types Definition Position Causes Mechanism of labor Diagnosis Progress of labor Management
🔹 A process of positional adaptation of the fetal head to the various segments of
🔹 First stage:
1.Exclude cephalo-pelvic disproportion.
🔹
the pelvis to complete childbirth:
A.Engagement: The occiput is defexed. The engagement diameter is occipto-
2.Management of prolonged labor:
-Adequate fuids,decrease vaginal examination to avoid rupture of
🔹
frontal (11.5 cm) enter the oblique diameter of the pelvis.
🔹 B.Flexion: When the occiput meet resistance of pelvic foor.
C. Internal rotation: When the presenting part reached the level of greatest
membranes, antibiotics and analgesia (epidural).
3.Partograph to monitor progress of labor.
🔹 🔹
dimension --> the occiput turned anterior toward the symphisis pubis: 4.Electronic F.H.S. monitoring.
1)Long anterior rotation, 3/8 circle: Abdominal: Second stage:
-Completed as occipto-anterior (90%) -Abnormal contour of abdomen. 1. Nearly 90% rotates to OA and management as normal vaginal delivery may be assisted by:
-The following factors need to be present:
🔹
-Non engagement of head (primigravida)
Vaginal:
🔹
-Oxytocins to augment uterine contractions
-Low (outlet) forceps.
🔹
1.Normal adequate pelvis
Occipto-Posterior
-Cephalic-Vertex presentation.
-The occiput is posterior and defexed
🔹 R.O.P is more common than L.O.P. due to
1. Abnormal shape of pelvis (commonest
cause), Android, anthropoid, fat.
2.Head should be well flexed ? a)Head is felt high, early rupture of membranes.
b)The posterior fontanel is palpated posterior,
🔹
Prolonged labor (1st and 2nd stages), early rupture of membranes.
Abnormal uterine action
-Ventouse delivery.
2. Face to pubis:
🔹
dextro-rotation of uterus and presence of 3.Adequate amount of amniotic fluid. Prolapse of umbilical cord
🔹
A. Chin anterior B. Chin posterior 2.Contracted pelvis. anterior fontanel is palpated anterior (Defexion -Episiotomy should be done (Generous).
🔹Maternal
presentation pelvic colon. 4.Efficient uterine contractions. Fetal distress
Incidence: Common; 10-20% of deliveries. 3. Anterior situation of placenta. 5.Average sized head of the head). -? Assist by low forceps (outlet).
C)Late in labor, a big caput succedaneum distress.
6.Good tone of pelvic floor muscles. 3.persistent OP and D.T.A:
2). Direct occipto-posterior: face to pubis (5%):
- Short posterior rotation, 1/8 circle: 🔹
masking the fontanelles and sutures.
U.S:
-Usually CS.
-? Controversy for the use of manual rotation or killand forceps rotation or ventouse rotation.
It has a mechanism of labor, the occiput is delivered by fexion, but the diameter
which distend the vulva is occipto-frontal (11.5 cm) liable to perineal tear -->
Confirm the diagnosis.
🔻 Indications of C.S. in O.P:
1.Cephalo-pelvic disproportion.
episiotomy should be done.
3). Persistent occipto-posterior and deep transverse arrest of the OP (short 2.Failure of progress of labor and maternal distress.
Ant. Rotation of occipto-anterior, 1/8 circle) 5%: -Causes: Uterine atony,more 3.Fetal distress.
common abnormal shape of pelvis, or contracted pelvis. 4.Persistent O.P., deep transverse arrest.
- No further mechanism of labor obstructed labor. 5.Other indications for C.S.: (P.I.H., previous C.S.,
elderly primigravida, etc…)
Any presentation other than vertex (i.e.a
longitudinal lie, cephalic with the vertex as the
presenting part) is called malpresentation.
▪️ Mento-Anterior:
a)Engagement and descent:
the engagement diameter is submento-bregmatic (9.5 cm)
Definition b)Extension.
C)Internal rotation of chin (1/8 circle anterior).
🔹 I- Longitudinal lie: (99%) ▪️Primary:
d)Flexion:
The diameter distend the vulva is submento-vertical (12 cm).
1)Mento-Anterior:
i -Exclude contracted pelvis and cephalo-pelvic disproportion.
a)Cephalic:
i. Vertex -Occiptoposterior (Malposition).
ii.Face presentation. Cephalic presentation in which the head is
Due to congenital malformation as anencephaly,
▪️
dolico-cephalus, congenital goitre.
