to the relationship between denominator and the pelvis that makes the spontaneous delivery unfavourable,e.g;
Occipito posterior in vertex presentation Sacro posterior in breech presentation Mento posterior in face prsentation
Denominator
Most definable peripheral point in the presenting part,e.g; Occiput in Vertex Sacrum in Breech Mentum in Face Most of the malpositions correct themselves to normal due to flexion of the head at the atlantooccipital joint and occiput rotates forwards with additional uterine contactions.This mechanism favours the spontaneous vaginal delivery.
MALPRESENTATION
The lowest pole of the fetus that presents to the lower uterine segment and the cervix is presentation. Presentation other than vertex,i.e; breech,brow,face or shoulder,they are termed as malpresentation. Causes: 1.Idiopathic 5.Multiple pregnancy 2.Contracted Pelvis 6.Low lying placenta 3.Large baby 7.Preterm labour 4.Polyhydramnios 8.Anomalies of fetus or uterus
Anterioposterior
11cm 12cm 13.5cm
SUBOCCIPITO-BREGMATIC DIAMETER----9.5cm Middle of the anterior fontanelle to under surface of the occipital bone.The presenting diameter of the well flexed head in labour. SUBOCCIPITO-FRONTAL DIAMETER-------10cm From suboccipital region to prominence of forehead.Presents in partially flexed head. OCCIPITO-FRONTAL DIAMETER-----------11.5cm From root of nose to post fontanelle.A deflexed head presents with this diameter.
MENTO-VERTICAL DIAMETER-------------13cm From chin to furthest point of vertex and is known as brow presentation.This is usually large to pass through normal pelvis.
SUBMENTO_BREGMATIC DIAMETER----9.5cm Chin to anterior fontanelle.Clinically face presentation.
Incidence
-1:500 deliveries This is an obstetric emergency because of the risk of cord compression and for occlusion of umbilical arteries going into spasm causing fetal asphyxia.
Aetiology
Ill fitting presenting part:
-Breech esp. Flexed or footling breech -Transverse lie -Face presentation Multiparity: 80% cases,cord prolapse occur in multiparous patient as the fetal head remain free until the time of delivery. Preterm labour: small size baby with copious amount of liqour. Unduly Long Cord: Artificial rupture of membrane with poorly applied presenting part.
Diagnosis
A loop of cord is felt in vagina or may be seen at the
vulva.
Fetal heart irregularities especially a variable
deceleration pattern on CTG without obvious cause strongly suggests occult cord prolapse.
Can also be diagnosed on Ultrasound.
MANAGEMENT
Its an emergency situation and an indication for
immediate Caesarean Section if baby is alive and vaginal delivery cannot be effected immediately. Aim of management is to prevent the presenting part from occluding the cord. This can be done by following ways..
1...Displacing the presenting part by putting hand in vagina to avoid pressure on the cord.
4...Infusion of 500ml warm saline in bladder through 16 size catheter may be an alternative. The cord is kept in the vagina to keep it warm and moist to prevent arteries going into spasm. Along all these measures,assistants should at the same time: Establish IV access with 16 G cannula Take blood for Haemoglobin and X-match Give an H2 receptor agonist Call anaesthetist and peadiatricion
When the fetus is alive and cervix is fully dilated,immediate vaginal delivery should be made by using forceps if presenting part is descending with each contraction. Vaginal delivery should be done with full preparations for Caesarean Section. If fetus is dead ,labour is left to continue untill eventually vaginal delivery takes place.
Prevention
During antenatal period patients should be counselled
REFERENCES
Dewhursts textbook of Obstetrics &
Gynaecology(Eighteenth Edition)
Obstetrics By Ten Teachers(Seventeenth Edition)
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