Secondary:
The perineum is liable to tear.
e)Restitution. ▪️In labor:
-Vaginal examination: palpation of nose, mouth
ii -Management of prolonged labor.
iii. If labor progresses well --> Episiotomy.
Due to the diameter which distend the vulva is submento-
f)External rotation.
iii.Brow presentation. Developed in labor due to extension of defexed and vertical (12cm).
▪️
completely extended, with the occiput in
Types
🔹
b)Breech presentation. (3%)
II-Transverse and oblique lie. (1%)
Face presentation contact with the fetal back.
🔹
A. Chin anterior B. Chin posterior
head in occipito-posterior
1.Contracted pelvis.
Mento-Posterior:
1)Long internal rotation --> Mento-Anterior.
chin.
- U.S.: confirmation of diagnosis.
iv-? Assisted delivery by low (outlet) Forceps.
V-C.S. (common).
🔹
Shoulder presentation.
🔹 III-Complex (compound) presentation.
IV-Cord presentation and prolapse.
Incidence Rare; 1 in 500 deliveries. 2.Prematurity.
3.Multipara (Pendulous abdomen).
4.Macrosomia.
• 30%- Late (prolonged labor).
•The chin rotates 3/8 circle anterior and delivered as mento-anterior.
Differential diagnosis:
- Frank breech. 2)Mento-Posterior:
i -30% --> internal rotation into Mento-Anterior
2) Direct Mento-Posterior:
(manage as M.A.).
🔷
The chin rotates 1/8 circle posterior. No further mechanism -, labor is obstructed and
vaginal delivery is impossible ii.Direct MP, persistent M.P. or Deep-Transverse Arrest -> Vaginal delivery is impossible -> C.S.
Maternal:
i.Multiparity (Pendulous abdomen). 3)Persistent MP or Deep Transverse: Arrest - No mechanism of labor, obstructed
ii.Contracted pelvis and abnormal shape of the labor, vaginal delivery is impossible.
pelvis
(Android, Anthropoid or Platypeloid).
iii. Uterine anomalies (Bicorunate, Arcuate,
Subseptate, or Septate).
iv. Associated pelvic tumors (Uterine fibroid,
The engagement diameter is occipto-mental (14
Malpresentation Broad ligament fibroid or Ovarian cyst)
cm);so vaginal delivery is impossible.
Causes
🔷 Fetal:
i.Prematurity.
Cephalic presentation in which the head is
midway between fexion and extension.
I.Transient brow:
Early in labor: if good uterine contraction, average-size fetus, average amniotic fuid 🔹 Vaginal examination in labor: Palpation of
and adequate pelvis -, the brow converts into face or vertex. anterior fontanel, frontal suture, supra- orbital
ii.Multiple pregnancies. Brow presentation The orbital bridge and anterior fontanel The same as face presentation.
iii. Congenital malformations (anomalies):
Hydrocephalus, Anencephaly. 🔹
present at the pelvic inlet.
Incidence Rare; 1 in 1500 deliveries.
II.Persistent brow:
Late in labor (2nd stage): the prognosis is poor for
🔹U.S: confirm the diagnosis.
ridge and may be the root of the nose.
🔷
iv.IUFD (loss of tone).
Ill.Combined:
i.Placenta previa.
vaginal delivery or impossible.
Management is C.S.
ii.Polyhydramnios.
🔷 🔹 A. Clinical I. In pregnancy:
🔹
🔹
Maternal complications:
.Prolonged labor, obstructed labor.
Malpresentation
1) In pregnancy:
a) Abdominal:
a) External cephalic version E.C.V.
b) External pedalic version E.P.V.
🔹
🔹
Abnormal uterine actions (Inertia).
Early rupture of membranes.
i. Fundal level → ↓ Gestational age.
ii. Transverse diameter of the uterus is greater.
II. In labor:
a) Before rupture of fetal membranes: • Trial of ECV or EPV.
🔹
🔹
High incidence of instrumental delivery and C.S
Maternal distress. The presenting part is the shoulder. The fetal
• Dorso-posterior.
1. Prematurity.
2. Multiparity (30%).
iii. Fundal grip → empty. b) After ruptures of fetal membranes: • C.S.
Genital tract trauma (Perineum, vagina, cervix, rupture
Transverse lie head and breech occupy opposite maternal
• Dorso-anterior.
3. Multiple pregnancies (Twins). • In average-size fetus → no mechanism of labor;obstructed labor. iv. Head and buttocks at both iliac and lumbar.
v. Pelvic grip → empty. 🔸
c) Neglected shoulder:
Criteria (clinical signs):
🔹
uterus). • Dorso-superior. • Vaginal delivery is impossible.
iliac fossae or lumbar region (left & right) 4. Placenta previa. • Prolonged labor.
🔹 Postpartum hemorrhage. • Dorso-inferior. vi. F.H.S. at level of umbilicus.
5. Polyhydramnios. • Maternal distress.
🔹 Infections (in labor or puerperium). 2) In labor:
1. Abdominal → same. • Fetal distress or fetal death.
🔹 Genital prolapse.
Cervical incompetence and Recurrent 2. Vaginal → Early rupture of membranes and
• Prolapse congested arm.
Complications 🔹Maternal death
abortions.
🔹
prolapse of the arm.
B. Ultrasound:– Confirm diagnosis
🔻
• Signs of obstructed labor (pathological Retraction ring = Bandl’s ring)
Management:• C.S.
🔷 Fetal complications:
Increase the incidence of fetal and neonatal morbidity and
🔹 A. During pregnancy:
🔹
mortality compared to normal vertex presentation.
🔹 Intracranial hemorrhage. External cephalic version (ECV):
🔹 Asphyxia. – Transform the breech into cephalic, abdominally.
🔹 Injury of spinal cord. – The advantage is to reduce the risks and complications of breech child-birth.
🔹
🔹
Rupture liver or spleen.
Scalp injuries, cephalohematoma, 📍
– Success → 35-60%.
Time:
Fracture of bones (Femur, Humerus, Mandible) or
🔻 Difficulties or complications arising during breech delivery –Between 32w→36w of pregnancy.
🔹Brachial plexus injuries and Facial palsy.
dislocation of joints.
🔹
A. Difficulties at level of buttocks:
I. Arrest of buttocks at inlet:
–Before 32 ws, spontaneous version (common) or recurrence.
– After 36 ws → Difficult due to ↓ amniotic fluid and ↑ size of fetus.
🔹
Causes: - Big fetus. - Contracted inlet. - Uterine inertia. –It is performed under U.S guidance to assess the operator and electronic fetal monitor.
II. Arrest of buttocks at outlet:
Causes: - Contracted outlet. - Frank breech. - Rigid perineum. - Uterine inertia. 📍
Tocolytic drugs may be given to relax the uterus.
Contraindications:
i. Placenta previa or abruption.
B. Difficulties at level of shoulder: ii. Scar in the uterus; e.g. C.S., Myomectomy
iii. oligohydramnios or hydramnios.
C. C.S.:
• Causes:
iv. IUGR – nonassuring F.H.S Indications of C.S. in breech delivery:
− Extension of one or both arms.
v. P.I.Hvi. Congenital anomalies of the uterus or fetus (Hydrocephalus).vii. Multiple pregnancy (Twins). 1.Contracted pelvis.
− Nuchal displacement of the arm.
🔹 Position:
the nominated part is the sacrum.
• Due to early traction of body fetus before fulldilatation of cervix or wrong rotation of thebody of the fetus. viii.Contracted pelvis (C.S. in labor).
ix. Patient’s refusal.
2.Preterm or post-term <37 ws → ≥42 ws.
3.Fetal weight: Estimated <2 Kg or >4 Kg.
C. Difficulties in delivery of the After-coming head: 4.Hyper-extended head.
1. Sacro-Anterior (left or right). Mode of delivery of breech 5.Primipara.
🔹
Causes:
🔹
2. Sacro-Posterior (left or right). • Abdominal: A. Spontaneous vaginal birth.– Premature fetus.– Second twin. 6.Failure of progress of trial labor or complicated breech.
Types Fetal: − Extension of the head.
by fatema okoff Mechanism of delivery of buttocks: –Head palpated in fundus (fundal grip). − Incomplete cervical dilatation. B. Assisted vaginal birth. (partial assisted breech). 7.Patient refuses trial labor.
1. Complete (flexion) → buttocks and feet. i. Preterm labor (50%). i. Engagement:the engagement diameter is bitrochanteric = 10cm ( in oblique 8. Fetal distress.
–Buttocks felt by pelvic grip. − Rigid perineum. C. C.S.
2. Incomplete: ii. Multiple pregnancies. diameter of the pelvis). 9. Previous C.S. or other uterine scars.
–F.H.S.: heard at or above umbilicus − Contracted outlet.
a) Frank breech: breech with extended legs. iii. Congenital anomalies (hydrocephalus). ii. Internal rotation:Anterior buttocks rotate forward 1/8 circle to be born below 10.Associated complications need C.S. (e.g.placenta previa,
• Vaginal (in labor):
🔹 ✳️For successful and safe vaginal birth to occur, the following recommendations:
B. Assisted vaginal birth: (selective trial of labor):
Breech presentation occurs when the fetal iv. Intra-uterine fetal death IUFD. − Backward rotation of the occiput.
b) Knee presentation. symphysis pubis.Posterior buttocks delivered by lateral rotation of spine placental abruption, P.I.H.,Diabetes, etc….).
🔻
–Rounded buttocks, feet (heel), anus, male
pelvisor lower extremities engage the maternal Maternal:
🔹
c) Footling iii. The body will easily slip out till shoulder. genitalia and sacrum. Complications of breech delivery
pelvicinlet, i.e, Fetus presents by it’s podalic i. Placenta previa. 1.Fetal weight: 2 Kg → 3.8 Kg.
Breech presentation Mechanism of delivery of shoulder: –Differential diagnosis: shoulder presentation, • Breech carries high incidence of perinatalmorbidity and mortality, also maternal morbidityand mortality due
🔹
parts(Buttocks, feet) ii. fundal placental implantation 2.37 ws → 41 ws gestation.
🔹
i. Engagement:the engagement D. is bisacromial D. (12cm) enter the same oblique as face. to difficult and prolonged laborand operative delivery
Incidence: 3% in labor, more frequent early iii. Abnormal shape of the uterus (Bicornuate, 3.Adequate normal pelvis.
that of buttocks. •U.S. (level II): A. Fetal complications:
in pregnancy (6%at 32 ws, 25% at 28 ws) unicornuate or septate). 4.No hyper-extended head.
ii. Internal rotation (1/8 circle anterior).Anterior shoulder is born followed by posterior i. Confirm diagnosis. • Fatal:
iii. Uterine fibroid. 5.Complete breech and Frank.
🔻
ii. Exclude congenital malformations. i. Intracranial hemorrhage (75% of perinatal mortality).
iv. Hydramnios. 6.Multipara (? Primipara).
Mechanism of delivery of After-coming head: iii. Estimate amniotic fluid.
🔹Idiopathic (unexplained)
ii. Asphyxia (20%) due to:
i. Engagement:the engagement D. is the sub-occipito-frontal(10cm). Enter the
opposite oblique D. of pelvis.
iv. Fetal size.v. Hyperextension of head.
vi. Placental location.
a) Delay delivery of after-coming head.
b) Cord compression. ✳️
7.No associated complications
Important elements for successful vaginal birth:
I. First stage:
ii. Internal rotation:the occiput rotates 1/8 circle anterior → behindsymphisis pubis. c) Aspiration of amniotic fluid/meconium.
i.Continuous electronic F.H.R. monitoring.
iii. After-coming head delivered by Flexion:the diameter which distend the perineum is iii. Injury of spinal cord (cervical spines)
iv. Rupture liver or spleen. ii.Partograph to monitor the progress of labor.
occipto-frontal. Diameter = 11.5 cm → needs episiotomy II. Second stage:
• Nonfatal:
i. Fracture Femur, Humerus or Mandible. –A senior, skilled obstetrician, team support foranaesthesia, neonatologist and assistant inoperative theatre ready for C.S.
ii. Brachial plexus injury.
iii. Facial palsy. ✳️ The delivery itself is managed with watchful Waiting of obstetrician and cooperative relaxed woman.
i. Avoiding all temptations to pull on the breechand allowing spontaneous delivery to umbilicus.
🔹
iv. Late complications: paraplegia, epilepsy and mental retardation ?
B. Maternal complications:
Mainly from prolonged, operative delivery or anaesthesia:
ii. Allowing delivery of fetal legs by abducting thethighs.
iii. Rotation of fetal trunk, so sacrum is anterior.
i. Birth canal injuries. iv. Gentle traction on fetal bony pelvis untilscapulae are visible.
v. Rotation of fetal trunk to allow delivery of elbow by cross fetal chest.
ii. Postpartum hemorrhage.
iii. Infections. vi. Careful manipulation of shoulder
iv. Prolapse.
v. Delivery of After-coming head:
• Adequate episiotomy should be done to avoid severe compression of the head.• Careful manipulation of After-coming head to
maintain head flexion during delivery.
Three methods can be used:
1. Burns-Marshall method: Depends on the weight of the fetus for descent of the head in pelvis.
2. Jaw flexion and shoulder traction (Mauriceau-Smellie-veit).
3. Forceps delivery:With long forceps with perineal curve (Piper’s Forceps).
🔹 A process of positional adaptation of the fetal head to the various segments of
🔹 First stage:
1.Exclude cephalo-pelvic disproportion.
🔹
the pelvis to complete childbirth:
A.Engagement: The occiput is defexed. The engagement diameter is occipto-
2.Management of prolonged labor:
-Adequate fuids,decrease vaginal examination to avoid rupture of
🔹
frontal (11.5 cm) enter the oblique diameter of the pelvis.
🔹 B.Flexion: When the occiput meet resistance of pelvic foor.
C. Internal rotation: When the presenting part reached the level of greatest
membranes, antibiotics and analgesia (epidural).
3.Partograph to monitor progress of labor.
🔹 🔹
dimension --> the occiput turned anterior toward the symphisis pubis: 4.Electronic F.H.S. monitoring.
1)Long anterior rotation, 3/8 circle: Abdominal: Second stage:
-Completed as occipto-anterior (90%) -Abnormal contour of abdomen. 1. Nearly 90% rotates to OA and management as normal vaginal delivery may be assisted by:
-The following factors need to be present:
🔹
-Non engagement of head (primigravida)
Vaginal:
🔹
-Oxytocins to augment uterine contractions
-Low (outlet) forceps.
🔹
1.Normal adequate pelvis
Occipto-Posterior
-Cephalic-Vertex presentation.
-The occiput is posterior and defexed
🔹 R.O.P is more common than L.O.P. due to
1. Abnormal shape of pelvis (commonest
cause), Android, anthropoid, fat.
2.Head should be well flexed ? a)Head is felt high, early rupture of membranes.
b)The posterior fontanel is palpated posterior,
🔹
Prolonged labor (1st and 2nd stages), early rupture of membranes.
Abnormal uterine action
-Ventouse delivery.
2. Face to pubis:
🔹
dextro-rotation of uterus and presence of 3.Adequate amount of amniotic fluid. Prolapse of umbilical cord
🔹
A. Chin anterior B. Chin posterior 2.Contracted pelvis. anterior fontanel is palpated anterior (Defexion -Episiotomy should be done (Generous).
🔹Maternal
presentation pelvic colon. 4.Efficient uterine contractions. Fetal distress
Incidence: Common; 10-20% of deliveries. 3. Anterior situation of placenta. 5.Average sized head of the head). -? Assist by low forceps (outlet).
C)Late in labor, a big caput succedaneum distress.
6.Good tone of pelvic floor muscles. 3.persistent OP and D.T.A:
2). Direct occipto-posterior: face to pubis (5%):
- Short posterior rotation, 1/8 circle: 🔹
masking the fontanelles and sutures.
U.S:
-Usually CS.
-? Controversy for the use of manual rotation or killand forceps rotation or ventouse rotation.
It has a mechanism of labor, the occiput is delivered by fexion, but the diameter
which distend the vulva is occipto-frontal (11.5 cm) liable to perineal tear -->
Confirm the diagnosis.
🔻 Indications of C.S. in O.P:
1.Cephalo-pelvic disproportion.
episiotomy should be done.
3). Persistent occipto-posterior and deep transverse arrest of the OP (short 2.Failure of progress of labor and maternal distress.
Ant. Rotation of occipto-anterior, 1/8 circle) 5%: -Causes: Uterine atony,more 3.Fetal distress.
common abnormal shape of pelvis, or contracted pelvis. 4.Persistent O.P., deep transverse arrest.
- No further mechanism of labor obstructed labor. 5.Other indications for C.S.: (P.I.H., previous C.S.,
elderly primigravida, etc…)
Any presentation other than vertex (i.e.a
longitudinal lie, cephalic with the vertex as the
presenting part) is called malpresentation.
▪️ Mento-Anterior:
a)Engagement and descent:
the engagement diameter is submento-bregmatic (9.5 cm)
Definition b)Extension.
C)Internal rotation of chin (1/8 circle anterior).
🔹 I- Longitudinal lie: (99%) ▪️Primary:
d)Flexion:
The diameter distend the vulva is submento-vertical (12 cm).
1)Mento-Anterior:
i -Exclude contracted pelvis and cephalo-pelvic disproportion.
a)Cephalic:
i. Vertex -Occiptoposterior (Malposition).
ii.Face presentation. Cephalic presentation in which the head is
Due to congenital malformation as anencephaly,
▪️
dolico-cephalus, congenital goitre.
Secondary:
The perineum is liable to tear.
e)Restitution. ▪️In labor:
-Vaginal examination: palpation of nose, mouth
ii -Management of prolonged labor.
iii. If labor progresses well --> Episiotomy.
Due to the diameter which distend the vulva is submento-
f)External rotation.
iii.Brow presentation. Developed in labor due to extension of defexed and vertical (12cm).
▪️
completely extended, with the occiput in
Types
🔹
b)Breech presentation. (3%)
II-Transverse and oblique lie. (1%)
Face presentation contact with the fetal back.
🔹
A. Chin anterior B. Chin posterior
head in occipito-posterior
1.Contracted pelvis.
Mento-Posterior:
1)Long internal rotation --> Mento-Anterior.
chin.
- U.S.: confirmation of diagnosis.
iv-? Assisted delivery by low (outlet) Forceps.
V-C.S. (common).
🔹
Shoulder presentation.
🔹 III-Complex (compound) presentation.
IV-Cord presentation and prolapse.
Incidence Rare; 1 in 500 deliveries. 2.Prematurity.
3.Multipara (Pendulous abdomen).
4.Macrosomia.
• 30%- Late (prolonged labor).
•The chin rotates 3/8 circle anterior and delivered as mento-anterior.
Differential diagnosis:
- Frank breech. 2)Mento-Posterior:
i -30% --> internal rotation into Mento-Anterior
2) Direct Mento-Posterior:
(manage as M.A.).
🔷
The chin rotates 1/8 circle posterior. No further mechanism -, labor is obstructed and
vaginal delivery is impossible ii.Direct MP, persistent M.P. or Deep-Transverse Arrest -> Vaginal delivery is impossible -> C.S.
Maternal:
i.Multiparity (Pendulous abdomen). 3)Persistent MP or Deep Transverse: Arrest - No mechanism of labor, obstructed
ii.Contracted pelvis and abnormal shape of the labor, vaginal delivery is impossible.
pelvis
(Android, Anthropoid or Platypeloid).
iii. Uterine anomalies (Bicorunate, Arcuate,
Subseptate, or Septate).
iv. Associated pelvic tumors (Uterine fibroid,
The engagement diameter is occipto-mental (14
Malpresentation Broad ligament fibroid or Ovarian cyst)
cm);so vaginal delivery is impossible.
Causes
🔷 Fetal:
i.Prematurity.
Cephalic presentation in which the head is
midway between fexion and extension.
I.Transient brow:
Early in labor: if good uterine contraction, average-size fetus, average amniotic fuid 🔹 Vaginal examination in labor: Palpation of
and adequate pelvis -, the brow converts into face or vertex. anterior fontanel, frontal suture, supra- orbital
ii.Multiple pregnancies. Brow presentation The orbital bridge and anterior fontanel The same as face presentation.
iii. Congenital malformations (anomalies):
Hydrocephalus, Anencephaly. 🔹
present at the pelvic inlet.
Incidence Rare; 1 in 1500 deliveries.
II.Persistent brow:
Late in labor (2nd stage): the prognosis is poor for
🔹U.S: confirm the diagnosis.
ridge and may be the root of the nose.
🔷
iv.IUFD (loss of tone).
Ill.Combined:
i.Placenta previa.
vaginal delivery or impossible.
Management is C.S.
ii.Polyhydramnios.
🔷 🔹 A. Clinical I. In pregnancy:
🔹
🔹
Maternal complications:
.Prolonged labor, obstructed labor.
Malpresentation
1) In pregnancy:
a) Abdominal:
a) External cephalic version E.C.V.
b) External pedalic version E.P.V.
🔹
🔹
Abnormal uterine actions (Inertia).
Early rupture of membranes.
i. Fundal level → ↓ Gestational age.
ii. Transverse diameter of the uterus is greater.
II. In labor:
a) Before rupture of fetal membranes: • Trial of ECV or EPV.
🔹
🔹
High incidence of instrumental delivery and C.S
Maternal distress. The presenting part is the shoulder. The fetal
• Dorso-posterior.
1. Prematurity.
2. Multiparity (30%).
iii. Fundal grip → empty. b) After ruptures of fetal membranes: • C.S.
Genital tract trauma (Perineum, vagina, cervix, rupture
Transverse lie head and breech occupy opposite maternal
• Dorso-anterior.
3. Multiple pregnancies (Twins). • In average-size fetus → no mechanism of labor;obstructed labor. iv. Head and buttocks at both iliac and lumbar.
v. Pelvic grip → empty. 🔸
c) Neglected shoulder:
Criteria (clinical signs):
🔹
uterus). • Dorso-superior. • Vaginal delivery is impossible.
iliac fossae or lumbar region (left & right) 4. Placenta previa. • Prolonged labor.
🔹 Postpartum hemorrhage. • Dorso-inferior. vi. F.H.S. at level of umbilicus.
5. Polyhydramnios. • Maternal distress.
🔹 Infections (in labor or puerperium). 2) In labor:
1. Abdominal → same. • Fetal distress or fetal death.
🔹 Genital prolapse.
Cervical incompetence and Recurrent 2. Vaginal → Early rupture of membranes and
• Prolapse congested arm.
Complications 🔹Maternal death
abortions.
🔹
prolapse of the arm.
B. Ultrasound:– Confirm diagnosis
🔻
• Signs of obstructed labor (pathological Retraction ring = Bandl’s ring)
Management:• C.S.
🔷 Fetal complications:
Increase the incidence of fetal and neonatal morbidity and
🔹 A. During pregnancy:
🔹
mortality compared to normal vertex presentation.
🔹 Intracranial hemorrhage. External cephalic version (ECV):
🔹 Asphyxia. – Transform the breech into cephalic, abdominally.
🔹 Injury of spinal cord. – The advantage is to reduce the risks and complications of breech child-birth.
🔹
🔹
Rupture liver or spleen.
Scalp injuries, cephalohematoma, 📍
– Success → 35-60%.
Time:
Fracture of bones (Femur, Humerus, Mandible) or
🔻 Difficulties or complications arising during breech delivery –Between 32w→36w of pregnancy.
🔹Brachial plexus injuries and Facial palsy.
dislocation of joints.
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A. Difficulties at level of buttocks:
I. Arrest of buttocks at inlet:
–Before 32 ws, spontaneous version (common) or recurrence.
– After 36 ws → Difficult due to ↓ amniotic fluid and ↑ size of fetus.
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Causes: - Big fetus. - Contracted inlet. - Uterine inertia. –It is performed under U.S guidance to assess the operator and electronic fetal monitor.
II. Arrest of buttocks at outlet:
Causes: - Contracted outlet. - Frank breech. - Rigid perineum. - Uterine inertia. 📍
Tocolytic drugs may be given to relax the uterus.
Contraindications:
i. Placenta previa or abruption.
B. Difficulties at level of shoulder: ii. Scar in the uterus; e.g. C.S., Myomectomy
iii. oligohydramnios or hydramnios.
C. C.S.:
• Causes:
iv. IUGR – nonassuring F.H.S Indications of C.S. in breech delivery:
− Extension of one or both arms.
v. P.I.Hvi. Congenital anomalies of the uterus or fetus (Hydrocephalus).vii. Multiple pregnancy (Twins). 1.Contracted pelvis.
− Nuchal displacement of the arm.
🔹 Position:
the nominated part is the sacrum.
• Due to early traction of body fetus before fulldilatation of cervix or wrong rotation of thebody of the fetus. viii.Contracted pelvis (C.S. in labor).
ix. Patient’s refusal.
2.Preterm or post-term <37 ws → ≥42 ws.
3.Fetal weight: Estimated <2 Kg or >4 Kg.
C. Difficulties in delivery of the After-coming head: 4.Hyper-extended head.
1. Sacro-Anterior (left or right). Mode of delivery of breech 5.Primipara.
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Causes:
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2. Sacro-Posterior (left or right). • Abdominal: A. Spontaneous vaginal birth.– Premature fetus.– Second twin. 6.Failure of progress of trial labor or complicated breech.
Types Fetal: − Extension of the head.
by fatema okoff Mechanism of delivery of buttocks: –Head palpated in fundus (fundal grip). − Incomplete cervical dilatation. B. Assisted vaginal birth. (partial assisted breech). 7.Patient refuses trial labor.
1. Complete (flexion) → buttocks and feet. i. Preterm labor (50%). i. Engagement:the engagement diameter is bitrochanteric = 10cm ( in oblique 8. Fetal distress.
–Buttocks felt by pelvic grip. − Rigid perineum. C. C.S.
2. Incomplete: ii. Multiple pregnancies. diameter of the pelvis). 9. Previous C.S. or other uterine scars.
–F.H.S.: heard at or above umbilicus − Contracted outlet.
a) Frank breech: breech with extended legs. iii. Congenital anomalies (hydrocephalus). ii. Internal rotation:Anterior buttocks rotate forward 1/8 circle to be born below 10.Associated complications need C.S. (e.g.placenta previa,
• Vaginal (in labor):
🔹 ✳️For successful and safe vaginal birth to occur, the following recommendations:
B. Assisted vaginal birth: (selective trial of labor):
Breech presentation occurs when the fetal iv. Intra-uterine fetal death IUFD. − Backward rotation of the occiput.
b) Knee presentation. symphysis pubis.Posterior buttocks delivered by lateral rotation of spine placental abruption, P.I.H.,Diabetes, etc….).
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–Rounded buttocks, feet (heel), anus, male
pelvisor lower extremities engage the maternal Maternal:
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c) Footling iii. The body will easily slip out till shoulder. genitalia and sacrum. Complications of breech delivery
pelvicinlet, i.e, Fetus presents by it’s podalic i. Placenta previa. 1.Fetal weight: 2 Kg → 3.8 Kg.
Breech presentation Mechanism of delivery of shoulder: –Differential diagnosis: shoulder presentation, • Breech carries high incidence of perinatalmorbidity and mortality, also maternal morbidityand mortality due
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parts(Buttocks, feet) ii. fundal placental implantation 2.37 ws → 41 ws gestation.
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i. Engagement:the engagement D. is bisacromial D. (12cm) enter the same oblique as face. to difficult and prolonged laborand operative delivery
Incidence: 3% in labor, more frequent early iii. Abnormal shape of the uterus (Bicornuate, 3.Adequate normal pelvis.
that of buttocks. •U.S. (level II): A. Fetal complications:
in pregnancy (6%at 32 ws, 25% at 28 ws) unicornuate or septate). 4.No hyper-extended head.
ii. Internal rotation (1/8 circle anterior).Anterior shoulder is born followed by posterior i. Confirm diagnosis. • Fatal:
iii. Uterine fibroid. 5.Complete breech and Frank.
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ii. Exclude congenital malformations. i. Intracranial hemorrhage (75% of perinatal mortality).
iv. Hydramnios. 6.Multipara (? Primipara).
Mechanism of delivery of After-coming head: iii. Estimate amniotic fluid.
🔹Idiopathic (unexplained)
ii. Asphyxia (20%) due to:
i. Engagement:the engagement D. is the sub-occipito-frontal(10cm). Enter the
opposite oblique D. of pelvis.
iv. Fetal size.v. Hyperextension of head.
vi. Placental location.
a) Delay delivery of after-coming head.
b) Cord compression. ✳️
7.No associated complications
Important elements for successful vaginal birth:
I. First stage:
ii. Internal rotation:the occiput rotates 1/8 circle anterior → behindsymphisis pubis. c) Aspiration of amniotic fluid/meconium.
i.Continuous electronic F.H.R. monitoring.
iii. After-coming head delivered by Flexion:the diameter which distend the perineum is iii. Injury of spinal cord (cervical spines)
iv. Rupture liver or spleen. ii.Partograph to monitor the progress of labor.
occipto-frontal. Diameter = 11.5 cm → needs episiotomy II. Second stage:
• Nonfatal:
i. Fracture Femur, Humerus or Mandible. –A senior, skilled obstetrician, team support foranaesthesia, neonatologist and assistant inoperative theatre ready for C.S.
ii. Brachial plexus injury.
iii. Facial palsy. ✳️ The delivery itself is managed with watchful Waiting of obstetrician and cooperative relaxed woman.
i. Avoiding all temptations to pull on the breechand allowing spontaneous delivery to umbilicus.
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iv. Late complications: paraplegia, epilepsy and mental retardation ?
B. Maternal complications:
Mainly from prolonged, operative delivery or anaesthesia:
ii. Allowing delivery of fetal legs by abducting thethighs.
iii. Rotation of fetal trunk, so sacrum is anterior.
i. Birth canal injuries. iv. Gentle traction on fetal bony pelvis untilscapulae are visible.
v. Rotation of fetal trunk to allow delivery of elbow by cross fetal chest.
ii. Postpartum hemorrhage.
iii. Infections. vi. Careful manipulation of shoulder
iv. Prolapse.
v. Delivery of After-coming head:
• Adequate episiotomy should be done to avoid severe compression of the head.• Careful manipulation of After-coming head to
maintain head flexion during delivery.
Three methods can be used:
1. Burns-Marshall method: Depends on the weight of the fetus for descent of the head in pelvis.
2. Jaw flexion and shoulder traction (Mauriceau-Smellie-veit).
3. Forceps delivery:With long forceps with perineal curve (Piper’s Forceps).
